Manual Muscle Tests of Upper and Lower Extremities
Shoulder Flexion (anterior deltoid):
Position of Patient: short sitting with arms at sides, elbow slightly flexed, forearm pronated (to
avoid supination by long head of biceps)
Test: Patient flexes shoulder to 90 degrees without rotation or horizontal movement. The
scapula should be allowed to abduct and upwardly rotate. The normal ratio of scapular to
humeral movement after the first 20 degrees is 2:1 – there are 2 degrees of glenohumeral
motion to each 1 degree of scapulothoracic motion.
Instructions to patient: raise your arm forward to shoulder height. Hold it. Don’t let me push it
down.
Grading:
Grade 5 (normal): holds end position (90 degrees) against maximal resistance.
Grade 4 (good): Holds end position against strong to moderate resistance.
Grade 3 (fair): Completes test range (90 degrees) but tolerates no resistance.
Grade 2 (poor): Completes partial range of motion.
Grade 1 (trace): examiner feels or sees contractile activity in the anterior deltoid, but no motion
occurs.
Grade 0 (zero): no contractile activity.
If for any reason the patient is unable to sit, the test can be conducted in the side-lying position.
In this posture, the examiner cradles the test arm at the elbow before asking the patient to flex
the shoulder.
Elbow Flexion (Biceps Brachii)
Position of patient: Short sitting with arms at sides. To test the biceps, the forearm should be
supinated.
Position of therapist: Stand in front of patient, toward the test side. Hand giving resistance is
contoured over the flexor surface of the forearm proximal to the wrist. The other hand applies
counterforce by cupping the palm over the anterior superior surface of the shoulder.
Test: Patient flexes elbow through range of motion.
Instructions to patient: Bend your elbow, hold it, don’t let me pull it down.
Grade 5 (normal): completes available range and hold firmly against maximal resistance
Grade 4 (good): completes available range against strong to moderate resistance but the end
point may not be firm
Grade 3 (fair): completes available range with each forearm position with no manual resistance.
Grade 2 (poor): Completes partial range of motion.
Grade 1 (trace): Examiner can palpate a contractile response in each of the three muscles for
which a trace grade is given
Grade 0 (zero): no palpable contractile activity.
Knee Extension (Quadriceps femoris)
Position of Patient: Short sitting. Place wedge or pad under the distal thigh to maintain the
femur in the horizontal position. An experienced examiner may replace the padding under the
thigh with his hand. Hands rest on the table on either side of the body for stability, or may
prefer to grasp the table edge. The patient should be allowed to lean backward to relieve
hamstring muscle tension. Do not allow the patient to hyperextend the knee because this may
lock it into position.
Position of therapist: Stand at the side of limb to be tested. The hand giving resistance is
contoured over the anterior surface of the distal leg just above the ankle. Resistance is applied
in a downward direction (toward the floor) in the direction of knee flexion.
Test: Patient extends knee through available range of motion but not beyond 0 degrees.
Grade 5 (Normal): Hold end position against maximal resistance. Most physical therapists will
not be able to break the normal knee extensors.
Grade 4 (good): Holds end position against strong to moderate resistance.
Grade 3 (fair): completes available range and holds the position without resistance.
Grade 2 (poor): completes available range of motion
Grade 1 (trace): contractile activity can be palpated in muscle through the tendon. No joint
movement occurs.
Grade 0 (zero): No palpable contractile activity.
Knee Flexion (all hamstring muscles)
Position of Patient: prone with limbs straight and toes handing over the edge of the table. Test
may start in about 45 degrees of knee flexion.
Position of therapist: Standing next to limb to be tested. Hand giving resistance is contoured
around the posterior surface of the leg just above the ankle. Resistance is applied in the
direction of knee extension. The other hand is placed over the hamstring tendons on the
posterior thigh (optional).
Test: Patient flexes knee while maintaining leg in neutral rotation.
Instructions to patient: bend your knee, hold it, don let me straighten it.
Grade 5 (normal): Resistance will be maximal, and the end knee flexion position (approximately
90 degrees) cannot be broken.
Grade 4 (good): End knee flexion position is held against strong to moderate resistance.
Grade 3 (fair): holds end range position but tolerates no resistance.
Grade 2 (poor): completes available range of motion in side-lying.
Grade 1 (trace): tendons become prominent, but no visible movement occurs.
Grade 0 (zero): no palpable contraction of the muscles, and tendons do not stand out.
Ankle Dorsiflexion (anterior tibialis)
Position of Patient: With patient sitting, the knee is flexed at 90 degrees.
Position of Therapist: The therapist sits in front of testing limb and supports the leg just above
the posterior aspect of the ankle joint.
Test: The patient dorsiflexes the ankle joint foot without extending the great toe. Pressure is
applied on the dorsum of the foot (in the direction of plantar flexion and eversion).
Instructions to patient: Pull your foot up to the ceiling
Grade 5 (normal): hold end position against maximal resistance
Grade 4 (good): holds end position against strong to moderate resistance
Grade 3 (fair): completes range of motion and holds position without resistance
Grade 2 (poor): completes range of motion
Grade 1 (trace): contractile activity can be palpated, no joint movement occurs
Grade 0 (zero): no palpable contraction of the muscles
Mnemonic to help standardize procedure:
D – demonstrate and/or explain MMT position
R – request the subject to assume the MMT position
A – Adjust the subject’s position manually if necessary
P – Place your hands on the subject to administer the MMT
E – execute with verbal cues (“hold!”) and apply manual pressure