MANUAL MUSCLE TEST

(MMT)
• Understanding the Kendall muscle
• Understanding the Kendall muscle
classification is one of the most important
classification
requirements isto one of the
conduct the most important
manual muscle
requirements
test to conduct the manual muscle
test
 Class I
• One-joint muscles
• exhibit the maximal strength when it
maximally shortened (maximus strength will
be at the end range). 
ex = deltoid, pec major, glut max, iliopsoas,
and soleus
 Class II
Two-joint and multipoint muscles that act like one-
joint

ex = sartorius, tib anterior and posterior, peroneus longus,

brevis, , tertius and all scapular muscles
 Class III
• Two-joint muscles that shorten over one-joint
and lengthen over the other to provide
maximal contraction and strength 
(maximum strength will be at the midrange )
Ex = rectus femoris, hamstrings, and gastrocs
MANUAL MUSCLE TEST FOR SCAPULAR MUSCLES •
 Movements

• Elevation

• Depression
 Movements

• Abduction (protraction)

• Adduction (retraction)
 Movements

• Upward rotation

• Downward rotation
Movements
 Elevation
Shoulder
Girdle
Movements
Abduction
Adduction

Rot
atio
Upw n
Ro nw

ard
Do
tati ard
w
on

Depression
COMBINED SHOULDER AND SCAPULAR
MUSCLES
SCAPULAR ELEVATION
• 1. Trapezius (upper fibers)
• 2. Levator scapulae 
•  
Trapezius (upper fibers)
• 1) Origin:
• - External occipital protuberance
• - superior nuchal line
• - Ligamentum nuchae
• - Spinous process of seventh cervical vertebra
• 2) Insertion:
• - Lateral 1/3 of clavicle
• - Acromion process of scapula
• 3) Action:
• - The trapezius upper fibers elevate the scapula.
• - With the insertion fixed and acting: unilaterally, the upper fibers extend
laterally flex and rotate the head and joints of the cervical vertebrae so that the face
turn toward the opposite side.
• - With the insertions fixed and acting: bilaterally the upper trapezium extends
the head and neck.
•  
• Levator Scapulae:
• 1) Origin: Transverse processes of first four
cervical vertebrae.
• 2) Insertion: Medial border of scapula between
superior angle and root of spine.
• 3) Action:
• - With the origin fixed, elevates the scapula and
assists in rotation, so that the glenoid cavity
faces caudally.
• - With the insertion fixed and acting
unilaterally, it rotates and flexed the cervical
vertebrae to the same side
• - Acting bilaterally, the levator scapulae may
assist in extension of the cervical spine.
• Range of motion:
• With full range of motion the shoulder is
brought up with a distance of approximately 3
fingers separating it with the ear inferior lobe.
Gravity-Resisted Test (Grades 5, 4, and 3)

Command: "Pull your shoulders upward as

much as you can
Gravity-Eliminated Test (Grades Below 3)
Stabilization is
unnecessary with this test.
Palpate upper trapezius
near its insertion on the
clavicle
• Individual muscle test for upper fiber of
trapizus
UPPER TRAPEZIUS
• Apply resistance
simultaneously over
superior aspect of
acromion in an inferior
direction and over
posterior aspect of
occiput in the direction
of anterior and
contralateral neck flexion
• Individual muscle of levator scapulae ?
• Individual muscle test for levator scapulae

the levator muscle is more likely a scapular

elevator when elevation occurs with the
scapula in a downward rotation position, as in
shrugging the shoulder when the hand is
behind the body
 Lower trapizus muscle
SCAPULAR DEPRESSION AND ADDUCTION
• Trapezius (lower fibers)
• 1) Origin: Spinous processes of sixth through
twelfth thoracic vertebrae.
• 2) Insertion: Apex of spine of scapula

• 3) Action:
• - The trapezius lower fibres mainly depress
the scapula.

• upward rotation of the scapula (in

conjunction with the superior fibers)
Test procedures
 Stabilize with one hand over
posterior aspect of opposite
thorax

Apply resistance over lateral aspect of scapula

in direction of scapular abduction and
elevation.

Command: "Pull your arm slightly up and pull your scapula down and in
• . Palpate lower trapezius between root of
scapular spine and spinous processes of lower
thoracic vertebrae (

Instructions to Patient: "Try to lift your arm from the table past your
ear."
 Trapezius (middle fibers)
scapular adduction
• 1) Origin: Spinous processes of first
through fifth thoracic vertebrae.
• 2) Insertion: Superior lip of spine of
scapula.
• 3) Nerve Supply: Accessory ventral
ramus: C2, C3, C4.
• 4) Action:
• - The trapezius middle fibers are
mainly responsible for the scapula
adduction.
• Range of Motion:
• From the abduction position to the adduction
position, the scapula travels a distance
equivalent to the space formed by 3 to 4
fingers.
Gravity-Resisted Test (Grades 5, 4, and 3)

Stabilize with one hand over opposite thora

prevent trunk rotation.

Apply resistance over lateral aspect of scapula

in direction of scapular abduction
Command: Raise your arm up (in horizontal abduction) and adduct the
scapula
 Gravity-Eliminated Test (Grades Below 3)

Command: "Pull your arm slightly

backward and bring your scapula back
and in --

Seated with shoulder abducted to 90° and in full lateral rotation, elbow
slightly flexed. Upper extremity should be supported on a firm, smooth
surface. Talcum powder and a cloth may be placed between limb and
supporting surface to reduce friction

Lateral rotation of the humerus is critical during this test in order to achieve
maximum activation of the middle trapezius muscle
• SCAPULAR ADDUCTION AND DOWNWARD
ROTATION
RHOMBOID MAJOR AND MINOR
• 1) Origin:
• * Major: Spinous processes of second through
fifth thoracic vertebrae.
• * Minor:
• - Spinous processes of seventh cervical and
first thoracic vertebrae.
• 2) Insertion:
• - Major: By fibrous attachment to medial
border of scapula between the spine and inferior
angle.
• - Minor: Medial border at root of spine of
scapula.
• 3) Nerve supply: Dorsal scapular nerve: C4, C5.
• 4) Action:
• Adduct and elevate the scapula, and rotate it
so that the glenoid cavity faces caudally.
• Range of Motion
• The range of motion is similar in distance as
for the adduction of scapula.
 Gravity-Resisted Test (Grades 5, 4, and 3)
Patient Starting Position: Prone lying with affected arm medially
rotated and adducted across back and shoulders relaxed

Stabilize with one hand over contralateral

thorax

Apply resistance on vertebral border of scapula

in direction of scapular abduction and upward
rotation.

Command: Pull your arm up and bring your scapula down and in
 Gravity-Eliminated Test (Grades Below 3)

Seated with arm to be tested behind back.

Shoulder in medial rotation and adduction so
dorsum of hand is in contact with ipsilateral
gluteal region.

Stabilize over ipsilateral shoulder girdle to

prevent trunk rotation while palpating
rhomboids between vertebral border of scapula
and spinous processes of C7 to T5

Instructions to Patient: "Try to move your hand

away from your back."
 RHOMBOIDS
SCAPULAR ADDUCTION AND DOWNWARD ROTATION

The fingertips of one hand palpate the muscle under the vertebral border
of the scapula.
• Weakness: The scapula abducts and the inferior angle
rotates outward. The strength of adduction and extension
of the humerus is diminished by loss of rhomboid fixation of the
scapula.
• Ordinary function of the arm is affected less by loss of the rhomboid
strength than by loss of either trapezius or serratus anterior strength.

• Shortness: The scapula is drawn into a position of adduction and

elevation. Shortness tends to accompany
paralysis or weakness of the serratus anterior, because
the rhomboids are direct opponents of the serratus.
 COMMON SUBSTITUTION

• 1. Tipping of scapula anteriorly; occurs via

contraction of pectoralis minor muscle and
can be detected by movement of humeral
head toward examining table.
• 2. Rotation of trunk toward side being tested;
can be controlled by careful stabilization of
thorax.
• Substitution by Middle Trapezius
• The middle fibers of the trapezius can
substitute for the adduction component of the
rhomboids. The middle trapezius cannot,
however, substitute for the downward rotation
component. When substitution occurs, the
patient's scapula will adduct with no downward
rotation (no glenoid down occurs). Only
palpation can detect this substitution for sure.
SERRATUS ANTERIOR
SCAPULAR ABDUCTION AND UPWARD ROTATION
•
Origin: Outer surfaces and superior borders of the upper eight
or nine ribs.
Insertion: Costal surface of the medial border of the
scapula.
Action: With the origin fixed, abducts the scapula, rotates the
inferior angle laterally and the glenoid cavity cranially, and
holds the medial border of the scapula firmly against the rib
cage.
• In addition, the lower fibers may depress the scapula, and the
upper fibers may elevate it slightly.

• Starting from a position with the humerus fixed in

flexion and the hands against a wall), the serratus acts to
displace the thorax posteriorly as the effort is made to push
the body away from the wall.
SERRATUS ANTERIOR
SCAPULAR ABDUCTION AND UPWARD
ROTATION
• The serratus always should be tested in
shoulder flexion to minimize the synergy with
the trapezius.
 Gravity-Resisted Test (Grades 5, 4, and 3)
Therapist position and grasp:
Therapist is standing sideway
beside the treatment table at
the level of the patient's head.
The arm of the patient is in
front of him. The proximal
hand grasps around the
patient's elbow and the distal
hand grasps around the
patient's wrist and forearm

Command: Push your arm in front of you as if you want to reach the ceiling
 Gravity-Eliminated Test (Grades Below 3)

Patient Starting Position: Sitting with arm flexed at 90° and arm resting on a table.
2.Therapist Position and Grasps: Therapist stands behind the patient and stabilizes the
thorax with. Proximal hand placed over the shoulder.
3.Command: "Push your arm forward sliding it on the table
 Grade 1 and palpation
• Support the patient's arm at the elbow,
maintaining it above 90° .
• Use the other hand to palpate the serratus with
the tips of the fingers just in front of the inferior
angle along the axillary border (
 Alternative test
Patient raises arm to approximately 130° of flexion
with the elbow extended. (Examiner is reminded
that the arm can be elevated up to 60° without
using the serratus.) The scapula should upwardly
rotate (glenoid facing up) and abduct without
winging

Instructions to Patient: "Raise your arm forward

over your head. Keep your elbow straight; hold it!
Don't let me push your arm down."
 Grading
Grade 5 (Normal):
Scapula maintains its abducted and rotated position against
maximal resistance given on the arm just above the elbow in a
downward direction.
Grade 4 (Good):
Scapular muscles "give" or "yield“ against maximal resistance
given on the arm. The glenohumeral joint is held rigidly in the
presence of a strong deltoid, but the serratus yields, and the
scapula moves in the direction of adduction and downward
rotation.
Grade 3 (Fair)
Scapula moves through full range of motion without winging
but can tolerate no resistance other than the weight of the arm.
• For Grade 2 Patient performs shoulder flexion
and upward rotation of scapula through
partial ROM against no resistance.
• For Grade 1 No motion, but a palpable
contraction is present..
• For Grade 0 No motion or contraction is
present.
• Range of Motion:
• In general the abduction displacement of the
scapula is approximately equivalent to the
space of 2 to 4 fingers.
•
• Effect of Weakness of the Serratus Anterior
Muscle
• The main sign of weakness of the serratus
anterior muscle will be the winging of the
scapula. A subject with a paralyses serratus
muscle will not be able to raise the arm
overhead.
S T A N D I N G TEST
Medial winging due to serratus anterior weakness
during resisted shoulder flexion. With serratus anterior weakness,
the scapula wings medially during shoulder flexion when
upward rotation of the scapula is required.
Patient with a lesion of the long thoracic nerve and
paresis of the left serratus anterior.
 Scapular winging
• Two types based on direction of top-medial
corner of scapula
• medial winging serratus anterior (long thoracic
nerve)
• lateral winging ( trapezius (CN XI - spinal
accessory nerve)
 Medial Winging
• Introduction
• caused by deficit in serratus anterior  due to injury to the long thoracic
nerve (C5,6,7

physical exam    
•superior medial scapula elevates and migrates medial       
      
 Lateral Winging
•caused by deficit in trapezius due to spinal accessory nerve injury (CNXI)     

• Physical examsuperior medial scapula drops

downward and lateral
– shoulder girdle appears depressed or drooping
Pectoralis minor
• WEAKNESS OF THE PECTORALIS MINOR
Weakness may contribute to difficulty in
controlling the shoulder girdle, particularly during
upper extremity weightbearing activities such as
crutch walking. It may also decrease the stability of
the scapula during activities requiring downward
rotation of the scapulothoracic joint, since
weakness of the pectoralis minor disrupts the force
couple for scapular downward rotation.
• TIGHTNESS OF THE PECTORALIS MINOR
Tightness of the pectoralis minor will pull the scapula into an
anterior tilt . Additionally tightness of the pectoralis minor
may, with the other muscles of its force couple, contribute to
the “rounded shoulder” posture. Individuals with shortened
pectoralis minor muscles exhibit less posterior tilting and
more internal rotation of the scapula during shoulder
elevation . The alterations in scapular motions during
shoulder elevations reported in individuals with shortened
pectoralis minor muscles may increase the risk of
impingement syndromes in these individuals
Tightness of the pectoralis minor. Tightness of the
pectoralis minor muscle pulls the scapula into an anterior tilt. In
supine the shoulder with tightness looks more forward than the
opposite side.
• Summary
SCAPULAR DYSKINESIS & ITS
RELATION TO SHOULDER PAIN
 SCAPULAR DYSKINESIS
It is defined as observable alterations in the position
of the scapula & the patterns of scapular motion in
relation to thoracic cage
Classification of scapular dyskinesis patterns and
positions can help to determine treatment
Factors responsible
Bony posture or injury
contractures & other flexibility problems
Alteration in muscle function
SCAPULAR EVALUATION SHOULD INCLUDE

• Postural evaluation
• Resting Scapular Evaluation
• Dynamic Evaluation of scapular motion
 STATIC EVALUATION

• SCAPULAR EVAL SHOULD BE DONE FROM

POSTERIOR ASPECT
• FIRSTLY SCAPULA SHOULD BE EVALUATED IN
STATIC POSITION AS IN LONG-STANDING
SCAPULAR DYSKINESIS,RESTING WINGING
MAY BE SEEN
 DYNAMIC EVALUATION
• Should be examined in both elevating &
lowering phase of motion
• Muscle weakness & mild dyskinesis is
commonly seen in lowering phase of arm
movement
• These commonly present as hitch or jump in
otherwise smooth motion of scapula and may
be more noticeable with several repetitions
KIBLER’S CLASSIFICATION OF
SCAPULAR DYSKINESIS
TYPE I
PROMINENCE OF
INFERIOR MEDIAL
SCAPULAR BORDER
ABNORMAL ROTATION
AROUND TRANSVERSE
AXIS
INDICATES WEAKNESS
OF LOWER TRAP, LAT
DORSI, SERR ANT
OR
TIGHT PECT
MINOR,MAJOR
TYPE II
CLASSIC WINGING

PROMINENCE OF
ENTIRE MEDIAL
SCAPULAR BORDER
ABNORMALROTATION
AROUND VERTICAL AXIS
INDICATES WEAKNESS
OF SERR
ANT,RHOMBOIDS,ALL
FIBERS OF TRAP
TYPE III
PROMINENCE OF
SUPERIOR MEDIAL
SCAPULAR BORDER
WITH SUPEROR
TRANSLATION OF
ENTIRE SCAPULA
INDICATES
OVERACTIVITY OF
LEVATOR SCAPULAE &
IMBALANCE OF UPPER
& LOWER TRAP FORCE
COUPLE
 TESTS PERFORMED TO INDICATE WEAKNESS
OF SCAPULAR MUSCLES

• Isometric scapular pinch test

• Wall push- ups
• Lateral scapular slide test
• Scapular assistance test
• Scapular retraction test
ISOMETRIC SCAPULAR PINCH TEST
 WALL PUSH - UPS

• Wall push ups are effective for evaluating

serratus anterior strength
• Abnormalities may be noted with 5 to 10 Wall
push –ups
WALL PUSH – UPS (S T A N D I N G TEST)
 LATERAL SCAPULAR SLIDE TEST
• Inferior – medial angle of scapula is palpated &
marked on both the sides
• The reference point on the spine is nearest spinous
process,which is marked
• Distance is measured on both the sides in three
different positions,-
• At resting position
• With hands on hips, with fingers anterior &thumb posterior
• With the arms at 90 degrees with internal rotation
• A 1.5 cm asymmetry is the threshold for abnormality
LATERAL SCAPULAR SLIDE TEST
SCAPULAR ASSISTANCE TEST
During abduction or forward
elevation, assistance is provided
by manually stabilizing the
scapula and rotating inferior
border of scapula as the arm
moves
This proc simulates force couple
activity of serratus ant and lower
trap
Elimination or modification of
symptoms indicate these
muscles should be major focus in
rehab.
SCAPULAR RETRACTION TEST

• The examiner stabilizes

the medial scapular
border as the arm is
elevated or externally
rotated.
• Relief of impingement
symptoms is a positive
test