1. Long case ..Active and passive stretching for wrist extensors 2. Mmt trunk flexors

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active passive stretching wrist extensors physiotherapy technique long case

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MMT manual muscle testing trunk flexors grades technique positions

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Here is a complete, detailed breakdown of both topics for your long case:

1. Active and Passive Stretching for Wrist Extensors

Anatomy Relevant to Stretching

The primary wrist extensor muscles are:

Extensor Carpi Radialis Longus (ECRL)
Extensor Carpi Radialis Brevis (ECRB) - most commonly implicated in lateral epicondylitis
Extensor Carpi Ulnaris (ECU)

All originate at or near the lateral epicondyle and insert on the dorsal surface of the metacarpals. To stretch them, you need to bring the wrist into flexion (their antagonist motion) with the elbow in extension.

Passive Stretching of Wrist Extensors

Definition: The therapist moves the joint through range - the patient contributes no active muscle effort.

Technique

Patient position: Sitting or supine, elbow extended and resting on a surface.

Therapist position: Standing/sitting at the patient's side, facing the hand.

Hand placement:

One hand stabilizes the forearm just proximal to the wrist (dorsal surface)
The other hand cups the dorsum of the patient's hand

Procedure:

Maintain the elbow in full extension (stretches the extensors over a longer span and increases tension)
Slowly bring the wrist into full wrist flexion (palmar flexion)
Add ulnar deviation to increase the stretch further (targets ECRL and ECRB especially)
Once end-range is reached, apply gentle overpressure and hold
Hold time: 30 seconds, repeat 3-4 times per session

Important: The patient must remain relaxed - no active resistance. Therapist controls all force.

Merck Manual description: "Grasp the thumb side of the hand and bend wrist downward into wrist flexion. To increase the stretch, bend wrist toward the small finger (ulnar deviation) and pull, curling fingers into more flexion. Hold 30 seconds, 4 repetitions, 3 times/day."

Active Stretching of Wrist Extensors

Definition: The patient actively contracts antagonist muscles (wrist flexors) to move into the stretch position under their own power. No external force is applied.

Technique

Patient position: Sitting with the forearm resting on a table, elbow extended.

Procedure:

Patient actively contracts the wrist flexors (flexor carpi radialis, flexor carpi ulnaris)
Brings the wrist into full wrist flexion under their own effort
Can add active ulnar deviation at end range
Holds the position for 20-30 seconds, using their own muscle effort to maintain it
Repeat 5-10 times

Active-Assisted Stretching (commonly used in between)

Patient actively flexes the wrist as far as possible
Then the unaffected hand is used to apply gentle additional overpressure to increase range
Bridges the gap between pure active and pure passive

Key Differences: Active vs. Passive

Feature	Active	Passive
Who moves the joint	Patient (own muscle contraction)	Therapist
Reflexive response	May trigger stretch reflex (muscle spindle Ia afferent activation) if done too fast	Avoids stretch reflex if slow
Benefit	Increases neuromuscular control, reciprocal inhibition	Greater ROM gain, used when patient unable to move
Use case	Rehab maintenance, home exercise	Acute stiffness, post-immobilization, neurological cases
End-range force	Limited to patient's own strength	Therapist can provide more controlled overpressure

Physiological basis: A slow passive stretch activates muscle spindle Ia afferents which cause reflexive contraction of the same muscle (stretch reflex). To avoid this, passive stretches must be held slowly at end range (sustained/static), not applied as a ballistic force. Active stretching uses reciprocal inhibition - contraction of the agonist (wrist flexors) reflexively inhibits the antagonist (wrist extensors) via Ia inhibitory interneurons, making the stretch more effective.

Clinical Context (Long Case Considerations)

In lateral epicondylitis: ECRB is the main target; passive stretching of wrist extensors with elbow extended is first-line conservative management
In post-immobilization stiffness: begin with active-assisted stretching, progress to passive
In upper motor neuron lesions (spasticity): passive prolonged stretching helps prevent contracture of wrist extensors (wrist drop correction); care is needed due to hyperactive stretch reflex
Document: ROM at baseline, patient's pain during stretch (VAS), end-feel (soft/firm/hard)

2. Manual Muscle Testing (MMT) of Trunk Flexors

Muscles Being Tested

Primary trunk flexors:

Rectus abdominis (main trunk flexor)
External and internal obliques (assist flexion and rotation)
Iliopsoas (hip flexors assist in full sit-up but tested separately)

The MMT for trunk flexors tests vertebral column flexion, NOT hip flexion. The key movement is scapular clearance off the table (curl-up), not a full sit-up.

Testing Protocol (Based on Kendall / Daniels & Worthingham)

Note Before Testing

Test neck flexors first - they should be adequate before testing trunk
Patient should maintain chin tucked to minimize neck flexion contribution
If hip flexors are weak, stabilize the pelvis (therapist leans across, forearms on anterior iliac crests)

Grading Chart - Upper Abdominal (Trunk Raising) Test

Grade	Score	Position	Criterion
Normal	5/5	Supine, hands clasped behind head/neck	Flexes thorax through full ROM - inferior angle of scapulae clears the table
Good+	4+/5	Supine, hands at shoulders	Completes full movement
Good	4/5	Supine, arms crossed over chest	Completes full movement, scapulae clear table
Good-	4-/5	Supine, arms crossed over abdomen	Completes full movement
Fair+	3+/5	Supine, arms extended forward	Completes full movement
Fair	3/5	Supine, arms extended forward	Lifts until scapulae clear the table but cannot maintain once entering hip flexion phase
Fair-	3-/5	Supine, knees slightly flexed	Posterior pelvic tilt and keeps pelvis-thorax approximated as head lifts
Poor	2/5	Hook-lying (knees bent)	Can raise head off table (partial movement); OR with assisted lean-forward, rib cage depresses
Trace	1/5	Hook-lying	No visible movement but palpable/visible contraction of abdominals
Zero	0/5	Any	No palpable or visible contraction

Step-by-Step Test Execution

Setup:

Patient: Supine on a firm surface
Begin testing from Grade 5 and work down if the patient cannot complete

For Grade 5 (Normal):

Patient lies supine, fingertips lightly touching the back of the head
Instruct: "Tuck your chin and curl upward, lifting your head, neck, and shoulders off the table."
Patient flexes thorax until inferior angles of scapulae clear the table
The weight of the arms behind the head provides the resistance

For Grade 4 (Good):

Arms crossed over the chest
Same curl-up movement, scapulae must clear table

For Grade 3 (Fair):

Arms extended forward (in front of body, parallel to thighs)
Patient completes the movement with scapulae clearing the table

For Grades 2-0 (hook-lying position):

Move patient to hook-lying (supine, knees bent, feet flat)
Ask patient to lift head - if scapulae don't clear table → Grade 2
If patient cannot lift head, cradle their upper trunk and ask them to lean forward - if rib cage depresses → Grade 2
If no movement but you can palpate contraction of abdominals → Grade 1
No contraction felt at all → Grade 0

Lower Abdominal Test (Supplementary)

Tests lower rectus abdominis and deep abdominals (transversus abdominis):

Grade 5/5: Patient performs posterior pelvic tilt and holds lumbar spine flat on table while lowering both legs from 90° hip flexion to full extension (table level)
Grade 4/5: Holds flat while lowering legs to approximately 30-45°
Grade 3/5: Holds while lowering to approximately 60-75°
Grade 2/5: Can perform posterior pelvic tilt but cannot maintain it as legs lower
Grade 1: Palpable contraction only; no movement

Key Points for Long Case Presentation

Always test neck flexors first before trunk flexors
Stabilize the pelvis if hip flexors are weak (otherwise the pelvis will anteriorly tilt and substitute)
The movement tested is thoracic flexion (curl-up), not a full sit-up
Arm position is how you grade 3 through 5 - more proximal arm position = more resistance (longer lever arm)
Document which grade was achieved and what specific substitutions or compensations you observed
Normal daily function requires at least Grade 3 for basic transfers

Sources: Kendall's "Muscles: Testing and Function," Daniels & Worthingham "Muscle Testing: Techniques of Manual Examination," Merck Manual (wrist extensor stretch technique), Human Kinetics - Shelley "Principles of Goniometry and Manual Muscle Testing," Medical Physiology (Boron & Boulpaep) for stretch reflex physiology.

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