Review of Manual Muscle Strength Testing. Content 10/6/2014. ChiroCredit.com Presents. Manual Muscle Testing 206. Digits of the Lower Limb

Transcription

1 ChiroCredit.com Presents Manual Muscle Testing 206 Digits of the Lower Limb Instructor: Dr. John M. Wallman, DC 1 Content Review of Manual Muscle Strength Testing (MMST) Purposes, General Procedures, Grading Issues with lower limb digits Control Implications Athletic performance Health Muscle Tests Muscles in this course Origin and Insertion Action Procedures Research 5 projects 2 Review of Manual Muscle Strength Testing 3 1

2 MMST Review: Purposes Individual muscle strength tests Identifies the weak link - which muscle in the kinetic chain is normal, weak or too strong (1, 2) Balance Compared to opposite limb Compared to other muscles crossing same joint Improve Athletic performance Injury prevention (5) Health Safety Recovery from trauma, surgery and illness Identifying site of neurological lesion (6) 4 MMST Review: Procedures 1 Rep max exertion test on an isolated muscle Manual Muscle Strength Testing Procedure: Place the subject in a unique starting position The examiner exerts increasing pressure on a part of the subject s body in a specific direction while Asking the subject to resist the examiners pressure until they are resisting with as much force as possible Examiner increases pressure over 3-4 seconds until the subject s resistance is overcome 5 MMST Review: Grading (1) Basic More Detailed Scales 0 0 Zero 0% No contraction felt 1 1 Trace 5% Contraction easily felt, but not seen 2- Poor - 10% Moves through partial ROM gravity eliminated 2 2 Poor 20% Can move through partial ROM with moderate gravity reduction 2+ Poor + 30% Moves through partial ROM against gravity OR Moves through complete ROM gravity eliminated and holds against pressure 3- Fair- 40% Gradual release from test position 3 3 Fair 50% Can hold against gravity only moderate period of time 3+ Fair + 60% Holds test position against slight resistance 4- Good 70% Holds test position against slight to moderate pressure 4 4 Good 80% Can hold against gravity and some pressure 4+ Good + 90% Holds test position against moderate to strong pressure 5 5 Normal 100% Can hold against full pressure 6 2

3 Issues with Lower Limb Digits Used with permission D. Herscovitch via adventure-inspired.com 7 Control Few people develop toe dexterity to their maximum potential Lack of control impairs muscle MMST Improved control develops rapidly with specific applications Armless person changing diaper and other household tasks using toe dexterity v=oiq_xdooasw Armless man writing calligraphy holding brush with toes Used with permission CCOLI.com 8 Athletic Performance Stability / Balance Agility Implications Sport Specific Photo courtesy portaldemisterios.com Gait cycle Barefoot running Land on forefoot Kicking Soccer, football Bicycle Photo courtesy Raquel Baranow via Flikr 9 3

4 Implications Clinical Sprains / strains Bunions weakness of adductor hallucis Hammer toes and claw toes Corns callus on superior surface of toes as consequence of claw toes Plantar fasciitis Balance and fall prevention Follow up to trauma or surgery Photo courtesy Wikimedia Commons, Photo courtesy Microsoft 10 Implications Clinical Bunions Weakness of Adductor Hallux Primary Weakness of Abductor Hallux Secondary or absent Photo courtesy Wikimedia Commons, 11 Muscle Tests 12 4

5 Muscle Tests for This Course Hallucis Extensor Longus Flexor Longus Extensor Brevis Flexor Brevis Abductor Digitorum Extensor Longus Flexor Longus Extensor Brevis Flexor Brevis Digiti Minimi Abductor Photo courtesy PracticalPedal.com 13 Extensor Hallucis Longus - Anatomy Origin Fibula (middle ½ - anterior surface) (1) Photo courtesy Body Parts 3D Insertion Hallux: Distal phalanx (base-dorsum surface) Photo courtesy Wikimedia Commons 14 Extensor Hallucis Longus - Actions Prime Motions 1 st Toe distal phalanx and foot: Dorsiflexion Synergists Extensor hallucis brevis Photos courtesy morphopedics.wikidot.com 15 5

6 Ext. Hallucis Longus MMST Procedure Position Supine Foot: Plantar flexion 20 Hallux: Flexed Examiner Stabilization Contact Direction At feet Hold proximal phalanx in flexion Toe nail Into flexion 16 Ext. Hallucis Longus MMST Procedure Note stabilization of the proximal phalanx in flexion while testing the distal phalanx into extension. 17 Flexor Hallucis Longus - Anatomy Origin Fibula (distal 2/3 rd posterior) Photo courtesy Body Parts 3D (1) Insertion Hallux: Distal phalanx (base-plantar surface) Photo courtesy Wikimedia Commons 18 6

7 Flexor Hallucis Longus - Actions Prime Motions 1 st Toe distal phalanx and foot: Plantarflexion Synergists Flexor hallucis brevis Photos courtesy John Wallman 19 Flexor Hallucis Longus MMST Procedure Position Supine Foot: fully dorsiflexed Hallux: flexed Examiner Stabilization Contact Direction At feet Dorsum foot & proximal phalanx Distal phalanx, plantar surface Into extension 20 Flexor Hallucis Longus MMST Procedure Note contact on distal phalanx and stabilization on proximal phalanx. 21 7

8 Extensor Hallucis Brevis - Anatomy Origin Calcaneus (distal dorsum) (1) Photo courtesy Body Parts 3D Insertion 1 st Proximal phalanx (base-dorsum) Photo courtesy Body Parts 3D 22 Extensor Hallucis Brevis - Actions Prime Motions 1 st Toe proximal phalanx: Dorsiflexion Synergists Extensor hallucis longus Photos courtesy morphopedics.wikidot.com 23 Ext. Hallucis Brevis MMST Procedure Position Supine Ankle: Dorsiflexed Hallux: Plantar flexed Examiner At feet Stabilization Dorsum foot Contact Proximal phalanx Direction Into flexion 24 8

9 Ext. Hallucis Brevis MMST Procedure Note starting position with hallux flexed and contact on the proximal phalanx 25 Flexor Hallucis Brevis - Anatomy Origin Cuboid (infero/medial) and 3 rd cuneiform (infero/lateral) (1) Insertion 1 st Proximal phalanx (base-plantar) Public Domain via Wikimedia Commons 26 Flexor Hallucis Brevis - Actions Prime Motions 1 st Toe proximal phalanx: Plantarflexion Synergists Flexor hallucis longus Photos courtesy John Wallman 27 9

10 Brevis and Longus Imbalances Metatarsal Phalanges Normal Brevis imbalance Claw Toe - Type 1 Claw Toe Type 2 Brevis and longus imbalance Hammer Toe Longus imbalance 28 Image courtesy J. Wallman Flexor Hallucis Brevis MMST Procedure Position Supine Ankle: Plantar flexed Digits: Plantar flexed Examiner Stabilization Contact Direction At feet Sole Proximal hallux with finger tip Into extension 29 Flexor Hallucis Brevis MMST Procedure Note contact on the proximal phalanx

11 Abductor Hallucis - Anatomy Origin Calcaneus (medial process) (1) Insertion 1 st Toe proximal phalanx (base-medial) Public domain via Wikimedia Commons 31 Abductor Hallucis - Actions Prime Motions 1 st Toe proximal phalanx: Abduction Support longitudinal arch Synergists Longitudinal arch support Tibialis anterior Tibialis posterior Photos courtesy andy_5322 via Flkr 32 Abductor Hallucis MMST Procedure Position Supine Examiner At feet Stabilization Lateral hand on heel Contact Medial hand index finger on proximal hallux Direction Into adduction 33 11

12 Abductor Hallucis MMST Procedure Note contact on proximal phalanx and force into adduction. 34 Extensor Digitorum Longus - Anatomy Origin Tibia (lateral condyle), Fibula (proximal 3/4 th anterior surface) Insertion Toes 2-5 (base of middle phalanx and distal phalanx- dorsal surfaces) (1) Photo courtesy Body Parts 3D 35 Public domain via Wikimedia Commons Extensor Digitorum Longus - Actions Prime Motions 2 nd 5 th Toes distal phalanges [and foot]: Dorsiflexion Synergists Extensor digitorum brevis Photos courtesy articulacionesperifericas.wikispaces.com/el+tobillo 36 12

13 Ext. Digitorum Longus MMST Procedure Position Supine Foot: Plantar flexion 20 Digits: Flexed Examiner Stabilization Contact Direction At feet Hold proximal digits in flexion 2-5 toe nails (individually or as a group) Into flexion 37 Ext. Digitorum Longus MMST Procedure Note set up position with plantar flexion of foot and digits, stabilization of proximal phalanx in flexion and force contact on distal phalanx. 38 Flexor Digitorum Longus - Anatomy Origin Tibia (middle 3/5 th - posterior) (1) Photo courtesy Body Parts 3D Insertion Toes 2-5 (base of distal phalanx- plantar surface) Public domain via Wikimedia Commons 39 13

14 Flexor Digitorum Longus - Actions Prime Motions 2 nd 5 th Toes distal phalanges [and foot]: Plantarflexion Synergists Flexor digitorum brevis 40 Flexor Digitorum Longus MMST Procedure Position Supine Foot: dorsiflexed Digits: plantar flexed Examiner Stabilization Contact Direction At feet Ankle Distal digits 2-5 (individually or as a group) Into extension 41 Flexor Digitorum Longus MMST Procedure Note contact on distal phalanges 2-5, stabilization of proximal phalanges and force pulling into extension

15 Extensor Digitorum Brevis - Anatomy Origin Calcaneus (distal dorsum) Insertion 2 nd 4 th Extensor digitorum longus tendons (at metatarsal/phalanx junction lateral margin) (1) Image courtesy Body Parts 3D 43 Public domain via Wikimedia Commons Extensor Digitorum Brevis - Actions Prime Motions 2 nd 4 th Toes middle phalanges: Dorsiflexion Synergists Extensor digitorum longus 44 Ext. Digitorum Brevis MMST Procedure Position Supine Ankle: dorsiflexed Digits: Flexed Examiner Stabilization Contact At feet Dorsum foot Proximal phalanx digits 2-4 (individually or as a group) Direction Into flexion 45 15

16 Ext. Digitorum Brevis MMST Procedure Note contact on proximal phalanges of digits 2-4 and force into flexion 46 Flexor Digitorum Brevis - Anatomy Origin Calcaneus (medial process) (1) Insertion 2 nd -5 th Middle phalanx (plantar) Public domain via Wikimedia Commons 47 Flexor Digitorum Brevis - Actions Prime Motions 2 nd 5 th Toes middle phalanges: Plantarflexion Synergists Flexor digitorum longus 48 16

17 Flexor Digitorum Brevis MMST Procedure Position Supine Ankle: Plantar flexed Digits: Plantar flexed Examiner Stabilization Contact Direction At feet Sole Proximal phalanx digits 2-5 (individualy or as a group) with finger tip(s) Into extension 49 Flexor Digitorum Brevis MMST Procedure Note contact on proximal phalanges and force upward into extension. 50 Abductor Digiti Minimi - Anatomy Origin Calcaneus (lateral and medial processes) (1) Insertion 5 th Proximal phalanx (base-lateral) Public domain via Wikimedia Commons 51 17

18 Abductor Digiti Minimi - Actions Prime Motions 5 th Toe proximal phalanx: Abduction Synergists NA Note: Picture demonstrates abduction of all toes. Photos courtesy Rebecca via Flirk.com 52 Abductor Digiti Minimi MMST Procedure Position Examiner Stabilization Contact Direction Supine At feet Medial hand on heel Lateral hand index finger on mid-digiti minimi Into adduction 53 Abductor Digiti Minimi MMST Procedure 54 18

19 Research Muscle imbalance and reduced ankle joint motion in people with hammer toe deformity Study Design (3) 27 patients with hammer toe (claw toe) deformity and 31 age matched controls Measure proximal phalanx strength for flexion and extension using a dynamometer Measure metatarsal/phalangeal (MP) angle using CAT scan Calculate ratio of extensor : flexor strength 55 Results Research Extensor : Flexor strength ratios of proximal phalanx of digits 2 through 5 were times higher in hammer toe group vs. controls Conclusions Proximal digit muscle strength imbalance is correlated with hammer toe deformity and potentially a risk factor. Additional research is needed to determine if strengthening toe flexor muscles could potentially reverse or prevent hammer toe deformity. 56 Research Definitions of hammer toe and claw toe: an evaluation of the literature. Study Design (7) Literature Review Definitions of Hammer Toe vs. Claw Toe PubMed database, 81 potential articles, 42 with clear definitions of hammer toe or claw toe 57 19

20 Conclusions Research Claw toe: Extension of MP joint, flexion of IP joints Hammer Toe: Flexion of IP joints only. 58 Research Toe flexors strength and passive extension range of motion of the first metatarso-phalangeal joint in individuals with plantar fasciitis Study Design (4) 20 subjects with unilateral plantar fasciitis averaging 20 months duration and 20 age/sex matched controls with no symptoms Passive measurement of 1 st MP joint extension Peak isometric strength of 1 st digit flexors 59 Results Research No difference passive extension range of motion Significant weakness of involved side with plantar fasciitis vs. uninvolved side as well as controls Conclusions Extensibility of 1st toe not a factor with plantar fasciitis. Additional research is needed to determine if toe flexors weakness is a cause or a result of plantar fasciitis and if strengthening regimes for the toe flexors are effective interventions for plantar fasciitis

21 Research Interventions for preventing falls in older people living in the community. Study Design (8) Cochrane Systems Reviews Literature review 159 trials with 179K participants Methods evaluated included: exercises, tai chi, eyeglasses, removal of psychotropic medications, vitamin D, cataract surgery, home safety, non-slip shoes, cognitive behavior, pacemakers, education, multifactor interventions 61 Research Results Reduced rates of falls and risk of falling Exercise programs Home safety interventions Reduced rate of falls (not risk) Reduction or modification of medications 1 st cataract surgery Multi-focal to single focus lens (Tai Chi) Increase in falls Intervention to treat vision problems 62 Research Plantarflexion strength of the toes: age and gender differences and evaluation of a clinical screening test. Study Design (9) 20 male & 20 female young (ave years) vs. 20 & 20 older (ave years) Measure hallux and digits plantar flexion strength 63 21

22 Research Results Older group was: 32% less strength hallux flexion 27% less strength digit flexion Women 42% less strength hallux flexion than males No difference strength other digits Conclusions aging is associated with reduced plantarflexion strength of the toes. 64 Summary We Covered Review of Manual Muscle Strength Testing (MMST) Purposes, General Procedures, Grading Issues with lower limb digits Control Implications Athletic performance Health Muscle Tests Muscles in this course Origin and Insertion Action Procedures Research Thank you! 66 22

23 References 1. Ciesla N, Dinglas V, Fan E, Kho M, Kuramoto J, Needham D, Manual muscle testing: a method of measuring extremity muscle strength applied to critically ill patients. J Vis Exp Apr 12;(50) Fan E, Ciesla ND, Truong AD, Bhoopathi V, Zeger SL, Needham DM. Inter-rater reliability of manual muscle strength testing in ICU survivors and simulated patients. Intensive Care Med Jun;36(6): Kwon OY1, Tuttle LJ, Johnson JE, Mueller MJ., Muscle imbalance and reduced ankle joint motion in people with hammer toe deformity Clin Biomech (Bristol, Avon) Oct;24(8): doi: /j.clinbiomech Epub 2009 Jun Allen RH1, Gross MT., Toe flexors strength and passive extension range of motion of the first metatarsophalangeal joint in individuals with plantar fasciitis. J Orthop Sports Phys Ther Aug;33(8): Schrier JC1, Verheyen CC, Louwerens JW., Definitions of hammer toe and claw toe: an evaluation of the literature. J Am Podiatr Med Assoc May-Jun;99(3): Gillespie LD1, Robertson MC, Gillespie WJ, Sherrington C, Gates S, Clemson LM, Lamb SE., Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev Sep 12;9:CD doi: / CD pub3. 9. Menz HB1, Zammit GV, Munteanu SE, Scott G., Plantarflexion strength of the toes: age and gender differences and evaluation of a clinical screening test. Foot Ankle Int Dec;27(12): Texts: 5. Kendall and McCreary Muscles: Testing and Function with Posture and Pain 5th Edition, Daniels and Worthingham Muscle Testing, 9th Ed