2.

3-B
MOTOR SYSTEM EXAMINATION
Dr. Guzman
Legend: normal text lecture/old trans; Bates italics;
transers notes red text
INTRODUCTION
TRANSMISSION OF SIGNALS FROM THE MOTOR
CORTEX TO THE MUSCLES
2 Pathways for Motor Signals from Cortex to Spinal Cord:
1. DIRECT:
o Involves the corticospinal tract
o Concerned more with discrete and detailed
movements, esp. of the distal segments of the
limbs (esp. hands and fingers)
2. INDIRECT: involves the basal ganglia, cerebellum,
and various nuclei of the brainstem

Condition
Parkinsons Disease

Benign Essential
Tremor

o Most important output pathway from the motor cortex

o A.k.a the pyramidal tract because it forms the
pyramids of the medulla as it descends through the
brainstem
o Majority of the fibers cross in the lower medulla to the
opposite side, descending into the lateral corticospinal
tract of the spinal cord
o Terminations:
- interneurons in the intermediate regions of the
cord gray matter (mainly)
- sensory relay neurons in the dorsal horn (few)
- directly on the anterior motor neurons that cause
muscle contraction (very few)
o A few of the fibers do not cross to the opposite side in
the medulla but pass ipsilaterally down the cord in the
ventral corticospinal tracts (many fibers eventually
cross) FXN: control of bilateral postural movements
by the supplementary motor cortex

*In Bates, magkasama na yung muscle bulk, tone, and strength

under characteristics of muscle, and wala yung manual motor
testing.

If you see an abnormality, identify the muscle(s) involved.

Determine whether the abnormality is central or peripheral
in origin, and begin to learn which nerves innervate the
affected muscles.
EXAMINATION OF THE MOTOR SYSTEM
INSPECTION AND PALPATION
Body Positions
Observe during movement and at rest
Abnormal positions alert you to conditions such as monoor hemi- paresis from stroke.
Involuntary Movements
Note location, quality, rate, rhythm, amplitude, their
relation to posture, activity, fatigue, emotion, and other
factors
For this part, we also consulted a journal in the following link:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2929378/; definitions
lifted from it are in italicized red font. Kung gusto niyo lang naman
basahin

Tremors
Tremors are a specific type of continuous, involuntary
muscle activity that results in limb movement.
o Parkinsonian
o Metabolic
o Cerebellar
o Essential rubral
o Physiologic tremor
o Tremor of hepatic encephalopathy

CALDERON, GARCIA, HARDIN, MANABAT, SOLIS

Characteristics
Resting tremor
when patient voluntarily moves
affected limb
Head and other body parts can
also be affected
Tremor persists throughout
movement
Not associated with any other
neurological findings

Bates: rhythmic oscillatory movements divided into:

1. Resting (Static)Tremors
o Most prominent at rest
o May decrease or disappear with voluntary movement
o Relatively slow, fine, pill-rolling tremor of
parkinsonism, about 5/sec
2. Postural (Action) Tremors
o Appear when the affected part is actively maintaining
a posture
o Fine, rapid tremor of hyperthyroidism
o Tremors of anxiety and fatigue, and benign essential
(and sometimes familial) tremor
o Tremor may worsen somewhat with intention
3. Intention Tremors
o Absent at rest
o Appear with activity
o Often get worse as the target is neared
o Causes include disorders of cerebellar pathways, as
in multiple sclerosis

CORTICOSPINAL TRACT

OVERVIEW OF THE EXAMINATION

Inspection and Palpation
o Body position
o Involuntary movements
o Muscle bulk
MuscleTone
Manual Motor Testing
Coordination and Gait

August 11, 2014

PLM CM

Oral-Facial Dyskinesias
A.k.a tardive (late) dyskinesias
Rhythmic, repetitive, bizarre movements that chiefly
involve the face, mouth, jaw, and tongue grimacing,
pursing of lips, protrusions of tongue, opening and closing
of mouth, and deviations of jaw
Limbs and trunk involved less often
May be a late complication of psychotropic drugs such as
phenothiazines, and have then been termed
Also occur in long standing psychoses, in some elderly
individuals, and in some edentulous persons
Tics
Brief, repetitive, stereotyped, coordinated movements
occurring at irregular intervals
Examples include repetitive winking, grimacing, and
shoulder shrugging
Causes:
o Tourettes syndrome
o Drugs (e.g. phenothiazines and amphetamines)
Dystonia
Dystonic movements are somewhat similar to athetoid
movements, but often involve larger portions of the body,
including the trunk.
Grotesque, twisted postures may result.
Causes include
o drugs (e.g. phenothiazines)
o primary torsion dystonia
o spasmodic torticollis
Chorea
Repetitive, brief, irregular, somewhat rapid involuntary
movements that start in one part of the body and move
abruptly, unpredictably, and often continuously, to another
part.
Choreiform movements are brief, rapid, jerky, irregular,
and unpredictable
Occur at rest or interrupt normal coordinated movements
Unlike tics, they seldom repeat themselves
Face, head, lower arms, and hands: often involved
Causes
o Sydenhams chorea (with rheumatic fever)
o Huntingtons disease

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PLM CM

MOTOR SYSTEM EXAMINATION

Dr. Guzman

Athetosis
Slow, continuous, involuntary writhing movement that
prevents maintenance of a stable posture.
Slower and more twisting and writhing than choreiform
movements, and have a larger amplitude
Most commonly involve the face and the distal
extremities
Often associated with spasticity
Causes include cerebral palsy

Pseudoathetosis
In adults, athetosis can be due to a severe distal sensory
loss in which case it is called pseudoathetosis.
Choreoathetosis
Combination of chorea and athetosis
Most often caused by the dyskinetic form of cerebral palsy
in which dystonia is a frequent associated movement
disorder
Also associated with kernicterus and other causes of basal
ganglia injury
Ballism
A type of chorea that affects proximal joints such as
shoulder or hip. This leads to large-amplitude movements
of the limbs, sometimes with a flinging or flailing quality.
Clonus/Myoclonus
Clonus
o A series of involuntary, rhythmic, muscular
contractions and relaxations
Myoclonus:
o Sudden, brief, rapid jerks, involving the trunk or limbs.
It is associated with a variety of disorders (also found
in table of Generalized Seizures below).
o Sequence of repeated, often non-rhythmic, brief
shock-like jerks due to sudden involuntary contraction
or relaxation of one or more muscles.
o Distinguished from chorea by the fact that in
myoclonus, all the movements are quick, whereas in
chorea only some are.

Spasm
A sudden, involuntary contraction of a group of muscles
o Muscle cramps
o Oculogyric crisis
o Hemifacial cramps
o Blepharospasm
o Palatal myoclonus or nystagmus
o Hiccup

Seizure
I. PARTIAL SEIZURES
A. Simple Partial Seizures
Problem
Clinical
Manifestations
1a. With motor
Tonic and then clonic
symptomsmovements that start
Jacksonian
unilaterally in the hand,
foot, or face and spread
to other body parts on
the same side
1b. With motor
Turning of the head and
symptomseyes to one side, or
Other motor
tonic and clonic
movements of an arm
or leg without the
Jacksonian spread
2. With sensory Numbness, tingling;
symptoms
simple visual, auditory, or
olfactory hallucinations
such as flashing lights,
buzzing, or odors
3.With
A funny feeling in the
autonomic
epigastrium, nausea,
symptoms
pallor, flushing,
lightheadedness

Postictal
state
Normal
consciousness

Normal
consciousness

Normal
consciousness

4. With
psychiatric
symptoms

Anxiety or fear; feelings

of familiarity (dj vu) or
unreality; dreamy
states; fear or rage;
flashback experiences;
more complex
hallucinations

Normal
consciousness

B. Complex Partial Seizures

Clinical Manifestations
Postictal state
The seizure may or may not
Pt may remember initial
start with the autonomic or
autonomic or psychic
psychic symptoms that are
symptoms (which are
outlined above.
then termed an aura),
but is amnesic for the
Consciousness is impaired
rest of the seizure.
and the person appears
confused.
Temporary confusion
and headache may
Automatisms: motor
occur.
behaviors (chewing, smacking
the lips, walking about, and
unbuttoning clothes); and skilled
behaviors such as driving a car
C. Partial Seizures that Become Generalized
Resemble tonicclonic
As in a tonicclonic
seizures
seizure
Unfortunately, the patient may Two attributes indicate a
not recall the focal onset and
partial seizure that has
observers may overlook it.
become generalized: (1)
the recollection of an
aura, and (2) a unilateral
neurologic deficit during
the postictal period.
II. GENERALIZED SEIZURES
Clinical
Postictal state
Manifestations
A. Tonic
Pt loses
Confusion,
Clonic
consciousness
drowsiness,
Convulsion
suddenly and body
fatigue,
(grand mal)
stiffens into tonic
headache,
extensor rigidity
muscular aching,
and temporary
Breathing stops & pt
persistence of
becomes cyanotic
bilateral
A clonic phase of
neurologic
rhythmic muscular
deficits (e.g.
contraction follows
hyperactive
Breathing resumes
reflexes and
and is often noisy,
Babinski
with excessive
responses)
salivation.

Pt has amnesia
Injury, tongue biting,
for the seizure;
urinary incontinence
recalls no aura
may occur
B. Absence
A sudden brief lapse No aura recalled
of consciousness,
In petit mal
with momentary
absences, a
blinking, staring, or
prompt return to
movements of the
normal; in
lips and hands but
atypical
no falling.
absences, some
Two subtypes:
postictal
1. Petit mal absences
confusion
last less than 10
sec
2. Atypical absences
more than 10 sec.
C. Atonic
Sudden loss of
Either a prompt
Seizure, or
consciousness with
return to normal or
Drop Attack
falling but no
a brief period of
movements. Injury
confusion
may occur.
D. Myoclonus sudden, brief, rapid
Variable
jerks, involving the
trunk or limbs.
Problem

Normal
consciousness

CALDERON, GARCIA, HARDIN, MANABAT, SOLIS

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MOTOR SYSTEM EXAMINATION
Dr. Guzman

August 11, 2014

PLM CM

Muscular Atrophy:
Problem
May mimic
seizures but
are due to a
convention
reaction (a
psychological
disorder)

III. PSEUDOSEIZURES
Clinical Manifestations
Movements may have
personal symbolic
significance and often do
not follow a
neuroanatomic pattern.
Injury is uncommon.

Postictal
state
Variable

MUSCLE BULK AND APPEARANCE

This assessment is somewhat subjective and quite
dependent on the age, sex and the activity/fitness level of
the individual.
ASSESSMENT:
The patient should be in a gown so that the areas of
interest are exposed.
Using your eyes and hands, carefully examine the major
muscle groups of the upper and lower extremities (e.g.
biceps, triceps, deltoids, quadriceps, hamstring)
Palpation of the muscles will give you a sense of
underlying mass.
Palpation should not elicit pain.
The largest and most powerful groups are those of the
quadriceps and hamstrings of the upper leg (i.e. front
and back of the thighs).
They should be symmetrical bilaterally
They should also be appropriately developed, after making
allowances for the patients age, sex, and activity level

^FIGURE: right leg is smaller than the left one

If there is asymmetry, note pattern.
o Some allowance must be made for handedness (i.e.
right versus left hand dominance).
o If it follows particular nerve distribution, this suggests
a peripheral motor neuron injury
o Muscles which lose their lower motor innervation
become very atrophic.
Note similarity of bulk in the upper and lower extremities
o Spinal cord transection at the Thoracic level will
cause upper extremity muscle bulk to be normal or
even increased due to increased dependence on
arms for activity, mobility, etc.
o However, the muscles of the lower extremity will
atrophy due to loss of innervation and subsequent
disuse.
Note other processes (i.e. during history) that has resulted
in limited movement of a particular limb
o A broken leg that has recently been liberated from a
cast will appear markedly atrophic

o Refers to a loss of muscle bulk, or wasting

o Results from diseases of the peripheral nervous
system such as diabetic neuropathy, as well as
diseases of the muscles themselves.
o Other causes of muscular atrophy include motor
neuron diseases, diseases that affect the peripheral
motor system projecting from spinal cord, rheumatoid
arthritis, and protein-calorie malnutrition
o Process may be unilateral/ bilateral, proximal/distal
o Pay attention to the hands, shoulders, and thighs
o Thenar and hypothenar eminences should be full and
convex; spaces between the metacarpals should be
full or only slightly depressed
o Atrophy of hand muscles may occur with normal
aging
o Be alert for fasciculations. If absent, tap on the
muscle with a reflex -hammer to try to stimulate them.
Hypertrophy: increase in bulk w/ proportionate strength
Pseudohypertrophy: increased in bulk but w/ diminished
strength (seen in the Duchenne form of muscular
dystrophy)
Abnormal Finding
Flattening of thenar &
hypothenar eminences
Localized atrophy of
thenar eminence
Localized atrophy of
hypothenar eminence
Fasciculations with atrophy
& muscle weakness

Associated Condition
Atrophy
Median nerve damage
Ulnar nerve damage
Disease of peripheral
motor unit

MANUAL MOTOR TESTING

Testing of motor and sensory function requires a basic
understanding of normal anatomy and physiology. (see
Transmission of Signals from Motor Cortex to Muscles
above for brief pathway)
o Upper Motor Neurons (UMNs): part of the CNS;
composed of neurons whose cell bodies are located
in the brain or spinalcord
o Lower Motor Neurons (LMNs): part of the PNS;
made up of motor and sensory neurons with cell
bodies located outside of the brain and spinal cord.
The axons of the PNS travel to and from the
periphery, connecting the organs of action (e.g.
muscles, sensory receptors) with the CNS.
o Spinal nerve roots: bundle of axons that exit and
enter the spine at any given level and generally
connect to the same distal anatomic area; contain
both afferent and efferent nerves.
o Peripheral
nerve:
formed
ultimately
from
contributions of several spinal nerve roots (efferents);
follows a precise anatomic route on its way to
innervating a specific muscle.
Normal motor function depends on intact UMN and LMN
sensory pathways and input from other neurological
systems problems at any point: disorders of movement

^FIGURE: Diffuse Muscle Wasting. Note loss muscle bulk

in left hand due to peripheral denervation. Compare left and
right thenar eminences.

CALDERON, GARCIA, HARDIN, MANABAT, SOLIS

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Dr. Guzman

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PLM CM

Flaccidity: Loss of muscle tone (hypotonia), causing the

There should be no muscle movement when the limb is at

rest. Rare disorders (e.g. Amyotrophic Lateral Sclerosis)
result in death of the lower motor neurons and subsequent
denervation of the muscle causes twitching of the fibers
known as fasciculations, which can be seen on gross
inspection of affected muscles.
MUSCLE TONE
Slight residual tension maintained when a normal muscle
with an intact nerve supply is relaxed voluntarily
ASSESSMENT:
Ask the pt to relax. If tense, may show inc. resistance.
While supporting the elbow, flex and extend the patient's
fingers, wrist, and elbow, and put the shoulder through a
moderate range of motion (ROM)
To assess muscle tone in the legs, support the pts thigh
with one hand, grasp the foot with the other, and flex and
extend patient's ankle and knee.
There is normally a small, continuous resistance to
passive movement.
Observe for decreased (flaccid) or increased
(rigid/spastic) tone.
Be aware that many patients, particularly the elderly, often
have other medical conditions that limit joint movement.
Degenerative joint disease of the knee, for example, might
cause limited ROM, though tone should still be normal.
If the patient has recently injured the area or are in pain,
do not perform this aspect of the exam.
ABNORMALITIES
1. Increased resistance
o If suspected, determine whether it varies as
you move the limb or whether it persists
throughout the ROM and in both direction, for
example, during both flexion and extension.
o Feel for any jerkiness in the resistance.
2. Decrease resistance
o Suggest diseases of peripheral nervous
system, cerebellar disease, or acute stages of
SC injury.
o If suspected hold the forearm and shake the
hand loosely back and forth. Normally the
hands moves back and forth freely but is not
completely floppy.
3. Marked floppiness
o Indicates hypotonia, flaccidity, or peripheral
motor system disorder.
DISORDERS OF MUSCLE TONE*
Spasticity:
o Increased resistance that worsens at the extremes or
range that may occur when the UMN no longer
functions.
o Rate dependent, increasing with rapid movement
o Seen in Central corticospinal tract disease
Rigidity:
o Increased resistance throughout the ROM and in both
directions
o Not rate-dependent
o Lead-pipe rigidity: increased resistance that persists
throughout a movement arc, independent of rate of
movement
o Cogwheel
rigidity:
superimposed
ratchetlike
jerkiness with flexion and extension of the wrist or
forearm

CALDERON, GARCIA, HARDIN, MANABAT, SOLIS

limb to be loose or floppy, hperextensible, or flail-like;

occurs when the LMN is cut off from the muscles that it
normally innervates.
Paratonia: sudden changes in tone with passive ROM
o Mitgehen (moving with): sudden changes in tone with
passive ROM
o Gegenhalten (holding against): sudden increase in
tone making motion more difficult
Parkinsons Disease
o Disorder of the Extra Pyramidal System (EPS).
o The EPS normally contributes to initiation and
smoothness of movement.
o PD causes tonegenerating a ratchet-like
sensation (known as cog wheeling) when the
affected limbs are passively moved by the examiner.
* For Disorders that DO NOT DIRECTLY AFFECT the
muscles, upper or lower motor neurons can still alter tone
MUSCLE STRENGTH
As with muscle bulk, strength testing must take into
account the age, sex and fitness level of the patient
A frail, elderly, bed bound patient may have muscle
weakness due to severe deconditioning and not to intrinsic
neurological disease
Interpretation must also consider the expected strength of
the muscle group being tested (ex. quadriceps > biceps)
Normal people vary widely in their strength, variables such
as age, sex, and muscular training should be considered
when setting a standard.
A persons dominant side is usually slightly stronger than
the nondominant side.
General Considerations in Testing Muscle Strength
Test muscle strength by asking the patient to actively
resist your movement.
A muscle is strongest when shortest, and weakest when
longest.
If the muscles are too weak to overcome resistance, test
against gravity alone or with gravity eliminated.
o Ex. When the forearm rests in a pronated position
dorsiflexion at the wrist can be tested against gravity
alone.
o When the forearm is midway between pronation and
supination extension at the wrist can be tested with
gravity eliminated.
Finally, if the patient fails to move the body part, watch or
feel for weak muscular contraction.
It is generally quite helpful to directly compare right vs left
sided strength, as they should more or less be equivalent
(dominant side > non-dominant).
If there is weakness, try to identify a pattern which might
provide a clue as to the etiology of the observed decrease
in strength. In particular, make note of differences
between:
o Right vs Left
o Proximal muscles vs distal
o Upper extremities vs lower
If the weakness generalized, it is suggestive of a systemic
neurological disorder or global deconditioning.
Condition
Proximal weakness

Characteristics
Suggestive of myopathy

Distal weakness

Suggestive of peripheral
neuropathy
Suggestive of UMN dysfunction

Pyramidal weakness

Myositis (a rare condition characterized by idiopathic

muscle inflammation) causes the patient to experience
weakness but not pain.

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MOTOR SYSTEM EXAMINATION

Dr. Guzman
Grading of Muscle Strength
Grade (Bates)
0/5
1/5
2/5
3/5
4/5
5/5
Grade
(Harrisons)
0/5
1/5
2/5
3/5
44/5

4+
5/5

Description
No muscle movement
Slight contractility but no joint motion
Movement at the joint, but not against
gravity
Movement against gravity, but not against
added resistance
Movement against resistance, but less
than normal
Normal strength
Description
No muscle movement
Slight contractility but no joint motion
Movement at the joint, but not against
gravity
Movement against gravity, but not against
added resistance
Movement Against mild degree of
resistance*
Movement against resistance, but less
than normal
Movement against moderate resistance*
Movement against strong resistance*
Normal strength (full power)

Specifics of Muscle Strength Testing

Major Muscle Groups only
More detailed testing can be performed in the setting of
discrete/unexplained weakness
When performing the strength test, always take into
account the muscles involved, their corresponding
innervation and their specific actions
Take note of the differences in male and female strength
to avoid errors made by examiners due to subjectivity
Test

Intrinsic
muscles of
the hand
(C 8, T 1
ulnar nerve)

Procedure
Ask the patient to spread their
fingers apart against resistance
(abduction)
Squeeze them together, with your
fingers placed in between each of
their digits (adduction). Test each
hand separately.

Ask the patient to make a fist,

Test for Grip
squeezing their hand around two
Flexors of the
of your fingers.
fingers
If the grip is normal, you will not
(C 7, 8, T1)
be able to pull your fingers out.
Test each hand separately.

Test
opposition of The patient should try to touch the
the thumb (C
tip of the little finger with the
8, T 1 median
thumb, against your resistance.
nerve)

CALDERON, GARCIA, HARDIN, MANABAT, SOLIS

Muscles

Innervation

Action

Interossei

Ulnar nerve

Adduction/abduction
of fingers

Flexor
digitorum
profundus

Median n.
radial ; Ulnar n.
medial

Finger flexion

Extensor
radialis

Radial nerve

Wrist extension

Brachialis

Musculocutaneo
us nerve

Flexion and
supination of the
hand at the elbow
joint

Triceps brachii

Radial nerve

Extension of the
forearm

Pectoralis
major

Lateral and
medial pectoral
nerves

Shoulder adduction

Deltoid

Axillary nerve

Shoulder abduction

Iliopsoas

Femoral nerve

Hip flexion

Gluteus
maximus

Inferior gluteal
nerve

Hip extension

Quadriceps
femoris

Femoral nerve

Knee extension

Hamstrings

Sciatic nerve

Knee flexion

Muscles at
anterior
compartment
of the leg

Deep peroneal
nerve

Ankle dorsiflexion

Gastrocnemius
and Soleus

Sciatic nerve

Plantar flexion of
ankle

Picture

Notes
Weak finger abduction
occurs in ulnar nerve
disorders.
The
muscles
which
control adduction and
abduction of the fingers
are called the Interossei,
innervated by the Ulnar
Nerve.
A weak grip is seen in
cervical radiculopathy, de
Quervains tenosynovitis,
carpal tunnel syndrome,
arthritis,
and
epicondylitis.
The Flexor Digitorum
Profundus controls finger
flexion and is innervated
by the Median (radial )
and Ulnar (medial )
Nerves.
Look for weak opposition
of the thumb in median
nerve disorders such as
carpal tunnel syndrome

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Wrist flexion
(C7, 8, T1)

Have the patient try to flex their

wrist as you provide resistance.
Test each hand separately.
The muscle groups which control
flexion are innervated by the
Median and Ulnar Nerves.

Wrist
extension
(C 6, 7, 8)

Have the patient try to extend

their wrist as you provide
resistance
Damage to the radial nerve
wrist drop (loss of ability to extend
the hand at the wrist)
The nerve can be compressed
against the humerus for a
prolonged period of time when an
intoxicated
person
loses
consciousness with the inside
aspect of the upper arm resting
against a solid object (known as a
Saturday Night Palsy)

Have the patient bend their elbow

to ninety degrees while keeping
Elbow Flexion
their palm directed upwards.
(C 5, 6)
Then direct them to flex their
forearm
while you provide
resistance.

Elbow
Extension
(C 7, 8)

Shoulder
Adduction
(C5 thru T1)

Shoulder
Abduction
(C 5, 6)

Hip Flexion
(L 2, 3, 4)

Have the patient extend their

elbow against resistance while
the arm is held out (abducted at
the shoulder) from the body at
ninety degrees

Have the patient flex at the elbow

while the arm is held out from the
body at forty-five degrees.
Then provide resistance as they
try to further adduct at the
shoulder.

Have the patient flex at the elbow

while the arm is held out from the
body at forty-five degrees.
Then provide resistance as they
try to further abduct at the
shoulder

With the patient seated, place

your hand on top of one thigh and
instruct the patient to lift the leg
up from the table

CALDERON, GARCIA, HARDIN, MANABAT, SOLIS

August 11, 2014

PLM CM
The muscle groups which
control flexion are
innervated by the Median
and Ulnar Nerves.

Weakness of extension is
seen in peripheral nerve
disease,
from
radial
nerve damage, and in
central nervous system
disease,
producing
hemiplegia,
seen
in
stroke
or
multiple
sclerosis.

The main flexor (and

supinator) of the forearm
is the Brachialis Muscle
(along with the Biceps
Muscle). These muscles
are innervated by the
Musculocutaneous Nerve

The main extensor of the

forearm is the triceps
muscle. The Triceps is
innervated by the Radial
Nerve.

The main muscle of

adduction is the
Pectoralis Major, though
the Latissiumus and
others contribute as well.

The deltoid muscle,

innervated by the axillary
nerve, is the main muscle
of abduction.

The main hip flexor is the

Iliopsoas muscle,
innervated by the femoral
nerve.

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Hip Extension With the patient lying prone, direct

(L5, S1)
the patient to lift their leg off the
table against resistance

Hip
Abduction
(L 4, 5, S1)

Place your hands on the outside

of either thigh and direct the
patient to separate their legs
against resistance.
This movement is mediated by a
number of muscles

Hip
Adduction
(L2, 3, 4)

Place your hands on the inner

aspects of the thighs.
A number of muscles are
responsible for adduction.
They are innervated by the
obturator nerve

Knee
Extension
(L2, 3, 4)

Have the seated patient steadily

press their lower extremity into
your hand against resistance

Have the patient rest prone.

Knee flexion Then have them pull their heel up
(L4, L5, S1, 2)
and off the table against
resistance.

Ankle
Dorsiflexion
(L4, 5
tibialis
anterior)

Direct the patient to pull their toes

upwards while you provide
resistance with your hand.

Ankle Plantar
Have the patient step on the gas
Flexion (S 1,
while you provide resistance.
S 2)

CALDERON, GARCIA, HARDIN, MANABAT, SOLIS

August 11, 2014

PLM CM
The main hip extensor is
the gluteus maximus,
innervated by inferior
gluteal nerve.

Symmetric weakness of
the proximal muscles
suggests a myopathy*
Symmetric weakness of
distal muscles suggests a
polyneuropathy,
or
disorder of peripheral
nerves*
*for
abduction
and
adduction
A number of muscles are
responsible for
adduction. They are
innervated by the
obturator nerve

Extension is mediated by
the quadriceps muscle
group, which is
innervated by the femoral
nerve.

Flexion is mediated by
the hamstring muscle
group, via branches of
the sciatic nerve.

The muscles which

mediate dorsiflexion are
innervated by the deep
peroneal nerve.
The peroneal nerve is
susceptible to injury at
the point where it crosses
the head of the fibula
(laterally, below the
knee).
If injured, the patient
develops Foot Drop, an
inability to dorsiflex the
foot.
The gastrocnemius and
soleus, the muscles
which mediate this
movement, are
innervated by a branch of
the sciatic nerve (S1).
Plantar flexion and
dorsiflexion can also be
assessed by asking the
patient to walk on their
toes (plantar flexion) and
heels (dorsiflexion).

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2.3-B
August 11, 2014
PLM CM

MOTOR SYSTEM EXAMINATION

Dr. Guzman
Terminologies
In many cases it is more practical to use the following
terms: (Harrisons:Part16 chap 361 17 ed):
o Paralysis: no movement
o Severe weakness: movement with gravity eliminated
o Moderate weakness: movement against gravity but
not against mild resistance
o Mild weakness: movement against moderate
resistance
o Full strength
From Bates:
o Weakness/ paresis: impaired strength
o Paralysis/plegia: absence of strength
o Hemiparesis: weakness of one-half of the body
o Hemiplegia: paralysis of one-half of the body.
o Paraplegia: paralysis of the legs
o Quadriplegia: paralysis of all four limbs.

SPECIAL TECHNIQUES
FOR SUBTLE WEAKNESS: PRONATOR DRIFT
Pay attention to how the patient walks, uses and holds
their arms and hands as they enter the room, get up and
down from a seated position, move onto the
examination table, etc.
Test: PRONATOR DRIFT (for slight weakness of the
upper extremities) please refer to trans 2.3A Gait and
Station for procedure

LUMBOSACRAL RADICULOPATHY:
STRAIGHT-LEG RAISE
Tested if the patient has low back pain with nerve pain that
radiates down the leg, commonly called sciatica if in the
S1 distribution
Compression of the spinal nerve root as it passes through
the vertebral foramen causes a painful radiculopathy with
associated muscle weakness and dermatomal sensory
loss, usually from a herniated disc (usu at. L5-S1).
Look for confirming ipsilateral calf wasting and weak ankle
dorsiflexion
Place the patient in the supine position.

Raise the patients relaxed and straightened leg, flexing the

leg at the hip, then dorsiflex the foot.

Assess degree of elevation at which pain occurs, the quality

and distribution of the pain, and the effects of dorsiflexion.
(+) Straight leg test: pain radiating to the ipsilateral leg
(-) Straight leg test: tightness or discomfort in the buttocks
or hamstrings common in these maneuvers

Foot dorsiflexion can further increase leg pain in

lumbosacral radiculopathy, sciatic neuropathy, or both. Is
o (+) crossed straightleg-raising sign: Oncreased
pain when the contralateral healthy leg is raised
Assessment rationale stretches affected nerve roots
and sciatic nerve
Also examine motor and sensory function and reflexes at
the lumbosacral levels.
ASTERIXIS
Helps identify metabolic encephalopathy in patients whose
mental functions are impaired.
Caused by abnormal function of the diencephalic motor
centers that regulate agonist and antagonist muscle tone
and maintain posture.
Seen in liver disease, uremia, and hypercapnia.
Ask the patient to stop traffic by extending both arms, with
hands cocked up and fingers spread.

Watch for 1 to 2 minutes, coaxing the patient as necessary

to maintain this position.

Asterixis: sudden, brief, nonrhythmic flexion of the hands

and fingers
WINGING OF SCAPULA
Condition wherein the medial border of the scapula juts
backward
Looked for when the shoulder muscles seem weak or
atrophic suggests weakness of the serratus anterior
muscle, seen in muscular dystrophy or injury to the long
thoracic nerve

Ask the patient to extend both arms and push against your
hand or against a wall.

Observe the scapulae. Normally they lie close to the thorax.

In very thin but normal people, scapulae may appear
winged even when musculature is intact.

Common peripheral nerves, territories of innervation, and clinical correlates.

Peripheral
Nerve

Sensory
Innervation

Motor Innervation

Radial Nerve

Back of thumb,
index, middle, and
ring finger; back of
forearm
Palmar and dorsal
aspects of pinky and
of ring finger

Wrist extension and

abduction of thumb
in palmer plane

Ulnar Nerve

Median Nerve

Lateral
Cutaneous
Nerve of Thigh
Peroneal
Nerve

Contributing
Spinal Nerve
Roots
C6, 7, 8

Clinical Correlate

At risk for compression at humerus,

known as "Saturday Night Palsy

Abduction of fingers
(intrinsic muscles of
hand)

C7, 8 and T1

At risk for injury with elbow fracture.

Can get transient symptoms when
inside of elbow is struck ("funny
bone" distribution)

Palmar aspect of the

thumb, index, middle
and ring finger;
palm below these
fingers.
.Lateral aspect thigh

Abduction of thumb
perpendicular to
palm (thenar
muscles).

C8, T1

Compression at carpal tunnel

causes carpal tunnel syndrome

L1, 2

Can become compressed in obese

patients, causing numbness over its
distribution

Lateral leg, top of

foot

Dorsiflexion of foot
(tibialis anterior
muscle)

L4, 5; S1

Can be injured with proximal fibula

fracture, leading to foot drop
(inability to dorsiflex foot)

CALDERON, GARCIA, HARDIN, MANABAT, SOLIS

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