REIDER PART 1 24
12 Chapier 1__Terms and Technigues_
the appropriate joint against the force of gravity and additional applied resistance but is not felt to bc normal. Gradc 5 means that the muscle strength is considered normal; it is capable of moving the appropriate joint against gravity and against the normal amount of additional resistance.
Most muscles that the clinician encounters have at least grade 3 strength. Therefore, the technique described for each muscle group requires movement of the joint against the force of gravity, except in a few cases where such testing is awkward. If the muscle being tested is not capable of moving the appropriate joint against the force of gravity, the examiner should turn the patient so that the equivalent test can be performed with the force of gravity eliminated. For example, the usual method of testing the quadriceps femoris is with the patient seated on a tablc so that the knee is extended against the force of gravity (Fig. 1-9A). If the patient is unable to execute this maneuver, it means that the effective strength of the quadriceps is grade 2 or less. To further grade the muscle, the patient is instructed to lie on his or her side on the examination table with the knee flexed. The patient is then instructed to attempt to extend the knee with the lower leg and thigh supported by the examination table (Fig. 1-9B). In this fashion, the piane of motion is parallel to the ground and the force of gravity is thus eliminated. If the patient can extend the knee in this position, the quadriceps has grade 2 strength. If the patient is still unable to extend the knee, it means that the effective strength of the quadriceps is either grade 1 or grade 0. To distinguish between these two possibilities, the examiner again asks the patient to attempt to extend the knee with gravity eliminated while the examincr palpates the patient s quadriceps. If a con-traction of the muscle is felt or seen, grade 1 strength is present. Otherwise, the muscle is graded as 0.
The distinction between grade 5 and grade 4 muscle strength is somewhat arbitrary. In generał, a muscle is graded 4 when it is capable of contracting against gravity and additional resistance but weaker than the correspon-ding muscle on the other side of the body. Although this is a valuable rule of thumb, the examiner should remem-ber that, in the upper extremities, strength of correspon-ding muscles can vary between the dominant and the nondominant limbs.
Normal muscle strength varies trcmendously among individuals depending on body habitus, occupation, and prior conditioning. The relative strength and size of the patient and the examiner also influence the ability of the examiner to resist a given muscle group. Nevertheless, for each muscle or muscle group, the authors indicate the generał amount of resistance that an average examiner can expect to feel while examining an average patient.
The examiner should keep in mind that manuał testing mcasures the effective strength of the muscle group and can thus be diminished by factors, such as joint pain, which are extrinsic to the physiologic State of the muscle being tested.
Rcsistive testing can also yield additional diagnostic information. In particular, reproduction of the patient s pain during resistive testing of a particular muscle sug-gests a diagnosis of tendinitis, muscle strain, or contusion of the muscle-tendon unit being tested. Resisted contrac-tion of a muscle that crosses a painful joint can often elicit or exacerbate the associated joint pain.
Sensation Testing
The chapters that deal with the extremities contain sec-tions entitled Sensation Testing. These sections describe the testing for sensory deficits associated with peripheral
Figurę 1-9. A, Testing quadriceps strength against gravity and resistance. B, Testing strength of the right quadriceps with grav-ity eliminated. (Arrow shows direction of motion)
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