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Measurement of Joint Motion A Guide to Goniometry Cynthia C. Norkin, EdD, PT Former Associate Professor and Director School of Physical Therapy College of Health and Human Services Ohio University Athens, Ohio D. Joyce White, DSc, PT Associate Professor of Physical Therapy College of Health Professions University of Massachusetts Lowell Lowell, Massachusetts Measurement of Joint Motion A Guide to Goniometry THIRD EDITION Photographs by Jocelyn Greene Molleur and Lucia Grochowska Littlefield Illustrations by Timothy Wayne Malone Additional illustrations provided by Jennifer Daniell and Meredith Taylor Stelling F. A. Davis Company • Philadelphia F.A. Davis Company 1915 Arch Street Philadelphia, PA 10103 www.fadavis.com Copyright © 2003 by F.A. Davis Company Copyright © 2003 by F.A. Davis Company. All rights reserved. This book is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photo- copying, recording, or otherwise, without written permission from the publisher. Printed in the United States of America Last digit indicates print number : 10 9 8 7 6 5 4 3 2 1 Acquisitions Editor: Margaret Biblis Manager, Creative Development: Susan Rhyner Developmental Editor: Anne Seitz Cover Designer: Louis J. Forgione As new scientific information becomes available through basic and clinical research, recommended treatments and drug therapies undergo changes. The author(s) and publisher have done everything possible to make this book accu- rate, up to date, and in accord with accepted standards at the time of publication. The author(s), editors, and publisher are not responsible for errors or omissions or for consequences from application of the book, and make no warranty, expressed or implied, in regard to the contents of the book. Any practice described in this book should be applied by the reader in accordance with professional standards of care used in regard to the unique circumstances that may apply in each situation. The reader is advised always to check product information (package inserts) for changes and new information regarding dose and contraindications before administering any drug. Caution is especially urged when using new or infrequently ordered drugs. Library of Congress Cataloging-in-Publication Data Norkin, Cynthia C. Measurement of joint motion : a guide to goniometry / Cynthia C. Norkin, D. Joyce White ; photographs by Jocelyn Greene and Lucia Grochowska Littlefield ; illustrations by Timothy Wayne Malone ; additional illustrations provided by Jennifer Daniell and Meredith Taylor Stelling.— 3rd ed. p. cm. Includes bibliographical references and index. ISBN 0-8036-0972-8 1. Joints—Range of motion—Measurement. I. White, D. Joyce. II. Title. RD734.N67 2003 612.7′5–dc21 2003046244 Authorization to photocopy items for internal or personal use, or the internal or personal use of specific clients, is granted by F. A. Davis Company for users registered with the Copyright Clearance Center (CCC) Transactional Reporting Service, provided that the fee of $.10 per copy is paid directly to CCC, 222 Rosewood Drive, Danvers, MA 01923. For those organizations that have been granted a photocopy license by CCC, a separate system of payment has been arranged. The fee code for users of the Transactional Reporting Service is : 8036-0972/03 0 + $.10 To Alexandra, Taylor, and Kimberly. CCN To Jonathan, Alexander, and Ethan. DJW Preface The measurement of joint motion is an important motion of the spine are also added to coincide with component of a thorough physical examination of the current practice in some clinical settings. We introduce extremities and spine, one which helps health profession- illustrations to accompany anatomical descriptions so als identify impairments and assess rehabilitative status. that the reader will have a visual reminder of the joint The need for a comprehensive text with sufficient written structures involved in range of motion. New illustrations detail and photographs to allow for the standardization of bony anatomical landmarks and photographs of of goniometric measurement methods—both for the surface anatomy will help the reader align the goniome- purposes of teaching and clinical practice led to the ter accurately. In addition, over 180 new photographs development of the first edition of the Measurement of replace many of the older, dated photographs. Joint Motion: A Guide to Goniometry in 1985. Our Similar to earlier editions, the book presents goniom- approach included a discussion and illustration of testing etry logically and clearly. Chapter 1 discusses basic position, stabilization, end-feel, and goniometer align- concepts regarding the use of goniometry to assess range ment for each measurable joint in the body. The resulting of motion and muscle length in patient evaluation. text was extremely well received by a variety of health Arthrokinematic and osteokinematic movements, professional educational programs and was used as a elements of active and passive range of motion, hypomo- reference in many clinical settings. bility, hypermobility, and factors affecting joint motion In the years following initial publication, a consider- are included. The inclusion of end-feels and capsular and able amount of research on the measurement of joint noncapsular patterns of joint limitation introduces read- motion appeared in the literature. Consequently, in the ers to current concepts in orthopedic manual therapy and second edition, which was published in 1995, we created encourages them to consider joint structure while meas- a new chapter on the reliability and validity of joint uring joint motion. measurement and added joint-specific research sections Chapter 2 takes the reader through a step-by-step to existing chapters. We also expanded the text by adding process to master the techniques of goniometric evalua- structure, osteokinematics, arthrokinematics, capsular tion, including: positioning, stabilization, instruments and noncapsular patterns of limitation, and functional used for measurement, goniometer alignment, and the ranges of motion for each joint. recording of results. Exercises that help develop neces- The expanded third edition includes new research sary psychomotor skills and demonstrate direct applica- findings to help clarify normative range of motion values tion of theoretical concepts facilitate learning. for various age and gender groups, as well as the range Chapter 3 discusses the validity and reliability of of motion needed to perform common functional tasks. measurement. The results of validity and reliability stud- We added current information on the effects of subject ies on the measurement of joint motion are summarized characteristics, such as body mass, occupational and to help the reader focus on ways of improving and inter- recreational activities, and the effects of the testing preting goniometric measurements. Mathematical meth- process, such as the testing position and type of measur- ods of evaluating reliability are shown along with ing instrument, on range of motion. New to the third examples and exercises so that the readers can assess edition is the inclusion of muscle length testing at joints their reliability in taking measurements. where muscle length is often a factor affecting range of Chapters 4 to 13 present detailed information on motion. This addition integrates the measurement proce- goniometric testing procedures for the upper and lower dures used in this book with the American Physical extremities, spine, and temporomandibular joint. When Therapy Association’s Guide to Physical Therapy appropriate, muscle length testing procedures are also Practice. Inclinometer techniques for measuring range of included. The text presents the anatomical landmarks, vii viii PREFACE testing position, stabilization, testing motion, normal end- We hope this book makes the teaching and learning of feel, and goniometer alignment for each joint and motion, goniometry easier and improves the standardization and in a format that reinforces a consistent approach to eval- thus the reliability of this assessment tool. We believe uation. The extensive use of photographs and captions that the third edition provides a comprehensive coverage eliminates the need for repeated demonstrations by an of the measurement of joint motion and muscle length. instructor and provides the reader with a permanent We hope that the additions will motivate health profes- reference for visualizing the procedures. Also included sionals to conduct research and to use research results in is information on joint structure, osteokinematic and evaluation. We encourage our readers to provide us with arthrokinematic motion, and capsular patterns of restric- feedback on our current efforts to bring you a high- tions. A review of current literature regarding normal quality, user-friendly text. range of motion values; the effects of age, gender, and other factors; functional range of motion; and reliability CCN and validity is also presented for each body region to assist the reader to comply with evidence-based practice. DJW Acknowledgments We are very grateful for the contributions of the many Publisher, and Susan Rhyner, Manager of Creative people who were involved in the development and Development, for their encouragement, ingenuity, and production of this text. Photographer Jocelyn Molleur commitment to excellence. Thanks are also extended to applied her skill and patience during many sessions at Sam Rondinelli, Production Manager; Jack Brandt, the physical therapy laboratory at the University of Illustration Specialist; Louis Forgione, Design Manager; Massachusetts Lowell to produce the high-quality photo- Ona Kosmos, Editorial Associate; Melissa Reed, graphs that appear in this third edition. Her efforts Developmental Associate; Anne Seitz, Freelance Editor; combined with those of Lucia Grochowska Littlefield, and Jean-Francois Vilain, Former Publisher. We are who took the photographs for the first edition, are grateful to the numerous students, faculty, and clinicians responsible for an important feature of the book. who over the years have used the book or formally Timothy Malone, an artist from Ohio, used his talents, reviewed portions of the manuscript and offered insight- knowledge of anatomy, and good humor to create the ful comments and helpful suggestions. excellent illustrations that appear in this edition. We also Finally, we wish to thank our families: Cynthia’s offer our thanks to Jessica Bouffard, Alexander White, daughter, Alexandra, and Joyce’s husband, Jonathan, and Claudia Van Bibber who graciously agreed to be and sons, Alexander and Ethan, for their encouragement, subjects for some of the photographs. support, and tolerance of “time away” for this endeavor. We wish to express our appreciation to these dedi- We will always be appreciative. cated professionals at F. A Davis: Margaret Biblis, ix Reviewers Suzanne Robben Brown, MPH, PT Deidre Lever-Dunn, PhD, ATC Associate Professor & Chair Assistant Professor Department of Physical Therapy Department of Health Sciences Arizona School of Health Sciences Program Director Mesa, AZ Athletic Training Education University of Alabama Larry Chinnock, PT, EdD Tuscaloosa, AL Instructor/Academic Coordinator Department of Physical Therapy John T. Myers, PT, MBA Loma Linda University Instructor/Program Director School of Allied Health Professions Physical Therapy Assistant Program Loma Linda, CA Lorain County Community College Elyria, OH Robyn Colleen Davies, BHSCPT, MAPPSC, PT Lecturer James R. Roush, PhD, PT, ATC Department of Physical Therapy Associate Professor University of Toronto Department of Physical Therapy Toronto, Canada Arizona School of Health Science Mesa, AZ Jodi Gootkin, PT Site Coordinator Sharon D. Yap, PTA, BPS Physical Therapy Assistant Program Academic Coordinator of Clinical Education Broward Community College Physical Therapy Assistant Program Ft. Myers, FL Indian River Community College Fort Pierce, FL xi Contents PART I EXERCISE 4: Explanation of Goniometry EXERCISE 5: Testing Procedure for Goniometric Introduction to Goniometry ............1 Evaluation of Elbow Flexion CHAPTER 1 CHAPTER 3 Basic Concepts ............................................3 Validity and Reliability ..............................39 GONIOMETRY VALIDITY JOINT MOTION Face Validity Arthrokinematics Content Validity Osteokinematics Criterion-related Validity RANGE OF MOTION Construct Validity Active Range of Motion RELIABILITY Passive Range of Motion Summary of Goniometric Reliability Studies Hypomobility Statistical Methods of Evaluating Measurement Hypermobility Reliability Factors Affecting Range of Motion Exercises to Evaluate Reliability MUSCLE LENGTH TESTING EXERCISE 6: Intratester Reliability EXERCISE 7: Intertester Reliability CHAPTER 2 Procedures ................................................17 POSITIONING STABILIZATION EXERCISE 1: Determining the End of the Range of PART II Motion and End-feel Upper-Extremity Testing ................55 MEASUREMENT INSTRUMENTS Universal Goniometer CHAPTER 4 Gravity-dependent Goniometers (Inclinometers) Electrogoniometers The Shoulder ............................................57 Visual Estimation STRUCTURE AND FUNCTION EXERCISE 2: The Universal Goniometer Glenohumeral Joint ALIGNMENT Sternoclavicular Joint EXERCISE 3: Goniometer Alignment for Elbow Acromioclavicular Joint Flexion Scalpulothoracic Joint RECORDING RESEARCH FINDINGS Numerical Tables Effects of Age, Gender, and Other Factors Pictorial Charts Functional Range of Motion Sagittal-frontal-transverse-rotation Method Reliability and Validity American Medical Association Guide to Evaluation RANGE OF MOTION TESTING PROCEDURES: THE Method SHOULDER PROCEDURES LANDMARKS FOR GONIOMETER ALIGNMENT Explanation Procedure Flexion Testing Procedure Extension xiii xiv CONTENTS Abduction RESEARCH FINDINGS Adduction Effects of Age, Gender, and Other Factors Medial (Internal) Rotation Functional Range of Motion Lateral (External) Rotation Reliability and Validity RANGE OF MOTION TESTING PROCEDURES: FINGERS LANDMARKS FOR GONIOMETER ALIGNMENT CHAPTER 5 Metacarpophalangeal Flexion The Elbow and Forearm............................91 Metacarpophalangeal Extension STRUCTURE AND FUNCTION Metacarpophalangeal Abduction Humeroulnar and Humeroradial Joints Metacarpophalangeal Adduction Superior and Inferior Radioulnar Joints Proximal Interphalangeal Flexion RESEARCH FINDINGS Proximal Interphalangeal Extension Effects of Age, Gender, and Other Factors Distal Interphalangeal Flexion Functional Range of Motion Distal Interphalangeal Extension Reliability and Validity RANGE OF MOTION TESTING PROCEDURES: THUMB RANGE OF MOTION TESTING PROCEDURES: ELBOW AND LANDMARKS FOR GONIOMETER ALIGNMENT FOREARM Carpometacarpal Flexion LANDMARKS FOR GONIOMETER ALIGNMENT Carpometacarpal Extension Flexion Carpometacarpal Abduction Extension Carpometacarpal Adduction Pronation Carpometacarpal Opposition Supination Metacarpophalangeal Flexion MUSCLE LENGTH TESTING PROCEDURES: ELBOW AND Metacarpophalangeal Extension FOREARM Interphalangeal Flexion Biceps Brachii Interphalangeal Extension Triceps Brachii MUSCLE LENGTH TESTING PROCEDURES: FINGERS Lumbricals, Palmar and Dorsal Interossei CHAPTER 6 The Wrist ................................................111 PART III STRUCTURE AND FUNCTION Lower-Extremity Testing ..............181 Radiocarpal and Midcarpal Joints RESEARCH FINDINGS CHAPTER 8 Effects of Age, Gender, and Other Factors The Hip ....................................................183 Functional Range of Motion STRUCTURE AND FUNCTION Reliability and Validity Iliofemoral Joint RANGE OF MOTION TESTING PROCEDURES: WRIST RESEARCH FINDINGS LANDMARKS FOR GONIOMETRIC ALIGNMENT: THE Effects of Age, Gender, and Other Factors WRIST Functional Range of Motion Flexion Reliability and Validity Extension RANGE OF MOTION TESTING PROCEDURES: HIP Radial Deviation LANDMARKS FOR GONIOMETER ALIGNMENT Ulnar Deviation Flexion MUSCLE LENGTH TESTING PROCEDURES: WRIST Extension Flexor Digitorum Profundus and Flexor Digitorum Abduction Superficialis Adduction Extensor Digitorum, Extensor Indicis, and Extensor Medial (Internal) Rotation Digiti Minimi Lateral (External) Rotation MUSCLE LENGTH TESTING PROCEDURES CHAPTER 7 Hip Flexors (Thomas Test) The Hand ................................................137 The Hamstrings: Semitendinous, Semimembranosus, and Biceps Femoris (Straight Leg Test) STRUCTURE AND FUNCTION Tensor Fascia Latae (Ober Test) Fingers: Metacarpophalangeal Joints Fingers: Proximal Interphalangeal and Distal CHAPTER 9 Interphalangeal Joints Thumb: Carpometacarpal Joint The Knee..................................................221 Thumb: Metacarpophalangeal Joint STRUCTURE AND FUNCTION Thumb: Interphalangeal Joint Tibiofemoral and Patellofemoral Joints CONTENTS xv RESEARCH FINDINGS PART IV Effects of Age, Gender, and Other Factors Functional Range of Motion Testing of the Spine and Reliability and Validity Temporomandibular Joint ............293 RANGE OF MOTION TESTING PROCEDURES: KNEE LANDMARKS FOR GONIOMETER ALIGNMENT Flexion CHAPTER 11 Extension The Cervical Spine ..................................295 MUSCLE LENGTH TESTING PROCEDURES: KNEE STRUCTURE AND FUNCTION Rectus Femoris: Ely Test Atlanto-occipital and Atlantoaxial Joints Hamstring Muscles: Semitendinosus, Semimembranosus, Intervertebral and Zygapophyseal Joints and Biceps Femoris: Distal Hamstring Length Test RESEARCH FINDINGS Effects of Age, Gender, and Other Factors CHAPTER 10 Functional Range of Motion The Ankle and Foot ................................241 Reliability and Validity STRUCTURE AND FUNCTION RANGE OF MOTION TESTING PROCEDURES: Proximal and Distal Tibiofibular Joints CERVICAL SPINE Talocrural Joint LANDMARKS FOR GONIOMETER ALIGNMENT Subtalar Joint Flexion Transverse Tarsal (Midtarsal) Joint Extension Tarsometatarsal Joints Lateral Flexion Metatarsophalangeal Joints Rotation Interphalangeal Joints RESEARCH FINDINGS Effects of Age, Gender, and Other Factors CHAPTER 12 Functional Range of Motion Reliability and Validity The Thoracic and Lumbar Spine ............331 RANGE OF MOTION TESTING PROCEDURES: ANKLE STRUCTURE AND FUNCTION AND FOOT Thoracic Spine LANDMARKS FOR GONIOMETER ALIGNMENT: Lumbar Spine TALOCRURAL JOINT RESEARCH FINDINGS Dorsiflexion: Talocrural Joint Effects of Age, Gender, and Other Factors Plantarflexion: Talocrural Joint Functional Range of Motion LANDMARKS FOR GONIOMETER ALIGNMENT: TARSAL Reliability and Validity JOINTS RANGE OF MOTION TESTING PROCEDURES Inversion: Tarsal Joints ANATOMICAL LANDMARKS: FOR TAPE MEASURE Eversion: Tarsal Joints ALIGNMENT LANDMARKS FOR GONIOMETER ALIGNMENT: SUBTALAR Thoracic and Lumbar Flexion JOINT (REARFOOT) Lumbar Flexion Inversion: Subtalar Joint (Rearfoot) Thoracic and Lumbar Extension Eversion: Subtalar Joint (Rearfoot) Lumbar Extension Inversion: Transverse Tarsal Joint Thoracic and Lumbar Lateral Flexion Eversion: Transverse Tarsal Joint Thoracic and Lumbar Rotation LANDMARKS FOR GONIOMETER ALIGNMENT: METATARSOPHALANGEAL JOINT Flexion: Metatarsophalangeal Joint CHAPTER 13 Extension: Metatarsophalangeal Joint Abduction: Metatarsophalangeal Joint The Temporomandibular Joint................365 Adduction and Metatarsophalangeal Joint STRUCTURE AND FUNCTION Flexion: Interphalangeal Joint of the First Toe and Temporomandibular Joint Proximal Interphalangeal Joints of the Four Lesser Toes RESEARCH FINDINGS Extension: Interphalangeal Joint of the First Toe and Effects of Age, Gender, and Other Factors Proximal Interphalangeal Joints of the Four Lesser Toes Reliability and Validity Flexion: Distal Interphalangeal Joints of the Four Lesser RANGE OF MOTION TESTING PROCEDURES: Toes TEMPOROMANDIBULAR JOINT Extension: Distal Interphalangeal Joints of the Four LANDMARKS FOR RULER ALIGNMENT MEASURING Lesser Toes Depression of the Mandible (Mouth Opening) MUSCLE LENGTH TESTING PROCEDURES: Protrusion of the Mandible Gastrocnemius Lateral Deviation of the Mandible xvi CONTENTS APPENDIX A APPENDIX C Normative Range of Motion Goniometer Price Lists ............................383 Values ......................................................375 APPENDIX B APPENDIX D Joint Measurements by Body Numerical Recording Forms ..................387 Position....................................................381 Index........................................................393 CHAPTER 5 THE ELBOW AND FOREARM 91 CHAPTER 5 The Elbow and Forearm Structure and Function The proximal joint surface of the humeroradial joint is the convex capitulum located on the anterior lateral Humeroulnar and Humeroradial Joints surface of the distal humerus. The concave radial head on the proximal end of the radius is the opposing joint Anatomy surface. The humeroulnar and humeroradial joints between the The joints are enclosed in a large, loose, weak joint upper arm and the forearm are considered to be a hinged capsule that also encloses the superior radioulnar joint. compound synovial joint (Figs. 5–1 and 5–2). The proxi- Medial and lateral collateral ligaments reinforce the sides mal joint surface of the humeroulnar joint consists of the of the capsule and help to provide medial-lateral stability convex trochlea located on the anterior medial surface of (Figs. 5–3 and 5–4).1 the distal humerus. The distal joint surface is the concave When the arm is in the anatomical position, the long trochlear notch on the proximal ulna. axes of the humerus and the forearm form an acute angle Coronoid fossa Humerus Humerus Radial fossa Medial epicondyle Olecranon fossa Olecranon Lateral epicondyle process Lateral epicondyle Capitulum Trochlea Medial epicondyle Humeroradial Humeroradial joint joint Humeroulnar joint Radial head Humeroulnar joint Coronoid process Radial head Radius Radius Ulna Ulna FIGURE 5–1 An anterior view of the elbow showing the FIGURE 5–2 A posterior view of the elbow showing the humeroulnar and humeroradial joints. humeroulnar and humeroradial joints. 91 92 PA R T I I UPPER-EXTREMITY TESTING coronoid fossa of the humerus or until soft tissue in the Humerus anterior aspect of the elbow blocks further flexion. Medial epicondyle At the humeroradial joint, the concave radial head slides posteriorly on the convex surface of the capitulum Annular ligament during extension. In flexion, the radial head slides anteri- Joint orly until the rim of the radial head enters the radial fossa Radius capsule of the humerus. Medial Capsular Pattern collateral The capsular pattern is variable, but usually the range of ligament motion (ROM) in flexion is more limited than in exten- sion. For example, 30 degrees of limitation in flexion Ulna would correspond to 10 degrees of limitation in exten- FIGURE 5–3 A medial view of the elbow showing the medial sion.4 (ulnar) collateral ligament, annular ligament, and joint capsule. Superior and Inferior Radioulnar Joints at the elbow. The angle is called the “carrying angle.” Anatomy This angle is about 5 degrees in men and approximately The ulnar portion of the superior radioulnar joint 10 to 15 degrees in women.2 An angle that is greater includes both the radial notch located on the lateral (more acute) than average is called “cubitus valgus.” An aspect of the proximal ulna and the annular ligament angle that is less than average is called “cubitus varus.” (Fig. 5–5). The radial notch and the annular ligament Osteokinematics The humeroulnar and humeroradial joints have 1 degree Superior radioulnar joint of freedom; flexion-extension occurs in the sagittal plane around a medial-lateral (coronal) axis. In elbow flexion and extension, the axis of rotation lies approximately through the center of the trochlea.3 Radial head Radial notch Arthrokinematics At the humeroulnar joint, posterior sliding of the concave trochlear notch of the ulna on the convex trochlea of the humerus continues during extension until the ulnar olecranon process enters the humeral olecranon fossa. In flexion, the ulna slides anteriorly along the humerus until the coronoid process of the ulna reaches the floor of the Humerus Radius Ulna Annular ligament Lateral Radius epicondyle Ulnar notch Ulnar head Joint capule Ulnar styloid Radial styloid process process Lateral collateral ligament Ulna Inferior radioulnar joint FIGURE 5–4 A lateral view of the elbow showing the lateral FIGURE 5–5 Anterior view of the superior and inferior (radial) collateral ligament, annular ligament, and joint capsule. radioulnar joints. CHAPTER 5 THE ELBOW AND FOREARM 93 form a concave joint surface. The radial aspect of the Posterior radioulnar Articular disc joint is the convex head of the radius. ligament The ulnar component of the inferior radioulnar joint is the convex ulnar head (see Fig. 5–5). The opposing artic- ular surface is the ulnar notch of the radius. The interosseous membrane, a broad sheet of collage- nous tissue linking the radius and ulna, provides stability Ulnar styloid for both joints (Fig. 5–6). The following three structures Radial styloid process provide stability for the superior radioulnar joint: the process annular and quadrate ligaments and the oblique cord. Stability of the inferior radioulnar joint is provided by the Head of ulna articular disc and the anterior and posterior radioulnar Ulnar notch ligaments (Fig. 5–7).1 of radius Anterior radioulnar ligament Osteokinematics FIGURE 5–7 Distal aspect of the inferior radioulnar joint The superior and inferior radioulnar joints are mechani- showing the\ articular disc and radioulnar ligaments. cally linked. Therefore, motion at one joint is always accompanied by motion at the other joint. The axis for motion is a longitudinal axis extending from the radial head to the ulnar head. The mechanically linked joint is a synovial pivot joint with 1 degree of freedom. The motions permitted are pronation and supination. In pronation the radius crosses over the ulna, whereas in supination the radius and ulna lie parallel to one another. Annular Arthrokinematics ligament At the superior radioulnar joint the convex rim of the Quadrate ligament head of the radius spins within the annular ligament and Oblique cord the concave radial notch during pronation and supina- tion. The articular surface on the head of the radius spins posteriorly during pronation and anteriorly during supination. At the inferior radioulnar joint the concave surface of Radius Ulna the ulnar notch on the radius slides over the ulnar head. The concave articular surface of the radius slides anteri- orly (in the same direction as the hand) during pronation and slides posteriorly (in the same direction as the hand) Interosseous during supination. membrane Capsular Pattern According to Cyriax and Cyriax,4 Kaltenborn,5 and Magee,6 the capsular pattern is equal limitation of Anterior radioulnar ligament pronation and supination. Articular disc FIGURE 5–6 Anterior view of the superior and inferior radioulnar joints showing the annular ligament, quadrate liga- ment, oblique cord, interosseous membrane, anterior radioul- nar ligament, and articular disc. 94 PA R T I I UPPER-EXTREMITY TESTING TABLE 5–1 Elbow and Forearm Motion: Mean Values in Degrees from Selected Sources AAOS7,8 AMA9 Boone Greene Petherick & Azen10 & Wolf11 et al12 n 109* n 20† n 30‡ Motion Mean (SD) Mean (SD) Mean (SD) Flexion 150 140 142.9 (5.6) 145.3 (1.2) 145.8 (6.3) Extension 0 0 0.6 (3.1) Pronation 80 80 75.8 (5.1) 84.4 (2.2) Supination 80 80 82.1 (3.8) 76.9 (2.1) * Values are for males 18 months to 54 years of age. † Values are for 10 males and 10 females, 18 to 55 years of age. ‡ Values are for 10 males and 20 females, with a mean age of 24.0 years. Research Findings elbow and forearm. The male and female infants reported in the study by Wanatabe and colleagues14 had Effects of Age, Gender, and Other Factors more ROM in flexion, pronation, and supination than the older males in studies by Boone15 and by Walker and Table 5–1 shows the mean values of ROM for various coworkers.16 However, it can be difficult to compare motions at the elbow. The age, gender, and number of values obtained from various studies because subject subjects that were measured to obtain the values selection and measurement methods can differ. reported by the American Academy of Orthopaedic Within one study of 109 males ranging in age from 18 Surgeons (AAOS)7,8 and the American Medical months to 54 years, Boone and Azen10 noted a significant Association (AMA)9 in Table 5–1 were not noted. Boone difference in elbow flexion and supination between and Azen,10 using a universal goniometer, measured subjects less than or equal to 19 years of age and those active ROM in 109 males between the ages of 18 months greater than 19 years of age. Further analyses found that and 54 years. Greene and Wolf11 measured active ROM the group between 6 and 12 years of age had more elbow with a universal goniometer in 10 males and 10 females flexion and extension than other age groups. The aged 18 to 55 years. Petherick and associates12 measured youngest group (between 18 months and 5 years) had a active ROM with a universal goniometer in 10 males and significantly greater amount of pronation and supination 20 females with a mean age of 24.0 years. In addition to than other age groups. However, the greatest differences the sources listed in Table 5–1, Goodwin and cowork- between the age groups were small: 6.8 degrees of flex- ers13 found mean active elbow flexion to be 148.9 ion, 4.4 degrees of supination, 3.9 degrees of pronation, degrees when measured with a universal goniometer in and 2.5 degrees of extension.15 23 females between 18 and 31 years of age. Older persons appear to have difficulty fully extending their elbows to 0 degrees. Walker and associates16 found Age that the older men and women (between 60 and 84 years A comparison of cross-sectional studies of normative of age) in their study were unable to extend their elbows ROM values for various age groups suggests that elbow to 0 degrees to attain a neutral starting position for flex- and forearm ROM decreases slightly with age. Tables ion. The mean value for the starting position was 6 5–2 and 5–3 summarize the effects of age on ROM of the degrees in men and 1 degree in women. Boone and TABLE 5–2 Effects of Age on Elbow and Forearm Motion: Mean Values in Degrees for Newborns, Children, and Adolescents 2 Weeks to 19 Years of Age Wanatabe et al14 Boone15 2 wks–2 yrs 18 mos–5 yrs 6–12 yrs 13–19 yrs n 45 n 19 n 17 n 17 Motion Range of Means Mean (SD) Mean (SD) Mean (SD) Flexion 148–158 144.9 (5.7) 146.5 (4.0) 144.9 (6.0) Extension 0.4 (3.4) 2.1 (3.2) 0.1 (3.8) Pronation 90–96 78.9 (4.4) 76.9 (3.6) 74.1 (5.3) Supination 81–93 84.5 (3.8) 82.9 (2.7) 81.8 (3.2) CHAPTER 5 THE ELBOW AND FOREARM 95 TABLE 5–3 Effects of Age on Elbow and Forearm Motion: Mean Values in Degrees for Adults 20 to 85 Years of Age Boone15 Walker et al16 20–29 yrs 30–39 yrs 40–54 yrs 60–85 yrs n 19 n 18 n 19 n 30 Motion Mean (SD) Mean (SD) Mean (SD) Mean (SD) Flexion 140.1 (5.2) 141.7 (3.2) 139.7 (5.8) 139.0 (14.0) Extension 0.7 (3.2) 0.7 (1.7) 0.4* (3.0) 6.0* (5.0) Pronation 76.2 (3.9) 73.6 (4.3) 75.0 (7.0) 68.0 (9.0) Supination 80.1 (3.7) 81.7 (4.2) 81.4 (4.0) 83.0 (11.0) * The minus sign indicates flexion. Azen10 also found that the oldest subjects in their study Escalante, Lichenstein, and Hazuda,21in a study of 695 (between 40 and 54 years of age) had lost elbow exten- community-dwelling older subjects between 65 and 74 sion and began flexion from a slightly flexed position. years of age, found that females had an average of 4 Bergstrom and colleagues,17 in a study of 52 women and degrees more elbow flexion than males. 37 men aged 79 years, found that 11 percent had flexion contractures of the right elbow greater than 5 degrees, Body-Mass Index and 7 percent had bilateral flexion contractures. Body-mass index (BMI) was found by Escalante, Lichenstein, and Hazuda21 to be inversely associated Gender with elbow flexion in 695 older subjects. Each unit increase in BMI (kg/m2) was significantly associated with Studies seem to concur that gender differences exist for a 0.22 decrease in degrees of elbow flexion. elbow flexion and extension ROM but these studies are unclear concerning forearm supination and pronation Right versus Left Side ROM. Bell and Hoshizaki,18 using a Leighton Comparisons between the right and the left or between Flexometer, studied the ROM of 124 females and 66 the dominant and the nondominant limbs have found no males between the ages of 18 and 88 years. Females had clinically relevant differences in elbow and forearm significantly more elbow flexion than males. ROM. Boone and Azen10 studied 109 males between the Extrapolating from a graph, the mean differences ages of 18 months and 54 years, who were subdivided between males and females ranged from 14 degrees in into six age groups. They found no significant differences subjects aged 32 to 44 years, to 2 degrees in subjects between right and left elbow flexion, extension, supina- older than 75 years. Although females had greater tion, and pronation, except for the age group of subjects supination-pronation ROM than males, this increase was between 20 and 29 years of age, whose flexion ROM was not significant. Fairbanks, Pynsent, and Phillips,19 in a greater on the left than on the right. This one significant study of 446 normal adolescents, found that females had finding was attributed to chance. Escalante, Lichenstein, significantly more elbow extension (8 degrees) than males and Hazudal,21 in a study of 695 older subjects, found (5 degrees) when measured on the extensor aspect with a significantly greater elbow flexion on the left than on the universal goniometer. It is unclear from the method used right, but the difference averaged only 2 degrees. Chang, whether hyperextension of the elbow or the carrying Buschbacher, and Edlich22 studied 10 power lifters and angle was measured. Salter and Darcus,20 measuring 10 age-matched nonlifters, all of whom were right forearm supination-pronation with a specialized handed, and found no differences between sides in elbow arthrometer in 20 males and 5 females between the ages and forearm ROM. of 16 and 29 years, found that the females had an aver- age of 8 degrees more forearm rotation than males, Sports although the difference was not statistically significant. It appears that the frequent use of the upper extremities Thirty older females and 30 older males, aged 60 to 84 in sport activities may reduce elbow and forearm ROM. years, were included in a study by Walker and cowork- Possible causes for this association include muscle hyper- ers.16 Females had significantly more flexion ROM (1 to trophy, muscle tightness, and joint trauma from overuse. 148 degrees) than males (5 to 139 degrees), but males Chinn, Priest, and Kent,23 in a study of 53 male and 30 had significantly more supination (83 degrees) than female national and international tennis players, found females (65 degrees). Females had more pronation ROM significantly less active pronation and supination ROM than males, but the difference was not significant. in the playing arms of all subjects. Male players also 96 PA R T I I UPPER-EXTREMITY TESTING TABLE 5–4 Elbow and Forearm Motion During Functional Activities: Mean Values in Degrees Activity Flexion Pronation Supination Source Min Max Arc Max Max Arc Use telephone 42.8 135.6 92.8 40.9 22.6 63.5 Morrey24 75 140 65 Packer25 Rise from chair 20.3 94.5 74.2 33.8 9.5* 24.3 Morrey 15 100 85 Packer Open door 24.0 57.4 33.4 35.4 23.4 58.8 Morrey Read newspaper 77.9 104.3 26.4 48.8 7.3* 41.5 Morrey Pour pitcher 35.6 58.3 22.7 42.9 21.9 64.8 Morrey Put glass to mouth 44.8 130.0 85.2 10.1 13.4 23.5 Morrey Drink from cup 71.5 129.2 57.7 3.4† 31.2 27.8 Safaee-Rad26 Cut with knife 89.2 106.7 17.5 41.9 26.9* 15.0 Morrey Eat with fork 85.1 128.3 43.2 10.4 51.8 62.2 Morrey 93.8 122.3 28.5 38.2 58.8 97.0 Safaee-Rad Eat with spoon 101.2 123.2 22.0 22.9 58.7 81.6 Safaee-Rad 70 115 45 Packer * The minus sign indicates pronation. † The minus sign indicates supination. demonstrated a significant decrease (4.1 degrees) in Five healthy subjects participated in a study by Packer elbow extension in the playing arm versus the nonplaying and colleagues,25 which examined elbow ROM during arm. Chang, Buschbacher, and Edlich22 studied 10 power three functional tasks. A uniaxial electrogoniometer was lifters and 10 age-matched nonlifters and found signifi- used to determine ROM required for using a telephone, cantly less active elbow flexion in the power lifters than for rising from a chair to a standing position, and for in the nonlifters. No significant differences were found eating with a spoon. A range of 15 to 140 degrees of flex- between the two groups for supination and pronation ion was needed for these three activities. This ROM is ROM. slightly greater than the arc reported by Morrey and associates, but the activities that required the minimal and maximal flexion angles did not differ. The authors Functional Range of Motion suggest that the height of the chair, the type of chair arms, The amount of elbow and forearm motion that occurs and the positioning of the telephone could account for during activities of daily living has been studied by the different ranges found in the studies. several investigators. Table 5–4 has been adapted from Safaee-Rad and coworkers26 used a three-dimensional the works of Morrey and associates,24 Packer and video system to measure ROM during three feeding colleagues,25 and Safaee-Rad and coworkers.26 Morrey activities: eating with a spoon, eating with a fork, and and associates24 used a triaxial electrogoniometer to drinking from a handled cup. Ten healthy males partici- measure elbow and forearm motion in 33 normal pated in the study. The feeding activities required approx- subjects during performance of 15 activities. They imately 70 to 130 degrees of elbow flexion, 40 degrees of concluded that most of activities of daily living that were pronation, and 60 degrees of supination. Drinking with a studied required a total arc of about 100 degrees of cup required the greatest arc of elbow flexion (58 elbow flexion (between 30 and 130 degrees) and 100 degrees) of the three activities, whereas eating with a degrees of rotation (50 degrees of supination and 50 spoon required the least (22 degrees). Eating with a fork degrees of pronation). Using a telephone necessitated the required the greatest arc of pronation-supination (97 greatest total ROM. The greatest amount of flexion was degrees), whereas drinking from a cup required the least required to reach the back of the head (144 degrees), (28 degrees). Maximum ROM values during feeding whereas feeding tasks such as drinking from a cup (Fig. tasks were comparable with those reported by Morrey 5–8) and eating with a fork required about 130 degrees and associates. However, minimum values varied, possi- of flexion. Reaching the shoes and rising from a chair bly owing to the different chair and table heights used in (Fig. 5–9) required the greatest amount of extension the two studies. (between 16 and 20 degrees of elbow flexion). Among Several investigators have taken a different approach the tasks studied, the greatest amount of supination was in determining the amount of elbow and forearm motion needed for eating with a fork. Reading a newspaper (Fig. needed for activities of daily living. Vasen and associ- 5–10), pouring from a pitcher, and cutting with a knife ates27 studied the ability of 50 healthy adults to comfort- required the most pronation. ably complete 12 activities of daily living while their CHAPTER 5 THE ELBOW AND FOREARM 97 In a study published in 1949 by Hellebrandt, Duvall, and Moore,29 one therapist repeatedly measured 13 active upper extremity motions, including elbow flexion and extension and forearm pronation and supination, in 77 patients. The differences between the means of two trials ranged from 0.10 degrees for elbow extension to 1.53 degrees for supination. A significant difference between the measurements was noted for elbow flexion, although the difference between the means was only 1.0 degrees. Significant differences were also noted between measurements taken with a universal goniometer and those obtained by means of specialized devices, leading the author to conclude that different measuring devices could not be used interchangeably. The universal goniometer was generally found to be the more reliable device. Boone and colleagues30 examined the reliability of measuring six passive motions, including elbow exten- sion-flexion. Four physical therapists used universal goniometers to measure these motions in 12 normal males weekly for 4 weeks. They found that intratester reliability (r 0.94) was slightly higher than intertester reliability (r 0.88). Rothstein, Miller, and Roettger31 found high intra- tester and intertester reliability for passive ROM of FIGURE 5–8 Drinking from a cup requires about 130 degrees of elbow flexion. elbows were restricted in an adjustable Bledsoe brace. Forty-nine subjects were able to complete all of the tasks with the elbow motion limited to between 75 and 120 degrees of flexion. Subjects used compensatory motions at adjacent normal joints to complete the activities. Cooper and colleagues28 studied upper extremity motion in subjects during three feeding tasks, with the elbow unrestricted and then fixed in 110 degrees of flexion with a splint. The 19 subjects were assessed with a video- based, 3-dimensional motion analysis system while they were drinking with a handled cup, eating with a fork, and eating with a spoon. Compensatory motions to accom- modate the fixed elbow occurred to a large extent at the shoulder and to a lesser extent at the wrist. Reliability and Validity Many studies have focused on the reliability of gonio- metric measurement of elbow ROM. Most researchers have found intratester and intertester reliability of meas- uring elbow motions with a universal goniometer to be high. Comparisons between ROM measurement taken with different devices have also been conducted. Fewer studies have examined the reliability and concurrent FIGURE 5–9 Studies report that rising from a chair using the validity of measuring forearm supination and pronation upper extremities requires a large amount of elbow and wrist ROM. extension. 98 PA R T I I UPPER-EXTREMITY TESTING ment during each session. The three sessions were conducted by one physical therapist during a 2-week period. Within-session reliability was higher for the universal goniometer, as indicated by ICC values and 95 percent confidence intervals. Measurements taken with the Ortho Ranger correlated poorly with those taken with the universal goniometer (r 0.11 to 0.21), and there was a significant difference in measurements between the two devices. Goodwin and coworkers13 evaluated the reliability of a universal goniometer, a fluid goniometer, and an elec- trogoniometer for measuring active elbow ROM in 23 FIGURE 5–10 Approximately 50 degrees of pronation occur healthy women. Three testers took three consecutive during the action of reading a newspaper. readings using each type of goniometer on two occasions that were 4 weeks apart. Significant differences were elbow flexion and extension. Their study involved 12 found between types of goniometers, testers, and repli- testers who used three different commonly used universal cations. Measurements taken with the universal and fluid goniometers (large plastic, small plastic, and large metal) goniometers correlated the best (r 0.90), whereas the to measure 24 patients. Pearson product-moment corre- electrogoniometer correlated poorly with the universal lation values ranged from 0.89 to 0.97 for elbow flexion goniometer (r 0.51) and fluid goniometer (r 0.33). and extension ROM, whereas intraclass correlation coef- Intratester and intertester reliability was high during each ficient (ICC) values ranged from 0.85 to 0.95. occasion, with correlation coefficients greater than 0.98 Fish and Wingate32 found that the standard deviation and 0.90, respectively. Intratester reliability between of passive elbow ROM goniometric measurements (2.4 occasions was highest for the universal goniometer. to 3.4 degrees) was larger than the standard deviation ICC values ranged from 0.61 to 0.92 for the universal from photographic measurements (0.7 to 1.1 degrees). goniometer, 0.53 to 0.85 for the fluid goniometer, and These authors postulated that measurement error was 0.00 to 0.61 for the electrogoniometer. Similar to other due to improper identification of bony landmarks, inac- researchers, the authors do not advise the interchange- curate alignment of the goniometer, and variations in the able use of different types of goniometers in the clinical amount of torque applied by the tester. setting. Grohmann,33 in a study involving 40 testers and one Armstrong and associates34 examined the intratester, subject, found that no significant differences existed intertester, and interdevice reliability of active ROM between elbow measurements obtained by an over-the- measurements of the elbow and forearm in 38 patients. joint method for goniometer alignment and the tradi- Five testers measured each motion twice with each of the tional lateral method. Differences between the means of three devices: a universal goniometer, an electrogoniome- the measurements were less than 2 degrees. The elbow ter, and a mechanical rotation measuring device. was held in two fixed positions (an acute and an obtuse Intratester reliability was high (r values generally greater angle) by a plywood stabilizing device. than 0.90) for all three devices and all motions. Petherick and associates,12 in a study in which two Intertester reliability was high for pronation and supina- testers measured 30 healthy subjects, found that tion with all three devices. Intertester reliability for elbow intertester reliability for measuring active elbow ROM flexion and extension was high for the electrogoniometer with a fluid-based goniometer was higher than with a and moderate for the universal goniometer. universal goniometer. The Pearson product moment Measurements taken with different devices varied widely, correlation between the two devices was 0.83. A signifi- with 95 percent confidence intervals for mean device cant difference was found between the two devices. The differences of more than 30 degrees for most measures. authors concluded that no concurrent validity existed The authors concluded that meaningful changes in intrat- between the fluid-based and the universal goniometers ester ROM taken with a universal goniometer occur with and that these instruments could not be used inter- 95 percent confidence if they are greater than 6 degrees changeably. for flexion, 7 degrees for extension, and 8 degrees for Greene and Wolf11 compared the reliability of the pronation and supination. Meaningful changes in Ortho Ranger, an electronic pendulum goniometer, with intertester ROM taken with a universal goniometer occur the reliability of a universal goniometer for active upper if they are greater than 10 degrees for flexion, extension, extremity motions in 20 healthy adults. Elbow flexion and pronation, and greater than 11 degrees for supina- and extension were measured three times for each instru- tion. CHAPTER 5 THE ELBOW AND FOREARM 99 Range of Motion Testing Procedures: Elbow and Forearm Landmarks for Goniometer Alignment: Elbow and Forearm Lateral epicondyle Radial styloid process of humerus Ulnar styloid process FIGURE 5–12 Anterior view of the right upper extremity showing bony anatomical landmarks for goniometer align- FIGURE 5–11 Anterior view of the right upper extremity ment during the measurement of elbow and forearm ROM. showing surface anatomy landmarks for goniometer align- ment during the measurement of elbow and forearm ROM. Acromion process of scapula Humerus Lateral epicondyle of humerus Radial head Radial styloid Radius process Scapula Ulna Olecranon Ulnar styloid process process FIGURE 5–14 Posterior view of the right upper extremity FIGURE 5–13 Posterior view of the right upper extremity showing anatomical landmarks for goniometer alignment showing surface anatomy landmarks for goniometer align- during the measurement of elbow and forearm ROM. ment during the measurement of elbow and forearm ROM. RANGE OF MOTION TESTING PROCEDURES: ELBOW AND FOREARM 100 PA R T I I UPPER-EXTREMITY TESTING FLEXION tance to further motion is felt and attempts to overcome the resistance cause flexion of the shoulder. Motion occurs in the sagittal plane around a medial- lateral axis. Mean elbow flexion ROM ranges from 140 Normal End-feel degrees according to the AMA9 to 150 degrees according Usually the end-feel is soft because of compression of the to the AAOS.7,8 See Tables 5–1 to 5–3 for additional muscle bulk of the anterior forearm with that of the ante- information. See Figures 5–11 to 5–14. rior upper arm. If the muscle bulk is small, the end-feel may be hard because of contact between the coronoid Testing Position process of the ulna and the coronoid fossa of the humerus Position the subject supine, with the shoulder in 0 degrees and because of contact between the head of the radius of flexion, extension, and abduction so that the arm is and the radial fossa of the humerus. The end-feel may be close to the side of the body. Place a pad under the distal firm because of tension in the posterior joint capsule, the end of the humerus to allow full elbow extension. lateral and medial heads of the triceps muscle, and the Position the forearm in full supination with the palm of anconeus muscle. the hand facing the ceiling. Goniometer Alignment Stabilization See Figures 5–16 and 5–17. Stabilize the humerus to prevent flexion of the shoulder. 1. Center the fulcrum of the goniometer over the The pad under the distal humerus and the examining lateral epicondyle of the humerus. table prevent extension of the shoulder. 2. Align the proximal arm with the lateral midline of Testing Motion the humerus, using the center of the acromion process for reference. Flex the elbow by moving the hand toward the shoulder. 3. Align the distal arm with the lateral midline of the Maintain the forearm in supination during the motion radius, using the radial head and radial styloid (Fig. 5–15). The end of flexion ROM occurs when resis- process for reference. FIGURE 5–15 The end of elbow flexion ROM. The examiner’s hand stabilizes the humerus, but it must be positioned so it does not limit the motion. CHAPTER 5 THE ELBOW AND FOREARM 101 FIGURE 5–16 The alignment of the goniometer at the beginning of elbow flexion ROM. A towel is placed under the distal humerus to ensure that the supporting surface does not prevent full elbow exten- sion. As can be seen in this photograph, the subject’s elbow is in about 5 degrees of hyperextension. FIGURE 5–17 The alignment of the goniometer at the end of elbow flexion ROM. The proximal and distal arms of the goniometer have been switched from the starting position so that the ROM can be read from the pointer on the body of this 180-degree goniometer. RANGE OF MOTION TESTING PROCEDURES: ELBOW AND FOREARM 102 PA R T I I UPPER-EXTREMITY TESTING EXTENSION occurs when resistance to further motion is felt and attempts to overcome the resistance cause medial rota- Motion occurs in the sagittal plane around a medial- tion and abduction of the shoulder. lateral axis. Elbow extension ROM is not usually meas- ured and recorded separately because it is the return to Normal End-feel the starting position from the end of elbow flexion ROM. The end-feel may be hard because of contact between the ulna and the radius, or it may be firm because of tension Testing Position, Stabilization, and Goniometer in the dorsal radioulnar ligament of the inferior radioul- Alignment nar joint, the interosseous membrane, and the supinator The testing position, stabilization, and alignment are the muscle. same as those used for elbow flexion. Testing Motion Extend the elbow by moving the hand dorsally toward the examining table. Maintain the forearm in supination during the motion. The end of extension ROM occurs when resistance to further motion is felt and attempts to overcome the resistance cause extension of the shoulder. Normal End-feel Usually the end-feel is hard because of contact between the olecranon process of the ulna and the olecranon fossa of the humerus. Sometimes the end-feel is firm because of tension in the anterior joint capsule, the collateral liga- ments, and the brachialis muscle. PRONATION Motion occurs in the transverse plane around a vertical axis when the subject is in the anatomical position. When the subject is in the testing position, the motion occurs in the frontal plane around an anterior-posterior axis. Mean pronation ROM is 76 degrees according to Boone and Azen,10 and 84 degrees according to Greene and Wolf.11 Both the AMA9 and the AAOS7,8 state that pronation ROM is 80 degrees. See Tables 5–1 to 5–3 for additional ROM information. Testing Position Position the subject sitting, with the shoulder in 0 degrees of flexion, extension, abduction, adduction, and rotation so that the upper arm is close to the side of the body. Flex the elbow to 90 degrees, and support the forearm. Initially position the forearm midway between supination and pronation so that the thumb points toward the ceiling. Stabilization FIGURE 5–18 End of pronation ROM. The subject is sitting on the edge of a table and the examiner is standing facing the Stabilize the distal end of the humerus to prevent medial subject. The examiner uses one hand to hold the elbow close to rotation and abduction of the shoulder. the subject’s body and in 90 degrees of elbow flexion, helping to prevent both medial rotation and abduction of the shoulder. Testing Motion The examiner’s other hand pushes on the radius rather than on Pronate the forearm by moving the distal radius in a the subject’s hand. If the examiner pushes on the subject’s hand, volar direction so that the palm of the hand faces the movement of the wrist may be mistaken for movement at the floor. See Figure 5–18. The end of pronation ROM radioulnar joints. CHAPTER 5 THE ELBOW AND FOREARM 103 Goniometer Alignment 3. Place the distal arm across the dorsal aspect of the See Figures 5–19 and 5–20. forearm, just proximal to the styloid processes of the radius and ulna, where the forearm is most level 1. Center the fulcrum of the goniometer laterally and and free of muscle bulk. The distal arm of the proximally to the ulnar styloid process. goniometer should be parallel to the styloid 2. Align the proximal arm parallel to the anterior processes of the radius and ulna. midline of the humerus. FIGURE 5–19 The alignment of the goniometer in the begin- ning of pronation ROM. The goniometer is placed laterally to the distal radioulnar joint. The arms of the goniometer are FIGURE 5–20 Alignment of the goniometer at the end of aligned parallel to the anterior midline of the humerus. pronation ROM. The examiner uses one hand to hold the proximal arm of the goniometer parallel to the anterior midline of the humerus. The examiner’s other hand supports the forearm and assists in placing the distal arm of the goniometer across the dorsum of the forearm just proximal to the radial and ulnar styloid process. The fulcrum of the goniometer is proximal and lateral to the ulnar styloid process. RANGE OF MOTION TESTING PROCEDURES: ELBOW AND FOREARM 104 PA R T I I UPPER-EXTREMITY TESTING SUPINATION the elbow to 90 degrees, and support the forearm. Initially position the forearm midway between supination Motion occurs in the transverse plane around a longitu- and pronation so that the thumb points toward the ceil- dinal axis when the subject is in the anatomical position. ing. When the subject is in the testing position, the motion occurs in the frontal plane around an anterior-posterior Stabilization axis. Mean supination ROM is 82 degrees according to Stabilize the distal end of the humerus to prevent lateral Boone and Azen,10 and 77 degrees according to Greene rotation and adduction of the shoulder. and Wolf.11 Both the AMA9 and the AAOS7,8 state that supination ROM is 80 degrees. See Tables 5–1 to 5–3 for Testing Motion additional ROM information. Supinate the forearm by moving the distal radius in a dorsal direction so that the palm of the hand faces the Testing Position ceiling. See Figure 5–21. The end of supination ROM Position the subject sitting, with the shoulder in 0 degrees occurs when resistance to further motion is felt and of flexion, extension, abduction, adduction, and rotation attempts to overcome the resistance cause lateral rotation so that the upper arm is close to the side of the body. Flex and adduction of the shoulder. FIGURE 5–21 End of supination ROM. The examiner uses one hand to hold the elbow close to the subject’s body and in 90 degrees of elbow flexion, preventing lateral rotation and adduction of the shoulder. The examiner’s other hand pushes on the distal radius while supporting the forearm. CHAPTER 5 THE ELBOW AND FOREARM 105 Normal End-feel 2. Align the proximal arm parallel to the anterior The end-feel is firm because of tension in the palmar midline of the humerus. radioulnar ligament of the inferior radioulnar joint, 3. Place the distal arm across the ventral aspect of the oblique cord, interosseous membrane, and pronator teres forearm, just proximal to the styloid processes, and pronator quadratus muscles. where the forearm is most level and free of muscle bulk. The distal arm of the goniometer should be Goniometer Alignment parallel to the styloid processes of the radius and See Figures 5–22 and 5–23. ulna. 1. Center the goniometer medially and proximally to the ulnar styloid process. FIGURE 5–23 The alignment of the goniometer at the end of supination ROM. The examiner uses one hand to hold the FIGURE 5–22 Alignment of the goniometer at the beginning of proximal arm of the goniometer parallel to the anterior midline supination ROM. The body of the goniometer is medial to the of the humerus. The examiner’s other hand supports the fore- distal radioulnar joint, and the arms of the goniometer are arm while holding the distal arm of the goniometer across the parallel to the anterior midline of the humerus. volar surface of the forearm just proximal to the radial and ulnar styloid process. The fulcrum of the goniometer is proxi- mal and medial to the ulnar styloid process. MUSCLE LENGTH TESTING PROCEDURES: ELBOW AND FOREARM 106 PA R T I I UPPER-EXTREMITY TESTING Muscle Length Testing Procedures: the forearm in pronation. If the biceps brachii is short, it limits elbow extension when the shoulder is positioned in Elbow and Forearm full extension. If elbow extension is limited regardless of shoulder BICEPS BRACHII position, the limitation is caused by abnormalities of the The biceps brachii muscle crosses the glenohumeral, joint surfaces, shortening of the anterior joint capsule, humeroulnar, humeroradial, and superior radioulnar and collateral ligaments, or by muscles that cross only the joints. The short head of the biceps brachii originates elbow, such as the brachialis and brachioradialis. proximally from the coracoid process of the scapula (Fig. 5–24). The long head originates from the supraglenoid Starting Position tubercle of the scapula. The biceps brachii attaches Position the subject supine at the edge of the examining distally to the radial tuberosity. table. See Figure 5–25. Flex the elbow and position the When it contracts it flexes the elbow and shoulder and shoulder in full extension and 0 degrees of abduction, supinates the forearm. The muscle is passively lengthened adduction, and rotation. by placing the shoulder and elbow in full extension and Supra Glendoid Tubercle Coracoid Process Glenoid Fossa Acromion Process Long Head of the Biceps Short Head of the Biceps Radial Tuberosity Ulna Radius FIGURE 5–24 A lateral view of the upper extremity showing FIGURE 5–25 The starting position for testing the length of the origins and insertion of the biceps brachii while being the biceps brachii. stretched over the glenohumeral, elbow, and superior radioul- nar joints. CHAPTER 5 THE ELBOW AND FOREARM 107 Stabilization Goniometer Alignment The examiner stabilizes the subject’s humerus. The exam- See Figure 5–27. ining table and passive tension in the serratus anterior 1. Center the fulcrum of the goniometer over the muscle help to stabilize the scapula. lateral epicondyle of the humerus. 2. Align the proximal arm with the lateral midline of Testing motion the humerus, using the center of the acromion Extend the elbow while holding the forearm in prona- process for reference. tion. See Figures 5–26 and 5–25. The end of the testing 3. Align the distal arm with the lateral midline of the motion occurs when resistance is felt and additional ulna, using the ulna styloid process for reference. elbow extension causes shoulder flexion. Normal End-feel The end-feel is firm because of tension in the biceps brachii muscle. FIGURE 5–26 The end of the testing motion for the length of FIGURE 5–27 The alignment of the goniometer at the end of the biceps brachii. The examiner uses one hand to stabilize the testing the length of the biceps brachii. The examiner releases humerus in full shoulder extension while the other hand holds the stabilization of the humerus and now uses her hand to posi- the forearm in pronation and moves the elbow into extension. tion the goniometer. MUSCLE LENGTH TESTING PROCEDURES: ELBOW AND FOREARM 108 PA R T I I UPPER-EXTREMITY TESTING TRICEPS BRACHII contracts, it extends the shoulder and elbow. The long head of the triceps brachii is passively lengthened by plac- The triceps brachii muscle crosses the glenohumeral and ing the shoulder and elbow in full flexion. If the long humeroulnar joints. The long head of the triceps brachii head of the triceps brachii is short, it limits elbow flexion muscle originates proximally from the infraglenoid tuber- when the shoulder is positioned in full flexion. cle of the scapula (Fig. 5–28). The lateral head of the If elbow flexion is limited regardless of shoulder posi- triceps brachii originates from the posterior and lateral tion, the limitation is due to abnormalities of the joint surfaces of the humerus, whereas the medial head origi- surfaces, shortening of the posterior capsule or muscles nates from the posterior and medial surfaces of the that cross only the elbow, such as the anconeus and the humerus. All parts of the triceps brachii insert distally on lateral and medial heads of the triceps brachii. the olecranon process of the ulna. When this muscle Starting Position Position the subject supine, close to the edge of the exam- ining table. Extend the elbow and position the shoulder Medial head in full flexion and 0 degrees of abduction, adduction, and of triceps Olecranon rotation. Supinate the forearm (Fig. 5–29). process Stabilization Radius The examiner stabilizes the subject’s humerus. The Ulna weight of the subject’s trunk on the examining table and Lond head of triceps the passive tension in the latissumus dorsi, pectoralis minor, and rhomboid major and minor muscles help to Infra glenoid stabilize the scapula. tubercle Lateral head of triceps Head of humerus Scapula FIGURE 5–28 A lateral view of the upper extremity showing the origins and insertions of the triceps brachii while being stretched over the glenohumeral and elbow joints. FIGURE 5–29 The starting position for testing the length of the triceps brachii. CHAPTER 5 THE ELBOW AND FOREARM 109 Testing Motion Goniometer Alignment Flex the elbow by moving the hand closer to the shoul- See Figure 5–31. der. See Figures 5–30 and 5–28. The end of the testing 1. Center the fulcrum of the goniometer over the motion occurs when resistance is felt and additional lateral epicondyle of the humerus. elbow flexion causes shoulder extension. 2. Align the proximal arm with the lateral midline of the humerus, using the center of the acromion Normal End-feel process for reference. The end-feel is firm because of tension in the long head 3. Align the distal arm with the lateral midline of the of the triceps brachii muscle. radius, using the radial styloid process for refer- ence. FIGURE 5–30 The end of the testing motion for the length of FIGURE 5–31 The alignment of the goniometer at the end of the triceps brachii. The examiner uses one hand to stabilize the testing the length of the triceps brachii. The examiner uses one humerus in full shoulder flexion and the other hand to move the hand to continue to stabilize the humerus and align the proxi- elbow into flexion. mal arm of the goniometer. The examiner’s other hand holds the elbow in flexion and aligns the distal arm of the goniometer with the radius. 110 PA R T I I UPPER-EXTREMITY TESTING REFERENCES 18. 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