Handbook Musculoskeletal Assessment

BACHELOR OF PHYSIOTHERAPY
MUSCULOSKELETAL PRACTICAL HANDBOOK

BY
MUNISWARAN D. PUSHPANATHAN
HOE KEN KEONG
THARUSHENI MANIMARAN
PAVITHRA ANNAMALAI
FOR AIMST PHYSIOTHERAPY STUDENT USE ONLY

TABLE OF CONTENT
NO TOPIC PAGE NUMBER
1 ASSESMENT 1-6
2 RANGE OF MOTION MEASUREMENT (ROM) 7-70
3 MANUAL MUSCLE TESTING (MMT) 71-178
4 LIMB LENGTH MEASUREMENT 179
5 MUSCLE GIRTH MEASUREMENT 180-184
6 SPECIAL TEST 185-242
7 GAIT TRAINING 243-249
8 TRANSFER TECHNIQUE 250-251
9 JOINT MOBILIZATION 252-310
10 PROPRIOCEPTIVE NEUROMUSCULOR FACILITATION (PNF) 311-321
11 PASSIVE INTERVERTEBRAL MOTION 322-324
12 SOFT TISSUE MANIPULATION 325-329
13 MC KENZIE METHOD 330-352
REFERENCES
1. Orthopedic Physical Assessment 5th Edition by David J. Magee
2. Orthopedic Physical Assessment 6th Edition by David J. Magee
3. Therapeutic Exercise for Musculoskeletal Injuries 4th Edition by Peggy A. Houglum
4. PNF in Practice 3rd Edition by Susan A. Adler
5. Muscle Testing 10th Edition by Daniels and Worthingham’s
6. Therapeutic Exercise 5th Edition by Carolyn Kisner
7. Joint Range of Motion and Muscle Length Testing by Nancy Berryman Reese
8. 7 Steps to a Pain Free Life by Robin Mckenzie with Craig Kubey
ASSESSMENT
SUBJECTIVE
PATEINT PROFILE • NAME
• AGE
• GENDER
• ID NO
• OCCUPATION
• WEIGHT & HEIGHT
• ADDRESS
• D.O ASSESMENT
• D.O ADMISSION
• DR. DIAGNOSIS
• DR. MANAGEMENT: Conservative / Post – op (Procedures, Date)
• BLOOD PRESSURE, SPO2, RESPIRATORY RATE & PULSE RATE
CHIEF COMPLAIN/ • Patients own word or statement

PROBLEM
CURRENT HISTORY • Date/Duration of onset of symptom:

• Mechanism of injury: influence of posture, movement
• Condition: improved, stationary, deteriorated
• Weakness:
• Correlate with chief complaint
PAIN SCALE / VAS

• VAS Scale 1-10, present pain (location)
• Body chart Mark or color the injured or symptom part,

Label Left, Right, Posterior and Anterior View
1
ASSESSMENT
• Type of Dull aching, sharp shooting, cramping, throbbing, radiating, burning sensation/pressure
pain/Nature (Area of symptom)
• Onset sudden or gradual (Days, weeks, months or years)
• Aggravating factor posture, movement, or activities (VAS, & Duration)
• Irritability high/medium/low (tolerable or not)
• 24 hours behaviors AM/PM, (VAS Scale, influence posture and movement)
• Relieving/Easing medication, position, massage, application of cold/hot/analgesic cream

factor list down dosage to ease pain
PAST HISTORY
MEDICAL HISTORY DM, BP, Bronchial Asthma, Tuberculosis, Cardiac Problem, etc.
SURGERY HISTORY
FAMILY HISTORY Hereditary diseases
MEDICATION Dosage, Name of medication & (AM/PM)
SPECIAL QUESTION
• General health Poor / Fair / Healthy
• Investigation MRI, CT scan, Bone Scan, X-ray, Laboratory finding
• Pacemaker / hearing aid Yes / No
• Menopause Duration & Date (only for women after menopause)
• Bowel & bladder Normal / Incontinence
• Environmental history House /Office /Workplace type, toilet, car, pillow, bed. etc.
Nature of job: work type
• Recreation Sport / Activity (type & duration)
• Social / Personal Smoking, Alcohol, Drugs (duration, amount per day)

Sexual life
Mental health
2
ASSESSMENT
OBJECTIVE
ON OBSERVATION
General appearance
• Body type Ectomorph, Endomorph or Mesomorph
• Functional Independent / Dependent

status
• Postural
analysis in
Gait
3
ASSESSMENT
• Gait Abnormal gait patterns can occur as a result of pain or other changes in the body.
• Assistant walking frame/ crutches/ wheelchair/ brace/ walking stick / splint/

device/
• Accessories
4
ASSESSMENT
• Postural
deviation
While assessing posture, symmetry and rotations/tilts should be observed in the anterior, lateral
and posterior views. Assess:
1. Head alignment
2. Cervical, thoracic and lumbar curvature
3. Shoulder level symmetry
4. Pelvic symmetry
5. Hip, knee and ankle joint
• Deformity Observe for Flat foot (Pes Planus)/ Bunions (Hallux Valgus)/ /Hammertoe/Claw Toe/Mallet
Toe/High Arches (Pes Cavus)/ Haglund’s deformity, bow knee, knock knee, etc.
LOCAL OBSERVATION
• Skin redness, scarring, skin discoloration or type, open wounds, suture scar (measure), swelling,
muscle wasting
• Palpation Skin, Muscle Spasm, Trigger Point, Pulse
Grade Scoring
0 No tenderness
1 The patient says the area is tender
2 Patient winces due to pain
3 Patient winches and withdraws the affected part
4 Patient doesn’t allow touching the affected part
5
ASSESSMENT
EXAMINATION
JOINT RANGE OF MOTION Measure ROM at Affected part
CLEARING JOINT ROM Proximal and distal of unaffected side and part
MANUAL MUSCLE TESTING Check muscle strength affected part and clearing joint
(MMT)
MEASUREMENT Muscle girth, Swelling, Limb length
SPECIAL TEST Test to confirm diagnosis and find differential diagnosis
BMI Evaluate normal body mass index
SENSATION TEST Check hot, cold

Sharp and blunt at nerve root pathway along the peripheral joint
GAIT and BALANCE ANALYSIS Check the gait and balance component
REFLEX Check tendon reflex using tendon hammer
OUTCOME SCORE Using specific questionnaire for specific condition relating outcome measure.
EXAMPLE:
• NDI
• DASH
• KOOS
• OSWETRY
• Functional Gait Assessment
• Basic Amputee Mobility Score (BAMS)
ANALYSIS/ PHYSIOTHERAPY IMPRESSION

Based on finding
PLAN OF TREATMENT
Suggested treatment with short- and long-term goal with time frame
INTERVENTION
Precaution Check indication and contraindication
Treatment intervention • Procedure – position
• Dosage – repetition, sets, intensity, frequency, mode
EVALUATE – Post treatment analysis

REVIEW – Next appointment, SOAP findings, suggested treatment
6
CERVICAL - ROM
RANGE OF MOTION (ROM)

TABLE EXAMPLE:
MOVEMENTS ACTIVE PASSIVE END FEEL
RT LT RT LT A physical therapy term applied to the
passive end range of motion of a joint.
Normal movement is limited by any of a
number of factors, such as articular surface
contact, the extensibility of ligaments,
tendons or the opposition of soft tissue.
When therapist performs a passive range
of motion of particular joint, there will be
some type of limitation of motion based
one of these factors. The factors that is
most responsible for this limitation of the
motion will cause a particular ‘feel’ which
can help the therapist to diagnose the
problem in the joint.
Type of end feels:
• SOFT (SOFT TISSUE OPPOSITION):
when two soft tissue surfaces come
together producing a soft
compression, as when the back of
the thigh and calf muscle come
together during knee flexion.
• HARD (BONY): abrupt hard stop
where bone contact bone, as in
elbow extension when the
olecranon process moving against
the olecranon fossa.
• FIRM (SOFT TISSUE STRETCHES): a
firm or springy feeling stop where
there is some give as soft tissue, as
in a muscle, stretches when a joint
is moved. Ex: ankle dorsiflexion
7
CERVICAL - ROM
CERVICAL SPINE FLEXION (TAPE MEASUREMENT)
PATIENT POSITION Sitting erect
PATIENT ACTION After being instructed in motion desired, patient flexes neck maximally. Patient then
returns to starting position. This movement provides an estimate of range of motion
(ROM) and demonstrates to patient exact motion desired. If patient is able to touch
chin to chest, full flexion ROM is indicated. No further measurement is needed
TAPE MEASURE ALIGNMENT Palpate following bony landmarks (shown in Fig. 9-1) and align tape measure
accordingly. Tape measure should be aligned with 0 cm at tip of mandible
SUPERIOR Tip of mandible (chin)
INFERIOR Sternal notch
PATIENT/EXAMINER Patient flexes cervical spine through available ROM. Examiner measures distance
ACTION between sternal notch and chin; referred to as the final measurement
Starting position for measurement of cervical flexion using tape measure method.
Bony landmark (sternal notch) indicated by dot.
8
CERVICAL - ROM
CERVICAL SPINE FLEXION (GONIOMETER)
PATIENT ACTION After being instructed in motion desired, patient actively flexes cervical spine.
Patient then returns to starting position. This movement provides an estimate of
ROM and demonstrates to patient exact motion desired. Patient returns to
starting position and is manually positioned so that a line between the ear lobe
and base of nares is parallel to floor.
GONIOMETER ALIGNMENT Palpate following landmarks and align goniometer accordingly
STATIONARY ARM Perpendicular to floor
AXIS Ear lobe
MOVING ARM Base of nares
PATIENT/EXAMINER ACTION Patient performs active cervical flexion
Goniometer alignment at beginning range of cervical flexion
9
CERVICAL - ROM
CERVICAL SPINE EXTENSION (TAPE MEASUREMENT)
PATIENT ACTION After being instructed in motion desired, patient extends neck as far as
possible. Patient then returns to starting position. This movement provides
an estimate of ROM and demonstrates to patient exact motion desired
TAPE MEASURE ALIGNMENT Palpate following bony landmarks and align tape measure accordingly. Tape
measure should be aligned with 0 cm at tip of mandible
INFERIOR Sternal notch.
PATIENT/EXAMINER ACTION Patient extends cervical spine through available ROM. Examiner measures
distance between sternal notch and chin; referred to as the final
measurement
Starting position for measurement of cervical flexion using tape measure

method. Bony landmark (sternal notch) indicated by dot.
10
CERVICAL - ROM
CERVICAL SPINE EXTENSION (GONIOMETER)
PATIENT ACTION After being instructed in motion desired, patient actively extends cervical spine.
This movement provides an estimate of ROM and demonstrates to patient exact
motion desired. Patient returns to starting position and is manually positioned
so that a line between the ear lobe and base of nares is parallel to floor.
AXIS Ear lobe
MOVING ARM Base of nares
PATIENT/EXAMINER ACTION Patient performs active cervical extension
Goniometer alignment at beginning range of cervical extension
11
CERVICAL - ROM
CERVICAL SPINE LATERAL FLEXION (TAPE MEASUREMENT)
PATIENT ACTION After being instructed in motion desired, patient actively laterally flexes cervical
spine, bringing ear as close as possible to shoulder; no rotation, flexion, or
extension of cervical spine is allowed. Examiner must ensure patient does not
elevate shoulders during movement. Patient then returns to starting position. This
movement provides an estimate of ROM and demonstrates to patient exact
motion desired
TAPE MEASURE ALIGNMENT Palpate following landmarks and align tape measure accordingly. Tape measure
should be aligned with 0 cm at tip of mastoid process.
SUPERIOR Tip of mastoid process (behind ear)
INFERIOR Lateral tip of acromion process.
PATIENT/EXAMINER ACTION Patient laterally flexes cervical spine toward side of tape measure through
available ROM. Examiner measures distance from acromion process to mastoid
process; referred to as final measurement
Initial tape measure alignment for measurement of cervical lateral flexion.
12
CERVICAL - ROM
CERVICAL SPINE LATERAL FLEXION (GONIOMETER)
PATIENT ACTION After being instructed in motion desired, patient actively laterally flexes
cervical spine, bringing ear as close as possible to shoulder; no rotation, flexion,
or extension of cervical spine is allowed. Examiner must ensure patient does
not elevate shoulders during movement. Patient then returns to starting
position. This movement provides an estimate of ROM and demonstrates to
patient exact motion desired
GONIOMETER ALIGNMENT Palpate following bony landmarks and align goniometer accordingly
AXIS Spinous process of C7 vertebra
MOVING ARM Posterior midline of skull.
PATIENT/EXAMINER ACTION Patient performs active lateral cervical flexion. Examiner ensures that patient's
shoulders do not elevate during movement
End ROM of cervical lateral flexion. Bony landmark (spinous process of C7

vertebra) indicated by dot
13
CERVICAL - ROM
CERVICAL SPINE ROTATION (TAPE MEASUREMENT)
PATIENT ACTION After being instructed in motion desired, patient actively rotates cervical spine;
no flexion, extension, or lateral flexion of cervical spine is allowed. Examiner
must ensure patient does not rotate trunk during movement. Patient then
returns to starting position. This movement provides an estimate of ROM and
demonstrates to patient exact motion desired
TAPE MEASURE ALIGNMENT Palpate following landmarks and align tape measure accordingly. Tape
measure should be aligned with 0 cm at tip of mandible
INFERIOR Lateral tip of acromion process
PATIENT/EXAMINER ACTION Patient rotates cervical spine through available ROM toward side of tape
measure. Examiner ensures that patient's trunk does not rotate during
movement and measures distance from lateral tip of acromion process to tip
of mandible; referred to as final measurement
Initial tape measure alignment for measurement of cervical rotation.
14
CERVICAL - ROM
CERVICAL SPINE ROTATION (GONIOMETER)
PATIENT ACTION After being instructed in motion desired, patient actively rotates cervical spine;
no flexion, extension, or lateral flexion of cervical spine is allowed. Examiner
must ensure patient does not rotate trunk during movement. Patient then
GONIOMETER ALIGNMENT Palpate following landmarks and align goniometer. Note: Measurement occurs
from the top of patient's head.)
STATIONARY ARM Imaginary line connecting patient's two acromion processes.
AXIS Top of subject's head
MOVING ARM Nose
PATIENT/EXAMINER ACTION Patient rotates cervical spine through available ROM. Examiner ensures that
patient's trunk does not rotate
Goniometer alignment at beginning range of cervical rotation.
15
ELBOW - ROM
FLEXION
PATIENT POSITION Supine with upper extremity in anatomical position (see Note), folded towel under
humerus, proximal to humeral condyles.
STABILIZATION Over posterior aspect of proximal humerus.
EXAMINER ACTION After instructing patient in motion desired, flex patient's elbow through available ROM.
Return limb to starting position. Performing passive movement provides an estimate
of ROM and demonstrates to patient exact motion desired.
GONIOMETER Palpate the following bony landmarks and align goniometer accordingly.
ALIGNMENT
STATIONARY ARM Lateral midline of humerus toward acromion process.
AXIS Lateral epicondyle of humerus.
MOVING ARM Lateral midline of radius toward radial styloid process.
PATIENT/EXAMINER
Perform passive, or have patient perform active, elbow flexion
ACTION
Starting position for measurement of elbow flexion. Bony landmarks for goniometer
alignment (lateral aspect of acromion process, lateral humeral epicondyle, radial
styloid process) indicated by dots.
16
ELBOW - ROM
EXTENSION
PATIENT POSITION Supine with upper extremity in anatomical position, elbow extended as far as possible,
folded towel under distal humerus, proximal to humeral condyles.
STABILIZATION None needed.
EXAMINER ACTION Determine if elbow is extended as far as possible by either: a) asking patient to straighten
elbow as far as possible (if measuring active ROM); or, b) providing pressure across the
elbow in the direction of extension (if measuring passive ROM).
ALIGNMENT
STATIONARY ARM Lateral midline of humerus toward acromion process.
AXIS Lateral epicondyle of humerus.
MOVING ARM Lateral midline of radius toward radial styloid process.
PATIENT/EXAMINER
Perform passive, or have patient perform active, elbow extension
ACTION
Starting position for measurement of elbow extension. Bony landmarks for goniometer
alignment (lateral aspect of acromion process, lateral humeral epicondyle, radial styloid
process) indicated by dots.
17
ELBOW - ROM
FOREARM SUPINATION
PATIENT POSITION Seated or standing with shoulder completely adducted, elbow flexed to 90
degrees, forearm in neutral rotation.
STABILIZATION Over lateral aspect of distal humerus, maintaining 0 degrees shoulder adduction.
EXAMINER ACTION After instructing patient in motion desired, supinate patient's forearm through
available ROM, avoiding lateral rotation of shoulder or shoulder adduction past 0
degrees. Return limb to starting position. Performing passive movement provides
an estimate of ROM and demonstrates to patient exact motion desired.
GONIOMETER ALIGNMENT Palpate the following bony landmarks and align goniometer accordingly.
STATIONARY ARM Parallel with anterior midline of humerus.
AXIS On volar surface of wrist, in line with styloid process of ulna.
MOVING ARM Volar surface of wrist, at level of ulnar styloid process.
PATIENT/EXAMINER ACTION
Perform passive supination, or have patient perform active forearm supination
Starting position for measurement of forearm supination. Bony landmarks for

goniometer alignment (anterior midline of humerus and ulnar styloid process)
indicated by dot.
18
ELBOW - ROM
PRONATION
PATIENT POSITION Seated or standing with shoulder completely adducted, elbow flexed to 90 degrees,
forearm in neutral rotation.
STABILIZATION Over lateral aspect of distal humerus, maintaining shoulder adduction.
EXAMINER ACTION After instructing patient in motion desired, pronate patient's forearm through available
ROM, avoiding shoulder abduction and medial rotation. Return limb to starting
position. Performing passive movement provides an estimate of ROM and
demonstrates to patient exact motion desired.
ALIGNMENT
STATIONARY ARM Parallel with anterior midline of humerus.
AXIS In line with, and just proximal to, styloid process of ulna.
MOVING ARM Dorsum of forearm, just proximal to ulnar styloid process.
PATIENT/EXAMINER
Perform passive forearm pronation, or have patient perform active forearm pronation
ACTION
Starting position for measurement of forearm pronation. Bony landmarks for

goniometer alignment (anterior midline of humerus and ulnar styloid process)
indicated by line and dot.
19
SHOULDER – ROM
FLEXION
PATIENT POSITION Supine with shoulder in 0 degrees flexion, elbow fully extended, forearm in
neutral rotation with palm facing trunk.
STABILIZATION Over anterosuperior aspect of ipsilateral shoulder, proximal to humeral head.

Examiner action: After instructing patient in motion desired, flex patient's
shoulder through available range of motion (ROM) avoiding extension of spine.
Return limb to starting position. Performing passive movement provides an
estimate of ROM and demonstrates to patient exact motion desired.
GONIOMETER ALIGNMENT Palpate the following bony landmarks and align goniometer accordingly
STATIONARY ARM Lateral midline of thorax.
AXIS Midpoint of lateral aspect of acromion process.
MOVING ARM Lateral midline of humerus toward lateral humeral epicondyle.
PATIENT/EXAMINER ACTION Perform passive, or have patient perform active, shoulder flexion
Starting position for measurement of shoulder flexion. Bony landmarks for

goniometer alignment (lateral aspect of acromion process, lateral midline of
thorax, lateral humeral epicondyle) indicated by line and dots.
20
SHOULDER – ROM
EXTENSION
PATIENT POSITION Prone with shoulder in 0 degrees flexion, elbow fully extended, forearm in
neutral rotation with palm facing trunk.
STABILIZATION Over posterosuperior aspect of ipsilateral shoulder, proximal to humeral head
EXAMINER ACTION: After instructing patient in motion desired, extend patient's shoulder through
available ROM, avoiding rotation of trunk. Return limb to starting position.
Performing passive movement provides an estimate of ROM and demonstrates
to patient exact motion desired.
STATIONARY ARM Lateral midline of thorax.
AXIS Midpoint of lateral aspect of acromion process.
MOVING ARM Lateral midline of humerus toward lateral humeral epicondyle.
PATIENT/EXAMINER ACTION Perform passive, or have patient perform active, shoulder extension
Starting position for measurement of shoulder extension. Bony landmarks for

goniometer alignment (lateral aspect of acromion process, lateral midline of
thorax, lateral humeral epicondyle) indicated by line and dots.
21
SHOULDER – ROM
ABDUCTION
PATIENT POSITION Supine with arm at side, upper extremity in anatomical position.
STABILIZATION Over superior aspect of ipsilateral shoulder, proximal to humeral head.
EXAMINER ACTION After instructing patient in motion desired, abduct patient's shoulder through
available ROM, avoiding lateral trunk flexion. Return limb to starting position.
Performing passive movement provides an estimate of the ROM and
demonstrates to patient exact motion desired.
STATIONARY ARM Parallel to sternum.
AXIS Anterior aspect of acromion process.
MOVING ARM Anterior midline of humerus toward medial humeral epicondyle.
Perform passive, or have patient perform active, shoulder abduction

Starting position for measurement of shoulder abduction with patient in the

supine position. Bony landmarks for goniometer alignment (anterior aspect of
acromion process, midline of sternum, medial humeral epicondyle) indicated by
line and dots.
22
SHOULDER – ROM
ADDUCTION
PATIENT POSITION Supine with arm at side, upper extremity in anatomical position.
STABILIZATION Over superior aspect of ipsilateral shoulder, proximal to humeral head.
EXAMINER ACTION After instructing patient in motion desired, adduct patient's shoulder through
available ROM, avoiding lateral trunk flexion. Return limb to starting position.
Performing passive movement provides an estimate of ROM and demonstrates to
patient exact motion desired.
STATIONARY ARM Parallel to sternum.
AXIS Anterior aspect of acromion process.
MOVING ARM Anterior midline of humerus in line with medial humeral epicondyle.
Perform passive, or have patient perform active, shoulder adduction

Starting position for measurement of shoulder adduction with patient in the

supine position. Bony landmarks for goniometer alignment (anterior aspect of
acromion process, midline of sternum, medial humeral epicondyle) indicated by
line and dots.
23
SHOULDER – ROM
LATERAL ROTATION
PATIENT POSITION Supine with shoulder abducted to 90 degrees, elbow flexed to 90 degrees, forearm
pronated, folded towel under humerus.
STABILIZATION Place heel of hand over superior aspect of ipsilateral shoulder, proximal to humeral
head; fingers over ipsilateral scapula.
EXAMINER ACTION After instructing patient in motion desired, laterally rotate patient's shoulder
through available ROM, making sure the scapula does not lift off the table. Return
limb to starting position. Performing passive movement provides an estimate of
ROM and demonstrates to patient exact motion desired.
STATIONARY ARM Perpendicular to floor.
AXIS Olecranon process of ulna.
MOVING ARM Ulnar border of forearm toward ulnar styloid process.
PATIENT/EXAMINER
Perform passive, or have patient perform active, lateral rotation of the shoulder,
ACTION
stopping at the point of elevation of the scapula off the table
Starting position for measurement of shoulder lateral rotation. Landmarks for

goniometer alignment (olecranon and styloid processes of ulna) indicated by dots.
24
SHOULDER – ROM
MEDIAL ROTATION
PATIENT POSITION Supine with shoulder abducted to 90 degrees, elbow flexed to 90 degrees, forearm
pronated, folded towel under humerus.
STABILIZATION Place heel of hand over superior aspect of ipsilateral shoulder, proximal to humeral head,
and fingers over ipsilateral scapula.
EXAMINER ACTION After instructing patient in motion desired, medially rotate patient's shoulder through
available ROM, making sure the scapula does not lift off the table. Return limb to starting
position. Performing passive movement provides an estimate of ROM and demonstrates
to patient exact motion desired.
ALIGNMENT
STATIONARY ARM Perpendicular to floor.
AXIS Olecranon process of ulna.
MOVING ARM Ulnar border of forearm toward ulnar styloid process.
PATIENT/EXAMINER
Perform passive, or have patient perform active, medial rotation of the shoulder,
ACTION
stopping at the point of elevation of the scapula off the table
Starting position for measurement of shoulder medial rotation. Landmarks for

goniometer alignment (olecranon and styloid processes of ulna) indicated by dots.
25
WRIST – ROM
WRIST FLEXION (DORSAL ALIGNMENT)

PATIENT POSITION Seated, with shoulder abducted 90 degrees, elbow flexed 90 degrees, forearm
pronated, arm and forearm supported on table, hand off table with wrist in neutral
position.
STABILIZATION Over dorsal surface of forearm.
EXAMINER ACTION After instructing patient in motion desired, flex patient's wrist through available
ROM. Return wrist to neutral position. Performing passive movement provides an
STATIONARY ARM Dorsal midline of forearm toward lateral epicondyle of humerus.
AXIS Lunate.
MOVING ARM Dorsal midline of 3rd metacarpal.
PATIENT/EXAMINER Perform passive, or have patient perform active, wrist flexion

ACTION
Starting position for measurement of wrist flexion using dorsal alignment technique.
Bony landmarks for goniometer alignment (lateral epicondyle of humerus, lunate,
dorsal midline of 3rd metacarpal) indicated by dots.
26
WRIST – ROM
WRIST FLEXION (LATERAL ALIGNMENT)
PATIENT POSITION Seated, with shoulder abducted 90 degrees, elbow flexed 90 degrees, forearm pronated,
arm and forearm supported on table, hand off table with wrist in neutral position.
EXAMINER ACTION After instructing patient in motion desired, flex patient's wrist through available ROM.
Return wrist to neutral position. Performing passive movement provides an estimate of
ROM and demonstrates to patient exact motion desired.
ALIGNMENT
STATIONARY ARM Lateral midline of ulna toward olecranon process.
AXIS Triquetrum.
MOVING ARM Lateral midline of 5th metacarpal.
PATIENT/EXAMINER Perform passive, or have patient perform active, wrist flexion

ACTION
Starting position for measurement of wrist flexion using lateral alignment technique. Bony
landmarks for goniometer alignment (olecranon process of ulna, triquetrum, lateral
midline of 5th metacarpal) indicated by dots.
27
WRIST – ROM
WRIST EXTENSION (VOLAR ALIGNMENT)

PATIENT POSITION Seated, with shoulder adducted, elbow flexed 90 degrees, forearm supinated and
supported on table, wrist and hand off table with wrist in neutral position.
STABILIZATION Over ventral surface of forearm.
EXAMINER ACTION After instructing patient in motion desired, extend patient's wrist through available
GONIOMETER Palpate the following landmarks and align goniometer accordingly.

ALIGNMENT
STATIONARY ARM Volar midline of forearm toward bicipital tendon at elbow.
AXIS Lunate.
MOVING ARM Volar midline of 3rd metacarpal.
PATIENT/EXAMINER
Perform passive, or have patient perform active, wrist extension
ACTION
Starting position for measurement of wrist extension using volar alignment technique.
Bony landmarks for goniometer alignment (bicepital tendon at elbow, lunate, volar
midline of 3rd metacarpal) indicated by dots.
28
WRIST – ROM
WRIST EXTENSION (LATERAL ALIGNMENT)
pronated, arm and forearm supported on table, hand off table with wrist in neutral
position.
EXAMINER ACTION After instructing patient in motion desired, extend patient's wrist through available
STATIONARY ARM Lateral midline of ulna toward olecranon process.
AXIS Triquetrum.
MOVING ARM Lateral midline of 5th metacarpal.
PATIENT/EXAMINER ACTION Perform passive, or have patient perform active, wrist extension
Starting position for measurement of wrist extension using lateral alignment

technique. Bony landmarks for goniometer alignment (olecranon process of ulna,
triquetrum, lateral midline of 5th metacarpal) indicated by dots.
29
WRIST – ROM
ULNAR DEVIATION
pronated, upper extremity (UE) supported on table, wrist and hand in neutral position.
STABILIZATION Over dorsal surface of distal forearm.
EXAMINER ACTION After instructing patient in motion desired, adduct patient's wrist through available
ALIGNMENT
AXIS Capitate.
PATIENT/EXAMINER Perform passive, or have patient perform active, wrist adduction

ACTION
Starting position for measurement of wrist adduction. Bony landmarks for goniometer
alignment (lateral epicondyle of humerus, capitate, dorsal midline of 3rd metacarpal)
indicated by dots.
30
WRIST – ROM
RADIAL DEVIATION
pronated, UE supported on table, wrist and hand in neutral position.
STABILIZATION Over dorsal surface of distal forearm.
EXAMINER ACTION After instructing patient in motion desired, abduct patient's wrist through available
estimate of the ROM and demonstrates to patient exact motion desired.
AXIS Capitate.
Perform passive, or have patient perform active, wrist abduction
Starting position for measurement of wrist abduction. Landmarks for goniometer

alignment (lateral epicondyle of humerus, capitate, dorsal midline of 3rd
metacarpal) indicated by dots.
31
METACARPALS - ROM
METACARPOPHALANGEAL (MCP) ABDUCTION

PATIENT POSITION Seated, with forearm pronated, UE supported on table, wrist and hand in neutral
position
STABILIZATION Over metacarpals
EXAMINER ACTION After instructing patient in motion desired, abduct MCP joint to be examined through
available ROM. Return finger to neutral position. Performing passive movement
provides an estimate of ROM and demonstrates to patient exact motion desired
STATIONARY ARM Dorsal midline of metacarpal
AXIS Dorsum of MCP joint
MOVING ARM Dorsal midline of proximal phalanx
PATIENT/EXAMINER
Perform passive, or have patient perform active, MCP abduction
ACTION
Starting position for measurement of MCP abduction. Landmarks for goniometer

alignment (dorsal midline of metacarpal, dorsum of MCP joint, dorsal midline of
proximal phalanx) indicated by dot.
32
METACARPALS - ROM
METACARPOPHALANGEAL (MCP) OR INTERPHALANGEAL (PIP OR DIP) FLEXION
Measurement of 2nd MCP joint shown.
PATIENT POSITION Seated, with UE supported on table; wrist and hand in neutral position
STABILIZATION Over more proximal bone of joint (in this case, stabilization of a metacarpals is shown)
EXAMINER ACTION After instructing patient in motion desired, flex joint to be examined through
available ROM. Return finger to neutral position. Performing passive movement
provides an estimate of ROM and demonstrates to patient exact motion desired
STATIONARY ARM Dorsal midline of more proximal bone of joint (in this case, a metacarpal)
AXIS Dorsum of joint being examined (in this case, MCP joint)
MOVING ARM Dorsal midline of more distal bone joint (in this case, a proximal phalanx)
Perform passive, or have patient perform active, flexion of the joint

PATIENT/EXAMINER
ACTION
Starting position for measurement of MCP flexion. Landmarks for goniometer

alignment (dorsal midline of metacarpal, dorsum of MCP joint, dorsal midline of
proximal phalanx) indicated by dot.
33
METACARPALS - ROM
METACARPOPHALANGEAL (MCP) OR INTERPHALANGEAL (PIP OR DIP)

EXTENSION
Measurement of 2nd MCP joint shown.
PATIENT POSITION Seated, with UE supported on table, wrist and hand in neutral position
STABILIZATION Over more proximal bone of joint being examined (in this case, stabilization of
metacarpals is shown)
EXAMINER ACTION After instructing patient in motion desired, extend MCP joint to be examined
through available ROM. Return finger to neutral position. Performing passive
movement provides an estimate of ROM and demonstrates to patient exact
motion desired
STATIONARY ARM Dorsal midline of more proximal bone of joint (in this case, a metacarpal)
AXIS Dorsum of joint being examined (in this case, MCP joint)
MOVING ARM Dorsal midline of more distal bone of joint (in this case, a proximal phalanx)
PATIENT/EXAMINER ACTION Perform passive, or have patient perform active, extension of the joint
Starting position for measurement of MCP flexion. Landmarks for goniometer

alignment (dorsal midline of metacarpal, dorsum of MCP joint, dorsal midline
of proximal phalanx) indicated by dot.
34
METACARPALS - ROM
CARPOMETACARPAL (FIRST CMC) ABDUCTION
PATIENT POSITION Seated, with forearm neutral, UE supported on table; wrist and hand in neutral
position, thumb positioned along volar surface of 2nd metacarpal
STABILIZATION Over 2nd metacarpal
EXAMINER ACTION After instructing patient in motion desired, abduct 1st CMC joint by grasping 1st
metacarpal and moving thumb perpendicularly away from palm. Return thumb to
starting position. Performing passive movement provides an estimate of ROM and
GONIOMETER ALIGNMENT Palpate the following bony landmarks and align goniometer according
STATIONARY ARM Lateral midline of 2nd metacarpal
AXIS Radial styloid process
MOVING ARM Dorsal midline of 1st metacarpal
PATIENT/EXAMINER Perform passive, or have patient perform active, abduction of 1st CMC joint
ACTION
Starting position for measurement of 1st CMC abduction. Note that thumb is
positioned alongside volar surface of 2nd metacarpal. Landmarks for goniometer
alignment (lateral midline of 2nd metacarpal, radial styloid process, dorsal midline of
1st metacarpal) indicated by dot.
35
METACARPALS - ROM
CARPOMETACARPAL (FIRST CMC) FLEXION
PATIENT POSITION Seated, with forearm supinated; UE supported on table; wrist and hand in neutral
position; thumb positioned along lateral side of 2nd metacarpal
STABILIZATION Over ventral surface of wrist
EXAMINER ACTION After instructing patient in motion desired, flex 1st CMC joint by grasping 1st
metacarpal and moving thumb across palm. Return thumb to starting position.
Performing passive movement provides an estimate of ROM and demonstrates to
STATIONARY ARM Ventral midline of radius toward radial head
AXIS Ventral surface of 1st CMC joint
MOVING ARM Ventral midline of 1st metacarpal
PATIENT/EXAMINER ACTION Perform passive, or have patient perform active, flexion of 1st CMC joint
Starting position for measurement of 1st CMC flexion. Note that thumb is
positioned alongside lateral surface of 2nd metacarpal. Landmarks for goniometer
alignment (radial head, ventral surface of 1st CMC joint, ventral midline of 1st
36
METACARPALS - ROM
CARPOMETACARPAL (FIRST CMC) EXTENSION
PATIENT POSITION Seated, with forearm supinated; UE supported on table; wrist and hand in neutral
position, thumb positioned along lateral side of 2nd metacarpal
STABILIZATION Over ventral surface of wrist
EXAMINER ACTION After instructing patient in motion desired, extend 1st CMC joint by grasping 1st
metacarpal and moving thumb away from, but parallel to, palm. Return thumb to
starting position. Performing passive movement provides an estimate of ROM and
STATIONARY ARM Ventral midline of radius toward radial head
AXIS Ventral surface of 1st CMC joint
MOVING ARM Ventral midline of 1st metacarpal
PATIENT/EXAMINER Perform passive, or have patient perform active, flexion of 1st CMC joint
ACTION
Starting position for measurement of 1st CMC extension. Note that thumb is
positioned alongside lateral surface of 2nd metacarpal. Landmarks for goniometer
alignment (radial head, ventral surface of 1st CMC joint, ventral midline of 1st
37
METACARPALS - ROM
METACARPOPHALANGEAL (MCP) OR INTERPHALANGEAL (IP) FLEXION OF

THUMB
Measurement of 1st MCP joint shown.
PATIENT POSITION Seated, with forearm neutral; UE supported on table, wrist in neutral position, 1st
CMC joint in slight abduction
STABILIZATION 1st metacarpal (MCP) or proximal phalanx of thumb (IP). In this case, stabilization of
1st MCP is shown. Proximal joints should remain in neutral position (not flexed or
extended) during testing to prevent obstruction of full ROM by tension in thumb
extensor muscles.
EXAMINER ACTION After instructing patient in motion desired, flex joint through available ROM. Return
thumb to neutral position. Performing passive movement provides an estimate of
ROM and demonstrates to patient exact motion desire
STATIONARY ARM Dorsal midline of 1st metacarpal (MCP) or of proximal phalanx of thumb (IP)
AXIS Dorsum of 1st MCP or IP joint
MOVING ARM Dorsal midline of proximal phalanx of thumb (MCP) or distal phalanx of thumb (IP)
PATIENT/EXAMINER Perform passive, or have patient perform active, flexion of joint to be measured
ACTION
Starting position for measurement of 1st MCP flexion (thumb). Note that CMC joint
of thumb is positioned in slight abduction. Landmarks for goniometer alignment
(dorsal midline of 1st metacarpal, dorsum of 1st MCP joint, dorsal midline of proximal
phalanx) indicated by dot.
38
METACARPALS - ROM
METACARPOPHALANGEAL (MCP) OR INTERPHALANGEAL (IP) EXTENSION OF

THUMB
Measurement of IP joint shown
PATIENT POSITION Seated, with forearm neutral; UE supported on table, wrist in neutral position, 1st
CMC joint in slight abduction
STABILIZATION Over 1st metacarpal (MCP) or proximal phalanx of thumb (IP). In this case,
stabilization of proximal phalanx is shown
EXAMINER ACTION After instructing patient in motion desired, extend joint through available ROM.
Return finger to neutral position. Performing passive movement provides an
estimate of ROM and demonstrates to patient exact motion desired
GONIOMETER ALIGNMENT Palpate the following bony landmarks and align goniometer according
STATIONARY ARM Dorsal midline of 1st metacarpal (MCP) or of proximal phalanx of thumb (IP).
AXIS Dorsum of 1st MCP or IP joint.
MOVING ARM Dorsal midline of proximal phalanx of thumb (MCP) or distal phalanx of thumb (IP).
PATIENT/EXAMINER ACTION Perform passive, or have patient perform active, extension of joint to be measured
Starting position for measurement of IP extension (thumb). Note that CMC joint
of thumb is positioned in slight abduction. Landmarks for goniometer alignment
(dorsal midline of proximal phalanx, dorsum of IP joint, dorsal midline of distal
phalanx) indicated by orange lines and dot.
39
KNEE - ROM
FLEXION
PATIENT POSITION Supine, with lower extremities in anatomical position, towel roll under ipsilateral
ankle
STABILIZATION Over anterior aspect of thigh
EXAMINER ACTION After instructing patient in motion desired, flex patient's knee through available
ROM by sliding patient's foot along table toward pelvis. Return to starting position.
demonstrates to patient the exact motion desired
STATIONARY ARM Lateral midline of femur toward greater trochanter
AXIS Lateral epicondyle of femur
MOVING ARM Lateral midline of fibula, in line with fibular head and lateral malleolus
PATIENT/EXAMINER ACTION Perform passive, or have patient perform active, knee flexion by sliding foot
toward pelvis
Starting position for measurement of knee flexion. Towel roll under ipsilateral
ankle to promote full knee extension. Bony landmarks for goniometer alignment
(greater trochanter, lateral femoral epicondyle, lateral malleolus) indicated by dot
40
KNEE - ROM
EXTENSION
PATIENT POSITION Supine, with knee extended as far as possible; towel roll under ipsilateral ankle
STABILIZATION None needed
EXAMINER ACTION Determine whether knee is extended as far as possible by either: a) asking
patient to straighten knee as far as possible (if measuring active ROM), or b)
providing passive pressure on the knee in the direction of extension (if
measuring passive ROM)
STATIONARY ARM Lateral midline of femur toward greater trochanter
AXIS Lateral epicondyle of femur
MOVING ARM Lateral midline of fibula, in line with fibular head and lateral malleolus
End of knee extension ROM. Examiner is ensuring complete knee extension

through posteriorly directed pressure on the distal thigh. Bony landmarks for
goniometer alignment (greater trochanter, lateral femoral epicondyle, lateral
malleolus) indicated by dots.
41
LUMBAR - ROM
LUMBAR SPINE FLEXION (TAPE MEASUREMENT)

PATIENT POSITION Standing, feet shoulders' width apart
PATIENT ACTION Patient is instructed in desired motion. Running both hands down front of
both legs, patient flexes spine as far as possible while keeping knees
extended. Patient then returns to starting position. This movement provides
an estimate of range of motion (ROM) and demonstrates to patient exact
motion desired
TAPE MEASURE ALIGNMENT Palpate following bony landmarks and align tape measure accordingly
BASE LINE Midline of spine in line with posterior superior iliac spines (PSIS)
SUPERIOR 15 cm above base line landmark. Tape measure is aligned with 0 cm at base
line landmark and maintained against subject's spine
PATIENT/EXAMINER ACTION As patient flexes spine through available ROM, examiner allows tape measure
to unwind from tape measure case. Tape measure should be held firmly
against patient's skin during movement. Examiner records distance between
superior and base line landmarks
Starting position for measurement of lumbar flexion using tape measure

method. Bony landmarks for tape measure alignment (midline of spine in line
with PSIS, 15 cm above base line mark) indicated by dots.
42
LUMBAR - ROM
THORACOLUMBAR SPINE FLEXION (TAPE MEASUREMENT)
PATIENT ACTION Patient is instructed in desired motion. Running both hands down front of both
legs, patient flexes spine as far as possible while keeping knees extended. Patient
then returns to starting position. This movement provides an estimate of ROM and
BASE LINE Midline of spine in line with PSIS
SUPERIOR Spinous process of C7 vertebra
PATIENT/EXAMINER ACTION As patient flexes spine through available ROM, examiner allows tape measure to
unwind from tape measure case. Tape measure should be held firmly against
patient's skin during movement. Examiner records distance between superior and
base line landmarks; referred to as final measurement
Starting position for measurement of thoracolumbar flexion using tape measure

method. Bony landmarks for tape measure alignment (midline of spine in line with
PSIS, spinous process of C7 vertebra) indicated by dots.
43
LUMBAR - ROM
LUMBAR SPINE FLEXION (GONIOMETER)
PATIENT ACTION Patient is instructed in desired motion. Running both hands down front of both
legs, patient flexes spine as far as possible while keeping knees extended. Patient
then returns to starting position. This movement provides an estimate of ROM
and demonstrates to patient exact motion required
STATIONARY ARM Vertical to floor
AXIS Midaxillary line at level of lowest rib
MOVING ARM Along midaxillary line
PATIENT/EXAMINER ACTION Running both hands down front of legs, patient flexes spine as far as possible
while keeping knees extended
Starting position for measurement of lumbar flexion using goniometer

technique. Landmarks for goniometric alignment (midaxillary line at level of
lowest rib, mid-axillary line) indicated by dot.
44
LUMBAR - ROM
LUMBAR SPINE EXTENSION (TAPE MEASUREMENT)
PATIENT POSITION Standing, feet shoulders' width apart; hands on hips
PATIENT ACTION Patient is instructed in desired motion. Placing hands on waist, patient bends
backward as far as possible while keeping knees extended. Patient then returns
to starting position. This movement provides an estimate of ROM and
TAPE MEASURE ALIGNMENT Palpate following bony landmarks (shown in Fig, sure accordingly
BASE LINE Midline of spine in line with PSIS
SUPERIOR 15 cm above base line landmark
PATIENT/EXAMINER ACTION As patient extends spine through available ROM, examiner allows tape measure
to retract into tape measure case. Tape measure should be held firmly against
patient's skin during movement. Examiner records distance between superior
and base line landmarks
Starting position for measurement of lumbar extension using tape measure

method. Bony landmarks for tape measure alignment (midline of spine in line
with PSIS, 15 cm above base line mark) indicated by dots.
45
LUMBAR - ROM
LUMBAR SPINE EXTENSION (TAPE MEASUREMENT) PRONE LYING
PATIENT POSITION Prone; hands under shoulders. Stabilization belt placed across pelvis at
buttocks
PATIENT ACTION Patient is instructed in desired motion. Patient extends elbows and raises trunk
as far as possible. Although increased muscle activity will appropriately occur
across upper back, patient should relax muscles of lumbar spine. Patient then
TAPE MEASURE ALIGNMENT Palpate following landmarks and align tape measure accordingly
SUPERIOR Sternal notch
INFERIOR Perpendicular to, and in contact with, support surface
PATIENT/EXAMINER ACTION At end of ROM in prone extension, examiner measures distance from sternal
notch to support surface
Starting position for measurement of lumbar extension in prone using tape

measure method. Note stabilization belt across pelvis
46
LUMBAR - ROM
LUMBAR SPINE EXTENSION (GONIOMETER)
PATIENT POSITION Standing; feet shoulders' width apart
PATIENT ACTION Patient is instructed in desired motion. Patient crosses arms, placing hands on
opposite shoulders and bends backward as far as possible while keeping knees
extended. Patient then returns to starting position. This movement provides an
estimate of ROM and demonstrates to patient exact motion desired
AXIS Midaxillary line at level of lowest rib
MOVING ARM Along midaxillary line
PATIENT/EXAMINER ACTION Patient crosses arms, placing hands on opposite shoulders and bends backward
as far as possible; full extension of knees should be maintained
Starting position for measurement of lumbar extension using goniometer

technique. Landmarks (mid-axillary line at level of lowest rib, mid-axillary line)
indicated by dot.
47
LUMBAR - ROM
THORACOLUMBAR SPINE LATERAL FLEXION (TAPE MEASUREMENT)
PATIENT POSITION Standing, feet shoulders' width apart; palm of hand against thigh
PATIENT ACTION Patient is instructed in desired motion. Running hand down side of leg, patient
laterally flexes spine as far as possible. Patient keeps knees extended and does
not bend trunk forward or backward while performing movement. Patient then
LANDMARK With patient positioned in erect standing, mark is placed on thigh level with tip
of middle finger
PATIENT/EXAMINER ACTION Patient laterally flexes spine, running hand down side of leg as far as possible. At
maximal lateral flexion, position of the middle fingertip against thigh is marked
again
Starting position for measurement of thoracolumbar lateral flexion using the

tape measure method. Landmark indicated by dot at level of tip of middle finger
48
LUMBAR - ROM
LUMBAR SPINE LATERAL FLEXION (GONIOMETER)

PATIENT POSITION Standing; feet shoulders' width apart
PATIENT ACTION Patient is instructed in desired motion. Running hand down side of leg, patient
laterally flexes spine as far as possible. Patient keeps knees extended and does
not bend trunk forward or backward while performing movement. Patient then
GONIOMETER ALIGNMENT Palpate following bony landmarks (shown in Fig. 8-46) and align goniometer
accordingly
AXIS Spinous process of SI vertebra
MOVING ARM Spinous process of C7 vertebra
PATIENT/EXAMINER ACTION Running hand down side of leg, patient laterally flexes spine as far as possible
Starting position for measurement of lumbar lateral flexion using goniometer

technique. Landmarks for goniometer alignment (spinous process of S1 vertebra,
spinous process of C7 vertebra) indicated by dots
49
LUMBAR - ROM
THORACOLUMBAR SPINE ROTATION (TAPE MEASURE)
PATIENT POSITION Sitting erect, arms crossed and hands on opposite shoulders
PATIENT ACTION Patient is instructed in desired motion. Maintaining neutral position of spine and
arms crossed with hands on opposite shoulders, patient rotates spine as far as
possible. No lateral flexion should occur during rotation. Patient then returns to
starting position. This movement provides an estimate of ROM and
SUPERIOR Lateral tip of ipsilateral acromion
INFERIOR Greater trochanter of contralateral femur
PATIENT/EXAMINER ACTION As patient rotates spine through available ROM while holding tape measure on
superior landmark, examiner allows tape measure to unwind from tape
measure case. Examiner records distance between superior and inferior
landmarks; referred to as final measurement
Starting position for measurement of thoracolumbar rotation using tape

measure method and end ROM of thoracolumbar rotation
50
HIP - ROM
FLEXION
PATIENT POSITION Supine, with lower extremities in anatomical position
STABILIZATION Over anterior aspect of ipsilateral pelvis
EXAMINER ACTION After instructing patient in motion desired, stabilize ipsilateral pelvis with one hand
and flex patient's hip through available ROM with other hand. Ipsilateral knee
should be allowed to flex as well. Hip should not be flexed past the point at which
pelvic motion begins to occur (as detected by superior movement of ipsilateral ASIS
under examiner's stabilizing hand). Return limb to starting position. Performing
passive movement provides an estimate of the ROM and demonstrates to patient
exact motion desired
STATIONARY ARM Lateral midline of pelvis and trunk
AXIS Greater trochanter of femur
MOVING ARM Lateral midline of femur toward lateral femoral epicondyle
PATIENT/EXAMINER Perform passive, or have patient perform active, hip flexion. In either case, hip
ACTION flexion should not be allowed to continue past point at which pelvic motion is
detected
Starting position for measurement of hip flexion. Bony landmarks for goniometer
alignment (lateral midline of pelvis/trunk, greater trochanter, lateral femoral
epicondyle) indicated by dots.
51
HIP - ROM
EXTENSION
PATIENT POSITION Prone, with lower extremities in anatomical position
STABILIZATION Over posterolateral aspect of ipsilateral pelvis with palm of hand, while fingers
palpate ASIS
EXAMINER ACTION After instructing patient in motion desired, stabilize ipsilateral pelvis with one
hand and extend patient's hip through available ROM with other hand. Ipsilateral
knee should be kept extended to avoid limitation of hip extension by tight rectus
femoris muscle. Hip should not be extended past the point at which pelvic
motion begins to occur (as detected by inferior movement of ipsilateral ASIS
under examiner's stabilizing hand). Return limb to starting position. Performing
passive movement provides an estimate of the ROM and demonstrates to
STATIONARY ARM Lateral midline of pelvis and trunk
AXIS Greater trochanter of femur
MOVING ARM Lateral midline of femur toward lateral femoral epicondyle
PATIENT/EXAMINER ACTION Perform passive, or have patient perform active, hip extension. In either case,
hip extension should not be allowed to continue past point at which pelvic
motion is detected
Starting position for measurement of hip extension. Bony landmarks for

goniometer alignment (lateral midline of pelvis/trunk, greater trochanter, lateral
femoral epicondyle) indicated by dot
52
HIP - ROM
ABDUCTION
PATIENT POSITION Supine, with lower extremities in anatomical position
EXAMINER ACTION After instructing patient in motion desired, abduct patient's hip through
available ROM, avoiding hip rotation. Return limb to starting position.
demonstrates to patient exact motion desire
STATIONARY ARM Toward contralateral ASIS
AXIS Ipsilateral ASIS
MOVING ARM Anterior midline of ipsilateral femur, using midline of patella as reference
PATIENT/EXAMINER ACTION Perform passive, or have patient perform active, hip abduction
Starting position for measurement of hip abduction. Bony landmarks for

goniometer alignment (ipsilateral ASIS, contralateral ASIS, midline of patella)
indicated by dots and line.
53
HIP - ROM
ADDUCTION
PATIENT POSITION Supine with ipsilateral lower extremity in anatomical position, contralateral hip
abducted
EXAMINER ACTION After instructing patient in motion desired, adduct patient's hip through
available ROM, avoiding hip rotation. Return limb to starting position.
STATIONARY ARM Toward contralateral ASIS
AXIS Ipsilateral ASIS
MOVING ARM Anterior midline of femur, using midline of patella as reference.
PATIENT/EXAMINER ACTION Perform passive, or have patient perform active, hip adduction
Starting position for measurement of hip adduction. Contralateral hip is

abducted to allow room for adduction of ipsilateral hip. Bony landmarks for
goniometer alignment (ipsilateral ASIS, contralateral ASIS, midline of patella)
indicated by dots and line.
54
HIP - ROM
LATERAL ROTATION
PATIENT POSITION Seated, with hip and knee flexed to 90 degrees, folded towel under thigh; weight
equally distributed over both ischial tuberosities
STABILIZATION None needed, pelvis is stabilized by patient's weight
EXAMINER ACTION After instructing patient in motion desired, laterally rotate patient's hip through
available ROM by keeping the thigh stationary and moving the leg, foot, and ankle
medially. Return limb to starting position. Performing passive movement provides
an estimate of the ROM and demonstrates to patient exact motion desired
GONIOMETER ALIGNMENT Palpate following bony landmarks and align the goniometer accordingly
AXIS Midpoint of patella
MOVING ARM Anterior midline of tibia, along tibial crest
PATIENT/EXAMINER Perform passive, or have patient perform active, hip lateral rotation. Patient should
ACTION be instructed to maintain equal weight on both ischial tuberosities
Starting position for measurement of hip lateral rotation. Weight is distributed

evenly over both ischial tuberosities. Towel roll is placed under ipsilateral thigh to
position femur in horizontal plane. Bony landmarks for goniometer alignment
(midpoint of patella, tibial crest) indicated by dot and line.
55
HIP - ROM
MEDIAL ROTATION
PATIENT POSITION Seated, with hip and knee flexed to 90 degrees, folded towel under thigh; weight
equally distributed over both ischial tuberosities
STABILIZATION None needed; pelvis is stabilized by patient's weight
EXAMINER ACTION After instructing patient in motion desired, medially rotate patient's hip through
available ROM by keeping the thigh stationary and moving the leg, foot, and ankle
laterally. Return limb to starting position. Performing passive movement provides
an estimate of the ROM and demonstrates to patient exact motion desired
AXIS Midpoint of patella
MOVING ARM Anterior midline of tibia, along tibial crest
PATIENT/EXAMINER ACTION Perform passive, or have patient perform active, hip medial rotation. Patient
should be instructed to maintain equal weight on both ischial tuberosities
End of hip medial rotation ROM. Examiner's hand stabilizes thigh against table.
Bony landmarks for goniometer alignment (midpoint of patella, tibial crest)
indicated by dot and line.
56
ANKLE - ROM
ANKLE SUPINATION (PLANTARFLEXION)
PATIENT POSITION Supine or sitting, with knee flexed (as shown) or extended, ankle in anatomical
position
STABILIZATION Over posterior aspect of distal leg
EXAMINER ACTION After instructing patient in motion desired, plantarflex patient's ankle through
available ROM. Return to starting position. Performing passive movement
provides an estimate of the ROM and demonstrates to patient exact motion
desired
STATIONARY ARM Lateral midline of fibula, in line with fibular head
AXIS Distal to, but in line with lateral malleolus, at intersection of lines through lateral
midline of fibula and lateral midline of 5th metatarsal
MOVING ARM Lateral midline of 5th metatarsal
PATIENT/EXAMINER ACTION Perform passive, or have patient perform active, ankle plantarflexion
Starting position for measurement of ankle supination: Plantarflexion

component. Bony landmarks for goniometer alignment (fibular head, lateral
malleolus, lateral midline of 5th metatarsal) indicated by line and dots
57
ANKLE - ROM
ANKLE PRONATION (DORSIFLEXION)
PATIENT POSITION Supine or sitting, with knee flexed at least 30 degrees, ankle in anatomical position
STABILIZATION Over anterior aspect of distal leg
EXAMINER ACTION After instructing patient in motion desired, dorsiflex patient's ankle through
desired
STATIONARY ARM Lateral midline of fibula, in line with fibular head
AXIS Distal to, but in line with lateral malleolus, at intersection of lines through lateral
midline of fibula and lateral midline of 5th metatarsal
MOVING ARM Lateral midline of 5th metatarsal
PATIENT/EXAMINER ACTION Perform passive, or have patient perform active, ankle dorsiflexion
End of ankle pronation: dorsiflexion component ROM, showing proper hand

placement for stabilizing leg and dorsiflexing joint. Note that motion is achieved
through upward pressure on the plantar surfaces of metatarsals 4 and 5. Bony
landmarks for goniometer alignment (fibular head, lateral malleolus, lateral
midline of 5th metatarsal) indicated by line and dots
58
ANKLE - ROM
ANKLE PRONATION (DORSIFLEXION IN SUBTALAR NEUTRAL POSITION)
An assistant is needed to perform this measurement correctly
PATIENT POSITION Supine or sitting, with knee flexed at least 30 degrees, ankle in anatomical position
STABILIZATION Over head of talus
EXAMINER ACTION 1. Place patient's subtalar joint in neutral position as follows:

a. Grasp medial and lateral sides of talar head with thumb and index finger of one
hand.
b. With other hand, passively pronate and supinate foot until talar head is felt
equally against both thumb and index finger. This position is subtalar neutral.
2. Passively dorsiflex patient's ankle through available ROM with one hand, while
maintaining grasp on talus with opposite hand, assuring that subtalar neutral
position is maintained during entire range of dorsiflexion. Return to starting
position.
GONIOMETER ALIGNMENT Examiner #2 aligns goniometer as described for ankle dorsiflexion test () and reads
scale of goniometer
PATIENT/EXAMINER Examiner #1 performs passive, or has patient perform active, ankle dorsiflexion
ACTION while maintaining subtalar joint in neutral position
End of ankle pronation: dorsiflexion component ROM, with subtalar joint

maintained in neutral position, demonstrating proper alignment of goniometer at
end of range.
Examiner #1 maintains subtalar joint in neutral position while passively dorsiflexing
the ankle.
Examiner #2 performs goniometric measurement of motion.
59
ANKLE - ROM
ANKLE/FOOT SUPINATION (INVERSION)
PATIENT POSITION Seated, with ankle in anatomical position
EXAMINER ACTION After instructing patient in motion desired, invert patient's foot/ankle through
desired
GONIOMETER ALIGNMENT Palpate following bony landmarks and align goniometer according
STATIONARY ARM Anterior midline of tibia, in line with tibial crest
AXIS Anterior aspect of talocrural joint, midway between medial and lateral malleoli
MOVING ARM Anterior midline of 2nd metatarsal
PATIENT/EXAMINER ACTION Perform passive, or have patient perform active, ankle/foot inversion
Starting position for measurement of combined ankle/foot supination: inversion

component. Bony landmarks for goniometer alignment (tibial crest, anterior
midline of talocrural joint, anterior midline of 2nd metatarsal) indicated by orange
lines and dot
60
ANKLE - ROM
ANKLE/FOOT PRONATION (EVERSION)
PATIENT POSITION Seated, with ankle in anatomical position
EXAMINER ACTION After instructing patient in motion desired, evert patient's foot/ankle through
desired
GONIOMETER ALIGNMENT Palpate following bony landmarks and align goniometer according
STATIONARY ARM Anterior midline of tibia, in line with tibial crest
AXIS Anterior aspect of talocrural joint, midway between medial and lateral
malleoli.
MOVING ARM Anterior midline of 2nd metatarsal
PATIENT/EXAMINER ACTION Perform passive, or have patient perform active, ankle /foot eversion
End of combined ankle/foot pronation: eversion component ROM, showing

proper hand placement for stabilizing tibia and inverting ankle/foot. Bony
landmarks for goniometer alignment (tibial crest, anterior midline of talocrural
joint, anterior midline of 2nd metatarsal) indicated by lines and dot.
61
ANKLE - ROM
SUBTALAR SUPINATION (INVERSION) REFERENCE FROM ANATOMICAL ZERO
PATIENT POSITION Prone, with lower extremity to be measured in anatomical position; foot off end of
table. Opposite lower extremity positioned in hip flexion, abduction, and external
rotation with knee flexed
STABILIZATION Over distal aspect of ipsilateral leg
EXAMINER ACTION After instructing patient in procedure to be performed, invert patient's calcaneus
by moving it medially. Performing passive movement provides an estimate of the
ROM and demonstrates procedure to patient
STATIONARY ARM Posterior midline of leg (use of calipers is recommended for determining this line)
AXIS Over calcaneal tendon in line with malleoli
MOVING ARM Posterior midline of calcaneus (use of calipers is recommended for determining this
line)
Move patient's calcaneus until scale of goniometer reads 0 degrees. This is the 0-
degree starting position
PATIENT/EXAMINER Perform passive, or have patient perform active, calcaneal inversion

ACTION
Starting position for measurement of subtalar supination: inversion component,

referenced from anatomical zero. Position of contralateral lower extremity places
ipsilateral calcaneus in the frontal plane. Calipers are used to determine posterior
midline of leg and calcaneus (see text for instructions). Landmarks for goniometer
alignment (posterior midline of leg, calcaneal tendon in line with malleoli, posterior
midline of calcaneus) indicated by lines and dot.
62
ANKLE - ROM
SUBTALAR SUPINATION (EVERSION) REFERENCE FROM ANATOMICAL ZERO
PATIENT POSITION Prone, with lower extremity to be measured in anatomical position; foot off end of
table. Opposite lower extremity position in hip flexion, abduction, and external
rotation with knee flexed
STABILIZATION Over distal aspect of ipsilateral leg
EXAMINER ACTION After instructing patient in procedure to be performed, evert patient's calcaneus by
moving it laterally. Performing passive movement provides an estimate of the ROM
and demonstrates procedure to patient
GONIOMETER ALIGNMENT Palpate following landmarks and align goniometer according
STATIONARY ARM Posterior midline of leg (use of calipers is recommended for determining this line)
AXIS Over calcaneal tendon in line with malleoli
MOVING ARM Posterior midline of calcaneus (use of calipers* is recommended for determining
this line)
Move patient's calcaneus until scale of goniometer reads 0 degrees. This is the 0-
degree starting position
PATIENT/EXAMINER Perform passive, or have patient perform active, calcaneal eversion

ACTION
End of subtalar pronation: eversion component ROM, showing proper hand

placement for stabilizing tibia and everting subtalar joint. Landmarks for
goniometer alignment (posterior midline of leg, calcaneal tendon in line with
malleoli, posterior midline of calcaneus) indicated by lines and dot.
63
METATARSOPHALANGEAL - ROM
FIRST METATARSOPHALANGEAL (MTP) PLANTAR FLEXION
PATIENT POSITION Supine or seated with ankle in neutral position
STABILIZATION Over 1st metatarsal
EXAMINER ACTION After instructing patient in motion desired, flex patient's 1st MTP joint through
available ROM. Return limb to starting position. Performing passive movement
desired
STATIONARY ARM Medial midline of 1st metatarsal.
AXIS Medial aspect of 1st MTP joint
MOVING ARM Medial midline of proximal phalanx of great toe
PATIENT/EXAMINER ACTION Perform passive, or have patient perform active, MTP flexion
Starting position for measurement of 1st MTP joint flexion. Bony landmarks for
goniometer alignment (medial midline of 1st metatarsal, medial aspect of 1st MTP
joint, medial midline of proximal phalanx) indicated by lines and dot.
64
FIRST METATARSOPHALANGEAL (MTP) DORSIFLEXION
PATIENT POSITION Supine or seated, with ankle in neutral position
EXAMINER ACTION After instructing patient in motion desired, extend patient's 1st MTP joint
through available ROM. Return limb to starting position. Performing passive
movement provides an estimate of the ROM and demonstrates to patient exact
motion desired
STATIONARY ARM Medial midline of 1st metatarsal
AXIS Medial aspect of 1st MTP joint
MOVING ARM Medial midline of proximal phalanx of great toe
PATIENT/EXAMINER ACTION Perform passive, or have patient perform active, MTP extension
End of 1st MTP joint extension ROM, showing proper hand placement for
stabilizing 1st metatarsal and extending MTP joint. Bony landmarks for
goniometer alignment (medial midline of 1st metatarsal, medial aspect of 1st
MTP joint, medial midline of proximal phalanx) indicated by lines and dot
65
FIRST METATARSOPHALANGEAL (MTP) ABDUCTION
EXAMINER ACTION After instructing patient in motion desired, abduct patient's 1st MTP joint through
desired
STATIONARY ARM Dorsal midline of 1st metatarsal
AXIS Dorsal midline of 1st MTP joint
MOVING ARM Dorsal midline of proximal phalanx of great toe
PATIENT/EXAMINER ACTION Perform passive MTP abduction
Starting position for measurement of 1st MTP joint abduction. Bony landmarks for
goniometer alignment (dorsal midline of 1st metatarsal, dorsal aspect of 1st MTP
joint, dorsal midline of proximal phalanx) indicated by lines and dot.
66
FIRST METATARSOPHALANGEAL (MTP) ADDUCTION
EXAMINER ACTION After instructing patient in motion desired, adduct patient's 1st MTP joint through
desired
STATIONARY ARM Dorsal midline of 1st metatarsal
AXIS Dorsal midline of 1st MTP joint
MOVING ARM Dorsal midline of proximal phalanx of great toe
PATIENT/EXAMINER ACTION Perform passive MTP adduction
End of 1st MTP joint adduction ROM, showing proper hand placement for
stabilizing 1st metatarsal and adducting MTP joint. Bony landmarks for
goniometer alignment (dorsal midline of 1st metatarsal, dorsal aspect of 1st MTP
joint, dorsal midline of proximal phalanx) indicated by lines and dot.
67
METATARSOPHALANGEAL (MTP) OR INTERPHALANGEAL (PIP,DIP,IP) FLEXION
STABILIZATION Over more proximal bone of joint to be measured (in this case, stabilization of
metatarsals is shown)
EXAMINER ACTION After instructing patient in motion desired, flex joint to be measured through
available ROM. Return toe to starting position. Performing passive movement
desired
STATIONARY ARM Dorsal midline of more proximal bone of joint to be measured (in this case, the
metatarsal)
AXIS Dorsal midline of joint to be measured (in this case, the MTP joint)
MOVING ARM Dorsal midline of more distal bone of joint to be measured (in this case, the
proximal phalanx)
PATIENT/EXAMINER ACTION Perform passive, or have patient perform active, flexion of joint to be measured
Starting position for measurement of MTP joint flexion. Bony landmarks for
goniometer alignment (dorsal midline of metatarsal, dorsal aspect of MTP joint,
dorsal midline of proximal phalanx) indicated by lines and dot.
68
METATARSOPHALANGEAL (MTP) OR INTERPHALANGEAL (PIP,DIP,IP)

EXTENSION
STABILIZATION Over more proximal bone of joint to be measured (in this case, stabilization of
metatarsals is shown)
EXAMINER ACTION After instructing patient in motion desired, extend joint to be measured through
provides an estimate of the ROM and demonstrates to patient exact motion desire
STATIONARY ARM Dorsal midline of more proximal bone of joint to be measured (in this case, the
metatarsal)
AXIS Dorsal midline of joint to be measured (in this case, MTP joint)
MOVING ARM Dorsal midline of more distal bone of joint to be measured (in this case, the
proximal phalanx)
PATIENT/EXAMINER ACTION Perform passive, or have patient perform active, extension of joint to be measured
Starting position for measurement of MTP joint extension. Bony landmarks for
goniometer alignment (dorsal midline of metatarsal, dorsal aspect of MTP joint,
dorsal midline of proximal phalanx) indicated by lines and dot.
69
70
NECK - MMT
MMT GRADING
GRADING SCALE RANGE 0 – 5
0 None No visible or palpable contraction

1 Trace Visible or palpable contraction with no motion ( a 1 )
2 Poor Full ROM gravity eliminated
3 Fair Full ROM against gravity
4 Good Full ROM against gravity, moderate resistance
5 Normal Full ROM against gravity, maximal resistance
MODIFIED MMT
71
NECK - MMT
CERVICAL EXTENSION
GARDE 5 & 4
POSITION OF PATIENT Prone with head off end of table. Arms at sides.
INSTRUCTIONS TO THERAPIST Stand next to patient's head. Ask patient to lift head while looking at the
floor. If sufficient range is present, place hand applying resistance over
the parieto-occipital area. Place the other hand below the chin, ready to
support the head should it suddenly give way during resistance.
TEST Patient extends neck without tilting chin.
INSTRUCTIONS TO PATIENT “Push up on my hand but keep looking at the floor. Hold it. Don't let me
push it down.”
Grade 5: Patient holds test position against strong resistance. Therapist

GRADING must use clinical caution because these muscles are not strong, and their
maximum effort will not tolerate much resistance.
Grade 4: Patient holds test position against moderate resistance.
GRADE 3
POSITION OF PATIENT Prone with head off end of table. Arms at sides.
INSTRUCTIONS TO THERAPIST Stand next to patient's head with one hand supporting (or ready to
support) the forehead
TEST Patient extends neck without looking up or tilting chin.
INSTRUCTIONS TO PATIENT “Lift your forehead from my hand, and keep looking at the floor.”
GRADING Patient holds test position but without resistance.
72
NECK - MMT
GRADE 2, 1 & 0
POSITION OF PATIENT Supine with head fully supported by table. Arms at sides.
Stand at the patient's head, facing the patient. Place both hands under the
INSTRUCTIONS TO THERAPIST patient's head. Fingers should be distal to the occiput at the level of the
cervical vertebrae for palpation. Ask patient to push head into therapist's
hands without any tilt.
TEST Patient attempts to extend neck into table without tilt.
INSTRUCTIONS TO PATIENT “Try to push your head down into my hands.”
GRADING Grade 2: Patient moves through small range of neck extension by pushing
into therapist's hands.
Grade 1: Contractile activity palpated in cervical extensors.
Grade 0: No discernable palpable muscle activity.
73
NECK - MMT
CERVICAL FLEXION
GRADE 5 & 4
POSITION OF PATIENT Supine, with knees bent and feet on the table (hook lying), arms at side.
INSTRUCTIONS TO THERAPIST Stand next to patient's head. Ask patient to lift head from table while
keeping chin tucked in with eyes towards ceiling. If sufficient range is
present, place hand for resistance on patient's chin. Use two fingers only.
Other hand may be placed on chest, but stabilization is needed only
when the trunk is weak.
TEST Patient lifts head straight up from the table while tucking the chin. This is
a weak muscle group.
INSTRUCTIONS TO PATIENT “Lift your head from the table; keep your chin tucked in while looking at
the ceiling. Do not lift your shoulders off the table. Hold it. Don't let me
push your head down.”
GRADING Grade 5 and Grade 4: Patient able to hold test position against moderate
to mild two-finger resistance.
GRADE 3
GRADING No resistance is used
74
NECK - MMT
GRADE 2, 1 & 0
POSITION OF PATIENT Supine with head supported on table. Arms at sides.
INSTRUCTIONS TO THERAPIST Stand at head of table, facing patient. Fingers of both hands (or just the
index finger) are placed over the sternocleidomastoid muscles to palpate
them during test.
TEST Patient rolls head from side to side, keeping head supported on table.
INSTRUCTIONS TO PATIENT “Roll your head to the left and then to the right.”
GRADING Grade 2: Patient completes partial range of motion. The right

sternocleidomastoid produces the roll to the left side and vice versa.
Grade 1: No motion occurs, but contractile activity in one or both muscles
can be detected.
Grade 0: No motion and no discernable contractile activity detected.
75
NECK - MMT
CERVICAL ROTATION
GRADE 5, 4 & 3
POSITION OF PATIENT Supine with cervical spine in neutral (flexion and extension). Head
supported on table with face turned as far to one side as possible. Sitting is
an alternative position for all tests.
INSTRUCTIONS TO THERAPIST Stand at head of table, facing patient. Ask patient to turn head. If sufficient
range exists, place hand for resistance over the side of the patient's head
above the ear (Grades 5 and 4 only).
TEST Patient rotates head to neutral against maximum resistance. This is a strong
muscle group. Repeat for rotators on the opposite side. Alternatively, have
patient rotate from left side of face on table to right side of face on table.
INSTRUCTIONS TO PATIENT “Turn your head and face the ceiling. Hold it. Do not let me turn your head
back.”
GRADING Grade 5: Patient holds test position with maximum resistance. Grade 4:
Patient holds test position with moderate resistance. Grade 3: Patient
rotates head through full available range of motion to both right and left
without resistance.
GRADE 2, 1 & 0
POSITION OF PATIENT Sitting. Trunk and head may be supported against a high-back chair. Head
posture neutral.
INSTRUCTIONS TO THERAPIST Stand directly in front of patient.
TEST Patient tries to rotate head from side to side, keeping the neck in neutral
(chin neither down or up).
INSTRUCTIONS TO PATIENT “Turn your head as far to the left as you can. Keep your chin level.” Repeat
for turn to right.
GRADING Grade 2: Patient completes partial range of motion.

Grade 1: Contractile activity in sternocleidomastoid or posterior muscles
visible or evident by palpation. No movement.
Grade 0: No discernible palpable contractile activity.
76
SCAPULA - MMT
SCAPULAR ABDUCTION AND UPWARD ROTATION

GRADE 5, 4 & 3
POSITION OF PATIENT Short sitting with arm forward flexed to about 130° and then protracted in that
plane as far as it can move.
Stand at test side of patient. Ask patient to protract arm, to assess available
INSTRUCTIONS TO THERAPIST range and the patient's ability to achieve the test position. If successful, position
arm as noted above. Hand used for resistance grasps the upper arm just above
the elbow and gives resistance in a backward direction. The other hand stabilizes
the trunk just below the scapula on the same side, thus preventing trunk
rotation. The therapist should select a spot on the wall or ceiling that can serve
as a target for the patient to reach toward when the shoulder is at 130° of
elevation.
TEST Therapist resists protraction and elevation the arm at about 130° of flexion. The
patient holds against maximal resistance.
INSTRUCTIONS TO PATIENT “Hold your arm here. Don't let me move it.”
Grade 5: Scapula maintains its abducted and rotated position against maximal
GRADING resistance.
Grade 4: Scapular muscles “give” or “yield” against maximal resistance. The G-H
joint is normally held rigid in the presence of a strong deltoid, but if the serratus
yields, the scapula moves in the direction of adduction and downward rotation.
Grade 3: Scapula moves through full range of motion without winging, and
without resistance other than the weight of the arm
77
SCAPULA - MMT
GRADE 2
POSITION OF PATIENT Short sitting with arm flexed above 90° and supported by therapist.
INSTRUCTIONS TO THERAPIST Stand at test side of patient. One hand supports the patient's arm at the
elbow, maintaining it above the horizontal. The other hand is placed at the
inferior angle of the scapula with the thumb positioned along the axillary
border and the fingers along the vertebral border.
TEST Therapist monitors scapular motion by using a light grasp on the scapula at
the inferior angle. Therapist must be sure not to restrict or resist motion. The
scapula is observed to detect winging.
INSTRUCTIONS TO PATIENT “Hold your arm in this position” (i.e., above 90°). “Let it relax. Now hold your
arm up again. Let it relax.”
GRADING If the scapula abducts and rotates upward as the patient attempts to hold the
arm in the elevated position, the weakness is in the G-H muscles. If the
scapula does not smoothly abduct and upwardly rotate without the weight of
the arm or if the scapula moves toward the vertebral spine, the weakness is in
the serratus and should be graded a 2.
78
SCAPULA - MMT
GRADE 1 & 0
POSITION OF PATIENT Short sitting with arm forward flexed to above 90° (supported by therapist).
INSTRUCTIONS TO THERAPIST Stand in front of and slightly to one side of patient. Support the patient's arm at
the elbow, maintaining it above 90°. Use the other hand to palpate the serratus
with the tips of the fingers just in front of the inferior angle along the axillary
border
TEST Patient attempts to hold the arm in the test position.
INSTRUCTIONS TO PATIENT “Try to hold your arm in this position.”
GRADING Grade 1: Muscle contraction is palpable

Grade 0: No discernable palpable contraction.
79
SCAPULA - MMT
SCAPULAR ELEVATION
GRADE 5, 4 & 3
POSITION OF PATIENT Short sitting over end or side of table in erect posture. Hands relaxed in lap.
INSTRUCTIONS TO THERAPIST Stand behind patient. Ask the patient to elevate (shrug) the shoulders (Grade
3). If range is full and symmetrical, apply resistance. Contour hands over top
of both shoulders to give resistance in a downward direction. This muscle is
quite strong, so the therapist's arms should be nearly straight, transferring
the therapist's body weight through the arms to provide enough resistance. If
unilateral weakness is suspected (rare), testing each side separately may be
indicated.
TEST Patient elevates (shrugs) shoulders. The test is almost always performed on
both sides simultaneously
INSTRUCTIONS TO PATIENT “Shrug your shoulders.” OR “Raise your shoulders toward your ears. Hold it.
Don't let me push them down.”
GRADING Grade 5: Holds test position against maximal resistance
Grade 4: Patient holds test position against strong to moderate resistance.

The shoulder muscles may “give” at the end point.
Grade 3: Elevates shoulders through full available range without resistance.
80
SCAPULA - MMT
GRADE 2, 1 & 0
POSITION OF PATIENT Prone, fully supported on table. Head may be turned away from test side for
patient comfort and to reduce the potential contribution of the levator
scapulae
INSTRUCTIONS TO THERAPIST Stand at test side of patient. Support test shoulder in palm of one hand. The
other hand palpates the upper trapezius near its insertion above the
clavicle. A second site for palpation is the upper trapezius just adjacent to
the cervical vertebrae.
TEST With the therapist supporting the shoulder, the patient elevates the
shoulder (usually done unilaterally) toward the ear.
INSTRUCTIONS TO PATIENT “Raise your shoulder toward your ear (shrug).”
GRADING Grade 2: Patient completes full range of motion in gravity-minimized

position.
Grade 1: Upper trapezius fibers can be palpated at clavicle or neck. The
levator muscle lies deep and is more difficult to palpate in the neck
(between the sternocleidomastoid and the trapezius). It can be felt at its
insertion on the vertebral border of the scapula superior to the scapular
spine when the head is turned towards the side being tested.
81
SCAPULA - MMT
SCAPULAR ADDUCTION (RETRACTION)

GRADE 5, 4 & 3
POSITION OF PATIENT Prone with shoulder at edge of table. Shoulder is abducted to 90°. Elbow is
flexed to a right angle with forearm and hand hanging off table. Head may be
turned to either side for comfort.
INSTRUCTIONS TO THERAPIST Stand at test side close to patient's arm. Stabilize the contralateral scapular
area to prevent trunk rotation. Ask the patient to lift elbow toward the ceiling
(Grade 3). If able to complete full range, proceed to apply resistance in the
test position in a downward direction. Palpate the middle fibers of the
trapezius at the spine of the scapula from the acromion to the vertebral
column with the fingers of the other hand, as necessary.
TEST Patient horizontally abducts arm and adducts scapula.
INSTRUCTIONS TO PATIENT “Lift your elbow toward the ceiling. Hold it. Don't let me push it down.”
GRADING Grade 5: Holds test position against maximal resistance.

Grade 4: Holds test position against strong to moderate resistance. Grade 3:
Completes available range without manual resistance
82
SCAPULA - MMT
GRADE 2, 1 & 0
POSITION OF PATIENT Same as for Grade 5 test except that the therapist uses one hand to cradle
the patient's shoulder and arm, thus supporting the arm's weight, and the
other hand for palpation.
TEST Same as that for Grades 5 to 3.
INSTRUCTIONS TO PATIENT “Try to lift your elbow toward the ceiling.”
GRADING Grade 2: Completes full range of motion without the weight of the arm.
Grade 1 and Grade 0: A Grade 1 muscle exhibits contractile activity or slight
movement. There will be neither motion nor discernable palpable
contractile activity in the Grade 0 muscle.
83
SCAPULA - MMT
SCAPULAR DEPRESSION AND ADDUCTION

GRADE 5,4, & 3
POSITION OF PATIENT Prone with test arm over head to about 145° of shoulder elevation and
abduction (in line with the fibers of the lower trapezius). Forearm is in mid
position (neutral rotation) with the thumb pointing toward the ceiling. Head
should be turned to the test side.
INSTRUCTIONS TO THERAPIST Stand at test side. Ask patient to raise the arm from the table as high as
possible (Grade 3). If full range is present, provide resistance. Hand giving
resistance is contoured over the distal forearm, just above wrist. Resistance will
be given straight downward (toward the floor). Fingertips of the opposite hand
palpate below the spine of the scapula and across to the thoracic vertebrae,
following the muscle as it curves down to the lower thoracic vertebrae. If
patient cannot hold the test position with resistance given on the forearm,
apply resistance over distal humerus, above elbow (Grade 4).
INSTRUCTIONS TO PATIENT “Hold your arm. Don't let me push it down.”
GRADING Grade 5: Holds test position against strong resistance applied over the forearm.
Grade 4: Holds test position against strong resistance applied over the distal
humerus or light resistance over the forearm.
Grade 3: Patient raises arm from the table in test position against gravity, but
patient cannot tolerate manual resistance
84
SCAPULA - MMT
GRADE 2, 1 & 0
POSITION OF PATIENT Same as for Grade 5.
INSTRUCTIONS TO THERAPIST Stand at test side. Support patient's arm under the elbow
Patient attempts to lift the arm from the table. If the patient is unable to lift
TEST the arm because of a weak posterior and middle deltoid, the examiner
should lift and support the weight of the arm. In the presence of a weak
lower trapezius, the patient may substitute the middle trapezius and
rhomboids, causing a lowering of the arm into an abducted position.
INSTRUCTIONS TO PATIENT “Try to lift your arm from the table past your ear.”
Grade 2: Completes full scapular range of motion without the weight of the
GRADING arm.
Grade 1: Contractile activity can be palpated in the triangular area between
the root of the spine of the scapula and the lower thoracic vertebra (T7-
T12), that is, the course of the fibers of the lower trapezius.
Grade 0: No discernable palpable contractile activity.
85
SCAPULA - MMT
SCAPULAR ADDUCTION (RETRACTION) AND DOWNWARD ROTATION

GRADE 5, 4, & 3
POSITION OF PATIENT Prone. Head may be turned to either side for comfort. Shoulder is internally
rotated and the arm is adducted across the back with the elbow flexed and hand
resting on the back
INSTRUCTIONS TO THERAPIST Stand at test side. Ask patient to place hand at the small of the back and lift it
several inches away from the back (Grade 3). If patient can successfully place the
hand in this position, apply resistance in the test position. When the patient's
shoulder extensor muscles are Grade 3 or higher, the hand used for resistance is
placed on the humerus just above the elbow, and resistance is given in an
outward and downward direction. When the shoulder extensors are weak, place
the hand for resistance along the axillary border of the scapula. Resistance is
applied in a downward and outward direction.
The fingers of the hand used for palpation are placed deep under the vertebral
border of the scapula.
TEST Patient lifts the hand off the back, maintaining the arm position across the back.
At the same time the examiner is applying resistance above the elbow in an
outward direction. With strong muscle activity, the therapist's fingers will “pop”
out from under the edge of the scapular vertebral border.
INSTRUCTIONS TO PATIENT “Lift your hand. Hold it. Don't let me push it down.”
GRADING Grade 5: Completes available range and holds against maximal resistance. The
fingers will “pop out” from under the scapula when strong rhomboids contract.
Grade 4: Completes range and holds against strong to moderate resistance.
Fingers usually will “pop out.”
Grade 3: Completes range but tolerates no manual resistance at either the
humerus or scapula
86
SCAPULA - MMT
GRADE 2,1 & 0

POSITION OF PATIENT Short sitting with shoulder internally rotated and arm extended and
adducted behind back
INSTRUCTIONS TO THERAPIST Stand at test side; support arm by grasping the wrist. The fingertips of one
hand palpate the muscle under the vertebral border of the scapula.
TEST Patient attempts to move hand away from back.
INSTRUCTIONS TO PATIENT “Try to move your hand away from your back.”
GRADING Grade 2: Completes range of scapular motion. Grade 1 and Grade 0: A

Grade 1 muscle has palpable contractile activity. A Grade 0 muscle shows no
discernable palpable contractile activity.
87
SCAPULA - MMT
LATISSIMUS DORSI
GARDE 5, 4 & 3
POSITION OF PATIENT Prone with head turned to test side; arms are at sides and shoulder is
internally rotated (palm up).
Stand at test side. Ask patient to lift arm into shoulder extension and
INSTRUCTIONS TO THERAPIST adduction (keeping arm close to trunk) (Grade 3). If full range is
present, apply appropriate resistance. With shoulder in extension and
adduction and elbow extended, apply resistance with hand over medial
forearm above patient's wrist in direction of abduction and slight
flexion (outwards and down). No stabilization is needed because of
prone position.
TEST Patient lifts arm into extension and adduction (close to trunk).
INSTRUCTIONS TO PATIENT “Hold your arm. Don't let me move it.”
Grade 5: Patient holds test position against maximal resistance.

GRADING Grade 4: Patient holds test position against moderate resistance.
Grade 3: Completes range but tolerates no resistance.
Grade 2: Movement observable but range is limited.
Grade 1: Muscle activity is palpable.
Grade 0: No movement and no discernable muscle contraction is
occurring.
88
SHOULDER - MMT
SHOULDER FLEXION
GRADE 5, 4 & 3
POSITION OF PATIENT Short sitting with arms at sides, elbow slightly flexed, forearm pronated
INSTRUCTIONS TO THERAPIST Stand at test side. Ask patient to raise arm forward to shoulder height (90°),
keeping elbow straight. If full range is present (Grade 3), position arm in test
position (90°) and apply appropriate resistance. Therapist's hand giving
resistance is contoured over the distal humerus just above the elbow. The other
hand may stabilize the shoulder.
TEST Patient flexes shoulder to 90° with elbow straight without rotation or horizontal
movement. The scapula should be allowed to abduct and upwardly rotate.
INSTRUCTIONS TO PATIENT “Hold your arm. Don't let me push it down.”
GRADING Grade 5: Holds test position (90°) against maximal resistance.

Grade 4: Holds test position against strong to moderate resistance.
Grade 3: Completes test range (90°) without resistance
89
SHOULDER - MMT
GRADE 2, 1 & 0
POSITION OF PATIENT Side-lying position (test side up).
With patient side-lying to minimize gravity, stand behind patient and cradle
INSTRUCTIONS TO THERAPIST the test arm at the elbow. Then ask patient to flex the shoulder. (A powder
board may also be used.)
GRADE 1 & 0:
Stand behind patient. Fingers used for palpation are placed over the
superior and anterior surfaces of the deltoid over the shoulder joint
Grade 2: Completes full range of motion in gravity-minimized position.

GRADING Grade 1: Therapist feels or sees contractile activity in the anterior deltoid,
but no motion occurs.
90
SHOULDER - MMT
SHOULDER EXTENSION
GRADE 5, 4, 3 & 2
POSITION OF PATIENT Prone with arms at sides and shoulder internally rotated (palm up)
INSTRUCTIONS TO THERAPIST Stand at test side. Ask patient to lift arm as high as possible. If full range is
available (Grade 3), position arm in test position near end range and apply
appropriate resistance. The hand used for resistance is contoured over the
posterior arm just above the elbow.
TEST Patient raises arm off the table, keeping the elbow straight
INSTRUCTIONS TO PATIENT “Lift your arm as high as you can. Hold it. Don't let me push it down.”

Grade 4: Holds test position against strong resistance.
Grade 3: Completes available range of motion with no manual resistance
Grade 2: Completes partial range of motion.
91
SHOULDER - MMT
GRADE 1 & 0
POSITION OF PATIENT Prone with arms at sides and shoulder internally rotated (palm up).
INSTRUCTIONS TO THERAPIST Stand at test side. Fingers for palpation are placed on the posterior aspect
of the upper arm (posterior deltoid). Palpate over the posterior shoulder
just superior to the axilla for posterior deltoid fibers. Palpate the teres
major on the lateral border of the scapula just below the axilla. The teres
major is the lower of the two muscles that enter the axilla at this point; it
forms the lower posterior rim of the axilla.
TEST & INSTRUCTIONS TO PATIENTS Patient attempts to lift arm from table.
GRADING Grade 1: Palpable contractile activity in any of the participating muscles

but no movement of the shoulder.
Grade 0: No palpable contractile response in participating muscles.
92
SHOULDER - MMT
SHOULDER ABDUCTION
GRADE 5, 4 & 3
POSITION OF PATIENT Short sitting with arm at side and elbow slightly flexed.
INSTRUCTIONS TO THERAPIST Stand behind patient. Ask patient to lift arm out to the side to shoulder
level (test position) with arm in neutral rotation and elbow straight. If
sufficient range is present, proceed to test Grade 5. Therapist's hand giving
resistance is contoured over arm just above elbow. Resistance is given in a
downward direction.
TEST Patient abducts arm to 90°
INSTRUCTIONS TO PATIENT “Lift your arm out to the side to shoulder level. Hold it. Don't let me push
it down.”

Grade 4: Holds test position against strong resistance.
Grade 3: Completes range of motion to 90° without resistance
93
SHOULDER - MMT
GRADE 2
POSITION OF PATIENT Supine. Arm at side supported on table in neutral rotation (thumb pointed
outward)
INSTRUCTIONS TO THERAPIST Stand at test side of patient (therapist is shown on opposite side of test in
figure to clearly illustrate test procedure). Hand used for palpation is positioned
over the middle deltoid, lateral to acromial process on the superior aspect of
the shoulder.
TEST Patient attempts to abduct shoulder by sliding arm on table without rotating it.
A powder board or towel under the arm may be used to decrease friction.
INSTRUCTIONS TO PATIENT “Take your arm out to the side.”
GRADING Completes full range of motion in this gravity-minimized position or cannot

raise shoulder to 90° with elbow straight (cannot lift the weight of the
extended arm)
GRADE 1 & 0
POSITION OF PATIENT Supine with arm at side and elbow slightly flexed.
THERAPIST INSTRUCTIONS Stand at side of table at a place where the deltoid can be reached. Palpate the
deltoid on the lateral surface of the upper one third of the arm.
GRADING Grade 1: Palpable or visible contraction of deltoid with no movement. Grade 0: No

discernable palpable contractile activity.
94
SHOULDER - MMT
SHOULDER HORIZONTAL ABDUCTION

GRADE 5, 4 & 3
POSITION OF PATIENT Prone. Shoulder abducted to 90° and forearm off edge of table with elbow
straight.
INSTRUCTIONS TO THERAPIST Stand at test side. Ask patient to lift elbow up toward the ceiling. If full
range is present (Grade 3), apply appropriate resistance. Therapist's hand
giving resistance is contoured over posterior arm just above the elbow.
TEST Patient horizontally abducts shoulder. Care should be provided to not

allow the humerus to drop (lower), allowing substitution of the
rhomboids.
INSTRUCTIONS TO PATIENT “Lift your arm up toward the ceiling. Hold it. Don't let me push it down.”

Grade 3: Completes range of motion without manual resistance. Note the
elbow can be flexed for a Grade 3.
95
SHOULDER - MMT
GRADE 2, 1 & 0
POSITION OF PATIENT Short sitting.
INSTRUCTIONS TO THERAPIST Stand at test side. Support forearm under volar aspect and palpate over
the posterior surface of the shoulder just superior to the axilla.
TEST Patient attempts to horizontally abduct the shoulder. Be careful not to

allow the patient to drop the arm, substituting the rhomboids.
INSTRUCTIONS TO PATIENT “Try to move your arm backward.”
GRADING Grade 2: Moves through full range of motion.

Grade 1: Palpable contraction; no motion.
96
SHOULDER - MMT
SHOULDER HORIZONTAL ADDUCTION

POSITION OF PATIENT Whole Muscle: Supine. Shoulder abducted to 90°; elbow flexed to 90°. Clavicular
Head: Patient begins test with shoulder in 60° of abduction with elbow flexed.
Patient then is asked to horizontally adduct the shoulder in a slightly upward
diagonal direction.
Sternal Head: Patient begins test with shoulder in about 120° of abduction with
elbow flexed. Patient is asked to horizontally adduct the shoulder in a slightly
downward diagonal direction.
INSTRUCTIONS TO Stand at side of shoulder to be tested. Ask the patient to move the arm with elbow
THERAPIST flexed in horizontal adduction, keeping it parallel to the floor without rotation,
checking the range of motion. If the arm moves across the body in a diagonal
motion, test the sternal and clavicular heads of the muscle separately. If full range
is present in a horizontal adducted direction (Grade 3), test the whole muscle
together. Therapist's hand used for resistance is contoured around upper arm, just
proximal to elbow, allowing the forearm to hang free. Resistance is applied in the
direction opposite the trunk in the transverse plane.
Clavicular Head: Resistance is applied above the elbow in a downward direction
(toward floor) and outward (i.e., opposite to the direction of the fibers of the
clavicular head, which moves the arm diagonally up and inward)
Sternal Head: Resistance is applied above the elbow in an up and outward
direction (i.e., opposite to the motion of the sternal head, which is diagonally
down and inward).
TEST When the whole muscle is tested, the patient horizontally adducts the shoulder in
the transverse plane through the available range of motion. When the clavicular
head is tested, the patient's motion begins at 60° of abduction and moves up and
in across the body. When the sternal head is tested, the motion begins at 120° of
shoulder abduction and moves diagonally down and in toward the patient's
opposite hip.
INSTRUCTIONS TO PATIENT Both Heads: “Move your arm across your chest. Hold it. Don't let me pull it back.”
Clavicular Head: “Move your arm up and in.”
Sternal Head: “Move your arm down and in.”

Grade 4: Holds test position with strong to moderate resistance, but muscle
exhibits some “give” at end of range.
Grade 3: Completes available range of motion in all three tests (if appropriate)
with no resistance other than the weight of the extremity.
97
SHOULDER - MMT
GRADE 2, 1 & 0
POSITION OF PATIENT Supine. Arm is supported in 90° of abduction with elbow flexed to 90°.
ALTERNATE POSITION Patient is seated with test arm supported on table (at level of axilla) with
arm in 90° of abduction midway between flexion and extension and elbow
slightly flexed. Friction of the table surface should be minimized (as with a
powder board).
INSTRUCTIONS TO THERAPIST Stand at side of shoulder to be tested or behind the seated patient. If the
patient is supine, support the full length of the forearm and hold the limb at
the wrist. For both tests palpate the pectoralis major muscle on the anterior
aspect of the chest medial to the shoulder joint.
TEST Patient attempts to horizontally adduct the shoulder. The use of the
alternate test position, in which the arm moves across the table, precludes
individual testing for the two heads.
INSTRUCTIONS TO PATIENTS “Try to move your arm across your chest.” In seated position: “Move your
arm in towards your body.”
GRADING Grade 2: Patient horizontally adducts shoulder through available range of

motion with the weight of the arm supported by the therapist or the table.
Grade 1: Palpable contractile activity.
98
SHOULDER - MMT
SHOULDER EXTERNAL ROTATION

GRADE 5, 4 & 3
POSITION OF PATIENT Short sitting, with elbow flexed to 90° and forearm in neutral rotation,
perpendicular with the patient's trunk.
INSTRUCTIONS TO THERAPIST Stand in front of patient. Ask patient to move the forearm away from the
trunk. If full range is available (Grade 3), apply appropriate resistance. One
hand stabilizes the medial aspect of the elbow and the other hand provides
resistance at the dorsal (extensor) surface of the forearm, just proximal to the
wrist to avoid eliciting the wrist extensors. Resistance is given on the outside
of the forearm towards the trunk. Because this is not an anti-gravity position,
maximal resistance should be used, if appropriate.
TEST Patient externally rotates arm, pushing forearm away from trunk.
INSTRUCTIONS TO PATIENT “Push your forearm away. Hold it. Don't let me move it.”

Grade 4: Holds test position against strong resistance with some yield. Grade
3: Completes available range of motion without manual resistance.
99
SHOULDER - MMT
GRADE 2, 1 & 0
POSITION OF PATIENT Short sitting with elbow flexed to 90° and forearm in neutral rotation
with hand facing forward, supported on table with friction minimized by
therapist, powder board or other means.
INSTRUCTIONS TO THERAPIST Sit or stand on a low stool at test side of patient at shoulder level (picture
shows therapist on opposite side to avoid obstructing view). One hand
stabilizes the outside of the flexed elbow while the other hand palpates
for the tendon of the infraspinatus over the body of the scapula below
the spine in the infraspinous fossa. Palpate the teres minor on the
inferior margin of the axilla and along the axillary border of the scapula.
Supination may occur instead of the requested external rotation during
the testing of Grades 2 and 1. This motion can be mistaken for external
rotation.
TEST Patient attempts to move forearm away from the trunk.
INSTRUCTIONS TO PATIENT “Try to push your forearm away from your stomach.”
GRADING Grade 2: Completes available range in this gravity-eliminated position.

Grade 1: Palpation of either or both muscles reveals contractile activity
but no motion.
100
SHOULDER - MMT
SHOULDER INTERNAL ROTATION

GRADE 5, 4 & 3
POSITION OF PATIENT Short sitting with elbow flexed to 90°, forearm in neutral rotation,
perpendicular to the trunk.
INSTRUCTIONS TO THERAPIST Stand in front of patient and ask patient to pull forearm toward the
trunk. If full range is present (Grade 3), apply resistance. Stabilize the
outside of the elbow with one hand while the other hand provides
resistance at the volar (flexor) surface of the forearm, just proximal to
the wrist so as not to elicit wrist flexors. Resistance is given on the volar
surface in the direction away from the trunk. As in the tests for ER, this
is a gravity-minimized position, so maximal resistance is used, if
appropriate.
TEST Patient internally rotates arm, pulling forearm toward trunk.
INSTRUCTIONS TO PATIENT “Pull your forearm toward your stomach. Hold it. Don't let me pull it
out.”
GRADING Grade 5: Holds test position against maximum resistance.

Grade 4: Holds test position against strong resistance. Some yield is
felt.
Grade 3: Completes available range without manual resistance.
101
SHOULDER - MMT
GRADE 2, 1 & 0
POSITION OF PATIENT Short sitting or sitting at a table, with elbow flexed and forearm in
neutral rotation.
INSTRUCTIONS TO THERAPIST Stand at test side or sit on low stool. One hand stabilizes the forearm
while the other hand palpates for the tendon of the subscapularis, deep
in the axilla. NOTE: The hand of the therapist under the patient's hand
will eliminate friction in the Grade 2 test if a flat surface is being used.
Alternatively, a powder board can be used.
TEST Patient attempts to internally rotate arm, pulling forearm toward trunk.
INSTRUCTIONS TO PATIENT “Try to pull your forearm toward your stomach.”
GRADING Grade 2: Is not able to complete available range.

Grade 1: Palpable contraction occurs.
102
ELBOW - MMT
ELBOW FLEXION
GRADE 5, 4 & 3
POSITION OF PATIENT Short sitting with arms at sides. The following are the positions of
choice, but it is doubtful whether the individual muscles can be
separated when strong effort is used. The brachialis is independent of
forearm position.
Biceps Brachii: Forearm in supination
Brachialis: Forearm in pronation
Brachioradialis: Forearm in mid position between pronation and
supination
INSTRUCTIONS TO THERAPIST Stand in front of patient toward the test side. Ask patient to bend
elbow. If full range is present (Grade 3), apply appropriate resistance.
Therapist's hand giving resistance is contoured over the volar (flexor)
surface of the forearm proximal to the wrist. The other hand is placed
over the anterior surface of the shoulder and applies counterforce by
resisting any upper arm movement. No resistance is given in a Grade 3
test. The test elbow is cupped by the therapist's hand for support.
TEST Patient flexes elbow through range of motion.
INSTRUCTIONS TO PATIENT Grade 5 and Grade 4: “Bend your elbow. Hold it. Don't let me pull it
down.”
Grade 3: “Bend your elbow.”

Grade 4: Holds test position against strong to moderate resistance, but
the end point may not be firm.
Grade 3: Completes available range with each forearm position.
103
ELBOW - MMT
GRADE 2
POSITION OF PATIENT All Elbow Flexors: Short sitting with arm flexed to 90° and internally
rotated (to minimize gravity) and supported by therapist. Forearm is
supinated (biceps), pronated (brachialis), and in mid position
(brachioradialis).
Alternate Position for Patients Unable to Sit: Patient is side-lying with
arm supported at the elbow in 90° flexion to minimize gravity. Elbow is
flexed to about 45° with forearm supinated, pronated (for brachialis),
and in mid position.
INSTRUCTIONS TO THERAPIST All Three Flexors: Stand in front of patient and support flexed arm under
the elbow and wrist if necessary. Palpate the tendon of the biceps in the
antecubital space. On the arm, the muscle fibers may be felt on the
anterior surface of the middle two thirds of the biceps with the short
head lying medial to the long head. Palpate the brachialis in the distal
arm medial to the tendon of the biceps. Palpate the brachioradialis on
the lateral surface of the neutrally positioned forearm, where it forms
the lateral border of the cubital fossa.
TEST Patient attempts to flex the elbow.
INSTRUCTIONS TO PATIENT “Try to bend your elbow.”
GRADING Grade 2: Completes range of motion with gravity minimized (in each of
the muscles tested).
GRADE 1 & 0
POSITION OF PATIENT & THERAPIST Side-lying for all three muscles with therapist standing at test side. All
other aspects are the same as for the Grade 2 test.
TEST Patient attempts to bend elbow with hand supinated, pronated, and in
mid position.
GRADING Grade 1: Therapist can palpate a contractile response in each of the

three muscles for which a Grade 1 is given.
104
ELBOW - MMT
ELBOW EXTENSION
GRADE 5, 4 & 3
POSITION OF PATIENT Prone on table. The patient starts the test with the shoulder in 90° of
abduction and the elbow flexed to 90° and in neutral rotation (forearm
hanging over the side of the table).
INSTRUCTIONS TO THERAPIST Stand to the side of the patient. Ask patient to straighten the elbow. If
full range is present (Grade 3), apply appropriate resistance. Provide
support with one hand underneath the arm, just above the elbow. The
other hand is used to apply downward resistance on the distal dorsal
surface of the extended forearm just proximal to the wrist. Be sure to
have the elbow in minimal flexion, so as not to allow the patient to “lock
out” the elbow. This is especially important if hyperextension exists.
TEST Patient straightens elbow
INSTRUCTIONS TO PATIENT “Hold it. Don't let me bend it.”
GRADING Grade 5: Holds test position firmly against maximal resistance.

Grade 4: Holds test position against strong resistance, but there is a
“give” to the resistance at the end range.
Grade 3: Completes available range with no manual resistance
105
ELBOW - MMT
GRADE 2, 1 & 0
POSITION OF PATIENT Short sitting. The shoulder is abducted to 90° and neutral rotation with
the elbow flexed to about 45° to minimize gravity. The entire limb is
parallel to the floor.
INSTRUCTIONS TO THERAPIST Stand at test side of patient. For the Grade 2 test, support the limb at
the elbow. For a Grade 1 or 0 test, support the limb under the forearm
and palpate the triceps on the posterior surface of the arm just
proximal to the olecranon process.
TEST Patient attempts to extend the elbow.
INSTRUCTIONS TO PATIENT “Try to straighten your elbow.”
GRADING Grade 2: Completes available range with gravity minimized.

Grade 1: Therapist can feel tension in the triceps tendon just proximal
to the olecranon or contractile activity in the muscle fibers on the
posterior surface of the arm.
Grade 0: No discernable palpable muscle activity.
106
ELBOW - MMT
FOREARM SUPINATION
GRADE 5, 4, 3 & 2
POSITION OF PATIENT Short sitting; arm at side and elbow flexed to 90°; forearm in full
pronation to neutral. Alternatively, patient may sit at a table with elbow
supported.
INSTRUCTIONS TO THERAPIST Stand at side or in front of patient. Ask patient to turn the palm up as if
holding soup in the hand. If sufficient range is present, proceed to apply
resistance. One hand supports the elbow. Apply resistance with the heel
of the therapist's hand over the dorsal (extensor) surface at the wrist,
being careful not to grip the flexor surface of the forearm.
TEST Patient begins in pronation and supinates the forearm until the palm
faces the ceiling. Therapist resists motion in the direction of pronation.
INSTRUCTIONS TO PATIENT “Turn your palm up. Hold it. Don't let me turn it down. Keep your wrist
and fingers relaxed.”
For Grade 3: “Turn your palm up.”

Grade 3: Completes available range of motion without resistance.
Grade 2: Completes partial range of motion.
107
ELBOW - MMT
GRADE 1 & 0
POSITION OF PATIENT Short sitting. Arm and elbow are flexed as for the previous tests.
INSTRUCTIONS TO THERAPIST Support the forearm just distal to the elbow. Palpate the supinator
distal to the head of the radius on the dorsal aspect of the forearm.
TEST Patient attempts to supinate the forearm.
INSTRUCTIONS TO PATIENT “Try to turn your palm so it faces the ceiling.”
GRADING Grade 1: Slight contractile activity but no limb movement.

108
ELBOW - MMT
FOREARM PRONATION
GRADE 5, 4, 3 & 2
POSITION OF PATIENT Short sitting or may sit at a table. Arm at side with elbow flexed to 90°
and forearm in supination.
INSTRUCTIONS TO THERAPIST Stand at side or in front of patient. Ask patient to turn palm down from
supinated position. If sufficient range is present, proceed to apply
resistance in test position. Support the elbow. Hand used for resistance
applies resistance with hypothenar eminence over radius on the volar
(flexor) surface of the forearm at the wrist. Avoid pressure on the head
of the radius and gripping the forearm for patient comfort.
TEST Patient attempts to pronates the forearm. Therapist resists motion at the
wrist in the direction of supination for Grades 4 and 5.
INSTRUCTIONS TO PATIENT “Turn your palm down. Hold it. Don't let me turn it up. Keep your wrist
and fingers relaxed.”

Grade 3: Completes available range without resistance.
Grade 2: Complete partial range of motion
109
ELBOW - MMT
GRADE 1 & 0
POSITION OF PATIENT Short sitting or may sit at a table.
INSTRUCTIONS TO THERAPIST Stand to the side of the patient. Support the forearm just distal to the
elbow. The fingers of the other hand are used to palpate the pronator
teres over the upper third of the volar (flexor) surface of the forearm on
a diagonal line from the medial condyle of the humerus to the lateral
border of the radius.
TEST Patient attempts to pronate the forearm.
INSTRUCTIONS TO PATIENT “Try to turn your palm down.”
GRADING Grade 1: Visible or palpable contractile activity with no motion of the

part.
110
WRIST - MMT
WRIST FLEXION
GRADE 5, 4 & 3
POSITION OF PATIENT Short sitting. Forearm is supinated. Wrist is in neutral position or slightly
extended.
INSTRUCTIONS TO THERAPIST Sit or stand in front of the patient and ask the patient to bend the wrist
(Grade 3). If sufficient range is present, proceed to test strength by
placing the hand in the test position. One hand supports the patient's
forearm under the wrist while the other hand applies resistance over the
volar (palmar) surface of the hand.
To Test Both Wrist Flexors: Apply resistance to the palm of the test hand
using four fingers or hypothenar eminence. Resistance is given evenly
across the hand in a straight-down direction into wrist extension.
To Test the Flexor Carpi Radialis: Place the patient's wrist in radial
deviation and slight wrist extension. Resistance is applied with the index
and long fingers over the first and second metacarpal (radial side of the
hand) in the direction of extension and ulnar deviation.
To Test the Flexor Carpi Ulnaris: Place the wrist in ulnar deviation and
slight wrist extension. Resistance is applied over the fifth metacarpal
(ulnar side of the hand) in the direction of extension and radial deviation.
TEST Patient flexes the wrist, keeping the digits and thumb relaxed.
INSTRUCTIONS TO PATIENT “Hold it. Don't let me pull it down. Keep your fingers relaxed.”
GRADING Grade 5: Holds test position of wrist flexion against maximal resistance.
Grade 4: Holds test position of wrist flexion against strong to moderate
resistance.
Grade 3: Both Wrist Flexors: Patient flexes the wrist through full range
without resistance and without radial or ulnar deviation.
Flexor Carpi Radialis: Patient flexes the wrist in radial deviation through
full range without resistance. This is a small movement as compared with
ulnar deviation.
Flexor Carpi Ulnaris: Patient flexes the wrist in ulnar deviation through
full range without resistance
111
WRIST - MMT
GRADE 2
POSITION OF PATIENT Sitting with elbow supported on table. Forearm in mid position with hand
resting on ulnar side.
INSTRUCTIONS TO THERAPIST Support patient's forearm proximal to the wrist.
TEST Patient flexes wrist with the ulnar surface gliding across or not touching the
table. To test the two wrist flexors separately, hold the forearm so that the
wrist does not lie on the table and ask the patient to perform the flexion
motion while the wrist is in ulnar and then radial deviation.
INSTRUCTIONS TO PATIENT “Bend your wrist, keeping your fingers relaxed.”
GRADING Completes available range of wrist flexion with gravity minimized.
112
WRIST - MMT
GRADE 1 & 0
POSITION OF PATIENT Supinated forearm supported on table.
INSTRUCTIONS TO THERAPIST Support the wrist in flexion; the index finger of the other hand is used to
palpate the appropriate tendons. Palpate the tendons of the flexor carpi
radialis and the flexor carpi ulnaris in separate tests.
The flexor carpi radialis lies on the lateral palmar aspect of the wrist
lateral to the palmaris longus. The tendon of the flexor carpi ulnaris lies
on the medial palmar aspect of the wrist (at the base of the fifth
metacarpal).
TEST Patient attempts to flex the wrist.
INSTRUCTIONS TO PATIENT “Try to bend your wrist. Relax. Bend it again.” Patient should be asked to
repeat the test so the therapist can feel the tendons during both
relaxation and contraction.
GRADING Grade 1: One or both tendons may exhibit visible or palpable contractile
activity, but the part does not move.
113
WRIST - MMT
WRIST EXTENSION
GRADE 5, 4 & 3
POSITION OF PATIENT Short sitting. Elbow is flexed, forearm is fully pronated, and forearm is supported on the
table.
INSTRUCTIONS TO Sit or stand at a diagonal in front of patient. Ask the patient to lift hand (Grade 3). If
THERAPIST sufficient range is available, proceed to apply resistance by placing the patient's hand in
the test position of full extension. The hand used for resistance is placed over the dorsal
(extensor) surface of the metacarpals. To test all three muscles, the patient extends the
wrist without deviation. Resistance is given with four fingers or hypothenar eminence in
a forward and downward direction over the second to fifth metacarpals for Grades 4 and
5.
To test the extensor carpi radialis longus and brevis (extension with radial deviation),
position wrist in extension and radial deviation. Resistance is given on the dorsal
(extensor) surface of the second and third metacarpals (radial side of hand) in the
direction of flexion and ulnar deviation.
To test the extensor carpi ulnaris (extension and ulnar deviation), position wrist in
extension and ulnar deviation. Patient extends (lifts) the wrist, leading with the ulnar
side of the hand. Resistance is given on the dorsal (extensor) surface of the fifth
metacarpal (ulnar side of hand) in the direction of flexion and radial deviation.
TEST For the combined test of the three wrist extensor muscles, the patient extends the wrist
(lifts the hand) through the full available range. Do not permit extension of the fingers.
To test the two radial extensors, the patient extends the wrist, leading with the thumb
side of the hand. The wrist may be prepositioned in some extension and radial deviation
to direct the patient's motion.
To test the extensor carpi ulnaris, the patient extends the wrist, leading with the ulnar
side of the hand. The therapist may preposition the wrist to direct the movement toward
the ulna.
INSTRUCTIONS TO “Hold it. Don't let me push it down.” For Grade 3: “Bring your hand up.” (Add “to the
PATIENT side” when testing for radial or ulnar deviation.)
GRADING Grade 5: Holds test position against maximal resistance. Full extension is not required for
the tests of radial and ulnar deviation.
Grade 4: Holds test position of wrist extension against strong to moderate resistance
when all muscles are being tested. When testing the individual muscles, full wrist
extension range of motion will not be achieved.
Grade 3: Completes full range of motion without resistance in the test for all three
muscles. In the separate tests for the radial and ulnar extensors, the deviation required
precludes full range of motion.
114
WRIST - MMT
GRADE 2
POSITION OF PATIENT Forearm supported on table in neutral position.
INSTRUCTIONS TO THERAPIST Support the patient's wrist. This elevates the hand from the table and removes
friction.
TEST Patient extends the wrist.
INSTRUCTIONS TO PATIENT “Bend your hand back.”
GRADING Completes full range with gravity minimized.
GRADE 1 & 0
POSITION OF PATIENT Hand and forearm supported on table with forearm fully pronated.
INSTRUCTIONS TO Support the patient's wrist in extension. The other hand is used for palpation. Use
THERAPIST one finger to palpate one muscle in each test.
Extensor Carpi Radialis Longus: Palpate the tendon on the dorsum of the wrist in
line with the second metacarpal
Extensor Carpi Radialis Brevis: Palpate the tendon on the dorsal surface of the
wrist in line with the third metacarpal bone
Extensor Carpi Ulnaris: Palpate the tendon on the dorsal wrist surface proximal to
the fifth metacarpal and just distal to the ulnar styloid process
TEST Patient attempts to extend the wrist.
INSTRUCTIONS TO PATIENT “Try to lift your hand.”
GRADING Grade 1: For any given muscle, there is visible or palpable contractile activity, but
no wrist motion ensues.
Grade 0: No discernable contractile activity.
115
FINGERS - MMT
FINGER PIP FLEXION

GRADE 5, 4 & 3
POSITION OF PATIENT Forearm supinated, wrist in neutral. Finger to be tested is in slight flexion at the
metacarpophalangeal (MCP) joint
INSTRUCTIONS TO THERAPIST Hold all fingers (except the one being tested) in extension at all joints so as to
block the action of the profundus action. Isolation of the index finger may not be
complete. Ask the patient to bend the middle joint towards the proximal palm. If
full range is present (Grade 3), apply appropriate resistance. Therapist resists the
distal end of the middle phalanx of the test finger in the direction of extension.
TEST Patient flexes the PIP joint without flexing the DIP joint. Do not allow motion of
any joints of the other fingers. Repeat for other fingers, if indicated.
Alternatively, you can test all fingers together, combined test above). Flick the
terminal end of the finger being tested with the thumb to make certain that the
flexor digitorum profundus is not active; that is, the DIP joint goes into extension.
The distal phalanx should be relatively floppy.
INSTRUCTIONS TO PATIENT “Bend your index [then long, ring, and little] finger at the middle joint; hold it.
Don't let me straighten it. Keep your other fingers relaxed.”
GRADING Grade 5 and Grade 4: Holds against strong finger resistance. Grade 3: Completes
range of motion without resistance
116
FINGERS - MMT
GRADE 2, 1 & 0
POSITION OF PATIENT Forearm is in mid position to eliminate the influence of gravity on finger
flexion.
INSTRUCTIONS TO THERAPIST Same as for Grades 5, 4, and 3. Palpate the flexor digitorum superficialis on
the palmar surface of the wrist between the palmaris longus and the flexor
carpi ulnaris.
TEST Patient flexes the PIP joint.
INSTRUCTIONS TO PATIENT “Bend your middle finger.” (Select other fingers individually.)
GRADING Grade 2: Completes range of motion.

Grade 1: Palpable or visible contractile activity, which may or may not be
accompanied by a flicker of motion.
117
FINGERS - MMT
FINGER DIP FLEXION

GRADE 5, 4 & 3
POSITION OF PATIENT Forearm in supination, wrist in neutral, and proximal PIP joint in extension.
INSTRUCTIONS TO THERAPIST Stabilize the middle phalanx in extension by grasping it on either side. Ask
the patient to bend the tip of the finger. If full range is present (Grade 3),
apply appropriate resistance. Resistance is provided on the distal phalanx
in the direction of extension.
TEST Test each finger individually if indicated. Patient flexes distal phalanx of
each finger. Test all digits together by patient flexing all distal phalanxes
together.
INSTRUCTIONS TO PATIENT “Bend the tip (or tips) of your finger. Hold it (them). Don't let me
straighten it (them).”
GRADING Grade 5 and Grade 4: Able to hold flexed position against strong, finger
resistance.
Grade 3: Completes active range without resistance
118
FINGERS - MMT
GRADE 2, 1 & 0
POSITION OF PATIENT Forearm is in mid position to eliminate the influence of gravity on finger
flexion.
INSTRUCTIONS TO THERAPIST Same as for Grades 5, 4, and 3. Palpate the flexor digitorum superficialis
on the palmar surface of the wrist between the palmaris longus and the
flexor carpi ulnaris
TEST Patient flexes the DIP joint.
INSTRUCTIONS TO PATIENT “Bend your middle finger.” (Select other fingers individually.)
GRADING Grade 2: Completes range of motion.

Grade 1: Palpable or visible contractile activity, which may or may not be
accompanied by a flicker of motion.
119
FINGERS - MMT
FINGER MCP EXTENSION

GRADE 5, 4 & 3
POSITION OF PATIENT Forearm in pronation, wrist in neutral. MCP and IP joints are in relaxed
flexion posture.
INSTRUCTIONS TO THERAPIST Sit at table or side of patient. Stabilize the wrist in neutral. Place the index
finger of the resistance hand across the dorsum of all proximal phalanges
just distal to the MCP joints to stabilize. Ask the patient to straighten the
knuckles as far as possible. Demonstrate motion to patient and instruct to
copy. If full range is present (Grade 3), apply appropriate resistance. Give
resistance in the direction of flexion.
TEST Extensor Digitorum: Patient extends MCP joints (all fingers simultaneously),
allowing the IP joints to be in slight flexion
Extensor Indicis: Patient extends the MCP joint of the index finger.
Extensor Digiti Minimi: Patient extends the MCP joint of the 5th digit.
INSTRUCTIONS TO PATIENT “Straighten (lift) your knuckles as far as they will go.”
GRADING Grade 5 and Grade 4: Able to hold position with appropriate level of
resistance. (Extensor is not as strong as the flexor.)
Grade 3: Completes active range without resistance.
GRADE 2, 1 & 0
PROCEDURES Test is the same as that for Grades 5, 4, and 3 except that the forearm is in
the mid position. The four tendons of the extensor digitorum, the tendon of
the extensor indicis, and the tendon of the extensor digiti minimi are readily
apparent on the dorsum of the hand as they course in the direction of each
finger.
GRADING Grade 2: Completes range.

Grade 1: Visible tendon activity but no joint motion.
120
FINGERS - MMT
FINGER MCP FLEXION

GRADE 5, 4 & 3
POSITION OF PATIENT Short sitting or elbow flexed and resting on table with hand pointed up.
Forearm in neutral. Hand relaxed.
INSTRUCTIONS TO THERAPIST Sit in front or to the side of the patient. Demonstrate the intrinsic plus
position (see Fig. 5.178) to patient and insist on practice to get the motions
performed correctly and simultaneously. While stabilizing the metacarpals
(dorsum of hand on the table) to maintain flexion of the MCP joints, ask the
patient to lift the fingers so that IP joints are straight. This action tests the
lumbricals of each finger. If this position can be achieved (Grade 3), apply
appropriate resistance over each digit, one finger at a time, distal to the PIP
joint (pushing down).
To test the MCP flexion part of the lumbrical function, the patient should be
in the intrinsic plus position in fully pronated position. Stabilize the
metacarpals. Give resistance on the palmar PIP, in the direction of extension.
TEST Patient simultaneously flexes the MCP joints and extends the IP joints
(intrinsic plus position). Fingers may be tested separately if indicated. Do not
allow fingers to curl; they must remain extended.
INSTRUCTIONS TO PATIENT MCP joint portion: “Lift your fingers up. Hold them. Don't let me move your
fingers.” IP portion: “Hold your fingers straight. Don't let me bend them.”
GRADING Grade 5 and Grade 4: Patient holds position against strong resistance.
Resistance can be given to fingers individually because of the variant strength
of the different interossei and lumbricals and because the interossei and
lumbricals have different innervations.
Grade 3: Patient completes both motions correctly and simultaneously
without resistance.
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FINGERS - MMT
GRADE 2,1 & 0

POSITION OF PATIENT Forearm and wrist in mid position to remove influence of gravity. MCP
joints are fully extended; all IP joints are flexed.
INSTRUCTIONS TO THERAPIST Stabilize metacarpals.
TEST Patient attempts to flex MCP joints through full available range while
extending IP joints
INSTRUCTIONS TO PATIENT “Try to straighten your fingers while keeping your knuckles bent.”
Demonstrate motion to patient and allow practice.
GRADING Grade 2: Completes full range of motion in gravity-minimized position.

Grade 1: Except in the hand that is markedly atrophied, the palmar
interossei and lumbricals cannot be palpated. A grade of 1 is given for
minimal motion.
Grade 0: A grade of 0 is given in the absence of any discernable
palpable contraction.
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FINGERS - MMT
FINGER ABDUCTION
GRADE 5 & 4
POSITION OF PATIENT Forearm pronated, wrist in neutral. Fingers start in extension and
adduction. MCP joints in neutral and avoid hyperextension.
INSTRUCTIONS TO THERAPIST Sit at table or side of patient. Support the wrist in neutral. Ask the patient to
spread the fingers. If full range is present (Grade 3), apply appropriate
resistance. The fingers of the other hand are used to give resistance on the
distal phalanx, on the radial side of the finger, and the ulnar side of the
adjacent finger (i.e., they are squeezed together). The direction of
resistance will cause any pair of fingers to approximate.
TEST Abduction of fingers (individual tests):

Dorsal Interossei: Abduction of ring finger toward little finger Abduction of
middle finger toward ring finger Abduction of middle finger toward index
finger Abduction of index finger toward thumb The long (middle) finger
(digit 3, finger 2) will move one way when tested with the index finger and
the opposite way when tested with the ring finger, which shows a dorsal
interosseous on either side). When testing the little finger with the ring
finger, the abductor digiti minimi is being tested along with the fourth
dorsal interosseous.
Abductor Digiti Minimi: Patient abducts fifth digit away from ring finger.
INSTRUCTIONS TO PATIENT “Hold your fingers apart. Don't let me push them together.”
GRADING Grade 5 and Grade 4: Patient holds test position against strong finger
resistance. Alternatively, provide resistance for a Grade 5 test by flicking
each finger toward adduction; if the finger tested rebounds, the grade is 5.
Grade 3: Patient can abduct any given finger. Remember that the long finger
has two dorsal interossei and therefore must be tested as it moves away
from the midline in both directions
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FINGERS - MMT
GRADE 2, 1 & 0
PROCEDURES & GRADING Same as for higher grades in this test. A Grade 2 should be assigned if the
patient can complete only a partial range of abduction for any given finger.
The only dorsal interosseous that is readily palpable is the first at the base of
the proximal phalanx.
The abductor digiti minimi is palpable on the ulnar border of the hand.
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FINGERS - MMT
FINGER ADDUCTION
GRADE 5, 4 & 3
POSITION OF PATIENT Forearm pronated (palm down), wrist in neutral, and fingers extended and
adducted. MCP joints are neutral; avoid flexion.
INSTRUCTIONS TO THERAPIST Sit at table or to side of patient. Ask the patient to hold the fingers
together. If the patient is able (Grade 3) and resistance is appropriate,
grasp the middle phalanx on each of two adjoining fingers and try to pull
the finger in the direction of abduction for each finger tested. The
therapist is trying to “pull” the fingers apart. Each finger should be resisted
separately.
TEST Adduction of fingers (individual tests):

Adduction of little finger toward ring finger
Adduction of ring finger toward long finger
Adduction of index finger toward long finger
Adduction of thumb toward index finger
Occasionally there is a fourth palmar interosseous that some consider a
separate muscle from the adductor pollicis. In any event, the two muscles
cannot be clinically separated. Because the middle finger (also called the
long finger, digit 3, or finger 2) has no palmar interosseous, it is not tested
in adduction.
INSTRUCTIONS TO PATIENT “Hold your fingers together. Don't let me spread them apart.”
GRADING Grade 5 and Grade 4: Patient holds test position against strong finger
resistance. Distinguishing between Grades 5 and 4 is difficult and clinically,
perhaps not important. The grade awarded will depend on the amount of
the therapist's experience with normal hands.
Grade 3: Patient can adduct fingers toward middle finger
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FINGERS - MMT
GRADE 2, 1 & 0
PROCEDURES Same as for Grades 5, 4, and 3. For Grade 2, the patient can adduct each of the
fingers tested through a partial range of motion. The test for Grade 2 is begun with
the fingers abducted. Palpation of the palmar interossei is rarely feasible. By
placing the therapist's finger against the side of a finger to be tested, the therapist
may detect a slight outward motion for a muscle less than Grade 2.
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FINGERS - MMT
THUMB MCP AND IP FLEXION

GRADE 5,4,3,2 ,1 & 0
POSITION OF PATIENT Forearm in supination, wrist in neutral. Carpometacarpal (CMC) joint is at
0°; IP joint is at 0°. Thumb in adduction, lying relaxed and adjacent to the
second metacarpal.
INSTRUCTIONS TO THERAPIST Sit at table or to side of patient. Demonstrate thumb flexion and have
patient practice the motion. Stabilize the first metacarpal firmly to avoid any
wrist or CMC motion. Ask the patient to bend the thumb toward the palm,
keeping the IP straight. If the motion can be accomplished (Grade 3), apply
appropriate resistance with one-finger resistance to MCP flexion on the
proximal phalanx in the direction of extension.
TEST Patient flexes the MCP joint of the thumb, keeping the IP joints straight.
INSTRUCTIONS TO PATIENT “Don't bend the tip of the finger. Hold it. Don't let me pull it back.”
GRADING Grade 5 and Grade 4: Can hold position against strong thumb resistance.
Distinguishing between Grades 5 and 4 is difficult and clinically, perhaps not
important. The grade awarded will depend on the amount of the therapist's
experience with normal hands.
Grade 3: Completes full range of motion.
Grade 2: Cannot complete full range of motion.
Grade 1: Palpate the muscle by initially locating the tendon of the flexor
pollicis longus in the thenar eminence. Then palpate the muscle belly of the
FPB on the ulnar side of the longus tendon in the thenar eminence.
Grade 0: No discernable palpable activity.
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FINGERS - MMT
THUMB IP FLEXION
GRADE 5,4,3,2,1 & 0
POSITION OF PATIENT Forearm supinated with wrist in neutral and MCP joint of thumb in
extension.
INSTRUCTIONS TO THERAPIST Sit at table or side of patient. Stabilize the MCP joint of the thumb firmly in
extension by grasping the patient's thumb across that joint. Ask the
patient to bend the tip of the thumb. If sufficient range is present (Grade
3), apply resistance with the tip of your finger against the palmar surface
of the distal phalanx of the thumb in the direction of extension.
TEST Patient flexes the IP joint of the thumb.
INSTRUCTIONS TO PATIENT “Bend the end of your thumb. Hold it. Don't let me straighten it.”
GRADING Grade 5 and Grade 4: Patient tolerates maximal finger resistance from
therapist for Grade 5. This muscle is very strong, and a Grade 4 muscle will
also tolerate strong resistance.
Grade 3: Completes a full range of motion with minimal resistance
because gravity is minimized.
Grade 2: Holds test position.
Grade 1 and Grade 0: Palpate the tendon of the flexor pollicis longus on
the palmar surface of the proximal phalanx of the thumb. Palpable activity
is graded 1; no discernable palpable activity is graded 0.
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FINGERS - MMT
THUMB MCP & IP EXTENSION

GRADE 5,4 & 3
POSITION OF PATIENT Forearm in mid position, wrist in neutral with ulnar side of hand resting on
the table. Thumb relaxed in a flexion posture.
INSTRUCTIONS TO THERAPIST Sit or stand near the patient. Use the table to support the hand. Ask
patient to lift just the thumb. If full range is present (Grade 3), apply the
appropriate resistance over the dorsal surface of the distal phalanx of the
thumb in the direction of flexion.
TEST Patient lifts the thumb from the table, extending the IP joint of the thumb.
INSTRUCTIONS TO PATIENT “Hold it. Don't let me push it down.”
GRADING Grade 5 and Grade 4: This is not a strong muscle, so resistance must be
applied accordingly. The distinction between Grades 5 and 4 is based on
comparison with the contralateral normal hand and, barring that,
extensive experience in testing the hand.
Grade 3: Completes full range of motion without resistance.
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FINGERS - MMT
GRADE 2, 1 & 0
POSITION OF PATIENT Forearm in pronation with wrist in neutral and thumb in relaxed flexion
posture to start.
INSTRUCTIONS TO THERAPIST Stabilize the wrist over its dorsal surface. Stabilize the fingers by gently
placing the other hand across the fingers just below the MCP joints
TEST Patient extends distal joint of the thumb
INSTRUCTIONS TO PATIENT “Straighten the end of your thumb.”
GRADING Grade 2: Thumb completes range of motion.

Grade 1: Palpate the tendon of the extensor pollicis longus on the ulnar
side of the “anatomical snuffbox” or, alternatively, on the dorsal surface of
the proximal phalanx
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FINGERS - MMT
THUMB ABDUCTION
GRADE 5,4 & 3
POSITION OF PATIENT Dorsum of hand is on table with forearm in supination, wrist in neutral,
and thumb relaxed in adduction.
INSTRUCTIONS TO THERAPIST Sit or stand near the patient. Demonstrate the movement. Ask the patient
to lift the thumb to point towards the ceiling. If full range is present (Grade
3), apply appropriate resistance with index finger to the lateral aspect of
the proximal phalanx of the thumb in the direction of adduction.
TEST Patient abducts the thumb in a plane perpendicular to the palm. Observe
wrinkling of the skin over the thenar eminence.
INSTRUCTIONS TO PATIENT “Lift your thumb vertically until it points to the ceiling.” Demonstrate
motion to the patient.
GRADING Grade 5: Holds motion with maximal finger resistance.

Grade 4: Tolerates moderate resistance.
Grade 3: Completes full range of motion without resistance.
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FINGERS - MMT
GRADE 2, 1 & 0
POSITION OF PATIENT Forearm in mid position, wrist in neutral, and thumb relaxed in
adduction.
INSTRUCTIONS TO THERAPIST Stabilize wrist in neutral.
TEST Patient abducts thumb in a plane perpendicular to the palm.
INSTRUCTIONS TO PATIENT “Try to lift your thumb so it points at the ceiling.”
GRADING Grade 2: Completes partial range of motion.

Grade 1: Palpate the belly of the APB in the center of the thenar
eminence, medial to the OPP
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FINGERS - MMT
THUMB ADDUCTION
GRADE 5, 4 & 3
POSITION OF PATIENT Forearm in pronation, wrist in neutral, and thumb relaxed and hanging
down in abduction.
INSTRUCTIONS TO THERAPIST Sit or stand near the patient. Demonstrate the movement. Stabilize the
metacarpals of the four fingers by grasping the patient's hand around the
ulnar side. If full range is present (Grade 3), apply appropriate resistance on
the medial side of the proximal phalanx of the thumb in the direction of
abduction. Do not allow ulnar deviation. Alternatively, place a sheet of
paper between the thumb and the index finger (adduction) and ask the
patient to hold it while the therapist tries to pull the paper away. This is
strong movement and the patient should be able to hold a paper without
difficulty.
TEST Patient adducts the thumb by bringing the first metacarpal up to the second
metacarpal.
INSTRUCTIONS TO PATIENT “Bring your thumb up to your index finger.” OR “Hold the paper. Don't let
me pull it out.”
GRADING Grade 5 and Grade 4: Holds test position against strong resistance. Patient
can resist rigidly (Grade 5), or the muscle yields (Grade 4). Grade 3:
Completes full range of motion without resistance.
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FINGERS - MMT
GRADE 2, 1 & 0
POSITION OF PATIENT Forearm in mid position, wrist in neutral resting on table, and thumb in
abduction.
INSTRUCTIONS TO THERAPIST Stabilize wrist on the table, and use a hand to stabilize the finger
metacarpals
TEST Patient moves thumb horizontally in adduction.
INSTRUCTIONS TO PATIENT “Return your thumb to its place next to your index finger.” Demonstrate
motion to patient.
GRADING Grade 2: Completes full range of motion.

Grade 1: Palpate the adductor pollicis on the palmar side of the web space
of the thumb by grasping the web between the index finger and thumb.
The adductor lies between the first dorsal interosseous and the first
metacarpal bone. This muscle is difficult to palpate, and the therapist may
have to ask the patient to perform a palmar pinch to assist in its location.
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FINGERS - MMT
OPPOSITION (THUMB TO LITTLE FINGER)

GRADE 5,4,3,2,1 & 0
POSITION OF Forearm is supinated and supported on table, wrist in neutral, and thumb in adduction
PATIENT with MCP and IP flexion.
INSTRUCTIONS TO Sit or stand near patient. Ask patient to bring the thumb and little finger together (Grade
THERAPIST 3). The table provides stabilization of the hand. Both thumb and fifth digits should be
observed individually. If full range is present in each movement (Grade 3), apply
appropriate finger resistance at CMP joint of thumb and digit to test both actions
simultaneously.
Opponens Pollicis: Apply resistance for the opponens pollicis (OP) at the head of the 1st
metacarpal in the direction of lateral rotation, extension, and adduction.
Opponens Digiti Minimi: Give resistance for the opponens digiti minimi on the palmar
surface of the 5th metacarpal in the direction of medial rotation (flattening the palm).
TEST Patient approximates the pad of the thumb and pad of fifth digit. Such apposition must be
pad to pad and not tip to tip. Opposition also can be evaluated by asking the patient to
hold an object between the thumb and little finger (in opposition), which the therapist
tries to pull it away.
INSTRUCTIONS TO “Bring your thumb to your little finger and touch the two pads, forming the letter ‘O’ with
PATIENT your thumb and little finger.” Demonstrate motion to the patient and require practice.
GRADING Grade 5: Holds against maximal thumb resistance.

Grade 4: Holds against moderate resistance.
Grade 3: Moves thumb and fifth digit through full range of opposition without resistance.
Grade 2: Moves through range of opposition. (The two opponens muscles are evaluated
separately.)
Grade 1: Palpate the OP along the radial shaft of the 1st metacarpal. It lies lateral to the
APB. During Grades 5 and 4 contractions, the therapist will have difficulty in palpating the
OP because of nearby muscles. In Grade 3 muscles and below, the weaker contractions do
not obscure palpation. Palpate the opponens digiti minimi on the hypothenar eminence
on the radial side of the fifth metacarpal. The therapist should be careful not to cover the
muscle with the finger or thumb used for palpation lest any contractile activity be missed.
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ABDOMINAL - MMT
PRONE PLANK TEST

The prone plank test activates core musculature. Correct form consists of maintaining the spine in a neutral position
while maintaining scapular adduction and a posterior pelvic tilt. An anterior pelvic tilt reduces EMG activation.
POSITION OF PATIENT Prone on floor or mat.
INSTRUCTIONS TO THERAPIST From prone, ask patient to lift body weight onto toes and forearms. Elbows
should be under the shoulders, with scapulae adducted and hips level with
spine like a “plank”. Assess patient's ability to assume a plank position. If
successful, explain test to patient.
INSTRUCTIONS TO PATIENT “Raise your yourself onto your forearms and toes. Keep your body completely
straight. Suck your belly button into your spine”
SCORING A full plank position should be held for 120 seconds to be considered a Grade 5
test. Hold times of less than 90 seconds are Grade 4. Ability to assume the test
position but unable to hold results in a Grade 3. The alternate form (described
later) is scored a Grade 2.
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ABDOMINAL - MMT
SIDE BRIDGE ENDURANCE TEST

POSITION OF PATIENT Side-lying with legs extended, resting on the lower forearm with the elbow
flexed to 90°. Upper arm is crossed over chest
INSTRUCTIONS TO THERAPIST Stand or sit in front of patient. Ask patient to lift the hips off the table, keeping
the body in a straight line with the contracted core. Time the effort, observing
for quality and quantity of effort. Give patient feedback regarding posture; hips
and trunk should be level throughout the test
INSTRUCTIONS TO PATIENT “When I say ‘go!’ lift your hips off the table, keeping them in a straight line with
your body for as long as you can. I will be timing you.”
TEST Patient lifts hips off the table, holding the elevated position in a straight line with
the body on a flexed elbow. This position is maintained until the patient loses
form, fatigues, or complains of pain. The therapist times the effort.
SCORING Record the best time of two trials. Mean scores for men and women:
Men: 95(±32)s Women: 75(±32)s
TIMED PARTIAL CURL UP TEST

POSITION OF PATIENT Supine in hook lying position on a mat with arms at sides, palms facing down,
and the middle fingers touching a piece of tape affixed to the surface parallel to
the hand. A second piece of tape is affixed 12 cm (4.7 in) further than the initial
tape for those younger than 45 years and 8 cm (3.1 in) further for those 45 years
and older
INSTRUCTIONS TO THERAPIST Stand to the side of patient. Ask patient to perform a slow, controlled sit up in
time, lifting head and scapulae off the mat, while the middle finger reaches to
the second tape. If successful, use a metronome set to 40 beats/min to time
repetitions. Ask patient to curl up as many times as possible keeping time with
the metronome. The low back should be flattened before curl up
TEST The individual does as many curl ups as possible without pausing, to a maximum
of 75
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ABDOMINAL - MMT
ISOMETRIC TRUNK FLEXOR ENDURANCE TEST

POSITION OF PATIENT Sitting on table with wedge supporting the back at angle of 60° to the table. Hips
and knees flexed to 90°, with feet stabilized with a strap. Arms are folded across
the chest
INSTRUCTIONS TO THERAPIST Ask patient to hold test position when the wedge is pulled back 10 cm. Time
effort as soon as wedge is pulled back. Terminate test when the patient can no
longer maintain the 60° angle independently.
SCORING Ages 18 to 55 years (mean, 30 years), mean hold time = 178 seconds.
Exercisers held the test 3 times as long as nonexercisers (186 s vs. 68.25 s)
FRONT ABDOMINAL POWER TEST

POSITION OF PATIENT Supine on a mat with arms at sides, feet shoulder width apart, and knees bent
to 90°
INSTRUCTIONS TO THERAPIST Place a 2-kg medicine ball into the patient's hands. Then ask patient to lift arms
overhead and explosively project the medicine ball forward keeping the arms
straight. Feet and buttocks should remain on the floor throughout the test.
(Note: Feet may be secured manually or with a strap [not shown].) Measure
the distance the ball was projected from the tips of the feet to the point where
the ball landed. Patient should be sitting upright after the ball is thrown
SCORING 1.5 to 2 m was recorded in a group of 20-year-old men and women (standard
error of the mean [SEM], 24 cm)
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ABDOMINAL - MMT
UNILATERAL SUPINE BRIDGE TEST

POSITION OF PATIENT Supine with arms across chest with knees in hook lying
INSTRUCTIONS TO THERAPIST Stand to side of patient. Ask patient to lift both hips into a double-leg
bridge. When neutral spine and pelvis positions are achieved, ask patient
to extend one knee so leg is straight and thighs parallel to one another.
Ask patient to hold position as long as possible, timing the effort. Test is
terminated when patient is no longer able to hold a neutral pelvic
position, as noted by a 10° change in transverse or sagittal plane
alignment. Perform two trials, and average results.
SCORING A sample of 20 healthy male volunteers (mean age, 25.7 years) held test
position for an average of 23.0 seconds (16.5) with range of 3.1 to 59.5
seconds.
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TRUNK - MMT
TRUNK EXTENSION (LUMBAR SPINE)

GRADE 5 & 4
POSITION OF PATIENT Prone with fingertips lightly touching the side of the head
and shoulders in external rotation. The weight of the head
and arms essentially substitutes for manual resistance by
therapist.
INSTRUCTIONS TO THERAPIST Stand at side of patient to stabilize the lower extremities

just above the ankles. Ask patient to raise the head,
shoulders, and chest off the table. Observe quality of
motion and ability to hold the test position.
TEST Patient extends the lumbar spine until the entire trunk is
raised from the table (clears umbilicus).
INSTRUCTIONS TO PATIENT “Raise your head, shoulders, and chest off the table. Come
up as high as you can.”
GRADING The therapist distinguishes between Grade 5 and Grade 4

muscles by observing the response. The Grade 5 muscle
holds the test position like a lock; the Grade 4 muscle yields
slightly because of an elastic quality at the end point. The
patient with Grade 5 back extensor muscles can quickly
come to the end position and hold that position without
evidence of significant effort. The patient with Grade 4 back
extensors can come to the end position but may waver or
display some signs of effort.
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TRUNK - MMT
TRUNK EXTENSION (THORACIC SPINE)

GRADE 5 & 4
POSITION OF PATIENT Prone with head and upper trunk extending off the table from
about the nipple line. Hands should be lightly touching the side
of the head, with shoulders and elbows retracted (back).
INSTRUCTIONS TO THERAPIST Stand at side of patient to stabilize the lower limbs at the
ankle. Ask patient to raise the head, shoulders, and chest to
table level. (Note that this position does not require the same
degree of stabilization as the lumbar extension tests.)
TEST Patient extends thoracic spine to the horizontal. This will be a

small movement, and care should be made not to extend
farther than horizontal because further movement will cause
lumbar extension.
INSTRUCTIONS TO PATIENT “Raise your head, shoulders, and chest to table level.”
GRADING Grade 5: Patient raises the upper trunk quickly from its forward
flexed position to the horizontal with ease and no sign of
exertion
Grade 4: Patient raises the trunk to the horizontal level but

does so with obvious effort
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TRUNK - MMT
GRADE 3 (THORACIC & LUMBAR SPINE)

POSITION OF PATIENT Prone with arms at sides.
INSTRUCTIONS TO THERAPIST Stand at side of table. Stabilize lower extremities just above
the ankles.
TEST Patient extends spine, raising body from the table so that the
umbilicus clears the table
INSTRUCTIONS TO PATIENT “Raise your head, arms, and chest from the table as high as
you can.”
GRADING Patient completes the range of motion.
GRADE 2, 1 & 0
These tests are identical to the Grade 3 test except that the therapist must palpate the lumbar and thoracic spine
extensor muscle masses adjacent to both sides of the spine. The individual muscles cannot be isolated.
Grade 2: Patient completes partial range of motion.

Grade 1: Contractile activity is detectable but no movement.
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TRUNK - MMT
TRUNK FLEXION
GRADE 5
POSITION OF PATIENT Supine, with legs straight and fingertips lightly touching the
back of the head
INSTRUCTIONS TO THERAPIST Stand at side of table at level of patient's chest to ascertain

whether scapulae clear table during test. Ask patient to lift
head, shoulders, and back off table, keeping the chin pointed
to the ceiling. Observe motion for quality and effort. For a
patient with no other muscle weakness, the therapist does not
need to touch the patient. However, if the patient has weak hip
flexors, the therapist should stabilize the pelvis by leaning
across the patient on the forearms
TEST Patient flexes trunk through range of motion, lifting the trunk
until scapulae clear table. The neck should not flex.
INSTRUCTIONS TO PATIENT “Keep your chin pointed toward the ceiling and lift your head,
shoulders, and back off the table.”
GRADING Patient raises trunk until inferior angles of scapulae are off the
table. (Weight of the arms serves as resistance.)
GRADE 4
POSITION OF Supine with arms crossed over chest
PATIENT
TEST Other than the patient's arm position, all other aspects of the test are the
same as for Grade 5.
GRADING Patient raises trunk until scapulae are off the table. Resistance of arms is
reduced in the cross-chest position.
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TRUNK - MMT
GRADE 3
POSITION OF PATIENT Supine with arms outstretched in full extension above plane of
body
TEST Except for the patient's arm position, all other aspects of the test
are the same as for Grade 5. Patient lifts trunk until inferior
angles of scapulae are off the table. Position of the outstretched
arms “neutralizes” resistance by bringing the weight of the arms
closer to the center of gravity.
INSTRUCTIONS TO PATIENT “Keep your chin pointed to the ceiling as you raise your head,
shoulders, and arms off the table.”
GRADING Patient lifts trunk until inferior angles of scapulae are off the
table.
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GRADE 2, 1 & 0
Testing trunk flexion is rather clear-cut for Grades 5, 4, and 3. When testing Grade 2 and below, the results may be
ambiguous, but observation and palpation are critical for defendable results. To determine Grades 2 to 0, the patient
will be asked, in sequence, to raise the head, do an assisted forward lean, and cough.
POSITION OF Supine with arms at sides. Knees flexed.

PATIENT
INSTRUCTIONS Stand at side of table. Place the hand used for palpation at the midline of the thorax over
TO THERAPIST the linea alba, and use the four fingers of both hands to palpate the rectus abdominis
GRADNG Sequence 1: Head raise. Ask the patient to lift the head from the table. If the scapulae do
not clear the table, the Grade is 2. If the patient cannot lift the head, proceed to Sequence
2.
Sequence 2: Assisted forward lean. The therapist cradles the upper trunk and head off the
table and asks the patient to lean forward. If there is depression of the rib cage, the grade
is 2. If there is no depression of the rib cage but visible or palpable contraction occurs, the
grade assigned should be 1. If there is no activity, the grade is 0.
Sequence 3: Cough. Ask the patient to cough. If the patient can cough to any degree and
depression of the rib cage occurs, the grade is 2. (If the patient coughs, regardless of its
effectiveness, the abdominal muscles are automatically brought into play.) If the patient
cannot cough but there is palpable rectus abdominis activity, the grade is 1. Lack of any
discernable activity is Grade 0.
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TRUNK ROTATION
GRADE 5
POSITION OF PATIENT Supine with fingertips to the side of the head
INSTRUCTIONS TO THERAPIST Stand at the patient's waist level. Ask the patient to lift head and
shoulders, moving elbow to opposite hip. Repeat for other side.
Observe for adequate range, quality of movement and effort.
TEST With chin pointed to the ceiling, the patient flexes trunk and
rotates to one side. This movement is then repeated on the
opposite side so that the muscles on both sides can be
examined. Right elbow to left knee tests the right external
oblique and the left internal oblique. Left elbow to right knee
tests the left external oblique and the right internal oblique.
When the patient rotates to one side, the internal oblique
muscle is palpated on the side toward the turn; the external
oblique muscle is palpated on the side away from the direction
of turning.
INSTRUCTIONS TO PATIENT “With your chin pointed to the ceiling, lift your head and
shoulders from the table, taking your right elbow toward your
left knee. Then, with your chin pointed to the ceiling, lift your
head and shoulders from the table, taking your left elbow
toward your right knee.”
GRADING The scapula corresponding to the side of the external oblique

function must clear the table for a Grade 5.
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GRADE 4
POSITION OF PATIENT Supine with arms crossed over chest.
TEST Other than patient's arm position, all other aspects of the test are
the same as for Grade 5. The test is done first to one side and then
to the other.
GRADE 3
POSITION OF PATIENT Supine with arms outstretched above plane of body.
TEST Other than patient's arm position, all other aspects of the test are the
same as for Grade 5. The test is done first to the left and then to the
right.
GRADING Patient raises the scapula off the table. The therapist may use one
hand to check for scapular clearance.
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TRUNK - MMT
GRADE 2
POSITION OF PATIENT Supine with arms outstretched above plane of body
INSTRUCTIONS TO THERAPIST Stand at level of patient's waist. Palpate the external oblique
first on one side and then on the other, with one hand placed
on the lateral part of the anterior abdominal wall distal to the
rib cage. Continue to palpate the muscle distally in the
direction of its fibers until reaching the ASIS. At the same
time, palpate the internal oblique muscle on the opposite
side of the trunk. The internal oblique muscle lies under the
external oblique, and its fibers run in the opposite diagonal
direction. Therapists may remember this palpation procedure
better if they think of positioning their two hands as if both
hands were to be in the pants pockets or grasping the
abdomen in pain. (The external obliques run from out to in;
the internal obliques run from in to out.)
TEST Patient attempts to raise body and turn toward the right.
Repeat toward left side.
INSTRUCTIONS TO PATIENT “Keep your chin pointed to the ceiling while you lift your
head, reach toward your right knee.” (Repeat to left side for
the opposite muscle.)
GRADING Patient is unable to clear the inferior angle of the scapula

from the table on the side of the external oblique being
tested. However, the therapist must be able to observe
depression of the rib cage during the test activity.
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TRUNK - MMT
GRADE 1 & 0
POSITION OF PATIENT Supine with arms at sides. Hips flexed with feet flat on table.
INSTRUCTIONS TO THERAPIST Support patient's head as patient attempts to turn to one side.
(Turn to the other side in a subsequent test.) Under normal
conditions, the abdominal muscles stabilize the trunk when the
head is lifted. In patients with abdominal weakness the
supported head permits the patient to recruit abdominal
muscle activity without having to overcome the entire weight
of the head. One hand palpates the internal oblique on the side
toward which the patient turns (not illustrated) and the
external oblique on the side away from the direction of
turning. The therapist assists the patient to raise the head and
shoulders slightly and turn to one side. This procedure is used
when abdominal muscle weakness is profound.
TEST Patient attempts to flex trunk and turn to either side.
INSTRUCTIONS TO PATIENT “Try to lift up and turn to your right.” (Repeat for turn to the
left.)
GRADING Grade 1: The therapist can see or palpate muscular

contraction.
Grade 0: No discernable muscle contraction from the obliquus
internus or externus muscles.
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HIP - MMT
HIP FLEXION
GRADE 5,4 & 3
POSITION OF PATIENT Short sitting with thighs fully supported on table and legs hanging over the edge.
Patient may use arms to provide trunk stability by grasping table edge or with hands
on table at each side
INSTRUCTION TO Stand next to limb to be tested. Ask the patient to lift the thigh off the table. If
THERAPIST adequate range is present (thigh clears the table), proceed to apply maximum
resistance at midrange (Grade 5) over distal thigh just proximal to the knee joint,
being careful not to grasp the thigh.
TEST Patient flexes hip to end of range, clearing the table and maintaining neutral rotation.
The patient then brings the hip to midrange and holds that position against the
therapist's resistance, which is given in a downward direction toward the floor.
INSTRUCTION TO PATIENT Sit tall and hold your thigh up. Don't let me push it down
Grade 5: Patient holds test position against maximal resistance.

GRADING Grade 4: Patient holds test position against strong to moderate resistance. There
may be some “give” with maximum resistance, making the grade a 4.
Grade 3: Patient completes test range and holds the position without resistance
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GRADE 2: Patient Completes The Range Of Motion In Side-Lying Position
POSITION OF PATIENT Side-lying with limb to be tested uppermost and supported by therapist. Trunk in
neutral alignment. Lowermost limb may be flexed for stability. A powder board under
the upper limb may also be used to decrease friction.
INSTRUCTION TO Stand behind patient. Cradle test limb in one arm with hand support under the
THERAPIST slightly flexed knee. Opposite hand maintains trunk alignment at hip
TEST Patient flexes hip with supported limb. Knee is permitted to flex to prevent hamstring
tension
INSTRUCTION TO PATIENT Bring your knee up toward your chest
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HIP EXTENSION
GRADE 1 & 0
POSITION OF PATIENT Supine lying
INSTRUCTION TO Stand at side of limb to be tested. Test limb is supported under calf with hand behind
THERAPIST knee. Free hand palpates the muscle just distal to the inguinal ligament on the medial
side of the sartorius
TEST Patient attempts to flex hip
INSTRUCTION TO PATIENT Try to bring your knee up to your nose
GRADING Grade 1: Palpable contraction but no visible movement.

Grade 0: No discernable palpable contraction of muscle.
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HIP EXTENSION
GRADE 5, 4 & 3
POSITION OF PATIENT Prone. Arms may be at the side of the body or abducted to hold sides of table. (Note:
If there is a hip flexion contracture, immediately go to the test described for hip
extension modified for hip flexion tightness
INSTRUCTION TO THERAPIST Stand at level of pelvis on side of limb to be tested. Ask the patient to lift the leg off
the table as high as possible, while keeping the knee straight. If sufficient range is
achieved, place the hand providing resistance on the posterior leg just above the
ankle. The opposite hand may be used to stabilize or maintain pelvis alignment in the
area of the posterior superior spine of the ilium. This is a demanding test because of
the size of the muscle and the length of the lever arm.
TEST Patient extends hip through entire available range of motion. Resistance is given
straight downward toward the floor.
INSTRUCTION TO PATIENT Lift your leg off the table as high as you can without bending your knee. Hold it
GRADING Grade 5: Patient holds test position against maximal resistance.

Grade 4: Patient holds test position against strong to moderate resistance.
Grade 3: Completes range and holds the position without resistance
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GRADE 2: Completes Available Range Of Motion In Side-Lying Position.
POSITION OF PATIENT Side-lying with test limb uppermost. Knee straight and supported by therapist.
Lowermost limb is flexed for stability
INSTRUCTION TO Stand behind patient at thigh level. Therapist supports test limb just below the knee,
THERAPIST cradling the leg. Opposite hand is placed over the pelvic crest to maintain pelvic and
hip alignment.
TEST Patient extends hip through full range of motion
INSTRUCTION TO PATIENT Bring your leg back toward me. Keep your knee straight
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GRADE 1 & 0
POSITION OF PATIENT Prone lying
INSTRUCTION TO Stand at level of pelvis on side to be tested. Palpate hamstrings (deep into tissue with
THERAPIST fingers) at the ischial tuberosity. Palpate the gluteus maximus with deep finger
pressure over the center of the buttocks including the upper and lower fibers.
TEST Patient attempts to extend hip in prone position or tries to squeeze buttocks
together.
INSTRUCTION TO PATIENT Try to lift your leg from the table.” OR “Squeeze your buttocks together
GRADING Grade 1: Palpable contraction of gluteus maximus but no visible joint movement.
Contraction of gluteus maximus will result in narrowing of the gluteal crease.
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HIP ABDUCTION
GRADE 5, 4 & 3
POSITION OF PATIENT Side-lying with test leg uppermost. Start test with the hip slightly extended beyond
the midline and the pelvis rotated slightly forward. Lowermost leg is flexed for
stability.
INSTRUCTION TO Stand behind patient. Ask patient to lift the leg as high as possible, giving verbal and
THERAPIST tactile clues as necessary to keep the pelvis from rotating and the hip from flexing. If
sufficient range is achieved, place hand used to give resistance at the ankle. Applying
resistance at the ankle creates a longer lever arm, thus requiring more patient effort
to resist the movement. If the patient cannot hold the limb against resistance at the
ankle, then apply resistance at the lateral knee. The therapist is reminded always to
use the same lever in a given test sequence and in subsequent comparison tests.
TEST Patient abducts hip through the available range of motion without flexing the hip or
rotating it in either direction. Resistance is given in a straight downward direction.
INSTRUCTION TO PATIENT Lift your leg up and back. Hold it. Don't let me push it down
GRADING Grade 5: Holds test position against maximal resistance at the ankle.
Grade 4:Holds test position against strong to moderate resistance at the ankle (the
limb cannot hold the position) or with maximum resistance given at the knee.
Grade 3: Completes range of motion and holds test position without resistance. Hip
should not flex into frontal plane or rotate.
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GRADE 2: Completes Range Of Motion Supine With No Resistance And Minimal To Zero Friction.
POSITION OF PATIENT Supine Lying
INSTRUCTION TO Stand on side of limb being tested. One hand supports and lifts the limb by holding
THERAPIST it under the ankle to raise limb just enough to decrease friction. This hand offers no
resistance, nor should it be used to offer assistance to the movement. On some
smooth surfaces, such support may not be necessary.
The other hand palpates the gluteus medius just proximal to the greater trochanter
of the femur
TEST Patient abducts hip through available range
INSTRUCTION TO PATIENT Bring your leg out to the side. Keep your kneecap pointing to the ceiling.
GRADE 1 & 0
POSITION OF PATIENT Supine lying
INSTRUCTION TO Stand at the side of the limb being tested at level of thigh. One hand supports the
THERAPIST limb under the ankle just above the malleoli. The hand should provide neither
resistance nor assistance to movement. Palpate the gluteus medius on the lateral
aspect of the hip just above the greater trochanter. The weight of the opposite limb
stabilizes the pelvis. It is not necessary therefore to use a hand to manually stabilize
the contralateral limb.
TEST Patient attempts to abduct hip

.
INSTRUCTION TO PATIENT Try to bring your leg out to the side
GRADING Grade 1: Palpable contraction of gluteus medius but no movement of the part.
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HIP ADDUCTION
GRADE 5, 4 & 3
POSITION OF PATIENT Side-lying with test limb (lowermost) resting on the table.
INSTRUCTION TO Stand behind patient at knee level. Support uppermost limb (non-test limb) in 25° of
THERAPIST abduction with forearm, the hand supporting the limb on the medial surface of the
knee. Alternatively, the upper limb can be placed on a padded stool straddling the
test limb and approximately 9 to 12 inches high (not shown). Ask the patient to lift
the bottom leg to the uppermost one. If successful, place hand giving resistance on
the medial surface of the distal femur of the lower limb, just proximal to the knee
joint. Resistance is directed straight downward toward the table
TEST Patient adducts hip until the lower limb contacts the upper one.
INSTRUCTION TO PATIENT Lift your bottom leg up to your top one. Hold it. Don't let me push it down.”
For Grade 3: “Lift your bottom leg up to your top one. Don't let it drop
Grade 3: Completes full range; holds test position but without resistance
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HIP - MMT
GRADE 2: Patient Adducts Limb Through Full Range With Gravity Minimized.
POSITION OF PATIENT Supine. The non-test limb is positioned in some abduction to prevent interference
with motion of the test limb.
INSTRUCTION TO Stand at side of test limb at knee level. One hand supports the ankle and elevates it
THERAPIST slightly from the table surface to decrease friction as the limb moves across the
table. The therapist uses this hand neither to assist nor to resist motion. The
opposite hand palpates the adductor mass on the inner aspect of the proximal thigh.
In the supine test position for Grades 2, 1, and 0, the weight of the opposite limb
stabilizes the pelvis, so there is no need for manual stabilization of the non-test hip.
TEST Patient adducts hip without rotation. Toes stay pointed toward the ceiling
INSTRUCTION TO PATIENT Bring your leg in toward the other one.
GRADE 1 & 0
POSITION OF PATIENT Supine position
INSTRUCTION TO THERAPIST Stand on side of test limb. One hand supports the limb under the ankle. The other hand
palpates the adductor mass on the proximal medial thigh
TEST Patient attempts to adduct hip.
INSTRUCTION TO PATIENT Try to bring your leg in
GRADING Grade 1: Palpable contraction, no limb movement.

Grade 0: No discernable palpable contraction
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HIP EXTERNAL ROTATION

GRADE 5, 4 & 3
(Trunk may be supported by placing hands flat or fisted at sides of chair or table
INSTRUCTION TO Sit on a low stool or kneel beside limb to be tested. Ask the patient to turn the leg
THERAPIST in. If sufficient range is present, position leg in mid position between internal and
external rotation. Place the hand providing resistance on the medial aspect of the
ankle just above the malleolus. The other hand, which will offer counter-pressure,
is contoured over the lateral aspect of the distal thigh just above the knee.
Stabilization is provided in a medially directed force at the knee counteracting the
resistance provided at the ankle. The two forces are applied in counter-directions
for this rotary motion
TEST Patient externally rotates the hip.
INSTRUCTION TO PATIENT Don't let me turn your leg out
GRADING Grade 5: Holds test position in midrange against maximal resistance.

Grade 4: Holds test position in midrange against strong to moderate resistance.
Grade 3: Able to complete full range of motion with mild to no resistance
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HIP - MMT
GRADE 2: Completes External Rotation Range Of Motion. As The Hip Rolls Past The Midline, Minimal
Resistance Can Be Offered To Offset The Assistance Of Gravity.
POSITION OF PATIENT Supine. Test limb is in internal rotation
INSTRUCTION TO Stand at side of limb to be tested. The therapist may need to support the limb in
THERAPIST internal rotation because gravity tends to pull the limb into external rotation.
TEST Patient externally rotates hip in available range of motion. One hand may be used
to maintain pelvic alignment at lateral hip.
INSTRUCTION TO PATIENT Roll your leg out
GRADE 1 & 0
POSITION OF PATIENT Supine with test limb placed in internal rotation
INSTRUCTION TO THERAPIST Stand at side of limb to be tested.
TEST Patient attempts to externally rotate hip.
INSTRUCTION TO PATIENT Try to roll your leg out
GRADING The external rotator muscles, except for the gluteus maximus, are not palpable. If
there is any discernable movement (contractile activity), a grade of 1 should be
given; otherwise, a grade of 0 is assigned on the principle that whenever uncertainty
exists, the lesser grade should be awarded.
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HIP INTERNAL ROTATION

GRADE 5,4 & 3
INSTRUCTION TO Sit or kneel in front of patient. Ask the patient to move leg out, away from the other
THERAPIST leg while maintaining hip stabilization. If sufficient range is present, position leg in
mid position between internal and external rotation. Place the hand providing
resistance on the lateral surface of the ankle just above the malleolus. The other
hand, which offers counter-pressure, is contoured over the medial surface of the
distal thigh just above the knee. Stabilization is provided in a medially directed force
at the knee counteracting the lateral resistance provided at the ankle. Give
resistance in a medially directed force at the ankle.
TEST The limb should be placed in mid-range of hip rotation for best results

Grade 3: Able to complete full range of motion with mild to no resistance
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GRADE 2: Holds Test Position. As The Hip Rolls Inward Past The Midline, Minimal Resistance Can Be
Offered To Off Set The Assistance Of Gravity
POSITION OF PATIENT Supine. Test limb in partial external rotation
INSTRUCTION TO Stand next to test leg. Palpate the gluteus medius proximal to the greater trochanter
THERAPIST and the tensor fasciae latae over the anterolateral hip below the ASIS.
TEST Patient internally rotates hip through available range
INSTRUCTION TO PATIENT Roll your leg in toward the other one
GRADE 1 & 0
POSITION OF PATIENT Patient supine with test limb placed in external rotation
INSTRUCTION TO THERAPIST Stand next to test leg.
TEST Patient attempts to internally rotate hip. One hand is used to palpate the gluteus
medius
INSTRUCTION TO PATIENT Try to roll your leg in
GRADING Grade 1: Palpable contractile activity in either or both muscles.

Grade 0: No discernable contractile activity
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KNEE - MMT
KNEE FLEXION
GRADE 5,4 & 3
POSITION OF PATIENT Prone with knee flexed to 45°. Leg is in external rotation (toes pointing laterally).
INSTRUCTION TO Therapist resists knee flexion at the ankle using a downward and inward force
THERAPIST
TEST Patient flexes knee, maintaining leg in external rotation (heel away from therapist,
toes pointing toward therapist

Grade 3: Patient completes full range of motion without external resistance
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GRADE 2: Completes Available Range Of Motion In Side-Lying Position, With Gravity Minimized
POSITION OF PATIENT Side-lying with test limb (uppermost limb) supported by therapist or resting on
suitable height stool. Lower limb flexed for stability
INSTRUCTION TO THERAPIST Stand behind patient at knee level. One arm is used to cradle thigh, providing hand
support at medial side of knee. Other hand supports the leg at the ankle just above
the malleolus
TEST Patient flexes knee through available range of motion
INSTRUCTION TO PATIENT Bend your knee
GRADE 1 & 0
POSITION OF PATIENT Prone. Limbs are straight with toes extending over end of table. Knee is partially
flexed and supported at ankle by therapist
INSTRUCTION TO Stand next to test limb at knee level.

THERAPIST
TEST Patient attempts to flex knee.
INSTRUCTION TO PATIENT Try to bend your knee
GRADING Grade 1: Tendons become prominent, but no visible movement occurs.

Grade 0: No discernable contraction of the muscles; tendons do not stand out
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KNEE EXTENSION
GRADE 5,4 & 3
POSITION OF PATIENT Short sitting. Place a towel roll under the patient's distal thigh for comfort. The
patient's hands rest on the table on either side of the body for stability or may grasp
the table edge. The patient should be allowed to lean backward slightly to relieve
hamstring muscle tension. Do not allow the patient to hyperextend the knee because
this may lock the knee into position, thus masking weakness.
INSTRUCTION TO Stand at side of limb to be tested. Ask the patient to straighten the knee. If sufficient
THERAPIST range is present, position the knee in approximately 15° of knee flexion. Place the
palm of the hand providing resistance over the anterior surface of the distal leg just
above the ankle, using a straight arm technique because of the potential strength of
these muscles. For Grades 5 and 4, resistance is applied in a downward direction
toward the floor
TEST Patient extends knee through available range of motion but not beyond 0
INSTRUCTION TO PATIENT Hold it! Don't let me bend it
GRADING Grade 5: Holds test position against maximal resistance. The therapist should not be
able to break the Grade 5 knee extensors.
Grade 3: Completes available range, including the last
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GRADE 2: Completes Available Range Of Motion
POSITION OF PATIENT Side-lying with test limb uppermost. Lowermost limb may be flexed for stability.
Limb to be tested is held in about 90° of knee flexion. The hip should be in full
extension.
INSTRUCTION TO Stand behind patient at knee level. One arm cradles the test limb around the thigh
THERAPIST with the hand supporting the underside of the knee; alternatively, the test limb may
be placed on a powder board. The other hand holds the leg just above the malleolus.
TEST Patient extends knee through the available range of motion. The therapist
supporting the limb provides neither assistance nor resistance to the patient's
voluntary movement.
INSTRUCTION TO PATIENT Straighten your knee
GRADE 1 & 0
POSITION OF PATIENT Supine position
INSTRUCTION TO THERAPIST Stand next to limb to be tested at knee level. Hand used for palpation should be on
the quadriceps tendon just above the knee with the tendon “held” gently between
the thumb and fingers. The therapist also may want to palpate the patellar tendon
just below the knee
TEST Patient attempts to extend knee
INSTRUCTION TO PATIENT Push the back of your knee down into the table.” OR “Tighten your kneecap
GRADING Grade 1: Contractile activity can be palpated in muscle through the tendon. No joint
movement occurs.
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ANKLE - MMT
ANKLE PLANTAR FLEXION

GRADE 5, 4 & 3
POSITION OF PATIENT Patient stands on limb to be tested with knee extended, facing a wall. Patient
is likely to need external support; thus, fingers can be placed on the wall,
above shoulder height. Alternatively, no more than one or two fingers should
be used on a table (or other horizontal surface).
INSTRUCTIONS TO THERAPIST Assess range of motion of the ankle to assure sufficient range is present.
Demonstrate heel rise to patient. Then stand or sit with a lateral view of test
limb to ascertain height of heel rise. Ask patient to lift heel while keeping
knee straight. If patient can clear the floor by 2 inches, ask the patient to
continue lifting the heel until the patient can no longer achieve 1 inch of rise.
This is when the test is terminated. Patient should not bear weight through
arms.
TEST Patient raises heel from floor consecutively through maximum available range
at a rate of one rise every 2 seconds until patient no longer achieves 50% of
initial plantar range.
INSTRUCTIONS TO PATIENT “Stand on one leg. Lift your heel. Now down. Repeat this as many times as
possible, lifting your heel as high as you can.” Repeat test for other limb, if
both are tested.
GRADING Grade 5: Patient successfully completes 25 heel rises through full range of
motion without a rest between rises. Twenty-five heel rises elicit
approximately 60% of the maximum electromyographic activity of the plantar
flexors. 11 In the current standardized tests that have been in use for many
years, 25 repetitions are the accepted norm. However, a more recent study
suggests that the average number of repetitions in the sample studied is less
than 25 repetitions. The therapist should be aware that strength deficits in
the plantar flexors are common, particularly with advancing age, and strength
deficits will affect the heel rise portion of the gait cycle and thus reduce gait
speed.
Grade 4: A grade of 4 is conferred when the patient completes between 2 and
24 heel rises of at least 50% of initial heel raise height at a consistent rate of
one rise every 2 seconds using correct form in all repetitions. Grade 3: Able to
hold body weight once in a heel up position, but unable to raise body weight
from neutral more than one time. If the patient cannot complete at least one
correct full-range heel rise in the standing position, the grade must be less
than 3. Regardless of the force of resistance in a non-standing position for any
reason, the patient must be given a grade of less than 3
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GRADE 2
POSITION OF PATIENT Prone with feet off end of table.
INSTRUCTIONS TO Stand at foot of patient. Ask patient to flex and extend ankle to assure sufficient
THERAPIST range is present. Hand giving resistance is placed against the plantar surface at the
level of the metatarsal heads with foot in 80° of dorsiflexion. These muscles are
capable of tremendous force, which is why a more stable point of resistance is
needed.
TEST Patient plantar flexes ankle against manual resistance.
GRADING Holds test position against maximal manual resistance. Because of the functional
strength of these muscles, the therapist should not expect to break the contraction in
a Grade 2 (prone) test.
GRADE 1 & 0
POSITION OF PATIENT Prone with feet off end of table.
INSTRUCTIONS TO Stand at end of table in front of foot to be tested. One hand palpates
THERAPIST gastrocnemius-soleus activity by monitoring tension in the Achilles tendon just
above the calcaneus. The muscle bellies of the two muscles also may be palpated.
TEST Patient attempts to plantar flex the ankle.
INSTRUCTIONS TO PATIENT “Point your toes down, like a ballet dancer.”
Grade 1: Able to move through partial range. Contractile activity may be palpated
GRADING in muscle bellies. The best location to palpate the gastrocnemius is at midcalf with
thumb and fingers on either side of the midline but above the soleus. Palpation of
the soleus is best done on the posterolateral surface of the distal calf. In most
people with calf strength of Grade 3 or better, the two muscles can be observed
and differentiated during plantar flexion testing because their definition is clear.
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ANKLE - MMT
ANKLE DORSIFLEXION
GRADE 5,4,3,2,1 & 0
POSITION OF PATIENT Supine. (Note: The authors recommend the supine position for this test,
rather than an anti-gravity position, because of the mechanical advantage it
affords the therapist when providing adequate resistance to this very strong
muscle.)
INSTRUCTIONS TO THERAPIST Stand at foot of patient with patient's heel resting on table. Ask patient to
bring the foot up and in, towards the body. If sufficient range exists, place
hand providing resistance on the medial aspect of the foot over the first ray.
Resistance is provided down and out. This is a strong muscle, so applying
resistance with the hand and flexed forearm can help provide enough
resistance for a valid test. Additionally, this position is not against gravity, so
this test should be graded stringently.
TEST Patient dorsiflexes ankle and inverts foot, keeping toes relaxed.
INSTRUCTIONS TO PATIENT “Bring your foot up and in. Hold it! Don't let me pull it down.”

Grade 3: Completes available range of motion without resistance.
Grade 2: Completes only a partial range of motion.
Grade 1: Therapist will be able to detect some contractile activity in the
muscle, or the tendon will “stand out.” There is no joint movement. Palpate
the tendon of the tibialis anterior on the anteromedial aspect of the ankle at
about the level of the malleoli. Alternatively, palpate the muscle for
contractile activity over its belly just lateral to the “shin”.
170
ANKLE - MMT
FOOT INVERSION
GRADE 5,4,3 & 2
POSITION OF PATIENT Sitting with ankle in slight plantar flexion.
INSTRUCTIONS TO THERAPIST Sit on low stool in front of patient or on side of test limb (anti-gravity
position). With patient's heel resting on therapist's thigh, ask the patient
to move the foot down and in. Perform this movement passively if
needed. If sufficient active range exists, place stabilizing hand on the
posterior calf just above the malleoli. The majority of resistance is
toward forefoot abduction (up and out direction). Hand providing
resistance is placed on the foot with the hand providing resistance over
the medial side of the forefoot.
TEST Patient inverts foot through available range of motion.
INSTRUCTIONS TO PATIENT “Turn your foot down and in. Hold it. Don't let me move it.”
GRADING Grade 5: The patient holds the test position against maximal resistance.
Grade 4: The patient holds the test position against strong to moderate
resistance.
Grade 3: The patient will be able to invert the foot through the full
available range of motion.
Grade 2: The patient will be able to complete only partial range of
motion.
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GRADE 1 & 0
POSITION OF PATIENT Sitting or supine.
INSTRUCTIONS TO THERAPIST Sit on low stool or stand in front of patient. Palpate tendon of the tibialis
posterior between the medial malleolus and the navicular bone.
Alternatively, palpate tendon above the malleolus.
TEST Patient attempts to invert foot.
INSTRUCTIONS TO PATIENT “Try to turn your foot down and in.”
GRADING Grade 1: The tibialis posterior tendon will stand out if there is contractile
activity in the muscle. If palpable activity occurs in the absence of
movement, the grade is 1.
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FOOT EVERSION
GRADE 5,4,3 & 2
POSITION OF PATIENT Sitting with ankle in neutral position (midway between dorsiflexion and
plantar flexion). Test also may be performed with patient supine.
INSTRUCTIONS TO THERAPIST Sit on low stool in front of patient or stand at end of table if patient is
supine. Ask patient to turn foot down and out (eversion). If sufficient
range is present, place stabilizing hand at the ankle just above the
malleoli. Take care not to squeeze the distal tibia. Hand providing
resistance is contoured around the dorsum and lateral border of the
forefoot. Resistance is directed toward inversion and slight dorsiflexion
(up and in).
TEST Patient everts foot with depression of first metatarsal head and some
plantar flexion.
INSTRUCTIONS TO PATIENT “Turn your foot down and out. Hold it! Don't let me move it in.”

Grade 4: Patient holds test position against strong to moderate
resistance.
Grade 3: Patient completes available range of eversion but without
resistance
Grade 2: Patient will be able to complete only a partial range of eversion
motion.
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GRADE 1 & 0
POSITION OF PATIENT Short sitting or supine.
INSTRUCTIONS TO THERAPIST Sit on low stool or stand at end of table. To palpate the fibularis longus,
place fingers on the lateral leg over the upper one-third just below the
head of the fibula. The tendon of the muscle can be felt posterior to the
lateral malleolus but behind the tendon of the fibularis brevis. To palpate
the tendon of the fibularis brevis, place index finger over the tendon as it
comes forward from behind the lateral malleolus, proximal to the base of
the fifth metatarsal. The belly of the fibularis brevis can be palpated on
the lateral surface of the distal leg over the fibula.
GRADING Grade 1: Palpation will reveal contractile activity in either or both

muscles, which may cause the tendon to stand out. No motion occurs.
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TOES - MMT
HALLUX MP FLEXION
GRADE 5,4,3,2,1 & 0
POSITION OF PATIENT Sitting (alternate position: supine) with legs hanging over edge of table.
Ankle is in neutral position (midway between dorsiflexion and plantar
flexion).
INSTRUCTIONS TO THERAPIST Sit on low stool in front of patient. Alternate position: stand at side of
table near patient's foot. Test foot rests on therapist's lap. Ask the
patient to bend the big toe over finger. If sufficient range is present,
place stabilizing hand over the dorsum of the foot just below the ankle.
The index finger of the other hand is placed beneath the proximal
phalanx of the great toe. Alternatively, the tip of the finger (with very
short fingernails) is placed up under the proximal phalanx.
TEST Patient flexes great toe.
INSTRUCTIONS TO PATIENT “Bend your big toe over my finger. Hold it. Don't let me straighten it.”
GRADING Grade 5: Patient holds position against strong resistance.

Grade 4: Patient holds test position against moderate to mild resistance.
Grade 3: Patient completes available range of metatarsophalangeal (MP)
flexion of the great toe without resistance.
Grade 2: Patient completes only partial range of motion.
Grade 1: Therapist may note contractile activity but no toe motion.
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TOES - MMT
TOE MP FLEXION
GRADE 5,4,3,2,1 & 0
POSITION OF PATIENT Sitting with foot on therapist's lap. Alternate position: supine. Ankle is in
neutral (midway between dorsiflexion and plantar flexion).
INSTRUCTIONS TO THERAPIST Sit on low stool in front of patient. Alternate position: stand next to table
beside test foot. Ask the patient to bend the toes over therapist's fingers. If
sufficient range is present, place stabilizing hand over the dorsum of the
foot (as in test for flexion of the hallux). The index finger of the other hand is
placed under the MP joints of the four lateral toes to provide resistance to
flexion.
TEST Patient flexes lateral four toes at the MP joints, keeping the interphalangeal
(IP) joints neutral.
INSTRUCTIONS TO PATIENT “Bend your toes over my finger. Hold it!”
GRADING Grade 5: Patient holds position against strong resistance.

Grade 4: Patient holds test position against moderate to mild resistance.
Grade 3: Patient completes available range of metatarsophalangeal (MP)
flexion of the great toe without resistance.
Grade 2: Patient completes only partial range of motion.
Grade 1: Therapist may note contractile activity but no toe motion. Grade 0:
No discernable contractile activity.
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TOES - MMT
HALLUX AND TOE DIP AND PIP FLEXION

GRADE 5,4,3,2,1 & 0
POSITION OF PATIENT Sitting with foot on therapist's lap, or supine.
INSTRUCTIONS TO THERAPIST Sit on a short stool in front of the patient or stand at the side of the table
near the patient's foot. Ask the patient to curl toes (or big toe). If sufficient
range is present, place stabilizing hand over the anterior foot with the
fingers placed across the dorsum of the foot and the thumb under the
proximal phalanges (PIP) or distal phalanges (DIP) or under the IP of the
hallux. The other hand applies resistance using the four fingers or the
thumb under the middle phalanges (for the IP test), under the distal
phalanges for the DIP test, and with the index finger under the distal
phalanx of the hallux. Resistance will be minimal.
TEST Patient flexes the toes or hallux
INSTRUCTIONS TO PATIENT “Curl your toes; hold it. Curl your big toe and hold it.”
GRADING Grade 5 and Grade 4: Patient holds test position of toes and then hallux;
resistance in both tests may be minimal.
Grade 3 and Grade 2: Patient holds test position without resistance (Grade
3) or completes only a partial range (Grade 2).
Grade 1 and Grade 0: Minimal to no palpable contractile activity occurs.
Tendon of the flexor hallucis longus may be palpated on the plantar
surface of the proximal phalanx of the great toe.
177
TOES - MMT
HALLUX AND TOE DIP AND PIP EXTENSION

GRADE 5,4,3,2,1 & 0
POSITION OF PATIENT Sitting with foot on therapist's lap. Alternate position: supine. Ankle in
neutral (midway between plantar flexion and dorsiflexion).
INSTRUCTIONS TO THERAPIST Sit on low stool in front of patient, or stand beside table near the patient's
foot. Ask patient to straighten big toe or all the toes.
Lateral Toes: One hand stabilizes the metatarsals with the fingers on the
plantar surface and the thumb on the dorsum of the foot. The other hand
is used to give resistance with the thumb placed over the dorsal surface of
the proximal phalanges of the toes.
Hallux: Stabilize the metatarsal area by contouring the hand around the
plantar surface of the foot with the thumb curving around to the base of
the hallux. The other hand stabilizes the foot at the heel. For resistance,
place thumb over the MP joint or over the IP joint.
TEST Patient extends lateral four toes or extends hallux.
INSTRUCTIONS TO PATIENT “Straighten your big toe. Hold it.” OR “Straighten your toes and hold it.”
GRADING Grade 5 and Grade 4: Patient can extend the toes fully against variable
resistance (which may be small).
Grade 3 and Grade 2: Patient can complete range of motion with no
resistance (Grade 3) or can complete a partial range of motion (Grade 2).
Grade 1 and Grade 0: Tendons of the extensor digitorum longus can be
palpated or observed over dorsum of metatarsals. Tendon of the extensor
digitorum brevis often can be palpated on the lateral side of the dorsum of
the foot just in front of the malleolus. Palpable contractile activity is a
Grade 1; no discernable palpable contractile activity is a Grade 0.
178
TRUE & APPARENT LEG LENGTH TEST
PURPOSE To assess for leg length discrepancies.
PATIENT POSITION The patient is supine lying
EXAMINER POSITION The examiner stands adjacent to the limb to be tested
TRUE LEG LENGTH Using a flexible tape measure, the examiner measures the distance from the ASIS to the
PROCEDURE medial or lateral malleolus on the same side. The measurement is repeated on the other
side, and the results are compared
APPARENT LEG LENGTH Using a flexible tape measure, the examiner measures the distance from the umbilicus to
PROCEDURE the medial or lateral malleolus on the same side. The measurement is repeated on the other
side, and the results are compared
INDICATION OF A difference of 1 to 1.5 cm (0.4 to 0.6 inch) is considered normal. The examiner should keep
POSITIVE TEST in mind, however, that leg length differences within this range also may be pathological if
symptoms result
CLINICAL NOTES • Nutation (backward rotation) of the ilium on the sacrum results in a decrease in leg
(TRUE LENGTH) length, as does counternutation (anterior rotation) on the opposite side.
• If the iliac bone on one side is lower, the leg on that side usually is longer
179
GIRTH MEASUREMENT
Girths are circumference measures at standard anatomical sites around the body. It is measured with a tape and can be
used in determining body size, composition and to monitor changes in these parameters.
Head It is the maximum circumference of head when

tape is located superior to eyebrow and
positioned at back of the head.
Neck Tape is located perpendicular to the long axis

of the neck superior to larynx
Axilla /
upper arm
Mid-arm The measurement is taken around the mid

upper arm. This measurement is also known as
arm circumference, upper arm circumference,
biceps circumference or relaxed arm girth.
180
Elbow Measure right across cubital fossa
Mid The measurement is taken around upper third

Forearm of forearm and it is the maximal girth of the
forearm.
• 8cm from cubital fossa
Wrist It is the perimeter of wrist taken distal to the

styloid process of the ulna and radius.
Palm • length: measured from the tip of the

longest finger to the crease under the
palm.
• breadth: measured across the widest
area where the fingers join the palm.
• circumference: measured around the
palm of your dominant hand, just
below the knuckles, excluding the
thumb.
181
Chest Chest should be bare. The subject must stand
in normal erect posture. The measurement is
taken from under the axilla and around the
chest, passing by xyphoid process:
• Just below the axillary fold.

• At the level of nipple.
• At xyphoid process.
Waist Measurement is taken from the narrowest

part of the torso that is halfway between the
12th rib and the iliac crest. The subject should
stand comfortably erect with hands by the side
and must not be contracting any muscles.
Abdominal It is the perimeter distance around the torso at

the level of umbilicus. Abdominal muscles
should not be contracted.
182
Gluteal Subject stands with minimal clothing, with feet
together and no intentional muscle
contraction. Tape is placed compressing
overlying clothing but not the soft tissue. It is
the perimeter at level of greater posterior
protuberance of gluteals. It is also known as
buttock or hip circumference.
Thigh It is the circumference of the thigh measured

when subject stands with legs slightly parted.
Weight must be equally distributed on both
the legs.
• Proximal or Upper Thigh Girth: About

1cm below the gluteal fold and
horizontal to the long axis of femur.
• Mid-Thigh: Measurement is taken
from inguinal crease to the proximal
border of patella.
• Distal Thigh: It is measured from just
proximal to femoral condyles.
• tibial tubercle 20cm proximal
Knee Measurement is taken around the knee at

level of patella for joint swelling and 5cm
above and below the border of patella for
muscle wasting.
183
Calf Measurement is taken around the bulky area
of calf.
• tibial tubercle 15cm distal
Ankle It is the minimum circumference of the lower

leg, just proximal to malleoli.
Foot Arch circumference is the length from a point

on top of the foot, down around and over the
highest point in the foot arch, and back to the
same point on the top of the foot.
184
CERVICAL- SPECIAL TEST
FORAMINAL COMPRESSION TEST (SPURLING’S TEST)
PURPOSE The foraminal compression test is performed if the patient history includes a complaint of nerve
root symptoms, but these symptoms are diminished or absent at the time of examination. The
test is designed to provoke symptoms. It is especially useful if the patient has complained of
radicular symptoms on neck movement, especially side flexion. (Cervical radiculopathy)
PATIENT POSITION The patient is sitting
EXAMINER POSITION The examiner stands slightly behind the patient
TEST PROCEDURE The patient bends or side-flexes the head to the unaffected side first and then to the affected
side. The examiner places both hands on the top of the patient’s head. The examiner then
carefully presses straight down on the head, noting any manifestation of or change in signs and
symptoms
INDICATIONS OF A A positive test result is indicated if pain radiates into the arm (dermatome) during compression
POSITIVE TEST to the side to which the head is side flexed. The pain indicates pressure on a nerve root (cervical
radiculitis). Neck pain with no radiation into the shoulder or arm does not constitute a positive
test result.
CLINICAL • Bradley et al advocated doing this test in three stages, each of which is increasingly
NOTES/CAUTIONS provocative; if symptoms are produced, the examiner does not proceed to the next
stage. The first stage involves compression with the head in neutral. The second stage
involves compression with the head in extension. The final stage involves compression
with the head in extension and rotation to the unaffected side. If this is negative,
compression with the head in extension and rotation to the affected side is tested.
• Radiculitis implies pain in the dermatomal distribution of the affected nerve root.
• If pain is felt in the side opposite that to which the head is taken, this is called a reverse
Spurling’s sign. It indicates muscle spasm in conditions such as tension myalgia.
• Bilateral symptoms may indicate a myelopathy.
• A common clinical mistake is to pull the head into further rotation and extension when
loading the spine. Instead, the force should be compressive with no further rotation or
extension occurring.
The patient flexes the head

to one side and the examiner
presses straight down on the
head
185
JACKSON’S COMPRESSION TEST
PURPOSE This test is designed to provoke symptoms and is especially useful if the patient has
complained of radicular symptoms with neck rotation movements
EXAMINER POSITION The examiner stands slightly behind the patient
TEST PROCEDURE The patient rotates the head to the uninvolved side first. The examiner then places both hands
on top of the patient’s head and carefully presses straight down on the head. The test is
repeated with the head rotated to the involved side
INDICATIONS OF A The test result is positive if pain radiates into the arm, indicating pressure on a nerve root. The
POSITIVE TEST pain distribution (dermatome) can give some indication of which nerve root is affected
CLINICAL • This test is a modification of the foraminal compression test (Spurling’s test)
NOTES/CAUTIONS
186
DISTRACTION TEST
PURPOSE The distraction test is used to assess for cervical involvement in patients whose history
includes a complaint of radicular symptoms and who demonstrate radicular signs (e.g., pain
into a dermatome, a weak myotome) during the examination. It also may be used to help
differentiate nerve root pain (cervical spine) and shoulder pain.
EXAMINER POSITION The examiner stands immediately adjacent to the patient
TEST PROCEDURE The examiner places one hand under the patient’s chin and the other hand under the occiput.
The examiner then slowly lifts the patient’s head, in effect applying traction to the cervical
spine.
INDICATIONS OF A The test result is classified as positive if the pain is relieved or diminished when the head is
POSITIVE TEST lifted; this indicates that the pressure on nerve roots has been relieved.
CLINICAL • If the patient abducts the arms while traction is applied, the symptoms in the
NOTES/CAUTIONS shoulder often are further relieved or lessened, especially if the C4 or C5 nerve roots
are involved. Nevertheless, the test findings still indicate nerve root pressure in the
cervical spine, not a pathological condition of the shoulder.
• Increased pain on distraction may be the result of muscle spasm, ligament sprain,
muscle strain, dural irritability, or disc herniation.
• It may take a few minutes for the neurological symptoms to change.
187
VERTEBRAL ARTERY (CERVICAL QUADRANT) TEST
PURPOSE To determine the ability of the vertebral arteries to provide adequate blood flow to cortical
regions of the brain when placed in certain cervical positions.
• Vertebrobasilar ischemia
• Vertebral artery insufficiency
• Vertebrobasilar circulatory disorders
PATIENT POSITION The patient is supine.
EXAMINER The examiner is positioned at the head of the table

POSITION
TEST PROCEDURE If the patient history includes a complaint of arterial symptoms, the movements that are least
likely to cause the symptoms are tested first. The examiner passively takes the patient’s head and
neck into extension and side flexion. After this movement has been achieved, the examiner
rotates the patient’s neck to the same side and holds it for approximately 30 seconds unless
symptoms occur. Most commonly the test is done before mobilizing the cervical spine. In this
case, the examiner positions the patient in the position to be mobilized, holding the end range
for up to 30 seconds
INDICATIONS OF A With a positive test result, referring symptoms (see Relevant Signs and Symptoms in the
POSITIVE TEST preceding section) are provoked if the opposite artery is affected. This test must be done with
care. If dizziness or nystagmus occurs, the test is stopped immediately, because this is an
indication that the vertebral arteries are being compressed and compromised
CLINICAL • The DeKleyn-Nieuwenhuyse test performs a similar function but involves extension and
NOTES/CAUTIONS rotation rather than extension and side flexion. Both tests may be used to assess nerve
root compression in the lower cervical spine, but the symptoms will be different.
• To test the upper cervical spine, the examiner “pokes” the patient’s chin and follows with
extension, side flexion, and rotation of the cervical spine and holds the position for 30
seconds or until symptoms appear.
• The vertebral artery (cervical quadrant) test is similar to Spurling’s test for nerve root
compression. The chief difference is that no compressive force is placed through the spine
when the examiner is assessing blood fl ow.
The examiner
passively moves
the patient’s
head and neck
into extension
and side flexion
(1) and then
rotation (2),
holding for 30
seconds.
188
UPPER LIMB TENSION TESTS (ULTTs) (Brachial Plexus Tension or Elvey Test)
PURPOSE The upper limb tension tests (ULTTs) are designed to put stress or tension on the neurological
structures of the upper limb, although stress actually is put on all the tissues of the upper limb.
With these tests, the examiner looks for exacerbation of the patient’s symptoms. The
neurological tissue is differentiated by what is defined as sensitizing tests (e.g., neck side
flexion test). Modification of the position of the shoulder, elbow, forearm, wrist, and fingers
places greater stress on specific nerves (nerve bias). Limitations in upper extremity nerve
mobility may occur because of trauma or degeneration anywhere along the course of the spinal
cord, nerve roots, or peripheral nerves.
• Bilateral symptoms indicate a myelopathy (upper motor neuron lesion),

• unilateral symptoms indicate radiculopathy (lower motor neuron lesion).
PATIENT POSITION The patient lies supine on the treatment table. The head should be placed in a neutral position
with no pillow beneath the head or knees. The legs should not be allowed to cross
EXAMINER POSITION The examiner is positioned directly adjacent to the shoulder being tested.
TEST PROCEDURE The examiner decides which of the four tests would be relevant based on the patient’s
Symptoms. In each test, the unaffected side is tested first. The examiner positions the shoulder
first, followed by the forearm, wrist, fingers, and, last, because of its large ROM, the elbow.
This allows easier measurement of the available ROM, which can change as the condition
improves or worsens. Each phase is added until neurological symptoms are produced. Once
symptoms have been produced, the location of the symptoms is noted and the test is stopped.
To further “sensitize” the test, side flexion of the cervical spine may be performed to further
increase symptoms.
When the shoulder is positioned, it is essential to maintain shoulder depression
throughout the test so that the shoulder girdle remains depressed even with abduction. If the
shoulder is not held depressed, the test is less likely be effective. While the shoulder girdle is
depressed, the glenohumeral joint is taken to the appropriate abduction position (110° or 10°,
depending on the test), and the forearm, wrist, and fingers are taken to their appropriate end-
of-range position. For example, for most of the upper limb tension tests, the
fingers are extended and the wrist is in full extension, the forearm is supinated, and the elbow
is extended. If symptoms are minimal or no symptoms appear, the head and cervical spine are
taken into contralateral side flexion (sensitizing tests).
189
INDICATIONS OF A A positive test result is indicated by neurological symptoms along the course of the affected
POSITIVE TEST nerve. Because numerous structures are stressed by the test, the result should be considered
positive only if
1. the patient’s symptoms are reproduced
2. a difference is noted between the unaffected side and the symptom side
3. the symptoms are altered by the sensitizing test (i.e., neck movements).
CLINICAL • These stress tests are contraindicated if the neurological signs are worsening or in the
NOTES/CAUTIONS acute phase when the patient history is taken.
• During tension testing, symptoms are more easily aggravated with upper limb testing
than with lower limb testing.
• The elbow position often is not performed until last, because the large elbow ROM is
easiest to measure if the available range is being recorded to show change in the
condition over time.
• The tests are designed to stress tissues. In addition to the neurological tissues, they
stress some contractile and inert tissues. Differentiation among the types of tissues
depends on the signs and symptoms manifested.
ULTT 1
ULTT 2
ULTT 4
ULTT 3
190
ADSON’S TEST (Thoracic Outlet Syndrome)
PURPOSE is designed to assess anterior scalene syndrome, one of the four forms of thoracic outlet
syndrome. Given that anterior scalene syndrome is a neurovascular entrapment syndrome
caused by tight anterior and middle scalenes, the idea is to stretch and pull these muscles taut,
causing them to further compress the brachial plexus and subclavian artery, which run between
them.
PATIENT POSITION The test can be performed with the patient in either sitting or standing with their elbow in full
extension
EXAMINER POSITION The examiner stands behind the patient
TEST PROCEDURE The arm of the standing (or seated) patient is abducted 30 degrees at the shoulder and
maximally extended. The radial pulse is palpated and the examiner grasps the patient's wrist.
The patient then extends the neck and turns the head toward the symptomatic shoulder and is
asked to take a deep breath and hold it. The quality of the radial pulse is evaluated in
comparison to the pulse taken while the arm is resting at the patient's side. Some clinicians
have patients turn their head away from the side tested in a modified test.
INDICATIONS OF A The test is positive if there is a marked decrease, or disappearance, of the radial pulse. It is
POSITIVE TEST important to check the patient's radial pulse on the other arm to recognize the patient's normal
pulse. A positive test should be compared with the non-symptomatic side
CLINICAL NOTE • A positive finding occurs if the strength (not a change in the speed of the pulse) of the
radial pulse weakens, indicating compression of the subclavian artery between the
scalenes. Compression of the subclavian artery is used as an indicator of brachial plexus
compression, because one can assume that if the subclavian artery is being
compressed, then the brachial plexus is also being compressed. If the client experiences
the referral of sensory symptoms such as pain, tingling, or numbness into the upper
extremity during this test, this is also considered a positive finding and indicates direct
compression of the brachial plexus between the anterior and middle scalenes. Local
pain in the neck is not a positive finding.
• To further elicit a positive finding, the client may be asked to take in a deep breath and
hold it. Because the scalenes are muscles of inspiration, this causes them to contract
as they are being stretched, further increasing their tension and the possibility that
they will compress the neurovascular structures located between them. However,
taking in a deep breath could also increase symptoms from costoclavicular syndrome
and/or pectoralis minor syndrome forms of TOS, so taking in a deep breath could create
a false positive for anterior scalene syndrome.
191
ALLEN TEST (Thoracic Outlet Syndrome)

PURPOSE test done during the examination of the shoulder for the presence of Thoracic Outlet Syndrome
• Subclavian artery
• axillary artery
PATIENT POSITION The test is best performed with the patient in a relaxed sitting position
EXAMINER POSITION The examiner stands behind the patient
TEST PROCEDURE Patient arm to be tested should be in 90 degrees of abduction and full external rotation. The
elbow should be in 90 degrees of flexion. The patient rotates the head to the side opposite the
arm being tested while the examiner palpates the radial pulse. The examiner can also palpate
the radial pulse continuously as the patient moves from having the arm in a neutral position as
the patient moves the arm and head into the end position of the test.
INDICATIONS OF A The test is considered positive if the radial pulse becomes diminished or absent after rotation
POSITIVE TEST of the head.
192
SHOULDER – SPECIAL TEST
LOAD AND SHIFT TEST (ANTERIOR)
PURPOSE assess the anterior stability and mobility of the glenohumeral joint.
PATIENT The patient may be tested in the seated or the supine lying position. If tested in sitting, the patient
POSITION should be tested with no back support and with the hand of the test arm resting on the thigh
EXAMINER The examiner stands or sits slightly behind the patient and stabilizes the shoulder with one hand
POSITION over the clavicle and scapula. With the other hand, the examiner grasps the head of the humerus
with the thumb over the posterior humeral head and the fingers over the anterior humeral head
TEST • The humerus is gently pushed into the glenoid to seat it properly in the glenoid fossa so that
PROCEDURE the humeral head sits in neutral. This is the “load" portion of the test, and this seating of
the humerus allows true translation to occur. If the load is not applied to put the head in
neutral, the amount of movement found will not indicate the true amount of translation,
and the end feel will be altered.
• Next, the humeral head is pushed anteriorly to test for anterior instability or posteriorly to
test for posterior instability, and the amount of translation is noted. This is the "shift”
portion of the test. The affected side and the normal side should be compared for
differences. Differences between the two sides and reproduction of symptoms often are
considered more important than the amount of movement obtained.
INDICATIONS Translation of 25% of the humeral head diameter or less anteriorly from the neutral position is
OF A POSITIVE considered normal.
TEST
Grade Descriptions
1 Up to 50% of humeral head translation, with the head riding up to the glenoid
rim and spontaneous reduction
2 anterior translation, the humeral head has more than 50% translation, and the
head feels as though it is riding over the glenoid rim, but it spontaneously
reduces
3 a dislocation with no spontaneous reduction
Shoulder dislocations/ subluxations/labral tears (type 2 instability) and general joint laxity (type 1
instability) are examples of pathological conditions that can be detected with this test.
A. Load and shift test with the

patient in the seated starting
position. Note that the
humerus first is loaded, or
"centered," in the glenoid. The
examiner then shifts the
humerus anteriorly.
B. The position of the examiner's
hands in relation to the bones of
the shoulder. Note that the
examiner's left thumb holds the
spine of the scapula for stability
while the fingers stabilize the
clavicle
193
A. Initial position for load and shift test for anterior instability of the
shoulder with the patient in the supine lying position. The
examiner grasps the patient’s upper arm with the finger’s
posterior. The examiner’s arm positions the patient's arm and
controls its rotation. The arm is placed in the plane of the scapula,
abducted 45° to 60°, and maintained in 0° of rotation. The
examiner's arm places an axial load on the patient's arm through
the humerus. The examiner's fingers then shift the humeral head
anteriorly and anteroinferiorly over the glenoid rim.
B. The second position for the load and shift test for anterior stability
is as described in A for the initial position, except that the arm is
progressively laterally rotated in 10°- to 20° increments while the
anterior translation force is alternatively applied and released.
C. The examiner compares the normal and abnormal shoulders for
this difference in translation with the humeral rotation. The
degree of rotation required to reduce the translation is an
indicator of the functional laxity of the anterior inferior capsular
ligaments
LOAD AND SHIFT TEST (POSTERIOR)

PURPOSE To assess the posterior stability and mobility of the glenohumeral joint
PATIENT POSITION The patient sits with no back support and with the hand of the test arm resting on the thigh
EXAMINER The examiner stands or sits slightly behind the patient.

POSITION
TEST PROCEDURE The examiner stabilizes the shoulder with one hand over the clavicle and scapula. The other
hand grasps the head of the humerus with the thumb over the posterior humeral head and the
fingers over the anterior humeral head (right shoulder). The humerus then is gently pushed into
the glenoid to seat it properly in the glenoid fossa so that the humeral head sits in neutral. This
is the load portion of the test; seating the humerus centers it in the glenoid so that the amount
of posterior motion from the neutral position can be determined. The examiner then pushes
the humeral head posteriorly, noting the amount of translation. This is the shift portion of the
test.
INDICATIONS OF A Differences between the two sides and reproduction of symptoms are considered more
POSITIVE TEST important than the amount of movement obtained. Posterior movement is often compared
with anterior translation. Normally, posterior movement is equal to or greater than anterior
movement
194
A. Load and shift test with the

patient in the seated starting
position. Note that the
humerus first is loaded, or
"centered," in the glenoid.
The examiner then shifts the
humerus posteriorly
B. The position of the
examiner's hands in relation
to the bones of the shoulder.
Note that the examiner's left
thumb holds the spine of the
scapula for stability.
Load and shift test for posterior instability of the

shoulder with the patient in the supine-lying
position. The patient is supine on the examining
table. The arm is brought into approximately 90° of
forward elevation in the plane of the scapula. A
posteriorly directed force is applied to the humerus
with the arm in varying degrees of lateral rotation
195
CRANK TEST (ANTERIOR APPREHENSION)
PURPOSE • To determine whether the humerus will sublux or dislocate anteriorly out of the glenoid.
• To differentiate between dislocation/subluxation (apprehension) and impingement
(pain).
PATIENT POSITION The patient lies supine with the test arm close to the edge of the plinth
EXAMINER The examiner stands at the patient’s side, facing the shoulder to be tested
POSITION
TEST PROCEDURE The examiner places one hand beneath the elbow to support the upper extremity. The other
hand grasps the wrist and is responsible for movement of the shoulder into lateral rotation. The
examiner flexes the elbow to 90°, abducts the arm to 90°, and laterally rotates the shoulder
slowly, watching for apprehension. The shoulder is laterally rotated as far as possible. The hand
supporting the elbow then is moved to the anterior aspect of the humeral head. The examiner
should maintain the amount of lateral rotation without releasing pressure
INDICATIONS OF A A positive test for anterior instability is if apprehension is presented by the patient or if the
POSITIVE TEST patient reports pain.
Cool et al (physiotutor.com) - Differential diagnosis: shoulder pain
• if anterior shoulder pain gives an indication of a subacromial impingement
• if posterior shoulder pain gives an indication of internal posterosuperior glenoid
impingement
• NOTE*: Apprehension Test is used in combination of Relocation Test & Release Test
196
RELOCATION & RELEASE/SURPRISE TEST (ANTERIOR APPREHENSION)
PURPOSE • To differentiate between glenohumeral instability, dislocation and subluxation and
impingement
• This test should be done following the apprehension test especially if anterior instability is
suspected.
PATIENT The patient lies supine with the test arm close to the edge of the plinth
POSITION
EXAMINER The examiner stands at the patient’s side, facing the shoulder to be tested
POSITION
TEST The therapist pre-positions the shoulder at 90° of abduction and maximal external rotation. The
PROCEDURE examiner grasps the subject’s wrist and hand with his/her distal hand while applying a posterior force
to the humeral head while externally rotating the shoulder. Assess whether the patient loses the
apprehension, the pain decreases, and farther lateral rotation is possible before the apprehension
returns.
• This relocation sometimes is referred to as the Fowler sign or Fowler test or the Jobe
relocation test. The hand pressure on the humeral head is removed, and symptoms
are reassessed. For most patients, lateral rotation should be released before the
posterior stress is released.
INDICATIONS The patient’s apprehension in the laterally rotated position disappears with the posterior translation.
OF A POSITIVE The examiner may find that lateral rotation will increase and apprehension will return as the lateral
TEST rotation increases. The test result is considered positive if pain decreases during the relocation
maneuver, even if the patient felt no apprehension. If the arm is released ("release/surprise" test) in
the new acquired range pain and forward translation of the head are noted as positive test results.
CLINICAL If pain rather than apprehension increases on lateral rotation, the problem is more likely to be
NOTES impingement, and impingement tests should be performed.
With the relocation test, lateral rotation should be released before the posterior stress is released.
• If the patient’s symptoms decrease or are eliminated during the relocation test, the diagnosis
is glenohumeral instability, subluxation, dislocation, or impingement.
• Hamner et al: have suggested that if a posterior internal impingement is suspected, the
relocation test should be done in 100° to 120° of abduction.
• In patients with a primary impingement, the relocation test does not alter the pain. A
decrease in posterior pain when the relocation test is done posteriorly is a positive test result
for posterior internal impingement.
If the joint is normal, translation of the humeral head in the glenoid is less than with other tests,
because the crank test takes the joint into the close packed position.
If the arm is released (anterior release, or “surprise,” test) in the newly acquired range of the
relocation test, a positive test result is indicated by pain and forward translation of the head.
• The release maneuver (surprise test) should be done with care, because it often causes
apprehension and distrust in the patient, and it could cause a dislocation
• The pain that results from the release maneuver (surprise test) may be caused by anterior
shoulder instability, a labral lesion (Bankart or SLAP lesion), or bicipital peri tenonitis or
tendinosus. Most often this pain is related to anterior instability, because it is temporarily
produced by the anterior translation. The surprise test also has been reported to cause pain
in older patients with a pathological condition of the rotator cuff and no instability.
197
Crank test together with relocation and release test
A. Abduction and lateral rotation (crank test)

B. Adduction and lateral rotation combined with anterior
translation of the humerus, which may cause anterior
subluxation or posterior joint pain
C. Abduction and lateral rotation combined with posterior
translation of humerus (relocation test)
D. Surprise/Release test
198
JERK TEST (POSTERIOR APPREHENSION)
PURPOSE Tests for posterior instability/ torn posterior or posteroinferior labrum
PATIENT The patient sit / high sit with the arm by the side and the shoulder muscles relaxed.
POSITION
EXAMINER The examiner stands adjacent to the test arm

POSITION
TEST PROCEDURE The examiner grasps the elbow with one hand and the scapular with the other and elevates the
patient’s arm to 90° of adduction and internal rotation. Following this the examiner provides an
axial compression load to the humerus through the elbow maintaining the horizontally abducted
position. The compression force is maintained as the examiner moves the arm into horizontal
adduction.
INDICATIONS OF A A positive result is indicated by a sharp pain in the shoulder and sudden clunk as the humeral head
POSITIVE TEST slides off the back of the glenoid. When the arm is returned to the original position, a second jerk
may be observed, that of the humeral head returning to the glenoid
199
STRESS TEST (POSTERIOR APPREHENSION)
PURPOSE To assess the posterior stability (dislocation) and mobility of the glenohumeral joint
PATIENT POSITION The patient lies supine with the test arm close to the edge of the plinth
EXAMINER The examiner stands directly adjacent and slightly distal to the shoulder on the side closest to the
POSITION test arm.
TEST PROCEDURE The examiner grasps the patient’s elbow with one hand and holds the distal wrist with the other.
The patient’s shoulder is forward-flexed in the plane of the scapula to 90°. A posterior force then
is applied to the elbow. While applying the axial load to the elbow, the examiner horizontally
adducts and medially rotates the arm. The examiner palpates the head of the humerus with one
hand while the other hand pushes the head of the humerus posteriorly.
INDICATIONS OF A A positive test result is indicated by a look of apprehension or alarm on the patient’s face and
POSITIVE TEST resistance to further motion or by reproduction of symptoms. In either case, if the humeral head
moves posteriorly more the 50% of its diameter, posterior instability is evident. The movement
may be accompanied by a clunk as the humeral head passes posteriorly over the glenoid rim
CLINICAL • The test may also be performed with the arm in 90° of abduction.
NOTES/CAUTIONS • The test also may be done with the patient in the sitting position, but the scapula must
be stabilized.
• It is important to note that a positive test result is not specific for any one pathological
condition; rather, it helps guide the clinician in the reasoning process. Instability may be
a contributing factor in the development of the ultimate pathological condition.
• Pagnani and Warren reported that a positive test result is more likely to be marked
by pain than by apprehension. They reported that with atraumatic multidirectional
(inferior) instability, the test result is negative.
200
SULCUS SIGN
To assess inferior laxity within the glenohumeral joint
PURPOSE
PATIENT The patient stands with the arm by the side and the shoulder muscles relaxed.
POSITION
EXAMINER The examiner stands beside the patient

POSITION
TEST The examiner stabilizes the scapula with one hand over the clavicle and scapula.
PROCEDURE With the other hand, the examiner grasps the patient’s arm above the elbow and
pulls the arm distally (applies traction), looking for a sulcus at the end of the
acromion
INDICATIONS The presence of a sulcus under the acromion indicates inferior instability or
OF A POSITIVE glenohumeral laxity. The sulcus sign may be graded by measuring from the inferior
TEST margin of the acromion to the humeral head
GRADING GRADES MEASURERMENT

+1 <l cm
+2 1-2 cm
+3 >2cm
Positive sign
201
SUPRASPINATUS TEST ("EMPTY CAN" OR JOBE TEST)
PURPOSE To assess for tears of the supraspinatus tendon or muscle or for neuropathy of
the suprascapular nerve
PATIENT POSITION The patient is standing or sitting
EXAMINER POSITION The examiner stands in front of the patient.
TEST PROCEDURE Each of the examiner’s hands grasps one of the patient’s wrists. The patient’s arms
are abducted to 90° (actively by the patient or passively by the examiner) with
neutral (no) rotation, and the examiner provides resistance to elevation. The
patient’s shoulders then are medially rotated and angled forward 30° (as if
emptying a can) so that the patient’s thumbs point toward the floor in the plane
of the scapula; the examiner provides resistance to this scapular plane movement.
The two sides are compared.
Some researchers contend that testing the arm with the thumb up ("full can") is
best for maximum contraction of the supraspinatus.
202
YERGASON'S TEST
PURPOSE To check the ability of the transverse humeral ligament to hold the biceps tendon in
the bicipital groove
PATIENT POSITION The patient is sitting or standing
EXAMINER POSITION The examiner stands adjacent to the test arm
TEST PROCEDURE The examiner places one hand beneath the upper arm for support and stability; the
other hand grasps the wrist and will deliver the resistance to the arm. The examiner
flexes the patient’s elbow to 90° and stabilizes the patient’s arm against the thorax
with the forearm pronated. The examiner resists patient forearm supination while
the patient also laterally rotates the arm against resistance. The two sides are
compared
INDICATIONS OF A If the examiner palpates the biceps tendon in the bicipital groove during the
POSITIVE TEST supination and lateral rotation movement, the tendon will be felt to "pop out" of the
groove if the transverse humeral ligament is torn. Tenderness in the bicipital groove
alone, without dislocation, may indicate bicipital paratenonitis/tendinosis
Starting point to end point
203
SPEED'S TEST (BICEPS OR STRAIGHT ARM TEST)
PURPOSE To test for a pathological condition of the bicep’s tendon (Long head of the biceps
injury) and secondarily to test for labral SLAP lesions or strains of the distal biceps
PATIENT The patient is sitting or standing.

POSITION
EXAMINER The examiner stands adjacent to the test arm

POSITION
TEST PROCEDURE The examiner places one hand beneath the upper arm for support and stability;
the other hand grasps the wrist and will deliver the resistance to the arm. The test
may be done statically or dynamically (concentrically or eccentrically).
• If the test is done statically, the examiner positions the patient in the
forward flexed position at the angle at which the patient complained of
symptoms. The patient is asked to hold the position isometrically while the
examiner provides a downward isometric force at the wrist.
• For dynamic testing, the examiner resists concentric shoulder forward
flexion by the patient while the patient’s forearm is first supinated and then
pronated, and the elbow is completely extended. The test also may be
performed by forward flexing the patient's arm to 90° or to the position of
the complaint and then asking the patient to resist an eccentric movement
into extension, first with the arm supinated and then with it pronated.
The two sides are compared.
INDICATIONS OF A positive test result is increased tenderness in the bicipital groove, especially with
A POSITIVE TEST the arm supinated; this indicates bicipital paratenonitis or tendinosis. If the injury is
at the bicep’s insertion, the muscle is weak, and elbow flexion strength should be
tested
CLINICAL • Speed's test has been reported to cause pain; therefore, the test result will
NOTES/CAUTIONS be positive if the patient has a SLAP (type II) lesion.
• If profound weakness is found on resisted supination, a severe second or
third degree (rupture) strain of the distal biceps should be suspected.
• During dynamic movement, the humerus moves over the tendon; the
tendon moves minimally
204
DROP ARM TEST
PURPOSE used to assess for full thickness rotator cuff tears, particularly of the
supraspinatus. This can be useful when diagnosing sub-acromial pain
syndrome (shoulder impingement) or to differentiate between shoulder and
rotator cuff pathologies.
PATIENT POSITION The patient is sitting or standing.
EXAMINER POSITION Stand behind the seated/standing patient
TEST PROCEDURE Passively abduct the patient's arm to 90° and full external rotation, while
supporting the arm at the elbow.
Release the elbow support and ask patient to slowly lower the arm back to
neutral
INDICATION OF The test is negative if the patient is able to control the lowering of the arm
POSTIVE TEST slowly and without their symptoms occurring.
It is a positive test if there is a sudden dropping of the arm or weakness in

maintaining arm position during the eccentric part of abduction, there may
also be pain present while lowering the arm, suggesting a full thickness tear
to the supraspinatus
205
HAWKINS-KENNEDY IMPINGEMENT TEST
PURPOSE designed to reduce the space between the inferior aspect of the acromial arch and the
superior surface of the humeral head. The additional compressive forces subsequently put
pressure on the supraspinatus tendon, the tendon of the long head of the biceps, the
subacromial bursa, and/or the coracoacromial ligament.
PATIENT POSITION The patient may be standing or sitting
EXAMINER POSITION The examiner stands adjacent and slightly to the front of the shoulder to be tested
TEST PROCEDURE The examiner puts one hand on the patient’s elbow for support and stabilization and grasps
the wrist with the other hand. The examiner fl exes the elbow to 90°, forward-fl exes the arm
to 90°, and then forcibly medially rotates the shoulder. This movement pushes the
supraspinatus tendon against the anterior surface of the coracoacromial ligament and
coracoid process
INDICATIONS OF A Pain is a positive test result for supraspinatus paratenonitis/tendinosis or secondary

POSITIVE TEST impingement often associated with scapular control problems
CLINICAL • The test also may be performed in different degrees of forward flexion (vertically
NOTES/CAUTIONS “circling the shoulder”) or horizontal adduction (horizontally circling the shoulder)
• McFarland et al. described the coracoid impingement sign, which is the same as the
Hawkins-Kennedy test but involves horizontally adducting the arm across the body
10° to 20° before doing the medial rotation. This is more likely to approximate the
lesser tuberosity of the humerus and the coracoid process
• The Yocum test is a modification of the Hawkins-Kennedy test in which the patient’s
hand is placed on the opposite shoulder and the examiner elevates the elbow
• Park et al. found that combining tests gave better results. They found that the
Hawkins-Kennedy test, the painful arc sign, and a positive result on the infraspinatus
test gave the best probability of detecting impingement, whereas the painful arc sign,
drop arm test, and infraspinatus test were best for detecting full-thickness rotator
cuff tears
Hawkins-Kennedy impingement test demonstrates

the impingement sign by forcibly medially rotating
the proximal humerus when the arm is forward
flexed to 90°.
206
NEER IMPINGEMENT TEST
PURPOSE designed to reduce the space between the inferior aspect of the acromial arch and the
superior surface of the humeral head. The compressive forces subsequently put pressure
on the supraspinatus tendon, the tendon of the long head of the biceps, the subacromial
bursa, and/or the coracoacromial ligament.
PATIENT POSITION The patient may be standing or sitting.
EXAMINER POSITION The examiner stands lateral and slightly behind the shoulder to be tested
TEST PROCEDURE The examiner places one hand over the patient’s clavicle and scapula to help stabilize the
scapula and the other hand around the wrist or forearm. The examiner passively and
forcibly elevates the arm fully in the scapular plane and then medially rotates the arm.
This passive stress causes the greater tuberosity to jam against the anteroinferior border
of the acromion
INDICATIONS OF A A positive test result is indicated by an expression of pain on the patient’s face
POSITIVE TEST
CLINICAL • A positive test result may indicate an overuse injury to the supraspinatus muscle
NOTES/CAUTIONS and sometimes to the bicep’s tendon; these injuries often are associated with
scapular control problems.
• If the test result is positive when the test is done with the arm laterally rotated,
the examiner should check the acromioclavicular joint (acromioclavicular
differentiation test).
A positive result for the Neer

impingement test is indicated by pain
and its resulting facial expression when
the arm is forcibly flexed forward by the
examiner, jamming the greater
tuberosity against the anteroinferior
surface of the acromion.
207
ELBOW – SPECIAL TEST
LIGAMENTOUS VALGUS INSTABILITY TEST
PURPOSE To assess the integrity of the medial (ulnar) collateral ligament of the elbow
PATIENT POSITION The patient may be tested while sitting, standing, or lying supine
EXAMINER The examiner stands in front of the test elbow

POSITION
TEST PROCEDURE To stabilize the patient’s arm, the examiner uses one hand to stabilize the elbow and places the
other hand above the wrist. While palpating the ligament with the fingers of the left hand as
illustrated, the examiner applies an abduction or a valgus force at the distal forearm with the
right hand to test the medial collateral ligament (valgus instability). The force is applied several
times with increasing pressure, and the examiner notes any alteration in pain, stability, or ROM.
INDICATIONS OF A The examiner should note any laxity, decreased mobility, soft end feel, or altered pain compared
POSITIVE TEST with the uninvolved elbow
CLINICAL NOTES • Regan and Morrey: recommend doing the valgus stress test with the humerus in full
lateral rotation.
Because the medial collateral ligament is multipennate and is designed to resist stress in multiple
directions, the examiner should test the elbow in varying degrees of extension and flexion to test
the various fibers of the ligament
208
LIGAMENTOUS VARUS INSTABILITY TEST
PURPOSE To assess the integrity of the lateral (radial) collateral ligament of the elbow
PATIENT The patient may be tested while sitting, standing, or lying supine
POSITION

POSITION
TEST PROCEDURE To stabilize the patient’s arm, the examiner uses the left hand as illustrated to stabilize the elbow
and places the other hand above the wrist. With the patient’s elbow slightly flexed (20° to 30°)
and stabilized, and while palpating the ligament with the fingers of the left hand, the examiner
applies an adduction or a varus force to the distal forearm to test the lateral collateral ligament
(varus instability). The force is applied several times with increasing pressure, and the examiner
notes any alteration in pain, stability, or ROM
INDICATIONS OF A Normally, the examiner feels the ligament tense when stress is applied. Excessive laxity or a soft
POSITIVE TEST end feel indicates injury to the ligament (first-, second-, or third-degree sprain) and, especially
with a third-degree sprain, may indicate posterolateral joint instability
CLINICAL NOTES • Regan and Morrey recommend doing the varus stress test with the humerus in full medial
rotation.
Posterolateral elbow instability is the most common pattern of elbow instability in which there is
displacement of the ulna (accompanied by the radius) on the humerus so that the ulna supinates
or laterally rotates away from or off the trochlea.
209
GOLFER’S ELBOW TEST (MEDIAL EPICONDYLITIS)
PURPOSE Test for medial epicondylitis
PATIENT POSITION The patient should be seated or standing
EXAMINER POSITION The examiner stands adjacent of the test elbow
TEST PROCEDURE • Passive Technique

The therapist palpates the medial epicondyle and supports the elbow with one hand,
while the other hand passively supinates the patient’s forearm and fully extends the
elbow, wrist and fingers
• Active Technique
Patient actively flexes and pronates their wrist and forearm while the examiner resists
this motion
INDICATIONS OF A POSITIVE A positive test would be a complaint of pain or discomfort along the medial aspect of
TEST the elbow in the region of the medial epicondyle.
CLINICAL NOTES Pain along the medial epicondylar region of the elbow may also be caused by structural
damage to the ulnar nerve, ulnar collateral nerve, or the ulnar collateral ligament. It is
important to assess each of these structures prior to making any conclusions from this
test alone.
210
POLK’S TEST (MEDIAL & LATERAL EPICONDYLITIS)
PURPOSE To interpret test that can help the clinician differentiate between Lateral Epicondylitis and Medial
Epicondylitis.
PATIENT the patient seated and the elbow flexed, the patient is instructed to lift an object of approximately
POSITION 2.5 kg. An appropriately weighted sand bag, hand weight, heavy purse or thick book will usually suffice
for the purpose of the test.
TEST • Diagnosis of lateral epicondylitis

PROCEDURE The patient grasps the object with the palm facing the floor (pronation of the forearm) and is
instructed to attempt to lift it up the object. Pain produced in the elbow, typically in the region of the
lateral epicondyle, upon this manoeuvre is suggestive of Lateral Epicondylitis.
In the absence of lateral epicondylitis however, the patient usually performs this manoeuvre quite
easy and without pain.
• Diagnosis of medial epicondylitis

This phase involves the seated patient, with a flexed elbow. The patient is instructed to grasp the
object with the palm up (supination of the forearm) and attempt to lift the object. Elbow pain, usually
in the region of the medial epicondyle, produced with this manoeuvre is suggestive of Medial
Epicondylitis.
In the absence of medial epicondylitis, the patient performs this manoeuvre quite comfortably
Lateral Epicondylitis Medial Epicondylitis
211
COZEN'S TEST & MILL’S TEST (LATERAL EPICONDYLITIS)
PURPOSE To assess for lateral epicondylopathy/epicondylitis of the elbow
PATIENT POSITION The patient may be standing, sitting, or lying supine.

POSITION
TEST PROCEDURE • Method 1: Cozen’s Test

One of the examiner’s hands supports the patient’s elbow. The thumb of this hand rests on the
lateral epicondyle. The examiner’s other hand grasps the dorsal aspect of the patient’s hand. The
patient is asked to actively make a fist, pronate the forearm, and radially deviate and extend the
wrist while the examiner resists the motion.
• Method 2: Mill’s Test

The test may also be done passively by the examiner. While palpating the lateral epicondyle, the
examiner passively pronates the forearm and flexes the wrist fully; then, while holding these two
positions, the examiner extends the elbow. The symptoms would be the same as for the active
test.
INDICATIONS OF A A positive test result is indicated by a sudden, severe pain in the area of the lateral epicondyle of
POSITIVE TEST the humerus. The epicondyle may be palpated to determine the origin of the pain
CLINICAL NOTES Although classically designed to test for lateral epicondylitis, this technique can be used to test
for any pathological condition of the lateral epicondyle.
The examiner should be aware that the passive test stretches the radial nerve, which may lead to
symptoms that may be similar to those seen with tennis elbow.
METHOD 1 METHOD 2
212
MAUDSLEY’S TEST (LATERAL EPICONDYLITIS)
PURPOSE Test for lateral epicondylitis
PATIENT POSITION The patient should be seated with elbow supported fully pronated and extended or partially
flexed
EXAMINER POSITION The examiner sits in front of the test (finger)
TEST PROCEDURE First the examiner palpates lateral epicondyle and give axial force downward of the 3rd digit
of the hand while stabilizing more proximal. While examiner perform this maneuver ask
patient to resists extension. This causes stress to the extensor digitorum muscle and tendon
INDICATIONS OF A A positive sign would be pain or discomfort in the region of the lateral epicondyle
POSITIVE TEST
213
ELBOW FLEXION TEST (CUBITAL TUNNEL SYNDROME)
PURPOSE To assess for ulnar nerve entrapment in the cubital tunnel.
PATIENT POSITION The patient is sitting or standing
EXAMINER POSITION The examiner stands in front of the patient to observe and communicate with the patient.
No patient contact is required for this test.
TEST PROCEDURE The patient is asked to fully flex the elbows with extension of the wrists and abduction and
depression of the shoulder girdle. The patient is asked to hold this position for 3 to 5
minutes
INDICATIONS OF A Tingling or paresthesia in the ulnar nerve distribution of the forearm and hand indicate a
POSITIVE TEST positive test result
214
LUMBAR – SPECIAL TEST
SLUMP TEST
PURPOSE The slump test has become the most common neurological test for the lower limb. It is performed
to assess for movement restriction (impingement) of the dura and spinal cord and/or nerve roots
PATIENT The patient is seated on the edge of the examining table with the legs supported, the hips in neutral
POSITION position (i.e., no rotation, abduction, or adduction), and the hands behind the back. In this position,
the patient should have no symptoms
EXAMINER The examiner stands directly adjacent to the patient so as to control head and lower extremity
POSITION motion
TEST PROCEDURE The examination is performed in sequential steps. First, the patient is asked to “slump” the back
into thoracic and lumbar flexion. The examiner maintains the patient’s chin in the neutral position
to prevent neck and head flexion. If no symptoms are produced, the examiner places one hand on
the patient’s head and neck to control cervical and upper thoracic motion. The examiner then uses
the same arm that has the hand resting on the head to apply overpressure across the shoulders to
maintain flexion of the thoracic and lumbar spines. While this position is held, the patient is asked
to actively flex the cervical spine and head as far as possible (i.e., chin to chest). The examiner then
applies overpressure to maintain the cervical flexion of all three parts of the spine (cervical,
thoracic, and lumbar), using the hand of the same arm to maintain overpressure in the cervical
spine. Providing there are no symptoms, starting with the
normal leg, the examiner’s other hand is placed on the patient’s foot or lower extremity to control
lower extremity motion. The examiner then extends the patient’s knee. If that does not
produce symptoms, the examiner takes the patient’s foot into maximum dorsiflexion. The test is
repeated with the affected leg and then with both legs at the same time.
INDICATIONS OF If the patient is unable to fully extend the knee because of pain, the examiner releases the
A POSITIVE TEST overpressure to the cervical spine and the patient actively extends the neck. If the knee extends
farther, the symptoms decrease with neck extension, or the positioning of the patient increases
the symptoms, the test result is considered positive for increased tension in the neuromeningeal
tract. During the slump test, the examiner looks for reproduction of the neuropathological
symptoms, not just the production of symptoms. The test puts stress on certain tissues, so some
discomfort or pain is not necessarily symptomatic for the problem. For example, nonpathological
responses include pain or discomfort in the area of T8-T9 (in 50% of
normal patients), pain or discomfort behind the extended knee and hamstrings, symmetrical
restriction of knee extension, symmetrical restriction of ankle dorsiflexion, and symmetrical
increased range of knee extension and ankle dorsiflexion on release of neck flexion.
MODIFIED
SLUMP TEST
215
Sequence of subject postures in the slump test.
A. Patient sits erect with hands behind back.

B. Patient slumps lumbar and thoracic spine while either patient or examiner keeps
the head in neutral.
C. Examiner pushes down on shoulders while patient holds head in neutral.
D. Patient flexes head.
E. Examiner carefully applies overpressure to cervical spine.
F. Examiner extends patient’s knee while holding the cervical spine flexed.
G. while holding the knee extended and cervical spine flexed, the examiner
dorsiflexes the foot.
H. Patient extends head, which should relieve any symptoms. If symptoms are
reproduced at any stage, further sequential movements are not attempted.
216
MODIFIED
SLUMP TEST
Modifications of the slump test to stress specific nerve.
A. Basic ST1 test (spinal cord, nerve roots).

B. ST2 (obturator nerve).
C. ST3 (femoral nerve).
D. ST4 (spinal cord, nerve roots)
217
STRAIGHT LEG RAISE (SLR) / (LASÈGUE’S TEST)
PURPOSE To assess for impingement of the dura and spinal cord or nerve roots of the lower lumbar spine,
especially the sciatic nerve.
PATIENT POSITION The patient lies supine. The hip is medially rotated and adducted, and the knee is extended. The
head should be in a neutral position, and the hands should be at the sides
EXAMINER The examiner stands adjacent to the pelvis of the test leg. The examiner places one hand on the
POSITION patient’s knee to stabilize it in extension. The other hand grasps the patient’s ankle and is used
to lift the leg upward
TEST PROCEDURE The examiner flexes the patient’s hip until the patient complains of pain or tightness in the back
or back of the leg. The examiner then slowly and carefully lowers the leg back slightly (extends
it) until the patient feels no pain or tightness. The examiner passively dorsiflexes the patient’s
foot or asks the patient to actively fl ex the neck so that the chin is on the chest; or, the two
actions may be done simultaneously. Most commonly, foot dorsiflexion is done first.
INDICATIONS OF A If the pain is primarily back pain, it is more likely a disc herniation from pressure on the anterior
POSITIVE TEST theca of the spinal cord, or the pathological condition causing the pressure is more centrally
located. “Back pain only” patients who have a disc prolapse have smaller, more central
prolapses. If the pain is primarily in the leg, the pathological condition causing the pressure on
neurological tissues is more likely to be laterally located. A disc herniation or pathological
condition causing pressure between the two extremes is more likely to cause pain in both areas.
CLINICAL • The uninvolved side should be tested first.

NOTES/CAUTIONS • Both the neck flexion and foot dorsiflexion are considered provocative or sensitizing
tests for neurological tissue.
• Straight leg raise testing is one of the most common neurological tests of the lower
limb.
• This test is a passive test, and each leg is tested individually; the normal leg is tested
first. The examiner suspects hamstrings tightness, the hamstrings must also be cleared
by examination.
• Modifications of the straight leg raise test can be used to stress different peripheral
nerves to a greater degree; these are referred to as straight leg raise tests with a
particular nerve bias
• The neck flexion movement has also been called Hyndman’s sign, Brudzinski’s sign, and
Lidner’s sign.
• A contralateral positive test result is called the crossover sign or well leg test of
Fajersztjan. A positive crossover sign usually indicates a large disc protrusion and a poor
prognosis for conservative treatment
MODIFIED SLR
218
Straight leg raise test.

• Radicular symptoms are precipitated on the same side with straight leg
raising.
• The leg is lowered slowly until pain is relieved.
• The foot then is dorsiflexed, causing a return of symptoms; this indicates a
positive test result.
• To make the symptoms more provocative, the neck can be flexed by lifting
the head at the same time the foot is dorsiflexed
• If the test cause pain before 70′ of hip flexion, the lesion is probably in the sacroiliac joints. If the test cause pain
after 70′ the lesion is probably in the lumbar spine area. Primarily the L5’S1&S2 nerve roots. Sciatic nerve is
normally completely stretched at 70′, having an excursion of approximately 2 to 6 cm [ 0.8 to 2.4 inches].
• Patients who have difficulty lying supine, a modification straight leg raising test has been suggested. Patient in the
side-lying position with the test leg uppermost & the hip & knee at 90′. The lumbosacral spine is in neutral but
may be positioned for the patient. The examiner then passively extended the patient’s knee, noting pain,
219
resistance & reproduction of the patient’s symptoms for a positive test. The knee position on the affected side
compared with the on the good side.
• Although the sciatic nerve roots are commonly stretched at 70′ hip flexion, the ROM for Straight Leg Raising &
stress placed on the neurological tissue vary greatly from person to person.
• For example, very hypermobile patients may not show a positive straight leg raising test until 110′ to 120′ of hip
flexion, even in the presence of nerve root pathology.
• It is more important to compare the left & right sides for symptoms before deciding whether a lesion is caused by
stretching of the neurological tissue or arises from the joints or other soft tissue.
PRONE KNEE BEND

PURPOSE To test for femoral nerve entrapment or L2-L3 nerve root involvement
• Upper lumbar radiculopathy
• Femoral nerve entrapment
PATIENT POSITION The patient lies prone.
EXAMINER POSITION The examiner stands adjacent to the pelvis on the side of the test limb
TEST PROCEDURE One of the examiner’s hands is placed on the patient’s pelvis to feel for compensations. The
examiner’s other hand grasps the ankle of the lower extremity being tested. The examiner
passively fl exes the knee as far as possible so that the patient’s heel rests against the buttock.
At the same time, the examiner makes sure the patient’s hip is not rotated. The flexed knee
position should be maintained for 45 to 60 seconds
INDICATIONS OF A Unilateral neurological pain in the lumbar area, buttock, or anterior thigh may indicate an L2 or
POSITIVE TEST L3 nerve root lesion. This test also stretches the femoral nerve. Pain in the anterior thigh may
indicate tight quadriceps muscles or stretching of the femoral nerve. A careful history and pain
differentiation help delineate the problem
CLINICAL NOTE • If the examiner is unable to flex the patient’s knee past 90° because of a pathological
condition in the knee, the test may be performed by passive extension of the hip while
the knee is flexed as much as possible.
• If the rectus femoris is tight, the examiner should remember that taking the heel to the
buttock may cause anterior torsion to the ilium, which could lead to sacroiliac or lumbar
pain.
• The test may be modified to stress different peripheral nerves
MODIFIED PRONE
KNEE BEND
220
Prone knee bending test (PKB1)
which stresses the femoral nerve and L2-L4

nerve root. The examiner points to the
location in the lumbar spine where pain may
be expected with a positive test result.
SCHOBER TEST
PURPOSE used to determine if there is a decrease in lumbar spine range of motion (flexion), most
commonly as a result of ankylosing spondylitis
PATIENT POSITION Patient is standing
EXAMINER POSITION The examiner stands behind patients
TEST PROCEDURE Examiner marks the L5 spinous process by drawing a horizontal line across the patients back.
A second line is marked 10 cm above the first line. Patient is then instructed to flex/bend
forward as if attempting to touch his/her toes, examiner remeasures distance between two
lines with patient fully flexed. The difference between the measurements in erect and flexion
positions indicates the outcome of the lumbar flexion
INDICATIONS OF A Positive Schober’s Test: Less than 5cm increase in length with forward flexion: Decreased
POSITIVE TEST lumbar spine range of motion, ankylosing spondylitis
MODIFIED SCHOBER • Patient is standing, examiner marks both posterior superior iliac spine (PSIS) and then
TEST draws a horizontal line at the Centre of both marks
• A second line is marked 5 cm below the first line.
• A third line is marked 10 cm above the first line.
• Patient is then instructed to flex forward as if attempting to touch his/her toes,
examiner remeasures distance between the top and bottom line
221
SACROILIAC JOINT – SPECIAL TEST
APPROXIMATION TEST (TRANSVERSE POSTERIOR STRESS)

PURPOSE pain provocation test which stresses the SIJ structures, in particular, the posterior SIJ ligament,
to attempt to replicate patient’s symptoms
PATIENT POSITION The patient is side lying on the non-test side
EXAMINER POSITION The examiner stands adjacent to the patient’s pelvis
TEST PROCEDURE The examiner's hands are placed over the upper part of the iliac crest, pressing toward the
floor. The movement causes forward pressure on the sacrum.
INDICATIONS OF A An increased feeling of pressure in the sacroiliac joints indicates a possible sacroiliac lesion
POSITIVE TEST and /or a sprain of the posterior sacroiliac ligaments. A positive result is indicated by pain or
replication of the patient’s symptoms
A. Posterior view
B. Anterior view
222
GAPPING TEST (TRANSVERSE ANTERIOR STRESS)

PURPOSE To assess the ability of the sacroiliac joints to gap anteriorly (this test also assesses the integrity
of the anterior sacroiliac ligaments)
PATIENT POSITION The patient lies supine.
EXAMINER POSITION The examiner stands adjacent to the patient’s pelvis.
TEST PROCEDURE Crossing his or her arms, the examiner places a palm on each ASIS. The examiner then applies
crossed-arm pressure to the ASISs, pushing down and outward with the arms.
INDICATIONS OF A The test result is positive only if unilateral gluteal or posterior leg pain is produced, indicating
POSITIVE TEST a sprain of the anterior sacroiliac ligaments
CLINICAL • Care must be taken in performing this test. Pushing against the ASISs can elicit pain,
NOTE/CAUTION because the soft tissue is compressed between the examiner’s hands and the patient’s
pelvis. If this is the case, the patient can be instructed to place his or her hands on each
ASIS. The examiner then can push through the patient’s hand
223
SACROILIAC ROCKING (KNEE TO SHOULDER) TEST

PURPOSE To assess the integrity of the sacrotuberous ligament
PATIENT POSITION The patient lies supine
EXAMINER POSITION The examiner is positioned adjacent to the patient’s pelvis
TEST PROCEDURE The examiner flexes the patient’s knee and hip fully and then adducts the hip. The sacroiliac
joint is “rocked” by flexion and adduction of the patient’s hip. To do the test properly, the
examiner moves the knee toward the patient’s opposite shoulder. Some authors believe the
hip should be medially rotated as it is flexed and adducted to increase the stress on the
sacroiliac joint. Simultaneously, the sacrotuberous ligament may be palpated for tenderness.
INDICATIONS OF A Pain in the sacroiliac joints indicates a positive test result. While performing the test, the
POSITIVE TEST examiner may palpate the sacroiliac joint on the test side to feel for the slight amount of
movement that normally is present.
CLINICAL NOTE • This test is also called the sacrotuberous ligament stress test.
• For proper performance of this test, both the hip and the knee must demonstrate no
pathological conditions and must have full range of motion.
• Care must be taken when performing this test, because it puts a great deal of stress
on the hip and sacroiliac joints. If a longitudinal force is applied through the hip In a
slow, steady manner (for 15 to 20 seconds) in an oblique and lateral direction, further
stress is applied to the sacrotuberous ligament
224
HIP – SPECIAL TEST
TRENDELENBURG’S SIGN
PURPOSE To assess the stability of the hip and the ability of the hip abductors to stabilize the pelvis on the
femur. (Weakness of the hip abductors)
PATIENT POSITION The patient stands, unsupported.
EXAMINER POSITION The examiner is seated or kneeling directly in front of or directly behind the patient. The
examiner should be positioned so as to observe the position of the pelvis. No manual contact
is required; this is an observational test.
TEST PROCEDURE The patient is asked to stand on one lower limb, starting with the uninvolved side.
INDICATIONS OF A Normally, when a person stands on one leg with no additional support, the pelvis rises on the
POSITIVE TEST opposite side; this indicates a negative test result. A positive test result is indicated if the pelvis
on the opposite side (nonstance side) drops when the patient stands on the affected leg.
Dropping of the pelvis on the opposite side indicates a weak gluteus medius or an unstable hip
(e.g., as a result of hip dislocation) on the affected or stance side.
CLINICAL The test should always be performed on the unaffected side first so that the patient
NOTE/CAUTION understands what to do.
Negative test Positive test
225
THOMAS TEST
PURPOSE To assess for a hip fl exor contracture, which is the most common type of contracture of
the hip.
EXAMINER POSITION The examiner first checks the patient for excessive lordosis, which commonly is present with
tight hip flexors. The examiner then positions himself or herself to view the patient’s pelvis and
the angle of the lower extremity. The test can be done actively by the patient or passively by
the examiner (More common) while the examiner or patient stabilizes the contralateral leg into
flexion.
TEST PROCEDURE The examiner passively fl exes one of the patient’s hips, bringing the knee to the chest to flatten
the lumbar spine and stabilize the pelvis. The patient holds the flexed hip against the chest
while leaving the test leg relaxed in the start position.
INDICATIONS OF A If the patient does not have a flexion contracture, the test hip (the straight leg) remains on the
POSITIVE TEST examining table. If a contracture is present, the straight leg raises off the table as the other leg
is flexed to the chest, and the patient feels a muscle stretch end feel.
The angle of contracture can be measured. If the examiner pushes the lower limb down onto
the table, the patient may show an increased lordosis, which also indicates a positive test result.
CLINICAL If measurements are taken during the test, the examiner must be sure the restriction
NOTE/CAUTION is in the hip and not the pelvis or lumbar spine. If the leg does not lift off the table but abducts
as the other leg is flexed to the chest, this is called the J sign or stroke and indicates a tight
iliotibial band on the extended leg side.
The examiner also may passively hold the flexed limb in position instead of having the
patient holds the knee to the chest. When a patient actively holds the knee to the chest, some
contraction of the hip flexors may be present and the patient may not be able to fully relax the
test limb.
Negative test Positive test
226
OBER’S TEST
PURPOSE To assess the tensor fascia latae (iliotibial band) for tightness
PATIENT POSITION The patient is in the side-lying position with the lower leg flexed at the hip and knee for
stability. The upper leg is the test leg.
EXAMINER POSITION The examiner stands behind the thigh.
TEST PROCEDURE One of the examiner’s hands is placed beneath the patient’s knee to lift and support it, and
the other hand is placed on the pelvis to stabilize it and to assess for motion. The examiner
then passively abducts and extends the patient’s upper leg with the knee straight or flexed to
90°. The examiner slowly lowers the upper limb. For this test, it is important to extend the hip
slightly so that the iliotibial band passes over the greater trochanter of the femur. To do this,
the examiner stabilizes the pelvis when doing the test to prevent the pelvis from “falling
backward.” The examiner also watches the pelvis to make sure that it does not side-tilt as the
upper leg is lowered toward the treatment table.
INDICATIONS OF A If a contracture is present, the leg remains abducted and does not fall to the table. With a
POSITIVE TEST normal iliotibial band length, the foot should be able to touch the table without the pelvis
tilting.
CLINICAL Ober originally described the test with the knee flexed. However, a greater stretch is
NOTE/CAUTION put on the iliotibial band when doing the test with the knee extended. Also, when the knee is
flexed during the test, greater stress is placed on the femoral nerve. If neurological signs (i.e.,
neurological pain, paresthesia) occur during the test, the examiner should consider a
pathological condition affecting the femoral nerve.
Tenderness over the greater trochanter should lead the examiner to consider
trochanteric bursitis.
Ober’s test.
A. Knee straight.
B. the examiner passively extends
the hip to ensure that the tensor
fasciae latae runs over the greater
trochanter. A positive test result is
indicated if the leg remains
abducted while the muscles are
relaxed.
C. Test done with the knee flexed.
227
PATRICK’S TEST (FLEXION, ABDUCTION, AND EXTERNAL ROTATION [FABER] OR
FIGURE-FOUR TEST)
PURPOSE To assess for pathological conditions of the hip joint, iliopsoas spasm, or sacroiliac joint
dysfunction.
PATIENT POSITION The patient is supine. The test leg is flexed, and the contralateral leg is straight
EXAMINER POSITION The examiner stands adjacent to the patient’s test hip.
TEST PROCEDURE One of the examiner’s hands is placed on the knee of the test limb. The examiner’s other hand
is placed on the contralateral ASIS and will be used to stabilize the contralateral pelvis. The
examiner places the patient’s test leg so that the foot of the test leg is on top of the knee of
the opposite leg. The examiner then slowly lowers the knee of the test leg toward the
examining table.
INDICATIONS OF A A negative test result is indicated if the knee of the test leg falls to the table or at least is
POSITIVE TEST parallel to the opposite leg. A positive test result is indicated if the knee of the test leg remains
above the opposite straight leg. If the result is positive, the test indicates that the hip joint
may be affected, that iliopsoas spasm may be present, or that the sacroiliac joint may be
affected (if the patient has posterior pain).
CLINICAL FABER is the position of the hip when the patient begins the test. This test sometimes is
NOTE/CAUTION referred to as Jansen’s test
228
KNEE – SPECIAL TEST
ABDUCTION (VALGUS STRESS) TEST
PURPOSE To assess for one-plane (straight) medial instability, which means that the tibia moves away
from the femur (i.e., gaps) on the medial side.
PATIENT POSITION The patient is supine with the test knee in extension
EXAMINER POSITION The examiner stands adjacent to the lateral aspect of the knee
TEST PROCEDURE The unaffected knee is tested first. One of the examiner’s hands grasps the patient’s ankle, and
the other hand supports the lateral aspect of the knee joint. The examiner applies a valgus
stress at the knee (pushes the knee medially) while the ankle is stabilized in slight lateral
rotation either with the hand or with the leg held between the examiner’s arm and trunk. The
knee is tested first in full extension and then in slight flexion (20° to 30°) so that it is “unlocked.”
The two legs are compared
INDICATIONS OF A A positive test result is indicated if the tibia moves away from the femur excessively when a
POSITIVE TEST valgus stress is applied with the knee in extension. The normal abrupt end feel is lost with a
positive test result. Increased gapping with the knee in extension indicates injury to the medial
collateral ligament and the anterior cruciate ligament. Increased gapping with the knee slightly
flexed indicates injury primarily to the medial collateral ligament. If the test result is positive
when the knee is flexed to 20° to 30°, structures that may have been injured include:
• Medial collateral ligament
• Posterior oblique ligament
• Posterior cruciate ligament
• Posteromedial capsule
CLINICAL NOTE Positive test result on full extension is classified as a major disruption of the knee. The
examiner usually finds that one or more of the rotary tests also produce a positive result.
If the examiner applies lateral rotation to the foot when performing the test in
extension and finds excessive lateral rotation on the affected side, this is a sign of possible
anteromedial rotary instability.
The flexed part of the valgus stress test is considered the true test for one-plane medial
instability, because the cruciates are eliminated
229
ADDUCTION (VARUS STRESS) TEST
PURPOSE To assess for one-plane lateral instability (i.e., the tibia moves away from the femur an
excessive amount on the lateral aspect of the leg).
PATIENT POSITION The patient is supine with the test knee in extension
EXAMINER POSITION The examiner stands adjacent to the medial aspect of the knee.
TEST PROCEDURE The unaffected side is tested first. One of the examiner’s hands grasps the patient’s ankle, and
the other hand supports the medial aspect of the knee joint. The examiner applies a varus
stress at the knee (pushes the knee laterally) while the ankle is stabilized. The test is done first
with the knee in full extension and then with the knee in 20° to 30° of flexion. If the tibia is
laterally rotated in full extension before the test, the cruciate ligaments will be uncoiled and
maximum stress will be placed on the collateral ligaments. The two legs are compared.
INDICATIONS OF A The test result is positive if the tibia moves away from the femur more than on the normal
POSITIVE TEST side when a varus stress is applied and the end feel is modified (mushier). If excessive gapping
occurs when the knee is tested in full extension, primarily the lateral collateral ligament and
anterior cruciate ligament have been injured. If excessive gapping occurs when the knee is
flexed, primarily the lateral collateral ligament has been injured. If the test result is positive
when the knee is flexed 20° to 30° with lateral rotation of the tibia, the structures that may
have been
Injured are:
• Lateral collateral ligament
• Posterolateral capsule
• Arcuate-popliteus complex
• Iliotibial band
• Biceps femoris tendon
230
LACHMAN TEST
PURPOSE To test for one-plane anterior instability. Indicator of injury to the anterior cruciate ligament,
especially the (posterolateral band), Posterior oblique ligament, Arcuate-popliteus complex
EXAMINER POSITION The examiner is positioned adjacent to the involved leg.
TEST PROCEDURE The unaffected leg is tested first. One of the examiner’s hands grasps the patient’s tibia, and
the other hand stabilizes the femur. The examiner holds the patient’s knee between full
extension and 30° of flexion. This position is close to the functional position of the knee, in
which the ACL plays a major role. The patient’s femur is stabilized with one of the examiner’s
hands (the “outside” hand) while the proximal aspect of the tibia is moved or translated
forward with the other (“inside”) hand. The two legs are compared.
INDICATIONS OF A A positive test result is indicated by a “mushy” or soft end feel when the tibia is moved forward
POSITIVE TEST on the femur (increased anterior translation with medial rotation of the tibia) and
disappearance of the infrapatellar tendon slope. A false-negative test result may occur if the
femur is not properly stabilized, if a meniscal lesion blocks translation, or if the tibia is medially
rotated.
CLINICAL NOTE • Frank reported that to achieve the best results, the tibia should be slightly laterally
rotated and the anterior tibial translation force should be applied from the
posteromedial aspect. The hand on the tibia should apply the translation force.
• The Lachman test can be done a number of ways. The key is to make sure the patient
relaxes and the knee is held between full extension and 30º of flexion (see Orthopedic
Physical Assessment, fifth edition, pages 767-770,
• With acute trauma, swelling prevents the examiner from getting a true indication of
the joint’s mobility. The best time to assess joint laxity is immediately after the injury,
before swelling occurs, or in the chronic state. The examiner may need to allow time
for swelling to reduce before true joint mobility can be assessed.
231
ANTERIOR DRAWER TEST
PURPOSE To test instability anterior cruciate ligament (especially the anteromedial bundle)
PATIENT POSITION The patient’s knee is flexed to 90°, and the hip is flexed to 45°. In this position, the anterior
cruciate ligament is almost parallel with the tibial plateau.
EXAMINER The examiner sits on the assessment table facing the patient.
POSITION
TEST PROCEDURE The unaffected leg is tested first. To hold the patient’s foot on the table, the examiner gently
sits on the forefoot with the foot in neutral rotation. The examiner’s hands are placed around
and behind the tibia with the examiner's fingers palpating the posterior aspect of the knee to
ensure that the hamstring muscles are relaxed. The examiner draws the tibia forward on the
femur. The two legs are compared. For an accurate anterior drawer test, the examiner must
make sure the hamstrings are relaxed.
INDICATIONS OF A The normal amount of anterior movement that should be present is approximately 6 mm
POSITIVE TEST
CLINICAL NOTE • This examination must be performed with particular care, because the start position
could result in a false-positive anterior drawer test result for the anterior cruciate
ligament if a posterior sag (an indication of a posterior cruciate problem) goes unnoticed
before the test is started. If minimal or no swelling is present, the sag is evident because
of an obvious concavity distal to the patella.
• If only the anterior cruciate ligament is torn, the test result is negative, because other
structures (posterior capsule and posterolateral and posteromedial structures) limit
movement. In addition, hemarthrosis, a torn medial meniscus (posterior horn) wedged
against the medial femoral condyle, or hamstring spasm may result in a false negative
test result.
• Hughston points out that tearing of the coronary or menisco-tibial ligament can allow
the tibia to translate forward more than normal, even with an intact anterior cruciate
ligament. In this case, when the anterior drawer test is performed, anteromedial
rotation (subluxation) of the tibia occurs.
• When the anterior drawer test is done, if an audible snap or palpable jerk (Finochietto
jumping sign) occurs when the tibia is pulled forward, and the tibia moves forward
excessively, a meniscal lesion is likely in addition to the torn anterior cruciate ligament
• Weatherwax described a modified means of testing the anterior drawer (90-90 anterior
drawer test). The patient lies supine. The examiner flexes the patient’s hip and knee to
90° and supports the lower leg between the examiner’s trunk and forearm. The
examiner places the hands around the tibia, as with the standard test, and applies
sufficient force to slowly lift the patient’s buttock off the table.
• Feagin recommended that the drawer test be done with the patient sitting with the leg
hanging relaxed over the end of the examining table (sitting anterior drawer test). The
examiner places the hands as with the standardized test and slowly draws the tibia first
forward and then backward to test the anterior and posterior drawer. The examiner
uses the thumbs to palpate the tibial plateau movement relative to the femur. The
examiner also may note any rotational deformity. The advantage of doing the test this
way is that the posterior sag is eliminated, because the effect of gravity is eliminated.
232
ACL TEST
POSTERIOR DRAWER TEST

PURPOSE To test for Posterior cruciate ligament, Medial collateral ligament, and Posterior oblique ligament
damage
PATIENT The patient’s knee is flexed to 90°, and the hip is flexed to 45°
POSITION
EXAMINER The examiner sits on the assessment table facing the patient.
POSITION
TEST The unaffected leg is tested first. To hold the patient’s foot on the table, the examiner gently sits on
PROCEDURE the forefoot with the foot in neutral rotation. The examiner’s fingers are placed around and behind
the tibia, palpating the posterior aspect of the knee to ensure that the hamstring muscles are relaxed.
The position of the tibia relative to the femur should be noted before the test is done, in case the
posterior sag sign is present. After the anterior movement of the tibia on the femur, the posterior
movement of the tibia on the femur should be completed using the heels of the hand. In this part of
the test, the tibia is pushed back on the femur.
INDICATIONS If the PCL has been torn, the tibia will drop or slide back on the femur, and when the examiner pulls
OF A POSITIVE the tibia forward, a large amount of movement will occur, giving a false positive sign (see Posterior
TEST Sag Sign). Therefore, this test result should be considered positive only if it is shown that the posterior
sag is present. The two legs are compared.
233
MCMURRAY TEST
PURPOSE To assess for meniscal injuries in the knee.
EXAMINER POSITION The examiner stands adjacent to the test knee
TEST PROCEDURE The unaffected leg is tested first. One of the examiner’s hands grasps the patient’s heel, and
the other hand is placed on the knee to stabilize and support the lower extremity. The
examiner completely fl exes the patient's knee (the heel to the buttock). The examiner then
laterally rotates the tibia (for the medial meniscus) and extends the knee while holding the
rotation. The test is repeated in different amounts of flexion. The two legs are compared. The
test is repeated in a similar fashion with the tibia medially rotated to test the lateral meniscus
INDICATIONS OF A Indications of a positive test result include pain, a snap or grinding feeling, and limited
POSITIVE TEST rotation. The process of knee flexion and tibial lateral rotation (for the medial meniscus) or
medial rotation (for the lateral meniscus) is repeated several times in different amounts of
flexion.
CLINICAL NOTE • The anterior half of the meniscus is not as easily tested, because the pressure on the
meniscus is not as great.
• Kim et al. reported that meniscal lesions may be found on the medial side with medial
rotation and on the lateral side with lateral rotation.
Medial meniscus test Lateral meniscus test
234
APLEY’S TEST
PURPOSE To assess for meniscal and ligamentous injuries in the knee.
PATIENT POSITION The patient lies prone with the knee flexed to 90°.
EXAMINER POSITION The examiner is positioned adjacent to the test knee.
TEST PROCEDURE The unaffected leg is tested first. Both of the examiner’s hands grasp the patient’s foot and/or
ankle with the patient’s knee flexed. The patient’s thigh is anchored to the examining table by
the examiner’s knee. The examiner medially and laterally rotates the tibia, combined first with
distraction (to test the ligaments), and notes any restriction, excessive movement, or
discomfort. The process is repeated using compression (to test the meniscus) instead of
distraction. The two legs are compared.
INDICATIONS OF A A positive test result for a meniscus is indicated by pain and decreased rotation, with or without
POSITIVE TEST a click or catch during compression. If rotation plus distraction is more painful or shows
increased rotation relative to the unaffected side, the lesion is probably ligamentous.
CLINICAL NOTE • The patient may feel a clicking or catching during compression with this test.
Compression
Distraction
235
CLARKE’S SIGN (PATELLAR GRIND TEST)
PURPOSE To assess for patellofemoral dysfunction.
PATIENT POSITION The patient lies in supine with the knee extended.
EXAMINER POSITION The examiner stands adjacent to the patient’s knee.
TEST PROCEDURE The unaffected leg is tested first. The thenar web space of one of the examiner’s hands is
placed slightly proximal to the upper pole or base of the patella. The examiner presses down
several times with increasing force until pain is produced on the proximal aspect of the patella.
The patient then is asked to contract the quadriceps muscles after the examiner pushes down.
The test is repeated with the painful knee, and the amounts of pressure that cause pain are
compared.
INDICATIONS OF A A positive test result is indicated if the test causes retropatellar pain and the patient cannot
POSITIVE TEST hold a contraction. If the patient can complete and maintain the contraction without pain, the
test result is considered negative, as long as the same test on the unaffected leg does not
cause pain.
CLINICAL NOTE • Because a positive test result can be obtained on anyone if sufficient pressure is
applied to the patella, the amount of pressure applied must be carefully controlled
and compared with the opposite side. This is best done by repeating the procedure
several times, increasing the pressure each time and comparing the results with those
on the unaffected side.
• To test different parts of the patella, the knee may be tested in 30°, 60°, and 90° of
flexion and in full extension.
236
Q-ANGLE OR PATELLOFEMORAL ANGLE
PURPOSE To assess the alignment (Q-angle) of the lower extremity
PATIENT POSITION The patient is assessed in supine (most commonly) or while sitting. Research has shown that
different foot and hip positions alter the Q-angle; therefore, the foot should be in a neutral
position with regard to supination and pronation, and the hip should be in a neutral position
with regard to medial and lateral rotation.
EXAMINER POSITION The examiner’s position varies, but the examiner generally is located adjacent to the test knee
TEST PROCEDURE The unaffected leg is measured first. The examiner draws an imaginary line from the anterior
superior iliac spine (ASIS) to the midpoint of the patella on the same side and a second line
from the tibial tubercle to the midpoint of the patella. The angle formed by the crossing of
these two lines is called the Q-angle. During the measurement, which may be done either
using radiographs or physically on the patient, the quadriceps should be relaxed
INDICATIONS OF A Normally, the Q-angle is 13° for males and 18° for females when the knee is straight
POSITIVE TEST Grelsamer et al. reported that male and female values are similar when the patient’s height
is considered. Any angle less than 13° may be associated with chondromalacia patellae or
patella alta. An angle greater than 18° often is associated with chondromalacia patellae,
subluxing patella, increased femoral anteversion, genu valgum, lateral displacement of the
tibial tubercle, or increased lateral tibial torsion.
Physiopedia: In women, the Q angle should be less than 22 degrees with the knee in extension
and less than 9 degrees with the knee in 90 degrees of flexion. In men, the Q angle should be
less than 18 degrees with the knee in extension and less than 8 degrees with the knee in
90degrees of flexion. A typical Q angle is 12 degrees for men and 17 degrees for women
Valgus knee: valgus angle equal to or greater than 10°.
www.sportsinjuryclinic.net
237
CLINICAL NOTE There are numerous grading systems used for the classification of the knee deformity that
depend on the severity of deformation and the soft tissue involved. But the most recent one
describes three grades of valgus deformity that depend on the degree of the angle.
• Grade I: the deviation is less than 10°, passively correctable, with contracture of the
lateral soft tissue but without elongation of the medial collateral ligament.
• Grade II: the axial deviation ranges between 10 and 20°, the lateral structures are
contracted and the MCL is elongated but functional.
• Grade III: the axial deformity is greater than 20°, the lateral structures are tight and
the medial stabilizers are not functional
238
ANKLE – SPECIAL TEST
ANTERIOR DRAWER TEST- SUPINE
PURPOSE To test for injuries to the anterior talofibular ligament
PATIENT POSITION The patient lies supine with the foot relaxed. The patient’s foot should be hanging over the
edge of the table
EXAMINER POSITION The examiner stands adjacent to the test foot.
TEST PROCEDURE The unaffected ankle is tested first. One of the examiner’s hands stabilizes the distal tibia and
fibula. The thenar web space of the examiner’s other hand is placed over the patient’s anterior
talus. The examiner stabilizes the tibia and fibula, holds the patient’s foot in 20° of plantar
flexion, and draws the talus forward in the ankle mortise with the second hand. Normally, there
is some anterior movement when the test is performed, so the examiner should ensure that
the movement on the injured side is compared with the uninjured side
INDICATIONS OF A A positive result may be obtained on the anterior drawer test if only the anterior talofibular
POSITIVE TEST ligament is torn; however, anterior translation is greater if both the anterior talofibular and
calcaneofibular ligaments are torn, especially if the foot is tested in dorsiflexion. Sometimes, a
dimple appears over the area of the anterior talofibular ligament on anterior translation
(dimple, or suction, sign) if pain, muscle spasm, and swelling are minimal. If straight anterior
movement or translation occurs, the test result indicates both medial and lateral ligament
insufficiencies. This bilateral finding, which often is more evident in dorsiflexion, means that
the superficial and deep deltoid ligaments, as well as the anterior talofibular ligament and
anterolateral capsule, have been torn. If the tear is on only one side, only that side translates
forward more than normal. For example, with a lateral tear, the lateral side translates forward,
causing medial rotation of the talus and resulting in anterolateral rotary instability, which is
increasingly evident with increased plantar flexion of the foot
CLINICAL NOTE • In the plantar flexed position, the anterior talofibular ligament is perpendicular to the
long axis of the tibia. By adding inversion, which gives an anterolateral stress, the
examiner can increase the stress on the anterior talofibular ligament and the
calcaneofibular ligament.
• Ideally, the knee should be placed in 90° of flexion to alleviate tension on the Achilles
tendon. The test should be performed in plantar flexion and in dorsiflexion to test for
straight and rotational instabilities.
• The test also may be performed by stabilizing the foot and talus and pushing the tibia
and fibula posteriorly on the talus (method 2). In this case, excessive posterior
movement of the tibia and fibula on the talus indicates a positive test result.
239
Method A: Pulling
the foot forward.
Method B: Pushing
the leg backward
ANTERIOR DRAWER TEST – PRONE

PURPOSE To test for injuries to the anterior talofibular ligament.
PATIENT POSITION The patient lies prone with the foot extending over the end of the examining table
EXAMINER POSITION The examiner stands adjacent to the test foot
TEST PROCEDURE The unaffected ankle is tested first. One of the examiner’s hands stabilizes the distal tibia and
fibula. The thenar web space of the examiner’s other hand is placed over the posterior aspect
of the talus and calcaneus. The examiner pushes the heel steadily forward, while the other
hand stabilizes the distal tibia and fibula. The two sides are compared
INDICATIONS OF A Excessive anterior movement and a sucking in of the skin on both sides of the Achilles tendon
POSITIVE TEST indicate a positive test result. This test, like the previous one, indicates ligamentous instability,
primarily of the anterior talofibular ligament
240
TALAR TILT TEST
PURPOSE To determine whether the calcaneofibular ligament is torn
PATIENT POSITION The patient lies supine or in the side-lying position with the foot relaxed. If the patient is
tested in side lying, the test foot is positioned upward
EXAMINER POSITION The examiner stands adjacent to the test foot.
TEST PROCEDURE The unaffected ankle is tested first. One of the examiner’s hands is placed anterior to the
tibia on top of the navicular, and the other hand is positioned posterior to the tibia over the
calcaneus. The two thumbs are placed on the lateral aspect of the calcaneus. The foot is held
in the anatomical position (90°), which brings the calcaneofibular ligament perpendicular to
the long axis of the talus. The talus then is tilted first into adduction and then into abduction.
Adduction tests the calcaneofibular ligament and, to some degree, the anterior talofibular
ligament, by increasing the stress on the individual ligaments. Abduction stresses the deltoid
ligament, primarily the tibionavicular, tibiocalcaneal, and posterior tibiotalar ligaments,
which are components of the deltoid ligament. The two sides are compared.
INDICATIONS OF A Excessive motion or pain (or both) compared to the unaffected side indicates a positive test
POSITIVE TEST result
CLINICAL NOTE • The patient’s gastrocnemius muscle may be relaxed by flexion of the knee.
• If the foot is plantar flexed, the anterior talofibular ligament is more likely to be
tested (inversion stress test).
241
THOMPSON’S (SIMMONDS’) TEST - (ACHILLES TENDON RUPTURE)
PURPOSE To assess for tears (third-degree strain) of the Achilles tendon
PATIENT POSITION The patient lies prone or kneels on a chair with the feet over the edge of the table or chair
EXAMINER POSITION The examiner stands by the test leg.
TEST PROCEDURE Starting with the unaffected leg, the examiner squeezes each calf muscle in turn while the
patient remains relaxed
INDICATIONS OF A A positive test result for a ruptured Achilles tendon (third-degree strain) is indicated by the
POSITIVE TEST absence of plantar flexion when the muscle is squeezed
CLINICAL NOTE The examiner should be careful not to assume that the Achilles tendon is not ruptured if the
patient can actively plantar fl ex the foot while non-weight bearing. The long flexor muscles can
perform this function in the non-weight bearing stance, even with a rupture of the Achilles
tendon
Method A: Prone
lying position
Method B:
kneeling position
In each case, the

foot plantar-fl
exes (arrow) if
the test result is
negative.
242
GAIT TRAINING
GAIT TRAINING WITH WALKING AIDS
WEIGHT BEARING WEIGHT DEFINITION ASSISTIVE DEVICE LIKELY

STATUS BEARING USED
STATUS
ABBREVIATION
Non-weight bearing NWB No weight is permitted on the lower Two crutches. A walker is
extremity. used if the patient has
difficulty with balance or
coordination
Partial weight bearing PWB A general term used when no specific Two crutches.
amount of weight restriction is placed A walker is used if the
on weight bearing. Limitation is usually patient has difficulty with
to the patient’s comfort without balance or coordination.
evidence of pain or increased stress to Sometimes the physician
the injured segment. may order specific weight-
bearing restrictions such
as 50% PWB.
Toe-touch weight bearing TTWB Both terms are equivalent. This is a Two crutches.
Touch-down weight TDWB form of partial weight bearing with the A walker is used if the
bearing permitted amount being limited to patient has difficulty with
only a touch of the foot, usually the balance or coordination.
toe, on the ground. Sometimes the
physician may indicate a specific
percentage of weight to be borne on
the involved extremity (e.g., 10%
TTWB).
Weight bearing as WBAT There are no restrictions on the Two crutches,
tolerated patient’s weight-bearing status. The transitioning to one
patient is usually transitioning from crutch or cane before
using crutches to being able to walk walking without any
normally without them. The clinician assistive devices.
must work with the patient to ensure a
normal gait during progression from
assistive to no assistive devices.
Full weight bearing FWB There are no restrictions in the None
patient’s ability to bear weight on the
injured limb; he or she can walk
normally
243
GAIT TRAINING
GAIT PATTERN WITH CRUTCHES
TWO POINT GAIT PATTERN
THREE- POINT PATTERN GAIT

(NON WT BEARING)
THREE - POINT PATTERN GAIT

(PARTIAL WT BEARING)
FOUR-POINT GAIT PATTERN
244
GAIT TRAINING
SWING THROUGH
SWING TO
245
GAIT TRAINING
WALKING FRAME
FULL-WT BEARING GAITS
Pick up walker and move forward

1st leg moved and 2nd leg
PARTIAL-WT BEARING
GAITS
Involved leg moved forward 1st
NON-WT BEARING GAITS
246
GAIT TRAINING
STAIR CLIMBING
CRUTCH WALKING
UP WITH THE GOOD AND DOWN WITH BAD
GOING UP WITH HANDRAIL
1. Place both crutches under your arm on the injured side.

2. Grasp the handrail with your other hand, if possible.
3. Bring your good leg up to the next step. Let the injured leg trail behind.
4. Straighten your good leg and bring the crutches and injured leg up.
GOING DOWN WITH

HANDRAIL
1. Put the crutch on the lower step.

2. Lower your injured leg down to the lower step.
3. Support your weight between your crutch and handrail. Move your good
foot to the lower step
247
GAIT TRAINING
2 POINT GAIT • Ascending: Right Lower Extremity and then Left Lower Extremity,
then Right crutch and last Left crutch (good balance then crutch
together)
• Descending: Right crutch and last Left crutch. Then Right Lower
Extremity and Left Lower Extremity
3 POINT GAIT (NON WT BEARING) • Ascending: Weight partially on bad leg and crutch, the good leg is
lifted, then bad leg and crutches lifted up.
• Descending: First both crutch, then bad leg, then good leg.
3 POINT GAIT (PARTIAL WT • Ascending: Good leg, followed by both the crutch.
BEARING) • Descending: Both the crutch followed by good leg
4 POINT GAIT • Ascending: Right Lower Extremity and then Left Lower Extremity,
then Right crutch and last Left crutch.(good balance then crutch
together)
• Descending: right crutch and last left crutch. Then Right Lower
Extremity and then Left Lower Extremity
248
GAIT TRAINING
BED MOBILITY WITH WALKING FRAME AND CRUTCHES
1. Proper footwear is essential to prevent accidental falls

WALKING 2. Measure client for walker height. The top of the walker should line up with the crease
FRAME on the inside of the wrists when one is standing. Elbows should flex 15-30 degrees
when standing inside the walker with hands on the hand grips.
3. Explain and demonstrate how to walk with a walker.
4. From a sitting position, instruct patient to push up from the chair’s armrest to a
standing position. Do not use the walker to pull oneself up. It is not stable and could
result in injury. Apply gait belt if required for additional support.
5. Firmly grip both sides of the walker. Move the walker forward a short distance. The
base of the walker provides a broad base of support. Once patient is standing and feels
stable, move to the unaffected side. If using a gait belt, grasp the belt in the middle of
the patient’s back.
1. Proper footwear is essential to prevent accidental falls.

CRUTCHES 2. Ensure crutch height is correct. Axilla height crutches: When standing, the there
should be two to three finger widths from the axilla to the top of the crutch. The height
of the hand grip will be adjusted to allow the elbow to be flexed 15 to 30 degrees or to
the wrist crease. There are different crutch walking techniques that depend on the
patient’s ability to bear weight. Forearm crutches: The elbows should be flexed 15 to
30 degrees when holding the hand grips. The forearms should be supported roughly
mid-point between the wrist and elbow.
3. Explain and demonstrate how to walk with crutches.
4. From a sitting position, advise the patient to push up from the chair’s armrest to a
standing position. Stand to gain balance. Advise the patient to not lean on the
underarm supports.
249
TRANSFER TECHNIQUES
TRANSFER TECHNIQUES
Pivot transfers are useful for a person who is not able to walk safely between
PIVOT TRANSFER surfaces. “Pivot” indicates that the person bears at least some weight on one or both
legs and spins to move their bottom from one surface to another. A pivot transfer can
be performed in both squatted and full standing positions and can be completed with
anywhere from minimal assistance to total assistance from a caregiver or helper.
• Position the wheelchair directly next to the surface (bed, toilet, tub bench, car,
sofa, etc.). A slight angle of 30-45 degrees is helpful but not absolutely
necessary.
• Lock the wheelchair brakes and move the footrests out of the way of the feet.
The armrest on the side you will be transferring to can also be moved out of
the way if desired.
• Always talk to the person being transferred so that assistance is being given at
the appropriate time, allowing for coordination of efforts.
• Gait/transfer belt should be placed securely.
• Move person's bottom to the front of the surface they are sitting on so that
the feet are in firm contact with the floor.
• If needed, assistance can be given to block the person's knees to provide
additional support for weight bearing.
• To complete the transfer, the person should lean forward over their feet, use
their hands to push from the surface they are sitting on, swing their bottom
around to the adjacent surface and slowly sit back down.
250
TRANSFER TECHNIQUES
Technique shown is a “squat” pivot

THROUGH ARM TECHNIQUES • One caregiver in front, one behind allows for closer proximity of chair
• Best done into a wheelchair or chair where armrest can be removed
• Caregiver in front shifts his/her body weight backward as patient leans
forward, which elevates the patient’s hips
• Caregiver behind helps “steer” pelvis
251
JOINT MOBLIZATION – SPINE
Grade I small amplitude movement at the beginning of the available ROM
Grade II large amplitude movement at within the available ROM
Grade III large amplitude movement that reaches the end ROM
Grade IV small amplitude movement at the very end range of motion
Grade V high velocity thrust of small amplitude at the end of the available range and within its anatomical range
(manipulation)
In many places, you are obliged to obtain a written consent from your patient before applying grade 5 manipulation.
The grading scale has been separated into two due to their clinical indications:
Lower grades (I + II) used to reduce pain and irritability
Higher grades (III + IV) used to stretch the joint capsule and passive tissues which support and stabilize the joint so
increase range of movement.
The rate of mobilization should be thought of as an oscillation in a rhythmical fashion at: 2Hz - 120 movements per minute.
For 30 seconds - 1 minute
CERVICAL LONGITUDINAL (DISTRACTION) MOVEMENT

INDICATIONS Relaxing technique used to gain patient’s confidence.
RESTING POSITION Normal alignment of the head with the body
PATIENT POSITION Supine.
CLINICIANS AND HAND The clinician stands or sits by the head of the table, facing the patient. The patient’s head is
POSITION grasped and supported with one of the clinician’s hands behind the head; the thumb and
fingers are at the occiput. The other hand is placed under the chin
MOBILIZATION While maintaining the position of the upper extremities, the clinician leans back to produce
APPLICATION a gentle longitudinal pull of the neck.
NOTE The hand on the chin is for positioning only; no force is directed into the chin. This is often
the technique used to initiate a mobilization treatment session.
252
CERVICAL CENTRAL PA MOBILIZATIONS
INDICATIONS Midline pain, unilateral pain, or spasm; decreased mobility.
RESTING POSITION The cervical spine is in good alignment to allow the clinician to identify the level being treated.
Usually this is a position of proper alignment relative to the entire spine or slight cervical
flexion to expose a specific joint. Instructing the prone patient to tuck the chin tends to flatten
the cervical spine to provide good alignment for joint mobilization.
PATIENT POSITION The patient lies prone with his or her hands under the forehead and the chin slightly tucked.
If a mobilization table or specifically designed prone pillow is available, either of these may
be more comfortable for the patient; in either of these cases, the patient’s hands are not
under the forehead, but the arms are placed more comfortably at the sides.
CLINICIANS AND HAND The rehabilitation clinician stands at the head and places the thumbs on the spinous process
POSITION with the fingers relaxed, along the sides of the neck. C1 and C3 are usually too difficult to
palpate, but C2, C4, C5, C6, and C7 can usually be readily identified.
MOBILIZATION The clinician applies PA pressure with the thumbs through movement of his or her trunk over
APPLICATION the hands. The mobilization force is directed at a 45° angle because of the cervical facets’
orientation. This angle usually coincides with the line of the patient’s mandible.
NOTE The mobilization grades should be gentle at first; depending on the treatment goals, grades I
and II are used to relieve pain while grades III and IV improve joint mobility
253
CERVICAL UNILATERAL PA MOBILIZATIONS
INDICATIONS For lower cervical spine and for unilateral neck pain; decreased mobility.
RESTING POSITION The cervical spine is in good alignment to allow the clinician to identify the level to be treated.
Usually this is a position of proper alignment relative to the entire spine or slightly flexed to
expose the specific joint.
CLINICIANS AND HAND The rehabilitation clinician stands on the side that is to be treated. The thumbs are placed on
POSITION the articular pillar and with the downward force angled about 30° medially
MOBILIZATION The pressure is applied by the thumbs in a PA direction with a constant medially directed
APPLICATION pressure to maintain position on the articular pillar. In this example, the right thumb is the
palpating thumb while the left thumb delivers the mobilizing force. Notice that the vertical
thumb position and 45° angle of the arm allow the clinician to change force angles to be able
to apply the mobilization force parallel to the plane of the joint
NOTE Notations: The head may nod slightly, but there should be no rotation motion if the pressure
is applied correctly.
254
THORACIC CENTRAL PA MOBILIZATIONS
INDICATIONS Central or unilateral symptoms.
RESTING POSITION The thoracic spine should be relatively parallel to the floor with the patient prone on the
treatment table. A pillow is placed under the patient between the pelvis and mid-thoracic
spine to achieve this parallel position
CLINICIANS AND HAND The thumbs are placed directly over the spinous process (1), with the fingertips spread across
POSITION the back to act as stabilizers for the thumbs. The thoracic segment being treated determines
where the rehabilitation clinician stands. He or she stands at the head (2) if the upper
segments are treated and at the side (3) if the middle and lower segments are treated.
MOBILIZATION The pressure is applied so the thumbs create a line perpendicular to the back’s surface;
APPLICATION therefore, the thumb positions will change slightly as the hands move along the thoracic
spine. The force is transmitted from the clinician’s trunk through the arms to the thumbs.
Both thumbs may deliver the mobilization force, or the lower thumb palpates while the upper
thumb delivers the force. The fingers remain relaxed so the clinician can use them to perceive
joint motion
255
THORACIC UNILATERAL PA MOBILIZATION
INDICATIONS Used for unilateral symptoms.
RESTING POSITION As in the previous technique, the thoracic spine should be relatively parallel to the floor with
the patient prone on the treatment table.
PATIENT POSITION The patient lies prone with the head turned to the side being treated. The arms hang over
the side of the table.
CLINICIANS AND HAND The rehabilitation clinician stands on the side being treated and places his or her hands on
POSITION the patient’s back, with the thumb pads on the transverse process of the painful side and the
fingers buttressed over the back (figure 18.6). The transverse process is located by placing
one finger on the spinous process of the vertebra immediately above the vertebra to be
treated and another finger immediately lateral to that point and in touch with the first finger;
this is the transverse process. Remember that thoracic spinous processes extend one level
below their vertebra, so if you want to treat the T7 transverse process, go lateral to the T6
spinous process. The clinician’s shoulders and arms are directly over his or her hands.
MOBILIZATION The force is directed perpendicular to the surface.

APPLICATION
NOTE Notations: Clinician’s hand motion occurs as a result of trunk and leg movement, not thumb
movement. The side of treatment is usually the painful side.
256
THORACIC UNILATERAL COSTOVERTEBRAL PA MOBILIZATION
INDICATIONS Painful and restricted rib joints.
RESTING POSITION As with previous thoracic mobilizations, the thoracic spine should be relatively parallel to the
floor with the patient prone on the treatment table.
PATIENT POSITION The patient lies prone with the head turned to the side being treated. The arms hang over
the side of the table.
CLINICIANS AND HAND The costovertebral joint is located by placing two fingers adjacent and lateral to the spinous
POSITION process; the lateral edge of the lateral digit is over the joint. The ulnar border of the
rehabilitation clinician’s hand is placed over the costovertebral joint in alignment with the
patient’s rib. The other hand is placed on top of the second metacarpal and digit. Be sure
placement of the ulnar border is approximately two finger widths from the spinous process.
MOBILIZATION The pressure is applied perpendicular to the surface from the trunk through the shoulders
APPLICATION and into the hands (Anterior glide over the costovertebral joint)
NOTE The two-finger-width positioning for the treatment application is based on the patient’s
finger width, not the clinicians.
257
LUMBAR CENTRAL PA MOBILIZATION
INDICATIONS For hypomobility and central or unilateral pain and derangements.
RESTING POSITION The lumbar spine should be relatively parallel to the floor with the patient prone on the
treatment table. A pillow under the patient’s abdomen from the pelvis to the mid-thoracic
region may be necessary to maintain a level lumbar spine.
PATIENT POSITION The patient lies prone.
CLINICIANS AND HAND The clinician stands to the side of the patient at the lumbar spine level. The ulnar side of one
POSITION hand, with the other hand reinforcing the treatment hand, may be used to apply the
treatment force. The clinician’s shoulders are directly over his or her hands.
MOBILIZATION (Anterior glide) pressure is applied directly downward through the shoulders from the trunk.
APPLICATION
NOTE Maintain elbow extension while applying the treatment force.
LUMBAR UNILATERAL PA MOBILIZATION

INDICATIONS For unilateral symptoms.
RESTING POSITION The lumbar spine should be relatively parallel to the floor with the patient prone on the
treatment table. A pillow under the patient’s abdomen may be necessary to maintain a level
lumbar spine
PATIENT POSITION The patient lies prone with the head turned to the side being treated.
CLINICIANS AND HAND The rehabilitation clinician stands on the side to be treated and places the thumbs
POSITION immediately lateral to the spinous process, at the level being treated, with the fingers spread
across the back to provide stability and support to the thumbs
MOBILIZATION Anterior glide on either the right or the left side of the spinous process. The pressure is
APPLICATION applied directly downward through the shoulders.
NOTE The clinician’s shoulders are placed directly over his or her hands with the fingers relaxed.
LUMBAR CENTRAL PA MOBILIZATION LUMBAR UNILATERAL PA MOBILIZATION
258
LUMBAR ROTATION
INDICATIONS Unilateral restriction of movement or unilateral back or leg pain.
RESTING POSITION Patient position for all grades is side-lying, but specific position depends upon the grade.
The lumbar vertebrae are positioned in midrange flexion–extension by the amount of hip
flexion.
PATIENT POSITION The patient lies on the unaffected side with a pillow under the head. The top shoulder is
near the table’s side, and the elbow is flexed with the forearm resting on the side. The lower-
extremity position depends on the grade of pressure being applied. For grades I and II, the
hips and knees are flexed, with the top leg slightly more flexed than the bottom limb. In
grade III, the top shoulder is extended slightly more posteriorly, and the trunk is slightly
rotated so that the chest faces the ceiling and the torso is in a three-quarter position. The
bottom leg is more extended than in grades I and II; the top leg is flexed forward of the
bottom limb with its medial femoral condyle on the table or just off the edge, and the ankle
is hooked around the bottom leg. Grade IV position has the top knee more extended and
the distal tibia off the table (PICTURE C)
CLINICIANS AND HAND The clinician places his or her mobilizing hand on the pelvis. For grade III, the rehabilitation
POSITION clinician places the stabilizing hand on the patient’s shoulder and the mobilizing hand on the
pelvis with the fingers pointing forward. If the desired lumbar motion is more into extension,
then the hand is placed over the iliac crest with the clinician standing near the shoulder
(PICTURE B); but if the desired lumbar motion is flexion, the hand is placed over the greater
trochanter with the clinician standing near the pelvis. For grade IV, the clinician may need
to kneel on the table behind the patient or lower the table so the force can be directed more
easily from the clinician’s shoulders to the hand on the pelvis. The clinician’s knee behind
the patient’s back can also assist in stabilization.
MOBILIZATION For grades I and II, the clinician should produce a gentle rocking motion of the pelvis
APPLICATION (PICTURE A). The rocking motion is produced with movement caused by the hand on the
patient’s pelvis, not the hand on the shoulder
NOTE Motion for each grade should be a rotatory motion of the pelvis, not posterior-to-anterior
or inferior-to-superior.
A B C
259
JOINT MOBILIZATION - GLENOHUMERAL JOINT
260
OSCILLATION
INDICATIONS For general relaxation of the shoulder muscles before and after other joint mobilization
techniques.
SHOULDER POSITION 55° flexion and 20° to 30° horizontal abduction.
PATIENT POSITION Supine and relaxed with shoulder near edge of table.
CLINICIANS AND HAND Clinician stands on the side of the patient, facing the patient’s shoulder, and grasps the
POSITION patient’s distal forearm and wrist with both hands.
MOBILIZATION Mild distraction force perpendicular to the glenohumeral joint plane as oscillations are
APPLICATION performed
NOTE Distraction force is applied by the clinician’s body weight on the back foot while the clinician
gently pulls on the shoulder with the hand grasp on the forearm and wrist.
DISTRACTION
INDICATIONS To improve inferior capsular mobility.
PATIENT POSITION Supine with the involved shoulder as close to the side edge of the table as possible.
CLINICIANS AND HAND For a right shoulder, the clinician places his or her right hand in the axilla to stabilize the
POSITION glenoid. The left-hand grasps just proximal to the elbow joint.
MOBILIZATION A distraction force is applied to the humerus

APPLICATION
NOTE Good initial technique. A prolonged force is more effective, but oscillation combined with
distraction can also be used.
261
INFERIOR CAPSULE GLIDE/ CAUDAL GLIDE

INDICATIONS To improve inferior capsular mobility and glenohumeral abduction.
PATIENT POSITION Supine with involved shoulder as close to the side edge of the table as possible.
CLINICIANS AND HAND The mobilizing hand is on the superior aspect of the humerus as close as possible to the
POSITION acromion, and the stabilizing hand is on the middle to distal humerus. The mobilizing hand
web space should be over the superior humeral head just off the acromion.
MOBILIZATION The stabilizing hand holds the shoulder in its resting position while applying some distraction
APPLICATION (A) as the mobilizing hand applies a glide force in a caudal direction parallel to the joint’s surface
NOTE (B) If the supine body’s weight on the scapula is insufficient to stabilize the scapula, a stabilization
belt around the patient’s chest may be used to stabilize the scapula. The arm can be abducted
to a maximum of 60°, but initial glides should be performed in the resting
position. Once approximately 120° of flexion is achieved, an inferior glide can be performed
with the arm in an overhead position. Keep in mind that as the shoulder’s position changes,
the glenoid joint surface position also changes. Likewise, the mobilization force direction
changes as the joint plane changes: The force is directed inferiorly
A B
262
LATERAL GLIDE
INDICATIONS To increase all motions of the glenohumeral joint
SHOULDER POSITION 90° flexion with some horizontal abduction.
PATIENT POSITION Patient is supine with involved shoulder as close to the side edge of the table as possible.
CLINICIANS AND HAND The clinician faces the patient at shoulder level and grasps the patient’s humerus as
POSITION proximally as possible with the patient’s shoulder flexed to 90° and the patient’s arm resting
on the rehabilitation clinician’s shoulder
MOBILIZATION Lateral force is applied to the proximal humerus

APPLICATION
NOTE The clinician should remember to use proper body mechanics, keeping the back straight and
using the legs.
POSTERIOR GLIDE
INDICATIONS 55° flexion and 20° to 30° horizontal abduction.
SHOULDER POSITION To improve shoulder flexion and medial rotation by improving posterior capsular mobility
PATIENT POSITION Supine with shoulder as close to the side edge of the table as possible. A towel roll or wedge
can be placed under the scapula for stabilization.
CLINICIANS AND HAND The clinician abducts the patient’s arm and stands between the patient’s arm and trunk; the
POSITION clinician places the stabilizing hand proximal to the elbow and the mobilizing hand on the
proximal humerus just past the acromion.
MOBILIZATION The mobilizing hand applies a downward and slightly lateral force, while the stabilizing hand
APPLICATION applies slight traction to the patient’s glenohumeral joint at the patient’s elbow (PICTURE A)
NOTE An alternative technique is performed with the patient’s shoulder in medial rotation to gain
additional motion in that direction (PICTURE B). An advanced flexion technique can be
performed with the patient’s shoulder flexed to 90° and adducted with the elbow flexed. In
this position the rehabilitation clinician stabilizes the arm with a hand on the proximal
humerus. A downward mobilization force is applied with the mobilizing hand on the patient’s
elbow and the clinician’s forearm in line with the patient’s arm (PICTURE C)
263
A A
B C
C: used to exert a grade 1

distraction force with belt
assisted
264
ANTERIOR GLIDE
INDICATIONS To increase anterior capsule mobility so that glenohumeral extension and
lateral rotation improve.
PATIENT POSITION Prone with a towel or wedge support under the anterior clavicle and coracoid
process to stabilize the shoulder. The glenohumeral joint is off the side edge
of the table, and the shoulder is placed in its resting position.
CLINICIANS AND HAND POSITION The rehabilitation clinician stands between the patient’s arm and side, facing
the shoulder, and places the stabilizing hand on the distal humerus and the
mobilizing hand on the posterior aspect of the humeral head just distal to the
acromion.
MOBILIZATION APPLICATION As the stabilizing hand applies a distraction force, the proximal mobilizing
hand applies an anterior and slightly medial mobilization force (PICTURE A).
NOTE If additional motion is achieved but restriction in the anterior–inferior capsule

remains, an alternative position for mobilization is with the arm elevated. An
alternative technique can be used to increase lateral rotation by positioning
the arm in additional lateral rotation during the mobilization; however, in this
position there is a tendency for the clinician to extend the shoulder with the
patient in a prone position (PICTURE B)
A B
265
LATERAL ROTATION
INDICATIONS To improve lateral rotation of the glenohumeral joint.
PATIENT POSITION Supine with the arm in the scapular plane.
CLINICIANS AND HAND POSITION Clinician places the stabilizing hand over the distal humerus to apply distraction
and maintain the shoulder in lateral rotation. The heel of the mobilizing hand is
over the humeral head.
MOBILIZATION APPLICATION As the distal hand holds the arm in lateral rotation, the proximal hand applies an
inferior glide force
NOTE As more motion is gained, the technique can be applied in other open positions
closer to the end of motion.
266
JOINT MOBILIZATION – SCAPULOTHORACIC & CLAVICULAR
SCAPULAR DISTRACTION
INDICATIONS To improve movement between the scapula and thoracic ribs. The scapulothoracic
articulation is not a true joint, but the soft tissue is stretched to obtain normal
shoulder girdle mobility thus, increase scapular motions of elevation, depression,
protraction, retraction, rotation, upward and downward rotations, and winging
RESTING POSITION The scapula is resting against the thoracic cage
PATIENT POSITION Side-lying with the involved arm on top.
CLINICIANS AND HAND Clinician faces the patient at chest level. Clinician’s arm closest to the patient’s
POSITION head approaches the patient’s scapula from over the top of the shoulder.
Clinician’s arm most distant from the patient’s head is placed between the patient’s
arm and rib cage, and the fingers of both hands of the clinician are positioned along
the scapula’s vertebral border. The hand closest to the patient’s head grasps along
the scapula’s upper vertebral border.
MOBILIZATION APPLICATION For personal comfort and professional consideration, a pillow should be placed
between the patient and the clinician. As the shoulder is moved into retraction by
the clinician’s abdomen against the pillow positioned anteriorly to the patient’s
anterior shoulder and upper trunk, the fingers of both hands apply a force to tilt
the vertebral border of the scapula posteriorly away from the ribs.
267
SCAPULAR MOBILIZATION
CLINICIANS AND HAND The clinician’s cephalad hand is placed over the superior scapular border, and the
POSITION caudal hand is positioned with the web space and lateral index finger cradling the
inferior angle of the scapula
MOBILIZATION APPLICATION As the superior hand pushes the scapula in a caudal direction, the index finger of
the inferior hand pushes in a cranial direction to gain access under the inferior
angle of the scapula. Move the scapula in the desired direction by lifting from the
inferior angle or by pushing on the acromion process.
ACROMIOCLAVICULAR POSTERIOR GLIDE

INDICATIONS Hypomobility of the AC joint
RESTING POSITION Joint is in its physiological relaxed position with the arm at the side.
PATIENT POSITION Supine with the arm relaxed and supported at the side.
CLINICIANS AND HAND When the patient is supine, the clinician stands at the head for inferior glides and
POSITION at the side for anterior and posterior glides. One thumb is reinforced by the
clinician’s other thumb over the distal acromion while the fingers are used as
buttresses to support thumb motion on the AC joint.
MOBILIZATION APPLICATION An anterior-to-posterior mobilization force is applied to the anterior aspect of the
most lateral acromion. Force is applied parallel to the joint plane
NOTE This technique may also be performed with the patient sitting and the clinician
facing the patient to perform posterior and inferior glides or behind the patient to
perform anterior glides. (PICTURE B)
268
ACROMIOCLAVICULAR ANTERIOR GLIDE
INDICATIONS Hypomobility of the AC joint.
RESTING POSITION Joint is in its physiological position with the arm at the side.
PATIENT POSITION Seated with the arm relaxed and supported at the side.
CLINICIANS AND HAND Clinician stands behind the patient. The clinician’s thumb is positioned on the
POSITION posterior aspect of the most lateral acromion.
MOBILIZATION APPLICATION A posterior-to-anterior mobilization force is applied at the lateral end of the
posterior acromion. Force is applied parallel to the joint plane
NOTE This technique may also be performed with the patient supine
269
STERNOCLAVICULAR INFERIOR GLIDE
INDICATIONS Caudal glide to increase elevation of the clavicle.
RESTING POSITION Arm is relaxed at the side of the body.

CLINICIANS AND HAND Clinician’s thumb is placed on the proximal clavicle just lateral to the manubrium
POSITION at the clavicle’s superior aspect.
MOBILIZATION APPLICATION Force is applied inferiorly toward the patient’s waist
NOTE Force is applied parallel to the joint surface
STERNOCLAVICULAR POSTERIOR GLIDE

INDICATIONS Posterior glide to increase retraction
PATIENT POSITION Supine
CLINICIANS AND HAND POSITION Clinician’s thumb is placed on the proximal clavicle on its anterior aspect just
lateral to the manubrium
MOBILIZATION APPLICATION Force is applied posteriorly down toward the table
NOTE Force is applied parallel to the joint surface. Clinician may also stand at the
patient’s side.
270
STERNOCLAVICULAR SUPERIOR GLIDE
INDICATIONS Superior glide to increase depression of the clavicle
CLINICIANS AND HAND Clinician stands at the patient’s side near the waist, facing the patient’s head. Clinician’s
POSITION thumb is placed on the proximal clavicle along its inferior aspect just lateral to the
manubrium.
MOBILIZATION APPLICATION Push with your index finger in a superior direction
NOTE Force is applied parallel to the joint surface.
STERNOCLAVICULAR ANTERIOR GLIDE

INDICATIONS Anterior glide to increase protraction
CLINICIANS AND HAND Your fingers are placed superiorly and thumb inferiorly around the clavicle
POSITION
MOBILIZATION APPLICATION The fingers and thumb lift the clavicle anteriorly for an anterior glide
271
JOINT MOBILIZATION – ELBOW AND FOREARM JOINTS
HUMEROULNAR DISTRACTION
INDICATIONS Testing;
• initial treatment (sustained grade II)
• pain control (grade I or II oscillation)
• to increase flexion or extension (grade III or IV).
RESTING POSITION Elbow 70° flexion with 10° supination.
PATIENT POSITION Supine with elbow in resting position.
CLINICIANS AND HAND The clinician faces and stands alongside the patient. The patient’s wrist rests against
POSITION the clinician’s shoulder. The humerus is fixed using a stabilization strap, an assistant, or
the rehabilitation clinician’s hand. The stabilizing hand is placed over the anterior distal
humerus, and the mobilizing hand is placed just distal to the elbow joint on the forearm
MOBILIZATION APPLICATION The clinician applies a distraction force to the proximal humeroulnar joint at 45° angle
to the shaft of the bone by leaning backward.
NOTE The clinician’s weight transfer from the front to the back foot provides the distraction
force; the clinician’s arms should be relaxed. The fingers are together, using the hands
as a “paddle” to apply traction force over a larger area than if the fingers were spread
apart.
272
HUMEROULNAR DISTAL GLIDE
INDICATIONS To increase flexion.
PATIENT POSITION Supine with elbow in resting position.
CLINICIANS AND HAND POSITION The clinician faces and stands alongside the patient. Begin with the elbow in resting
position. Progress by positioning it at the end range of flexion. Place the fingers of
your medial hand over the proximal ulna on the volar
surface; reinforce it with your other hand.
MOBILIZATION APPLICATION First apply a distraction force to the joint at a 45° angle to the ulna, then while
maintaining the distraction, direct the force in a distal direction along the long axis
of the ulna using a scooping motion
distraction with distal

glide (scoop motion)
273
HUMEROULNAR MEDIAL GLIDE
INDICATIONS To relieve pain, improve elbow flexion or extension
RESTING POSITION Elbow 70° flexion with 10° supination
PATIENT POSITION Patient is supine or sitting
CLINICIANS AND The rehabilitation clinician faces and stands alongside the patient. The patient’s elbow is
HAND POSITION positioned in the humeroulnar joint’s resting position, and the distal forearm and wrist are
placed between the rehabilitation clinician’s lateral rib cage and medial humerus. The thenar
eminence of the rehabilitation clinician’s stabilizing hand is placed against the medial epicondyle
of the patient’s humerus, and the mobilizing hand is on the proximal lateral forearm near the
elbow joint.
MOBILIZATION The mobilizing hand applies a sustained 10 s pressure against the radius to create a medial glide
APPLICATION of the ulna with the humerus stabilized
NOTE An oscillation may also be used with this technique. The pressure against the medial elbow may
cause discomfort or injury to the ulnar nerve, so it must be applied with caution or with the use
of a towel for padding.
HUMEROULNAR LATERAL GLIDE

INDICATIONS To relieve pain, improve elbow flexion or extension
PATIENT POSITION Patient is supine or sitting, similar to the medial glide position
CLINICIANS AND The clinician’s hand placement is reversed from the positions for the medial glide, so the
HAND POSITION stabilizing hand is on the lateral epicondyle of the patient’s humerus and the mobilizing hand is
on the medial forearm immediately distal to the joint. The patient’s distal forearm and wrist are
secured between the clinician’s lateral ribs and humerus.
MOBILIZATION The mobilizing hand applies a lateral pressure against the proximal ulna on the medial forearm.
APPLICATION
274
HUMERORADIAL DISTRACTION
INDICATIONS To reduce pain, improve elbow extension and radial motion.
RESTING POSITION Full extension with full supination.
PATIENT POSITION Supine or sitting in a chair with the arm slightly abducted and supported on the table.
CLINICIANS AND Clinician stabilizes the arm with a hand on the distal humerus and the index finger palpating the
HAND POSITION humeroradial joint space. The mobilizing hand is placed around the lateral side distal radius but
not on the distal ulna.
MOBILIZATION The mobilization force is applied when the clinician moves his or her body weight to the back
APPLICATION foot; the clinician’s body is used to distract the elbow while applying a medially arched
distraction at the distal radius
NOTE The clinician uses body weight transfer from the front to back foot rather than arm force to
deliver the joint distraction.
HUMERORADIAL ANTERIOR GLIDE

INDICATIONS To reduce pain or increase flexion.
RESTING POSITION Resting Position: Full extension with full supination.
PATIENT POSITION Supine with humerus supported on a towel roll on the table.
CLINICIANS AND clinician places the stabilizing hand on the medial distal humerus and the mobilizing hand on the
HAND POSITION proximal radius, with the fingers on the posterior aspect and the thenar eminence on the
anterior aspect. The fingers are C-curved so the finger pads are on the posterior radius; all fingers
are adduced so they act as one unit, applying the mobilization force as one unit rather than four
individual fingers.
MOBILIZATION Finger pads move the radial head upward in a posterior-to-anterior direction
APPLICATION
NOTE Also called ventral glide, posterior-anterior glide, or PA glide.
275
HUMERORADIAL POSTERIOR GLIDE
INDICATIONS To reduce pain or increase extension
RESTING POSITION Full extension with full supination
PATIENT POSITION Supine with arm supported on a towel roll on the table.
CLINICIANS AND The rehabilitation clinician places the stabilizing hand on the medial distal humerus and the
HAND POSITION mobilizing hand on the proximal radius, with the fingers on its posterior aspect and the thenar
eminence on its anterior aspect, as described previously.
MOBILIZATION The thenar eminence on the anterior radius moves the radial head posteriorly.
APPLICATION
NOTE Also called a dorsal glide, an anterior–posterior glide, or an AP glide.
PROXIMAL HUMERADIAL DORSAL GLIDE

INDICATIONS To reduce pain or improve pronation.
PATIENT POSITION Sitting or supine with arm supported on the table.
CLINICIANS AND HAND The rehabilitation clinician faces the patient. The proximal ulna is stabilized by the medial
POSITION hand, and the mobilizing hand is wrapped around the radial head with the thenar eminence
on the anterior aspect and the finger pads on the posterior radius. If the clinician cannot
maintain the resting position with the stabilizing hand, the patient’s forearm and wrist may
be supported with a rolled towel or pillow.
MOBILIZATION A downward pressure is exerted from the rehabilitation clinician’s shoulder down through
APPLICATION the mobilizing hand to move the radial head posteriorly
276
PROXIMAL HUMERADIAL VENTRAL GLIDE
INDICATIONS To reduce pain or improve supination.
PATIENT POSITION Sitting with forearm supported on the table. The elbows are apart and the hands are
intertwined but relaxed to help anchor the distal forearm.
CLINICIANS AND HAND The stabilizing hand is placed around the proximal ulna at the olecranon process, and the
POSITION mobilizing hand is placed around the head of the radius with the palm on the dorsal surface
and the fingers anteriorly positioned.
MOBILIZATION Radial head is moved with a posterior-to-anterior force, using the heel of the hand
APPLICATION
Ventral glide
Dorsal glide
277
DISTAL HUMERADIAL LONGITUDINAL DISTRACTION
INDICATIONS Used prior to other mobilization techniques. Can be applied at the end-range position to
improve motion.
RESTING POSITION 10° supination
PATIENT POSITION Sitting or supine
CLINICIANS AND HAND With the clinician facing the patient, the clinician’s stabilizing hand is just proximal to the
POSITION patient’s elbow with the web space wrapped around the patient’s distal arm. The mobilizing
hand wraps around the anterior wrist and tilts the patient’s hand towards radial deviation.
The forearm of the mobilizing arm is in line with the patient’s forearm.
MOBILIZATION With the clinician’s main hand contact at the base of the patient’s thenar eminence, slack Is
APPLICATION taken up by pulling the forearm to distract the joint, and either an oscillating longitudinal pull
or a sustained traction is applied with the mobilizing hand. The clinician’s distraction force is
directed in line with the radial shaft.
NOTE This technique may be performed with the forearm in any position of comfort.
278
DISTAL RADIOULNAR ANTEROPOSTERIOR (AP) AND POSTEROANTERIOR (PA)
GLIDES
INDICATIONS To increase pronation and supination.
RESTING POSITION 10° supination
PATIENT POSITION Sitting or supine.
CLINICIANS AND HAND One hand is used to grasp the distal ulna and the other to grasp the distal radius proximal
POSITION to the wrist.
MOBILIZATION The pad on one thenar eminence is used to apply the AP force on one bone; the fingers of
APPLICATION the opposite hand, on the patient’s posterior forearm, are used to apply the PA force on the
other bone
NOTE The vertical forces applied by the two hands should be equal in timing and degree. An AP
force on the radius with a PA force on the ulna increases supination, and an AP force on the
ulna with a PA force on the radius increases pronation. Either oscillations or sustained
mobilization forces are appropriate. An alternative mobilization method is stabilizing the
ulna while applying an AP force on the radius to increase supination or applying a PA force
on the posterior radius to gain pronation.
279
JOJNT MOBILIZATION – WRIST & HAND
WRIST TRACTION
INDICATIONS General mobilization
RESTING POSITION Forearm can be in pronation, supination, or midway between. The wrist is in neutral with
slight ulnar deviation
PATIENT POSITION Supine on table or sitting with forearm resting on table. A towel is under the distal forearm
for comfort.
CLINICIANS AND HAND Clinician stabilizes the distal forearm with one hand around the forearm just proximal to the
POSITION wrist and places the mobilizing hand over the distal carpal row.
MOBILIZATION A traction force in a longitudinal direction is applied with the mobilizing hand
APPLICATION
NOTE The force can be either a sustained application or a traction oscillation.
280
WRIST DORSAL GLIDE
INDICATIONS To increase wrist flexion.
RESTING POSITION Neutral wrist flexion–extension with slight ulnar deviation and neutral forearm supination–
pronation
PATIENT POSITION As above procedure
CLINICIANS AND HAND Clinician places the stabilizing hand over the distal forearm as in the previous technique. The
POSITION mobilizing hand grasps around the hand over the distal carpal row.
MOBILIZATION Slight traction to the wrist with an AP mobilizing force is applied by the distal, mobilizing hand
APPLICATION
NOTE The force should be applied at an angle parallel to the wrist joint surface.
WRIST VOLAR GLIDE

INDICATIONS To increase wrist extension
RESTING POSITION Neutral in wrist flexion–extension with slight ulnar deviation and neutral forearm supination–
pronation
PATIENT POSITION Patient is sitting or supine. Patient’s forearm is in pronation and the wrist is in its resting
position.
CLINICIANS AND HAND The rehabilitation clinician places the stabilizing hand over the distal forearm just adjacent to
POSITION the wrist and the mobilizing hand over the distal carpal row.
MOBILIZATION Slight distraction of the wrist with a PA force is applied by the distal, mobilizing hand
APPLICATION
NOTE The force should be applied at an angle parallel to the wrist joint surface
VOLAR GLIDE DORSAL GLIDE
281
WRIST RADIAL GLIDE
INDICATIONS To increase ulnar deviation.
RESTING POSITION Neutral in wrist flexion-extension with slight ulnar deviation and neutral forearm supination-
pronation.
PATIENT POSITION Patient is sitting or supine. Patient’s forearm is positioned with the ulnar side upward and the
wrist in neutral. A rolled towel is placed under the distal forearm.
CLINICIANS AND HAND The rehabilitation clinician places the stabilizing hand over the distal radial aspect of the
POSITION forearm adjacent to the wrist joint and the mobilizing hand grasps the distal carpal row with
the fingers around the medial aspect of the patient’s wrist
MOBILIZATION A vertically upward mobilizing force is applied.

APPLICATION
NOTE Keep the hands relaxed with the mobilizing force coming from the shoulders.
WRIST ULNAR GLIDE

INDICATIONS To increase radial deviation.
RESTING POSITION Same position as for the radial glide
PATIENT POSITION Patient is supine or sitting. Patient’s forearm is positioned with the radial side upward and
the wrist in neutral. A rolled towel is placed under the distal forearm.
CLINICIANS AND HAND The clinician places the stabilizing hand over the distal forearm adjacent to the wrist joint
POSITION and the mobilizing hand grasps the distal carpal row with the thumb web around the lateral
aspect of the patient’s wrist.
MOBILIZATION A vertically downward mobilizing force is applied.

APPLICATION
NOTE Keep the hands relaxed with the mobilizing force coming from the shoulders.
282
CARPOMETACARPAL JOINT TRACTION
INDICATIONS To relieve pain or provide a general increase in joint mobility.
RESTING POSITION Midway between flexion and extension.
PATIENT POSITION Supine on table or seated with forearm resting on table and towel under distal forearm.
CLINICIANS AND HAND Clinician is seated or standing. The carpal is stabilized with a tip-to-tip pinch grasp. The
POSITION mobilizing hand uses a lateral finger-pinch grasp at the proximal metacarpal.
MOBILIZATION Metacarpal is pulled in the direction of its long axis

APPLICATION
NOTE The lateral surface of the index finger makes sufficient contact to provide adequate tension
to the joint’s capsule.
283
CARPOMETACARPAL ANTEROPOSTERIOR GLIDE
INDICATIONS To relieve pain or increase CMC joint extension.
CLINICIANS AND HAND Clinician is seated or standing. Clinician stabilizes the patient’s carpal with the thumb and
POSITION index finger of one hand, and then places the thumb and index finger of the other hand over
the metacarpal to be treated, with the thumb on the volar surface
MOBILIZATION An AP force is applied by the mobilizing hand on the metacarpal.

APPLICATION
NOTE Carpometacarpal joints 4 and 5 normally have more mobility than joints 2 and 3.
CARPOMETACARPAL POSTEROANTERIOR GLIDE

INDICATIONS To relieve pain or increase CMC joint flexion.
CLINICIANS AND HAND Clinician is seated or standing. The clinician’s grasps are similar to those described for AP
POSITION glides except that the clinician’s thumbs are placed on the dorsal surface and the fingers are
placed on the volar surface
MOBILIZATION PA force is applied to the metacarpal.

APPLICATION
NOTE If mobilizing the radial side, the clinician’s fingers grasp around the first web space of the
patient’s hand. If mobilizing the ulnar hand, the rehabilitation clinician grasps the ulnar
border of the hand.
CARPOMETACARPAL CARPOMETACARPAL
ANTEROPOSTERIOR GLIDE POSTEROANTERIOR GLIDE
284
THUMB TRACTION
INDICATIONS General mobilization of the joint.
RESTING POSITION The CMC joint is in mid-position between flexion–extension and abduction–adduction.
CLINICIANS AND HAND Stabilizing hand uses a tip-to-tip or lateral pinch grasp over the carpal bone, and the
POSITION mobilizing hand uses a lateral pinch grasp around the metacarpal’s proximal region adjacent
to the joint margin.
MOBILIZATION Distract the metacarpal along its longitudinal axis from the joint.
APPLICATION
NOTE Distraction can be either sustained or oscillating.
THUMB POSTEROANTERIOR/VOLAR GLIDE

INDICATIONS To relieve pain or increase thumb adduction.
PATIENT POSITION Supine on table or seated with forearm resting on table and towel under distal forearm. Palm
faces down.
CLINICIANS AND HAND Clinician stabilizes the trapezium and trapezoid, the proximal aspect of the joint, using the
POSITION thumb and index finger of one hand; the clinician holds the patient’s first metacarpal with
the opposite thumb along the posterior aspect and the index finger around the anterior
aspect.
MOBILIZATION Slight traction to the joint is applied, followed by a PA glide to the metacarpal
APPLICATION
NOTE Both the trapezium and trapezoid are stabilized in the proximal joint segment.
285
THUMB ANTEROPOSTERIOR/DORSAL GLIDE
INDICATIONS To relieve pain or increase thumb CMC abduction.
Palm faces down.
CLINICIANS AND HAND Clinician stabilizes the trapezium and trapezoid at the proximal aspect of the joint using
POSITION the thumb and index finger of one hand; the clinician holds the patient’s first metacarpal
with the opposite thumb along the posterior aspect and the index finger around the
anterior aspect.
MOBILIZATION This time, instead of the thumb providing the mobilizing force, the index finger on the
APPLICATION metacarpal’s volar surface provides an AP glide.
NOTE Clinician stabilizes both the trapezium and trapezoid at the proximal aspect of the joint
using the thumb and index finger of one hand; the clinician holds the patient’s first
metacarpal with the opposite thumb along the posterior aspect and the index finger
around the anterior aspect.
THUMB ANTEROPOSTERIOR/DORSAL GLIDE
THUMB POSTEROANTERIOR/VOLAR GLIDE
286
THUMB ULNAR GLIDE
INDICATIONS To relieve pain or increase flexion
PATIENT POSITION Patient is supine or seated with the ulna resting on the table. A rolled towel is under the
distal forearm. The forearm, wrist, and thumb are positioned in neutral.
CLINICIANS AND HAND With the proximal aspect of the joint stabilized using the thumb and index finger of one
POSITION hand, the rehabilitation clinician grasps the metacarpal with the other hand
MOBILIZATION Radial-to-ulnar glide is applied parallel to the joint surface.

APPLICATION
NOTE The thumb’s CMC joint is convex at its proximal joint surface.
THUMB RADIAL GLIDE

INDICATIONS To relieve pain or increase extension
PATIENT POSITION Patient is supine or seated with the hand supinated resting on the table. A rolled towel is
under the distal forearm. The forearm, wrist, and thumb are positioned in neutral.
CLINICIANS AND HAND With the proximal aspect of the joint stabilized using the thumb and index finger of one
POSITION hand, the rehabilitation clinician grasps the metacarpal with the other hand
MOBILIZATION Ventral to dorsal glide is applied parallel to the joint surface.

APPLICATION
THUMB ULNAR GLIDE THUMB RADIAL GLIDE
287
TABLE 1: MCP AND IP JOINT MOBILIZATION INFORMATION
288
MCP and IP TRACTION
INDICATIONS General mobilization and relaxation.
RESTING POSITION Specific flexion position depends on specific joint mobilized; see Table 1
PATIENT POSITION Supine on table or seated with forearm resting on table and towel under distal forearm
CLINICIANS AND HAND The proximal aspect of the joint is grasped with the stabilizing hand while the distal aspect
POSITION of the joint is grasped by the index finger and thumb of the mobilizing hand
MOBILIZATION Traction force in line with the longitudinal axis is applied perpendicular to the joint’s
APPLICATION surface.
NOTE Since the configurations of these joints are similar, this technique may be applied to any
of the IP or MCP joints.
MCP and IP ROTATION

INDICATIONS To improve accessory rotation motion of the joints.
CLINICIANS AND HAND The proximal aspect of the joint is grasped with a lateral pinch of the thumb and index
POSITION finger with the mobilizing hand using a similar grasp on the distal joint segment
immediately adjacent to the joint.
MOBILIZATION Traction is maintained while a medial rotation is applied, then a lateral rotation
APPLICATION
NOTE Rotation is an accessory motion that must be restored in order for the patient to have full
function of the joint and hand. If the finger is lacking the last few degrees of motion or the
hand cannot make a complete fist, it may be that rotation of the MCP is limited.
289
MCP and IP POSTEROANTERIOR AND ANTEROPOSTERIOR GLIDES
INDICATIONS • PA glide increases flexion motion
• AP glide increases extension motion.
CLINICIANS AND HAND The proximal aspect of the joint is stabilized while the distal aspect receives traction with
POSITION the stabilizing hand in a lateral pinch grasp on the proximal aspect and a similar grasp of the
mobilizing hand on the distal joint segment
MOBILIZATION While traction is maintained, either a PA force (to increase flexion) or an AP force (to
APPLICATION increase extension) is applied.
NOTE Because the joints are a concave surface moving on a convex surface, the mobilization force
is in the same direction as the joint’s roll or movement.
MCP and IP LATERAL GLIDES

INDICATIONS To improve abduction and adduction of the MCP and IP joints.
CLINICIANS AND HAND The proximal aspect of the joint is stabilized while the distal aspect receives traction with the
POSITION mobilizing hand rotated to the side of the joint rather than anteriorly and posteriorly to
deliver lateral mobilization force.
MOBILIZATION A radial or ulnar glide force is applied to the distal aspect of the joint, depending on the finger
APPLICATION and movement
• Radial glide improves abduction of MCPs 1 and 2, adduction of MCPs 4 and 5, and
radial abduction of MCP 3.
• Ulnar glide improves adduction of MCPs 1 and 2, abduction of MCPs 4 and 5, and
ulnar abduction of MCP 3.
NOTE Abduction and adduction occur as physiological motions at the MCP joints and accessory
motions at the IP joints. The thumb applies the mobilization force, so it is positioned on the
radial or ulnar aspect of the joint.
290
MCP and IP TRACTION
MCP and IP ROTATION
MCP and IP POSTEROANTERIOR

AND ANTEROPOSTERIOR GLIDES
MCP and IP LATERAL GLIDE
291
JOINT MOBILIZATION - HIP
TRACTION / INFERIOR GLIDE
INDICATIONS To help regain joint play. In grades I and II, to relieve pain.
RESTING POSITION 30° flexion and 30° abduction with slight lateral rotation.
CLINICIANS AND HAND The rehabilitation clinician grasps the distal tibia and fibula of the affected limb and places
POSITION the hip in a resting position.
MOBILIZATION The clinician leans backward, using his or her body weight to supply the traction force.
APPLICATION (PICTURE A)
NOTE If the patient has a history of knee disorders, an alternative position for an inferior glide is
to have the patient’s leg over the rehabilitation clinician’s shoulder. The clinician clasps his
or her hands around the proximal thigh and applies the inferior glide (PICTURE B)
PICTURE A PICTURE B
292
LATERAL GLIDE
INDICATIONS To increase hip adduction
CLINICIANS AND HAND The clinician stands at the patient’s side by the thigh. A strap is secured around the patient’s
POSITION proximal thigh and the clinician’s hips. The clinician places his or her cephalic hand on the
lateral pelvis to stabilize it and the caudal hand on the distal thigh.
MOBILIZATION With the patient’s thigh in slight flexion, the clinician transfers his or her weight from the
APPLICATION front limb to the back limb, pushing his or her body against the strap to apply the traction
force through the strap.
NOTE The patient’s hip can be placed in various positions of flexion and rotation for application of
superior or inferior distractions with the lateral glide
293
POSTERIOR (AP/DORSAL) GLIDE
INDICATIONS To increase hip flexion and medial rotation.
PATIENT POSITION Supine with the hip and knee flexed.
CLINICIANS AND HAND The degree of hip flexion depends on the technique used. When a belt is used, partial flexion
POSITION of the joints is necessary, with the belt placed around the distal thigh and secured to the
rehabilitation clinician’s shoulder. The clinician places the stabilizing hand under the
belt and the mobilizing hand over the anterior proximal thigh just distal to the inguinal
ligament.
MOBILIZATION With the elbow kept extended, the rehabilitation clinician applies a downward force on the
APPLICATION proximal thigh, using his or her lower extremities, while the patient’s thigh is kept stable with
the belt (PICTURE A)
NOTE An alternative position is with the hip in 90° flexion and about 10° adduction and the knee in
full flexion. The rehabilitation clinician applies the posterior glide force through the long axis
of the femur by leaning his or her body weight into the femur. Care must be taken not to
apply the mobilizing force through the patella (PICTURE B)
PICTURE A PICTURE B
294
MEDIAL GLIDE
INDICATIONS To increase hip abduction.
PATIENT POSITION The patient is side-lying on the unaffected hip while the clinician supports the distal thigh and
knee and positions the thigh in slight abduction and flexion
CLINICIANS AND HAND The mobilizing hand is placed on the proximal thigh between the greater trochanter and
POSITION pelvis.
MOBILIZATION The mobilizing force is applied downward, parallel to the joint’s plane.
APPLICATION
NOTE If the patient is large compared to the clinician, the assistance of another clinician to support
the patient’s limb may be needed. This technique may also be performed with the patient in
supine.
ANTERIOR (PA/VENTRAL) GLIDE

INDICATIONS To increase hip extension and lateral rotation.
PATIENT POSITION Prone with the knee flexed.
CLINICIANS AND The clinician supports the distal thigh using the stabilizing hand or a strap.
HAND POSITION
MOBILIZATION The mobilizing hand applies a downward force through an extended elbow; body weight
APPLICATION exerts the force. The hip can be placed in various rotation positions for additional techniques.
(PICTURE A)
NOTE In an alternative position, the patient is prone, with the hips on the edge of the table and the
noninvolved lower extremity supporting the body weight with the lower-extremity foot on the
floor. The clinician can either support the patient’s distal thigh in one hand or can have a
stabilizing strap over the shoulder and wrapped around the distal thigh (PICTURE B).
295
MEDIAL GLIDE
PICTURE A PICTURE B
ANTERIOR
(PA/VENTRAL) GLIDE
296
JOINT MOBILIZATION – KNEE (TIBIOFIBULAR JOINT)
PROXIMAL TIBIOFIBULAR JOINT ANTERIOR AND POSTERIOR GLIDES
INDICATIONS Restricted motion of the knee, ankle, or both
RESTING POSITION 25° of knee flexion with 10° of ankle plantar flexion.
PATIENT POSITION Supine with hip and knee flexed and foot resting on the tabletop.
CLINICIANS AND HAND Clinician stands at the side of the treatment table near the knee being treated and grasps
POSITION the fibular head with pads of thumb anteriorly and index and middle fingers posteriorly.
MOBILIZATION Fibular head is moved anteriorly, then posteriorly

APPLICATION
NOTE The weight of the leg anchored with the foot on the table stabilizes the tibia.
297
TIBIOFIBULAR DISTRACTION
INDICATIONS General restriction or general relaxation.
RESTING POSITION 20° to 25° flexion.
PATIENT POSITION Supine with knee supported in resting position.
CLINICIANS AND HAND The femur is stabilized with one hand proximal to the knee, and the mobilizing hand is placed
POSITION proximal to the ankle joint.
MOBILIZATION The tibia is pulled distally by the mobilizing hand while the stabilizing hand secures the thigh
APPLICATION
NOTE This technique is often used both prior to and after using grade III and IV mobilizations.
Traction: A
As above description
Alternative Traction: B
Patient in sitting high at edge of couch, while

lower limb in hanging. Therapist applies
traction towards the floor as shown in
picture with help of gravity
Alternative Traction: C
Patient in prone, while posterior thigh is

supported with belt. Therapist applies
traction as shown in picture. Therapist use
body weight traction backward during
traction
298
TIBIOFIBULAR ANTERIOR GLIDES
INDICATIONS To increase knee extension.
PATIENT POSITION Prone. The knee is flexed with the thigh supported on the table and the patient’s leg resting
on the rehabilitation clinician’s shoulder. A pad under the distal thigh will make the position
more comfortable for the patient and align the thigh more appropriately for the glide.
CLINICIANS AND HAND With the clinician at the foot of the table, the patient’s distal leg is supported on the
POSITION rehabilitation clinician’s shoulder. The clinician clasps his or her hands around the proximal
leg near the posterior knee and glides the tibia anteriorly on the femur
MOBILIZATION The glide force must be parallel to the plane of the joint surface. When the knee is moved
APPLICATION out of the resting position for mobilizations, the angle of force will also change since the
force must always be parallel to the tibia’s joint surface. (PICTURE A)
NOTE The hamstrings should remain relaxed to produce the most effective results.
• An alternative posterior-to-anterior mobilization technique is performed with the
patient prone and the rehabilitation clinician standing along the table’s side at the
level of the patient’s knee and rotated to face the patient’s foot. The clinician
supports the distal tibia with the knee at 30° flexion with the stabilizing hand. An
anterior force is applied by the mobilizing hand just distal to the posterior knee joint.
(PICTURE B)
• An anterior glide can also be performed with the patient sitting with the thighs on
the table and the legs freely hanging over the side. The clinician sits on a treatment
stool facing the patient and secures the patient’s leg between his or her knees to
place the knee in a resting position and places both hands over the posterior
proximal leg just below the knee.
PICTURE A PICTURE B
299
TIBIOFIBULAR POSTERIOR GLIDES
INDICATIONS To increase knee flexion motion.
PATIENT POSITION Patient is supine with a pad under the thigh to maintain the joint in a resting position.
CLINICIANS AND HAND The rehabilitation clinician stands near the treated knee and places the heels of his or her
POSITION hands on the anterior proximal tibia.
MOBILIZATION Mobilization Application: Posterior glide parallel to the tibia’s joint surface (PICTURE A)
APPLICATION
NOTE In an alternative position, the patient is sitting with the knee over the edge of the table and
the thigh supported on the table with a towel roll under the distal thigh. The clinician sits on
a treatment stool/standing facing the patient and secures the patient’s leg between his or
her knees to place the knee in a resting position. The rehabilitation clinician applies a
posterior glide at the tibial condyles. (PICTURE B)
PICTURE A PICTURE B
300
PATELLOFEMORAL LATERAL GLIDES
INDICATIONS Restricted medial-lateral motion of the patella.
RESTING POSITION Knee extension.
PATIENT POSITION The patient lies supine, and a rolled towel is placed under the knee for knee comfort and
support.
CLINICIANS AND HAND The clinician stands at the side of the treatment table near the knee being treated, and the
POSITION clinician’s thumb pads are on the medial aspect of the patella.
MOBILIZATION Thumbs move the patella laterally. Care must be taken to apply a lateral force, not a
APPLICATION downward or compressive force, on the patella.
NOTE Patellar mobility is necessary for full knee flexion–extension motion and tibial rotation.
PATELLOFEMORAL MEDIAL GLIDES

INDICATIONS Restricted medial-lateral motion of the patella.
PATIENT POSITION The patient lies supine, and a rolled towel is placed under the knee for comfort and support.
CLINICIANS AND HAND The clinician stands at the side of the treatment table near the knee being treated. The
POSITION clinician’s index finger pads are on the lateral aspect of the patella.
MOBILIZATION Finger pads move the patella medially. Care must be taken to apply a medial force, not a
APPLICATION downward or compressive force, on the patella.
PATELLOFEMORAL INFERIOR GLIDES

INDICATIONS Restricted inferior motion of the patella.
support.
POSITION clinician’s thumb and index finger are placed around the superior rim of the patella
MOBILIZATION The clinician glides the patella distally in an inferior direction toward the toes, being careful
APPLICATION not to compress the patella on the femur.
NOTE Patellar mobility is necessary for full knee flexion–extension motion and tibial rotation
301
PATELLOFEMORAL SUPERIOR GLIDES
INDICATIONS Restricted superior motion of the patella
RESTING POSITION Knee extension
support
POSITION clinician’s thumb and index finger are placed around the inferior rim of the patella.
MOBILIZATION The clinician’s thumb and index finger exert a cephalic force on the patella, avoiding
APPLICATION compression of the patella on the femur
PATELLOFEMORAL
LATERAL GLIDES
PATELLOFEMORAL
MEDIAL GLIDES
PATELLOFEMORAL PATELLOFEMORAL
INFERIOR GLIDES SUPERIOR GLIDES
302
ROTATIONAL GLIDE: ANTERIOR GLIDE OF THE MEDIAL TIBIAL CONDYLE
INDICATIONS Used to gain lateral tibial rotation in terminal knee extension
RESTING POSITION Resting position is 20° to 25° flexion, but this technique is often performed in an end-range
position.
PATIENT POSITION Prone with a pad under the distal femur for comfort.
CLINICIANS AND HAND The heel of one hand is on the posterior medial tibial plateau.
POSITION
MOBILIZATION A posterior-to-anterior (PA) glide of the medial posterior tibia on the femur to produce the
APPLICATION screw-home rotation for full knee extension
NOTE This technique is used to gain the last few degrees of extension in a knee.
ROTATIONAL GLIDE: POSTERIOR GLIDE OF THE MEDIAL TIBIAL CONDYLE

INDICATIONS Used to gain medial tibial rotation and knee flexion.
RESTING POSITION Resting position is 20° to 25° flexion, but this technique is often performed in an end-range
position.
PATIENT POSITION Patient is supine with the knee in flexion
CLINICIANS AND HAND Clinician places the heel of the hand on the medial tibial condyle anteriorly.
POSITION
MOBILIZATION An AP force is applied to the medial tibial condyle

APPLICATION
NOTE This technique may be used to acquire the last few degrees of knee flexion.
POSTERIOR GLIDE OF
THE MEDIAL TIBIAL
CONDYLE
ANTERIOR GLIDE OF THE MEDIAL

TIBIAL CONDYLE
303
JOINT MOBILIZATION – FOOT AND ANKLE
DISTAL TIBIOFIBULAR AP AND PA GLIDES
INDICATIONS Restricted ankle dorsiflexion, plantar flexion, or both.
RESTING POSITION 10° plantar flexion with slight inversion.
PATIENT POSITION An AP glide is performed with the patient supine. A PA glide is performed with the patient
prone and the distal extremity over the edge of the table.
CLINICIANS AND HAND For an AP glide, the clinician places the medial hand over the medial malleolus and lateral
POSITION tibia to stabilize the tibia and places the thenar eminence of the lateral hand over the lateral
malleolus and distal fibula. For a PA glide, the base of the lateral hand is placed over the
lateral malleolus while the medial hand stabilizes the distal tibia.
MOBILIZATION For an AP mobilization, a posterior glide is performed using a downward movement of the
APPLICATION lateral hand. For a PA mobilization, the anterior force is applied perpendicular to the plane
of the distal tibiofibular joint.
NOTE During dorsiflexion, the distal fibula normally moves superiorly and rotates medially relative
to the tibia. During plantar flexion, the distal fibula moves in the opposite directions. Normal
ankle motion depends on good fibular mobility. Restriction of joint play between the fibula
and tibia may require fibular mobilization in both AP and PA directions to restore normal
motion.
304
TALOCRURAL DISTRACTION
INDICATIONS To increase general joint play in the ankle joint; can also be used with lower grades of
mobilization to relieve pain.
RESTING POSITION 10° plantar flexion.
PATIENT POSITION Supine with knee and hip extended.
CLINICIANS AND HAND The rehabilitation clinician faces the foot and grasps the foot’s dorsum with both hands,
POSITION intertwining or overlapping the fingers of the two hands on top of the foot and placing the
thumbs on the plantar aspect
MOBILIZATION Clinician leans backward to apply a distraction force.

APPLICATION
NOTE This technique is also used to assist in relaxation before the application of grade III and IV
mobilization techniques.
305
TALOCRURAL ANTERIOR GLIDE
INDICATIONS To increase plantarflexion.
RESTING POSITION 10° plantar flexion/ The resting position is midway between inversion and
eversion.
PATIENT POSITION Prone, with the foot over the edge of the table.
CLINICIANS AND HAND Working from the end of the table, place your lateral hand across the dorsum of the foot to
POSITION apply a grade I distraction. Place the web space of your other hand just distal to the mortise
on the posterior aspect of the talus and calcaneus.
MOBILIZATION Push against the calcaneus in an anterior direction (with respect to the tibia); this glides the
APPLICATION talus anteriorly.
NOTE Alternate Position

• Patient is supine. Stabilize the distal leg anterior to the mortise with your proximal
hand. The distal hand cups under the calcaneus. When you pull against the calcaneus
in an anterior direction, the talus glides anteriorly.
TALOCRURAL POSTERIOR GLIDE

INDICATIONS To increase dorsiflexion
RESTING POSITION 10° plantar flexion
PATIENT POSITION Supine with knee extended and ankle over the end of the table with a rolled towel under the
distal leg for comfort.
CLINICIANS AND HAND The clinician faces the foot. The stabilizing hand is placed anteriorly around the distal leg at
POSITION the level of the malleoli, and the mobilizing hand is placed around the proximal dorsal foot
with the thumb and index finger adjacent to the distal aspect of the malleoli.
MOBILIZATION The talus is glided posteriorly in the plane of the joint

APPLICATION
NOTE Also known as a ventral glide or AP glide.
TALOCRURAL TALOCRURAL
ANTERIOR POSTERIOR
GLIDE GLIDE
306
ANTERIOR GLIDE OF TIBIA
INDICATIONS Restricted dorsiflexion.
RESTING POSITION 10° plantar flexion.
PATIENT POSITION The patient stands in a forward–backward stride position on a treatment table with the
treated extremity ahead of the uninvolved extremity. A mobilization strap is secured around
the distal tibia and fibula and the clinician’s hips and then adjusted for a comfortable length
CLINICIANS AND HAND Clinician places the web of the thumb and index finger of the stabilizing hands around the
POSITION anterior ankle joint and also stands in a forward–backward stride position
MOBILIZATION With knees partially flexed, the clinician uses the hips to pull the strap forward, moving body
APPLICATION weight from front to back leg
SUBTALAR DISTRACTION
SUBTALAR DISTRACTION
INDICATIONS To improve general mobility.
RESTING POSITION Midway between extreme positions of inversion and eversion.
PATIENT POSITION Patient is supine with the foot over the end of the table
CLINICIANS AND HAND Clinician faces the foot. The stabilizing hand grasps the talus anteriorly, and the mobilizing
POSITION hand cups the posterior calcaneus
MOBILIZATION The calcaneus is pulled distally along the long axis of the extremity.
APPLICATION
NOTE This technique can be used to relieve pain and is good to use before and after grade III and
IV techniques.
307
SUBTALAR MEDIAL GLIDE
INDICATIONS To increase eversion.
RESTING POSITION Midway between extreme positions of inversion and eversion
PATIENT POSITION Patient is side-lying on uninvolved extremity. Involved ankle is off the end of the table with
a towel roll placed under the distal leg.
CLINICIANS AND HAND The distal leg is stabilized with the cephalic hand over the lateral leg just proximal to the
POSITION ankle; the caudal hand is cupped around the calcaneus with the fingers and base of the hand
on the medial and lateral calcaneus
MOBILIZATION A downward medial glide is applied to the calcaneus. Slight traction during the medial glide
APPLICATION makes the technique more comfortable for the patient.
NOTE This technique may be applied with the patient in supine, but a downward force on the joint
is easier to apply than a lateral-to-medial force that is required with the patient supine.
SUBTALAR LATERAL GLIDE

INDICATIONS To increase subtalar inversion.
RESTING POSITION Midway between extreme positions of inversion and eversion.
PATIENT POSITION Patient is in side-lying on the involved side. The foot is over the end of the table and a towel
is under the distal leg
CLINICIANS AND HAND The rehabilitation clinician stabilizes the extremity with the cephalic hand over the medial
POSITION distal extremity immediately proximal to the malleoli. The mobilizing hand is cupped around
the calcaneus with the fingers and base of the hand on the lateral and medial calcaneus
MOBILIZATION The force applied occurs directly downward and parallel to the joint surface.
APPLICATION
NOTE This technique may be applied with the patient in supine, but a downward force on the joint
is easier to apply than a medial-to-lateral force that is required with the patient supine.
SUBTALAR MEDIAL GLIDE SUBTALAR LATERAL GLIDE
308
INTERTARSAL ANTERIOR GLIDE
INDICATIONS To increase midfoot plantar flexion.
RESTING POSITION Midway between inversion–eversion with 10° plantar

flexion.
PATIENT POSITION Prone.
CLINICIANS AND HAND Clinician grasps the midfoot with one thumb, reinforced by the other thumb over the bone
POSITION to be mobilized. Forefoot is stabilized with the hands while the thumbs provide the
mobilization
MOBILIZATION Thumbs perform a PA movement of the bone.

APPLICATION
NOTE Weight of the leg helps to stabilize the ankle.
INTERTARSAL POSTERIOR GLIDE

INDICATIONS To increase midfoot dorsiflexion.
RESTING POSITION Midway between inversion–eversion with 10° plantar flexion.
CLINICIANS AND HAND Clinician stabilizes rearfoot with one hand and places the thumb of the other hand on the
POSITION foot’s dorsum and the fingers on the plantar aspect of the bone to be mobilized.
MOBILIZATION Mobilizing hand applies an AP movement in the plane of the joint surface
APPLICATION
NOTE Placement of the plantar surface of the foot on the table may also be used to stabilize the
rearfoot.
INTERTARSAL POSTERIOR GLIDE

INTERTARSAL ANTERIOR GLIDE
309
TARSOMETATARSAL, MP & IP JOINT DISTRACTION
INDICATIONS To enhance general joint mobility and relaxation.
RESTING POSITION First toe: 20° dorsiflexion; toes 2 through 5: 20° plantar flexion.
PATIENT POSITION Patient is relaxed, supine on the table with pad under ankle and foot off the end of the table.
CLINICIANS AND Phalanx is grasped with the thumb and fingers while the metatarsal is stabilized with the opposite
HAND POSITION hand
MOBILIZATION Distraction force is applied to the phalanx

APPLICATION
NOTE May also be used prior to and following grade II and III joint mobilization techniques.
TARSOMETATARSAL, MP & IP JOINT ANTERIOR AND POSTERIOR GLIDES

INDICATIONS Anterior (dorsal) glides increase extension of these joints.
Posterior (ventral or plantar) glides increase flexion of these joints.
RESTING POSITION First toe: 20° dorsiflexion; toes 2 through 5: 20° plantar flexion.
PATIENT POSITION Patient is comfortable with foot over end of the table and a pad under the distal leg.
CLINICIANS AND For the MTP and tarsometatarsal joints, the metatarsal is stabilized with one hand while the
HAND POSITION mobilizing hand grasps the proximal phalanx. For the IP joints, the proximal phalanx is stabilized
by the clinician’s fingers and thumb.
MOBILIZATION For MTP and tarsometatarsal joints, an AP or a PA glide is applied. For IP joints, the mobilizing
APPLICATION force is applied to the base of the distal phalanx while the head of the proximal phalanx is
stabilized.
NOTE Slight traction is simultaneously applied to provide more comfort for the patient.
DISTRACTION AP/PA GLIDE
310
PROPRIOCEPTIVE NEUROMUSCULAR FACILITATION (PNF)
311
D1 Flexion (Flexion – Adduction – External Rotation with Elbow Flexion)
Starting Position Position the upper extremity in shoulder extension, abduction, and internal rotation, elbow
extension, forearm pronation, and wrist and finger extension with the hand about 8 to 12 inches
from the hip
(A) Starting position
Hand Placement Place the index and middle fingers of your (R) hand in the palm of the patient’s hand and your
left (L) hand on the volar surface of the distal forearm or at the cubital fossa of the elbow.
Verbal Commands As you apply a quick stretch to the wrist and finger flexors, tell the patient “Squeeze my fingers,
turn your palm up, pull your arm up and across your face,” as you resist the pattern.
Ending Position Complete the pattern with the arm across the face in shoulder flexion, adduction, external
rotation, partial elbow flexion, forearm supination, and wrist and finger flexion
(B) Ending position for D1 flexion of the upper extremity.
312
D1 Extension (Extension – Abduction – Internal Rotation with Elbow Flexion)
Starting Position Begin the pattern with the arm across the face in shoulder flexion, adduction, external
rotation, partial elbow flexion, forearm supination, and wrist and finger flexion
Hand Placement Grasp the dorsal surface of the patient’s hand and fingers with your (R) hand using a
lumbrical grip. Place your (L) hand on the extensor surface of the arm just proximal to the
elbow.
Verbal Commands As you apply a quick stretch to the wrist and finger extensors, tell the patient, “Open your
hand” (or “Wrist and fingers up”); then “Push your arm down and out.”
Ending Position Finish the pattern in shoulder extension, abduction, internal rotation; elbow extension;
forearm pronation; and wrist and finger extension
(B) Ending position for D2 extension of the upper extremity.
313
D2 Flexion (Flexion – Abduction – External Rotation with Elbow Extension)
Starting Position Position the upper extremity in shoulder extension, adduction, and internal rotation, elbow
extension, forearm pronation, and wrist and finger flexion. The forearm should lie across the
umbilicus.
Hand Placement Grasp the dorsum of the patient’s hand with your (L) hand using a lumbrical grip. Grasp the
dorsal surface of the patient’s forearm close to the elbow with your (R) hand.
Verbal Commands As you apply a quick stretch to the wrist and finger extensors, tell the patient, “Open your
hand and turn it to your face”; “Lift your arm up and out”; “Point your thumb out.”
Ending Position Finish the pattern in shoulder flexion, abduction, and external rotation, elbow extension,
forearm supination, and wrist and finger extension. The arm should be 8 to 10 inches from
the ear, the thumb should be pointing to the floor
(B) Ending position for D2 flexion of the upper extremity.
314
D2 Extension (Extension – Adduction – Internal Rotation with Elbow Extension)
Starting Position Begin the pattern in shoulder flexion, abduction, and external rotation, elbow
extension, forearm supination, and wrist and finger extension. The arm should be 8
to 10 inches from the ear, the thumb should be pointing to the floor
Hand Placement Place the index and middle fingers of your (R) hand in the palm of the patient’s hand
and your (L) hand on the volar surface of the forearm or distal humerus.
Verbal Commands As you apply a quick stretch to the wrist and finger flexors, tell the patient, “Squeeze
my fingers and pull down and across your chest.”
Ending Position Complete the pattern in shoulder extension, adduction, and internal rotation, elbow
extension, forearm pronation; and wrist and finger flexion. The forearm should cross
the umbilicus.
(B) Ending position for D2 extension of the upper extremity
315
D1 Flexion (Flexion – Adduction – External Rotation with Knee Flexion)

Starting Position Position the lower extremity in hip extension, abduction, and internal rotation, knee
extension, plantar flexion and eversion of the ankle, and toe flexion.
(A) Starting position (This pattern may also be initiated with the knee flexed and the
lower leg over the edge of the table)
Hand Placement Place your (R) hand on the dorsal and medial surface of the foot and toes and your (L)
hand on the anteromedial aspect of the thigh just proximal to the knee.
Verbal Commands As you apply a quick stretch to the ankle dorsiflexors and invertors and toe extensors,
tell the patient, “Foot and toes up and in; bend your knee; pull your leg over and
across.”
Ending Position Complete the pattern in hip flexion, adduction, and external rotation, knee flexion (or
extension), ankle dorsiflexion and inversion, toe extension. The hip should be
adducted across the midline, creating lower trunk rotation to the patient’s (L) side.
(B) Ending position for D1 flexion of the lower extremity
316
D1 Extension (Extension – Abduction – Internal Rotation with Knee Flexion)
Starting Position Begin the pattern in hip flexion, adduction, and external rotation, knee flexion (or
extension), ankle dorsiflexion and inversion, toe extension. The hip should be adducted
across the midline, creating lower trunk rotation to the patient’s (L) side.
Hand Placement Place your (R) hand on the plantar and lateral surface of the foot at the base of the toes.
Place your (L) hand (palm up) at the posterior aspect of the knee at the popliteal fossa
Verbal Commands As you apply a quick stretch to the plantar flexors of the ankle and toes, tell the patient,
“Curl (point) your toes; push down and out.
Ending Position Finish the pattern in hip extension, abduction, and internal rotation, knee extension or
flexion, ankle plantarflexion and eversion; and toe flexion.
(B) Ending position for D1 extension of the lower extremity
317
D2 Flexion (Flexion – Adduction – External Rotation with Knee Extension)
Starting Position Place the lower extremity in hip extension, adduction, and external rotation, knee
extension, ankle plantarflexion and inversion, and toe flexion.
Hand Placement Place your (R) hand along the dorsal and lateral surfaces of the foot and your (L) hand
on the anterolateral aspect of the thigh just proximal to the knee. The fingers of your
(L) hand should point distally
Verbal Commands As you apply a quick stretch to the ankle dorsiflexors and evertors and toe extensors,
tell the patient, “Foot and toes up and out; lift your leg up and out.
Ending Position Complete the pattern in hip flexion, abduction, and internal rotation, knee flexion (or
extension), ankle dorsiflexion and eversion; and toe extension.
(B) Ending position for D2 flexion of the lower extremity
318
D2 Extension (Extension – Abduction – Internal Rotation with Knee Extension)
Starting Position Begin the pattern in hip flexion, abduction, and internal rotation, knee flexion (or
extension), ankle dorsiflexion and eversion, and toe extension.
Hand Placement Place your (R) hand on the plantar and medial surface of the foot at the base of the toes
and your (L) hand at the posteromedial aspect of the thigh, just proximal to the knee.
Verbal Commands As you apply a quick stretch to the plantarflexors and invertors of the ankle and toe flexors,
tell the patient, “Curl (point) your toes down and in, push your leg down and in.”
Ending Position Complete the pattern in hip extension, adduction, and external rotation, knee extension;
ankle plantarflexion and inversion, and toe flexion
(B) Ending position for D2 extension of the lower extremity.
319
SPECIFIC TECHNIQUES WITH PNF

FOR GAIN STRENGTH
RHYTHMIC INITIATION Rhythmic initiation is used to promote the ability to initiate a movement pattern. After
the patient voluntarily relaxes, the therapist moves the patient’s limb passively
through the available range of the desired movement pattern several times so the
patient becomes familiar with the sequence of movements within the pattern. It also
helps the patient understand the rate at which movement is to occur. Practicing
assisted or active movements (without resistance) also helps the patient learn a
movement pattern.
REPEATED CONTRACTIONS Repeated, dynamic contractions, initiated with repeated quick stretches followed by
resistance, are applied at any point in the ROM to strengthen a weak agonist
component of a diagonal pattern.
REVERSAL OF ANTAGONISTS The reversal of antagonist’s technique involves stimulation of a weak agonist pattern
by first resisting static or dynamic contractions of the antagonist pattern. The reversals
of a movement pattern are instituted just before the previous pattern has been fully
completed. The reversal of antagonist’s technique is based on Sherrington’s law of
successive induction. There are two categories of reversal techniques available to
strengthen weak muscle groups.
SLOW REVERSAL Slow reversal involves dynamic concentric contraction of a stronger agonist pattern
immediately followed by dynamic concentric contraction of the weaker antagonist
pattern. There is no voluntary relaxation between patterns. This promotes rapid,
reciprocal action of agonists and antagonists
SLOW REVERSAL HOLD Slow reversal hold adds an isometric contraction at the end of the range of a pattern
to enhance end-range holding of a weakened muscle. With no period of relaxation,
the direction of movement is then rapidly reversed by means of dynamic contraction
of the agonist muscle groups quickly followed by isometric contraction of those same
muscles. This is one of several techniques used to enhance dynamic stability,
particularly in proximal muscle groups.
320
FOR GAIN FLEXIBILITY

Isometric contractions are maximally held 6 to 10s, relaxation occurs for 2 to 3 s, all concentric contractions are smooth
and against resistance.
HOLD–RELAX An extremity is brought to end motion in agonist pattern, isometric of tight muscle
(antagonist), relax, passive motion to new end range in agonist pattern (to stretch
tight muscle).
CONTRACT–RELAX Extremity is brought to end motion of agonist, isotonic contraction of antagonist

(tight muscle), relax, passive movement to end range in agonist pattern (to stretch
tight muscle)
SLOW REVERSAL–HOLD–RELAX Limb starts in the shortened position of the agonist (opposing muscle). The
antagonist (tight muscle) contracts concentrically to move to its shortened position
(bringing tight muscle to its end range), isometric contraction of tight muscle, relax,
stretch by unopposed concentric contraction of agonist (opposing) muscle.
PNF stretching uses techniques of hold– relax, contract–relax, and slow reversal–
hold–relax
321
Passive intervertebral motions (PIVMs)
Lumbar flexion
Position of patient: Side lying position
Procedure:
• The examiner flexes both of the patient's bent knees toward the chest by flexing the hips.
• Palpating between the spinous processes of the lumbar vertebrae with one hand (one finger on the spinous
process, one finger above, and one finger below the process), passively flexes and releases the patient's hips
by using the examiner's body weight.
• Feel the spinous processes "gap" or move apart on flexion.
Finding:
If this gapping does not occur between two spinous processes it’s considered as hypomobile; if it is excessive in
relation to the other gapping movements it’s indicates hypermobile.
Lumbar Extension
Procedure:
process, one finger above, and one finger below the process), passively extend and releases the patient's
hips by using the examiner's body weight.
• Feel the spinous processes "gap" or move apart on side flexion.
Finding:
relation to the other gapping movements it’s indicates hypermobile
322
Lumbar Side Flexion
Procedure:
process, one finger above, and one finger below the process), grasp the patient's uppermost leg and rotate
the leg upward, that will cause side flexion in the lumbar spine by tilting the pelvis.
• Feel the spinous processes "gap" or move apart on flexion.
Finding:
relation to the other gapping movements it’s indicates hypermobile.
Passive Accessory Intervertebral Movements (PAIVMs)

Position of patient: Prone
Procedure:
• The lumbar spinous processes are palpated beginning at L5 and working up to L1.
• The examiner positions the hands, fingers, and thumbs as shown in the figure to perform postero-anterior
central vertebral pressure (PACVP)
• Pressure is applied through the thumbs, with the vertebrae being pushed anteriorly.
• Apply the pressure slowly and carefully, until the feel of the movement can be recognized
• Determine quality of the movement through the range available and the end feel.
323
Postero-anterior unilateral vertebra pressure (PAUVP)
Procedure:
• Moves the finger laterally away from the tip of the spinous process about 2.5 to 4.0 cm (1.0 to 1.5 inches) so
that thumbs rest on the muscles overlying the lamina the transverse process of the lumbar vertebra
• The same anterior springing pressure is applied as in the central pressure technique.
• This springing pressure will cause a slight rotation of the vertebra at the opposite direction, which can be
confirmed by palpating the spinous process while doing the technique.
• The two sides should be evaluated and compared.
Transverse vertebral pressure (TVP)

Procedure:
• Placed finger along the side of the spinous process of the lumbar spine then applies a transverse springing
pressure to the side of the spinous process, which causes the vertebra to rotate in the direction of the
pressure.
• Feel for the quality of the movement
• Pressure should apply to both sides of the spinous process to compare the quality of movement through the
range available, and the end feel.
324
SOFT TISSUE MANIPULATION
PALPATIONS
GRADING
0 No pain
1 Patient complains of pain
2 Patient complains of pain and winces
3 Patient winces and withdraws the joint
4 Patient will not allow palpations of the structure
SOFT TISSUE MANIPULATIONS
SWEDISH MASSAGE STROKES
STROKE TECHNIQUE APPLICATION PURPOSE

Hands glide over Start and end of Relax muscle,
EFFLEURAGE skin with hands massage. Stroking reduce pain,
flat, fingers motion begins relieve edema,
together. distally and moves relax the
proximally toward patient
the heart. Pressure
is uniform in each
stroke, with
subsequent strokes
either deeper or
lighter. Elevating
the segment during
treatment aids
edema reduction
Fingers are kept Skin and underlying Mobilize

PÉTRISSAGE together but flex tissue are kneaded deeper tissue
at MCP joints to and lifted to to improve
lift and knead improve tissue muscle
tissue. mobility, relax circulation and
muscle, and relaxation
promote
circulation. When
using two hands,
one moves
clockwise and the
other
counterclockwise,
passing by each
other to lift tissue.
Applied during the
midmassage
treatment session.
325
Finger or thumb Small cross-section Break

FRICTION pads or elbow or circular motions adhesions or
moves in small are used to mobilize soften scar
areas. specific tissue. tissue to
improve area
mobility.
Percussion of Hands are Release lymph

TAPOTEMENT tissue or tapping cupped, with or fluid and
of tissue in a motion mucous
rhythmic manner, occurring from blockage or
usually with the relaxed wrists to stimulate
hands or fingers. tap on a afferent nerves.
surface, or if
fingers are used,
the fingers of
one hand
alternate with
those of the
other hand to
create a gentle
slapping of the
surface
326
GENERAL MYOFASCIAL TECHNIQUES
STROKE TECHNIQUE APPLICATION PURPOSE
Finger or thumb Finger or Relieve restricted

J-STROKE pad is used to thumb pad is fascial and scar
move skin used to apply tissue adhesions
against downward in small,
underlying pressure to pull localized areas.
tissue. skin over
underlying
tissue, using a
J-stroke in one
small area at a
time.
Fingers are most One or both Relax muscle

OSCILLATION
often used in a hands working spasm.
cupped position in the same
to roll back and direction move
forth over in a rhythmic,
muscle. oscillating
manner. The
movement is
relaxing for the
patient and
comfortable
Both hands are Hands move in Release

WRINGING
used opposite multidirectional
simultaneously directions to deep-tissue
to release tissue each other, restrictions.
restriction. applying a
deep-tissue
force to move
underlying
structures
against each
other.
327
Deep-tissue One hand Release

STRIPPING
release. anchors the adhesions of
tissue while the scar tissue or
other hand, adherent fascia.
elbow, or
forearm is used
to apply a
downward and
forward force
to stretch
tissue below
the skin.
Traction of Clinician grasps Used with

ARM OR LEG
extremity is wrist or ankle conditions of
PULL
applied then leans generalized
throughout the body weight tightness within
extremity away from limb the extremity.
through a full to provide
range of hip or traction.
shoulder Clinician walks
abduction the limb into
motion. abduction
while passively
rotating the
limb until
resistance is
perceived.
Resistance
releases with
continued
traction; then
abduction
continues
through the
motion.
In longitudinal
myofascial
release, fascial
tissue between
the hands is
stretched
328
Alternative
FINGER PAD myofascial release
applications using
stripping or
oscillation
techniques
KNUCKLE
ELBOW
329
MC KENZIE METHOD – CERVICAL
PROCEDURE
EXERCISE 1 • Head retraction means pulling the head backward. Sit on a chair or stool, look straight
Head Retraction in ahead, and allow yourself to relax completely. As you do this, your head will protrude
Sitting a little
• Move your head slowly but steadily backward until it is pulled back as far as you can
manage as you do this, it is important to keep your chin tucked down and in. In other
words, you must remain looking straight ahead and should not tilt the head backward
as in looking up.
• Once you have maintained this position for a few seconds, you should relax, and
automatically your head and neck will protrude again. Each time you repeat this cycle
of movements, you must make sure that the backward movement of the head and
neck is performed to the maximum possible degree.
• Remember to slowly think or say the words "pressure on, pressure off," as you do
the exercise. This helps you to hold each position just long enough and establishes a
rhythm in which to do the exercise
• The exercise can be made more effective by placing both hands on the chin and firmly
pushing the head even farther back
• This exercise is used mainly in the treatment of neck pain, as opposed to its
prevention. When used in the treatment of neck pain, the exercise should be
repeated 10 times per session, and the sessions should be spread evenly six to
eight times throughout the day. This means you should repeat the sessions about
every two hours. If you experience acute pains on attempting this exercise, you must
replace it with Exercise 3, Head Retraction in Lying. When used in the prevention
position of neck pain, the exercise should be repeated five or six times as many times
a day as required.
• If you find you can prevent neck pain by performing two sessions of this exercise,
then do two sessions a day, and if you can prevent it only by doing ten sessions a day,
do ten.
PICTURE 1:
The relaxed position

allows the head to
protrude
PICTURE 2:
The retracted position
330
PROCEDURE
PICTURE 3:
Retraction with
overpressure
PICTURE 4:
The retracted
position
EXERCISE 2 • This exercise should always follow Exercise 1. Remain seated and repeat Exercise 1
Neck Extension in a few times, then hold your head in the retracted position. Now you are ready to
Sitting start Exercise 2.
• Lift your chin up and tilt your head backward, as if you were looking up at the sky.
As you do this, do not allow your neck to move forward. With your head tilted back
as far as possible, repeatedly turn your nose just half an inch (about two
centimeters) to the right and then to the left of the mid line, all the time attempting
to move your head and neck even farther backward. Once you have done this for a
few seconds, return your head to the starting position. Again, each time you repeat
this cycle of movements, make sure your neck is extended as far as possible
• This exercise can be used both in the treatment and prevention of neck pain.
Exercise 2 is to be performed 10 times per session, and the sessions should be
spread evenly six to eight times throughout the day. If your pain is too acute to
tolerate Exercise 2, you should replace it with Exercise 3, Head Retraction in Lying.
Once you are fully practiced in Exercises 1 and 2 separately from one another, you
can combine these two exercises successfully into one exercise.
PICTURE 1:
Remain in
retracted
position
PICTURE 2:
Lift your chin up

and tilt your head
backward, as if
you were looking
up at the sky.
331
PROCEDURE
PICTURE 3:
With your head

tilted as far back as
possible, repeatedly
turn your nose just
half an inch to the
right and then to
the left of the
midline
EXERCISE 3 • Lie on a bed. Lie face up, with your head at a free-standing edge of the bed rather
Head Retraction in Lying than next to any headboard. For example, lie across a double bed or with your
head at the foot of a single bed. Rest your head and shoulders flat on the bed and
do not use a pillow
• Using your head alone, not your hands, push the back of your head into the
mattress and at the same time pull in your chin. The overall effect should be that
your head and neck move backward as far as possible while you keep facing the
ceiling. Once you have maintained this position for a few seconds, relax.
Automatically, your head and neck will return to the starting position. Each time
you repeat this cycle of movements, make sure that the backward movement of
your head and neck is carried out to the maximum possible degree.
• This exercise is used mainly in the treatment of acute neck pain. It is used mostly
by people who have gained no benefit from exercises done in the sitting or
standing position. It is an effective exercise, but not as demanding as most of the
others. When you have completed 10 head retractions, you must evaluate the
effects of this exercise on your pain. If the pain has centralized or decreased in
intensity, you can safely continue this procedure. In this case you should repeat
the exercise 10 times per session and spread the sessions evenly six to eight times
throughout the day or night. (Since you already are in bed at night, night is a good
time to repeat this exercise)
• If, however, the pain has increased considerably or extends farther away from the
spine, or if you have developed "pins and needles," or numbness, in the fingers,
you must stop the exercise and seek advice from a health professional.
PICTURE 1:
Rest your head and

shoulders flat on
the bed.
332
PROCEDURE
PICTURE 2:
Push the back of your

head into the mattress
and at the same time
pull in your chin
EXERCISE 4 • This exercise should always follow Exercise 3. You must again lie on the bed, face
Neck Extension in Lying up. Before you can start Exercise 4, you must support your head by placing one
hand under it. Now move up along the bed until your head, your neck, and the
top of your shoulders are extended over the edge.
• While continuing to support your head with your hand, lower your head slowly
toward the floor. Now, gradually remove your hand and bring your head and neck
as far backward as you can, so that you can see as much as possible of the floor
directly under you. In this position, repeatedly turn your nose just half an inch
(about two centimeters) to the right and then to the left of the midline all the
time attempting to move your head and neck farther backward. Once you have
reached the maximum amount of extension, try to relax in this position for two
to three seconds.
• In order to return to the resting position, first place one hand behind your head,
then help your head back to the horizontal position and move your body down
along the bed until your head is lying fully on the bed again. It is important that,
following this exercise, you do not get up from the bed immediately but that
instead you rest for a few minutes with your head flat on the bed. Do not use a
pillow
• As with Exercise 3, this exercise is used mainly in the treatment of acute neck
pain. Also as with Exercise 3, it is effective, yet not as demanding as most of the
others. Until the acute symptoms have subsided, Exercise 4 is to follow Exercise
3, and Exercise 4 should be done only once per session. Once you no longer have
acute pains, exercises 3 and 4 should be replaced by Exercises 1 and 2.
PICTURE 1:
Rest your head and

shoulders flat on
the bed.
333
PROCEDURE
PICTURE 2:
Place one hand under

your head and extend
your head, your neck,
and the top of your
shoulders over the
edge of the bed
PICTURE 3:
While supporting your

head, lower it slowly
toward the floor.
PICTURE 4:
Gradually remove your
hand and bring your
head and neck as far
backward as you can.
PICTURE 5:
Repeatedly turn your

nose just half an inch to
the right and then to
the left of the midline
334
PROCEDURE
EXERCISE 5 • Sit on a chair. Repeat Exercise 1 a few times, then hold your head in the retracted
Side bending of the Neck position.
• Bend your neck sideways and move your head toward the side on which you feel
most of the pain. Do not allow the head to turn. In other words, keep looking
straight ahead and bring your ear-not your nose-close to your shoulder. It is
important that you keep the head well retracted as you do this. The exercise can
be made more effective by using the hand of the painful side, placing it over the
top of your head, and gently but firmly pulling your head even farther toward the
painful side.
• Once you have maintained this position for a few seconds, return your head to
the starting position.
• This exercise is used specifically for the treatment of pain felt only to one side or
pain felt much more to one side than the other. Until your symptoms have
centralized, Exercise 5 is to be repeated 10 times per session and the sessions are
to be spread evenly six to eight times throughout the day.
PICTURE 1:
PICTURE 2:
Bend your neck

sideways and move
your head toward the
side on which you feel
most of the pain.
PICTURE 3:
Gently but firmly pull

your head even farther
toward the painful
side.
335
PROCEDURE
EXERCISE 6 • Sit on a chair, repeat Exercise 1 a few times, then hold your head in the retracted
Neck Rotation position. Turn your head far to the right and then far to the left, as though you
were about to cross a street.
• As you do this, it is important that you keep the head well retracted. If you
experience more pain as you turn to one side than to the other, continue the
exercise by rotating only to the more painful side. As you repeatedly turn to that
side, the pain should gradually centralize or decrease. But if the pain increases and
fails to centralize, continue the exercise by rotating only to the less painful side.
Once you have the same amount of pain when turning to either side, or have no
pain when turning to either side, continue the exercise by rotating to both sides.
• The exercise can be made more effective by using both hands and gently but firmly
pushing your head even farther into rotation. Once you have maintained the
position of maximum rotation for a few seconds, return your head to the starting
position.
• This exercise can be used in the treatment of neck pain as well as for its
prevention. When used in the treatment of pain or stiffness of the neck, the
exercise is to be performed 10 times per session, and the sessions are to be spread
evenly six to eight times throughout the day. Whether or not centralization or a
decrease in pain has taken place, Exercise
• 6 must always be followed by Exercises 1 and 2. When used in the prevention of
neck problems, the exercise should be repeated five or six times every two or
three days or as often as required.
PICTURE 1:
PICTURE 2:
Turn your head far to

the right and then far
to the left.
PICTURE 3:
Use both hands and

gently but firmly push
your head even farther
into rotation.
336
PROCEDURE
EXERCISE 7 • Sit on a chair, look straight ahead, and allow yourself to relax completely. Drop
Neck Flexion in Sitting your head forward and let it rest with your chin as close as possible to your chest.
Place your hands behind the back of your head and interlock your fingers . Now
let your arms relax so that your elbows point down toward the floor. In this
position, the weight of your arms will pull your head down farther and bring your
chin closer to your chest.
• This exercise can be made more effective by using your hands and gently but
firmly pulling your head onto your chest. Once you have maintained the position
of maximum neck flexion for a few seconds, return your head to the starting
position.
• This exercise is used mainly for the treatment of headache. but can also be applied
to resolve residual neck pain or stiffness. Once the acute symptoms have
subsided. In both cases, it should be repeated only two or three times per session,
and the sessions should be spread evenly six to eight times throughout the day.
• When used in the treatment of headaches, Exercise 7 should be performed in
conjunction with Exercise 1. When used in the treatment of neck pain or stiffness,
Exercise 7 must always be followed by Exercises 1 and 2.
PICTURE 1:
Sit on a chair, look straight

ahead, and allow yourself to
relax completely.
PICTURE 2:
Drop your head forward and

let it rest with your chin as
close as possible to your chest
PICTURE 3:
Place your hands behind the

back of your head and
interlock your fingers.
PICTURE 4:
Let your arms relax so the

elbows point down toward
the floor
337
THE MCKENZIE METHOD - LUMBAR SPINE
PROCEDURE
EXERCISE 1 • Lie face down with your arms next to your body. Your arms should be straight but
Prone lying relaxed. Your head should be turned to one side. Stay in this position, then take a few
deep breaths, and then relax completely for two or three minutes. You must make a
conscious effort to remove all tension from the muscles in your lower back
• With an acute lumbar kyphosis, add pillows to accommodate the deformity as
needed for pain
• Used mainly in the treatment of acute back pain (back pain that has begun recently
and is sharp, as opposed to chronic back pain, which has gone on for a long time and
is rather a dull ache).
• The exercise sessions should be spread evenly six to eight times throughout the day.
This means that you should repeat the sessions about every two hours. In addition,
you should lie face down whenever you are resting.
Exercise 2 • Exercise 2 must be done only after Exercise 1 has been completed. Remain face down
Extension in in the same position you used in Exercise 1.
Elbow- prone lying • Now place your elbows under your shoulders so that you lean on your forearms.
During this exercise (as with Exercise 1), begin by taking a few deep breaths and then
allowing the muscles in the lower back to relax completely.
• Remain in this position for two to three minutes.
338
PROCEDURE
EXERCISE 3 • Remain facedown, but with your head forward rather than to the side.
Extension in Forearm- • Place your hands under your shoulders in the position you would use for a push-up.
prone lying Now you are ready to commence Exercise 3. Straighten your elbows and push the
top half of your body the part from the pelvis on up-up as far as pain permits.
• As you do this, it is important that you completely relax the pelvis, hips, and legs.
Keep your pelvis, hips, and legs hanging and allow your back to sag. Your pelvis will
naturally move downward.
• Once you have maintained this position for a second or two, lower yourself to the
starting position. Each time you repeat the cycle of movements in this exercise, try
to raise your upper body a little higher, so that by the last repetition of this exercise
within a session your back is extended as much as possible and your arms are as
straight as possible with your elbows locked.
• Each time you straighten your arms, remember to hold the sag for a second or two,
because this is a key part of the exercise. If you feel your pain is decreasing or
centralizing (or both}, you may maintain the sag for longer than one or two seconds.
• Remember to slowly think or say the words "pressure on, pressure off," as you do the
exercise. This helps you to hold each position just long enough and establishes a
rhythm in which to do the exercise.
• Most useful and effective first-aid procedure in the treatment of acute lower back
pain. The exercise can also be used to treat stiffness of the lower back and to prevent
lower back pain from recurring once you have fully recovered.
• When used in the treatment of either pain or stiffness, the exercise should be
performed ten times per session. Again, exercise sessions should be spread evenly
six to eight times throughout the day.
• Remember that if your pain has centralized, it may have increased in the middle of
your back after it has disappeared from one side or from your leg. This does not
indicate that you are not responding or benefitting. In fact, this is a good response,
and you should continue with the exercises
Remain facedown
Place your hands

under your shoulders
in the push-up
position.
Straighten your
elbows and push the
top half of your body
up as far as pain
permits
339
PROCEDURE
At the end of the

exercise, your back
is extended as
much as possible
and your arms are
as straight as
possible.
Sustained Extension • Patient lies prone with the table positioned in extension, creating a gradual and sust
ained extension stress to the lumbar spine.
• Gradually lift the table up into more extension
Use this for patients:
1. kyphotic deformity
2. Major derangements
3. To expose an anterior derangement
Extension in Forearm- • Symmetrical overpressure is applied using body weight through arms by therapist
prone lying with and maintained while the patient performs back extension
physiotherapy assisted • The effectiveness of Exercise 3 can be improved greatly by holding the pelvis down.
There are two main ways to do this. Another person can place pressure on your lower
back. Or you can construct a simple device for keeping your pelvis in place: you can
use an ironing board and either a seat belt or a strong leather belt or strap. Place the
belt or strap around the ironing board and your waistline. The added pressure
frequently determines whether Exercise 3 succeeds or fails
340
PROCEDURE
Extension with belt

&
Self-overpressure
extension in forearm
341
PROCEDURE
Exercise 4 • Stand upright, with your feet slightly apart. Place your hands at the back with the
Extension in Standing fingers pointing backward. You are now ready to begin Exercise 4
• Bend your trunk backward at the waist as far as you can, using your hands as a
fulcrum. As you do this, it is important that you keep your knees straight. Once you
have maintained this position for a second or two, return to the starting position.
Each time you repeat the cycle of movements in this exercise, try to bend backward
a little farther so that by the last repetition your back is extended as far as possible
• When you are in acute pain, Exercise 4 may replace Exercise 3 if circumstances
prevent you from exercising in the lying position.
• Repeat 10 times per session, six to eight sessions a day.
• Once you are fully recovered and no longer have lower back pain, Exercise 4 is your
main tool in the prevention of further lower back problems. As a preventive measure,
repeat Exercise 4 every once in a while whenever you find yourself working in a
forward-bent position. Perform the exercise before the pain appears.
• It can be done easily at public or business settings,
Picture 1: Stand
upright, with your
feet slightly apart.
Place your hands in
the small of your
back with your
fingers pointing
backward
Picture 2: Bend your

trunk backward at
the waist as far as
you can, using your
hands as a fulcrum
342
PROCEDURE
Extension • Mobilization pressure applied to lumbar spine in neutral or with the lumbar spine in
Mobilization extension (prone on elbows)
• Apply 10‐15 repetitions, gradually increasing force.
• Set up same as exercise prone with an extension force applied and suustained for 5
Extension to 10 second. A high velocity, short amplitude thrust is applied.
Manipulation • Only perform once or at the most, twice.
• Guide them from a kyphotic position to an upright position by anteriorly rotating

Posture Correction
the pelvis and increasing the lumbar lordosis. Show patient how to maintain this po
sition through the use of a lumbar roll.
Slouch Overcorrect • Instruct patient to slouch, then move to an upright siting position with maximal
lordosis,repeat this sequence 10 times. Back off 10% from maximal lordosis on the
last repetition. This is considered optimal siting posture.
343
PROCEDURE
Extension • Position yourself to perform Exercise 1 and allow yourself to relax for a few minutes
with Hips Off Center • Remain facedown, then shift your hips away from the painful side. That is, if your
pain usually is more on the right side, you must move your hips three or four inches
to the left and once more completely relax for a few minutes.
• While allowing the hips to remain off-center, lean on the elbows as described in
Exercise 2 and relax for an additional three or four minutes.
• You are now ready to begin Exercise 3. With your hips still off-center, complete one
session of Exercise 3 and then relax once more. You may need to repeat the exercise
several times, but before beginning each session of 10, ensure that your hips are still
off-center: remember, away from the painful side
• Even with your hips in the off-center position, try in each repetition to move higher
and higher. Reach the maximum amount of extension possible, at which point your
arms should be completely straight.
• For the next three or four days, continue to perform Exercises 1, 2, and 3 from the
modified starting position described in the three steps above. The
• Used in derangement with unilateral or asymmetrical symptoms that have not
responded to extension
Move your hips away from

the pain.
344
PROCEDURE
With hips off-center, lean

on elbows
With hips off-center, lean
on elbows
With hips off-center, you

are ready to begin Exercise
3.
345
PROCEDURE
Exercise 5 • Lie on your back with your knees bent and your feet flat on the floor or bed. Bring
Flexion in supine both knees up toward your chest. Place both hands around your knees and gently
but firmly pull your knees as close to your chest as pain permits
• Once you have maintained this position for a second or two, lower the legs and return
to the starting position.
• It is important that you do not raise your head as you perform this exercise. It also is
important that you do not straighten your legs as you lower them. Each time you
repeat the cycle of movements in this exercise, try to pull your knees a little closer to
the chest, so that by the last repetition of this exercise you have flexed your back as
much as possible.
• You can use this exercise to treat stiffness in the lower back that may have developed
since your injury began. While damaged tissues may now have healed, they may also
have shortened and become less flexible. It is now necessary to restore their elasticity
and full function by performing flexion exercises
• Begin these exercises with caution. Do only five or six repetitions per session, and
repeat the sessions three or four times a day. As you have probably realized, once
your knees are bent in this exercise, you have eliminated the lordosis. Therefore, in
order to correct any distortion that may result, this and all other flexion exercises
(that is, Exercise 5, Exercise 6, and Exercise 7) must always be followed immediately
by a session of Exercise 3, Extension in Lying
Lie on your back with your

knees bent and your feet flat
on the floor or bed.
Bring both knees up toward

your chest
Place both hands around

your knees and gently but
firmly pull your knees as
close to your chest as pain
permits.
346
PROCEDURE
Exercise 6 • Begin doing Exercise 6 only after you have completed one week of Exercise 5,
Flexion in Sitting whether or not Exercise 5 has been successful in reducing your pain or stiffness.
• Sit on the edge of a steady chair. Your knees and feet should be well apart. Rest your
hands on your legs. Bend your trunk forward and grasp your ankles or touch the floor
with your hands. Return immediately to the starting position. Each time you repeat
the cycle of movements in this exercise, try to bend down a little farther so that by
the last repetition of this exercise you have flexed your back as much as possible and
your head is as close as possible to the floor.
• This exercise can be made more effective by holding onto your ankles with your
hands and pulling yourself down farther
• You must do only five or six repetitions of Exercise 6 per session. Sessions are to be
repeated three to four times a day. Exercise 6 must always be followed immediately
by Exercise 3.
Sit on the edge of a

steady chair with
your knees and
feet well apart and
rest your hands on
your legs
Bend your trunk

forward and grasp
your ankles or
touch the floor
with your hands
Hold onto your

ankles and pull
yourself down
farther
Or even farther.
347
PROCEDURE
• Begin doing Exercise 7 only after you have completed two weeks of Exercise 6,
Exercise 7 whether or not Exercise 6 has been successful in reducing your pain or stiffness .
Flexion in standing • Stand upright, with your feet well apart. Allow your arms to hang loosely by your
side. Bend forward and run your fingers down your legs as far as you can comfortably
reach. Return immediately to the upright standing position. Each time you repeat the
cycle of movements in this exercise, try to bend down a little farther so that by the
last repetition of this exercise within a session you have flexed your back as much as
possible and your fingertips are as close as possible to the floor.
• You must do only five or six repetitions of Exercise 7 per session. Sessions are to be
repeated once or twice a day. Exercise 7 must always be followed immediately by
Exercise 3. For three months after you have become pain-free, Exercise 7 must never
be performed in the first four hours of your day
Stand upright with

your feet well
apart and allow
your arms to hang
loosely by your
side
Bend forward and

run your fingers
down your legs as
far as you can
comfortably reach
Flexion in Supine
with Clinician Over
Pressure
348
PROCEDURE
Extension in Prone Sagittal Overpressure

with Hips Off Center • Position hypothenar eminences on TPs of painful segment. Pt performs Exercise 3
with
Clinician Overpressure Lateral Overpressure
• Commonly used technique
• Pressure is applied at the ribs and iliac crest. Pt perform Exercise 3.
Extension Mobilization • Performed the same as Exercise 3 expect the hips are positioned off center, away
with Hips Off Center from the painful side.
• Once in this position, the extension mobilization is performed.
• This is a force progression for a derangement with a lateral component.
• Perform after procedures Extension with Hips Off Center and Extension in Prone
with Hips Off Center with Clinician Overpressure
• The position is the same as in above procedure but the technique is modified by
Rotation Mobilization in applying pressure first to the TP on one side, then the other side to produce a
Extension rocking effect
• Force is directed anterior and slightly medially. Repeat 10 times.
• Generally used to reduce derangements with unilateral or asymmetrical symptoms
that have remained unchanged with previous procedures
• Only one manipulative thrust should be performed during a treatment session

Rotation Manipulation • Pre-manipulative testing must shoe favorable result before performing
in Extension manipulation
349
PROCEDURE
Self-Correction of • The direction of side gliding is named by the direction that the shoulder moved,
Lateral Shift or Side Gliding rather than the hips.
• Used for self-correction of lateral shift and taught as home exercise program
after manual correction lateral shift
Manual Correction of • Procedure is used for patients with a relevant lateral shift deformity
Lateral Shift • 2 important keys: Correct the lateral shift
deformity, THEN restore full extension
350
PROCEDURE
Flexion in • This procedure creates an asymmetrical flexion stress and is applied when there is a
Step Standing • deviation in flexion
• Can occur in derangement (anterior/lateral) or dysfunction (ANR)
• Raise the leg that is OPPOSITE the side to which the deviation in flexion occurs
• Restore lordosis between each rep
Rotation in • This procedure is used in the management of derangements that have not improved or have
Flexion • worsened with sagittal plane movements.
• Patient limits their pelvis off the mat, places it off center, away from the painful side.
The knees are then raised until they are over the hips and lowered to the mat
(towards the painful side)
• Hold the position 2‐3 minutes
351
PROCEDURE
Rotation • Same as above procedure but with the patient’s knees resting on the clinician thighs and a
Mobilization mobilization pressure applied through patient’s knees while simultaneously anchoring their
in Flexion contralateral shoulder
Rotation Manipulation • Same procedure as above but a high velocity, low amplitude thrust applied through
in Flexion the patient’s knees.
• Only one manipulative procedure should be performed during a session
352

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BACHELOR OF PHYSIOTHERAPY

MUSCULOSKELETAL PRACTICAL HANDBOOK

FOR AIMST PHYSIOTHERAPY STUDENT USE ONLY

2 RANGE OF MOTION MEASUREMENT (ROM) 7-70

3 MANUAL MUSCLE TESTING (MMT) 71-178

4 LIMB LENGTH MEASUREMENT 179

5 MUSCLE GIRTH MEASUREMENT 180-184

6 SPECIAL TEST 185-242

7 GAIT TRAINING 243-249

8 TRANSFER TECHNIQUE 250-251

9 JOINT MOBILIZATION 252-310

10 PROPRIOCEPTIVE NEUROMUSCULOR FACILITATION (PNF) 311-321

11 PASSIVE INTERVERTEBRAL MOTION 322-324

12 SOFT TISSUE MANIPULATION 325-329

13 MC KENZIE METHOD 330-352

CHIEF COMPLAIN/ • Patients own word or statement

CURRENT HISTORY • Date/Duration of onset of symptom:

PAIN SCALE / VAS

• Body chart Mark or color the injured or symptom part,

• Onset sudden or gradual (Days, weeks, months or years)

• Aggravating factor posture, movement, or activities (VAS, & Duration)

• Irritability high/medium/low (tolerable or not)

• 24 hours behaviors AM/PM, (VAS Scale, influence posture and movement)

• Relieving/Easing medication, position, massage, application of cold/hot/analgesic cream

FAMILY HISTORY Hereditary diseases

MEDICATION Dosage, Name of medication & (AM/PM)

• Investigation MRI, CT scan, Bone Scan, X-ray, Laboratory finding

• Pacemaker / hearing aid Yes / No

• Menopause Duration & Date (only for women after menopause)

• Bowel & bladder Normal / Incontinence

• Recreation Sport / Activity (type & duration)

• Social / Personal Smoking, Alcohol, Drugs (duration, amount per day)

• Functional Independent / Dependent

• Assistant walking frame/ crutches/ wheelchair/ brace/ walking stick / splint/

MEASUREMENT Muscle girth, Swelling, Limb length

SPECIAL TEST Test to confirm diagnosis and find differential diagnosis

BMI Evaluate normal body mass index

SENSATION TEST Check hot, cold

REFLEX Check tendon reflex using tendon hammer

ANALYSIS/ PHYSIOTHERAPY IMPRESSION

EVALUATE – Post treatment analysis

RANGE OF MOTION (ROM)

PATIENT POSITION Sitting erect

SUPERIOR Tip of mandible (chin)

INFERIOR Sternal notch

CERVICAL SPINE FLEXION (GONIOMETER)

PATIENT POSITION Sitting erect

GONIOMETER ALIGNMENT Palpate following landmarks and align goniometer accordingly

STATIONARY ARM Perpendicular to floor

AXIS Ear lobe

MOVING ARM Base of nares

PATIENT/EXAMINER ACTION Patient performs active cervical flexion

Goniometer alignment at beginning range of cervical flexion

CERVICAL SPINE EXTENSION (TAPE MEASUREMENT)

PATIENT POSITION Sitting erect

SUPERIOR Tip of mandible (chin)

INFERIOR Sternal notch.

Starting position for measurement of cervical flexion using tape measure

CERVICAL SPINE EXTENSION (GONIOMETER)

PATIENT POSITION Sitting erect

GONIOMETER ALIGNMENT Palpate following landmarks and align goniometer accordingly

STATIONARY ARM Perpendicular to floor

AXIS Ear lobe

MOVING ARM Base of nares