Knee and Ankle Manual Muscle Testing

Knee flexion

Muscles: Hamstring, popliteus

Grade 4 & 5: Resistance is applied to posterior ankle.

Grade 3: Prone, knee extended. "Bend your knee.”

Grade 2: Side-lying, lower leg flexed. Examiner cradles test limb. “Bend your knee.”

Grade 1: Prone, limb slightly flexed. Palpate medial and lateral hamstring tendons just above the knee.

Substitution for knee flexion

If biceps femoris is stronger than medial hamstrings, leg will externally rotate during knee flexion.

If semitendinosus and semimembranosus are stronger, leg will internally rotate during knee flexion.

Lateral biceps - biceps femoris

Prone, knee flexed and slight external rotation

Examiner is standing on the opposite side and stabilizes the test pelvis

Weakness: Unable to hold the position

Medial hamstring test - semi muscles

Prone, knee flexed and slight internal rotation

Examiner is standing on the opposite side and stabilizes the test pelvis

Weakness: Unable to hold the position

Popliteus

Sitting with knee flexed and lateral rotation of tibia on femur (foot pointing outwards).

Patient does medial rotation of tibia of femur

• Weakness of popliteus or gastroc. may interfere with initiating knee flexion

• Substitution of sartorius by hip flexion as knee flexion occurs

Knee extension

Muscle: Quadriceps femoris

Grade 4 & 5: Resistance is applied to anterior ankle.

Grade 3: Short sitting, knee flexed. Examiner places hand/towel under thigh. "Lift your lower leg to straighten your leg.”

Grade 2: Side-lying, lower and test leg flexed. Examiner cradles test limb. “Straighten your knee.”

Grade 1: Supine. Examiner places hand underneath limb and palpates quadriceps tendon, just above knee. “Back your knee back into the table.”

Ankle plantarflexion

Muscles: Gastrocnemius, soleus, tibialis posterior, plantaris, peroneus longus & brevis, flexor digitorum longus, flexor halluces longus

Examiner demonstrates heel raise. “Raise your heels and go on your tiptoes and come down. Do this 25 times without stopping. You can use two fingers to hold onto the bed.”

Grade 5: Completes a minimum of 25 heel raises without rest and fatigue.

Grade 4: Completes 24-10 without rest and fatigue.

Grade 3: Completes 9-1 without rest or fatigue.

Grade 2: Prone with feet off the end of the table. “Point your toes down.”

Grade 1: Prone with feet of the table. Palpate at Achilles tendon, “Point your toes down.”

• Both - Achilles tendon

• Gastrocnemius - midcalf with thumb and fingers on either side of midline above soleus

• Soleus - posterior lateral surface of distal calf

Soleus

Examiner demonstrates heel raise with knee slightly flexed. “Raise your heels and go on your tiptoes and come down. Do this 20 times.”

Grade 5: Completes a minimum of 20 heel raises without rest and fatigue.

Grade 4: Completes 19-10 without rest and fatigue.

Grade 3: Completes 9-1 without rest or fatigue.

Grade 2: Prone with knee flexed to 90°. “Point your toes up to the ceiling.”

Grade 1: Prone with feet of the table. Palpate at posterior lateral surface of distal calf.

Dorsiflexion & inversion

Muscles: Tibialis anterior, peroneus tertius, extensor digitorum longus, extensor halluces longus

Grade 4 & 5: The examiner is seated next to foot, holding posterior ankle. Resistance is applied in the direction of version and planterflexion.

Grade 3: Short sitting. “Bring your foot up and in.”

Grade 2: Supine, foot extended off the end of the bed. Stabilize posterior ankle. “Bring your foot up and in.”

Grade 1: Supine, palpate tibialis anterior on anterolateral aspect of tibia.

Subtalar inversion

Muscles: Tibialis anterior, tibialis posterior, flexor digitorum longus, flexor halluces longus, soleus, extensor hallucis longus

Grade 4 & 5: Resistance is applied over medial foot, in direction of eversion.

Grade 3: Side-lying on test side with ankle slightly plantarflexed, foot off the table. Stabilize anteromedial aspect of tibia. “Bring your foot in.”

Grade 2: Supine, with foot off the bed. Stabilize the anteromedial aspect. “Bring your foot in.”

Grade 1: Supine, palpate tibialis posterior directly distal and posterior to medial malleolus.

Subtalar eversion

Muscles: Peroneus longus, peroneus brevis

Grade 4 & 5: Resistance is applied over lateral foot, in direction of inversion.

Grade 3: Side-lying on test side with ankle neutral, foot off the table. Stabilize under leg (tibial side). “Bring your foot out.”

Grade 2: Supine, with foot off the bed. Stabilize the leg. “Bring your foot out.”

Grade 1: Supine, palpate tendon of peroneus longus and brevis just posterior to lateral mallelolus.

Hallux and toe MP flexion

Muscles: Lumbricals, flexor hallucis brevis

Grade 4 & 5: Resistance is applied under the big toe and the rest of the toes.

Grade 3: Seated or supine, ankle neutral. If patient is seated, foot rests on the thigh of the examiner. Examiner stabilizes metatarsals. Hallux brevis: “Curl your big in.” + Lumbricals: “Curl your toes in.”

Lumbricals and flexor hallucis brevis are not palpable.

MP extension

Muscles: Extensor digitorum longus, extensor digitorum brevis

Grade 4 & 5: Resistance is applied on top of the big toe and the rest of the toes.

Grade 3: Seated or supine, ankle neutral. If patient is seated, foot rests on the thigh of the examiner. Examiner stabilizes metatarsals. Hallux brevis: “Extend your toes out.” + Lumbricals: “Extend your toes out.”

Lumbricals and flexor hallucis brevis are not palpable.

IP flexion

Muscles: Flexor digitorum longus, flexor digitorum brevis, flexor hallucis longus

Grade 4 & 5: Resistance is applied under the big toe and the rest of the toes.

Grade 3: Seated or supine, ankle neutral. If patient is seated, foot rests on the thigh of the examiner. Examiner stabilizes metatarsals and proximal phalanges. “Curl your big in.” + Curl your toes in.”

IP extension of big toe
Muscle: Extensor hallucis longus

Grade 4 & 5: Resistance is applied over the big toe.

Grade 3: Seated or supine, ankle neutral. If patient is seated, foot rests on the thigh of the examiner. Examiner stabilizes metatarsals and proximal phalanges. “Extend your big toe.”