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

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 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:

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

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

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

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

Fair (3+): patient can hold against gravity and resist minimal pressure (<25%); 1-24% efford from examiner.

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

Fair (3-): Gradual release from test position; cannot hold against gravity.

Poor (2+): Ability to move through full ROM in a gravity eliminated (GE)* position; can hold against resistance (in GE position) at end-range only; can only move through partial range against gravity.

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. 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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