Manual Muscle Testing: Shoulder Flexion

Original Editor - Claire Knott

Top Contributors - Hollie Webb, Madison Gore, Claire Knott, Kaley Golden, Wanda van Niekerk, Kim Jackson, Joao Costa, Nikhil Benhur Abburi and Tony Varela  

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Introduction

The purpose of manual muscle testing (MMT), is to detect weakness and imbalances of a mucle or tendon. The initial MMT provides a baseline that initiates the restorative process of muscle strength, stability, and function via therapeutic exercise (strengthening).

Shoulder Flexion Osteokinematic and Arthrokinematic Movements:

From 0-60 degrees, the scapula and clavicle elevate, the humeral head begins to glide inferiorly and rotates posteriorly.

From 60-90 degrees, the humeral head is seated in the glenoid fossa and rotates posteriorly, the clavicle and scapula continue to elevate but the scapula beings to upwardly rotate.

From 90-180 degrees, the scapula upwardly rotates, the clavicle rotates posteriorly, and the humeral head rotates posteriorly while still seated in the glenoid fossa.

Muscles Involved in Shoulder Flexion:

• Deltoid (anterior)
• Coracobrachialis
• Biceps Brachii

Grading MMT:

Break Test:

PT gradually applies pressure until the muscle being tested cannot maintain testing position or until the patient shows signs of not being able to resist the pressure applied.

Grading:

• Based on a system in the ability to move through full ROM, against gravity or hold the tested part in a given position against gravity establishes the grade 3 (FAIR).

Normal (5): Holds test position against strong pressure or does not “BREAK” from test position; > 95% effort

Good (4+): Holds against moderate to strong pressure; 75-95% effort

Good (4): Holds test position against moderate pressure; 50-74% effort

Good (4-): patient can hold against gravity plus slight to moderate pressure; 25-49% effort force

Fair (3+): patient can hold against gravity and additional minimal pressure (<25%); 1-24%

Fair (3): can hold against gravity; no additional force applied

Fair (3-): Gradual release from test position, once the limb is placed vs gravity

Poor (2+): Ability to move through full ROM with gravity eliminated against resistance or to hold against resistance at end-range; Anti-gravity muscle can move through partial range

Poor (2): Muscle or muscle group that can move through complete ROM with gravity eliminated with no external resistance

Poor (2-): Ability to move through partial range with GE

Trace (1): Tendon becomes prominent or feeble contraction palpated in the muscle; no visible movement of the limb or joint; gravity eliminated

Zero (0): No evidence of contraction, either visual or during palpation

What is Gravity Eliminated (GE)?

• When testing weak muscles, patient must be positioned such that muscles are in a working position with gravity eliminate
• Occurs in the Transverse plane

Coracobrachialis:

Patient Position:

• Sitting or Supine

Therapist Position

• Therapist to stand on ipsilateral side
• Palpation shoulder flexors
• No stabilization is necessary

How to perform the MMT:

• PT places patient supine on table with shoulder flexion in lateral rotation, with the elbow completely flexed and forearm supinated.
• Therapist preforms PROM to show the patient the motion and to make sure they can achieve full range. The patient is then asked to actively perform the motion.
• The physical therapist applies pressure against the anteromedial surface of the distal humerus, in the direction of extension and slight abduction and asks the patient to resist the movement.

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Anterior Deltoid:

Patient Position:

• Sitting

Therapist Position:

• Therapist stands behind the patient
• Stabilizes the scapula

How to perform the MMT:

• Shoulder is placed in approximately 60 degrees of abduction, slight flexion, and slight lateral rotation.
• Therapist preforms PROM to show the patient the motion and make sure they can achieve full range. The patient is then asked to actively perform the motion.
• The physical therapist applies pressure against the anteromedial surface of the arm. The therapist is trying to pull the patient into adduction and slight extension.
• The patient is asked to resist the movement (meaning that the patient will be pushing into abduction and flexion).

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Biceps Brachii:

Patient Position:

• Supine or seated

Therapist Position

• Standing on ipsilateral side of arm that is being tested
• Stabilize on the ipsilateral elbow

How to perform the MMT:

• Physical therapist places the patients shoulder and elbow in slight flexion and the forearm in full supination.
• Physical therapist then actively moves the patient into complete elbow flexion, then asks the patient to repeat the same motion passively.
• Patient is returned to the starting test position and the physical therapist stabilizes the elbow with one hand, and wraps their fingers around the distal ventral side of the patients forearm.
• The physical therapist attempts to pull in patient into elbow extension.
• The patient attempts to not let the physical therapist move them by pulling into elbow flexion.

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