MLT Muscle(s) Patient Position Therapist position Stabilization Limb Position Picture Put biceps on slack by bending elbow. Pectoralis Minor Supine, arm at side, elbows extended, supinated Head of Table and observe for anterior tilt. **MEASURE from acromion to if difference bilaterally Thenar eminence on coracoid process roll hand down and push diagonally out Put coracobrachialis on slack by bending elbow and lifting humerus off If shoulder can be further depressed then biceps/coracobrachialis is also tight Pectoralis Major (Clavicular Fibers) Pectoralis Major (Sternal Fibers) GH internal rotators GH External Rotators Supine, Edge of arm off Supine, Edge of arm off Supine, shoulder 90⁰ abducted, elbow at edge of and flexed to 90⁰ Supine, shoulder 90⁰ abducted, elbow at edge of and flexed to 90⁰ Table supports scapula. Hold at wrist and elbow Table supports scapula. Hold at wrist and elbow Table stabilizes scapula Move wrist *May need towel roll under distal end of humerus to make sure parallel with. Table stabilizes scapula Stabilize anterior shoulder and move wrist *May need towel roll under distal end of humerus to make sure parallel with. Place arm into horizontal abduction with elbow extended and shoulder in lateral rotation (palm up) 135⁰ abduction with elbow extended (in line with ASIS). Shoulder should be laterally rotated (palm up) ** MEASURE lateral epicondyle to External rotation so that back of forearm is down toward. **MEASURE if less than 90⁰. Parallel with, medial epicondyle and ulna Internal rotation so palm is down towards. **MEASURE ALWAYS (normal is 70⁰) One handed Goni- Perpendicular to floor, medial epicondyle, and ulna
Biceps LH Teres Major, Rhomboids, and Latissimus Dorsi Extensor Carpi Radialis Longus/Brevis Supine, arm at side, supinated. Edge of arm off Supine, arms at sides, elbows extended At head of facing down towards patients head Table stabilizes scapula. Support elbow and wrist Hold elbow and wrist Support elbow in extension. Hold metacarpals in ulnar dev and wrist flexion Shoulder Extension to ~40⁰, Pronation, Elbow Extension **MEASURE if you lose position at last moved joint Bilateral quick screen: ask them to raise arms up, palms up, overhead close to ears, keep elbows straight Then uninvolved side first **MEASURE parallel with, GH joint, along humerus should be 180⁰ Elbow Extension, Pronation, Ulnar Deviation, Wrist Flexion *no norm value compare bilaterally Flexor Carpi Ulnaris Support elbow in extension and pull down on MCPs Elbow Extension, Supination, Radial Deviation, Wrist Extension Flexor Carpi Radialis Extensor Digitorum Finger Flexors Support elbow in extension and pull down on MCPs Hold with both hands at MCP S Elbow Extension, Supination, Ulnar Deviation, Wrist Extension Elbow Extension, Pronation, Wrist Flexion, MCP Flexion *no norm value compare bilaterally. Test all fingers individually after hand as a whole Elbow Extension, Supination, Wrist Extension, MCP Extension, PIP Extension, DIP
Extension *no norm value compare bilaterally. Supinator Pronator Teres Triceps Supine, Elbow at 90⁰ degrees abduction and flexion. Forearm Neutral Supine Standing to side of pt Support elbow and move at wrist Support distal humerus and move at wrist Support elbow and shoulder Pronate Forearm until feel first resistance **MEASURE with goni (normal Is 80⁰) Elbow Extension, Supinate Forearm **MEASURE with goni (normal Is 80⁰) If you know lats/teres are not tight: Shoulder Flexion, Elbow Flexion OR If they are tight (can t go into 180 flexion) Elbow Flexion first then Shoulder Flexion. Let off on elbow flexion to see if they can go further if so then triceps are the limitation Lumbricals on, forearm is neutral Support wrist in neutral position, hold DIP and MCP Extend MCP s, flex IP s, push DIP to palm passively
Stretching Muscle(s) Patient Position Therapist Position Stabilization Limb Position Picture Support wrist and gently push down on humerus towards the Pectoralis Major (Clavicular Fibers) Pectoralis Major (Sternal Fibers) Supine, Edge of arm off Supine, Edge of arm off **Elbow will not effect stretch Table supports scapula. Hold at wrist and gently push down and humerus **Elbow will not effect stretch Place arm into horizontal abduction with elbow extended and shoulder in lateral rotation (palm up) Push arm down towards 135⁰ abduction with elbow extended (in line with ASIS). Shoulder should be laterally rotated (palm up) Push arm diagonally out and down towards Pectoralis Minor Supine, arms to side, palms up OR OR Sidelying Stabilize at forearm and thenar eminence on coracoid process For seated and sidelyingstabilize scapula with one hand and push with other hand at coracoid process Gather up slack and push down in a diagonal down direction GH Internal Rotators Supine, elbow flexed and abducted to 90⁰ Table supports scapula. Other hand on forearm Bring into External rotation Push forearm down towards GH External Rotators Supine, elbow flexed and abducted to 90⁰ Table supports scapula. Stabilize anterior shoulder. Other hand on forearm Bring into Internal rotation Push forearm down towards
Teres Major, Rhomboids, Latissimus Dorsi Stabilize forearm and push down on humerus towards To stretch JUST LATSstabilize iliac crest Supine To Stretch JUST TERESstabilize under scapula Bring arm overhead and pull down towards Upper Trapezius Biceps (or supine), Arm relaxed to side Supine, arm at side, supinated Standing behind pt Push down at acromion and support neck in position with little force Table stabilizes scapula, hold elbow and force should be down onto forearm Resist elbow flexion and supination Head/neck:rotate towards, sidebend away, flex. Scapular depression Extend shoulder to end range, pronate, extend elbow to end range Extensor Digitorum Resist Finger extension Flex MCP, Flex wrist, Extend elbow Extensor Carpi Radialis Longus/Brevis Resist wrist extension and radial deviation Flex wrist, Ulnarly Deviate, Extend Elbow
Flexor Carpi Ulnaris Resist wrist flexion and ulnar deviation Extend wrist, Radially deviate, Extend elbow Flexor Carpi Radialis Resist wrist flexion and radial deviation Extend wrist, Ulanarly deviate, Extend elbow Finger Flexors Pronator Teres Resist Finger flexion Supine, forearm neutral Resist pronation Extend MCP, Extend wrist, Extend elbow Supinate wrist and extend elbow Supinator Supine elbow abducted and flexed to 90⁰ Use lumbrical grip to hold Pronate wrist Triceps Supine/Sitting Behind pt or next to pt Resist elbow extension Flex elbow and extend shoulder Intrinsics on Stabilize wrist and hold fingers resisting extension with MCP extended. Flex DIP, Flex PIP, Extend MCP
Muscle(s) Upper Trapezius Patient Position AROM/PROM Elevate Shoulder, upward rotation of head. Same side bending. Lateral rotation. Extension Standing behind pt MMT Therapist Position Stabilization Pressure Direction One hand on head (less force). And force hand on acromion of shoulder Diagonal upper corner and down on shoulder. Try to pull apart Picture Middle Deltoid Anterior Deltoid Posterior Deltoid Full abduction up to head Standing behind pt Full abduction up to head Standing in front of pt Full abduction up to head Standing behind pt Stabilize scapula. Fore at distal end of humerus Stabilize scapula. Force at distal end of humerus Full abduction up to head Hold 90⁰ abduction,neutral rotation. Force down into adduction Hold 90⁰ abduction, slight shoulder flexion, slight external rotation. Force is mostly adduction and slight extension Hold 90⁰ abduction, slight shoulder extension, slight internal rotation. Force is mostly adduction and slight flexion Supraspinatus Scaption Standing, 70⁰ elevation, internal rotation Stabilize shoulder. Force arm on distal forearm Force wrist down toward body
Biceps/Brachialis Elbow flexion while supinated or Supine Elbow just short of 90⁰ of flexion, supinated. In front of pt Stabilize posterior distal humerus and force arm on distal forearm Resist forearm extension Serratus Anterior Shoulder flexionprotraction at end of range or Standing Behind pt Stabilize lateral border of scapula. Force arm on distal forearm Push down into extension of shoulder and downward rotation Triceps/Anconeus Middle Trapezius Supine, shoulder flexed to 90⁰ Elbow slightly flexed less than 90⁰. IF GH problems prone with arm Extend elbow off Next to pt Horizontal abduction with scapular retraction. External rotation (thumb up- not just supination) Prone Next to pt Table stabilizes shoulder. Support distal humerus and force arm is at distal forearm Support scapula on opposite side with thumb feeling retracting side. Force arm on distal forearm Force down into flexion. Arm in 90⁰ abduction, external rotation, retracted scapula. Force down try to break scapula not arm. Lower Trapezius Upward angle abduction with thumb up shoulder blade down and in. Prone Next to pt Support scapula on opposite side with thumb feeling retracting side. Force arm on distal forearm Arm in 135⁰ abduction, external rotation, retracted scapula. Force down try to break scapula not arm.
Pectoralis Major (Clavicular Fibers) Pectoralis Major (Sternal Fibers) Horizontal Abduction Supine Abduction from opposite ASIS to 135⁰ Supine Stabilize opposite shoulder. Force arm is on proximal forearm distal to elbow. Stabilize on opposite ASIS. Force arm is on proximal foream just distal to elbow Slight internal rotation and horizontal adduction. Toward ASIS GH Internal Rotators GH Lateral Rotators Latissimus Dorsi Rhomboids/ Levator Scap Internal rotation from neutral External rotation from neutral Supine, elbow tucked to side at 90⁰, neutral Prone elbow off edge of 90⁰, neutral. Humerus still resting on Extension with palm facing ceiling Prone Retract, downward rotation, elevation of scapula Prone. Slight external rotation, slight hyperextension shoulder, flexed elbow (tuck elbow behind back) Counterpressure against outer aspect of distal humerus. Force against distal forearm Counterpressure under distal humerus. Force against distal forearm Stabilize acromion or opposite hip. Force arm on distal forearm Force arm on acromion and other hand on humerus. Force into external rotation Force into internal rotation Force down towards floor Push down into depression and outward to break retraction
Supinator and Biceps Supination to pronation Supine. Elbow flexed to almost 90⁰. Start in supination next to pt Lumbrical grip, thenar eminence over dorsal surfaces Pull into pronation Supinator Supination to pronation Supination. Flex shoulder and elbow. Start in supination Next to pt Lumbrical grip, thenar eminence over dorsal surfaces Ask them to bring thumb to ear Brachioradialis Pronator Teres/ Quadratus Forearm neutral, elbow flexion Pronation to Supination Supine. Elbow flexed to almost 90⁰ next to side. Start in pronation next to pt Stabilize distal humerus posteriorly. Force on distal forearm Stabilize elbow next to body. Lumbrical grip thenar eminence over dorsal surface Force is down into elbow extension Pull into supination Flexor Carpi Radialis Flexor Carpi Ulnaris Extensor Carpi Radialis Longus Wrist flexion and radial deviation Wrist flexion and ulnar deviation Wrist Extension and Radial Deviation on. Supination, wrist flexion, radial deviation on. Supination, wrist flexion and radial deviation on elbow extended (not all the way), fingers Stabilize distal forearm (under wrist). Force on 1 st met Stabilize distal wrist (under). Force on 5 th met Hold wrist and 1 st or 2 nd MC s with 2 or 3 fingers Pull into extension and ulnar deviation Force into extension and radial deviation Force in direction of flexion and ulnar deviation
Extensor Carpi Radialis Brevis Extensor Carpi Ulnaris Extensor Digitorum Adductor Pollicis Extension and Radial Deviation Extension and ulnar devition Extend wrist and MCP s Adduction of thumb relaxed, wrist extension and radial deviation on with elbow flexed and closed to body. Fingers relaxed, wrist extension and radial deviation Fingers relaxed, wrist extension, ulnar deviation. Slight wrist extension. MCP extension with phalanges relaxed (make an E ) on. Squeeze thumb to palm Hold wrist and 1 st or 2 nd MC s with 2 or 3 fingers Stabilize distal forearm (under). Stabilize MC s. Force arm doesn t have to be parallel because smaller muscles don t require body weight Stabilize wrist. Force against medial surface of thumb Force in direction of flexion and ulnar deviation Apply resistance along 5 th MC and pull diagonally down into flexion and radial deviation Push down on each finger individually Try to pull thumb from palm (Abduction) Flexor Pollicis Brevis Abductor Digiti Minimi Flex thumb Abduct pinky.. Abduct fingers Stabilize wrist. Force against palmar surface of thumb Stabilize hand. Force on ulnar side of pinky Try to extend thumb Try to push pinky in Opponens Digiti Minimi Touch pinky to thumb, arm on. Stabilize 1 st MC. Force against palmar side of pinky Try to pull pinky apart from thumb
Flexor Digiti Minimi Flexion of pinky, arm on. Flex pinky Stabilize hand. Force against palmar surface of pinky Try to extend pinky Dorsal Interossei Abduction of fingers on. Spread fingers Stabilize adjacent finger Push into adduction for each finger Palmar Interossei Lumbricals Adduction of fingers Extension of IPs with flexion of MPs on. Squeeze fingers together on. Extension of IPs with flexion of MPs Stabilize adjacent finger Stabilize wrist in slight extension. Force against dorsal surface of middle and distal phalanges. Then on palmar surface Try to pull fingers apart Force down into finger flexion and then up into finger extension Abductor Pollicis Brevis Abduction of thumb, arm on. Abducted them Stabilize hand. Force on proximal phalanx Push thumb into palm (adduction) Opponens Pollicis Touch pinky to thumb. Hold pinky to thumb Stabilize hand. Force against 1 st MC Try to pull apart. Into extension and adduction with lateral rotaiton
Flexor Pollicis Longus Flexor Pollicis Brevis Palmaris Longus Flexor Digitorum Superficialis Flexor Digitorum Profundus Flex thumb at DIP Flex thumb Strongly cupping palm of hand with fingers extended and wrist in slight flexion Flexion of IP s Make a fist, flexing DIP s, Flex DIP of thumb. Flex MCP on supinated. Same position as ROM on supinated. Stabilize MC s in neutral position. Push against palmar surface of thumb DIP Stabilize wrist. Push against palmar surface of proximal phalanx Fore against thenar and hypothenar eminences Stabilize MC s and wrist in neutral position. Force against palmar surface of middle phalanx Try to pull into extension Try to pull into extension Try to flatten the palm of the hand and extend the wrist Pull into extension Flex DIP Stablize MCP, PIP, Wrist Pull into extension Extensor Pollicis Brevis Extension of MCP of thumb in neutral on. Thumb extended Stabilize wrist. Force against dorsal surface of proximal phalanx Pull into flexion Extensor Pollicis Longus Extension of IP of thumb in neutral on. Thumb extended Stabilize hand. Force against dorsal surface of IP Pull into flexion
Abductor Pollicis Longus Abduction and slight extension of distal and first MC in neutral on. Thumb flexed into palm Stabilize wrist. Force against lateral surface of distal end of first MC Pull into adduction and flexion
MRE Muscle(s) Patient Position Therapist Position Stabilization Resistance Shoulder Flexion Anterior distal arm. If elbow is s/painfree to Supine At Head Table distal forearm Posterior distal arm. Shoulder If elbow is s/painfree to Extension Supine At Head Table distal forearm Shoulder Abduction Supine, Elbow Flexed to 90 At Head At Clavicle Distal arm lateral aspect Shoulder Adduction Supine, Elbow Flexed to 90 At Head At Clavicle Distal arm medial aspect Shoulder Internal Rotation Supine, Elbow Flexed to 90 At Head At Clavicle Distal forearm anterior aspect Shoulder External Rotation Supine, Elbow Flexed to 90 At Head At Clavicle Distal forearm posterior aspect Scapular Elevation Supine, Sidelying,or Sitting At Head or Behind facing the pt N/A Scapular Depression Scapular Supine, Sidelying, or Sitting At Head or Behind facing the pt N/A Protraction Sidelying or Behind or Beside Scapular Retraction Sidelying or Behind or Beside Trunk to prevent trunk rotation Trunk to prevent trunk rotation Superior aspect of shoulder girdle, just above clavicle Hand: pt attempts to reach down toward feet/push hand into PT hand Elbow: push elbow into PT hand Anterior shoulder/head of humerus Posterior shoulder Elbow Flexion Supine At side, head Upper humerus Anterior distal forearm Elbow Extension Supine At side, head Upper humerus Posterior distal forearm Forearm Pronation Supine, Elbow flexed to 90 At side, facing pt Humerus Interlaced grip radius of distal forearm
Muscle(s) Patient Position Therapist Position Stabilization Resistance Forearm Supination Supine, Elbow flexed to 90 At side, facing pt Humerus Wrist Flexion, Supinated or Standing Palmar aspect of forearm Interlaced grip radius of distal forearm At level of metacarpals on palmar side At level of metacarpals on dorsal side Wrist Extension or Standing Dorsal aspect of forearm Wrist Radial Deviation or Standing Distal Forearm 2 nd metacarpal Wrist Ulnar Deviation or Standing Distal Forearm 5 th metacarpal Wrist Extension with Radial Deviation (D1) or Standing Distal Forearm 1 st MC or 2 nd MC Wrist Extension with Ulnar Deviation (D1) or Standing Distal Forearm 5 th metacarpal Wrist Flexion with Radial Deviation (D2), Supinated or Standing Distal Forearm 1 st MC or 2 nd MC Wrist Flexion with Ulnar Deviation (D2), Supinated or Standing Distal Forearm 5 th metacarpal