Lab Workbook
ANATOMY
Manual Muscle Testing
Lower Trapezius
Patient: prone
Fixation: place on hand below the scapula on the opposite side
Test: adduction and depression of the scapula with lateral rotation
of the inferior angle. The arm is placed diagonally overhead (in “Y”
position), in line with the lower fibers of the trapezius. Lateral
rotation of the shoulder joint occurs along with elevation, so it
usually is not necessary to further rotate the shoulder to bring the
scapula in to lateral rotation
Pressure: against the distal forearm, in a downward direction
toward the table
Weakness: allows the scapula to ride upward and tilt forward,
with depression of the coracoid process. If the upper trap is tight,
it helps to pull the scapula upward and acts as an opponent to a
weak low trap.
Middle Trapezius
Patient: prone
Fixation: place one hand on the opposite scapular area to prevent
trunk rotation
Test: adduction of the scapula, with upward rotation (lateral
rotation of the inferior angle) and without elevation of the
shoulder girdle. The test position is obtained by placing the
shoulder in 90* abduction and in lateral rotation sufficient to bring
the scapula into lateral rotation of the inferior angle. Observe the
scapula
Pressure: against the distal forearm, in a downward direction
toward the table
Weakness: results in abduction of the scapula and a forward
position of the shoulder. The middle and low trap reinforce the
thoracic spine extensors. Weakness of these fibers of the trapezius
increased the tendency toward a kyphosis
Rhomboids
Patient: prone
Fixation: none
Test: adduction and elevation of the scapula, with medial rotation
of the inferior angle. To obtain this position of the scapula and
leverage for pressure in the test, the arm is placed with the elbow
flexed, the humerus is adducted toward the side of the body in
slight extension and slight lateral rotation.
Pressure: the examiner applies pressure with one hand against the
patient;;s arm, in the direction of abducting the scapula and
rotating the inferior angle laterally and against the patients
shoulder, with the other hand in the direction of depression
Weakness: the scapula abduction and the inferior angle rotates
outward. The strength of adduction and extension of the humerus
is diminished by loss of rhomboid fixation of the scapula. Ordinary
function of the arm is affected less by loss of the rhomboid
strength than by loss of either trapezius or serratus anterior
strength
Serratus anterior
Patient: sitting
Fixation: subject may hold on to table with other hand
Test: the ability of the serratus to stabilize the scapula in a position
of abduction and lateral rotation, with the arm in a position of
approximately 120-130* of flexion. This test emphasizes the
upward rotation action of the serratus in an abducted position.
Pressure: against the dorsal surface of the forearm, downward in
the direction of extension, and slight pressure against the lateral
border of the scapula, in the direction of rotating the inferior angle
medially.
Weakness: Makes it difficult to raise the arm in flexion. Results in
winging of scapula.
Scapular Kinesia
Motions to consider: Bilateral shoulder abduction, bilateral internal and
external rotation, wall push-up with protraction
Observe for normal scapular kinematics throughout the arc of motion. Also
important to note areas of pain and if the patient is able to continue motion
past the point of pain.
Observe for medial or inferior border winging, delayed abduction (or
abduction that occurs too quickly), excessive elevation, or upward/
downward scapular rotation
Rhomboid dominance
o Arms positioned at side with elbow bent to 90 degrees.
o Instruct patient to laterally rotate the shoulder.
o Adduction of the scapula within first 35 degrees is considered a
positive test
DIFFERENTIAL DIAGNOSIS
VBI (vertebral artery insufficiency) testing:
Many fields of thought but it is very difficult to truly elicit these
symptoms.
Currently we practice the following:
o Have patient lay in supine
o Ask them to focus on your nose
o Fully rotate the head and have them count backwards from 10
o Any symptoms = a positive test
o This should also be performed in pre-manipulative holds and
post manipulation into newly gained ranges
o
How do you differentiate vestibular from VBI?
o Head on body
o Body on head
Neurologic screen:
Hoffman- flick the middle finger. And okay sign is positive for upper
motor neuron lesion
Babinski
Clonus: quick stretch to either ankle or wrist. Looking for beating > 3-4
times
Ligament Instability Testing:
Sharp Purser: for transverse ligament
Alar Ligament: for alar ligament
Jefferson Fracture: fracture of C1 vertebrae
Neural testing
Median Nerve ULTT
Ulnar Nerve ULTT
Radial Nerve ULTT
Nerve palpation
Cervical radiculopathy clinical prediction rule
Rotation less than 60 degrees to the affected side
Positive ANTT- median nerve
Positive Spurling’s
Positive Distraction
Postural
Plumb line
o Sagittal view - plumb line is placed just anterior to the lateral
malleolus and should pass through:
o ear lobe
o bodies of cervical vertebrae
o acromion
o mid-axillary line (divide thorax in half)
o bodies of lumbar vertebrae
o slightly posterior to the hip joint
o slightly anterior to the axis of the knee joint
o slightly anterior to the lateral malleolus
Postural assessment
o Postural assessment starts the moment you call the patient in from
the waiting room
o Assess posture both in standing and in sitting
o Look at overall posture then start from the top down:
What main postural category do they fall in?
Forward head, rounded shoulders
Kypho-lordosis
Hyperlordosis
Flatback
Swayback
Head posture
Forward head?
Flat cervical spine?
Laterally flexed or rotated to one side?
Shoulder height
Equal?
Downsloping?
Scapular position
Abducted/adducted
Upward/downward rotation
Elevation/depression
Anteriorly/posterior tilted
Winging present?
Inferior angle winging indicates pec weakness
Medial border winging indicates serratus weakness
Humeral position
Medially or laterally rotated?
Sulcus sign present?
Shoulder tests
Cluster 1
o Hawkins Kennedy: Pain reproduction with resisted internal rotation
with glenohumeral joint in 90 degrees of elevation indicated rotator
cuff dysfunction/impingement syndrome
o
o Neers: Pain reproduction with overpressure in full elevation indicates
rotator cuff dysfunction/impingement syndrome.
o Empty/ Full can: Resist elevation in 90 degrees of scaption in alternately
externally and internally rotated positions. A difference in symptoms can
indicate rotator cuff dysfunction/impingement syndrome. (ER can implicate
supraspinatus, IR can implicate infraspinatus, although little supporting
evidence exists for this)
Clusters 2
o Resisted ER:
o Painful arc: A pattern of shoulder pain between 45 and 120 degrees of
neutral abduction indicates impingement syndrome
o Hawkins Kennedy: Pain reproduction with resisted internal rotation
with glenohumeral joint in 90 degrees of elevation indicated rotator
cuff dysfunction/impingement syndrome
Instability testing:
o Load/Shift: With axial loading, glide the humerus anteriorly and posterity.
Symptom reproduction or crepitus is a positive test for labral derangement of
other interarticular pathology.
o Apprehension: Apprehension of the patient with external rotation of the shoulder
at 90 degrees abduction
o Relocation: Relief of apprehension with external rotation of the shoulder at 90O
abduction corroborates a positive apprehension test for instability.
Internal derangement/labral pathology testing:
o Crank: In supine, with the shoulder flexed to 110O, apply long-axis pressure
simultaneously with ER/IR. Symptom reproduction or crepitus is a positive test for
labral derangement of other interarticular pathology.
o Clunk: With axial loading, glide the humerus anteriorly and posterity. Symptom
reproduction or crepitus is a positive test for labral derangement of other
interarticular pathology.
o O’Brien’s: Pain reproduction with resistance to elevation in horizontally adducted
position can indicate AC joint or anterior labral dysfunction
Biceps dysfunction testing:
o Biceps Load: Resisted biceps flexion in elevation is associated with LHBT dysfunction
or SLAP lesion
o Speeds: Resist elevation in 90 degrees of scaption and external rotation. Pain
reproduction associated with LHBT dysfunction
