Daniels and worthinghams muscle testing free download pdf

Techniques of Manual Examination and

Performance Testing

10 TH EDITION

Dale Avers | PT, DPT, PhD, FAPTA

Professor
Department of Physical Therapy Education
College of Health Professions
SUNY Upstate Medical University
Syracuse, New York

Marybeth Brown | PT, PhD, FAPTA, FACSM

Professor Emeritus
Physical Therapy Program, Biomedical Sciences
University of Missouri
Columbia, Missouri

2
Table of Contents

Cover image

Title Page

Copyright

Dedication

Tribute page
Helen J. Hislop, PT, PhD, FAPTA — A Tribute

Preface

Alphabetical List of Muscles

A

3
Introduction
Brief History of Muscle Testing

How to Use This Book

Names of the Muscles

Anatomical Authorities

The Convention of Arrows in the Text

References

Chapter 1 Principles of Manual Muscle Testing

Muscle Test

References

Chapter 2 Relevance and Limitations of Manual Muscle Testing

Relevance and Limitations

References

Chapter 3 Testing the Muscles of the Neck

Testing the Muscles of the Neck

Capital Extension

Cervical Extension

Capital Flexion (Chin Tuck)

Cervical Flexion

Flexion to Isolate a Single Sternocleidomastoid

Cervical Rotation

References

Chapter 4 Testing the Muscles of the Trunk and Pelvic Floor

Trunk Extension

Elevation of the Pelvis

Trunk Flexion

Trunk Rotation

Core Tests

Quiet Inspiration

Forced Expiration

Pelvic Floor

References

Chapter 5 Testing the Muscles of the Upper Extremity

Introduction to Shoulder Girdle Strength Testing

Scapular Abduction and Upward Rotation

Scapular Elevation

Scapular Adduction (Retraction)

4
 Scapular Depression and Adduction

Scapular Adduction (Retraction) and Downward Rotation

Latissimus Dorsi

Introduction to Testing the Deltoid

Shoulder Flexion

Shoulder Extension

Shoulder Abduction

Shoulder Horizontal Abduction

Shoulder Horizontal Adduction

Introduction to the Rotator Cuff

Shoulder External Rotation

Shoulder Internal Rotation

Elbow Flexion

Elbow Extension

Forearm Supination

Forearm Pronation

Wrist Flexion

Wrist Extension

Introduction to Testing the Muscles of the Hand

Finger PIP and DIP Flexion

PIP Tests

DIP Tests

Finger MCP Extension

Finger MCP Flexion

Finger Abduction

Finger Adduction

Thumb MCP and IP Flexion

Thumb MCP and IP Flexion

Thumb IP Flexion

Thumb MCP and IP Extension

Thumb MCP and IP Extension

Thumb Abduction

Thumb Abduction

Thumb Abduction

Thumb Adduction

Opposition (Thumb to Little Finger)

Grip Strength

References

Chapter 6 Testing the Muscles of the Lower Extremity

Hip Flexion

Hip Flexion, Abduction, and External Rotation With Knee Flexion

5
 Hip Extension

Hip Abduction

Hip Abduction From Flexed Position

Hip Adduction

Hip External Rotation

Hip Internal Rotation

Knee Flexion

Knee Extension

Ankle Plantar Flexion

Foot Dorsiflexion and Inversion

Foot Inversion

Foot Eversion With Plantar Flexion

Hallux and Toe MP Flexion

Hallux and Toe MP Flexion

Hallux and Toe DIP and PIP Flexion

Hallux and Toe MP and IP Extension

References

Chapter 7 Alternatives to Manual Muscle Testing

Alternatives to Manual Muscle Testing

References

Chapter 8 Testing Functional Performance

Chair Stand

Gait Speed

Physical Performance Test and Modified Physical Performance Test

Timed Up and Go

Stair Climb

Floor Rise

Gait

References

Chapter 9 Handheld Muscle Dynamometry

Shoulder Flexion

Shoulder Extension

Shoulder Abduction

Shoulder External Rotation

Shoulder Internal Rotation

Elbow Flexion

Elbow Extension

Wrist Extension

Hip Flexion

6
 Hip Extension

Hip Abduction

Hip External Rotation

Hip Internal Rotation

Knee Flexion

Knee Extension

Foot Dorsiflexion and Inversion

References

Chapter 10 Case Studies

Introduction

References

Index

List of Muscles by Region

Head and Forehead

Eyelids

Ocular Muscles

Nose

Mouth

Ear

Jaw (Mastication)

Tongue

Pharynx

Palate

Larynx

Neck

Back

Thorax (Respiration)

Abdomen

Perineum

Upper Extremity

Lower Extremity

7
Copyright

3251 Riverport Lane

St. Louis, Missouri 63043

DANIEL AND WORTHINGTON'S MUSCLE TESTING, TENTH EDITION

ISBN: 978-0-323-56914-9
Copyright © 2019, Elsevier Inc. All Rights Reserved.

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Because of rapid advances in the medical sciences, in particular, independent verification of
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Last digit is the print number 9 8 7 6 5 4 3 2 1

8
Dedication

To my students and colleagues, who continue to challenge me to be the best I can be.
—, Dale Avers

This book is dedicated to my wonderful colleagues, who are the true backbone of our
profession, and to my students, for these are the men and women who have made my
days tremendously fun and totally worthwhile. This book is also dedicated to Helen J.
Hislop—friend, mentor, and incredible woman.
—, Marybeth Brown

9
Tribute page

10
Helen J. Hislop, PT, PhD, FAPTA — A Tribute
In 2013 the physical therapy profession lost one of the brightest beacons it had ever known. Helen
Hislop was an extraordinary woman who changed the course of our profession, in part by
implementing heightened standards of academic success and by creating the DPT and PhD degrees
during her tenure at the University of Southern California. She also took the editorship of Physical
Therapy, the professional journal of the American Physical Therapy Association, and transformed it
from an anecdotal “how to” magazine into a scientific journal with genuine credibility in the
medical community. The sheer magnitude of her contributions is probably beyond that of any
physical therapist in the history of our profession.
One of the most notable achievements in Helen's repertoire was her authorship of four editions of
the classic text, Daniels and Worthingham's Muscle Testing: Techniques of Manual Examination. First
published in 1946, the original Daniels, Williams, and Worthingham book was a “how to” manual
for testing the patient with poliomyelitis. Although the book was modified to some extent over the
next 30 years, the practice of physical therapy changed considerably during that time span and the
earlier muscle testing book did not reflect the expansion of the profession to include the testing of
neurological patients, the testing of men and women with orthopedic injuries and joint
replacements, and contending with the burgeoning older adult population. Helen became involved
in shepherding the book to a more contemporary text beginning with the 6th edition, and when the
book was published in 1995, it reflected a sea change. Beautiful anatomical drawings produced
under Helen's direction were incorporated, the testing of new patient populations was added, and
there was the inclusion of new muscle tests that had evolved from clinical practice that were far
more accurate than those described in previous texts, such as the 25× heel rise. Although these
changes were the product of Helen's vision, the contributions of her coauthor, Jacqueline
Montgomery, MA, PT, were of tremendous importance as Jackie was a clinician with her finger on
the pulse of clinical practice.
In 2010, Helen called to ask if I would become a contributor to the 9th edition, and I agreed. After
multiple trips to Helen's home in North Carolina it became apparent that her declining health was
going to preclude completion of the book without a great deal more help. We worked for another
year, but with looming deadlines and the need for a move away from “manual” muscle testing, and
the inclusion of functional testing, it became necessary to enlist additional help. Dale Avers, PT,
DPT, PhD, FAPTA, was asked to be an author and edition 9 continued to evolve in response to
changing practice.
Even with multiple hospitalizations and further declines in health, Helen continued to be a vital
contributor to edition 9. At all times she was “in charge.” Her fortitude was extraordinary; once a
vision was planted in her brain, there was no dissuading her from the task at hand. She never saw
the final completed copy of edition 9 but she contributed to each and every one of the enormous
changes brought forth in the new book. Even though Helen is gone, her contributions will persist
through many more iterations of this text.
Wherever Helen may be, there is no question she is lustily singing Gilbert and Sullivan tunes,
engaging those around her in lively and insightful conversation, regaling anyone who will listen
with tales of Scottish history, and making people laugh. Hopefully, too, she has caught the “big
fish” that eluded her for her entire 84 years.
Rest in peace, dear friend.
— Mb

11
Preface
For more than 70 years, Daniels and Worthingham's Muscle Testing has been informing students and
practitioners about the art and science of manual muscle testing. Over the past seven decades there
have been nine editions of the text, not including this current edition.
So, why an Edition 10? Muscle Testing has evolved into a different entity during its lengthy
history. Initially a primer on how to test muscles affected by poliomyelitis, Daniels and
Worthingham's Muscle Testing book now reflects the muscle testing requirements for a far broader
scope of practice. Additionally, muscle testing techniques are now appropriate for patients who
range in age from young adults to those who have lived 100 or more years (material appropriate for
children may be found in other sources). Building on manual testing, this edition includes power
testing and endurance testing, as well as alternate testing using free-weights, weight machines,
elastic bands, body weight, functional testing, and most recently, handheld dynamometry. The tests
included in this edition are far more evidence-based than they have been in the past due to the
contributions of numerous researchers who have advanced our understanding of assessment. In
many instances, normative values now exist and they have been included in Edition 10. Finally, for
the beginning practitioner, exercises have been added to help the new therapist in the design of
appropriate treatment programs. Thus, as the health professions have evolved, so too has muscle
testing. We believe this book is the most up-to-date muscle testing book available, with detailed
“how to” information on hundreds of tests. Importantly, this new edition is evidence-based, an
imperative in our contemporary health-care system.
For those of you with historical perspective, it is evident that a number of editors and
contributors to Muscle Testing have come and gone over the years. The historical figures associated
with the early editions of this text are long gone, but each made important contributions and passed
the mantle to the next generation of scholars. Now, it is we who are the caretakers of the book and
in due time we too will pass the torch to younger individuals with their fingers on the pulse of
practice and scholarship. Why us? We were chosen because of a long and rich association with
Helen Hislop, the previous author who was at the helm of the book for nearly 40 years. Helen
valued our clinical expertise and anatomical knowledge and gave her blessing to this change of the
book's leadership. We hope you will be pleased with our efforts.
We are enormously grateful to our forebears for the work that went into the creation of this text.
We are grateful as well to the individuals who helped in the creation of the book, particularly our
developmental editor, Linda Wood, who has skillfully guided the development of five editions of
the book. We also thank Yoshi Miyake for the drawings of the new tests and Jeanne Robertson for
the new anatomical drawings. For the original videos, we thank Judith Burnfield, whose work we
have built upon in developing the new videos for this edition. Additional thanks go to the
individuals who contributed to and reviewed sections of the book during its development: Richard
Bohannan, PT, PhD, FAPTA, of Campbell University; Christopher Neville, PT, PhD, of Upstate
Medical University; and Kevin Neville, PT, DPT, of Upstate Medical University. We are grateful for
their valuable insights. We are also grateful for the four second-year DPT students from Upstate
Medical University who were the models for many of the illustrations in the new edition: Melanie
Chapman, Marissa Coppola, Kathryn Dziwulski, and Vanessa Sweet. And finally, we thank the
team at Elsevier including Sarah Vora, Michael Fioretti, and many others whose behind-the-scenes
work helped bring the book to fruition.
Dale Avers PT, DPT, PhD, FAPTA
Marybeth Brown PT, PhD, FAPTA

12
13
Alphabetical List of Muscles

14
A
215 Abductor digiti minimi (foot)
159 Abductor digiti minimi (hand)
224 Abductor hallucis
171 Abductor pollicis brevis
166 Abductor pollicis longus
180 Adductor brevis
225 Adductor hallucis
179 Adductor longus
181 Adductor magnus
173 Adductor pollicis
144 Anconeus
53 Arytenoid
Oblique
Transverse
27 Auriculares

15
B
140 Biceps brachii
192 Biceps femoris
141 Brachialis
143 Brachioradialis
26 Buccinator
120 Bulbospongiosus

16
C
34 Chondroglossus
116 Coccygeus
139 Coracobrachialis
5 Corrugator supercilii
117 Cremaster
50 Cricothyroid [Cricothyroideus]

17
D
133 Deltoid [Deltoideus]
23 Depressor anguli oris
24 Depressor labii inferioris
14 Depressor septi
101 Diaphragm
78 Digastricus [Digastric]

18
E
149 Extensor carpi radialis brevis
148 Extensor carpi radialis longus
150 Extensor carpi ulnaris
158 Extensor digiti minimi
154 Extensor digitorum
212 Extensor digitorum brevis
211 Extensor digitorum longus
221 Extensor hallucis longus
155 Extensor indicis
168 Extensor pollicis brevis
167 Extensor pollicis longus

19
F
209 Fibularis brevis
208 Fibularis longus
210 Fibularis tertius
151 Flexor carpi radialis
153 Flexor carpi ulnaris
216 Flexor digiti minimi brevis (foot)
160 Flexor digiti minimi brevis (hand)
214 Flexor digitorum brevis
213 Flexor digitorum longus
157 Flexor digitorum profundus
156 Flexor digitorum superficialis
223 Flexor hallucis brevis
222 Flexor hallucis longus
170 Flexor pollicis brevis
169 Flexor pollicis longus

20
G
205 Gastrocnemius
190 Gemellus inferior
189 Gemellus superior
32 Genioglossus
77 Geniohyoid [Geniohyoideus]
182 Gluteus maximus
183 Gluteus medius
184 Gluteus minimus
178 Gracilis

21
H
33 Hyoglossus

22
I
176 Iliacus
66 Iliocostalis cervicis
90 Iliocostalis lumborum
89 Iliocostalis thoracis
38 Inferior longitudinal (tongue) [Longitudinalis inferior]
41 Inferior pharyngeal constrictor [Constrictor pharyngis inferior]
84–87 Infrahyoids (see Sternothyroid, Thyrohyoid, Sternohyoid,
Omohyoid)
136 Infraspinatus
102 Intercostales externi
103 Intercostales interni
104 Intercostales intimi
219 Interossei, dorsal (foot) [Interossei dorsales]
164 Interossei, dorsal (hand) [Interossei dorsales]
165 Interossei, palmar or volar [Interossei palmares]
220 Interossei, plantar [Interossei plantares]
69 Interspinales cervicis
98 Interspinales lumborum
97 Interspinales thoracis
70 Intertransversarii cervicis
99 Intertransversarii thoracis and lumborum
121 Ischiocavernosus

23
L
52 Lateral cricoarytenoid [Cricoarytenoideus lateralis]
30 Lateral pterygoid [Pterygoideus lateralis]
130 Latissimus dorsi
17 Levator anguli oris
115 Levator ani (includes Puborectalis, Pubococcygeus, and Iliococcygeus)
15 Levator labii superioris
16 Levator labii superioris alaeque nasi
3 Levator palpebrae superioris
127 Levator scapulae
46 Levator veli palatini
107 Levatores costarum
60 Longissimus capitis
64 Longissimus cervicis
91 Longissimus thoracis
74 Longus capitis
79 Longus colli
218 Lumbricales (foot) [Lumbricals]
163 Lumbricales (hand) [Lumbricals]

24
M
28 Masseter
31 Medial pterygoid [Pterygoideus medialis]
21 Mentalis
42 Middle pharyngeal constrictor [Constrictor pharyngis medius]
94 Multifidi
48 Musculus uvulae
75 Mylohyoid [Mylohyoideus]

25
N
13 Nasalis

26
O
54 Oblique arytenoid [Arytenoideus obliquus]
59 Obliquus capitis inferior
58 Obliquus capitis superior
110 Obliquus externus abdominis
11 Obliquus inferior oculi
111 Obliquus internus abdominis
10 Obliquus superior oculi
188 Obturator externus [Obturatorius externus]
187 Obturator internus [Obturatorius internus]
1 Occipitofrontalis
87 Omohyoid [Omohyoideus]
161 Opponens digiti minimi
172 Opponens pollicis
4 Orbicularis oculi
25 Orbicularis oris

27
P
36 Palatoglossus
49 Palatopharyngeus
162 Palmaris brevis
152 Palmaris longus
177 Pectineus
131 Pectoralis major
129 Pectoralis minor
186 Piriformis
207 Plantaris
88 Platysma
51 Posterior cricoarytenoid [Cricoarytenoideus posterior]
12 Procerus
147 Pronator quadratus
146 Pronator teres
174 Psoas major
175 Psoas minor
114 Pyramidalis

28
Q
191 Quadratus femoris
100 Quadratus lumborum
217 Quadratus plantae
196–200 Quadriceps femoris (see Rectus femoris, Vastus
intermedius, Vastus medialis longus, Vastus medialis oblique,
Vastus lateralis)

29
R
113 Rectus abdominis
72 Rectus capitis anterior
73 Rectus capitis lateralis
56 Rectus capitis posterior major
57 Rectus capitis posterior minor
196 Rectus femoris
7 Rectus inferior
9 Rectus lateralis
8 Rectus medialis
6 Rectus superior
125 Rhomboid major [Rhomboideus major]
126 Rhomboid minor [Rhomboideus minor]
20 Risorius
71 Rotatores cervicis
96 Rotatores lumborum
95 Rotatores thoracis

30
S
45 Salpingopharyngeus
195 Sartorius
80 Scalenus anterior
81 Scalenus medius
82 Scalenus posterior
194 Semimembranosus
62 Semispinalis capitis
65 Semispinalis cervicis
93 Semispinalis thoracis
193 Semitendinosus
128 Serratus anterior
109 Serratus posterior inferior
108 Serratus posterior superior
206 Soleus
123 Sphincter ani externus
122 Sphincter urethrae
63 Spinalis capitis
68 Spinalis cervicis
92 Spinalis thoracis
61 Splenius capitis
67 Splenius cervicis
83 Sternocleidomastoid [Sternocleidomastoideus]
86 Sternohyoid [Sternohyoideus]
84 Sternothyroid [Sternothyroideus]
35 Styloglossus
76 Stylohyoid [Stylohyoideus]
44 Stylopharyngeus
132 Subclavius
105 Subcostales
134 Subscapularis
37 Superior longitudinal (tongue) [Longitudinalis superior]
43 Superior pharyngeal constrictor [Constrictor pharyngis
superior]
145 Supinator
75–78 Suprahyoids (see Mylohyoid, Stylohyoid, Geniohyoid,
Digastricus)
135 Supraspinatus

31
32
T
29 Temporalis
2 Temporoparietalis
185 Tensor fasciae latae
47 Tensor veli palatini
138 Teres major
137 Teres minor
55 Thyroarytenoid [Thyroarytenoideus]
85 Thyrohyoid [Thyrohyoideus]
203 Tibialis anterior
204 Tibialis posterior
39 Transverse lingual [Transversus linguae]
112 Transversus abdominis
22 Transversus menti
119 Transversus perinei profundus
118 Transversus perinei superficialis
106 Transversus thoracis
124 Trapezius
142 Triceps brachii

33
U
48 Uvula (see Musculus uvulae)

34
V
198 Vastus intermedius
197 Vastus lateralis
199 Vastus medialis longus
200 Vastus medialis oblique
40 Vertical lingual [Verticalis linguae]

35
Z
18 Zygomaticus major
19 Zygomaticus minor

36
Introduction
This 10th edition presents manual muscle testing within the context of strength testing. Classic
muscle testing is a fundamental skill of every physical therapist and is essential to the diagnosis and
assessment of movement impairments. However, as manual muscle testing has come under
scientific scrutiny, it is obvious that its use to evaluate and assess strength as a component of
functional movement patterns and tasks is inadequate. Therefore, in addition to the classic
presentation of manual muscle testing, this edition presents methods of strength testing that are
valid, objective, and applicable across various settings.
A number of noteworthy changes have been made in the new edition. First and foremost, it is a
modern 21st century text that has been thoroughly researched. Each test presented is backed by
evidence, and the utility of each muscle testing approach is presented in context with alternative
options. Throughout the text there are updated testing methods. Origins, insertions, and actions of
key muscles for each manual muscle test are now included and precede the description of most test
procedures. Additionally, for each specific muscle (e.g., serratus anterior, tibialis anterior), there are
exercises that the therapist can use to strengthen weak muscles in patients. Each recommended
exercise has been demonstrated, in most instances, to elicit at least 40% of maximum voluntary
strength. Thus exercises are sufficiently rigorous to induce genuine strength increases in patients.
Chapter 7 presents a variety of strength testing methods using common equipment. Although
this chapter was introduced in the previous edition, additional tests have been added to it and
modifications to other tests were made. Additional normative values have been included and
values for reliability, validity and specificity are now part of the text, when these values exist.
Chapter 8 describes functional tests that have a significant strength component. Age-based norms
are included when available, and patient scenarios are presented that provide the rationale for each
recommended approach to strength testing. Finally, there is a new Chapter 9 on handheld
dynamometry, an emerging technology that offers an additional means of distinguishing between
limbs that have subtle strength differences and an opportunity for more precise testing. Normative
values for handheld dynamometry have also been included when normative values exist. We
believe that you will find this a very different text from Edition 9 and a welcome addition to your
library.
Muscle strength is a critical component of functional movement. Assessment must include
accurate measurement of the quantity of strength within the context of functional tasks and
movement. Especially for the lower extremities, methods that allow the expansion of the findings of
manual muscle testing from an impairment to a function level are needed. Quantitative assessment
promotes accurate assessment of progress and patient performance within the context of age-based
normative values. Although few “hard numbers” of threshold strength levels exist for specific
functional movements, we have identified the known muscles that have been correlated with a
specific task and, in some cases, have suggested values that may serve as a target for the minimum
strength required for a specific functional task.
The manual muscle testing portion of this book, as in previous editions, directs its focus on
manual procedures. For the most part, joint motions (e.g., hip flexion) rather than individual
muscles (e.g., iliopsoas) are the focus of this text because of the contributions of more than one
muscle to a movement. Although prime movers of a movement can be identified, secondary or
accessory movers may be equally important and should not be overlooked or underestimated.
Rarely is a prime mover the only active muscle, and rarely is it used under isolated control for a
given movement. For example, knee extension is the prerogative of the five muscles of the
quadriceps femoris, yet none of these five extend the knee in isolation from its synergists.
Regardless, definitive activity of any muscle in a given movement can be precisely detected by
electromyography, and such studies, when they exist, are now included as important pieces of
evidence in this updated text.
Range of motion in this book is presented only to illustrate the range required to test a movement
correctly. A consensus of typical ranges is presented with each test, but the techniques of
measurement used are not within the scope of this text.

37
38
Brief History of Muscle Testing
Wilhelmine Wright and Robert W. Lovett, MD, Professor of Orthopedic Surgery at Harvard
University Medical School, were the originators of the muscle testing system that incorporated the
effect of gravity.1,2 Janet Merrill, PT, Director of Physical Therapeutics at Children's Hospital and the
Harvard Infantile Paralysis Commission in Boston, an early colleague of Dr. Lovett, stated that the
tests were used first by Wright in Lovett's office gymnasium in 1912.3 The seminal description of the
tests used largely today was written by Wright and published in 19121; this was followed by an
article by Lovett and Martin in 19164 and by Wright's book in 1928.5 Miss Wright was a precursor of
the physical therapist of today, there being no educational programs in physical therapy in her
time, but she headed Lovett's physical therapeutic clinic. Lovett credits her fully in his 1917 book,
Treatment of Infantile Paralysis,6 with developing the testing for polio. In Lovett's book, muscles were
tested using a resistance-gravity system and graded on a scale of 0 to 6. Another early numerical
scale in muscle testing was described by Charles L. Lowman, MD, founder and medical director of
Orthopedic Hospital, Los Angeles.7 Lowman's system (1927) covered the effects of gravity and the
full range of movement on all joints and was particularly helpful for assessing extreme weakness.
Lowman further described muscle testing procedures in the Physiotherapy Review in 1940.8
H.S. Stewart, a physician, published a description of muscle testing in 1925 that was very brief
and was not anatomically or procedurally consistent with what is done today.9 His descriptions
included a resistance-based grading system not substantially different from current use: maximal
resistance for a normal muscle, completion of the motion against gravity with no other resistance
for a grade of fair, and so forth. At about the time of Lowman's book, Arthur Legg, MD, and Janet
Merrill, PT, wrote a valuable small book on poliomyelitis in 1932. This book, which offered a
comprehensive system of muscle testing, was used extensively in physical therapy educational
programs during the early 1940s; muscles were graded on a scale of 0 to 5, and a plus or minus
designation was added to all grades except 1 and zero.10
Among the earliest clinicians to organize muscle testing and support such testing with sound and
documented kinesiologic procedures in the way they are used today were Henry and Florence
Kendall. Their earliest published documents on comprehensive manual muscle testing became
available in 1936 and 1938.11,12 The 1938 monograph on muscle testing was published and
distributed to all Army hospitals in the United States by the U.S. Public Health Service. Another
early contribution came from Signe Brunnström and Marjorie Dennen in 1931; their syllabus
described a system of grading movement rather than individual muscles as a modification of
Lovett's work with gravity and resistance.13
The first comprehensive text on muscle testing was written by Lucille Daniels, MA, PT; Marian
Williams, PhD, PT; and Catherine Worthingham, PhD, PT, published in 1946.14 These three authors
prepared a comprehensive handbook on the subject of manual testing procedures that was concise
and easy to use. It remains one of the most used texts the world over and is the predecessor for all
subsequent editions of Daniels and Worthingham's Muscle Testing including this edition.
The Kendalls (together and then Florence alone after Henry's death in 1979) developed and
published work on muscle testing and related subjects for more than 6 decades15-17 Their first edition
of Muscles: Testing and Function appeared in 1949.15 Earlier, the Kendalls had developed a
percentage system ranging from 0 to 100 to express muscle grades as a reflection of normal; they
reduced the emphasis on this scale, only to return to it in the latest edition (1993), in which Florence
again advocated the 0 to 10 scale.17 The contributions of the Kendalls should not be considered as
limited to grading scales, however. Their integration of muscle function with posture and pain in
two separate books15,16 and then in one book17 is a unique and extremely valuable contribution to the
clinical science of physical therapy.
Muscle testing procedures used in national field trials that examined the use of gamma globulin
in the prevention of paralytic poliomyelitis were described by Carmella Gonnella, Georgianna
Harmon, and Miriam Jacobs, all physical therapists.18 The later field trials for the Salk vaccine also
used muscle testing procedures.19 The epidemiology teams at the Centers for Disease Control were
charged with assessing the validity and reliability of the vaccine. Because there was no other
method of accurately “measuring” the presence or absence of muscular weakness, manual muscle
testing techniques were used.
A group from the D.T. Watson School of Physiatrics near Pittsburgh, which included Jesse

39
Wright, MD; Mary Elizabeth Kolb, PT; and Miriam Jacobs, PT, PhD, devised a test procedure that
eventually was used in the field trials.20 The test was an abridged version of the complete test
procedure but did test key muscles in each functional group and body part. It used numerical
values that were assigned grades, and each muscle or muscle group also had an arbitrary assigned
factor that corresponded (as closely as possible) to the bulk of the tissue. The bulk factor multiplied
by the test grade resulted in an “index of involvement” expressed as a ratio.
Before the trials, Kolb and Jacobs were sent to Atlanta to train physicians to conduct the muscle
tests, but it was decided that experienced physical therapists would be preferable to maintain the
reliability of the test scores.20 Lucy Blair, then the Poliomyelitis Consultant in the American Physical
Therapy Association, was asked by Catherine Worthingham of the National Foundation for
Infantile Paralysis to assemble a team of experienced physical therapists to conduct the muscle tests
for the field trials. Kolb and Jacobs trained a group of 67 therapists in the use of the abridged muscle
test.20 This work of determining the presence or absence of weakness and paralysis had enormous
impact on the eventual approval of the Salk vaccine. A partial list of participants was appended to
the Lilienfeld paper in the Physical Therapy Review in 1954.19

40
How to Use This Book
The general principles that govern manual muscle testing are described in Chapter 1. Chapter 2
describes the purposes and limitations of manual muscle testing, placing manual muscle testing in
the context of strength testing across settings. Chapters 3 through 7 present traditional and updated
techniques for testing motions of skeletal muscle groups in the body region covered by that chapter.
Chapter 4 reflects additional changes to practice through the expansion of the trunk muscle strength
testing section, particularly trunk endurance; the pelvic floor muscle testing section; and the
respiratory muscle section. Chapter 7 describes methods of strength testing using equipment and
instruments, and Chapter 8 is devoted to functional tests, which have become critical for successful
documentation. Students should learn manual muscle testing within the context of strength testing
to avoid some of the limitations described in Chapter 2. Chapter 9 is completely new and describes
manual testing using a handheld dynamometer and includes normative values where they exist.
Chapter 10 provides case studies to describe different methods of strength testing in various patient
populations and settings.
For instant access to anatomical information without carrying a large anatomy text to a muscle
testing session, see the Ready Reference Anatomy section on Evolve. This chapter is a synopsis of
muscle anatomy, muscles as part of motions, muscle innervations, and myotomes.
To assist readers, each muscle has been assigned an identification number based on a regional
sequence, beginning with the head and face and proceeding through the neck, thorax, abdomen,
perineum, upper extremity, and lower extremity. This reference number is retained throughout the
text for cross-referencing purposes. Two lists of muscles with their reference numbers are
presented, one alphabetical and one by region, to assist readers in finding muscles in the Ready
Reference section. These can also be found on the inside front and back covers of the book.

41
Names of the Muscles
Muscle names have conventions of usage. The most formal usage (and the correct form for many
journal manuscripts) is the terminology established by the Federative International Committee on
Anatomical Terminology (FCAT) in 1998. However, common usage often neglects these prescribed
names in favor of shorter or more readily pronounced names. The authors of this text make no
apologies for not keeping strictly to formal usage. Most of the muscles cited follow Terminologia
Anatomica. Others are listed by the names in most common use. The alphabetical list of muscles
(see the inside front cover of the book) gives the name used in this text and the correct Terminologia
Anatomica term, when it differs, in parentheses.

42
Anatomical Authorities
The authors of this book relied on both the American and British versions of Gray's Anatomy as
principal references for anatomical information, as well as Sabotta's Atlas of Human Anatomy.
Because proficiency in muscle testing can only be achieved if the practitioner has a thorough
understanding of anatomy, anatomical drawings are presented throughout the book, many in cross-
section format, and descriptions of origins and insertions and functions are provided in multiple
places, in detail and in abbreviated form.

43
The Convention of Arrows in the Text
Red arrows in the text denote the direction of movement of a body part, either actively by the
patient or passively by the examiner. The length and direction of the arrow indicates the relative
excursion of the part.

Black arrows in the text denote resistance by the examiner.

It is important to remind the reader that mastery of muscle testing, whether performed manually
or using a strength-testing device, requires substantial practice. The only way to acquire proficiency
in clinical evaluation procedures is to practice over and over again. As experience with patients
matures over time, the nuances that can never be fully described for the wide variety of patients
encountered by the clinician will become as much intuition as science. Muscle testing continues to
be among the most fundamental skills of the physical therapist and others who are concerned with
abnormalities of human motion. The skill of manual muscle testing is a critical clinical tool that
every physical therapist must not only learn but also master. A physical therapist who aspires to be
recognized as a master clinician will not achieve that status without acquiring exquisite skills in
manual muscle testing and precise assessment of muscle performance.

44
References
1. Wright WG. Muscle training in the treatment of infantile paralysis. Boston Med Surg J.
1912;167:567–574.
2. Lovett RW. Treatment of infantile paralysis. Preliminary report. JAMA. 1915;64:2118.
3. Merrill J. Personal letter to Lucille Daniels dated January 5. 1945.
4. Lovett RW, Martin EG. Certain aspects of infantile paralysis and a description of a method
of muscle testing. JAMA. 1916;66:729–733.
5. Wright WG. Muscle Function. Paul B. Hoeber: New York; 1928.
6. Lovett RW. Treatment of Infantile Paralysis. 2nd ed. Blakiston's Son & Co.: Philadelphia; 1917.
7. Lowman CL. A method of recording muscle tests. Am J Surg. 1927;3:586–591.
8. Lowman CL. Muscle strength testing. Physiotherap Rev. 1940;20:69–71.
9. Stewart HS. Physiotherapy: Theory and Clinical Application. Paul B. Hoeber: New York; 1925.
10. Legg AT, Merrill J. Physical therapy in infantile paralysis. W.F. Prior: Hagerstown, MD;
1932. Mock. Principles and Practice of Physical Therapy. Vol. 2.
11. Kendall HO. Some interesting observations about the after care of infantile paralysis
patients. J Excep Child. 1936;3:107.
12. Kendall HO, Kendall FP. Care During the Recovery Period of Paralytic Poliomyelitis. U.S. Public
Health Bulletin No. 242. U.S. Government Printing Office: Washington, D.C.; 1938.
13. Brunnstrom S, Dennen M. Round table on muscle testing. [New York: Annual Conference of
the American Physical Therapy Association, Federation of Crippled and Disabled, Inc.
(mimeographed)] 1931.
14. Daniels L, Williams M, Worthingham CA. Muscle Testing: Techniques of Manual Examination.
W.B. Saunders: Philadelphia; 1946.
15. Kendall HO, Kendall FP. Muscles: Testing and Function. Williams & Wilkins: Baltimore; 1949.
16. Kendall HO, Kendall FP. Posture and Pain. Williams & Wilkins: Baltimore; 1952.
17. Kendall FP, McCreary EK, Provance PG. Muscles: Testing and Function. 4th ed. Williams &
Wilkins: Baltimore; 1993.
18. Gonella C, Harmon G, Jacobs M. The role of the physical therapist in the gamma globulin
poliomyelitis prevention study. Phys Ther Rev. 1953;33:337–345.
19. Lilienfeld AM, Jacobs M, Willis M. Study of the reproducibility of muscle testing and certain
other aspects of muscle scoring. Phys Ther Rev. 1954;34:279–289.
20. Kolb ME. Personal communication. [October] 1993.

45
CHAPTER 1

46
Principles of Manual Muscle Testing

Grading System
Overview of Test Procedures
Criteria for Assigning a Muscle Test Grade
Screening Tests
Preparing for the Muscle Test
Exercises
Prime Movers
Summary

47
Muscle Test
Grading System
Grades for a manual muscle test are recorded as numeric ordinal scores ranging from zero (0),
which represents no discernable muscle activity, to five (5), which represents a maximal or best-
possible response or as great a response as can be evaluated by a manual muscle test. Because this
text is based on actions (e.g., elbow flexion) rather than tests of individual muscles (e.g., biceps
brachii), the grade represents the performance of all muscles contributing to that action.
The numeric 0 to 5 system of grading is the most commonly used muscle strength scoring
convention across health care professions. Each numeric grade (e.g., 4) can be paired with a word
grade (e.g., good) that describes the test performance in qualitative, but not quantitative, terms. (See
table.) Use of these qualitative terms is an outdated convention and is not encouraged because these
terms tend to misrepresent the strength of the tested action. For knee extension, forces that are less
than 50% of average and therefore not “normal” are often graded 5.1 Knee extension actions graded
as 4 may generate forces as low as 10% of maximal expected force, a level clearly not described
appropriately as “good.” For this reason, the qualitative terms have largely been removed from this
book. The numeric grades are based on several factors that will be addressed later in this chapter.
Numeric Score Qualitative Score
5 Normal (N)
4 Good (G)
3 Fair (F)
2 Poor (P)
1 Trace activity (T)
0 Zero (no activity) (0)

Overview of Test Procedures

Break Test
Manual resistance is applied to a limb or other body part after it has actively completed its test
range of motion against gravity. The term resistance is always used to denote a concentric force
provided by the tester that acts in opposition to contracting muscles. Manual resistance should
always be applied opposite to the muscle action of the participating muscle or muscles. The patient
is asked to hold the body segment at or near the end of the available range, or at the point in the
range where the muscle is most strongly challenged. At this point, the patient is instructed to not
allow the therapist to “break” the hold while the therapist applies manual resistance. For example, a
seated patient is asked to flex the elbow to its end range (Grade 3); when that position is reached,
the therapist applies resistance just proximal to the wrist, trying to “break” the muscle's hold and
thus allow the forearm to move downward into extension. This is called a break test, and it is the
procedure most commonly used in manual muscle testing nowadays. However, there are
alternatives to the break test for grading specific muscle actions.
As a recommended alternative procedure, the therapist may choose to place the muscle or muscle
group to be tested in the end or test position, after ensuring that the patient can complete the
available range (Grade 3), before applying additional resistance. In this procedure the therapist
ensures correct positioning and stabilization for the test.

Make Test
An alternative to the break test is the application of manual resistance against an actively
contracting muscle or muscle group (i.e., opposite the direction of the movement) that matches the
patient's resistance but does not overcome it. During the maximum contraction, the therapist
gradually, over approximately 3 seconds, increases the amount of manual resistance until it
matches the patient's maximal level. The make test is not as reliable as the break test, therefore
making the break test the preferred test.

Active Resistance Test

Resistance is applied opposite the actively contracting movement throughout the range, starting at
the fully lengthened position. The amount of resistance matches the patient's resistance but allows

48
the joint to move through the full range. This kind of manual muscle test requires considerable skill
and experience to perform and is not reliable; thus its use is not recommended as a testing
procedure but may be effective as a therapeutic exercise technique.

Application of Resistance
The principles of manual muscle testing presented here and in all published sources since 1921
follow the basic tenets of muscle length–tension relationships, as well as those of joint mechanics.2,3
In the case of the elbow flexion, for example, when the elbow is straight, the biceps are long but the
lever is short; leverage increases as the elbow flexes and becomes maximal at 90°, where it is most
efficient. However, as flexion continues beyond that point, the biceps are short and their lever arm
again decreases in length and efficiency.
In manual muscle testing, external force in the form of resistance is applied at the end of the
range or after backing off slightly from the end of range in the direction opposite the actively
contracting muscle. For some muscle actions (e.g., knee flexion), this backing off is considerable—to
the point that the primary muscles tested are at what may be considered mid-range. Two-joint
muscles are typically tested in mid-range where length-tension is more favorable. Ideally, all
muscles and muscle groups should be tested at optimal length-tension, but there are many
occasions in manual muscle testing where the therapist is not able to distinguish between Grades 5
and 4 without putting the patient at a mechanical disadvantage. Thus the one-joint brachialis,
gluteus medius, and quadriceps muscles are tested at end range and the two-joint hamstrings and
gastrocnemius muscles are tested in mid-range.
Critical to the accuracy of a manual muscle test are the location of the applied resistance and the
consistency of application across all patients. The placement of resistance is typically near the distal
end of the body segment to which the tested muscle attaches. There are exceptions to this rule. One
exception is when resistance cannot be provided effectively without moving to a more distal body
segment. In the case of shoulder and hip internal and external rotators, this involves applying
resistance through the hand placed on the distal forearm or lower leg. Another exception involves
patients with a shortened limb segment as in an amputation. Take for example a patient with a
transfemoral amputation. Even if the patient could hold against maximum resistance while
abducting the hip, the weight of the lower limb is so reduced and the therapist's lever arm for
resistance application is so short, that a grade of 5 cannot be assumed regardless of the resistance
applied. A patient holding against maximum resistance may still struggle with the force demands
of walking with a prosthesis. If a variation is used, the therapist should make a note of the
placement of resistance to ensure consistency in testing.
The application of manual resistance should never be sudden or uneven (jerky). The therapist
should apply resistance with full patient awareness and in a somewhat slow and gradual manner,
slightly exceeding the muscle's force as it builds over 2 to 3 seconds to achieve the maximum
tolerable intensity. Applying resistance that slightly exceeds the muscle's force generation will more
likely encourage a maximum effort and an accurate break test.
The therapist also should understand that the weight of the limb plus the influence of gravity is
part of the test response. Heavier limbs and longer limb segments put a higher demand on the
muscles that move them. Therefore lifting the lower limb against gravity can demand more than
20% of the “normal strength” of the hip muscles.4 In contrast, lifting the hand against gravity
requires less than 3% of the normal strength of the wrist muscles.4 When the muscle contracts in a
parallel direction to the line of gravity, it is noted as “gravity minimal.” It is suggested that the
commonly used term “gravity eliminated” be avoided because, of course, that can never occur
except in a zero-gravity environment.
Weakened muscles are tested in a plane horizontal to the direction of gravity with the body part
supported on a smooth, flat surface in such a way that friction force is minimal (Grades 2, 1, and 0).
A powder board may be used to minimize friction. For stronger muscles that can complete a full
range of motion in a direction against the pull of gravity (Grade 3), resistance is applied
perpendicular to the line of gravity (Grades 4 and 5). Acceptable variations to antigravity and
gravity-minimal positions are discussed in individual test sections.

Stabilization
Stabilization of the body or segment is crucial to assigning accurate muscle test grades. Patients for
whom stabilization is particularly important include those with weakness in stabilizing muscles

49
(e.g., scapular stabilizers) when testing the shoulder muscles and those who are particularly strong
in the tested muscle action.
Numerous muscles, some seemingly remote, can contribute as stabilizers to the performance of
tested muscle actions. However, muscle test performance is not meant to be dependent on muscles
other than the prime movers. To give an extreme example, shoulder abduction on the left side
should not be dependent on the trunk muscles on the right side. Therefore a patient with weak
trunk muscles and limited sitting balance should be supported and stabilized either through patient
positioning or by a stabilizing hand on the right shoulder.
A muscle or muscle group that is particularly strong may also require patient stabilization if the
full capacity of a muscle group is to be accurately tested.5 For example, a tester may not be able to
break the knee extension action of a patient who is allowed to rise off of a support surface during
the performance of a break test. However, the same patient, properly stabilized by the tester, an
assistant, or a belt during testing, may not be able to hold against maximum tester resistance and
thus break the muscle contraction, indicating that the patient has a muscle test grade of 4 rather
than 5.

Criteria for Assigning a Muscle Test Grade

The grade given on a manual muscle test comprises both subjective and objective factors. Subjective
factors include the therapist's impression of the amount of resistance given during the actual test
and then the amount of resistance the patient actually holds against during the test. Objective
factors include the ability of the patient to complete a full range of motion or to hold the test
position once placed there, the ability to move the part against gravity, or an inability to move the
part at all. All these factors require clinical judgment, which makes manual muscle testing a skill
that requires considerable practice and experience to master. An accurate test grade is important not
only to establish the presence of an impairment but also to assess the patient's longitudinal status
over time. Clinical reasoning is necessary for the therapist to determine the causes for the lack of
ability to complete the full range or hold the position, ascertain which is most applicable, and
decide whether manual muscle testing is appropriate.
Consistent with a typical orthopedic exam, the patient is first asked to perform the active