Legal Report

Medico-Legal Journal
2017, Vol. 85(1) 2332
! The Author(s) 2016
The assessment of grip strength Reprints and permissions:
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after upper limb injuries DOI: 10.1177/0025817216681690
journals.sagepub.com/home/mlj
in medico-legal practice

HJCR Belcher

Abstract
Four hundred adult claimants underwent medico-legal assessment following upper limb injuries. Dynamometry was
performed on each using the Jamar five handle-position test. Injury causes loss of power and there is a significant
relationship between the percentage loss of power and the measured whole limb impairment. This paper presents a
new approach for the analysis of the tests. The normal physiological lengthtension pattern of muscle is maintained in the
majority of claimants albeit with modifications due to the specific effects of injury on hand function. This paper provides
normative data for the analysis of dynamometry in this population and makes recommendations for parameters that
suggest that a test is a true reflection of capacity and thus useable in court.

Keywords
Dynamometry, grip strength, Jamar, hand injury, medicolegal, assessment, disability, sub-maximal, malingering

Dynamometry is only valid when a patient exerts a

Introduction maximal voluntary eort. It has been noted that
One of the purposes of a medico-legal report is to pro-
vide the court with an assessment of disability resulting It is a common misconception that all tests that gener-
from an injury. The mainstay of the assessment of func- ate numbers are necessarily objective. This is particu-
tional outcome from a hand injury is clinical examin- larly true of grip and pinch measurements. These tests
ation. This information is used by the expert to rely heavily on subject motivation and are therefore
comment on the ability of the claimant to perform subjective.1
their normal daily activities, to care for themselves, to
return to work and to compete on the open job market. A number of technical approaches have been adopted
This information is used to calculate the quantum of to detect sub-maximal eort.2 These include repetitive
the claim. testing, the rapid exchange and the rapid simultaneous
Hand function is a product of sensation, movement grip strength tests. Although these have been reported
and power. Loss of power is a common complaint to detect feigned hand weakness, they are relatively
amongst claimants. Measuring grip strength is a logical time-consuming and rarely performed properly in the
and seemingly objective approach to assessing this com- clinical setting.
plaint. The most widely used method of assessing Muscle contractions can be described based on two
power is the measurement of grip strength using a variables: length and tension. Muscles achieve their
Jamar dynamometer (Figure 1). This is an adjustable greatest active tension when close to an ideal length,
hand-held device that measures grip strength over ve
settings varying from 1 38 to 3 38 inches, in half-inch
increments. It is isometric in use, with almost no per- Basing House, Furnace Lane, Cowden, Kent, UK
ceptible motion of the handles, regardless of grip
Corresponding author:
strength. A muscle contraction is described as isometric HJCR Belcher, Independent Hand Surgeon, Basing House, Furnace Lane,
if the muscle tension changes but the muscle length Cowden, Edenbridge, Kent TN8 7JU, UK.
remains the same. Email: harry.belcher@nhs.net
24 Medico-Legal Journal 85(1)

which is usually their resting length. When stretched or the ve settings as a ratio of either the maximum read-
shortened beyond this, whether due to the action of the ing or the mean of the ve settings. This approach neg-
muscle itself or by an outside force, the maximum ates the dierence in power between curves and reveals
active tension generated decreases. The power gener- that although an injury to a hand diminishes power, the
ated by a muscle plotted against length exhibits a normal physiological curve is maintained.4,5
skewed bell-shaped curve3 (Figure 2). The physiological The loss of the bell-shaped curve was proposed by
characteristics of muscle are paralleled by the varying Stokes6 as a sign of feigning in his paper entitled The
power that can be applied over the ve settings of the seriously uninjured hand. In a subsequent paper, the
Jamar dynamometer; the maximum power being same author showed attening of the dynamometry
almost always achieved at either setting 2 or 3. power curves in patients suspected of being of low
Dierent approaches have been used to analyse the eort and volunteers who were deliberately feigning
data from the Jamar ve-position test to allow more weakness.7 Subsequent studies in volunteers who had
objective analysis. The visual analysis of the grip been instructed to feign weakness have not corrobo-
strength curves is subjective. As a result, a comparison rated these ndings.8,9 Nevertheless, the concept of a
of two curves with identical ratios but dierent power at curve has gained traction as evidence of sub-max-
can suggest erroneously loss of the normal physio- imal eort. Consequently, analytical techniques have
logical relationship between muscle length and power. focused exclusively on the issue of curve variation. It
The eect of varying power is solved by normalisation is, however, my experience that the curves obtained in
of the data by expressing the relationship of power at clinical and medico-legal dynamometry are often atyp-
ical rather than at.
I have previously alluded to the diculty in relying
on dynamometry results in medico-legal practice.10
It has been long recognised that the interpretation of
dynamometry results in clinical practice is hampered by
the absence of objective criteria for analysis.4 Much of
the technical literature on dynamometry has involved
studies on volunteers rather than patients. There are no
publications on the use and interpretation of dynamo-
metry in medico-legal practice. The purpose of this
review is to analyse the results of dynamometry in a
large group of patients undergoing medico-legal assess-
ment, to improve the methodology of interpretation
and to provide objective criteria of what is satisfactory
test performance.

Methods
A consecutive and unselected group of adult claimants
Figure 1. Front and side views of a Jamar dynamometer being who had suered unilateral upper limb injuries were
used on position-2. assessed for the purpose of the preparation of

Figure 2. The length tension relationship of muscle fibres (Adapted from Gordon et al.3).
Belcher 25

medico-legal reports. At the time of assessment, the

information obtained from the claimants and their
medical records included basic demographics, interval
from injury (months) and hand dominance. The clinical
examination was comprehensive and included the use
of goniometers for range of movement, monolament
hair and static two-point discrimination for sensation
as well as photography. Following examination, the
whole limb impairment was calculated from these nd-
ings according to published guidelines.11
Power testing was performed with a Jamar
dynamometer, utilising the ve handle-position test
(Figure 1). The tests were performed with the claimants
seated with their arms at their sides, the elbows exed
to 90 , the forearms mid-prone and wrists in neutral.
The test protocol comprised a single test at each Jamar
position. The sequence started from the rst and nar-
rowest position on the uninjured hand, followed by the
rst position on the injured hand, the second position
on the uninjured hand, etc. A number of calculations
were performed on the data obtained.

Maximum: The strongest result over the ve positions

was noted for each hand.
Position: The handle position of the maximum result
was identied and if for example this same reading
occurred at positions 2 and 3, the result has been
recorded as 2.5.
Mean: The average of the ve results was calculated for Figure 3. (a) The grip strength at the five positions of both
each hand. hands of a male claimant plotted showing the power exerted at
Dierence: The percentage dierence of the maximum each handle position. The method of calculation of the curve
variation score is shown. (b) The normalised curve for the
power between the injured and uninjured hands was
injured hand is plotted and compared with the mean values for
calculated by the formula (Pinjured  Puninjured)/ the male population. The method of calculation of the curve
((Pinjured Puninjured)/2)  100 deviation score is shown.
Plotting: The grip strengths at the ve positions were
plotted on a graph to produce an power curve
(Figure 3). to provide a mean percentage score (Figure 3).
Normalisation: The curves obtained from the ve Statistical analysis is one-tailed as a score of zero
results in each hand were normalised by division indicates a perfect match. Increasing scores reect
of each value by the calculated mean. Two further increasing curve atypia.
calculations were made from the normalised values. Statistics: Comparisons between groups used the
Curve variation: The dynamism of the curves was Students t-test, Mann-Whitney, Chi-squared tests
assessed by calculation of the coecient of variation and analysis of variance; correlation calculations
between the ve results for each hand (standard devi- were performed by either the Pearson or
ation/mean) which was multiplied by 100 to produce Spearman tests as appropriate. Signicance has
a percentage score (Figure 3). Statistical analysis is been assessed at the 5% level. The results are pre-
two-tailed as low scores indicate attened curves sented as mean (standard deviation) or median
and high scores indicate atypical and eccentric curves. (25% and 75% percentiles) for data that was not
Curve deviation: The shape of the curves was assessed normally distributed.
by calculating the percentage dierences between
each of the ve normalised values and the mean
normalised values in all uninjured hands for that
Results
handle position. The results were corrected for sex
using the data presented below. The sum of the A total of 400 patients with a mean age of 39.1 (13.9)
absolute percentage dierences was divided by ve years with a male to female ratio of precisely 3:1 were
26 Medico-Legal Journal 85(1)

assessed at a mean of 21.4 (15.4) months after

Personal characteristics
injury. The median whole limb impairment score was There was a small but signicant dierence in shape of
9(220)%. curves between the sexes. These gures were used as
The maximum grip strength was signicantly reference values for the calculation of the curve devi-
reduced in injured hands compared with uninjured ation scores to provide greater precision (Table 1).
(all 30.5  13.1 vs. 43.9  11.8 kg, men 33.4  13.3 vs. The mean power varied across the age groups
48.5  9.7 kg, women 21.9  7.8 vs. 30.2  5.3 kg). The in both injured (<30 years 32.5  13.4, 3039 years
median loss of grip strength in injured hands was 32.8  13.1, 4049 years 31.9  14.5, 50 years
30(1360)%. This was not aected by gender, age or 24.9  10.8 kg, p < 0.001) and uninjured hands (<30
hand dominance. years 45.3  11.0, 3039 years 48.2  12.3, 4049 years
The normalised gures show a subtle and signicant 45.1  11.5, 50 years 36.8  9.3 kg, p < 0.001).
dierence in the shape of the curves between uninjured There were 364 right-handed claimants with injuries
and injured hands (Figure 4). to 195 dominant and 169 non-dominant hands. The 36
left-handed claimants had injuries to 19 dominant and
17 non-dominant hands. There were no signicant dif-
ferences in any measures due to dominance in either
injured or uninjured hands.

Injury type
Twelve injury groups were identied: amputation (71),
burn/laceration (21), complex (14), contusion/crush
(38), ngertip (27), fracture of ngers (26), fracture of
hand (19), fracture of wrist (42), nerve alone (30), nerve
and tendon (36), sprain (45) and tendon alone (31). The
whole limb impairment percentages varied signicantly
between the injury groups (Figure 5). These dierences
were broadly paralleled by the dynamometry results
(Figure 6).
In the 71 claimants who had sustained digital
amputations, there was a signicant relationship
between the loss of power and number of phalanges
removed (Figure 7). There were nine claimants
who had lost complete ngers comprising two central
ngers (2), index ngers (3), middle ngers (2) and
ring ngers (2). The median loss of power for
these four groups was 89%, 24%, 39% and 61%,
respectively.
The claimants who had sustained nerve injuries
included 27 who had divided their median (10), ulnar
(14) or both median and ulnar nerves (3), principally at
the wrist level. The median loss of power for these three
Figure 4. The mean measured and normalised grip strength for
groups was very uniform, being 47%, 42% and 43%,
the entire population. Note the subtle shift in the curves caused
by injury, which was significant at all points (p < 0.001).
respectively.

Table 1. The mean normalised values for the five handle positions in the uninjured hands for men and women.

Handle position 1 2 3 4 5

Male 0.80  0.14* 1.18  0.09* 1.14  0.1 1.02  0.08* 0.87  0.09*
Female 0.86  0.16 1.21  0.11 1.15  0.09 0.98  0.11 0.81  0.11
The values are significantly different at all but one position (*p < 0.001). These provided the reference values for the calculation of the curve deviation
in each sex.
Belcher 27

Figure 5. Median calculated functional impairment (75% percentiles) in the 12 injury groups with the overall median value
indicated by the vertical line (??p < 0.01).

Figure 6. Median power loss (75% percentiles) in the injured hands in the 12 injury groups with the overall median value indicated
by the vertical line (?p < 0.05, ??p < 0.01).

Handle position Curve physiology

The maximum grip was achieved at either position There was an increase in the curve variation observed in
2 or 3 in 99% of the uninjured hands. There was no injured hands compared with uninjured hands overall
dierence between the sexes. The injured hands (22.2(17.528.3)% vs. 19.0(15.423.0)%, p < 0.001).
had signicantly greater variation with peak grip There also was a signicant dierence in the curve
strength occurring in handle positions other than 2 deviation between injured and uninjured hands
and 3 in 16% of cases (Table 2). Deviation from (10.4(6.816.7)% vs. 7.1(5.010.2)%, p < 0.001). There
the positions 2 and 3 was signicantly correlated was no dierence in the curve variation and deviation
with loss of grip strength in the injured hands scores between any of the injury groups. All groups
(Figure 8). exhibited physiological curves despite the variety
28 Medico-Legal Journal 85(1)

Figure 7. Median power loss (75% percentiles) observed in the 71 injured hands compared with the number of phalanges lost
(there are 14 phalanges in each hand; three for each finger and two for each thumb). The number of patients in each group is indicated
within the columns (p < 0.001).

Table 2. The handle position at which the maximum grip was observed in the injured and uninjured hands in the entire population
showing dispersal from the central handle positions (p < 0.0001).

Handle position 1 1.5 2 2.5 3 3.5 4 4.5 5

Injured 6 1 148 38 149 10 33 5 10
Uninjured 0 1 233 56 101 5 4 0 0

of injuries. This was observed even in patients who had the reference range for normality representing 50% of
lost whole ngers or suered nerve injury albeit with the population. In 108 injured hands, both scores were
some alteration in curve proles (Figure 9). Curve within the normal range. Scores lying outside the 5%
physiology was unaected by gender, age or hand statistical level identify signicant outliers. At least one
dominance. score was outside these limits in 108 injured hands. In
the 69 hands that had abnormal curve variation, 8
exhibited attened curves and 61 had a variety of atyp-
Correlations ical curves (Figure 10). Comparison of the types of
There was a strong correlation between the loss of grip injury between the claimants whose curve physiology
strength in the injured hands and whole limb impair- was signicantly abnormal with those whose scores
ment (Table 3). Both the whole limb impairment and were within the normal interquartile range revealed the
power loss were correlated with the curve physiology in two groups to be very well matched. However, the
the injured hands as measured by curve variation and abnormal group were older (42  15 years vs. 36  13
deviation. Neither was correlated with curve physiology years, p 0.002), had a higher whole limb impairment
in the uninjured hands. There was, however, a signi- (14(329)% vs. 6(014)%, p < 0.001) and had greater
cant relationship between curve physiology between the power loss (55(2989)% vs. 17(938)%, p < 0.001) than
injured and uninjured hands. those with normal curve physiology.

Compliance Discussion
The 25% and 75% intervals for the curve variation and This paper describes the use of dynamometry as part of
curve deviation scores in the uninjured hands provide the assessment of an unselected and heterogeneous
Belcher 29

group of adult patients who were engaged in litigation

following both bony and soft tissue injuries of the
upper limb. It demonstrates that injury causes loss of
power and that there is a signicant relationship
between the percentage loss of power and the severity
of injury as judged by calculation of the whole limb
impairment. It has demonstrated the specic impact
of amputation and nerve injury on power.
It has been shown that although injury causes loss of
power, the physiological bell-shaped curve is main-
tained in the majority of claimants albeit with minor
modications due to the specic eects of injury on
hand function. This information is consistent with pre-
vious studies after injury.4,5 The subtle dierence in
curve shape between injured and uninjured hands has
been observed previously4 and may reect the eects of
denervation, the loss of digits, movement and tendon
function.
An obvious eect of injury is the change in the
handle position at which maximal grip strength was
applied in some injured hands. The correlation between
Figure 8. Power loss in all injured hands and the calculated
altered handle position and power loss can be explained
polynomial trend line for each Jamar handle position demon-
strating increased loss of power associated with maximum grip
by the loss of muscle eciency at wide and narrow
occurring at positions other than 2 and 3 (R 0.34, p < 0.001). positions. It is unlikely that any test with maximum
grip outside the central handle positions provides an

Figure 9. Mean measured and normalised power in the (a) 9 patients who had sustained amputation of one or more whole fingers
and (b) 27 patients who had sustained divisions of their median, ulnar or both nerves. The median curve variation and deviation scores
are provided for each population.
30 Medico-Legal Journal 85(1)

Table 3. Correlation between percentage power loss and the curve physiology measures in both injured and uninjured hands.

Curve Curve Curve Curve

variation variation deviation deviation
R value significance Power loss (injured) (uninjured) (injured) (uninjured)

Whole limb impairment 0.46 0.22 0.04 0.24 0.05

p < 0.0001 p < 0.0001 NS p < 0.0001 NS
Power loss 0.13 0.03 0.38 0.02
p < 0.01 NS p < 0.0001 NS
Curve variation (injured) 0.41 0.68 0.17
p < 0.0001 p < 0.0001 p < 0.001
Curve variation (uninjured) 0.30 0.41
p < 0.0001 p < 0.0001
Curve deviation (injured) 0.25
p < 0.0001

Figure 10. Three individual cases showing varieties of abnormal curves in injured hands. (a) A curve with normal dynamism but an
inverse non-physiological profile. (b) An atypical non-physiological curve. (c) A classic and absolute flat line.

accurate reection of that claimants true functional specically to address this failing. The design of this
abilities. The same dispersal of maximal handle settings measure is intuitive. It does not depend on sophisti-
has also been observed in normal volunteers who were cated statistical methodology and its calculation is
feigning weakness. It is suggested that the observation straightforward on widely available spreadsheet
of maximum grip at handle positions 1 or 5 is indicative software.
of feigning.9 Although very atypical curves are detectable by
The dynamometry data have been assessed by two either measure, the curve deviation measure has
further methods: one old and one new. The concept of proved capable of detecting atypia that would other-
measuring curve variation by one method or another wise be unmeasurable (Figure 10(a) and (b)).
has been previously described.12 This measure is Although this type of curve would be detected by
intended and is sensitive for the detection of a at visual inspection, the scoring system provides an object-
curve. However, it is not capable of detecting all atyp- ive method of identifying outliers.
ical curves, which are the more common occurrence. The purpose of this paper is to broaden the reper-
The curve deviation measure has been created toire for the assessment of dynamometry and to
Belcher 31

provide criteria by which a test result can be accepted as Eight claimants were identied who had at lines
a valid result and thus useable in court. Apart from with curve variations below the lower 5% limit. This
disability claims, I have in the past been asked to pro- group comprising seven men and one woman had a
vide evidence in three cases where there was doubt median whole limb impairment of 9%. Most had sus-
about the ability of the defendants with a previous his- tained signicant injuries excepting one, who although
tory of a hand injury to exert sucient pressure to hold complaining of ulnar nerve symptoms from a contusion
a knife, to pull a trigger and to strangle. It is therefore to the elbow region, had no objective signs of dys-
important for an expert to be condent that an assess- function. This claimant, who is illustrated in
ment of strength is valid. Figure 10(c), had grip strengths of 4 kg at each handle
In scientic circles, the level of proof to test a position. I have no doubt that this particular claimant
hypothesis is generally set at a 5% chance that any was feigning weakness. However, I am generally
observation would have happened by chance, equiva- cautious about attributing abnormal test results to
lent to about two standard deviations from the mean. malingering. Although the at line is apparently
In legal circles, the level of evidence required is pathognomic of malingering, I would argue that there
the balance of probabilities which is equivalent to may be logical reasons for this type of pattern in some
a likelihood of over 50%. With this in mind, I have situations. If the dynamometer is in contact with a
used measures that show the ranges that were neuroma in the rst web-space or there is a mechanical
observed in 50% of the normal hands. Therefore, problem in the wrist joint, the exertion of a given force
the results in an injured hand whose curve physiology will cause a uniform amount of pain, irrespective of the
falls within this range can in my opinion be accepted. handle position.
The results that fall outside the 50% levels cannot Test results have to be interpreted with regard to the
necessarily be relied upon. The results outside the clinical situation and pejorative labels avoided even if
5% level should be disregarded and may indicate sub- there is no other possible explanation for an atypical
maximal eort. result. It is not the experts role to determine motiv-
The results have shown that the dynamometry ation or label claimants but to give objective evidence
curves of only about a quarter of the injured hands to the court. If test results are inexplicable, it is su-
fall within a normal range as dened by the data cient to state that and to allow the court to draw its
obtained from the uninjured hands. Furthermore, own conclusions.
about one quarter of the injured hands had one or The curve analysis is dependent on the data from
both scores that were outside the 5% range. the uninjured hands being representative of normality.
Unintentional submaximal eort may be exerted as a The mean values obtained are a good match with
result of pain, fear of re-injury or what I refer to as loss those obtained by others in normal subjects.14 The
of condence. Intentional submaximal eort may be observation of minor but signicant dierence in
exerted for secondary gain. It has been previously esti- curve shape between women and men almost certainly
mated that the incidence of illness deception in medico- reects diering hand size and has been accounted for
legal practice and certain categories of benet claims is in the calculation of the curve deviation scores. I have
between 20 and 50%. The manifestations include symp- noted on many occasions that an erratic curve in an
tom exaggeration10 and submaximal eort on testing.13 injured hand is associated with some atypia in
The causes for curve atypia are multiple and will the contralateral uninjured hand. This impression
include the direct physical eects of an injury as well is supported by the signicant correlation in curve
as psycho-social factors. physiology shown between injured and injured hands.
The majority of abnormal curves were eccentric It is therefore possible that the data from this popula-
rather than at. Whilst some atypia is explicable due tion does not properly dene normal physiology.
to the direct eects of injury such as stiness or loss of Further studies in normal subjects are required either
tendon action, many of the curves obtained could not to verify or modify the reference ranges presented in
be explained on the basis of clinical examination or the this paper.
injuries sustained. There was, within the 400 claimants, Dynamometry using the Jamar ve-position tech-
a group of 82 who had no measurable disability and nique is a quick, simple and low-cost method of assess-
whose median power loss was 14.6%. Twenty of these ing power. It is important that clinical examination
patients had signicantly abnormal curve proles. provides valid information to allow calculation of
Although these patients may have had some residual quantum in civil claims and capacity in criminal
symptoms, scarring, numbness in functionally unim- cases. This paper has presented a new method for
portant areas and minor stiness, it is more dicult assessment and attempted to dene criteria by which
to explain curve atypia in them than in those in dynamometry can be judged to provide reliable results
whom there is obvious dysfunction or loss of a digit. to the court.
32 Medico-Legal Journal 85(1)

Declaration of conflicting interests 6. Stokes HM. The seriously uninjured hand weakness of
The author(s) declared no potential conicts of interest with grip. J Occup Med 1983; 25: 683684.
respect to the research, authorship, and/or publication of this 7. Stokes HM, Landrieu KW, Domangue B, et al.
article. Identification of low-effort patients through dynamo-
metry. J Hand Surg Am 1995; 20A: 10471056.
8. Niebuhr BR and Marion R. Detecting sincerity of effort
Funding when measuring grip strength. Am J Phys Med Rehabil
The author(s) received no nancial support for the research, 1987; 66: 1624.
authorship, and/or publication of this article. 9. Tredgett M, Pimble LJ and Davis TR. The detection of
feigned hand weakness using the five position grip
strength test. J Hand Surg 1999; 24B: 426428.
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