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measurement-of-joint-motion-a-guide-to-goniometry

VIEWS: 50 PAGES: 32

									  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

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Acquisitions Editor: Margaret Biblis
Manager, Creative Development: Susan Rhyner
Developmental Editor: Anne Seitz
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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-
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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
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                                 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


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