Dr.

Muhammad Ali-ur-Rasheed
Lecturer , Department of
Physiotherapy.
Sargodha Medical College.
Tecniques of manual examination
The grading system
Grades for a manual muscle test are recorded as numerical
scores ranging from zero (0), which represents no activity, to
five ( 5 ) , which represents a "normal" or best-possible
response to the test or as great a response as can be
evaluated by a manual muscle test.
Because this text is based on tests of motions rather than
tests of individual muscles, the grade represents the
performance of all muscles in that motion.
The 5 to 0 system of grading is the most commonly used
convention.
Each numerical grade can be paired with a word that
describes the test performance in qualitative terms. These
qualitative terms, when written, are capitalized to indicate
that they too represent a score. This does not mean that the
test grades are quantitative in any manner.
The word range may be used in two senses.
First, it may refer to the amount of movement
which occurs in a joint. Secondly, it may refer to
the amount of shortening or lengthening of a
muscle as it acts to produce or control
movement.
Range of movement at a joint This is the total
quantity of movement when a joint is moved to
its full extent.
Muscle
When a muscle contracts and performs a
movement it is said to have acted through a
certain range.
When a muscle is fully stretched and contracts
to the limit of its normal capacity it is described
as having contracted and produced a
movement in full range.
For purposes of description full range is broken
down into three components which overlap.
Outer range of contraction is from full stretch of the
muscle to mid point of the full range.
Inner range of contraction is from the above-
mentioned mid point to full contraction.
Middle range of contraction is any distance between
the middle of the outer range and the middle of the
inner range.
Middle range of contraction is that in which many
muscles work most of the time when they are
producing movement.
The Break Test
Manual resistance is applied to a limb or other body part after it
has completed its range of movement or after it has been
placed at end range by the examiner.
The term "resistance" is always used to denote a force that acts
in opposition to a contracting muscle.
Manual resistance should always be applied in the direction of
the "line of pull" of the participating muscle or muscles. At the
end of the available range, or at a point in the range where the
muscle is most challenged,
the patient is asked to hold the part at that point and not allow
the examiner to "break" the hold with manual resistance.
An alternative to the break test is the application of manual
resistance against an actively contracting muscle or muscle
group
(i.e., against the direction of the movement as if to prevent
that movement).
This may be called an "active resistance" test. During the
motion, the examiner gradually increases the amount of
manual resistance until it reaches the maximal level the subject
can tolerate and motion ceases.
This kind of manual muscle test requires considerable skill and
experience to perform.
For example, a seated subject is asked to flex the elbow to its
end range; when that position is reached, the examiner applies
resistance at the wrist, trying to force the elbow to "break" its
hold and move downward into extension.
This is called a break test, and it is the procedure most
commonly used in manual muscle testing today.
The principles of manual muscle testing follow the basic tenets
of muscle length-tension relationships as well as those of joint
mechanics, for example biceps brachii
In manual muscle testing, the application of external force
(resistance) at the end of the range in one-joint muscles allows
consistency of procedure rather than an attempt to select the
estimated midrange position.
In two-joint muscles (e.g., the medial or lateral hamstring
muscles), the point of maximum resistance is generally at or
near midrange.
The point on an extremity or part where the examiner should
apply resistance is near the distal end of the segment to which
the muscle attaches.
Other exceptions to the general rule of applying distal
resistance include contraindications such as a painful condition
or a healing wound in a place where resistance might otherwise
be given.
The application of manual resistance to a part should never be
sudden or uneven (jerky). The examiner should apply resistance
somewhat slowly and gradually, allowing it to build to the
maximum tolerable intensity.
The application of resistance permits an assessment of
muscular strength when it is applied in the opposite direction to
the muscular force or torque.
 The knowledge and skill of the examiner determine the
accuracy and defensibility of a manual muscle test. Specific
aspects of these qualities include the following:
1. Knowledge of the location and anatomical features of the
muscles in a test.
2. Knowledge of the direction of muscle fibers and their "line of
pull" in each muscle.
3. Knowledge of the function of the participating muscles (e.g.,
synergists, prime movers, accessories).
4. Consistent use of proper positioning and stabilization
techniques for each test procedure. These ways include patient
position (via body weight), the use of a firm surface for testing,
muscle activity by the patient, and manual fixation by the
examiner
5. Ability to identify patterns of substitution in a given test and
how they can be detected based on a knowledge of which other
muscles can be substituted for the one(s) being tested.
6. Ability to detect contractile activity during both contraction and
relaxation, especially in minimally active muscle.
7. Sensitivity to differences in contour and bulk of the muscles
being tested in contrast to the contralateral side or to normal
expectations based on such factors as body size, occupation, or
leisure activities.
8. Awareness of any deviation from normal values for range of
motion and the presence of any joint laxity or deformity.
9. Understanding that the muscle belly must not be grasped at any
time during a manual muscle test except specifically to assess
tenderness or pain and muscle mass.
The examiner should test normal muscles at every opportunity,
especially when testing the contralateral limb in a patient with a
unilateral problem.
In almost every instance when the examiner cannot break the
patient's hold position, a grade of 5 (Normal) is assigned.
This value must be accompanied by the ability to complete a
full range of motion or maintain end-point range against
maximal resistance.
Grade 4 is used to designate a muscle group
that is able to complete a full range of motion
against gravity and can tolerate strong
resistance without breaking the test position.
The Grade 4 muscle "gives" or "yields" to some
extent at the end of its range with maximal
resistance. When maximal resistance clearly
results in a break, the muscle is assigned a
grade of 4 (Good).
The Grade 3 muscle test is based on an objective
measure. The muscle or muscle group can complete a
full range of motion against only the resistance of
gravity.
If a tested muscle can move through the full range
against gravity but additional resistance, however
mild, causes the motion to break, the muscle is
assigned a grade of 3 (Fair).
A grade of 3 (Fair) may be said to represent a definite
functional threshold for each movement tested,
indicating that the muscle or muscles can achieve the
minimal task of moving the part upward against
gravity through its range of motion.
The Grade 2 (Poor) muscle is one that can
complete the full range of motion in a position
that minimizes the force of gravity. This position
often is described as the horizontal plane of
motion.
The Grade 1 (Trace) muscle means that the
examiner can detect visually or by palpation
some contractile activity in one or more of the
muscles that participate in the movement being
tested (provided that the muscle is superficial
enough to be palpated).
The examiner also may be able to see or feel a
tendon pop up or tense as the patient tries to
perform the movement. There is, however, no
movement of the part as a result of this
minimal contractile activity.
Any position/procedure.
The Grade 0 (Zero) muscle is completely
quiescent on palpation or visual inspection.
 Elbow flexion
Muscles involved
1. Biceps
2. Brachialis
3. Brachoradialis
• Range of motion
• 0 degree to 150 degree
• Others
Pronator teres
Extensor carpi radialis longus
Flexor carpi radialis
Flexor carpi ulnaris
Origion
long head :Scapula (supraglenoid tubercle)
Capsule of glenohumeral joint
and glenoid labrum
short head: Scapula (coracoid process, apex)
Insertion : Radius (radial tuberosity)
Bicipital aponeurosis
Origion : Humerus (shaft anterior, distal 1/2)
Intermuscular septa (medial)
Insertion : Ulna (tuberosity and coronoid
process)
Origion : Humerus (lateral supracondylar ridge,
proximal 2/3) Lateral intermuscular
septum
Insertion : Radius (distal end just proximal to
styloid process)
Position of Patient: Short sitting with arms at
sides.
Position of Therapist: Stand in front of patient
toward the test side. Hand giving resistance is
contoured over the flexor surface of the
forearm proximal to the wrist
The other hand applies counterforce by cupping
the palm over the anterior superior surface of
the shoulder.
No resistance is given in a Grade 3 test, but the
test elbow is cupped by the examiner's hand
Instructions to Patient
Grades 5 and 4: "Bend your elbow. Hold it.
Don't let me pull it down."
Grade 3: "Bend your elbow."
Grading
Grade 5 (Normal): Completes available range
and holds firmly against maximal resistance.
Grade 4 (Good): Completes available range
against strong to moderate resistance, but the
end point may not be firm.
Grade 3 (Fair): Completes available range with
each forearm position with no manual
resistance.
Grade 2 (Poor)
Position of Patient
All Elbow Flexors: Short sitting with arm
abducted to 90° and supported by examiner
Alternate Position for Patients Unable to Sit:
Supine. Elbow is flexed to about 45°
Test: Patient attempts to flex the elbow.
Instructions to Patient: "Try to bend your
elbow."
Grading
Grade 2 (Poor): Completes range of motion of
the muscles tested
Grade 1 (Trace): Examiner can palpate a
contractile response in each of the three
muscles for which a Trace grade is given.
Grade 0 (Zero): No palpable contractile activity.
Position of Therapist
All Three Flexors: Stand in front of patient and
support abducted arm under the elbow and
wrist if necessary
Palpate the tendon of the biceps in the
antecubital space
On the arm, the muscle fibers may be felt on
the anterior surface of the middle two thirds
with the short head lying medial to the long
head.
Palpate the brachialis in the distal arm medial
to the tendon of the biceps.
Palpate the brachioradialis on the proximal
volar surface of the forearm, where it forms the
lateral border of the cubital fossa
Any Question ???
Thanx