Department of Physical Therapy/HRP/MU
Clinical Evaluation & Procedures
MANUAL MUSCLE TESTING: KEY TO GRADING AND NOTATION
10
Normal
5/5
Ability to complete test movement and/or hold test position against gravity
and maximum (strong) pressure.
9
Good +
4+/5
Ability to complete test movement and/or hold test position against gravity
and slightly less than maximum (moderate to strong) pressure.
8
Good
4/5
Ability to complete test movement and/or hold test position against gravity
and moderate pressure.
7
Good -
4-/5
Ability to complete test movement and/or hold test position against gravity
and slightly less than moderate (slight to moderate) pressure.
6
Fair +
3+/5
Ability to complete test movement and/or hold test position against gravity
and minimal (slight) pressure.
5
Fair
3/5
Ability to complete test movement and/or hold test position against gravity
but cannot hold if even slight pressure is applied.
4
Fair -
3-/5
Ability to complete at least 1/2 of test movement against gravity. Cannot
complete full test movement against gravity. NOTE: Kendall, et al.: a very
gradual release from anti-gravity test position.
3
Poor +
2+/5
Ability to initiate test movement against gravity, but completes less than 1/2
of test movement range. OR
Ability to complete test movement in a gravity lessened position against
slight resistance throughout the range. OR
Ability to complete test movement and hold test position in a gravity
lessened position against slight pressure.
2
Poor
2/5
Ability to complete test movement in gravity lessened position
1
Poor -
2-/5
Ability to initiate or complete partial test movement in a gravity lessened
position with friction reduced; unable to complete full range of test
movement.
T
Trace
1/5
Feeble but palpable muscle contraction or prominent tendon during muscle
contraction with no visible motion of the part.
0
Zero
0/5
No palpable muscle contraction.
Page 1 of 5
MANUAL MUSCLE TESTING: KEY TO TESTING & GRADING
ANKLE PLANTAR FLEXORS IN STANDING
(especially gastrocnemius & soleus)
From: Daniels and Worthingham (2002). Muscle Testing: Techniques of Manual Examination, 5th edition.
NOTE: Some of this information conflicts with information provided in Kendall. You have a handout that discusses the
similarities and differences in the approaches to MMT taken by Daniels and Worthingham and Kendall. This information is for
your information to provide you with additional information and insight into testing this muscle group.
Standing:
Position of patient: Patient stands on limb to be tested with knee extended (for gastrocnemius and soleus
mm); or knee flexed (to test soleus m.). Patient is likely to need external support; no more than one or two
fingers should be used on a table (or other surface) for balance assist only.
Position of therapist: Standing or sitting with a lateral view of test limb. Be sure to guard the pt. in case
balance is lost.
Test: Patient raises heel from floor consecutively through full range of plantar flexion. When testing the soleus
muscle, the pt. must maintain the flexed position of the knee.
Instructions to patient: Therapist demonstrates correct heel rise to patient. "Stand on your right leg: go up on
your tiptoes; now down. Repeat." Repeat test for left limb.
Grading:
5/5 (N):
Patient successfully raises heel from floor through range of motion of plantar flexion. Pt. should
completes minimum of 20 times in good form and without apparent fatigue.
The tibialis posterior and the peroneus longus and brevis muscles must be 5/5 or 4/5 to stabilize
the forefoot and provide counter pressure against the floor.
(Note: Twenty heel rises represent over 60 percent of maximum electromyo-graphic activity of the
plantar flexors.)
4/5 (G):
A grade 4/5 is given if pt. can complete full range of motion between 10-19 times and then has
difficulty in completing the movement.
3/5 (F):
1-9 times
2+/5 (P): patient can just clear the heel from the floor and cannot get up on the toes for the end of test
position
There is no Grade 2 from the standing position
Prone
2+/5 (P +): Pt. Position: prone with feet off end of table, patient able to plantar flex through available range of
motion against maximal resistance
2/Poor
patient completes plantar flexion range but tolerates no resistance
2-/Poor -
patient completes only a partial range of motion
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1/5 or 0/5 (Trace or Zero):
Test: Pt. is asked to plantar flexe ankle through full range of motion.
1/5 (T):
Tendon reflects some contractile activity in muscle, but no joint motion occurs. Contractile
activity may be palpated in muscle bellies. The best location to palpate the Gastrocnemius is
at midcalf with thumb and fingers on either side of the midline but above the Soleus.
Palpation of the Soleus is best done on the posterolateral surface of the distal calf. In most
people with calf strength of Grade 3 or better, the two muscles can be observed &
differentiated during plantar flexion testing because their definition is clear.
0/5 (Zero): No palpable contraction.
HELPFUL HINTS:
1. If the patient is unable to perform a standing plantar flexion test but has a stable forefoot, a different application
of pressure (resistance) may be used with the patient supine. The resistance is applied against the sole of the
foot with the forearm while the heel is cupped with the hand of the same arm and the ankle is forced into
dorsiflexion.
2. If for any reason the patient cannot lie prone, an alternative is to use the supine position for nonweight-bearing
testing. Grades are awarded based on the amount of pressure applied and pt. position is documented as a way
of qualifying/clarifying the grade assigned.
3. During standing plantar flexion tests, the Tibialis posterior and the Peroneus longus and brevis muscles must
be Grade 5/5 or 4/5 to stabilize the forefoot to attain and hold the tiptoe position.
4. During standing heel rise testing, it is important to be sure that the patient maintains a fully erect posture. If the
subject leans forward, such posture can bring the heel off the ground, creating a testing artifact.
5. In the test that isolates the Soleus action, the knee is placed in flexion to put "slack" on the Gastrocnemius
head which crosses the knee joint (put the gastrocnemius at a disadvantage by shortening it over both the knee
and the ankle joint during the test).
Page 3 of 5
MANUAL MUSCLE TESTING: KEY TO GRADING TRUNK MUSCLES
(see also Kendall page 176 & pages where specific tests are described)
ANTERIOR TRUNK FLEXORS: UPPER ABDOMINAL MUSCLE TEST (trunk raising)
10 N
5/5
Able to correctly complete test movement (flex the vertebral column and keep it flexed while
entering the hip-flexion phase and coming to a sitting position) with hands clasped behind head.
9 G+ 4+/5
Able to correctly complete test movement with hands at shoulders.
8 G
4/5
Able to correctly complete test movement with arms crossed at the chest.
7 G-
4-/5
Able to correctly complete test movement with arms crossed at the abdomen.
6 F+
3+/5
Able to correctly complete test movement with arms extended forward.
5 F
3/5
Able to correctly perform posterior pelvic tilt and flex the vertebral column with arms extended
forward, but is unable to maintain the trunk flexion when attempting to enter the hip-flexion
phase of the test movement.
4 F-
3-/5
In supine position with knees slightly flexed (rolled towel under knees), able to tilt the pelvis
posteriorly and keep the pelvis and thorax approximated as the head is raised from the table.
2 P
2/5
Same position as 3-/5 grade: able to tilt the pelvis posteriorly but unable to maintain it as head is
raised from the table.
T T
1/5
Same position as 3-/5 grade: When patient attempts to depress the chest or tilt the pelvis
posteriorly, a contraction can be felt in the anterior abdominal muscles, but there is not
approximation of the pelvis and thorax.
0 Zero 0/5
No palpable muscle contraction.
LATERAL TRUNK FLEXION: see Kendall page 144 & 176.
NOTE: anterior trunk flexors: lower abdominal muscle test is on the next page
Page 4 of 5
MANUAL MUSCLE TESTING: KEY TO GRADING TRUNK MUSCLES
(see also Kendall page 176 & pages where specific tests are described)
ANTERIOR TRUNK FLEXORS: LOWER ABDOMINAL MUSCLE TEST
(holding low back flat during leg lowering, arms folded across the chest)
10 N
5/5
Able to perform posterior pelvic tilt and hold low back flat on table while lowering the legs to the
fully extended position or just short of 0 degrees (table level).
9 G+ 4+/5
Able to perform posterior pelvic tilt and hold low back flat on table while lowering the legs to an
angle of 15 degrees with the table. **
8 G
4/5
Able to perform posterior pelvic tilt and hold low back flat on table while lowering the legs to an
angle of 30 degrees with the table. **
7 G-
4-/5
Able to perform posterior pelvic tilt and hold low back flat on table while lowering the legs to an
angle of 45 degrees with the table. **
6 F+
3+/5
Able to perform posterior pelvic tilt and hold low back flat on table while lowering the legs to an
angle of 60 degrees with the table. **
5 F
3/5
Able to perform posterior pelvic tilt and hold low back flat on table while lowering the legs to an
angle of 75 degrees with the table. **
4 F-
3-/5
and lower: a leg lowering test is not performed.
** It is at this point that the pelvis begins to move in the direction of an ant. pelvic tilt.
NOTE ALSO: if the patient exhibits any of the following faulty movement patterns:
1. excessive participation of the rectus abdominus throughout leg lowering.
2. excessive participation of head and neck for stabilization.
3. increased intra-abdominal pressure to stabilize lumbar spine (holding breath).
OBLIQUE TRUNK RAISING: see Kendall page 146 & 176.
BACK EXTENSION: see Kendall page 140.
10 N
5/5
Able to complete test movement with hands behind the head.
8
4/5
Able to complete test movement with hands clasped behind the back.
G
5-6, F-F+, 3-3+/5
Able to partially complete test movement so that the xiphoid process is raised slightly
with the hands clasped behind the back.
Kendall: Back extensor "weakness is best described as slight, moderate, or marked, for purpose of grading,
based on the judgement of the examiner
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