Manual Muscle Testing

Yasser Moh. Aneis, PhD, MSc., PT.

Lecturer of Physical Therapy
Basic Sciences Department
 Manual Muscle Testing

Evaluation of the function and strength of individual muscles

and muscles group based on effective performance of a
movement.
 Muscle Strength

The maximal amount of tension or force that a muscle

can voluntarily exert in one maximal effort.
Factors Affecting Strength
1. Age:
A decrease in strength occurs with increasing
age due to deterioration in muscle mass.
2. Sex:
Males are generally stronger than females.
3. Type of Muscle Contraction :
More tension can be developed during an
eccentric contraction than during an isometric
contraction.
4. Muscle Size:
The larger the cross sectional area of a muscle,
the greater the strength of the muscle.
5. Speed of Muscle Contraction:
When a muscle contracts concentrically the
force of the contraction decreases as the speed
of the contraction increases.
6. Previous Training Effect:
Strength performance depends up on the ability
of the nervous system to activate the muscle
mass.
7. Joint Position:
Regardless of the type of muscle contraction, a
muscle contracts with more force when it is
stretched.
8. Fatigue:
As the patient fatigue, muscle strength decrease.
9. Others:
The patient’s level of motivation, level of pain,
occupation, and dominance are other factors
that may affect strength.
Types of Muscle Contraction
1. Isometric (Static) Contraction:
This occurs when there is tension developed in
the muscle but the muscle length does not
change.
2. Isotonic Contraction:
The muscle develops constant tension against a
load or resistance with change in length.
i. Concentric Contraction:
Tension is developed in the muscle and the
origin and insertion of the muscle move closer
together. The muscle shortens.
 ii. Eccentric Contraction:
Tension is developed in the muscle and the
origin and insertion of the muscle move further
apart, the muscle lengthens.

A-B-C : Concentric Contraction

of Biceps Brachii Muscle.

E-F : Eccentric Contraction of

Biceps Brachii Muscle.
Functional Classification of Muscle:
 Prime Mover or Agonist:
A muscle or group of muscles that makes the
major contribution to the movement at the joint.
 Antagonist:
A muscle or group of muscles that has an
opposite action to the prime mover's. the
antagonist relaxes as the agonist moves the part
through a ROM.
 Synergists:
A muscle that contracts and works a long with the
agonist to produce the desired movement.
Range of Muscle Work:
The full range in which a muscle work is divided into
parts, outer, inner and middle ranges.
 Outer Range:
Is from a position where the muscle is on full stretch
to a position half way through the full range of
motion.
 Inner Range:
Is from a position half way through the full range of
motion to a position where the muscle is fully
shortened.
 Middle Range:
It is the portion of the full range between the
midpoint of the outer range and the midpoint of
the inner range.

The range of movement produced by contraction of brachialis(A) & Triceps (B)

 Individual Versus Group Muscle Test

 Muscles with a common action or actions may be

tested as a group or a muscle may be tested
individually.

 For ex., flexor Carpi ulnaris and flexor Carpi radialis

may be tested together as a group in the action of
wrist flexion. Flexor carpi ulnaris may be tested more
specifically in the action of wrist flexion with ulnar
deviation.
Muscle Testing Assessment Procedures
 Explanation and Instruction:
The therapist demonstrates and /or explains
briefly the movement to be performed.
 Assessment of Normal Muscle Strength:
Initially assess and record the strength of the
uninvolved limb to determine the patient's
normal strength.
 Patient Position:
The patient is positioned to isolate the muscle or
muscle group to be tested.
Ensure the patient is comfortable and well
supported.
 Stabilization:
Prevent substitutions and trick movements by
making use of the following methods:
1. The patient normal muscles
2. The patient's body weight
3. The patient position
4. External forces
 Substitution and Trick Movement:
When muscles are weak or paralyzed, other
muscles may take over or gravity may be used to
perform the movement.
Manual Muscle Testing Grades
 Zero 0/5
The subject demonstrates no palpable muscle
contraction.
 Trace 1/5
The subject's muscle contraction can be palpated, but
there is no joint movement.
 Poor 2/5
The subject completes range of motion with gravity
eliminated.
 Fair 3/5
The subject completes ROM against gravity without
manual resistance
 Good 4/5
The subject completes ROM against gravity with
moderate resistance.
 Normal 5/5
The subject completes ROM against gravity with
maximal resistance.
 Poor Minus 2-/5
The subject does not complete ROM in a gravity
eliminated position.
 Poor Plus 2+/5
The subject is able to initiate movement against
gravity.
 Fair Minus 3-/5
The subject does not complete the range of motion
against gravity, but does complete more than half of
the range.
 Fair Plus 3+/5
The subject completes ROM against gravity with only
minimal resistance.
 Good Minus 4-/5
The subject completes ROM against gravity with
minimal-moderate resistance.
 Good Plus 4+/5
The subject completes ROM against gravity with
moderate-maximal resistance.
Contraindications and Precautions of MMT
 Inflammation.
 Pain
 Cardiovascular problems.
 Abdominal surgery or herniation.
 Fatigue.
 Extreme debility.
Goniometry
 Goniometry
The technique of quantifying human joint active or passive
range of motion.
Purpose of Goniometric assessment:
 To establish the existing range of motion
available in a joint.
 To aid in diagnosis and determining the
patient’s joint function.
 To reassess the patient’s status after
treatment.
 To develop the patient’s interest in and
motivation for the treatment.
Defining Movement
 Passive (PROM) – no effort by the patient
 Active (AROM) – patient performs the movement
themselves
 Assistive (AAROM) – someone else helps the
patient through the ROM
 Hypermobility – excessive ROM
 Hypomobility – less than normal ROM
Factors That Influence Range of Motion:
 Reliability:
factors that will improve reliability include
removal of tight and restrictive clothing, and
measuring at the same time of day.
 Age: generally the younger the subject, the
greater the range of motion.
 Sex: women tend to have greater ranges than
men.
 Joint structures: some persons, because of
genetics or posture, normally have hypermobile
or hypomobile joints.
Types of goniometers
Universal goniometers:
plastic or metal protractor like device with
moveable and stationary arms of varying lengths
 Gravity Dependent Goniometers – Inclinometers:
report position of distal or proximal segment
relative to the line of gravity
 Electrogoniometers:
potentiometer detects changes in position of two
segments
Parts of the Goniometer
 axis of rotation
 non-moving (Stationary arm)
 moving arm
 reading numbers
 Procedures
 Patient position
 Locating joint axis
 Locating stationary arm
 Locating moving arm
 Reading goniometer
 Recording goniometer measures (the mean of 2 or 3 trials
is more accurate)
Contraindications and Precautions for ROM Testing:
 Dislocation or unhealed fracture.
 Surgical procedures to tendons, ligaments,
muscles, joint capsule or skin.
 Infections or inflammatory process.
 Marked osteoporosis.
 Hyper mobile or sublaxated joint.
 Painful conditions.
 Hematoma.
Shoulder flexion
- Shoulder hyperextension

- shoulder abduction
 Shoulder internal rotation

Shoulder external rotation

Elbow flexion and extension
 END FEEL
Nature of the motion barrier that characterizes the type of
tissue limiting range.

Normal or Physiologic END FEEL:

 Hard
 Soft
 Firm
 Capsular stretch
 Hard (bony):
An abrupt, hard stop to movement when bone
contacts bone; for ex.: Passive elbow extension.
the olecranon process contacts the olecranon
fossa.
 Soft (soft tissue opposition):
When two body surfaces come together a soft
compression of tissue is felt, for ex.: in passive
knee flexion, the posterior aspects of the calf and
thigh come together.
 Firm (soft tissue stretch):
Firm or springy sensation that has some give when
a muscle is stretched for ex.: passive ankle
dorsiflexion performed with the knee in extension
is stopped due to tension in the gastrocnemius
muscle.
 Capsular stretch:
Hard arrests to movement with some give when
the joint capsule or ligaments are stretched. The
feel is similar to stretching a piece of leather, for
ex.: passive shoulder external rotation.
Long and Round Measurement
 Long measurement:
Total: Measure the length of the upper limb from
acromion to the radial styloid process.

Segmental: - Measure the length of the humerus

from acromion to the lateral epicondyle.

- Measure the length of radius and ulna from lateral

epicondyle of humerus to the radial styloid process.
 Round measurement:

Muscle atrophy: measure around the midpoint of

the arm and around the upper third of the forearm.

Joint edema: measure around the centre of the

elbow joint (centre of the capital fossa) and 3cm &
6cm above and below.
Cervical & Lumbar Spine ROM
Spinal Column
 Cervical Spine ROM

Seven Cervical Vertebrae Forming The

Cervical Spine, Including The First&
Second Ones ( Atlas & Axis )

Construction of the Spinal Vertebra

- Vertebral bodies: Weight bearing.
- Neural arch: Protect Neural Elements.
- Bony Processes: increase the efficiency of
muscle action.
- The atlas (C1) and the axis (C2),
have structures unlike those of any
other vertebra.

- The atlas has no vertebral body and

is shaped like a ring with an anterior
and a posterior arch.

- Has no spinous process. Superiorly,

it has a fovea, or dishlike depression,
that holds the occiput of the skull.

- The articulation of the atlas with the

skull is called the atlantooccipital
joint. At this joint, the head nods on
the spine.
 The atlantooccipital joint allows approximately 10‫آ‬°
to 15‫آ‬° of flexion and extension and no lateral flexion
or rotation.
 The weight of the head is transferred to the cervical
spine via C2, the axis.
 The articulation with the atlas occurs via a pillar
(odontoid process or dens ) projecting from the
superior surface of the axis that fits into the atlas and
locks the atlas into a pivoting joint. (the most mobile
of the cervical joints).
 allowing approximately 10‫آ‬° of flexion and extension,
accounts for 50% of the rotation in the cervical
vertebrae and no lateral flexion.
 Because of the short spinous processes, the shape of
the discs, and the backward and downward
orientation of the articulating facets, movement in
the cervical region is greater than in any other region
of the vertebral column.

 Forward flexion: 0 to 45 degrees.

 Extension: 0 to 45 degrees.
 Lateral Flexion: 0 to 45 degrees.
 Lateral Rotation: 0 to 80 degrees.
Methods to Measure the Range
of Motion of the Cervical Spine
Radiographs.

 inclinometers.

Tape measures.
Forward flexion: 0 to 45 degrees.

Extension: 0 to 45 degrees.

Lateral Flexion: 0 to 45 degrees.

Lateral Rotation: 0 to 80 degrees.
 Lumbar Spine ROM

•Five lumbar vertebrae and the sacrum

making up the lumbar spine.

•The size of the vertebral body increases

from L1 to L5, due to the increasing loads
that each lower lumbar vertebral level has
to absorb.
 The collective range of motion in the lumbar region is:
- Lumbar flexion (60°)
- Lumbar Extension (30°)
- Lumbar lateral flexion (30- 40°)
- Lumbar rotation (45°)
 The lumbosacral joint is the most mobile of the
lumbar joints, accounting for a large proportion of the
flexion and extension in the region.
 Of the flexion and extension in the lumbar vertebrae,
75% may occur at this joint, with 20% of the remaining
flexion at L4-L5 and 5% at the other lumbar levels.
- Lumbar flexion (60°)

- Lumbar rotation (45°)

 Clinical Methods to Assess Lumbar ROM
•Spinal flexion:
- By measuring the degrees of forward inclination of the
trunk in relation to the longitudinal axis of the body. The
examiner should fix the pelvis with his hands.
 - By indicating the level the fingertips reach along
the patient leg. For instance, fingertips to the
patella; or fingertips to mid-tibia.
- By measuring the distance in inches or centimeters
between the fingertips and the floor.
- By the steel or plastic tape measuring method:

o The most accurate clinical method of measuring

true motion of the spine in flexion.
o With the patient standing, the tape is held over the
spinous process of C7, and the distal tape held over
the spinous process of S1.
o As the patient bends forward, the spinous processes
spread, this will be indicated by lengthening of the
tape measure.
o In the normal healthy adult, there is, on the average,
an increase of 4 inches in forward flexion. If the
patient bends forward with his back straight (as in
rheumatoid arthritis), the tape will not record
motion.
o One is able to record motion of the thoracic spine by
taping from the spinous process of C7 to T12.
o Usually if the total spine in flexion is 4 inches the
examiner will find that 1inch occurs in the dorsal
spine, and 3 inches occurs in the lumbar spine.
 Spinal lateral bending:

While the patient is standing, the knee joint is used as a

fixed point .Record distance of finger tips from the knee
joint on lateral bending.
 Spinal extension:
while the patient is standing ,measure from C7 to L5
then ask the patient to extend his back and measure
again the distance will decrease .
 Spinal rotation:

To estimate the degrees of rotation of the spine, the

pelvis must be held firmly by the examiner’s hands
and the patient is instructed to rotate to the left side
then to the right side then you have to compare
between the degree of rotation on both sides.