The document presents a detailed manual muscle testing (MMT) guide for knee flexion and extension, including test positions, grading scales, and the muscles involved. It specifies the procedures for assessing muscle strength from normal to poor, outlining patient positioning and examiner instructions. Key muscle groups such as the hamstrings for knee flexion and quadriceps for knee extension are described, alongside their origins, insertions, and actions.

1. TOPIC: MMT FOR KNEE
PRESENTED TO: DR. ASIF WATTOO
PRESENTED BY: AMBREEN SADAF
BSOT02153303
The University Of Lahore

2. Muscles of the knee joint

3. Contents:
 Knee Flexion
 Knee Extension
Learning Objectives
 Range of motion
 Muscles
 Origin
 Insertion
 Nerve supply
 Action
 Procedure for MMT

4. Knee Flexion

5. Muscle of knee Flexion

6. Knee Flexion Range of motion: 0-135*
MUSCLES ORIGIN INSERTION
Biceps Femoris
Long Head
Ischium(tuberosity)
Sacrotuberous ligament
Aponeurosis (posterior)
Fibula
Fibular collateral ligament
Short Head (may
be absent)
Femur
Lateral intramuscular
septum
Tibia
(lateral condyle)
Semitendinosus Ischial tuberosity Tibia
Pes anserine
Deep fascia of leg
Semimembranosus Ischial tuberosity
Sacrotuberous ligament
Distal Aponeurosis
Tibia

7. Cont..
Accessory muscles:
 Gracilis
 Tensor fasciae latae (knee
flexed more than 30°)
 Sartorius
 Popliteus
 Gastrocnemius
 Plantaris

8. MMT for grade 5 (Normal) ,4 (Good) and 3 (Fair)
 There are three basic muscle tests for hamstrings at Grades 5
and 4.
 The examiner should test first for the aggregate of the three
hamstring muscles (with the foot in midline).
Hamstring muscles
 HAMSTRING MUSCLES IN AGGREGATE
 MEDIAL HAMSTRING TEST (SEMITENDINOSUS AND
SEMIMEMBRANOSUS)
 LATERAL HAMSTRING TEST (BICEPS FEMORIS)

9. HAMSTRING MUSCLES IN AGGREGATE
 Position of Patient: Prone with limbs straight and toes
hanging over the edge of the table .
 Position of Therapist: Standing next to limb to be tested.
 Test: Patient flexes knee while maintaining leg in neutral
rotation.
 Instructions to Patient: “Bend your knee. Hold it! Don't let
me straighten it.”

10. MEDIAL HAMSTRING TEST (SEMITENDINOSUS
AND SEMIMEMBRANOSUS)
 Position of Patient: Prone with knee flexed to less than 90°.
leg in internal rotation.
 Position of Therapist: Hand giving resistance grasps the
leg at the ankle. Resistance is applied in an oblique
direction.
 Test: Patient flexes knee, maintaining
the leg in internal rotation.

11. LATERAL HAMSTRING TEST (BICEPS FEMORIS)
 Position of Patient: Prone with knee flexed to less
 than90°. Leg is in external rotation.
 Position of Therapist: Therapist resists knee flexion at the
ankle using a downward and inward force.
 Test: Patient flexes knee, maintaining leg in external
rotation.

12. Grading the Hamstring Muscles (Grades 5 to 3 )
Grade 5 (Normal) for All Three Tests:
 Resistance will be maximal, and the end knee flexion
position (approximately 90°) cannot be broken.
Grade 4 (Good) for All Three Tests:
 End knee flexion position is held against strong to moderate
resistance.
Grade 3 (Fair) for All Three Tests:
 Holds end range position but tolerates no resistance

13. Cont..

14. MMT for Grade 2 (Poor )
 Position of Patient: Side-lying with test limb
 Position of Therapist: Standing behind patient at knee
level.
 Test: Patient flexes knee through available range of motion.
 Instructions to Patient: “Bend your knee.”
GRADING
Grade 2 (Poor): Completes available range of motion
inside-lying position.

15. MMT for Grade 1 (Trace) and Grade 0 (Zero)
 Position of Patient: Prone.
 Position of Therapist: Standing next to test limb at knee
level.
 Test: Patient attempts to flex knee.
 Instructions to Patient : “Try to bend your knee.”
GRADING
Grade 1 (Trace):
 No visible movement.
Grade 0 (Zero):
 No palpable contraction.

17. Knee Extension

18. Knee extension muscles

19. Knee Extension Range of motion: 135*-0*
MUSCLES ORIGIN INSERTION
Rectus Femoris Ilium (anterior
inferior iliac spine).
Acetabulum
(groove above)
Capsule of hip joint
Aponeurosis
(anterior)
Aponeurosis (posterior)
Patella (base via quadriceps tendon)
Tibial tuberosity via ligamentum
Patellae
Vastus intermedius Femur (shaft, upper
2/3 lateral and
anterior surfaces)
Intermuscular
septum (lateral)
Aponeurosis
Patella
Tibia
Tibial tuberosity via ligamentum patellae
Vastus lateralis Femur
Lateral
Intermuscular
septum
Aponeurosis
Patella
Lateral expansion to capsule of knee joint
and Lliotibial tract.

20. Knee Extension Range of motion: 135*-0*
MUSCLES ORIGIN INSERTION
Vastus medialis
Longus
Femur linea aspera,
medial lip,
Intertrochanteric
line
Tendon of adductor
Magnus
Aponeurosis (deep)
Patella (medial border)
Tibial tuberosity via ligamentum
patellae
Vastus medialis
Oblique
Femur: Linea
aspera (distal),
supracondylar line.
Intramuscular
septum
Aponeurosis to capsule of knee joint
Patella (medial aspect)
Quadriceps tendon (medial)
Tibial tuberosity via ligamentum
Patellae.
Accessory muscles: Tensor fasciae latae

21. Cont..
Accessory muscles:
 Tensor fasciae latae

22. MMT for grade 5 (Normal) ,4 (Good) and 3 (Fair)
 Position of Patient: Short sitting. Place wedge or pad under
the distal thigh to maintain the femur in the horizontal
position.
 Position of Therapist: Standing at side of limb to be tested.
 Test: Patient extends knee through available range of
motion but not beyond 0°.
 Instructions to Patient: “Straighten your knee. Hold it!
Don't let me bend it. “

23. Grading
 Grade 5 (Normal): Holds end position against maximal
resistance.
 Grade 4 (Good): Holds end position against strong to
moderate resistance.
 Grade 3 (Fair): Completes available range and holds the
position without resistance.

24. MMT for Grade 2 (Poor)
 Position of Patient: Side-lying with test limb uppermost.
 Position of Therapist: Standing behind patient at knee
level.
 Test: Patient extends knee through the available range of
motion
 Instructions to Patient: “Straighten your knee.”
GRADING
Grade 2 (Poor):
 Completes available range of motion.

25. MMT for Grade 1 (Trace) and Grade 0 (Zero)
 Position of Patient: Supine.
 Position of Therapist: Standing next to limb to be tested at
knee level.
 Test: Patient attempts to extend knee.
 Instructions to Patient: “Push the back of your knee down in
to the table.”
 OR
 “Tighten your knee cap.”

26. Grading
Grade 1 (Trace):
 Contractile activity can be palpated in muscle through the
tendon.
 No joint movement occurs.
Grade 0 (Zero):
 No palpable contractile activity.

27. References
 MMT by Daniels and Worthinghams.
 Atlas of human body by Frank H Netter.