A Guide To The Modified Tardieu Scale

©2024, John Olver and the Epworth Medical Foundation

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Epworth Rehabilitation has conducted a Spasticity Management Clinic at its campuses in Richmond and Hawthorn since 2009. In this specialised interdisciplinary clinic, patients with a wide variety of neurological diagnoses have their spasticity assessed and managed.

One of the key intentions of the clinic is to assess patient outcomes following treatment. The main outcomes involve changes in patient function and are measured by goal attainment scaling.

For measuring spasticity in individual muscles, we have adopted the use of the Modified Tardieu Scale. An issue with using this scale is in recording the measurements of each individual muscle with respect to starting positions, finishing positions and the angle at which a muscle response occurs.

Individual clinicians can use different techniques and angular measurements, which makes comparison of results before and after treatment inconsistent.

The aim of this App is to outline a protocol for the use of the Modified Tardieu Scale in the most commonly injected muscles of the upper and lower limb. This App has been compiled using the expertise of physiotherapists, occupational therapists and rehabilitation medicine physicians.

Acknowledgements

This App would not be possible without the generous support provided by the Epworth Medical Foundation, the Australian Physiotherapy Association and Physiotherapy ReSearch Epworth Rehabilitation (PRoSpER).

Glossary
About The Tardieu Scale
The Starting Position
Modified Tardieu Scale Criteria

Upper Limb
Shoulder Rotators
Pectoralis Major
Subscapularis
Teres Major
Latissimus Dorsi
Elbow Flexors
Biceps Brachii Long Head
Brachialis
Brachioradialis
Elbow Extensors
Triceps Brachii Long Head
Triceps Brachii Lateral Head
Triceps Brachii Medial Head
Forearm Pronators
Pronator Teres
Pronator Quadratus
Wrist Flexors
Flexor Carpi Radialis
Flexor Carpi Ulnaris
Finger Flexors
Flexor Digitorum Superficialis
Flexor Digitorum Profundus
Thumb Muscles
Flexor Pollicis Longus
Flexor Pollicis Brevis
Adductor Pollicis
Hand Muscles
Intrinsic Finger Flexors (lumbricals)

Lower Limb
Hip Adductors
Adductor Brevis
Adductor Longus
Adductor Magnus
Hip Flexors
Psoas Major
Knee Flexors
Semimembranosus
Semitendinosus
Biceps Femoris
Knee Extensors
Vastus Lateralis
Vastus Medialis
Vastus Intermedius
Rectus Femoris (prone)
Rectus Femoris (supine)
Ankle Plantarflexors
Gastrocnemius
Soleus
Ankle Invertor
Tibialis Posterior
Toe Flexors
Flexor Digitorum Longus
Flexor Digitorum Brevis
Flexor Hallucis Longus

Appendix 1 Case Study
References

Glossary

10MWT 10 Metre Walk Test
6MWT 6 Minute Walk Test
+ve Positive
-ve Negative
< Less than
= Equals
> Greater than
AFO Ankle foot orthosis
AL Adductor Longus
AM Adductor Magnus
APB Adductor Pollicis Brevis
C1-7 Cervical spine level
СТ Computed Tomography
DF Dorsiflexion
DIP Distal Interphalangeal
FCR Flexor Carpi Radialis
FCU Flexor Carpi Ulnaris
FDL Flexor Digitorum Longus
FDP Flexor Digitorum Profundus
FDS Flexor Digitorum Superficialis
FEM Femur
FHL Flexor Hallucis Longus
FPB Flexor Pollicis Brevis
FPL Flexor Pollicis Longus
Gastroc Gastrocnemius
GHJ Glenohumeral Joint
HUM Humerus
IP Interphalangeal
LUM Lumbricals
L1-5 Lumbar spine level
MCP Metacarpophalangeal
PF Plantarflexion
PG Plantargrade
PIP Proximal Interphalangeal
PQ Pronator Quadratus
R Radius
R1 The angle of muscle reaction
R2 The angle of full range of motion
REC FEM Rectus Femoris
ROM Range of motion
T1-12 Thoracic spine level
TBI Traumatic Brain Injury
Tib Tibia
TS Tardieu Scale
U Ulnar
UN Ulnar Nerve
US Ultrasound
V1 Moving the limb as slow as possible
V2 Moving the limb at the speed of the segment falling under gravity
V3 Moving the limb as fast as possible
X The dynamic tone component of the muscle

About the Tardieu Scale

The Tardieu Scale, which was originally developed by Guy Tardieu (Tardieu et al., 1954), is based on four key principles:

Apply a passive stretch on a relaxed muscle.
Maintain a consistent position of proximal segments.
Measure the angle at which the resistance interrupts passive movement.
Compare the angles of arrest in stretching manoeuvres of different speeds, from extremely slow to rapid (i.e., the spasticity angle).

Following multiple revisions by Held and Pierrot-Deseilligny (1969), Boyd and Graham (1999) and Gracies et al. (2010), the Tardieu Scale evolved to the version known presently as the Modified Tardieu Scale.

Both the Tardieu Scale and the Modified Tardieu Scale involve testing the resistance of spastic muscles to passive stretching at different velocities and grading the resistance, using an ordinal scale.

The Starting Position

Standardise the resting positions prior to stretching the muscle.

Based on the definition of R2 being the full ROM of the joint, the starting position of the muscle being tested should be at rest in its shortest position.

The more distal joint is held in the shortest position (for multi-joint muscles) whereas the proximal joint is held in a standardised position, throughout.

For example, when measuring finger flexors, the wrist is held at 30° extension to start the stretch, not at maximum flexion.

The angle, zero, is based on the anatomical position.

Use a quiet room with minimal stimulation and, if possible, at the same time of day as the previous assessment.

Other body segments, particularly head and neck, should also be maintained in a standardised position.

Test the upper limb in the sitting position.

The elbow should be flexed to 90° and the shoulder held in a neutral position when testing the wrist and fingers.

Test the lower limb in a supine position.

Limit and keep the number of stretching manoeuvres consistent prior to the V1/V3 test, as they will impact on stretch reflex excitability.

Modified Tardieu Scale Criteria

The most recent versions of the scale use the following criteria:

Patients are positioned sitting to test the upper limbs and supine to test the lower limbs.

Four measurements:

The angle of ROM during V1 (R2)
The angle of muscle reaction during V3 (R1)
The quality of muscle reaction during V3 (0-5)
The dynamic tone component of the muscle (X)

Three speed definitions:

V1 is moving the limb as slow as possible
V2 is moving the limb at the speed of the segment falling under gravity
V3 is moving the limb as fast as possible

Quality of Muscle Reaction score (0-5):

0 is no resistance to passive ROM
1 is slight resistance during passive movement with no clear catch
2 is a clear catch at a precise angle followed by a release
3 is fatiguable clonus (< 10 seconds when maintaining the pressure)
4 is unfatiguable clonus (> 10 seconds when maintaining the pressure)
5 is an immovable joint

The angle of full ROM (R2) is taken at a very slow speed (V1) measured with a universal goniometer. The angle of muscle reaction (R1) is defined as the angle at which a catch or clonus is found during a quick stretch (V3), and is measured with the goniometer.

The difference between R2 and R1 is referred to as the spasticity angle and reflects the dynamic tone component of the muscle. The larger the spasticity angle, the more spastic the muscle.

Pectoralis Major

Shoulder Rotators

Pectoralis Major
Action	Internal rotation of the shoulder joint, adduction of the arm.
Origin	Medial half of the clavicle and anterior surfaces of the sternum and cartilages of the first six ribs.
Insertion	Lateral lip of the bicipital groove of the humerus.
Innervation	Medial Pectoral Nerve (C7, C8, T1) and lateral pectoral nerve (C5, C6).
Tardieu Testing
Patient position	Sitting.
Measurement considerations	Neutral GHJ rotation = 0° External rotation = +ve Internal rotation = -ve
Starting limb position	Shoulder abducted to 90°, GHJ maximum internal rotation. Elbow flexed at 90°, forearm neutral.
End limb position	Maximum external rotation of GHJ, with shoulder maintaining the same abduction angle.
Other considerations	Patient may lie supine, especially if the shoulder is painful, otherwise, a second person is required to stabilise the scapula and the GHJ in the sitting position. The sternocostal head of the muscle, which is the larger part, is the prime mover for horizontal flexion. The clavicular head assists in shoulder flexion, while the sternocostal head assists with shoulder extension from a flexed position.

Goniometer landmarks

Control - Coronal (front) view

Control - Lateral view

Patient - Coronal (front) view

Patient - Lateral view

Subscapularis

Shoulder Rotators

Subscapularis
Action	Internal rotation and adduction of the humerus, stabilisation of the shoulder.
Origin	Subscapular fossa.
Insertion	Lesser tubercle of the humerus.
Innervation	Upper subscapular nerve, lower subscapular nerve (C5, C6).
Notes	Latissimus dorsi is a much stronger adductor than subscapularis and, therefore, subscapularis is tested in flexion to minimise the impact of latissimus dorsi on testing. It is most important that the clinician palpate and observe the muscles around the shoulder.
Tardieu Testing
Patient position	Sitting.
Measurement considerations	Neutral GHJ rotation = 0° Internal rotation = -ve External rotation = +ve
Starting limb position	Shoulder flexed to 90°, elbow flexed to 90°. Maximum internal rotation of the GHJ.
End limb position	Maximum external rotation of the GHJ.
Other considerations	Subscapularis is under the scapula and can be accessed laterally. Palpate to differentiate between teres major. Patient may lie supine, especially if the shoulder is painful, otherwise a second person to stabilise the scapula and GHJ in the sitting position is required. When the arm is raised, subscapularis draws the humerus forward and downward.

Goniometer landmarks

Control - Coronal (front) view

Patient - Coronal (front) view

Teres Major

Shoulder Rotators

Teres Major
Action	Internal rotation of the shoulder joint.
Origin	Inferior angle of the scapular.
Insertion	Medial ridge of the bicipital groove of the humerus.
Innervation	Lower subscapular nerve (C5, C6).
Notes	Latissimus dorsi is a much stronger adductor than teres major and, therefore, testing of teres major is performed in flexion to minimise the impact of latissimus dorsi. Teres major is an internal rotator and adductor of the humerus and assists latissimus dorsi in drawing the previously raised humerus downwards and backwards. It also helps to stabilise the humeral head in the glenoid cavity. It is most important that the clinician palpate and observes the muscles around the shoulder.
Tardieu Testing
Patient position	Sitting.
Measurement considerations	Neutral GHJ rotation = 0° Internal rotation = -ve External rotation = +ve
Starting limb position	Shoulder flexed to 90°, elbow flexed to 90°. Maximum internal rotation of the GHJ.
End limb position	Maximum external rotation of the GHJ.
Other considerations	Palpate to differentiate between subscapularis. Teres major is more superficial. The patient may lie supine, especially if the shoulder is painful, otherwise, a second person to stabilise the scapula and GHJ in the sitting position is required.

Goniometer landmarks

Control - Coronal (front) view

Patient - Coronal (front) view

Latissimus Dorsi

Shoulder Rotators

Latissimus Dorsi
Action	Internal rotation, adduction and extension of the arm.
Origin	Spinous processes of the lower thoracic vertebrae, lumbosacral fascia and posterior crest of the ilium.
Insertion	Intertubercular groove of the humerus.
Innervation	Thoracodorsal nerve (C6, C7, C8).
Tardieu Testing
Patient position	Sitting, with a second person to stabilise the scapula and GHJ. Laterally flex the patient’s trunk away from the arm being measured. The patient may lie supine, especially if the shoulder is painful.
Measurement considerations	Neutral GHJ rotation = 0° Internal rotation = -ve External rotation = +ve
Starting limb position	Shoulder in maximum abduction. Maximum internal rotation of the GHJ.
End limb position	Maximum external rotation of the GHJ.
Other considerations	Palpate to differentiate between teres, subscapularis and pectoralis. Many patients will have difficulty achieving this range of abduction, so document abduction angle that test is completed in.

Goniometer landmarks

Control - Coronal (front) view

Control - Aerial view

Patient - Coronal (front) view

Patient - Aerial view

Biceps Brachii Long Head

Elbow Flexors

Biceps Brachii Long Head
Action	Supination and flexion at the elbow.
Origin	Long head: supraglenoid tubercle of scapula.
Insertion	Radial tuberosity.
Innervation	Musculocutaneous nerve (C5, C6).
Notes	The long head of the biceps helps to flex the shoulder in the first 30° of elevation. The short (distal/anterior) and long heads have distinct insertions. The short head insertion allows greater efficiency of elbow flexion at 90°. The short head is a more efficient supinator when the forearm is in pronation or neutral. The long head is a more efficient supinator when the forearm is in supination. The long head assists in shoulder flexion. In general, the biceps brachii is the primary and most powerful supinator of the forearm and supinates the forearm in the absence of resistance.
Tardieu Testing
Patient position	Sitting with the scapula and head of the humerus supported.
Measurement considerations	Maintain maximum forearm pronation throughout test. Elbow in full extension = 0° Flexion = -ve
Starting limb position	The shoulder is placed in 10° of extension. Maximum elbow flexion, maximum forearm pronation.
End limb position	Maximum elbow extension.
Other considerations	It is technically not possible to differentiate the elbow flexors through the forearm position. The protocol is based on the position that will most likely place the muscle in maximum stretch. Palpation and observation are integral to differentiation. When determining whether to inject this muscle, the clinician must consider the role of the biceps brachii as an active supinator. The clinician must consider not injecting the biceps brachii if pronation is the primary resting position and the pronators are also spastic.

Goniometer landmarks

Control - Lateral view

Patient - Lateral view

Brachialis

Elbow Flexors

Brachialis
Action	Flexion at elbow.
Origin	Anterior surface of the distal half of the humerus and medial intermuscular septum.
Insertion	Ulnar tuberosity and volar surface of the coronoid process.
Innervation	Musculocutaneous nerve (C5, C6).
Notes	The brachialis is the strongest flexor of the elbow joint, as it is closer to the axis of the joint and only stretches over one joint in contrast to the biceps. A small contraction of the muscle consequently leads to a larger flexion of the elbow. It makes up the floor of the cubital fossa.
Tardieu Testing
Patient position	Sitting, with the scapula and head of the humerus supported.
Measurement considerations	Elbow in full extension = 0° Flexion = -ve
Starting limb position	Shoulder flexion to 90° Neutral GHJ rotation = 0° Maximum forearm supination and maximum elbow flexion.
End limb position	Maintain shoulder and GHJ position, as above and maximum elbow extension and forearm supination.
Other considerations	It is technically not possible to differentiate the elbow flexors through the forearm position. The protocol is based on the position that will most likely place the muscle in maximum stretch. Palpation and observation are integral to differentiation. If unable to supinate the forearm, the clinician should simply test brachialis in a comfortable forearm position. If unable to flex the shoulder to 90°, test brachialis in a comfortable shoulder flexion, to take the stretch off the long head of biceps brachii.

Goniometer landmarks

Control - Lateral view

Patient - Lateral view

Brachioradialis

Elbow Flexors

Brachioradialis
Action	Flexion at elbow with the forearm in mid-prone position.
Origin	Lateral supracondylar ridge of the humerus.
Insertion	Base of the radial styloid.
Innervation	Radial nerve (C5, C6).
Notes	Brachioradialis is capable of both pronation and supination, depending on the position of the forearm.
Tardieu Testing
Patient position	Sitting, with the scapula and head of the humerus supported.
Measurement considerations	Maintain mid-prone forearm position throughout the test. Maximum elbow extension = 0° Flexion = -ve
Starting limb position	GHJ neutral. Maximum elbow flexion in mid-prone forearm position.
End limb position	Maximum elbow extension, while maintaining mid-prone forearm position.
Other considerations	It is technically not possible to differentiate the elbow flexors through the forearm position. The protocol is based on the position that will most likely place the muscle in maximum stretch. Palpation and observation are integral to differentiation. If unable to achieve a neutral forearm position, palpate to differentiate between the biceps brachii and brachialis.

Goniometer landmarks

Control - Lateral view

Patient - Lateral view

Triceps Brachii Long Head

Elbow Extensors

Triceps Brachii Long Head
Action	Extension at elbow, extension at shoulder (long head).
Origin	Infraglenoid tubercle of the scapula.
Insertion	Via a common tendon, the three heads of triceps brachii insert into the dorsal aspect of the olecranon of the ulna.
Innervation	Radial nerve (C7, C8, T1).
Tardieu Testing
Patient position	Sitting, with the scapula and head of the humerus supported.
Measurement considerations	Maximum elbow flexion = approximately 145 ̊ Full extension = 0 ̊ Flexion = +ve
Starting limb position	Shoulder flexed to 90 ̊, maximum elbow extension, forearm supination.
End limb position	Maximum elbow flexion, forearm supination. To differentiate between the long, lateral and medial heads of the triceps brachii, bring the GHJ into 90 ̊ of flexion. Palpate to differentiate between the three heads of triceps brachii.
Other considerations	Each head of the triceps brachii has a different pattern of force and activity during different shoulder elevations. The long head contributes to elbow extension more at shoulder elevation and the medial head takes over at > 90° of shoulder elevation.

Goniometer landmarks

Control - Lateral view

Patient - Lateral view

Triceps Brachii Lateral Head

Elbow Extensors

Triceps Brachii Lateral Head
Action	Extension at elbow.
Origin	Dorsal surface of the humerus above the groove for the radial nerve.
Insertion	Via a common tendon, the three heads of triceps brachii insert into the dorsal aspect of the olecranon of the ulnar.
Innervation	Radial nerve (C7, C8, T1).
Injection site	Immediately posterior to the insertion of deltoid.
Notes	There is choice regarding which head of triceps to inject.
Tardieu Testing
Patient position	Sitting, with the scapula and head of the humerus supported.
Measurement considerations	Maximum elbow flexion = approximately 145 ̊ Full extension = 0 ̊ Flexion = +ve
Starting limb position	GHJ neutral, maximum elbow extension, forearm supination.
End limb position	Maximum elbow flexion, forearm supination.
Other considerations	To differentiate between the long, lateral and medial heads of the triceps brachii, bring the GHJ into 90 ̊ of flexion. Palpate to differentiate between the three heads of triceps brachii. Each head of the triceps brachii has a different pattern of force and activity during different shoulder elevations. The long head contributes to elbow extension more at shoulder elevation and the medial head takes over at > 90° of shoulder elevation.

Goniometer landmarks

Control - Lateral view

Patient - Lateral view

Triceps Brachii Medial Head

Elbow Extensors

Triceps Brachii Medial Head
Action	Extension at elbow.
Origin	Dorsal surface of shaft of the humerus, below groove for the radial nerve.
Insertion	Via a common tendon, the three heads of triceps brachii insert into the dorsal aspect of the olecranon of the ulna.
Innervation	Radial nerve (C7, C8, T1).
Injection site	Three fingerbreadths proximal to the medial epicondyle of the humerus.
Tardieu Testing
Patient position	Sitting, with the scapula and head of the humerus supported.
Measurement considerations	Maximum elbow flexion = approximately 145 ̊ Full extension = 0 ̊ Flexion = +ve
Starting limb position	GHJ neutral, maximum elbow extension, forearm supination.
End limb position	Maximum elbow flexion, forearm supination.
Other considerations	To differentiate between long, lateral and medial heads of the triceps brachii, bring the GHJ into 90 ̊ of flexion. Palpate to differentiate between the three heads of triceps brachii. Each head of the triceps brachii has a different pattern of force and activity during different shoulder elevations. The long head contributes to elbow extension more at shoulder elevation and the medial head takes over at > 90° of shoulder elevation.

Goniometer landmarks

Control - Lateral view

Patient - Lateral view

Pronator Teres

Forearm Pronators

Pronator Teres
Action	Pronation of forearm. Assists with elbow flexion.
Origin	Common flexor tendon, medial supracondylar ridge of the humerus and the coronoid process of the ulna.
Insertion	Midway along the lateral surface of the radius.
Innervation	Median nerve (C6, C7).
Notes	Pronator quadratus is the prime mover in pronation. It receives help from pronator teres during rapid pronation.
Tardieu Testing
Patient position	Sitting.
Measurement considerations	Neutral rotation = 0° (mid-prone) Supination = +ve Pronation = -ve
Starting limb position	Maximum elbow extension, with forearm in full pronation and hand gripping a pen, if possible.
End limb position	Maximum forearm supination with elbow extended.
Other considerations	Hold the elbow in flexed position and straighten slowly. If the forearm pronates, pronator teres may have more spasticity than pronator quadratus. If the patient is unable to maintain elbow extension while supinating the forearm (for example, the elbow flexes), this is indicative of pronator teres spasticity.

Goniometer landmarks

Control - Lateral view

Control - Coronal (front) view

Patient - Lateral view

Patient - Coronal (front) view

Pronator Quadratus

Forearm Pronators

Pronator Quadratus
Action	Pronation of forearm.
Origin	Medial, anterior surface of the ulna.
Insertion	Lateral, anterior surface of the radius.
Innervation	Median nerve (anterior interosseous nerve) (C8, T1).
Notes	Pronator quadratus is the prime mover in pronation and receives help from pronator teres during rapid pronation.
Tardieu Testing
Patient position	Sitting.
Measurement considerations	Neutral rotation = 0° (mid-prone) Supination = +ve Pronation = -ve
Starting limb position	Elbow flexed to 90° with forearm in full pronation and hand gripping a pen, if possible.
End limb position	Elbow flexed to 90° with maximum forearm supination.
Other considerations	Hold the elbow in flexed position and straighten slowly. If the forearm pronates, pronator teres may have more spasticity than pronator quadratus. If the patient is unable to maintain elbow extension while supinating the forearm (for example, the elbow flexes), this is indicative of pronator teres spasticity.

Goniometer landmarks

Control - Coronal (front) view

Control - Lateral view

Patient - Coronal (front) view

Patient - Lateral view

Flexor Carpi Radialis

Wrist Flexors

Flexor Carpi Radialis
Action	Flexion at wrist.
Origin	Common flexor tendon, medial epicondyle of the humerus and coronoid process of the ulna.
Insertion	FCR: base of 2nd and 3rd metacarpal. FCU: pisiform, hamate and 5th metacarpal.
Innervation	FCR: median nerve (C6, C7, C8). FCU: ulnar nerve (C8 and T1).
Notes	Observe hand posture to aid clinical decision making. FCU is a stronger wrist flexor than FCR and the power generator for manual labour.
Tardieu Testing
Patient position	Sitting.
Measurement considerations	Neutral wrist extension = 0 ̊ Flexion = -ve Extension = +ve
Starting limb position	Fingers/thumb fully flexed to reduce impact of finger flexors on wrist.
End limb position	Fingers/thumb maintained in flexion, wrist extended as much as possible.
Other considerations	The goniometer is placed on the ulnar side of the wrist. It can differentiate between FCU and FCR by the amount of measured deviation, however, the Modified Tardieu score does not differentiate between these two muscles.

Goniometer landmarks

Control - Lateral view

Patient - Lateral view

Flexor Carpi Ulnaris

Wrist Flexors

Flexor Carpi Ulnaris
Action	Flexion at wrist.
Origin	Common flexor tendon, medial epicondyle of the humerus and coronoid process of the ulna.
Insertion	FCR: base of 2nd and 3rd metacarpal. FCU: pisiform, hamate and 5th metacarpal.
Innervation	FCR: median nerve (C6, C7, C8). FCU: ulnar nerve (C8 and T1).
Notes	Observe hand posture to aid clinical decision making. FCU is a stronger wrist flexor than FCR and the power generator for manual labour.
Tardieu Testing
Patient position	Sitting.
Measurement considerations	Neutral wrist extension = 0 ̊ Flexion = -ve Extension = +ve
Starting limb position	Fingers/thumb fully flexed to reduce impact of finger flexors on wrist.
End limb position	Fingers/thumb maintained in flexion, wrist extended as much as possible.
Other considerations	The goniometer is placed on the ulnar side of the wrist. It can differentiate between FCU and FCR by the amount of measured deviation, however, the Modified Tardieu score does not differentiate between these two muscles.

Goniometer landmarks

Control - Lateral view

Patient - Lateral view

Flexor Digitorum Superficialis

Finger Flexors

Flexor Digitorum Superficialis
Action	Flexion of the proximal interphalangeal (PIP) joint of the fingers.
Origin	Common flexor tendon, the medial epicondyle of the humerus and the coronoid process of the ulna.
Insertion	Bases of middle phalanges of digits 2 to 5.
Innervation	Median nerve (C7, C8, T1).
Tardieu Testing
Patient position	Sitting.
Measurement considerations	Full DIP and PIP joint extension = 0 ̊ Flexion = -ve Hyperextension = +ve
Starting limb position	Wrist in 30° extension, if possible. MCP joints in neutral position, DIP joints extended, PIP joints in maximum flexion (approximately 130°).
End limb position	Wrist and MCP joints unchanged, PIP joints in as much extension as possible.
Other considerations	Stabilise DIP joints and MCP joints when moving PIP joints through passive range of movement. The fingers can be tested individually, as it is possible to isolate digit injection under ultrasound. Note, with respect to resting hand position, if FDS is involved, look for PIP flexion and DIP extension.

Goniometer landmarks

Control - Lateral view

Control - Aerial view

Patient - Lateral view

Patient - Aerial view

Flexor Digitorum Profundus

Finger Flexors

Flexor Digitorum Profundus
Action	Flexion of distal phalanx of fingers.
Origin	Upper 3⁄4 of volar and medial aspects of the ulna.
Insertion	Bases of distal phalanges of digits 2 to 5.
Innervation	Median nerve (medial digits) / ulnar nerve (lateral digits) C7, C8, T1.
Notes	Ulnar 2 digits more superficial, medial 2 digits deeper.
Tardieu Testing
Patient position	Sitting.
Measurement considerations	Full DIP extension = 0 ̊ Flexion = -ve Hyperextension = +ve
Starting limb position	Wrist in 30° extension, if possible. MCP joints in neutral, PIP joints in neutral and DIP joints in maximum flexion (approximately 90°).
End limb position	Wrist in 30° extension, if possible. MCP joints in neutral, PIP joints in neutral and DIP joints in as much extension as possible.
Other considerations	It may be difficult to maintain all other joints in a stable position, however, if the clinician can observe DIP joint flexion at the onset of measurement, this indicates tightness in the FDP. Note if the fingernails are digging into the palm at the onset of assessment. This may also indicate FDP spasticity.

Goniometer landmarks

Control - Lateral view

Control - Aerial view

Patient - Lateral view

Patient - Aerial view

Flexor Pollicis Longus

Thumb Muscles

Flexor Pollicis Longus
Action	Flexion of the distal phalanx of the thumb.
Origin	Anterior surface of the body of the radius, from bicipital tuberosity to attachment of pronator quadratus and interosseous membrane.
Insertion	Anterior surface of base of the distal phalanx of the thumb.
Innervation	Anterior interosseous nerve, median nerve (C7, C8, T1).
Tardieu Testing
Patient position	Sitting.
Measurement considerations	Flexion = -ve Full extension = 0° Hyperextension = +ve
Starting limb position	Wrist in 30° extension if possible, MCP joint in full extension. IP joint is measured in full flexion (approximately 80°).
End limb position	Wrist in 30° extension if possible, maintain MCP joint in extension, maximum IP joint extension.
Other considerations	Stabilise the thumb MCP joint when measuring FPL, to stabilise the joint in extension.

Goniometer landmarks

Control - Lateral view

Patient - Lateral view

Flexor Pollicis Brevis

Thumb Muscles

Flexor Pollicis Brevis
Action	Flexion of MCP joint of thumb.
Origin	Deep head: trapezoid and capitate. Superficial head: ridge of trapezium and flexor retinaculum.
Insertion	Radial side of base of the proximal phalanx of the thumb.
Innervation	Deep head: Ulnar nerve. Superficial head: Median nerve.
Tardieu Testing
Patient position	Sitting.
Measurement considerations	Flexion = -ve Full extension = 0° Extension = +ve
Starting limb position	Wrist in neutral, MCP in full flexion. DIP joint in full extension
End limb position	Wrist in neutral, maximum MCP extension.
Other considerations	Hold the 1st metacarpal joint when measuring FPB to stabilise it when extending the MCP joint. Stabilise the IP joint during testing, to maintain joint extension.

Goniometer landmarks

Control - Lateral view

Patient - Lateral view

Adductor Pollicis

Thumb Muscles

Adductor Pollicis
Action	Adduction of the CMC joint of the thumb
Origin	Transverse head: Palmar base of metacarpal bone 3. Oblique head: Capitate bone, palmar bases of metacarpal bones 2 and 3.
Insertion	Radial side of base of the proximal phalanx of the thumb.
Innervation	Deep branch of ulnar nerve (C8, T1).
Tardieu Testing
Patient position	Sitting.
Measurement considerations	Abduction +ve Neutral = 0° Adduction =-ve
Starting limb position	Wrist in neutral. CMC and MCP in full adduction.
End limb position	Wrist in neutral, maximum CMC and MPC abduction.
Other considerations	Most powerful intrinsic muscle of the hand. Essential for functions that require pinching and gripping. Additionally, the adductor pollicis aids the later stages of opposition of the thumb.

Goniometer landmarks

Control - Aerial view

Patient - Aerial view

Intrinsic Finger Flexors (lumbricals)

Hand Muscles

Intrinsic Finger Flexors (lumbricals)
Action	Flexion at MCP joints.
Origin	Radial aspect of tendon sheath of FDP.
Insertion	Extensor expansion on dorsum of proximal phalanges.
Innervation	Digits 1 and 2 - median nerve (C8, T1). Digits 3 and 4 - ulnar nerve (C8, T1).
Tardieu Testing
Patient position	Sitting.
Measurement considerations	MCP extension = +ve MCP flexion = -ve
Starting limb position	Wrist in neutral, PIP and DIP joints in full flexion, MCP joints in full flexion (approximately 90°).
End limb position	Maintain wrist in neutral with PIP and DIP joints fully flexed, maximum MCP joint extension.
Other considerations	Measure MCP joint angle from ulnar side of hand.

Goniometer landmarks

Control - Lateral view

Patient - Lateral view

Adductor Brevis

Hip Adductors

Adductor Brevis
Action	Adduction at the hip joint.
Origin	Inferior pubic ramus.
Insertion	Pectineal line and linea aspera (deep to the pectineus and adductor longus).
Innervation	Anterior division of the obturator nerve.
Differential diagnosis	Tightness of the secondary hip flexors, such as adductor brevis, would, in theory, contribute to an excessive anterior pelvic tilt.
Notes	Due to the bulk of adductors and the quantity of toxin needed to be injected, if all adductors are indicated, consider an obturator nerve block.
Tardieu Testing
Patient position	Supine, with hip and knee neutral.
Measurement considerations	Anatomical midline position of the hip = 0° Adduction (towards midline) = -ve Abduction (away from midline) = +ve
Starting limb position	Maximum hip adduction.
End limb position	Maximum hip abduction.
Phase of gait cycle	May cause hip adduction in stance or swing phase.
Gait cycle observation	Scissoring gait.
Other considerations	Differentiate between adductor brevis, longus and magnus with palpation. Often, another person is needed to stabilise the opposite thigh/pelvis during testing. The adductors help to stabilise lateral movement of the trunk when standing or balancing on an unstable surface, therefore, before injecting, the clinician must consider this role in the presence of severe lower limb weakness.

Goniometer landmarks

Control - Coronal (front) view

Patient - Coronal (front) view

Adductor Longus

Hip Adductors

Adductor Longus
Action	Adduction, flexion and medial rotation of the hip joint.
Origin	Medial portion of the superior pubic ramus.
Insertion	Middle third of linea aspera of the femur.
Innervation	Anterior division of the obturator nerve.
Differential diagnosis	The most anterior of the adductor group of muscles. Adductor longus is a large, flat muscle that covers adductor magnus and brevis.
Notes	Due to the bulk of adductors and quantity of toxin needed to be injected, if all adductors are indicated, consider an obturator nerve block.
Tardieu Testing
Patient position	Supine, with hip and knee neutral.
Measurement considerations	Anatomical midline position of the hip = 0° Adduction (towards midline) = -ve Abduction (away from midline) = +ve
Starting limb position	Maximum hip adduction.
End limb position	Maximum hip abduction.
Phase of gait cycle	May cause hip adduction in stance or swing phase.
Gait cycle observation	Scissoring gait.
Other considerations	Differentiate between adductor brevis, longus and magnus with palpation. Often, another person is needed to stabilise the opposite thigh/pelvis during testing. The adductors help to stabilise lateral movement of the trunk when standing or balancing on an unstable surface, therefore, before injecting, the clinician must consider this role in the presence of severe lower limb weakness.

Goniometer landmarks

Control - Coronal (front) view

Patient - Coronal (front) view

Adductor Magnus

Hip Adductors

Adductor Magnus
Action	Adduction and extension of the femur (ischiocondylar part).
Origin	Ischiopubic ramus and ischial tuberosity.
Insertion	Linea aspera of the femur; the ischiocondylar part inserts on the adductor tubercle of the femur.
Innervation	Posterior division of the obturator nerve; tibial nerve (ischiocondylar part).
Differential diagnosis	The ischiocondylar part of adductor magnus is a hamstring muscle by embryonic origin and action, therefore, it is innervated by the tibial nerve.
Notes	Due to the bulk of adductors and the quantity of toxin needed to be injected, if all adductors are indicated, consider an obturator nerve block.
Tardieu Testing
Patient position	Supine, with hip and knee neutral.
Measurement considerations	Anatomical midline position of the hip = 0° Adduction (towards midline) = -ve Abduction (away from midline) = +ve
Starting limb position	Maximum hip adduction.
End limb position	Maximum hip abduction.
Phase of gait cycle	May cause hip adduction in stance or swing phase.
Gait cycle observation	Scissoring gait.
Other considerations	Differentiate between adductor brevis, longus and magnus with palpation. Often, another person is needed to stabilise the opposite thigh/pelvis during testing. The adductors help to stabilise lateral movement of the trunk when standing or balancing on an unstable surface, therefore, before injecting, the clinician must consider this role in the presence of severe lower limb weakness.

Goniometer landmarks

Control - Coronal (front) view

Patient - Coronal (front) view

Psoas Major

Hip Flexors

Psoas Major
Action	Hip flexion.
Origin	Bodies and transverse processes of lumbar vertebrae.
Insertion	Lesser trochanter of the femur (with iliacus) via iliopsoas tendon.
Innervation	Branches of the ventral primary rami of spinal nerves L2 to L4.
Tardieu Testing
Patient position	Supine.
Measurement considerations	Neutral hip position = 0° Hip flexion = -ve Hip extension = +ve
Starting limb position	Maximum hip flexion with the pelvis on the edge of the plinth to allow for hip extension. Pelvis must remain in neutral during testing.
End limb position	Maximum hip extension, maintaining posterior tilt as much as possible. Speed is V2.
Phase of gait cycle	Flexes the hip from toe-off through to early swing.
Gait cycle observation	Excessive anterior pelvic tilt, increased lumbar lordosis and reduced hip extension in terminal stance.
Other considerations	Differentiate from rectus femoris by avoiding maximum knee flexion.

Goniometer landmarks

Control - Lateral view

Patient - Lateral view

Semimembranosus

Knee Flexors

Semimembranosus
Action	Hip extension, knee flexion.
Origin	Upper, outer surface of the ischial tuberosity.
Insertion	Medial condyle of the tibia.
Innervation	Tibial nerve.
Tardieu Testing
Patient position	Supine.
Measurement considerations	Full knee extension = 0° Flexion = -ve Hyperextension = +ve
Starting limb position	Hip in 90° flexion, with maximum knee flexion.
End limb position	Hip in 90° flexion, with maximum knee extension.
Phase of gait cycle	The semimembranosus has two roles; firstly, to extend the hip in early stance and, secondly, to decelerate the tibia in late swing.
Gait cycle observation	Increased knee flexion in terminal swing and at initial contact.
Other considerations	Palpate to differentiate between the hamstrings. Medial to lateral: semimembranosus, semitendinosus and biceps femoris. Consider testing hamstrings in 30° to 40° hip flexion, to replicate hip position at late swing/early stance phase of gait.

Goniometer landmarks

Control - Lateral view

Patient - Lateral view

Semitendinosus

Knee Flexors

Semitendinosus
Action	Hip extension, knee flexion.
Origin	Ischial tuberosity (common tendon with biceps femoris).
Insertion	Medial surface of the tibia (via pes anserinus).
Innervation	Tibial nerve.
Differential diagnosis	Pes anserinus is the common insertion for the gracilis, sartorius, and semitendinosus muscles.
Tardieu Testing
Patient position	Supine.
Measurement considerations	Full knee extension = 0° Flexion = -ve Hyperextension = +ve
Starting limb position	Hip in 90° flexion, with maximum knee flexion.
End limb position	Hip in 90° flexion, with maximum knee extension.
Phase of gait cycle	The semitendinosus has two roles; firstly, to extend the hip in early stance and, secondly, to decelerate the tibia in late swing.
Gait cycle observation	Increased knee flexion in terminal swing and at initial contact.
Other considerations	Palpate to differentiate between the hamstrings. Medial to lateral: semimembranosus, semitendinosus and biceps femoris. Consider testing hamstrings in 30° to 40° hip flexion to replicate hip position at late swing/early stance phase of gait.

Goniometer landmarks

Control - Lateral view

Patient - Lateral view

Biceps Femoris

Knee Flexors

Biceps Femoris
Action	Hip extension, knee flexion.
Origin	Long head: ischial tuberosity. Short head: lateral lip of the linea aspera.
Insertion	Head of fibula and lateral condyle of the tibia.
Innervation	Long head: tibial nerve. Short head: common fibular (peroneal) nerve.
Differential diagnosis	The long head of biceps femoris has a secondary action of hip adduction which is important to consider in scissoring gait.
Tardieu Testing
Patient position	Supine. Speed is V2.
Measurement considerations	Full knee extension = 0° Flexion = -ve Hyperextension = +ve
Starting limb position	Hip in 30° to 40° of flexion with maximum knee flexion.
End limb position	Hip in 30° to 40° of flexion with maximum knee extension.
Phase of gait cycle	The biceps femoris has two roles; firstly, to extend the hip in early stance (long head) and, secondly, to decelerate the tibia in late swing (both heads).
Gait cycle observation	Increased knee flexion in terminal swing and at initial contact.
Other considerations	Palpate to differentiate between the hamstrings. Medial to lateral: semimembranosus, semitendinosus and biceps femoris. Consider testing hamstrings in 30° to 40° hip flexion to replicate hip position at late swing/early stance phase of gait.

Goniometer landmarks

Control - Lateral view

Patient - Lateral view

Vastus Lateralis

Knee Extensors

Vastus Lateralis
Action	Knee extension.
Origin	Lateral lip of the linea aspera, greater trochanter and intertrochanteric line.
Insertion	Patella and medial patellar retinaculum.
Innervation	Femoral nerve.
Differential diagnosis	Differentiate from rectus femoris with hip extension.
Tardieu Testing
Patient position	Sitting on the edge of the bed.
Measurement considerations	Full knee extension = 0° Flexion = +ve Extension = -ve
Starting limb position	Maximum knee extension.
End limb position	Drop leg and observe movement quality into flexion. Speed = V2
Phase of gait cycle	Acts eccentrically in terminal stance and early swing, some support of extension in early stance, and stiff-legged gait in swing phase.
Gait cycle observation	May contribute to knee hyperextension in stance phase and stiff-legged gait in swing phase.
Other considerations	Differentiate from rectus femoris with hip extension.

Goniometer landmarks

Control - Lateral view

Patient - Lateral view

Vastus Medialis

Knee Extensors

Vastus Medialis
Action	Knee extension.
Origin	Medial intermuscular septum, medial lip of the linea aspera, intertrochanteric line and tendon of adductor magnus.
Insertion	Patella and medial patellar retinaculum.
Innervation	Femoral nerve.
Differential diagnosis	Differentiate from rectus femoris with hip extension
Tardieu Testing
Patient position	Sitting on the edge of the bed.
Measurement considerations	Full knee extension = 0° Flexion = +ve Extension = -ve
Starting limb position	Maximum knee extension.
End limb position	Drop leg and observe movement quality into flexion. Speed = V2.
Phase of gait cycle	Acts eccentrically in terminal stance and early swing.
Gait cycle observation	May contribute to knee hyperextension in stance phase and stiff-legged gait in swing phase.
Other considerations	Differentiate from rectus femoris with hip extension.

Goniometer landmarks

Control - Lateral view

Patient - Lateral view

Vastus Intermedius

Knee Extensors

Vastus Intermedius
Action	Knee extension.
Origin	Anterior and lateral surface of the femur.
Insertion	Patella.
Innervation	Femoral nerve.
Differential diagnosis	Differentiate from rectus femoris with hip extension.
Tardieu Testing
Patient position	Sitting on the edge of the bed.
Measurement considerations	Full knee extension = 0° Flexion = +ve Extension = -ve
Starting limb position	Maximum knee extension.
End limb position	Drop leg and observe movement quality into flexion. Speed = V2
Phase of gait cycle	Acts eccentrically in terminal stance and early swing.
Gait cycle observation	May contribute to knee hyperextension in stance phase, and stiff-legged gait in swing phase.
Other considerations	Differentiate from rectus femoris with hip extension.

Goniometer landmarks

Control - Lateral view

Patient - Lateral view

Rectus Femoris (prone)

Knee Extensors

Rectus Femoris (prone)
Action	Hip flexion, knee extension.
Origin	Straight head: anterior inferior iliac spine Reflected head: groove above the acetabulum.
Insertion	Patella and tibial tuberosity (via the patellar ligament).
Innervation	Femoral nerve.
Differential diagnosis	To differentiate from vasti muscles, have the patient sitting on the edge of the bed with 90° hip flexion.
Tardieu Testing
Patient position	Prone is the standardised position for testing rectus femoris, however, the supine position can be used when the person is unable to lie prone. Prone: Pelvis neutral, hip neutral, knee extended. Bend knee quickly. Useful to monitor hip flexion or pelvic retraction during testing. Supine: Pelvis neutral, hip neutral, knee extended. Drop the lower leg over the side of the bed with gravity and support at the angle of catch or clonus. Useful for people unable to lie prone or on a small plinth.
Measurement considerations	Full knee extension = 0° Flexion = +ve Hyperextension = -ve
Starting limb position	Hip neutral, knee extended.
End limb position	Maximum knee flexion.
Phase of gait cycle	Acts eccentrically in terminal stance.
Gait cycle observation	Stiff-legged gait. May contribute to knee hyperextension in stance phase, and stiff-legged gait in swing phase.
Other considerations	To differentiate from vasti muscles, have the patient sitting on the edge of the bed with 90° hip flexion.

Goniometer landmarks

Control - Lateral view

Patient - Lateral view

Rectus Femoris (supine)

Knee Extensors

Rectus Femoris (supine)
Action	Hip flexion, knee extension.
Origin	Straight head: anterior inferior iliac spine. Reflected head: groove above the acetabulum.
Insertion	Patella and tibial tuberosity (via the patellar ligament).
Innervation	Femoral nerve.
Differential diagnosis	To differentiate from vasti muscles, have the patient sitting on the edge of the bed with 90° hip flexion.
Tardieu Testing
Patient position	The supine position is used when the person is unable to lie prone, however prone is the standardised position for testing rectus femoris.
Supine	Pelvis neutral, hip neutral, knee extended. Drop the lower leg over the side of the bed with gravity and support at the angle of catch or clonus. Useful for people unable to lie prone or on a small plinth.
Measurement considerations	Full knee extension = 0° Flexion = +ve Hyperextension = -ve
Starting limb position	Hip neutral, knee extended.
End limb position	Maximum knee flexion. Speed is V2.
Phase of gait cycle	Acts eccentrically in terminal stance.
Gait cycle observation	May contribute to knee hyperextension in stance phase, and stiff-legged gait in swing phase.

Goniometer landmarks

Control - Lateral view

Patient - Lateral view

Gastrocnemius

Ankle Plantarflexors

Gastrocnemius
Action	Plantarflexion of the ankle; flexion of the knee.
Origin	Medial head: above the medial femoral condyle. Lateral head: above the lateral femoral condyle.
Insertion	Dorsum of the calcaneus via the Achilles tendon.
Innervation	Tibial nerve.
Differential diagnosis	Differentiate from soleus with knee flexion.
Notes	Gastrocnemius is associated with dynamic activities, such as jumping and running.
Tardieu Testing
Patient position	Supine.
Measurement considerations	PG = 0° PF = -ve DF = +ve
Starting limb position	Knee in full extension, ankle in full PF.
End limb position	Knee extended with maximum ankle DF.
Phase of gait cycle	Midstance and early swing phase.
Gait cycle observation	Reduced foot clearance in swing phase, potentially exhibiting drop foot with active DF (i.e. not a flaccid drop foot).
Other considerations	Soleus may contribute to reduced foot clearance in swing phase and knee hyperextension in stance phase. Differentiate from soleus with knee flexion.

Goniometer landmarks

Control - Lateral view

Patient - Lateral view

Soleus

Ankle Plantarflexors

Soleus
Action	Plantarflexion of the ankle.
Origin	Posterior surface of the head and upper shaft of the fibula, the soleal line of the tibia.
Insertion	Dorsum of the calcaneus via the Achilles tendon.
Innervation	Tibial nerve.
Differential diagnosis	Differentiate from gastrocnemius with knee extension.
Tardieu Testing
Patient position	Supine.
Measurement considerations	PG = 0° PF = -ve DF = +ve
Starting limb position	Knee flexed at 90°, ankle in full PF.
End limb position	Maintain knee flexed at 90° with maximum ankle DF.
Phase of gait cycle	Midstance and early swing phase.
Gait cycle observation	Hyperextension of the knee in stance phase and reduced foot clearance in swing phase, potentially exhibiting drop foot with active DF (i.e. not a flaccid drop foot). Soleus may contribute to reduced foot clearance in swing phase and knee hyperextension in stance phase.
Other considerations	Differentiate from gastrocnemius with knee extension.

Goniometer landmarks

Control - Lateral view

Patient - Lateral view

Tibialis Posterior

Ankle Invertor

Tibialis Posterior
Action	Foot inversion, assists in plantarflexion.
Origin	Interosseous membrane, posteromedial surface of the fibula, posterolateral surface of the tibia.
Insertion	Tuberosity of the navicular, cuneiform bones, cuboid, metatarsals 2 to 4.
Innervation	Tibial nerve.
Tardieu Testing
Patient position	Supine.
Measurement considerations	Measure through the second metatarsal. Neutral ankle joint = 0° Inversion = -ve Eversion = +ve
Starting limb position	Ankle in full PF and inversion.
End limb position	Maximum ankle eversion maintaining PF at the ankle.
Phase of gait cycle	Stance phase.
Gait cycle observation	Inversion (i.e. patient is on the outer boarder of their foot) during stance. Often presents as equinovarus (inversion and plantarflexion).
Other considerations	Observation of equinovarus during swing phase is likely a result of tibialis anterior, whereas equinovarus during stance phase is more likely to be due to tibialis posterior. To differentiate tibialis posterior spasticity from PF spasticity, test in plantarflexion.

Goniometer landmarks

Control - Aerial view

Patient - Aerial view

Flexor Digitorum Longus

Toe Flexors

Flexor Digitorum Longus
Action	Flexes the metatarsophalangeal, PIP and DIP joints of digits 2 to 5; plantarflexes the foot.
Origin	Posterior surface of the tibia, below the soleal line.
Insertion	Bases of the distal phalanges of digits 2 to 5.
Innervation	Tibial nerve.
Notes	The long toe flexors are active in the mid-stance phase of walking. The FHL and FDL assist in raising the heel from the ground.
Tardieu Testing
Patient position	Supine.
Measurement considerations	Measure the DIP joint. Neutral extension = 0° Hyperextension = +ve Flexion = -ve
Starting limb position	Maximum knee extension with the ankle joint plantargrade, PIP joint neutral and maximum flexion of the DIP joint.
End limb position	Maximum knee extension with the ankle plantargrade, PIP joint neutral and maximum extension of the DIP joint.
Phase of gait cycle	Terminal stance.
Gait cycle observation	Toe clawing during mid to terminal stance.
Other considerations	Differentiate from short toe flexors +/- ankle DF. Callous and reddening of the top of the toes may be indicative of spasticity of the toe flexors.

Goniometer landmarks

Control - Lateral view

Patient - Lateral view

Flexor Digitorum Brevis

Toe Flexors

Flexor Digitorum Brevis
Action	Flexes the metatarsophalangeal and PIP joints of digits 2 to 5.
Origin	Tuberosity of the calcaneus, plantar aponeurosis, intermuscular septae.
Insertion	Base of the middle phalanx of digits 2 to 5 after splitting to allow passage of the FDL tendons.
Innervation	Medial plantar nerve.
Notes	Flexor hallucis brevis flexes the metatarsophalangeal joint of the great toe (a task that is critical in gait).
Tardieu Testing
Patient position	Supine.
Measurement considerations	Test each toe separately. Measure the PIP joint with the DIP joint in extension. Neutral = 0° Hyperextension = +ve Flexion = -ve
Starting limb position	Maximum knee extension with the ankle joint plantarflexed, DIP joint extension and maximum flexion of the PIP joint.
End limb position	Maximum knee extension with the ankle joint plantarflexed, DIP joint extension and maximum extension of the PIP joint.
Phase of gait cycle	Terminal stance.
Gait cycle observation	Toe clawing during mid to terminal stance.
Other considerations	Differentiate from the long toe flexors +/- ankle dorsiflexion. Callous and reddening of the top of the toes may be indicative of increased spasticity of the toe flexors.

Goniometer landmarks

Control - Lateral view

Patient - Lateral view

Flexor Hallucis Longus

Toe Flexors

Flexor Hallucis Longus
Action	Flexes the IP joint of big toe.
Origin	Middle half of the posterior surface of the tibia and interosseous membrane.
Insertion	Bases of the distal phalanges of the great toe.
Innervation	Tibial nerve.
Notes	The long toe flexors are active in the mid-stance phase of walking. The FHL and FDL assist in raising the heel from the ground.
Tardieu Testing
Patient position	Supine.
Measurement considerations	Measure the IP joint of the big toe Neutral extension = 0° Hyperextension = +ve Flexion = -ve
Starting limb position	Maximum knee extension with the ankle plantarflexed, with neutral metatarsophalangeal joint and maximum flexion of the IP joint.
End limb position	Maximum knee extension with the ankle plantarflexed, with neutral metatarsophalangeal joint and maximum extension of the IP joint.
Phase of gait cycle	Mid to terminal stance.
Gait cycle observation	First IP joint flexion or clawing of the big toe.
Other considerations	Callous and reddening of the tip of the big toe may be indicative of spasticity of the FHL.

Goniometer landmarks

Control - Lateral view

Patient - Lateral view

Appendix 1: Case Study

Patient background

Demographics

Age: 39 years old
Gender: Female

Past Medical History

Spina Bifida diagnosed at 2 years of age
Surgical repair of lumbar spine as child: laminectomy, detethering of spinal cord, removal of lipomas
Developed back and neck pain in teens – laminectomy and detethering

Previous spasticity intervention

Oral medications:

Baclofen – has trialled various doses (currently 3 x 10mg/day)

Botulinum toxin-A injections:

Intermittently from 25 years old until present

Surgical intervention:

Bilateral Achilles tendon release as an 8-year-old for toe walking
Lower limbs surgeries completed when 34 years old:
- Vulpius calf lengthening Right leg
- Strayer’s calf lengthening Left leg
- Aponeurotic lengthening tibialis posterior bilaterally
- Wore AFO’s for approximately 1 year post surgery then weaned as aggravated back pain and did not like aesthetics

Assistive devices:

Trialled different AFO’s and shoe inserts throughout childhood, adolescence and adulthood with varied effectiveness

Social history

Lives at home with husband and two young sons (2yo and 8yo)
Works 3 days/week in disability support (admin-based role)
Enjoys spending time with friends and family and being fit and active

Previous level of function

Independent mobility throughout childhood
Was able to run as a child
Significant mobility decline and increase in low back pain following 2nd pregnancy (required a frame and was a household ambulator for last 2 months of pregnancy)
Has been seeing a sport physiotherapist for >10 years focussing on strengthening ankle dorsiflexors and hip extensors
Minimal neurological physiotherapy input

Patient assessment

History of presenting complaint

Referral to spasticity clinic reporting the following primary physical concerns:

Difficulty keeping up with young children for longer distances e.g. walking to school or playing at the park
Reduced bilateral foot clearance causing stumbles, trips and falls
Increase in global bilateral lower limb tightness (rated as 8/10 on an average over the past 7 days)
Increase in low back pain (rated as 5/10 when standing or sitting)
Difficulty accessing feet and dressing lower limbs, rated as 6/10
Requiring rail to ascend and descend stairs, currently descending backwards (carries young son up flight of stairs, safety risk to her and her son)
Unable to wear heels (has two functions later in the year requiring heels)
Unable to walk to coffee shop with colleagues

Referred for three-dimensional motion analysis due to complexity of gait. Findings included:

Right tibial torsion and femoral anteversion causing knee varus & extension thrust in mid-stance & increased valgus in swing
Right and left gastrocnemius, soleus and tibialis posterior spasticity & hypertonicity contributing to reduced dorsiflexion in swing & increased inversion at push off, as well as knee hyperextension & plantarflexion coupling in stance
Right and left co-contraction of rectus femoris & medial hamstring bilaterally causing increased knee flexion at initial contact & reduced knee extension at terminal swing
Bilateral hip extensor weakness, abdominal weakness & lumbar spine hyper-lordosis contributing to increased anterior pelvic tilt & posterior trunk lean throughout gait
Bilateral hip abductor & pelvic weakness contributing to right Trendelenburg & pelvic retraction throughout gait

Initial Functional Assessment

	Pre- Injection Mobility
Transfers	Independent, no aids (FIM 7)
Gait	Independent indoors and outdoors, no aid (FIM 7)
Stairs	Independent, with rail, reciprocal pattern (FIM 6) Note: descends stairs backwards to assist with knee control
10 metre walk test	Self-selected: 8.8s, 0.9m/s Fast: 6.1s, 1.6m/s Note: walking speed was not a reported concern compared to walking quality especially over longer distances
6-minute walk test	480m, 1.3m/sec 4 x catch on left and 6 x catches on right
Walking endurance	Dependent on speed, terrain, crowds 10 minutes before increased falls risk and catching
Falls	Variable - can be several per day or months without 5 falls over prior month reported
Running	Unable

Initial walking

Initial Physical Assessment

Hip assessment

		Left	Right
Flexors	R2 (PROM extension)	20°	20°
	R1 (muscle reaction)	0°	20°
	Tardieu score	2	1
	Strength	4/5	4/5
Extensors	PROM (flexion, knee @ 90°)	125°	125°
Extensors	Strength	3/5	3/5
Adductors	R2 (PROM abduction)	35	35
	R1 (muscle reaction)	35	35
	Tardieu Score	1	1
	Strength	4/5	4/5
Abductors	Strength	3/5	3/5

Knee assessment

		Left	Right
Flexors	R2 @ 90° HF (PROM extension)	-35°	-10°
	R1 @ 90° HF (muscle reaction)	-75°	-50°
	Tardieu score @ 90° HF	2	2
	R2 @ 30° HF (PROM extension)	0	0°
	R1 @ 30° HF (muscle reaction)	-40°	-20°
	Tardieu score @ 30° HF	2	2
	Strength	2/5	3/5
Extensors	R2, RF (PROM flexion)	135°	135°
	R1, RF (muscle reaction)	50°	100°
	Tardieu score, RF	2	2
	R2, vastii (PROM flexion)	115°	115°
	R1, vastii (muscle reaction)	65°	90°
	Tardieu score, vastii	2	2
	Strength	4/5	4/5

Knee flexors

Hamstring MTS @ 90 deg HF

Hamstring MTS @ 30 deg HF

Rapid alternating knee flexion/extension in sitting

Knee extensors

Rec fem MTS

Vastii MTS

Rapid alternating knee flexion in prone

SL squat

Ankle assessment

		Left	Right
Plantarflexors	R2, gastroc (PROM DF)	25°	25°
	R1, gastroc (muscle reaction)	-5°	10°
	Tardieu score, gastroc	4	2
	R2, soleus (PROM DF)	5°	15°
	R1, soleus (muscle reaction)	-15°	0°
	Tardieu score, soleus	4	2
	Strength	4/5	4/5
Dorsiflexors	PROM (PF)	40°	40°
Dorsiflexors	Strength	3/5	4/5
Invertors	R2, tib post (PROM eversion)	40°	40°
	R1, tib post (muscle reaction)	15°	40°
	Tardieu score, tib post	3	1
	Strength	4/5	4/5
Evertors	PROM (inversion)	45°	45°
	Strength	3/5	4/5

Ankle PF’s

MTS – gastroc

MTS – soleus

Rapid foot tapping

Calf raises

Ankle invertors

MTS – tib post

Stance phase inversion

Goal attainment scale

Patient goal #1: I want to walk up and down a flight of stairs independently

SMART goal #1: To be able to ascend/descend 14 stairs independently, with 1 x rail, forward facing and using a reciprocal pattern in 8 weeks

+2	Much better than expected	Ascend/descend 14 stairs independently, reciprocal pattern with no rail, forward facing in 8/52
+1	More than expected	Ascend 14 stairs with no rail, and descend with 1 x rail, independently, forward facing, reciprocal pattern in 8/52
0	Likely (predicted) outcome	Ascend/descend 14 stairs independently with 1 x rail, forward facing and reciprocal pattern in 8/52
-1	Less than expected outcome	Requires either 2 x rails or a non-reciprocal pattern to ascend/descend 14 stairs independently, forward facing in 8/52
-2	Much less than expected outcome	Unable to ascend/descend 14 stairs independently, forward facing, in 8/52

Patient goal #2: I want to stumble less when I walk

SMART goal #2: To be able to reduce frequency of toe catching during a 6-minute walk test from 10 to ≤5 in 8 weeks

+2	Much better than expected	0 episodes of toe catching during a 6mwt in 8/52
+1	More than expected	1-2 episodes of toe catching during a 6mwt in 8/52
0	Likely (predicted) outcome	3-5 episodes of toe catching during a 6mwt in 8/52
-1	Less than expected outcome	5-8 episodes of toe catching during a 6mwt in 8/52
-2	Much less than expected outcome	>8 episodes of toe catching during a 6mwt in 8/52

Patient goal #3: I want to look less disabled when I walk

SMART goal #3: Improve self-rated quality of walking from 4/10 to ≥6/10 in 8 weeks

**Note: quality rated as an average of all walking over the previous 7 days

+2	Much better than expected	Self-rated walking quality: 9-10/10 in 8/52
+1	More than expected	Self-rated walking quality: 7-8/10 in 8/52
0	Likely (predicted) outcome	Self-rated walking quality: 5-6/10 in 8/52
-1	Less than expected outcome	Self-rated walking quality: 3-4/10 in 8/52
-2	Much less than expected outcome	Self-rated walking quality: 0-2/10 in 8/52

Patient intervention

Multidisciplinary team decision

Botulinum toxin-A injections to left lower limb as per table below

Muscle, Dosage and Technique	Rationale & considerations
Gastrocnemius 100u (50u each head) U/S	Reduce toe catching Reduce effort required in controlling knee hyper-extension Improve translation of tibia over foot enabling a better push off Previously has responded well, hoping for a good effect in conjunction with quads
Soleus 100u U/S
Tibialis posterior 75u U/S	Reduce stance phase inversion Reduce fear of falling due to unstable foot late stance
Rectus femoris 100u <(50u, 2 x sites) U/S	Improve knee flexion early to mid-swing Enhance push off Improve ability to flex knee and bring weight forward when descending stairs Quads are strong enough Yet to trial rectus femoris injection Patient perceives this as being a primary limitation in walking and stair descent

Twice weekly physiotherapy and once weekly exercise physiology
Daily home exercise and walk program
Review in spasticity clinic in 8 weeks
- Re-assess goal attainment
- Re-assess bilateral spasticity, strength and function
- Further consideration of left hamstring and right calf botulinum toxin-A injection

Physiotherapy program

Comprehensive exercise program to include:
- Strengthening and ROM of ankle plantarflexors, dorsiflexors and evertors
- Strengthening of knee flexors and extensors predominantly eccentrically
- Hip and pelvic complex dissociation and activation
- Ongoing trunk mobility and stability
- Gait re-training
- Cardiovascular fitness
Re-explore assistive devices to assist with foot clearance and maximise safety including AFO’s and ASO’s
Trial toe spreaders
Trial community mobility devices to enhance participation with family and help fatigue management

Patient review (8-weeks post Botulinum Toxin-A injection)

Functional Review

	Pre- Injection Mobility	Post- Injection Mobility
Transfers	Independent, no aids (FIM 7)	Independent, no aids (FIM 7)
Gait	Independent indoors and outdoors, no aid (FIM 7)	Independent indoors and outdoors, no aid (FIM 7)
Stairs	Independent, with rail, reciprocal pattern (FIM 6)	Independent, no rail, reciprocal pattern (FIM 7)
10 metre walk test	Self-selected: 8.8s, 0.9m/s Fast: 6.1s, 1.6m/s	Self-selected: 7.5s, 1.3m/s Fast: 5.5s, 1.8m/s
6-minute walk test	480m, 1.3m/sec 4 x catch on L and 6 x catches on R	544m, 1.5m/sec 1 x catch on L and 2 x catches on R
Walking endurance	10 minutes before ↑ falls risk and catching	15 minutes before ↑ falls risk and catching
Falls	5 falls over prior month	2 falls over prior month
Running	Unable	Unable

Goal Review

Goal	Pre-injection	Post-injection	GAS rating
Stairs	Independent, with rail, reciprocal pattern, descending backwards	Independent, no rail, reciprocal pattern, forward facing	+2
Toe catching	10 catches during 6mwt	3 catches during 6mwt	+1
Walking quality	Self-rated quality of walking: 4/10	self-rated quality of walking: 6/10	0

Current mobility

Current ascend stairs

Current descend stairs

References

Ansari, N. N., Naghdi, S., Arab, T. K., & Jalaie, S. (2008). The interrater and intrarater reliability of the Modified Ashworth Scale in the assessment of muscle spasticity: limb and muscle group effect. Neuro Rehabil, 23(3), 231-237.
Ansari, N. N., Naghdi, S., Arab, T. K., & Jalaie, S. (2008). The interrater and intrarater reliability of the Modified Ashworth Scale in the assessment of muscle spasticity: limb and muscle group effect. Neuro Rehabil, 23(3), 231-237.
Ansari, N. N., Naghdi, S., Moammeri, H., & Jalaie, S. (2006). Ashworth Scales are unreliable for the assessment of muscle spasticity. Physiother Theory Pract, 22(3), 119-125.
Ansari, N. N., Naghdi, S., Younesian, P., & Shayeghan, M. (2008). Inter- and intrarater reliability of the Modified Modified Ashworth Scale in patients with knee extensor poststroke spasticity. Physiother Theory Pract, 24(3), 205-213. doi: 10.1080/09593980701523802
Ashford, S., & Turner-Stokes, L. (2006). Goal attainment for spasticity management using botulinum toxin Physiother Res Int, 11(1), 24-34. doi:10.1002/pri.36
Ashford, S., & Turner-Stokes, L. (2018). Spasticity in adults: Management using botulinum toxin: National guidelines. London: Royal College of Physicians of London.
Ashford, S., & Turner-Stokes, L. (2013). Systematic review of upper-limb function measurement methods in botulinum toxin intervention for focal spasticity. Physiother Res Int, 18(3), 178-189.
Ashworth B. (1964). Preliminary trial of carisprodal in multiple sclerosis. Practitioner, 192:54-542.
Boyd, R. N., & Graham, K. H. (1999). Objective measurement of clinical findings in the use of botulinum toxin type A for the management of children with cerebral palsy. Eur J of Neurol 6(S4), S23-S35.
Brashear, A., & Elovic, E. (2010). Spasticity: Diagnosis and management. New York: Demos Medical Publishing.
Deloitte Access Economics. (2013). The economic impact of stroke in Australia. Retrieved from http:// strokefoundation.com.au/site/media/Final-Deloitte- Stroke-Report-14-Mar-13.pdf
Demetrios, M., Gorelik, A., Louie, J., Brand, C., Baguley, I. J., & Khan, F. (2014). Outcomes of ambulatory rehabilitation programmes following botulinum toxin for spasticity in adults with stroke. J of Rehabil Med, 46(8), 730-737 738p. doi:10.2340/16501977-1842
Esquenazi, A., Novak, I., Sheean, G., Singer, B. J., & Ward, A. B. (2010). International consensus statement for the use of botulinum toxin treatment in adults and children with neurological impairments: Introduction. Eur J of Neurol, 17(S2), 1-8.
Fleuren JF, Voerman GE, Erren-Wolters CV, Snoek GJ, Rietman JS, Hermens HJ et al. (2010). Stop using the Ashworth Scale for the assessment of spasticity. J Neurol Neurosurg Psychiatry, 81,46–52.
Gracies, J. M., Elovic, E., McGuire, J., & Simpson, D. (1997). Traditional pharmacological treatments for spasticity part I: Local treatments. Muscle Nerve, 20(S6), 61-91.
Gracies, J. M., Nance, P., Elovic, E., McGuire, J., & Simpson, D. M. (1997). Traditional pharmacological treatments for spasticity part II: General and regional treatments. Muscle Nerve, 20(S6), 92-120.
Gracies J-M, Marosszeky J, Renton R, Sandaman J, Gandevia S, Burke D. (2000). Short term effects of dynamic lycra splints on upper limb in hemiplegia patients. Arch Phys Med Rehabil, 81:1547-1555.
Gracies J-M, Burke K, Clegg NJ, Browne R, Rushing C, Fehlings D, Matthews D, Tilton A, Delgado MR. (2010) Reliability of the Tardieu Scale for assessing spasticity in children with cerebral palsy. Arch Phys Med Rehabil. 91(3),:421-428. doi: 10.1016/j.apmr.2009.11.017
Haugh A, Pandyan A, Johnson G. (2006). A systematic review of the Tardieu Scale for the measurement of spasticity. Disabil Rehabil.28(15),899-907.
Held JP, Pierrot-Deseilligny E.(1969). Reeducation Motrice des Affections Neurologiques, Paris France: JB Bailiere et Fils, 31–42
Ivanhoe, C. B., & Reistetter, T. A. (2004). Spasticity: The misunderstood part of the upper motor neuron syndrome. Am J of Phys Med Rehab, 83(10), S3-S9. doi:10.1097/01.phm.0000141125.28611.3e
Keenan, M., Haider, T., & Stone, L. (1990). Dynamic electromyography to assess elbow spasticity. J Hand Surg,15(4), 607-614.
Kiresuk, T. J., & Sherman, M. R. E. (1968). Goal attainment scaling: A general method for evaluating comprehensive community mental health programs. Community Ment Health J, 4(6), 443-453.
Lance, J. W. (1980). The control of muscle tone, reflexes, and movement: Robert Wartenberg lecture. Neurology, 30(12), 1303-1313.
Moore E, Williams G, Olver J, Bryant A, Banky M. (2015). The effectiveness of therapy on outcome following BoNT-A injection for focal spasticity in adults with neurological conditions - systematic review. Brain Injury, 29(6), 676-687.
Mehrholz J, Wagner K, Meissner D, Grundmann K, Zange C, Koch R et al. (2005). Reliability of the Modified Tardieu Scale and the Modified Ashworth Scale in adult patients with severe brain injury: a comparison study. Clin Rehabil, 19, 751–759.
Olver, J., Esquenazi, A., Fung, V. S. C., Singer, B. J., & Ward, A. B. (2010). Botulinum toxin assessment, intervention and aftercare for lower limb disorders of movement and muscle tone in adults: International consensus statement. Eur J Neurol, 17(S2), 57-73.
Pandyan, A., Gregoric, M., Barnes, M., Wood, D., Wijck, F., Burridge, J., Hermens, H., Johnson, A. (2005). Spasticity: Clinical perceptions, neurological realities and meaningful measurement. Disabil Rehabil, 27(1-2), 2-6. doi:10.1080/09638280400014576
Pandyan, A. D., Vuadens, P., van Wijck, F. M. J., Stark, S., Johnson, G. R., & Barnes, M. P. (2002). Are we underestimating the clinical efficacy of botulinum toxin (type A)? Quantifying changes in spasticity, strength and upper limb function after injections of Botox® to the elbow flexors in a unilateral stroke population. Clin Rehabil, 16(6), 654-660.
Pandyan, A. D., Johnson, G. R., Price, C. I., Curless, R. H., Barnes, M. P., & Rodgers, H. (1999). A review of the properties and limitations of the Ashworth and modified Ashworth Scales as measures of spasticity. Clin Rehabil, 13(5), 373-383.
Patrick, E., & Ada, L. (2006). The Tardieu Scale differentiates contracture from spasticity whereas the Ashworth Scale is confounded by it. Clin Rehabil, 20(2), 173-181. doi: 10.1191/0269215506cr922oa
Sanger TD, Delgado MR, Gaebler-Spira D, Hallett M, Mink JW. (2003). Task Force on childhood motor disorders, classification and definition of disorders causing hypertonia in childhood. Pediatrics,111,: e89–e97.
Sheean, G., Lannin, N. A., Turner-Stokes, L., Rawicki, B., & Snow, B. J. (2010). Botulinum toxin assessment, intervention and after-care for upper limb hypertonicity in adults: International consensus statement. Eur J Neurol, 17(S2), 74-93.
Singh, P., Joshua, A. M., Ganeshan, S., & Suresh, S. (2011). Intra-rater reliability of the modified Tardieu scale to quantify spasticity in elbow flexors and ankle plantar flexors in adult stroke subjects. Ann Indian Acad Neurol, 14(1), 23-26.
Tardieu G, Rondont O, Mensch J, Dalloz J-C, Monfraix C, Tabary J-C. (1957). Responses electromyographiques a l’etirement musculaire chez l’homme normal. Rev Neurol, 97, 60-61.
Tardieu G, Shentoub S, Delarue R. (1954). A la recherche d’une technique de measure de la spasticite. Rev Neurol, 91(2), 143-144.
Turner-Stokes, L. (2009). Goal attainment scaling (GAS) in rehabilitation: A practical guide. Clin Rehabil, 23(4), 362-370. doi:10.1177/0269215508101742
Urban, P. P., Wolf, T., Uebele, M., Marx, J. J., Vogt, T., Stoeter, P., Bauermann, T., Weibrich, C., Vucurevic, G.D., Schneider, A., Wissel, J. (2010). Occurence and clinical predictors of spasticity after ischemic stroke. Stroke, 41(9), 2016-2020. doi:10.1161/strokeaha.110.581991
Williams, G., Olver, J., De Graaff, S., & Singer, B.J. (2012). The use of botulinum toxin type A in the management of adult-onset focal spasticity: A survey of Australian allied health professionals. Aust Occup Ther J, 59(4), 257-264. doi:10.1111/j.1440-1630.2012.01027.
Yelnik, A. P., Simon, O., Parratte, B., & Gracies, J.M. (2010). How to clinically assess and treat muscle overactivity in spastic paresis. J Rehabil Med, 42(9), 801-807. doi:10.2340/16501977-0613
Yelnik, A., Albert, T., Bonan, I., & Laffont, I. (1999). A clinical guide to assess the role of lower limb extensor overactivity in hemiplegic gait disorders. Stroke, 30(3), 580-585.

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A Guide To The Modified Tardieu Scale

Acknowledgements

Contents

Upper Limb

Shoulder Rotators

Elbow Flexors

Elbow Extensors

Forearm Pronators

Wrist Flexors

Finger Flexors

Thumb Muscles

Hand Muscles

Lower Limb

Hip Adductors

Hip Flexors

Knee Flexors

Knee Extensors

Ankle Plantarflexors

Ankle Invertor

Toe Flexors

Glossary

About the Tardieu Scale

The Tardieu Scale, which was originally developed by Guy Tardieu (Tardieu et al., 1954), is based on four key principles:

The Starting Position

Modified Tardieu Scale Criteria

The most recent versions of the scale use the following criteria:

Patients are positioned sitting to test the upper limbs and supine to test the lower limbs.

Four measurements:

Three speed definitions:

Quality of Muscle Reaction score (0-5):

Goniometer landmarks

START:Control

FINISH:Control

Control - Coronal (front) view

Control - Lateral view

START:Patient

FINISH:Patient

REACTION:Patient

Patient - Coronal (front) view

Patient - Lateral view

Goniometer landmarks

START:Control

FINISH:Control

Control - Coronal (front) view

START:Patient

FINISH:Patient

REACTION:Patient

Patient - Coronal (front) view

Goniometer landmarks

START:Control

FINISH:Control

Control - Coronal (front) view

START:Patient

FINISH:Patient

REACTION:Patient

Patient - Coronal (front) view

Goniometer landmarks

START:Control

FINISH:Control

Control - Coronal (front) view

Control - Aerial view

START:Patient

FINISH:Patient

REACTION:Patient

Patient - Coronal (front) view

Patient - Aerial view

Goniometer landmarks

START:Control

FINISH:Control

Control - Lateral view

START:Patient

FINISH:Patient

REACTION:Patient

Patient - Lateral view

Goniometer landmarks

START:Control

FINISH:Control

Control - Lateral view

START:Patient

FINISH:Patient