Introduction to manual muscle
testing
Manual Muscle Testing
RHS 221
Dr. Afaf Ahmed Shaheen
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A. VISUAL OBSERVATION

Major part of physical assessment constant gathering of information
contributes to determining the patient’s
problem thus formulating appropriate
assessment plan
What to look for:
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body posture
muscle contour
body proportions
symmetrical or compensatory motion in functional
activities
colour of skin
condition of skin
creases of skin (increased edema loss of crease)
* In order to do a proper assessment the body part being
assessed must be exposed!
(Clarkson, 2000)
Observation &PALPATION

Examination by tactile sense – feel
Palpation assesses:
• Bony and soft tissue contours
• Soft tissue consistency
• Skin temperature
• Texture
*Visual & palpatory assessment is important to
locate bony landmarks for alignment of
goniometers.
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PALPATION CONT’D
Palpation determines:
1. Presence or absence of muscle contraction
therefore assessing strength
2. Locate structures in order to stabilize them to
isolate joint movement.
3. To identify irregularities of bone and soft tissue.
*All bodies are not alike thus the more you palpate
the more proficient you become.
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PALPATION CONT’D
Palpation technique:
 patient must be comfortable
 keep patient warm
 body part well supported thus muscles are relaxed
 visual observation
 palpate with pads of index & middle finger - occasionally thumb
 finger nails must be short
 no sharp rings
 warm hands
 fingers are in direct contact with skin “not through clothing”
 use sensitive but firm touch
 palpate muscle & tendon by having patient isometrically contracts
muscle against resistance followed by relaxation - palpate muscle &
tendon during contraction & relaxation
 palpate tendons - fingers (index & middle) placed across long axis of
tendon - roll across tendon
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(Clarkson, 2000)
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SUPPORT PATIENT’S LIMB
support the patients limb at its centre of
gravity - near upper & middle 1/3 of
segment
 all joints must be supported when lifting or
moving the limb - don’t let a limb hang

(Clarkson, 2000)
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JOINT MOVEMENTS

RANGE OF MOTION
 the
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amount of movement that occurs at a joint
ACTIVE RANGE OF MOTION
 the
amount of movement the patient
voluntarily moves the body part through
without any external assistance.

PASSIVE RANGE OF MOTION
 the
amount of movement that an external
force (therapist) moves the body part through
without any assistance from the patient
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JOINT MOVEMENTS CONT’D

In order to assess for ROM the therapist must
have an understanding of the anatomy of the
area involved. The boney configuration of the
joint, the soft tissue in the area, the movements
that take place at the joint and the limiting
factors of the joint.
(Clarkson, 2000)
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ASSESSMENT CONTRAINDICATIONS
AND PRECAUTIONS
Active and Passive ROM Are
Contraindicated:
 In a region where there is a recent
dislocation or unhealed fracture.
 Immediately following surgery to tendons,
ligaments, muscles, joint capsules or skin.
 When myositis ossificans is present.
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Extra Care with AROM & PROM
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Infectious or inflammatory process in a joint
Patient is on medication for pain or muscle relaxants
Osteoporosis or fragile bones is a factor
In assessing hyper mobile or subluxed joints
Painful conditions
Hemophilia
Hematoma in the region especially in the elbow, hip or
knee
If bony ankylosis is suspected
After an injury disrupting soft tissue (tendons, muscles or
ligaments)
In the region of a newly united fracture
After prolonged immobilization of a part
(Clarkson, 2000)
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ASSESSMENT OF ACTIVE ROM
client performs AROM at affected joint &
joints proximal and distal
 therapist observes all joints separately,
bilaterally and symmetrically

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ASSESSMENT OF ACTIVE ROM
CONT’D
Provides info about:
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Patient’s willingness to move the joint.
Coordination.
Level of consciousness.
Attention span.
Joint ROM.
Movements that cause or increase pain.
Muscle strength.
Ability to follow instructions.
Ability to perform functional activities.
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ASSESSMENT OF ACTIVE ROM
CONT’D
AROM maybe decreased due to:
 Restricted joint mobility.
 Muscle weakness.
 Pain.
 Inability to follow instructions.
 Unwillingness to move.
(Clarkson, 2000)
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ASSESSMENT OF PROM
Determines:
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amount of movement at joint
greater than AROM due to elastic stretch of muscle
tissue and decreased bulk
Perform PROM to:
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establish joints ROM
determine quality of movement throughout ROM & end
feel
determine whether a capsule or noncapsular pattern is
present
presence of pain
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(Clarkson, 2000)
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NORMAL LIMITING FACTORS &
END FEELS

unique anatomical structure of a joint
determines the direction & magnitude of
the joints ROM
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NORMAL LIMITING FACTORS &
END FEELS CONT’D
Limiting Factors:
 Stretching of soft tissue
 Stretching of ligaments or joint capsule
 Apposition of soft tissue
 Bone contacting bone
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NORMAL LIMITING FACTORS &
END FEELS CONT’D
End Feel:
 the sensation transmitted to the therapist’s hands at the
extreme end of the passive ROM indicates the structures
that limit the joint movement - may be normal
(physiological) or abnormal (pathological)
1. Normal End Feel

when full Rom & normal anatomy of joint stops movement
2. Abnormal End Feel
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decrease or increase in the ROM or normal ROM exists but
other structures other than the normal anatomy stop joint
movement
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Normal End Feel Examples:
Hard (bony)
bone contacts bone
 hard abrupt stop
 painless
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 e.g.
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Elbow extension
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Normal End Feel Examples
Cont’d
Soft (soft tissue apposition)
 soft compression of tissue (muscle)
 e.g.
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Knee & elbow flexion
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Normal End Feel Examples
Cont’d
Firm (soft tissue stretch)
 firm or springy sensation with slight give
 feeling depends on the thickness of the
tissue - Achilles has stronger give to it
than that of wrist flexion
 e.g.
Dorsi flexion with extended knee
(gastrocnemius)
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Normal End Feel Examples
Cont’d
Firm (capsular stretch)
 hard arrest to movement with some give
when joint capsule or ligament stretched
 like stretching leather
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 e.g.
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Passive external rotation of shoulder
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Abnormal (Pathologic) End Feels
Hard
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An abrupt hard stop to movement when bone
contacts bone, or a bony grating sensation,
when rough articular surfaces pass over each
other. Loose bodies, degenerative joint disease,
dislocations, or a fracture.
Soft
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Boggy sensation that indicates the presence of
synovitis or soft tissue edema.
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Abnormal (Pathologic) End Feels
Cont’d
Firm
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A springy sensation or a hard arrest to
movements with some give, indicating
muscular, capsular or ligamentous
shortening.
Springy Block
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A rebound is seen or felt and indicates the
presences of an internal derangement.
e.g. knee with a torn meniscus.
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Abnormal (Pathologic) End Feels Cont’d
Empty
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No sensation (end feel) before the end of passive ROM due to pain.
This may be caused by:
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Extra-articular abscess
a neoplasm (abnormal growth of tissue)
 acute bursitis
 joint inflammation
 fracture
Spasm
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A hard sudden stop to passive movement that is often accompanied
by pain is indicative of an acute or subacute arthritis, the presence
of a severe active lesion or fracture.
If pain is absent a spasm end feel may indicate a lesion of the CNS
with resultant increase muscular tonus.
(Clarkson, 2000)
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End feel Activity
Find 2 of each of the following end feels
1. Hard (bony)
2. Soft (soft tissue apposition)
3. Firm (soft tissue stretch)
4. Firm (capsular stretch)
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ROM Instrumentation
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Universal Goniometer
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OB Goniometer
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Tape measure
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ASSESSMENT PROCEDURE
Passive Joint Range of Movement:
1.
2.
Expose the area
Explanation and instruction
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3.
explain verbally or demonstrate by passively moving patient’s limb
through test movement.
Assessment of the normal ROM
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uninvolved side first
involved side
* if uninvolved side can’t be used - rely on past experience
taking into account age, sex, dominance & occupation
4. Measurement procedure:
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patient position
trick movements or substitute
stabilization
measurement
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Universal Goniometer
Most common device used to measure
joint angles or ROM
 180-360 degree protractor
 One axis which joins two arms
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 One
stationary arm
 One moveable arm
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Size of goniometer is determined by size
of the joint being assessed
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Measurement Procedureuniversal goniometer
Goniometer placement: The goniometer
should be placed lateral to the joint, just off
the surface of the limb .
 Axis: The axis of the goniometer should
be placed over the axis of movement of
the joint
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 Eg.
Bony prominance
 Anatomical landmark
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Goniometer Placement Cont’d:
Stationary arm: lies parallel to the
longitudinal axis of the fixed proximal joint
segment and/or points toward a distant
bony prominence
 Movable arm: lies parallel to the to the
longitudinal axis of the moving distal joint
segment and/or points toward a distant
bony prominence

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Measurement using the
Goniometer:
1.
2.
3.
4.
5.
Have the client actively move through joint
ROM.
Therapist identifies end feel at the joint being
measured.
Therapist aligns goniometer appropriately for
the joint to be measured.
If able, the therapist moves client through the
final few degrees of PROM.
Therapist records goniometer measurement.
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Lets try it
ROM will be covered in detail during Occth 583 however you should
attempt to learn the basics as you will have very little time to practice.
Measurements are actually quite simple.
Shoulder Flexion
 Wrist radial and ulnar deviation
 Finger MCP flexion
 Hip Flexion
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Ankle Dorsiflexion / Plantarflexion
 Abduction of the Great Toe
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MANUAL MUSCLE TESTING
Definition:
 A procedure for the evaluation of the
function and strength of individual muscles
and muscle groups based on effective
performance of a movement in relation to
the forces of gravity and manual
resistance.
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PREREQUISITES TO MANUAL
MUSCLE TESTING:
1.
2.
3.
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5.
6.
Knowledge of joint motion
Origin and insertion of muscles
Function of muscles and substitution patterns
Ability to palpate the muscle or its tendon
To distinguish between normal and atrophied
contour
Grading parameters
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CONTRAINDICATIONS:
(same as for ROM and PROM)
1.
2.
3.
4.
Inflammation
Pain
Joint instability
Increased tone-unreliable
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EXTRA CARE MUST BE TAKEN:
1.
2.
3.
History of Cardiovascular problems
Abdominal surgery or herniation of the
abdominal wall
In conditions where fatigue or overwork
may be detrimental (MS)
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DEFINITIONS:
Muscle strength
 maximal amount of tension or force that a
muscle or muscle group can voluntarily exert in
one maximal effort, when type of muscle
contraction, limb velocity, and joint angle are
specified.
Muscle endurance
 the ability of a muscle or a muscle group to
perform repeated contractions, against a
resistance, or maintain an isometric contraction
for a period of time.
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Range of muscle work
 the full range in which a muscle works
refers to the muscle changing from a
position of full stretch and contracting
to a position of maximal shortening.
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Outer range
 A position where the muscle is on full stretch to
a position halfway through the full range.
Inner range
 A position halfway through the full range to a
position where the muscle is fully shortened.
Middle range
 The portion of full range between the midpoint of
the outer range and the mid point of the inner
range.
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Passive insufficiency
 ROM is limited by length of muscle e.g.
Hamstrings.
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Active insufficiency
 when a muscle crosses two or more joints
it performs simultaneous actions at all the
involved joints. The muscle is unable to
produce effective tension at all joints =
active insufficiency.
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Muscle Contractions:
Isometric (static) contraction
 tension developed within a muscle but the
muscle does not change length.
Isotonic contraction
 constant tension against a load of resistance.
Concentric contraction
 tension developed within the muscle and the
muscle shortens.
Eccentric contraction
 tension developed within the muscle and the
muscle lengthens.
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FACTORS AFFECTING
STRENGTH:
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Age
Sex
Type of muscle contraction
Muscle size
Speed of muscle contraction
Previous training effect
Joint position
Length - Tension Relations
Diurnal Variation
Temperature
Fatigue
Motivation, level of pain, body type, occupation and
dominance are other factors that may affect strength.
(Clarkson, 2000)
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JOINT POSITIONS
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Close-Packed Position
 joint
surfaces are fully congruent and cannot be
pulled apart
 - maximal tension in joint capsule and ligaments
*Avoid close-packed position when muscle testing
as joint can be locked into position in the
presents of a weak prime mover.
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JOINT POSITIONS CONT’D
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Loose-Packed Position
 joint
surfaces are least congruent
 greatest laxity of capsule and ligament
 resting position of joint
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TERMS USED IN MUSCLE
TESTING:
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Prime movers
Patient position: allows for function
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A.G. - movements upward in vertical plane
 G.E. - movements in the horizontal plane
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Stabilization
Test Position and Test Movement
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TERMS USED IN MUSCLE
TESTING CONT’D
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Resistance
Palpation
Substitution
Methods:
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a) Isometric Holdings: Force applied after
the motion is completed during inner range.
(combination isotonic-isometric resistance)
 b) Isotonic contraction: Resistance to the
ongoing movement.***
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TERMS USED IN MUSCLE
TESTING CON’T

Grading: Manual muscle grading is based on
3 factors
a. The ability of the muscle or muscle group to move
the part through a complete ROM: against gravity,
gravity eliminated etc.
b. The amount of manual resistance that can be given
to a contracted muscle or muscle group.
c. Evidence of the presence or absence of a
contraction in a muscle or muscle group.
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MMT - CONVENTIONAL
GRADING
5 (Normal): full ROM against gravity with maximum resistance
4 (Good):
full ROM against gravity with moderate resistance
3 (Fair):
ROM against gravity with no resistance
2 (Poor):
full ROM with gravity eliminated
1 (Trace): No ROM - palpable or observable flicker (Evidence of
slight contractility)
0 (Zero):
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No palpable or visible flicker
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MMT - CONVENTIONAL
GRADING Cont’d
5 AG full ROM with maximum resistance
4 AG full ROM with moderate resistance
4- AG greater than ½ ROM with moderate resistance
3+AG less than ½ ROM with minimum resistance
3 AG full ROM with no resistance
3- AG greater than ½ ROM
2+ AG less than ½ ROM
2 GE full ROM
2- GE greater than ½ ROM
1+ GE less than ½ ROM
1 No ROM - palpable or observable flicker
0
No palpable or visible flickerRHS 221
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MMT - CONVENTIONAL GRADING
hands and feet (No AG or GE positions)
5
4
3
2
1
0
- Full ROM with maximum resistance
- Full ROM with moderate resistance
- Full ROM with no resistance
- Part of available ROM
- No ROM - palpable or observable flicker
- No palpable or visible flicker
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Testing procedure (pg 109 manual)
1.
2.
3.
4.
5.
Screen - Put client in against gravity (AG) position for
segment being tested.
Have them do the movement – find the muscle
(palpate)
If able to go through full range = min 3, if partial
movement grade accordingly
Add resistance – give grade according to the amount of
resistant provided
If unable to move AG then put in gravity eliminated
position (GE) and have them do the movement – grade
the muscle accordingly
Note for hands and feet there is no GE
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