Dermatomes and Myotomes

and its clinical special test in

upper limb and lower limb
What is Dermatomes?
Dermatomes are areas on the surface of the skin that are control by specific
nerve roots from the spinal cord
Skin (sensation) is innervated by a single nerve roots called the
dermatomes

What is myotomes?
Myotomes correspond to muscles that are controlled by specific nerve roots
from the spinal cord
Muscles (movement) are innervated by singe nerve roots called myotomes

Nerves and nerve roots are typically injured by compression or stretching

forces
When a nerve root is damaged a deficit may occur in the corresponding
limb
The evaluation of nerve root damage can be done by testing dermatomes
and myotomes
 Dermatome (sensory) test:
Pain sensation (pin prick) and light
touch sensation (cotton wool)

Pinprick test
Gently touches the skin with the pin or back end and
asks the patient whether it feels sharp or blunt
Light touch test
Dabbing a piece of cotton wool on an area of skin
 Procedure
Test for abnormalities in sensitivity by pin or cotton.
The patient should close his/her eyes and give the therapist feedback
with regards to various stimuli.
All tests should be done on a specific dermatomes and should be
compared bilaterally.
The sensory function of touch involves sensing surfaces and their
textures and qualities.
Pinprick test and light touch test
Both test should be demonstrated to the patient first.
Both test begin distally and then move proximally
Test Dermatomes at dots Upper Body Test Ponits
C2 - Occipital Protuberance
FRONT C3 - Supraclavicular Fossa
C4 - Acromioclavicular Joint
C5 - Lateral Antecubital Fossa
C6 - Thumb
C7 - Middle Finger
C8 - Little Finger
T1 - Medial Antecubital Fossa
T2 - Apex of Axilla

Lower Body Test Points

L1 - Upper Anterior Thigh
L2 - Mid Anterior Thigh
L3 - Medial Femoral Condyle
L4 - Medial Malleolus
L5 - Dorsum 3rd MTP Joint
S1 - Lateral Heel
S2 - Popliteal Fossa
S3 - Ischial Tuberosity
S5 - Perianal Area
BACK Upper Body Test Ponits
C2 - Occipital Protuberance
C3 - Supraclavicular Fossa
C4 - Acromioclavicular Joint
C5 - Lateral Antecubital Fossa
C6 - Thumb
C7 - Middle Finger
C8 - Little Finger
T1 - Medial Antecubital Fossa
T2 - Apex of Axilla

Lower Body Test Points

L1 - Upper Anterior Thigh
L2 - Mid Anterior Thigh
L3 - Medial Femoral Condyle
L4 - Medial Malleolus
L5 - Dorsum 3rd MTP Joint
S1 - Lateral Heel
S2 - Popliteal Fossa
S3 - Ischial Tuberosity
S5 - Perianal Area
Upper Body Test Ponits
C2 - Occipital Protuberance
C3 - Supraclavicular Fossa
C4 - Acromioclavicular Joint
C5 - Lateral Antecubital Fossa
C6 - Thumb
C7 - Middle Finger
C8 - Little Finger
T1 - Medial Antecubital Fossa
T2 - Apex of Axilla
V1 - Ophthalmic Division of Trigeminal Nerve (Upper Face)
V2 - Maxillary Division of Trigeminal Nerve (Mid Face)
V3 - Mandibular Division of Trigeminal Nerve (Lower Face)
Full Dermatome Map
Myotome (motor) test:

What is myotomes?
Myotomes correspond to muscles that are controlled by specific nerve
roots from the spinal cord
Muscles (movement) are innervated by singe nerve roots called
myotomes
Myotomes and Differentiating Nerve Lesions

C1 Myotome Upper cervical flexion

C2 Myotome Upper cervical extension/ Neck Rotation
C3 Myotome Cervical lateral flexion
C4 Myotome Shoulder shrugs (upper trapezious)
C5 Myotome Shoulder abduction and external rotation (infraspinatus)
C6 Myotome Elbow flexion and wrist extension
C7 Myotome Elbow extension and wrist flexion
C8 Myotome Thumb extension and ulnar deviation
T1 Myotome Finger adduction and abduction
L1 Myotome Hip flexion
L2 Myotome Hip flexion (also adduction and medial rotation)
L3 Myotome Leg/knee extension
L4 Myotome Dorsiflexion
L5 Myotome Great/Big toe extension
S1 Myotome Ankle plantar flexion and eversion/knee flexion
S2 Myotome Ankle plantar flexion and knee flexion
S3 Myotome None
S4 Myotome Bladdar and rectum
Cervical Plexus: C1-C4 nerve roots innervate the diaphragm, shoulder and neck.

Brachial Plexus : C5-T1 nerve roots innervate the upper limbs

Lumbosacral Plexus: L1- L5, S2 nerve roots innervate the lower extremity
Upper Extremity Nerve Routes

C4 tested with resisted shoulder shrugs/elevation

C5 tested with resisted shoulder abduction
C6 tested with resisted elbow flexion/ wrist extension
C7 tested with resisted wrist flexion
C8 tested with resisted thumb extension
T1 fingers abduction & adduction

Lower Extremity Nerve Routes

The quick test for the lower extremity, to rule out a nerve root injury is to have the
athlete do a squat.

L1-L2 tested with resisted hip flexion

L3 tested with resisted knee extension
L4 tested with resisted foot dorsi flexion
L5 tested with resisted great toe extension
S1/S2 tested with plantar flexion
The Motor System (myotomes) Test of
Upper limb and Lower limb
Note the position of the body that the patient assumes when sitting on the
examination table.
Paralysis or weakness may become evident when a patient assumes an
abnormal body position.
A central lesion usually produces greater weakness in the extensors than in
the flexors of the upper extremities, while the opposite is true in the lower
extremities: a greater weakness in the flexors than in the extensors
Systematically examine all of the major muscle groups of the
body.

For each muscle group:

1.Note the appearance or muscularity of the muscle (wasted, highly
developed, normal).
2.Feel the tone of the muscle (flaccid, clonic, normal).
3.Test the strength of the muscle group.
Since this rating scale is skewed towards weakness, many clinicians
further subclassify their finding by adding a + or -, e.g., 5- or 3+
 Muscle Strength Grading:
0 No muscle contraction is detected
A trace contraction is noted in the muscle by palpating the muscle
1 while the patient attempts to contract it.

The patient is able to actively move the muscle when gravity is

2 eliminated.
The patient may move the muscle against gravity but not against
3 resistance from the examiner .

The patient may move the muscle group against some resistance from
4 the examiner.
The patient moves the muscle group and overcomes the resistance of
5 the examiner. This is normal muscle strength.
 C5- Shoulder
Starting with the deltoids, ask the patient to raise both their arms in front of
them simultaneously as strongly as then can while the examiner provides
resistance to this movement. Compare the strength of each arm.

The deltoid muscle is innervated by the C5 nerve root via the axillary nerve.
 C5- Shoulder
Next, ask the patient to extend and raise both arms in front of them. Ask the
patient to keep their arms in place while they close their eyes and count to 10.
Normally their arms will remain in place. If there is upper extremity weakness
there will be a positive pronator drift, in which the affected arm will pronate
and fall. This is one of the most sensitive tests for upper extremity weakness.

Pronator drift is an indicator of upper motor neuron weakness. In upper motor

neuron weakness, supination is weaker than pronation in the upper extremity,
leading to a pronation of the affected arm.

The patient to the left does not have a pronator drift.

 C6- Elbow flexion
Test the strength of lower arm flexion by holding the patient's wrist from above
and instructing them to "flex their hand up to their shoulder". Provide resistance
at the wrist. Repeat and compare to the opposite arm. This tests the biceps
muscle.

The biceps muscle is innervated by the C5 and C6 nerve roots via the
musculocutaneous nerve.
 C6- Wrist Extension
Test the strength of wrist extension by asking the patient to extend their wrist
while the examiner resists the movement. This tests the forearm extensors.
Repeat with the other arm.

The wrist extensors are innervated by C6 and C7 nerve roots via the radial
nerve. The radial nerve is the "great extensor" of the arm: it innervates all the
extensor muscles in the upper and lower arm.
 C7- Elbow extension
Now have the patient extend their forearm against the examiner's resistance.
Make certain that the patient begins their extension from a fully flexed position
because this part of the movement is most sensitive to a loss in strength. This
tests the triceps. Note any asymmetry in the other arm.

The triceps muscle is innervated by the C6 and C7 nerve roots via the radial
nerve.
 C8- Finger Flexion
Examine the patient's hands. Look for intrinsic hand, thenar and hypothenar muscle
wasting.

Test the patient's grip by having the patient hold the examiner's fingers in their fist
tightly and instructing them not to let go while the examiner attempts to remove
them. Normally the examiner cannot remove their fingers. This tests the forearm
flexors and the intrinsic hand muscles. Compare the hands for strength asymmetry.

Finger flexion is innervated by the C8 nerve root via the median nerve.
 C8- Finger abduction & adduction
Test the intrinsic hand muscles once again by having the patient abduct or "fan
out" all of their fingers. Instruct the patient to not allow the examiner to compress
them back in. Normally, one can resist the examiner from replacing the fingers.

Finger abduction or "fanning" is innervated by the T1 nerve root via the ulnar
nerve.
 C8 & T1- Thumb Opposition
To complete the motor examination of the upper extremities, test the strength of
the thumb opposition by telling the patient to touch the tip of their thumb to the
tip of their pinky finger. Apply resistance to the thumb with your index finger.
Repeat with the other thumb and compare.

Thumb opposition is innervated by the C8 and T1 nerve roots via the median
nerve.
 L1 & L2 : Hip Flexion
Proceeding to the lower extremities, first test the flexion of the hip by asking the
patient to lie down and raise each leg separately while the examiner resists.
Repeat and compare with the other leg. This tests the iliopsoas muscles.

Hip flexion is innervated by the L2 and L3 nerve roots via the femoral nerve.
 L3: Knee Extension
Test extension at the knee by placing one hand under the knee and the other on
top of the lower leg to provide resistance. Ask the patient to "kick out" or extend
the lower leg at the knee. Repeat and compare to the other leg. This tests the
quadriceps muscle.

Knee extension by the quadriceps muscle is innervated by the L3 and L4 nerve

roots via the femoral nerve.
 L4: Ankle Dorsiflexion
Test dorsiflexion of the ankle by holding the top of the ankle and have the patient
pull their foot up towards their face as hard as possible. Repeat with the other
foot. This tests the muscles in the anterior compartment of the lower leg.

Ankle dorsiflexion is innervated by the L4 and L5 nerve roots via the peroneal
nerve.
 L5: Great toe extension

Ask the patient to move the large toe against the examiner's resistance "up
towards the patient's face". This tests the extensor halucis longus muscle.

The extensor halucis longus muscle is almost completely innervated by the L5

nerve root
 S1&s2: Ankle plantar flexion and
eversion/knee flexion
Holding the bottom of the foot, ask the patient to "press down on the gas pedal" as
hard as possible. Repeat with the other foot and compare. This tests the
gastrocnemius and soleus muscles in the posterior compartment of the lower leg.

Ankle plantar flexion is innervated by the S1 and S2 nerve roots via the tibial nerve.

Test flexion at the knee by holding the knee from the side and applying
resistance under the ankle and instructing the patient to pull the lower leg
towards their buttock as hard as possible. Repeat with the other leg. This tests
the hamstrings.

The hamstrings are innervated by the L5 and S1 nerve roots via the sciatic
nerve.
Ankle Plantar Flexion Knee Flexion
 Levels Of Injury
with specific muscles
C4

Further innervation of
diaphragm & paraspinal
muscles
 L1 to S5
Lower Limb Muscles
L1/2 Hip Flexors
L3 Knee Extensors
L4 Ankle Dorsiflexors
L5 Long Toe Extensors
S1/2 Ankle Plantarflexors
Complete and Incomplete Spinal Cord Injury:

An incomplete injury means that the ability of the spinal cord to convey messages to
or from the brain is not completely lost; some sensation and movement is possible
below the level of injury.

A complete injury is indicated by a total lack of sensory and motor function below
the level of injury. But the absence of motor and sensory function below the injury
site does not necessarily mean that there are no remaining intact axons or nerves
crossing the injury site, just that they do not function appropriately following the
injury.