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Muscle Strength Testing. University of the Philippines Manila COLLEGE OF ALLIED MEDICAL PROFESSIONS PT 142 Assessment in Physical Therapy Mitch B. Encabo , MPA, PTRP Edited for instruction by: Aila Nica J. Bandong , PTRP. LEARNING OBJECTIVES .

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muscle strength testing

Muscle Strength Testing

University of the Philippines Manila


PT 142 Assessment in Physical Therapy

Mitch B. Encabo, MPA, PTRP

Edited for instruction by:

AilaNica J. Bandong, PTRP

learning objectives

At the end of the session the students should be able to:

  • Define muscle strength and their functional implications
  • Discuss basic considerations in performing muscle strength testing
  • Differentiate methods of doing muscle strength testing
    • Discuss Daniels and Worthingham’s manual muscle testing
    • Discuss modified tests used in assessing muscle strength
      • Instrumental muscle strength testing
      • Functional muscle strength testing
  • Discuss probable conditions that require modifications of the standard technique
muscle strength testing3
  • Refers to the determination of the strength of a muscle or muscle group
  • Does not reflect muscle function
  • Test based on the
    • Effective performance of movement
    • Manual resistance
    • Gravity
muscle strength testing4


  • Diagnostic
  • Examine the improvement or deterioration of a patient’s status over time
  • Predictive or prognostic tool
  • Determine the extent of strength loss
  • Outcome measures in clinical research
  • Determine the need for compensatory measures or assistive devices
  • Helps in the formulation of the treatment plan
  • Evaluates the effectiveness of treatment
muscle strength vs endurance

Muscle Strength

  • Force production
  • Voluntary exertion in one maximal effect
  • Results in isotonic or isometric contractions
  • Gross indicator of functional ability

Muscle Endurance

  • Repeated contractions
  • Maintenance of isometric contraction
muscle weakness
  • Any reduction of the normal ability of the muscle to generate force
  • Causes:
    • Muscle strain
    • Pain, reflex inhibition
    • PNI, Nerve root lesion, UMNL
    • Tendon pathology, avulsion, rupture
    • Prolonged disuse/immobilization
    • Psychological overlay
test performance
Test Performance
  • Muscle origin, insertion and action
  • Function of participating muscles
  • Patterns of substitution
  • Ability to detect contractile activity
  • Ability to palpate muscle or tendon
  • Ability to detect atrophy
  • Recognize abnormal position or movement
test performance9
Test Performance
  • Awareness of deviation from normal ROM , laxity or deformities
  • Identify muscles with the same innervation
  • Relationship of diagnosis to sequence and extent of test
  • Ability to modify test procedures as necessary
  • Effect of fatigue
  • Effect of sensory loss and movement
evaluation of muscle strength
Evaluation of Muscle Strength
  • Detect substitution whenever weakness exist
  • Accurate grading of muscle strength
basic considerations
  • Observation
  • Palpation
  • Positioning
  • Stabilization
  • Resistance
  • Validity and reliability
observation and palpation
Observation and Palpation
  • Observe the size and contour of muscles
  • Palpate contractile tissues
  • Patient comfort
  • Depends partly on the effect of gravity
  • Use position that offers the best fixation of the body as a whole
  • Use antigravity positions as applicable
  • Two jointed muscles
  • Proximal attachment of muscles
  • Used to isolate the desired action to a specific joint
  • Stabilize the part proximal to the part being tested
  • Stabilization of the proximal attachment of the muscle through:
    • Muscle tension
    • Gravitational pull
    • External pressure from

manual stabilization

  • Force that acts in opposition to a contracting muscle
  • Applied in the direction opposite the line of pull
  • Must never be sudden or jerky
  • Applied gradually, but not to slowly, to allow the patient to “get set and hold”
  • Applied uniformly
  • Long lever arm vs Short lever arm
  • Break test vs Active resistance test
validity and reliability
Validity and Reliability
  • Inherent limitation
    • Types of muscle contractions
    • Rate of tension development
  • Affected by
    • Difference in testing methods
    • Magnitude of resistance
    • Force application, point of application, speed
    • Factors
      • Patient factors
      • Therapist factors
      • Environmental factors
      • Others
validity and reliability18
Validity and Reliability
  • Patient Factors
    • Age
    • Gender
    • Pain
    • Fatigue
    • Lower motor

neuron disease

    • Spasticity
  • Therapist factors
    • Experience
    • Manner and content

of instructions

    • Interaction
  • Environmental factors
    • Temperature
    • Distractions
  • Other factors
    • Muscle factors
    • Psychological factors
    • Methodological factors
methods of mmt

What is being tested?


Type of Contraction

Method of Grading

daniels and worthingham mmt
Daniels and Worthingham MMT
  • Criteria used in assigning a muscle grade
  • Factors considered include the following:
  • Subjective Factors
  • Examiner’s impression of the amount of resistance to give before the actual examination
  • Amount of resistance that the patient tolerates during the actual test

Objective Factors

  • Ability of the patient to move the body part against gravity
  • Ability of the patient to complete full range of motion
  • Ability of the patient to hold the position once at the end of the range of motion

Other Factors

  • Amount of manual resistance applied
  • Ability of the muscle to move the part through the full ROM
  • Effect of gravity
  • Evidence of contraction
daniels and worthingham mmt grading
Daniels and Worthingham MMT: GRADING
  • Normal ( N or 5 )
    • Full range against maximum resistance and gravity
  • Good ( G or 4 )
    • Full range against moderate resistance and gravity
    • “Gives” or “yields” at the end of the range given maximum resistance
    • Functional threshold for the lower extremity
  • Fair Plus ( F+ or 3 )
    • Full range against mild resistance and gravity
    • “Gives” or “yields” to some extent at the end of its range given moderate or maximum resistance
    • For users of orthosis
  • Fair ( F or 3 )
    • Full range against gravity
    • “Gives” at the end of the range against mild resistance
    • Functional threshold for the upper extremities
daniels and worthingham mmt grading23
Daniels and Worthingham MMT: GRADING
  • Poor ( P or 2 )
    • Full range, gravity eliminated
  • Poor Minus ( P- OR 2 - )
    • Partial range gravity eliminated
  • Trace ( T or 1 )
    • Visible or palpable contraction
    • No movement of the body part
  • Zero (0)
    • No visible or palpable contraction
how to document
How to Document???

All muscles of the trunk and extremities are grossly graded 5/5 EXCEPT:

® Shoulder abductors – 3/5

® Knee flexors – 3/5

Significance: Muscle weakness 2 to deconditioning

how to document25
How to Document???

All the muscles of the wrist and hand are grossly

graded 5/5 EXCEPT:

® wrist flexors – 4/5

® radial deviators – 4/5 ( 10 deg )

Significance: Muscle weakness 2 to pain brought about by reflex inhibition

how to document26
How to Document???

All of the muscles of the lower limb are grossly graded as 5/5 EXCEPT for

® hip extensors = 4/5 (0-90 degrees)

® hip adductors = 4/5 (0-20 degrees)

Significance: Muscle weakness due to prolonged immobilization, range test was used 2 to contractures of the hip flexors and adductors

daniels and worthingham mmt limitations
Daniels and WorthinghamMMT:LIMITATIONS
  • Presence of UMNL/ Spasticity
  • Presence of joint instability due to chronic flaccidity
  • Presence of severe contractures


  • Hands and toes
  • Face
  • Neck
  • Weight bearing muscles
  • Children
hands and toes
Hands and Toes
  • Weight is minimal so effect of gravity is unimportant and need not be considered
  • Tested in either gravity eliminated or gravity-assisted position
  • Grading:
    • 5 Full range with max resistance
    • 4 Full range with mod resistance
    • 3 Full ROM (whether gravity eliminated or assisted)
    • 2 Partial ROM (whether gravity eliminated or assisted)
    • 1 Palpable or observable flicker of muscle contraction
  • Not always practical or possible to palpate muscle, apply resistance, or position the patient
  • Grading:
    • N/F (N)or light impairment

Completes test movement with ease and control

    • WF Moderate impairment that affects the degree of active motion

Performs test with difficulty

    • NF Severe impairment

Minimal muscle contraction

    • 0 Absent
  • Using gravity eliminated position when testing for neck flexion and extension is impractical
  • A muscle grade of 2 is assigned when the patient can complete partial ROM while in a gravity resisted position

Weight Bearing Muscles

  • To be resisted maximally, some muscles require the assistance of body weight
  • For gastrocnemius and soleus only
  • May not cooperate with standard MMT procedures
  • 2-5 y/o can initiate test position, but they cannot sustain it because they don’t understand the concept of exerting counterforce vs examiners resistance
  • Needs to be modified for 4-6 y/o
daniels and worthingham modified tests
Daniels and Worthingham:MODIFIED TESTS
  • Combined tests for the extremities
  • Quickie tests
    • Squatting
    • Walking on heels and toes
  • Break test
    • Movement cannot be totally prevented but can be minimized by telling the patient “don’t let me move you”
  • Evaluation of functional activities
    • Donning and doffing
    • Gripping the examiners hand

Daniels and Worthingham:CONSIDERATIONS

  • Always start the test at grade 3
  • In case a movement needs to be tested in the non-standard position , indicate the position used
  • When in doubt about the grade assigned to a muscle group place a (?) beside the grade
  • Note special cases ( MMT of fingers or toes, UMNL )
  • Freedom from discomfort or pain
  • Quiet non-distracting well ventilated environment
  • Adequately firm and wide plinth with adjustable height
  • Minimal position changes
  • Presence of all materials needed for the test
instrumented muscle testing
Instrumented Muscle Testing
  • Advantage: increases the level of accuracy and reliability of strength testing
  • Instruments/ devices
    • Cable tensiometer
    • Strain gauge
    • Hand-held dynamometer
    • Modified sphygmomanometer
    • Grip strength dynamometer
    • Pinch meter
instrumented muscle testing limitations
Instrumented Muscle Testing: LIMITATIONS
  • Measures isometric strength only
  • Not useful for testing trunk strength

Instrumented Muscle Testing: CONSIDERATIONS

  • Reliability is reasonable
  • Important to standardize strength
  • Instruments are not interchangeable
dynamic muscle testing
Dynamic Muscle Testing
  • Makes more sense since muscles function dynamically
  • Machine use: Isokinetic machines
isokinetic testing machine limitations
Isokinetic Testing Machine: LIMITATIONS
  • Validity has not yet been established
  • Movement occurring at constant speed is artificial
  • Positions and movement constraints are not realistic
functional muscle testing
Functional Muscle Testing
  • Utilized in cases when muscle strength cannot be tested by MMT:
    • Presence of spasticity and flaccidity
    • Patients with poor comprehension
    • Patients who are unable to follow instructions
  • Observations and description of certain movements or activities of the patient

Clarkson & Gilewich(1989), Musculoskeletal Assessment. Joint Range of Motion and Manual Muscle Strength: Williams & Wilkins.

Erickson and McPhee(1993) Clinical Evaluation. In Delisa: Rehabilitation Principles and Practice (2nd ed). Philadelphia: JB Lippincott Company.

Harms - Ringdahl(1993)International Perspectives in Physical Therapy.Muscle Strength. New York: Churchill Livingstone.

Hislop and Montgomery(2002): Daniels and Worthingham’s Muscle Testing: Techniques of Manual Examination(7th ed) Philadelphia:WB Saunders Company.

Kendall,McCreary, Provance: Muscle Testing and Function (4th ed)Baltimore: Williams and Wilkins, 1993.

Magee(1997) Orthopedic Physical Assessment(3rd ed) Philadelphia: WB Saunders Company.

Tobis and Hong (1990) Muscle Testing in Kottke and Lehmann: Krusen’s Handbook of Physical Medicine and Rehabilitation (4th Ed) Philadelphia:WB Saunders Company