WK 2: Tests & Measures — Goni & MMT

based off goni & MMT lectures!

What is a one joint muscle?

A muscle that only crosses 1 joint

(ex. brachialis, gluteus maximus, soleus)

What is a 2 joint muscle?

A muscle that crosses 2 joints

(ex. biceps brachii, quadriceps, hamstrings)

What is a multi-articular muscle?

A muscle that crosses more than 2 joints

(ex. flexor digitorum profundus)

What is muscle strength?

The maximum amount of tension that a muscle or muscle group can voluntary exert in one maximal effort

What is muscle torque?

The tendency of a *force to turn a lever around an axis of rotation

*Force could be gravity, muscle tension, or an external resistance

What are the 3 primary types of contractions?

Name them & define them

1. Isometric = tension occurs in the muscle, but no movement occurs & the muscle length doesn’t change

2. Isotonic = muscle develop constant tension against a load or force w/ movement occurring & muscle length changing

3. Isokinetic = muscle contracts at a constant rate of movement (velocity/same speed)

What are the 2 types of isotonic contractions?
Name them & define them

1. Concentric = tension develops in the muscle as it shortens; origin & insertion come closer together as muscle contracts

2. Eccentric = tension develops in the muscle as it lengthens; origin & insertion move further apart

What is muscle endurance?

The ability of a muscle/muscle group to perform repeated contractions against a resistance OR maintain an isometric contraction for a period of time

What is muscle fatigue?

Diminish response of the muscle to generate force

What are the 4 causes of muscle fatigue?

1. Lack of energy stores or oxygen

2. Decrease in conduction impulses at myoneural junction

3. Protective inhibitory influences from the CNS

4. Overwork

What is overwork?

A phenomenon that causes temporary or permanent loss in strength in an already weakened muscle

1. What does it mean when a muscle is “fully lengthened”?

2. What does it mean when a muscle is “midway”?

3. What does it mean when a muscle is “fully shortened”?

1. Full stretch to halfway through the full range

2. Halfway through the full range to fully shortened

3. Spans from midpoint to end range

What is the prime mover or agonist muscle?

Muscle/muscle group that makes major contribution to the movement at the joint

(ex. during a bicep curl, the biceps brachii is the prime mover)

What is a synergist?

Muscle/muscle group that works with agonist to produce desired effect

(ex. during a bicep curl, the brachialis is the synergist)

What is an antagonist?

Muscle/muscle group that has an opposite action to the agonist; it may relax to allow movement or contract concurrently to control/slow movement

(ex. during a bicep curl, the triceps brachii is the agonist)

What are the 10 factors that affect strength?

1. Age — strengths peaks in your 20s

2. Gender

3. Muscle size

4. Speed of muscle contraction — slow & controlled + going through full ROM = max muscle gains

5. Type of contraction — concentric, eccentric, isometric

6. Diurnal variation — strength follows a regular daily cycle, so you should attempt to test/retest MMT at the same time of day

7. Temperature — warmer muscles generate way more force

8. Previous training effect — familiarity of test situation + enhanced neuromuscular recruitment may occur

9. Fatigue — strength ↓ as muscle fatigues

10. Other: motivation, pain, UE/LE dominance, body type

How does joint position affect muscle strength?

• Changes the angle of pull = change in joint position changes the distance between the axis of rotation (fulcrum), the muscle force, & the torque

• Length-tension relationship = muscles can contract w/ greater force when in mid-range

What are the three main criteria used to determine a patient's Manual Muscle Testing (MMT) grade?

1. Evidence of a muscle contraction (whether you can see or feel the muscle working)

2. Ability to move against gravity (whether the limb moves up against gravity or needs a gravity-minimized position)

3. Amount of manual resistance (how much pushing force from the clinician the muscle can hold against)

What are the clinical criteria for an MMT grade of 5/5 (Normal)?

The patient can complete full available range of motion (ROM) against gravity and hold the position against strong manual resistance applied by the examiner

How is an MMT grade of 4+/5 (Good plus) defined?

The muscle can complete full available range of motion against gravity and yield only to nearly strong (mod-max) resistance.

What is the criterion for an MMT grade of 4/5 (Good)?

The muscle moves the joint through full available range of motion against gravity and holds against moderate manual resistance.

What is considered a 4-/5 (Good minus) as an MMT grade?

The muscle achieves full available ROM against gravity, but can only withstand nearly moderate (min-mod) manual resistance before breaking

What is the criteria for an MMT grade of 3+/5 (Fair plus)?

The muscle completes full available range of motion against gravity and can hold against only slight manual resistance.

What performance defines an MMT grade of 3/5 (Fair)?

The muscle moves the body part through its full available range of motion against gravity, but gives way immediately if any manual resistance is added.

What performance characterizes an MMT grade of 3-/5 (Fair minus)?

The muscle moves the joint against gravity through at least 50% of the range, but cannot reach full range of motion, and cannot tolerate manual resistance.

What criteria define an MMT grade of 2+/5 (Poor plus)?

The muscle moves through full available range of motion in a gravity-minimized (gravity-eliminated) position and can hold against slight manual resistance.

What criteria defines an MMT grade of 2/5 (Poor)?

The muscle achieves full available range of motion in a gravity-minimized position with no added manual resistance.

What performance leads to an MMT grade of 2-/5 (Poor minus)?

The muscle moves through at least 50% of the ROM in a gravity-minimized position, but cannot achieve full range.

What characterizes an MMT grade of 1+/5 (Trace plus)?

Minimal observable joint movement (less than 50% ROM) in a gravity-minimized position with no added resistance.

How do you identify an MMT grade of 1/5 (Trace)?

There is no visible movement at the joint, but you can feel (palpate) or see a faint muscle contraction or tendon flicker.

What defines an MMT grade of 0/5 (Zero)?

Completely absent muscle activity, no observable movement and no palpably detectable muscle contraction.

What is the difference between testing in an against-gravity position vs. a gravity-minimized position?

• Against-gravity position = requires lifting the body part straight up against the earth's pull (used for testing grades 3 to 5) + applying resistance

• Gravity-minimized position = limb is positioned parallel to the ground (ex. supported on a table) so gravity doesn't resist the motion (used for weak muscles, grades 0 to 2) + no resistance applied

How does the length-tension relationship affect muscle strength during testing?

Muscles generate maximum contractile force when tested at their mid-range length because the sarcomeres (actin and myosin cross-bridges) have optimal overlap

What is the optimal angle of muscle pull for generating maximum joint movement torque?

90 degrees relative to the lever arm (bony segment)

• At 90 degrees, 100\% of the muscle force produces rotational force (torque) around the joint axis

Why is isometric MMT typically performed in the mid-range (halfway point) of a joint's motion?

This position combines optimal muscle length-tension with favorable muscle pull angle, allowing the muscle to demonstrate peak force output

What are the 4 contraindication to MMT?

1. if test will disrupt tissue healing

2. post-cardiac surgeries w/ sternal precautions

3. severe, acute pain

4. acute inflammation

What are the 4 precautions to MMT?

1. following neurosurgery

2. following abdominal, eye, or IVD pathology

3. hernias

4. when overwork/severe fatigue is a concern

With a pt who has sternal precautions ('Move in the Tube'), what 4 upper body movements are not allowed?

1. No shoulder horizontal abduction

2. No excessive shoulder extension

3. No shoulder elevation above 90 degrees

4. No pushing/pulling heavy loads

*these stress and pull apart the healing sternum

Case Scenario: A patient 6 weeks post rotator cuff repair flexes their shoulder to 90 degrees against gravity, but the arm breaks immediately when resistance is applied. What is the MMT grade?

3/5 (Fair)

pt moved through full available range of motion against gravity, but could not hold against any added manual resistance

During shoulder flexion MMT (w/ gravity), where should the clinician place their stabilizing hand?

Proximal to the joint, over the ipsilateral shoulder girdle (clavicle and scapula) to prevent shoulder shrugging or trunk compensation

What 2 compensatory movements might a patient use during shoulder flexion (w/ gravity) MMT?

1. Scapular elevation (shoulder shrugging using upper trapezius)

2. Leaning the trunk backward (using spinal extension/momentum to lift the arm)

*shows weakness of anterior deltoid

Case Scenario: A patient recovering from an incomplete spinal cord injury attempts gravity minimized hip flexion. No visible leg movement occurs, but you feel a slight flicker in the quadriceps. What grade is present?

1/5 (Trace)

There is palpable muscle activity without actual joint movement.

Why is identifying a Grade 1/5 (Trace) muscle contraction clinically significant in spinal cord injury recovery?

It proves that motor nerve pathways across the spinal lesion are intact or re-innervating (they’re working!), showing active neurological recovery rather than complete motor paralysis

If a patient achieves Grade 1/5 in sitting for hip flexion, what test position should be tried next to evaluate gravity-minimized active movement?

Side-lying position with the upper leg supported, allowing hip flexion without having to lift the weight of the leg against gravity

Case Scenario: During hip abduction MMT, the patient rotates their pelvis backward and flexes the hip while lifting the leg. Is this test valid?

No, because the pt substituted w/ the tensor fasciae latae (TFL) and hip flexors instead of isolating the gluteus medius

How should a clinician correct improper substitution during hip abduction MMT?

Reposition the leg into slight extension with neutral rotation, firmly stabilize the pelvis to block pelvic rotation, and instruct the patient to lift straight up towards the ceiling

How should a therapist explain to a patient why their movement effort was corrected during strength testing?

1. Explain clearly that while they are moving their limb, extra muscles are helping out

2. The goal of the test is to isolate the specific target muscle so treatment can focus on strengthening the exact spot that needs help

Are standard 0-5 numerical MMT grades recorded during a quick myotome screen?

No; myotomes are documented as Intact (normal nerve drive) or Impaired/Weak, rather than assigning MMT grades

Knowledge Question: A patient completes full shoulder abduction against gravity, but breaks under manual resistance. What MMT grade is assigned?

3/5 (Fair)

Moving through full range against gravity without tolerating manual resistance is the definition of Grade 3

Knowledge Question: A PT evaluation records a patient's hip abduction MMT as 2/5. What position was the patient placed in for this grade?

Supine position

a gravity-minimized position where the leg slides outward on the treatment table

“Pt lying prone raising arm up into shoulder extension”

What muscle motion + muscles are being tested here, and what initial baseline grade is achieved if the patient completes full ROM against gravity?

• Shoulder Extension against gravity

  • Testing posterior deltoid, latissimus dorsi, and teres major

• 3/5 = movement occurs through full available ROM against gravity before applying resistance

“Pt experiencing patellar knee pain during squatting and step descent”

A patient reports pain below the kneecap when coming down stairs. What prime mover muscle group is involved, and what muscle contraction phase causes difficulty during stair descent?

• Prime Mover = Quadriceps

• Contraction Phase = Eccentric contraction

Descending stairs requires the quadriceps to actively lengthen under load to lower the body weight smoothly

Clinical Application: If a patient scores 5/5 on an IE for quadriceps MMT but still struggles controlling step descent during therapy, why might this occur?

Traditional MMT observes static isometric strength in sitting, whereas stair descent requires dynamic eccentric control

1. What is the correct position for against gravity wrist extension MMT?

2. What direction of manual force do you apply through the wrist to test the strength of the extensors for against gravity wrist extension MMT?

1. Forearm fully resting pronated on the surface with hand extended over the edge

2. Towards the floor (into flexion)

How do muscle muscle contraction types compare in their ability to generate maximal tension force?

• Eccentric generates the highest force potential

• Isometric generates moderate force potential

• Concentric generates the lowest force potential

Eccentric > Isometric > Concentric

Define the four ranges of muscle work shown in this picture

1. Full range = from fully lengthened to fully shortened position

2. Outer range = from fully lengthened to midpoint of ROM

3. Inner range = from midpoint of ROM to fully shortened

4. Middle range = central point of range, spanning across the midpoint

How do intra-tester and inter-tester reliability compare in MMT?

Intra-tester reliability (same examiner re-testing) is higher than inter-tester reliability (different examiners testing)

What major factor limits the maximum strength grade (5/5) a clinician can measure during MMT?

The clinician's own physical strength; the pt may be stronger than you!

What is the difference between individual muscle testing and group muscle testing?

• Individual Muscle Testing = Isolates a specific muscle

• Group Muscle Testing = Tests multiple muscles that share the same joint action together (e.g., testing all wrist flexors)

Where should stabilization hand force be placed during an MMT?

Near the proximal origin of the muscle/joint being tested to prevent compensation and provide a firm anchor

Where should manual resistance hand force be placed during an MMT?

Just distal to the tested joint, taking care never to cross two joints with resistance hand placement

What is the break test procedure, and how long must resistance be held?

1. Joint is placed in mid-range

2. Manual pressure is applied gradually (minimum, moderate, to maximum) until the muscle breaks hold

pressure must be held for 3 to 5 seconds

Why do patients perform muscle substitutions or compensations during MMT?

When a target muscle is weak, neighboring strong muscles recruit to achieve joint motion, often without the patient realizing it

What are four common body compensations to watch for during strength evaluation?

"1. Shoulder shrugging (upper trapezius compensation).

What 9 pieces of information can an examiner gather by assessing Active Range of Motion (AROM)?

1. Patient willingness to move

2. Level of consciousness

3. Ability to follow instructions

4. Attention span

5. Coordination

6. Joint range of motion (ROM)

7. Pain provocation

8. Ability to perform functional activities

9. Muscle strength

What is meant by the term 'end feel' in joint motion assessment?

Resistance or sensation transmitted to the therapist's hands at the extreme limit of passive range of motion (PROM), indicating which anatomical structure (bone, muscle, ligament, or capsule) limits further movement

What is a normal 'hard' end feel, and what is a classic anatomical example?

Painless, abrupt stop occurring when bone contacts bone

ex. elbow extension; olecranon process contacts the olecranon fossa

What is a normal 'soft' end feel, and what is a classic anatomical example?

Yielding compression felt when two soft body surfaces press together (soft tissue approximation)

ex. elbow flexion; bicep muscle belly compresses against the forearm

What is a normal 'firm' end feel, and what structures produce it?

Firm or springy sensation with slight give produced by the tension of stretched muscles, ligaments, or joint capsules

*think of stretching leather or the max stretch of a TB

What characterizes an abnormal 'hard' end feel, and what clinical conditions cause it?

An abrupt hard stop or bony grating sensation occurring before the expected end range or in a joint that normally does not have a hard stop

• causes = degenerative joint disease (DJD), fracture, or joint dislocation

What is an abnormal 'soft-boggy' end feel, and what does it indicate clinically?

Mushy, squishy sensation felt during passive movement

• indicates the presence of intra-articular fluid, such as joint effusion, synovitis, or tissue edema

What is an abnormal 'firm' end feel, and what tissue changes cause it?

A hard arrest to movement with slight give occurring earlier in the range than normal

• indicates pathological shortening or tightness of muscles, joint capsule, or ligaments

What is an abnormal 'springy block' end feel, and what mechanical pathology causes it?

A distinct rebound effect seen or felt at the limit of movement

• Indicates internal derangement within the joint, such as a torn meniscus or loose cartilage body blocking complete joint clearance

What is an abnormal 'empty' end feel?

Pt stops passive movement due to severe pain before the therapist feels any physical mechanical resistance or tissue restriction

ex. acute bursitis or severe joint inflammation

What is an abnormal 'spasm' end feel?

A sudden, involuntary muscular stop to passive movement, frequently accompanied by pain

• often linked to acute tissue injury or underlying neurological conditions

What is a joint capsule?

A fibrous, pouch-like envelope found on synovial joints that encloses the joint cavity, providing passive stability while containing synovial fluid

What is a 'capsular pattern' of restriction?

When does it occur? Where does it occur?

A pattern of passive range of motion (PROM) restriction specific to a joint

• occurs when the entire joint capsule is inflamed, adherent, or tight

• happens in joints that rely on muscular control rather than pure ligamentous support

What are the 4 key features of a close-packed position & clinically, when is it used?

1. Maximum congruity

2. Relative compression/approximation

3. maximal joint stability

4. maximal tautness of major ligaments (no further motion available in that direction)

used to assess the structural integrity of ligaments and the joint capsule

What are the key features of a joint's loose-packed position & clinically, when is it used?

1. least congruity

2. joint surface distraction

3. minimal stability

4. slackened ligaments

this position is ideal for performing manual joint mobilization techniques

What are the 4 contradictions to testing ROM?

1. Suspected joint subluxation or dislocation

2. Acute fracture

3. disruption to healing tissues

4. Presence of myositis ossificans (bone forming inside muscle or soft tissue) or ectopic ossification (bone forming where it shouldn’t)

What are the 4 precautions to ROM testing?

1. pain

2. osteoporosis (fragile bone structure)

3. Hypermobile joints

4. prolonged immobilization

What is hypomobility, and what are its 3 causes?

A reduction in normal joint movement compared to established norms or the contralateral healthy joint

• Causes:

  • mild muscle shortening

  • structural contractures

  • connective tissue diseases such as Scleroderma (hardening/thickening of CT) or Dupuytren's contracture

What is a contracture?

Adaptive shortening of soft tissues that surround or cross a joint (skin, fascia, muscle, capsule), resulting in significant resistance to active or passive stretch & limited ROM

• Described by the motion/action of the shortened muscle (ex. elbow fraction contraction)

What is a myostatic contracture?

Muscle shortening without specific tissue pathology

What is a pseudomyostatic contracture?

A limitation in ROM caused by central nervous system hypertonicity (muscle spasticity or rigidity)

What is an arthrogenic or periarticular contracture?

Intra-articular structural pathology (synovial adhesions, chronic joint inflammation osteophyte formation) leading to limited ROM

What is a fibrotic (irreversible) contracture, and how does it differ from other contracture types?

Permanent, non-reversible loss of soft tissue extensibility due to extensive fibrotic changes and scar tissue replacing normal tissue, making it non-correctable even with surgical or conservative stretching

What is hypermobility? What’s the difference between generalized and localized hypermobility?

Joint ROM exceeding normal standard limits or in comparison to the contralateral side

• Generalized hypermobility = multiple joints; often congenital, as in Ehlers-Danlos Syndrome

• Localized hypermobility = one joint as a compensatory reaction to stiffness in an adjacent joint

What is the Beighton score, and what are the diagnostic cutoff scores for hypermobility?

A 9-point screening tool used to assess generalized joint laxity

What 4 primary factors dictate joint stability?

1. Joint integrity

2. Elastic energy

3. Passive stiffness

4. Muscle activation

Why is the hip joint structurally more stable than the glenohumeral joint?

Hip joint is a ball-and-socket joint w/ a deep bony socket (acetabulum) vs. the GH joint has a shallow glenoid cavity that offers minimal articular containment

What is passive stiffness in the context of joint stability?

Resistance generated by the resting tension of muscles and fascial layers surrounding a joint; increases naturally as a joint approaches its end ROM

How does dynamic muscle activation contribute to joint stability?

Increases active stiffness in the muscles & the joint it crosses.

• Timing and magnitude of agonist, antagonist, & synergist contractions are important for proper joint function

What is the difference between joint instability and joint hypermobility?

• Joint instability = functional loss and is typically symptomatic

• Hypermobility = excessive movement range, predisposes to instability but is often asymptomatic

What is articular joint instability?

Abnormal patterns of coupled & translatory movement (ex. uneven wear & tear of meniscus)

What is ligamentous joint instability?

Instability that can lead to multiple planes of abnormal motion (ex. chronic ankle sprains)

Why do physical therapists test ROM in both standard and functional positions?

• Standard positioning = gravity can assist movement to assess maximum available structural ROM

• Functional positioning = movement against gravity, helping the clinician evaluate if muscle weakness contributes to limited ROM

What is goniometry, and how do intra-tester and inter-tester reliability compare?

The clinical measurement of joint angles using a goniometer

• Intra-tester reliability = same examiner performing repeat measurements is higher than

• inter-tester reliability = different examiners taking measurements

Intra-tester is more reliable than inter-tester

What is the acceptable degree difference for inter-tester reliability (different clinicians) in goniometric measurements?

3-5 degrees

What are the 3 components of a universal goniometer?

1. axis

2. stationary arm

3. moving arm