Testing the Muscles of the Upper Extremity



Testing the Muscles of the Upper Extremity


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PLATE 2


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FIGURE 5-1

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FIGURE 5-2



Scapular Abduction and Upward Rotation


(Serratus anterior)






Introduction to Scapular-Thoracic Muscle Testing


A primary role of the thoracic-scapular muscles is to provide stabilization of the scapula so that the scapular-humeral muscles may work efficiently to produce movement at the glenohumeral joint. Stabilization of upward rotation of the scapula is a primary consideration when evaluating function of the shoulder girdle. In the absence of strong scapular-thoracic muscles, dyskinesia may occur at the glenohumeral joint such that the scapula may rotate downward rather than the humerus moving upward. This in turn decreases the sub-acromial space contributing to impingement syndromes at the glenohumeral joint. External resistance to the upper extremity that often occurs with lifting activities may exacerbate this problem. Also, the more elevation of the upper extremity that is required for the task, the higher the risk for impingement.


The serratus often is graded incorrectly, perhaps because the muscle arrangement and the bony movement are unlike those of axial structures. The test procedure is in keeping with known kinesiologic and pathokinesiologic principles. The scapular muscles, however, do need further dynamic testing with electromyography, magnetic resonance imaging, and other modern technology before completely reliable functional diagnoses can be made.


The supine position, although best for isolating the serratus anterior, is not recommended at any grade level. The supine position allows too much substitution that may not be noticeable. Lying supine on the table gives added stabilization to the scapula so that it does not “wing” and protraction of the arm may be performed by the clavicular portion of the pectoralis minor.



Preliminary Examination


Observation of the scapulae, both at rest and during active and passive shoulder flexion, is a routine part of the test. Examine the patient in the sitting position with hands in the lap.


Palpate the vertebral borders of both scapulae with the thumbs; place the web of the thumb below the inferior angle; the fingers extend around the axillary borders (Figure 5-4).


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FIGURE 5-4


Specific Elements


Position and symmetry of scapulae:

Determine the position of the scapulae at rest and whether the two sides are symmetrical, although minor asymmetry is normal.


The normal scapula lies close to the rib cage with the vertebral border nearly parallel to and from 1 to 3 inches lateral to the spinous processes. The inferior angle is on the chest wall. The most prominent abnormal posture of the scapula is “winging,” in which the vertebral border tilts away from the rib cage, a sign indicative of serratus anterior weakness (Figure 5-5). Other abnormal postures are abduction and downward rotation of the scapula. If the inferior angle of the scapula is tilted away from the rib cage, check for tightness of the pectoralis minor, weakness of the trapezius, and spinal deformity.


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FIGURE 5-5

Scapulohumeral rhythm improves the shoulder’s range of motion and consists of integrated movements of the glenohumeral, scapulothoracic, acromioclavicular, and sternoclavicular joints. It occurs in sequential fashion to allow full functional motion of the shoulder complex. To complete 180° of shoulder abduction, the overall ratio of glenohumeral to scapulothoracic motion is 2 : 1.



Scapular range of motion:

Within the total arc of 180° of shoulder forward flexion and abduction are 120° of glenohumeral abduction and 60° of scapular rotation. Glenohumeral and scapular movements occur not as separate motions, but as synchronous motions throughout the range.



Passively raise the test arm completely above the head in forward flexion to determine scapular mobility. The scapula should start to rotate at about 30°, although there is considerable individual variation. Scapular rotation continues until about −20° to −30° from full flexion.


Check that the scapula basically remains in its rest position at ranges of shoulder flexion less than 30° of forward flexion (the position is variable among subjects). If the scapula moves a lot as the glenohumeral joint moves through from 0 to 60°—that is, if in this range they move as a unit—there is limited glenohumeral motion. Above 30° and to about 150° or 160° in both active and passive motion, the scapula moves in concert with the humerus.


The serratus should always be tested in shoulder flexion to minimize the synergy with the trapezius.


If the scapular position at rest is normal, ask the patient to raise the test arm above the head in the sagittal plane. If the arm can be raised well above 90° (glenohumeral muscles must be at least Grade 3 to do this), observe the direction and amount of scapular motion that occur. Normally, the scapula rotates forward in a motion that is controlled by the serratus, and if erratic or “uncoordinated” motion occurs, the serratus is most likely weak. The normal amount of motion of the vertebral border from the start position is about the breadth of two fingers (Figure 5-7). If the patient is able to raise the arm with simultaneous rhythmical scapular upward rotation, proceed with the test sequence for Grades 5 and 4.


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FIGURE 5-7



Grade 5 (Normal) and Grade 4 (Good)






Alternate Test (Grades 5, 4, and 3)









Grade 2 (Poor)







Scapular Elevation


(Trapezius, upper fibers)


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FIGURE 5-13


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FIGURE 5-14






Grade 5 (Normal) and Grade 4 (Good)










Grade 2 (Poor), Grade 1 (Trace), and Grade 0 (Zero)




Grading




Grade 1 (Trace):


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.




Scapular Adduction


(Trapezius, middle fibers)


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FIGURE 5-20


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FIGURE 5-21






Grade 5 (Normal), Grade 4 (Good), and Grade 3 (Fair)





Position of Therapist:

Standing at test side close to patient’s arm. Stabilize the contralateral scapular area to prevent trunk rotation. There are two ways to give resistance; one does not require as much strength as the other.



1. When the posterior deltoid is Grade 3 or better: The hand for resistance is placed over the distal end of the humerus, and resistance is directed downward toward the floor (see Figure 5-23). The wrist also may be used for a longer lever, but the lever selected should be maintained consistently throughout the test.


2. When the posterior deltoid is Grade 2 or less: Resistance is given in a downward direction (toward floor) with the hand contoured over the shoulder joint (Figure 5-24). This placement of resistance requires less adductor muscle strength by the patient than is needed in the test described in the preceding paragraph.


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FIGURE 5-24

The fingers of the other hand can palpate the middle fibers of the trapezius at the spine of the scapula from the acromion to the vertebral column if necessary (Figure 5-25).


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FIGURE 5-25






Alternate Test for Grades 5, 4, and 3







Test:

Patient maintains scapular adduction.





Scapular Depression and Adduction


(Trapezius, lower fibers)


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FIGURE 5-27


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FIGURE 5-28






Grade 5 (Normal) Grade 4 (Good), and Grade 3 (Fair)









Grade 2 (Poor), Grade 1 (Trace), and Grade 0 (Zero)




Grading






Scapular Adduction and Downward Rotation


(Rhomboids)


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FIGURE 5-33


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FIGURE 5-34




The test for the rhomboid muscles has become the focus of some clinical debate. Kendall and co-workers claim, with good evidence, that these muscles frequently are underrated; that is, they are too often graded at a level less than their performance.1 At issue also is the confusion that can occur in separating the function of the rhomboids from those of other scapular or shoulder muscles, particularly the trapezius and the pectoralis minor. Because the rhomboids are innervated only by C5, a test for the rhomboids, correctly conducted, can confirm or rule out a nerve root lesion at this level. With these issues in mind, the authors present first their method and then, with the generous permission of Mrs. Kendall, her rhomboid test as another method of assessment.




Grade 5 (Normal), Grade 4 (Good), and Grade 3 (Fair)







Aug 25, 2016 | Posted by in RHEUMATOLOGY | Comments Off on Testing the Muscles of the Upper Extremity

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