Clinical Neurophysiology Practice 4 (2019) 199–211

Contents lists available at ScienceDirect

Clinical Neurophysiology Practice

journal homepage: www.elsevier.com/locate/cnp

Review article

Needle EMG muscle identification: A systematic approach to needle

EMG examination q
Daniel L. Menkes ⇑, Robert Pierce
Oakland University William Beaumont School of Medicine, Beaumont Health, Royal Oak, MI, USA

a r t i c l e i n f o a b s t r a c t

Article history: The proper performance of needle electromyography (EMG) requires that the examiner obtain a brief but
Received 22 April 2019 comprehensive history, perform a directed examination and generate a short differential diagnosis as
Received in revised form 31 July 2019 part of the initial patient encounter. Equally as important is to set reasonable expectations for this study’s
Accepted 23 August 2019
performance as electronic media do not necessarily portray all of the nuances of an electrodiagnostic
Available online 21 October 2019
study. In addition to these preliminary steps, this minimonograph discusses equipment used in EMG
evaluations, EMG examination techniques, muscles commonly sampled, pain reduction techniques,
Keywords:
and special considerations that may require study modification such as anticoagulation, lymphedema,
Needle electromyography
Muscle sampling
obesity and supervening infection. Clinicians performing these studies will maximize useful data collec-
Electrodiagnosis tion while minimizing patient discomfort if all of these recommendations are followed.
Waveform analysis Ó 2019 Published by Elsevier B.V. on behalf of International Federation of Clinical Neurophysiology. This
Neuroanatomy is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/
4.0/).

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200
2. Clinical evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200
3. Preparing the patient for the study. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200
4. Selection of muscles for examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201
5. Anatomical localization of the muscle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201
6. Performing the EDX medicine consultation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201
6.1. Needle EMG techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201
6.2. Needle electrodes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201
6.3. Needle insertion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201
6.4. Needle movement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202
6.5. Data collection/EMG activity analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202
6.6. Resting muscle. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202
6.7. Contracting muscle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203
6.8. Other considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203
6.9. Pain control/minimization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203
6.10. Overview of adjunctive ultrasound . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203
7. Special considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 204
8. After the study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 204
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 204
Conflict of interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 204
Appendix A: Testing specific muscles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 204
Comments: Examining this muscle usually results in less discomfort to the patient than when the abductor pollicis brevis is examined. . . . 204
Rhomboid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205

q
Presented as a workshop at the AANEM annual meeting in Phoenix, AZ on September 13, 2017.
⇑ Corresponding author at: OUWB School of Medicine, 3555 West 13 Mile Road, Suite N120, Royal Oak, MI 48073, USA.
E-mail address: [email protected] (D.L. Menkes).

https://doi.org/10.1016/j.cnp.2019.08.003
2467-981X/Ó 2019 Published by Elsevier B.V. on behalf of International Federation of Clinical Neurophysiology.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
200 D.L. Menkes, R. Pierce / Clinical Neurophysiology Practice 4 (2019) 199–211

Comments: Spontaneous activity detected in this muscle will help to substantiate a C5 radiculopathy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205
Pronator teres . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205
Localization: Insert the needle 2–3 cm distal and 1 cm medial to the biceps brachii tendon (the edge of the muscle may be palpated in this
location). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205
Extensor indicis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205
Extensor digitorum [formerly the extensor digitorum communis] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205
Gluteus medius . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206
Adductor longus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206
Biceps femoris short head . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206
Fibularis longus (Peroneus longus) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206
Flexor digitorum longus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206
Tensor fascia lata. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206
First dorsal interosseous, pedis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206
Masseter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206
Appendix B. Reducing the discomfort of the needle examination. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207
Needle handling techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207
Patient interactions to optimize cooperation on clinical needle EMG . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207
Appendix C: Needle electrode types . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208
Concentric needle electrodes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208
Monopolar electrodes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208
Single-fiber electrodes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208
Appendix D: Special problems to consider prior to needle EMG. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208
Anticoagulants and bleeding disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208
Infection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209
Cardiac valvular disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209
Obesity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209
Skin considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209
A. Clinical evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209
B. Plan the study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209
C. Prepare the patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209
D. Needle EMG technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209
E. Evaluating insertional and spontaneous activity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 210
F. Evaluating voluntary activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 210
G. Special considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 210
H. Reducing the discomfort of the needle EMG . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 210
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 210

1. Introduction vider as well as any new diagnostic possibilities that arise during
one’s own abbreviated history and physical. Additional historical
A broad knowledge base is required for performing an electro- information may be obtained during the needle examination. This
diagnostic (EDX) medicine consultation. It includes understanding serves an additional purpose of distracting the patient from the
of anatomy, normal physiology, pathophysiology, EDX medicine discomfort of this portion of the examination.
techniques, basic principles of electricity, as well as signal process- It is important to include clinically-weak muscles during the
ing and analysis. A successful examination requires patient rapport needle examination. For example, if an L5 radiculopathy is sus-
and cooperation. A successful needle examination requires atten- pected and the extensor hallucis longus is the only weak muscle,
tion to a number of specific issues in a series of steps: it should be included in the study. You should also review the
results of any previous studies to help design selection and order
 Clinical evaluation of the muscles to test. One should plan the study to answer the
 Patient preparation questions as efficiently as possible with the least degree of patient
 Muscle selection discomfort.
 Muscle localization
 Muscle examination
 Special Considerations 3. Preparing the patient for the study

Most patients will have received information about the needle

2. Clinical evaluation examination prior to the study and may have a few questions.
Nonetheless, it is still helpful to explain that this examination dif-
The referring provider’s clinical history and physical examina- fers from the nerve conduction studies in that no external electrical
tion should be reviewed before beginning the EDX medicine con- stimuli are applied. The patient should also be informed that noth-
sultation. While not obligatory, it is recommended that verbal ing is inserted through the needle or removed from the needle as it
informed consent be obtained and documented prior to the perfor- will only be used to record muscle activity. One of the authors typ-
mance of any EDX procedure. It is strongly recommended that the ically explains needle electromyography (EMG) as a ‘‘muscle
examiner establish the salient features of the patient’s history microphone.” You should explain that the needle will be inserted
along with the performance of a directed examination in order to into a number of muscles and that there will be some discomfort,
verify or amend the initial clinical impression. A successful EDX which is unavoidable but generally well-tolerated. You should also
consultation will address the questions posed by the referring pro- explain that needles are discarded after each use. Do not use state-
 D.L. Menkes, R. Pierce / Clinical Neurophysiology Practice 4 (2019) 199–211 201

ments such as, ‘‘A fine wire electrode will be placed . . .” Many will  Needle EMG techniques
be caught unaware seconds later when they feel a needle stick, and  Data collection/EMG activity analysis
the patient will lose confidence in you. The patient will appreciate  Pain minimization
knowing approximately how long the study will take and how
many muscles will be examined. Prepare the skin over each muscle 6.1. Needle EMG techniques
with alcohol or other appropriate agent before needle insertion.
Although this has not been shown to reduce infection, many needle The ability to record normal and abnormal electrical activity
EMG videos depict this behavior leading patients to expect that from muscle is operator dependent. Needle EMG requires a num-
this will be performed. Before each needle insertion, you should ber of skills and knowledge (Appendix E). Needle placement and
inform the patient of the approximate location and alert them to data recording are absolutely necessary in order to obtain accurate
an imminent ‘‘stick or poke.” and reliable waveforms. This critical step is generally underempha-
sized. A few simple guidelines allow this crucial aspect of needle
4. Selection of muscles for examination EMG examinations to be performed correctly and efficiently. The
following discussion outlines some of the considerations.
The groups of muscles to be tested are initially selected on the
basis of the clinical hypotheses (e.g., proximal muscles for myopa- 6.2. Needle electrodes
thy, single limb for radiculopathy, widespread for motor neuron
disease, etc.) The individual muscles selected for examination There are a variety of needle electrode lengths and types. Nee-
should be superficial, easily palpated, and readily identified. They dle electrode selection depends on a number of patient and exam-
should be located away from major vessels, nerve trunks, and vis- iner considerations (Appendices B and C). Needle electrodes must
cera. Select muscles that are less uncomfortable for the patient. For be sterile. Disposable, standard electrodes are available at a reason-
example, the thenar and small foot muscles are often more uncom- able cost and should be used for each patient. While more expen-
fortable, and they should only be tested when the information is sive needle electrodes, such as single fiber needle EMG electrodes,
not available from other muscles. Exceptions to this general guide- may be sterilized and reused, this is not recommended for those
line would be an evaluation for ulnar neuropathies and median employed in routine practice. Such electrodes are typically sharp
neuropathy at the wrist. The first dorsal interosseous pedis is use- and undistorted. Rarely, they may not be sharp and will resist
ful in polyneuropathy examinations and will be described later in insertion. If an electrode penetrates the skin with difficulty, pass-
this monograph. Since the appearance of motor unit action poten- ing it through a sterile cotton ball or sponge may identify snags
tials (MUAPs) can vary greatly between different muscles, the mus- from bent tips. To determine if a batch of electrodes are not well
cles selected should be familiar to the examiner, both in how to made, they should be examined under a low power microscope.
test the muscle and the range of normal findings. Needles must be straight. A needle that has been bent should not
be straightened for continued use since a small break in the insu-
lation may cause a short circuit and result in needle EMG signal
5. Anatomical localization of the muscle distortion.
The recording surface must be the correct size and shape, as
A needle EMG examination is inextricably linked to human well as absolutely clean. Disposable, sterile needles from the man-
anatomy. A thorough knowledge of musculoskeletal anatomy is ufacturer may rarely be left with a very thin, poorly conducting
essential to the successful practice of EDX medicine. Most impor- film on the surface. This film increases the impedance and may
tantly, the practitioner must always be confident of which muscle cause a low-voltage, irregular, positive waveform (popping noise).
is being examined. Achieving that certainty is easily accomplished This must be recognized since it may be mistaken for end-plate
when the EDX medicine consultant is confident of needle place- noise, positive sharp waves, or fibrillation potentials. The film
ment through a detailed knowledge of the pertinent anatomy may be dispersed within a few seconds in the muscle. If not, the
(see Appendix A) (Geiringer, 1999; Leis and Schenk, 2012). Knowl- needle should be replaced. The shaft must be stable in the hub to
edge of anatomy is preferable to fixed distances for identifying the prevent it from breaking off in a patient. The connections to the
optimal point for needle insertion. Estimates of where to insert the cable must be intact. A poor connection can result in intermittent
needle based upon fixed distances from an anatomical landmark 60 Hz or irregular interference. Electrical impedance should be
quickly fail in practice. A fixed distance will mean one thing in checked if a break or short is suspected (correct impedance at
an infant, another in an obese adult, and quite another in a tall 60 Hz is 5–20 kO).
adult. Apparent muscle locations vary with limb and joint position There is a debate as to whether concentric needles or monopo-
as well as with associated edema and pathological processes that lar needles should be used for the needle EMG examination. While
result in atrophy or hypertrophy. It is only through a detailed there are some differences, they are relatively minor. Nonetheless,
understanding of the three dimensional relationships that do not it is important that the examiner use the same type of needle elec-
vary among patients that allows a practitioner to develop confi- trode that was used in obtaining the normal values used in his or
dence in needle electrode placement. If sufficiently superficial, her laboratory. The authors prefer concentric needles because they
the muscle to be tested should be palpated during intermittent do not require a surface reference, the signal is crisper, and the
contraction to localize its borders with the examiner’s thumb examination may be conducted more rapidly.
and index finger before needle insertion in order to define the opti-
mal insertion site. The location of end-plate regions should also be
6.3. Needle insertion
taken into account so that they may be avoided.
The muscle to be tested should be palpated during intermittent
6. Performing the EDX medicine consultation contraction to localize its borders with the examiner’s thumb and
index finger. It is helpful to make the skin taut at the site of inser-
An EDX medicine consultation includes a number of distinct tion, particularly where the skin is loose. The taut skin is best
skills that are described in detail below: pulled a short distance distally over the muscle to reduce bleeding
202 D.L. Menkes, R. Pierce / Clinical Neurophysiology Practice 4 (2019) 199–211

(when released, the skin will pull back over the needle site in the Either resting or contracting muscle may be tested initially. Resting
muscle). The needle electrode should be held firmly in the fingers muscle is preferred first since it is sometimes more difficult to
like a pen and inserted smoothly and quickly through the skin into obtain full relaxation than a contraction. However, if a muscle is
the subcutaneous tissue or superficial layers of the muscle at already contracting at the desired level on insertion, it should be
approximately a 45 degrees angle. This minimizes the force neces- tested in that position. Do not intermittently relax and contract a
sary to achieve penetration, and it also may distract the patient muscle at one site. That leads to more local muscle injury, bleeding,
prior to skin puncture. Rest the hand holding the needle on the skin and subsequent pain.
in order to make needle movement comfortable and precise. Your
opposite hand is located on the boundaries of the muscle for assis- 6.6. Resting muscle
tance in localization during needle movement. A small flick of the
examiner’s index finger over the intended insertion site may assist The resting muscle is tested for spontaneous activity at a gain of
in reducing the patient’s perceived discomfort (Boon et al., 2008). 50 mV/cm. When the needle is well within the muscle, it should be
During needle insertion and the study of insertional activity, the left undisturbed for a number of seconds to listen for fascicula-
study is best served if the patient is not asked to do anything more tions. It is not always easy to obtain muscle relaxation. In tense
than relax. There are many pertinent reasons to avoid relying on patients or during a painful examination, relaxation can be
patient input for your localization of a muscle. No voluntary con- enhanced by:
tractions should be required to confirm needle placement, for the
following reasons:  Carefully positioning the patient at the beginning to provide the
best relaxation and save time overall
 Some patients are not capable of activating one or any muscle  Adequately supporting the limb and, at times, passively manip-
(e.g., with nerve palsy, hemiparesis, coma, upper motor neuron ulating the limb
disorders, or non-organic weakness, etc.).  Contraction of an antagonist
 Some muscles are not palpable from the surface in any patient,  Distraction with conversation
(e.g., tibialis posterior).  Reassurance
 Voluntary contractions can be misleading. As an example, if the  Changing needles
needle is mistakenly placed in the flexor carpi radialis rather
than the targeted pronator teres, testing localization with fore- Once you have the needle under the skin, a more gentle move-
arm pronation will not reveal the error, as both muscles sub- ment of the needle can be used to pierce the superficial fascia. As
serve this function. the fascia is approached, listen for the rumbling of ‘‘distant” motor
 Patients tend to become less comfortable with needle EMG as units. The muscle might not be relaxed enough to proceed, and
time passes. The sequence of palpation, contraction, repalpa- pushing the needle into a moderately or strongly contracting mus-
tion, needle insertion, and recontraction takes time, which cle may be unnecessarily painful. Give specific directions about
extends the length of the examination. how to relax the muscle. For example, ‘‘Roll that thigh out toward
 The patient’s confidence in you might waiver if you spend as me.” Medical terms such as ‘‘dorsiflex your ankle” should be
much time searching for each muscle as examining it. Diagnos- avoided. A similar outcome can be obtained by saying, ‘‘Toes up
tic ultrasound may be useful for precise placement of the needle towards your nose.” It is not useful to simply request that the
electrode into the muscle, especially in patients with a large patient relax, especially at increasingly higher volumes on your
body mass index. Other uses of ultrasound are summarized part. The typical responses are, ‘‘I thought I was relaxed,” or, ‘‘I’m
later in this monograph. as relaxed as I can be with your sticking that needle in me.”
 Above all, you must be completely confident that you are exam- Tonic pressure should be kept on the needle hub while studying
ining the muscle that you intended to study. insertional activity. If you do not, particularly with concentric nee-
dle electrodes, there will be a tendency for the electrode to
6.4. Needle movement

The muscle is examined by moving the needle along a straight

line into the muscle in short steps (0.5–1 mm). Large movements
are more painful and end-plate areas may not be recognized. The
needle should not be released between movements. The pace of
needle movement should not be rushed. A brief pause (1 s or more)
between each site is needed to listen and watch for slower onset
abnormal activity. The needle is advanced in 5 to 30 such steps
depending on muscle diameter. After traversing the diameter, the
needle is withdrawn from the muscle, but not from the skin, and
then reinserted at a different angle in the same location; 2–4 such
passes through the muscle are made until an adequate number of
sites within the muscle have been examined. Most texts describe
the standard needle EMG examination as requiring 5 sites in each
of 4 quadrants be evaluated so that 20 total sites have been sam-
pled per muscle. However, 3 sites in 2–4 quadrants may be suffi-
cient. Significant amounts of spontaneous activity are usually
observed with the first few sampling sites.

6.5. Data collection/EMG activity analysis

The muscle should be examined at multiple sites both at rest

and during contraction using the methods previously described. Fig. 1. Flexor carpi ulnaris.
 D.L. Menkes, R. Pierce / Clinical Neurophysiology Practice 4 (2019) 199–211 203

‘‘bounce” back out of the muscle at the same distance that you just
moved it inward. Insertions should be smooth, firm, and with small
amplitude forward movements of 0.5 mm or so. There is no advan-
tage in using hard jabbing motions as they may cause pain.

6.7. Contracting muscle

The contracting muscle is examined using the same needle

methods as for resting muscle. The contracting muscle is best
examined with the muscle held at a level of contraction that acti-
vates a few motor units (low-to-moderate effort). Selective activa-
tion of the muscle of interest and adjacent muscles is needed to
determine needle position when examining deep muscles, muscles
that are difficult to palpate, or small muscles. Steps in testing a
contracting muscle include:

 Withdrawing the needle to a subcutaneous position before ask-

ing for muscle contraction.
 Positioning the limb and muscle and initiating contraction
before moving the needle into the muscle. Advance the needle
until you encounter MUAPs with a rapid rise time and a sharp,
clicking sound. Fig. 3. Brachialis.
 Proper limb positioning such that the activity of synergistic and
adjacent muscles is limited.
 Asking the patient to perform a movement that only requires
activation of the muscle being examined.
 Palpating the contracting muscle in order to help guide the nee-
dle movement.

6.8. Other considerations

Small muscles are best tested with an oblique needle course

through the muscle to lengthen the needle’s path. Deep muscles
and obese patients require a needle of adequate length. If the nee-
dle were to break off, it would likely do so at its hub, which is its
weakest point. If a needle were to be inserted to a depth greater
than its length and it broke, it would be difficult to remove. Some
muscles, such as the deep paraspinal muscles, may be difficult to
reach without a long needle, even in average-sized patients. Nee-
dles of up to 120 mm length should be available and should be
used in such circumstances.

Fig. 4. Serratus anterior.

6.9. Pain control/minimization

Most patients are able to tolerate the discomfort of the needle

examination without difficulty, but a few need special approaches.
A review article on safety and pain in EDX studies summarizes the
salient features of needle EMG associated pain (Boon et al., 2008).
Pain minimization requires attention to all interactions with the
patient, in particular the techniques of the needle examination
itself. Approaches that can be helpful in all patients are described
in Appendix C.

6.10. Overview of adjunctive ultrasound

Ultrasound has been evolving as an adjunctive electrodiagnostic

methodology based on its ability to assess normal and pathological
anatomy (Boon et al. 2012a, 2012b). A complete discussion of neu-
Fig. 2. Opponens pollicis. romuscular ultrasound is beyond the scope of this discuss save for
204 D.L. Menkes, R. Pierce / Clinical Neurophysiology Practice 4 (2019) 199–211

a brief description of using this technique for needle EMG guid- Comments: Spontaneous activity detected in this muscle local-
ance. However, it can be summarized as allowing the examiner izes the lesion proximal to Guyon’s canal, the site of ulnar neuropa-
to sample muscles in patients with atypical surface anatomy, sig- thy at the wrist.
nificant body mass index, deep muscles, denervated muscles and Localization: Insert the needle 5–8 cm distal to the medial epi-
muscles often not routinely examined such as the diaphragm condyle along an imaginary line from the medial epicondyle to the
(Boon et al., 2008). Ultrasound was also demonstrated to improve pisiform bone as depicted in Fig. 1.
sampling accuracy in a cadaveric model, especially in less experi- Activation: Abduction of the little finger away from the hand.
enced examiners (Boon et al., 2011). In summary, ultrasound guid- Innervation: Median nerve; lateral cord; lower trunk; C8-T1
ance should be considered in situations wherein the examiner has Utility: Abnormalities confirm pathology in the median nerve
a concern about accurate needle placement. distribution distal to the carpal tunnel. It is also useful for assessing
lower trunk brachial plexopathies and C8-T1 radiculopathies.
7. Special considerations

Comments: Examining this muscle usually results in less

A number of special issues presented by a few patients must be
discomfort to the patient than when the abductor pollicis
considered before initiating the needle examination. As the article
brevis is examined.
by London (2017) addresses many of these items, only a brief sum-
mary will be listed in Appendix D and includes:
Localization: At the midpoint of the first metacarpal shaft, in
the groove between the metacarpal bone and abductor pollicis bre-
 Anticoagulants and bleeding disorders
vis (see the top cross section in Fig. 2). The muscle is studied where
 Infection
it attaches to the medial side of the bone. In most patients, no other
 Cardiac valvular disease
muscle overlies the opponens at this point.
 Obesity
Activation: Opposition of thumb across the palm.
 Skin conditions
Innervation: Musculocutaneous nerve; lateral cord; upper
trunk; C5-C6
8. After the study Utility: Diagnose lesions of the musculocutaneous nerve, upper
trunk brachial plexopathy, or C5-C6 radiculopathy.
Before leaving the room, check to be sure that all puncture sites Comments: Examining this muscle usually results in less dis-
are dry and that no bruising is evident. If bleeding is still present, comfort to the patient than when the biceps brachii is examined.
1–2 min of firm pressure applied by either the EDX examiner or Localization: In the distal one-third of the arm, push the biceps
the patient will usually stop it. An ice pack is useful to minimize (see the axial cross section in Fig. 3) medially and insert the elec-
additional bleeding if a small hematoma has formed. Ensure that trode in the groove between biceps and triceps (see the longitudi-
the patient can get dressed unassisted, or be sure they have help. nal section in Fig. 3). Direct it down and medially, toward the
Some patients ask about persisting discomfort after the examina- anterior aspect of the humeral shaft.
tion. They can be advised that their muscles may ache for a few Activation: Elbow flexion; the degree of forearm pronation–
hours, but this will usually disappear overnight. If necessary, mild supination is irrelevant.
analgesics such as non-steroidal anti-inflammatory agents may be Innervation: Long thoracic nerve; C5, C6, C7
used, (e.g., acetaminophen). Utility: Often affected in acute brachial neuritis along with
muscles supplied by the anterior interosseous nerve (flexor pollicis
Acknowledgements longus, median nerve portion of the flexor digitorum profundus,
and the pronator quadratus). It is also a ‘‘root collateral” that
The author would like to thank Jasper R. Daube, MD and Steve R. may be abnormal with a cervical radiculopathy.
Geiringer, MD, who authored the previous version of this manu- Comments: A ‘‘root collateral” indicates a muscle innervated by
script as published by the American Association of Neuromuscular a nerve that originates proximal to a plexus such that its involve-
and Electrodiagnostic Medicine [AANEM] formerly known as the ment favors root level pathology. Cervical root collateral muscles
American Association of Electrodiagnostic Medicine [AAEM]. This should be sampled if there has been previous cervical spine sur-
version has been updated with that organization’s express written
permission.

Conflict of interest

I confirm that I have read the Journal’s position on issues

involved in ethical publication and affirm that this report is consis-
tent with those guidelines.
Daniel L. Menkes, M.D. has received travel expenses from Neu-
rotron, Inc.

Appendix A: Testing specific muscles

Note: In the arm, ‘‘lateral” refers to the thumb side of the arm,
while ‘‘medial” refers to the ulnar side of the arm.
Innervation: Ulnar nerve; medial cord; lower trunk; C8-T1
Utility: Abnormalities localize pathology in the ulnar nerve ter-
ritory proximal to the wrist. It is also useful for assessing lower
trunk brachial plexopathies and C8-T1 radiculopathies. Fig. 5. Lower extremity muscles. Extensor hallucis longus.
 D.L. Menkes, R. Pierce / Clinical Neurophysiology Practice 4 (2019) 199–211 205

gery from a posterior approach. Another example of a root collat- Extensor digitorum [formerly the extensor digitorum communis]
eral is the rhomboid, which is described in the next section.
Localization: In the mid or anterior axillary line, isolate 1 rib by Innervation: Radial nerve; posterior interosseous nerve; poste-
placing 2 fingers in the adjacent interspaces, anterior to the bulk of rior cord; middle and lower trunks; C7, C8
the latissimus dorsi (see the top cross section in Fig. 4), but poste- Utility: Useful for determining the presence of a C7-C8 radicu-
rior to the breast tissue in a woman. Needle electrode insertion is lopathy, radial neuropathy, or posterior interosseous neuropathy.
directly between your fingers, as serratus anterior is the only mus- Localization: Superficial, readily palpable muscle that is bor-
cle between the skin and the rib. dered laterally by muscles innervated directly from the radial
Activation: Elevation and reaching forward with the arm, (i.e., nerve, rather than from the posterior interosseous. Localization is
scapular protraction). Providing resistance is sometimes necessary. best obtained by palpation of the active muscle in the center of
the proximal third of the forearm dorsum, during selective exten-
Rhomboid sion of the middle finger. It is important to distinguish the radial-
innervated wrist extensors supplied by the posterior interosseous
Innervation: Dorsal scapular nerve; C4, C5 nerve from the extensor digitorum, formerly designated the exten-
Utility: Often affected in acute brachial neuritis. A ‘‘root collat- sor digitorum communis (EDC). These groups are easily separable
eral” that may be abnormal with a C5 radiculopathy. Useful in dif- by a groove between them and the EDC. The radial-innervated
ferentiating a C5 radiculopathy from an upper trunk brachial wrist extensors are just lateral to the groove, whereas the EDC is
plexopathy. just medial to it. The muscles lateral to the groove are easily mov-
able (anatomists label them the ‘‘movable wad”). The EDC and the
extensor carpi ulnaris just medial to it are fixed to the underlying
Comments: Spontaneous activity detected in this muscle will
tissues.
help to substantiate a C5 radiculopathy.
Activation: Extension of middle finger.
Innervation: Deep branch of fibular (formerly peroneal) nerve;
Localization: Beneath the trapezius. Origin from lateral mass of
fibular division of sciatic nerve; lumbosacral plexus; L5, S1
upper thoracic vertebrae. Insertion on lower third of medial scapu-
Utility: Useful for determining the presence of a deep fibular
lar border. Can be palpated during activation in some muscular
(deep peroneal) neuropathy, sciatic neuropathy, or L5
patients.
radiculopathy.
Activation: Hand in the small of the back with palm pushing
Localization: At the junction of the middle and lower thirds of
posterior against the examiner. Posterior (dorsal) pressure against
the leg, one-third of the distance from the tibial shaft to the lateral
resistance of the elbow on the hip can be used in patients unable to
border of the leg. The electrode is directed deep and medially. The
make this first maneuver. Caution is required since penetration too
tibialis anterior is just lateral to the shaft of the tibia. Insert the
deeply could enter the pleural cavity.
electrode one-third the distance laterally around that quadrant to
avoid piercing the thick tibialis anterior tendon. Angle the needle
Pronator teres
from lateral to medial, rather than aiming it straight down, because
the belly of the extensor hallucis longus is thin and vertically ori-
Innervation: Median nerve; lateral cord; upper and middle
ented (see cross section in Fig. 5).
trunk; C6-C7
Activation: Great toe extension; be certain the needle is pulled
Utility: Useful for determining the presence of a C6-C7 radicu-
back into the subcutaneous tissue before the patient contracts this
lopathy, upper/middle trunk brachial plexopathy, or a proximal
muscle.
median neuropathy.
Comments: The most proximal muscle innervated by the med-
ian nerve. It should be unaffected in pronator syndrome. Sponta-
neous activity in this muscle may help to confirm a C6 or C7
radiculopathy when similar abnormalities are identified in radial
nerve-innervated muscles innervated by the same nerve root.

Localization: Insert the needle 2–3 cm distal and 1 cm medial to

the biceps brachii tendon (the edge of the muscle may be
palpated in this location).

Activation: Have the patient flex the elbow, which is a sec-

ondary action of the muscle. This is less uncomfortable than having
the patient pronate, which may bend the needle.

Extensor indicis

Innervation: Posterior interosseous branch of the radial nerve;

posterior cord; lower and middle trunks; C7-C8
Utility: Useful for determining the presence of a C7-C8 radicu-
lopathy, middle/lower trunk brachial plexopathy, radial neuropa-
thy, or posterior interosseous neuropathy.
Localization: Originates at the posterior surface of the lower
half of the ulnar shaft and adjacent interosseous membrane. Insert
the needle 5–7 cm proximal to the ulnar styloid just radial to the
shaft of the ulna.
Activation: Extend the index finger. Fig. 6. Cranial muscles. Tongue (genioglossus).
206 D.L. Menkes, R. Pierce / Clinical Neurophysiology Practice 4 (2019) 199–211

Gluteus medius Flexor digitorum longus

Innervation: Superior gluteal nerve; lumbosacral plexus; L4- Innervation: Tibial nerve; sciatic nerve; lumbosacral plexus;
L5-S1 L5-S1
Utility: Useful for differentiating a sciatic neuropathy from an Utility: Abnormalities confirm pathology outside the distribu-
L5 radiculopathy or lower lumbar plexopathy, as it is not inner- tion of the fibular (peroneal) nerve.
vated by the sciatic nerve. (Note: The gluteal muscles should be Localization: Distal third of the leg, immediately posterior to
examined if the patient is being evaluated for a radiculopathy the tibia at a depth of 2–3 cm. Needle insertion just behind the
and the patient has undergone lumbar spine surgery in the past. ventral (posterior) surface of the tibia usually passes through some
Their involvement favors a diagnosis of radiculopathy.) of the soleus, which can be distinguished by selective activation.
Localization: The anterior border of gluteus medius is defined Occasionally, the tibialis posterior is entered first. (Note: Both are
by the line joining the anterior superior iliac spine (ASIS) and innervated by the tibial nerve such that needle EMG abnormalities
greater trochanter. The electrode is inserted parallel to this line, in one or the other have virtually the same diagnostic significance.)
at its midpoint and just posterior to it. Activation: Toe flexion with the ankle slightly dorsiflexed. The
Activation: Internal rotation of the thigh. Needle insertion as tibialis posterior can be distinguished by slight plantar flexion.
described above places it in the anterior fibers of gluteus medius,
allowing internal rotation to be used for activation. If more poste- Tensor fascia lata
rior locations are needed, the gluteus medius can be readily acti-
vated with the patient lying on the contralateral side and the Innervation: Superior gluteal nerve; lumbosacral plexus; (L4),
foot resting on the bed while the knee is gently raised toward L5
the ceiling. Utility: A truncal or proximal muscle such that it is useful in dif-
ferentiating a sciatic neuropathy from an L5 radiculopathy or lower
Adductor longus lumbar plexopathy. (Note: Similar function to the gluteus medius,
which has the same innervation.)
Innervation: Obturator nerve; lumbar plexus; L2, L3 Localization: One-half the distance between the anterior iliac
Utility: Abnormalities confirm obturator nerve distribution spine and the greater trochanter. Vertical entry is needed, since
involvement. This muscle helps to differentiate femoral neuropa- the muscle is often deep.
thy from upper lumbar plexopathy/radiculopathy. Activation: Most patients can provide excellent MUAP control
Localization: Both borders are readily palpable for needle with gentle internal hip rotation, and full relaxation with external
placement in the proximal 20% of the medial thigh with the knee rotation.
flexed to 90 degrees and abducted. If the needle is placed too distal,
approaching the adductor canal of Hunter, it could easily enter the First dorsal interosseous, pedis
adductor magnus, which is also supplied by the sciatic nerve.
Investigation of a possible obturator neuropathy could thereby be Innervation: Deep branch of the fibular (peroneal) nerve; sci-
compromised. atic nerve; lumbosacral plexus; L5, S1
Activation: With the patient lying on the back with the knee Utility: One of the first muscles involved with a distal symmet-
flexed and externally rotated, minimal elevation of the knee readily ric axonal polyneuropathy.
activates a number of motor unit potentials without the examiner Localization: The index finger of one hand is placed in the
needing to resist the motion. notch between metatarsal heads I and II. The needle is inserted just
distal to your finger, and directed slightly toward the index finger
Biceps femoris short head upon which this muscle acts. This muscle is less painful, is less sub-
ject to trauma than other intrinsic foot muscles, and is the most
Innervation: Fibular division of sciatic nerve; lumbosacral distal muscle in the body. This muscle is therefore very sensitive
plexus; L5-S1 to even mild, distal motor axon loss.
Utility: Abnormalities confirm that the pathological site is prox- Activation: Plantar flexion of the toes against resistance.
imal to the common fibular (common peroneal) nerve. Innervation: Hypoglossal nerve; cranial nerve XII
Localization: The needle is inserted just lateral or just medial to Utility: Confirms pathology rostral to the foramen magnum in
the lateral hamstring tendon, at the proximal popliteal crease, then persons undergoing needle EMG for a presumed diagnosis of motor
directed to underneath the tendon. If the muscle is studied more neuron disease.
proximally, the short and long heads cannot be distinguished. At Localization: Midpoint between tip of the chin and the angle of
the more distal point only short head muscle fibers will be encoun- the jaw, medial to the mandible. The tongue is found deep here,
tered, to help exclude proximal damage to the fibular division of after the electrode passes through mylohyoid (see Fig. 6 with the
the sciatic nerve. skin reflected and geniohyoid (see the sagittal section in Fig. 6)
Activation: Partial knee flexion. muscles.
Activation: Protrusion of the tongue. Ask the patient to stick
Fibularis longus (Peroneus longus) out the tongue.

Innervation: Superficial fibular nerve; fibular nerve; fibular Masseter

division of sciatic nerve; lumbosacral plexus; L5-S1
Utility: Abnormalities confirm pathology in the distribution of Innervation: Motor nucleus of the third division of the trigem-
the superficial fibular (peroneal) nerve. inal nerve (mandibular division); cranial nerve V
Localization: Readily palpable, immediately lateral to the ante- Utility: Will be normal in cases of infranuclear facial nerve
rior tibial muscle, in the proximal third of the leg. lesions.
Activation: Plantar flexion of the foot with a minimum of Localization: Insert the needle 2–3 cm distal to the angle of the
eversion. jaw and 2 cm cephalad to the lower edge of the mandible with the
 D.L. Menkes, R. Pierce / Clinical Neurophysiology Practice 4 (2019) 199–211 207

jaw open. (Note: The muscle belly is easily palpated when the  Continue reassurance and verbal sympathy for the patient
patient is asked to clench the teeth.) throughout the study.
Activation: Jaw closure.  Reassure the patient that the discomfort of the test is not long
lasting.
Appendix B. Reducing the discomfort of the needle examination
 Move the needle gently and slowly.
 Begin with the most important muscle (e.g., paraspinal muscles
Needle handling techniques
in suspected radiculopathy).
 Avoid hyperventilation.
A description of the procedure, patient engagement, setting
 Inform patients that they can take analgesics prior to the test if
expectations, and using short, gentle needle movements should
they are concerned about the pain.
minimize the discomfort experienced during needle EMG. How-
 Change needles if there is increased resistance to needle
ever, there will be patients who are unwilling or unable to tolerate
movement.
this examination.
 Rarely, but if all else fails, it may be necessary to use a narcotic
Here are some recommendations that will help improve patient
such as fentanyl by injection at the start of the test.
tolerance of the discomfort that does occur.
Under most circumstances, thorough explanation of the proce-
 Tell the patient that some areas of the muscle may be uncom-
dure and a kind, understanding, and sympathetic manner with
fortable (near small nerves).
adult patients will be sufficient to complete the needle examina-
 Tell the patient that you will move away from such areas if they
tion. Some patients inquire if they can take acetaminophen with
tell you about the pain.
codeine before the examination. While this is quite acceptable, it
 Quickly move a short distance away from an area where the
is probably of limited benefit. On rare occasions, it may be neces-
patient has increased pain.
sary to use a short-term parenteral analgesic such as fentanyl.
 Penetrate through dorsal rather than ventral skin if possible
Chloral hydrate may be helpful in children. Some institutions
(e.g., opponens rather than abductor pollicis brevis, and bra-
now require conscious sedation by a qualified professional (e.g.,
chialis rather than biceps brachii).
anesthesiologist).
 Whenever feasible, direct the needle to follow a path nearly
parallel to the muscle fibers, rather than perpendicular to them.
Patient interactions to optimize cooperation on clinical needle EMG
While there will be no difference in the appearance of the wave
forms observed, normal or abnormal, the tangential approach is
Introductions in the examining room:
less painful.
 Use a secondary muscle function for contraction (e.g. the prona-
 Greet patient, introducing yourself
tion of the pronator teres can be quite painful as the muscle tor-
 Confirm patient’s name and test
ques around the electrode). The secondary function of elbow
 Confirm clinical problem requiring needle EMG
flexion pulls the needle along in a linear path that is generally
 Briefly describe purpose of test
much more easily tolerated.
 Briefly describe test components and length of time
 Use a 1-joint muscle if possible. For example, the gastrocnemius
 Reassure patient about test
is an extremely strong muscle and obtaining its contraction
 Ask about possible contraindications or confounding factors
using pressure against your hand can be difficult if not impossi-
such as:
ble. The soleus has the same S1 innervation, and can be much
 Medications such as anticoagulants, and acetyl-
more readily activated by plantar flexion.
cholinesterase inhibitors
 Select muscle testing in which nothing of importance lies
 Allergies and reactions such as alcohol or iodine
between the skin and the targeted muscle except perhaps sub-
 Pertinent medical problems such as sub-acute bacterial
cutaneous tissue. Some muscle approaches require piercing
endocarditis
other structures first, which may add discomfort, greater risk,
 Reassure patient about absence of significant risk
and uncertainty about needle location. Examples include: (1)
the distal approaches to the flexor pollicis longus, flexor digito-
Discussion of the discomfort of test by physician:
rum longus, and extensor indicis; (2) the medial approaches to
the flexor digitorum profundus and the pronator quadratus; and
 Review specific components of test
(3) the lateral chest approach to the serratus anterior.
 Provide understanding of need for discomfort
 Describe options for dealing with discomfort:
Pain is most common if the needle is in the end-plate region. As
 Patient choice on how to proceed
the needle is moved through the muscle, end-plate noise will be
 Tolerate as best as possible
recognized as the needle tip approaches. When this is apparent
 Move needle or stimulating electrodes to different sites
from the presence of end-plate noise or spikes, the needle should
 Change needle type
be quickly moved to another area. Sometimes, movement in every
 IM medication if needed
direction is plagued by end-plate activity. In this situation, the nee-
 Discontinue individual muscle or entire test if necessary
dle should be completely withdrawn and reinserted a short dis-
tance away. Localized burning pain occurs if the needle is
During needle EMG:
inserted in the immediate region of pain nerve terminals in the
skin, and also requires withdrawing and reinserting the needle
 Describe nature and purpose of needle examination
through the skin.
 Explain cleansing with alcohol and use of gloves
A number of methods can help a patient tolerate a full
 Describe use of disposable electrodes
evaluation:
 Describe need to record at rest and with voluntary contraction
 Use as small needle movements as possible (0.5 mm)
 Reassure the patient that everyone experiences some discom-
 Do not change level of voluntary contraction with needle in
fort during the test, but almost all are able to tolerate it.
muscle
208 D.L. Menkes, R. Pierce / Clinical Neurophysiology Practice 4 (2019) 199–211

 Do not move the joint with needle in muscle Monopolar electrodes

 Move needle only in straight lines through muscle
 Redirect needle only in subcutaneous tissue Monopolar needle electrodes are TeflonTM coated fine needle
 Ask patient frequently how they are doing electrodes, usually made of stainless steel, and can have a very fine
 Respond to each clue that they are having discomfort by a gauge and an extremely sharp point. The recording surface is usu-
change in technique ally somewhat larger than a standard CNE, resulting in different
 Warn before each new needle insertion characteristics of the recorded potentials. The area of the exposed
 Describe need for and nature of any unusual or particularly surface may change as the TeflonTM insulation near the tip is dam-
uncomfortable recordings aged or pulled back from repeated needle insertions. In the past,
 Reassure patient about quality of cooperation and recordings these needles were reused. This is no longer recommended, as dis-
frequently posable needles have become the standard of care.
 Maintain local pressure on each site to stop all bleeding after
testing
Single-fiber electrodes
 Ask for a chaperone when examining intimate areas irrespec-
tive of stated gender
Single-fiber EMG is being performed with decreasing frequency
 Keep patient covered at all times everywhere except the area
in favor of using disposable CNEs, which can assess jitter but not
being tested
fiber density. Single-fiber electrodes have a fine 25 wire exposed
on the lateral surface of the shaft of a needle as the active elec-
After the test:
trode. These electrodes may also develop barbs or bent tips, but
can be readily sharpened without damage to the active electrode.
 Reassure patient about their cooperation
Microscopic examination is needed, since a damaged tip will result
 Sympathize with their discomfort
in damage to muscle fibers, and prevent reliable recording from
 Indicate that useful data was recorded
single fibers. They should be examined after every use. The impe-
 Describe results to the extent appropriate
dance of the small surface of a single-fiber electrode is much higher
 Ask if they have questions or concerns before they leave
than that of a monopolar or a standard CNE and cannot be reduced
by cleaning or etching. These electrodes should be examined at
Appendix C: Needle electrode types
regular intervals for pitting or local damage to the surface of the
active electrode which, if present, are best corrected by sanding
with fine emery paper. These electrodes are much more suscepti-
Concentric Needles Monopolar ble to noise if the electrode surface is dirty (high impedance) or
Needles if improperly seated in the connecting cable.
Recording area Smaller (stable) Larger (variable)
Recording Stable Variable; may
Appendix D: Special problems to consider prior to needle EMG
properties polarize
Background Less noise (better Noise from
Anticoagulants and bleeding disorders
common mode surrounding
rejection) muscles
Patients with a variety of bleeding disorders may be referred for
Reference Needle shaft Separate surface
an EDX medicine consultation. The EDX medicine consultant must
electrodes electrode
examine each case individually, carefully weighing the potential
Motor unit Smaller Larger
risks and benefits. Regarding antiplatelet agents, neither aspirin
potentials
nor clopidogrel pose a significant bleeding risk. Needle EMG may
Motor unit More reliable Less reliable
proceed as usual, although additional direct pressure to the sites
quantitation
sampled may be required on a case-by-case basis.
Discomfort No difference, if Less than non-
Warfarin therapy does not pose a significant risk with an
disposable disposable
INR < 3.0 (Boon et al., 2012b). A greater degree of anticoagulation
Cost More expensive Less expensive
is not an absolute contraindication, but caution should be exer-
cised. Notwithstanding, hematoma formation from needle EMG is
rare even in high risk muscles such as the paraspinals (Geiringer,
1999). Therefore, needle EMG need not be deferred simply because
the patient is anticoagulated. While these data cannot be defini-
Concentric needle electrodes tively extrapolated to dabigatran or other anticoagulants, the risk
is likely low as well. Nonetheless, it is prudent to perform a risk/
Concentric needle electrodes (CNEs) are made of a bare needle benefit assessment in such instances. If the needle EMG is per-
shaft (reference electrode) and a central platinum wire (active formed, it is prudent to examine the minimum number of muscles,
electrode) insulated from the shaft. All standard CNEs are beveled especially deep muscles, to study each muscle briefly, and to avoid
to a fine tip with an exposed central core 125 by 500 mm. There are tight fascial spaces, if possible. After each muscle is examined,
4 common sizes of needles available: 25 mm (30 gauge), 37 mm place firm pressure on the needle puncture site for 1–5 min to stop
(26 gauge), 50 mm (26 gauge), and 75 mm (20 gauge). The needle bleeding or bruising. It is often possible to proceed to another mus-
is a detachable electrode connected to the preamplifier by a cable. cle while maintaining local pressure on the previous puncture site.
Because of the narrow gauge electrodes are particularly delicate Thrombocytopenia may be encountered in some patients. If the
and need careful handling. CNEs are most fragile at the junction platelet count is above 30,000/mm2, the study can usually be per-
of the shaft and the hub, and they may bend or break at that loca- formed. Needle EMG should be avoided in patients with hemophi-
tion. The beveled cutting edge of the concentric needle electrodes lia who have inhibitors. For these and more uncommon bleeding
may be more likely to induce bleeding than monopolar needle diatheses, it may be necessary to consult with a hematologist
electrodes, which are cone-shaped. before proceeding.
 D.L. Menkes, R. Pierce / Clinical Neurophysiology Practice 4 (2019) 199–211 209

Infection B. Plan the study

Special precautions are needed in the use of needle electrodes 1. Review nerve conduction studies. Do they support the
in patients who are demented and those who have a history of viral hypothesis or suggest a different etiology?
hepatitis, acquired immune deficiency syndrome (AIDS), and other 2. Decide which muscle to test.
potentially transmittable diseases. The author treats all patients as a. Test most likely involved muscles. If normal, test other mus-
potentially infectious and recommends that universal precautions cles with similar supply or distribution. If abnormal, confirm
be observed at all times. Thus, these needles should always be dis- in another muscle.
carded after use in specially-designed containers. The use of gloves b. Superficial muscles are preferable to deep muscles.
by the physician is strongly recommended when performing the c. Palpable muscles are preferable to those that cannot be
needle examination, not only for patients who have a potentially palpated.
transmittable disease, but to protect the EDX medicine consultant d. Familiar muscles are preferable. One should attempt to
from unrecognized agents. become familiar with as many muscles as possible.
e. Stay away from dangerous areas (pleura, arteries).
f. Have a reason for each muscle examined. If you think about
Cardiac valvular disease
examining a muscle, then you probably should.
g. Other considerations:
Patients with rheumatic or other types of valvular disease and
i. Myopathy, unilateral study recommended (one side should
patients with prosthetic valves are at risk of developing endocardi-
be preserved for biopsy).
tis as a result of transient bacteremias. However, the risk from nee-
ii. Paraspinal muscles, if abnormal, consider sampling the other
dle EMG is similar to the risk from repeated venipunctures in
side.
which prophylactic antibiotics are not used. Therefore, prophylac-
iii. Define the rostral/caudal limits of paraspinal muscle
tic antibiotics for such patients undergoing an EDX medicine con-
abnormalities.
sultation are not required.

C. Prepare the patient

Obesity
1. Greet patient; identify yourself.
Patients with a large body mass index present problems of 2. Confirm understanding of their problem.
locating and palpating muscles that need to be studied. For exam- 3. Explain the purpose of the study; identify disease process and
ple, it may be difficult to palpate the spinous processes used as a severity.
landmark for paraspinal muscle insertion. Diagnostic ultrasound 4. Explain the test (e.g., muscle recording, test muscles, no shocks
may prove valuable in this situation (O’Neill, 2008). With extra pal- or electricity).
pation and manipulation, landmarks can often be distinguished. If 5. Advise that there is some discomfort, but minimized (pain aver-
landmarks cannot be appreciated, muscles that are near the pleural ages a 3 on a scale of 1–10).
cavity, viscera, or neurovascular bundles may have to be elimi- 6. Inform that the test will not be performed without their con-
nated from the study (e.g., serratus anterior). For obese patients, sent, and that the study will be discontinued on request.
the standard 50 mm needle will not be long enough to reach some
muscles. A 75 or 120 mm needle should be chosen at the start of D. Needle EMG technique
the study.
1. Identify muscle by palpation of selective activation.
Skin considerations 2. Wipe muscle with alcohol.
3. Retract the skin.
Inspect the skin over the muscle to be examined before insert- 4. Set parameters (50 mV/div for spontaneous activity, 200 lv/div
ing the needle to avoid superficial veins or varicosities. Tortuous for voluntary activity). On many machines, sweep speeds can
arteries or anomalous vessels can be detected by palpation. Avoid be varied.
areas of infection, ulceration, dermatitis, and venous stasis. Scars a. Upper or left screen
should also be avoided since there may have been associated dam- i. Sweep can be set at half (10 divisions) or full screen (20
age to the underlying muscle. If the lower extremity is ischemic, divisions).
the small foot muscles or even leg muscles may need to be avoided. ii. Sweep speed can be varied:
Foot intrinsic muscle sampling should be performed with caution 10 ms/div reproduces what is seen on oscilloscope with
in patients with severe diabetes mellitus. Severely swollen lower a 100 ms (half) or 200 ms (full) sweep time.
extremities will make the examination difficult, as edema fluid 50 ms/div at full screen width.
may leak after the needle puncture. If the edematous limb has Full 1 s sweep, easier analysis of firing frequency and
macerated or has very thin skin, a judgment will have to be made pattern.
about the safety of the needle EMG. On general principle, a risk Evaluation of duration of insertional activity.
benefit analysis should be conducted, discussed with the patient, Evaluation of slow initial and terminal component long
and documented. duration waveforms.

A. Clinical evaluation b. Right or lower screen

i. Superimposition or rastering of multiple traces of the
1. Review clinical history and examination from record. Perform a same triggered MUAP. (The standard number of traces
focused (yet thorough) neuromuscular history and is 5.)
examination. ii. Sweep speed can be varied (5 ms/div is standard).
2. Define the question/hypothesis: What is the differential iii. Filters: Low frequency filter (LFF): 30 Hz; High fre-
diagnosis? quency filter (HFF): 20 kHz
210 D.L. Menkes, R. Pierce / Clinical Neurophysiology Practice 4 (2019) 199–211

5. If quantification of MUAPS is performed, the technique should c. In patients with thrombocytopenia, if the platelet count is
be identical to a standard reference. above 30,000/mm2, the study can be performed safely.
6. Support muscle by hand. For uncommon bleeding disorders, consult a hematologist.
7. Warn patient. 2. Infection precautions.
8. Pull skin taut, quick stick through skin. Hold needle like pen and a. All patients should be considered infectious such that uni-
insert needle at an angle. Brace hand on muscle. versal precautions should be practiced.
b. Special precautions should be taken in patients with
E. Evaluating insertional and spontaneous activity dementia or a history of viral hepatitis, AIDS, and other
potentially transmittable diseases.
1. Move needle in short steps (0.5–1 mm); large movements c. Always discard needles in specially designed containers.
are more painful. d. Always use gloves (for any patient).
2. Move in straight line from insertion through muscle. 3. Cardiac valvular disease.
3. Don’t release between steps. a. Risk of needle EMG in patients with rheumatic or other
4. Pause at least 1–2 s to listen for slow fibrillations. type of valvular disease or with prosthetic valves is similar
5. Rest hand on muscle; brace for stability. to that of repeated venipuncture. Prophylactic antibiotics
6. Make 3–4 passes of 5–10 steps in a straight line through are not necessary.
muscle. 4. Obesity
a. Explore different areas of muscle with each pass. a. May present problems of locating and palpating muscle. If
b. Move obliquely through muscle with each pass. landmarks cannot be appreciated, certain muscles may
c. Withdraw needle from muscle, but not skin, between passes. need to be eliminated from the study (e.g., serratus
It may be necessary to look at completely different areas of anterior, diaphragm). Diagnostic ultrasound may be
the same muscle (e.g., inflammatory myopathies) Ultra- useful for precise localization within the muscle to be
sound may be of additional value in localizing areas that of examined.
greater abnormality. b. Standard 50-mm needle may not be long enough. Use a 75-
7. Don’t contract muscle with needle in muscle (painful, lacer- or 120-mm needle.
ates muscle, and bends needle). 5. Skin considerations.
8. Remember: Careful positioning of the patient at the begin- a. Examine skin over the muscle before inserting needle.
ning, adequate support and passive manipulation of the b. Avoid superficial veins or varicosities.
limb, contraction of antagonist muscles, distraction with c. Avoid areas of infection (cellulitis), dermatitis, and venous
conversation, and reassurance are all methods to improve stasis.
relaxation during evaluation of spontaneous activity. d. Avoid areas of lymphedema (persistent leak of fluid, risk of
development of infection).
F. Evaluating voluntary activity e. Use special care with thin brittle skin (e.g., patients on
steroids).
1. Same needle methods as for resting muscle.
2. Withdraw needle to a subcutaneous position before initiating
muscle contraction. H. Reducing the discomfort of the needle EMG
3. Best examined with weak muscle contraction, with only 1–3
motor units firing at a time. Too strong of a contraction will 1. Use proper needle handling techniques.
activate too many MUAPs at once, making it more difficult to 2. Make only short movements.
analyze. 3. Tell patients that some areas of the muscle may be more
4. Advance needle until you reach MUAPs with a rapid rise time uncomfortable).
(0.5 ms) and sharp clicking sound. Only assess MUAPs with 4. Tell them that you will move away from them if they tell you
short rise time. about the pain.
5. Know duration of MUAPs for various muscles. Units in some 5. Watch/listen for end-plate activity and move away from it.
muscles always look long and large. 6. Develop patient rapport:
6. Avoid MUAPs at edge of muscle. a. Reassure the patient that everyone experiences some
7. Move from one site to another site quickly. Look at units in one discomfort.
site, evaluate their characteristics, and then move to another b. Continue reassurance and verbal sympathy throughout the
site. ‘‘Spend a little time looking at a lot of units.” study.
8. Be objective. Avoid seeing what you expect to see. Specificity is c. Reassure the patient that the discomfort is not long
more important than sensitivity. lasting.
d. Move the needle gently and slowly.
G. Special considerations e. Begin with most important muscles.
f. Inform patients that they can take analgesics prior to the
1. Anticoagulants and bleeding disorders. test.
a. Examine each case individually, weighing risks and benefits g. Change needles when increased resistance is encountered.
with the understanding that the current literature indicates
that there is minimal risk in performing needle EMG in
patients taking Coumadin for anticoagulation when the
INR is < 3. References
b. If needle EMG is performed, minimize the number of deep
muscles examined (e.g., paraspinals), avoid tight fascial Boon, A.J., Smith, J., Harper, C.M., 2012a. Ultrasound applications in
spaces if possible (e.g. tibialis anterior–anterior compart- electrodiagnosis. PM & R 4, 37–49.
Boon, A.J., Alsharif, K.I., Harper, C.M., Smith, J., 2008. Ultrasound-guided needle EMG
ment), and apply direct pressure over the puncture site of the diaphragm: technique description and case report. Muscle Nerve 38,
for 1–2 min after the examination. 1623–1626.
 D.L. Menkes, R. Pierce / Clinical Neurophysiology Practice 4 (2019) 199–211 211

Boon, A.J., Oney-Marlow, T.M., Murthy, N.S., Harper, C.M., McNamara, T.R., Smith, J., Leis, A.A., Schenk, M.P., 2012. Atlas of Electromyography and Nerve Conduction
2011. Accuracy of electromyography needle placement in cadavers: non-guided Studies. Oxford University Press, New York.
vs. ultrasound guided. Muscle Nerve 44, 45–49. London, Z., 2017. Safety and pain in electrodiagnostic studies. Muscle Nerve 55,
Boon, A.J., Gertken, J.T., Watson, J.C., Laughlin, R.S., Strommen, J.A., Mauermann, M. 149–159.
L., et al., 2012b. Hematoma risk after needle electromyography. Muscle Nerve O’Neill, J.M. (Ed.), 2008. Musculoskeletal ultrasound: anatomy and technique.
45, 9–12. Springer Verlag, New York.
Geiringer, S.R., 1999. Anatomic Localization for Needle Electromyography. Hanley &
Belfus, Philadelphia.