Manual Muscle Testing

Question 1

Iliopsoas (psoas major emphasis)

Answer 1

Patient: Supine.

Fixation: stabilizes the opposite iliac
crest. The quadriceps stabilize the knee in extension.

Test: Hip flexion in a position of slight abduction and slight lateral rotation.

Pressure: Against the anteromedial aspect of the leg, in the direction of extension and slight abduction, directly opposite the line of pull of the psoas major from the origin of the lumbar spine

Question 2

Sartorius

Answer 2

Patient: Supine.

Fixation: None necessary by the examiner. The patient may hold on to the table.

Test: Lateral rotation, abduction, and flexion of the
thigh, with flexion of the knee.

Pressure: Against the anterolateral surface of the lower thigh, in the direction of hip extension, adduction, and medial rotation, and against the leg, in the direction of knee extension. The examiner’s hands are in a position to resist the lateral rotation of the hip joint by pressure
and counterpressure

Question 3

Tensor Fasciae Latae

Answer 3

Patient: Supine.

Fixation: The patient may hold on to the table. Quadriceps action is necessary to hold the knee extended. Usually, no fixation is necessary by the examiner, but if there is instability and the patient has difficulty in maintaining the pelvis firmly on the table, one of the examiner’s hands should support the pelvis anteriorly, on the opposite side.

Test: Abduction, flexion, and medial rotation of the hip, with the knee extended.

Pressure: Against the leg, in the direction of extension and adduction. Do not apply pressure against the rotation component.

Question 4

Hip ADDuctors

Answer 4

Patient: Lying on the right side to test the right (and
vice versa), with the body in a straight line and the lower extremities and lumbar spine straight.

Fixation: The examiner holds the upper leg in abduction. The patient should hold on to the table for stability.

Test: Adduction of the underneath extremity upward from the table, without rotation, flexion, or extension of the hip or tilting of the pelvis.

Pressure: Against the medial aspect of the distal end of the thigh, in the direction of abduction (i.e., downward toward the table). Pressure is applied at a point above the knee to avoid strain of the tibial collateral ligament.

Question 5

Hip Medial Rotators

Answer 5

The medial rotators of the hip joint consist of the tensor fasciae latae, gluteus minimus and gluteus medius (anterior fibers).

Patient: Sitting on a table, with the knees bent over the side and the subject holding on to the table.

Fixation: The weight of the trunk stabilizes the patient during this test. Stabilization is also given in the form of counterpressure, as described below under Pressure.

Test: Medial rotation of the thigh, with the leg in a position of completion of the outward arc of motion.

Pressure: With one hand, the examiner applies counterpressure at the medial side of the lower end of the thigh. With the other hand, the examiner applies pressure to the lateral side of the leg, above the ankle, pushing the leg inward in an effort to rotate the thigh laterally.

Question 6

Hip Lateral Rotators

Answer 6

Patient: Sitting on a table, with the knees bent over the side and the subject holding on to the table.

Fixation: The weight of the trunk stabilizes the patient during this test. Stabilization is also given in the form of counterpressure, as described below under Pressure.

Test: Lateral rotation of the thigh, with the leg in a position of completion of the inward arc of motion.

Pressure: With one hand, the examiner applies counterpressure at the lateral side of the lower end of the thigh. With the other hand, the examiner applies pressure to the medial side of the leg, above the ankle, pushing the leg
outward in an effort to rotate the thigh medially.

Question 7

Gluteus Minimus

Answer 7

Patient: Side-lying.

Fixation: The examiner stabilizes the pelvis.

Test: Abduction of the hip in a position neutral between flexion and extension and neutral in regard to rotation.

Pressure: Against the leg, in the direction of adduction and very slight extension.

Question 8

Gluteus

- Hip ABDuction with slight EXtension & Lateral Rotation

Answer 8

Patient: Side-lying, with the underneath leg flexed at the hip and knee and the pelvis rotated slightly forward to place the posterior gluteus medius in an antigravity position.

Fixation: The muscles of the trunk and the examiner stabilize the pelvis. (See Note on facing page.)

Test (Emphasis on Posterior Portion): Abduction of
the hip, with slight extension and slight external rotation. The knee is maintained in extension. Differentiating the posterior gluteus medius is very important. Hip abductors, when tested as a group, may be normal in strength, even though a precise test of the gluteus medius may reveal appreciable weakness. When external rotation of the hip joint is limited, do not allow the pelvis to rotate backward to obtain the appearance of hip joint external rotation. With backward rotation of the pelvis, the tensor fasciae latae and gluteus
minimus become active in abduction. Even though pressure may be applied properly, in the right direction, against the gluteus medius, the specificity of the test is greatly diminished. Weakness of the gluteus medius may
become apparent immediately because of the subject’s
inability to hold the precise test position, the tendency
for the muscle to cramp, or an attempt to rotate the pelvis
backward to substitute with the tensor fasciae latae and
the gluteus minimus.
Pressure: Against the leg, near the ankle, in the direction of adduction and slight flexion; do not apply pressure
against the rotation component. The pressure is applied against the leg for the purpose of obtaining a long lever. To determine normal strength, strong force is
needed, and this force can be obtained by the examiner with the added advantage of a long lever. There is relatively little danger of injuring the lateral knee joint, because it is reinforced by the strong iliotibial tract.

Question 9

Gluteus Maximus

Answer 9

Patient: Prone, with knee flexed 90° or more. (The more
the knee is flexed, the less the hip will extend because
of restricting tension of the rectus femoris anteriorly.)
Fixation: Posteriorly, the back muscles; laterally, the
lateral abdominal muscles; and anteriorly, the opposite
hip flexors fix the pelvis to the trunk.
Test: Hip extension, with the knee flexed.
Pressure: Against the lower part of the posterior thigh,
in the direction of hip flexion.

Question 10

Biceps Femoris

Answer 10

Patient: Prone.
Fixation: The examiner should hold the thigh firmly
down on the table.
Test: Flexion of the knee between 50° and 70°, with the
thigh in slight lateral rotation and the leg in slight lateral
rotation on the thigh.
Pressure: Against the leg, proximal to the ankle, in the
direction of knee extension. Do not apply pressure
against the rotation component.

Question 11

Semitendinosus & Semimembranosus

Answer 11

Patient: Prone.
Fixation: The examiner should hold the thigh down
firmly on the table. (To avoid covering the muscle belly
of the medial hamstrings, fixation is not illustrated.)
Test: Flexion of the knee between 50° and 70°, with t h e
thigh in medial rotation and the leg medially rotated on
the thigh.
Pressure: Against the leg, proximal to the ankle, in t h e
direction of knee extension. Do not apply p r e s s u re
against the rotation component.

Question 12

Quadriceps Femoris

Answer 12

Patient: Sitting, with the knees over the side of the table
and holding on to the table.
Fixation: The examiner may hold the thigh firmly down
on the table. Alternatively, because the weight of the
trunk is usually sufficient to stabilize the patient during
this test, the examiner may put a hand under the distal
end of the thigh to cushion that part against table pressure.
Test: Full extension of the knee joint, without rotation
of the thigh.
Pressure: Against the leg, above the ankle, in the direction
of flexion.

Question 13

Tibialis Anterior

Answer 13

Patient: Supine or sitting (with knee flexed if any gastrocnemius
tightness is present).
Fixation: The examiner supports the leg, just above the
ankle joint.
lest: Dorsiflexion of the ankle joint and inversion of the
foot, without extension of the great toe.
Pressure: Against the medial side, dorsal surface of the
foot, in the direction of plantar flexion of the ankle joint
and eversión of the foot.

Question 14

Tibialis Posterior

Answer 14

Patient: Supine, with the extremity in lateral rotation.
Fixation: The examiner supports the leg, above the ankle
joint.
Test: Inversion of the foot, with plantar flexion of the
ankle joint.
Pressure: Against the medial side and plantar surface of
the foot, in the direction of dorsiflexion of the ankle
joint and eversion of the foot.

Question 15

Peroneus Longus and Brevis

Answer 15

Patient: Supine, with the extremity medially rotated, or
side-lying (on the opposite side).
Fixation: The examiner supports the leg, above the ankle
joint.
Test: Eversion of the foot, with plantar flexion of the ankle
joint.
Pressure: Against the lateral border and sole of the foot,
in the direction of inversion of the foot and dorsiflexion
of the ankle joint.

Question 16

Soleus

Answer 16

Patient: Prone, with the knee flexed at least 90°.
Fixation: The examiner supports the leg, proximal to
the ankle.
Test: Plantar flexion of the ankle joint, without inversion
or eversión of the foot.
Pressure: Against the calcaneus (as illustrated), pulling
the heel in a caudal direction (i.e., in the direction of
dorsiflexing the ankle). When weakness is marked, the
patient may not be able to hold against pressure at the
heel. When weakness is not marked, more leverage is
necessary and is obtained by applying pressure simultaneously
against the sole of the foot.

Question 17

Gastrocnemius

Answer 17

Patient: Standing. (Patients may steady themselves with
a hand on the table, but they should not take any weight
on the hand.)
Test Movement: Rising on toes, pushing the body
weight directly upward.
Resistance: Body weight.

Question 18

Anterior Neck Flexors

Answer 18

Patient: Supine, with the elbows bent and the hands
overhead, resting on the table.
Fixation: Anterior abdominal muscles must be strong
enough to give anterior fixation from the thorax to the
pelvis before the head can be raised by the neck flexors.
If the abdominal muscles are weak, the examiner can
provide fixation by exerting firm, downward pressure on
the thorax. Children approximately 5 years of age and
younger should have fixation of the thorax provided by
the examiner.
lest: Flexion of the cervical spine by lifting the head
from the table, with the chin depressed and approximated
toward the sternum.
Pressure: Against the forehead in a posterior direction.
(For grading, see facing page.)
Modified Test: In cases of marked weakness, have the
patient make an effort to flatten the cervical spine on the
table, approximating the chin toward the sternum.
Pressure: Against the chin in the direction of neck extension.

Question 19

Back Extensors

Answer 19

Patient: Prone, with hands clasped behind the buttocks
(or behind the head).
Fixation: Hip extensors must give fixation of the pelvis
to the thighs. The examiner stabilizes the legs firmly on
the table.
Test Movement: Trunk extension to the subject’s full
range of motion.
Resistance: Gravity. Hands behind the head, or hands
behind the lower back.

Question 20

Upper Abs

Answer 20

Patient: Supine, with legs extended. If the hip flexor
muscles are short and prevent posterior pelvic tilt with
flattening of the lumbar spine, place a roll under the
knees to passively flex the hips enough to allow the back
to flatten. (Arm positions are described below under
Grading.)
Fixation: None necessary during the initial phase of the
test (i.e., trunk curl), in which the spine is flexed and the
thorax and pelvis are approximated. Do not hold the feet
down during the trunk-curl phase. Stabilization of the
feet will allow hip flexors to initiate trunk raising by
flexion of the pelvis on the thighs.
Test Movement: Have the subject do a trunk curl slowly,
completing spine flexion and, thereby, the range of motion
that can be performed by the abdominal muscles.
Without interrupting the movement, have the subject
continue into the hip flexion phase (i.e., the sit-up) to
obtain strong resistance against the abdominal muscles
and, thereby, an adequate strength test.
Resistance: During the trunk-curl phase, resistance is
offered by the weight of the head and upper trunk, and
by the arms placed in various positions. However, the resistance
offered by the weight of the head, shoulders and
arms is not sufficient to provide an adequate test for
strength of the abdominal muscles.