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ELBOW
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ELBOW FLEXION

Tested muscles:
1. Biceps brachii:
- Origins:
a) Short head: Apex of coracoids process of scapula.
b) Long head: Supra-glenoid tubercle of scapula.
- Insertion: Tuberosity of radius and aponeurosis of biceps brachii.
- Nerve supply: Musculocutaneous nerve (C5, C6).
- Actions:
a) Flexes the shoulder joint.
b) The long head may assist with abduction, if the humerus is laterally rotated.
c) With the origin fixed, it flexes the elbow joint, moving the arm toward the humerus
and supinates the forearm.
- With the insertion fixed, it flexes the elbow joint, moving the humerus toward the
forearm, as in pull-up or chinning exercises.
2. Brachialis:
- Origins:
a) Distal ½ of anterior surface of humerus.
b) Medial and lateral inter-muscular septae.
- Insertion: Tuberosity and coronoid process of ulna.
- Nerve supply: Musculocutaneous nerve and small branch from radial nerve (C5,
C6).
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- Actions:
- With the origin fixed, it flexes the elbow joint, moving the forearm toward the
humerus.
- With the insertion fixed, it flexes the elbow joint, moving the humerus towards the
forearm as in pull up or chinning exercises.
3. Brachioradialis:
- Origins:
a) Proximal 2/3 of lateral supracondylar ridge of humerus.
b) Lateral inter-muscular septum.
- Insertion: Lateral side of base of styloid process of radius.
- Nerve supply: Radial nerve (C5, C6).
- Actions:
a) Flexes the elbow joint.
b) Assists in pronating the forearm to mid-position.

Accessory muscles:
- Flexor muscles of the wrist and fingers, arising from media epicondyle of humerus.

Range of motion:
The range of motion of elbow flexion is of 0° to 145°-160°. This range of
motion may be limited by:
a) Contact of muscle masses on volar aspect of arm and forearm.
b) Contact of coronoid process with coronoid fossa of humerus.
Test procedures:
The test procedures for the elbow flexor muscles may be performed in
different manners that will allow the therapist to isolate brachioradialis from biceps
and brachialis:
a) The brachioradialis works at its best when the flexion of the elbow is performed in
mid position.
b) The biceps brachii works at its best when the flexion of the elbow is performed
with the forearm in supination.
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c) Since brachialis is inserted in the ulna, the position of the forearm whether in
supination or pronation, does not affect the action of this muscle in elbow flexion.
For this purpose, all the following procedures, though they are described for
the elbow flexors group of muscles, perform both with the forearm in supination
(biceps brachii and brachialis) and in mid position (brachioradialis).
* Grade 3 “Fair strength”:
- Patient starting position: Sitting, arms along side of the body; the forearm in:
a) Supination: When testing for biceps brachii and brachialis.
b) Mid-position: When testing for brachioradialis.
- Therapist position and grasps: Therapist stands behind the patient near the patient’s
affected arm. The proximal hand is placed on the shoulder, while the distal hand
grasps the arm over the elbow. Both grasps are used to stabilize the patient upper arm.
- Command: “Bend your elbow, relax”.
* Grades 4 and 5: “Good and Normal strength”:
- Patient starting position: Same as for “Grade 3”.
- Therapist position and grasps: Therapist stands in front of the patient near the
affected arm. The proximal hand grasps the upper arm to stabilize it, while the distal
hand is applying resistance at the level of wrist joint.
- Resistance:
a) Grade 4: Moderate leading resistance in a form of pressing down is given directly
opposite the line of motion.
b) Grade 5: Maximum resistance is given throughout the range of motion, plus a
“hold” kept at the end of the range.
- Command: Same as for “Grade 3”, plus “hold” at the end of the range when testing
for “Grade 5”.
* Grade 2 “Poor strength”:
- Patient starting position: Supine lying, with shoulder abducted to 90° and laterally
rotated. It may also be performed with the patient sitting on a low stool or kneeling on
the floor. The arm is in 90° abduction resting on the table. The forearm is placed in:
a) Supination: When testing biceps brachii and brachialis.
b) Mid-position: When testing brachioradialis.
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- Therapist position and grasps: Therapist stands beside the table near the affected
arm. The proximal hand grasps the upper arm to stabilize it.
- Command: Same as for “Grade 3”.
* Grade 1 and 0 “Trace and Zero strength”:
- Patient starting position: Same as for “Grade 2”.
- Therapist position and grasps: Same as for “Grade 2” but the distal hand palpates
tendon of biceps brachii in the ante-cubital space and brachioradialis muscle bulk on
the antero-lateral aspect of the elbow.
- Command: Same as for “Grade 3”.

Effects of weakness:
a) Biceps brachii and brachialis:
- Weakness of these muscles decreases ability to flex the forearm against gravity,
especially when the forearm is in supination. There is then marked interference with
such daily activities as feeding oneself or combing hair.
Substitution: If the biceps and brachialis are weak as in a musculocutaneous nerve
lesion, the patient will pronate the forearm before he flexes using brachioradialis,
extensor carpi radialis longus, pronator teres and wrist flexor muscles.
b) Brachioradialis:
- Decreases the strength of elbow flexion.
- Decreases supination and pronation to the midline.
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MUSCLE TESTING FOR ELBOW FLEXION
Grade “3”
Fair Strength
Grade “4, 5”
Good and Normal
Strength
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Grade “2”
Poor Strength
Grade “1, 0”
Trace and Zero
Strength
Note:
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ELBOW EXTENSION

Muscle tested:
1. Triceps brachii:
- Origin:
a) Long head: Infra-glenoid tubercle of scapula.
b) Short head: Lateral and posterior surfaces of proximal ½ of body of humerus and
lateral inter-muscular septum.
c) Medial head: Distal 2/3 of medial and posterior surfaces of humerus.
- Insertions:
a) Posterior surface of olecranon process of ulna.
b) Ante-brachial fascia.
- Nerve supply: Radial nerve (C6, C7, C8, T1).
- Actions:
a) Extends the elbow joint.
b) May stabilize the ulna during pronation.

Accessory muscles:
- Extensors of the wrist and fingers, arising from lateral condoyle of humerus.

Range of motion:
The range of motion of elbow extension is from 0° to 145°-160°. This range of
motion may be limited by:
a) Tension of anterior radial and ulnar collateral ligaments of elbow joint.
b) Tension of flexor muscles of forearm.
c) Contact of olecranon process with olecranon fossa on posterior aspect of humerus.
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 Test procedures:
a. Grade 3 “Fair strength”:
- Patient starting position: Supine lying with shoulder flexed to 90° and elbow flexed.
- Therapist position and grasps: Therapist stands beside the table at the level of
patient’s affected shoulder. The proximal hand fixes the upper arm by grasping it just
above the elbow joint.
- Command: “Extend your elbow, relax”.
* Grades 4 and 5 “Good and Normal strength”:
- Patient starting position: Same as for “Grade 3”.
- Therapist position and grasps: Same as for “Grade 3”, plus the distal hand is used to
give resistance on the posterior surface of the wrist.
- Resistance:
a) Grade 4: Moderate leading resistance is given in a form of pressing down directly
opposing the line of motion.
b) Grade 5: Maximum resistance is given throughout the range of motion, plus a
“hold” position is kept at the end of the range.
- Command: Same as for “Grade 3”, plus “hold” at the end of the range of motion
when testing for Grade 5.
* Grade 2 “Poor strength”:
- Patient starting position:
a) Sitting on a low stool, with arm supported on table. The shoulder is in 90° of
abduction and elbow flexed.
b) Supine lying with shoulder abducted to 90° and laterally rotated; elbow flexed.
- Therapist position and grasps: Therapist stands behind the patient if he is sitting;
and at the head of the table if he is lying. The proximal hand stabilizes the upper arm
by grasping it above the elbow joint.
- Command: Same as for “Grade 3”.
* Grades 1 and 0 “Trace and Zero strength”:
- Patient starting position: Same as for “Grade 2”.
- Therapist position and grasps: Same as for “Grade 2”, plus the distal hand may
palpate muscle contraction and the posterior surface of the arm.
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Effect of weakness:
a) Decreases the ability to extend the elbow against gravity.
b) Interference with daily functions, which involve elbow extension as in reaching
upward toward a high shelf.
c) Loss of ability to throw objects or push with the extended elbow.
d) An individual is handicapped in using crutches or cane, since he cannot extend his
elbow and transfer weight to his hand.
NOTES:
a) For “Grades 3, 4 and 5”, they may also be performed in the prone lying position.
The difference between the supine and prone positions may be explained as follows:
- When the shoulder is horizontally abducted (as in prone), the long head of triceps is
shortened over both the shoulder and the elbow joints.
- When the shoulder is flexed (as in supine), the long head of triceps is shortened over
the elbow joint, while elongated over the shoulder joint.
b) While the triceps and anconeus act together in extending the elbow joint, it may be
useful to differentiate these two muscles. Since the belly of the anconeus muscle is
below the elbow joint, it can be distinguished from the triceps by palpation.
c) The branch of the radial nerve to the anconeus, arising near the mid humeral level,
is quite long. It is possible for a lesion to involve only this branch, leaving the triceps
unaffected. Paralysis of the anconeus reduces the strength of elbow extension.
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MUSCLE TESTING FOR ELBOW EXTENSION
Grade “3”
Fair Strength
Grade “4, 5”
Good and Normal
Strength
Grade “2”
Poor Strength
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Grade “1, 0”
Trace and Zero
Strength
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FOREARM SUPINATION

Muscles tested:
1. Biceps brachii:
- Refer to the laboratory on “Elbow flexor muscles” for its anatomical description.
b. Supinator:
- Origins:
a) Lateral epicondyle of humerus.
b) Radial collateral ligament of elbow joint.
c) Annular ligament of radius.
- Insertion: Lateral surface of upper 1/3 of body of radius, covering part of anterior
and posterior surfaces.
- Nerve supply: Radial nerve (C5, C6, C7).
Action: Supinates the forearm.

Accessory muscle:
- Brachioradialis.

Range of motion:
The range of motion of supination from the mid position is approximately 0°
to 90°. This range of motion may be limited by:
a) Tension of volar radioulnar ligament and ulnar collateral ligament of wrist joint.
b) Tension of oblique cord and lowest fibers of interosseous membrane.
c) Tension of pronator muscles of forearm.
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
Test procedures:
* Grades 3 and 2 “Fair and Poor strength”:
- Patient starting position: Sitting with the arm at side. The elbow is flexed to 90° and
forearm pronated. Muscles of the wrist and fingers are relaxed.
- Therapist position and grasps: Therapist is in front of the patient, standing beside
the affected arm. The proximal hand is stabilizing the elbow and upper arm against
the patient’s side to avoid shoulder movements. The distal hand may support the
forearm if necessary.
- Command: “Turn your palm in the direction of the ceiling, relax”.
NOTE:
a) A “Fair 3 grade” is given when patient supinates the forearm through full ROM.
b) A “Poor 2 Grade” is given when patient supinates the forearm through partial
ROM.
b. Grades 4 and 5 “Good and Normal strength”:
- Patient starting position: Same as for “Grades 3 and 2”.
- Therapist position and grasps: Same as for “Grades 3 and 2” but the distal hand is
used to give resistance at the level of the wrist.
- Resistance: Resistance is given on the dorsal surface of the distal end of radius, with
counter pressure against the ventral surface of the ulna:
Grade 4: A moderate leading resistance is given through full range of motion.
Grade 5: A maximum resistance is given through full range of motion, plus a “hold”
position kept at the end of the range.
- Command: Same as for “Grades 3 and 2”, plus “hold” at the end of the range of
motion when testing for “Grade 5”.
c. Grades 1 and 0 “Trace and Zero strength”:
- Patient starting position: Same as for the other “Grades”.
- Therapist position and grasps: Same as for the other grades but the distal hand is
used to palpate muscle contraction of supinator muscle on the radial side of forearm
(if overlying wrist extensor muscles are not functioning) the tendon of Biceps Brachii
in the ante-cubital space.
- Command: Same as for “Grade 3 and 2”.
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Effect of weakness of supinators:
a) Allows the forearm to remain in a pronated position.
b) Interferes with many functions of the upper extremity, particularly those involved
in feeding oneself.
NOTE:
a) To isolate “Supinator muscle”, the test may be performed with the elbow in
complete flexion and shoulder in 90° flexion. This position renders the biceps brachii
less effective by being in a shortened position.
b) Care should be taken to avoid maximal resistance, as with maximal resistance the
biceps will come into action and may produce severe “Cramp” that will leave the
muscle sore for several days.
c) In a radial nerve lesion involving the supinator muscle, the test position cannot be
maintained. The forearm will fail to hold the fully supinated position even though the
biceps in normal.
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MUSCLE TESTING FOR FOREARM SUPINATION
Grade “3, 2”
Fair and Poor
Strength
Grade “4, 5”
Good and Normal
Strength
Grade “1, 0”
Trace and Zero
Strength
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Note:
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FOREARM PRONATION

Muscles tested:
1. Pronator teres:
- Origin:
a) Humeral head:
.. Immediately above medial condoyle of humerus.
.. Common flexor tendon.
.. Deep ante-brachial fascia.
b) Ulnar head: Medial side of coronoid process of ulna.
- Insertion: Middle of lateral surface of radius.
- Nerve supply: Median nerve (C6, C7).
- Actions:
a) Pronates the forearm.
b) Assists in flexion of the elbow joint.
2. Pronator teres:
- Origin: Medial side of anterior surface distal ¼ of ulna.
- Insertion: Lateral side of anterior surface of distal ¼ of radius.
- Nerve supply: Median nerve (C7, C8, T1).
- Action: Pronates the forearm.

Accessory muscle:
- Flexor carpi radialis
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
Range of motion:
The range of motion of forearm pronation from the mid position is of 0° to
90°. The range of motion may be limited by:
a) Tension of dorsal radioulnar, ulnar collateral and dorsal radio-carpal ligaments.
b) Tension of lowest fiber of interosseous membrane.

Test procedures:
* Grades 3 and 2 “ Fair and Poor strength”
- Patient starting position: Same as for the “Supinator muscles” but the forearm is in
supination.
- Therapist position and grasps: Same as for the “Supinator muscles”.
- Command: “Turn your palm in the direction of the floor, relax”.
NOTES:
a) A “Grade 3” is given for full range of motion.
b) A “Grade 2” is given for partial range of motion.
* Grades 4 and 5 “Good and Normal strength”:
- Patient starting position: Same as for “Grades 3 and 2”.
- Therapist position and grasps: Same as for “Grades 3 and 2” but the distal hand is
used to give resistance at the level of the wrist.
- Resistance: Resistance is given on the volar surface of the distal end of radius, with
counter-pressure against the dorsal surface of the ulna for derotation.
- Command: Same as for “Grades 3 and 2”, plus “hold” at the end of the range when
testing for “Grade 5”
* Grade 1 and 0 “Trace and Zero strength”:
- Patient starting position: Same as for the other grades.
- Therapist position and grasps: Same as for “Grades 3 and 2” but the distal hand is
used to palpate the muscle contraction of “Pronator teres” on upper third of volar
surface of forearm, on a diagonal line from medial condyle of humerus to lateral
border of radius.
- Command: Same as for “Grades 3 and 2”.
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NOTE: Patient should not be allowed to medially rotate or abduct the upper arm
during pronation. This movement makes the range of motion in pronation appear
complete and allows forearm to roll into a pronated position.
Effect of weakness:
a) Allow a supinated position of the forearm.
b) Interferes with many daily activities such as turning a doorknob, using a knife to
cut meats or turning the hand downward in picking up a cup or other object.
NOTE:
- To isolate the pronator quadrates, the test may be performed with the elbow in
complete flexion in order to make “Pronator teres” less effective by being in a
shortened position.
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MUSCLE TESTING FOREARM PRONATION
Grade “3, 2”
Fair and Poor
Strength
Grade “4, 5”
Good and Normal
Strength
Grade “1, 0”
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Trace and Zero
Strength
Note:
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