Testing and Function with Posture and Pain

5th Edition

Florence Peterson Kendall Elizabeth Kendall McCreary Patricia Gelse Provance Mary Mclntyre Rodgers William Anthony Romani

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Library of Congress Cataloging-in-Publication Data Muscles, testing and functions / Florence Peterson Kendall...[et al.] 5th ed.

Rev. ed. of: Muscles, testing and function / Florence Peterson Kendall, Elizabeth Kendall McCreary, Patricia Geise Provance. 4th ed. ©1993 Includes bibliographical references and index. ISBN 0-7817-4780-5 (alk. paper)

1. Muscles—Examination. 2. Physical therapy. 3. Pain 4. Posture disorders 5. Exercise. 1. Kendall, Florence Peterson, 1910- II. Kendall, Florence Peterson. 1910- [DNLM: 1. Muscles-physiology. 2. Musculoskeletal Diseases—diagnosis. 3. Musculoskeletal Diseases—therapy. 4. Posture. WE 500 M9872 2005] RM701.M87 2005 616.740754—dc22


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06 07 08 09 2 34 56789 10

Florence Kendall

Henry Otis Kendall, RT.


Co-author of Hirst and second editions, and Posture and Pain

Former Director of Physical Therapy Department, Children's Hospital, Baltimore, Maryland; Supervisor of Physical Therapy, Baltimore Board of Education; Instructor in Body Mechanics, Johns Hopkins School of nursing; private practice.

Dedicated to Our Families, Our Students, and Our Patients

Foreword to the Fifth Edition

The fifth edition of Muscles, Testing and Function with Posture and Pain by Florence P. Kendall and her four associate authors (two of whom are new to this edition) continues to provide rehabilitation professionals with a wealth of knowledge and background in this all-important aspect of the patient/client examination process. Florence and Henry Kendall were pioneers in the early development and refinement of the art and science of muscle testing as evidenced by the publication of the first edition of this text in 1949. Each succeeding edition (1971, 1983, and 1993) further refined and expanded the methods of evaluating muscle performance and function, and further recognized the need for understanding the relationships between muscle imbalances and their resultant faulty postures and pain syndromes. This text has become the "gold standard" for practice.

This latest edition contains many new features. As one would expect from Florence Kendall, a physical therapist who has never let a moment go by without mentoring, teaching, and sharing her deep insights, she has once again shown us the importance of maintaining currency with professional developments affecting practice.

This book's underlying philosophy is that we must always return to the tried and true basics that make us more reflective practitioners regarding the appropriate tests and measures selections needed to be better able to devise and select intervention strategies concurrent with examination findings. The sections on posture, face, head, neck, trunk, extremities and respiration detail innervation, joint movement, muscle strength tests, painful conditions and exercise interventions. The presentation, photos and graphics were recognized for their clarity from the very first edition, and this standard of excellence continues with this fifth edition. There is absolutely no doubt that this latest edition of Muscles, Testing and Function with Posture and Pain will continue to be the text of choice for students, clinicians and faculty involved in these crucial aspects of the examination, evaluation and diagnostic processes of the musculoskeletal system.

I feel so privileged to have been asked to write this foreword for my colleague, my friend, and my mentor. One must always stand in awe of this truly remarkable woman's contributions over more than three score years. Her enthusiasm for and love of the material that make up this text's "heart and soul" is evident in all of Florence's professional endeavors. The comprehensiveness of the text makes it continually stand the test of time, just as the primary author has stood the test in her chosen profession of physical therapy.

Marilyn Moffat, FT, PhD, FAPTA, CSCS


Department of Physical Therapy New York University


For more than half a century, through four editions, MUSCLES, Testing and Function has earned a place in the annals of history. It has served as a textbook for students and as a reference book for practitioners in various medical and allied health fields. The first edition (1949) was augmented three years later by the publication of Posture and Pain. Subsequently, parts of this book were added and, by the fourth edition, all of PoS' ture and Pain had been incorporated into MUSCLES, Testing and Function, and Posture and Pain went out of print. Starting with the first edition, this book has been published in nine foreign languages.

While each edition has added new material and made changes, this fifth edition has "undergone an overhaul." The book now follows the logical order of the body, beginning at the head and ending at the feet. By re-organizing, the number of chapters has been reduced from twelve to seven. The chapters, excluding 1 and 2, have also been organized in a meaningful manner: introduction, innervation, joints, range of motion, muscle length tests, muscle strength tests, faulty and painful conditions, case studies, followed by corrective exercises and references.

There are new and revised charts, drawings, and photographs, many in color, throughout the text. The importance of innervation has been emphasized by moving it from the end of the book, as it was in the fourth edition, and placing each segment at the beginning of the respective chapters. New features such as "Classic Kendall" and "Historical Notes" allow the reader to benefit from the senior author's seventy years of practice in the field of Physical Therapy.

Chapter 1 addresses the fundamental concepts relative to the succeeding chapters.

Of particular importance, is the recognition of four classifications for strength testing, and a revised key to muscle grading. At the end of the chapter, a segment about poliomyelitis and post-polio syndrome includes charts that show the results of six manual muscle tests on one-patient over a fifty-year period.

Chapter 2, the Posture Chapter, contains photographs and drawings that illustrate both ideal and faulty posture of adults. Section II discusses the postural examination. Section III is devoted to posture of children, and the last section is devoted to scoliosis.

Chapter 3 is about the head and face. An introduction has been added, but otherwise remains as in the fourth edition with innervation at the beginning of the chapter. A two-page chart about the Muscles of Deglutition has been placed at the end of the chapter.

Chapter 4 discusses good and faulty postures of the neck. Material that had been elsewhere in the previous editions has been appropriately placed in this chapter. Included are three pages full of photographs about joint movements, posture of the neck, and exercises. A page of color photographs shows the incorrect and the correct positions at a computer. Another page of color photographs along with text shows and explains the various massage movements used to help stretch tight muscles.

Chapter 5, the Trunk and Respiratory Muscles, begins with a discussion of the spine and the back muscles. A page with four photographs demonstrates a misdiag-nosis related to strength of back muscles. The section on abdominal muscle testing includes photographs of exercises for the external oblique in sitting. The section on respiration has been appropriately placed at the end of this chapter. There are new color photographs depicting diaphragmatic and chest movements during inspiration and expiration.

Chapter 6 is devoted to the shoulder girdle and the upper extremity. Of particular significance are the five pages devoted to definitions, illustrations, and a two-page chart related to articulations of the shoulder girdle. With recognition of the vertebroscapular and the cos-toscapular articulations, the shoulder girdle is no longer an incomplete girdle. (The so-called "scapulothoracic joint" may be considered redundant.)

There is also a new Finger Range of Motion Chart, new drawings of the Glenohumeral Joint, and 22 new color photos. There are additional Case Studies and one page of text on overuse injuries.

Chapter 7 covers the lower extremity. Many new photographs have been added. Especially important are those on page 389 that help to illustrate how errors in interpretation of test results can lead to a misdiagnosis. Four new pages with numerous color photographs illustrate and explain the modified Ober test and a test for hip flexor length that includes the tensor fasciae latae. At the end of the chapter, there are charts with mus cle test results showing the symmetry in Guillain Barré syndrome as compared to the lack of symmetry in cases of poliomyelitis. New to the appendix is the addition of the article entitled Isolated Paralysis of the Serratas Anterior Muscle.


Throughout the years, many people have contributed to the lasting value of this book. A page devoted to acknowledgments provides the opportunity to recognize them. A special tribute goes to the artist, William E. Loechel, and the photographer, Charles C. Krausse, Jr., whose superb work for the first edition of Muscles, Testing and Function (1949) and for Posture and Pain (1952) "has stood the test of time." Their work plays a major role in all subsequent editions.

By the second edition of Muscles, Testing and Function, the art work by Ranice Crosby, Diane Abeloff and Marjorie Gregerman was added to the text. Their excellent portrayal of the cervical, brachial, lumbar and sacral plexus illustrations has remained part of all subsequent editions. Some new photographs were added to the third edition, thanks to Irvin Miller, physical therapist. By the fourth edition, the tradition of excellence was continued with additional photography by Peter J. Andrews. By chance, Peter became an excellent subject for some of the photographs!

In this fifth edition, Diane Abeloff has again assisted with new drawings. For the illustrations on several pages of exercises, we thank George Geise. We sincerely appreciate the work of the photographers, Susan and Robert Noonan. Patricia Provance, co-author in the fourth edition, has helped to coordinate the work of the artist and of the photographers, and has supplied numerous photographs. For help with proof-reading and assistance in the literature research, we thank two physical therapy students at the University of Maryland School of Medicine, Beth Becoskie and Rebecca Sauder. We appreciate the help from Sue Carpenter, (co-author of Golfers Take Care of your Back), for her timely assistance.

To Marilyn Moffat, for writing the Foreword, we extend our most sincere appreciation.

The following groups of people have helped with the fifth edition.

The four co-authors, whose names appear in gold letters on the cover of this book, have cooperated in re organizing and expanding the text, adding new illustrations, new pages of exercises, and additional references.

Lippincott, Williams & Wilkins, represented by Susan Katz, Pamela Lappies, Nancy Evans, and Nancy Peterson, sponsored the production of this book.

Anne Seitz and her staff have engineered and produced the publication of this fifth edition. Color has been added to many of the pages, and items that deserve special attention have been "boxed" giving the book a new look.

The family members of the senior author deserve special recognition for their part in the successful completion of all five editions of this book!

Starting with the grandchildren, there are many photographs depicting various tests in which David and Linda Nolte and Kendall McCreary participated as willing and helpful subjects. Many of the photographs appeared in earlier editions and continue into this edition. Kirsten Furlong White and Leslie Kendall Furlong have been of great assistance in preparing the manuscripts for this fifth edition.

The three daughters, Susan, Elizabeth, and Florence Jean have participated since childhood, with Susan and Elizabeth (at the ages of nine and seven) being the subjects for the facial tests in the first edition! They participated, also, as teenagers and young adults.

Elizabeth, as co-author of the third, fourth and fifth editions, has been a major contributor.

With respect to Susan and her husband, Charles E. Nolte, their help has been beyond measure. For the past twenty-seven years, I have had the privilege of living with them. They have shared in the frustrations that accompanied the preparation of three editions, and shared in the joy of the finished products.

Foto Met Kleur Grijs

Contents in Brief

Foreword vii Preface ix Acknowledgments xi

1 Fundamental Concepts 1

2 Posture 49

3 Head and Face 119

4 Neck i4i

5 Trunk 165

6 Upper Extremity 245

7 Lower Extremity 359

Appendices A and B 465 Glossary G-I Suggested Readings S R -1 Index 1-1


Foreword vii Preface ix Acknowledgments I xi

1 Fundamental Concepts 1

Introduction 3

Manual Muscle Testing 4, 5

Objectivity in Muscle Testing 6-8

Musculoskeletal System 9

Joints: Definitions & Classification, Chart 10

Gross Structure of Muscle 11

Range of Motion and Muscle Length 12

Classification for Strength Tests 13

Strength Testing Procedures 14-17

Suggested Order of Muscle Tests 18

Grading Strength 19-24

Key to Muscle Grading 23

Nerve Plexus 25

Spinal Nerve and Muscle Charts 26-29 Treatment Fundamentals 30, 31 Neuromuscular Problems 32, 33 Musculoskeletal Problems 34, 35 Treatment Procedures 36 Treatment Modalities 37 Polio: Factors Influencing Treatment 38

Polio and Postpolio Muscle Tests 39-43 Complications of Polio 44 Post-Polio Suggested Readings 45 References 46,47

Posture 49

Introduction 51

Section I: Fundamentals of Posture Posture and Pain 52 Body Segments 53

Anatomical and Zero Positions, and Axes 54 Basic Planes and Center of Gravity 55 Movements in the Coronal Plane 56 Movements in the Sagittal Plane 57 Movements in the Transverse Plane 58 The Standard Posture 59-63

Section II: Postural Alignment

Types of Postural Alignment 64

Segmental Alignment: Side View 65-69

Abdominal Muscles in Relation to Posture 70-71

Sway-Back Posture 72

Ideal Alignment: Posterior View 73

Faulty Alignment: Posterior View 74, 75

Handedness: Effect on Posture 76

Faulty Posture: Side and Back Views 77

Shoulders and Scapulae 78, 79

Posture of Feet, Knees and Legs 80-83

Radiograph of Legs 84

Sitting Posture 85

Section III: Postural Examinations

Procedure for Postural Examination 86-88

Postural Examination Chart 89

Good and Faulty Posture: Summary Chart 90, 91

Faulty Posture: Analysis and Treatment, Charts 92,93

Faulty Leg, Knee, and Foot Positions, Chart 94 Acquired Postural Weakness 95

Section IV: Posture of Children

Factors Influencing Children's Posture 96, 97 Good and Faulty Posture of Children 98-100 Normal Flexibility According to Age Level 101 Flexibility Tests: Charts 102, 103 Problems with "Physical Fitness Tests" 104, 105

Section V: Scoliosis

Introduction 107

Scoliosis from Neuromuscular Disease 108 Postural Examination, and Chart 109-111 Functional Scoliosis 112 Exercises and Supports 113, 114 Early Intervention 115 Corrective Exercises 116 References 117

Head and Face 119

Introduction 121

Section I: Innervation

Cranial Nerves and Deep Facial Muscles 122

Cervical Nerves and Superficial Facial and Neck Muscles 123

Temporomandibular Joint Movement 124

Cranial Nerve and Muscle Chart 124, 125

Section II: Facial and Eye Muscles

Facial and Eye Muscles, Charts 126, 127 Facial and Eye Muscles Tests 128-133

Section III: Facial Paralysis

Muscles of Deglutition 138, 139

References 140

Neck HI

Introduction 143

Section I: Innervation and Movements 144 Spinal Cord and Nerve Roots 144 Spinal Nerve and Muscle Chart 144 Cervical Plexus 145

Joint Movements of the Cervical Spine 146 Neck Range of Motion 147

Section II: Neck Muscles 148

Anterior and Lateral Neck Muscles, Charts 148, 149 Suprahyoid and Infrahyoid Muscles 150, 151 Cervical Spine Extension and Flexion 152 Faulty Head and Neck Positions 153

Section III: Neck Muscle Tests 154 Anterior Neck Flexors 154 Error in Testing Neck Flexors 155 Anterolateral Neck Flexors 156 Posterolateral Neck Flexors 157 Upper Trapezius 158

Section IV: Painful Conditions 159 Tight Posterior Neck Muscles 159 Upper Trapezius Strain 160 Cervical Nerve Root Pressure 160 Computer Ergonomics 161

Section V: Treatment 162

Massage of Neck Muscles 162 Exercises to Stretch Neck Muscles 163

References 164

Trunk and Respiratory Muscles 165

Introduction 167

Section I: Trunk 168

Innvervation, cliart 168 Joints of Vertebral Column 168

Trunk Range of Motion 169 Movements of Vertebral Column 169 Movements of Spine and Pelvis 172 Tests for Length of Posterior Muscles 174 Variation in Length of Posterior Muscles 175 Trunk Muscles 176

Neck and Back Extensors, Illustration 177 Neck and Back Extensors, Charts 178-179 Back and Hip Extensors 180 Back Extensors: Testing and Grading 181 Strong Back Extensors, Misdiagnosed 182 Quadratus Lumborum 183 Lateral Trunk Flexors and Hip Abductors 184 Lateral Trunk Flexors: Testing and Grading 185 Oblique Trunk Flexors: Testing and Grading 186

Section II: Abdominal Muscles 187

Analysis of Curled-Trunk Sit-Ups 187

Movements during Curled-Trunk Sit-Ups 188-189

Muscles during Curled-Trunk Sit-Ups 190-192

Trunk Movement 193

Rectus Abdominis, Illustration 194

External Oblique, Illustration 195

Internal Oblique, Illustration 196

Tranversus Abdominis, Illustration 197

Obliques: Weakness and Shortness 198

Divisions of Abdominal Muscles, Chart 199

Differentiating Upper and Lower Abdominals 200-201

Upper Abdominal Muscles: Testing and Grading 202-203

Abdominal Muscle Weakness: Trunk Raising 204

Abdominal and Hip Flexor Imbalance 205

Sit-Up Exercises 206-208

Therapeutic Exercises: Trunk Curl 209

Abdominal Muscles During Leg Lowering 210-211

Lower Abdominals: Testing & Grading 212-213

Abdominal Muscle Weakness: Leg Lowering 214

Therapeutic Exercises: Posterior Pelvic Tilt 215

Therapeutic Exercise: Trunk Rotation 216 Marked Abdominal Muscle Weakness 217-218

Section III: Painful Conditions of Low Back 219 Low Back Enigma 219 Low Back Pain 219-222 Anterior Pelvic Tilt 223-225 Back Supports 226 Hip Extensor Weakness 227 Posterior Pelvic Tilt 228 Lateral Pelvic Tilt 229 Lifting 230-231

Treatment for Back Weakness 232

Section IV: Muscles of Respiration 233 Introduction 233 Therapeutic Objectives 234 Primary Muscles of Respiration 235-237 Accessory Muscles of Respiration 237-238 Respiratory Muscle Chart 239 Muscles of Respiration 240-241

Corrective Exercises 242-243

References 244

6 Upper Extremity and Shoulder Girdle 245

Introduction 247

Section I: Innervation

Brachial Plexus 248, 249

Cutaneous Distribution Nerves 250

Spinal Nerve and Motor Point Chart 251

Nerves to Muscles: Motor and Sensory and Motor Only and Chart 252, 253

Scapular Muscle Chart 253

Chart of Upper Extremity Muscles 254-255

Cutaneous Nerves—Upper Limb 256, 257

Section II: Hand, Wrist, Forearm and Elbow

Movements—Thumb and Finger Joints 258

Movements—Wrist, Radioulnar and Elbow 259 Chart for Analysis of Muscle Imbalance 260

Strength Tests

Thumb Muscles 261-268

Digiti Minimi 269-271

Dorsal and Palmar Interossei 272, 273

Lumbricales and Interossei 274—276

Palmaris Longus and Brevis 277

Extensor Indicis and Digiti Minimi 278

Extensor Digitorum 279

Flexor Digitorum Superficialis and Profundus 280,281

Flexor Carpi Radialis and Ulnaris 282, 283

Extensor Carpi Radialis and Ulnaris 284, 285

Pronator Teres and Quadratus 286, 287

Supinator and Biceps 288, 289

Biceps Brachii and Brachialis 290, 291

Triceps Brachii and Anconeus 292, 293

Brachioradialis 294

Range of Motion Chart 295

Strength Testing of Thumb and Fingers 295

Joint Measurement Chart 296

Section III: Shoulder

Joints and Articulations 297-299

Charts: Shoulder Girdle Articulations 300, 301

Combined Shoulder & Scapular Muscles 302

Movements of Shoulder Girdle & Scapula 303

Movements of Shoulder Joint 304, 305

Length of Humeral and Scapular Muscles 306

Test for Length of Pectoralis Minor 307

Test for Tightness of Muscles that Depress the Coracoid Process Anteriorly 307

Tests for Length of Pectoralis Major 308

Tests for Length of Teres Major,

Latissimus Dorsi and Rhomboids 309

Tests for Length of Shoulder Rotators 310, 311

Upper Extremity Muscle Chart 312

Strength Tests—Shoulder Coracobrachialis 313 Supraspinatus 314 Deltoid 315-317

Pectoralis Major, Upper and Lower 318,319

Pectoralis Minor 320

Shoulder Lateral Rotators 321

Shoulder Medial Rotators 322

Teres Major & Subscapularis 323

Latissimus Dorsi 324, 325

Rhomboids, Levator Scapulae and Trapezius 326-331

Serratus Anterior 332-337

Section IV: Painful Conditions of Upper Back Weakness of Upper Back 338 Short Rhomboids 338 Middle & Lower Trapezius Strain 339 Back Pain from Osteoporosis 340

Painful Conditions of the Arm

Thoracic Outlet Syndrome 341

Coracoid Pressure Syndrome 342, 343

Teres Syndrome (Quadrilateral Space Syndrome) 344

Pain from Shoulder Subluxation 345

Tight Shoulder External Rotators 345

Cervical Rib 345

Section V: Case Studies

Case 1: Radial Nerve Lesion 347

Case 2: Radial, Median, & Ulnar Nerve 348, 349

Case 3: Probable C5 Lesion 350

Case 4: Lateral and Medial Cord 351

Case 5: Partial Brachial Plexus Lesion 352-354

Case 6: Stretch Weakness Superimposed on a Peripheral Nerve Injury 355

Overuse Injuries 356 Corrective Exercises 357 References 358

Motor Point Radial Nerve
Introduction 361

Section I: Innervation

Lumbar Plexus, Sacral Plexus 362, 363 Spinal Nerve and Muscle Chart 364 Spinal Nerve and Motor Point Chart 365 Chart of Lower Extremity Muscles 366, 367 Nerves to Muscles: Motor & Sensory 368 Cutaneous Nerves of the Lower Limb 369

Section II: Joint Movements

Movements of Toes, Foot, Ankle and Knee 370, 371

Movements of Hip Joint 372, 373

Joint Measurement Chart 374

Treatment of Muscle Length Problems 375

Test for Length of Ankle Plantar Flexors 375

Test for Length of Hip Flexor Muscles 376, 380

Hip Flexor Stretching 381

Problems with Hamstring Length Testing 382

Tests for Length of Hamstring Muscles 383, 384

Short Hamstrings 385, 386

Effect of Hip Flexor Shortness 387

Errors in Testing Hamstring Length 388, 389

Hamstring Stretching 390

Ober and Modified Ober Test 391-394

Hip Flexor Length Testing 395-397

Tensor Fasciae Latae Stretching 398

Section III: Muscle Strength Tests

Chart for Analysis of Muscle Imbalance 399

Toe Muscles 400-409

Tibialis Anterior 410

Tibialis Posterior 411

Peroneus Longus and Brevis 412

Ankle Plantar Flexors 413-415

Popliteus 416

Hamstrings and Gracilis 417-419 Quadriceps Femoris 420,421


Hip Flexors 422,423

Sartorius 424

Tensor Fasciae Latae 425

Hip Adductors 426-428

Medial Rotators of Hip Joint 429

Lateral Rotators of Hip Joint 430, 431

Gluteus Minimus 432

Gluteus Medius 433

Gluteus Medius Weakness 434

Trendelenberg Sign & Hip Abductor Weakness 435

Gluteus Maximus 436,437

Leg Length Measurement 438

Apparent Leg Length Discrepancy 439

Section IV: Painful Conditions Foot Problems 440-443 Shoes and Shoe Corrections 444-446 Knee Problems 447,448 Leg Pain 449 Tight Tensor Fasciae Latae and ITB 449, 450 Stretched Tensor and ITB 450, 451 Protruded Intervertebral Disk 452 Piriformis Muscle and Sciatic Pain 453, 454 Neuromuscular Problems 454 Case 1: Peroneal Nerve Injury 455 Case 2: Lumbosacral Nerves 456, 457 Case 3: L5 Lesion 458 Case 4: Guillain-Barre 459 Case 5: Guillain-Barre' 460 Case 6: Polio 461 Corrective Exercises 462,463 References 464

Appendix A: Spinal Segment Distribution to Nerves and Muscles 465-467

Charts 468-472

Appendix B: Isolated Paralysis of the Serratus Anterior Muscle 473-480

Glossary G—1

Suggested Readings SR-1

Index 1-1

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