Clinical Reliability of Manual Muscle Testing

Middle Trapezius and Gluteus Medius Muscles

ETHEL FRESE,
MARYBETH BROWN,
and BARBARA J. NORTON

The purposes of this study were to develop a protocol to examine the reliability
of manual muscle testing in a clinical setting and to use that protocol to assess
the interrater reliability of manually testing the strength of the middle trapezius
and gluteus medius muscles. One hundred ten patients with various diagnoses
participated as subjects, and 11 physical therapists participated as examiners in
this study. The results showed that interrater reliability for right and left middle
trapezius and gluteus medius muscles was low. The percentage of therapists
obtaining a rating of the same grade or within one third of a grade ranged from
50% to 60% for the four muscles. This study indicates that using manual muscle
testing to make accurate clinical assessments of patient status is of questionable
value.
Key Words: Manual muscle testing, Muscle hypotonia, Physical therapy.

Manual muscle testing is an impor-
tant clinical tool used by physical ther-
apists to determine a patient's muscle
strength. Muscle testing originated in
the United States in the early 1900s
during the study of muscle function in
patients with poliomyelitis. Despite the
change in the role of manual muscle
testing with the end of the last polio-
myelitis epidemic in this country, it
remains an important clinical tool for
assessing the muscular causes of move-
ment dysfunction. Testing of muscles is
considered to be an essential prerequi-
site for treatment program planning and
modification. The results of manual
muscle testing also are used to make
clinical judgments concerning the pa-
tient's progress or deterioration, as well
as to assess the effectiveness of a partic-
ular treatment.
The study of the reliability of exam-
iners performing manual muscle tests is
Mrs. Frese is Instructor, Department of Physical
Therapy, St. Louis University, 1504 S Grand Blvd,
St. Louis, MO 63104 (USA). She was a master's
degree student, Program in Physical Therapy,
School of Medicine, Washington University, St.
Louis, MO, when this study was completed.
Dr. Brown is Instructor, Program in Physical
Therapy, PO Box 8083, School of Medicine, Wash-
ington University, 660 S Euclid Ave, St. Louis, MO
63110.
Mrs. Norton is Instructor, Program in Physical
Therapy, School of Medicine, Washington Univer-
sity.
This study was completed in partial fulfillment
of the requirements for Mrs. Frese's master's-degree,
Washington University.
This article was submitted April 14, 1986; was
with the authors for revision 10 weeks; and was
accepted August 27, 1986. Potential Conflict of In-
terest: 4.
necessary if the tests are to be used.
Manual muscle testing reliability in a
clinical setting has been studied mini-
mally. Lilienfeld et al found muscle test
grades from Zero to Normal assigned by
12 to 39 examiners in four different
trials to be within one grade, although
the testing method was controlled be-
cause the examiners were trained by the
same instructor.1 Iddings et al also found
manual muscle testing to be reliable
among 10 examiners whose ratings were
within one grade in 90.6% of the trials.2
All of the subjects in both of these stud-
ies had the diagnosis of poliomyelitis,
and the examiners were highly skilled in
manual muscle testing.
The reliability of manual muscle tests
has been the most difficult to achieve
for grades greater than Fair because of
the examiner's subjective judgment of
the amount of resistance applied during
the test. One of the problems central to
manual muscle testing is the variable
"frame of reference" for making an as-
sessment. Such subjective judgments in-
clude determining what is normal mus-
cle strength for an individual given the
person's age and size, in addition to the
relative strengths of the tester and pa-
tient.3-6
Many other factors influence the re-
producibility of a manual muscle test.
The testing method may vary among
therapists (eg, Kendall and McCreary7
vs Daniels and Worthingham8), both be-
cause the therapists' training may have
differed and because physical therapists
tend to develop their own techniques
and standards for grading muscle
strength. Other variables that influence
the accuracy of a muscle test are 1) the
point and line of force application, 2)
the magnitude of resistive force, 3) the
speed of resistive force application, 4)
the duration of the contraction, 5) the
degree of cooperation from the patient,
6) fatigue, 7) various distracting influ-
ences, 8) the type of instructions given,
9) the tone of the therapist's voice, and
10) the amount of interaction between
the therapist and patient.4,9-15
Beasley attempted to increase objec-
tivity in manual muscle testing by de-
veloping a standardized scale of norms
for muscle strength.16 Using an elec-
tronic myodynagraph, Beasley found a
discrepancy between the percentage of
Normal strength assigned in a manual
muscle test and the percentage of
strength found by a quantitative meas-
ure.16 The Good muscle strength group,
usually rated at 75% of Normal in the
manual muscle testing system,7 had only
43% of the Normal value on Beasley's
standardized scale. The Fair group had
a rating of only 9% of Normal, rather
than 50% of Normal usually assigned.
The Poor group, ordinarily rated at 25%
of Normal on the manual scale, had a
rating of only 2.6% of Normal on the
standardized scale. The standard devia-
tions showed considerable overlap in the
percentage of Normal scores in grades
below Fair, indicating poor differentia-
tion in grades below Fair, the range in
which manual muscle testing suppos-
edly is more accurate.16
The purposes of this study were to
develop a protocol to examine the reli-

1072 PHYSICAL THERAPY


ability of manually testing muscle
strength in a physical therapy depart-
ment and to use that protocol to assess
the interrater reliability for manually
testing the middle trapezius and gluteus
medius muscles. We chose the two mus-
cles indicated 1) because we wanted to
examine muscles from both the upper
and lower extremities and 2) because
the selected muscles are difficult to test
owing to the stabilization required by
other muscle groups during testing. In
addition, the two muscles selected for
study frequently are found to be weak
in patients. The hypothesis was that a
staff of physical therapists working to-
gether in a physical therapy department
would demonstrate interrater reliability
in testing the middle trapezius and glu-
teus medius muscles.
METHOD
Subjects
One hundred ten patients, who were
referred for physical therapy at St. Louis
University Hospital, participated in the
study. The patients had various muscu-
loskeletal and neurological disorders in-
cluding low back pain, degenerative
joint disease, cervical pain, gunshot
wound, chondromalacia, rheumatoid
arthritis, and connective tissue disease.
The patients had to exhibit sufficient
range of motion to allow the body part
to be placed in the test position and
either pain-free motion or pain that did
not interfere with the muscle test. The
test group consisted of 50 female and 60
male subjects, aged 15 to 76 years, with
a mean age of 41 years (± 15 years).
Examiners
Eleven staff physical therapists at St.
Louis University Hospital served as the
examiners. All examiners were gradu-
ates of accredited university programs.
Seven were graduates of the same uni-
versity, 2 others graduated from another
university, and the remaining 2 thera-
pists graduated from two other different
schools. The mean number of years of
experience of the staff members was 2.3
± 1.2 years. Eight of the therapists pre-
ferred the Kendall and McCreary mus-
cle testing technique,7 2 preferred that
of Daniels and Worthingham,8 and 1
used both.
Each therapist received a work sheet
with 10 spaces for 10 different patients.
Next to each space was the name of the
therapist with whom the examiner had
been paired randomly for that particular
Volume 67 / Number 7, July 1987
patient. A different therapist's name ap-
peared in each space so every examiner
was paired with 1 of 10 different thera-
pists. Each therapist also received a sec-
ond work sheet with 10 spaces to be
used for recording muscle grades of an-
other therapist's patient when her name
appeared on that therapist's list for that
patient. Each examiner then selected 10
patients to be included in the study. The
Appendix gives the muscle testing scale
and definitions that all of the therapists
used.
Testing Procedures
Manual muscle testing was performed
during the patient's daily treatment ses-
sion. A rest period of at least three min-
utes was allowed between the two ex-
aminers' tests and the two therapists
kept their results confidential. The ex-
aminers used a "break" test, and for the
gluteus medius muscle test, the patient's
hip was placed in as much extension as
possible.
Testing Sequence
The testing sequence involved the fol-
lowing steps:
1. The examiner first identified a pa-
tient suitable for the study.
2. The examiner performed the middle
trapezius and gluteus medius muscle
tests bilaterally. The side and muscle
to be tested first was assigned ran-
domly before the beginning of the
test phase. The examiner used her
accustomed technique of muscle test-
ing to determine the appropriate
grade and repeated the test several
times, if needed, to assign a grade.
She then recorded the grades in the
appropriate space on her work sheet.
3. A second therapist, who had been
paired randomly with her for that
patient, then performed the same
two muscle tests in the same order,
but using her own testing technique.
The second therapist also repeated
the test several times, if necessary, to
determine a grade. She then recorded
the grades on her work sheet.
Data Analysis
Cohen's weighted Kappa (Kw) deter-
mination17 was used as an index of
agreement for interrater reliability. This
index weighs disagreements by the
amount of disagreement. A weight ma-
trix (Tab. 1) was designed for the scores
RESEARCH
obtained in the study and gave the ratio-
scaled degrees of disagreement assigned
to each cell. Each cell in the matrix
represents one score for each examiner.
For example, the cell for Normal-Nor-
mal had a weight value of 1.0, the cell
for Good-Normal was 0.7, and the cell
for Poor minus-Normal was 0.0.
To determine whether eliminating the
pluses and minuses would improve the
reliability coefficient, we compressed
the original scores into afive-pointscale.
Pluses and minuses were assigned the
same score as the main grade (eg, Fair
plus and Fair minus became Fair), and
a weight matrix was designed for these
scores.
The muscle test scores of every patient
whom Therapist 1 examined were com-
pared with the scores of each of the other
10 therapists with whom she was paired.
An interrater reliability coefficient then
was computed for Therapist 1. This
process was repeated for each therapist
so that an interrater reliability coeffi-
cient was computed for all 11 exam-
iners. By doing so, we wanted to deter-
mine whether any particular therapist
appeared to be less reliable compared
with the other 10, and whether the
school the therapist graduated from or
her years of experience were factors af-
fecting reliability.
RESULTS
Table 2 summarizes the percentages
of the total number of subjects on which
the examiners agreed, in addition to per-
centages of agreement within several
ranges of disparity (ie, fractions of grades
they were apart). The percentage of sub-
jects on whom the same grade was ob-
tained by two examiners ranged from
28% to 45% for the four muscles, and
for 89% to 92% of the subjects we found
either complete agreement or agreement
within one grade.
The percentage of patients who were
rated Fair plus or above by one or both
examiners was 88% for the right middle
trapezius muscle, 90% for the left mid-
dle trapezius muscle, 91% for the right
gluteus medius muscle, and 95% for the
left gluteus medius muscle. One or both
examiners assigned a grade of Normal
in 50% of the tests for the right middle
trapezius muscle, in 44% of the tests for
the left middle trapezius muscle, in 67%
of the tests for the right gluteus medius
muscle, and in 70% of tests for the left
gluteus medius muscle.
Table 3 gives the interrater reliability
coefficients for both the original and the
1073
compressed muscle testing scores. The TABLE 1
reliability for the original scores was low, Weight Matrix for Original Scoresa
ranging from .11 to .58. Compressing
the scores did not change the interrater Muscle Test Muscle Test Scores for Examiner 2
reliability coefficient appreciably (.26- Scores for
Examiner 1 P- P P+ F- F F+ G- G G+ N- N
.42). Even for grades below Fair, we
found poor interrater reliability. P- 1.0 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0.0
P 0.9 1.0 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1
Table 4 summarizes the results of P+ 0.8 0.9 1.0 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2
comparing each of the examiners with F- 0.7 0.8 0.9 1.0 0.9 0.8 0.7 0.6 0.5 0.4 0.3
every other examiner for each test. Re- F 0.6 0.7 0.8 0.9 1.0 0.9 0.8 0.7 0.6 0.5 0.4
liability coefficients ranged from .04 to F+ 0.5 0.6 0.7 0.8 0.9 1.0 0.9 0.8 0.7 0.6 0.5
.66 with no pattern of high reliability G- 0.4 0.5 0.6 0.7 0.8 0.9 1.0 0.9 0.8 0.7 0.6
being established by any one therapist. G 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 0.9 0.8 0.7
G+ 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 0.9 0.8
Those therapists with more clinical ex-
N- 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 0.9
perience did not demonstrate any N 0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0
greater level of reliability than those who a
had graduated more recently. The Eleven possible scores ranging from P - to N.
school from which the therapist gradu-
ated did not appear to affect reliability TABLE 2
because those therapists who graduated Percentage of Agreement Among Scores for Subjectsa
from the same university did not dem-
onstrate any greater reliability among Musclesb
each other than the therapists who grad- Grade RMT LMT RGM LGM
uated from different schools. Therapist
3 demonstrated low reliability coeffi- n % n % n '% n %
cients on all four tests (.08-. 19). Same grade 31 28 32 29 52 47 50 45
1/3 grade apart 24 22 27 25 11 10 17 15
2/3 grade apart 19 17 23 21 24 22 15 14
DISCUSSION 1 grade apart 25 23 15 14 14 13 16 15
1 1/3 grades apart 6 5 8 7 4 4 7 6
Using Cohen's weighted Kappa deter- 1 2/3 grades apart 5 5 4 4 1 1 5 5
mination, we found interrater reliability Within 1 grade apart 68 62 65 60 49 45 48 44
for manually testing the strength of mid- Same grade or within 1
dle trapezius and gluteus medius mus- grade 99 90 97 89 101 92 98 89
cles in a clinical setting to be poor. When a
Each grade was divided into thirds with the use of pluses and minuses; therefore, the
the results were expressed as percentages difference between 2 and 2+ was considered 1/3, the difference between 2 - and 2+ was
of agreement, however, they were simi- 2/3, and the difference between 2 and 3 was one grade.
lar to the findings of Lilienfeld et al1 and b
RMT-right middle trapezius, LMT-left middle trapezius, RGM-right gluteus medius, LGM-
Iddings et al2 who reported good relia- left gluteus medius.
bility within one grade among experi-
enced examiners (more experienced
TABLE 3
than those in our study). The results
Interrater Reliability of Original and Compressed Scores
(28%-47% agreement) did not agree
with those of Williams,10 who found that Musclesa
two examiners agreed completely be- Conditions RMT LMT RGM LGM
tween 60% and 75% of the time. The N
examiners in our study agreed more fre- Kwb Kw Kw Kw
quently on the gluteal muscle tests than Original 110 .58 .29 .25 .11
on the middle trapezius muscle tests for Compressed 110 .26 .26 .30 .42
reasons we could not determine. We a
RMT-right middle trapezius, LMT-left middle trapezius, RGM-right gluteus medius, LGM-
also found poor interrater reliability in left gluteus medius.
grades below Fair, which agrees with b
Kw = weighted Kappa coefficient.
Beasley's16 finding of poor differentia-
tion in grades below Fair.
The distribution of the scores might strating an accurate measure of agree-
Compressing the scores by eliminat- have affected the reliability or agree- ment. Because we established the crite-
ing pluses and minuses did not appre- ment coefficient. Because the majority rion of pain not interfering with the
ciably change the interrater reliability of the subjects' scores were Fair plus or muscle test, some of the weaker patients
coefficients. The coefficient for the right greater for all of the muscles (88%-95%), may have been excluded from the study.
middle trapezius muscle decreased, pos- the scores were not well distributed One procedural problem that could
sibly because the interval widened be- across all possible muscle grades. This have affected our results was the diffi-
tween grades with pluses and minuses skewed distribution might have reduced culty of positioning some of the patients
when they were compressed (eg, Fair spuriously the magnitude of the Kappa for a particular test. Different therapists
plus-Good minus was changed to Fair- coefficient. A broader range of scores adjusted the procedure differently to
Good). should improve the chances of demon- solve the problem.

1074 PHYSICAL THERAPY

 RESEARCH
progress or deterioration, therefore,
TABLE 4
would be questionable despite reliability
Interrater Reliability Among Therapists
within one grade.
Musclesa Manual muscle testing is an inexpen-
Therapist RMT LMT RGM LGM sive, relatively quick, and convenient
b
method for assessing a patient's muscle
Kw Kw Kw Kw strength. In view of the results of this
1 .22 .15 .31 .58 study, however, physical therapists
2 .21 .52 .34 .55 should consider supplementing their
3 .19 .16 .08 .13 manual muscle test scores with isoki-
4 .06 .33 .52 .44 netic testing, dynamometry, or tensiom-
5 .42 .25 .48 .38
etry. Griffin et al compared the results
6 .28 .30 .26 .34
7 .42 .63 .50 .29 of manual muscle testing with isokinetic
8 .15 .47 .66 .37 testing for knee extensor muscles in pa-
9 .37 .46 .25 .29 tients with neuromuscular disease and
10 .14 .28 .56 .49 found that a lack of strength improve-
11 .62 .04 .20 .11 ment or a decrease in strength was dem-
a onstrated by both manual muscle testing
RMT-right middle trapezius, LMT-left middle trapezius, RGM-right gluteus medius, LGM-
left gluteus medius.
and isokinetic testing.18 They also
b
Kw = weighted Kappa coefficient. found, however, that in patients with a
manual muscle test score of 9 to 10
(Normal minus-Normal), isokinetic
APPENDIX testing revealed either muscle strength
Muscle Testing Scale and Definitions* deficits or improvement not detectable
with manual muscle testing methods.
Normal (5) able to hold the test against gravity and maximum They concluded that isokinetic testing
resistance, or to move the part into the test adds valuable information when pa-
position and hold against gravity and maximum tients have manual muscle test scores of
pressure
Normal. Bohannan found a significant
Normal minus (5-) same as for Normal except slightly less resistance
can be given
reliability correlation between manual
Good plus (4+) same as for Good but slightly more resistance muscle test scores and dynamometer
can be given test scores for knee extensor muscles,
Good (4) same as for Normal except able to hold against which indicated that both testing meth-
moderate resistance ods measure muscle strength similarly.19
Good minus (4-) same as for Good but slightly less resistance can He found a significant difference, how-
be given ever, between theoretical percentage
Fair plus (3+) able to hold the test position against gravity, or to manual muscle test scores and calcu-
move the part into the test position and hold lated dynamometer percentage test
against gravity and slight resistance
scores, which indicated that theoretical
Fair (3) able to hold the test position against gravity, or to
move the part into the test position and hold
percentage scores based on manual mus-
against gravity cle testing are likely to overestimate a
Fair minus (3-) able to release gradually from the test position patient's muscle strength. Supplement-
against gravity, or to move the part toward the ing manual muscle test scores with iso-
test position against gravity almost through full kinetic testing, dynamometry, or ten-
range siometry would decrease the subjectivity
Poor plus (2+) able to move the part through full range with in assessing a patient's disability.
gravity eliminated, but against slight resistance
Poor (2) able to move the part through full range with Further study is needed in this area
gravity eliminated with each therapist being paired more
Poor minus (2-) able to move the part through partial range with than twice with another therapist. One
gravity eliminated potential study might incorporate sev-
Trace (1) muscle contraction can be palpated eral staff in-service training sessions be-
Zero (0) no contraction can be elicited fore the start of testing to help standard-
a
Adapted from Kendall and McCreary7 and Daniels and Worthingham.8 ize the muscle testing techniques among
the staff members as much as possible.
Reliability then could be reassessed to
The patients' age did not appear to be clinical value, especially when consid- determine whether any improvement is
a factor in the low interrater reliability ering the differences between Poor and noted. Garraway et al were able to in-
coefficients because the scores for the Fair, or Fair and Good, versus the dif- crease the proportion of examinations
youngest and the oldest subjects in the ference between Good and Normal. The for stroke assessment, which included
study were not consistently any farther interval between each of these pairs of motor function, in which total agree-
apart than those of the subjects in the grades is one grade, although the thera- ment was reached from 41% to 68%
middle age range. pists' subjective judgments of patient after standardizing definitions, discus-
Achieving reliability within one function may have been quite different. sion and interpretation of instructions
grade, as in this study, has questionable The accuracy of assessments of patient by the examiners, and practice.20

Volume 67 / Number 7, July 1987 1075

CONCLUSIONS
The results of this study do not sup-
port the research hypothesis that staff
physical therapists can perform manual
muscle tests reliably in a clinical setting.
The results do demonstrate that the
therapists are reliable within one grade;
however, this degree of reproducibility
1. Lilienfeld AM, Jacobs M, Willis M: A study of
the reproducibility of muscle testing and certain
other aspects of muscle scoring. Phys Ther
Rev 34:279-289, 1954
2. Iddings DM, Smith LK, Spencer WA: Muscle
testing: Part 2. Reliability in clinical use. Phys
Ther Rev 41:249-256, 1961
3. Molnar GE, Alexander J, Grutfield N: Reliability
of quantitative strength measurements in chil-
dren. Arch Phys Med Rehabil 60:218-221,
1979
4. Editorial: The accuracy of the manual muscle
test. Arch Phys Med Rehabil 35:515-517,
1954
5. Bechtol CO: Grip test: The use of a dynamom-
eter with adjustable hand spacing. J Bone Joint
Surg [Am] 36:820-824, 1954
6. Nicholas JA, Sapega A, Kraus H, et al: Factors
influencing manual muscle tests in physical
therapy. J Bone Joint Surg [Am] 60:186-190,
1978
7. Kendall FP, McCreary EK: Muscles: Testing
and Function, ed 3. Baltimore, MD, Williams &
Wilkins, 1983
1076
may not be adequate for making clinical
judgments. Supplementing muscle test
scores with isokinetic testing, dyna-
mometry, or tensiometry is suggested.
The development of a standardized
method of muscle testing is needed so
that different examiners can obtain
comparable results in a clinical setting.
Standardizing the resistance given in
REFERENCES
8. Daniels L, Worthingham C: Muscle Testing:
Techniques of Manual Examination, ed 4. Phil-
adelphia, PA, W B Saunders Co, 1980
9. Smidt GL, Rogers MW: Factors contributing to
the regulation and clinical assessment of mus-
cular strength. Phys Ther 62:1283-1290, 1982
10. Williams M: Manual muscle testing: Develop-
ment and current use. Phys Ther Rev 36:797-
805,1956
11. Wintz MN: Variations in current manual muscle
testing. Phys Ther Rev 39:466-475, 1959
12. Johannson CA, Kent BE, Shepard KF: Rela-
tionship between verbal command volume and
magnitude of muscle contraction. Phys Ther
63:1260-1265,1983
13. Westers BM: Factors influencing strength test-
ing and exercise prescription. Physiotherapy
68:42-44, 1982
14. Gonnella C, Harmon G, Jacobs M: The role of
the physical therapist in the gamma globulin
poliomyelitis prevention study. Phys Ther Rev
33:337-345, 1953
grades of Good and Normal so that
subjective judgment is minimized is an
area in which further study is needed.
Acknowledgments. We thank the
physical therapy staff of St. Louis Uni-
versity Hospital for their cooperation
and Carolyn Heriza for her advice in
planning the study.
15. Trombly CA: Occupational Therapy for Physi-
cal Dysfunction, ed 2. Baltimore, MD, Williams
& Wilkins, 1982, pp 173-229
16. Beasley WC: Quantitative muscle testing: Prin-
ciples and applications to research and clinical
services. Arch Phys Med Rehabil 42:398-425,
1961
17. Cohen J: Weighted Kappa: Nominal scale
agreement and provision for scaled disagree-
ment or partial credit. Psychol Bull 70:213-
220,1968
18. Griffin JW, McClure MH, Bertorini TE: Sequen-
tial isokinetic and manual muscle testing in
patients with neuromuscular disease. Phys
Ther 66:32-35, 1986
19. Bohannan RW: Manual muscle test scores and
dynamometer test scores of knee extension
strength. Arch Phys Med Rehabil 67:390-392,
1986
20. Garraway WM, Akhtar AJ, Gore SM, et al:
Observer variation in the clinical assessment
of stroke. Age Ageing 5:233-240, 1976
PHYSICAL THERAPY