MUSCLE STRENGTH TESTING

Lecture Notes

Muscle Strength

Muscle strength testing is an important component of the physical exam that can reveal
information about neurologic deficits. It is used to evaluate weakness and can be
effective in differentiating true weakness from imbalance or poor endurance. 

The function of muscle strength testing is to evaluate the complaint of weakness, often
when there is a suspected neurologic disease. It is an integral part of the neurologic
exam, especially for patients with stroke, brain injury, spinal cord injury, neuropathy,
amyotrophic lateral sclerosis, and a host of other neurologic problems.

Assessing the patient’s ability to flex or extend the extremities against resistance
tests muscle strength. Clinicians use a 5-point scale to rate muscle strength. The
most commonly accepted method of evaluating muscle strength is the Medical Research
Council Manual Muscle Testing scale. 

GRADE MUSCLE RESPONSE

5 full power of contraction against gravity and resistance or normal muscle strength
_ _
_ _ _
_ 4 _ fair but not full strength against gravity and a moderate amount of resistance or slight
_
_ _ weakness
_ 3 5 just sufficient strength to overcome the force of gravity or moderate weakness
_ 2 ability to move but not to overcome the force of gravity or severe weakness
_ 1 _ minimal contractile power (weak muscle contraction can be palpated but no movement is
_
_ _ _ noted) or very severe weakness
_ _ 0 no movement
_ _
_
__ _ A stick figure may be used to record muscle strength and is a
__ _ precise form of documenting findings. Distal and proximal
_
_
strength in both upper and lower extremities is recorded using
_ the 5-point scale. Assessment of muscle strength may be as
_ detailed as necessary. One may quickly test the strength of the
_ proximal muscles of the upper and lower extremities, always
_ comparing both sides. The strength of the finer muscles that
_ control the function of the hand (hand grasp) and the foot
(dorsiflexion and plantar flexion) can then be assessed.
Proper technique must be employed during testing to ensure valid results. Tight or
restrictive clothing should be removed so that the examiner can visualize the muscles
being tested and observe for muscle twitch. The unaffected or less affected side should
be tested first to gauge contralateral strength for comparison; all four limbs should be
tested for completeness and to help guide the differential diagnosis based on patterns of
weakness, such as upper extremity only, lower extremity only, or proximal muscles
rather than distal.
 Procedure Nerve and nerve roots
1. Identify the patient. Introduce yourself.
2. Perform hand hygiene. Don disposable gloves, if necessary.
3. CHECK for factors interfering with communication, ability to respond and
other injuries.
4. Assess upper extremities.
Ask the patient to do the following:
A. Hold out his arms straight and try to bend his fingers as he maintains Radial nerve, C7
the position.
B. Keep his fingers together as you pull them apart. Ulnar nerve, T1
C. Spread his fingers apart as you push them together. Radial & ulnar nerve C7,
T1
D. Turn hands, palm facing upward, and instruct him to touch the base of Median nerve, T1
the small finger using his thumb.
E. Make a fist as you try to put his wrists down. Radial nerve, C6
F. Flex arms upward and try to pull your arms out. Musculocutaneous nerve,
C5, C6
G. In the same position, exert force to the patient’s arms and instruct to Radial nerve, C7
resist it.
H. Raise his arms sideward with his elbows flexed then try to put force by Axillary nerve, C5
pushing it down.
5. Assess lower extremities.
Ask the patient to do the following:
A. Raise your leg and not to put it down and resist the force you exert. Femoral nerve, L3
B. Slightly bend his knees and put force to totally bend his knees as the Femoral nerve, L3, L4
patient resists it.
C. In the same position, put force to straighten his legs as the patient Sciatic nerve, S1
resists the force exerted.
D. Push knees out and resist the force exerted as you push them together. Sup. Gluteal nerve, L4, L5
E. Push knees together and resist the force exerted as you pull them away Obturator nerve, L2-L4
from each other.
F. Bend foot up towards the face, try to push it down. Deep Peroneal nerve, L5
G. Bend toes up towards the face, try to push it down. Deep Peroneal nerve, L4,
L5
H. Push foot down the floor and try to push it up. Tibial nerve S1, S2
6. Ensure patient safety. Remove gloves and perform hand hygiene.
7. Make the necessary documentation.

Assessing muscle strength for unconscious patients.

Upper Extremity Strength
Conscious individual Have the patient hold arms out
horizontally, palms up, with eyes
closed.  If there is upper limb
weakness, the affected side will
"drift" or pronate within 30
seconds.
Lower Extremity Strength
 With the patient lying in a supine
position, bend the knees to 30
degrees.  If there is weakness in
the lower extremities, the
affected leg will drift downward
within 30 seconds.
 With patient in supine position,
flex both knees and support
under one of examiners arms. 
 Allow one heel to rest on the
bed.  Extend the other leg at the
knee and allow it to drop gently
to the bed.  Compare the speed
of drop for both legs.

Unconscious individual Lift both patient's arms together.  Position patient supine. Flex the
While protecting the limbs from knees with both feet on the
injury, release both arms bed. Release the knees
together.  A paralysed arm will fall simultaneously. A paralysed leg
more rapidly. will fall to an extended position
and the hip will rotate externally. 
The normal leg will stay flexed for
a few seconds and gradually
assume the previous position.