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Proper Introduction
- Hi, my name is student clinician ______. Today I'm going to be performing an extremity exam on you. If at any time you experience any pain or discomfort please let me know. If you have any questions feel free to ask. Any thing that happens here today will be held in strict confidence. Do I have your permission to begin?
- We would first clear the spine, then work proximal to distal. The muscle tests are based on the mechanoreceptor theory which is based off Hilton's Law.
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Sternoclavicular joint muscle test.
- Pectoralis major superior (clavicular branch)
- Pt supine, arm extended to 90o, palm facing dr. Dr pulls down and out (45o) from the patient
- Challenge: have patient push on SC joint in direction of adjustment (M-L, A-P, slight I-S)
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Sternoclavicular adjustment, same side
- Segmental contact point: medial side of SC joint
- Contact point: soft pisiform of inside hand
- Stabilization hand: lateral side of head of humerus, gently tractioning P and I, the distal end of the shoulder complex
- Line of Correction: M-L, A-P along the line of the clavicle (usually I-S)
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Sternoclavicular Adjustment, Opposite Side
- Segmental Contact Point: Medial side of the SC joint
- Contact Point: Soft pisiform of outside hand
- Stabilization Hand: Tractioning P and I the distal end of the involved SC joint
- Line of Correction: M-L, A-P, along the line of the clavicle (usually I-S)
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Sternoclavicular Adjustment, Side Lying
- Patient Position: Side lying, involved side down
- Stabilization Hand: Doctor supports pts head (cervical spine)
- Contact Point: Soft pisiform of inferior hand
- Segmental Contact Point: Medial side of the SC joint
- Line of Correction: M-L, A-P, along the line of the clavicle (usually I-S)
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Acromioclavicular Joint Muscle Test
- Coracobrachialis
- Pt supine arms fully flexed, by side, at level of rib cage.
- Dr stands at head of table and pushes elbow down in an arc towards ipsilateral ASIS.
- Challenge: Have patient put opposite arm on AC joint and muscle test again.
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Acromioclavicular Adjustment, Supine
- Pt supine with arm abducted and elbow flexed 90o
- Contact Point: End of the thumb and
- 2nd digit midddle metacarpal joint (pincher contact)
- Stabilization Hand: Holding patients elbow so arm is parallel with the floor.
- Line of Correction: S-I
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Acromioclavicular Joint Adjustment, Web Contact
- Pt seated, arm abducted and elbow flexed to 90o
- Contact point: Web of hand
- Stabilization Hand: Outside hand grasping the flexed elbow joint keeping the shoulder in an abducted 90o position (can also use knee)
- Line of Correction: S-I
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Acromioclavicular Joint Adjustment, Chiro-Chiro Contact
- Pt seated, dr seated beside pt
- Segmental Contact Point: 1/2" medial to the AC joint (distal 1/3 of clavicle)
- Contact Point: Dominant chiropractic index finger (or two laced together)
- Stabilization: Pt's abducted arm rested on dr's shoulder
- Line of Correction: S-I
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Anterior Inferior Humerus Muscle Test
- Anterior deltoid
- Pt supine, arms extended to about 45oDr pushes downwards on both forearms
- NOTE: With the GH jt, muscle test Anterior deltoid and teres major before considering adjusting either one.
- Challenge: Muscle testing teres major
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Anterior Inferior Humerus Adjustment Supine
- Dr on same side of table
- Segmental Contact Point: Olecranon of involved side and lateral glenohumeral joint
- Contact Point: Palms of the hands
- Line of Correction: I-S and A-P
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Anterior Inferior Humerus Adjustment Seated
- Pt seated with hand on opposite shoulder
- Segmental Contact Point: Olecranon of involved side
- Contact Point: Palms of hands with fingers interlocked
- Stabilization: Dr's SC joint against the spine of the scapula
- Line of Correction: M-L, A-P, I-S
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Posterior Humerus Muscle Test
- Teres Major (only muscle test that you put your hand on the joint you're testing)
- Pt places back of hand in small of back and relaxes elbow below the plane of the table.
- Dr takes the outside hand and contacts the elbow, with the inside hand contacts the anterior aspect of the GH joint.
- While the superior hand stabilizes the GH joint, the inferior hand pulls upward from A-P
- Cavitations of the joint is indicative of muscle imbalances within the shoulder.
- Challenge: muscle test anterior deltoid
- NOTE: With the GH joint muscles, test both the anterior deltoid and the teres major before considering adjusting either one.
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Posterior Humerus Adjustment
- Pt prone
- Segmental Contact Point: Posterior aspect of GH joint.
- Contact Point: Knife edge of inside hand
- Stabilization Hand: Outside hand grasping around the arm abouve the flexed elbow joint with the shoulder abducted and slightly extended. Outside hand applies slight long axis traction
- Line of Correction: P-A, M-L (slightly)
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Glenohumeral Distraction
- When a majority or all of the upper extremity muscles are weak and the spine is clear.
- MOI= lateral impact to the GH, AC or SC compressing these joints.
- Pt porne with shoulder flexed at 90o
- Contact Point: Interlocked hands or fingers
- Line of Correction: M-L (slightly I-S)
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Biceps Tendon Muscle Test
- Pt supine, Dr stabilizes pts flexed elbow on the inside thigh. Dr places hands around forearm of the pts flexed elbow and pulls towards the Dr's body.
- Challenge: Push lateral against biceps tendon
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Biceps Tendon Adjustment
- 3 Part Move:
- 1. Pt is supine with the involved arm extended. Dr stands on involved side. With S hand, Dr takes thumb and finds biceps tendon (2" below the greater and lesser tubercles of humerus)
- Place thumb tip against L portion of tendon, with rest of hand and fingers, rotate soft tissue of arm from L-M.
- Dr's I hand brings pts shoulder intou abduction and external rotation.
- While moving the arm, the S hands thumb contact maintains rotation obtained in first part.
- 2. Again, the S thumb and hand rotates soft tissue from L-M removing slack/tension from arm.
- Once the slack is removed impulse/thrust (wrist roll) from the thumb L-M.
- The pts arm is in 90o of shoulder abduction and 90o of elbow flexion.
- 3. Bring the pts arm back to adduction and extension while maintaining thumb contact.
- Take any remaining slack/tension out of arm from L-M and impulse L-M
- 3 L-M tissue pulls and 2 L-M impulses
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Scapulothoracic Articulation Criteria
- Must meet 2 of 3 criteria to adjust
- 1. Difference in Apley's Scratch test
- 2. Reduced scaption motion
- 3. Compare internal rotation of shoulders while patient is supine
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Scapulothoracic Articulation Adjustment
- Pt prone
- Inferior Angle:
- SCP: P/I angle of scapula
- CP: Heel of hand or knife edge of outside hand
- LOC: I-S
- Medial Border of Scapula
- Doctor opposite side of table
- SCP: medial border of scapula
- CP: Knife edge of inferior hand
- LOC: M-L
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2 Rules for Adjusting Elbow
- 1. If medial, doctor must stand on medial side of arm, if lateral, dr must stand on lateral side of arm
- 2. If adjusting ulna, hand must be supinated, if adjusting radius, hand must be pronated
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Elbow Baseline Muscle Test
- Triceps
- Pt supine with shoulder flexed to 45o and elbow flexed to approximately 90o, wrist in neutral position
- Dr stabilizes the pts elbow on their thigh and pushes the forearm towards the table
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Elbow Muscle Test Ulna
Muscle test triceps with wrist in flexion
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Posterior Medial Ulna
- Pt supine with elbow extended and hand supinated
- SCP: Proximal medial ulna approximately 1" distal to medial epicondyle
- CP: End of thumb and 2nd digit DIP joint or web of medial hand
- Stabilization Hand: Outside hand grasping the lateral arm, ensuring the pts lateral elbow is firmly stabilized against the doctors forearm
- LOC: M-L, P-A, and I-S
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Posterior Lateral Ulna
- Pt supine with elbow extended and hand supinated
- SCP: Proximal lateral ulna approximately 1" distal to olecranon on the olecranon ridge
- CP: End of thumb and 2nd digit DIP joint or four finger tips of the lateral hand
- Stabilization Hand: M hand grasping M arm, ensuring the pts M elbow is firmly stabilized against the doctors forearm
- LOC: L-M, P-A, and I-S
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Elbow Radius Muscle Test
- Triceps
- Pt supine with shoulder and elbow flexed to 90o, wrist in extension
- Dr stabilizes the patients elbow on their thigh and pushes the forearm towards the pt
- To differentiate b/w PL radius & AM radius test Brachioradialis
- Pt turns thumb towards body, elbow flexed at 90o and doctor tries to pull elbow into extension
- If strong, PL radius; if weak, AM radius
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Posterior Lateral Radius Adjustment
- Pt supine with elbow extended and hand pronated
- SCP: Proximal lateral radius aproximately 1/4" distal to radial head
- CP: End of the thumb against the lateral proximal radial head
- Stabilization Hand: Medial hand grasping the medial arm, ensuring the pts medial elbow is firmly stabilized against the doctors forearm
- LOC: L-M, P-A, I-S
- To retest the muscle, have to test triceps with wrist in extension, not brachioradialis since it was already strong
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Anterior Medial Radius Adjustment
- Pt supine w/ elbow extended and hand supinated initially, take the CP and roll the forearm into pronation so the CP rolls onto the SCP
- SCP: Proximal anterior medial radial head
- CP: End of the thumb against the anterior medial proximal radial head in the cubital fossa
- Stabilization Hand: Outside hand grasping the lateral arm, ensuring the pts lateral elbow is firmly stabilized against the drs forearm
- LOC: M-L, A-P, & I-S
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Carpals Adjustment
- Pinch, Distract, Shear
- Criteria = decreased motion and symptoms
- Pt seated, elbow extended, hand pronated
- SCP = carpal on 1/2 of fixated joint
- CP = thumb and thumb
- LOC = p-a and a-p
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Wrist Muscle Test
- Opponens Pollicis
- Pt's thumb and 5th carpal opposed. Dr tries to pull the fingers apart using his/her same fingers
- If weak consider anterior lunate (MC)
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Anterior Lunate Adjustment
- Pt supine with elbow extended and hand supinated
- SCP = anterior lunate
- CP = dominate thumb under non-dominate thumb
- LOC = A-P
- NO WHIPPING ACTION!
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Posterior Lunate Adjustment
- Pt supine with elbow extended and hand pronated
- SCP = Posterior lunate
- CP = dominate thumb under non-dominate thumb
- LOC = P-A
- NO WHIPPING ACTION
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2nd - 5th Metacarpal Rotation
- Criteria = 2nd - 5th digit nail angles toward the 5th digit
- Pt seated with elbow extended and hand pronated
- SCP = Involved metacarpal on medial side of the bone proximal to the MCP joint
- CP = Thumb of dominant hand, other hand distract the involved MCP joint
- LOC = M-L
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PIP and DIP Joint Rotation
- Criteria = decreased ROM of the jt
- Pt seated with elbow extended and hand pronated
- SCP = distal to the involved joint while stabilizing proximal to the joint
- CP = thumb of dominant hand, other hand distracts the joint
- LOC = M-L or L-M
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1st MCP Joint
- Criteria = decreased ROM of the joint
- Pt seated with elbow extended and hand pronated
- SCP = distal to the involved MCP joint while stabilizing proximal to the joint
- CP = thumb of dominant hand, other hand distracts the joint
- LOC = P-A and slight long axis distraction
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Criteria For Adjusting Jaw
- Pain in TMJ
- Popping/Clicking/Snapping in joint
- Tracking problems with TMJ
- Muscle Weakness (TIME)
- Eye problems (focusing, nystagmus, strabismus)
- Ear Problems (tinitus, white noise)
- Bruxism - grinding teeth
- Unresolved cervical subluxation
- Neck problems
- Opening/Closing problems
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Superior/Lateral/Posterior Jaw aka Anterior Disc Adjustment
- Criteria = 3 or more positives on criteria list
- Pt seated with head rested on doctor's waist
- SCP = involved TMJ
- CP #1 = 5th MCP
- CP #2 = 1st MCP
- CP #3 = Soft pisiform
- Stabilization Hand = The upper cervical spine and non-involved TMJ
- LOC = With the patients mouth ajar, P-A, S-I, and L-M
- The doctors hand follows through and slides off the body of the mandible towards the patients opposite axilla
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Anterior Jaw aka Posterior Disc
- Criteria = Three or more positives on the criteria list
- Pt seated with head resting on doctors waist
- SCP = Mental protuberance
- CP = DIP of chiro finger overlapping DIP of other chiro finger
- LOC = with the pts mouth open apply constant A-P pressure while the pt closes the mouth. (3 times, increasing the pressure each time)
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Posterior Rib Angle Muscle Test
- Serratus Anterior
- Pt has arm fully extended with wrist in neutral position and hand in fist position
- Have patient punch up to the ceiling to stress the muscle.
- If you have someone really muscular then drop the arm down 1/2 way then muscle test to take pec major out of the way
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Posterior Rib Angle Adjustment
- Dr stands on opposite side
- Pt prone
- SCP = rib angle
- CP = Fingertips or knife edge of hand
- LOC = Superior for an inferior rib and inferior for a superior rib; Then take a knife edge contact on the involved rib and a medial to lateral impulse on the patients exhalation
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Costotransverse and Costovertebral Muscle Test
- Rhomboid
- Pt has arm flexed at a 45o angle. Dr tries to externally rotate the arm while the patient tries to maintain the initial position. (this muscle test is for the first 5 ribs only)
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Costotransverse and Costovertebral Adjustment
- Dr same side
- Pt prone
- SCP = P, S surface of the rib head
- CP = Pisiform of S hand
- SH = thenar pad of I hand on opposite TP
- LOC = Part 1 P-A impulse on pts inhalation, Part 2 S-I impulse on pts exhalation
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Costosternal or Costochondral Muscle Test
- Pec Major Sternal Division
- Pt supine arm extended and palm facing dr
- Dr pushes arm up and out
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Costosternal Adjustment
- Dr stands opposite side
- Pt supine
- SCP = prominent rib (upper 6)
- CP = fingertips or knife edge of hand
- LOC = S for I rib, I for S rib, impulse on pts inhalation, then take a knife edge contact on involved rib and a M-L impulse on pts exhalation
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Costochondral A Adjustment
- Dr opposite side
- Pt supine
- SCP = hook sternum with S hand and I hand contacts A rib
- CP = Fingertips hook with S hand and knife edge of I hand
- LOC = S hand hook pulls towards the sternum and knife edge hand pushes M-L
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Anterior Dorsals Adjustment
- Pt may present with pain upon palpation of SP
- Look for flattened area - pottinger's saucer
- T9-T12 have pt tuck chin
- T4-T9 have pt extend head
- T1-T3 have pt flex knees and put feet on table
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