MANUAL MUSCLE
TESTING
The clinical assessment procedure is used to grade the
strength of muscle in relation to the forces of gravity and
manual resistance
Joe Schoess, PT,DPT,OCS
MMT Pioneers
Dr. Robert Lovett and Wilhelmina Wright (1920’s)
• Introduced MMT, origin stems from the Rx of poliomyelitis
• Their system had 3 grades
• Normal / Partially Paralyzed / Wholly paralyzed
Daniels & Worthingham (1940’s)
• Developed against gravity and gravity eliminated positions
Henry and Florence Kendall
• Refined techniques with % grading
• Published 1st edition of their text in 1949
Florence Kendall (1919~2006) is considered an icon in Phys
Therapy She was born in Warman MN, the 11th child of Swedish
Conditions with marked
weakness
• Polio
• Spinal cord injury (SCI)
• Physical impairments associated with
stroke
• Multiple sclerosis (MS)
• Peripheral nerve injury (PNI)
• Tendon/muscle injury and surgery
• Other???
Objectives / Aims
• Understand MMT procedures and terminology
consistent with Kendall text
• Identify factors that influence testing procedures
• Apply MMT grading system to objectify strength
• Deliver a MMT break test (isometric contraction)
Manual Muscle Testing: Considerations
• MMT is a clinical method used to quantify (grade)
strength
• The grading system has been standardized, and for the
most part, has been accepted across medical
professions
• Though the grading system has been standardized, the
delivery of the resistive force and the interpretation of a
muscle’s response remains somewhat open for debate
• For example, can anyone really define ‘normal’
strength?
Additional Considerations
Muscle strength is quantified in clinical practice
• To guide judgments on diagnosis, prognosis, & treatmen
• To measure progress, and assess the efficacy of
treatment
Listed below are other strength measurement tools
• Hand held devices (myometer)
• Free weight, and isotonic rep-max testing methods
• Isokinetic and isometric strength testing machines
• Others ???
Terminology
• Test position: describes how the patient is position
• Gravity eliminated or against gravity
• Fixation: methods used to support the extremity or
sometimes, to apply counter-pressure
• Manual resistance: the gradual application of force
delivered in the opposing direction of the muscle being
tested
• Break test: isometric resistance with gradual build up until
point the patient’s resistance is overcome
• Substitutions: compensations in posture, position or
movement displayed by the patient during testing
• Caused by weakness, poor instructions, inadequate fixation
Quantifying Strength
• Isotonic
• Testing strength with constant external
resistance
• Isokinetic
• Resistance through ROM at a constant velocity
• Isometric*
• Generate force against an immovable resistance
• MMT
• Hand held dynamometry
How Do We Use MMT?
• MMT is used as an evaluation tool and to indicate
functional performance
• MMT provides us with information to assist with
differential diagnosis, prognosis, and treatment
• MMT serves as a method of measuring progress to
establish efficacy of our treatments
Background Information
• Anatomy:
• surface
• bony landmarks
• muscles
• origins
• insertions
• actions
• Innervations
Grading Systems
• Accuracy in grading involves proper positioning,
application and direction of resistance, fixation of
the patient
• Grade by
• Letter: 0 T P F G N
• Number: 0 1 2 3 4 5
• Percentages- 0%, 5%, 20%, 50%, 80%, 100%
Number System
• 0: no contraction
• 1: contraction without movement (T)
• 2-: partial movement in horizontal plane
• 2: full movement in horizontal plane (P)
• 2+: hold against minimal resistance
in horizontal plane (gravity-eliminated
position)
• 2+: partial ROM against gravity
Number System Cont
• 3-: gradual release from gravity test position
• 3: holds test position without resistance(F)
• 3+: holds test position with minimal resistance
• 4: holds test position with moderate resistance
(G)
• 5: holds test position with max resistance (N)
Letter System
• 0: No evidence of muscle contraction
• Trace: Palpable muscle contraction
• Poor: Movement in horizontal plane
• Fair: Can hold part against gravity, but not against
resistance
• Good: Can hold against moderate resistance
• Normal: Can hold against maximum resistance
Other Factors
• Gravity
• factor in grades above a grade 2
• factor in about 60% of the extremity muscles
• Not a factor in smaller mm ex wrist, fingers, toes
• a one-test position is used when gravity is not
a factor
• slightly different grading system
• specific muscles
One-Test Position GRADING
SCALE
• utilized with muscles where gravity has little effect
on joint
• 0: no muscle contraction
• 1: muscle contraction without movement
• 2: partial ROM
• 3: full ROM without resistance
• 3+: full ROM with minimal resistance
• 4: full ROM with moderate resistance
• 5: full ROM with max resistance
Other Factors
• Pain
• ROM limitations
• Spasticity
• Fatigue
• Patient population: geriatrics & pediatrics
• Mobility Limitations
MMT Basic Rules
• Subject position: position needs to offer best fixation of the
body part being tested
• Stabilize: typically done proximal to the part being tested
• Test position: patient positioned to maximize the effect of
gravity on the muscle being tested. Test here first if possible
• Test position: utilize the horizontal plane whenever testing
muscles too weak for against-gravity testing
• 1-joint muscles: end-range joint position
• 2-joint muscles: mid-range joint position
MMT Basic Rules
• Apply resistance: in the opposite direction of the
muscle being tested
• Speed of resistance: gradually apply resistance to
the muscle
• Allow patient to “get set and hold.”
• Long lever arm: use whenever possible for better
strength discrimination
• Short lever arm: use if accessory muscle(s) do not
provide sufficient stabilization
MMT: Real world application
Verify that there are no precautions or contraindications
Obtain permission and feedback (both verbal and non-verbal) from patient
before and during testing
Use the correct test position for the targeted muscle(s)
Verify that your patient can use the muscle to move a joint through full ROM
Use methods of touch to help the patient identify the muscle targeted for
testing
Use appropriate WIDE hand placements and grips, and deliver an appropriate
application of force during testing
Perform a BREAK test method of assessment
Compare strength results to the contralateral side
Score and correctly interpret the results with words or letters of the interval
grading scales and become proficient in scoring results with both methods
Partner up and List 3 Pros/Cons each
Pros
Cons
