Manual Muscle Testing (MMT) is a clinical assessment technique used by healthcare professionals to evaluate the strength and function of individual muscles or muscle groups. It involves the systematic application of resistance while the patient contracts specific muscles, allowing the examiner to assess the muscle's ability to generate force and produce movement. Here's a detailed overview: 1. **Purpose**: MMT is used to: - Identify muscle weakness or imbalance. - Assess the extent and location of neuromuscular dysfunction. - Monitor changes in muscle strength over time. - Guide treatment planning and rehabilitation interventions. 2. **Procedure**: - **Patient Positioning**: The patient is positioned appropriately to isolate and activate the muscle being tested. - **Instruction**: Clear instructions are provided to the patient regarding the desired movement and level of effort. - **Stabilization**: Adjacent joints or body segments may be stabilized to prevent compensatory movements. - **Resistance Application**: The examiner applies resistance, typically manually, in the direction opposite to the muscle's action, gradually increasing it while the patient contracts the muscle. - **Observation**: The examiner observes the quality of muscle contraction, noting factors such as initiation, strength, endurance, and any signs of fatigue or compensation. - **Grading**: Muscle strength is graded on a scale ranging from 0 to 5: - 0: No contraction detected. - 1: Muscle flicker, but no movement. - 2: Movement occurs, but not against gravity. - 3: Movement against gravity, but not against resistance. - 4: Movement against some resistance, but not full strength. - 5: Full strength, normal movement against full resistance. 3. **Applications**: - **Clinical Diagnosis**: MMT helps identify muscle weakness or dysfunction associated with various conditions, such as neuromuscular disorders, orthopedic injuries, and neurological impairments. - **Treatment Planning**: Assessment findings from MMT guide the selection of appropriate therapeutic interventions, including strengthening exercises, manual therapy techniques, and functional training. - **Rehabilitation Monitoring**: Serial MMT evaluations track changes in muscle strength and function during the rehabilitation process, informing progression and adjusting treatment goals as needed. 4. **Considerations**: - **Reliability and Validity**: MMT results may vary based on factors such as examiner experience, patient cooperation, and testing conditions. Standardized protocols and repeated assessments can enhance reliability. - **Limitations**: MMT may not be suitable for assessing deep muscles or muscles affected by pain, and results may be influenced by factors such as fatigue, motivation, and neurological impairment. - **Clinical Judgment**: Interpretation of MMT findings requires clinical judgment,.

1. MANUAL MUSCLE TESTING
(MMT)
II Semester
Exercise therapy I-A
Lecture I
Vinu K Varghese
MPT (Musculoskeletal
and Sports)
Assistant Professor

2. At the end of this session, students will be
able to determine the muscle strength of
human subject, as per the following
criteria:
1. Choose the best position in which the
therapist must place himself to evaluate
each muscle or group of muscles.

3. 2. Place the subject (pt) in a suitable
position that will allow him perform each
task required to evaluate his muscle
strength.
3. Establish the subject's passive range of
motion.

4. 4. Palpate the tendon or the muscle fibers
being evaluated.
5. Support and stabilize the subject when
necessary.
6. Obtain the maximal response from the
subject and observe the contraction and
the movement.
7. Identify possible substitutions and try to
avoid them.

5. 8. Apply manual resistance in the suitable
arm when necessary.
9. Write the quotation of the evaluated
muscle strength and note any limitation of
ROM.
10. Record in writing the results of each
muscle or group of muscle’s test.

6. Introduction
Definition
Purpose and Uses
Grades
Principles of MMT

7. Indications
Contraindications
Precautions
Limitations
Procedure
Factors affecting muscle strength
Instrumentation

8. Manual muscle testing is used to
determine the extent and degree of
muscular weakness resulting from injury,
disease or disuse.
A base for planning therapeutic procedures
and periodic re-testing.
An important tool for all members in a
health team.

9. Muscle testing is a procedure for
evaluating the function and strength of
individual muscles and muscles group.
It is based on effective performance of a
movement in relation to the forces of
gravity and manual resistance through
available ROM.

10. MUSCULAR STRENGTH
The maximal amount of tension or force
that a muscle or muscle group can
voluntarily exert in a maximal effort, when
type of muscle contraction, limb velocity
and joint angle are specified.

11. MUSCULAR ENDURANCE
The ability of a muscle or a muscle group
to perform repeated contractions against
resistance or maintain an isometric
contraction for a period of time.

12. MUSCLE POWER
Refers to a great force production over a
short period of time, such as in fast leg
kicks and explosive jumping.
Require strength and speed to develop
force quickly.
POWER = STRENGTH x SPEED

13. RANGE OF MUSCLE WORK
The full range in which a muscle work
refers to the muscle changing from a
position of full stretch and contracting to a
position of maximal shortening.
Outer range: Is from a position where the
muscle is on full stretch to position halfway
through the full ROM.

14. Inner range: Is from a position halfway
through the full range to a position where
the muscle is fully shortened.
Middle range: Is the portion of the full
range between the mid-point of the outer
range and the midpoint of the inner range.

15. E.g. Hamstring muscle at the back of the
thigh
Middle Range
Inner Range Outer Range

16. ACTIVE INSUFFICIENCY
The active insufficiency of a muscle that
crosses two or more joints occurs when:
The muscle produces simultaneous
movement at all of the joints it crosses and
reaches such a shortened position that it
no longer has the ability to develop
effective tension.

17. When a muscle is placed in a shortened
position of active insufficiency, it is
described as putting the muscle on slack.

18. PASSIVE INSUFFICIENCY
Occurs when a multi-joint muscle is
lengthened to its fullest extent at both
joints, but also preventing the full range of
motion of each joint it crosses.

19. MUSCLE CONTRACTION
1. Isometric
2. Isotonic
a) Concentric
b) Eccentric

20. FUNCTIONAL CLASSIFICATION OF
MUSCLES
1. Agonist / Prime mover
2. Antagonist
3. Synergist
a. Neutralizing / Counter-acting synergists
b. Conjoint synergists
c. Stabilizing / Fixating synergists

21. INDIVIDUAL vs GROUP MUSCLE TEST
Muscles with a common action or actions
may be tested as a group or a muscle may
be tested individually.
For example, flexor carpi ulnaris and flexor
carpi radialis may be tested together as a
group in wrist flexion.

22. Flexor carpi ulnaris may be tested more
specifically in the action of wrist flexion
with ulnar deviation.

23. BREAK TEST
Resistance applied at the end of the tested
range is termed as the BREAK test.
For one joint muscle resistance is applied
at the end of ROM.
For two joint muscle resistance is applied
at the mid of ROM.

24. MAKE TEST
Resistance is applied throughout the test is
called MAKE test.

25. CLINICAL USES
1. The severity of problem can be
understand. (A diagnostic tool)
2. Can plan treatment goals
3. Determine the extent and degree of
muscular weakness resulting from injury,
disease or disuse.

26. 4. Correlating muscle picture within level
innervations. (Myotomes)
5. Prevents deformities by locating problem
areas.
6. Help and evaluate effectiveness of
treatment to the therapist.

27. 1. MRC Scale
2. OXFORD Scale
3. KENDALL Scale
4. +/- Scale

28. MEDICAL RESEARCH COUNCIL (MRC)
SCALE
MRC
Scale
Explanation
0 No contraction
1 Flickering contraction
2 Full ROM with eliminated gravity
3 Full ROM with against gravity
4 Full ROM with against gravity with
minimal resistance
5 Full ROM with against gravity
With maximal resistance

29. OXFORD SCALE
OXFORD
Scale
Explanation
0 No contraction is present
1 There is flickering contraction
2 Full ROM with gravity counter
balance (eliminated)
3 Full ROM with against gravity
4 Full ROM with against gravity +
added resistance
5 Muscle function normally

30. KENDALL SCALE
KENDALL
Scale
Explanation
NONE No visible or palpable
contraction
TRACE visible or palpable contraction
POOR Full ROM gravity eliminated
FAIR Full ROM against gravity
GOOD Full ROM against gravity,
moderate resistance
NORMAL Full ROM against gravity,
maximal resistance

31. (+) OR (-) SCALE
0 : No contraction
1 : Feeble contraction in muscle, but no visible movement
MOVEMENT IN HORIZONTAL PLANE
2- : Moves through partial ROM
2 : Moves through complete ROM
ANTIGRAVITY POSITION
2+ : Moves through partial ROM
3- : Gradual release from test position
3 : Holds test position (no added pressure)
3+ : Holds test position against slight pressure
4- : Holds test position against slight to moderate pressure
4 : Holds test position against moderate pressure
4+ : Holds test position against moderate to strong pressure
5 : Holds test position against strong pressure

32. 1. Position
2. Stabilization
3. Demonstration
4. Application of grades
5. Application of resistance
6. Checking normal strength
7. Objectivity
8. Documentation

33. 1. POSITION
PATIENT POSITION
The patient is positioned to isolate the
muscle or muscle group to be tested in
either gravity elimination (Minimized) or
against gravity position.
Ensure that the patient is comfortable and
well supported. The muscle or muscle
group being tested is placed in full outer
range, with only slight tension.

34. JOINT POSITION
Changes depend up on their performance.
Distal part of the joint is moved.

35. 2. STABILIZATION
 Patient could stabilizes itself in antigravity
position.
• Patient’s normal muscles
• Body weight
• Pt’s position
HAND PLACEMENT
 Proximal hand: At origin of muscle and proximal
to the stabilizing joint.
 Distal hand: Distally, offering
resistance/assistance

36. 3. DEMONSTRATION
 Demonstrate the desired movement.
 Application of resistance
4. APPLICATION OF GRADES
 Always start with grade 3
 Isolation of muscles should be tested.

37. 5. APPLICATION OF RESISTANCE
 Applied slowly and gradually.
 Increasing or decreasing manual
resistance
 Opposite to the line of pull.
 Use long lever
 Apply force distally

38. 6. CHECKING NORMAL STRENGTH
 Normal side first
7. OBJECTIVITY
 Palpation/observation of tendon/muscle
8. DOCUMENTATION
 Help for next level of treatment.
 Help for checking improvement of
treatment.

39. Used in different medical and physical
assessments or examinations
LMN diseases
Multiple Sclerosis (MS)
Muscular dystrophy (MD)
Amyotropic Lateral Sclerosis (ALS)
Myasthenia Gravis(MG)
Gullian – Barre (GB) Syndrome
Musculoskeletal disorders

40. Cerebral palsy (CP)
Cardiovascular disease / Brain injury
Dislocated / Unhealed fractures
Myositis ossificans
Parkinson’s disease
Pain
Inflammation
Subluxation
Hemophilia
Osteoporosis (OP)

41. Consider all contraindications
Be gentle
Respect pain
Know the available ROM
Follow the principles of MMT
Patient comfort
Record
Medications
Extra care in resistance

42. UMN lesions
Restricted ROM due to Transcranial
Doppler
Pain and swelling
Understanding instructions
Only strength not endurance can assess

43. 1. Explanation and instruction
2. Assessment of normal strength
3. Patient position
4. Stabilization
5. Substitution / tricky movements
6. Conventional methods
7. Alternating techniques

44. Used to streamline the muscle strength
assessment, avoid unnecessary testing
and avoid fatiguing / discouraging the
patient.
The therapist may screen the patient
through the information from:
1. The previous assessment of the patient's
AROM.
2. Reading the patient’s chart or previous
muscle test result.

45. 3. Observing the patient while performing
functional activities.
4. Beginning all muscles testing at a
particular grade, (usually a grade of 3)

46. 1. Age
2. Sex
3. Type of muscle contraction
4. Muscle size
5. Speed of muscle contraction
6. Previous training effect
7. Joint position
8. Fatigue

47. 1. Hand held dynamometer
2. Pinch guage
3. Cable tensiometer
4. Free weight

48. HANDHELD DYNAMOMETER

50. PINCH GUAGE

51. CABLE TENSIOMETER

52. Reference:
1. Daniels and Worthingham’s
Muscle Testing -Techniques of
Manual Examination, 8th edition.