CHAPTER- 7
MANUAL MUSCLE
TESTING
CHAPTER: 7
MANUAL MUSCLE TESTING
HISTORY OF MANUAL MUSCLE TESTING (MMT)
Wilhelmine Wright & Robert W. Lovett (M.D), Professor of orthopedic Surgery at Harvard
University Medical School, were the originators of the muscle testing system.
In Lovett's (1917) book, muscles were tested using a ‘resistance gravity system’ & graded on
a scale of 0 to 6.
Lowman described muscle testing procedures in the "Physiotherapy Review" in 1940. Legg
(M.D) & Janet Merrill (P.T) wrote a valuable small book on Poliomyelitis in 1932. This book,
which offered a comprehensive system of muscle testing, was used extensively in physical
therapy educational programs during the early 1940s. Here muscles were graded a scale of
0 to 5, & a ‘plus’ or ‘minus’ designation was added to all grades except 1 & zero.
The first comprehensive test on muscle testing was written by Lucille Daniels (M.A, P.T),
Marian Williams (Ph.D., P.T) & Catherine Worthingham (Ph.D., P.T) & was published in
1946. These three authors prepare a comprehensive hand book on the subject of manual
testing procedures that was concise & easy to use. It remains one of the most used texts in
the world over at the present time & is the predecessor of both the sixth & this seventh
edition of "Daniels & Worthingham's Muscle Testing."
[Hislop. H. J & Montgomery. J, 1995, 6 th ed, pp 9-10]
BASIC PRINCIPLES OF MANUAL MUSCLE TESTING (MMT)
Definition:
A manual muscle test is a test of the voluntary muscle strength of individual muscles in their
function as prime mover (Agonist).
The grading system
Rating muscle tests is a skill that takes a long time to learn and perform with reliability. It is
important to learn how much resistance a “normal” muscle can tolerate to know when a
muscle is not performing to its potential. All tests must be performed bilaterally and the
unaffected side should be tested first. This is crucial because the tester can then get an
accurate idea of how much resistance the unaffected side can tolerate and what would be
considered normal for the patient.
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MANUAL MUSCLE TESTING
The scale below is comprised of both subjective and objective factors. The subjective is the
examiner knowing how much resistance to give and how much resistance the patient can
tolerate. The objective factors include: if the patient can complete the available range of
motion, move against gravity, and if he/she can hold this position. All of these factors make
accuracy in rating a muscle test difficult, but with practice intra-tester error can be kept at a
minimum.
Dr. Robert W. Lovett introduces a method of muscle testing using gravity resistance as an
objective measure for grading muscle strength. A description of muscle grading based on
the Lovett system & published in 1932 listed the following:






Gone: no contraction felt
Trace: muscle can be felt to tighten, but can’t produce movement
Poor: produce movement with gravity eliminated, but can't function against gravity
Fair: can raise part against gravity
Good: can rise part against outside resistance as well as against gravity
Normal: can overcome a greater amount of resistance than a good muscle.
[Muscle testing & functions]
Grading Scale: (Daniel & Worthingham 1995)






Grade 5: Patient can hold the position against maximum resistance and through
complete range of motion.
Grade 4: Patient can hold the position against strong to moderate resistance, has
full range of motion.
Grade 3: Patient can tolerate no resistance but can perform the movement through
the full range of motion.
Grade 2: Patient has all or partial range of motion in the gravity eliminated
position.
Grade 1: The muscle/muscles can be palpated while the patient is performing the
action in the gravity eliminated position.
Grade 0: No contractile activity can be felt in the gravity eliminated position.
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MANUAL MUSCLE TESTING
OXFORD grade scale:
 Grade 5: Patient can hold the position against maximum resistance and through
complete range of motion.
 Grade 4: Patient can hold the position against strong to moderate resistance, has
full range of motion.
 Grade 3: Patient can tolerate no resistance but can perform the movement through
the full range of motion.
 Grade 2: Patient has all or partial range of motion in the gravity eliminated
position.
 Grade 1: The muscle/muscles can be palpated while the patient is performing the
action in the gravity eliminated position.
 Grade 0: No contractile activity can be felt in the gravity eliminated position.
Factors considering muscle strength:
Three factors are considered in the assessment of muscle strength:
1. Ability of the muscle to contract
2. Ability or inability of the muscle to move through range
3. Amount of resistance which can be give to the working muscle
(Human movement)
Requirements for muscle testing:
1.
2.
3.
4.
5.
Knowledge of muscle & joint structure
Knowledge of nerve supply & function of particular muscle
Knowledge of test procedures & grading of muscle
The ability to observe, handle & palpate any muscle accurately & sensitively
The ability to recognize muscle substitution
(Human movement 2ND Ed)
Preparation for Manual muscle testing:







The room should be worm light & quiet
Should have firm examination table
Give an explanation to the patient about the reason for the test
Suitable state of undress
Maintain comfortable well supported position so that, if possible the patient can see
the tested area
The physiotherapist should previously read the medical notes & ask the patient
about the problems
Observe posture &muscle wasting
(Human movement 2nd Ed)
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MANUAL MUSCLE TESTING
Test position:
1. During testing grade 0 to 2 provide more support & move in horizontal plane
2. During testing grade 3 to 5 the positions are against gravity
Human movement
Technique of muscle testing:











Adequate fixation should be maintained
All joint should be tested through their available range either by active movement
when possible or by passive movement
The resistance may be given through the range of movement by the physiotherapist
hand
Resistance should be smooth adjustable & its line directly opposite to the line of
pull of muscle tendon
Trick movement (Substitution movement) should be eliminated
All possible tests should be carried out in one position before moving to the
patient another position
The patient should be given an appreciation
The, result should be memorized as the test proceeds & recorded during the rest
period for the patient
The patient should not be fatigue
On the completion of the test, the ‘muscle chart’ should be signed, dated, & filed
Also regularity should be maintained
Human movement 2nd ed
©Therapeutic Exercise Hand Book
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CHAPTER: 7
MANUAL MUSCLE TESTING
MMT IN UPPER LIMB
SHOULDER FLEXION:
Muscles:


Anterior Deltoid
Corocobrachialis
N.B: I in the absence of a deltoid the patient
may attempt to flex the shoulder with the
biceps brachii, by first externally rotating
shoulder. To avoid this, the arm should be
kept in the mid position between internal &
external position rotation.
Grade 5 & Grade 4:


Patient position: Short sitting, Elbow slightly flexed
& fore arm Pronated.
Test:
 Give downward resistance at 90 degree flexion
position. Tell the patient "hold it; don't let me
push it down".
 If hold end position (90 degree) against maximum
resistance, it is G-5.
 If hold end position against strong to, moderate
resistance, it is G-4.
Grade 3:
 Patient position: Short sitting, Elbow slightly

flexed & fore arm Pronated.
Test:
 Flex shoulder at 90 degree position. Ask patient
to hold their.
 If patient can hold that position, it is G-3. But can't
tolerate resistance.
Grade 2, Grade 1 & Grade 0:


Patient position: Side lying with test side is up.
Test:
 Instruct patient to flex shoulder at 90 degree position.
 If patient can complete ROM, it is G-2
 If there is contraction (Therapist can feel) but no movement, it is G-1.
 If there is no movement or contraction, it is G-0.
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MANUAL MUSCLE TESTING
SHOULDER EXTENSION:
Muscles:



Latissimus dorsi
Teres major
Posterior deltoid
Grade 5 & Grade 4:
 Patient position: Prone with arms at sides & shoulder internally rotated.

G-5 & G-4
Test:
 Patient raises arm off the table. Give resistance & ask the patient to hold it &" don't
let me push it down".
 G-5: Complete available range against maximum resistance.
 G-4: Complete available range against moderate resistance.
Grade 3, Grade 2, Grade 1 & Grade 0:


Patient position: Prone with arms at sides & shoulder internally rotated.
Test:
 Patient raises arm off the table.
 G-3: Complete available range of motion with no manual resistance.
 G-2: Complete partial ROM or complete FROM in side lying with tested side up.
 G-l: Therapist palpate over the posterior shoulder just superior to the axilla for
posterior deltoid fiber. If contraction occurs then it is G-1.
 G-0: No contractile response in participating muscle.
[G- 3]
©Therapeutic Exercise Hand Book
[G-0]
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MANUAL MUSCLE TESTING
SHOULDER ABDUCTION:
Muscle:


Middle Deltoid
Supraspinatus
Grade 5 to Grade 3:


Patient position: Short sitting, with arm side
& Elbow slightly flexed.
Test:
 Patient abducts his arm 90 degree. Apply
resistance downwards & ask patient to
hold it, not to go the therapist
G-5 & G-4
downwards.
 If hold in maximum resistance it is G-5, moderate resistance it is G-4.
 Only can abduct at 90 degree but can't tolerate any resistance it is G-3.
Grade 2 to Grade 0:


Patient position: Supine lying with arm ;r. side, supported on the table. Fore arm
Pronated.
Test:
 Patient attempts to abduct shoulder by sliding arm on table without rotating it.
 If complete FROM: it is G-2
 If palpable or visible contraction of Deltoid with no movement, it is G-l.
 If no movement or contraction it is G-0
[G-3]
©Therapeutic Exercise Hand Book
[G-2 to 0]
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MANUAL MUSCLE TESTING
SHOULDER ADDUCTION:
Muscle:

Pectoralis major
Grade 5 to Grade 4:


Patient position: Supine, 90 degree shoulder
abduction, 90 degree elbow flexion,
Test:
 Move arm across the chest, give resistance
ask patient to hold it. Don't let me pull it
back.
 If need maximum resistance it is G-5,
moderate resistance it is G- 4.
G- 5 & G- 4
Grade 3:


Patient position: Supine, Shoulder at 90 degree of abduction & Elbow 90 flexion.
Test:
 Support patient's fore arm & ask to adduct the shoulder.
 If complete available range it is G-3.
Grade 2 to Grade 0:
 Patient position: Patient is seated with test arm supported on table (at level of axilla)

with arm in 90 degree of abduction & Elbow slightly flexed.
Test:
 Patient tries to horizontally adduct his shoulder
 If patient horizontally adduct shoulder through available range of motion with the
weight of the arm supported by the examiner or the table. It is G-2.
 G-1: palpable contraction but no movement. G-0: no movement or contraction.
G-3
G- 2 to 0
©Therapeutic Exercise Hand Book
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MANUAL MUSCLE TESTING
SHOULDER EXTERNAL ROTATION:
Muscle:


Infraspinatus
Teres minor
Grade 5 to Grade 3:


Patient position: Prone with head turn
towards tested side. Shoulder abducted 90
degree with arm fully supported on table, fore
arm hanging vertically over edge of the table.
Test:
 Patient raises his fore arm & gives
resistance externally. Ask patient to hold
G- 5 & G-4
it; don't let it push me down.
 If hold fore arm in two finger resistance, it is G-5. Need moderate resistance, G-4.
 G-3: If complete available ROM but; is unable to take any manual resistance.
Grade 2 to Grade 0:


Patient position: Prone with head turn towards tested side, trunk is edge of the table.
The entire hangs downs loosely from the shoulder in neutral rotation, palm facing table.
Test:
 Patient attempts to externally rotate the shoulder.
 If complete available range (palm race forward), it is G- 2.
 If contraction but no movement, G-1. No contraction G-0.
[G-3]
©Therapeutic Exercise Hand Book
[G- 2 to 0]
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MANUAL MUSCLE TESTING
SHOULDER INTERNAL ROTATION:
Muscle:
 Subscapularis
Grade 5 to Grade 3:


Patient position: Prone lying with head
turn towards tested side. Shoulder abducted
90 degree with arm fully supported on table,
fore arm hanging vertically over edge of the
table.
Test:
 Moves towards internal rotation. Give
resistance & ask to hold it, don't let me
push it down.
 If hold maximum resistance, G-5. Moderate resistance, G-4
 If complete available range with no resistance- G-3
G-5 & G-4
Grade 2 to Grade 0:


Patient position: Prone lying with head turn towards tested side, trunk is edge of the
table. The entire hangs downs loosely from the shoulder in neutral rotation, palm facing
table.
Test:
 Patient infernally rotates arm with thumb leading so that the palm faces out away
from the table.
 G-2: Complete available range. G-l: Palpable contraction occurs but no movement.
 G-0: No movement or palpable contraction
[G- 3]
©Therapeutic Exercise Hand Book
[G-2 to 0]
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MANUAL MUSCLE TESTING
ELBOW FLEXION:
Muscle:



Biceps
Brachialis
Brachioradialis
Grade 5 to Grade 3:


Patient position: Short sitting with arm sides.
 For Biceps brachii: Fore arm supination.
 For Brachialis: Fore arm pronation
 For Brachioradialis: Fore arm is mid position between supination & pronation.
Test:
 Flex elbow against resistance
 G-5: Can hold in maximum resistance
 G-4: Hold in moderate resistance.
 G-3: Complete available range of motion with no manual resistance (Figure- next page)
G-5(Brachialis)
G-5(Brachioradialis)
G-5(Biceps)
Grade 2 to Grade 0:


Patient position: Short sitting with arm abducted to 90 degree & supported by
examiner. Fore arm is supinated (biceps), Pronated (For Brachialis), & in mid position
(For Brachioradialis).
Test:
 Patient attempts to flex the elbow.
 G-2: Complete ROM against gravity.
 G -1: Palpable contractions-occurs but no movement.
 G 0: No contraction or movement occurs.
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MANUAL MUSCLE TESTING
G-3
G-2 to 0
ELBOW EXTENSION:
Muscle:
 Triceps brachii.
Grade 5 to Grade 3:


Patient position: prone lying. The arm 90 degree abduction & tore arm 90 degree
flexion, with hanging vertically over the side of the table.
Test:
 Extend elbow against resistance & ask the patient to hold it, don't let me bend
 G-5: Can hold in maximum resistance
 G-4: Can hold in minimum resistance.
 G-3: Can extend available range with no manual resistance
Grade 2 to Grade 0:


Patient position: Short sitting. The arm is 90 degree abducted, elbow flex 45 degree.
The entire limb is horizontal to the floor.
Test:
 Patient attempts to extend the elbow
 G-2: Complete available range in the absence of gravity
 G-1: Contraction occurs but no movement
 G-0: No movement or no evidence of muscular activity
[G-5 & 4]
[G- 3]
©Therapeutic Exercise Hand Book
[G- 2 to 0]
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MANUAL MUSCLE TESTING
MMT IN LOWER LIMB
HIP FLEXION:
Muscle:


Psoas major
Iliacus
Grade 5 to Grade 3:


Patient position: Short sitting, with thigh fully
supported on table & legs hanging over the edge.
Patient may use arm to provide trunk stability
by grasping table edge or with hands on table at
each side.
Test:
 Patient flex hip & ask “lift your leg off the
table & don't let me push it down
 G-5: Thigh clear table against maximum
resistance
G-5 & 4
 G-4: Hip flexion against moderate resistance
 G-3: Patient complete test range & holds the position without resistance
Grade 2 to Grade 0:


Patient position: Side lying with tested limb upward
Test:
 Patient flexes supported hip. Knee is permitted to flex to prevent hamstring tension.
Patient complete ROM with gravity eliminated.
 G-1: Palpable contraction but no visible movement. G-0: Normal or visible
contraction.
G-3
©Therapeutic Exercise Hand Book
G-2 to 0
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MANUAL MUSCLE TESTING
HIP EXTENSION:
Muscle:


Gluteus maximus
Hamstring
G-5 & 4
Grade 5 to Grade 3:


Patient position: Prone position.
Test:
 Patient extends the hip against
resistance. Ask him “lift your leg off
the table as high as you can
without bending your knee
 G-5: Holds test position against maximum resistance.
 G-4: Hold moderate resistance
 G-3: Complete range & hold the position without resistance
Grade 2 to Grade 0:


Patient position: Side lying with tested leg up
Test:
 Bring the leg back, don't bend the knee.
 G-2: Complete FROM. G-l: Palpable contraction but no movement
 G-O: No movement or palpable contraction
[G-3]
©Therapeutic Exercise Hand Book
[G- 2 to 0]
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MANUAL MUSCLE TESTING
HIP ABDUCTION:
Muscle:


Gluteus medius
Gluteus minimus
Grade 5 to Grade 3:


Patient position: Side lying with the
G- 5 & 4
tested leg upward. Lowermost leg is
flexed for stability.
Test:
 Lift the leg upward, against resistance
& ask the patient ‘hold it don't let me
push it down’
 G-5: Complete available range with maximum resistance
 G-4: Moderate resistance
 G-3: Compete available range of motion & hold that position without resistance
Grade 2 to Grade 0:


Patient position: Supine position.
Test:
 Abduct hip thorough available range
 G-2: Complete available range of motion, gravity eliminated.
 G-1: Palpable contraction but no ROM. G-0: No palpable contraction or ROM
[G-3]
©Therapeutic Exercise Hand Book
[G- 2 to 0]
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MANUAL MUSCLE TESTING
HIP ADDUCTION:
Muscle:





Adductors Magnus
Adductor brevis
Adductor longus
Pectineus
Gracilis
G-5 & 4
Grade 5 to Grade 3:


Patient position: Side lying with tested
limb upward.
Test:
 Patient adducts hip until the lower
limb contracts the upper one. Ask
the patient ‘lift your bottom leg up to your top one. Hold it; don’t let me push it
down."
 G-5: Complete full range, hold end position against maximum resistance
 G-4: Complete full movement in moderate resistance
 G-3: Complete full movement, hold end position but takes no resistance
Grade 2 to Grade 0:


Patient position: Supine position.
Test:
 Adduct hip without rotation. G-2: Can adduct limb through full range.
 G-1: palpable contraction without limb movement. G-0: No limb movement &
contraction.
G-3
G-2 to 0
©Therapeutic Exercise Hand Book
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MANUAL MUSCLE TESTING
KNEE FLEXION:
Muscle:

Hamstring muscle
G- 5 & 4
Grade 5 to Grade 3:


Patient position: Prone lying
Test:
 Ask the patient "bend your knee, hold
it, and don’t let me straighten it"
 G-5: Can hold in maximum resistance.
G-4: Can hold in moderate resistance.
 G-3: Hold end range position but
tolerates no resistance
Grade2 to Grade 0:


Patient position: Side lying with tested side upward.
Test:
 Flex the knee. G-2: Complete available ROM in side lying.
 G-1: palpable tendon become prominent but no movement.
 G-0: No movement or palpable contraction.
[G-3]
©Therapeutic Exercise Hand Book
[G- 2 to 0]
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MANUAL MUSCLE TESTING
KNEE EXTENSION:
Muscle:

Quadriceps
Grade 5 to Grade 3:


Patient position: Short sitting
Test:
 Extend the knee. Ask patient "Straighten
your knee. Held it, don’t let me bend it."
 G-5: Hold end position against maximum
resistance
 G- 4: Hold end position in moderate
resistance
 G-3: Complete available range without resistance
G- 5 & 4
Grade 2 to grade 0:


Patient position: Side lying with tested leg upwards
Test:
 Straighten the knee. G-2: Complete available-ROM.
 G-l: No motion but palpable muscle contraction.
 G-0: No movement & palpable contraction.
[G-3]
©Therapeutic Exercise Hand Book
[G-2 to 0]
Page 18
CHAPTER: 7
MANUAL MUSCLE TESTING
MMT IN TRUNK MUSCLES
TRUNK EXTENSION:
Grade 5 to Grade 4: (Lumber spine)


Patient position: Prone with clasped behind head.
Test: Ask the patient "Raise your head, shoulder & chest off the table. Come up as high
as you can."The examiner distinguishes between Grade 5 & Grade 4 muscles by the
nature of the response. The grade-5 muscle holds like a lock, the Grade 4 muscle yield
slightly because of an elastic quality at the end pint. The patient with normal back
extensor muscles can quickly come to the end position & hold that position without
evidence of significant effort. The patient with Grade 4 back extensors can come to the
end position but may waver or display some signs of effort.
G- 5 & 4
Grade 5 to Grade 4: (Thoracic spine)


Patient position: Prone with head & upper trunk extending off the table from about the
nipple line.
Test:
 Ask the patient “Raise your head, shoulder & chest to table level"
 G-5: Patient is able to raise the upper trunk quickly from its forward flexed position
to the horizontal with ease & no sign of exertion.
 G-4: Patient is able to raise the trunk to the horizontal level but does it somewhat
laboriously.
G- 5 & 4
©Therapeutic Exercise Hand Book
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MANUAL MUSCLE TESTING
Grade 3 (thoracic & lumbar spine):


Patient position: Prone with arm sides.
Test:
 Patient extend spine, raising body from the table so that umbilicus clears the table.
 G-3: Patient completes the ROM. But
cont hold.
G-3
Grade 2 to Grade 0 (thoracic & lumbar):
Test: These tests are identical to the Grade 3
test, except that the examiner must palpate
the lumbar & thoracic spine extensor
muscle masses adjacent to both sides of the
spine. The individual muscles can't be
isolated.
 G-2: Patient complete partial ROM. G-l: Contractile activity is detectable but re
movement.
 G-0: No contractile activity.
G-2 to 0
TRUNK FLEXION:
Muscle:



Rectus abdominis
External oblique
Internal oblique
Grade 5:


Patient position: Supine with hands clasped behind head
Test:
 Patient flexes trunk through range of motion. A curl- up emphasized & trunk is
curled until scapulae clear table.
 G-5: Complete ROM, until inferior angle of scapula is off the table, as in a sit-up
©Therapeutic Exercise Hand Book
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CHAPTER: 7
MANUAL MUSCLE TESTING
G-5
Grade 4:


Patient position: Supine with arms crossed
over chest.
Test: Same as grade 5
 G-4: Patient complete ROM, & rises
trunk until scapula are off the table.
 Resistance of the arms is reduced in the
cross-chest position.
G-4
Grade 3:


Patient position: Supine with arms outstretched in full extension above piece of body.
Test:
 Patient flexes trunk until inferior angles
G-3
of scapula are off the table. Position of
the outstretched arms "neutralizes"
resistance by bringing the weight of the
arms closer to the center of gravity.
 G-3: Patient complete ROM & flexes
trunk until inferior angles of scapula
are off the table.
Grade 2 to 0:
G- 2 to 0
Patient position: Supine with arm side, knee
flexes.
Test:
Ask the patient to lift the head from the table.
If scapula doesn't clear the table G-2, only
contraction G-l, No contraction, it is G-0.
©Therapeutic Exercise Hand Book
Page 21