02/01/2016
Clinical Assessment of
Wrist and Hand:
Occupational Therapist’s
Perspective
Punita V. Solanki
MSc (O.T.), ADCR (Mumbai)
Occupational Therapist
4th Annual National Conference of
Society for Hand Therapy, India
12th & 13th December, 2015
Pune, Maharashtra, India
Mobile: +91‐9820621352 (Official)
+91‐9167180215 (Personal)
Email: therapistindia@gmail.com
Table of Contents
1. Applied Anatomy & Biomechanics of Wrist & Hand.
2. Patient’s Detailed Injury & Occupational History.
3. Clinical Observation.
4. Triage and Quick Screening & Sensory Assessment
5. Volume Test.
6. Range of Motion Testing.
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7. Palpation and Manual Muscle Testing.
8. Special Provocative Tests.
9. Standardized Functional Tests and Outcomes Measures.
10. Prevalence and Economic Impact.
11. Quiz Time.
12. Take‐Home Message.
13. Acknowledgements and References.
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“The hands that help are holier than the
lips that pray”
~ Robert Green Ingersoll
(American Political Leader)
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Applied Anatomy of Wrist and Hand
19 Bones & 19 Joints
in the Hand
(5 CMC, 5 MCP,
5 PIP & 4 DIP)
3 of 8 Carpal
Bones + Radius +
Radio‐Ulnar Disc
(TFCC)
(Wrist Complex)
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Anatomy of Right Hand ‐ Dorsal Surface
Applied Anatomy of Wrist and Hand
3 Arches of Hand
Carpal Tunnel
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Anatomy of Right Hand ‐ Volar Surface
Biomechanics of Wrist and Hand
Wrist Complex (Radio‐carpal Joint): 2° of Freedom of Motion
(FoM) (Sagittal & Frontal Plane Motions)
CMC joint of Thumb: 3° of FoM (Sagittal, Frontal & Transverse)
MCP Joints Fingers: 2° of FoM (Sagittal & Frontal)
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MCP Joint Thumb: 3° of FoM (Sagittal, Frontal & Transverse)
PIP Joints: 1° of FoM (Sagittal Plane: from Extension to Flexion
with No Hyperextension ‐ 0° to 110°) (Thumb: 0° to 90°)
DIP Joints: 1° of FoM (Sagittal Plane: from Extension to Flexion
with slight Hyperextension. (0° to 90° & 0° to 5°‐10°)
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Biomechanics of Wrist and Hand
Functional (Resting) Posture of Wrist and Hand
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Wrist: 15° ‐ 30° Extension + 10° ‐ 15° Ulnar Deviation.
CMC Thumb: Midway between Flex ‐ Ext & Ab ‐ Ad
MCP Thumb: Slight Flexion
MCP Fingers: 45° to 60° of Flexion
PIP Thumb & Fingers: Slight Flexion of about 10°
DIP Fingers: Slight Flexion of about 5°
Biomechanics of Wrist and Hand
Functional Positions of Wrist
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Most of the activities of daily living are accomplished between
the wrist positions of 10° Flexion to 35° Extension. Greatest arc of
motion up to 63° Extension is employed during rising from a chair
whilst weight bearing over the hand.
Biomechanics of Wrist and Hand
Position of Immobilization (Closed Packed Position) of
Wrist and Hand
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Wrist: 30° ‐ 35° Extension + Neutral or 5° ‐ 10° Ulnar Deviation.
CMC Thumb: Full Opposition
MCP Thumb: Full Opposition
MCP Fingers: 90° of Flexion
PIP Thumb & Fingers: Full Extension (0°)
DIP Fingers: Full Extension (0°)
(In these positions, the ligaments of each joints are taut/shortened)
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Assessment
“Assessment is the first step towards
successful goal setting, treatment
planning and optimal return to
occupational roles (ADL, Work & Leisure)”
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Patient’s Detailed Injury History
Injury History:
 Mechanism of injury/disease (Onset, Duration & Progress)
 Location of pain, character of pain, intensity of pain (VAS score)
 H/o swelling, abnormal sensitivity e.g. paresthesia, burning,
stiffness, weakness, difficulty in activities of daily living, work &
leisure/play activities
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 Past/Previous H/o similar injuries or any related, associated
co‐morbidities (physical, psychological, social, environmental).
Patient’s Detailed Occupational History
Occupational History:
 Demographic History
 Dominance of hand
 Occupation
 Abilities and Inabilities in Function (ADL, Work & Leisure)
 Full time/part time/permanent/temporary/free‐lance job
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 Availability of sick leaves, work shifts, regional transfers to
locality in the vicinity of residence, part time return to work, etc
 Level of work, work assistance, travel to & fro work, rest breaks
 Presence of inherent risk factors of work‐related MS disorders
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Clinical Observation
Observe for: (Bilateral)
Localized or generalized swelling
Trophic changes e.g. change in color of the skin, appearance of the
skin (skin creases, shiny or scaly skin), moisture of the skin (hyper or
hypo hidrosis), skin temperature, hair changes, appearance of nails,
local bruising or wounds due to injury etc
Bony projections (due to degeneration e.g. Heberden’s nodes or
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subluxation or dislocation or malunion e.g. dinner fork deformity in
malunited distal radius #)
Attitude of the wrist and hand whilst at rest and during activity or
exercise session or presence of any deformities.
Prominent contractured skin over the palm e.g. Dupuytren’s
contracture or any other contractures
Wasting of muscles
Clinical Observation
Localized Swelling & Trophic Changes
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Clinical Observation
Deformity or Attitude of the Wrist & Hand
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Clinical Observation
Wasting of Muscles
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Clinical Observation
Dupuytren’s Contracture
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Triage and Quick Screening
Clinical Observation of Bilateral Wrist and Hand Appearance.
Quick Check on Bilateral Wrist and Hand Movements:
 Up‐Down & Side‐Side Movement of Wrist
 Extension of Hand Joints, Table Top Position, Claw/Hook
Position, Fist Position, Spreading and Gathering of Fingers and
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Counting of Fingers.
Root Assessment: Against Resistance
(Break Test)
 C6: Wrist Extensors
 C8: Middle Finger DIP Flexors
 T1: Little Finger Abductors
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Triage and Quick Screening
Exclusive Peripheral Nerve Innervations (Autonomous Zones)
 Radial nerve: 1st dorsal web space of hand
(Anatomical snuff box)
 Median nerve: Distal phalanx (tip) of index finger (2nd finger)
Other: Tip of thumb
 Ulnar nerve: Distal phalanx (tip) of little finger (5th finger)
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Sensory Assessment
Superficial sensory assessment on dermatome distribution of
wrist and hand and recording it as:
(0: Absent, 1: Impaired with % Loss or 2: Intact)
Deep sensory assessment:
 Deep Pressure
 Weber’s (Moberg’s) Two‐Point Discrimination Test
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( Normal: <6mm, Fair: 6‐10 mm, Poor: 11‐15 mm, Protective: 1
point perceived, Anesthetic: 0 points perceived)
(Functional needs e.g. winding a watch: 6 mm, handling precision
tools: 12 mm and gross tools: >15 mm)
 Dellon’s Moving Two‐Point Discrimination Test: Functional
implications. Normal recognition: 2‐5 mm
Sensory Assessment & Volume Test
Semmes‐Weinstein Test: Grid pattern of assessment of hand
and finger’s light touch sensation. Only one point, is tested in
each square.
Stereognosis or tactile gnosis : Dellon’s modification of
Moberg’s Pick‐up Test (Normal subjects can name the object
within 3 seconds of contact)
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Vibratory sense: Distal to Proximal assessment over bony
prominences with vibrating tuning fork.
Hand Volume Test:
Measure tape or Volumetric assessment. Bilateral assessment
for comparison
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Range of Motion Testing
Types of Goniometer for Wrist and Hand Range of Motion
Testing.
Norms of Range of Motion values by various academic bodies
e.g. American Academy of Orthopaedic Surgeons, American
Medical Association, American Society for Surgery of the Hand.
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Standardized positions of the patients, of the joints of wrist
and hand, & the goniometer, whilst performing range of motion
testing.
Methods of documentations of Range of Motion. Bilateral
assessments along with documenting norms and end feels.
A 5‐degree margin of error is acceptable for goniometric
measurements of joints in the hand by an experienced examiner
using standardized protocols.
~ (Bear‐Lehman, J and Abreu, BC;1989)
Range of Motion Testing
Types of Finger Goniometer (FG):
Rolyan Finger/Toe Goniometer
Jamar 8‐Inch Goniometer
Rolyan Flexion/Hyperextension FG
Baseline Stainless Steel FG
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Range of Motion Testing
Documentation Template
Joints
Thumb
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Left Hand
PROM
End
Feel
Right Hand
PROM
End
Feel
Norms
ROM
End
Feel
CMC Flexion
0° ‐ 15°
Firm*
CMC Extension
0° ‐ 20°
Firm*
CMC Palmar Abduction
0° ‐ 45°
Firm†
CMC Radial Abduction
0° ‐ 70°
Firm*
MCP Flexion
0° ‐ 50°
Firm*
MCP Hyperextension
0° ‐ 10°
Firm†
IP Flexion
0° ‐ 80°
Firm*
IP Hyperextension
0° ‐ 15°
Firm†
* American Academy of Orthopaedic Surgeons (Opposition is Measured with Measure Tape)
† American Society for Surgery of the Hand; Method Used: Finger Goniometry
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Palpation and Manual Muscle Testing
Standardized position of the patients, of the joints of wrist and hand
& of the examiner, whilst performing muscle testing.
Accuracy of strength grading depends upon:
 stable position of the patient
 the fixation of the part proximal to the tested part
 precision of test position
 the direction and amount or pressure/resistance
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Methods of manual muscle testing e.g. Break Vs. Make test,
Scoring: MRC, Daniels & Worthingham, Kendall & McCreary; Subjective
Vs. Objective methods of evaluation.
Consistency in methods of documentations of muscle testing.
Bilateral assessments for comparison
Purpose of Evaluation: Diagnosis, treatment outcome or prognostic
value of treatment used.
Manual Muscle Testing
Some Facts about Wrist and Hand Muscle Strength
“Weakness” is used as an overall term covering a range of strength
from zero (0) to fair (3) in non‐weight bearing upper limb muscles.
The strength of the finger flexors is over twice that of the extensors.
FDS is the strongest muscle of the extrinsics of hand.
2nd & 4th digital flexor tendon sheath annular pulley system plays an
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important role in maintaining a constant moment arm for finger flexors.
The excursion of the flexors > extensors, extrinsics > intrinsics.
The position of the thumb & the relationship between hand &
forearm are the most important differences between power grip Vs
precision handling.
Dominant hand grip and pinch strength is more than the
non‐dominant hand by 10%.
Palpation and Manual Muscle Testing
Documentation Template
Joint
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Muscles
MMT*
Left
MMT*
Right
CMC Flexion
FPB & FPL
5
5
CMC Extension
EPL & EPB,
3+
5
CMC Palmar
Abduction
APB & APL
5
5
CMC Radial
Abduction
APB & APL
4‐
5
MCP Flexion
FPB
5
5
MCP
Hyperextension
EPB
3+
5
IP Flexion
FPL
5
5
IP
Hyperextension
EPL
5
5
Opposition
OP
5
5
Dynamometer/
Electr. MMT(Kgs)
* Oxford’s Modified Research Council (MRC) MMT Grading System
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Grip & Pinch Testing
Grip and Pinch Strength Testing and Hand Muscle Endurance
Testing (As per the Recommendations of ASHT, 1981)
Subject: should be in supported seated posture
Shoulder: adducted & neutrally rotated
Elbow: flexed at 90°
Forearm: neutral position
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Wrist: 0° to 30° extension & between 0° to 15° of ulnar deviation
Hip & knees: when seated should be at 90° of flexion
Feet: flat on the ground.
Three trials are taken of each hand with a 2‐3 minute rest between
trials and the score is the average of the three trials.
Jamar Dynamometer (Set at second position from all of 5 positions)
Grip & Pinch Testing
Grip and Pinch Strength Testing and Hand Muscle Endurance
Testing (As per the Recommendations of ASHT, 1981)
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Grip, Pinch & Hand Endurance Testing
Grip and Pinch Strength Testing and Hand Muscle Endurance
Testing (As per the Recommendations of ASHT, 1981)
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Grip Strength Assessment Tools
Grip and Pinch Strength Testing and Hand Muscle Endurance
Testing (As per the Recommendations of ASHT, 1981)
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Pinch Strength Assessment Tools
Grip and Pinch Strength Testing and Hand Muscle Endurance
Testing (As per the Recommendations of ASHT, 1981)
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Special Provocative Tests
Tests for Neurological Dysfunction
Carpal Tunnel
Phalen’s Test (hold wrists
flexed together for 1 min)
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Tinel’s Test
(tap median nerve in carpal
tunnel)
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Special Tests
Tests for Neurological Dysfunction
Ulnar Nerve:
 Froment’s Sign
 Jeanne’s Sign
 Card Test
 Egawa’s Sign
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Median Nerve:
 Clasping Test (Benediction Attitude/Pointing Index)
 Pen Test
 Kiloh Nevin Sign
 Ape or Simian Hand
Radial Nerve:
 Wrist Drop
Special Provocative Tests
Tests for Tendons & Muscles
Finkelstein’s Test
DeQuervain’s Tenosynovitis
Sweater Finger Sign
FDP Tendon Rupture (R Finger)
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Special Provocative Tests
Tests for Ligaments, Capsule and Joint Instability
Scapholunate instability
Watson’s Test
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Triangular Fibrocartilage Injury
Loaded Circumduction
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Special Provocative Tests
Tests for Circulation and Swelling
Allen Test
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Functional Tests
Jebson‐Taylor Hand Function Test.
Minnesota Rate of Manipulation Test.
Purdue Pegboard Test.
Crawford’s Small Parts Dexterity Test.
Box and Block Test.
Nine‐Hole Peg Test.
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Simulated Activities of Daily Living Examination. (19 subtests
or tasks are tested and timed.
Functional Outcomes Measures
Patient Reported Outcome Measures (PROM)
Disability of the arm, shoulder and hand questionnaire (DASH):
a region‐specific 30‐item questionnaire is the most widely tested
instrument in patients with wrist and hand injuries & established
measurement properties
Quick DASH: established measurement properties
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Patient Rated Wrist Hand Evaluation Outcome Questionnaire
(PRWHE): good construct validity and responsiveness &
established measurement properties
Michigan Hand Outcomes Questionnaire (MHQ): sufficiently
responsive & good value to patients with hand injuries
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Functional Outcomes Measures
Patient Reported Outcome Measures (PROM)
Modern Activity Subjective Survey of 2007 (MASS07)
The Boston Carpal Tunnel Questionnaire (CTQ) scale: most
sensitive to clinical change & established measurement properties
Upper Extremity Functional Index (UEFI) & Upper Extremity
Functional Scale (UEFS)
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Functional Tests & Outcomes Measures
PROM
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Score Items
Validity (V)
Reliability (R)
DASH
30
Self reported
Valid
Reliable
Responsive
Quick
DASH
11
Self reported
Valid
Reliable
Responsive
PRWHE
15
Self reported
Criterion
Validity
Test‐retest Reliability
Internal consistency
Boston
CTQ
11
Self reported
Face, content
construct V
Test‐retest Reliability
Response Rate: 90%
MHQ
65
Self reported
Valid
Test‐retest Reliability
MASS07
10
Self reported
Valid
Reliable
UEFI
20
Self reported
Valid
Test‐retest Reliability
Internal consistency
Prevalence and Economic Impact
Reference: de Putter CE, Selles RW, Polinder S, Panneman MJ,
Hovius SE, van Beeck EF. Economic Impact of Hand and Wrist
Injuries: Health‐care Costs and Productivity Costs in a Population
‐Based Study. J Bone Joint Surg Am. 2012 May 2;94(9):e56.
Doi: 10.2106/JBJS.K.00561.
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Conclusion: Hand and wrist injuries not only constitute a
substantial part of all treated injuries but also represent a
considerable economic burden, with both high health‐care and
productivity costs. Hand and wrist injuries should be a
priority area for research in trauma care, and further research
could help to reduce the cost of these injuries, both to the
health‐care system and to society.
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Take Home Message
“The hands are the instruments of man's intelligence.”
~ Association Montessori Internationale
Assess, Assess and Assess in the Beginning, During and After
the Treatment. It is the first most important step towards
successful outcome.
Diagnosis is often based on clinical assessment, Investigations
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are to confirm the findings, for objective documentation for
progress notes, for insurance purpose, for legal implications.
Be observant, update your knowledge and refine your clinical
skills with perfect practice.
(“Perfect practice makes man perfect.”)
Quiz Time
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Which test is this? This is for dorsal interossei (abductors) of
the middle finger. With the hand kept flat on a table palmer
surface down, the patient is asked to move his middle finger
sideways.
Answer: Egawa Test
Quiz Time
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Which hand function test is this?
Answer: Minnesota Rate of Manipulation Test
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Quiz Time
Say True or False:
 Maximum degree of wrist extension up to 65° is needed whilst
getting up from sitting posture with arms in weight bearing position.
Answer: True
 Circumduction is possible only in those joints with three degrees of
freedom of motion.
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Answer: False
 Protective sensory recovery is the first sign of sensory system
recovery.
Answer: True
 Heberden's nodes are hard or bony swellings that can develop in the
distal interphalangeal joints (DIP) due to Rheumatoid Arthritis.
Answer: False
Quiz Time
Select the Best Correct Response:
1. The strongest muscle amongst all the extrinsic muscles
of the hand is
a. Flexor Digitorum Profundus
b. Flexor Digitorum Superficialis
c. Flexor Pollicis Longus
d. Extensor Digitorum Communis
Key: b (Flexor Digitorum Superficialis)
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2. If the patient is unable to make a fist despite normal PROM of
all joints of the wrist & hand, when there is limitation in TAM/
TPM & absence of pain, (Extensor Plus Deformity) is due to
a. Tendon Tightness/Adhesions
b. Joint Arthritis
c. Tendonitis
d. Tenosynovitis
Key: a
Acknowledgements
I thank my teachers, senior colleagues, sub‐ordinates from
various departments and occupational therapy students of my
alma mater (Seth G. S. Medical College & King Edward VII
Memorial Hospital), for the rich experience, in the field of
orthopaedic rehabilitation, in my forming career years of my life,
in the past more than 18 years.
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I take this opportunity to thank Dr. Apurva A. Patel Sir,
Specialized Hand Orthopaedic Surgeon from Western Suburbs
of Mumbai, India, for the valuable experience that I have gained
in the past two years from his umpteen number of upper limb
case referrals.
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Recommended Reading & References
Chapter 7: Forearm, Wrist and Hand. In Orthopedic Physical
Assessment. Eds David J. Magee. 5th Edition. 2008 Elsevier.
Norkin CC, White DJ. Measurement of Joint Motion: A Guide
to Goniometry. 2nd Edition. 1995. F. A. Davis Company.
Nordin M, Frankel VH. Basic Biomechanics of the
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Musculoskeletal System. 3rd Edition. 2001. LWW.
Kendall FP, McCreary EK, Provance PG. Muscles Testing and
Function. With Posture and Pain. 4th Edition. 1993. William &
Wilkins.
Pandey S, Pandey AK. Clinical Orthopaedic Diagnosis. 2nd
Edition. 2000.
And many more………………………………………………………………………!
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