Manual Muscle Testing: Shoulder Flexion

Original Editor - Claire Knott

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

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Introduction

Manual Muscle Tests (MMT) represent an imperative form of assessing muscle/tendon strength (or lack there of). The numerical grades, provided by the examiner, demonstrate a consistent form of documentation. Upon evaluation, performing a MMT will provide a baseline measurement that the examiner can refer back to when/if needed. The examiner must regularly perform MMT’s throughout the rehabilitation process, for dependability. Consistency of documentation

Performing a MMT requires positioning specific to the muscles actions. Because of this specificity, the examiner can determine the muscle that is causing the movement deficit.

Upon evaluation, performing a MMT of the shoulder flexors will provide a baseline measurement that is easily documented. This documentation component demonstrates the patient response to the interventions provided by the examiner.

The purpose of manual muscle testing (MMT), is to detect weakness and imbalances of a mucle or tendon. The initial MMT provides a baseline measurement that easily documents the patients strength, or lack there of

Shoulder Flexion Osteokinematic and Arthrokinematic Movements:

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

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

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

Muscles Involved in Shoulder Flexion:

• Deltoid (anterior)
• Coracobrachialis
• Biceps Brachii

Grading MMT:

Purpose:

MMT grades are given subjectively, by the examiner, based on the patients strength. Examiners assign numerical grades, used to represent the patients ability/inability to: (1) resist the external pressure (fair 3+ and higher); (2) actively resist the force of gravity (fair 3); or, (3) move through range of motion (fair 3- and lower). These numerical grades represent a consistent form of measurement that reveals if the patient progresses, regresses, or remains the same

Break Test:

If the patient can actively hold against gravity, the examiner will gradually apply pressure perpendicular to the testing position. The test is considered over if the muscle being tested cannot maintain the origanal testing position, or if the patient begins to show any adverse signs/symptoms to the applied pressure. If the examiner is unable to break, or move, the patient out of testing position, the muscle strength is considered normal (5).

Grading:

• MMT grades are given subjectively, from the examiner, based on the patients strength. The numerical system used represents the patient ability/inability to: (1) resist the examiners pressure (Fair 3+ and higher); (2) actively hold against gravity (Fair 3); or, (3) move through muscle range (fair 3- and lower).

Normal (5): Able to hold test position and resist strong pressure; examiner is unable to "break" the test position; > 95% effort from examiner.

Good (4+): Able to hold test position and resist moderate to strong pressure before muscle failure; 75-95% effort from examiner.

Good (4): Able to hold test position and resist moderate pressure before muscle failure; 50-74% effort from examiner.

Good (4-): Able to hold against gravity and resist slight to moderate pressure before muscle failure; 25-49% effort from examiner.

Fair (3+): Able to hold against gravity and resist minimal pressure before muscle failure; 1-24% effort from examiner.

Fair (3): Able to hold against gravity; no additional force applied.

Fair (3-): Unable to hold agaisnt gravity; patient gradually falls from test position.

Poor (2+): Unable to hold against gravity; achieves only partial ROM against gravity; in a gravity eliminated (GE)* postion, able to move through full ROM with resistance at end-range only.

Poor (2): Unable to hold against gravity; able to move through full ROM in a GE position.

Poor (2-): Unable to hold agasint gravity; able to move through partial range in a GE position.

Trace (1): No osteokinematic movement; examiner is able to palpate a contraction of the muscle/tendon.

Zero (0): No osteokinematic movement, visable, or palpable contraction of muscle or tendon.

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

• Standing on ipsilateral side of the arm being tested
• No stabilzation is necessary if trunk is stable

How to perform the MMT:

• The examiner asks the patient to assume a hooklying position on the table.
• The examiner passively moves the shoulder in flexion, slight external rotation, the elbow fully flexed, and forearm in supination. Positioning this way will decrease the assistance of the biceps brachii.
• The examiner then asks the patient to perform the actions without assistance, to assure their achievement of full ROM.
• If no pain is present, the examiner resets the patient to starting test positon and applies resistance against the anteromedial surface of the distal humerus, in the direction of extension and slight abduction.
• The patient attempts to not let the examiner move them by using a counteracting force of shoulder flexion and adduction until there is a break or examiner expresses the test is over.

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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 80 degrees of abduction, slight flexion, and slight lateral rotation. The examiner passively takes the patient into approximately 60 degrees of shoulder flexion and complete elbow extension to show the patient the motion. The patient is then asked to actively perform the motion.
• For stabilization, the examiner will wrap the 2nd-4th digits of the hand closest to the patient on the anterior ipsilateral shoulder that is being tested. While the physical therapist fingers are stabilizing the anterior part of the shoulder, the palm of the same hand will be stabilizing the spine of scapula.
• The examiner then wraps their fingers of the movement hand around the distal anterior surface of the humerus. Once the movement hand is placed in that position, the examiner attempts to break the patient position by pulling them into shoulder extension and adduction.
• 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:

• Examiner places the patients shoulder and elbow in slight flexion and the forearm in full supination.
• Examiner then passively 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. The examiner stabilizes the elbow with one hand and wraps their fingers around the distal ventral side of the patients forearm.
• Examiner attempts to pull in patient into elbow extension.
• The patient attempts to not let the examiner move them by pulling into elbow flexion.

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