





Appraise the importance and clinical benefits of test
and measurements
Demonstrate how to prepare environment, equipment
and patient for evaluation procedures.
Have the ability to conduct gross and individual
muscle testing.
Classify and identify different grades of muscle
evaluation.
Apply different techniques of muscle testing with
respect to both therapist and patient mechanical
advantage.
Show professional behaviour and attitude

Manual Muscle Testing (MMT) is a procedure for the
evaluation of the function and strength of individual
muscles and muscles group based on effective
performance of a movement in relation to the forces
of gravity and manual resistance through the
available ROM. This procedure depends on the
knowledge, skill. And experience of the examiner.

Muscle testing is an integral part of physical
examination. It provides information, not obtained
by other procedures, that is useful in differential
diagnosis, prognosis and treatment of
neuromuscular and musculoskeletal disorders


The therapist must be a keen observer and be experienced
in muscle testing to detect minimal muscle contraction,
movement, and/or muscle wasting and substitutions or
trick movements.
Is to provide information that may be of assistance to a
number of health professionals in differential diagnosis,
treatment planning and prognosis, but it has limitations in
the treatment of neurological disorders where there is an
alteration in muscle tone if reflex activity is altered or if
there is a loss of cortical control due to lesions of the
central nervous system

To asses muscle strength, the therapist must have a
sound knowledge of anatomy (including joint
motions, muscle origin and insertion, and muscle
function) and surface anatomy (to know where a
muscle or its tendon is best palpated).

A consistent method of manually testing
muscle strength is essential to assess
accurately a patient’s present status, progress,
and the effectiveness, of the treatment program

1.
2.
3.
4.
There are many ways for measurements:
Quick muscle testing. Ankle\shoulder\ hip..
Gross muscle testing.
Individual muscle testing.
Functional muscle testing( for pediatrics only).
Other equipments:



Isokinetic Dynamometer.
Isometric Dynamometer.
Tensiometer.

1.
2.



3.
4.
5.
6.
7.
There are many steps to do manual muscle testing:
Gravity. It is important to know the force of a muscle.
Resistance. Use it when a muscle can perform action against
gravity, this include either:
Minimal resistance.
Moderate resistance.
Maximal resistance.
Range of motion. Is it complete\ full or incomplete\ partial ROM.
Position of patient. Supine, sideline, prone, sitting, standing……
Position of therapist\ examiner. Inner hand\outer hand,
stabilization…
Substitutions\ trick movements.
Verbal command\instruction
Muscular strength:

The maximal amount of tension or force that a muscle or muscle
group can voluntary exert in one maximal effort, when type of
muscle contraction, limb velocity, and joint angle are specified.
Muscular endurance:

The ability of a muscle or muscle group to perform repeated
contraction, against resistance, or maintain the an isometric
contraction for a period of time.
Range of muscle work:
The full range in which a muscle work refers to the
muscle changing from a position of full stretch and
contracting to a position of maximal shortening. The
full range is divided into part, outer, inner, and
middle ranges.
Outer
range
Middle
range
Inner
range
Outer range:
Is from a position where the muscle is on full stretch to a position half
way though the full range of motion.
Inner range:
is from a position halfway through the full range to a position where
the muscle is fully shortened.
Middle range:
is the portion of the full range between the mid-point of the outer
range and the midpoint of the inner range.
1- Explanation and instruction:
The therapist demonstrate and or explains briefly the
movement to be performed and or passively moves
the patient’s limb through the test movement.
2- Assessment of normal muscle strength:
Initially assess and record the strength of the
uninvolved limb to determine the patients normal
strength.
3- Patient position:
The patient is positioned to isolate the muscle or
muscle group to be tested in either gravity eliminated
or against gravity position.
4- Stabilization:
Stabilize the site of attachment of the origin of the muscle
so that the muscle has a fixed point from which to pull.
Prevent substitution and trick movements by making use
of the following methods:
A- the patient’s normal muscles.
B- the patient’s body weight.
C- the patient position.
D- external forces.
5- Substitution and trick movements:
When muscles are weak or paralyzed, other muscles may
take over or gravity may be used to perform the
movements normally carried out by the weak muscles.
Manual grading of muscle strength is based on three factors:
1- Evidence of contraction:
No palpable or observation muscle contraction (grade 0) or a
palpable or observable muscle contraction and no joint motion
(grade 1).
2- Gravity as a resistance:
The ability to move the part through the full available range of
motion gravity eliminated (grade 2) or against gravity (grade
3) the most objective part of test.
3- Amount of manual resistance:
The ability to move the part through the full available range of
motion against gravity and against manual resistance (grade 4)
or maximal manual resistance (grade5).
A- Break test
Manual resistance is applied to a limb or other body part after
it has completed its range of movement or after it has been
placed at end range by the examiner. Manual resistance should
always be applied in the direction of the line of pull of the
participating muscle or muscles. At the end of the available
range, or a point in the range where the muscle is most
challenged, the patient is asked to hold the part at that point
and not allow the examiner to break the hold with manual
resistance.
B- Active resistance test
An alternative to the break test is the application of
manual resistance against an actively contracting muscle
or muscle group (i.e., against the direction of the
movement as if to prevent that movement). During the
motion, the examiner gradually increases the amount of
manual resistance until it reaches the maximal level the
subject can tolerate and motion ceases.
Biceps brachii i.e. – when the elbow is straight, the
biceps lever is short; leverage increases as the elbow
flexes and becomes maximal (most efficient) at 90
degrees, but as flexion continues beyond that point, the
lever arm again decreases in length and efficiency.

Two joint muscles – the point of maximum resistance is
generally at or near midrange

Apply resistance near the distal end of the segment to
which the muscle is attached.


Resistance should never be sudden or uneven.

Apply resistance slowly and gradually, allowing it to build to the
maximum tolerable intensity
Grades represent an examiner’s assessment of the
strength or weakness of a muscle or a muscle group. In
manual muscle testing, grading is based on a system in
which the ability to hold the tested part in a given
position against gravity.
 With gravity.
 Against gravity.
 With gravity eliminated.


The grade of Fair (3) is the most objective grade because
the pull of gravity is a constant factor
Grades for a manual muscle test are recorded as
numerical scores ranging from (0), which represents
no activity, to five(5), which represents a normal or
best possible response to the test or as great a
response as can be evaluated by a manual muscle test.
Each numerical grade can be paired with a word that
describes the test performance in quantitative terms.






Grade 0-no muscle contraction
Grade 1-flicker of contraction
Grade 2-full range of motion in gravity
eliminated plane
Grade 3- full range of motion against gravity
Grade 4- full range of motion against gravity
with half maximal resistance
Grade 5- full range of motion against gravity
with maximal resistance
The grade 5 (Normal) Muscle:
The patient has an ability to complete a full range of motion
or maintain end-point range against gravity and maximal
resistance.
The grade 4 (Good) Muscle:
The patient has an ability to complete a full range of motion
against gravity and can tolerate strong resistance without
breaking the test position
The grade 3 (Fair) Muscle:
The grade 3 muscle test is based on an objective measure.
The patient has an ability to complete a full range of
motion against only the resistance of gravity.
The grade 2 (Poor) Muscle:
The patient has an ability to complete a full range of motion
in a position that minimizes the force of gravity. This
position often is described as the horizontal plane of
motion.
The grade 1 (Trace) Muscle:
The examiner can detect visually or by palpation some
contractile activity in one or more of the muscles that
participate in the movement being tested.
The grade 0 (Zero) Muscle:
Muscle is completely quiescent on palpation or visual
inspection.

Use of a plus or minus addition to a MMT grade is
discouraged except in three istances- Fair +, poor + and
poor –

Fair Plus 3+: The subject completes ROM against
gravity with only minimal resistance

Poor Plus 2+: The subject is able to initiate movement
against gravity

Poor Minus 2-: The subject does not complete ROM in a
gravity eliminated position
Observation of the patient before the examination will
provide valuable clues to muscular weakness and
performance deficits. For example, the examiner can:
 Watch the patient as he or she enters the treatment area to
detect gross abnormalities of gait.
 Watch the patient sit and rise from a chair, fill out
admission or history forms, or remove street clothing.
 Ask the seemingly normal patient to walk on the toes and
then on the heels.
 Ask the patient to grip the examiner’s hand.
 Perform gross checks of bilateral muscle groups.
The examiner and the patient must work in harmony if the test session
is to be successful, some basic principles should be present:
1- The patient should be as free as possible from discomfort or pain
for the duration of each test.
2- The environment for testing should be quiet. The temperature
should be comfortable for the partially disrobed subject.
3- The plinth or mat table for testing must be firm to help stabilize the
part being tested.
4- Patient position should be carefully organized so that position
changes in a test sequence are minimized.
5- All materials needed for the test must be at hand. This is
particularly important when the patient is anxious for any reason or
is too weak to be safely left untended.
Definition of validity:
Means that a test actually measures what it is suppose to measure.
Reliability
Definition of reliability:
Is the repeatability and the extent to each comparable results are
achieved every time a test repeated. If a muscle test is repeated by
one or more therapist who obtain the same grade every time, then
the test is reliable.
Types of reliability:
1- Interrater reliability means that another person who performs the
test should arrive at same results, to an acceptable extend.
2- Intrarater reliability means that one person should come up with the
same results on every repetition of the test within acceptable level.







There may be variation in the assessment of the true effort expended by a
patient in a given test.
The patient’s willingness to endure discomfort or pain may vary.
The patient’s ability to understand the test requirements may be limited in
some case because of comprehension and language barriers.
The motor skills for the test may be beyond some patient.
Lassitude and depression may cause the patient to be indifferent to the test
and the examiner.
Cultural, social, and gender issues may be associated with palpation and
exposure of a body part for testing.
Though not an individual variation but causing considering differences in
grading are the size and non-comparability between big versus small
muscles.