ANATOMIC LOCALIZATION

Steve R. Geiringer, M.D.

I. Introduction

Many residents doing needle electromyography for the-first time will start the examination of a
muscle by palpating the general area, having the patient contract that muscle, palpating again
and having the patient contract again. Finally, the needle is inserted and the patient is again
asked to contract to "test” whether the needle is in the correct location. This situation is not
ideal, and a detailed knowledge of surface and 3D anatomy is crucial for several reasons:

1. The patient might not be able to activate a muscle. This might be from peripheral nerve
injury, hemiparesis, coma, upper motor neuron disorders, hysteria or other reasons.

2. In an obese patient, a given muscle simply might not be palpable because of the soft
tissue between it and the skin.

3. All of the palpation and contracting, repalpation and recontracting take time. When this
is added up over the course of an entire examination, and over the course of a day, the
time factor becomes significant.

4. By knowing the anatomy, one can make the EMG examination much more tolerable to
the patient. Knowing the direction of muscle fibers, origins and insertion, kinesiology
and place-ment of muscles in relation to other muscles helps to speed the exam along.

5. The patient's confidence in you, crucial for a successful EMG, will be compromised if you
are spending a minute or more palpating a forearm searching for a muscle before finally
inserting the electrode.

6. Above all, you need to be absolutely certain you know what muscle you are examining.

II. General Guidelines

1. Do not get accustomed to memorizing the number of centimeters or finger breadths

from a landmark to find a muscle. For example, one book lists the short head of biceps
femoris as four finger breadths above the fibular head. While these general rules might
be okay for the "average” patient, they will be worthless in a child or newborn infant,
and just as worthless in a very tall patient. By knowing the anatomic landmarks, you will
never need to rely on generalized measurements; anatomic landmarks are always
correct on the patient you find them on.

2. Once you know where you are going to insert the needle electrode, pierce the skin
quickly, do not nudge it through. Be careful, however, to only enter the subcutaneous
tissue at first. Never jab the needle into a muscle without first making sure that muscle
is relaxed. Many muscles, e.g. lumbar paraspinals, will usually flinch involuntarily when

Page 1 of 18
 the electrode pierces the skin. Stop at that point, wait for the muscle to relax, and then
gently advance the needle through the superficial fascia into the resting muscle.

3. When inserting the needle, whenever possible follow the direction of the muscle fibers.
This is not always possible, for example with paraspinal muscles, iliopsoas, etc.

4. A common error among beginning electromyographers is to search for abnormal

spontaneous activity with too many insertions per muscle. The zero to 4+ scale of
grading fibrillations is based on 30 or so insertions per muscle (i.e. about five to six
thrusts of one-half to one millimeter in each of five to six directions per muscle). When
you are starting needle examinations for the first time, count the number of insertions
within each muscle, and do not go beyond 30. If significant abnormality exists, it will
present itself within 30 insertions.

5. After studying insertional activity, but before having the patient voluntarily contract a
muscle, pull the electrode back into the subcutaneous tissue. A forceful muscle
contraction while the needle is within the muscle can be very painful, and can actually
lead to the electrode being bent. With the needle in the subcutaneous, have the patient
lightly contract (you will see the "distant" motor units on the screen), then gently insert
the electrode through the superficial fascia into the muscle. It is relatively painless to
move the needle through the muscle during a light contraction i.e. two to four motor
units present. It is painful, however, to move the needle through a forcibly contracting
muscle.

NOTE:
1. In the following descriptions, the abbreviation given after each muscle name
corresponds to that used in our laboratory.

2. If one (or more) root levels predominates for a given muscle, it (they) are underlined.

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MUSCLE: Abductor Digiti Quinti (hand) – ADQH
PERIPHERAL NERVE: Ulnar (lower trunk, medial cord)
ROOT LEVELS: C8, T1
POSITIONING OF PATIENT: Arm at side, forearm fully supinated
LOCALIZATION: Directly at the medial border of the hand, at the midpoint
between the distal wrist crease and the metacarpophalangeal
crease.
ACTIVATION: Abduction of digit five

MUSCLE: Abductor Pollicis Brevis – APB

PERIPHERAL NERVE: Median (lower trunk, medial cord)
ROOT LEVELS: C8, T1
POSITIONING OF PATIENT: Arm at side, forearm fully supinated
LOCALIZATION: Parallel to first metacarpal shaft, in line with the mid-shaft of
the extended first phalanx of the thumb
ACTIVATION: Abduction of thumb i.e. movement of thumb out of the plane of
the palm
PITFALLS: Do not stray too far from the radial edge of the thenar
eminence. If the needle is too deep or too medial, it could be in
flexor pollicis brevis, the deep head of which is ulnar innervated.
NOTES: The motor units in APB are generally found close to the surface.
This muscle is painful to examine so don't bury the needle; use
no more than 1 cm of needle length.

MUSCLE: Anconeus - A
PERIPHERAL NERVE: Radial (middle and lower trunks, posterior cord)
ROOT LEVELS: C7, C8
POSITIONING OF PATIENT: Forearm lying across body
LOCALIZATION: Place your index finger on the lateral epicondyle, your middle
finger on the olecranon process and your thumb on the ulnar
shaft one-quarter of the distance down the forearm. These
three digits now outline anconeus.
ACTIVATION: Elbow extension
PITFALLS: None, if the above directions are followed.
NOTES: This muscle is essentially a distal extension of triceps, and is the
last muscle innervated by the radial nerve before the spiral
groove. It is therefore helpful with localization of spiral groove
lesions.

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MUSCLE: Biceps Brachii - BB
PERIPHERAL NERVE: Musculocutaneous (upper trunk, lateral cord)
ROOT LEVELS: C5, C6
POSITIONING OF PATIENT: Arm at side, elbow flexed to 300, forearm pronated
LOCALIZATION: Distal one-third of arm, directly into muscle belly, approaching
biceps from its lateral side
ACTIVATION: Elbow flexion with the forearm in supination
PITFALLS: Motor unit recruitment is often difficult, as biceps is a two joint
muscle whose primary action is also carried out by an adjacent
one joint muscle, brachialis. Consider using brachialis if you
have trouble recruiting motor units in biceps.

MUSCLE: Brachialis - BR
PERIPHERAL NERVE: Musculocutaneous (upper trunk, lateral cord)
ROOT LEVELS: C5, C6
POSITIONING OF PATIENT: Arm at side, elbow flexed to 30°
LOCALIZATION: In the distal one-third of the arm, push the biceps medially and
insert the needle just lateral to the lateral border of biceps and
aim slightly downward.
ACTIVATION: Elbow flexion
PITFALLS: The cephalic vein lies between biceps and triceps, and can be
inadvertently pierced by the needle while examining brachialis.

MUSCLE: Brachioradialis - B
PERIPHERAL NERVE: Radial (upper trunk, posterior cord)
ROOT LEVELS: C5, C6
POSITIONING OF PATIENT: Forearm fully supinated. Place your index finger in the
antecubital fossa, pointing proximal.
LOCALIZATION: Brachioradialis is the first muscle lateral to your finger,
anywhere from the elbow crease to the apex of the fossa.
ACTIVATION: Elbow flexion with the forearm in mid pronation-supination
PITFALLS: If the needle is placed too lateral it could be in the wrist
extensors. If it is too distal and too deep, it could be in flexor
pollicis longus.
NOTES: Brachioradialis is the first muscle innervated by the radial nerve
after its course through the spiral groove; therefore it can be
helpful for localization of radial palsies. The motor units tend to
be small and spiky.

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MUSCLE: Deltoid - D
PERIPHERAL NERVE: Axillary (upper trunk, posterior cord)
ROOT LEVELS: C5, C6
POSITIONING OF PATIENT: Arm at side
LOCALIZATION: One-third of way down the line between the acromion process
and deltoid insertion.
ACTIVATION: Arm abduction
NOTES: The above approach is for the middle deltoid fibers. The
anterior or posterior fibers can also be studies independently if
needed, for example with an axillary neuropathy.

MUSCLE: Diaphragm - DIA

PERIPHERAL NERVE: Phrenic
ROOT LEVELS: C3, C4, C5, (C6)
POSITIONING OF PATIENT: Supine
LOCALIZATION: Depress the abdomen with your extended fingers so that the
skin is pulled down across the costal margin. Immediately
lateral to the midclavicular line, insert the electrode parallel to
the body surface, hugging the undersurface of the rib cage. The
origin of the abdominal muscles will be reached first, at about 1
to 1-1/2 cm. Insert the electrode beyond this point, and the
diaphragm is reached anywhere from 2-1/2 to 4 cm in from the
skin.
ACTIVATION: Respiration
PITFALLS: Do not attempt to put a needle in the diaphragm if the patient
is quite obese. You will need to be able to depress the
abdomen enough to insert the needle below the level of the
ribs, yet fairly parallel with the body surface.

MUSCLE: Extensors Carpi Radialis Longus and Brevis - ECRL, ECRB

PERIPHERAL NERVE: Radial (upper and middle trunks, posterior cord)
ROOT LEVELS: C6, C7
POSITIONING OF PATIENT: Forearm fully pronated, elbow flexed to 30◦
LOCALIZATION: Visualize the line connecting the lateral epicondyle and the
radial styloid process. The wrist extensors are approached at
the point 25% of the distance down this line, i.e. closer to the
epicondyle.
ACTIVATION: Wrist extension
PITFALLS: If the needle is too lateral, it will be in brachioradialis. If the
needle is too medial, it will be in extensor digitorum communis.
NOTES: ECRL and ECRB are not usually distinguishable in electro-
myography.

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MUSCLE: Extensor Carpi Ulnaris - ECU
PERIPHERAL NERVE: Posterior interosseous branch of radial (middle and lower
trunks, posterior cord)
ROOT LEVELS: C7, C8
POSITIONING OF PATIENT: Forearm fully pronated or forearm lying across stomach
LOCALIZATION: Proximal one-half of forearm, immediately dorsal to the ulnar
shaft
ACTIVATION: Wrist extension combined with ulnar deviation
PITFALLS: The needle inserted too laterally will be in extensor digitorum
communis.

MUSCLE: Extensor Digitorum Communis - EDC

PERIPHERAL NERVE: Posterior interosseous branch of radial (middle and lower
trunks, posterior cord)
ROOT LEVELS: C7, C8
POSITIONING OF PATIENT: Forearm fully pronated
LOCALIZATION: Brachioradialis and the radial wrist extensors (ECRL, ECRB)
comprise a “moveable mass”. Just medial to this group is a
groove separating it from EDC, which itself is relatively
immoveable. The electrode is therefore inserted just medial to
and parallel to that groove, in the proximal one-half of the
forearm.
ACTIVATION: Extension of digits 2 through 5
PITFALLS: If the needle is too lateral, it will be in the wrist extensors. If it
is too medial, it can be in the extensor carpi ulnaris. Insertion
too distally could result in the needle being in the tendons of
EDC or in the thumb extensors.
NOTES: EDC is the first muscle innervated by the posterior interosseous
nerve after the nerve emerges from supinator.

MUSCLE: Extensor Pollicis Longus - EPL

PERIPHERAL NERVE: Posterior interosseous branch of radial (middle and lower
trunks, posterior cord)
ROOT LEVELS: C7, C8
POSITIONING OF PATIENT: Forearm fully pronated
LOCALIZATION: Insert the needle at the junction of the middle and lower thirds
of the dorsal forearm, midway between the ulna and radius.
ACTIVATION: Extension of distal phalanx of thumb
PITFALLS: If the needle is placed too medial (toward the ulna), it can be in
extensor indicis.
NOTES: It can be difficult to separate the EPL from abductor pollicis
longus or extensor pollicis brevis, but the peripheral nerve and
root level innervations are the same.

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MUSCLE: First Dorsal Interosseous (hand) - FDIH
PERIPHERAL NERVE: Ulnar (lower trunk, medial cord)
ROOT LEVELS: C8, T1
POSITIONING OF PATIENT: Arm at side, forearm in neutral i.e. midway between pronation-
supination, i.e. resting on ulnar border of hand
LOCALIZATION: Needle is inserted parallel to second metacarpal shaft, directly
into the bulk of the muscle. The muscle can be approached
from its distal or proximal end.
ACTIVATION: Abduction of the second digit
PITFALLS: If FDIH is quite atrophic, the needle could enter adductor
pollicis (also ulnar innervated) or the thenar group (mostly
median innervated).
NOTES: FDIH tends to have large motor units. If motor unit morphology
and recruitment at a gain of 500 microvolts/div looks like other
muscles on 200 microvolts, call it normal.

MUSCLE: Flexor Carpi Radialis - FCR

PERIPHERAL NERVE: Median (upper and middle trunks, lateral cord)
ROOT LEVELS: C6, C7
POSITIONING OF PATIENT: Forearm fully supinated
LOCALIZATION: Place your index finger in the antecubital fossa, pointing
proximal. Flexor Carpi Radialis is the first muscle medial to your
finger at the level of the apex of the antecubital fossa.
ACTIVATION: Wrist flexion
PITFALLS: If the needle is too proximal, it will be in pronator teres. If it is
inserted too distal, it will be in flexor digitorum superficialis.

MUSCLE: Flexor Carpi Ulnaris - FCU

PERIPHERAL NERVE: Ulnar (lower trunk, medial cord)
ROOT LEVELS: C8, T1
POSITIONING OF PATIENT: Forearm fully supinated
LOCALIZATION: Proximal one-third of forearm, directly medial
ACTIVATION: Wrist flexion with ulnar deviation
PITFALLS: The needle must be inserted directly at the medial border of the
forearm. If it is too anterior (by far the most common mistake
when attempting to study FCU), it will be in flexor digitorum
superficialis, a muscle innervated by the median nerve. If the
needle is too distal, the muscle becomes tendinous and
aponeurotic. Additionally, this is a very thin muscle so the
needle must stay quite superficial. It is important that the
muscle stay in FCU rather than flexor digitorum profundus (see
note #1 below).

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NOTE #1: FCU is occasionally innervated above the point of entrapment in
ulnar neuropathies "at the elbow". Flexor digitorum profundus
is always innervated below the point of entrapment in these
situations and is therefore a "safer" muscle to examine to
localize an ulnar neuropathy to the elbow.
NOTE #2: FCU is often described as having C7 innervation. This is only
possible in the 15% or so of anomalous cases where the ulnar
nerve receives a contribution from the lateral cord. Otherwise,
all ulnar-innervated muscles are purely C8, T1, from the lower
trunk and medial cord.

MUSCLE: Flexor Digitorum Profundus-Ulnar (Medial) Heads - FDP

PERIPHERAL NERVE: Ulnar (lower trunk, medial cord)
ROOT LEVELS: C8, T1
POSITIONING OF PATIENT: Forearm pronated and lying across abdomen
LOCALIZATION: Middle one-third of forearm, immediately medial to the ulnar
shaft
ACTIVATION: Flexion of the distal phalanges of digits four and five
NOTES: In the anatomic position, the flexor forearm is the medial one-
half, not the ventral one-half; the extensor forearm is the lateral
one-half, not the dorsal one-half. The ulnar shaft divides these
territories on the dorsal side in the proximal forearm. FDP is
not reachable with the forearm supinated, as the ulnar shaft
will be directly against the table.

MUSCLE: Flexor Pollicis Longus - FPL

PERIPHERAL NERVE: Anterior interosseus branch of median (middle and lower
trunks, lateral and medial cords)
ROOT LEVELS: C7, C8
POSITIONING OF PATIENT: Forearm in full supination
LOCALIZATION: Place your index finger along the course of the superficial radial
artery in the distal forearm, with the tip of your finger pointing
proximal. Follow that line up to the mid forearm. The pulse is
no longer palpable here as the artery is covered by
brachioradialis. The artery overlies FPL, so the needle is
inserted just lateral to your finger, aiming downward and
medial.
ACTIVATION: Flexion of distal phalanx of thumb
PITFALLS: If the needle is too superficial, it will lie in brachioradialis.

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MUSCLE: Infraspinatus - IN
PERIPHERAL NERVE: Suprascapular (upper trunk)
ROOT LEVELS: C5, C6
POSITIONING OF PATIENT: Side lying, arm draped across front of body
LOCALIZATION: Halfway between the scapular spine and the inferior tip of the
scapula, midway between the lateral and medial borders of the
scapula. That is, directly in the center of the infraspinous fossa.
ACTIVATION: External rotation of arm. Activation is usually possible simply by
having the patient lift the arm off the table.
PITFALLS: Rarely, the lateralmost fibers of infraspinatus are innervated by
the axillary nerve after it supplies teres minor. Avoid studying
the lateral fibers of infraspinatus for this reason.

MUSCLE: Latissimus Dorsi - LAT

PERIPHERAL NERVE: Thoracodorsal -Middle Subscapular (upper, middle, lower
trunks, posterior cord)
ROOT LEVELS: C6, C7, C8
POSITIONING OF PATIENT: Supine or side lying
LOCALIZATION: Posterior axillary fold, directly lateral to the inferior tip of the
scapula
ACTIVATION: Extension/adduction of humerus
PITFALLS: The needle inserted too superior and medial might be in the
teres major or minor.

MUSCLE: Paraspinals - Cervical - PC

PERIPHERAL NERVE: Posterior Primary Rami
ROOT LEVELS: C1 through T1
POSITIONING OF PATIENT: Side lying on opposite side, neck fully flexed and supported by a
pillow. The shoulder should be dropped loose by the side and
relaxed.
LOCALIZATION: The cervical paraspinals are oriented downward and outward
from the spinous processes at an angle approaching 45◦. Low
cervical paraspinal muscles are, therefore, examined adjacent
to the T1 spinous process. The electrode is inserted
perpendicular to the skin and must travel through trapezius
before reaching the paraspinals. This transition is usually easily
seen, felt and heard, as there is a fascial plane separating the
two, and motor units are often seen in trapezius.
ACTIVATION: Gentle neck extension, with the needle in subcutaneous tissue
first
PITFALLS: This is perhaps the most difficult group of muscles to relax.
Gentle neck flexion is occasionally helpful in relaxing the
extensors, i.e. the paraspinals.

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MUSCLE: Pectoralis Major - PM
PERIPHERAL NERVE: Medial and lateral pectoral nerves (middle and lower trunks,
lateral and medial cords)
ROOT LEVELS: C7, C8, T1
POSITIONING OF PATIENT: Supine
LOCALIZATION: Anterior axillary fold, in direct vertical line with the coracoid
process
ACTIVATION: Adduction of humerus

MUSCLE: Pronator Quadratus - PRQ

PERIPHERAL NERVE: Anterior interosseous branch of median (middle and lower
trunks, lateral and medial cords)
ROOT LEVELS: C7, C8, T1
POSITIONING OF PATIENT: Arm at side, forearm fully supinated, wrist flexed
LOCALIZATION: The muscle width is the same as its length, covering the distal
20% or so of the forearm, anterior to the interosseous
membrane. Insert the electrode just anterior to the ulnar shaft
and perpendicular to it.
ACTIVATION: Forearm pronation
PITFALLS: Without the wrist flexed, the ulnar nerve and artery can be
easily pierced by the electrode.
NOTES: Never approach PRQ directly from the volar forearm. Flexor
tendons and the median nerve are in the way.

MUSCLE: Pronator Teres - PRT

PERIPHERAL NERVE: Median (upper and middle trunks, lateral cord)
ROOT LEVELS: C6, C7
POSITIONING OF PATIENT: Forearm fully supinated
LOCALIZATION: With the index finger in the antecubital fossa pointing proximal,
pronator teres is the first muscle medial to your finger,
immediately distal to the antecubital vein.
ACTIVATION: Elbow flexion or, if necessary, forearm pronation
PITFALLS: A common mistake is for the needle to be inserted too distally,
in which case it will be in flexor carpi radialis. If the needle is
inserted too medially, it will be in either flexor carpi ulnaris or
flexor digitorum superficialis.
NOTES: Pronator Teres is often mistakenly used to rule out a proximal
median neuropathy, e.g. pronator syndrome, when carpal
tunnel syndrome is present. Generally, a muscle naming a
syndrome is spared in that syndrome. For example, the branch
to pronator teres comes off the median nerve before the
muscle entraps the nerve in pronator syndrome. Use flexor
carpi radialis in this situation.

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MUSCLE: Rhomboid Major - RM
PERIPHERAL NERVE: Dorsal Scapular
ROOT LEVELS: (C4), C5-directly from nerve root
POSITIONING OF PATIENT: Prone, elbow bent so hand is resting under abdomen or resting
in the small of the back
LOCALIZATION: Midway between the medial scapular border and spinous
processes, adjacent to (medial to) the level of the scapular spine
ACTIVATION: Scapular adduction, i.e. patient lifts elbow off table
PITFALLS: It can be very difficult to differentiate rhomboid from the more
superficial middle trapezius. In well muscled individuals, the
fascial plane between the two can usually be perceived on
needle insertion.
NOTES: Rhomboid is often discussed as the only muscle easily studied
on electromyography that is supplied by one nerve root level
only (C5). The dorsal scapular nerve comes directly off the C5
root, but occasionally also gets a contribution from the C4 root.

MUSCLE: Serratus Anterior - SA

PERIPHERAL NERVE: Long thoracic
ROOT LEVELS: C5, C6, C7
POSITIONING OF PATIENT: Lying on opposite side, arm stretched across table in front of
body
LOCALIZATION: In the mid or anterior axillary line, isolate one rib by placing two
fingers in two interspaces just anterior to the bulk of latissimus
dorsi. Needle insertion is directly between your fingers, as
serratus anterior is the only muscle between the skin and the
rib at that point. It lies directly on the surface of the rib.
ACTIVATION: Elevation and reaching forward with the arm; providing
resistance is sometimes necessary.
PITFALLS: 1. Keep your fingers in place in interspaces during needle
examination, to avoid slippage of the needle and possible
pneumothorax, which has been reported.

2. Serratus anterior can be difficult to isolate in an obese

patient, because of the difficulty palpating the ribs.

3. Do not attempt to approach serratus anterior at the medial,

inferior scapular border, as some books describe. First of all, it
is nearly impossible to direct the needle from anterior to
posterior as would be necessary, and second, it is impossible to
differentiate the action of serratus (i.e. shoulder protraction)
from that of subscapularis, which lies directly beneath it at this
point.

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MUSCLE: Supraspinatus - SS
PERIPHERAL NERVE: Suprascapular (upper trunk)
ROOT LEVELS: C5, C6
POSITIONING OF PATIENT: Lying on opposite side of body, arm at side
LOCALIZATION: At the medial one-third of the scapular spine, insert the needle
immediately superior to the scapular spine. Aim the electrode
perpendicular to the skin, not parallel to it.
ACTIVATION: Arm abduction
PITFALLS: Pneumothorax has been reported with needle examination of
supraspinatus. In thin patients, be certain to direct the needle
toward the depth of the suprascapular fossa and not in a
horizontal plane.

MUSCLE: Trapezius-Middle - TRAP

PERIPHERAL NERVE: Spinal accessory (cranial nerve 11), cervical plexus
ROOT LEVELS: CN11, C3, C4
POSITIONING OF PATIENT: Prone
LOCALIZATION: Directly medial to the medial edge of the scapular spine. Keep
the electrode superficial, just under subcutaneous tissue.
ACTIVATION: Scapular adduction
PITFALLS: If needle insertion is too deep, it will be in the rhomboid. On
needle insertion, particularly in well muscled individuals, one
can sometimes feel the fascial plane between trapezius and
rhomboid. Activation of these two muscles is the same.

MUSCLE: Trapezius-Upper - TRAP

PERIPHERAL NERVE: Spinal accessory (cranial nerve 11), cervical plexus
ROOT LEVELS: CN11, C3, C4
POSITIONING OF PATIENT: Side lying, arm at side
LOCALIZATION: Superior border of shoulder, immediately medial to
acromioclavicular joint
ACTIVATION: Shoulder elevation
PITFALLS: Avoid inserting the needle too medially, i.e. toward the base of
the neck, as it could enter levator scapula at this point.
NOTES: Some controversy exists about whether the innervation from
the cervical plexus, C3,4, is just proprioceptive or also motor.
Most anatomists believe that motor function to trapezius is
purely or primarily supplied by the spinal accessory nerve.

MUSCLE: Triceps - T
PERIPHERAL NERVE: Radial (upper, middle, lower trunks, posterior cord)
ROOT LEVELS: C6, C7, and C8
POSITIONING OF PATIENT: Forearm across body but with elbow still resting on table
LOCALIZATION: Distal one-third of arm, directly in line with lateral epicondyle.
This approach is to the lateral head.
ACTIVATION: Elbow extension
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MUSCLE: Abductor Hallucis - AH
PERIPHERAL NERVE: Medial plantar branch of tibial
ROOT LEVELS: S1, S2
POSITIONING OF PATIENT: Supine
LOCALIZATION: Halfway between the prominence of the navicular bone and the
plane of the sole. Insert the electrode parallel to the long axis
of the foot.
ACTIVATION: Can be difficult. Ask the patient to fan or curl the toes.
PITFALLS: AH, being superficially placed, is quite susceptible to local
trauma. The isolated presence of scattered fibrillation
potentials in AH should not be taken as significant. First dorsal
interosseous (pedis) is preferred as a distal muscle to screen for
polyneuropathy, being both more distal and less susceptible to
local trauma than AH.

MUSCLE: Adductor Longus - AL

PERIPHERAL NERVE: Obturator
ROOT LEVELS: L2, L3, L4
POSITIONING OF PATIENT: Supine, thigh slightly abducted
LOCALIZATION: Directly medial, in proximal 20% of thigh
ACTIVATION: Thigh adduction
PITFALLS: By far the most common mistake is needle placement too distal.
The electrode can easily enter adductor magnus, which is partly
innervated by the sciatic nerve.
NOTES: This muscle is critical when differentiating an L3 or L4 root
lesion or lumbar plexopathy from a femoral mononeuropathy.

MUSCLE: Anterior Tibialis - AT

PERIPHERAL NERVE: Deep branch of peroneal
ROOT LEVELS: L4, L5
POSITIONING OF PATIENT: Supine
LOCALIZATION: At the junction of the middle and upper thirds of the leg, one-
quarter of the distance from the tibial shaft to the lateral border
of the leg.
ACTIVATION: Ankle dorsiflexion. The patient will sometimes reflexively
extend the toes in the same motion, and extensor digitorum
longus can substitute for anterior tibialis. If necessary, hold the
toes in flexion while the patient dorsiflexes the ankle.
PITFALLS: A needle placed too laterally can be in extensor digitorum
longus.

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MUSCLE: Biceps Femoris - Short Head - SHB
PERIPHERAL NERVE: Common Peroneal
ROOT LEVELS: L5, S1
POSITIONING OF PATIENT: Prone. Pillow under ankle for relaxation if necessary.
LOCALIZATION: At the level of the superior crease of popliteal fossa,
immediately medial or lateral to the tendon of biceps-long
head. At this distal level, long head is tendinous, short head is
muscular.
ACTIVATION: Knee flexion
PITFALLS: The most common mistake is needle insertion too proximal,
where long head and short head are both muscular. At this
level, the peroneal innervated short head cannot be
differentiated from the sciatic innervated long head.
NOTES: Short head of biceps is usually only examined when localizing a
peroneal injury to the fibular head, in which situation short
head is spared.

MUSCLE: Extensor Hallucis Longus - EHL

PERIPHERAL NERVE: Deep branch of peroneal
ROOT LEVELS: L5, S1
POSITIONING OF PATIENT: Supine
LOCALIZATION: At the junction of the middle and lower thirds of the leg, one-
third of the distance from the tibial shaft to the lateral border of
the leg. The needle is directed down and medial, under the
tendon of anterior tibialis.
ACTIVATION: Great toe extension - be certain the needle has been pulled
back into subcutaneous tissue before the patient contracts this
muscle.
PITFALLS: If the needle is inserted too close to the tibial shaft, it will pierce
the thick tendon of anterior tibialis.

MUSCLE: External Hamstring - EH

PERIPHERAL NERVE: Long head – sciatic; Short head - common peroneal
ROOT LEVELS: Long head - L5, S1, S2
Short head - L5, S1
POSITIONING OF PATIENT: Prone
LOCALIZATION: At mid-thigh, just medial to the palpable groove between vastus
lateralis and external hamstring.
ACTIVATION: Knee flexion. Make sure the electrode is in subcutaneous tissue
first.
PITFALLS: The hamstring muscles are harder to differentiate when the
patient is side lying, as the muscles tend to sag together toward
the table.

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MUSCLE: First Dorsal Interosseous (Pedis) - FDIP
PERIPHERAL NERVE: Lateral plantar branch of tibial
ROOT LEVELS: S1, S2
POSITIONING OF PATIENT: Supine
LOCALIZATION: Place your index finger on the dorsum of the web space
between the first and second toes, pointing distal. Pull your
finger from distal to proximal until it wedges between the first
two metatarsal heads. Insert the electrode immediately distal
to your finger and angle it toward the second toe.
ACTIVATION: Have the patient curl or fan the toes to attempt activation.
Some patients cannot voluntarily activate the FDIP.
PITFALLS: This muscle is often atrophic in chronic neurogenic conditions.
The needle can easily be moved too ventrally, and will be near
the intrinsic muscles on the flexor side of the foot.
NOTES: Needle examination of the FDIP is probably the most sensitive
indicator of early, distal motor denervation. Buried in the web
space, FDIP is not nearly as subject to local trauma as abductor
hallucis and, especially, extensor digitorum brevis.

MUSCLE: Gluteus Maximus - GMX

PERIPHERAL NERVE: Inferior Gluteal
ROOT LEVELS: L5, S1, S2
POSITIONING OF PATIENT: Prone
LOCALIZATION: Midpoint of line connecting posterior inferior iliac spine (PIIS)
and greater trochanter.
ACTIVATION: Hip extension. Flex knee to 90◦ to minimize hip extensor action
of hamstrings, then have patient lift knee off table.
Alternatively, hip abduction.
PITFALLS: The sciatic nerve lies medial and distal to the correct insertion
point for gluteus maximus.
NOTES: In very obese patients, gluteus maximus can still usually be
reached immediately next to and at the superior extent of the
gluteal crease.

MUSCLE: Gluteus Medius - GMD

PERIPHERAL NERVE: Superior Gluteal
ROOT LEVELS: L4, L5, S1
POSITIONING OF PATIENT: Supine
LOCALIZATION: The anterior border of gluteus medius is defined by the line
between the anterior superior iliac spin, (ASIS) and greater
trochanter. The needle is inserted parallel to this line, at its
midpoint, and just inside (i.e. posterior to) the line.

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ACTIVATION: Internal rotation of thigh. Insertion of the electrode as
described above places it in the anterior fibers of gluteus
medius, allowing internal rotation to be used for activation.
This motion can be carried out smoothly, as opposed to thigh
abduction which is a cruder motion, and which less easily allows
for smooth recruitment of motor units.
PITFALLS: The needle placed too anterior will be in tensor fascia lata,
although this muscle has the same nerve root and peripheral
nerve innervation.
NOTES: Gluteus medius is always accessible to the needle electrode,
regardless of how obese the patient is. The skin is always
adherent to ASIS, with little fat overlying, and gluteus medius
can be approached there.

MUSCLE: Iliopsoas - IL
PERIPHERAL NERVE: Femoral
ROOT LEVELS: L2, L3
POSITIONING OF PATIENT: Supine
LOCALIZATION: Immediately distal to the inguinal ligament, half way between
the femoral pulse and ASIS. This is one muscle in which the
needle generally cannot be inserted parallel to the fibers.
ACTIVATION: Hip flexion
PITFALLS: The femoral nerve and artery lie medial to the point of correct
needle insertion.

MUSCLE: Internal Hamstring - IH

PERIPHERAL NERVE: Sciatic
ROOT LEVELS: L4, L5, S1
POSITIONING OF PATIENT: Prone
LOCALIZATION: Level of mid-thigh, at or just medial to the posterior midline of
thigh
ACTIVATION: Knee flexion. Make sure needle is subcutaneous tissue first.

MUSCLE: Medial Gastrocnemius - MG

PERIPHERAL NERVE: Tibial
ROOT LEVELS: L5, S1, S2
POSITIONING OF PATIENT: Supine
LOCALIZATION: Medial border of leg, midway between knee and ankle
ACTIVATION: Ankle plantarflexion. Medial gastrocnemius can be very difficult
to activate because soleus, immediately underneath, is a one
joint muscle with the same action, therefore at a better
mechanical advantage.
NOTES: Motor units tend to be large in MG; they are probably normal if
they appear otherwise normal in morphology and recruitment
on a gain of 500 microvolts.

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MUSCLE: Paraspinals - Lumbosacral - PLS
PERIPHERAL NERVE: Posterior Primary Rami
ROOT LEVELS: L1 through S1
POSITIONING OF PATIENT: Prone, pillow under hips for relaxation if necessary
LOCALIZATION: Adjacent to the appropriate level, and along the line that
parallels the spine and runs through the posterior superior iliac
spine. When possible, examine the deeper layers of the
paraspinal muscles, because less root level overlap occurs there.
ACTIVATION: Gentle arching of the low back into lordosis; make certain the
needle is in subcutaneous tissue first. Look at voluntary motor
units only if this is important in the overall electrodiagnostic
picture; it often isn't.
NOTE #1: Lumbosacral paraspinals are generally more relaxed when the
patient is prone, and both sides can be examined without
changing position.
NOTE #2: S1 is definitely represented in the paraspinals, controversy
exists about S2. If there is S2 representation, it is likely
inconsistent and incomplete.

MUSCLE: Peroneus Longus - PL

PERIPHERAL NERVE: Superficial branch of peroneal
ROOT LEVELS: L5, S1
POSITIONING OF PATIENT: Supine or side lying
LOCALIZATION: Straddle the fibular head with your index and middle fingers,
pointing proximal. Pull straight down to the junction of the
upper and middle thirds of the leg and your fingers will be
surrounding peroneus longus.
ACTIVATION: Eversion/plantarflexion of ankle
PITFALLS: The fibular head can be difficult to palpate in a very obese
patient.

MUSCLE: Posterior Tibialis - PT

PERIPHERAL NERVE: Tibial
ROOT LEVELS: L5, S1
POSITIONING OF PATIENT: Supine
LOCALIZATION: Junction of middle and lower thirds of leg, directly along tibial
shaft, i.e. anterior to the soleus muscle.
ACTIVATION: Plantar flexion/inversion of ankle. The needle inserted too
proximal will be in flexor digitorum longus, with the same
peripheral nerve and root level innervation.
PITFALLS: In heavily muscled individuals, it may be impossible to reach
posterior tibialis, as the muscle is buried between the tibia and
fibula, lying on the interosseous membrane.
NOTES: Controversy exists about whether PT can be reliably reached. It
can in the majority of individuals, provided the distal placement
noted above is used.
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MUSCLE: Quadriceps-Vastus Medialis - VM
PERIPHERAL NERVE: Femoral
ROOT LEVELS: L3, L4
POSITIONING OF PATIENT: Supine
LOCALIZATION: The distal 20% of the medial thigh. At this level, the oblique
fibers of vastus medialis are angled at nearly 45◦ toward the
patella, and the needle should parallel them.
ACTIVATION: Have the patient push the back of the knee into the table, or if
necessary, lift the leg off the table with the knee straight.
PITFALLS: If the needle is too proximal and posterior, it could be in the
medial hamstring or adductor magnus, innervated by different
nerves.
NOTES: The vastus lateralis (VL) portion of quadriceps can also be
examined. The advantage is that it is a huge, bulky muscle,
impossible to miss on the lateral thigh. Disadvantages include
the fact that the needle needs to pierce the iliotibial band to
reach VL, and the lateral quadriceps is not as easy to activate as
the medial, when the knee is already in full extension, as when
the patient is supine.

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