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Tibialis Anterior Manual Muscle Testing (MMT) for an Active Population
Tibialis Anterior Manual Muscle Testing (MMT) is a technique used to assess the strength of the tibialis anterior muscle in an active population. This muscle, which is located in the anterior part of the lower leg, is important in ankle dorsiflexion and toe flexion, key movements in activities such as running and jumping. Tibialis Anterior MMT can help assess the muscular strength of the tibialis anterior and determine the level of activity
Transcript
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This is Brent of the Brookbush Institute,
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...blank
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and in this video we're talking about
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tibialis anterior manual muscle testing
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for an active population. In this
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video, we're going to talk about more
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provocative ways to test the tibialis
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anterior for those individuals who
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started out active or athletic and end
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up coming to us with some postural
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dysfunction or some sort of pain. I think
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manual muscle testing has lost some
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favor with this group of professionals-
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being the sports medicine, orthopedic and
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human movement science professionals,
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because although that one through five
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grading scale is great in a clinical
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setting, once you really get into the
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3+ to 5, which is what we're using,
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it becomes a little ambiguous. We don't
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generally see those individuals who
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can't move a limb against gravity. We
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don't generally see those individuals
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whose "fair" on a test is going to be
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sufficient enough to get them back to
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their previous level of activity. We
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need to find ways of making these tests
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more provocative and find a grading
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scale that will work for us to help us
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track how our patients and clients are
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doing, as well as help determine what
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intervention we should be using or
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shouldn't be using with that individual.
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I'm going to have my friend, Melissa, come
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out. She's going to help me demonstrate.
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It is important that you learn the
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positions for manual muscle testing for
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each one of these muscles, regardless
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of whether they're active or not. We're
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going to be testing the tibialis
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anterior. It's important that you
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understand that if you had to take
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gravity out of this test, because their
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that weak, deconditioned, or there's some
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sort of neurological dysfunction, then that
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position would be on the side. If all you
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needed was a "fair" and you
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just need that person to be able to pick
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up their foot against gravity, all I'd
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have to do is flip Melissa's feet around,
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have her legs dangling and be able to
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pick up her feet. But then, we get into
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activity. Let's say Melissa has
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come in and
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is complaining about knee pain. I've
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had her do an overhead squat assessment, and
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I can see that her feet flattened.
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Under normal conditions, I think you'd
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all agree that if we just- "Dorisflex
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flex for me and invert. Good." If I just
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had her do this and I pulled, I could
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probably pull her off the table by her
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tibialis anterior. You're all going,
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"Wait a second, that means her tibialis
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anterior is strong." But like I said, she has
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feet flat. I know there's something wrong
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with her inverters. Let's go ahead and
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back up. We're going to find a way to
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make this test more provocative. With
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that being said, I'm no longer going to
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use 3+, 4, 4+, and 5. That's the
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Kendall scale. We're going to leave that
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with those tests. Those have been
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researched and we have some data on those
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scores. I'm going to use just a different
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very simple test. That testing score
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is- "Go ahead and pull up."
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One score is "strong"- she can hold the position
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I put her foot into, in this case, without
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any sort of compensation with a
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significant amount of resistance.
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Another score she could get is "weak"-
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when I pull on her foot, it
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gives with pretty
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minimal resistance. A very common one,
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and this is one that hopefully gets
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your anatomy geek-out, human
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movement science geek-out brains
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thinking is I have her pull up and I pull
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down on her foot. The first thing I
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see is her toes flare up and
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she pulls me into some eversion with her
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dorsiflexion. So, now we have "with
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compensation." We have "strong"- she
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maintains the optimal position; "weak"- she
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just breaks; and now we have "with
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compensation." I said that should
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make your anatomy geek brains work, because
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you need to start thinking about what muscles
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are trying to compensate,
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what muscles are
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synergistically dominant and are trying to take
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over for an inhibited tibialis anterior
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if we see additional toe extension and
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eversion. The last score
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I would give a test like this is- I pull
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on her foot and she goes, "Ow." She
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goes, "Ow," so that hurts, and that's
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going to be "with pain." If
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you're not a licensed professional, it's
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going to be a good indicator that you
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probably need to refer this person out
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to a licensed professional. If you are a
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licensed professional, obviously, we know
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that might mean that we have to go in a
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totally different direction with our
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testing. Let's get into the test
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itself. The traditional manual muscle
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test is- "Go ahead and dorsiflex and
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invert with me." I would then take my full
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hand, because I don't want pressure points here.
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That probably just hurts being
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poked with a finger. You want to
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take that whole hand and try to pull her
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down into dorsiflexion and eversion
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against her tibialis anterior. Can
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she hold that? Oh, she seems pretty
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strong. Like I said, I'm trying to find
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ways of making this more provocative. The
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common compensation pattern for the
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tibialis anterior involves this eversion
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and toes flare up. What dorsiflexors
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evert and extend the toes? You have
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extensor hallucis longus and extensor
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digitorum longus, your EHL and EDL, who
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have a propensity to become
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synergistically dominant. For a tibialis
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anterior, that's being inhibited by a
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short, overactive gastroc complex.
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How am I going to get those
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muscles out of this test? I'm going to
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have her pull up and in, flex her toes,
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and now I've reciprocally inhibited her
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long toe extensors. Now let's see if
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she can maintain. And all of a sudden,
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it's not so easy for her. She's actually
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breaking under fairly minimal resistance,
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considering how strong we need our
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tibialis anterior to be.
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Here's the last thing we're going to do to
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make this a little bit more provocative.
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We're all aware of this kind of
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relationship where if you're not strong
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and have good neuromuscular control
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within a certain range of motion, you're
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probably going to lose that range of
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motion. When Melissa came in to see me,
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she was lacking dorsiflexion. What I
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did today only fixed one of her
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ankles, because I figured it would be fun
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to watch her walk in circles. I only
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fixed her right ankle and here's why. Not
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only do I want her to be able to hold
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dorsiflexion and inversion with toes
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flexed, but I want her to be able to do that
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throughout her entire range of motion.
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She's not going to have as much
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strength in the shortened position or
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the maximally shorten position, but she
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should have some strength throughout
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that full range of motion. You'll
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find that you'll get somebody's
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mobility back, help them into
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dorsiflexion and inversion with toes
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down, and sometimes after you let go,
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you'll see them drop back into their
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comfortable or prior range of motion. You
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might find that it takes a little
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resistance, but the same thing- all of a
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sudden it's like- and then they stop at
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the range of motion they had
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neuromuscular control or strength in
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before. All of these particular signs
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as we've gone through this are
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indications of weakness. You might
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have to make some notes that say "only weak
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in new range of motion, five to
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15 degrees of dorsiflexion." These are
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definitely some results that give us an
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indication that maybe we should be doing
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a little bit more tibialis anterior
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activation or a little bit more
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tibialis anterior strengthening.
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Just because- "go ahead and throw both
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feet up" we could use the traditional
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test- "don't worry about your toes, just
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pull your feet up as hard as you can."
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Even though the traditional test would
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allow me to pull her right off the table
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by her tibialis anterior, if she's
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coming in here complaining
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of pain, she has flat foot, and when I'm a
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little bit more careful about how I do
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this test- I don't let her use her
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overactive synergists I make her go all
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the way to end range, and hold it, and
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then I apply pressure, and if there's a little
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weakness- we're not done. If
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returning back to "normal activity" for
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this individual includes any sort of
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sport, athletic endeavor, resistance
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training, then we have more work to do. There
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you have it. This isn't the
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traditional manual muscle testing, but it's
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manual muscle testing for an active
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population. We see that Melissa
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is testing a little weak at her end
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range. The other things we might
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see would be "strong," that's what we're
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working for. We could have seen
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"with compensation," which would have been
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toes flare and into eversion. We don't
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want that, which is why we also
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curl the toes on this test. Of
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course, the last result that you might
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get is "with pain," which, if you're not
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a licensed professional, that's probably
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time to refer out or at least check
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with a licensed professional to make
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sure that this person is safe to
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continue on with activity. I look forward
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to hearing about you guys using this
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test. I'll talk with you soon.
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