Manual Muscle Testing Lab: Shoulder Flexion

Sequence of Testing for Manual Muscle Testing Lab

• Review pertinent information related to the skill, including patient position and indications.
• PROM (Passive Range of Motion) should be assessed.
• AROM (Active Range of Motion) should be assessed.
• Stabilization is important during the testing procedure.
• Hand placement for applying force needs to be considered.
• The direction of the applied force is a key component.
• Be aware of potential substitutions the patient might use.
• Demonstrations will cover skills for MMT Grades 3-5.
• Students will practice skills for MMT Grades 0-2 as outlined in the Muscle Testing text.

Shoulder Flexion (Daniels and Worthingham p. 125)

• Stabilizing Hand Placement involves placing the hand on the shoulder of the extremity being tested.
• Force Hand Placement is over the distal humerus, just above the elbow.
• Force Direction should be downward (inferior).
• Possible substitutions include:
  • Biceps Brachii (Elbow flexion)
  • Upper Trapezius (Scapular Elevation)
  • Pectoralis Major (Shoulder Horizontal adduction)
  • The patient may lean backward

Shoulder Abduction (Daniels and Worthingham p. 133)

• Stabilizing Hand Placement involves placing a hand on the shoulder of the extremity being tested.
• Force Hand Placement is over the distal humerus, just above the elbow.
• Force Direction should be downward (inferior).
• A possible substitution is Biceps Brachii (Shoulder ER).

Shoulder External Rotation (prone) (Daniels and Worthingham p. 147)

• Stabilizing Hand Placement involves hand supporting the elbow to provide counter pressure at the end of range.
• Force Hand Placement is over the dorsal (extensor) surface of the forearm as near but proximal to the wrist to avoid eliciting the wrist extensors.
• Force Direction should be Downward (backward).
• There are minimal substitutions as test position isolates muscles being tested, Shoulder abduction.
  • In sitting, Middle Deltoid Abduction may be used, and Patient sidebends trunk towards testing side.

Shoulder Internal Rotation (prone) (Daniels and Worthingham p. 151)

• Stabilizing Hand Placement involves Hand on lateral aspect of elbow to provide counterforce.
• Force Hand Placement is over the volar (flexor) surface of the forearm just proximal to the wrist to avoid eliciting the wrist flexors.
• Force Direction should be downward (forward).
• There are minimal substitutions as test position isolates muscles being tested, shoulder adduction.
  • In Sitting patients may use Pectoralis Major, Latissimus Dorsi (Horizontal Adduction) or Patient sidebends trunk away from testing side.

Elbow Flexion (Daniels and Worthingham p. 157)

• In testing the Biceps Brachii and Brachialis the shoulder should be in neutral with forearm in supination and elbow flexed to mid-range.
• In testing the Brachioradialis the shoulder should be in neutral position with forearm in mid-position (neutral) between pronation and supination.
• Stabilizing Hand Placement involves hand on the posterior aspect of the upper arm, just above the elbow applying counterforce to resist any upper arm movement.
• Force Hand Placement is over the volar (flexor) surface of the forearm (biceps brachii and Brachialis) or radial surface of the forearm (Brachioradialis) just proximal to the wrist in order to avoid eliciting the wrist flexors.
• Force Direction should be downward (inferior).
• Patient's trunk moves backward to resist testing motion.

Elbow Extension (prone) (Daniels and Worthingham p. 162)

• Stabilizing Hand Placement: The hand should be underneath the proximal humerus above the elbow.
• Force Hand Placement: The placement should be on the distal dorsal surface of the extended forearm just proximal to the wrist.
• Force Direction is downward (inferior).
• Substitutions are more common with Grades 0-2
  • External rotation of the shoulder (in sitting) or Horizontal Adduction (when distal extremity fixed, common with Cervical SCI injuries)

Elbow Extension (supine)

• Not pictured in the text (PhysioU video reference).
• Stabilizing Hand Placement: Placing hand on distal, anterior aspect of humerus maintaining the shoulder at 90 degrees flexion.
• Force Hand Placement: Positioning the hand on the distal dorsal surface of the forearm just proximal to the wrist.
• Force Direction: Downward (inferior).
• Latissimus Dorsi (shoulder extension) can be used for substitution.

Forearm Supination (Daniels and Worthingham p. 169)

• Stabilizing Hand Placement: Maintain stability by placing a hand to support the proximal elbow.
• Force Hand Placement: Apply the heel of the hand over the dorsal (extensor) surface of the wrist.
• Force Direction: Apply force in the direction of pronation (medial).
• Substitution: Use of of external rotation and adduction of the arm as forearm supination is attempted.

Forearm Pronation (Daniels and Worthingham p. 173)

• Stabilizing Hand Placement includes Hand supporting the proximal elbow.
• Force Hand Placement: Applying the force over the radius on the volar (flexor) surface of the forearm at the wrist.
• Force Direction: Provide a supination (lateral) force.
• A substitution will present as Internal rotation and abduction of the arm as forearm pronation is attempted.

Wrist Flexion (Daniels and Worthingham p. 177)

• In testing the Flexor Carpi Radialis, place patient's wrist in radial deviation and slight wrist extension. Apply resistance over first and second metacarpals (radial side) in the direction of extension and ulnar deviation.
• In testing of the Flexor Carpi Ulnaris, place wrist in ulnar deviation and slight wrist extension. Apply resistance over fifth metacarpal (ulnar side) in the direction of extension and radial deviation.
• Stabilizing Hand Placement involves hand supporting the forearm under the dorsal aspect wrist.
• Force Hand Placement should be placed over the volar (palmar) surface of the hand.
• Force Direction is downward (inferior).
• A substitution can come through Biceps Brachii and Brachialis (elbow flexion).

Wrist Extension (Daniels and Worthingham p. 184)

• Testing Extensor Carpi Radialis longus and brevis is performed by placing their wrist in radial deviation and wrist extension. Apply resistance over dorsal surface of the 2nd and 3rd metacarpals (radial side) in the direction of flexion and ulnar deviation.
• To test the Extensor Carpi Ulnaris, place patient's wrist in ulnar deviation and wrist extension. Apply resistance on over dorsal aspect of fifth metacarpal (ulnar-side) in the direction of flexion and radial deviation.
• Stabilizing Hand Placement: Hand supporting the forearm under the volar aspect of the wrist.
• Force Hand Placement: Over the dorsal surface of the metacarpals.
• Force Direction is downward (inferior).
• Finger extensors may contribute to the motion if the patient is not cued to relax.

Thumb Abduction (Daniels and Worthingham p. 219)

• Stabilizing Hand Placement involves placing support over the metacarpals of the four fingers and the wrist, table for support.
• Force Hand Placement should be placed on the finger or thumb on the distal end of the first metacarpal.
• Force Direction should be is in adduction.
• Extensor Pollicis Brevis substituting APL if line of pull is toward the dorsal surface of the forarm is a common error.

Thumb Extension (Daniels and Worthingham p. 216)

• Stabilizing Hand Placement involves placing Patient's hand supported by the table in fully supinated position.
• Force Hand Placement involves placing finger positioning over the dorsal surface of the distal phalanx.
• Force Direction is in flexion.
• The muscles of the thenar eminence (APB, FPB and AP) can extend the IP joint by flexing the CMC joint.

Finger PIP and DIP flexion (Daniels and Worthingham p. 189)

• Stabilizing Hand Placement, the patients hand should be supported by the table in fully supinated position.
• Force Hand Placement should be finger over the dorsal surface of the distal phalanges.
• The appropriate Force Direction is Extension. The muscles of the thenar eminence (APB, FPB and AP) can extend the IP joint by flexing the CMC joint.

Finger MCP Extension (Daniels and Worthingham p. 197)

• Stabilizing Hand Placement involves supporting Patients hand supported by the table in pronation.
• Fource Hand Placement will involve placing your hand across the dorsum of all proximal phalanges just distal to the MCP joints
• The proper direction is Flexion. The muscles of the thenar eminence (APB, FPB and AP) can extend the IP joint by flexing the CMC joint.

Hip Flexion (Daniels and Worthingham p. 238)

• Stabilizing Hand Placement involves placing the Patient in a Supported Short-sitting on edge of table. A hand may be placed on patient's ipsilateral shoulder.
• Force Hand Placement placement should be over the distal thigh just proximal to the knee joint
• The Force Direction is Downward (extension).
• The patient may use one or a combination of the following Substitutions:
• Sartorius muscle will result in ER and abduction of the hip
• Tensor Fasciae Latae substituting for hip flexion, internal rotation and abduction.
• To enhance length tension of the hip flexors a patient will flex the trunk or lean back

Hip Extension (group and glute max) (Daniels and Worthingham p. 238)

• For Stabilizing Hand Placement: place your hand on the pelvis to maintain alignment in the area of the PSIS
• Force Hand Placement involves either the:
  • Hip Ext Group where the Patients knee is extended, place your hand on their posterior leg just above the ankle, or for
• Glute Max where the Patient should have they knee flexed to 90 degrees. and hand on the posterior thigh just above the knee
• Force Direction is Downward (Flexion)
• A patient may utilize different Substitutes which are seen by:
  • rotating upwards of the pelvis toward the testing side
  • substituting Gultemax by flexing the knee .

Hip Abduction (Daniels and Worthingham p. 262)

• For stabilizing purposes Hand Placement may include Hand placement on the pelvis to maintain alignment
• In terms of Force Hand Placement, it is possible to use various lever arms which include the ankle. In a situation where the patient can not hold, apply resistance at the lateral knee
• Force Direction: Downward (Adduction)
• To substitute it is common to see cases of:
  • Hip-Hiking the pelvis
  • External Rotation and Flexion acting as sub for Sartorius
• A common fault results when the Tensor Fascia Latae substitution, the test position will begin wth active hip flexion or the hip already positioned in flexion

Hip Adduction (Daniels and Worthingham p. 270)

• For stability place your hand on the non-test leg in 25 degrees of abduction with forearm over the uppermost leg and lastly supporting leg on medial surface of knee
• When applying Force Hand Placement, it is key to apply the force n the medial surface of the distal femur of the lower leg, just proximal to the knee joint.
• Force Direction: Downward (Abduction)
• The common substitution to hip adduction will be the patient attempting to substitute hip flexors for adductors by internally rotating the hip. Patients will turn supine.

Hip Internal Rotation (Daniels and Worthingham p. 259)

• In performing MMT for the Internal Hip rotators, contour your hand over the medial aspect of the distal thigh just above the knee for counter-pressure
• When applying the resistance and using a Force Hand Placement: apply pressure to the On the lateral surface of the ankle just above the malleolus
• In this case the Force Direction used is the Inward towards rotation

External rotation (Daniels and Worthingham p. 256)

• When applying the Force Hand Placement, put the load on the medial surface of the ankle just above the malleolus
• In performing this, use the contralateral had to stabilize contouring over the lateral aspect of the distal thigh just above the knee
• The proper force direction for testing should be outwards towards rotation
• The main compensation involves sidebending of the trunk and pelvis toward testing side

Knee Flexion (Daniels and Worthingham p. 276)

• In order to stabilize properly during this test using Stabilizing Hand Placement, The hamstrings themselves can cause excessive cramping on, but stabilizing the, over the hamstring tendons of posterior thigh is helpful
• Force should be applied to the leg just above the foot, specifically to The posterior surface
• This push that Force Hand Placement allows will cause downward extension
• Its likely the compensation of a patient may be an effort to utilize their Hip or Gastrocs

Knee Extension (Daniels and Worthingham p. 280)

• Stabilizing Hand Placement involves supporting the Thigh which is a key for stabilization . This may be via the table that supports the leg, the proximal or underneath thigh
• The best way to apply a smooth force is by applying Force Hand Placement: specifically Over the anterior surface of the distal leg just above the ankle using a straight-arm technique.
• The patient may have altered mechanics when extending or trying to extend the knee, which will make them extend their trunk backward
• In Gravity-eliminated the patient may internally and outwardly switch the load to quads and hip

Ankle Dorsiflexion (Daniels and Worthingham p. 291)

• You should try to provide stabilization and balance where possible. for an Ankle Dorsiflexion is by supporting their thigh with.
• Apply Force on the medial aspect, that contours over the first Ray
• Force Direction: Downward (Flexion)

Ankle Plantarflexion (Heel Raise) (Daniels and Worthingham p. 286)

• When evaluating planter flexion MMT, there usually is not stabilization hand needed.
• Grade 5: Successfully complete 25 heel raises through full ROM without rest between rises
• Grade 4: Patient completes between 2-24 at at least 50% of intial with consistent rate for, rise every 2 seconds between
• Grade 3: If the patinets are unable to complete more than 2 repetitions but can hold weight once, that is a passing grade
• Grade 2: A patient that is is Prone- lying the exam table while maintaining test and maximal manuel and can preform in this postion recieves this grade
• If there is ability to at least move throught range that will grade is grade 1 , but if zero palpable grade is 0.

Great Toe Extension (Daniels and Worthingham p. 309)

• Be sure that the Stabilization of foot is still by the heel.
• By maintaining a good amount of Force around the arch, try contouring you had around the around the plantar so surface of the foot, with the thumbs base curving
• The best direction in which to place force is Downward (flexion)

Latissimus Dorsi (Daniels and Worthingham p. 121)

• Stabilizing Hand Placement None is because of patient position
• When applying the correct pressure, you can over their medial above the wrist
• The direction is the patient pulling and slight outward away of trunk
• One Potential substitution involves the rotation of the trunk to opposite

Pectoralis Major

• Patient will be tested at the Anterosuperior however it cant rest (not on its belly)
• Because of this the placement of the conturing is very easy and allows free of the forearm
• At the test, you will see a horizontal away from the trunk, and towards the sides
• A bad testing will result in a rotation by the test patients opposed side

Latissimus Dorsi Length Test

• Stabilizing Hand Placement: Involves placing Hands over the ipsilateral ribcage.
• Movement Hand Placement is achieved by Contouring the distal humerus just proximal to the elbow while keeping the shoulder in external rotation.
• Force Direction is flexion.
• Normal End Feel: Firm.

Pectoralis Major upper and Lower fibers

• Stabilizing Hand Placement involves having a "Forearm across patient's trunk" to aid with stabilizing which then cues them to hold the tester am across chest.
• Movement Hand Placement is reached when you contour the distal humerus just proximal to the elbow while keeping the shoulder in external rotation
• The directional movement needed depends on the Upper fibers90 deg abduction and full rotation or Lower fibers120 deg abduction and full rotation
• Results are determined if it parallel or lower compared to the table in which case it is a passing.

Biceps Brachii (Norkin and White p. 127)

• Stabilizing Hand Placement: Over the proximal humerus. The examining table helps to stabilize the scapula
• Movement Hand Placement: Over the forearm just proximal to the wrist. Test position begins with shoulder in full extension, elbow supported in flexion, wrist netural.
• Force Direction: Elbow extension -Forearm pronation
• Normal end feel: FIRM
• Short and tight biceps means patients will face limits when performing shoulder extension or putting their arm out. When the patient holds it in flexion, they limit full body ability to flex.

Finger Flexors

• Stabilizing Hand Placement: Over the proximal forearm to prevent ebow flexion
• Movement Hand Placement: Over the MCP, PIP and DIP Joints
• Force Direction: Test begins with elbow extended, MCP, PIP, DIP, and wrist moved into extension
• Normal and Feel FIRM
• If these muscle in specific (FDP/FDS) are short, it limits wrist extension by 10-15 degrees when the elbow, PIP, and MCP joints are in full, no value. And if regardless, the MCP/DIP and PIP remain consistent then, it is a result of additional abnormalities to ligament, Joint muscles such as palmaris longus ,

Finger Extensors

• Stabilizing Hand Placement: Over the proximal forarm to prevent elbow flexion
• Movement Hand Placement: Test begins with elbow extended, MCP, PIP, DIP, and wrist moved into flexion while forearm ispronated no support
• Force Direction: Wrist moved into flexion while maintaining MCP, PIP, DIP
• Shortness means wrist ability will be affected and flexion can be reduced if they contract. Additional limitations would be signs of muscle or tendon damage.

Thomas test (assessment)

• Stabilizing Hand Placement: Therapist holds the hip in nontested felxion in order prevent lowback or any type of hip from overcompensation or arch
• Movement Hand Placement: Supporting the testing leg underneath the knee
• Force Direction:
• Firm
• The direction for the force to be applied is pulling the leg and the ankle down towards the table in hip extension

Ober’s Test

• Normal And feel FIRM
• The test begins with the hand stabilizer the waist with the examiner.
• Then the supporting examiners hand pushes on medial.
• Force will bring and take the knee and bring it hip extension and abduction.
• Any range above 10 with horizontal means tight

Straight Leg Raise (SLR) for Hamstrings

• Stabilizing Hand Placement needs to hold and lock out the knee from flexion.
• Movement Hand Placement: At the posterior aspect, use the hand to support the testing leg
• Normal end feel is that when the patient reaches 80 degrees from flex that is means normal.

Distal Hamstring Length Test

• Stabilization: Stabilize the femur
• Movement: Hold ankle above fib/tib and move to extenstion
• Normal FEEL: FIRM
• CLINICALLY< 10 DEG

Dorsiflexion ROM Assessment

• For a good grip and stabilizing support, hold where leg
• Apply with thumb down and pull medial