Muscle Examination

Patient’s Name: [claimant_full_name]

Claim ID: case_id#]

Examiner: [case_owner_desk_name]

Muscle Examination
Please assess claimant’s muscle strength on a scale of 0-5 as defined below.
KEY
5
Muscle contracts against full resistance
4
Strength reduced, but contraction can still move joint against resistance
3
Strength further reduced such that joint can be moved only against gravity with examiner’s
resistance completely removed
2
Muscle can only move if resistance of gravity is removed
1
Only a trace or flicker of movement is seen or felt, or fasciculation are observed
0
No movement
Please note any evidence of spasm or contracture.
LEFT
CERVICAL

Flexion
Extension
Lateral Flexion

RIGHT

LEFT RIGHT
SHOULDER

Thoraco-Lumbar Flexion

Adduction

Extension
Lateral Flexion
ELBOW
HIP

KNEE
ANKLE

HALLUX

TOES*

Flexion
Extension
Abduction
Adduction
External Rotation
Internal Rotation
Flexion
Extension

Flexion
Extension
Abduction

WRIST

THUMB

External Rotation
Internal Rotation
Flexion
Extension
Pronation
Supination
Flexion
Extension
Radial Deviation
Ulnar Deviation
M.P. Flexion

Plantar Flexion
Dorsi Flexion

I. P. Flexion
M.P. Extension

Inversion
Eversion
M.P. Flexion

I.P. Extension
CMC Abduction
CMC Radial Adduction

I. P. Flexion
M.P. Extension

CMC Opposition

I. P. Extension
M.P. Flexion
I. P. Flexion
M.P. Extension

FINGER
INDEX

I. P. Extension
MIDDLE

M.P. Flexion
M.P. Extension
P.I.P. Flexion
P.I. P. Extension
D.I.P. Flexion
D.I.P. Extension
M.P. Flexion
M.P. Extension
P.I.P. Flexion
P.I. P. Extension
D.I.P. Flexion
D.I.P. Extension

Patient’s Name: [claimant_full_name]

Claim ID: case_id#]

Examiner: [case_owner_desk_name]
RING
M.P. Flexion
M.P. Extension
P.I.P. Flexion
P.I. P. Extension
D.I.P. Flexion
D.I.P. Extension
LITTLE

M.P. Flexion
M.P. Extension
P.I.P. Flexion
P.I. P. Extension
D.I.P. Flexion
D.I.P. Extension

*If the 1st toe has been amputated please evaluate toes 2-5 and specify the toe(s).

DESCRIBE GAIT AND STATION: If an assistive device is used for ambulation, comment on its
medical necessity and the patient’s ability to walk without it.

DESCRIBE DEXTERITY: include observation of ability to pinch, grasp and manipulate small and
large objects. Is claimant able to make a fully closed fist? Can the fingers be opposed?
Grip Strength (0-5/5):

Left: 0 1 2 3 4 5 Right: 0 1 2 3 4 5

EFFORT ON EXAM:

GOOD ____ FAIR ____

POOR ____

Evaluator: _______________________________________________ Date: _________________