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Full text of "Measure of joint ROMs, Guide to Goniometry"

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Measurement 
of Joint Motion 

A Guide to Goniometry 






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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 



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FIRST INDIAN EDITION 20O4 
<£> 2003 by F.A. Davis Company 



84-5 



This edition has been published in India by arrangement with F.A, Davis Company, 1915 
Arch Street, Philadelphia, PA 10103- All rights reserved. No- part of this publication may be 
reproduced, stored in a retrieval system, or transmitted in any form or by any means, 
electronic, mechanical, photocopying, recording or otherwise, without prior written 
permission from the publisher. 

For Sale in India, Pakistan, Bangladesh, Burma, Bhutan and Nepal only. 

Printed in India 

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* 



To Alexandra, Taylor, and Kimberly. 

CCN 

To Jonathan, Alexander, and Ethan. 

DJW 



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Preface 



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The measurement of joint motion is an important 
component of a thorough physical examination of the 
extremities and spine, one which helps health profession- 
als identify impairments and assess rehabilitative status. 
The need for a comprehensive text with sufficient written 
detail and photographs to allow for the standardization 
of goniometric measurement methods — both for the 
purposes of teaching and clinical practice led to the 
development of the first edition of the Measurement of 
Joint Motion: A Guide to Goniometry in 1985. Our 
approach included a discussion and illustration of testing 
position, stabilization, end-feel, and goniometer align- 
ment for each measurable joint in the body. The resulting 
text was extremely well received by a variety of health 
professional educational programs and was used as a 
reference in many clinical settings. 

In the years following initial publication, a consider- 
able amount of research on the measurement of joint 
motion appeared in the literature. Consequently, in the 
second edition, which was published in 1995, we created 
a new chapter on the reliability and validity of joint 
measurement and added joint-specific research sections 
to existing chapters. We also expanded the text by adding 
structure, osteokinematics, arthrokinematics, capsular 
and noncapsular patterns of limitation, and functional 
ranges of motion for each joint. 

The expanded third edition includes new research 
findings to help clarify normative range of motion values 
for various age and gender groups, as well as the range 
of motion needed to perform common functional tasks. 
We added current information on the effects of subject 
characteristics, such as body mass, occupational and 
recreational activities, and the effects of the testing 
process, such as the testing position and type of measur- 
ing instrument, on range of motion. New to the third 
edition is the inclusion of muscle length testing at joints 
where muscle length is often a factor affecting range of 
motion. This addition integrates the measurement proce- 
dures used in this book with the American Physical 
Therapy Association's Guide to Physical Therapy 
Practice. Inclinometer techniques for measuring range of 



motion of the spine are also added to coincide with 
current practice in some clinical settings. We introduce 
illustrations to accompany anatomical descriptions so 
that the reader will have a visual reminder of the joint 
structures involved in range of motion. New illustrations 
of bony anatomical landmarks and photographs of 
surface anatomy will help the reader align the goniome- 
ter accurately. In addition, over 180 new photographs 
replace many of the older, dated photographs. 

Similar to earlier editions, the book presents goniom- 
etry logically and clearly. Chapter 1 discusses basic 
concepts regarding the use of goniometry to assess range 
of motion and muscle length in patient evaluation. 
Arthrokinemaric and osteokinematic movements, 
elements of active and passive range of motion, hypomo- 
bility, hypermobility, and factors affecting joint motion 
are included. The inclusion of end-feels and capsular and 
noncapsular patterns of joint limitation introduces read- 
ers to current concepts in orthopedic manual therapy and 
encourages them to consider joint structure while meas- 
uring joint motion. 

Chapter 2 takes the reader through a step-by-step 
process to master the techniques of goniometric evalua- 
tion, including: positioning, stabilization, instruments 
used for measurement, goniometer alignment, and the 
recording of results. Exercises that help develop neces- 
sary psychomotor skills and demonstrate direct applica- 
tion of theoretical concepts facilitate learning. 

Chapter 3 discusses the validity and reliability of 
measurement. The results of validity and reliability stud- 
ies on the measurement of joint motion are summarized 
to help the reader focus on ways of improving and inter- 
preting goniometric measurements. Mathematical meth- 
ods of evaluating reliability are shown along with 
examples and exercises so that the readers can assess 
their reliability in taking measurements. 

Chapters 4 to 13 present detailed information on 
goniometric testing procedures for the upper and lower 
extremities, spine, and temporomandibular joint. When 
appropriate, muscle length testing procedures are also 
included. The text presents the anatomical landmarks, 



VII 



Vltl 



PREFACE 



testing position, stabilization, testing motion, normal end- 
feet, and goniometer alignment for each joint and motion, 
in a format that reinforces a consistent approach to eval- 
uation. The extensive use of photographs and captions 
eliminates the need for repeated demonstrations by an 
instructor and provides the reader with a permanent 
reference for visualizing the procedures. Also included 
is information on joint structure, osteokinematic and 
arthrokinematic motion, and capsular patterns of restric- 
tions. A review of current literature regarding normal 
range of motion values; the effects of age, gender, and 
other factors; functional range of motion; and reliability 
and validity is also presented for each body region to 
assist the reader to comply with evidence-based practice. 



We hope this book makes the teaching and learning of 
goniometry easier and improves the standardization and 
thus the reliability of this assessment tool. We believe 
that the third edition provides a comprehensive coverage 
of the measurement of joint motion and muscle length. 
We hope that the additions will motivate health profes- 
sionals to conduct research and to use research results in 
evaluation. We encourage our readers to provide us with 
feedback on our current efforts to bring you a high- 
quality, user-friendly text. 

CCN 
DJW 




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Acknowledgments 



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We are very grateful for the contributions of the many 
people who were involved in the development and 
production of this text. Photographer Jocelyn Molleur 
applied her skill and patience during many sessions at 
the physical therapy laboratory at the University of 
Massachusetts Lowell to produce the high-quality photo- 
graphs that appear in this third edition. Her efforts 
combined with those of Lucia Grochowska Littlefield, 
who took the photographs for the first edition, are 
responsible for an important feature of the book. 
Timothy Malone, an artist from Ohio, used his talents, 
knowledge of anatomy, and good humor to create the 
excellent illustrations that appear in this edition. We also 
offer our thanks to Jessica Bouffard, Alexander White, 
and Claudia Van Bibber who graciously agreed to be 
subjects for some of the photographs. 

We wish to express our appreciation to these dedi- 
cated professionals at F. A Davis: Margaret Biblis, 



Publisher, and Susan Rhyner, Manager of Creative 
Development, for their encouragement, ingenuity, and 
commitment to excellence. Thanks are also extended to 
Sam Rondinelli, Production Manager; Jack Brandt, 
Illustration Specialist; Louis Forgione, Design Manager; 
Ona Kosmos, Editorial Associate; Melissa Reed, 
Developmental Associate; Anne Seitz, Freelance Editor; 
and Jean-Francois Vilain, Former Publisher. We are 
grateful to the numerous students, faculty, and clinicians 
who over the years have used the book or formally 
reviewed portions of the manuscript and offered insight- 
ful comments and helpful suggestions. 

Finally, we wish to thank our families: Cynthia's 
daughter, Alexandra, and Joyce's husband, Jonathan, 
and sons, Alexander and Ethan, for their encouragement, 
support, and tolerance of "time away" for this endeavor. 
We will always be appreciative. 



ix 



- 



Reviewers 



Suzanne Robben Brown, MPH, PT 
Associate Professor & Chair 
Department of Physical Therapy 
Arizona School of Health Sciences 
Mesa, AZ 

Larry Chinnock, PT, EdD 
Instructor/Academic Coordinator 
Department of Physical Therapy 
Loma Linda University 
School of Allied Health Professions 
Loma Linda, CA 

Robyn Colleen Davies, BHSCPT, MAPPSC, PT 

Lecturer 

Department of Physical Therapy 

University of Toronto 

Toronto, Canada 

Jodi Gootkin, PT 

Site Coordinator 

Physical Therapy Assistant Program 

Broward Community College 

Ft. Myers, FL 



Deidre Lever-Dunn, PhD, ATC 
Assistant Professor 
Department of Health Sciences 
Program Director 
Athletic Training Education 
University of Alabama 
Tuscaloosa, AL 

John T Myers, PT, MBA 
Instructor/Program Director 
Physical Therapy Assistant Program 
Lorain County Community College 
Elyria, OH 

James R. Roush, PhD, PT, ATC 
Associate Professor 
Department of Physical Therapy 
Arizona School of Health Science 
Mesa, AZ 

Sharon D. Yap, PTA, BPS 

Academic Coordinator of Clinical Education 

Physical Therapy Assistant Program 

Indian River Community College 

Fort Pierce, FL 



XI 



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PART I 

Introduction to Goniometry 

CHAPTER 1 

Basic Concepts 

GONIOMETRY 
JOINT MOTION 

Arthrokinematics 

Osteokinematics 
RANGE OF MOTION 

Active Range of Motion 

Passive Range of Motion 

Hypomobility 

Hypermobility 

Factors Affecting Range of Motion 
MUSCLE LENGTH TESTING 

CHAPTER 2 

Procedures 



.1 
.3 



POSITIONING 
STABILIZATION 
EXERCISE 1: Determining the End of the Range of 
Motion and End-feel 

MEASUREMENT INSTRUMENTS 

Universal Goniometer 

Gravity-dependent Goniometers (Inclinometers) 

Electrogoniometers 

visual Estimation 

EXERCISE 2: The Universal Goniometer 
ALIGNMENT 

EXERCISE 3: Goniometer Alignment for Elbow 
Flexion 
RECORDING 

Numerical Tables 

Pictorial Charts 

Sagittal-frontal-transverse-rotation Method 

American Medical Association Guide to Evaluation 
Method 
PROCEDURES 

Explanation Procedure 

Testing Procedure 



.17 



EXERCISE 4: Explanation of Goniometry 
EXERCISE 5: Testing Procedure for Goniometric 
Evaluation of Elbow Flexion 

CHAPTER 3 

Validity and Reliability 

VALIDITY 

Face Validity 

Content Validity 

Criterion-related Validity 

Construct Validity 
RELIABILITY 

Summary of Goniometric Reliability Studies 

Statistical Methods of Evaluating Measurement 
Reliability 

Exercises to Evaluate Reliability 

EXERCISE 6: Intratester Reliability 

EXERCISE 7: Intertester Reliability 



PART II 
Upper-Extremity Testing 

CHAPTER 4 

The Shoulder 



39 



.55 



.57 



STRUCTURE AND FUNCTION 

Gtenohumerat joint 

Sternoclavicular joint 

Acromioclavicular Joint 

Scalpulothoracic Joint 
RESEARCH FINDINGS 

Effects of Age, Gender, and Other Factors 

Functional Range of Motion 

Reliability and Validity 
RANGE OF MOTION TESTING PROCEDURES: THE 

SHOULDER 
LANDMARKS FOR GONIOMETER ALIGNMENT 

Flexion 
: Extension 



xiii 






XIV 



CONTENTS 



Abduction 

Adduction 

Medial (internal) Rotation 

Lateral (External) Rotation 

CHAPTER 5 

The Elbow and Forearm. 



.91 



STRUCTURE AND FUNCTION 

Humeroulnar and Humeroradial joints 

Superior and Inferior Radioulnar joints 
RESEARCH FINDINGS 

Effects of Age, Gender, and Other Factors 

Functional Range of Motion 

Reliability and Validity 
RANGE OF MOTION TESTING PROCEDURES: ELBOW AND 

FOREARM 
LANDMARKS FOR GONIOMETER ALIGNMENT 

Flexion 

Extension 

Pronation 

Supination 
MUSCLE LENGTH TESTING PROCEDURES: ELBOW AND 

FOREARM 

Biceps Brachii 

Triceps Brachii 



CHAPTER 
The Wrist . 



STRUCTURE AND FUNCTION 
Radiocarpal and Midcarpal Joints 

RESEARCH FINDINGS 

Effects of Age, Gender, and Other Factors 

Functional Range of Motion 

Reliability and Validity 
RANGE OF MOTION TESTING PROCEDURES: WRIST 
LANDMARKS FOR GONIOMETRiC ALIGNMENT: THE 

WRIST 

Flexion 

Extension 

Radial Deviation 

Ulnar Deviation 
MUSCLE LENGTH TESTING PROCEDURES: WRIST 

Flexor Digitorum Profundus and Flexor Digitorum 
Superficialis 

Extensor Digitorum, Extensor Indicis, and Extensor 
Digiti Minimi 

CHAPTER 7 

The Hand 



.111 



.137 



STRUCTURE AND FUNCTION 
Fingers: Metacarpophalangeal Joints 
Fingers: Proximal interphalangeal and Distal 

Interphalangeal Joints 
Thumb: Carpometacarpal Joint 
Thumb: Metacarpophalangeal Joint 
Thumb: Interphalangeal joint 



RESEARCH FINDINGS 

Effects of Age, Gender, and Other Factors 

Functional Range of Motion 

Reliability and Validity 
RANGE OF MOTION TESTING PROCEDURES: FINGERS 
LANDMARKS FOR GONIOMETER ALIGNMENT 

Metacarpophalangeal Flexion 

Metacarpophalangeal Extension 

Metacarpophalangeal Abduction 

Metacarpophalangeal Adduction 

Proximal Interphalangeal Flexion 

Proximal Interphalangeal Extension 

Distal Interphalangeal Flexion 

Distal Interphalangeal Extension 
RANGE OF MOTION TESTING PROCEDURES: THUMB 
LANDMARKS FOR GONIOMETER ALIGNMENT 

Carpometacarpal Flexion 

Carpometacarpal Extension 

Carpometacarpal Abduction 

Carpometacarpal Adduction 

Carpometacarpal Opposition 

Metacarpophalangeal Flexion 

Metacarpophalangeal Extension 

Interphalangeal Flexion 

Interphalangeal Extension 
MUSCLE LENGTH TESTING PROCEDURES: FINGERS 

Lumbricals, Palmar and Dorsal Interossei 

PART 111 

Lower-Extremity Testing 181 

CHAPTER 8 

The Hip 183 

STRUCTURE AND FUNCTION 

Iliofemoral Joint 
RESEARCH FINDINGS 

Effects of Age, Gender, and Other Factors 

Functional Range of Motion 

Reliability and Validity 
RANGE OF MOTION TESTING PROCEDURES: HIP 
LANDMARKS FOR GONIOMETER ALIGNMENT 

Flexion 

Extension 

Abduction 

Adduction 

Medial (Internal) Rotation 

Lateral (External) Rotation 
MUSCLE LENGTH TESTING PROCEDURES 

Hip Flexors (Thomas Test) 

The Hamstrings: Semitendinous, Semimembranosus, 
and Biceps Femoris (Straight Leg Test) 

Tensor Fascia Latae (Ober Test) 



CHAPTER 9 

The Knee 

STRUCTURE AND FUNCTION 
Tibiofemoral and Patellofemoral joints 



.221 



CONTENTS 



XV 



RESEARCH FINDINGS 

Effects of Age, Gender, and Other Factors 

Functional Range of Motion 

Reliability and Validity 
RANGE OF MOTION TESTING PROCEDURES: KNEE 
LANDMARKS FOR GONIOMETER ALIGNMENT 

Flexion 

Extension 
MUSCLE LENGTH TESTING PROCEDURES: KNEE 

Rectus Femoris: Ely Test 

Hamstring Muscles: Semitendinosus, Semimembranosus, 
and Biceps Femoris: Distal Hamstring Length Test 



CHAPTER 10 

The Ankle and Foot 



.241 



STRUCTURE AND FUNCTION 

Proximal and Distal Tibiofibular joints 

Talocrural Joint 

Subtalar Joint 

Transverse Tarsal (Midtarsal) Joint 

Tarsometatarsal joints 

Metatarsophalangeal Joints 

Interphalangeal Joints 
RESEARCH FINDINGS 

Effects of Age, Gender, and Other Factors 

Functional Range of Motion 

Reliability and Validity 
RANGE OF MOTION TESTING PROCEDURES: ANKLE 

AND FOOT 
LANDMARKS FOR GONIOMETER ALIGNMENT: 

TALOCRURAL JOINT 

Dorsiflexion: Talocrural Joint 

Plantarflexion: Talocrural Joint 
LANDMARKS FOR GONIOMETER ALIGNMENT: TARSAL 

JOINTS 

inversion: Tarsal joints 

Eversion: Tarsal Joints 
LANDMARKS FOR GONIOMETER ALIGNMENT: SUBTALAR 

JOINT (REARFOOT) 

Inversion: Subtalar joint (Rearfoot) 

Eversion: Subtalar Joint (Rearfoot) 

Inversion: Transverse Tarsal Joint 

Eversion: Transverse Tarsal Joint 
LANDMARKS FOR GONIOMETER ALIGNMENT: 

METATARSOPHALANGEAL JOINT 

Flexion: Metatarsophalangeal Joint 

Extension: Metatarsophalangeal Joint 

Abduction: Metatarsophalangeal Joint 

Adduction and Metatarsophalangeal Joint 

Flexion: Interphalangeal Joint of the First Toe and 
Proximal Interphalangeal Joints of the Four Lesser Toes 

Extension: Interphalangeal Joint of the First Toe and 
Proximal Interphalangeal joints of the Four Lesser Toes 

Flexion: Distal Interphalangeal Joints of the Four Lesser 
Toes 

Extension: Distal Interphalangeal Joints of the Four 
Lesser Toes 
MUSCLE LENGTH TESTING PROCEDURES: 

Gastrocnemius 



PART IV 

Testing of the Spine and 
Temporomandibular Joint 



.293 



CHAPTER 1 1 

The Cervical Spine 

STRUCTURE AND FUNCTION 

Atlanto-occipital and Atlantoaxial joints 

Intervertebral and Zygapophyseal Joints 
RESEARCH FINDINGS 

Effects of Age, Gender, and Other Factors 

Functional Range of Motion 

Reliability and Validity 
RANGE OF MOTION TESTING PROCEDURES: 

CERVICAL SPINE 
LANDMARKS FOR GONIOMETER ALIGNMENT 

Flexion 

Extension 

Lateral Flexion 

Rotation 



CHAPTER 1 2 

The Thoracic and Lumbar Spine 

STRUCTURE AND FUNCTION 

Thoracic Spine 

Lumbar Spine 
RESEARCH FINDINGS 

Effects of Age, Gender, and Other Factors 

Functional Range of Motion 

Reliability and Validity 
RANGE OF MOTION TESTING PROCEDURES 
ANATOMICAL LANDMARKS: FOR TAPE MEASURE 

ALIGNMENT 

Thoracic and Lumbar Flexion 

Lumbar Flexion 

Thoracic and Lumbar Extension 

Lumbar Extension 

Thoracic and Lumbar Lateral Flexion 

Thoracic and Lumbar Rotation 



.295 



.331 



CHAPTER 1 3 

The Temporomandibular Joint ,365 

STRUCTURE AND FUNCTION 

Temporomandibular Joint 
RESEARCH FINDINGS 

Effects of Age, Gender, and Other Factors 

Reliability and Validity 
RANGE OF MOTION TESTING PROCEDURES: 

TEMPOROMANDIBULAR JOINT 
LANDMARKS FOR RULER ALIGNMENT MEASURING 

Depression of the Mandible (Mouth Opening) 

Protrusion of the Mandible 

Lateral Deviation of the Mandible 



XVI 



CONTENTS 



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APPENDIX A 

Normative Range of Motion 

Values 



.375 



APPENDIX B 

Joint Measurements by Body 

Position . 



.381 



APPENDIX C 

Goniometer Price Lists 383 

APPENDIX D 

Numerical Recording Forms 387 

Index 393 



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Objectives 



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ON COMPLETION OF PART 1 THE READER WILL BE ABLE TO: 

5. Describe the parts of universal, fluid, and 



1, Define: 



gomometry 

planes and axes 

range of motion 

end-feel 

muscle length testing 

reliability 

validity 

Identify the appropriate planes and axes for 
each of the following motions: 

flexion-extension, abduction-adduction, and 
rotation 

Compare: 

active and passive ranges of motion 
arthrokinematie and osteokinematic motions 
soft, firm, and hard end-feels 
hypomobility and hypermobility 
capsular and noncapsular patterns of 

restricted motion 
one-, two-, and multijqinc muscles 
reliability and validity 
intratester and intertester reliability 



4. Explain the importance of: 



testing positions 

stabilization 

clinical estimates of range of motion 

recording starting and ending positions 



pendulum goniometers 

6. List: 

the six-step explanation sequence 

the 12-step testing sequence 

the 10 items included in recording 

7. Perform a goniometric evaluation of the 
elbow joint including: 

a clear explanation of the procedure 
positioning of a subject in the testing position 
adequate stabilization of the proximal joint 

component 
a correct determination of the end of the range 

or motion 
a correct identification of the end-feel 
palpation of the cotrecc bony landmarks 
accurate alignment of the goniometer 
correct reading of the goniometer and record- 
ing of the measurement 

8. Perform and interpret intratester and 
intertester reliability tests including standard 
deviation, coefficient of variation, correlation 
coefficients, and standard error of measure- 
ment. 



r 



CHAPTER 1 



Basic Concepts 




This book is designed to serve as a guide to learning the 
technique of human joint measurement called goniome- 
try. Background information on principles and proce- 
dures necessary for an understanding of goniometry is 
found in Part 1. Practice exercises are included at appro- 
priate intervals to help the examiner apply this informa- 
tion and develop the psychomotor skills necessary for 
competency in goniometry. Procedures for the goniomet- 
ric examination of joints and muscle length testing of the 
upper extremity, lower extremity, and spine and 
temporomandibular joint are presented in Parts 2, 3, and 
4, respectively. 

SK Goniometry 

The term go niometry is derived from two Greek words ,, 
Jjonia, meaning angle, and_ metron y meaning measure . 



Therefore, goniometry refers to the measurem ent of^ 
angles, in p articular t he measurement of angles c reated at 
human joints by the bones of the body. The examiner 
obtains these measurements by placing the parts of the 
measuring instrument, called a goniometer, along the 
bones immediately proximal and distal to the joint being 
evaluated. Goniometry may be used to determine both a 
particular joint position and the total amount of motion 
available at a joint. 



Example: The elbow joint is evaluated by placing 
the parrs of the measuring instrument on the 
humerus (proximal segment) and the fore- 
arm (distal segment) and measuring either a 
specific joint position or the total arc of motion 




■"29fa.ttmm, 



FIGURE 1-1 The upper left 
extremity of a subject in the 
supine position is shown. The 
parts of the measuring instru- 
ment have been placed along 
the proximal (humerus) and 
distal (radius) components 
and centered over the axis of 
the elbow joint. When the 
distal component has been 
moved toward the proximal 
component (elbow flexion), a 
measurement of the arc of 
motion can be obtained. 



PART I INTRODUCTION TO GONIOMETRV 



Goniometry is an important part of a comprehensive 
examination of joints and surrounding soft tissue. A 
comprehensive examination typically begins by inter- 
viewing the subject and reviewing records to obtain an 
accurate description of currenr symptoms; functional 
abilities; occupational, social and recreational activities; 
and medical history. Observation of the body to assess 
bone and soft tissue contour, as well as skin and nail 
condition, usually follows the interview. Gentle palpation 
is used to determine skin temperature and the quality of 
soft tissue deformities and to locate pain symptoms in 
relation to anatomical structures. Anthropometric mea- 
surements such as leg length, circumference, and body 
volume may be indicated. 

The performance of active joint motions by the subject 
during the examination allows the examiner to screen for 
abnormal movements and gain information about the 
subject's willingness to move. If abnormal active motions 
are found, the examiner performs passive joint motions 
in an attempt to determine reasons for joint limitation. 
Performing passive joint motions enables the examiner to 
assess the tissue that is limiting the motion, detect pain, 
and make an estimate of the amount of motion. 
Goniometry is used to measure and document the 
amount of active and passive joint motion as well as 
abnormal fixed joint positions. Resisted isometric muscle 
contractions, joint integrity and mobility tests, and 
special tests for specific body regions are used in conjunc- 
tion with goniometry to help identify the injured anatom- 
ical structures. Tests to assess muscle performance and 
neurological function are often included. Diagnostic 
imaging procedures and laboratory tests may be 
required. 

Goniometric data used in conjunction with other 
information can provide a basis for: 

• Determining the presence or absence of impairment 

• Establishing a diagnosis 

• Developing a prognosis, treatment goals, and plan 
of care 

• Evaluating progress or lack of progress toward 
rehabilitative goals 

• Modifying treatment 

• Motivating the subject 

• Researching the effectiveness of therapeutic tech- 
niques or regimens; for example, exercises, medica- 
tions, and surgical procedures 

• Fabricating orthoses and adaptive equipment 

Sfi Joint Motion 

Arthrokinematks 

Motion at a joint occurs as the result of movement of one 
joint surface in relation to another. Arthrokinematks is 
the term used to refer to the movement of joint surfaces. 
The movements of joint surfaces are described as slides 



(glides!, spins, and rolls. 1 A slide (glide), which is a trans- 
latory motion, is the sliding of one joint surface over 
another, as when a braked wheel skids. A spin is a rotary 
(angular) motion, similar to the spinning of a toy top. Ail 
points on the moving joint surface rotate at a constant 
distance around a fixed axis of motion. A roll is a rotary 
motion similar to the rolling of the bottom of a rocking 
chair on the floor, or the roiling of a tire on the road. In 
the human body, glides, spins, and rolls usually occur in 
combination with each other and result in movement of 
the shafts of the bones. 

Osteokinematics 

Osteokincmatics refers to the movement of the shafts of 
bones rather than the movement of joint surfaces. The 
movements of the shafts of hones are usually described in 
terms of the rotary morion produced, as it the movement 
occurs around a fixed axis of motion. Goniometry mea- 
sures the angles created by the rotary motion of the shafts 
of the bones. However, some translator)' motion usually 
accompanies rotary motion and creates a slightly chang- 
ing axis of motion during movement. Nevertheless, most 
clinicians find the description of osteokinematic move- 
ment in terms of rotary motion sufficiently accurate and 
use goniometry to measure osteokinematic movements. 

Planes and Axes 

Osteokinematic motions are classically described as 
raking place in one of the three cardinal planes of the 
body (sagittal, frontal, transverse) around three corre- 
sponding axes (medial-lateral, anterior-posterior, verti- 
cal). The three planes lie at right angles to one another, 
whereas the three axes lie at right angles both to one 
another and to their corresponding planes. 

The sagittal plane proceeds from the anterior to the 
posterior aspect of the body. The median sagittal plane 
divides the body into right and left halves. The motions 
of flexion and extension occur in the sagittal plane (Fig. 
1-2). The axis around which the motions of flexion and 
extension occur may be envisioned as a line that is 
perpendicular to the sagittal plane and proceeds from 
one side of the body to the other. This axis is called a 
medial-lateral axis. All motions in the sagittal plane take 
place around a medial-lateral axis. 

The frontal plane proceeds from one side of the body 
to the other and divides the body into front and back 
halves. The motions that occur in the frontal plane are 
abduction and adduction {Fig, 1-3). The axis around 
which the motions of abduction and adduction take 
place is an anterior-posterior axis. This axis lies at right 
angles to the frontal plane and proceeds from the ante- 
rior to the posterior aspect of the body. Therefore, the 
anterior-posterior axis lies in the sagittal plane. 

The transverse plane is horizontal and divides the 
body into upper and lower portions. The motion of rota- 



CHAPTER 1 BASIC CONCEPTS 



Medial-lateral axis 



Sagittal 
plane 

A 




FIGURE 1-2 The shaded areas indicate the sagittal plane. This 
plane extends from the anterior aspect of the body to the poste- 
rior aspect. Motions in this plane, such as flexion and exten- 
sion of the upper and tower extremities, take place around a 
medial-lateral axis 




Anterior - posterior 

axis 



FIGURE 1-3 The frontal plane, indicated by the shaded area, 

extends from one side of the body to the other. Motions in this 
plane, such as abduction and adduction of the upper and lower 
extremities, take place around an anterior-posterior axis. 



tion occurs in the transverse plane around a vertical axis 
(Fig. 1-4A and B). The vertical axis lies at right angles to 
the transverse plane and proceeds in a cranial to caudal 
direction. 

The motions described previously are considered to 
occur in a single plane around a single axis. Combination 



motions such as circumduction (flexion-abduction-exten- 
sion-adduction) are possible at many joints, but because 
of the limitations imposed by the uniaxial design of the 
measuring instrument, only motions occurring in a single 
plane are measured in goniornetry. 

The type of motion that is available at a joint varies 



Vertical axis 

4 



Transverse 
plane 




Vertical 

axis 



r> 




FIGURE 1-4 (A) The trans- 
verse plane is indicated by the 
shaded area. Movements in 
this plane take place around a 
vertical axis. These motions 
include rotation of the head 
(B), shoulder, [A), and hip, as 
well as pronation and supina- 
tion of the forearmJ 



PART t INTRODUCTION TO CONIOMETRY 



according to the structure of the joint. Some joints, such 
as the interphalangeal joints of the digits, permit a large 
amount of motion in only one plane around a single axis: 
flexion and extension in the sagittal plane around a 
medial-lateral axis. A joint that allows motion in only 
one plane is described as having 1 degree of freedom of 
motion. The interphalangeal joints of the digits have 1 
degree of freedom of motion. Other joints, such as the 
glenohumeral joint, permit motion in three planes 
around three axes: flexion and extension in the sagittal 
plane around a medial-lateral axis, abduction and adduc- 
tion in the frontal plane around an anterior-posterior 
axis, and medial and lateral rotation in the transverse 
plane around a vertical axis. The glenohumeral joint has 
three degrees of freedom of motion. 

The planes and axes for each joint and joint motion to 
be measured are presented for the examiner in Chapters 
4 through 13. 

BE Range of Motion 

Range of morion (ROM) is the arc of motion that occurs 
at a joint or a series of joints. 2 The starting position for 
measuring all ROM, except rotations in the transverse 
plane, is the anatomical position. Three notation systems 
have been used to define ROM: the 0- to 180-degree 
system, the 180- to 0-degree system, and the 360-degree 
system. 

In the 0- to 180-degree notation system, the upper 
and lower extremity joints are at degrees for flexion- 
extension and abduction-adduction when the body is 
in anatomical position (Fig. 1-5A). A body position in 
which the extremity joints are halfway between medial 
(internal) and lateral (external) rotation is degrees 
for the ROM in rotation (Fig. 1-5B). An ROM normally 
begins at degrees and proceeds in an arc toward 180 
degrees. This 0- to 180-degree system of notation, 
also called the neutral zero method, is widely used 
throughout the world. First described by Silver 3 in 
1923, its use has been supported by many authorities, 
including Cave and Roberts, 4 Moore, 5,6 the American 
Academy of Orthopaedic Surgeons, 7 ' 8 and the American, 
Medical Association. 9 



Example: The ROM for shoulder flexion, which 
begins with the shoulder in the anatomical position 
(0 degrees) and ends with the arm overhead in full 
flexion (180 degrees), is expressed as to 180 
degrees. ' 

In the preceding example, the portion of the extension 
ROM from full shoulder flexion back to the zero starting 
position does not need to be measured because this ROM 
represents the same arc of motion that was measured in 
flexion. However, the portion of the extension ROM that 
is available beyond the zero starting position must be 




FIGURE 1-5 {A) In the anatomical position, the forearm is 
supinated so that the palms of the hands face anteriorly. (B) 
When the forearm is in a neutral position (with respect to rota- 
tion), the palm of the hand faces the side of the body. 

measured (Fig. 1—6). Documentation of extension ROM 
usually incorporates only the extension that occurs 
beyond the zero starting position. The term extension, as 
it is used in this manual, refers to both the motion that is 
a return from full flexion to the zero starting position 
and the motion that normally occurs beyond the zero 
starting position. The term hyperextension is used to 
describe a greater than normal extension ROM. 

Two other systems of notation have been described. 
The 180- to 0-degree notation system defines anatomical 
position as 180 degrees. 10 An ROM begins at 180 
degrees and proceeds in an arc toward degrees. The 
360-degree notation system also defines anatomical posi- 
tion as 180 degrees. n ' 12 The motions of flexion and 
abduction begin ac 180 degrees and proceed in an arc 
toward degrees. The motions of extension and adduc- 
tion begin at 180 degrees and proceed in an arc toward 
360 degrees. These two notation systems are more diffi- 
cult to interpret than the 0- to 180-degree notation 
system and are infrequently used. Therefore, we have not 
included them in this text. 



Active Range of Motion 

Active range of motion is the arc of motion attained by a 
subject during unassisted voluntary joint motion. Having 



CHAPTER 1 



BASIC CONCEPTS 



lrm is 

iy- (B) 

> rota- 



SIOM 

•ccurs 
an, as 
hat is 
sition 
: zero 
ed to 

fibed. 
tmical 
t 180 
.. The 
i posi- 
\i and 
in arc 
dduc- 
jward 
! dic- 
tation 
ve not 




d by a 
Saving 



*'0/> 



FIGURE 1-6 Shoulder flexion and extension. Flexion begins 
with the shoulder in the anatomical position and the forearm 
in the neutral position. The ROM in flexion proceeds from the 
zero position through an arc of 180 degrees. The long, bold 
arrow shows the ROM in flexion, which is measured in 
goniometry. The short, bold arrow shows the ROM in exten- 
sion, which is measured in goniometry. 



a subject perform active ROM provides the examiner 
with information about the subject's willingness to move, 
coordination, muscle strength, and joint ROM. If pain 
occurs during active ROM, it may be due to contracting 
or stretching of "contractile" tissues, such as muscles, 
tendons, and their attachments to bone. Pain may also be 
due to stretching or pinching of noncontractile (inert) 
tissues, such as ligaments, joint capsules, bursa, fascia, 
and skin. Testing active ROM is a good screening tech- 
nique to help focus a physical examination. If a subject 
can complete active ROM easily and painlessly, further 
testing of that motion is probably not needed. If, 
however, active ROM is limited, painful, or awkward, 
the physical examination should include additional test- 
ing to clarify the problem. 



Passive Range of Motion 

Passive range of motion is the arc of motion attained by 
an examiner without assistance from the subject. The 
subject remains relaxed and plays no active role in 
producing the motion. Normally passive ROM is slightly 
greater than active ROM 13 ' 14 because each joint has a 
small amount of available motion that is not under 
voluntary control. The additional passive ROM that is 
available at the end of the normal active ROM is due to 
the stretch of tissues surrounding the joint and the 
reduced bulk of relaxed muscles. This additional passive 
ROM helps to protect joint structures because it allows 
the joint to absorb extrinsic forces. 

Testing passive ROM provides the examiner with 
information about the integrity of the articular surfaces 
and the extensibility of the joint capsule, associated liga- 
ments, muscles, fascia, and skin. To focus on these issues, 
passive ROM rather than active ROM should be tested 
in goniometry. Unlike active ROM, passive ROM does 
not depend on the subject's muscle strength and coordi- 
nation. Comparisons between passive ROMs and active 
ROMs provide information about the amount of motion 
permitted by the joint structure (passive ROM) relative 
to the subject's ability to produce motion at a joint 
(active ROM). In cases of impairment such as muscle 
weakness, passive ROMs and active ROMs may vary 
considerably. 

Example: An examiner may find that a subject with 
a muscle paralysis has a full passive ROMNjut no 
active ROM at the same joint. In this instance, the : 
joint surfaces and the extensibility of the joint 
capsule, ligaments, and muscles are sufficient to ; 
allow foil passive ROM. The lack of muscle 
strength is prevents active motiQn at the joint. .: ■ 

The examiner should test passive ROM prior to 
performing a manual muscle test of muscle strength 
because the grading of manual muscle tests is based on 
completion of a joint ROM. An examiner must know the 
extent of the passive ROM before initiating a manual 
muscle test. 

If pain occurs during passive ROM, it is often due to 
moving, stretching, or pinching of noncontractile (inert) 
structures. Pain occurring at the end of passive ROM 
may be due to stretching of contractile structures as well 
as noncontractile structures. Pain during passive ROM is 
not due to active shortening (contracting) of contractile 
tissues. By comparing which motions (active versus 
passive) cause pain and noting the location of the pain, 
the examiner can begin to determine which injured 
tissues are involved. Having the subject perform resisted 
isometric muscle contractions midway through the 
ROM, so that no tissues are being stretched, can help 
to isolate contractile structures. Having the examiner 



8 



PART I INTRODUCTION TO GONIOMETRY 



table i-i Normal End-feets 



£nd'fee$: 



Structure 



Example 



Soft 
Firm 



Hard 



Soft tissue approximation 
Muscular stretch 
Capsular stretch 
Ligamentous stretch 

Bone contacting bone 



■V . - : ' . :::;■■ 



Knee flexion (contact between soft tissue of posterior teg and posterior thigh) 
Hip flexion with the knee straight (passive elastic tension of hamstring muscles) 
Extension of metacarpophalangeal joints of fingers (tension in the anterior capsule) 
Forearm supination (tension in/the palmar radioulnar ligament of the inferior 

radioulnar joint, interosseous membrane, oblique cord) 
Elbow extension (contact between the olecranon process of the ulna and the 

olecranon fossa of the humerus) 



perform joint mobility and joint integrity tests on the 
subject can help determine which noncontractile struc- 
tures are involved. Careful consideration of the end-feel 
and location of tissue tension and pain during passive 
ROM also adds information about structures that are 
limiting ROM. 

End-feel 

The amount of passive ROM is determined by the unique 
structure of the joint being tested. Some joints are struc- 
tured so that the joint capsules limit the end of the ROM 
in a particular direction, whereas other joints are so 
structured that ligaments limit the end of a particular 
ROM. Other normal limitations to motion include 
passive tension in soft tissue such as muscles, fascia, and 
skin, soft tissue approximation, and contact of joint 
surfaces. 

The type of structure that limits a ROM has a charac- 
teristic feel that may be detected by the examiner who is 
performing the passive ROM. This feeling, which is 
experienced by an examiner as a barrier to further 
motion at the end of a passive ROM, is called the 
end-feel. Developing the ability to determine the charac- 
ter of the end-feel requires practice and sensitivity. 
Determination of the end-feel must be carried out slowly 
and carefully to detect the end of the ROM and to distin- 
guish among the various normal and abnormal end-feels. 
The ability to detect the end of the ROM is critical to the 



table 1-2 Abnormal End-feels 



, 



feet 



safe and accurate performance of goniomerry. The ability 
to distinguish among the various end-feels helps the 
examiner identify the type of limiting strucrure. Cyriax, 15 
Kaltenborn, 16 and Paris' 7 have described a variety of 
normal (physiological) and abnormal (pathological) end- 
feels. 18 Table 1-1, which describes normal end-feels, and 
Table 1-2, which describes abnormal end-feels, have 
been adapted from the works of these authors. 

In Chapters 4 through 13 we describe what we believe 
arc the normal end-feels and the structures that limit the 
ROM for each joint and motion. Because of the paucity 
of specific literature in this area, these descriptions are 
based on our experience in evaluating joint motion and 
on information obtained from established anatomy 19,20 
and biomechanics texts~'~ 27 There is considerable 
controversy among experts concerning the structures 
that limit the ROM in some parts of the body. Also, 
normal individual variations in body structure may cause 
instances in which the end-feel differs from our descrip- 
tion. 

Examiners should practice trying to distinguish 
among the end-feels. In Chapter 2, Exercise 1 is included 
for this purpose. However, some additional topics 
regarding positioning and stabilization must be 
addressed before this exercise can be completed. 

Hypomobility 

The term hypomobility refers to a decrease in passive 



ixampks 



Soft 

"" ' 

Firm 
Hard 



Empty 



Occurs sooner or later in the ROM than is usual, or in a 

joint that normally has a firm or hard end-feel. Feels 

boggy. 
Occurs sooner or later in the ROM than is usual, or in a 

joint that normally has a soft or hard end-feel. 
Occurs sooner or later in the ROM than is usual or in a 

joint that normally has a soft or firm end-feel. 

A bony grating or bony block is felt. 



No real end-feel because pain prevents reaching end of 

ROM. No resistance is feft except for patient's protec- 
tive muscle splinting or muscle spasm. 



Soft tissue edema 
Synovitis 

Increased muscular tonus 

Capsular, muscular, ligamentous, and fascia? shortening 

Chondromalacia ,; ■; 

Osteoarthritis , ; ^; : 

Loose bodies in joint 

Myositis ossificans 

Fracture 

Acute joint inflammation 

Bursitis: 

Abscess 

Fracture- : / ;''.'"• ■; : ; : T; '.'■/..-.■.■,''' '■'>'■■':, //v^'v:' :'!■■■■ 

Psychogenic disorder ■'?/!> '!v' '^ : : V--v ; ' 



ROM 
that jc 

occurs 
ity fr< 

ROM 
maiitii 
joint 5 
well a 
has b 
such ; 
spina! 
conse 
scar c 
tions 
also i 
move 
In ad 
been 

Cap! 

Cyrij 

invol 

parte 
mo tii 
a cap 
numl 
prop 



Glen 



m 

;Fore 



:Wris 



Han 
C 

c 



Hip 



Kn< 

:Anj 
Sui 

Mil 
Fo< 



Ad: 



CHAPTER 1 BASIC CONCEPTS 



hty 
the 

of 
nd- 
and 
ave 

tove 
the 

city 
are 

and 

i<>,20 



ROM that is substantially less than normal values for 
that joint, given the subject's age and gender. The end-feel 
occurs earlier in the ROM and may be different in qual- 
ity from what is expected. The limitation in passive 
ROM may be due to a variety of causes including abnor- 
malities of the joint surfaces or passive shortening of 
joint capsules, ligaments, muscles, fascia, and skin, as 
well as inflammation of these structures. Hypomobility 
has been associated with many orthopedic conditions 
such as osteoarthritis, 28,29 adhesive capsulitis, 30,31 and 
spinal disorders. 32 ' 33 Decreased ROM is a common 
consequence of immobilization after fractures 34 ' 35 and 
scar development after burns. 36 ' 37 Neurological condi- 
tions such as stroke, head trauma, and cerebral palsy can 
also result in hypomobility owing to loss of voluntary 
movement, increased muscle tone, and immobilization. 
In addition, metabolic conditions such as diabetes have 
been associated with limited joint motion. 38 ' 39 

Capsular Patterns of Restricted Motion 

Cyriax 15 has proposed that pathological conditions 
involving the entire joint capsule cause a particular 
pattern of restriction involving all or most of the passive 
motions of the joint. This pattern of restriction is called 
a capsular pattern. The restrictions do not involve a fixed 
number of degrees for each motion, but rather, a fixed 
proportion of one motion relative to another motion. 



Example: The capsular pattern for the elbow joint 
is a greater limitation of flexion than of extension. 
The elbow joint normally has a passive flexion 
ROM of to 150 degrees. If the capsular involve- 
ment is mild, the subject might lose the last 15 
degrees of flexion and the last 5 degrees of exten- 
sion so that the passive flexion ROM is 5 to 135 
degrees. If the capsular involvement is more severe, 
the subject might lose the last 30 degrees of flexion 
and the first 10 degrees of extension so that the 
passive flexion ROM is 10 to 120 degrees. 

Capsular patterns vary from joint to joint (Table 1-3). 
The capsular pattern for each joint, as presented by 
Cyriax 15 and Kalrenborn, 16 is listed at the beginning of 
Chapters 4 through 13. Studies are needed to test the 
hypotheses regarding the cause of capsular patterns and 
to determine the capsular pattern for each joint. Studies 
by Fritz and coworkers, 41 and Hayes and colleagues 42 
have examined the construct validity of Cyriax's capsular 
pattern in patients with arthritis or arthrosis of the 
knee. Although differing opinions exist, the findings 
seem to support the concept of a capsular pattern of 
restriction for the knee but with more liberal interpreta- 
tion of the proportions of limitation than suggested by 
Cyriax. 15 



table 1-3 Capsular Patterns of Extremity Joints 



issive 



Cteaohicroerai jo r 

Elbow complex (humeroulnar, humeroradial, proxi- 

ma re lio ■-. •• joii ' ;) 
Forearm (proximal and distal radioulnar joints) 

Wrist (radiocarpal and midcarpal joints) 



Hand 



etacarpal joint — digit 1- 



Carpometacarpal joint— digits 2-5 
Metacarpophalangeal and interpbalangeal joints 



Knee (tibiofemoral joint) 
AnWe (talocrural joint) 
Subtalar joint 

" - ■'. ai join! 

~*M. 

arsophalangeal joint— digit 1 
itarxaprntiangeai joint — digits 2-5 
'"to phalangeal joints 

V%/ted from Cyriax, 15 Kaltenborn, 17 and Dyrek. 40 



Greatest loss of lateral rotation, moderate loss of abduction, minimal ioss of 

media! rotation. ■ 

Loss of flexion greater than loss of extension. Rotations full and painless except 

=n i dv i • -..' • a es 
Equal ioss of supination and. pronation, pr;ty:occ.i!rring.i? elbow has fnairfed : 

;- strict! -. s si isxion i , ixten i 
.Equal fcsi of fiexion and extension,- sli'ght'ioss of ulnar and radial deflation'.-. 

(Cyriax). 
Equal loss of al! motions (Kaltenborn). 

Loss of abduction (Cyriax). Loss of abduction greater than extension 

(Kaitenbom). 
Equal ioss of aii motions. 

,, -< to . - ,- I xios ande ten oi Cyrl . 
Restricted in all motions, but loss of flexion greater than loss of other motions 

*;;|KajtenBQr^i 

.'Greatest toss of medial rotation, and flexion, some' toss of .abduction, slight loss 

of extension, tittle of no lass of adduction and iatera! rotation (Cyriax). 
Greatest toss of medial rotation, followed by iess restriction of extension, 

.;-,.--', i,- n a d'ai • : • ion (Kail '■ • rn 
Loss of flexion greater than extension. 

■ Fplan flexion greater '•• n doi ■' & '•< 
Loss of inversion (varus). 
Loss of inversion (adduction and medial rotation); other motions full. 

Loss of extension greater than flexion,. .-.....-. . _\ ,'■-.-.. \ ' i .:■.; 
! ..• of lexio'n greatei t la < exte ision. 
Loss of i ensicm greates '■>- fexton 



10 



PART I INTRODUCTION TO CONIOMETRY 



Hertling and Kessler 43 have thoughtfully extended 
Cyriax's concepts on causes of capsular patterns. They 
suggest that conditions resulting in a capsular pattern of 
restriction can be classified into two genera! categories: 
"{1) conditions in which there is considerable joint effu- 
sion or synovial inflammation, and (2) conditions in 
which there is relative capsular fibrosis." 43 

Joint effusion and synovial inflammation accompany 
conditions such as traumatic arthritis, infectious arthri- 
tis, acute rheumatoid arthritis, and gout. In these condi- 
tions the joint capsule is distended by excessive 
intra-articular synovial fluid, causing the joint to main- 
tain a position that allows the greatest intra-articular 
joint volume. Pain triggered by stretching the capsule and 
muscle spasms that protect the capsule from further 
insult inhibit movement and cause a capsular pattern of 
restriction. 

Relative capsular fibrosis often occurs during chronic 
low-grade capsular inflammation, immobilization of a 
joint, and the resolution of acute capsular inflammation. 
These conditions increase the relative proportion of 
collagen compared with that of mucopolysaccharide in 
the joint capsule, or they change the structure of the 
collagen. The resulting decrease in extensibility of the 
entire capsule causes a capsular pattern of restriction. 

Noncapsular Patterns of Restricted Motion 

A limitation of passive motion that is not proportioned 
similarly to a capsular pattern is called a noncapsular 
pattern of restricted motion. 15,43 A noncapsular pattern 
is usually caused by a condition involving structures 
other than the entire joint capsule. Internal joint 
derangement, adhesion of a part of a joint capsule, 
ligament shortening, muscle strains, and muscle contrac- 
tures are examples of conditions that typically result 
in noncapsular patterns of restriction. Noncapsular 
patterns usually involve only one or two motions of a 
joint, in contrast to capsular patterns, which involve all 
or most motions of a joint. 

Example: A strain of the biceps muscle may result 
in pain and restriction at the end of the range of ,;■ 
passive elbow extension. The passive motion of 
s eibow, flexiori would -not beartected. 



Hypermobility 

The term hypermobility refers to an increase in passive 
ROM that exceeds normal values for that joint, given the 
subject's age and gender. For example, in adults the 
normal ROM for extension at the elbow joint of the 
fingers is about degrees.* 5 An ROM measurement of 90 
degrees or more of extension at the elbow is well beyond 
the average ROM and is indicative of a hypermobile 
joint in an adult. Children have some normally occurring 



specific instances of increased ROM as compared with 
adults. For example, neonates 6 to 72 hours old have 
been found to have a mean ankle dorsiflexion passive 
ROM of 59 degrees, 44 which contrasts with the mean 
adult ROM of between 12 45 and 20 7 degrees. The 
increased motion that is present in these children is 
normal for their age. If the increased motion should 
persist beyond the expected age range, it would be 
considered abnormal and hypermobility would be pres- 
ent. 

Hypermobility is due to the laxity of soft tissue struc- 
tures such as ligaments, capsules, and muscles that 
normally prevent excessive motion at a joint. In some 
instances the hypermobility may be due to abnormalities 
of the joint surfaces. A frequent cause of hypermobility is 
trauma to a joint. Hypermobility also occurs in serious 
hereditary disorders of connective tissue such as Ehlers- 
Danlos syndrome, Marfan syndrome, rheumatoid arthri- 
tis, and osteogenesis imperfecta. One of the typical 
physical abnormalities of Down syndrome is hypermo- 
bility. In this instance generalized hypotonia is thought 
to be an important contributing factor to the hypermo- 
bility. 

Hypermobility syndrome (HMS) or benign joint 
hypermobility syndrome (BjHS) is used to describe 
otherwise healthy individuals who have generalized 
hypermobility accompanied by musculoskeletal symp- 
toms. 46 ' 47 An inherited abnormality in collagen is 
thought to be responsible for the joint laxity in these 
individuals. 48 Traditionally, the diagnosis of HMS 
involves the exclusion of other conditions, a score of at 
least "4" on the Beighton scale (Table 1-4), and arthral- 
gia for longer than 3 months in four or more joints. 49,50 
Other criteria have also been proposed, which include 
additional joint motions and extra-articular signs. 47 ' 48 ' 50 
According to Grahame 47 the following joint motions 
should also be considered: shoulder lateral rotation 
greater than 90 degrees, cervical spine lateral flexion 
greater than 60 degrees, distal interpha'langeal joint 
hyperextension greater than 60 degrees, and first 
metatarsophalangeal joint extension greater than 90 
degrees. 

Factors Affecting Range of Motion 

ROM varies among individuals and is influenced by 
factors such as age, gender, and whether the motion is 
performed actively or passively. A fairly extensive 
amount of research on the effects of age and gender on 
ROM has been conducted for the upper and lower 
extremities as well as the spine. Other factors relating to 
subject characteristics such as body mass index (BMI), 
occupational activities, and recreational activities may 
affect ROM but have not been as extensively researched 
as age and gender. In addition, factors relating to the test- 
ing process, such as the testing position, type of instru- 



Total 

Adap 

mem 
time 

surei 

exan 

later 

infoi 

feati 

4 tb 

char 

able. 

Ic 

the « 

shou 

the < 

samt 

are i 

norr 

situs 

with 

extn 

not 

tion 

berv 
sis: 

som 
righ 
Alle 
to s 
fori 
wit! 
Ami 
othc 
text 
wer 
mea 
I 
text 



CHAPTER 1 



BASiC CONCEPTS 



11 



table 1-4 Beighton Hypermobihty Score 




Passively appose thumb to forearm 

Right.. -_ 

Left 

Passively extend fifth MCP joint more than 90" 
■■ "Rights- ■ 

Left " 

Hyper ■ ribow more than 10° 

■"/;Rtptf : : 

Left':"-/. ":■■.. : . 

Hyperexterid knee more than 10° 
Right' 
Left 

Piace palms on floor by flexing trunk with 
. knees' straight 



Total Beighton Score = sum of points. 

Adapted from Beighton. 4 ' 



0-.9 



ment employed, experience of the examiner, and even 
time of day have been identified as affecting ROM mea- 
surements. A brief summary of research findings that 
examine age and gender effects on ROM is presented 
later in the chapter. To assist the examiner, more detailed 
information about the effects of age and gender on the 
featured joints is presented at the beginning of Chapters 
4 through 13. Information on the effects of subject 
characteristics and the testing process is included if avail- 
able. 

Ideally, to determine whether an ROM is impaired, 
the value of the ROM of the joint under consideration 
should be compared with ROM values from people of 
the same age and gender and from studies that used the 
same method of measurement. Often such comparisons 
are not possible because age-related and gender-related 
norms have not been established for all groups. In such 
situations the ROM of the joint should be compared 
with the same joint of the individual's, contralateral 
extremity, providing that the contralateral extremity is 
not impaired or used selectively in athletic or occupa- 
tional activities. Most studies have found little difference 
between the ROM of the right and left extremities. 28, 45 ' 
51-57 A few studies 58 "" 60 have found slightly less ROM in 
some joints of the upper extremity on the dominant or 
right side as compared with the contralateral side, which 
Allender and coworkers 55 attribute to increased exposure 
to stress. If the contralateral extremity is inappropriate 
for comparison, the individual's ROM may be compared 
with average ROM values in the handbook of the 
American Academy of Orthopaedic Surgeons 7 ' 8 and 
other standard texts. 9, 61_65 However, in many of these 
texts, the populations from which the average values 
were derived, as well as the testing positions and type of 
m easuring instruments used, are not identified. 

Average ROM values published in several standard 
texts and studies are summarized in tables at the begin- 



ning of Chapters 4 through 13 and in Appendix A. The 
average ROM values presented in these tables should 
serve as only a general guide to identifying normal versus 
impaired ROM. Considerable differences in average 
ROM values are noted between the various references. 

Age 

Numerous studies have been conducted to determine the 
effects of age on ROM of the extremities and spine. 
General agreement exists among investigators regarding 
the age-related effects on the ROM of the extremity 
joints of newborns, infants, and young children up to 
about 2 years of age. 44, 66 ~ 70 These effects are joint- and 
motion specific but do not seem to be affected by gender. 
In comparison with adults, the youngest age groups have 
more hip flexion, hip abduction, hip lateral rotation, 
ankle dorsiflexion, and elbow motion. Limitations in hip 
extension, knee extension, and plantar flexion are 
considered to be normal for these age groups. Mean 
values for these age groups differ by more than 2 stan- 
dard deviations from adutt mean values published by the 
American Academy of Orthopaedic Surgeons, 7 the 
American Medical Association, 9 and Boone and Azen. 45 
Therefore, age-appropriate norms should be used when- 
ever possible for newborns, infants, and young children 
up to 2 years of age. 

Most investigators who have studied a wide range of 
age groups have found that older adult groups have 
somewhat less ROM of the extremities than younger 
adult groups. These age-related changes in the ROM of 
older adults also are joint and motion specific but may 
affect males and females differently. Allander and associ- 
ates 58 found that wrist flexion-extension, hip rotation, 
and shoulder rotation ROM decreased with increasing 
age, whereas flexion ROM in the metacarpophalangeal 
(MCP) joint of the thumb showed no consistent loss of 
motion. Roach and Miles 71 generally found a small 
decrease (3 to 5 degrees) in mean active hip and knee 
motions between the youngest age group {25 to 39 years) 
and the oldest age group (60 to 74 years). Except for hip 
extension ROM, these decreases represented less than 15 
percent of the arc of motion. Stubbs, Fernandez, and 
Glenn 53 found a decrease of between 4 percent and 30 
percent in 11 of 23 joints studied in men between the 
ages of 25 and 54 years. James and Parker 13 found 
systematic decreases in 10 active and passive lower 
extremity motions in subjects who were between 70 and 
92 years of age. 

As with the extremities, age-related effects on spinal 
ROM appear to be motion specific. Investigators have 
reached varying conclusions regarding how large a 
decrease in ROM occurs with increasing age. Moll and 
Wright 72 found an initial increase in thoracolumbar 
spinal mobility (flexion, extension, lateral flexion) in 
subjects from 15 to 24 years of age through 25 to 34 
years of age followed by a progressive decrease with 



12 



PART I INTRODUCTION TO CONIOMETRY 



;'; 






increasing age. These authors concluded that age atone 
may decrease spinal mobility from 25 percent to 52 
percent by the seventh decade, depending on the motion. 
Loebl 73 found that thoracolumbar spinal mobility (flex- 
ion-extension) decreases with age an average of 8 degrees 
per decade. Fitzgerald and colleagues 7 "' found a system- 
atic decrease in lateral flexion and extension of the 
lumbar spine at 20-year intervals but no differences in 
rotation and forward flexion. Youdas and associates 75 
concluded that with each decade both females and males 
lose approximately 5 degrees of active motion in neck 
extension and 3 degrees in lateral flexion and rotation. 

Cender 

The effects of gender on the ROM of the extremities and 
spine also appear to be joint and motion specific. 

Bell and Hoshizaki 76 found that females across an age 
range of 18 to 88 years had more flexibility than males 
in 14 of 17 joint motions tested. Beighton, Solomon, and 
Soskoline, 49 in a study of an African population, found 
that females between and 80 years of age were more 
mobile than their male counterparts. Walker and 
coworkers, 77 in a study of 28 joint motions in 60- to 84- 
year olds, reported that 8 motions were greater in 
females and 4 motions were greater in males. Looking at 
the spine, Moll and Wright 72 found that female thora- 
columbar left lateral flexion exceeded male left lateral 
flexion by 11 percent. On the other hand, male mobility 
exceeded female mobility in thoracolumbar flexion and 
extension. 

8K Muscle Length Testing 

Muscle length is the greatest extensibility of a muscle- 
tendon unit. 2 It is the maximal distance between the 
proximal and the distal attachments of a muscle to bone. 
Clinically, muscle length is not measured directly but 
instead is measured indirectly by determining the end of 
the ROM of the joint(s) crossed by the muscle. 78 ' 79 
Muscle length, in addition to the integrity of the joint 
surfaces and the extensibility of the capsule, ligaments, 
fascia, and skin, affects the amount of passive ROM of a 
joint. The purpose of testing muscle length is to ascertain 
whether hypomobility or hypermobiliry is caused by the 
length of the inactive antagonist muscle or other struc- 
tures. By ascertaining which structures are involved, the 
health professional can choose more specific and more 
effective treatment procedures. 

Muscles can be categorized by the number of joints 
they cross from their proximal to their distal attach- 
ments. One-joint muscles cross and therefore influence 
the motion of only one joint. Two-joint muscles cross 
and influence the motion of two joints, whereas multi- 
joint muscles cross and influence multiple joints. 

No difference exists between the indirect measurement 



of the length of a one-joint muscle and the measurement 
of joint ROM in the direction opposite to the muscle's 
active motion. Usually, one-joint muscles have sufficient 
length to allow full passive ROM at the joint they cross. 
If a one-joint muscle is shorter than normal, passive 
ROM in the direction opposite to the muscle's action is 
decreased and the end-feel is firm owing to a muscular 
stretch. At the end of the ROM the examiner may be able 
to palpate tension within the musculotendinous unit if 
the structures are superficial. In addition, the subject may 
complain of pain in the region of the tight muscle and 
tendon. These signs and symptoms help to confirm 
muscle shortness as the cause of the joint limitation. 

If a one-joint muscle is abnormally lax, passive tension 
in the capsule and ligaments may initially maintain a 
normal ROM. However, with time, these joint structures 
often lengthen as well and passive ROM at the joint 
increases. Because the indirect measurement of the length 
of one-joint muscles is the same as the measurement of 
joint ROM, we have not presented specific muscle length 
tests for one-joint muscles. 

Example: The length of one-joint hip adductors 
such as the adductor longus, adductor magnus, and 
adductor brevis is assessed by measuring passive 
hip abduction ROM. The indirect measurement of 
the length of these hip adductor muscles is identical 
to the measurement of passive hip abduction ROM 
(Fig. 1-7). 

In contrast to one-joint muscles, the length of two- 
joint and multijoint muscles is usually not sufficient to 
allow full passive ROM to occur simultaneously at all 
joints crossed by these muscles. 80 This inability of a 
muscle to lengthen and allow full ROM at all of the 
joints the muscle crosses is termed passive insufficiency. 
If a two-joint or multijoint muscle crosses a joint the 
examiner is assessing for ROM, the subject must be posi- 
tioned so that passive tension in the muscle does not limit 
the joint's ROM. To allow full ROM at the joint under 
consideration and to ensure sufficient length in the 
muscle, the muscle must be put on slack at all of the 
joints the muscle crosses that are not being assessed. A 
muscle is put on slack by passively approximating the 
origin and insertion of the muscle. 



EXAMPLE: The triceps is a two-joint muscle that 
extends the elbow and shoulder, The triceps is 
passively insufficient during full shoulder flexion 
and full elbow flexion. When an examiner assesses 
elbow flexion ROM, the shoulder must be in a 
neutral position so there is sufficient length in 
the biceps to allow full extension at the elbow 
(Fig. 1-8). 



; : '/ 


Fl 


": 


tr. 


.:. 




■ v 


tc 


p; 


hi 



F 

cl 
ir 
tl 



CHAPTER 1 BASIC CONCEPTS 



13 



FIGURE 1-7 The indirect measurement of 
the muscle length of one-joint hip adduc- 
tors is the same as measurement of passive 
hip abduction ROM. 




FIGURE 1-8 During the measurement of 
elbow flexion ROM, the shoulder must be 
in neutral to avoid passive insufficiency of 
the triceps, which would limit the ROM. 




To assess the length of a two-joint muscle, the subject 
is positioned so that the muscle is lengthened over the 
proximal or distal joint that the muscle crosses. This joint 

is held in position while the examiner attempts to further 
lengthen the muscle by moving the second joint through 



full ROM. The end-feel in this situation is firm owing to 
the development of passive tension in the stretched 
muscle. The length of the two-joint muscle is indirectly 
assessed by measuring passive ROM in the direction 
opposite to the muscle's action at the second joint. 



14 



PART I INTRODUCTION TO CONIOMETRV 




FIGURE 1-9 To assess the length of the two-joint triceps 
muscle, elbow flexion is measured while the shoulder is posi- 
tioned in flexion. 



Example: To assess the length of a two-joint muscle 
such as the triceps, the shoulder is positioned and 
held in full flexion. The elbow is flexed until 
tension is felt in the triceps, creating a firm end-feel. 
The length of the triceps is determined by measur- 
ing passive ROM of elbow flexion with the shoul- 
der in flexion (Fig. 1-9). 

The length of multijoint muscles is assessed in a 
manner similar to that used in assessing the length of 
two-joint muscles. However, the subject is positioned and 
held so that the muscle is lengthened over all of the joints 
that the muscle crosses except for one last joint. The 
examiner attempts to further lengthen the muscle by 
moving the last joint through full ROM. Again, the end- 
feel is firm owing to tension in the stretched muscle. The 
length of the multijoint muscle is indirectly determined 
by measuring passive ROM in the direction opposite to 
the muscle's action at the last joint to be moved. 
Commonly used muscle length tests that indirectly assess 
two-joint and multijoint muscles have been included at 
the end of Chapters 4 through 13 as appropriate. 



REFERENCES 

1. MacConaill, MA, and Basmajian, JV: Muscles and Movement: A 

Basis For Human Kinesiology, ed 2, Robert E. Kriegcr, New York, 
1977. 

2. American Physical Therapy Association: Guide to Physical 
Therapist Practice, ed 2. Phys Ther 8 1 :9, 2001. 

3. Silver, D: Measurement of the range of motion in joints, j Bone 
Joint Surg 21:569, 1923. 

4. Cave, EF, and Roberts, SM: A method for measuring and recording 
joint function. J Bone Joint Surg 18:455, 1936. 

5. Moore, ML: The measurement of joint motion. Part 11: The technic 
of goniometry. Phys Ther Rev 29:256, 1949. 

6. Moore, ML: Clinical assessment of joint motion. In Basmajian, JV 
(ed): Therapeutic Exercise, ed 4. Williams &C Wilkins, Baltimore, 
1984. 

7. American Academy of Orthopaedic Surgeons: Joint Motion: 
Methods of Measuring and Recording. AAOS, Chicago, 1965. 

8. Greene, WB, and Heckman, JD (eds): The Clinical Measurement of 
Joint Motion. American Academy of Orthopaedic Surgeons, 
Rosemont, III., 1994. 

9. American Medical Association: Guides to the Evaluation of 
Permanent Impairment, ed 3. A.V1A, Milwaukee, 1990. 

10. Clark, WA: A system of joint measurement. J Orthop Surg 2:687, 
1920. 

1 1. West, CC: Measurement of joint motion. Arch Phys Med Rehabil 
26:414, 1945. 

12. Cole, TM, and Tobis, JS: Measurement of Musculoskeletal 
Function. In Kottke, FJ, and Lehmann, JF (eds}: Krusenn's 
Handbook of Physical Medicine and Rehabilitation, ed 4. WB 
Saunders, Philadelphia, 1990. 

13. James, B, and Parker, AW: Active and passive mobility of lower 
limb joints in elderlv men and women. Am J Phys Med Rehabil 
68:162, 1989. 

14. Ball, P, and Johnson, GR: Reliability of hindfoot goniometry when 
using a flexible electrogoniometer. Clin Biomech 8:13, 1993. 

15. Cyriax, J: Textbook of Orthopaedic Medicine: Diagnosis of Soft 
Tissue Lesions, ed 8. Bailliere Tindall, London, 1982, 

)6. Kaltenborn, FM: Manual Mobilization of the Extremity Joints, ed 
4. Olaf Norlis Bokhandel, Oslo. 

17. Paris, SV: Extremity Dysfunction and Mobilization. Institute Press, 
Atlanta, 1980. 

18. Cookson, JC, and Kent, BE: Orthopedic manual therapy: An 
overview. Part I. Phys Ther 59:136, 1979. 

19. Williams, P, et al: Gray's Anatomy of the Human Body, ed 38. 
Churchill Livingstone, New York, 1 995. 

20. Moore, KL, and Dalley, AF: Clinically Oriented Anatomy, ed 4. 
Williams & Wilkins, Baltimore, 1999. 

21. Kapandji, IA: Physiology of the Joints, Vol 1, ed 2. Churchill 
Livingstone, London, 1970. 

22. Kapandji, LA: Physiology of the Joints, Vol 2, ed 2. Williams &1 
Wilkins, Baltimore, 1970. 

23. Kapandji, IA: Physiology of the joints, Vol 3, ed 2. Churchill 
Livingstone, London, 1970. 

24. Steindlcr, A: Kinesiology of the Human Body. Charles C. Thomas, 
Springfield, 111., 1955. 

25. Gowiae, BA, and Milner, M: Understanding the Scientific Basis for 
Human Movement, ed 3. Williams Sc Wilkins, Baltimore, 1988. 

26. Levangie, PK, and Norkin, CC: joint Structure and Function, ed 3. 
FA Davis, Philadelphia, 2001. 

27. Soderbcrg, GL: Kinesiology: Application to Pathological Motion. 
Williams Sc Wilkins, Baltimore, 1986. 

28. Steultjens, MPM, et al: Range of joint motion and disability in 
patients with osteoarthritis of the knee or hip. Rheumatology 
39:955, 2000. 

29. Messier, SP, et al: Osteoarthritis of the knee: Effects on gait, 
strength, and flexibility. Arch Phys Med Rehabil 73:29, 1992. 

30. Stam, HW: Frozen shoulder: A review of current concepts. 
Physiotherapy 80:588, 1994. 

31. Roubal, PJ, Dobrirr, D, and Placzek, JD: Glenohumeral gliding 
manipulation following interscalcne brachial plexus block in 
patients with adhesive capsulitis. 1 Orthop Sports Phys Ther 24:66, 
1996. 



If 



K 



3: 

3: 

4i 





4 


ss 




B 


4- 


Si 








H 


4. 


| 


4. 


I 


4' 


|. 


4! 


1 


4! 



51 



5: 



5( 



CHAPTER 1 



BASIC CONCEPTS 



15 



ivemtnt: A 
New York, 

;> Physical 

its. J Bone 

d recording 

The technic 

smajian, JV 
Baltimore, 

K Motion: 
>, 1965. 
surement of 
■ Surgeons, 

iluation of 

Surg 2:687, 

fed Rehabil 

culoskelctal 
: Krusenn's 
, id 4. WB 

ity of lower 
Acd Rehabil 

imetry when 
1993, 
losis of Soft 

iry joints, ed 

stitute Press, 

therapy: An 

iody, ed 38. 

atomy, cd 4. 

2. Churchill 

Williams & 

2. Churchill 

s C. Thomas, 

.tific Basis for H 
Hire, 1988. 
unction, ed 3. 

jicaS Motion. 

i disability in 
Lheumatology 

ects on gait, 
[9, 1992. 
jnt concepts. 



32. Hagen, KB, et al: Relationship between subjective neck disorders 57. 
and cervical spine mobility and motion-related pain in male 
machine operators. Spine 22:1501, 1997. 

33. Hermann, KM, and Reese, CS: Relationship among selected meas- 58. 
ures of impairment, functional limitation, and disability in patients 

with cervical spine disorders. PhysTher 81:903, 2001. 

34. MacKenzie, EJ, et al: Physical impairment and functional outcomes 59. 
six months after severe lower extremity fractures. J Trauma 
34:528, 1993. 

35. Chesworth, BM, and Vandervoorr, A A: Comparison of passive 60. 
stiffness variables and range of motion in uninvoived and involved 

ankle joints of patients following ankle fractures. Phys Ther 
75:254, 1995. 61. 

36. Staley, MJ, and Richard, RL: Burns. In O'Sullivan, SB and Schmirz, 

Tj (eds): Physical Rehabilitation: Assessment and Treatment, ed 4. 62. 
' FA Davis, Philadelphia, 2000. 

37. Johnson, J, and Silverberg, R: Serial casting of the lower extremity 63. 
to correct contractures during the acute phase of burn care. Phys 

Ther 75:262, 1995. 

38. Schultc, L, et al: A quantitative assessment of limited joint mobility 64. 
in patients with diabetes. Arthritis Rheum 10:1429, 1993. 

39. Salsich, GB, Mueller, Mj, and Sahrmann, SA: Passive ankle stiffness 

in subjects with diabetes and peripheral neuropathy versus and age- 65. 
matched comparison group. Phys Ther 80:352, 2000. 

40. Dyrek, DA: Assessment and treatment planning strategies for 
musculoskeletal deficits. In O'Sullivan, SB, and Schmitz, TJ (eds): 66. 
Physical Rehabilitation: Assessment and Treatment, ed 3, FA Davis, 
Philadelphia, 1994. 

41. Fritz, JM, et al: An examination of the selective tissue tension 67. 
scheme, with evidence for the concept of a capsular pattern of the 

knee. PhysTher 78:1046, 1998. 

42. Hayes, KW, Petersen, C, and Falconer, j: An examination of 68. 
Cyriax's passive motion tests with patients having osteoarthritis of 

the knee. Phys Ther 74:697, 1994. 

43. Hertling, DH, and Kessler, RM: Management of Common 
Musculoskeletal Disorders, ed 3. JB Lippincott, Philadelphia, 1996. 69. 

44. Waugh, KG, et al: Measurement of selected hip, knee and ankle 

joint motions in newborns. Phys Ther 63:1616, 1983. 70. 

45. Boone, DC, and Azen, SP: Normal range of motion of joints in 

male subjects, j Bone Joint Surg Am 61:756, 1979. 71. 

46. Everman, DB, and Robin, NH: Hypermobiliry syndrome. Pediatr 

Rev 19:111, 1998. 72. 

47. Grahame, R: Hypermobiliry not a circus act. Int J Clin Pract 
54:314, 2000. ' " 73. 

48. Russek, LN: Hypermobiliry syndrome. PhysTher 79:59, 1999. 

49. Beighton, P, Solomon, L, and Soskolne, CL: Articular mobility in 74. 
an African popularion. Ann Rheum Dis 32:23, 1973. 

50. Bird, HA: joint hypermobiliry: Report from Special Interest Groups 

of the annua] meeting of the British Society of Rheumatology. Br J 75. 
Rheumatol 31:205, 1992. 

51. Roaas, A, and Andersson, GB; Normal range of motion of the hip, 76. 
knee and ankle joints in male subjects, 3CM0 years of age. Acta 
Othop Scand 53:205, 1982. 

52. Chang, DE, Buschbacher, LP, and Edlich, RF: Limited joint mobil- 77. 
ity in power lifters. Am J Sports Med 16:280, 1988. 

53. Ahlbcrg, A, Moussa, M, and Al-Nahdi, M: On geographical varia- 78. 
tions in the normal range of joint motion. Clin Orthop Rel Res 
234:229,1988. ' 79. 

54. Schwarze, DJ, and Denton, JR: Normal values of neonatal limbs: 
An evaluation of 1000 neonates. J Res Pediatr Orthop 13:758, 
1993. 

55. Stefanyshyn, DJ, and Ensberg, JR: Right to left differences in the 80. 
ankle joint complex range of motion. Med Sci Sports Exerc 26:551, 

1993. 

56. Mosley, AM, Crosbie, J, and Adams, R: Normative data for passive 
ankle plantarflexion-dorsiflexion flexibility. Clin Biomcch 16:514, 
2001. 



Escalanate, A, et al: Determinants of hip and knee flexion range: 

Results from the San Antonio Longitudinal Study of Aging. 

Arthritis Care Res 12:8, 1999. 

Allender, E, et al: Normal range of joint movements in shoulder, 

hip, wrist and thumb with special reference to side: A comparison 

between two populations. Int J Epidemiol 3:253, 1974. 

Stubbs, NB, Fernandez, JE, and Glenn, W.M: Normative data on 

joint ranges of motion for 25- to 54-year old males, int J Ind 

Ergonomics 12:265, 1993. 

Escalante, A, Lichtenstein, MJ, and Hazuda, HP: Determinants of 

shoulder and elbow flexion range: Results from the San Antonio 

longitudinal study of aging. Arthritis Care Res 12:277, 1999. 

Kendall, FP, McCreary, EK, and Provance, PG: Muscles: Testing 

and Function, cd 4. Williams & Wilkins, Baltimore, 1993. 

Hoppenfeld, S: Physical Examination of the Spine and Extremities. 

Appleton-Century-Crofts, New York, 1976. 

Esch, D, and l.epley, M: Evaluation of joint Motion: Methods of 

Measurement and Recording. University of Minnesota Press, 

Minneapolis, 1974. 

Clarkson, HM: Musculoskeletal Assessment: Joint Range of 

Motion and Manual Muscle Strength, ed 2. Lippincott, Williams & 

Wilkins, Philadelphia, 2000. 

Palmer, ML, and Epler, M: Fundamentals of Musculoskeletal 

Assessment Techniques. Lippincott, Williams & Wilkins, 

Philadelphia, 1998. 

Drews, JE, Vraciu, JK, and Pellino, G: Range of motion of the 

joints of the lower extremities of newborns. Phvs Occup Ther 

Pediatr 4:49, 1984. 

Phelps, E, Smith, LJ, and Hallum, A: Normal range of hip motion 

of infants between nine and 24 months of age. Dev Med Child 

Neurol 27:785, 1 985. 

Wanatabe, H, et al: The range of joint motions of the extremities in 

healthy Japanese people: The differences according to age. Nippon 

Seikeigeka Gakkai Zasshi 53:275, 1979. Cited in Walker, JM: 

Musculoskeletal development: A review. Phys Ther 71:878, 1991. 

Schwar/e, DJ, and Denton, JR: Normal values of neonatal limbs: 

An evaluation of 1000 neonates, j Pediatr Orthop 13:758, 1993. 

Broughton, NS, Wright, j, and Menelaus, MB: Range of knee 

motion in normal neonates. J Pediatr Orthop 13:263, 1993. 

Roach, KE, and Miles, TP: Normal hip and knee active range of 

motion: The relationship to age. Phys Ther 71:656, 1991. 

Moll, JMH, and Wright, V: Normal range of spinal mobility. Ann 

Rheum Dis 30:381, 1971. 

Loebl, WY: Measurement of spinal posture and range of spinal 

movement. Ann Phys Med 9:103, 1967. 

Fitzgerald, GK, et al: Objective assessment with establishment of 

normal values for lumbar spinal range of motion. Phys Ther 

63:1776, 1983. 

Youdas, JW, et al: Normal range of motion of the cervical spine: An 

initial goniometric study. Phys Ther 72:770, 1992. 

Bell, RD, and Hoshizaki, TB: Relationship of age and sex with 

range of morion: Seventeen joint actions in humans. Can J Appl Sci 

6:202, 1981. 

Walker, JM, et al: Active mobility of the extremities older subjects. 

Phys Ther 64:919, 1984. 

Gajdosik, RL, et at: Comparison of four clinical tests for assessing 

hamstring muscle length. J Orthop Sports PhysTher 18:614, 1993. 

Tardieu, G, Lespargot, A, and Tardieu, C: To what extent is the 

tibia-calcaneum angle a reliable measurement of the triceps surae 

length: Radiological correction of the torque-angle curve. Eur J 

Appl Physiol 37:163, 1977. 

Gajdosik, RL, Hailett, JP, and Slaugher, LL: Passive insufficiency of 

two-joint shoulder muscles. Clin Biomech 9:377, 1994. 



meral gliding 
cus block in 
■s Ther 24:66, 







CHAPTER 2 




fi ;.. 



Procedures 



Competency in goniometry requires that the examiner 
acquire the following knowledge and develop the follow- 
ing skills. 

The examiner must have knowledge of the following 
for each joint and motion: 

. 1. /Testing positions 

2. Stabilization required 

3. Joint s-tructure and function 

4. Normal end-feels 

5. Anatomical bony landmarks 

6. Instrument alignment 

The examiner must have the skill to perform the fol- 
lowing for each joint and motion: 

1. Position and stabilize correctly 

2. Move a body part through the appropriate range 
of motion 

3. Determine the end of the range of motion (end- 
feel) 

4. Palpate the appropriate bony landmarks 

5. Align the measuring instrument with landmarks 

6. Read the measuring instrument 

7. Record measurements correctly 

W Positioning 

Positioning is an important part of goniometry because it 
is used to place the joints tn a zero starting position and 
to help stabilize the proximal joint segment. Positioning 
affects che amount of tension in soft tissue structures 
(capsule, ligaments, muscles) surrounding a joint. A test- 
'ng position in which one or more of these soft tissue 
structures become taut results in a more limited range of 
motion (ROM) than a position in which the same struc- 
tures become lax. As can be seen in the following exam- 




ple, the use of different testing positions alters the ROM 
obtained for hip flexion. 

Example: A testing position in which the knee is 
flexed yields a greater hip flexion ROM than a test- 
ing position in which the knee is extended. When 
the knee is extended, hip flexion is prematurely lim- 
ited by tension in the hamstring muscles. 

If examiners use the same position during successive 
measurements of a joint ROM, the relative amounts of 

Tension in the soft tissue structures should be the same as 
in previous measurements. Therefore, a comparison of 
ROM measurements taken in the same position should 
yield similar results. When different testing positions are 
used for successive measurements of a joint ROM, more 
variability is added to the measurement' - * and no basis 
for comparison exists. 

Testing positions refer to the positions of the body 
that we recommend for obtaining goniometric measure- 
ments. The series of testing positions that are presented 
in this text are designed to: 

1. Place the joint in a starting position of degrees 

2. Permit a complete ROM 

3. Provide stabilization for the proximal joint seg- 
ment 

If a testing position cannot be attained because of 
restrictions imposed by the environment or limitations of 
the subject, the examiner must use creativity to decide 
how to obtain a particular joint measurement. The alter- 
native testing position that is created must serve the same 
three functions as the recommended testing position. The 
examiner must describe the position precisely in the sub- 
ject's records so that the same position can be used for all 
subsequent measurements. 

17 



5S=ffi» : ,v.;:--"" 



18 



PART I INTRODUCTION TO CONIOMETRY 



Testing positions involve a variety of body positions 

such as supine, prone, sitting, and standing. When an 
examiner intends to test several joints and motions dur- 
ing one testing session, the goniometric examination 
should be planned to avoid moving the subject unneces- 
sarily. For example, if the subject is prone, all possible 
measurements in this position should be taken before the 
subject is moved into another position. Table 2-1, which 
lists joint measurements by body position, has been 
designed to help the examiner plan a goniometric exam- 
ination. 

PS Stabilization 

The testing position helps to stabilize the subject's body 
and proximal joint segment so that a motion can be iso- 
lated to the joint being examined. Isolating the motion to 
one joint helps to ensure that a true measurement of the 
motion is obtained rather than a measurement of com- 
bined motions that occur at a series of joints. Positional 
stabilization may be supplemented by manual stabiliza- 
tion provided by the examiner. 



Example: Measurement of medial rotation of the 

hip joint performed with the subject in a sitting 
position (Fig. 2-1 A}. The pelvis (proximal segment) 
is partially stabilized by the body weight, but the 
subject is moving her trunk and pelvis during hip 
rotation. Additional stabilization should be provid- 
ed by the examiner and the subject (Fig. 2-lB). The 
examiner provides manual stabilization for the 
pelvis by exerting a downward pressure on the iliac 
crest of the side being tested. The subject is instruct- 
ed to shift her body weight over the hip being test- 
ed to help keep the pelvis stabilized. 

For most measurements, the amount of manual stabi- 
lization applied by an examiner must be sufficient to 
keep the proximal joint segment fixed during movement 
of the distal joint component. If both the distal and the 
proximal joint components are allowed to move during 
joint testing, the end of the ROM is difficult to deter- 
mine. Learning how to stabilize requires practice because 
the examiner must stabilize with one hand while simul- 



table 2-v Joint Measurements by Body Position 



~" ~ T ~* 




firtine .- 


'W'tteT^'^ ■■'■"■ 


Si|5frtf«g: : };' : M:;.: 


IHMIils- 


Shoulder 




. Extension 


Flexion 






- 






Abduction 


■~~ .' ' ■ 




■ -?---mi?<, 






Medial rotation 


:"- ;",-' 




: :-\- . 






Lateral rotation 


;-',-.../. 


• ---.---,,- J. 


Elbow 






Flexion 






Forearm 








Pronation 

... Supination 




Wrist 








..;.-. Flexion;..;: .■ 

Extension 
v. Radial deviation 1 
. Ulnar deviation 

All motions 


.-- * --" 


Hand 




Extension 


Flexion 


Medial rotation 




Hip;^ 






Abduction 
Adduction 


Lateral rotation 




Knee 






Flexion 






Ankle and foot 




Subtalar inversion 


Dorsiflexion 


Dorsiflexion : 


"'■''■ ' '- .%"; 






Subtalar aversion. 


Plantar flexion 

Inversion 

Eversion 

Midtarsa! inversion 
Midtarsal eversion 


Plantar flexion 

Inversion 
.■;"*/' Eversion. 

. . Midtarsat. inversion "', 
Midtarsal eversion 




Toes 






AH motions 


. All motions.; ; ;■ 




Cervical spine 








Flexion 




■ . .■' 








':-:;■ Extension 




'.■/:■ ■■■ ■ 








Lateral flexion 




\ ' ;. 








: Rotation 




Thoracolumbar 


spine 






'.;;-■ Rotation 


Ffexfon 


-. ;' . ' 










Extension 
Lateral flexion 


Temporomandibular joint 






' Depression . : v.: 












..: Anterior protrusion 












Lateral deviation ■ . ■: . : 





tanec 
hand 
segm 
are b 



CHAPTER 2 PROCEDURES 



19 



he 



stabi- H 

IBt CO 

.'rnent m 

id the 1 
luring 

deter- 1 
rcause 

iimnl- ■§ 



'I 




FIGURE 2-1 (A) The consequences of inadequate stabilization. The examiner has failed to stabilize the subject's 
pelvis and trunk; therefore, a lateral tilt of the pelvis and lateral flexion of the trunk accompany the motion of hip 
medial rotation. The range of medial rotation appears greater than it actually is because of the added motion from 
the pelvis and trunk. (B) The use of proper stabilization. The examiner uses her right hand to stabilize the pelvis 
(keeping the pelvis from raising off the table) during the passive range of motion (ROM). The subject assists in 
stabilizing the pelvis by placing her body weight on the left side. The subject keeps her trunk straight by placing 
both hands on the table. 



taneously moving the distal joint segment with the other 
hand. The techniques of stabilizing the proximal joint 
segment and of determining the end of a ROM (end-feel) 
are basic to goniometry and must be mastered prior to 



learning how to use the goniometer. Exercise 1 is 
designed to help the examiner learn how to stabilize and 
determine the end of the ROM and end-feel. 



20 



PART I INTRODUCTION TO CONIOMETRV 




EXERCISE 1 



DETERMINING THE END OF THE RANGE OF MOTION 
AND END-FEEL 



This exercise is designed to help the examiner determine the end of the ROM and to differen- 
tiate among the three norma! end-feels: soft, firm, and hard. 

ELBOW FLEXION: SOFT END-FEEL 
Activities: See Figure 5-15 in Chapter 5. 

1. Select a subject. 

2. Position the subject supine with the arm placed close to the side of the body. A towel roll is 
placed under the distal end of the humerus to allow full elbow extension. The forearm is 
placed in full supination with the palm of the hand facing the ceiling. 

3. With one hand, stabilize the distal end of the humerus (proximal joint segment) to prevent 
flexion of the shoulder. 

4. With the other hand, slowly move the forearm through the full passive range of elbow flex- 
ion until you feel resistance limiting the motion. 

5. Gently push against the resistance until no further flexion can be achieved. Carefully note 
the quality of the resistance. This soft end-feel is caused by compression of the muscle bulk 
of the anterior forearm with that of the anterior upper arm. 

6. Compare this soft end-feel with the soft end-feel found in knee flexion (see knee flexion in 
Chapter 9). 

ANKLE DORSIFLEXION: FIRM END-FEEL 
Activities: See Figure 10-14 in Chapter 10. 

1. Select a subject. 

2. Place the subject sitting so that the lower leg is over the edge of the supporting surface and 
die knee is flexed at least 30 degrees. 

3. With one hand, stabilize the distal end of the tibia and fibula to prevent knee extension and 
hip motions. 

4. With the other hand on the plantar surface of the metatarsals, slowly move the foot through 
the full passive range of ankle dorsiflexion until you feel resistance limiting the motion. 

5. Push against the resistance until no further dorsiflexion can be achieved. Carefully note the 
quality of the resistance. This firm end-feel is caused by tension in the Achilles tendon, the 
posterior portion of the deltoid ligament, the posterior talofibular ligament, the calcaneo- 
fibular ligament, the posterior joint capsule, and the wedging of the talus into the mortise 
formed by the tibia and fibula. 

6. Compare this firm end-feel with the firm end-feel found in metacarpophalangeal (MCP) 
extension of the fingers (see Chapter 7), 






-:,..;, 



CHAPTER 2 PROCEDURES 



21 



ELBOW EXTENSION: HARD END-FEEL 
Activities: 

1 . Select a subject. 

2. Position the subject supine with the arm placed close to the side of the body. A small rowel 
roll is placed under the distal end of the humerus to allow full elbow extension. The fore- 
arm is placed in full supination with the palm of the hand facing the ceiling. 

3. With one hand resting on the towel roll and holding the posterior, distal end of the 
humerus, stabilize the humerus (proximal joint segment) to prevent extension of the shoul- 
der. 

4. With the other hand, slowly move the forearm through the full passive range of elbow 
extension until you feel resistance limiting the motion. 

5. Gently push against the resistance until no further extension can be attained. Carefully note 
the quality of the resistance. When the end-feel is hard, it has no give to it. This hard end- 
fee! is caused by contact between the olecranon process of the ulna and the olecranon fossa 
of the humerus. 

6. Compare this hard end-feel with the hard end-feel usually found in radial deviation of the 
wrist (see radial deviation in Chapter 7). 



- iltx y?£ -. Ji ii— as*j U .i~:"-: -V- 



l^iJV :./.ri:c :i>^ ,:>.;- .7^^ 



3BS Measurement Instruments 

A variety of instruments are used to measure joint 
motion. These instruments range from simple paper trac- 
ings and tape measures to electrogoniometers and 
motion analysis systems. An examiner may choose to use 
a : particular instrument based upon the purpose of the 
measurement (clinical versus research), the motion being 
measured, and the instrument's accuracy, availability, 
cost, ease of use, and size. 



Universal Goniometer 

The universal goniometer is the instrument most com- 
monly used to measure joint position and motion in the 
clinical setting. Moore 5 ' 15 designated this type of 
goniometer as "universal" because of its versatility. It can 
be used to measure joint position and ROM at almost all 
joints of the body. The majority of measurement tech- 
niques presented in this book demonstrate the use of the 
universal goniometer. 



22 



PART 1 INTRODUCTION TO CONIOMETRY 



Universal goniometers may be constructed of plastic 
(Fig. 2-2) or metal (Fig. 2-3) and are produced in many 
sizes and shapes, but adhere to rhe same basic design. 
Typically the design includes a body and two thin exten- 
sions called arms — a stationary arm and a moving arm 
(Fig. 2-1). 

The body of a universal goniometer resembles a pro- 
tractor and may form a half circle or a full circle (Fig. 



2-5). The scales on a half-circle goniometer read from 
to 180 degrees and from 180 to degrees. The scales on 
a full-circle instrument may read either from to 180 
degrees and from 180 to degrees, or from to 360 
degrees and from 360 to degrees. Sometimes full-circle 
instruments have both 180-degree and 360-degree scales. 
Increments on the scales may vary from 1 to 10 degrees, 
but 1- and 5-degree increments are the most common. 



n^': 



A 



.f/* R«|iPE"*J3 f 






B 



■"■ : ■ 



o 




m 






^: 



FIGURE 2-2 Plastic universal 
goniometers are available in dif- 
ferent shapes and sizes. Some 
goniometers have full-circle bod- 
ies {A,B,C,E), whereas others 
have half-circle bodies (D). The 
14-inch goniometer (A) is used to 
measure large joinrs such as the 
hip, knee, and shoulder. Six- to 8- 
ineh goniometers (B,C,D) are 
used to assess midsized joints 
such as the wrist and ankle. The 
small goniometer (£) has been 
cut in length from a 6-inch 
goniometer (C) to make it easier 
to measure the fingers and toes. 




FIGURE 2-3 These metal goni- 
ometers are of different sizes but all 
have half-circle bodies. Metal 
goniometers with full-circle bodies 
are also available. The smallest 
goniometer is specifically designed 
to lie on the dorsal or ventral sur- 
face of the fingers and toes while 
measuring joint motion. 




n versa! 

in dif- 
Somc.; 

\c bod- 

"triers 
>). The 
used to 

(is the 
t- m8- 
h are 

joints 
k'. The 
s been : 
fi-sneh 

easier 
toes. 



STATIOHAHY ARM 



FIGURE 2-4 The body of this universal goniomerer forms a 
half citcle. The stationary arm is an integral part of the body of 
the goniometer. The moving arm is attached to the body by 
either a rivet or a screw so that it can be moved independently 
frotn the body. In this example, the moving arm has a cut-out 
portion sometimes referred to as a "window." The window 
permits the examiner to read the scale on the body of the 
instrument. 



Traditionally, the arms of a universal goniometer are 
designated as moving or stationary according to how 
they are attached to the body of the goniometer. The sta- 
tionary arm is a structural part of the body of the 
goniometer and cannot be moved independently from the 
body. The moving arm is attached to the center of the 
body of most plastic goniometers by a river that permits 
the arm to move freely on the body. In some metal 
goniometers, a screwlike device (thumb knob) is used to 
attach the moving arm. Often the screvvlike device may 
be tightened to hold the moving arm in a certain position 



CHAPTER 2 PROCEDURES 



23 




FIGURE 2-5 The body of the goniometer may be either a half 
circle {top) or a full circle {bottom). 



or loosened to allow free movement. The moving arm 
may have one or more of the following features: a 
pointed end, a black or white line extending the length of 
the arm, or a cut-out portion (window) (Fig. 2-6). 
Goniometers that are used to measure ROM on radi- 
ographs have an opaque white line extending the length 
of the arms and opaque markings on the body. These fea- 
tures help the examiner to read the scales. 

The length of the arms varies among instruments from 
approximately 1 to 14 inches. These variations in length 
represent an attempt on the part of the manufacturers to 
adapt the size of the instrument to the size of the joints. 
The cost of the instruments also varies {See Appendix B: 
Features and Cost of Universal and Gravity-Based 
Goniometers). 




gom- 

nir all 
vletnf 

".liilCS 
LlllfSt 

igned 
I s»r- 
whilc 




(, 


A 


V 


) 

_— t- MT1 



FIGURE 2-6 These goniome- 
ters have a number of features 
that make reading the instru- 
ments easier. The half-circle 
goniometer at the top has a 
moving arm with cut-out 
areas at both ends and in the 
middle, as well as a black cen- 
ter line. The half-circle 
goniometer in the middle has 
a cut-out area only at the end 
of its moving arm. The full- 
circle plastic goniometer {bot- 
tom) has a black center line 
along both the moving and the 
stationary arms. 



24 



PART I INTRODUCTION TO GONIOMETRY 



Example: a universal goniometer with 14-inch arms 
is appropriate for measuring motion at the knee 
joint because the arms are long enough to permit 
alignment with the greater trochanter of the femur 
and the lateral malleolus of the tibia (Fig. 2-7 A). A 
universal goniometer with short arms would be dif- 
ficult to use because the arms do not extend a suffi- 
cient distance along the femur and tibia to permit 
alignment with the bony- landmarks (Fig. 2-7B). A 
goniometer with long arms would be awkward for 
measuring the MCP joints of the hand. 



Gravity-Dependent Goniometers 
(Inclinometers) 

Although not as common as the universal goniometer, 
several other types of manual goniometers may be found 
in the clinical setting. Gravity-dependent goniometers or 
inclinometers use gravity's effect on pointers and fluid 
levels to measure joint position and motion (Fig. 2-8). 
The pendulum goniometer consists of a 360-dcgree pro- 
tractor with a weighted pointer hanging from the center 
of the protractor. This device was first described by Fox 
and Van Breemen 7 in 1934. The fluid (bubble) goniome- 
ter, which was developed by Schcnkar 8 in 1956, has a 




FIGURE 2-7 Selecting the right- 
sized goniometer makes it easier 
to measure joint motion. (A) The 
examiner is using a fuil-cirele 
instrument with 'long arms to 
measure knee flexion ROM. The 
arms of the goniometer extend 
along the distal and proximal 
components of the joint ro within 
a few inches of the bony land- 
marks {black dots) that are used 
to align the arms. The proximity 
of the ends of the arms to the 
landmarks makes alignment easy 
and helps ensure that the arms 
are aligned accurately. (B) The 
small half-circle metal goniome- 
ter is a poor choice for measuring 
knee flexion ROM because the 
landmarks are so far from the 
ends of the goniometer's arms 
that accurate alignment is diffi- 
cult. 



fluid 

is sii 

360- 

OB 

mot: 

grav 

plan 

mag 

plan 

and 

able 

thar 

and 

h 
men 
lorn 
note 
atio 
havi 
the 
mal 
vert 
mer 
min 
cult 
def, 

i 
ters 
sho 
exa 
Tue 
a s 



CHAPTER 2 PROCEDURES 



25 



neter, 
ound 
:rs or . 
fluid ■ 
2-8). ; 
: pro- 
:cnter 
y Fox 
iomc- 
has a 







m 



FIGURE 2-8 Each of these gravi- 
ty-dependent goniometers uses a 
weighted pointer (A,B,D) or bub- 
ble (C) to indicate the position of 
the goniometer relative to the verti- 
cal pull of gravity. All of these 
inclinometers have a rotating dial 
so that the scale can be zeroed with 
the pointer or bubble in the start- 
ing position. 



he right- >■ 
it easier 
(A) The ' 
ull-circle | 
arms to ;; 
DM. The I 
r extend ' 
proximal 
to within ] 
my land- 
are used : 
Koximiry 
ns to the 
nent easy 
the arms 
: (B) The 
goniome- 
neasuring 
cause the 
from the 
er's arms 
■x is diffi- 



fiuid-fiiied circular chamber containing an air bubble. It 
is similar to a carpenter's level but, being circular, has a 
360-degree scale. Other inclinometers such as the Myrin 
OB Goniometer and the CROM (cervical range of 
motion) device use a pendulum needle that reacts to 
gravity to measure motions in the frontal and sagittal 
planes and use a compass needle that reacts to the earth's 
magnetic field to measure motions in the horizontal 
plane. A fairly large selection of manual inclinometers 
and a few digital inclinometers are commercially avail- 
able. Generally these instruments are more expensive 
than universal goniometers (See Appendix B: Features 
and Cost of Universal and Gravity-Based Goniometers). 
Inclinometers are attached to or held on the distal seg- 
ment of the joint being measured. The angle between the 
long axis of the distal segment and the line of gravity is 
noted. Inclinometers may be easier to use in certain situ- 
ations than universal goniometers because they do not 
have to be aligned with bony landmarks or centered over 
the axis of motion. However, it is critical that the proxi- 
mal segment of the joint being measured be positioned 
vertically or horizontally to obtain accurate measure- 
i merits; otherwise, adjustments must be made in deter- 
I mining the measurement. 6,9 Inclinometers are also diffi- 
cult to use on small joints 10 and where there is soft tissue 
ideformity or edema. 6,9 

| Although universal and gravity-dependent goniome- 
l^ts may all be available within a clinical setting, they 
|Shou!d not be used interchangeably. 11-14 For example, an 
ipaminer should not use a universal goniometer on 
piesday and an inclinometer on Wednesday to measure 
| a subject's knee ROM. The goniometers may provide 



slightly different results, making comparisons for judging 
changes in ROM inappropriate. 

Electrogoniometers 

Electrogoniometers, introduced by Karpovich and 
Karpovich 15 in 1959, are used primarily in research to 
obtain dynamic joint measurements. Most devices have 
two arms, similar to those of the universal goniometer, 
which are attached to the proximal and distal segments 
of the joint being measured. 16-19 A potentiometer is con- 
nected to the two arms. Changes in joint position cause 
the resistance in the potentiometer to vary. The resulting 
change in voltage can be used to indicate the amount of 
joint motion. Potentiometers measuring angular displace- 
ment have also been integrated with strain gauges 20,21 
and isokinetic dynamometers 22 for measuring resistive 
torque. Flexible electrogoniometers with two plastic end- 
blocks connected by a flexible strain gauge have been 
designed to measure angular displacement between the 
end-blocks in one or two planes of motion. 3,13 

Some electrogoniometers resemble pendulum 
goniometers. 23,24 Changes in joint position cause a 
change in contact between the pendulum and the small 
resistors. Contact with the resistors produces a change in 
electric current, which is used to indicate the amount of 
joint motion. 

Electrogoniometers are expensive and take time to cal- 
ibrate accurately and attach to the subject. Given these 
drawbacks, electrogoniometers are used more often in 
research than in clinical settings. Radiographs, photo- 
graphs, film, videotapes, and computer-assisted video 



26 



PART I INTRODUCTION TO GONIOMETRY 




THE UNIVERSAL GONIOMETER 



The following activities are designed to help the examiner become familiar with the universal 

goniometer. 

Equipment: Full-circle and half-circle universal goniometers made of plastic and metal. 

Activities: 

1 . Select a goniometer. 

2. Identify the type of goniometer selected (full-circle or half-circle) by noting the shape of the 
body. 

3. Differentiate between the moving and the stationary arms of the goniometer. (Remember 
that the stationary arm is an integral part of the body of the goniometer.) 

4. Observe the moving arm to see if it has a cut-out portion. 

5. Find the line in the middle of the moving arm and follow it to a number on the scale. 

6. Study the body of the goniometer and answer the following questions: 

a. Is the scale located on one or both sides? 

b. Is it possible to read the scale through the body of the goniometer? 

c. What intervals are used? 

d. Does the face contain one or two scales? 

7. Hold the goniometer in both hands. Position the arras so that they form a continuous 
straight line. When the arms are in this position, the goniometer is at degrees. 

8. Keep the stationary arm fixed in place and shift the moving arm while watching the num- 
bers on the scale, either at the tip of the moving arm or in the cut-out portion. Shift the 
moving arm from to 45, 90, 150, and 180 degrees. 

9. Keep the stationary arm fixed and shift the moving arm from degrees through an esti- 
mated 45-degree arc of motion. Compare the visual estimate with the actual arc of motion 
by reading the scale on the goniometer. Try to estimate other arcs of motion and compare 
the estimates with the actual arc of motion. 

10. Keep the moving arm fixed in place and move the stationary arm through different arcs of 
motion. 

11. Repeat steps 2 to 10 using different goniometers. 



motion analysis systems are other joint measurement 
methods used more commonly in research settings- 
Visual Estimation 

Although some examiners make visual estimates of joint 
position and motion rather than use a measuring instru- 
ment, we do not recommend this practice. Several 
authors suggest the use of visual estimates in situations in 
which the subject has excessive soft tissue covering phys- 



ical landmarks. 25,26 Most authorities report more accifc 
rate and reliable measurements with a goniometer thanl 
with visual estimates. 27 ~ 33 Even when produced by M 
skilled examiner, visual estimates yield only subjective! 
information in contrast to goniometric measurements;! 
which yield objective information. However, estimates! 
are useful in the learning process. Visual estimates madJI 
prior to goniometric measurements help to reduce errof|| 
attributable to incorrect reading of the goniometer. If tH|l 
goniometric measurement is not in the same quadrant m 



CHAPTER 2 PROCEDURES 



27 




FIGURE 2-9 The examiner is using a grease pencil to mark the location of the subject's left acromion 
process. Note that the examiner is using the second and third digits of her left hand to palpate the bony 
landmark. 



nore accu; 
neter thattl 
uced by M 
| subjecting 
Surements,| 
j estimates! 
iates madl 
iuce errors| 
■leter. If th| 
uadrant 31 



;| the estimate, the examiner is alerted to the possibility 

:'| that the wrong scale is being read. 

si After the examiner has read and studied this section 

M on measurement instruments, Exercise 2 should be com- 
pleted. Given the adaptability and widespread use of the 

;;| universal goniometer in the clinical setting, this book 

I focuses on teaching the measurement of joint motion 

;j using a universal goniometer. 



m Alignment 

Goniometer alignment refers to the alignment of the 
arms of the goniometer with the proximal and distal seg- 
ments of the joint being evaluated. Instead of depending 
on soft tissue contour, the examiner uses bony anatomi- 
cal landmarks to more accurately visualize the joint seg- 
ments. These landmarks, which have been identified for 
all joint measurements, should be exposed so that they 
may be identified easily (Fig. 2-9). The landmarks should 
be learned and adhered to whenever possible. The sta- 
tionary arm is often aligned parallel to the longitudinal 
axis of the proximal segment of the joint, and the mov- 
ing arm is aligned parallel to the longitudinal axis of the 
mstal segment of the joint (Fig. 2-10). In some situations, 




FIGURE 2-10 When using a full-circle goniometer to measure 
ROM of elbow flexion, align the stationary arm of the instru- 
ment parallel to the longitudinal axis of the proximal part (sub- 
ject's humerus) and align the moving arm parallel to the longi- 
tudinal axis of the distal part (subject's forearm). 



--/-=- ,--■ 



28 



PART I INTRODUCTION TO CONIOMETRY 




FIGURE 2-11 [A) When the examiner uses a half-circle goniomecer to measure left elbow flexion, 
aligning the moving arm with the subject's forearm causes the pointer to move beyond the goniome- 
ter body, which makes it impossible to read the scale. (B) Reversing the arms of the instrument so that 
the stationary arm is aligned parallel to the distal part and the moving arm is aligned parallel to the 
proximal part causes the pointer to remain on the body of the goniometer, enabling the examiner to 
read the scale along the pointer. 



because of limitations imposed by either the goniometer 
or the subject (Fig. 2-1 1A), it may be necessary to reverse 
the alignment of the two arms so that the moving arm is 
aligned with the proximal part and the stationary arm is 



aligned with the distal parr (Fig. 2-11B). Therefore, v/tf. 
have decided to use the term proximal arm to refer ro th;- 
arm of the goniometer that is aligned with the proximal! 
segment of the joint. The term distal arm refers to rW| 



arm 
2-1; 
poir 
is cc 
T 
ap p , 

bein 

char 

mus 

ful { 

that 

a Ppi 

arm: 
Se grr 
rhef 
E: 
goni 
Wh e 
goni 
goni 
J owe 
be di 
one j 
180 
whic 
esrirr 
error 
Anot 
vals 
Parti 



CHAPTER 2 PROCEDURF 



, 



I 










X 



FIGURE 2-J.2 Throughout the 
book we use the term "proxi- 
mal arm" to indicate the arm of 
the goniometer that is aligned 
with the proximal segment of 
the joint being examined. The 
term "distal arm" is used to 
indicate the arm of the 
goniometer that is aligned with 
the distal segment of the joint. 
During the measurement of 
elbow flexion, the proximal 
arm is aligned with the 
humerus, and the distal arm is 
aligned with the forearm. 



arm aligned with the distal segment of the joint (Fig. 
2-12}. The anatomical landmarks provide reference 
points that help to ensure that the alignment of the arms 
is correct. 

The fulcrum of the goniometer may be placed over the 
ipproximate location of the axis of motion of the joint 
being measured. However, because the axis of motion 
changes during movement, the location of the fulcrum 
must be adjusted accordingly. Moore 6 suggests that care- 
ful alignment of the proximal and distal arms ensures 
that the fulcrum of the goniometer is located at the 
approximate axis of motion. Therefore, alignment of the 
arms of the goniometer with the proximal and distal joint 
segments should be emphasized more than placement of 
the fulcrum over the approximate axis of motion. 

Errors in measuring joint position and motion with a 
goniometer can occur if the examiner is not careful. 
When aligning the arms and reading the scale of the 
goniometer, the examiner must be at eye level with the 
goniometer to avoid parallax. If the examiner is higher or 
lower than the goniometer, the alignment and scales may 
be distorted. Often a goniometer will have several scales, 
one going from to 180 degrees and another going from 
180 to degrees. Examiners must carefully determine 
which scale is correct for the measurement, If a visual 
estimate is made before the measurement is taken, gross 
errors caused by reading the wrong scale will be obvious. 
Another source of error is misinterpretation of the inter- 
ns on the scale. For example, the smallest interval of a 
particular goniometer may be 5 degrees, but an examin- 



er may believe the interval represents 1 degree. In this 
case the examiner would incorrectly read 91 degrees 
instead of 95 degrees. 

After the examiner has read this section on alignment, 
Exercise 3 should be completed. 



3K Recording 

Goniometric measurements are recorded in numerical 
tables, pictorial charts, or within the written text of 
an evaluation. Regardless of which method is used, 
recordings should provide enough information to permit 
an accurate interpretation of the measurement. The fol- 
lowing items are recommended to be included in the 
recording: 

1. Subject's name, age, and gender 

2. Examiner's name 

3. Date and time of measurement 

4. Make and type of goniometer used 

5. Side of the body, joint, and motion being meas- 
ured; for example, left knee flexion 

6. ROM, including the number of degrees at the 
beginning of the motion and the number of 
degrees at the end of the motion 

7. Type of motion being measured; that is, passive or 
active motion 

8. Any subjective information, such as discomfort or 
pain, that is reported by the subject during the 
testing 



30 



PART ! INTRODUCTION TO GONIOMETRY 




GONIOMETER ALIGNMENT FOR ELBOW FLEXION 



The following activities are designed to heip the examiner learn how to align and read the 
goniometer. 

Equipment: Full-circle and half-circle universal goniometers of plastic and metal in var- 
ious sizes and a skin-marking pencil. 

Activities: See Figures 5-15 to 5-17 in Chapter 5. 

1. Select a goniometer and a subject. 

2. Position the subject so that he or she is supine. The subject's right arm should be positioned 
so that it is close to the side of the body with the forearm in supination (palm of hand faces 
the ceiling). A towel roll placed under the distal humerus helps to ensure that the elbow is 
fully extended. 

3. Locate and mark each of the following landmarks with the pencil: acromion process, lat- 
eral epicondyle of the humerus, radial head, and radial styloid process. 

4. Align the proximal arm of the goniometer along the longitudinal axis of the humerus, 
using the acromion process and the lateral epicondyle as reference landmarks. Make sure 
that you are positioned so that the goniometer is at eye level during the alignment process. 

5. Align the distal arm of the goniometer along the longitudinal axis of the radius, using the 
radial head and the radial styloid process as reference landmarks. 

6. The fulcrum should be close to the lateral epicondyle. Check to make sure that the body 
of the goniometer is not being deflected by the supporting surface. 

7. Recheck the alignment of the arms and readjust the alignment as necessary. 

8. Read the scale on the goniometer. 

9. Remove the goniometer from the subject's arm and place it nearby so it is handy for mea- 
suring the next joint position. 

10. Move the subject's forearm into various positions in the flexion ROM, including the end 
of the flexion ROM. At each joint position, align and read the goniometer. Remember that 
you must support the subject's forearm while aligning the goniometer. 

11. Repeat steps 3 to 10 on the subject's left upper extremity. 

12. Repeat steps 4 to 10 using goniometers of different sizes and shapes. 

13. Answer the following questions: 

a. Did the length of the goniometer arms affect the accuracy of the alignment? Explain. 

b. What length goniometer arms would you recommend as being the most appropriate for 
this measurement? Why? 

c. Did the type of goniometer used (full-circle or half-circle) affect either joint alignment 
or the reading of the scale? Explain. 

d. Did the side of the body that you were testing make a difference in your ability to align 
the goniometer? Why? 



10. 



Any objective information obtained by the exam- 
iner during testing, such as a protective muscle 
spasm, crepitus, or capsular or noncapsular pat- 
tern of restriction 

A complete description of any deviation from the 
recommended testing positions 



If a subject has normal pain-free ROM during active 
or passive motion, the ROM may be recorded as normal 
(N) or within normal limits (WNL). To determine 

whether the ROM is normal, the examiner should com- 
pare the ROM of the joint being tested with ROM val- 



ues from people of the same age and gender, and from 
studies that used the same method of measurement. Text 
and ROM tables that demonstrate mean values by age 
with information on gender and methods of measure- 
ment arc presented at the beginning of Chapters 4 
through 13. A selection of ROM values is also presented 
at the beginning of testing procedures for each motion 
and in Appendix A. The ROM of the joint being tested 
may also be compared with the same joint of the subject's 
contralateral extremity, provided that the contralateral 
extremity is neither impaired nor used selectively in ath- 
letic or occupational activities. 



CHAPTER 2 PROCEDURES 



31 



If passive ROM appears to be decreased or increased 
when compared with normal values, the ROM should be 
measured and recorded. Recordings should include both 
the starting and the ending positions to define the ROM. 
A. recording that includes only the total ROM, such as 50 
degrees of flexion, gives no information as to where a 
motion begins and ends. Likewise, a recording that lists 
;-20 degrees (minus 20 degrees) of flexion is open to mis- 
interpretation because the lack of flexion could occur at 
either the end or the beginning of the ROM. 
; A motion such as flexion that begins at degrees and 
ends at 50 degrees of flexion is recorded as 0-50 degrees 
of flexion (Fig. 2-13A). A motion that begins with the 
joint flexed at 20 degrees and ends at 70 degrees of flex- 
: ion is recorded as 20-70 degrees of flexion (Fig. 2-1 3B). 
The total ROM is the same (50 degrees) in both 
instances, but the arcs of motion are different. 

Because both the starting and the ending positions 
have been recorded, the measurement can be interpreted 



correctly. If we assume that the normal ROM for this 
movement is to 150 degrees, the subject who has a flex- 
ion ROM of 0-50 degrees lacks motion at the end of the 
flexion ROM. The subject with a flexion ROM of 20-70 
degrees lacks motion at the beginning and at the end of 
the flexion ROM. The term hypomobile may be applied 
to both of these joints because both joints have a less- 
than-normal ROM. 

Sometimes the opposite situation exists, in which a 
joint has a greater-than-normal range of motion and is 
hypermobiie. If an elbow joint is hypermobile, the start- 
ing position for measuring elbow flexion may be in 
hyperextension rather than at degrees. If the elbow was 
hyperextended 20 degrees in the starting position, the 
beginning of the flexion ROM would be recorded as 20 
degrees of hyperextension (Fig. 2-14). To clarify that the 
20 degrees represents hyperextension rather than limited 
flexion, a "0" representing the zero starting position, 
which is now within the ROM, is included. An ROM 




FIGURE 2-13 A recording of 

ROM should include the begin- 
ning of the range as well as the 
end. {A} In this illustration, the 
motion begins at degrees and 
ends at 50 degrees so that the 
total ROM is 50 degrees. (B) In 
this illustration, the motion 
begins at 20 degrees of flexion 
and ends at 70 degrees, so that 
the total ROM is 50 degrees. 
For both subjects, the total 
ROM is the same, 50 degrees, 
even though the arcs of motion 
are different. 



32 PART I INTRODUCTION TO GONIOMETRY 




/ 



^, 



FIGURE 2-14 This subject has 
20 degrees of hyperextension 

at her elbow. In this case, 
motion begins at 21) degrees of 
hyperextension and proceeds 
th rough the 0-degrec position 

to 150 decrees of flexion. 



: 



that begins at 20 degrees of hyperextension and ends at 
150 degrees of flexion is recorded as 20-0-150 degrees 
of flexion. 

Some authorities have suggested the use of plus ( + ) 
and minus (-) signs to indicate hypomobility and hyper- 
mobility. However, the use of these signs varies depend- 
ing on the authority consulted. To avoid confusion, we 
have omitted the use of plus and minus signs. A ROM 
that does not start with degrees or ends prematurely 
indicates hypomobility. The addition of zero, represent- 
ing the usual starting position within the ROM indicates 
hypermobility. 

Numerical Tables 

Numerical tables typically list joint motions in a column 

down the center of the form (Fig. 2-15), Space to the left 
of the central column is reserved for measurements taken 



on the left side of the subject's body; space to the right is 
reserved for measurements taken on the right side of 
the body. The examiner's initials and the date of testing 
are noted at the top of the measurement columns. 
Subsequent measurements are recorded on the same form 
and identified by the examiner's initials ami the date at 
the top of the appropriate measurement column. This 
format makes it easy to compare a series of measure- 
ments to identify problem motions and then to track 
rehabilitative response over time. Examples of numerical 
recording tables are included in Appendix C. 

Pictorial Charts 

Pictorial charts may be used in isolation or combined 
with numerical tables to record ROM measurements. 
Pictorial charts usually include a diagram of the normal 

starting and ending positions of the motion (l-'ig. 2-16). 



Name Paul Jones 
Left 


Age 57 




Gender M 

Right 






JW 


JW 


Examiner 


JW 












4/1/02 


3/18/02 


Date 


3/18/02 












0-9S 


0-73 


Hip 
Flexion 


0-118 












0-5 


0-5 


Extension 


0-12 












0-28 


0-18 


Abduction 


0-32 












0-12 


0-6 


Adduction 


0-15 












0-35 


0-24 


Medial Rotation 


0-42 












0-40 


0-35 


Lateral Rotation 


0-44 














-j: 


Comments: 











FIGURE 2-15 This numeri- 
cal table records the results f 
of ROM measurements of a 
subject's left and right hips. 
The examiner has recorded 
her initials and the date of 
testing at the top of each col- 
umn of ROM measurements. 
Note that the right hip was 
tested once, on March IS, 
2002, and the left hip was 
tested twice, once on March 
IS, 2002, and again on April 
1,2002. 



CHAPTER 2 PROCEDURES 



33 



JW 
3/18/02 



JW 
4/1/02 



ibject has] 
.'xcension i 
nis case,- 
legrees of | 
proceeds! 
posiciort:| 
ion. 



e right is. 
r side o£ 
)f resting;! 
columns. 
i me form 
e date at 
mn. This 
measurer 
to track;! 
nim erica! 




JW 
3/1 8/94 -e 



FIGURE 2-16 This pictorial chart records the results of flexion ROM measurements of a subject's left 
hip. For measurements taken on March 18, 2002, note the to 73 degrees of left hip flexion; for meas- 
urements taken on April 1, 2002, note the to 98 degrees of left hip flexion. (Adapted with permission 
from Range of Motion Test, New York University Medical Center, Rusk Institute of Rehabilitation 

Medicine.) 



:ombined 
tirements. 
ie normal 
g. 2-16). 



is numert- 
the results 
nents of a 
right hips. 
s recorded 
he date of 
>f each col- 
isuremcnts. 
ht hip was 
March IS, 
ft hip was 
on March 
in on April 



Sagittal-Frontal-Transverse-Rotation Method 

Another method of recording, which may be included in 
a written text or formatted into a table, is the sagittal- 
frontal-transverse-rotation (SFTR) recording method, 
developed by Gerhardt and Russe. 34,35 Although it is 
rarely used in the United States, its advantages have been 
described by Miller. 9 In the SFTR method, three numbers 
are used to describe all motions in a given plane. The first 
and last numbers indicate the ends of the ROM in that 
plane. The middle number indicates the starting position, 
which would be in normal motion. 

In the sagittal plane, represented by S, the first num- 
ber indicates the end of the extension ROM, the middle 
number the starting position, and the last number the 
end of the flexion ROM. 

Example; Tf a subject has 50 degrees of shoulder 
extension and 170 degrees of shoulder flexion, 
these morions would be recorded: Shoulder S: 
5 0-0-tfQ degrees. 



sssssmmm 



In the frontal plane, represented by F, the first number 
indicates the end of the abduction ROM, the middle 
number the starting position, and the last number the 
end of the adduction ROM. The ends of spinal ROM in 



the frontal plane (lateral flexion) are listed to the left first 
and to the right last. 

Example: If a subject has 45 degrees of hip abduc- 
tion and 15 degrees of hip adduction, these motions 
would be recorded: Hip F: 45-0-15 degrees. 

In the transverse plane, represented by T, the first 
number indicates the end of the horizontal abduction 

ROM, the middle number the starting position, and the 
last number the end of the horizontal adduction ROM. 

Example: If a subject has 30 degrees of shoulder 
horizontal abduction and 135 degrees of shoulder 
horizontal adduction, these motions would be 
recorded: Shoulder T: 30^-0-135. degrees. 

Rotation is represented by R. Lateral rotation ROM, 
including supination and eversion, is listed first; medial 
rotation ROM, including pronation and inversion, is list- 
ed last. Rotation ROM of the spine to the left is listed 
first; rotation ROM to the right is listed last. Limb posi- 
tion during measurement is noted if it varies from 
anatomical position. "F90" would indicate that a meas- 
urement was taken with the limb positioned in 90 
degrees of flexion. 



1; 



34 



PART I INTRODUCTION TO CONSOMETRY 



EXAMPLE: If a subject has 35 degrees of lateral rota- 
tion ROM of the hip and 45 degrees of medial rota- 
■■.:.:;.. tion ROM of the hip, and these motions were 
measured with the hip in 90 degrees of flexion, 
these motions would be recorded: Hip R: (F90) 
35-0-45 degrees. ; 

Hypomobility is noted by the lack of as the middle 
number or by less-than-normal values for the first and 
last numbers, which indicate the ends of the ROM. 

EXAMPLE: If elbow flexion ROM was limited and 

a subject could move only between 20 and 90 
degrees of flexion, it would be recorded: Elbow S: 
0-20-90 degrees. The starting position is 20 
degrees of flexion, and the end of the ROM is 90 
degrees of flexion. 



-■■'J [ : ' • avs 



i'3W?^] '. 'P^'T::-' \ ^^■■iy--":^^ 



A fixed-joint limitation, ankylosis is indicated by the 
use of only two numbers. The zero starting position is 
included to clarify in which motion the fixed position 
occurs. 

Example: An elbow fixed in 40 degrees of flexion 
would be recorded: Elbow S: 0-40 degrees. 

American Medical Association Guide to 

Evaluation Method 

Another system of recording restricted motion has been 
described by the American Medical Association in the 
Guides to the Evaluation of Permanent Impairment. 36 
This book provides ratings of permanent impairment for 
all major body systems, including the respiratory, cardio- 
vascular, digestive, and visual systems. The longest chap- 
ter focuses on impairment evaluation of the extremities, 
spine, and pelvis. Restricted active motion, ankylosis, 
amputation, sensory loss, vascular changes, loss of 
strength, pain, joint crepitation, joint swelling, joint 
instability, and deformity are measured and converted to 
percentage of impairment for the body part. The total 
percentage of impairment for the body part is converted 
to the percentage of impairment for the extremity, and 
finally to a percentage of impairment for the entire body. 
Often these permanent impairment ratings are used, 
along with other information, to determine the patient's 
level of disability and the amount of monetary compen- 
sation to be expected from the employer or the insurer. 
Physicians and therapists working with patients with per- 
manent impairments who are seeking compensation for 
their disabilities should refer to this book for more detail. 
The system of recording restricted motion found in 
the Guides to the Evaluation of Permanent Impair- 
ment also uses the 0-to-180-degree notation method. 
The neutral starting position is recorded as degrees; 



motions progress toward I St) degrees. However, the 

recording system proposed in the Guides In the 
Evaluation of Permanent Impairment docs differ from 

other recording systems described in our test. In this sys- 
tem, when extension exceeds the neutral starting posi- 
tion, it is referred to as hyperextension and is expressed 
with the plus I '■ ) symbol. l : or example, motion .it the 
MCP joint of a finger from 15 degrees of hyperextension 
to 45 degrees of flexion would be recorded as ■■•- 15 to 45 
degrees. The plus j + ) symbol is used to emphasize the 
fact that the joint has hyperextension. 

In this system, the minus (-) symbol is used to empha- 
size the fact that a joint has an extension lag. When the 
neutral (zero) starting position cannot be attained, an 
extension lag exists and is expressed with the minus sym- 
bol. For example, motion at the MCP joint of a finger 
from 15 degrees of flexion to 45 degrees of flexion would 
be recorded as -15 to 45 degrees. 

Sfi Procedures 

Prior to beginning a goniometric evaluation, the examin- 
er must; 

• [Determine which joints and motions need to be 
tested 

• Organize the testing sequence by body position 

• Gather the necessary equipment, such as goniome- 
ters, towel rolls, and recording forms 

• Prepare an explanation of the procedure for the 
subject 

Explanation Procedure 

The listed steps and the example that follows provide the 
examiner with a suggested format for explaining 
goniomerry to a subject. 

Steps 

1. Introduction asid explanation of purpose 

2. Explanation and demonstration of goniometer 

3. Explanation and demonstration of anatomical 
landmarks 

4. Explanation and demonstration of testing position 

5. Explanation and demonstration of examiners and 
subject's roles 

6. Confirmation of subject's understanding 

Lay rather than technical terms are used in the exam- 
ple so that the subject can understand the procedure. 
During the explanation, the examiner should try to 
establish a good rapport with the subject and enlist the 
subject's participation in the evaluation process. After 
reading the example, the examiner should practice 
Exercise 4. 

EXAMPLE: Explanation of Goniomerry 



CHAPTER 2 PROCEDURES 



35 



vcr, the 
to thM 
: <-T ftt>!5| 
this sys- 
ng post. 
^pressed I 
n at the] 
xrension 1 
1 5 to 45^ 
asize the 

> empha; : a 
Vht-ii the 
lined, an 
n us sym4 
' a tingei;. 
i.>n wouldM 



Introduction and Explanation of Purpose 

Introduction: My name is 

(occupational title). 



I am a 



c examitK 

;ed to be;l 

isition 

goniome- 

re for thei 



irovide thfcj 
.xplainingi 



•e 

otneter 
anatoinicatj 

ng position;! 
timer's andf 

S 

i the exam; 
procedure; 
mid try to 
id enlist tfe j 
:kcss. Aftef 
.Id practice j 



Explanation: I understand that you have been hav- 
ing some difficulty moving your elbow. I am 
going to measure the amount of morion that you 

have at your elbow joint to see if it is equal to, 
less than, or greater than normal. I will use this 
information to plan a treatment program and 

iSffi assess its effectiveness. 

J Demonstration: The examiner flexes and extends 
his or her own elbow so that the subject is able 
to observe a joint motion. 

2. Explanation and Demonstration of Goniometer 

■ Explanation: The instrument that I will be using to 
obtain the measurements is called a goniometer. 
It is similar to a protractor, but it has two exten- 
sions called arms. 

' : Demonstration: The examiner shows the goniome- 
ter to the subject and encourages the subject to 
ask questions. The examiner shows the subject 
how the goniometer is used by holding it next to 
his or her own elbow. 

3. Explanation and Demonstration of Anatomical 
Landmarks 

Explanation: To obtain accurate measurements, I 
will need to identify some anatomical land- 
marks. These landmarks help me to align the 
arms of the goniometer. Because these landmarks 
are important, I may have to ask you to remove 
certain articles of clothing, such as your shirt or 
blouse. Also, to locate some of the landmarks, I 
may have to to press my fingers against your 
skin. 

Demonstration; The examiner shows the subject an 
easily identified anatomical landmark such as the 
ulnar styloid process. 

4. Explanations and Demonstration of Recom- 
mended Testing Positions 

Explanation: Certain testing positions have been 
established to help make joint measurements 
easier and more accurate. Whenever possible, 
I would like you to assume these positions. I 
will be happy to help you get into a particular 
position. Please 'let me know if you need assis- 
tance. 

Demonstration: The sitting or supine positions. 

■5. Explanation and Demonstration of Examiner's and 
Subject's Roles During Active Motion 
Explanation: I will ask you to move your arm in 

exactly the same way that I move your arm. 
Demonstration: The examiner takes the subject's 



arm through a passive ROM and then asks the 
subject to perform the same motion. 

6. Explanation and Demonstration of Examiner's and 
Subjects Roles During Passive Motion 

Explanation: I will move your arm and take a 
measurement. You should relax and let me do all 
of the work. These measurements should not 
cause discomfort. Please let me know if you have 
any discomfort and I will stop moving your arm. 

Demonstration: The examiner moves the subject's 
arm gently and slowly through the range of 
elbow flexion. 

7. Confirmation of Subject's Understanding 

Explanation: Do you have any questions? Are you 

ready to begin? 

Testing Procedure 

The testing process is initiated after the explanation of 
goniometry has been given and the examiner is assured 
that the subject understands the nature of the testing 
process. The testing procedure consists of the following 
12-step sequence of activities. 

Steps 

1. Place the subject in the testing position. 

2. Stabilize the proximal joint segment. 

3. Move the distal joint segment to the zero starting 
position. If the joint cannot be moved to the zero 
starting position, it should be moved as close as 
possible to the zero starting position. Slowly 
move the distal joint segment to the end of the 
passive ROM and determine the end-feel. Ask the 
subject if there was any discomfort during the 
motion. 

4. Make a visual estimate of the ROM. 

5. Return the distal joint segment to the starting 
position. 

6. Palpate the bony anatomical landmarks. 

7. Align the goniometer. 

8. Read and record the starting position. Remove 
the goniometer. 

9. Stabilize the proximal joint segment. 

10. Move the distal segment through the full ROM. 

11. Replace and realign the goniometer. Palpate the 
anatomical landmarks again if necessary. 

12. Read and record the ROM. 

Exercise 5, which is based on the 12-step sequence, 
affords the examiner an opportunity to use the testing 
procedure for an evaluation of the elbow joint. This exer- 
cise should be practiced until the examiner is able to per- 
form the activities sequentially without reference to the 
exercise. 



36 



PART I INTRODUCTION TO GONIOMETRY 




EXERCISE 4 

EXPLANATION OF GCNiOMETRY 



Equipment: A universal goniometer. 

Activities: Practice the following six steps with a subject. 

1. Introduce yourself and explain the purpose of goniometric testing. Demonstrate a joint 

ROM on yourself. 

2. Show the goniometer to your subject and demonstrate how it is used to measure a joint 
ROM. 

3. Explain why bony landmarks must be located and palpated. Demonstrate how you would 
locate a bony landmark on yourself, and explain why clothing may have to be removed. 

4. Explain and demonstrate why changes in position may be required. 

5. Explain the subject's role in the procedure. Explain and demonstrate your role in the pro- 
cedure. 

6. Obtain confirmation of the subject's understanding of your explanation. 




IX EEC I Si 5 



TESTING PROCEDURE FOR GONIOMETRIC EVALUATION 
OF ELBOW FLEXION 



Equipment: A universal goniometer, sktn-marking pencil, recording form, and pencil. 
Activities: See Figures 5-15 to 5-1 7 in Chapter 5. 



1. Place the subject in a supine position, with the arm to be tested positioned close to the side 
of the body. Place a towel roll under the distal end of the humerus to allow full elbow 
extension. Position the forearm in full supination, with the palm of the hand facing the 
ceiling. 

2. Stabilize the distal end of the humerus to prevent flexion of the shoulder. 

3. Move the forearm to the zero starting position and determine whether there is any motion 
(extension) beyond zero. Move to the end of the passive range of flexion. Evaluate the end- 
feel. Usually the end-feel is soft because of compression of the muscle bulk on the anteri- 
or forearm in conjunction with that on the anterior humerus. Ask the subject if there was 
any discomfort during the motion. 

4. Make a visual estimate of the beginning and end of the ROM. 

5. Return the forearm to the starting position. 

6. Palpate the bony anatomical landmarks (acromion process, lateral epicondyle of the 
humerus, radial head, and radial styloid process) and mark with a skin pencil. 

7. Align the arms and the fulcrum of the goniometer. Align the proximal arm with the later- 
al midline of the humerus, using the acromion process and lateral epicondyle for reference. 
Align the distal arm along the lateral midline of the radius, using the radial head and the 
radial styloid process for reference. The fulcrum should be close to the lateral epicondyle 
of the humerus. 

8. Read the goniometer and record the starting position. Remove the goniometer. 

9. Stabilize the proximal joint segment (humerus). 

10. Perform the passive ROM, making sure that you complete the available range. 

11. When the end of the ROM has been attained, replace and realign the goniometer. Palpate 
the anatomical landmarks again if necessary. 

12. Read the goniometer and record your reading. Compare your reading with your visual esti- 
mate to make sure that you are reading the correct scale on the goniometer. 



CHAPTER 2 PROCEDURES 



37 






fFERENCES 

1, Rorhsrein, JM, Miller, PJ, and Roettger, F: Goniometric reliability 19. 

in a clinical setting. Phys Ther 63:1611, 1983. 
Ekstrand, J, et al: Lower extremity goniometric measurements: A 
study to determine their reliability. Arch Phys Med Rehabil 63:171, 20. 
1982 

3. Ball, P, and Johnson, GR: Reliability of hindfoot goniometry when 21. 
using a flexible electrogoniometer. Clin Biomech 8:13, 1993 

4. Sabar, JS, et al: Goniometric assessment of shoulder range of 
motion: Comparison of testing in supine and sitting positions. Arch 

Phys Med Rehabil 79:64,1998. 22. 

5. Moore, ML: The measurement of joint motion. Part II: The technic 
of goniometry. Phys Ther Rev 29:256, 1949. 

6. Moore, ML: Clinical assessment of joint motion. In Basmajian, JV 23. 
(ed): Therapeutic Exercise, ed 3, Williams & Wilkins, Baltimore, 

1978. 

7. Fox, RF, and Van Brcemen, j: Chronic Rheumatism, Causation and 24. 
Treatment, Churchill, London, 1934, p 327. 

8. Schenkar, WW: Improved method of joint motion measurement. 

N Y J Med 56:539, 1956. 25. 

9. Miller, Pj: Assessment of joint motion. In Rothstein, JM (ed): 
Measurement in Physical Therapy. Churchill Livingstone, New 26. 
York, 1985. 

10. Clarkson, HM: Musculoskeletal Assessment: Joint Range of 27. 
Motion and Manual Muscle Strength, ed. 2. Lippincott Williams &C 
Wilkins, Philadelphia, 2000. 

11. Perhcrick, M, L-t al: Concurrent validity and imertcsrer reliability of 28. 
universal and fluid-based goniometers for active elbow range of 
motion. Phys Ther 68:966, 1988. 

12. Rhcault, W, et al: Intertester reliability and concurrent validity of 29. 
fluid-based and universal goniometers for active knee flexion. Phys 

Ther 68:1676, 1988. 30. 

13. Goodwin, j, et al: Clinical methods of goniometry: A comparative 
study. Disabil Rehabil 14:10, 1992. 31. 

!4. Rome, K, and Cowicson, F: A reliability study of the universal 

goniometer, fluid goniometer, and electrogoniometer for the meas- 32. 

urement of ankle dorsifiexion. Foot Ankle 17:28, 1996. 

15. Karpovich, PV, and Karpovich, GP: Electrogoniometer: A new 33. 
device for study of joints in action. Fed Proc 18:79, 1959. 

16. Kettelkanip, DB, Johnson, RC, Smidt, GL, et al: An electrogonio- 34. 
metric study of knee motion in normal gait. J Bone Joint Surg Am 
52:775, 1970. 35. 

17. Krmtzen, KM, Bates, BT, and Hamill, J: Electrogoniometry of post- 
surgical knee bracing in running. Am J Phys Med Rehabil 62:172, 

1983. 36. 

18. Carey, JR, Patterson, JR, and Hollcnstcin, PJ: Sensitivity and rctia- 






bility of force tracking and joint-movement tracking scores in 
healthy subjects. Phys Ther 68:1087, 1988. 

Torburn, L, Perry, J, and Gronfey, JK: Assessment of rcarfoot 
motion: Passive positioning, one- legged standing, gait. Foot Ankle 

19:688:1998. 

Vandervoort, A A, et al: Age and sex effects on mobility of the 
human ankle. J Gerontol 47;M17, 1992. 

Chesworth, BM, and Vandervoort, AA: Comparison of passive 
stiffness variables and range of motion in uninvolved and involved 
ankle joints of patients following ankle fractures. Phys Ther 
75:Z53, 1995 

Gajdosik, RL, Vander Linden, DW, and Williams, AK: Influence of 
age on length and passive elastic stiffness characteristics of the calf 
muscles-tendon unit of woman. Phys Ther 79:827, 1999. 
Clapper, MP, and Wolf, SL: Comparison of the reliability of the 
Orthorangcr and the standard goniometer for assessing active 
lower extremity range of motion. Phys Ther 68:214, 1988. 
Greene, BL, and Wolf, SL: Upper extremity joint movement: 
Comparison of two measurement devices. Arch Phys Med Rehabil 
70:288, 1989. 

American Academy of Orthopaedic Surgeons: joint Motion: A 
Method of Measuring and Recording. AAOS, Chicago, 1965. 
Rowe, CR: Joint measurement in disability evaluation. Clin Orthop 
32:43, 1964. 

Watkins, MA, et al: Reliability of goniometric measurements and 
visual estimates of knee range of motion obtained in a clinical set- 
ting. Phys Ther 71:90, 1991. 

Youdas, JW, Carey, JR, and Garrett, TR: Reliability of measure- 
ments of cervical spine range of motion: Comparison of three meth- 
ods. Phys Ther 71:98, 1991. 

Low, JL: The reliability of joint measurement. Physiotherapy 
62:227, 1976. 

Moore, ML: The measurement of joint motion. Part I: Introductory 
review of the literature. Phys TherRev 29:195, 1949. 
Salter, N: Methods of measurement of muscle and joint function, j 
Bone Joint Surg Br 34:474, 1955. 

Minor, MA, and Minor, SD: Patient Evaluation Methods for the 
Health Professional. Resron, VA, 1985. 

Greene, WB, and Heckman JD (eds): The Clinical Measurement of 
Joint Morion. AAOS, Rosemont, 111., 1994. 
Gerhardt, jj, and Russe, OA; International SFTR. Method of 
Measuring and Recording Joint Motion. Hans Hubcr, Bern, 1975. 
Gerhardt, JJ: Clinical measurement of joint motion and position in 
the neutral-zero method and SFTR; Basic principles, int Rehabil 
Med 5:161, 1983. 

American Medical Association: Guides to the Evaluation of 
Permanent Impairment, ed 3. AMA, Milwaukee, 1990. 




■ ■ -^a-ff-- :. 



I CHAPTER- . 3 



Validity and Reliability 




m Validity 

For goniometry to provide meaningful information, 
measurements must be valid and reliable. Currier 1 states 
that validity is "the degree to which an instrument mea- 
sures what it is purported to measure; the extent to 
which it fulfills its purpose." Stated in another way, the 
validity of a measurement refers to how well the meas- 
urement represents the true value of the variable of inter- 
est. The purpose of goniometry is to measure the angle of 
joint position or range of joint motion. Therefore, a valid 
goniometric measurement is one that truly represents the 
actual joint angle or the total range of motion (ROM). 

Face Validity 

There are four main types of validity: face validity, 
content validity, criterion-related validity, and construct 
validity. 2 ' 5 Most support for the validity of goniometry is 
in, the form of face, content, and criterion-related valid- 
ity. Face validity indicates that the instrument generally 
appears to measure what it proposes to measure — that it 
is plausible. ~' s Much of the literature on goniometric 
measurement does not specifically address the issue of 
validity; rather, it assumes that the angle created by align- 
ing the arms of a universal goniometer with bony land- 
marks truly represents the angle created by the proximal 
and distal bones composing the joint. One infers that 
changes in goniometer alignment reflect changes in joint 
angle and represent a range of joint motion. Portney and 
Watkins 3 report that face validity is easily established for 
some tests such as the measurement of ROM, because 
the instrument measures the variable of interest through 
direct observation. 



Content Validity 

Content validity is determined by judging whether or not 
an instrument adequately measures and represents the 

domain of content — the substance — of the variable of 
interest. 2 ""' Both content and face validity are based on 
subjective opinion. However, face validity is the most 
basic and elementary form of validity, whereas content 
validity involves more rigorous and careful considera- 
tion. Gajdosik and Bohannon 6 state, "Physical therapists 
judge the validity of most ROM measurements based on 
their anatomical knowledge and their applied skills of 
visual inspection, palpation of bony landmarks, and 
accurate alignment of the goniometer. Generally, the 
accurate application of knowledge and skills, combined 
with interpreting the results as measurement of ROM 
only, provide sufficient evidence to ensure content valid- 
icy." 



Criterion-related Validity 

Criterion-related validity justifies the validity of the 
measuring instrument by comparing measurements made 
with the instrument to a well-established gold standard 
of measurement — the criterion. 2-5 If the measurements 
made with the instrument and criterion are taken at 
approximately rhe same time, concurrent validity is 
tested. Concurrent validity is a type of criterion-related 
validity.* - ' Criterion-related validity can be assessed 
objectively with statistical methods. In terms of goniom- 
etry, an examiner may question the construction of a 
particular goniometer on a very basic level and consider 
whether the degree units of the goniometer accurately 
represent the degree units of a circle. The angles of the 



39 



40 PART I INTRODUCTION TO GONIOMETRY 






goniometer can be compared with known angles of a 
protractor — the criterion. Usually the construction of 
goniometers is adequate, and the issue of validity focuses 
on whether the goniometer accurately measures the angle 
of joint position and ROM in a subject. 

Criterion-related Validity Studies of 
Extremity Joints 

The best gold standard used to establish criterion-related 
validity of goniometric measurements of joint position 
and ROM is radiography. Several studies have examined 
extremity joints for the concurrent validity of goniomet- 
ric and radiographic measurements. Gogia and associ- 
ates 8 measured the knee position of 30 subjects with 
radiography and with a universal goniometer. Knee posi- 
tions ranged from to 120 degrees. High correlation 
{correlation coefficient [r] = 0.97) and agreement (inrra- 
class correlation coefficient [ICQ = 0.98) were found 
between the two types of measurements. Therefore 
goniometric measurement of knee joint position was 
considered to be valid. Enwemeka 9 studied the validity of 
measuring knee ROM with a universal goniometer by 
comparing the goniometric measurements taken on 10 
subjects with radiographs. No significant differences 
were found between the two types of measurements 
when ROM was within 30 to 90 degrees of flexion 
(mean difference between the two measurements ranged 
from 0.5 to 3.8 degrees). However, a significant differ- 
ence was found when ROM was within to 15 degrees 
of flexion (mean difference 4.6 degrees). Ahlbach and 
Lindahl 10 found that a joint-specific goniometer used to 
measure hip flexion and extension in 14 subjects closely 
agreed with radiographic measurements. 

Criterion-related Validity Studies of the Spine 

Various instruments used to measure ROM of the spine 
have also been compared with a radiographic criterion, 
although some researchers question the use of radio- 
graphs as the gold standard given the variability of ROM 
measurement taken from spinal radiographs.' 1 Three 
studies that contrasted cervical range of motion (cervical 
ROM) measurements taken with gravity-dependent 
goniometers with those recorded on radiographs found 
concurrent validity to be high. Herrmann, in a study of 
11 subjects, noted a high correlation (r = 0.97) and 
agreement (ICC = 0.98) between radiographic measures 
and pendulum goniometer measures of head and neck 
flexion-extension. Ordway and colleagues 13 simultane- 
ously measured cervical flexion and extension in 20 
healthy subjects with a cervical ROM goniometer, a 
computerized tracking system, and radiographs. There 
were no significant differences between measurements 
taken with the cervical ROM and radiographic angles 
determined by an occipital line and a vertical line, 
although there were differences between the cervical 



ROM and rhe radiographic angles between the occiput 

and C-7. Tousignanr and coworkers 1 "' measured cervical 
flexion and extension in 31 subjects with a cervical ROM 
goniometer and radiographs that included cervical and 
upper thoracic motion. They found a high correlation 
between the two measurements (r = 0.97). 

Studies that compared clinical ROM measurement 
methods for the lumbar spine with radiographic results 
report high to low validity. Macrae and Wright 1 '' mea- 
sured lumbar flexion in 342 subjects by using a tape 
measure, according to the Schober and modified Schober 
method, and compared these results with those shown in 
radiographs. Their findings support the validity of these 
measures: correlation coefficient values between the 
Schober method and the radiographic evidence were 0.90 
(standard error = 6.2 degrees), and between the modified 
Schober and the radiographs were 11.97 (standard error 
= 3.3 degrees). I'ortek and associates, 1 '" in a study of 1 1 
males, found no significant difference between lumbar 
flexion and extension ROM measurement taken with a 
skin distraction method and single inclinometer 
compared with radiographic evidence, but correlation 
coefficients were low (0.42 to 0.57). Comparisons may 
have been inappropriate because measurements were 
made sequentially rather than concurrently, with subjects 
in varying testing positions. Radiographs and skin 
distraction methods were performed on standing 
subjects, whereas inclinometer measurements were 
performed in subjects sitting for flexion and prone for 
extension. Burdert, Brown, and Fall, 1 ' in a study of 27 
subjects, found a fair correlation between measurements 
taken with a single inclinometer and radiographs for 
lumbar flexion (r = 0.73}, and a very poor correlation 
for lumbar extension (r = 0. 15). Mayer and coworkers 18 
measured lumbar flexion and extension in 12 patients 
with a single inclinometer, double inclinometer, and radi- 
ographs. No significant difference was noted between 
measurements. Saur and colleagues, 1 " in a study of 54 
patients, found lumbar flexion ROM measurement taken 
with two inclinometers correlated highly with radi- 
ographs (r = 0.98). Extension ROM measurement corre- 
lated with radiographs to a fair degree (r = 0.75). Samo 
and associates"" used double inclinometers and radi- 
ographs to measure 30 subjects held in a position of flex- 
ion and extension. Radiographs resulted in flexion values 
that were 1 1 to 15 degrees greater than those found with 
inclinometers, and extension values that were 4 to 5 
degrees less than those found with inclinometers. 



Construct Validity 

Construct validity is the ability of an instrument to meas- 
ure an abstract concept (construct)' or to be used to 
make an inferred interpretation.' There is a movement 

within rehabilitative medicine to develop and validate 



r 

f 

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4 to 5 




CHAPTER 3 VALIDITY AND RELIABILITY 



41 



i meas- 

ised to 
vement 
alidate 



measurement tools to identify functional limitations and 
predict disability. 21 Joint ROM may be one such mea- 
surement tool. In Chapters 4 through 13 on measure- 
ment procedures, we have included the results of research 
studies that report joint ROM observed during func- 
tional tasks. These findings begin to quantify the joint 
'motion needed to avoid functional limitations. Several 
researchers have artificially restricted joint motion with 
splints or braces and examined the effect on func- 
jion. 22-24 It appears that many functional tasks can be 
completed with severely restricted elbow or wrist ROM, 
providing other adjacent joints are able to compensate. A 
recent study by Hermann and Reese 2i examined the rela- 
tionship between impairments, functional limitations, 
and disability in 80 patients with cervical spine disorders. 
The highest correlation (r = 0.82) occurred between 
impairment measures and functional limitation mea- 
sures, with ROM contributing more to the relationship 
than the other two impairment measures of cervical 
muscle force and pain. Triffitt 26 found significant corre- 
lations between the amount of shoulder ROM and the 
ability to perform nine functional activities in 125 
patients with shoulder symptoms. Wagner and 
colleagues 27 measured passive ROM of wrist flexion, 
extension, radial and ulnar deviation, and the strength of 
the wrist extensor and flexor muscles in 18 boys with 
Duchenne muscular dystrophy. A highly significant nega- 
tive correlation was found between difficulty performing 
functional hand tasks and radial deviation ROM (r = 
-0.76 to -0.86) and between difficulty performing func- 
tional hand tasks and wrist extensor strength (r = -0.61 
to -0.83). 

SI Reliability 

The reliability of a measurement refers to the amount of 
consistency between successive measurements of the 
same variable on the same subject under the same condi- 
tions. A goniometric measurement is highly reliable if 
successive measurements of a joint angle or ROM, on the 
same subject and under the same conditions yield the 
same results. A highly reliable measurement contains 
little measurement error. Assuming that a measurement is 
valid and highly reliable, an examiner can confidently use 
its results to determine a true absence, presence, or 
change in dysfunction. For example, a highly reliable 
goniometric measurement could be used to determine the 
presence of joint ROM limitation, to evaluate patient 
progress toward rehabilitative goals, and to assess the 
effectiveness of therapeutic interventions. 

A measurement with poor reliability contains a large 
amount of measurement error. An unreliable measure- 
ment is inconsistent and does not produce the same 
results when the same variable is measured on the same 
subject under the same conditions. A measurement that 



has poor reliability is not dependable and should not be 
used in the clinical decision-making process. 

Summary of Goniometric Reliability Studies 

The reliability of goniometric measurement has been the 
focus of many research studies. Given the variety of 
study designs and measurement techniques, it is difficult 
to compare the results of many of these studies. 
However, some findings noted in several studies can be 
summarized. An overview of such findings is presented 
here. More information on reliability studies that pertain 
to the featured joint is reviewed in Chapters 4 through 
13. Readers may also wish to refer to several review arti- 
cles and book chapters on this topic. 6 - 28 - J0 

The measurement of joint position and ROM of 
the extremities with a universal goniometer has gener- 
ally been found to have good-to-excellent reliability. 
Numerous reliability studies have been conducted on 
joints of the upper and lower extremities. Some studies 
have examined the reliability of measuring joints held in 
a fixed position, whereas others have examined the reli- 
ability of measuring passive or active ROM. Studies that 
measured a fixed joint position usually have reported 
higher reliability values than studies that measured 
ROM. 8,12,31,32 This finding is expected because more 
sources of variation and error are present in measuring 
ROM than in measuring a fixed joint position. 
Additional sources of error in measuring ROM include 
movement of the joint axis, variations in manual force 
applied by the examiner during passive ROM, and vari- 
ations in a subject's effort during active ROM. 

The reliability of goniometric ROM measurements 
varies somewhat depending on the joint and motion. 
ROM measurements of upper-extremity joints have been 
found by several researchers to be more reliable than 
ROM measurements of lower-extremity joints, 33,34 
although opposing results have likewise been reported. 35 
Even %vithin the upper or lower extremities there are 
differences in reliability between joints and motions. For 
example, Hellebrandt, Duvall, and Moore, 36 in a study 
of upper-extremity joints, noted that measurements of 
wrist flexion, medial rotation of the shoulder, and abduc- 
tion of the shoulder were less reliable than measurements 
of other motions of the upper extremity. Low 37 found 
ROM measurements of wrist extension to be less reliable 
than measurements of elbow flexion. Greene and Wolf 38 
reported ROM measurements of shoulder rotation and 
wrist motions to be more variable than elbow motion 
and other shoulder motions. Reliability studies on ROM 
measurement of the cervical and thoracic spine in which 
a universal goniometer was used have generally reported 
lower reliability values than studies of the extremity 
joints. 17,39 " 42 Many devices and techniques have been 
developed to try to improve the reliability of measuring 



42 



PART I INTRODUCTION TO CONIOMETRY 



'.' 












I 



. 



spinal motions. Gajdoslk and Bohannon 6 suggested that 
the reliability of measuring certain joints and motions 
might be adversely' affected by the complexity of the 
joint. Measurement of motions that are influenced by 
movement of adjacent joints or muitijoint muscles may 
be less reliable than measurement of motions of simple 
hinge joints. Difficulty palpating bony landmarks and 
passively moving heavy body parts may also play a role 
in reducing the reliability of measuring ROM of the 
lower extremity and spine. 6 '- 13 

Many studies of joint measurement methods have 
found intratester reliability to be higher than intertester 
reliability. 'MW7JWWM> Reliability was higher when 
successive measurements were taken by the same exam- 
iner than when successive measurements were taken by 
different examiners. This is true for srudies that mea- 
sured joint position and ROM of the extremities and 
spine with universal goniometers and other devices such 
as joint-specific goniometers,' pendulum goniometers, 
tape measures, and flexible rulers. Only a few studies 
found intertester reliability to be higher than intratester 
reliability. 63 "**' In most of these studies, the time interval 
between repeated measurements by the same examiner 
was considerably greater than the time interval between 
measurements by different examiners. 

The reliability of goniometric measurements is 
affected by the measurement procedure. Several srudies 
found rhat intertester reliability improved when all the 
examiners used consistent, well-defined testing positions 
and measurement methods.' , ' M6,47 ' 67 Intertester reliabil- 
ity was lower if examiners used a variety of positions and 
measurement methods. 

Several investigators have examined the reliability of 
using the mean (average) of several goniometric meas- 
urements compared with using one measurement. Low 1 ' 
recommends using the mean of several measurements 
made with the goniometer to increase reliability over one 
measurement. Early studies by Cobe 6S and Hewitt 69 also 
used the mean of several measurements. However, Boone 
and associates 33 found no significant difference between 
repeated measurements made by the same examiner 
during one session and suggested that one measurement 
taken by an examiner is as reliable as the mean 
of repeated measurements. Rorhstein, Miller, and 
Roettgcr, 4 ' in a study on knee and elbow ROM, found 
that intertester reliability determined from the means of 
two measurements improved only slightly from the 
intertester reliability determined from single measure- 
ments. 

The authors of some texts on goniometric methods 
suggest the use of universal goniometers with longer 
arms to measure joints with large body segments such as 
the hip and shoulder. 2 * 1 -' ' 71 Goniometers with shorter 
arms are recommended to measure joints with small 
body segments such as the wrist and fingers, Robson, 72 



using a mathematical model, determined that gonioinj 
tcrs with longer arms are more accurate in measuring a| 
angle than goniometers with shorter arms. C mm ' uTiuterlfl 
with lunger arms reduce the effects of errors in rhe placed 
man or the goniometer axis. I lowevec Rorhsu-in, Mijl e | 
and Roettgcr found no difference in reliability anion! 
large plastic, large metal, and small plastic universal 
goniometers used to measure knee .xnd elbow R0\}| 
Riddle. Rorhstein, and Lamb' 1 '' also reported no dit&i 
ence 111 reliability between large and sin. ill plastic univeri 
sal goniometers used to measure shoulder ROM. 

Numerous srudies have compared tiie measureme'iitS 
values and reliability ol different types of devices used If 
measure joint ROM. Universal, pendulum, and fjnj| 
goniometers, joint-specific devices, tape measures, an<£l 
wire tracing are some of the devices that have b& 
compared. Studies comparing clinical measurement! 
devices have been conducted on the shoulder, 36 ;" 
elbow,'' 1 - 5 " - i! '-" ; " i wrist, ^^ hand, 5 -'-'" ' s '" hip 77 -i 
knee," ' ' "*■"" ankle. s| cervical spine, ' , '-' l:J, '" , ' s2 a: 
thoracolumbar spine. i """-' !l -"- ,! '"""" Many studies ha| 
found differences in values and reliability between me* 
sureiuent devices, whereas some stuelies have reported 
differences. 

In conclusion, on the basis of reliability studies ar| 
our clinical experience, we recommend the tollowii 
procedures to improve the reliability of goniomei 
measurements 1 [able }-\ i. Kxamincis should use con: 
tent, well-defined testing positions and anatomical lani 
marks to align the arms of the goniometer. Durii 
successive measurements of passive ROM, examine; 
should strive to apply the same amount of manual fop 
to move the subject's body. During successive nieastiB 
ments of active ROM, the subject should be ur«ed 
exert the same effort to perform a motion. To rcdm 
measurement variability, it is prudent to take repeal 
measurements on a subject with rhe same type of mal 
surcmenr device, for example, an examiner should ta| 
all repeated measurements of an ROM with a unive 
goniometer, rather than taking the iirst nu-asureme: 
with a universal goniometer and the second mcasurcme; 
wirh an inclinometer. We believe most examiners find 
easier and more accurate to use a large uuiverj 
goniometer when measuring joints with Luge bo) 
segments, and a small goniometer when measuring joiajj 
with small body segments. Inexperienced examiners m| 
wish to take several measurements and record rhe mi 
(average) ol those measurements to improve rcliabili! 
but one measurement is usually sufficient lor more ex; 
rienced examiners using good technique. I-'inally, it 
important to remember that successive measurements 
more reliable if taken by rhe same examiner rather tl 
by different examiners. The mean standard deviation 
repeated ROM measurement of extremity joints taken 
one examiner using a universal goniometer lias be«ll 



CHAPTER 3 VALIDITY AND RELIABILITY 



43 



nomc- 
ingan 
neters 
place- 
Vliller, 
imong 
iversal 

IIOM. 

differ- 

inivcr- 



*s and 
owing 
metric 
ronsis- 
I land- 
)uring 
niners 
I force 
asure- 
*ed to 
reduce 
peared 
E mea- 
d take 
i versa! 
emcnt 
ement 
find it 
i versa! 
body 
joints 
:s may 
mean 
ability, 
: expe- 
', it is 
pts are 
r than 
ion of 
ten by 
i been 



table 3-1 Recommendations for improving the Reliability of Goniometric Measurements 



Use consistent, well-defined positions 

Use consistent, well-defined anatomical landmarks to align the goniometer 

Use the same amount of manual force to move subject's body part during successive measurements of passive ROM 

Urge subject to exert trie same effort to move the body part during successive measurements of active ROM 

Use the same device to take successive measurements 

Use a goniometer that is suitable in size to the joint being measured 

If examiner is less experienced/ record the mean of several measurements rather than a single measurement 

Have the same examiner take successive measurements, rather than a different examiner 



found to range from 4 to 5 degrees. 33,35 Therefore, to 
show improvement or worsening of a joint motion meas- 
ured by the same examiner, a difference of about 5 
degrees (1 standard deviation) to 10 degrees (2 standard 
deviations) is necessary. The mean standard deviation 
increased to 5 to 6 degrees for repeated measurements 
taken by different examiners. 33,35 These values serve as a 
general guideline only, and will vary depending on the 
joint and motion being tested, the examiners and proce- 
dures used, and the individual being tested. 

Statistical Methods of Evaluating 
Measurement Reliability 

Clinical measurements are prone to three main sources of 
variation: (1) true biological variation, (2) temporal 
variation, and (3) measurement error. 91 True biological 
variation refers to variation in measurements from 
one individual to another, caused by factors such as age, 
sex, race, genetics, medical history, and condition. 
Temporal variation refers to variation in measurements 
made on the same individual at different times, caused by 
changes in factors such as a subject's medical (physical) 
condition, activity level, emotional state, and circadian 
rhythms. Measurement error refers to variation in meas- 
urements made on the same individual under the same 
conditions at different times, caused by factors such as 
the examiners (testers), measuring instruments, and 
procedural methods. For example, the skill level and 
experience of the examiners, the accuracy of the meas- 
urement instruments, and the standardization of the 
measurement methods affect the amount of measurement 
error. Reliability reflects the degree to which a measure- 
ment is free of measurement error; therefore, highly reli- 
able measurements have little measurement error. 

Statistics can be used to assess variation in numerical 
data and hence to assess measurement reliability. 91 ' 92 A 
digression into statistical methods of testing and express- 
ing reliability is included to assist the examiner in 
correctly interpreting goniometric measurements and in 
understanding the literature on joint measurement. 
Several statistics — the standard deviation, coefficient of 
variation, Pearson product moment correlation coeffi- 
cient, intraclass correlation coeffirient, and standard 
error of measurement — are discussed. Examples that 



show the calculation of these statistical tests are 
presented. For additional information, including the 
assumptions underlying the use of these statistical tests, 
the reader is referred to the cited references. 

At the end of this chapter, two exercises are included 
for examiners to assess their reliability in obtaining 
goniometric measurements. Many authors recommend 
that clinicians conduct their own studies to determine 
reliability among their staff and patient population. 
Miller 29 has presented a step-by-step procedure for 
conducting such studies. 

Standard Deviation 

In the medical literature, the statistic most frequently 
used to indicate variation is the standard deviation. 91,92 
The standard deviation is the square root of the mean of 
the squares of the deviations from the data mean. The 
standard deviation is symbolized as SD, s, or sd. If we 
denote each data observation as x and the number of 
observations as n, and the summation notation £ is used, 
then the mean that is denoted by x, is: 



Vx 



mean 



x = 



Two formulas for the standard deviation are given 
below. The first is the definitional formula; the second is 
the computational formula. Both formulas give the same 
result. The definitional formula is easier to understand, 
but the computational formula is easier to calculate. 



Standard deviation - SD 




SD 



The standard deviation has the same units as the orig- 
inal data observations. If the data observations have a 
normal (bell-shaped) frequency distribution, 1 standard 
deviation above and below the mean includes about 68 
percent of all the observations, and 2 standard deviations 
above and below the mean include about 95 percent of 
the observations. 



44 



PART I INTRODUCTION TO CONIOMETRY 



m-U 



table 3-2 Three Repeated ROM Measurements (in Degre)es)}Taken oh Five] Subjects 



t'Measurimmt 



Total 



Mean of Tfrree Measimemens fjj 



57 
66 

66 

35: 
45 



55 

65 
70 

40 
48 



r- ^ /-* (59+67 + 70+39+45) * mrM 

Grand mean (x) = ' - $° degrees. 



6S 


177 


70 


201 


74 


210 


42 


117 


42 


135 



59 
67 
70 
39 

•15 



at 

I 
su 

su 

th( 
ail 



SD 



It is important to note that several standard deviations 
may be determined from a single study and represent 
different sources of variation. 9 ' Two of these standard 
deviations are discussed here. One standard deviation 
that can be determined represents mainly iwtersubject 
variation around the mean of measurements taken of a 
group of subjects, indicating biological variation. This 
standard deviation may be of interest in deciding whether 
a subject has an abnormal ROM in comparison with 
other people of the same age and gender. Another stan- 
dard deviation that can be determined represents intra- 
subject variation around the mean of measurements 
taken of an individual, indicating measurement error. 
This is the standard deviation of interest to indicate 
measurement reliability. 

An example of how to determine these two standard 
deviations is provided. Table 3-2 presents ROM meas- 
urements taken on five subjects. Three repeated meas- 
urements (observations) were taken on each subject by 
the same examiner. 

The standard deviation indicating biological variation 
(intersubject variation) is determined by first calculating 
the mean ROM measurement for each subject. The mean 
ROM measurement for each of the five subjects is found 
in the last column of Table 3-2. The grand mean of the 
mean ROM measurement for each of the five subjects 
equals 56 degrees. The grand mean is symbolized by X. 
The standard deviation is determined by finding the 
differences between each of the five subjects' means and 
the grand mean. The differences are squared and added 
together. The sum is used in the definitional formula for 
the standard deviation. Calculation of the standard devi- 



ation indicating biological variation is found in Table 
3-3. 

The standard deviation indicating biological variation 
equals 1,5.6 degrees. This standard deviation denotes 
primarily intersubject variation. Knowledge of intcrsub- : 
jcct variation may be helpful in deciding whether a 
subject has an abnormal ROM in comparison with 
people of the same age and gender, If a normal distrib 
tion of the- measurements is assumed, one way of inter-' 
preting this standard deviation is to predict that about 6$ 
percent of all the subjects' mean ROM measurement^ 
would fall between 42.4 degrees and 69.6 degrees (plus; 
or minus i standard deviation around the grand mean 
56 degrees). Wc would expect that about 95 percent 
all the subjects' mean ROM measurements would fall; 
between 28. K degrees and S3.2 degrees (plus or minus J 
standard deviations around the grand mean of 5$ 
degrees). 

The standard deviation indicating measurement errp| 
(intrasubjeci variation) also is determined by first caks§ 
lating the mean ROM measurement for each subji 
However, this standard deviation is determined by fim 
ing the differences between each of the three repeal 
measurements taken on a subject and the mean of tbjf 
subject's measurements, The differences are squared aiil 
added together. The sum is used in the definitional 
formula for the standard deviation. Calculation of t|§ 
standard deviation indicating measurement error fo| 
subject I is found in Table 3-4. 

Referring to Table 3-2 and using the same procedi|| 
as shown in Table 3-4 for each subject, the standsff 
deviation for subject I = 5.3 degrees, the standard de! 



table 3-3 Calculation of the Standard Deviation Indicating Biological Variation in Degrees' 



1, 

;2S 
3 
4 
5 



59 
67 

70 
39 
45 



56 
56 
56 
56 

56 



3 

11 

14 

-17 

-n 



Stt= 



| 

tiOE 

app 

wit) 

the. 
deg) 
indj 
of/tj 
erro 



T(x-X) 2 = 9+121+196+289+121 = 736 degrees; SD = 



ZQt-x')' 



J 736 





CHAPTER 3 VALIDITY AND RELIABILITY 



45 



'fin tor S" U J — 

h'ect 3 = ^-O degrees, the standard deviation for 

.^ a = 3.6 degrees, and the standard deviation for 

k' 5 ■= 3-0 degrees. The mean standard deviation for 

S ^ £ { the subjects combined is determined by summing 

a . '■ o c -.^i=Tts' standard deviations and dividing by the 
the five suojc>-« 

number of subjects, which is 5: 



i 



1 variatt| 
n denote 
f intersud; 
A'hether i 
with oti| 
d distril^ 
>' of int|l 
rabont6|i 
suremenf; 
;rees f| 
d mean;i| 
percent ofi 
vould fal 
■r minusi 
in of Si 

iient error! 
irst caici|i 
h subject! 
J by findij 
repeated! 
in of thatl 
tared andi 
:finirional| 
:>n of thjjj 
error forf 

irocedure'l 

standard! 

lard dem 



■ 5 3 + 2.6 + 4.0 + 3.6 + 3.0 _ 



18.5 



3.7 degrees 



table 3-4 Calculation of the Standard 
Deviation Indicating Measurement Error in 




57 
55 
65 



59 
59 
59 



-2 

-4 
6 



.4 
16 
36 



y^-j-p = 4+16+36 = 56 degrees. 

SD= fiEp = if a 5.3 degrees 



The standard deviation indicating intrasubject varia- 
tion equals 3.7 degrees. This standard deviation is 
appropriate for indicating measurement error, especially 
if the repeated measurements on each subject were taken 
within a short period of time. Note that in this example 
the standard deviation indicating measurement error (3.7 
degrees) is much smaller than the standard deviation 
indicating biological variation (13.6 degrees). One way 
of interpreting the standard deviation for measurement 
error is to predict that about 68 percent of the repeated 
measurements on a subject would fall within 3.7 degrees 
(I standard deviation) above and below the mean of the 
repeated measurements of a subject because of measure- 
ment error. We would expect that about 95 percent of the 
repeated measurements on a subject would fall within 
7.4 degrees (2 standard deviations) above and below the 
mean of the repeated measurements of a subject, again 
because of measurement error. The smaller the standard 
deviation, the less the measurement error and the better 
the reliability. 

Coefficient of Variation 

Sometimes it is helpful to consider the percentage of vari- 
ation rather than the standard deviation, which is 
expressed in the units of the data observation (measure- 
ment). The coefficient of variation is a measure of varia- 
tion that is relative to the mean and standardized so that 
the variations of different variables can be compared. 
Hie coefficient of variation is the standard deviation 
divided by the mean and multiplied by 100 percent. It is 



a percentage and is not expressed in the units of the orig- 
inal observation. The coefficient of variation is symbol- 
ized by CV and the formula is: 

SD 
coefficient of variation = CV = ^^(100)% 

x 

For the example presented in Table 3-2, the coefficient 
of variation indicating biological variation uses the stan- 
dard deviation for biological variation (standard devia- 
tion = 13.6 degrees). 



CV = ^i 



100)% 



13.6 
56 



|100)% = 24.3% 



The coefficient of variation indicating measurement 
error uses the standard deviation for measurement error 
(standard deviation = 3.7 degrees) 

CV = -^-(100)% = —(100)% = 6.6% 
x 56 

In this example the coefficient of variation for mea- 
surement error {6.6 percent) is less than the coefficient of 
variation for biological variation (24.3 percent). 

Another name for the coefficient of variation indicat- 
ing measurement error is the coefficient of variation of 
replication. 93 The lower the coefficient of variation of 
replication, the lower the measurement error and the 
better the reliability. This statistic is especially useful in 
comparing the reliability of two or more variables that 
have different units of measurement; for example, 
comparing ROM measurement methods recorded in 
inches versus degrees. 

Correlation Coefficients 

Correlation coefficients are traditionally used to measure 
the relationship between two variables. They result in a 
number from -1 to +1, which indicates how well an 
equation can predict one variable from another vari- 
able. 2 ^*' 91 A +1 describes a perfect positive linear 
(straight-line) relationship, whereas a —1 describes a 
perfect negative linear relationship. A correlation coeffi- 
cient of indicates that there is no linear relationship 
between the two variables. Correlation coefficients are 
used to indicate measurement reliability because it is 
assumed that two repeated measurements should be 
highly correlated and approach a +1. One interpretation 
of correlation coefficients used to indicate reliability is 
that 0.90 to 0.99 equals high reliability, 0.80 to 0.89 
equals good reliability, 0.70 to 0.79 equals fair reliability, 
and 0.69 and below equals poor reliability. 94 Another 
interpretation offered by Portney and Watkins 3 states 
that correlation coefficients above 0.75 indicate good 
reliability, whereas those below 0.75 indicate poor to 
moderate reliability. 



46 



PART I INTRODUCTION TO GONIOMETRY 



Because goniomctric measurements produce ratio 
level data, the Pearson product moment correlation coef- 
ficient has been the correlation coefficient usually calcu- 
lated to indicate the reliability of pairs of goniometric 
measurements. The Pearson product moment correlation 
coefficient is symbolized by r, and its formula is 
presented following this paragraph. If this statistic is used 
to indicate reliability, x symbolizes the first measurement 
and y symbolizes the second measurement. 



r - — 



T (x-x)(y-y) 



VlU-*) 2 Vv(y-y>* 



Referring to the example in Table 3-2, the Pearson 
correlation coefficient can be used to determine the rela- 
tionship between the first and the second ROM meas- 
urements on the five subjects. Calculation of the Pearson 
product moment correlation coefficient for this example 
is found in Table 3-5. The resulting value of r = 0.98 
indicates a highly positive linear relationship between the 
first and the second measurements. In other words, the 
two measurements are highly correlated. 



V (x-x](y~y) 



r = 



VlM) 2 Vy( } -y) 2 

650.6 



V738.8 V597.2 



650.6 



(27.2) (24.4) 



0.9S 



The Pearson product moment correlation coefficient 

indicates association between the pairs of measurements 
rather than agreement. Therefore, to decide whether the 
two measurements are identical, the equation of the 
straight line best representing the relationship should be 
determined. If the equation of the straight line represent- 
ing the relationship includes a slope b equal to 1, and an 
intercept a equal to 0, then an r value that approaches 
+ 1 also indicates that the two measurements are identi- 
cal. The equation of a straight line is y = a +bx, with x 
symbolizing the first measurement, y the second mea- 



surement, a the intercept, and b the slope. The equation 

for a slope is: 



slope * b = ifc^irzi 

lAx-x)- 



The equation tor an intercept is: intercept a 
j - y ■ hx 

For our example, the slope and intercept are calcu-i 
latcd as follows: 



b = -fr-xMy-y? - 650 - 6 



0.88 



Ax-x) 



738.8 



ii = y -- bx ~ 55.6 - 0.88(53.8) - S.26 

The equation of the straight line best representing the 
relationship between the first and the second measure- 
ments in the example is y - 8.26 + O.SK.v. Although the 
r vakii' indicates high correlation, the two measurements'! 
are not identical given the linear equation. 

due concern in interpreting correlation coefficients isj 
that the value of the correlation coefficient is markedly; 
influenced by the range of the measurements. •""' ' -1 The! 
greater the biological variation between individuals tori 
the measurement, the more extreme the r value, so thatrj 
is closer to -I or -f- 1. Another limitation is the fact that] 
the Pearson product moment correlation coefficient can 
evaluate the relationship between only two variables ora 
measurements at a rime. 

To avoid the need for calculating and interpreting] 
both the correlation coefficient and a linear equation, 
some investigators use the intraclass correlation coeffi- 
cient (ICC) to evaluate reliability. The intraclass correla-; 
cion coefficient is symbolized as ICC. The ICC aiso'j 
allows the comparison of two or more measurements at] 
a time; one can think of it as an average correlation 1 
among all possible pairs of measurements.'" This statis- 
tic is determined from an analysis of variance model,, 
which compares different sources of variation. The ICCf 
is conceptually expressed as the ratio of the variances 



table 3-s Calculation of the Pearson Product Moment Correlation Coefficient for the first (.v) and 
Second (y) ROM Measurements in Degrees 



Subject' 


-yja? 


1 


57 


2 


66 


B 


66 


::4 ■■; 


3'5 


"5 


45 



(XX) 



mm 



(x-x)(y-y) 



55 

65 

70 
40 

48 



3.2 

12.2 

,T2.2 
-18.8 
-~8.8 



-0.6 
9.4 

14.4 

-15.6 

-7.6 



-1.92 
114.68 

1 75.68 

293.28 

68.88 



(x-xf 



10.24 
148.84 

148.84 

353.44 

77.44 



(yjyf 




57 + 66 + 66 + 35 + 45 



X = 



= 53.8 degrees; y 



= 650.60 



55 -r 65 t- 70 + 40 - ; 4& 



I = 738.80 



~ 55.6 degrees. 



v = 597.20 



CHAPTER 3 VALIDITY AND RELIABILITY 



47 



sociaced with the subjects, divided by the sum of the 
riance associated with the subjects plus error vari- 
cp v6 The theoretical limits of the ICC are between 

■ + |. +| indicates perfect agreement {no error vari- 
ance), whereas indicates no agreement (large amount of 
err or variance). 

There are six different formulas for determining ICC 
values based on the design of the study, the purpose of 
the study, and the type of measurement. 3,96,97 Three 
models have been described, each with two different 
forms. In Model !, each subject is tested by a different set 
of testers, and the testers are considered representative of 
a larger population of testers — to allow the results to be 
generalized to other testers, in Model 2, each subject is 
tested by the same set of testers, and again the testers are 
considered representative of a larger population of 
testers. In Model 3, each subject is tested by the same set 
of testers, but the testers are the only testers of interest — 
the results are not intended to be generalized to other 
testers. The first form of all three models is used when 
single measurements (1) are compared, whereas the 
second form is used when the means of multiple mea- 
surements (k) are compared. The different formulas for 
the ICC are identified by two numbers enclosed by 
parentheses. The first number indicates the model and 
the second number indicates the form. For further discus- 
sion, examples, and formulas, the reader is urged to refer 
to the following texts 3 and articles. 9 ***" 98 

In our example, a repeated measures analysis of vari- 
ance was conducted and the ICC (3,1) was calculated as 
0.94. This ICC model was used because each measure- 
ment was taken by the same tester, there was only an 
interest in applying the results to this tester, and single 
measurements were compared rather than the means of 
several measurements. This ICC value indicates a high 
reliability between the three repeated measurements. 
However, this value is slightly lower than the Pearson 
product moment correlation coefficient, perhaps due to 
the variability added by the third measurement on each 
subject. 

Like the Pearson product moment correlation coeffi- 
cient, the ICC is also influenced by the range of mea- 
surements between the subjects. As the group of subjects 
becomes more homogeneous, the ability of the ICC to 
detect agreement is reduced and the ICC can erroneously 
indicate poor reliability. 3 - 96 - 99 Because correlation coeffi- 
cients are sensitive to the range of the measurements and 
do not provide an index of reliability in the units of the 
measurement, some experts prefer the use of the standard 
aviation of the repeated measurements (intrasubject 
standard deviation) or the standard error of measure- 
ment. to assess reliability. 4,99 ' 100 

Standard Error of Measurement 

ne standard error of measurement is the final statistic 
that we review here to evaluate reliability. It has received 



support because of its practical interpretation in estimat- 
ing measurement error in the same units as the measure- 
ment. According to DuBois, 101 "the standard error of 
measurement is the likely standard deviation of the error 

made in predicting true scores when we have knowledge 
only of the obtained scores." The true scores (measure- 
ments) are forever unknown, but several formulas have 
been developed to estimate this scatistic. The standard 
error of measurement is symbolized as SEM, SE mi;aS) or 
Smcis- If the standard deviation indicating biological vari- 
ation is denoted SD X , a correlation coefficient such as the 
intraclass correlation coefficient is denoted ICC, and the 
Pearson product moment correlation coefficient is 
denoted r, the formulas for the SEM arc: 



SEM = SD r Vl-ICC 



Of 



SEM = SD. V VW 

The SEM can also be determined from a repeaced 
measures analysis of variance model, The SEM is equiv- 
alent to the square root of the mean square of the 
error. !02,103 Because the SEM is a special case of the 
standard deviation, 1 standard error of measurement 
above and below the observed measurement includes the 
true measurement 68 percent of the time. Two standard 
errors of measurement above and below the observed 
measurement include the true measurement 95 percent of 
the time. 

It is important to note that another statistic, the stan- 
dard error of the mean, is often confused with the stan- 
dard error of measurement. The standard error of the 
mean is symbolized as SEM, SE.vi, SEj, or S*. 2,4,91 ' 92 The 
use of the same or similar symbols to represent different 
statistics has added much confusion to the reliability 
literature. These rwo statistics are not equivalent, nor do 
they have the same interpretation. The standard error of 
the mean is the standard deviation of a distribution of 
means taken from samples of a population. 1 ' 2,92 It 
describes how much variation can be expected in the 
means from future samples of the same size. Because we 
are interested in the variation of individual measure- 
ments when evaluating reliability rather than the varia- 
tion of means, the standard deviation of the repeated 
measurements or the standard error of measurement is 
the appropriate statistical tests to use. 104 

Let us return to the example and calculate the stan- 
dard error of the measurement. The value for the intra- 
class correlation coefficient (ICC) is 0.94. The value for 
SD X . , the standard deviation indicating biological varia- 
tion among the 5 subjects, is 13.6. 



SEM = $>D X Vl-ICC 
13.6 Vl-0.94 = 13.6 Vo06 = 3.3 degrees 



48 



PART I INTRODUCTION TO GONIOMETRY 



Likewise, if we use the results of the repeated meas- 
ures analysis of variance to calculate the SEM, the SEM 
eq uals t he square root of the mean square of the error = 

VWS = 3.3 degrees. 

In this example, about two thirds of the time the true 
measurement would be within 3.3 degrees of the 
observed measurement. 

Exercises to Evaluate Reliability 

The two exercises that follow (Exercises 6 and 7) have 
been included to help examiners assess their reliability in 
obtaining goniometric measurements. Calculations of the 
standard deviation and coefficient of variation are 



included in the belief that understanding is reinforced by 
practical application. Exercise 6 examines intratester reli- 
ability. Lntratester reliability refers to the amount of 
agreement between repeated measurements of the same 
joint position or ROM by the same examiner (tester). An 
intratester reliability study answers the question: How 
accurately can an examiner reproduce his or her own 
measurements? Exercise 7 examines intertester reliabil- 
ity. Intertester reliability refers to the amount of agree- 
ment between repeated measurements of the same joint 
position or ROM by different examiners (testers). An 
intertester reliability study answers the question: How 
accurately can one examiner reproduce measurements 
taken by other examiners? 




EXERCISE 6 

INTRATESTER RELIABILITY 



1. Select a subject and a universal goniometer. 

2. Measure elbow flexion ROM on your subject three times, foiiowing the steps outlined in 
Chapter 2, Exercise 5. 

3. Record each measurement on the recording form (see opposite page) in the column labeled 
x. A measurement is denoted by x. 

4. Compare the measurements. If a discrepancy of more than 5 degrees exists between meas- 
urements, recheck each step in the procedure to make sure that you are performing the steps 
correctly, and then repeat this exercise. 

3, Continue practicing until you have obtained three successive measurements that are within 
5 degrees of each other. 

6. To gain an understanding of several of the statistics used to evaluate reliability, calculate the 
standard deviation and coefficient of variation by completing the following steps. 

a. Add the three measurements together to determine the sum of the measurements. V is the 
symbol for summation. Record the sum at the bottom of the column labeled x. 

b. To determine the mean, divide this sum by 3, which is the number of measurements. The 
number of measurements is denoted by «. The mean is denoted by x. Space to calculate 
the mean is provided on the recording form. 

c. Subtract the mean from each of the three measurements and record the results in the 
column labeled x-x. 

d. Square each of the numbers in the column labeled x-x, and record the results in the 
column labeled [x-x) 1 . 

e. Add the three numbers in column (x-x} 1 to determine the sum of the squares. Record the 
results at the bottom of the column labeled {x-x) 2 . 

f. To determine the standard deviation, divide this sum by 2, which is the number of meas- 
urements minus 1 («-l). Then find the square root of this number. Space to calculate the 
standard deviation is provided on the recording form. 

g. To determine the coefficient of variation, divide the standard deviation by the mean. 
Multiply this number by 100 percent. Space to calculate the coefficient of variation is 
provided oh the recording form. 

7. Repeat this procedure with other joints and motions after you have learned the testing 
procedures. 



CHAPTER 3 VALIDITY AND RELIABILITY 



49 



RECORDING FORM FOR EXERCISE 6. INTRATESTER RELIABILITY 

Follow the steps outlined in Exercise 6. Use this form to record your measurements and 
the result of your calculations. 



Subject's Name 



Date 



Examiner's Name 



joint and Motion 



Right or Left Side 



Passive or Active Motion 



Type of Goniometer . 



Measurement 


X 


x—x 


(x-x) 2 


3C 


;: i 










2- 










; 3 










w = 3 


Ix= 




Kx-x) 1 = 


V.T 2 = 



Mean of the three measurements = x 



V-. 



Standard deviation 



or use SD 



- * 


(x-x) 1 


V 


lx 2 - 


n 



n-\ 



Coefficient of variation = ~^- (100)% 



^'v ■4:y^a^ 'a?s i« M fleMSgSfeaBiSS : -■'■■ ■■■t.-iUX&tt- ■■--'-: :-." -i-JSwSgsli ,.-:. ■■:■., Ss&tt.'-- ■ 






50 



PART I INTRODUCTION TO GONIOMETRY 




EXERCISE 7 



SM "> 



.... ... ... 



INTERTESTER RELIABILITY 



1. Select a subject and a universal goniometer. 

2. Measure elbow flexion ROM on your subject once, following the steps outlined in Chapter 
2, Exercise 5. 

3. Ask two other examiners to measure the same elbow flexion ROM on your subject, using 
your goniometer and following the steps outlined in Chapter 2, Exercise 5. 

4. Record each measurement on the recording form (see opposite page) in the column labeled 
.x. A measurement is denoted by x. 

5. Compare the measurements. If a discrepancy of more than 5 degrees exists between meas- 
urements, repeat this exercise. The examiners should observe one another's measurements 
to discover differences in technique that might account for variability, such as faulty align- 
ment, lack of stabilization, or reading the wrong scale. 

6. To gain an understanding of several of the statistics used to evaluate reliability, calculate the 
mean deviation, standard deviation, and coefficient of variation by completing the follow- 
ing steps. ■ 

a. Add the three measurements together to determine the sum of the measurements. X is the 
symbol for summation. Record the sum at the bottom of the column labeled x. 

b. To determine the mean, divide this sum by 3, which is the number of measurements. The 
number of measurements is denoted by n. The mean is denoted by x. Space to calculate 
the mean is provided on the recording form. 

c. Subtract the mean from each of the three measurements, and record the results in the 
column labeled x-x. 

d. Square each of the numbers in the column labeled x-x and record the results in the 
column labeled (x-je) 2 . 

e. Add the three numbers in column (.x-x)~ to determine the sum of the squares. Record the 
results at the bottom of column (x-x)~. 

i. To determine the standard deviation, divide this sum by 2, which is the number of mea- 
surements minus 1 (n - 1). Then find the square root of this number. Space to calculate 
the standard deviation is provided on the recording form. 

g. To determine the coefficient of variation, divide the standard deviation by the mean. 
Multiply this number by 100 percent. Space to calculate the coefficient of variation is 
provided on the recording form. 

7. Repeat this exercise with other joints and motions after you have learned the testing proce- 
dures. 

RECORDING FORM FOR EXERCISE 7. INTRATESTER RELIABILITY 

Follow the steps outlined in Exercise 7. Use this form to record your measurements and 
the results of your calculations. 



Subject's Name 



Date. 



Examiner 1. Name 



Examiner 2. Name 



Examiner 3. Name- 



Joint and Motion 



Right or Left Side 






: 



REFERE: 



Passive or Active Motion 



Type of Goniometer . 



1. 


O 




^S 


1, 


K. 




R 


3. 


P< 




R. 




Sa 


4. 


R 




*! 




r 


5. 


Si 




re 


6. 


G 




[■£ 




ai 


7. 


A 




ID 




l: 


S. 


G 




rr 


9. 


E 




Si 



CHAPTER 3 VALIDITY AND RELIABILITY 51 



Measurement 


X 


x-x 


(x-x) 2 


x 2 


1 










2 










3 










« = 3 


lx = 




l[x-x) 2 = 


£** = 



Mean of the three measurements = x 



lx 



Standard deviation = / — = 

(»-D 



or use SD = 



(Tx) 

Z.XT- 

n 

71-1 

SD 



Coefficient of variation = 2ii(l00)% 

x 



REFERENCES 



L Currier, DP: Elements of Research in Physical Therapy, ed 3. 

Williams & Wilkins, Baltimore, 1990, p 171. 
2. Kerlinger, FN: Foundations of Behavioral Research, ed 2. Holt, 

Rinehart, & Winston, New York, 1973. 
i- Portney, LG, and Watkins, MP: Foundations of Clinical 

Research: Applications to Practice, ed 2. Prentice-Hall, Upper 

Saddle River, NJ, 2000. 
*■ Rothstein, JM: Measurement and clinical practice: Theory and 

application. In Rothstein, JM (ed): Measurement in Physical 

Therapy. Churchill Livingstone, New York, 1985. 
* Sims, J, and Arnell, P: Measurement validity in physical therapy 

research, Phys Ther 73:102, 1993. 

Gajdosik, RL, and Bohannon, RW: Clinical measurement of 

range of motion: Review of goniometry emphasizing reliability 

and validity. Phys Ther 67:1867, 19S7. 

American Physical Therapy Association: Standards for tests and 

measurements in physical therapy practice. Phys Ther 71:589, 

1991. 

Gogia, PP, et ah Reliability and validity of goniometric measure- 
ments at the knee. Phys Ther 67:192, 1987. 

Enwemeka, CS: Radiographic verification of knee goniometry, 

Scand j Rehabil Med 18:47, 1986. 



6. 



10. 



11. 



12, 



13. 



14. 



15. 



16. 



17. 



18. 



Ahlback, SO, and Lindahl, O: Sagittal mobility of the hip-joint. 
Acta Orthop Scand 34:310, 1964. 

Chen, j, et al: Meta-analysis of normative cervical motion. Spine 
24:1571, 1999. 

Herrmann, DB: Validiry study of head and neck flexion-exten- 
sion morion comparing measurements of a pendulum goniome- 
ter and roentgenograms. J Orthop Sports Phys Ther 11:414, 
1990. 

Orway, NR, et al: Cervical sagittal range-of-motion analysis 
using three methods. Spine 22:501, 1997. 
Tousignanr, M, et aS: Criterion validiry of the cervical range of 
motion (CROM) goniometer for cervical flexion and extension. 
Spine 25:324, 2000. 

Macrae, JF, and Wright, V: Measurement of back movement. 
Ann Rheum Dis 28:584, 1969. 

Ponek, I, et al: Correlation between radiographic and clinical 
measurement of lumbar spine movement. Br j Rheumarot 
22:197, 1983. 

Burdett, RG, Brown, KE, and Fall, MP: Reliability and validity 
of four instruments for measuring lumbar spine and pelvic posi- 
tions. Phys Ther 66:677, 1986. 

Mayer, TG, et al: Use of noninvasive techniques for quantifica- 
tion of spinal range-of-moiion in normal subjects and chronic 
low-back dysfunction patients. Spine 9:588, 1984. 



: 



'«;■ 

■ 



52 



PART I INTRODUCTION TO GONIOMETRY 



m 



1- 



. 



m 
■ 



19. Saur, PM, ct ah Lumbar range of motion: Reliability and validity 
of the inclinometer technique in the clinical measurement of 
trunk flexibility. Spine 21:1332, 1996. 

20. Samo, DG, ct al: Validity of three lumbar sagittal motion meas- 
urement methods: Surface inclinometers compared with radi- 
ographs. J Occup Environ Med 39:209, 1997. 

21. Campbell, SK: Commentary: Measurement validity in physical 
therapy research. Phys Ther 73: 1 10, 1993, 

22. Vasen, AP, ct al: Functional range of motion of the elbow. J Hand 
Surg 20A:288, 1995. 

23. Cooper, JE, ct al: Elbow joint restriction: Effect on functional 
upper limb motion during performance of three feeding activi- 
ties. Arch Phys Med Rchabii 7-4:805, 1993. 

24. Nelson, DL: Functional wrist motion. Hand Clin 13:83, 1997. 

25. Hermann, KM, and Reese, CS: Relationships among selected 
measures of impairment, functional limitation, and disability 
in patients with cervical spine disorder. Phys Ther 81:903, 
2001. 

26. Triffilt, I'D: The relationship between motion of the shoulder 
and the stated ability to perform activities of daily living, j Bone 
Joint Surg 80:41, 1998. 

27. Wagner, MB, et at: Assessment of hand function in Duchennc 
muscular dystrophy. Arch Phys Med Rchabii 74:801, 1993. 

28. Moore, Ml.: Clinical assessment of joint motion. In Basmajian, 
JV (ed): Therapeutic Exercise, cd 3. Williams & Wilkins, 
Baltimore, 1978. 

29. Miller, PJ: Assessment of joint motion. In Rothstcin, JM (ed): 
Measurement in Physical Therapy. Churchill Livingstone, New 
York, 1985. 

30. Lea, RD, and Gerhardt, jj: Current concepts review: Range-of- 
motion measurements. J Bone Joint Surg Am 77:784, 1995. 

31. Grohmann, JEL: Comparison of two methods of goniometrv. 
Phys Ther 63:922, 1983. 

32. Hamilton, GF, and Lachenhruch, PA: Reliability of goniometers 
in assessing finger joint angle. Phys Ther 49:465, 1969. 

33. Boone, DC. et al: Reliability of goniometric measurements. Phys 
Ther 58:1355, 1978. 

34. Pandya, S, ct al: Reliability of goniometric measurements in 
patients with Duchennc muscular dystrophy. Phys Ther 65:1339, 
1985. 

35. Bovens, AMP, et al: Variability and reliability of joint measure- 
ments. Am j Sport Med 18:58, 1990. 

36. Hellcbrandt, FA, Duvall, EN, and Moore, ML: The measurement 
of joint motion. Part III: Reliability of goniometry. Phys Ther Rev 
29:302, 1949. 65:1339, 19S5. 

37. Low, JL: The reliability of joint measurement. Physiotherapy 
62:227, 1976. 

38. Greene, BL, and Wolf, SL: Upper extremity joint movement: 
Comparison of two measurement devices. Arch Phys Med 
Rehabil 70:299, 1989. 

39. Tucci, SM, et al: Cervical motion assessment: A new, simple and 
accurate method. Arch Phys Med Rchabii 67:225, 1986. 

40. Youdas, JW, Carey, JR, and Garrett, TR: Reliability of measure- 
ments of cervical spine range of motion: Comparison of three 
methods. Phys Ther 7 1 :2, 1 99 1 . 

41. Fitzgerald, GK, et al: Objective assessment with establishment of 
norma! values for lumbar spine range of motion. Phys Ther 
63:1776, 1983. 

42. Nitschke, JE, et al: Reliability of the American Medical 
Association Guides' model for measuring spinal range of motion. 
Spine 24:262, 1999. 

43. Mayerson, NH, and Milano, RA: Goniometric measurement reli- 
ability in physical medicine. Arch Phys Med Rehabil 65:92, 
1984. 

44. "Watkins, MA, ct al: Reliability of goniometric measurements and 
visual estimates of knee range at motion obtained in a clinical 
setting. Phys Ther 71:90, 1991. 

45. Riddle, DL, Rothstcin, JM, and Lamb, RL: Goniometric reliabil- 
ity in a clinical setting: Shoulder measurements. Phys Ther 
67:668, 1987. 

46. Eksrrand, J, et al: Lower extremity goniometric measurements: A 
study to determine their reliability. Arch Phys Med Rchabii 
63:171, 1982. 

47. Rothstein, JM, Miller, PJ, and Roettger, RF: Goniometric relia- 



biluv m .i cluucal vetting: Hh<.w ,ibJ knee itti-'.iNtuvinents K ?.: 
Ther 63.1611, I ''Si. 

48. Solgaard, S, i-r al: Reproducibility ui goniomcirt HI ;he a, 
Sc.ind J Rihabi! Mod fS;i. I"S6. 

49. I'.itel. KV Itur.ileMvr -Hid oiwrsrcr reh.ilihly oj she mclinanja 
tcr in measurim; lumbar HeMon [abstract f, Phvs J'hcr 7i-\jil 

1W2, ""*■ 

50. I .(.veil. !W. Kntlisitrut, JM, .ins! Personuis, Wj : Reliability of c 
ical measurements <il lumbar tofdoMi taken with a flexible nill 
Phys I'licr fi9 : ««i, |>«i9, "' ( " 

51. I'arilcn. |1>, cs al: Hip ilcMon cimit-icHifev A eolnpansn 
measurement methods. Arch Pins Med Rehabil (i*>:l>2l), 1935! 

52. Joiisun. SK. ami dross. Ml: Iii;r.te\a:miier reliability, intr(4 
aiumcr reliability, .ukI mean caJues for 11111c lower ex 
skeletal measures in lieahhy nnv,tl tottivhipinrn. f Pflhtipjjj 
Phys Ther ±.i-.lX\, 1997 

53. I Iveru, RA, Roihsiein, JM, and Limb, HI : Gontomctrie refill 
uy in .1 clinical selling. Phys i lief £>.S-fi'"2, l L 'NS. 

54. l>tamond. JE. el ah Reliability ol .1 iltabctiv iom evaluation. 
Ther 69:797. 1'JS-i. 

55. M.icl'ermiil. |(... ei ah Intratcstct and uiu-m-sier reliability! 
gonloineiric measurement ui passive lateral shoulder rotatj 
j Kind Ther !2:IN~. l«W. 

56. Armstrong, AS), et ,il: Reliability ol range -ol motion measji 
men! 111 the elbow ,lnj 'orearne | Shoulder klbow Sure 7:j 
IV9S-. 

57. Boon, A|, .uui Smith. J: Manual scapular stabilization: list 
<m shoulder rot.tt11.11.1l range .>i motion Arch Phys Med RtS 

si: i >^8, 2mm. 

5S. I lorger, MM: The reliability ot goniometric measurements 
active and pawivc urisi motions. Am | (keup [her 443 

I ' * sj 5 f . 

59. Litis. I'., bnitc.n, A. and GoddanJ, JR.- Joint angle nu'.isiirert 
A comparative siuily r.| the reliability 11! goinoiiieiry antbj 
tracing !-.r [he hand! Clm Reh.tbtl I 1:314, H'f". 

60. IVlk-cchia. (.1 . and liobautHiu. RW: Active lateral neck I 
range 1.1 malum mc.tsnrimeitis obtained sv 1 1 1 1 .1 
goniometer. Reliability and estuu.it-.-> 1.1 normal. | Manipuj 
Physiol IJu-r 21:443. I <**«. 

61. N'llsstin. N: Measuring passive cervical motion: A study ofji 
biliry.J Manipulative Physio! i'her lSr29.\, f*»5. 

62. Willi, mis, R, ti al: Reliability ot tile modilied-tnodifieiJ ! 
ant! ddiibie nu liuitnieirr nietlii k|s (tir uie.isuim:; lumbar I 
ativi cMensiiiii. Phys Ther r 3:26, 1993. 

63. Meiib.Higti.JI: Measurement ut head motion. Part II: Ant 
menial study ol head motion m .idtili males. Phys ("her 4 
P'h4. 

64. Kalugun, JA. et al; Inter- an, I inir.tresier reliahilily ol 111c, 
neek motions with tape measure and Myiin Craviiy-RefvS 
Iximometer, .1 Orilinp Sports Hits I'her Ul:.MN. I 989, 

65. I. apn.nio I'ucci, 1>. e; ah liur.jiester and mieriester reliabil. 
the ceriieal r.ni!;e of motum. Arch Phys. Med Rehabil 72 
1 *J I . 

66. I aSt.iyo, I'C . ami Wheeler, I'l : Reliability ot passive wri 
1011 and ('Meusion goiiKiinetric nieasuremetus: A lliultit?! 
siiidy. I'hvs Iher 74; I (,2, 1994. 

67. Mayer, !'G, ei ah Spinal range ol motion. Spme 22:I976,:|| 

68. iaihe, MM: The rane,e oi acme motion at the wrist of 5) 
adults. J Heine Joint Surg Br ll): _ (.3, t l >J.S. 

69. Hewits, |): The range ot active motion .11 the wrist ol VQ 
J I'oiie Joint Surg lir H);~7S, |«»2K. 

70. Palmer. Ml., and hpler, M: t1uuc.il Assessment I'ruccduS 
Physical Therapy, cd 1. IB 1 ippmcott, Philadelphia. 199S- 

71. (larkson, IIM: Musculoskeletal Assessiiuui: Joint Mlp 
Motion and Manual Muscle Strength, ed 1. Williams iC vfl}| 
li.ihuuore, ItMKi. 

72. Robsoii, I': A method to reduce the variable error ill joint;! 
measurement. Ann Plus Med 8:2h2, t9*i6. 

73. CJoodwin. ), ei al: (..luiic.il niethods ol goniometry: A cofle 
live study. I'lisahil Rehabil 14:10, |4'.»j. 

74. Petherick. M. el al: Coitcurrclll validity and uitertesterfclB 
of imi'. eis.ll and iluid-hase'd gonioiueiers tut active elbt>VK| 
ot nmiiiin. Phys [ hci hK^i.n, |ns,S. 

75. Brown, A, et ah V.lliditv .ind reliahilitv o( the IVMer ha(l|| 



CHAPTER 3 VALIDITY ANO RELIABILITY 



53 



atioft and therapy system in hand-injured patients. J Hand Ther 
13:37,2000. 

Weiss PL, et al: Using the Exos Handmastcr to measure digital 
range 'of morion: Reliability and validity. Med Eng Phys 16:323, 

1994. 

riaoWt, MP, and Wolf, SL: Comparison of the reliability of 
the Orthoranger and the standard goniometer for assessing 
active lower extremity range of motion. Phys Ther 68:214, 

„ £i|j S on JB, Rose, SJ, and Sahrman, SA: Patterns of hip rotation: 
* A comparison berween healthv subjects and patients with tow 

back pain. Phys Ther 70:537, 1990. 
~9 Rheault, W, et al: Inicrtesrer reliability and concurrent validity of 

fluid-based and universal goniometers for active knee flexion. 

Phys Ther 68:1676, 1988. 
nn Bartholomy, JK, Chandler, RE, and Kaplan, SE: Validity analysis 

of fluid goniometer measurements of knee flexion [ahstract|. 

Phys Ther 80:546,2000. 
St Rome, K, and Cowieson, F: A reliability study of the universal 

goniometer, fluid goniometer, and elecirogoniomeicr for the 

measurement of ankle dorsiftexion. Foot Ankle Int 17:28, 1996. 

82. White, DJ, et al: Reliability of three methods of measuring cervi- 
cal motion [abstract]. Phys Ther 66:771, 1986. 

83. Reynolds, PMG; Measurement of spinal mobility: A comparison 
of three methods. Rheumatolo Rehabil 14:180, 1975. 

84. Miller, MH, et al: Measurement of spinal mobility in the sagittal 
plane: New skin distraction technique compared with established 
methods. J Rheumatol 11:4, 1984. 

85.. Gill, K, et al: Repeatability of four clinical methods for assess- 
ment of lumbar spinal motion. Spine 13:50, 1988. 
86. Lindahl, 0: Determination of the sagittal mobility of the lumbar 

: : , spine.. Acta Orthop Scand 37:241, 1966. 
87.', White, Dj, et al: Reliability of three clinical methods of measttr- 
:'■•''•;.• .ing lateral flexion in the thoracolumbar pine [abstract], Phys 
■■'i'/l Ther 67:759, 1987. 

88.':: Mayer, RS, et a!: Variance in the measurement of sagittal lumbar 
'range of motion among examiners, subjects, and instruments, 
r^Spine 20:1489, 1995. 
89, r.Chen, SP, et al: Reliability of the lumbar sagittal motion meas- 



urement methods: Surface inclinometers. J Occtip Environ Med 
39:217, 1997. 

90. Breum, J, Wilberg, J, and Bolton, JE: Reliability and concurrent 
validity of the BROM II for measuring lumbar mobility. J 
Manipulative Physiol Ther 18:497, 1995. 

91. Colton, T: Statistics in Medicine. Little, Brown, Boston, 1974. 

92. Dawson-Saunders, B, and Trapp, RG: Basic and Clinical 
Biostatistics. Appk-ton & f.ange, NorwaSk, CI', 1990. 

93. Francis. K: Computer communication: Reliability. Phvs Ther 
66:1140,1986. 

94. Blesh, TE: Measurement in Physical Education, ed 2. Ronald 
Press, New York, [974. Cited by Currier, DP: Elements of 
Research in Physical Therapv, ed 3. Williams & Wilkins, 
Baltimore, 1990. 

95. Bland, JM, and Airman, DG: Measurement error and correlation 
coefficients, [statistics notes], BMJ 313:41, 1996. 

96. Lahey, MA, Downey, RG, and Saal, FE: Intraclass correlations: 
There's more there than meets the eve. Psychol Bull 93:5S6, 
1983, 

97. Shout, PE, and Fleiss, JL: Inrraclass correlations: Uses in assess- 
ing rater reliability. Psychol Bull 86:420, 1979. 

98. Krebs, DE: Computer communication: Intraclass correlation 
coefficients. Phys Ther 64:1581, 1984. 

99. Stratford, P: Reliability: Consistency or differentiating among 
subjects? [letters to the editor], Phys Ther 69:299, 1989. 

100. Bland, JM, and Airman, DG: Measurement error, [statistics 
notes). BMJ 312:1654, 1996. 

101. DuBois, PH: An Introduction to Psychological Statistics. Harper 
& Row, New York, 1965, p 401. 

102. Stratford, P: Use of the standard error as a reliability index of 
interest: An applied example using elbow flexor strength data. 
Phys Ther 77:745, 1997. 

103. Eliasziw, M, et al: Statistical methodology for the concurrent 
assessment of interrater and inrrarater reliability: Using 
goniometric measurement as an example. Phvs Ther 74:777, 
1994. 

104. Bartko, JJ: Rationale for reporting standard deviations rather 
than standard errors of the mean. Am J Psvchiatry 142:1060, 
1985. 



RT II 




Upper-Extremity 
Testing 



Objectives 



■OH COMPLETION OF PART ii THE READER WILL BE ABLE TO: 



L Identify: 

Appropriate planes and axes for each 

upper-extremity joint motion 
Structures that limit the end of the range of 

motion 
Expected normal end-feels 

2. Describe: 

Testing positions used for each upper- 
extremity joint motion and muscle length 
test 

Goniometer alignment 

Capsular pattern of restricted motion 

Range of motion necessary for selected 

'■'■■. functional activities 

3. Explain: 

How age, gender, and other factors can 

affect the range of motion 
How sources of error in measurement can 
.,:: affect testing results 

4. Perform a goniometric measurement of any 
upper-extremity joint including: 

A clear explanation of the testing proce- 
dure 
Proper positioning of the subject 
Adequate stabilization of the proximal 
joint component 



Correct determination of the end of the 
range of motion 

Correct identification of the end-feel 

Palpation of the appropriate bony land- 
marks 

Accurate alignment of the goniometer and 
correct reading and recording 

5. Plan goniometric measurements of the 
shoulder, elbow, wrist, and hand that are 
organized by body position 

6. Assess intratestcr and intcrtester reliability 
of goniometric measurements of the upper- 
extremity joints using methods described in 
Chapter 3. 

7. Perform tests of muscle length at the shoul- 
der, elbow, wrist, and hand including: 

A clear explanation of the testing proce- 
dure 
Proper positioning of the subject in the 

starting position 
Adequate stabilization 
Use of appropriate testing motion 
Correct identification of the end-feel 
Accurate alignment of the goniometer and 
correct reading and recording 



The testing positions, stabilization techniques, end-feels, and goniometer alignment for the joints of the 
upper extremities are presented in Chapters 4 through 7. The goniometric evaluation should follow the 
f2-step sequence presented in Exercise 5 in Chapter 2. 



55 



$S"; ?■'**< 



: ' ".'■' .: 



CHAPTER 4 



We Shoulder 



wwwwu//: 




Glenoid fossa 



Coracoict process 



Acromion 
process 



Scapula 



SK Structure and Function 

Clenohunrieral Joint 

Anatomy 

The glenohumeral joint is a synovial ball-and-socket 

joint. The ball is the convex head of the humerus, which 
faces medially, superiorly, and posteriorly with respect to 
the shaft of the humerus (Fig. 4-1 ). The socket is formed 
by the concave glenoid fossa of the scapula. The socket is 
shallow and smaller than the humeral head but is deep- 
ened and enlarged by the fibrocartilaginous glenoid 
labrum. The joint capsule is thin and lax, blends with the 
glenoid labrum, and is reinforced by the tendons of the 
rotator caff muscles and by the glenohumeral (superior, 
middle, inferior) and coracohumerai ligaments (Fig. 4-2). 

Osteqkinematics 

The glenohumeral joint has 3 degrees of freedom. The 
motions permitted at the joint are flexion-extension, 
aoduction-adduction, and medial-lateral rotation. In 
addition, horizontal abduction and horizontal adduction 
are functional motions performed at the level of the 
shoulder and are created by combining abduction and 
extension an( j adduction and flexion, respectively. Full 
jange of motion (ROM) of the shoulder requires 
numeral, scapular, and clavicular motion at the gleno- 
urneral, sternoclavicular, acromioclavicular, and scapu- 
lothorack joints. 

Arthrokinematics 

.. ,. 10n at tne glenohumeral joint occurs as a rolling and 

& ot the head of the humerus on the glenoid fossa. FIGURE 4-1 An anterior view of the glenohumeral joint. 




-Humerus 



57 



58 PART II UPPER-EXTREMITY TESTING 



Coracoid process 






® 






Sj : 



I ■ 




Cofacohumeral 
ligament 

Greater 
tubercle 

Lesser 

tubercle 



Glenohumeral 
ligament 



FIGURE 4—2 An anterior view of the glenohumeral joint show- 
ing the coracohumeral and glenohumeral ligaments. 



The direction of the sliding is opposite to the movement 
of the shaft of the humerus. The humeral head slides 
posteriorly and inferioriy in flexion, anteriorly and supe- 
riorly in extension, inferioriy in abduction, and superi- 
orly in adduction. In lateral rotation, the humeral head 
slides anteriorly on the glenoid fossa. In medial rotation, 
the humeral head slides posteriorly. The sliding motions 
help to maintain contact between the head of the 
humerus and the glenoid fossa of the scapular during the 
rolling motions. 

Capsular Pattern 

The greatest restriction of passive motion is in lateral 
rotation, followed by some restriction in abduction and 
less restriction in medial rotation. 1 

Sternoclavicular Joint 
Anatomy 

The sternoclavicular {SC} joint is a synovial joint linking 
the medial end of the clavicle with the sternum and the 



cartilage of the first rib [Fig. 4-3/U. The joint surfaces are 
saddle -shaped. The clavicular joint surface is convex 
ccphalocaudally and concave anreropostcriorly. The 
opposing joint surface, located at the notch formed by 
the manubrium of the sternum and the first costal carti- 
lage, is concave ccphalocaudaily and convex anteropos- 
terior!}". An articular disc divides the joint into two 
separate compartments. 

The associated joint capsule is strong and reinforced 
by anterior and posterior SC ligaments dig. 4-.WJL These 
ligaments limit anterior-posterior movement ol the 
medial end of the clavicle, 1 he costoclavicular ligament, 
which extends from the inferior surface of the medial end 
of the clavicle to the first rib, limits clavicular elevation 
and protraction. The interclavicular ligament extends 
from one clavicle to another and limits excessive interior 
movement of the clavicle." 

Osteokinematics 

The SC joint has i degrees t»I freedom, and motion! 
consists of movement of the clavicle on the sternum. 
These motions are described by rlic movement at the 
lateral end »l the clavicle. Clavicular motions include, 
eievatiou-depressmn, prorracrion-rccraainn. and ante- 
rior-posterior rotation.' ■■' 



Clamcle 




I SI Rib 



ol 
sternum 



1 si costal carulags 



Wiercfaviculac teamen! 




Castociavicuia 
igamont 



Aniesior sternoclavicular 
ligament 



HGURF 4-3 \A) An .ulterior view of the sternoclavicular (SQi 
joint showing the hone structures and articular disc. (Bl As| 
anterior view of the SC" joint showing the mterchvictilar, St?| 
and costoclavicular liniments. 



Aci 



Act< 



Acre 
proc 



FIGI 

larj< 



faces are 
. convex 
rly. The 
rmed by 
tal carri. 

■ reropos- 
aro two 

in forced 
i). These 
ot the 
igamt'nt, 
.•dial end 
■levation 

extends 

■ inferior 



motion 
iter num. 
t at the 

include 
d ante- 







firthrokinematia 

During clavicular elevation and depression, the convex 
surface of the clavicle slides on the concave manubrium 
in a direction opposite the movement of the lateral end 
of the clavicle. In protraction and retraction, the concave 
portion of the clavicular joint surface slides on the 
convex surface of the manubrium in the same direction 
as the lateral end of the clavicle. In rotation, the clavicu- 
lar joint surface spins on the opposing joint surface. In 
summary, the clavicle slides inferioriy in elevation, supe- 
riorly in depression, anteriorly in protraction, and poste- 
riorly in retraction. 

Acromioclavicular Joint 

Anatomy 

The acromioclavicular (AC) joint is a synovial joint link- 
ing the scapula and the clavicle. The scapular joint 
surface is a concave facet located on the acromion of the 
scapula (Fig. 4—4). The clavicular joint surface is a 
convex facet located on the lateral end of the clavicle. 
The joint contains a fibrocartilaginous disc and is 
surrounded by a weak joint capsule. The superior and 
inferior AC ligaments reinforce the capsule (Fig. 4—5). 
The coracoclavicular ligament, which extends between 



CHAPTER •) THE SHOULDER 59 



Claviete 



Coracoclavicular ligament 

Acromioclavicular ligament 




CoracoacromiaS 
ligament 



FIGURE 4-5 An anterior view of the acromioclavicular (AC) 
joint showing the coracoclavicular, acromioclavicular, and cora- 
coacromial ligaments. 



Clavicle 



/ 



1st Rrb 



% 



■s 



artilage 



f 



jclavicular 
ent 



Lit (SO 
(B) An 
iar, SC, 



Acromioclavicular joint 



Acromion 
process 



Scapula 




FIGURE 4-4 A posterior-superior view of the acromioclavicu- 
lar joint. 



the clavicle and the scapular coracoid process, provides 
additional stability. 

Osteokinematics 

The AC joint has 3 degrees of freedom and permits 
movement of the scapula on the clavicle in three planes. 3 
Numerous terms have been used to describe these 
motions. Tilting (tipping) is movement of the scapula in 
the sagittal plane around a coronal axis. During anterior 
tilting the superior border of the scapula and glenoid 
fossa moves anteriorly, whereas the inferior angle moves 
posteriorly. During posterior tilting (tipping) the superior 
border of the scapula and glenoid fossa moves posteri- 
orly, whereas the inferior angle moves anteriorly. 

Upward and downward rotations of the scapula occur 
in the frontal plane around an anterior-posterior axis. 
During upward rotation the glenoid fossa moves 
cranially, whereas during downward rotation the glenoid 
fossa moves caudally. 

Protraction and retraction of the scapula occur in the 
transverse plane around a vertical axis. During protrac- 
tion (also termed medial rotation, or winging) the 
glenoid fossa moves medially and anteriorly, whereas the 
vertebral border of the scapula moves away from the 
spine. During retraction (also termed lateral rotation) the 
glenoid fossa moves laterally and posteriorly, whereas 
the vertebral border of the scapula moves toward the 
spine. The terms abduction-adduction have been used 
by various authors to indicate the motions of upward 



60 



PART II UPPER-EXTREMITY TESTING 



table 4-1 Shoulder Complex Motion: Mean Values in Degrees from Selected Sources 



Motion 



AAOS s 



AMA £ 



Flexion 

Extension 
Abduction 
Medial rotation 

Lateral rotation 



180 

60 

180 

70 

90 



150 
50 

180 
90 
90 



'Values are for male subjects 18 months to 54 years of age. 
' Values are for male and female subjects 1 8 to 55 years of age. 



Boone and Azen' 
n ■--■ 109' 



Mean (SD) 



166.7 (4.7) 

62.3 (9.5) 
184.0 (7.0) 

68.8 (4.6) 
103.7 (8.5) 



Greene and Wolfl 

Mean (SD)' 



155.8 (1.4) 

167.6 (1.8) 

48.7 (2.8) 

83.6 (3.0) 



Ffexiort 
Extensa 
Medial 
: Lateral; 
Abduct 






■ 
■"■ 



J. 



■ «g a 



rotation-downward rotation as well as protraction- Arthrokinematics 
retraction. ~' 4 

Arthrokinematics 

Motion of the joint surfaces consists of a sliding of the 

concave acromial facet on the convex clavicular facet. 
Acromial sliding on the clavicle occurs in the same direc- 
tion as movement of the scapula. 

Scapulothoracic Joint 

Anatomy 

The scapulothoracic joint is considered to be a functional 
rather than an anatomical joint. The joint surfaces are 
the anterior surface of the scapula and the posterior 
surface of the thorax. 

Osteokinematics 

The motions that occur at the scapulothoracic joint are 
caused by the independent or combined motions of the 
sternoclavicular and acromioclavicular joints. These 
motions include scapular elevation-depression, upward- 
downward rotation, anterior-posterior tilting, and 
protraction-retraction (also called medial-lateral rota- 
tion). 



Morion consists of a sliding ol the scapula on the thpE 

M Research Findings 

Effects of Age, Gender, and Other Factors 

I able 4-1 shows the mean values ol shoulder comi 
ROM measurements obtained from various sources.:. 
data on age, fender, and number of subjects rhat\§ 
measured to obtain the values reported for rhe Ameri 
Academy ot Orthopaedic Surgeons iAAOSf in fl 
and tor the American Medical Association (AMA) S '> 
not noted. Boone and A/en measured active ROM] 
a universal goniometer in 10M males between IS mofl 
and 54 years ot age. Green* and Wolf'" 1 measured a| 
ROM with a universal goniometer in 10 males! 
I!) females aged IS to 55 years. Unless otherwise nq 
the reader should assume that shoulder ROM refer; 
shoulder complex ROM. 

Few studies have specifically measured glenol 
ROM using clinical cools such as a universal Ronton 
rhe gicnohumerai joint is generally considered 
contribute about 120 degrees ol flexion and betvve| 
and 120 degrees of abduction ro shoulder corffl 
motions. 1 In general, the overall ratio of glcnohumej 



scapuli 
given 1 
dec co 
joint. | 
ROM 
; and Tc 
! gonton 
, years, 
athlete 
" and,. Is 
colleag 
female 
% years. " 
; the sea 
humeri 
estahli: 

Age 

. A revk 

; Table < 

from b 

. Wanati 

■merits 

The nil 

nieasui 



table 4-2 Glenohumeral Motion: Mean Values in Degrees from Selected Sources 



Lannah et ol 12 



M* 



Bonn &r Smith" 



sot 



Mouon 



Mean (SO) 



Mean (SD) 



Flexion 
Extension 
Abduction 
Medial rotation 
Lateral rotation 



* Values are for male and female subjects 12 to 18 years of age, 

* Values are for subjects who were elite tennis players 11 to 1 7 years of arje 



Ellenbeckeretat™ 

Males 

n= 713* 



Mean (SD) 



Ellenbeckcreti 

Females 
n = 90*1 



Mean ir(S0m 



106.2 (10.2) 












ggB 


$ Afcfon 


20.1 (5.8) 












.^H 


'i — "~ JL ^- 


128.9 (9.1) 












: ^m 


I Restion 


49.2 (9.0) 








62.S (12.7) 


50.9 (12.6) 


56.3 (H13) ] 


| f^tensit 


94.2 (12.2) 








108.1 (14.1) 


102.8 (10.9) 


104.6 (10.3HJH 


1 -&&&A 


bjects 21 to 40 


years 


of 


age. 








I l-ateral, 

1 -^Nucti 



CHAPTER 4 THE SHOULDER 



61 



lis 



"T4 3 Effects of Age on Shoulder Complex Motions for Newborns through Adolescents: 
gj a n' Values in Degrees 



Flexion 
Extension 



Lateral rotation 



F/r 
»= 45 

172-180 
72-90 

:".- it 



Boone'* 



■ 7-5 )TJ ■ 


■■■; ^t-zyri'..:,:-:-.-.'--- 


^..-?.<Wl49.yrs.-- 


»= 79 


n= 17 - 


a ^17 


V ji- ^ ,. 


sWilM^^iSillli 


*J -' ' 5, 


168.8 (3.7) 


169.0 (3.5) 


167.4 (3.9) 


68.9 (6.6) 


wimmM&iiMjiptmm 


64.0 (9.3) 


sira«#;#«#fts 


-''i (:. i 


, & i ( • 3 


ri • , -■■ 


*o; • f3 , ) 


::«:rf«|flgfc' S (fei| 


mz^izM^MmM 


184.7 (3.8) 


iii • (4 1) 



scapuiothoracic motion during flexion and abduction is 
. en • 2:l. 3 ' 9_n Therefore, about two-thirds of shoul- 
der complex motion is attributed to the glenohumeral 
joint; Table .4-2 shows the mean values of glenohumeral 
ROM: obtained from three sources. Lannan, Lehman, 
ancfc-To!and 1:z measured passive ROM using a universal 
goniometer in 20 males and 40 females aged 21 to 40 
years; Boon and Smith 13 examined 50 high school 
athletes (32 females and 18 males} for passive medial 
and lateral glenohumeral rotation. Ellenbecker and 
colleagues 1 ? measured active rotation in 113 male and 90 
female elite tennis players between the ages of 1 1 and 1 7 
years. These three studies used manual stabilization of 
the: scapula and universal goniometers to obtain gleno- 
hurneral measurements. More studies are needed to 
establish normative values for glenohumeral ROM, espe- 
cially: in older adults. 

A review of shoulder complex ROM values presented in 
Table 4—3 shows very slight differences among children 
from birth through adolescence. Values from the study by 
Wanatabe and coworkers 15 were derived from measure- 
ments of passive ROM of Japanese males and females. 
The mean values listed from Boone 16 were derived from 
measurements of active ROM taken with a universal 



goniometer on Caucasian males. Although the values 
obtained from Wanatabe and coworkers 15 for infants are 
greater than those obtained from Boone 16 for children 
between the ages of 1 and 19 years, it is difficult to 
compare values across studies. Within one study, Boone 16 
and Boone and Azen 7 found that shoulder ROM varied 
little in boys between 1 and 19 years of age. 

There is some indication that children have greater 
values than adults for certain shoulder complex motions. 
Wanatabe and coworkers 15 found that the ROM in 
shoulder extension and lateral rotation was greater in 
Japanese infants than the average values typically 
reported for adults. Boone and Azen 7 found significantly 
greater active ROM in shoulder flexion, extension, 
lateral rotation, and medial rotation in male children 
between 1 and 19 years of age compared with findings in 
male adults between 20 and 54 years of age. However, 
they found no significant differences in shoulder abduc- 
tion owing to age. 

Table 4-4 summarizes the effects of age on shoulder 
complex ROM in adults. There appears to be a trend for 
older adults (between 60 and 93 years of age) to have 
lower mean values than younger adults (between 20 and 
39 years of age) for the motions of extension, lateral rota- 
tion, and abduction. Values cited from Boone 16 were 
obtained from measurements made with a universal 



TABLE4-4 Effects of Age on Shoulder Complex Motion in Adults 20 to 93 Years of Age: Mean Values 
in Degrees ' . 



Motion 



:^#ai]rolat?8p 
i^iidiolwlS;? 



20-29 yn 

:'-.rl-±',t9:": 



Mean (5p>* 



5S.3 

65.9 

100.0 



(5.9) 
(8.3) 
(4.0) 
(7 2) 

i9M). 



Boone'* 



30-39 yn 
n- IS 



4(^S4yr$ 
n-19 



Walker etal" 
t0 S< in 



Mean. (SO) 



16SA 

57 5 

67.1 

101 5 

1&2 8 



- ,: 
(4.2) 
(6.9) 

1.7 jy 



Mean (SDl 



165 1 
56 1 
68.3 
97.5 



f5,2) : 
(7.9) 
(3.8) 
(3.5) 

(9.5) 



Mean (SO) 



160.0 (11.0) 
38 (11.0) 
59 (16.0) 

vV: : md;:(i-3;o> :; :: 
islolpitp 



Downey et ajtf 
~~£l 93y7T 



; Mean JSD}< 



165.0 (10.7) 

65.0 (11.7) 

80.6 (11.0) 

15? J 07 AY' 



62 



PART I! UPPER-EXTREMITY TESTING 



goniometer of active ROM in male subjects. The values 
from Walker and associates 17 were obtained from meas- 
urements of active ROM in 30 male subjects using a 
universal goniometer. The values from Downey, Fiebert, 
and Stackpoie-Brown 18 were obtained from measure- 
ments of active ROM made with a universal goniometer 
in 140 female and 60 male shoulders. It is interesting to 
note that the standard deviations for the older groups are 
much larger than the values reported for the younger 
groups. The larger standard deviations appear to indicate 
that ROM is more variable in the older groups than in 
the younger groups. However, the fact that the measure- 
ments of the two oldest groups were obtained by differ- 
ent investigators should be considered when drawing 
conclusions from this information. 

In addition to the evidence for age-related changes 
presented in Tables 4-3 and 4-4, West, 19 Clarke and 
coworkers, 20 and Allander and associates 21 have also 
identified age-related trends. West 19 found that older 
subjects had between 15 and 20 degrees less shoulder 
complex flexion ROM and 10 degrees less extension 
ROM than younger subjects. Subjects ranged in age from 
the first decade to the eighth decade. Clarke and cowork- 
ers 20 found significant decreases with age in passive 
glenohumeral lateral rotation, total rotation, and abduc- 
tion in a study that included 60 normal males and 
females ranging in age from 21 to 80 years. Mean reduc- 
tion in these three glenohumeral ROMs in those aged 71 
to 80 years compared with those aged 21 to 30 years, 
ranged from 7 to 29 degrees. Allander and associates, 21 
in a study of 517 females and 203 males aged 33 to 70 
years, also found that passive shoulder complex rotation 
ROM significantly decreased with increasing age. 

Gender 

Several studies have noted that females have greater 
shoulder complex ROM than males. Walker and 
coworkers, 17 in a study of 30 men and 30 women 
between 60 and 84 years of age, found that women had 
statistically significant greater ROM than their male 
counterparts in all shoulder motions studied except for 
medial rotation. The mean differences for women were 
20 degrees greater than those of males for shoulder 
abduction, 11 degrees greater for shoulder extension, and 
9 degrees greater for shoulder flexion and lateral rota- 
tion. Allander and associates, 21 in a study of passive 
shoulder rotation in 208 Swedish women and 203 men 
aged 45 to 70 years, likewise found that women had a 
greater ROM in total shoulder rotation than men. 
Escalante, Lichenstein, and Hazuda 22 studied shoulder 
flexion in 687 community- dwelling adults aged 65 to 74 
years and found that women had 3 degrees more flexion 
than men. 

Gender differences have also been noted in gleno- 
humeral ROM; Clarke and associates, 20 in a study that 
included 60 males and 60 females, found that females 



had greater glenohumeral ROM tor shoulder abduction 
as well as lateral and total rotation. Six age groups with 
subjects between 20 and 40 years of age were included in 
rhe study. These gender differences were present in all age 
groups. Males had, on average, 92 percent of the ROM 
of' their female counterparts, rhe difference being most 
marked in abduction. Laiman, Lehman, and Tolanil, in 
a study of 40 women and 20 men aged 21 to 40 years, 
found that women had statistically significant greater 
amounts of glenohumeral flexion, extension, abduction, 
medial and lateral rotation than men. The mean differ- 
ences typically varied between 3 and 8 degrees. Boon and 
Smith, 1 ' in a study of 32 females and 18 males aged 12 
to IS years, reported that females had significantly more 
lateral and total rotation than males. The mean differ- 
ence in lateral and total rotation was 4.5 and 9, 1 degrees, 
respectively. Hllenbecker and colleagues 1 '' studied 113 
male and 90 female elite tennis players aged 11 to 17 
years (see Table 4-2). Their data seem to indicate that the 
females had greater ROM than males for glenohumeral 
medial and lateral rotation, although no statistical tests"; 
focused on the effect of gender on ROM. 

Testing Position 

A subject's posture and resting position have been shown ] 
to affect certain shoulder complex morions. Kebactse, ■ 
McClure, and Pratt, 2 ' in a study of 34 healthy adults, i 
measured active shoulder abduction and scapula ROM: 
while subjects were sitting in both erect and slouched:-; 
trunk postures. There was significantly less active shoul- % 
der abduction ROM in the slouched than in rhe erects 
postures (mean difference = 23.6 degrees). The slouched % 
posture also restdted in more scapula elevation during G.f 
to 90 degrees of abduction and less scaptda posterior tilt- 1 
ing in the interval between 90-degree and maximal! 
abduction. 

Sabari and associates - ' 1 studied 30 adult subjects andf 
noted greater amounts of active and passive shoulder^ 
abduction measured in the supine than in the sitting posi-| 
tion. The mean differences in abduction ranged from 3.0.:. 
to 7.1 degrees. On visual inspection of the data theK-S 
were also greater amounts of shoulder flexion in chef; 
supine versus the sitting position; however, these differ- ■-. 
ences did not attain significance. | 

Body- Mass Index 

Escalante, Lichenstein, and Hazuda" 2 studied shoulder- 
complex flexion ROM in 695 community-dwelling: 
subjects, aged 65 to 74 years, who participated in the San.: 
Antonio Longitudinal Study of Aging, They found no:; 
relationship between shoulder flexion and body-mass;; 
index. 

Sports 

Several studies of professional and collegiate baseball; 
players have found a significant increase in lateral rota-- 



CHAPTER 4 THE SHOULDER 



63 



abduction 
oups witt t 

iciudcd k | 
r in al! agt 
the ROM 
eing most | 
>Jand,'~i a | 
40 years,, 
nt greater 
ibd 



.-an differ; 

Boon and 
:s aged 12 
intly more 
.-an differ. 
. i degrees, 
.idied 113 

11 to 1? 1 
ce that the 
lohumenl 
stical tests 






pen s 

Kebaetse, 
:hv a 



mla ROM 
1 slouched 
rive shoul- 
i the erect 

e slouched 
n duringO 
scerior tilt- 
i maximal 

jbjects and I 
e shoulder! 
itting posi-.J 
d from 2m 
data therl 
ion in thfei 
uese differ- 1 



d shoulder 
:y-d\veliins 
1 in the Sail 
found no 
bodv-mass 



te baseba|l 
ueral rotaM 



tiort ROM ant * a decrease in medial rotation ROM of the 
L oU |der complex in the dominant shoulder compared 
with the nondominant shoulder. These differences have 
i^en found in position players as well as in pitchers. 
Rjeliani and coworkers 25 studied 148 professional base- 
ball players (72 pitchers and 76 position players) with no 
history of shoulder problems. Mean lateral rotation 
ROM measured with the shoulder in 90 degrees of 
abduction was 113.5 degrees in the dominant arm and 
99,9 degrees in the nondominant arm. Mean medial rota- 
tion ROM, recorded as the highest vertebral level 
reached behind the back and converted to a numerical 
value, was significantly less in the dominant arm. There 
were no significant differences between the dominant and 
the nondominant arms in shoulder flexion and shoulder 
lateral rotation measured with the arm at the side of the 
body. A study by Baltaci, Johnson, and Kohl 26 of 15 
collegiate pitchers and 23 position players had similar 
findings. Pitchers had an average of 14 degrees more 
lateral rotation, and 11 degrees less medial rotation in 
the dominant versus nondominant shoulders. Position 
players had an average of 8 degrees more lateral rotation 
and 10 degrees less medial rotation in the dominant 
shoulder. All measurements of rotation were taken with 
the shoulder in 90 degrees of abduction. 

Decreases in shoulder medial rotation ROM have also 
been noted in the dominant (playing) compared with the 
nondominant (nonplaying) arms of tennis players. Chinn, 
Priest, and Kent, 27 in a study of 83 national and interna- 
tional men and women tennis players aged 14 to 50 
years, found a significant decrease in active medial rota- 
tion ROM of the shoulder complex in the playing versus 
the nonplaying arm (mean difference = 6.8 degrees in 
males, 11.9 degrees in females). Men also had a signifi- 
cant increase in lateral rotation ROM in the playing 
compared with the nonplaying arm. A study by Kibler 
and colleagues 28 of 39 members of the U. S. Tennis 
Association National Tennis Team and touring profes- 
sional program found a decrease in passive glenohumera! 
medial rotation ROM, an increase in glenohumeral 
lateral rotation ROM, and a decrease in total rotation 
ROM in the playing versus the nonplaying arm. The 
differences in medial rotation ROM increased with age 
and years of tournament play. A study by Ellenbecker 
and associates' 4 of 203 junior elite tennis players aged 11 
to 17 years reported a significant decrease in active 
medial rotation ROM and total rotation ROM of the 
glenohumeral joint in the playing versus the nonplaying 
ar m. The average differences in medial rotation ROM 
were 11 degrees in the 113 males and 8 degrees in the 90 
females. There were no significant differences in gleno- 
humeral lateral rotation ROM between playing and 
nonplaying arms. 

Power lifters were found to have decreased ROM in 
shoulder complex flexion, extension, and medial and 
'ateral rotation compared with nonlifters in a study by 



Chang, Buschbacker, and Edlich. 29 Ten mate power lifters 
and 10 aged-matched male nonlifters were included in 
the study. The authors suggest that athletic training 
programs that emphasize muscle strengthening exercise 
without stretching exercise may cause progressive loss of 
ROM. 

Functional Range of Motion 

Numerous activities of daily living (ADL) require 
adequate shoulder ROM. Tiffitt, 30 in a study of 25 
patients, found a significant correlation between the 
amount of specific shoulder complex motions and the 
ability ro perform activities such as combing the hair, 
putting on a coat, washing the back, washing the 
contralateral axilla, using the toilet, reaching a high shelf, 
lifting above the shoulder level, pulling, and sleeping on 
the affected side. Flexion and adduction ROM correlated 
best with the ability to comb the hair, whereas medial and 
lateral rotation ROM correlated best with the ability to 
wash the back. 

Several studies 31,32 have examined the ROM that 
occurs during certain functional tasks (Table 4-5). A 
large amount of abduction (112 degrees) and lateral rota- 
tion is required to reach behind the head for activities 
such as grooming the hair (Fig 4-6), positioning a neck- 
tie, and fastening a dress zipper. Maximal flexion (148 
degrees) is needed to reach a high shelf (Fig. 4-7), 
whereas less flexion (36 to 52 degrees) is needed for self- 
feeding tasks (Fig 4-8). Thirty-eight to 56 degrees of 
extension and considerable medial rotation and horizon- 
tal abduction are necessary for reaching behind the back 
for tasks such as fastening a bra (Fig 4—9), tucking in a 
shirt, and reaching the perineum to perform hygiene 
activities. Horizontal adduction is needed for activities 
performed in front of the body such as washing the 
contralateral axilla (104 degrees) and eating (87 degrees). 
If patients have difficulty performing certain functional 
activities, evaluation and treatment procedures need to 
focus on the shoulder motions necessary for the activity. 
Likewise, if patients have known limitations in shoulder 
ROM, therapists and physicians should anticipate patient 
difficulty in performing these tasks, and adaptations 
should be suggested. 



Reliability and Validity 

The intratester and intertester reliability of measurements 
of shoulder motions with a universal goniometer have 
been studied by many researchers. Most of these studies 
have presented evidence that intratester reliability is 
better than intertester reliability. Reliability varied 
according to the motion being measured. In other words, 
the reliability of measuring certain shoulder motions was 
better than the reliability of measuring other motions. 
Hellebrandt, Duvall, and Moore, 33 in a study of 77 



64 PART II UPPER-EXTREMITV TESTING 



TABLE4-5 Maximal Shoulder Complex Motion Necessary for Functional Activities: Mean Values 
in Degrees K V P J :; " 



Activity 



Motion 



Mean (SO) 



Source 



Eating 



Flexion 

Flexion 

Abduction 

Medial rotation 

Horizontal adduction* 



52 (8) 

36 (14) 

22 (7) 

18 (10) 

87 (29) 



Matsen* 31 
Safaee-Rad et a\ U2 
Safaee-Rad et at 
Saiaee-Rad et o! 
Matseri 



Drinking with a cup 



Flexion 
Abduction 
Medial rotation: 



43 (16) 
31 (9) 
23 (12) 



Safaee-Rad et al 
Sataee-Rad et al 
Safaee-Rad et al 



Washing axilla 
Combing hair 



Flexion 

Horizontal adduction 
Abduction 
Horizontal adduction 



52 (14) 

104 (12) 

112 (10) 

54 (27) 



Matsen 
Matsen 
Matsen 
Matsen 



Maximal elevation 
Maximat reaching up back 



Flexion/abduction 
Horizontal adduction 
Extension 
Horizontal abduction* 



MS (11) 

55 (17) 

56 (13) 
69 (11) 



Matsen 
Matsen 
Matsen 
Matsen 



Reaching perineum 



Extension 
Horizontal abduction 



38 

86 



(10) 
(13) 



Matsen 
Matsen 



• Eight normal subjects were assessed with electromagnetic sensors on the humerus. 

' Ten norma! male subjects were assessed with a three-dimensional video recording system. 

'The degree starting position for measuring horizontal adduction and horizontal abduction was in 90 degrees oi 




FIGURE 4-6 Reaching behind the head requires a large 

amount of abduction (112 degrees)" and lateral rotation of the 
shoulder. 




FIGURE 4-7 Reaching objt'errs on ;i (rtf-h shelf requires l4*J 
cttarves nf shoulder flexion.. 



CHAPTER 4 THE SHOULDER 



65 



-Radefli 

-RaiJftal 
-Rad et| 



i=t»'l 



#: 



;;J;-SvV; 



'M % 






BK 



cqiiirc: 




Hi!: 



:FIGURE 4-8 Feeding tasks require 36 to 52 degrees of shoul- 
der flexion, 35 ' 32 ; ; " : 



: patients, found the intratester reliability of measurements 
of active ROM of shoulder complex abduction and 
medial rotation. to be less than the intratester reliability of 
shoulder flexion, extension, and lateral rotation. The 

■mean difference between the repeated measurements 

.ranged from 0.2 to 1,5 degrees. Measurements were 
taken with a universal goniometer and devices designed 

s : »y the U.S. Army for specific joints. For most ROM 
measurements taken throughout the body, the universal 
goniometer was a more dependable tool than the special 

i devices. 

;,:,.-.Booae and coworkers 34 examined the reliability of 
measuring passive ROM for lateral rotation of the shoul- 
der complex, elbow extension-flexion, wrist ulnar devia- 
t'on, hip abduction, knee extension-flexion, and foot 
'"version. Four physical therapists used universal 
goniometers to measure these motions in 12 normal 
ma ' es on ce a week for 4 weeks. Measurement of lateral 
rotation ROM of the shoulder was found to be more reli- 
e l han that of the other motions tested. For all 
cottons except lateral rotation of the shoulder, intra- 
e | Eer re l>ability was noted to be greater than intertester 
Ee la ° la ty Intratester and intertester reliability was simi- 




F1GURE 4-9 Reaching behind the back to fasten a bra or 
bathing suit requires 56 degrees of extension, 69 degrees of 
horizontal abduction, 31 and a large amount of medial rotation 
of the shoulder. 



lar (r *= 0.96 and 0.97, respectively) for lateral rotation 
ROM. 

Pandya and associates, 35 in a study in which five 
testers measured the range of shoulder complex abduc- 
tion of 150 children and young adults with Duchenne 
muscular dystrophy, found that the intratester intraclass 
correlation coefficient (ICC) for measurements of shoul- 
der abduction was 0.84. The intertester reliability for 
measuring shoulder abduction was lower (ICC=0.67). In 
comparison with measurements of elbow and wrist 
extension, the measurement of shoulder abduction was 
less reliable. 

Riddle, Rothstein, and Lamb 3fi conducted a study to 
determine intratester and intertester reliability for passive 
ROM measurements of the shoulder complex. Sixteen 



66 



PART II 



UPPER-EXTREMITY TESTING 



physical therapists, assessing in pairs, used rwo different 
sized universal goniometers (large and small) for their 
measurements on 50 patients. Patient position and 
goniometer placement during measurements were not 
controlled. ICC values for intratester reliability for all 
motions ranged from 0.87 to 0.99. ICC values for 
intertester reliability for flexion, abduction, and lateral 
rotation ranged from 0.84 to 0.90. Intertester reliability 
was considerably lower for measurements of horizontal 
abduction, horizontal adduction, extension, and medial 
rotation, with ICC values ranging from 0.26 to 0.55. 
The authors concluded that passive ROM measurements 
for all shoulder motions can be reliable when taken by 
the same physical therapist, regardless of whether large 
or small goniometers are used. Measurements of flexion, 
abduction, and lateral rotation can be reliable when 
assessed by different therapists. However, because 
repeated measurements of horizontal abduction, hori- 
zontal adduction, extension, and medial rotation were 
unreliable when taken by more than one tester, these 
measurements should be taken by the same therapist. 

Greene and Wolf 8 compared the reliability of the 
Ortho Ranger, an electronic pendulum goniometer, with 
that of a standard universal goniometer for active upper 
extremity motions in 20 healthy adults. Shoulder 
complex motions were measured three times with each 
instrument during three sessions that occurred over a 
2-week period. Both instruments demonstrated high 
intra-session correlations (ICCs ranged from 0.98 to 
0.87), but correlations were higher and 95 percent confi- 
dence levels were much lower for the universal goniome- 
ter. Measurements of medial rotation and lateral rotation 
were less reliable than measurements of flexion, exten- 
sion, abduction, and adduction. There were significant 
differences between measurements taken with the Ortho 
Ranger and the universal goniometer. Interestingly, there 
were significant differences in measurements between 
sessions for both instruments. The authors noted that the 
daily variations that were found might have been caused 
by normal fluctuation in ROM as suggested by Boone 
and colleagues, 34 or by daily differences in subjects' 
efforts while performing active ROM. 

Bovens and associates, 37 in a study of the variability 
and reliability of nine joint motions throughout the 
body, used a universal goniometer to examine active 
lateral rotation ROM of the shoulder complex with the 
arm at the side. Three physician testers and eight healthy 
subjects participated in the study. Intratester reliability 
coefficients for lateral rotation of the shoulder ranged 
from 0.76 to 0.83, whereas the intertester reliability 
coefficient was 0.63. Mean intratester standard devia- 
tions for the measurements taken on each subject ranged 
from 5.0 to 6.6 degrees, whereas the mean intertester 
standard deviation was 7.4 degrees. The measurement of 



lateral rotation ROM of the shoulder was more reliable 
than ROM measurements of the ton-arm and wrist. 

Mean standard deviations between repeated measure- 
ment of shoulder lateral rotation ROM were- similar to 
those of the forearm and larger than those of the wrist. 

Sahari and associates"' 1 examined intra rarer reliability 
in the measurement of active and passive shoulder 
complex tlexion and abduction ROM when 30 adults 
were positioned in supine and sitting positions. The iCCs 
between two trials by the same tester tor each procedure 
ranged in value from 0.94 to 0.99, indicating high intra- 
tester reliability, regardless of whether the measurements 
were active or passive, or whether they were taken with 
the subject in the supine or the sirring position. ICCs 
between measurements taken in supine compared with 
taken in sitting positions ranged from 0.6-1 to 0.8 I . There 
were no significant differences between comparable flex- 
ion measurements taken in supine and sitting positions. 
However, significantly greater abduction ROM was 
found in the supine than in the sitting position. 

In a study by MacDcrmid and colleagues, l!i two expe- 
rienced physical therapists measured passive shoulder 
complex rotation ROM in 34 patients with a variety of 
shoulder pathologies. A universal goniometer was used to 
measure lateral rotation with the shoulder in 20 to 30 
degrees of abduction. Intratester ICCs (0.88 and 0.93) 
and intertester ICCs (0.85 and 0,80) were high. 
Intratester standard errors of measurement (SEMs) (4,9 
and 7.0 degrees) and intertester SEMs (7.5 and 8.0 
degrees) also indicated good reliability. The SEMs indi- 
cate that differences of 5 to 7 degrees could he attributed:' 
to measurement error when the same tester repeats a' 
measurement, and about 8 degrees could be attributed to 
measurement error when different testers take a meas- 
urement. 

Boon and Smith 1, studied 50 high school athletes to: 
determine the reliability of measuring passive shoulder*] 
rotation ROM with and without manual stabilization of? 
the scapula, lour experienced physical therapists work-! 
ing in pairs took goniometric measurements with the 
shoulder in 90 degrees of abduction and repeated those 
measurements 5 days later. Scapular stabilization, which 
resulted in more isolated glenohumeral motion, produced;;,: 
significantly smaller ROM values than when the scapuisf 
was not stabilized. According to the authors, intratester ■ 
reliability for medial rotation was poor for nonscnbilized, 
motion | ICC = 0.23. SF.M = 20.2 degrees), and good for 
stabilized motion (ICC = 0.60, SEM =• 8.0). The authors 
state that intratester reliability for lateral rotation was 
good for both nonsrabilized (ICC ~ 0.79, SEM = .5.6) 
and stabilized motion (ICC = 0.53. SEM = 9.1). 
Intertester reliability for medial rotation improved from 
nonsrabilized morion (ICC = 0.13, SEM = 21.5) to. 
stabilized motion (ICC = 038, SEM = 10.0), and was 



CHAPTER A THE SHOULDER 



67 



:: 



- om parable for both nonsrabilized and stabilized lateral 
rotation (ICC = 0.84, SEM = 4.9 and ICC = 0.78, SEM 
» 6.6), respectively. 

-The reliability of measurement devices other than a 
universal goniometer for assessing shoulder ROM has 
a lso been studied and is briefly mentioned here. 
Intratester and intertester reliability for the different 
motions and methods varied widely. Green and associ- 
ates 33 investigated the reliability of measuring active 
shoulder complex ROM with a plurimeter-V inclinome- 



ter in six patients with shoulder pain and stiffness. 
Tiffitt, Wildin, and Hajioff 40 studied the reliability of 

using an inclinometer to measure active shoulder 
complex motions in 36 patients with shoulder disorders. 
Bower 41 and Clarke and coworkers 20 examined the reli- 
ability of measuring passive glenohumeral motions with 
a hydrogoniometer. Croft and colleagues'' 2 investigated 
the reliability of observing shoulder complex flexion and 
lateral rotation, and sketching the ROMs onto diagrams 
that were then measured with a protractor. 






5V& ' 



68 



PART II UPPER-EXTREMITY TESTING 



Range of Motion Testing Procedures: The Shoulder 



Full ROM of the shoulder requires movement at the 
glenohumeral, SC, AC, and scapulothoracic joints. To 
make measurements more informative, we suggest 
using two methods of measuring the ROM of the shoul- 
der. One method measures passive motion primarily at 
the glenohumeral joint. The other method measures 
passive ROM at ait the joints included in the shoulder 
complex. 

We have found the method that measures primarily 
glenohumeral motion is helpful in identifying gleno- 
humeral joint problems within the shoulder complex. 
The ability to differentiate and quantify ROM at the 
glenohumeral joint from other joints in the shoulder 
complex is important in diagnosing and treating many 
shoulder conditions. This method of measuring gleno- 
humeral motion requires the use of passive motion and 
careful stabilization of the scapula. Active motion is 
avoided because it results in synchronous motion 



throughout the shoulder complex, making isolation of 
glenohumeral motion difficult. ( icftain studies have 
begun establishing some normative values (Tabic 4-2) 
and assessing the reliability of this measurement method. 
The second method measures full morion of the shoul- 
der complex and is useful in evaluating the functional 
ROM of the shoulder. This more traditional method of 
assessing shoulder motion incorporates the stabilization 
ol the thoracic spins and rib cage. Tissue resistance to 
further motion is typically due to the stretch of structures ■ 
connecting the clavicle to the sternum, and the scapula to.'-; 
the ribs iuul spine. ROM values for shoulder complex 
motion are presented in Tables 4-1, 4— i, and 4-4. Both 
methods of measuring the ROM of the shoulder are 
presented in the following discussions of stabilization 
techniques and end-feels, However, the alignment of the., 
goniometer is the same tor measuring gicnohtimerai andl 
shoulder complex morions. 






Landmarks for Goniometer Alignment 



nor" 



■■.. - 







FIGURE 4-10 An anterior view of the humerus, clavicle, 
sternum, and scapula showing surface anatomy landmarks 
for aligning the goniometer. 



Scapula 



S;ernum 







Acromion 



Grealef : 
tubercle ii 
>3B 



Humerus 



Lalerai 
epiconcfyi*; I j 



Media! 
upicondyfB ;• 



l-'ICiL-IU-! 4-t 1 An anterior view of the humerus, clavicle, '.„, 
sternum, and scapula showing bony anatomical landmarks ^ 
for aligning the goniometer. 



CHAPTER 4 THE SHOULDER 



69 




"-■ : 



FIGURE 4-12 A lateral view of the upper arm showing surface anatomy landmarks for aligning the 
goniometer. 



Lesser tubercule 




Olecranon 



Lateral 

epicondyle of humerus 



Greater 
tubercule 



FIGURE 4-13 A lateral view of the upper arm showing bony anatomical landmarks for aligning the 
goniometer. 



■& 

';-.* 



OS 
LU 

Q 

—i 

O 

X 

LU 

Z 

h- 

</i 

LU 

Q 

LU 
U 
O 

c 
O 

z 

(/> 

LU 

z 
o 

§ 

LU 

o 

LU 

o 

Z 

< 

OS 



70 



PART II UPPER-EXTREMITY TESTING 



FLEXION 



Motion occurs in the sagittal plane around a medial- 
lateral axis. Mean shoulder complex flexion ROM is 180 
degrees according to the AAOS, 1 167 degrees according 
to Boone and Azen, 7 and 150 degrees according to the 
AMA.* 5 Mean glenohumera! flexion ROM is 106 degrees 
according to Lannan, Lehman, and Toland 12 and 120 
degrees according to Levangie and Norkin. 3 See Tables 
4—1 to 4—4 for additional information. 

Testing Position 

Place the subject supine, with the knees flexed to flatten 
the lumbar spine. Position the shoulder in degrees of 
abduction, adduction, and rotation. Place the elbow in 
extension so that tension in the long head of the triceps 
muscle does not limit the motion. Position the forearm in 
degrees of supination and pronation so that the palm of 
the hand faces the body. 

Stabilization 

Glenohumeral Flexion 

Stabilize the scapula to prevent posterior tilting, upward 

rotation, and elevation of the scapula. 



Shoulder Complex Flexion 

Stabilize the thorax to prevent extension of the spine and! 
movement of the ribs. The weight of the trunk may assist 
stabilization. 

Testing Motion 

Flex the shoulder by lifting the humerus off the examin- 
ing table, bringing the hand up over the subject's head, 
Maintain the extremity in neutral abduction and adduc- 
tion during the motion. 

Glenohumeral Flexion 

The end of glenohumeral flexion ROM occurs when: 
resistance to further motion is felt and attempts to over! 
come the resistance cause upward rotation, posterior tilt! 
ing, or elevation of the scapula (Fig. 4-14). 

Shoulder Complex Flexion 

The end of shoulder complex flexion ROM occurs whef 
resistance to further motion is felt and attempts to over-; 
come the resistance cause extension of the spine o£ 
motion of the ribs (Fig. 4-15). 






v.. 



CHAPTER 4 THE SHOULDER 



71 



[ Y assist 



-xanuljt 

's head, 

adducS 



8 wh.<S| 
to over- 

riorriH 



to over? 
pine m 




FIGURE 4-14 The end of the ROM of glenohumeral flexion. The examiner stabilizes the lateral border 
of the scapula with her hand. The examiner is able to determine that the end of the ROM has been 
reached because any attempt to move the extremity into additional flexion causes the lateral border of the 
scapula to move anteriorly and laterally. 




FIGURE 4—15 The end of the ROM of shoulder complex flexion. The examiner stabilizes the subject's 
trunk and ribs with her hand. The examiner is able to determine that the end of the ROM has been 
reached because any attempt to move the extremity into additional flexion causes extension of the spine 
and movement of the ribs. 



OS 

LU 

Q 

_l 

Ol 
X 

UJ 
I 

1- 

• • 

UJ 

Q 

LU 

u 

o 

a 
O 

z 

CD 

z 
o 

o 

— 

o 

— 

o 

'.Z ; 

< 



72 



PART II UPPER-EXTREMITY TESTING 



Normal End-feel 

Glenohumeral Fiexion 

The end-feel is firm because of tension in the posterior 
band of the coracohumeral ligament and in the posterior 
joint capsule, and the and in the posterior deltoid, teres 

minor, teres major, and infraspinatus muscles. 

Shoulder Complex Flexion 

The end-feel is firm because of tension in the costocla- 
vicular ligament and SC capsule and ligaments, and the 
latissimus dorsi, sternocostal fibers of the pectoralis 
major and pectoralis minor, and rhomboid major and 
minor muscles. 



Goniometer Alignment 

This goniometer alignment is used for measuring gleno- '■■' f 
humeral and shoulder complex fiexion (Figs. 4~l6 
through 4-18). 

1. Center the fulcrum of the goniometer over the 

lateral aspect of the greater tubercle. 

2. Align the proximal arm parallel to the midaxillary 
line of the thorax, 

3. Align the distal arm with the lateral midline of the 
humerus. Depending on how much flexion and 
medial rotation occur, the lateral epicondyle of the 
humerus or the olecranon process of the ulnar may 
be helpful references. 






■ 






.. 



FIGURE 4-16 The alignment of the goniometer at the beginning of the ROM of glenohumeral and shoul- 
der complex flexion. 



I 



CHAPTER 4 THE SHOULDER 



73 



■ 4-16 




'« thef 

: of the 
>n and 
' of the 

armay. 




i%&#!$$P^ 




J 




FIGURE 4-17 The alignment of the goniometer at the end of the ROM of glenohumera! flexion. The 
examiner's hand supports the subject's extremity and maintains the goniometer's distal arm in correct 
alignment over the lateral epicondyle. The examiner's other hand releases its stabilization and aligns the 
goniometer's proximal arm with the lateral midline of the thorax. 





>/-fi 



y 




vv^ ':'-' 



FIGURE 4-18 The-alignment of the goniometer at the end of the ROM of shoulder complex flexion. 
More ROM is noted during shoulder complex flexion than in glenohumera! flexion. 



74 



PART I! 



UPPER-EXTREMITY TESTING 



EXTENSION 



Motion occurs in the sagittal plane around a medial- 
lateral axis. Mean shoulder complex extension ROM is 
62 degrees according to Boone and Azen, 7 60 degrees 
according to the AAOS, 5 and 50 degrees according to the 
AMA. 6 Mean glenohumeral extension ROM is 20 
degrees as cited by Lannan, Lehman, and Toland. 12 See 
Tables 4-1 to 4-4 for additional information. 

Testing Position 

Position the subject prone, with the face turned away 
from the shoulder being tested. A pillow is not used 
under the head. Place the shoulder in degrees of abduc- 
tion, adduction, and rotation. Position the elbow in slight 
flexion so that tension in the long head of the biceps 
brachii muscle will not restrict the motion. Place the 
forearm in degrees of supination and pronation so that 
the palm of the hand faces the body. 

Stabilization 

Glenohumeral Extension 

Stabilize the scapula at the inferior angle or at the 
acromion and coracoid processes to prevent elevation 



and anterior tilting (inferior angle moves posteriorly) of 
the scapula. 

Shoulder Complex Extension 

The examining table and the weight of the trunk stabi- 
lize the thorax to prevent forward flexion of the spine. 
The examiner can also stabilize the trunk to prevent 
rotation of the spine. 

Testing Motion 

Extend the shoulder by lifting the humerus off the exam- 
ining table. Maintain the extremity in neutral abduction 
and adduction during the motion. 

Glenohumeral Extension 

The end of ROM occurs when resistance to further 
motion is felt and attempts to overcome the resistance 
cause anterior tilting or elevation of the scapula (Fig. : 
4-19). 

Shoulder Complex Extension 

The end of ROM occurs when resistance to further 
motion is felt and attempts to overcome the resistance i 
cause forward flexion or rotation of the spine (Fig. 
4-20). 



CHAPTER 4 



THE SHOULDER 



75 



eriorly} tf- 



unk stabi-! 
the spine, - 
:o prevent 



the exam- 
abduction: 



to further! 
resistance! 
.puia (Fig. | 



to further! 
resistance! 
pine (Fig,! 




FIGURE 4-19 The end of the ROM of gienohumeral extension. The examiner is stabilizing the inferior 
angle of the scapula with her hand. The examiner is able to determine that the end of the ROM in exten- 
sion has been reached because any attempt to move the humerus into additional extension causes scapula 
to tilt anteriorly and to elevate, causing the inferior angle of the scapula to move posteriorly. Alternatively, 
the examiner may stabilize the acromion and coracoid processes of the scapula. 




FIGURE 4-20 The end of the ROM of shoulder complex extension. The examiner stabilizes the subject's 
trunk and ribs with her hand. The examiner is able to determine that the end of the ROM has been 
reached because any attempt to move the extremity into additional extension causes flexion and rotation 
of the spine. 



- "-" 1 

— < i 

O ; 

<Si | 
U4 | 

' Xi- I 

"SI 

::'?■:■* 
O 



76 



PART II 



UPPER-EXTREMITY TESTING 



Normal End-feel 

Glenohumeral Extension 

The end-fee! is firm because of tension in the anterior 
band of the coracohumerai ligament, anterior joint 
capsule, and clavicular fibers of the pectoralis major, 
coracobrachial, and anterior deltoid muscles. 

Shoulder Complex Extension 

The end-feel is firm because of tension in the SC capsule 
and ligaments, and in the serratus anterior muscle. 



■2K| 



Goniometer Alignment 

This goniometer alignment is used for measuring glea|j 
humeral and shoulder complex extension (Figs. 4-21 to' 
4-23). " 

1. Center the fulcrum of the goniometer over tfe'j 
lateral aspect of the greater tubercle. j 

2. Align the proximal arm parallel to the midaxitjaS 
line of the thorax. I 

3. Align the distal arm with the lateral midline of tjri 
humerus, using the lateral epicondyle of 
humerus for reference. 



.©•;. 

o: 

Lil'.':l 

° : >. 

■ Z:-'i 
<:M 
QUI 







FIGURE 4-21 The alignment of the goniometer at the beginning of the ROM of glenohumeral and shoul- 
der complex extension. 



CHAPTER 4 THE SHOULDER 



77 



1-21 to; 

ver the 

axitlaty 

s of the 
of the 




FIGURE 4-22 The alignment of the goniometer at the end of the ROM in glenohumeral extension. The 
examiner's left hand supports the subject's extremity and holds the distal arm of the goniometer in correct 
alignment over the lateral epicondyle of the humerus. 







FIGURE 4-23 The alignment of the goniometer at the end of the ROM in shoulder complex extension. 
The examiner's hand that formerly stabilized the subject's trunk now positions the goniometer 



78 



PART II UPPER-EXTREMITY TESTING 



o 

X 
(/> 

U-l 

X 
Cn 

kU 

a; 
D 
Q 

LU 

u 

O 

a: 

Z 



z 
o 

§ 

— 

o 



ABDUCTION 



I Motion occurs in the frontal plane around an anterior- 
| posterior axis. Mean shoulder complex abduction ROM 
I is 180 degrees according to the AAOS 5 and AMA, 6 and 
| 184 degrees according to Boone and Azen. 7 
I Glenohumeral abduction ROM is 129 degrees as noted 
| by Lannan, Lehman, and Toland, 12 -and 90 or 120 
I degrees according to Levangie and Norkin. See Tables 
i 4-1 to 4-4 for additional information. 



1 Testing Position 

Position the subject supine, with the shoulder in lateral 
rotation and degrees of flexion and extension so that 
the palm of the hand faces anteriorly. If the humerus is 
not laterally rotated, contact between the greater tubercle 
of the humerus and the upper portion of the glenoid fossa 
or the acromion process will restrict the motion. The 
elbow should be extended so that tension in the long 
head of the triceps does not restrict the motion. 



^ I Stabilization 

2 I Glenohumeral Abduction 

1 Stabilize the scapula to prevent upward rotation and 
I elevation of the scapula. 



Shoulder Complex Abduction 

Stabilize the thorax to prevent lateral flexion of the spine. 
The weight of the trunk may assist stabilization. 

Testing Motion 

Abduct the shoulder by moving the humerus laterally 
away from the subject's trunk. Maintain the upper; 
extremity in lateral rotation and neutral flexion and!; 
extension during the motion. 

Glenohumeral Abduction 

The end of ROM occurs when resistance to further- 
motion is felt and attempts to overcome the resistance 
cause upward rotation or elevation of the scapula (Fig. 
4-24). 

Shoulder Complex Abduction 

The end of ROM occurs when resistance to further 
motion is felt and attempts to overcome the resistance 
cause lateral flexion of the spine (Fig. 4-25). 



; ; 



>i 



CHAPTER 4 THE SHOULDER 



79 



■ b Pme;i 



ateral| 
U PPC 
on anil 



further | 
sistanct, | 
'la (Fill 



further; 
sistana 





FIGURE 4-24 The end of 
the ROM of glcnohumeral 

abduction. The examiner 
stabilizes the lateral border 
of the scapula with her 
hand to detect upward 
rotation of the scapula. 
Alternatively, the examiner 
may stabilize the acromion 
and coracoid processes of 
the scapula to detect eleva- 
tion of the scapula. 




FIGURE 4-25 The end of the ROM of shoulder complex 
abduction. The examiner stabilizes the subject's trunk and ribs 
with her hand to detect lateral flexion of the spine and move- 
ment of the ribs. 



LU 

Q 

_i 

o 
I 

l/J 
m 

X 

)-■ 

LU 

O 
Q 

LU 

U 

o 

as 
ex. 

O 
Z 

<•> 

LU 



80 



PART II UPPER-EXTREMITY TESTING 



Normal End-feel 

Gfcnohumeral Abduction 

The end-feel is usually firm because of tension in the 
middle and inferior bands of the glenohumeral ligament, 

inferior joint capsule, and the teres major, and clavicular 
fibers of the pectoralis major muscles. 

Shoulder Complex Abduction 

The end-feel is firm because of tension in the costoclavic- 
ular ligament, sternoclavicular capsule and ligaments, 
and latissimus dorsi, sternocostal fibers of the pectoralis 

major, and major and minor rhomboid muscles. 



Goniometer Alignment 

This goniometer alignment is used tor n 



^ Urin S SMI 



numeral and shoulder complex abduction digs. 4_?h ffl 
4-781 Mm 



4-2S) 



1. Center the fulcrum of the goniometer close try; 
anterior aspect of the acromial process. 

2. Align the proximal arm so that it is parallel tol 
midline of the anterior aspect of the sternum.1 

3. Align the distal arm with the anterior midliiiel 
the humerus. Depending on the amount of aril 
tion and lateral rotation that has occurred SH 
medial epicondyle may be a help hi I reference, Mm 



o 

2 







FIGURE 4-26 The alignnie|| 

the goniometer at the beginning 1 ! 
the ROM in glenohumeral ■ i< 
shouitler complex abduction. 




m!1 ''»ggle| 
ffigs.4-2p 

.r close to : 
.•ss, 

parallel to 
sternum..--; 
ior midliiti 
unit of ab| 
occurred 
reference 



\c .ilignme 
the beginn 

.nnlunneral 
abduction.-; 



CHAPTER 




THE SHOULDER 



81 



FIGURE 4-27 The alignment 
of die goniometer at the end of 
the ROM in glenohumeral 
abduction. The examining 
table or the examiner's hand 
can support the subject's 
extremity and align the 
goniometer's distal arm with 
the anterior midline of the 
humerus. The examiner's other 
hand has released its stabiliza- 
tion of the scapula and is hold- 
ing the proximal arm of the 
goniometer parallel to the ster- 
num. 



FIGURE 4-28 The alignment of the goniometer at the end of 

the ROM in shouldet complex abduction. Note that the 
humerus is laterally rotated and the medial epicondyle is a help- 
ful anatomical landmark for aligning the distal arm of the 
goniometer. 






82 



PART II UPPER-EXTREMITY TESTING 



3 
O 
X 

LU 

X 

H 

LU 

Q 

u 

O;' 
•;eu'l 

H 



z I 
2 

si 

u. i 

o | 

LU I 

u 1 
z 

■< 



ADDUCTION 



Morion occurs in the frontal plane around an antero- 
posterior axis. Adduction is not usually measured and 
recorded because it is the return to the zero starting posi- 
tion from full abduction. 



MEDIAL (INTERNAL) ROTATION 



When the subject is in anatomical position, the motion 
occurs in the transverse plane around a vertical axis. 
When the subject is in the testing position, the motion 
occurs in the sagittal plane around a coronal axis. Mean 
shoulder complex medial rotation is 69 degrees according 
to Boone and Azcn, 7 70 degrees according to the AAOS/ 
and 90 degrees according to the AMA, 5 Mean gieno- 
humeral medial rotation is 49 degrees according to 
Lannan, Lehman, and Toland, 12 54 degrees according to 
Ellenbecker, 1 " 1 and 63 degrees according to Boon and 
Smith. 1 ' See Tables 4-1 to 4-4 for additional informa- 
tion. 

Testing Position 

Position the subject supine, with the arm being tested in 
90 degrees of shoulder abduction. Place the forearm 
perpendicular to the supporting surface and in degrees 
of supination and pronation so that the palm of the hand 
faces the feet. Rest the full length of the humerus on the 
examining table. The elbow is not supported by the 
examining table. Place a pad under the humerus so that 
the humerus is level with rhe acromion process. 



Stabilization 

Clcnohumeral Medial Rotation 

In the beginning of the ROM, stabilization is often 
needed at the- distal end of rhe humerus to keep the shoul- 
der in 90 degrees ol abduction. Toward the end of the 

ROM, the clavicle and enroeoid and acromion processes 
of the scapula are stabilized to prevent anterior tilting 
and protraction of the scapula. 

Shoulder Complex Medial Rotation 

Stabilization is often needed at the distal (.'n^ of the 
humerus ro keep the shoulder in 90 degrees of abduction. 
The thorax may be stabilized by the weight of the 
subject's trunk or with the examiner's hand to prevent 
flexion or rotation of the spine. 

Testing Motion 

Medially rotate the shoulder by moving the forearm ante- 
riorly, bringing the palm of rhe hand toward the floor, i 
Maintain the shoulder in 90 degrees of abduction and the s 
elbow in 90 degrees of flexion during rhe motion. 

Cilenohumeral Medial Rotation 

"rhe end of ROM occurs when resistance to further 
motion is felt and attempts ro overcome the resistance: 
cause an anrcrior tilt or protraction of the scapula (Pig, :■■ 
4-29). 

Shoulder Complex Medial Rotation 

1 he end of ROM occurs when resistance to furthers 
motion is felt and attempts to overcome the resistance! 
cause flexion or rotation of the spine (Pig. 4-,i0). 



>" is often 

p the shout 

end of th e 

>ii pr< vessel 
t-'i'ior tjltin^I 



end of thei 
■ abduction,. 
ight «f the? 
to prevent; 



rearm ante- 
d the floot i 
:ion and the 
rion. 



to furtheg; 
e resistance:: 
;apula (Fig| 




CHAPTER 4 THE SHOULDER 



83 





FIGURE 4-29 The end of the ROM of glenohumera! media! (internal) rotation. The examiner stabilizes 
the acromion and coracoid pro-cesses of the scapula. The examiner is able to determine that the end of 
the ROM has been reached because any attempt to move the extremity into additional medial rotation 
causes the scapula to tilt anteriorly or protract. The examiner should also maintain the shoulder in 90 
degrees of abduction and the elbow in 90 degrees of flexion during the motion. 



to further 
e resistance 
30). 






I 










FIGURE 4-30 The end of the ROM of medial (internal) rotation of the shoulder complex. The examiner 
stabilizes the distal end of the humerus to maintain the shoulder in 90 degrees of abduction and the elbow 
in 90 degrees of flexion during the motion. Resistance is noted at the end of medial rotation of the shoul- 
der complex because attempts to move the extremity into further motion cause the spine to flex or rotate. 
The clavicle and scapula are allowed to move as they participate in shoulder complex motions. 



Q 

Z) 
O 
X. 

UJ 

c/v 

UJ 

CSS; 

D 

Q '/ 
uu 
U 
O 

0. 

U: 

P. 
uj 



84 



PART II UPPER- EXTREM ITY TESTING 



Normal End I Feel 

Glenohumeral Medial Rotation 

The end-feel is firm because of tension in the posterior 

joint capsule and the infraspinatus and teres minor 

muscles. 

Shoulder Complex Medial Rotation 

The end-feel is firm because of tension in the sternoclav- 
icular capsule and ligaments, the costoclavicular liga- 
ment, and the major and minor rhomboid and trapezius 
muscles. 



Goniometer Alignment 

This goniometer alignment is used for measuring pi 
humeral and shoulder complex medial rotational 
4-31 to 4-33). "■"" 

1. Center the fulcrum of the goniometer , 
olecranon process. 

2. Align the proximal arm so that it is either p|| 
dicular to or parallel with the floor, 

3. Align the distal arm with the ulna, using the of 
non process and ulnar styloid for reference. 



5 

:s- 

U_'. 

o 

UJ 

a 
z 







FIGURE 4-31 The alignment of the goniometer ar the beginning of medial rotation ROM of the glerto- 
humcral joint and shoulder complex. 




:" :■ .'::■'. .: / ■ ■ ,;..: . • , L v V 



FIGURE 4-32 The alignment of the goniometer at the end of medial rotation ROM of the glenohumeral 

joint. The examiner uses one hand to support the subject's forearm and the distal arm of the goniometer. 
The examiner's other hand holds the body and the proximal arm of the goniometer. 






■ 




, 4~33 The alignment of the goniometer at the end of medial rotation ROM of the shoulder 
complex. 



— ' 

o.: 

X. 

UJ 

OS 

ear 

.Z 
;P-< 

:WlV. ; - 

UJ 

5 



o 

-z 

QJ, 



86 



PART II 



UPPER-EXTREMITY TESTING 



LATERAL (EXTERNAL) ROTATION 



When the subject is in anatomical position, the motion 
occurs in the transverse plane around a vertical axis. 
When the subject is in the testing position, the motion 
occurs in the sagittal plane around a coronal axis. Mean 
shoulder complex lateral rotation is 90 degrees according 
to the AAOS 5 and AMA 6 and 104 degrees according to 
Boone and Azen. 7 Mean glenohumeral medial rotation is 
94 degrees according to Lannan, Lehman, and Toland, 12 
104 degrees according to Ellenbecker, 14 and 108 degrees 
according to Boon and Smith. 13 See Tables 4-1 to 4-4 for 
additional information. 

Testing Position 

Position the subject supine, with the arm being tested in 
90 degrees of shoulder abduction. Place the forearm 
perpendicular to the supporting surface and in degrees 
of supination and pronation so that the palm of the hand 
faces the feet. Rest the full length of the humerus on the 
examining table. The elbow is not supported by the 
examining table. Place a pad under the humerus so that 
the humerus is level with the acromion process. 

Stabilization 

Glenohumeral Lateral Rotation 

At the beginning of the ROM, stabilization is often 
needed at the distal end of the humerus to keep the shoul- 



der in 90 degrees of abduction. Toward the end of rhe 
ROM, the spine of the scapula is stabilized to prevent 
posterior tilting and retraction. 

Shoulder Complex Lateral Rotation 

Stabilization is often needed at the distal end of the 
humerus to keep the shoulder in 90 degrees of abduc- 
tion. To prevent extension or rotation of the spine, the 
thorax may be stabilized by the weight of the subject's 
trunk or by the examiner's hand. 

Testing Motion 

Rotate the shoulder laterally by moving the forearm 
posteriorly, bringing the dorsal surface of the palm of the 
hand toward the floor. Maintain the shoulder in 90 ■■ 
degrees of abduction and the elbow in 90 degrees of flex- 
ion during the motion. 

Glenohumeral Lateral Rotation 

The end of ROM occurs when resistance to further;: 
motion is felt and attempts to overcome the resistance 
cause a posterior tilt or retraction of the scapula (Fig,;: 
4-34). 

Shoulder Complex Lateral Rotation 

The end of ROM occurs when resistance to further 
motion is felt and attempts to overcome the resistance; 
cause extension or rotation of the spine (Fig. 4-35). 






CHAPTER 4 THE SHOULDER 87 



.if the 
■event 






further 
i stance 
la {Pig. 




FIGURE 4-34 The end of lateral rotation ROM of the glcnohumeral joint. The examiner's hand stabi- 
lizes the spine of the scapula. The end of the ROM in latetal rotation is reached when additional motion 
causes the scapula to posteriorly tilt or retract and push against the examiner's hand. 











IwSisSiiv. iH ' 




FIGURE 4-35 The end of lateral rotation ROM of the shoulder complex. The examiner stabilizes the 
distal humerus to prcvenr shoulder abduction beyond 90 degrees. The elbow is maintained in 90 degrees 

of flexion during the motion. 



D 

_r 

Z>- 

O 

x. 

in: 

UJ 

xr 

LU 

OS" 

LU 

o 

a. 

Us. 

z 

p 

(/5 
UJ 

z:* 

2 ? 

>- 

o 

o 

uu 
U 

< 



88 



PART li UPPER-EXTREMITY TESTING 



Normal End-feel 
Gknohumeral Lateral Rotation 

The end-feel is firm because of tension in the anterior 
joint capsule, the three bands of the glenohumera! liga- 
ment, and the coracohumeral ligament, as well as in the 
subscapulars, the teres major, and the clavicular fibers of 
the pectoralis major muscles. 
Shoulder Complex Lateral Rotation 

The end-feel is firm because of tension in the SC capsule 
and ligaments and in the latissimus dorsi, sternocostal 
fibers of the pectoralis major,- pectoralis minor, and serra- 
tus anterior muscles. 



V : :i 



■ ; 




■.'■..'■ ■■ : . ■"■"..■ 



Goniometer Alignment 

This goniometer alignment is used for measuring gleno- 
humeral and shoulder complex lateral rotation (Figs. 
4-36 to 4-38). 

1. Center the fulcrum of the goniometer over the 
olecranon process. 

2. Align the proximal arm so that it is either parallel 
to or perpendicular to the floor. 

3. Align the distal arm with the ulna, using the 
olecranon process and ulnar styloid for reference. 



i^^m 



i's-**% 



; 



J 



A 




J; > 
: I 




FIGURE 4-36 The alignment of the goniometer at the beginning of lateral rotation ROM of the gleno- 
humeral joint and shoulder complex. 



■>: 



asur 'ng glcn^J 
"Otation (Figj :; 

icter over fall 

either paraS] e ] j 

ia, using fa 
for reference, 




tMWisRWs 






CHAPTER 4 THE SHOULDER 



■ ■■■ ' ■ ■-.■; 



89 












FIGURE 4-37 The alignment of the goniometer at the end of lateral rotation ROM of the glenohumeral joint. The examiner's 
hand supports the subject's forearm and the distal arm of the goniometer. The examiner's other hand holds the body and proximal 
arm of the goniometer. The placement of the examiner's hands would be reversed if the subject's right shoulder were being tested. 




siillB; 




; 







FIGURE 4-38 The alignment of the goniometer at the end of lateral rotation ROM of the shoulder 
complex. 



,*.~ . . ■ .--- 



90 



PART il UPPER-EXTREMITY TESTING 



REFERENCES 22. 

1. Cyriax, JH, and Cyriax, PJ: illustrated Manual of Orthopaedic 
Medicine. Butterworths, London, 1983. 23. 

2. Culbam, E, and Peat, M: Functional anatomy of rhe shoulder 
complex. J Orthop Sports Phys Ther 18:342, 1993. 

3. Levangie, P, and Norkin, C: Joint Structure and Function: A 24. 
Comprehensive Analysis, ed 3. f r A Davis, Philadelphia, 2001. 

4. Kalrenborn, FM: Manual Mobilization of the Extremity Joints, 

ed 5. Olaf Norlis Bokhandel, Oslo, 1999. 25. 

5. American Academy of Orthopaedic Surgeons: Joint Motion: 
Method of Measuring and Recording. AAOS, Chicago, 1965. 26, 

6. American Medical Association: Guides to the Evaluation of 
Permanent impairment, ed 3. AMA, Chicago, 1988. 

7. Boone, DC, and Azen, SP: Normal range of motion in male 27. 
subjects. J Bone Joint Surg Am 61:756, 1979. 

8. Greene, BL, and Wolf, ST.: Upper extremity joint movement: 
Comparison of two measurement devices. Arch Phys Med -jjj 
Rehabil 70:288, 1989. 

9. Soderberg, GL: Kinesiology: Application to Pathological Motion. 
Williams & Wiikins, Baltimore, 1986. ' 29. 

10. Doody, SG, Freedman, L, and Waterland, JC: Shoulder move- 
ments during abduction in the scapular plane. Arch Phys Med ^q 
Rehabil 51:595, 1970. 

1 1. Poppen, NK, and Walker, PS: Forces at the glenohumeral joint in 
abduction. Clin Orthop 135:165, 1978. 31 

12. Lannan, D, Lehman, T, and Toiand, M: Establishment of norma- 
tive data for the range of motion of the glenohumeral joint. 52 
Master of Science Thesis, University of Massachusetts Lowell, 

1996. 

13. Boon, Aj, and Smith, J: Manual scapular stabilization: Its effect 33 
on shoulder rotational range of motion. Arch Phys Med Rehabil 
81:978,2000. 

14. Fllenbecker, TS, et al: Glenohumeral joint internal and external ^.j 
rotation range of motion in elite junior tennis players. J Orthop 
Sports Phys Ther 24:336, 1996. 5 s. 

15. Wanatabe, H, et al: The range of joint motions of the extremities 
in healthy Japanese people: The difference according to age. 
Nippon Seikeigeka Gakkai Zasshi 53:275, 1979. Cited by 5^ 
Walker, JM: Musculoskeletal development: A review. Phys Ther 
71:878, 1991. 

16. Boone, DC: Techniques of measurement of joint motion. yj 
(Unpublished supplement to Boone, DC, and Azen, SP: Normal 

range of motion in male subjects, j Bone Joint Surg Am 61:756, ^g 

1979.) 

17. Walker, JM, et al: Active mobility of the extremities in older 
subjects. Phys Ther 64:919, 1984. 39 

18. Downey, PA, Fiebert, i, and Stackpole-Brown, JB: Shoulder range 
of motion in persons aged sixty and older [abstract], Phys Ther 
71:S75, 1991. 

1 9. West, CC: Measurement of joint motion. Arch Phys Med Rehabil 40 
26:414, 1945. 

20. Clarke, GR, et al: Preliminary studies in measuring range of 
morion in normal and painful stiff shoulders. Rheumatol Rehabil 4] 
14:39, 1975. 

21. AlSander, E, er ah Normal range of joint movement in shoulder, 47 
hip, wrist and thumb with special reference to side: A compari- 
son between two populations. Int J Epidemiol 3:253, 1974. 



bscalantc, A. I.tchcnitcin, Mj. and Hn/uda, HP; Delefunnatsts of 
shoulder and elbow flexion range: Results from [he San Antonio 
longitudinal -irmly tit ajdng. Arthritis Can- Kes 12:277, 1999. 
Kckictse, M, McChsrc, P, aiui I'r.nr, NA: Thoracic position effect 
on shoulder range ol motion, strength, and thrccdimcusiourd 
scapular kinematics. Arch PbV.* Med Rehabil 8ft.9'45, t«W*. 
Sahara, |S, et al: (>oiitomctric assessment of shoulder range of 
motion: Comparison ot resting in supine and sitting positions. 
Arch Phys Med Rehabil 79:-64* I99S. 

liighaut, Lli, et al: Shoulder motion and laxity in the professional 
baseball player. Am J Sports Med 25:609, 1997. 
baltaci, (i, Johnson, K, and Kohl i h Shoulder range of motion 
characteristics in collegiate baseball players. [ Sports Med I'hvs 
Illness 41:2 36, 2001. 

Chinn, (J, Priest, JD, and Kent, HA: Upper extremity range of 
motion, grip strength and girth in highly skilled tennis players. 
Phys Ther 54:474,' 1 974. 

Kihk-r, Wb, er al: Shoulder range of motion in cine tennis play- 
ers: Fitcct oi age and years of tournament play. Am j Sports Med 
24:274, I 44;,. 

Chang. DF. buschbaeker. LP. and Fdtich, RF: Limited joint 
mobility in power lifters. Am J Sports Med lf>:2K0, 19SS. 
liflitl, Pi>; Ike relationship between mutton ot the shoulder and 
flu: stated ability to perform activities tit daily hying. J hone joint 
Surg 80:41, 1<*%. 

Maisen, fi A. et ai: Practical Evaluation and Management at the 
Shoulder. Wli Saunders, Philadelphia, 1994, 
Saiace -Had, K. et al: Normal tunctional range ot niotion ot upper 
limb iiiints during performance oi three reeding activities.. Arch 
Phvs Med Rehabil ~l:50i. IV'Mi. 

I It-llebrantit, FA, Dueall, I.N, and Moore, ML: Hie measurement 
of joint niotion. Part 111; Reliability ot gomometrv. Phys Ther Rev 
2 l ';302. 1949. 

Boone, DC. et ah Ischabiiitv ot goniomctf tc measurements. I'bys 
Ther 5S:l.i55, 19"N. 

Pandya, S, et al: Reliability oi gotiiometrk tiieasiireiiients in 
patients with Duchciuie muscular dystrophy, Phys liter 65:1339, 
ISK.v 

Riddle, DL, Kothstcm, JM, ;md lamb. RL; Ooniomclric reliabil- 
ity in a clinical setting: Shoulder measurements. I'hvs Ther 
n":66S, I9S~. 

Bovcns, AMP, et al: Variability and reliability o! |ouu measure- 
ments. Am J Sports Med 18:58, 199tt, 

MacDerinid, JC, et al: lutraicster and intertesicr reliability tif 
"oniomctric measurement oi passive lateral shoulder rotation. 
j Hand liter 12:13" |9<m. 

Green, A, et al: A standardized protocol tor measurement of 
range ol movement ot the shoulder using the Pluriuieter -V incli- 
nometer and assessment ot its mtrarater and mterrater reliability. 
Arthritis Care KV> 1 l;45, D»S. 

Titliit, I'D, Wildin, C, and llaiioft, D: The reproducibility tif 
measurement oi shoulder moveinenl. Acta Orthop Stand T (>:522, 
I W, 

Btrax-r, KD; i'hc hydi'ogonioinctcr atul assessment ol glctio- 
h nine rat joint motion. A us! j Physiol her 28: 12, L'S2. 
Croft, P, et al: Observer variability in measuring elevation 
and external rotation ot the shoulder, lit | Rheumatol 3 3:942, 
I9V4. 



ni:inis of 
Antonio 
1 999. 

"I! effect 

itj^iorial 
l<Ji>. 

raiifjc of 

■muttons, 

ft'ssional 

I motion 
l«l i'hys 

range of 

players, 

■i is jil.iy- 
irts Mtd 

tsd [otai 

ikk"f and 

Hll j' lillC 

nr or the 

■ it ii f> per 
i. - -. Arch 

•urcmciu 

I her Rev 

li(S. I'hys 

nents in 

■vS:[.;.59 ( 

rdi.ibii- 
>vs Thcr 



' ll-V III 

rotation. 

■mem of 
•-V mcli- 

■ll;il'iliiv. 

hiiity of 

~t>:.U2. 

I tk'iH)- 

.lcv.it ion 
53:'H2, 



r 



■': 



■ 



CHAPTER 5 



":...; r**- 1 -- ' 




The Elbow and Forearm 



BS Structure and Function 

Humeroulnar and Humeroradial joints 

Anatomy 

The humeroulnar and humeroradial joints between the 
upper arm and the forearm are considered to be a hinged 
compound synovial joint (Figs. 5—1 and 5—2). The proxi- 
mal joint surface of the humeroulnar joint consists of the 
convex trochlea located on the anterior medial surface of 
the distal humerus. The distal joint surface is the concave 
trochlear notch on the proximal ulna. 



Coronoid fossa 

\ 

Radial fossa J?; 
"Lateral epicondyle 

Capitulum 

Humeroradial 
joint 



Humerus 




Medial epicondyle 



Trochlea 



Humerou'nar joint 



Coronoid process 



Radius 



FIGURE 5-1 An anterior view of the elbow showing the 
humeroulnar and humeroradial joints. 



The proximal joint surface of the humeroradial joint is 
the convex capitulum located on the anterior lateral 
surface of the distal humerus. The concave radial head on 
the proximal end of the radius is the opposing joint 
surface. 

The joints are enclosed in a large, loose, weak joint 
capsule that also encloses the superior radioulnar joint. 
Media! and lateral collateral ligaments reinforce the sides 
of the capsule and help to provide medial-lateral stability 
(Figs. 5-3 and 5-4). ' 

When the arm is in the anatomical position, the long 
axes of the humerus and the forearm form an acute angle 



Humerus 



Olecranon 

process 



Media! 
epicondyle 



Humeroulnar 
joint 



Olecranon fossa 




Lateral epicondyle 



Humeroradial 

joint 



Radial head 



Radius 



FIGURE 5-2 A posterior view of the elbow showing the 

humeroulnar and humeroradial joints. 

91 



92 



PART t! UPPER-EXTREMITY TESTING 



Humerus 




Radius 



Medial epicondyle 



Joint 

capsule 



Medial 
collateral 
gament 



Ulna 



FIGURE 5-3 A medial view of the elbow showing the medial 
(ulnar) collateral ligament, annular ligament, and joint capsule. 



at the elbow. The angle is called the "carrying angle," 
This angle is about 5 degrees in men and approximately 
10 to 15 degrees in women. - An angle that is greater 
(more acute) than average is called "cubitus valgus." An 
angle that is less than average is called "cubitus varus." 

Osteokinematics 

The humeroulnar and humeroradial joints have 1 degree 
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 

Arthrokinem atks 

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 



Lalern 
epicondyle 



Joint capule 




Radius 



Ulna 



Lateral collateral ligament 

FIGURE 5-4 A lateral view of the elbow showing the lateral 
(radial) collateral ligament, annular ligament, and joint capsule. 



coronoid fossa of the humerus or until soft tissue in the 
anterior aspect of the elbow blocks further flexion. 

At the humeroradial joint, the concave radial head 
slides posteriorly on the convex surface of the capitulum 
during extension. In flexion, the radial head slides anteri- 
orly until the rim of the radial head enters the radial fossa 
of the humerus. 

Capsular Pattern 

The capsular pattern is variable, but usually the range of 
motion (ROM) in flexion is more limited than in exten- 
sion. For example, 30 degrees of limitation in flexion 
would correspond to 10 degrees of limitation in exten- 
sion. 4 

Superior and Inferior Radioulnar joints 

Anatomy 

The ulnar portion of the superior radioulnar joint 
includes both the radial notch located on the lateral 
aspect of the proximal ulna and the annular ligament 
(Fig. 5-5). The radial notch and the annular ligament 



Superior radioulnar joint 



Radial head 



Radius 



Ulnar notch 



Radial styloid process 




Radial notch 



Ulna 



Ulnar head 



Ulnar styloid 
process 



.-:■ : 



.■;[ 



Inferior radioulnar joint 

FIGURE 5-5 Anterior view of the superior and inferior |. 
radioulnar joints. 




*ge of | 
;xten- ; 
exion 
:xt£iw 



]Oint 
lateral 
anient 
anient 



CHAPTER 5 THE ELBOW AND FOREARM 



93 



form a concave joint surface. The radial aspect of the 
joint is the convex head of the radius. 

Xhe ulnar component of the inferior radioulnar joint is 
the convex ulnar head (see Fig. 5-5). The opposing artic- 
yjgp 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 
f or both joints (Fig. 5-6). The following three structures 
provide stability for the superior radioulnar joint: the 
annular and quadrate ligaments and the oblique cord. 
Stability of the inferior radioulnar joint is provided by the 
articular disc and the anterior and posterior radioulnar 
ligaments (Fig. 5-7). ' 

Osteokinematics 

The superior and inferior radioulnar joints are mechani- 
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 



Posterior radioulnar 
ligament 



Articular disc 



fiadial styloid 
process 




Ulnar 
styloid 
process 



Head o! ulna 



Ulnar notch 
of raciius 



Anterior radioulnar 
ligament 



FIGURE 5-7 Distal aspect of the inferior radioulnar joint 

showing thc\ articular disc and radioulnar ligaments. 



[ 

■ 



>tch 



sr head 



a^ styloid 
cess 

nl 
interior 



Annular 
ligament 



Oblique cord 



Radius 



Interosseous 
membrane 




Quadrate ligament 



Anterior radioulnar ligament 



Articular disc 



HGURE 5-6 Anterior view of rhe superior and inferior 
radioulnar joints showing the annular ligament, quadrate liga- 
rnunt i oblique cord, interosseous membrane, anterior radioul- 
nar ligament, and articular disc. 



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. 

Arthrokinematics 

At the superior radioulnar joint the convex rim of the 
head of the radius spins within the annular ligament and 
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 
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) 
during supination. 

Capsular Pattern 

According to Cyriax and Cyriax, 4 Kakenborn, 5 and 

Magee, 6 the capsular pattern is equal limitation of 
pronation and supination. 



94 



PART II UPPER-EXTREMITY TESTING 



table 5-1 Elbow and Forearm Motion: Mean Values in.C^gre0s^oi^r3e)ected''Sdjjrte.$: 



AAOS*- 8 



AMA* 



_ 



Boone 
& AzerT° 
n = 109* 



Greene 
EtWotf 11 
n = 20> 



Petherick 

et a! lz 
n= 30* 



Motion 



Mean (SD) 



Mean (SD) 



Mean (SD) 



Flexion 


150 


140 


142.9(5.6) 


145.10-2) 


Extension 








0,6(3.1) 




Pronation 


V: 80 


80 


75.8 (5.1) 


84.4 (2.2) 


Supination 


80 


80 


82.1 (3.8) 


76.9(2.1) 



145.8(6.3) 



* Values are for males 1 8 months to 54 years of age. 

1 Values are for 10 males and 10 females, 18 to 55 years of age. 

' Values are for 1 males and 20 females, with a mean age of 24.0 years. 



Research Findings 



Effects of Age, Gender, and Other Factors 

Table 5—1 shows the mean values of ROM for various 
motions at the elbow. The age, gender, and number of 

subjects that were measured to obtain the values 
reported by the American Academy of Orthopaedic 
Surgeons (AAOS) 7,8 and the American Medical 
Association (AMA) 9 in Table 5-1 were not noted. Boone 
and Azen, 10 using a universal goniometer, measured 
active ROM in 109 males between the ages of 18 months 
and 54 years. Greene and Wolf 11 measured active ROM 
with a universal goniometer in 10 males and 10 females 
aged 18 to 55 years. Petherick and associates 12 measured 
active ROM with a universal goniometer in 10 males and 
20 females with a mean age of 24.0 years, In addition to 
the sources listed in Table 5-1, Goodwin and cowork- 
ers 13 found mean active elbow flexion to be 148.9 
degrees when measured with a universal goniometer in 
23 females between 18 and 31 years of age. 

Age 

A comparison of cross-sectional studies of normative 
ROM values for various age groups suggests that elbow 
and forearm ROM decreases slightly with age. Tables 
5-2 and 5-3 summarize the effects of age on ROM of the 



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 ■al 1 *! 

2 wks-2 yrs 

n = 45 



Boone 15 



18 mos-Syrs 
/»= 19 



6-1 2 yrs 
n= 17 



13-19 yrs 
n = 17 



lotion 



Range of Means 



Mean (SD) 



Mean (SD) 



Mean (SO} 



Flexion 
Extension 
Pronation 
Supination 



148-158 

90-96 
81-93 



144.9(5.7) 

0.4 (3.4) 

78.9 (4.4) 

84.5(3.8) 



146.5 (4.0) 

2.1 (3.2) 

76.9 (3.6) 

82.9 (2.7) 



144.9 (6.0) 

0.1 (3.8) 

74.1 (5.3) 

81.8(3.2) 



elbow and fort-arm. The male and female infants 
reported in the study by Wanatabe and colleagues'"' had 
more ROM in flexion, pronation, and supination than 
the older males in studies by Boone and by Walker and 
coworkers.'" However, it can be difficult to compare 
values obtained from various studies because subject 
selection and measurement methods can (.lifter. 

Within one study of 109 males ranging in age from 18 . 
months to 54 years, Boone ami Azcn noted a significant 1 
difference in elbow flexion and supination between 
subjects less than or equal to I 9 years of age and those 
greater than 19 years of age. further analyses found that: 
the group between 6 and 12 years of age had more elbow: 
flexion and extension than other age groups. TheJ 
youngesr group (between IS months and 5 years) had a 
significantly greater amount of pronation and supination. 
than other age groups. However, the greatest differences 
between the age groups were small: 6.8 degrees of flex- 
ion, 4.4 degrees of supination, 3.9 degrees of pronation, -; 
and 2.5 degrees of extension. ' jj 

Older persons appear to have difficulty fully extending; 
their elbows to degrees. Walker and associates'" founcb 
that the older men and women {between 6(1 and S4 years: 
of age) in their study were unable to extend their elbows % 
to degrees to attain a neutral starting position for flex-.: 
ion. The mean value for the starting position was 6j 
degrees in men and I degree in women. Boone and,; 



Ft 
& 
P( 

Si 



Ge 




CHAPTER 5 THE ELBOW AND FOREARM 



95 



"7 BLE 5 „3 Effects of Age on Elbow and Forearm Motion: Mean Values in Degrees for Adults 20 to 85 
Years of Age 



■'■-'"v^"':'--.^.' 






Mean (SO) 



Extensra 



140.1(5.2) 

0.7 (3.2) 

76:i.0.9y 

80.1 (3.7) 



•The minus sign indicates flexion. 



."■:"; Scon-e' 1 



30-39 yrs 



m (50) 



: 141.7.(3.2) 

fi|IO.:7:(1.7) 
f;;73:6(4.3) 



40-54 yrs 

it =-19 .'. 



Mean (SD) 



1 39.7 (5.8) 
-0.4* (3.0) 
75.0 (7.0) 
81.4 (4.0) 



Walker et al 16 

60-85 yrs 
ri=30 



Mean ($&} 



139.0 (14.0) 
-6.0*. (5,0)- 
68.0 (9:0) 
83.0 (11. 0> 



I 



Azen 10 also found that the oldest subjects in their study 
(between 40 and 54 years of age} had lost elbow exten- 
sion and began flexion from a slightly flexed position. 
Bergstrom and colleagues, 17 in a study of 52 women and 
37 men aged 79 years, found that 11 percent had flexion 
contractures of the right elbow greater than 5 degrees, 
and 7 percent had bilateral flexion contractures. 



Gender 

Studies seem to concur that gender differences exist for 
elbow flexion and extension ROM but these studies are 
unclear concerning forearm supination and pronation 
ROM, Bell and Hoshizaki, 18 using a Leighton 
Flexometer, studied the ROM of 124 females and 66 
males between the ages of 18 and 88 years. Females had 
significantly more elbow flexion rhan males. 
Extrapolating from a graph, the mean differences 
between males and females ranged from 14 degrees in 
subjects aged 32 to 44 years, to 2 degrees in subjects 
older than 75 years. Although females had greater 
supination-pronation ROM than males, this increase was 
not significant. Fairbanks, Pynsent, and Phillips, 19 in a 
study of 446 normal adolescents, found that females had 
significantly more elbow extension (8 degrees) than males 
(5 degrees) when measured on the extensor aspect with a 
universal goniometer. It is unclear from the method used 
whether hyperextension of the elbow or the carrying 
™gle was measured. Salter and Darcus, 20 measuring 
'Orearm supination-pronation with a specialized 
anhrometer in 20 males and 5 females between the ages 
16 and 29 years, found that the females had an aver- 
se of 8 degrees more forearm rotation than males, 
a though the difference was not statistically significant, 
ibrrty older females and 30 older males, aged 60 to 84 
years, were included in a study by Walker and cowork- 
142 Fema!e s had significantly more flexion ROM (1 to 
k * degrees) than males (5 to 139 degrees), but males 
^significantly more supination {83 degrees) than 
males (65 degrees). Females had more pronation ROM 
males, but the difference was not significant. 



Escalante, Lichenstein, and Hazuda, 21 in a study of 695 
community-dwelling older subjects between 65 and 74 
years of age, found that females had an average of 4 
degrees more elbow flexion than males. 

Body-Mass Index 

Body-mass index (BMI) was found by Escalante, 
Lichenstein, and Hazuda 21 to be inversely associated 
with elbow flexion in 695 older subjects. Each unit 
increase in BMI (kg/m 2 ) was significantly associated with 
a 0.22 decrease in degrees of elbow flexion. 

Right versus Left Side 

Comparisons between the right and the left or between 
the dominant and the nondominant limbs have found no 

clinically relevant differences in elbow and forearm 
ROM. Boone and Azen 10 studied 109 males between the 
ages of 18 months and 54 years, who were subdivided 
into six age groups. They found no significant differences 
between right and left elbow flexion, extension, supina- 
tion, and pronation, except for the age group of subjects 
between 20 and 29 years of age, whose flexion ROM was 
greater on the left than on the right. This one significant 
finding was attributed to chance. Escalante, Lichenstein, 
and Hazuda!, 21 in a study of 695 older subjects, found 
significantly greater elbow flexion on the left than on the 
right, but the difference averaged only 2 degrees. Chang, 
Buschbacher, and Edlich 22 studied 10 power lifters and 
10 age-matched nonlifters, all of whom were right 
handed, and found no differences between sides in elbow 
and forearm ROM. 

Sports 

It appears that the frequent use of the upper extremities 
in sport activities may reduce elbow and forearm ROM. 
Possible causes for this association include muscle hyper- 
trophy, muscle tightness, and joint trauma from overuse. 

Chinn, Priest, and Kent, 23 in a study of 53 male and 30 
female national and international tennis players, found 
significantly less active pronation and supination ROM 
in the playing arms of all subjects. Male players also 



96 



PART II UPPER-EXTREMITY TESTINC 



table 5-4 Elbow and Forearm Motion During Functional Activs. »s: Mean Values in Degrees 



Activity 



Use telephone 

Rise from chair 

Open door 
Read newspaper 
Pour pitcher 
Put glass to mouth 
Drink from cup 
Cut with knife 
Eat with fork 

Eat with spoon 



Mln 



42.8 
75 
20.3 
15 : 
24.0 
77.9 
35.6 
44. S 
71.5 
89.2 
85.1 
93.8 
101.2 
70 



•The minus sign indicates pronation. 
'The minus sign indicates supination. 



Flexion 



Max 



135.6 
140 

94.5 
100 

57.4 
104.3 

58.3 
130.0 
129.2 
106.7 
128.3 
122.3 
123.2 
115 



Arc 



92.8 

65 

74.2 

85 

33.4 

26.4 

■ 

22.7 
85.2 
57.7 
17.5 
43.2 
28.5 
22.0 
45 



Pronation Supination 



Max 



40.9 



35.4 
48.8 
42.9 
10.1 
-1,4* 
41.9 
10.4 
38.2 
22.9 



Max 



22.6 

9.5* 

23.4 

-7.3- 

21.9 

13.4 

31.2 

26.9* 

51.8 

58.8 

58.7 



Arc 



63.5 

24.3 

58.8 
41.5 

64.8 
23.5 
27.8 
15.0 
62.2 
97.0 
81.6 



Source 



Morrey''"' 
Packer 25 

Morrey 

Packer 

Morrey 

Morrey 

Morrey 

Morrey 

Safaee-Rad** 

Morrey 

Morrey 

Safaee-Rad 

Safaee-Rad 

Packer 



'A ■ 



demonstrated a significant decrease (4.1 degrees) in 
elbow extension in the playing arm versus the nonplaying 
arm. Chang, Buschbacher, and Edlich 22 studied 10 power 
lifters and 10 age-matched nonlifters and found signifi- 
cantly less active elbow flexion in the power lifters than 
in the nonlifters. No significant differences were found 
between the two groups for supination and pronation 
ROM. 

Functional Range of Motion 

The amount of elbow and forearm motion that occurs 
during activities of daily living has been studied by 
several investigators. Table 5—4 has been adapted from 
the works of Morrey and associates, 24 Packer and 
colleagues, 25 and Safaee-Rad and coworkers. 26 Morrey 
and associates - '' used a triaxial electrogoniomcter to 
measure elbow and forearm motion in 33 normal 
subjects during performance of 15 activities. They 
concluded that most of activities of daily living that were 
studied required a total arc of about 100 degrees of 
elbow flexion (between 30 and 130 degrees) and 100 
degrees of rotation (50 degrees of supination and 50 
degrees of pronation). Using a telephone necessitated the 
greatest total ROM. The greatest amount of flexion was 
required to reach the back of the head (144 degrees), 
whereas feeding tasks such as drinking from a cup (Fig. 
5-8) and eating with a fork required about 130 degrees 
of flexion. Reaching the shoes and rising from a chair 
(Fig. 5-9) required the greatest amount of extension 
(between 16 and 20 degrees of elbow flexion). Among 
the tasks studied, the greatest amount of supination was 
needed for eating with a fork. Reading a newspaper (Fig. 
5-10), pouring from a pitcher, and cutting with a knife 
required the most pronation. 



Five healthy subjects participated in a study by ['acker 
and colleagues, which examined elbow ROM during 
three functional tasks. A uniaxial ek-crmgoniometer was 
used to determine ROM required tor uMtig a telephone, 
tor rising from a chair to a standing position, and for 
earing with a spoon. A range of 15 to 140 degrees of flex- 
ion was needed tor these three activities. "This ROM is 
slightly greater than the arc reported by Morrey and 
associates, but the activities that required the minimal 
and maximal flexion angles did tint dittcr. The authors 
suggest that the height ot the chair, the type of chair arms, 
and the positioning of the telephone could account for 
the different ranges found in the studies. 

Safaee-Rad and coworkers"" used a three-dimensional 
video system to measure ROM during three feeding 
activities: eating with a spoon, eating with a fork, and 
drinking from a handled cup. Ten healthy males partici- ; 
pated in the study. The feeding activities required approx- 
imately ~0 to 130 degrees ot elbow flexion, 40 degrees of 
pronation, and 60 degrees of supination. Drinking with a 
cup required the greatest arc ol elbow flexion (58 
degrees! ot the three activities, whereas eating with a 
spoon required the least ill degrees 1. Fating with a fork 
required the greatest arc of pronation-supination (97, 
degrees), whereas drinking from a cup required the least 
(28 degrees). Maximum ROM values during feeding; 
tasks were comparable with those reported by Morrey; 
and associates. However, minimum values varied, possi- 
bly owing to the different chair and table heights used in. 
the two studies. 

Several investigators have taken a different approach 
in determining the amount of elbow and forearm morion 
needed tor activities of daily living. Vaseii and associ- 
ates' 1 studied the ability of 50 healthy adults to comfort-.-: 
ably complete 12 activities of daily living while their 



CHAPTER 5 THE ELBOW AND FOREARM 



97 




FIGURE ;5-8. Drinking from a cup requires about 130 degrees 
of.elbow flexion. 

elbows were restricted in an adjustable Bledsoe brace, 
forty-rune 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 colleagues 28 studied upper extremity motion 
in. subjects: during three feeding tasks, with the elbow 
unrestricted and then fixed in 110 degrees of flexion with 
a splinc.;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 
eat ' n g >yith 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. 

ReiiafcMtity and Validity 

Many:: studies. 1 have focused on the reliability of gonio- 
metric measurement of elbow ROM. Most researchers 
v% ;WWnd: intratester and intertester reliability of meas- 
uring .elbow motions with a universal goniometer to be 
"'gh^Gornparisons between ROM measurement taken 
WI % .different: devices have also been conducted. Fewer 
stu ^<?;S;;jliaye; examined the reliability and concurrent 

validity, of measuring forearm supination and pronation 
ROM 



In a study published in 1949 by Hellebrandt, Duvall, 
and Moore, 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 colleagues 30 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=0.8S). 

Rothstein, Miller, and Roettger 3 ' found high intra- 
tester and intertester reliability for passive ROM of 








FIGURE 5-9 Studies report that rising from a chair using the 
upper extremities requires a large amount of elbow and : , w f l ?> ! 
extension. 



98 



PART II UPPER-EXTREMITY TESTING 




FIGURE 5-10 Approximately 50 degrees of pronation occur 

during the action of reading a newspaper. 

elbow flexion and extension. Their study involved 12 
testers who used three different commonly used universal 
goniometers (large plastic, small plastic, and large metal) 
to measure 24 patients, Pearson product-moment corre- 
lation values ranged from 0.89 to 0.97 for elbow flexion 
and extension ROM, whereas intraclass correlation coef- 
ficient (ICC) values ranged from 0.85 to 0.95. 

Fish and Wingate 32 found that the standard deviation 
of passive elbow ROM goniometric measurements (2.4 
to 3.4 degrees) was larger than the standard deviation 
from photographic measurements (0.7 to 1.1 degrees). 
These authors postulated that measurement error was 
due to improper identification of bony landmarks, inac- 
curate alignment of the goniometer, and variations in the 
amount of torque applied by the tester. 

Grohmann, 33 in a study involving 40 testers and one 
subject, found that no significant differences existed 
between elbow measurements obtained by an over-the- 
joint method for goniometer alignment and the tradi- 
tional lateral method. Differences between the means of 
the measurements were less than 2 degrees. The elbow 
was held in two fixed positions (an acute and an obtuse 
angle) by a plywood stabilizing device. 

Petherick and associates, 12 in a study in which two 
testers measured 30 healthy subjects, found that 
intertester reliability for measuring active elbow ROM 
with a fluid-based goniometer was higher than with a 
universal goniometer. The Pearson product moment 
correlation between the two devices was 0.83. A signifi- 
cant difference was found between the two devices. The 
authors concluded that no concurrent validity existed 
between the fluid-based and the universal goniometers 
and that these instruments could not be used inter- 
changeably. 

Greene and Wolf 11 compared the reliability of the 
Ortho Ranger, an electronic pendulum goniometer, with 
the reliability of a universal goniometer for active upper 
extremity motions in 20 healthy adults. Elbow flexion 

and extension were measured three times for each instru- 



ment during each session, i he three sessions were 
conducted by one physical therapist during a 2-week 

period, Withm -session reliability was higher for the 
universal goniometer, as indicated by ICC values and 9S 
percent confidence intervals. Measurements taken with: 
the Ortho Hanger correlated poorly with those taken 
with the universal goniometer ir -~ 0.11 to 0.21), and 
there was a significant difference in measurements 
between the two devices. 

Goodwin and coworkers 1 ' evaluated the reliability of 
a universal goniometer, a fluid goniometer, and an elec- 
trogoniomctcr for measuring active elbow ROM in 1$ 
healthy women. Three testers took three consecutive 
readings using each type of goniometer on two occasions 
that were 4 weeks apart. Significant differences were: 
found between types of goniometers, testers, and repliH 
cations. Measurements taken with the universal and fluid 
goniometers correlated the best (r -= 0.90), whereas the 
electrogotiiometer correlated poorly with the universal 
goniometer Ir - 0.51) and fluid goniometer ir ■- 0.33),; 
Intratester and intertester reliability was high during each 
occasion, with correlation coefficients greater than Q.9S 
and 0.90, respectively, Intratester reliability between: 
occasions was highest for the universal goniometer; 
ICC values ranged from 0,61 to 0,92 for the universal; 
goniometer, 0,53 to 0.85 for the fluid goniometer, ani 
ii.00 to 0.61 for rlie electrogonionieter. Similar to other 
researchers, the authors do not advise the interchange-; 
able use of different types of goniometers in the clinical 
setting. 

Armstrong and associates"" examined the mtratesteg 
intertester, and interdevice reliability of active ROM 
measurements of the elbow and forearm in 5S patients! 
live testers measured each motion twice with each of the 
three devices: a universal goniometer, an elect rogoniomt'. 
ter, and a mechanical rotation measuring device.; 
Intratester reliability was high ir values generally greater 
than G.903 for all three devices and all motions. 
Intertester reliability was high for pronation and supin^; 
tion with all three devices. Intertester reliability torclboff; 
flexion and extension was high for the elect rogoniomereg 
and moderate for [he universal goniometer 
Measurements taken with different devices varied widetj| 
with 95 percent confidence intervals for mean devw|- 
differences or more than 50 degrees tor most measure^ 
The authors concluded that meaningful changes in intrat- 
ester ROM taken with a universal goniometer occur Wtt| 
95 percent confidence if they are greater than 6 degree?: 
for flexion, 7 degrees for extension, and S degrees fm 
pronation and supination. Meaningful changes w 
intertester ROM taken with a universal goniometer ocoig 
if they are greater than 10 degrees for flexion, extcnsiO|j 
and pronation, and greater than 1 I degrees for sUpuBf 
tion. 




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CHAPTER 5 THE ELBOW AND FOREARM 



99 



ens were 
a 2-wce|( 

r tnr the 
ics and 9j 
Liken with 
ose taken 

).!!), and 
surcments 



.lability o$ 
d an elec-J 
XVi in 23"o 
>nsec«cive 
occasions 
ek'cs were 
ind rcpls- 
I and fluid 
aercas the 

universal 
" = 0.33). 
iring each 
than 0.98 

between 
>niomerer.,, : . 

universal.! 
neter, arid?' 
r to other I 
erchange- 
ic clinical^ 

ntratester, 
ve ROM 
■ patients, 
.ich ot the 
•goniome- 
^ device. 
!y greatei 
motions, 
d snpina-.: 
for elbow-' 
Miiometeri 
niomereii'l 
x\ widely, 
.in device 
measures. : 
in intrat- 
ccur with 
6 degrees 
;grces tor 
anges in 
:ter occur 
xtension, 
r sttpina- 



Range of Motion Testing Procedures: Elbow and Forearm 

Landmarks for Goniometer Alignment: Elbow and Forearm 






Lateral epicondyle 
of humerus 





Ulnar styloid process 



"FIGURE 5-11 Anterior view of the right upper extremity 
[showing surface anatomy, landmarks for goniometer align- 
ment during the measurement of elbow and forearm ROM. 



FIGURE 5-12 Anterior view of the righr upper extremity 
showing bony anatomical landmarks for goniometer align- 
ment during the measurement of elbow and forearm ROM. 



Acromion process 

oi scapula Hunwus 



Latera! epicondyle ot humerus 
Radial head 
Radius 



Radial 
styloid 

process 




/.HGURE 5-13 Posterior view of the riglu upper extremity 
|?howing surface anatomy landmarks for goniometer align- 
ment during the measurement of elbow and forearm ROM. 



FIGURE 5-14 Posterior view of the right upper extremity 
showing anatomical landmarks for goniometer alignment 
during the measurement of elbow and forearm ROM. 



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100 



PART II UPPER-EXTREMITY TESTING 



FLEXION 



.Motion occurs in che sagictal plane around a medial- 
lateral axis. Mean elbow flexion ROM ranges from 140 
degrees according to the AMA 9 to 150 degrees according 
to the AAOS." 8 See Tables 5-1 to 5-3 for additional 

information. Sec Figures 5-1 1 to 5-14. 

Testing Position 

Position the subject supine, with the shoulder in degrees 
of flexion, extension, and abduction so that the arm is 
close to the side of the body. Place a pad under the distal 
end of the humerus to allow full elbow extension. 
Position the forearm in full supination with the palm of 
the hand facing the ceiling. 

Stabilization 

Stabilize the humerus to prevent flexion of the shoulder. 

The pad under the distal humerus and rhe examining 
table prevent extension of the shoulder. 

Testing Motion 

Flex the elbow by moving the hand toward the shoulder. 
Maintain the forearm in supination during the motion 
(Fig. 5-15). The end of flexion ROM occurs when resis- 



tance (*> further motion is fell and attempts to overcome 
the resistance cause ili-xiiiii or the shoulder. 

Normal End-feel 

UmjuUv the end-lccl is soft because oi compression of the 

muscle hulk oi the anterior forearm with that of the ante- < 

nor upper arm. If che muscle hulk is small, the end-fee) 
may be hard because of contact between che comnoid 
process of the ulna anil che coroiioid toss.: of the humerus 
and because of contact between the he. id of the radius : 
.md 'lie radial fossa of the humerus. The end-feel may he 
firm because of tension in rhe posterior joint capsule, the ; ; 
lateral and medial heads oi the triceps muscle, and the 
anconeus muscle. 

Goniometer Alignment 
Sec Figures 5-16 and 5-17, 

f. (".enter rhe fulcrum of the tjoniometcr over the 

lateral cpicoiuivle oi the humerus. 
1. Align the proximal arm with the lateral midline of 

the humerus, using the center of the acromion.: 

process for reference. 
>. Align the distal arm with the Literal midline of the 

radius, using the radial head and radial styloid; 

process for reference. 



'. 



■ 





FIGURE 5-15 The end of elbow flexion ROM. The examiner's hand stahih/es the humerus, hat it must 
be positioned so it does not limit the motion. 



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CHAPTER 5 THE F.LBOVJ 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 hyperexiension. 




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 tfie pointer on the body of this 180-degree goniometer. 



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102 



PART II UPPER-EXTREMiTY TESTING 



EXTENSION 



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Morion occurs in the sagittal plane around a mcdial- 
laieral axis. Elbow extension ROM is not usually meas- 
ured and recorded separately because it is the return to 
the starting position from the end of elbow flexion ROM. 

Testing Position, Stabilization, and Goniometer 
Alignment 

The testing position, stabilization, and alignment are the 
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 



J Motion occurs in the transverse plane around a vertical 

I axis when the subject is in the anatomical position. When 

| the subject is in the testing position, the motion occurs in 

I the frontal plane around an anterior-posterior axis. Mean 

I pronation ROM is 76 degrees according to Boone and 

I Azen, 10 and 84 degrees according to Greene and Wolf." 

| Both the AMA 9 and the AAOS 7 - 8 state that pronation 

| ROM is 80 degrees. See Tables 5-1 to 5-3 for additional 

1 ROM information. 

I Testing Position 

| Position the subject sitting, with the shoulder in degrees 

J of flexion, extension, abduction, adduction, and rotation 

| so that the upper arm is close to the side of the body. 

3 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 

Stabilize the distal end of the humerus to prevent medial 
rotation and abduction of the shoulder. 

Testing Motion 

Pronate the forearm by moving the distal radius in a 
volar direction so that the palm of the hand faces the 
floor. See Figure 5-18. The end of pronation ROM 



occurs when resistance to tunhe 
attempts to overcome flic resistaw 
tion and abduction of the shoulder 




Normal End-feel 

'The end-feel may be hard because of contact be 

ulna and the radius, or it may be firm becauseajt 

in the dorsal radioulnar ligament of the inferirji 

nar joint, the interosseous membrane, and th&< 

muscle. 



CMiomtterAW 

proxMb' 10 
, Xflgn the pro 

- midline ^ the 



FIGURE 5- IS 
on die edge of 
subject. The ex 
the subject's 
ro prevent hot 
The examiner' 
the subject's In 
movement of 
radioulnar jo 




CHAPTER 5 THE ELBOW AND FOREARM 



103 



Goniometer Alignment 

See Figures 5-19 and 5-20. 

1 Cencer the fulcrum of the goniometer laterally and 

proximally ro the ulnar styloid process. 
■} Align the proximal arm parallel to the anterior 

midline of the humerus. 



3. Place the distal arm across the dorsal aspect of the 
forearm, just proximal to the sryloid processes of 
the radius and ulna, where the forearm is most level 
and free of muscle bulk. The distal arm of the 
goniometer should be parallel to the styloid 
processes of the radius and ulna. 










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-\ 



I 



FIGURE 5-19 The alignment of the goniometer in the begin- 
ning of pronation ROM. The goniometer is placed laterally ro 
the distal radioulnar joint. The arms of the goniometer are 
aligned parallel to the anterior midline of the humerus. 





FIGURE 5-20 Alignment of the goniometer at the end of 
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. 



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PART il UPPER-EXTREMITY TESTING 



Motion occurs in the transverse plane around a longitu- 
dinal axis when the subject is in the anatomical position. 
When rhe subject is in the testing position, the motion 
occurs in the frontal plane around an anterior-posterior 
axis. Mean supination ROM is 82 degrees according to 
Boone and Azen, 10 and 77 degrees according to Greene 
and Wolf." Both the AMA 9 and the AAOS 7 - 8 state that 
supination 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 degrees 

of flexion, extension, abduction, adduction, and rotation 
so that the upper arm is close to the side of the body. Flex 



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Stabilization 

Srabifae the distal end i.t tin- humcrm to prevent lateral j 

rotation ami adduuioit i>t the >lmindcr. 



Testing Motion 

Supiwuc rfif forearm hv moving llw dlst;i1 radius in a 
dorsal direction «> that the palm nl ^ h - liid f;,ccs rl « 
Ccili.m. See IT-.urc S-2 i . The end oi solution ROM 
occurs when resistance (u further motion is felt and g 

attempts to overcome thy resistance cause lateral ronuion. 
anil adduction or the shoulder. 



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CHAPTER 5 THE ELBOW AND FOREARM 



105 



Normal End-feel 

The end-feel is firm because of tension in the palmar 

radioulnar ligament of the inferior radioulnar joint, 
oblique cord, interosseous membrane, and pronator ceres 
and pronator quadratus muscles. 

Coniometer Alignment 
See Figures 5-22 and 5-23. 

..;¥: Center the goniometer medially and proximally to 
the ulnar styloid process. 



2, Align the proximal arm parallel to the anterior 
midline of the humerus. 

3, Place the distal arm across the ventral aspect of the 
forearm, just proximal to the styloid processes, 
where the forearm is most level and free of muscle 
bulk. The distal arm of the goniomerer should be 
parallel to the styloid processes of the radius and 
ulna. 






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WJRE 5-22 Alignment of the goniomerer at the beginning of 

fe T- "- R0M ' The b ° dy ° f tllC S° niomcrer is mcdial TO the 
rat radioulnar joint, and the arms of the goniometer are 
: ; ■■■ a «cl to the anterior midline of the humerus. 



FIGURE 5-23 The alignment of the goniometer at the end of 
supination 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 fore- 
arm while holding the distal arm of the goniometer across the 
volar surface of the forearm just proximal to the radial and 
ulnar styloid process. The fuicrum of the goniometer is proxi- 
mal and medial to the ulnar styloid process. 



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106 PART II UPPER-EXTREMITY TESTING 

Muscle Length Testing Procedures: 
Elbow and Forearm 



BICEPS BRACHII 



The biceps brachii muscle crosses the gienohumeral, 
humeroulnar, humeroradial, and superior radioulnar 

joints. The short head of the biceps brachii originates 
proximally from the coracoid process of the scapula (Fig. 
5-24). The long head originates from the supraglenoid 
tubercle of the scapula. The biceps brachii attaches 
distaity to the radial tuberosity. 

When it contracts it flexes the elbow and shoulder and 
supinates the forearm. The muscle is passively lengthened 
by placing the shoulder and elbow in full extension and 



Supra Glendoid Tubercle 
Glenoid Fossa 



Short Head of 

the Biceps 




Coracoid Process 

Acromion Process 



Long Head ol the Biceps 



Radial Tuberosity 



Radius 



I FIGURE 5-24 t \ Sareral view of the upper extremity showing 

I the origins and insertion of the biceps brachii while being 

j stretched over the gienohumeral, elbow, and superior radioul- 

1 nar joints. 



the forearm in print. ition. if the biceps brachii is short, it 
limits elbow extension when the shoulder is positioned in 
full extension. 

It elbow extension is limited regardless of shoulder 
position, tile limitation is caused b\ abnormalities <■■■. the 
jouit surfaces, shortening ot the anterior joint capsule, 
and collateral ligaments, or by muscles that cross only the 
elbow, such as the brachials and brachioradialts. 

Starting Position 

Position the subject supine at the edge ot (he examining 
table. See Figure ^-25. Ilex the elbow and position the 

shoulder in full extension and decrees of abduction, 
adduction, and rotation. 



HGUR1-. 5-25 The starling position for testing the length of 
the biceps brachii. 



::; -". § 





CHAPTER 5 THE ELBOW AND FOREARM 



107 



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Stabilization 

The examiner stabilizes the subject's humerus. The exam- 
ining table and passive tension in the serratus anterior 
muscle help to stabilize the scapula. 

Testing motion 

Extend the elbow while holding the forearm in prona- 
tion. See Figures 5-26 and 5-25. The end of the testing 
motion occurs when resistance is felt and additional 
elbow extension causes shoulder flexion. 

Normal End-feel 

The end-feel is firm because of tension in the biceps 
brachii muscle. 



Goniometer Alignment 

See Figure 5-27. 

1. Center the fulcrum of the goniometer over the 
lateral epicondyle of the humerus. 

2. Align the proximal arm with the lateral midline of 
the humerus, using the center of the acromion 
process for reference. 

3. Align the distal arm with the lateral midline of the 
ulna, using the ulna styloid process for reference. 




FIGURE 5-26 The end of the testing motion for the length of 
'he biceps brachii. The examiner uses one hand ro stabilize the 
"umeius in full shoulder extension while the other hand holds 
the forearm in pronation and moves the elbow into extension. 



FIGURE 5-27 The alignment of the goniometer at the end of 
resting the length of the biceps brachii. The examiner releases 
rhe stabilization of the humerus and now uses her hand to posi- 
tion the goniometer. 



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PART li UPPER-EXTREMITY TESTING 




TRICEPS BRACHII 



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The triceps brachii muscle crosses the glenohumeral and 
humeroulnar joints. The long head of the triceps brachii 
muscle originates proxtmally from the infraglenoid tuber- 
cle of che scapula (Fig. 5-28). The lateral head of the 
triceps brachii originates from the posterior and lateral 
surfaces of che humerus, whereas the medial head origi- 
nates from the posterior and medial surfaces of the 
humerus. All parts of the triceps brachii insert distally on 
the olecranon process of the ulna. When this muscle 



I 



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I 



Media! hoad 
of triceps 




infra glenoid 
tubercle 



contracts, it extends the shoulder' and elbow, i he long 
head of tiic triceps brachii is passively lengthened by plac* 
i(i*4, the shoulder ami elbow in full flexion. It the long 
head of the triceps brachii is short, it limits elbow flexion 
when the shoulder is positioned in full flexion. 

If elbow flexion is limited regardless of shoulder pnsi- : 
lion, the limitation ts due to abnormalities of the joint. 
surfaces, shortening of the posterior capsule or muscles 
that cross only the elbow, such as the anconeus and the: 
lateral and medial heads of the triceps brachii. 

Starting Position 

Position the sub|t-ct supine, close to the edge of the exam- 
ining table. Kxtend the dhow and position the shoulder 
in full flexion and degrees of abduction, adduction, and 
rotation. Stipulate the forearm (Fig. 5-29). 

Stabilization 

The examiner stabilizes the subject's humerus. The 
weight of the subject's trunk on the examining table and 
the passive tension in the tatissunuis dorsi, pectoralis 
minor, aiul rhomboid major and minor muscles help to 
stabilize tile scapula. I 



Scapuia 



| FIGURE 5-28 A lateral view of the upper extremity showing 
i 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. 



Testh 

Flex t 

der. S 
motio 

elbow 

Norn 

The e 

of the 




CHAPTER 5 THE ELBOW AND FOREARM 



109 



Testing Motion 

Flex the elbow by moving the hand closer to the shoul- 
der. See Figures 5-30 and 5-28. The end of the testing 
motion occurs when resistance is felt and additional 
elbow flexion causes shoulder extension. 

Normal End-feel 

The end-feel is firm because of tension in the long head 
of the triceps brachii muscle. 



Goniometer Alignment 

See Figure 5-31. 

1. Center the fulcrum of the goniometer over the 
lateral epicondyle of the humerus. 

2. Align the proximal arm with the lateral midline of 
the humerus, using the center of the acromion 
process for reference. 

3. Align the distal arm with the lateral midline of the 
radius, using the radial styloid process for refer- 
ence. 



he 

:nd 

.Uis 

to 







HGURE 5-30 The end of the testing motion for the length of 
the triceps brachii. The examiner uses one hand to stabilize rhe 
.humerus in full shoulder flexion and the other hand to move the 
e lbow into flexion. 






FIGURE 5-31 The alignment of the goniometer at the end of 
testing the length of the triceps brachii. The examiner uses one 
hand to continue to stabilize the humerus and align the proxi- 
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 



PART II UPPER-EXTREMITY TESTING 



REFERENCES 18. 

S, I.evniigie, PK, and Norkin, CC: Joint Structure and Function: A 

Comprehensive Analysis, ed 3. FA Davis, Philadelphia, 2001. ]<j_ 

2. Hoppenfeld, S: Physical Examination of the Spine and Extremities. 
Appleton-Cenuiry-Crofts, New York, 1977. 

3. Morrey, 1JF, and Chao, FYS: Passive motion of the elbow joint. J ?f) 
Bone Joint Surg Am 58:50, 1976. 

4. Cyriax, JH, and Cyriax, PJ: Illustrated Manual of Orthopaedic 21. 
Medicine. Bnttcrworrhs, London, 1983. 

5. Kaltenborn, FM: Manual Mobilization of the Extremity joints, ed 

5. Olaf Norlis Bofchandel, Oslo, 1999. 22. 

6. Magee, DJ: Orthopedic Physical Assessment, cd. 2. WB Saunders, 
Philadelphia, 1992. 23. 

7. American Academy of Orthopaedic Surgeons: Joint Morion: 
Methods of Measuring and Recording. AAOS, Chicago, 1965. 

S. Green, WB, and Heckman, JD (eds): The Clinical Measurement of 24. 

Joint Motion. American Academy of Orthopaedic Surgeons, 

Rosemont, 11!., 1994. 
9. American Medical Association: Guides to the Evaluation of -15 

Permanent Impairment, ed 3. AMA, Chicago, 1988. 
10. Boone, DC, and Azcn, SP: Normal range of motion in male 26. 

subjects. J Bone Joint Surg Am 61:756, 1979. 
il. Greene, BL, and Wolf, SL: Upper extremity joint movement: 

Comparison of two measurement devices. Arch Phys Med Rchabil 2^ 

70:288, 1989. 

12. Petherick, M, et aS: Concurrent validity and intertestcr reliability of 1^ 
universal and fluid-based goniometers for active elbow range of 
morion. Phys Ther 68:966," 1988. 

13. Goodwin, J, et al; Clinical methods of goniometry: A comparative 7*1 
srudy. Disabil Rehabil, 14:10, 1992. 

14. Wanarabe, H, et ah The range of joint motions of the extremities 

in healthy Japanese people: The difference according to age. ^ 

Nippon Seikeigcka Gakkai Zasshi 53:275, 1999. (Cited in Walker. 
JM: Musculoskeletal development: A review. Phvs Ther 71:878, j| 

1991.) 

15. Boone, DC: Techniques of measurement of joint motion. 
{Unpublished supplement to Boone, DC, and Av.en, SP: Normal ^1 
range of morion in male subjects. J Bone Joint Surg Am 61:756, 
1979.) 5i , 

16. Walker, JM, et al: Active mobility of the extremities in older 
subjects, Phys Ther 64:919, 1984. ' 34, 

17. Bergstrom, G, et al: Prevalence of symptoms and signs of joint 
impairment. Scand j Rchabil Med 17:173, 1985. 



Beil, R|i, .imS Ho-dii/aki. IB: Krljiiorpttups ui age and vv* with 
r.mee rit [i>nnii!i i*l seventeen foml aetnitis :n humans. (an | App! 
Spt S,i it.IiYI. !'>Xl. 

Fturtunkv, t< . I'yrisem, PB. ami I'lnllips, M: t Quantitative rneas- 
ufvt*u-tir** ol jEiuit mobility ui adoleseent'.. Ann Kbetini lh\ -l.i:2S8 
l l 'K4. 

Salter, N. and IXircuN, MDt Ehc arupUtnde <>! rorearru and of 
hunuT.it rotation. 1 A11.1! S" 7 ;-!)! - , I'fSi. 

F.ic.i l.i nte. A. l.ichcii-.k-in. M|. and 1 l.t/udn. ill': Uets-ntjill.mt.Stjf 
shoulder and dhow ttexioil r,HK3r: ReMilis iroin the b,tu Antonio 
1. 'nignudui.il Siutly ui Aging. AnJifitK S are Rev ]2.i . I9m*j. 
(. ban;-:, HE. Buwbh.ii.hei, I I* am! Edhch. Rl : Limited |oiiir nubil- 
ity in power Inters. Am I Spurt". Med !l>:2SU, i l 'SS. 
ChiiiH, C.J, i'rie>i. 111, and Kent, BA: t -jpjH'i extremity range uf 
motion, grip -.tivngih -ino girth n: high!*- \JtiJ1ed Icwm piavers 
I'lsi.% Ther i4;-i"'4. IV4. 

Miiffry, 111-. Asicvw. KN. and < li.it 1. I YS; A biiiuieeh.intca! Miidyof 
normal iuneiioiia! elbow motion, ] Bone [earn Nurg Ant ft i:S72 
1 'IS [ . 

Packer. 11 . et ah 1" N.imiiiuig the elbow during hiflc5H»n:iS activities, 
OsXttp I'tier (Rev Ukil.i, I WO. 

SaUeeK.kl. R. et .it: Norma! futtcitotul range ot uintioi! ol upper 
limb i"iiu^ during performance ".' three feeding .icttvittcs. Arch 
I'hy-. Med Kehahi! ~1:5iH, i'Wii, 

\ .1-.VH. Al'. er .il: l'~uttctk>tul range ol muiiiiii 01 the elbow, ] Hand 
Sure; 20A: 2SS. IW5. 

tUmpcK |E, et al: Elbow jotrtt ri-MrjctiiHi: Effect on 'uticiional 
upper limb moiion during pcrtoritiaiice ut three Seeding activities. 
Arch Phys Med Rehahil 74;S05. tVJ.s. 

! lelieinandi, 1A, Duv.iSi, EN, and Moore. Ml : The ine.i-earemcni : 
11! |uini motion. Par; [||: Reliability of Giim»:iie;rt. Phys ["her Rev 
2"»:3<i2, i'l-l 1 *. 

Boone. [K . e( .1': Keliaoiliie of t;omoiiK-:rie :!ua-.tire!iiems. Phys 
Ther SKtIU5, l l >"S. ' ; 

Roih>!ein. JM. Miller. PJ. and Koellger, RE: (ionioinelfic rehahil- ; 
it v in .1 elmie.il \ctting: Mbow and knee nsejMirettHrrtti. I'll vv Ther 
63:161 I. r>S>. 

Eisli, UK. and VCmgate. 1.: Souree> of uoniome-trie error at the 
elbow. Phys Tiler <v>:Wi(>i>. t'JS.5. 

C»ro(iman:i, JIT : C-oiiip.»n-«on oi tv,o methods ot gonteiuieiry. Phys ■ 
Iher dj- l >12, I V S 

Armstrong, All, et ah Reliability o! raiige-of-uiotion measurement ' 
in the elbow and forearm. J Shoulder Elbow Sun; ":5">, l l '9S. 



1 



Ra 
At 

Th 
Th 



Tr 



F. 
Ch 



L-X with 

> J Appl 

c mens- : l 
43-.2SS 

arid of ; i 



riiuns of 
Antonio *! 
1999. 
it mobil- ; 

r.inyc of 
players, . 

study of 



land. 



surement . 
TherRev ". 

:ius. Phys-i 

c reliabil- 
?hy« Ther 

or at the 

ic'try. Phys 

.lSurement., 
, 1998. 



f^ TT A T> HP T7 T? A 



The Wrist 




Structure and Function 



Radiocarpal and Midcarpal Joints 
Anatomy 

The radiocarpal joint attaches the hand to the forearm. 
The proximal joint surface consists of the lateral and 
medial facets on the distal radius and radioulnar articu- 



Trapezium 



First metacarpal 



Radius 



Third metacarpal 




Pisiform 

Triquetrium 
Midcarpal joint 
Hamate 



Fifth 
metacarpal 



FIGURE 6-1 An anterior (palmar) view of the wrist showing 
,j&c radiocarpal and midcarpal joints, 



lar disc (Fig. 6-1; see also Fig. 5-7). ' The disc connects 
the medial aspect of the distal radius to the distal ulna. 
The radial facets and the disc form a continuous concave 
surface. 2,3 The distal joint surface includes three bones 
from the proximal carpal row: the scaphoid, lunate, and 
triquetrium (Fig. 6-1). The carpal bones, which are 
connected by interosseous ligaments, form a convex 
surface. The lateral radial facet articulates with the 
scaphoid, and the medial radial facet with the lunate. The 
radioulnar disc articulates with the triquetrium and, to a 
lesser extent, the lunate. The pisiform, although found in 
the proximal row of carpal bones, does not participate in 
the radiocarpal joint. The joint is enclosed by a strong 
capsule and reinforced by the palmar radiocarpal, ulno- 
carpal, dorsal radiocarpal, ulnar collateral, and radial 
collateral ligaments, as well as numerous intercarpal liga- 
ments (Figs. 6-2 and 6-3). 

The midcarpal joint is considered to be a functional 



Radial collateral ligament 



Palmar radiocarpal 
ligament 




Ulnar collateral 
ligament 



Ulnocarpal ligament 



FIGURE 6-2 An anterior (palmar) view of the wrist showing 
the palmar radiocarpal, ulnocarpal, and collateral ligaments. 

Ill 



112 PART II UPPER-EXTREM ITY TESTING 






Radial collateral 

ligament 



Radius 




Dorsal radiocarpal 
ligament 



FIGURE 6-3 A posterior view of the wrist showing the dorsal 
radiocarpal and collateral ligaments. 



rather than an anatomical joint. It has a joint capsule that 
is continuous with each intercarpal joint and some 
carpometacarpal and intermetacarpal joints. The joint 
surfaces are reciprocally convex and concave and consist 
of the scaphoid, lunate, and triquetrum proximally, and 
the trapezium, trapezoid, capitate, and hamate bones 
distally (Fig. 6-1). Many of the ligaments that reinforce 
the radiocarpal joint also support the midcarpat joint 
(Figs. 6-2 and 6-3). 

Osteokinematics 

The radiocarpal and midcarpal joints are of the condy- 
loid type, with 2 degrees of freedom. 2 The wrist complex 

(radiocarpal and midcarpal joints) permits flexion-exten- 
sion in the sagittal plane around a medial-lateral axis, 
and radial-utnar deviation in the frontal plane around an 
anterior-posterior axis. Both joints contribute to these 
motions. 4 "*' Some sources also report that a small amount 
of supination-pronation occurs at the wrist complex, 7 
but this rotation is not usually measured in the clinical 
setting. 



Arthrokinematics 

Motion nt the radiocarpal joint occurs because the 
convex surfaces of the proximal row of carp, lis sheie on 
the concave surfaces oi the radius and radioulnar disc. 
The proximal row of carpals slides in a direction oppo- 
site to the movement of the liand.' ,,s The carpals move 
itnrsally on the radius and disc during wrist flexion, and 
ventrally toward the palm during wrist extension, [hiring 
ulnar deviation, the carpals slide iti a radial direction. 
During radial deviation, they slide in an ulnar direction. 
Motion at the midcarpal joint occurs because the 
distal row of carpals slides on the proximal row. Dunns 
flexion, the convex surfaces of the capitate and hamate 
slide dorsally on the concave surfaces of portions of the 
Scaphoid, lunate, and triquetrum. '•* The surfaces of the 
trapezium and trapezoid are concave and slide volarly on 
the convex surface of the scaphoid. During extension, the 
capitate and hamate slide volarly on the scaphoid, lunate, 
and triquetrum; the trapezium ,\nJ the trapezoid slide 
dorsally on the scaphoid. Dunn;; radial deviation, the 
capitate and hamate slide ulnar) r, and the trapezium and 
trapezoid slide dorsally. In ulnar deviation, the capitate 
and hamate slide radially; the trapezium aiul trapezoid 
slide volarly. 

Capsular Pattern 

Cyriax and Cynax" report that the capsular pattern at 
the wrist is an equal limitation of flexion and extension 
and a slight limitation of radial and ulnar deviation. 
Kalrenboru ' notes that the capsular pattern is ,\n equal 
restriction in all motions. 



£ Research Findings 

Effects of Age, Gender, and Other Factors 

Table 6—1 provides range of motion (ROM) information 
for all wrist motions. The age, gentler, and number ot 
subjects that were measured to obtain the values reported 
by the American Academy of Orthopaedic Surgeons 



i 

! 

i 

S 

f 

a 
c 
c 

/ 

T 
c 

G 

b 

V; 
la 

1 

ul 
m 

V: 

pi 

n< 



table 6-1 Wrist Motion: Mean Values in Degrees from Selected Sources 



AAOS? 



AMA 1 



Boone & Azen ,J 
a = 109* 



Motion 



Mean (SD) 



Flexion 
Extension 
Radial deviation 
Ulnar deviation 



80 
70 
20 
30 



60 
60 
20 
30 



76.4 (6.3) 
74.9 (6.4) 
21.5(4.0) 
36.0 (3.8) 



* Values are for males 18 months to 54 years of age. 

1 Values are for 10 males and 10 females, 18 to 55 years of age. 

'Values are for 20 males and 20 females {ages unknown). 



Greene & Wolf 14 



Mean (SD) 



73.3(2.1) 
64.9 (2.2) 
25.4 (2.0) 
39.2 (2.1) 



Ryu et at** 
n = 40 iv ; 



Mean 




CHAPTER 6 THE WRIST 



113 



•able 6-2 Effects of Age on Wrist Motion: Mean Values in-Degrees for Newborns, Children, 
an d Adolescents 




2wfcs-2yrs 

n = 45 " 



18mos-5yr$ 
n=19 



n = 17 



■■13-49 yr<# 
n=17 



Range of Means 



Meao(SD) 



Meon&p) 



Mean (SO), 



pinion 
'Extension;- 
"Radial deviation 
Ulnar deviation 



88-96 
82-89 



82.2(3.8) 
76. 1 (4.9) 
24^2(3.7) 
38.7 (3.6) 



76.3(5,6) 
78.4 (5.9) 

21.3 (4;i) 

35.4(2:4) 



75.4 (4,5) 
72.9(6.4) 
19.7 (3.0) 
35.7 (4.2) 



(AAOS) 10 ' 11 and the American Medical Association 
(AMA) 12 were not noted. Boone and Azen, u using a 
universal goniometer, measured active ROM in 109 
healthy male subjects aged 18 months to 54 years. 
Greene and Wolf, 14 using a universal goniometer, meas- 
ured active ROM in 10 males and 10 females aged 18 
to 55 years. The values presented in Table 6-1 for Ryu 
and associates' 5 were obtained with a hand goniometer 
from 20 males and 20 females {ages unknown). Other 
studies which provide normative wrist ROM data 
for various age and gender groups include Slogaard 
and colleagues, 16 Solveborn and Olerud, 17 Stubbs and 
coworkers, 18 Walker and associates, 19 and Chaparro and 
colleagues. 20 

Age 

Table 6-2 provides wrist ROM values for newborns and 
children. Although caution must be used in drawing 
conclusions from comparisons between values obtained 
by different researchers, the mean flexion and extension 
values for infants from Wanatabe and coworkers 21 are 
larger than values reported for males aged 18 months to 
19 years reported by Boone. 22 The ROM values for both 
ulnar and radial deviation for the youngest age group (18 
months to 5 years) were significantly larger than the 
values for other age groups reported by Boone 22 and 
presented in Tables 6-2 and 6-3. Boone and Azen 13 
noted that wrist extension ROM values were significantly 



larger for males 6 to 12 years of age than for those in 
other age groups. 

Table 6-3 provides wrist ROM values obtained with 
universal goniometers from male adults. Boone and 
Azen 1 '' found a significant difference in wrist flexion and 
extension ROM between males less than or equal to 19 
years of age and those who were older. However, the 
effects of age on wrist motion in adults from 20 to 54 
years of age appear to be very slight. Values for flexion 
and extension in adults 60 years of age and older, as 
presented by Walker and associates 19 and Chaparro and 
colleagues, 20 are less than values for other age groups 
presented by Boone. 22 Chaparro and colleagues 20 further 
divided the 62 male subjects in their study into four age 
groups: 60 to 69 years of age, 70 to 79 years of age, 80 
to 89 years of age, and older than 90 years of age. They 
found a trend of decreasing ROM with increasing age, 
with the oldest group having significantly lower wrist 
flexion and ulnar deviation values than the two youngest 
groups. 

Four other studies offer additional information on the 
effects of age on wrist motion. Hewitt, 23 in a study of 
112 females between 1 1 and 45 years of age, found slight 
differences in the average amount of active motion in 
different age groups. A group of 17 individuals ranging in 
age from 11 to 15 years had slightly less flexion and 
radial deviation but more ulnar deviation and extension 
than the general average. Allander and coworkers, 24 in a 



table 6-3 Effects of Age on Wrist Motion: Mean Values in Degrees for Men 



:B6one 2 



20-29 yrs 

n= 19 



30-39 yrs 
n - 18 . 



,40-54 yrs 
n - 19 



WaFKer etW 9 

60-85 yrs' , 
n -=- 3D 



:"-■ ,: 



Chaparro et ai ? 
6O^90t yrs 




Mifonl 



Flexion 
.Extension 

tedial deviation 
ulnar deviation 



Mean (^O) 



76 A (5.5) 
77.5(5,1) 
21.4(3.6) 
35.1 (3.8) 



"MeaiT.i$D) 



74.9 (4.0) 
72.8 (6.9) 
20.3(3.1) 
36,1 (2.9) 



Mean (SO) 



72.8 (8.9) 
71.6(6.3) 
21.6(5.1) 

34,7(4.5) 



Mean (SO) 



62.0 (12.0) 
61.0 (6.0) 
20.0 (6.0) 

28.0 (7.0) 



50.8 (13.8) 
44.0 (9.9) 

35.0 (9.5) 



114 



PART II UPPER-EXTREMITY TESTING 



■■:.?; .'■ 



study of 309 Icelandic females, 208 Swedish females, and 
203 Swedish males ranging in age from 33 to 70 years, 
found that with increasing age there was a decrease in 
flexion and extension ROM at both wrists. Males lost an 
average of 2.2 degrees of motion every 5 years. Bell and 
Hoshizaki 25 studied 124 females and 66 males ranging in 
age from 18 to 88 years. A significant negative correla- 
tion was noted between range of motion and age for 
wrist flexion-extension and radial-ulnar deviation in 
females, and for wrist flexion-extension in males. As age 
increased, wrist motions generally decreased. There was 
a significant difference among the five age groups of 
females for all wrist motions, although the difference was 
not significant for males. Stubbs, Fernandez, and Glenn 18 
placed 55 male subjects between the ages of 25 and 54 
years into three age groups. There was no significant 
difference among the age groups for wrist flexion, exten- 
sion, and radial deviation ROM. A significant difference 
in ulnar deviation (7 degrees) was found between the 
oldest and the youngest age groups, with the oldest group 
having less motion. 

Gender 

The following four studies offer evidence of gender 
effects on the wrist joint, with most supporting the belief 
that women have slightly more wrist ROM than men. 
Cobe, 26 in a study of 100 college men and 15 women 
ranging in age from 20 to 30 years, found that women 
had a greater active ROM in all motions at the wrist than 
men. Allander and coworkers 24 compared wrist flexion 
and extension ROM in 203 Swedish men and 208 
Swedish women between the ages of 45 and more than 
70 years of age, and noted that women had significantly 
greater motion than men. Both studies measured active 
motion with joint-specific mechanical devices. Walker 
and associates, 19 in a study of 30 men and 30 women 
aged 60 to 84 years found that the women had more 
active wrist extension and flexion than the men, whereas 
the men had more ulnar and radial deviation than the 
women. These differences were statistically significant for 
wrist extension (4 degrees) and ulnar deviation (5 
degrees). Chaparro and colleagues 20 examined wrist flex- 
ion, extension, and ulnar deviation ROM in 62 men and 
85 women from 60 to more than 90 years of age. Women 
had significantly greater wrist extension (6.4 degrees) and 
ulnar deviation {3.0 degrees) than men. 

Right versus Left Sides 

Study results vary as to whether there is a difference 
between left and right wrist ROM. Boone and Azen, 13 in 
a study of 109 normal males between 18 months and 54 
years of age, found no significant difference in wrist flex- 
ion, extension, or radial and ulnar deviation between 
sides. Likewise, Chang, Buschbacher, and Edlich 27 found 
no significant difference between right and left wrist flex- 
ion and extension in the 10 power lifters and 10 



nonliftcrs who were their subjects. Solgaard and cowork- 
ers'" studied <S males and 23 females aged 24 to fi5 years. 
Right and left wrist extension and radial deviation 
differed significantly, but the differences were small and 
not significant when the total range (i.e., flexion and 
extension) was assessed. The authors srateit that the : 
opposite wrist could be satisfactorily used as a reference. ■ 

In contrast, several studies have found the left wrist to ' 
have greater ROM than the right wrist. C'olx."'' measured 
wrist motions in the positions of pronation and supina- 
tion in l(K) men and 15 women. He found that men had -' 
greater ROM in their left wrist than in their right for all [ 
motions excepr ulnar deviation measured in pronation. 
I lowever. he reported that the women had greater wrist 
motion on the right except for extension in pronation' 
and radial deviation in supination. So statistical tests ; 
were conducted in the 1^28 study, hut Allander and asso- 
ciates - '' reported that a recalculation of the original data 
collected by Cobe found a significantly greater ROM on 
the left. Cube"" suggests that the heavy work that men 
performed using their right extremities may account for: 
the decrease in right-side motion in comparison with left- 
side motion. 

Allander and associates/'' in a study subgroup of 309 
Icelandic women aged 34 to 6 I years found no significant 
difference between the right and the left wrists. However, 
a subgroup of 208 women and 203 Swedish men in the 
study showed significantly smaller ranges of wrisi flexion 
and extension on the right than on the left, independent 
of gender. The authors state that these differences may be 
due to a higher level of exposure to trauma ol the right 
hand in a predominantly right-handed society. Solveborn 
and Oleriul 1 measured wrist ROM in I b healthy 
subjects in addition to 123 patients with unilateral tennis 
elbow. Among the healthy subjects a significantly greater 
ROM was found for wrist flexion and extension on the 
left compared with the right. However, mean differences 
between sides were only 2 degrees. The authors 
concurred with Boone and Azen' * that a patient's healthy 
limb can be used to establish a norm for comparing with 
the affected side. 

Testing Position 

Several studies have reported differences in wrist ROM 
depending on the testing position used during measure- 
ment. Cobe, 2 " in a study of 100 men and 15 women, 
found that ulnar deviation ROM was greater in supina- 
tion, whereas radial deviation was greater in pronation, 
interestingly, the total amount of ulnar and radial devia- 
tion combined was similar between the two positions. 
Hewitt 2 ' measured wrist ROM in I !2 females in supina- 
tion and pronation and found that ulnar deviation was 
greater in supination, whereas radial deviation, flexion, 
an<.\ extension were greater in pronation. Werner and 
Handler," in a review article, also stated that ulnar devi- 
ation has a greater ROM when the forearm is supinated 



t- 



CHAPTER 6 THE WRIST 



115 



ovf O 

J years. 

;vl atio ft ; 
'all 3n s- 



■hen the forearm is pronnted. They noted that 
Jr I nd ulnar deviation ROMs become minimal when 

3 t ; sr is fully flexed or extended. No specific refer- 

.'"for these: observations were cited. 
;!">■ ■■i tri an <ind : Plnkston 28 examined the effect of three 
- entty used goniometric testing positions on active 

st radial and ulnar deviation ROiM in 100 subjects {63 
* les 37 females). In Position One the subject's arm was 
'the' side, with the elbow flexed to 90 degrees and the 
f rearm fully pronated. In Position Two the shoulder was 
■ 90 degrees of flexion, with the elbow extended and the 
hand prone. In Position Three the subject's shoulder was 
in 90 degrees of abduction, with the elbow in 90 degrees 
of flexion and the hand prone (in this position the fore- 
irin is nv -'neutral pronation). Ulnar deviation and the 
total range: of radial and ulnar deviation were signifi- 
cantly gteater when measured in Position Three. Radial 
deviation was significantly greater when the subject was 
in Position Three or Position Two than in Position One. 
The difference between the means for the three positions 
was approximately 3 degrees. 

Marshall, Morzall, and Shealy~ evaluated 35 men 
and 19 women for wrist ROM in one plane of motion 
while the subjects were fixed in secondary wrist and fore- 
arm positions. For example, during the measurement of 
radial and ulnar deviation, the wrist was alternatively 
positioned in degrees, 40 degrees of flexion, and 40 
degrees of extension. These three wrist positions were 
repeated with the forearm in 45 degrees of pronation and 
90 degrees of pronation. The effects of the secondary 
wrist and forearm postures, although statistically signifi- 



cant, were small (less than 5 degrees), except for the 
effect of wrist flexion and extension on radial deviation. 
Radial deviation ROM was greatest when performed in 
wrist extension and lowest in wrist flexion, with a 
decrease of over 30 percent. The authors believed that the 
changes that occur in wrist ROM with positional alter- 
ations might have been due to changes in contact 
between articular surfaces and taurness of ligaments that 
span the wrist region. 

Functional Range of Motion 

Several investigators have examined the range of motion 
that occurs at the wrist during activities of daily living 
(ADLs) and during the placement of the hand on the 
body areas necessary for personal care. Tables 6-4 and 
6-5 are adapted from the works of Brurnfield and 
Champoux, 30 Ryu and associates, 15 Safaec-Rad and 
colleagues, 31 and Cooper and coworkers. ,_ Differences in 
ROM values reported for certain functional tasks were 
most likely the result of variations in task definitions, 
measurement methods, and subject selection. However, 
in spite of the range of values reported, certain trends are 
evident. 

A review of Table 6—4 shows that the majority of 
ADLs required wrist extension and ulnar deviation. 
Drinking activities generally required the least amount of 
extension (6 to 24 degrees) and the smallest arc of motion 
(13 to 20 degrees). Using the telephone {Fig. 6-4), turn- 
ing a steering wheel or a doorknob, and rising from a 
chair (see Fig. 5-9) required the greatest amounts of 



table 6-4 'Wrist Motions During Functional Activities: Mean Values in Degrees 



;,4ciWty 



am • ' 



Extension*^ 



7 ^;:::- 

Ulnar Deviation 1 



'The minus sign denotes flexion. 
The minus sign denotes radial deviation. 
Values from Ryu et al were extrapolated from graphs. 



/ SOUTtg ■' 



£■.!.:■■>■■_ ..■:-.'.■■■:-... . -■'■-■.- "J '■■';.?■ 


J: \ Mm - 


: : Max 


'■''#£;■:■ 


,J0Wn 


; Mex. " 


/.,' Arc . . 




Put glass to mouth 


11,2 


24.0 


12.8 








Brurnfield 30 


Drink from glass 


2 


22 


20 


5 


20 


15 


Ryu*' s 


Drink from handled cup 


-7.5* 


5.9 


13.4 


8.3 


16.1 


7.8 


Safaee-Rad" 


Eat with fork 


9.3 


36.5 


27.7 








Brurnfield 


. 


3.3 


17.7 


14.4 


3.2 


-4.9 f 


8.1 


Safaee-Rad 


feeding tasks: fork, spoon, cup 


-6.8* 


20.9 


27.2 


18.7 


-2.4* 


21.1 


Copper (males)' 2 


Cut with knife 


-3.5" 


20.2 


23.7 








Brurnfield 




-30" 


~5' 


25 


12 | 


27 


15 


Ryu : 


Pour from pitcher 


8.7 


29.7 


21.0 








Brurnfield 




-20" 


22 


42 


12 


32 


20 


Ryu 


Turn doorknob 


-40" 


45 


85 


-2* 


32 


34 


Ryu 


Use telephone 


-0.1* 


42.6 


42.7 








Brurnfield 




-15" 


40 


55 - 


-10+ 


12 


22 


Ryu 


Tum steering wheel 


-IS* 


45 


60 


-17' 


27 


44 


Ryu 


Rise from chair 


0.6 


63.4 


62.8 








Brurnfield 




-10' 


60 


70 


5 


30 


25 


Ryu 



116 PART It UPPER-EXTREMITY TESTING 





FIGURE 6-4 Using a telephone requires approximately 40 

degrees of wrist extension. 



extension (40 to 64 degrees) and arc of motion (43 to 85 
degrees). Turning a doorknob (Fig. 6-5) involved the 
.greatest amount of flexion (40 degrees). The greatest 
amounts of ulnar deviation (27 to 32 degrees) were noted 
while rising from a chair, turning a door knob and steer- 
ing wheel, and pouring from a pitcher. 

Table 6-5 provides information on wrist position 
during the placement of the hand on the body areas 
commonly touched during personal care. The majority of 
positions required wrist flexion, and less overall wrist 
motion than the activities of daily living presented in 
Table 6-4. Among the positions studied, placing the palm 
to the front of the chest consistently required the greatest 
amount of wrist flexion, whereas placing the palm to the 
sacrum required the greatest amount of ulnar deviation. 

Brumfield and Champoux 30 used a uniaxial electrogo- 



HCiURF. 6-5 Turning a dcHirknuh requires 40 degrees of wrist 
flexion and 45 decrees ot wrist extension. 



niomcter to determine the range wrist flexion and exten- 
sion during 15 AIM. performed by 12 men and 7 wometvif 
ranging from 25 to 60 years ot age. They determined thato;': 
ADl.s such as eating, drinking and using a telephone^ 
were accomplished with 5 degrees of flexion to i5 
degress til extension. Personal care activities that M 
involved placing the hand on the body required 20 ■§ 
degrees of flexion to I 5 degrees of extension. 1 he authors 
concluded that an arc of wrist motion of 45 degrees (10' : Jf 
degrees of flexion to 35 degrees of extension) is sufficient:;'-; 
to perform most ot the activities studied. 

Palmer and coworkers' * used a triaxial elcctrogo-. ■;■ 
niomcter to study 10 normal subjects while they 
performed 52 tasks. A range of 32.5 degrees of flexion, 
58. 6 degrees of extension, 23.0 degrees of radial devia- 
tion, and 21.5 degrees of ulnar deviation was used in 
performing ADLs and personal hygiene. During thesef|§ 
tasks the average amount of motion was about 5 degrees y 
of flexion, 30 degrees of extension, 10 degrees of radial 



table 6-5 Wrist Motions During Hand Placement Needed for Personal Care Activities: Mean Values 
in Degrees ■ . 



Flexion 



Ulnar Dev 



Radial Dev 



"Activity 



Mean (SD) 



Hand to top of head 
Hand to occiput 
Hand to front of chest 
Hand to sacrum 
Hand to foot 



MeahA(SD)- .Mean (SO) Mean (S D) Source j 



'1 2.7 (9.9) 



14.2 (10.6) 

0.8 (14.6) 



2.3 (12.5) 

20.9 (13,9) 

0.9 (17.6) 

18.9 (8.9) 

24.5 (16.7) 

0.6 (9.8) 

19.5 (19.3) 



16.1 (12.7) 

9.7 (11.9) 

47.8 (16.8) 

8.7 (12.2) 



5.1 (10,3) 



Brumfield ' 

Ryu 15 

Brumfield 1 

Ryu i 

Brumfield j 

Ryu 

Brumfield^ 

Ryu 

Brumfield; 

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CHAPTER 6 THE WRIST 



117 



deviation, and 15 degrees of ulnar deviation. ROM 

values for individual tasks were not presented in the 

study. 

Ryu anc ^ associates found that 31 examined tasks 
could be performed with 54 degrees of flexion, 60 
degrees of extension, 17 degrees of radial deviation, and 
40 degrees of ulnar deviation. The 40 normal subjects {20 
men and 20 women) were evaluated with a biaxial elec- 
trpgoniometer during performance of palm placement 
activities* personal care and hygiene, diet and food prepa- 
ration, and miscellaneous ADLs. 

Studies by Safaee-Rad and coworkers 31 and Cooper 
and coworkers 32 examined wrist ROM with a video- 
based three-dimensional motion analysis system during 
three feeding tasks: drinking from a cup, eating with a 
fork, and eating with a spoon. The 10 males studied by 
Safaee-Rad and coworkers used from 10 degrees of wrist 
flexion to 25 degrees of extension, and from 20 degrees 
of ulnar deviation to 5 degrees of radial deviation during 
the tasks. Cooper and coworkers examined 10 males and 
9 females during feeding tasks, with the elbow unre- 
stricted and then fixed in 1 10 degrees of flexion. With the 
elbow unrestricted, males used from 7 degrees of wrist 
flexion to 21 degrees of extension, and from 19 degrees 
of ulnar deviation to 2 degrees of radial deviation. 
Females had similar values for flexion and extension but 
used from 3 degrees of ulnar deviation to 18 degrees of 
radial deviation. Both studies found that drinking from a 
cup required less of an arc of wrist motion than eating 
with a fork or spoon. 

Nelson 34 took a different approach to determining the 
amount of wrist motion necessary for carrying out func- 
tional tasks. He evaluated the ability of 12 healthy 
subjects (9 males and 3 females) to perform 123 ADLs 
with a splint on the dominant wrist that limited motion 
to 5 degrees of flexion, 6 degrees of extension, 7 degrees 
of radial deviation, and 6 degrees of ulnar deviation. All 
123 activities could be completed with the splint in place, 
with 9 activities having a mean difficulty rating of greater 
than or equal to 2 (could be done with minimal difficulty 
or frustration and with satisfactory outcome). The most 
difficult activities included: putting on/taking off a 
brassiere (Fig. 6-6), washing legs/back, writing, dusting 
low surfaces, cutting vegetables, handling a sharp knife, 
cutting meat, using a can opener, and using a manual 
eggbeater. It should be noted that these subjects were 
pain free and had normal shoulders and elbows to 
compensate for the restricted wrist motions. The ability 
to generalize these results to a patient population with 
pam and multiply involved joints may be limited. 

Repetitive trauma disorders such as carpal tunnel 
syndrome and wrist/hand tendinitis have been noted to 
occur more frequently in performing certain types of 
work, sports, and artistic endeavors. To elucidate the 
cause of these higher incidences of injury, studies have 
been conducted on the wrist positions used, the amount 




FIGURE 6-6 A large amount of wrist flexion is needed to 

fasten a bra or bathing suit. This is one of the most difficult 
activities to perform if wrist morion is limited. 



and frequency of wrist motions required during grocery 
bagging, 35 grocery scanning, 3 * piano playing, 37 industrial 
work, 3 " handrim wheelchair propulsion, 39-40 and in play- 
ing sports such as basketball, baseball pitching, and 
golf. 6,41 The reader is advised to refer directly to these 
studies to gain information about the -amount of wrist 
ROM that occurs during these activities. In general, an 
association has been noted between activities that require 
extreme wrist postures and the prevalence of hand/wrist 
tendinitis. 42 Tasks that involve repeated wrist flexion and 
extreme wrist extension, repetitive work with the hands, 
and repeated force applied to the, base of the palm and 
wrist have been associated with carpal tunnel 
syndrome. 43 

Reliability and Validity 

In early studies of wrist motion conducted by Hewitt 23 
and Cobe, 2 '' both authors observed considerable differ- 
ences in repeated measurements of active wrist motions. 
These differences were attributed to a lack of motor 
control on the part of the subjects in expending maximal 
effort. Cobe suggested that only average values have 



118 



PART II 



UPPER-EXTREMITY TESTING 






much validity and that changes in ROM should exceed 5 
degrees to be considered clinically significant. 

Later studies of incratester and intertester reliability 
were conducted by numerous researchers. The majority 
of these investigators found that intratester reliability was 
greater than intertester reliability, that reliability varied 
according to the motion being tested, and that different 
instruments should not be used interchangeably during 
joint measurement. 

Hellebrandt, Duvall, and Moore 44 found that wrist 
motions measured with a universal goniometer were 
more reliable than those measured with a joint-specific 
device. Measurements of wrist flexion and extension 
were less reliable than measurements of radial and ulnar 
deviation, although mean differences between successive 
measurements taken with a universal goniometer by a 
skilled tester were 1.1 degrees for flexion and 0.9 degrees 
for extension. The mean differences between successive 
measurements increased to 5.4 degrees for flexion and 
5.7 degrees for extension when successive measurements 
were taken with different instruments. 

In a study by Low, 45 50 testers using a universal 
goniometer visually estimated and then measured the 
author's active wrist extension and elbow flexion. Five 
testers also took 10 repeated measurements over the 
course of 5 to 10 days. Mean error improved from 12.8 
degrees for visual estimates to 7.8 degrees for goniomet- 
ric measurement. Intraobserver error was less than inter- 
observer error. The measurement of wrist extension was 
less reliable than the measurement of elbow flexion, with 
mean errors of 7.8 and 5.0 degrees respectively. 

Boone et al 4ft conducted a study in which four testers 
using a universal goniometer measured ulnar deviation 
on 12 male volunteers. Measurements were repeated over 
a period of 4 weeks. Intratester reliability was found to 
be greater than intertester reliability. The authors 
concluded that to determine true change when more than 
one tester measures the same motion, differences in 
motion should exceed 5 degrees. 

In a study by Bird and Stowe, 47 two observers repeat- 
edly measured active and passive wrist ROM in three 
subjects. They concluded that interobserver error was 
greatest for extension (±8 degrees), and least for radial 
and ulnar deviation (±2 to 3 degrees). Error during 
passive ROM measurements was slightly greater than 
during active ROM measurements. 

Greene and Wolf 14 compared the reliability of the 
OrthoRanger, an electronic pendulum goniometer, with a 
universal goniometer for active upper-extremity motions 
in 20 healthy adults. Wrist ROM was measured by one 
therapist three times with each instrument during each of 
three sessions over a 2-week period. There was a signifi- 
cant difference between instruments for wrist extension 
and ulnar deviation. Within-session reliability was 
slightly higher for the universal goniometer (intraclass 
correlation coefficient [ICC] 0.91 to 0.96) than for the 



OrthoRanger il( ( 0..N.S to 0. c >2's. The 95 percent confi- 
dence level, which represents the variability around the 
mean, ranged from ".(■> to l >. i degrees tor the goniometer, 
and from 18.2 to 25.6 degrees for the OrthoRanger. The 
authors concluded that the OrthoRanger provided no 
advantages over the universal goniometer. 

Solgaard and coworkers'" found intratester standard 
deviations of 5 to 8 degrees and intertester standard devi- 
ations of 6 ro 10 degrees in a study of wrist and forearm 
motions involving > i healthy subjects. Measurements 
were taken with a universal goniometer by four testers on 
three different occasions. The coefficients of variation 
{percent variation) between (esters were greater lor ulnar 
and radial deviation than for flexion, extension, prona- 
tion, ami supination. 

Horger " conducted a study in which 13 randomly 
paired therapists performed repeated, measurements of 
active and passive wrisr motions on -IS patients. 
I herapists were tree ro select their own method oi meas- 
urement with a universal goniometer. Tile six specialized 
hand therapists used an ulnar alignment lor flexion and 
extension, whereas the uonspeciaii/ed therapists used 
a radial goniometer alignment. Intratester reliahiliiy of 
both active and passive wrist morions were highly reli- 
able (all ICCs above 0.9(0 tor ail motions. Intratester"; 
reliability was consistently higher than iiitencstcr relia- 
bility (ICC 0.66 to O.VI). Standard errors of measure- 
ments iSl'M) ranged from 2.6 to 4.4 for intratester values 
and from 3.0 to S.2 tor intertester values. Agreement 
between measures was better tor flexion and extension 
than for radial and ulnar deviation. Intertester reliability 
coefficients for measurements of active motion I Kit! 0.78 ; 
to 0.9 I ) were slightly higher than coefficients lor passive 
motion ilC X." 0.b6 to 0.861 except for radial deviation. 
Generally, reliability was higher tor the specialized thera- 
pists than for the nonspccialized therapists. The author 
determined that the presence of pain reduced the reliabil- 
ity of both active and passive measurements, but active 
measurements were alfected more than passive measure-: 
incurs. 

l.aStayo and Wheeler'''' studied the intratester and 
intertester reliability of passive ROM measurements of.; 
wrist flexion and extension in 120 pajients as measured'; 
by 32 randomly paired therapists, who used three gonio- \ 
metric alignments (ulnar, radial, and dorsal-volar). The ; 
reliability of measuring wrisr flexion ROM was consis- 'j 
tently higher than that oi measuring extension ROM. 
Mean intratester ICCs for wrist flexion were 0.86 for 
radial, 0.87 tor ulnar, and 0.92 tor dorsal alignment. 
Mean intratester ICCs for wrist extension were 0.80 for 
radial, 0,80 for ulnar, and 0.84 for volar alignment. The; 
authors recommended that these three alignments, 
although generally having good reliability, should not be., 
used interchangeably because there were some significant' 
differences between the measurements taken with the;, 
three alignments. The authors suggested that the dorsal-.: 






CHAPTER 6 THE WRIST 



119 



volar alignment should be the technique of choice for 
measuring passive wrist flexion and extension, given its 
higher reliability. In an invited commentary on this study, 
Flower 50 suggested using the fifth metacarpal, which is 
easier to visualise and align with the distal arm of the 
goniometer in the ulnar technique, rather than the third 



metacarpal, which was used in the study. Flower noted 
that the presence and fluctuation of edema on the dorsal 

surface of the hand may reduce the reliability of the 
dorsal alignment and necessitate the use of the ulnar 
(fifth metacarpal) alignment in the clinical setting. 



Range of Motion Testing Procedures: Wrist 




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alignment during the measurement of wrist ROM. 







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120 



PART II UPPER-EXTREMITY TESTING 



FLEXION 



This motion occurs in rhe sagittal plane around a medial- 
lateral axis. Wrist flexion is sometimes referred to as 
volar or palmar flexion. Mean wrist flexion ROM values 
are 60 degrees according to the AMA' 2 and 76 degrees 

according to Boone and Azen. 1 - 5 See Tables 6-1 to 6-3 for 

additional information. 

Testing Position 

Position the subject so that he or she is sitting next to a 
supporting surface with the shoulder abducted to 90 
degrees and the elbow flexed to 90 degrees. Place the 
forearm midway between supination and pronation so 
that the palm of the hand faces the ground. Rest the fore- 
arm on the supporting surface, but leave the hand free to 
move. Avoid radial or ulnar deviation of the wrist and 
flexion of the fingers. If the fingers are flexed, tension in 
the extensor digitorum communis, extensor indicis, and 
extensor digiti minimi muscles will restrict the motion. 

Stabilization 

Stabilize the radius and ulna to prevent supination or 
pronation of the forearm and motion of the elbow. 

Testing Motion 

Flex the wrist by pushing on the dorsal surface of the 
third metacarpal, moving the hand toward the floor (Fig. 
6-9). Maintain the wrist in degrees of radial and ulnar 
deviation. The end of flexion ROM occurs when resis- 
tance to further motion is felt and attempts to overcome 
the resistance cause the forearm to lift off the supporting 
surface. 



Normal End-feel 



The end-feel 
radiocarpal 



is hrm because of tension in the dorsal 
ligament and the dorsal joint capsule. 



Tension in the extensor carpi radialis brevis and longus; 
and extensor carpi ulnaris muscles may also contribute to? 
the linn end-feel. 

Goniometer Alignment 

See Figures 6-10 and 6-11. 

1 . Center the fulcrum of the goniometer on rhe lateral? 

aspect of the wrist over the rriquemsm. 
1. Align the proximal arm with the lateral midline of? 

the ulna, using the olecranon and ulnar styloid 

processes for reference. 
3. Align the distal arm with the lateral midline of the s 

litth metacarpal. !>o nor use rile soft tissue of the . 

hyporhenar eminence tor reference. 

Alternative Goniometer Alignment 
This alternative goniometer alignment is recommended 
by the AMA Guides to the l-.i'ahuitkm o/ Vcrtuatient' 
Itnjuirmi'nt 1 - and LaStoya and Wheeler,' 1 " although 
edema may make accurate alignment over rhe dorsal.; 
surfaces of the forearm and hand difficult. 

I . Center the fulcrum of the goniometer over the capi-;i 
fate on rhe dorsal aspect of the wrist joint. 

1. Align the proximal arm along rhe dorsal midline of 
the forearm. 

,i. Align the distal arm with the dorsal aspect of the 
third metacarpal. 




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FIGURE 6-9 The end of wrist flexion ROM. Only about three-quarters of' the subject's forearm is 
supported by the examining table, so that there is sufficient space tor the hand to complete the motion. 



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CHAPTER 6 THE WRIST 



121 




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FIGURE 6-10 The alignment of the goniometer at the beginning of wrist flexion ROM. 





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FIGURE 6-11 At the end of wrist flexion ROM the examiner uses one hand to align the distal arm of 
the gonimeter with the fifth metacarpal while maintaining the wrist in flexion. The examiner exerts pres- 
sure on the middle of the dorsum of the subject's hand and avoids exerting pressure directly on the fifth 
metacarpal because such pressure will distort the goniometer alignment. The examiner uses her other 
hand to stabilize the forearm and hold the proximal arm of the goniometer. 



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PART !l UPPER-EXTREMITY TESTING 



EXTENSION 



I Motion occurs in the sagittal plane around a medial- 
| lateral axis. Wrist extension is sometimes referred to as 
I dorsal flexion. Mean wrist extension ROM values are 60 
J degrees according to the AMA U and 75 degrees accord- 
I ing to Boone and Azcn. 13 See Tables 6-1 to 6—3 for addi- 

I tional information. 

I 

I Testing Position 

Position the subject sitting next to a supporting surface 

with the shoulder abducted to 90 degrees and the elbow 
flexed to 90 degrees. Place the forearm midway between 
supination and pronation so that the palm of the hand 
faces the ground. Rest the forearm on the supporting 
surface, but leave the hand free to move. Avoid radial or 
ulnar deviation of the wrist, and extension of the fingers. 
If the fingers are held in extension tension in the flexor 
digitorum superficialis and profundus muscles will 
restrict the motion. 

Stabilization 

Stabilize the radius and ulna to prevent supination or 
pronation of the forearm, and motion of the elbow. 

Testing Motion 

Extend the wrist by pushing evenly across the palmar 
surface of the metacarpals, moving the hand in a dorsal 
direction toward the ceiling (Fig. 6-12). Maintain the 
| wrist in degrees of radial and ulnar deviation. The end 
| of extension ROM occurs when resistance to further 
motion is felt and attempts to overcome the resistance 
cause the forearm to lift off of the supporting surface. 



Normal End-feel 

Usually the eml-fccl is firm because of tension in the 
palmar radiocarpal ligament, ulnocarpal ligament, and 
palmar joint capsule. Tension in the pahnaris longus, 
flexor carpi radialts, and flexor carpi ulnaris muscles may 
also contribute to me firm end-feel. Sometimes the end- 
feel is hart! because of contact between the radius and the 
carpal hones. 

Goniometer Alignment 
See Figures 6-13 and 6-14. 

1. Center the fulcrum of the goniometer on the lateral 
aspect of the wrist over the triquetrum. 

2. Align the proximal arm with the lateral midline of 
the ulna, using the olecranon and ulnar styloid 
process tor reference. 

3. Align the distal arm with the lateral midline of the 
fifth metacarpal. Do not use the soil tissue of the 
hvporhenar eminence for reference. 

Alternative Goniometer Alignment 

This alternative alignment is recommended by the A MA 

Guides !<> the EiwIhmhm m/ Vcnnum-nt Impairment 12 

and LaStayo and Wheeler.'" although edema may nuke 
accurate alignment over the palmar surfaces ot the fore- 
arm and hand difficult. 

!. Center the fulcrum over the wrist joint at the level 

of the capitate. 
2. Align the proximal arm with the palmar midline of 

the forearm. 
,i. Align the distal arm with the palmar midline of the 
third metacarpal. 














FIGURE 6-12 Ar the end of the wrist | 
extension ROM, the examiner stabilizes 
the subject's forearm witii one hand itna; 
uses her other hand to hold the subjects ; 
wrist in extension. The examiner is care-.: 
ful to distribute pressure equally aeross^ 
the subject's metacarpals. 



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CHAPTER 6 THE WR)ST 123 




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FIGURE 6-13 The alignment of the goniometer at the beginning of wrist extension ROM. 



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FIGURE 6-14 At the end of the ROM of wrist extension, the examiner aligns the distal goniometer arm 
with the fifth metacarpal while holding the wrist in extension. The examiner avoids exerting excessive 
pressure on the fifth metacarpal. 



§ 124 PART (I U P P ER- EXTREM I T Y TESTiNG 




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RADIAL DEVIATION 



Motion occurs in the frontal plane around an anterior- 
posterior axis. Radial deviation is sometimes referred to 
as radial flexion or abduction. jVlean radial deviation 
ROM is 20 degrees according to the AMA' 2 and 25 
degrees according to Greene and Wolf. N See Tables 6-1 
to d-i for additional information. 

Testing Position 

Position the subject sitting next to a supporting surface 
with the shoulder abducted to 90 degrees and the elbow 
flexed to 90 degrees. Place the forearm midway between 
supination and pronation so that the palm of the hand 
faces the ground. Rest the forearm and hand on the 
supporting surface. 

Stabilization 

Stabilize the radius and ulna to prevent pronation or 
supination of the forearm and elbow flexion beyond 90 
degrees. 

Testing Motion 

Radially deviate the wrist by moving the hand toward the 
thumb (Fig. 6-15). Maintain the wrist in degrees of 
flexion and extension. 12 The end of radial deviation 



ROM occurs when resistance to further motion is felt 
and attempts to overcome the resistance cause the elbow 
to flex. 

Normal End-feel 

Usually the end-fee! is hard because of contact between 
the radial styloid process and the scaphoid, but it may be 
firm because of tension in the ulnar collateral ligament, 
the ulnocarpa! ligament, and the ulnar portion of the 
joint capsule. Tension in the extensor carpi ulnaris and 
flexor carpi ulnaris muscles may also contribute to the 
firm end-feel. 

Goniometer Alignment 

See Figures 6-16 and 6-17. 

1 . Center the fulcrum of the goniometer on the dorsal 
aspect of the wrist over the capitate. 

2. Align the proximal arm with the dorsal midline of 
the forearm, if the shoulder is in 90 degrees of 
abduction and the elbow is in 90 of flexion, the 
lateral epicondyle of the humerus can be used for 
reference. 

3. Align the distal arm with the dorsal midline of the 
third metacarpal. Do not use the third phalanx for, 
reference. 




FIGURE 6-15 The examiner stabilizes the subject's forearm to prevent flexion of the elbow beyond 90 
degrees when the wrisc is moved into radial deviation. The examiner avoids moving the wrist into either 
flexion or extension. 




CHAPTER 6 THE WRIST 



125 







FIGURE 6-16 The alignment of rhe goniometer at the start of radial deviation ROM. The examining 
table can be used to support the hand. 




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FIGURE 6-17 The alignment of the goniometer at the end of the radial deviation ROM. The examiner 
must center the fulcrum over the dorsal surface of the capitate. If the fulcrum shifts to the ulnar side of 
the wrist, there will be an incorrect measurement of excessive radial deviation. 




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PART M UPPER-EXTREMITY TESTING 




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ULNAR DEVIATION 



Motion occurs in the frontal plane around an anterior- 
posterior axis. Ulnar deviation is sometimes referred to as 
ulnar flexion or adduction. Mean ulnar deviation ROM 
is 30 degrees according to the AMA ! ~ and 39 degrees 
according to Greene and Wolf. 14 See Tables 6-1 to 6-3 
for additional information. 

Testing Position 

Position the subject sitting next to a supporting surface 
with the shoulder abducted to 90 degrees and the elbow 
flexed to 90 degrees. Place the forearm midway between 
supination and pronation so that the palm of the hand 
faces the ground. Rest the forearm and hand on the 
supporting surface. 



ec 



y i Stabilization 

"J | Stabilize the radius and ulna to prevent pronation or 

| supination of the forearm and less than 90 degrees of 

| elbow flexion. 

1 

I Testing Motion 

I Deviate the wrist in the ulnar direction by moving the 
I hand toward the little finger (Fig. 6-1 8}. Maintain the 




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wrist in degrees of flexion and extension, and avoid 
rotating the hand. The end of ulnar deviation ROM 
occurs when resistance to further motion is felt and 
attempts to overcome the resistance cause the elbow to 
extend. 



Normal End-feel 

The end-feel is firm because of tension in the radial 
collateral ligament and the radial portion of the joint 
capsule. Tension in the extensor pollicis brevis and 
abductor pollicis longus muscles may contribute to the 
firm enci-feel. 

Goniometer Alignment 
See Figures 6-19 and 6-20. 

1. Center the fulcrum of the goniometer on the dorsal 
aspect of the wrist over the capitate. 

2. Align the proximal arm with the dorsal midline of! 
the forearm. If the shoulder is in 90 degrees of 
abduction and the elbow is in 90 degrees of flexion, 
the lateral epicondyle of the humerus can be used 
for reference. 

3. Align the distal arm with the dorsal midline of the : 
third metacarpal. Do not use the third phalanx for; 
reference. 



'■/'^■:'^; : :^ 





FIGURE 6-18 The examiner uses one hand to stabilize the subject's forearm and maintain die elbow in 

90 degrees of flexion. The examiner's other hand moves the wrist into ulnar deviation, being careful not 
to flex or extend the wrist. 



CHAPTER 6 THE WRIST 



127 



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FIGURE 6-19 The alignment of the goniometer at the beginning of ulnar deviation ROM. Sometimes if 
a half-circle goniometer is used, the proximal and distal arms of the goniometer will have to be reversed 
so that the pointer remains on the body of the goniometer at the end of the ROM. 



'■■".'.'.. 




FIGURE 6-20 The alignment of the goniometer at the end of the ulnar deviation ROM. The examiner 
must center the fulcrum over the dorsal surface of the capitate. If the fulcrum shifts to the radial side of 
the wrist, there will be an incorrect measurement of excessive ulnar deviation. 



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1 128 PART II UPPER-EXTREMITY TESTING 

:| 

Muscie Length Testing Procedures: 
Wrist 



FLEXOR DIGITORUM PROFUNDUS AND 
FLEXOR DIGITORUM SUPERFICIAL^ 



The flexor digitorum profundus crosses the elbow, wrist, 
metacarpophalangeal (MCP), proximal interphalangeal 
(PIP), and distal interphalangeal (DIP) joints. The flexor 
digitorum profundus originates proximally from the 
upper three-fourths of the ulna, the coronoid process of 
the ulna, and the interosseus membrane (Fig. 6-21). This 
muscle inserts discally onto the palmar surface of 
the bases of the distal phalanges of the fingers. When 
it contracts, it flexes the MCP, PIP, and DIP joints of 
the fingers and flexes the wrist. The flexor digitorum 
profundus is passively lengthened by placing the elbow, 
wrist, MCP, PIP, and DIP joints in extension. 

The flexor digitorum superficial crosses the elbow, 
wrist, MCP, and PIP joints. The humeroulnar head of the 
flexor digitorum superficial muscle originates proxi- 



mally from the medial epicondyle of the humerus, the 
ulnar collateral ligament, and the coronoid process of the 
ulna (Fig. 6-22). The radial head of the flexor digitorum 
superficial muscle originates proximally from the ante-! 
rior surface of the radius. It inserts distaily via two siip s | 
into the sides of the bases of the middle phalanges of the! 
fingers. When the flexor digitoroum superficial 
contracts, it flexes the MCP and PIP joints of the fingers^ 
and flexes the wrist. The muscle is passively lengthened! 
by placing the elbow, wrist, MCP, and PIP joints in extent 
sion. 

If the flexor digitorum profundus and flexor digitorum! 
superficialis muscles are short, they will limit wrist exten- 
sion when the elbow, MCP, PIP, and DIP joints arc posi-:* 
tioned in extension. If passive wrist extension is limited!! 
regardless of the position of the MCP, PIP, and DIP jointsp 
the limitation is due to abnormalities of wrist joint 
surfaces or shortening of the palmar joint capsule^; 
palmar radiocarpal ligament, ulnocarpal ligament, 
palmaris longus, flexor carpi radialis, or flexor carpi: 
ulnaris muscles. 



5. 

P. 
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el 

Pi 



Flexor digitorum profundus 







FIGURE 6-21 An anterior view of the forearm showing the attachments of the flexor digitorum profun- 
dus muscle. 



Medial epicondyle 
of humerus 



Flexor digitorum superficialis 




Radius 



FIGURE 6-22 An anterior view of the forearm and hand showing the attachments of the flexor digito- 
rum superficialis muscle. 



CHAPTER 6 THE WRIST 



129 



s 
e 
is 
rs 

:d 

ii- 

m 

li- 
st- 
ed 
its, 
int 
ile, 
nt, 
irpi 



Starting Position 

position the subject sitting next to a supporting surface 
with the upper extremity resting on the surface. Place the 
elbow, MCP, PIP, and DIP joints in extension (Fig. 6-23). 
Pronate the forearm and place the wrist in neutral. 



Stabilization 

Stabilize the forearm to prevent elbow flexion. 




FIGURE 6-23 The starting position for testing the length of the flexor digitorum profundus and flexor 
digitorum superficiafis muscles. 





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130 



PART II UPPER-EXTREMITY TESTING 



| 



Testing Motion 

Hold the MCP, PIP, and DIP joints in extension while 
extending the wrist (Figs. 6-24 and 6-25). The end of 
the testing motion occurs when resistance is felt and 
additional wrist extension causes the fingers or elbow to 
flex. 



End-feel 

The end-feel is firm because of tension in the flexor digi- 
torum profundus and flexor digitorum superficialis 
muscles. 




FIGURE 6-24 The end of the testing motion for the length of the flexor digitorum profundus and flexor 
digitorum superficialis muscles. The examiner uses one hand to stabilize the forearm, while the other hand 
holds the fingers in extension and moves the wrist into extension. The examiner has moved her right 
thumb from the dorsal surface of the fingers to allow a clearer photograph, but keeping the thumb placed 

on the dorsal surface would help to prevent the fingers from flexing at rhe PIP joints. 



Flexor digitorum superficialis 
(radial head) 




Flexor digitorum 

superficialis 

(humeral + ulnar heads) 



Flexor digitorum 
profundus 



FIGURE 6-25 A lateral view of the forearm and hand showing the flexor digitorum profundus and flexor 
digitorum superficialis being stretched over the elbow, wrist, MCP, PIP, and DIP joints. 




/"<■■" 



digj. : 



CHAPTER 6 THE WRIST 



131 



Coniometer Alignment 

See Figure 6-26. 

1 Center the fulcrum of the goniometer on the lateral 
aspect of the wrist over the triquetxum. 

2 Align the proximal arm with the lateral midline of 
the ulna, using the olecranon and ulnar styloid 
process for reference. 

3 Align the distal arm with the lateral midline of the 
fifth metacarpal. Do not use the soft tissue of the 
hypothenar eminence for reference. 







mattr- 1- 




FIGURE 6-26 The alignment of the goniometer at the end of testing the length of the flexor digitorum 
profundus and flexor digitorum superficialis muscles. 



in 

5 



t/5 

—I 
U 

a 

LU 
U 

o 

a. 
O 

z 

p 

LU 

H- 
H 

I 

o 
z 

UJ 

—i 

uu 

_i 

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132 



PART II 



UPPER-EXTREMITY TESTING 



EXTENSOR DIGiTORUM, EXTENSOR 
INDICIS, AND EXTENSOR DIGITI MINIMI 



The extensor digitorum, extensor incticis, and extensor 
digiti minimi muscles cross the elbow, wrist, and MCP, 
PIP, and DIP joints. When these muscles contract, they 
extend the MCP, PIP, and DIP joints of the fingers and 
extend the wrist. These muscles are passively lengthened 
by placing the elbow in extension, and the wrist, MCP, 
PIP, and DIP joints in full flexion. 

The extensor digitorum originates proximally from 
the lateral epicondyle of the humerus and inserts distaily 
onto the middle and distal phalanges of the fingers via the 
extensor hood (Fig. 6-27), The extensor indicis originates 
proximally from the posterior surface of the ulna and the 
interosseous membrane. This muscle inserts distaily onto 
the extensor hood of the index finger. The extensor digiti 
minimi also originates proximally from the lateral 
epicondyle of the humerus but inserts distaily onto the 
extensor hood of the little finger. 

If the extensor digitorum, extensor indicis, and exten- 
sor digiti minimi muscles are short, they will limit wrist 
flexion when the elbow is positioned in extension and the 
MCP, PIP, and DIP joints are positioned in full flexion. If 
wrist flexion is limited regardless of the position of the 
MCP, PIP, and DIP joints, the limitation is due to abnor- 
malities of joint surfaces of the wrist or shortening of the 
dorsal joint capsule, dorsal radiocarpal ligament, exten- 
sor carpi radiaiis longus, extensor carpi radialis brevis, or 
extensor carpi ulnaris muscles. 



■ 



Radius 



Extensor 
digitorum 




Distal phalanx 

Middle phalanx 



Proximal phalanx 




Ulna 
Extensor indicis 



Extensor digiti 
minimi 






FIGURE 6-27 A posterior view of the forearm and hand show-: 
ing the distal attachments of the extensor digitorum, extensor/ 
indicis, and extensor digit minimi muscles. 



Si 

St 









I phalanx 
i phalanx 



phalanx 



■ a 
I 



land show- 
11, extensor 



1 
'■fl 



Starting Position 

position the subject sitting next to a supporting surface. 
Ideally, the upper arm and the forearm should rest on the 
supporting surface, but the hand should be free to move 
into flexion. Place the elbow in extension and the MCP, 

PIP, and DIP joints in full flexion (Fig, 6-28). Place the 
forearm in pronation and the wrist in neutral. 

Stabilization 

Stabilize the forearm to prevent elbow flexion. 



CHAPTER 6 THE WRIST ~~!33 

Testing Motion 

Hold the MCP, PIP, and DIP joints in full flexion while 
flexing the wrist (Figs. 6-29 and 6-30). The end of the 
testing motion occurs when resistance is felt and add" 
tional wrist flexion causes the fingers to extend or th 
elbow to flex. 

Normal End- feel 

The end-feel is firm because of tension in the extenso 
digitorum, extensor indicis, and extensor digiti minimi 
muscles. 




FIGURE 6-28 The starting position for testing the length of the extensor digitorum, extensor indicis, and 
extensor digit minimi muscles. The forearm must be elevated or the hand positioned off the end of the 
examining table to allow room for finger and wrist flexion. 



in 

a 

1 1 1 

O 
U 



« 

a. 

^ 1 
Z 

"J 

r 

Z 

LU 



m 

5 



134 



PART II UPPER-EXTREMITY TESTING 




I &- : M 



% 
.: 

■ 

: 



■ 

I 



FIGURE 6-29 The end of the testing motion for the fength of the extensor digitorum, extensor indicis, 
and extensor digit minimi muscles. One of the examiner's hands stabilizes the forearm, while the other 
hand holds the fingers in full flexion and moves the wrist into flexion. 



Humerus 



Extensor digitorum 



Radius 




Lateral epicondyte 
of humerus 



minimi 



Extensor indicis 
tendon 



FIGURE 6-30 A posterior view of the forearm and hand showing the extensor digitorum, extensor indi- 
cis, and extensor digit minimi muscles stretched over the elbow, wrist, MCP, PIP, and DIP joints. 



J 



CHAPTER 6 THE WRI ST 



135 



^iometer Alignment 

sti Figure 6-31. 
J. Center the fulcrum of the goniometer on the lateral 

aspect of the wrist over the triquetrum. 
2. Align the proximal arm with the lateral midline of 



the ulna, using the olecranon and ulnar styloid 
process for reference. 
3, Align the distal arm with the lateral midline of the 
fifth metacarpal. Do not use the soft tissue of the 
hypothenar eminence for reference. 





FIGURE 6-31 The alignment of the goniometer at the end of testing the length of the extensor digito- 
rum, extensor indicis, and extensor digit minimi muscles. 



136 



PART 



UPPER-EXTREMITY TESTING 



REFERENCES 25. 

Linscheid, RL: Kinematic considerations of the wrist. Clin Orthop 

202:27, 1986. 26. 

Levangie, PK, and Norkin, CC: joint Structure and Function: A 

Comprehensive Analysis, ed 3. FA Davis, Philadelphia, 2001. . ?7. 

Kaltenborn, FM: Manual Mobilization of the Joints, Vol I: The 

Extremities, ed 5. Olaf Norlis Bokhandel, Oslo, Norway, 1999. ?8. 

Sarrafian, SH, Melamed, JL, and Goshgarian, GM: Study of wrist 

motion in flexion and extension. Clin Orthop 126:153, 1977, 29. 

Youm,Y, et al: Kinematics of the wrist: I. An experimental study 

of radial-ulnar deviation and flexion-extension. J Bone Joint Surg 

(Am) 60:423, 1978. 30 . 

Werner, SL, and Planchcr, KD: Biomechanics of wrist injuries in 

sports. Clin Sports Med 17:407, 1998. 31 

Ritt, M, et al: Rotational stability of the carpus relative to the 

forearm. J Hand Surg20A:305, 1995. 

Kisner, C, and Colby, LA: Therapeutic Exercise: Foundations and 32. 

Techniques, ed 4. FA Davis, Philadelphia, 2002. 

Cyriax, JH, and Cyriax, PJ: Illustrated Manual of Orthopaedic 

Medicine. Butterworths, London, 1983. 33^ 

American Academy of Orthopaedic Surgeons: joint Motion: 

Methods of Measuring and Recording. AAOS, Chicago, 1965. 34 

Greene, WB, and Heckman, JD {eds):Thc Clinical Measurement 35 

of Joint Motion. American Academy of Orthopaedic Surgeons, 

Rosemont, III., 1994. ' 36 . 

American Medical Association: Guides to the Evaluation of 

Permanent Impairment, ed 3. AMA, Chicago, 1990. 37 i 

Boone, DC, and Azen, SP: Normal range of motion in male 

subjects. J Bone Joint Surg (Am) 61:756, 1979. 3g f 

Greene, Bl., and Wolf, SL: Upper extremity joint movement: 

Comparison of two measurement devices. Arch Phys Med Rehabil 33 

70:288,1989. 

Ryu, J, et al: Functional ranges of motion of the wrist joint, j 4Q 

Hand Surg 16A:409, 1991. 

Solgaard, S, et al: Reproducibility of goniometry of the wrist. 

Scandj Rehabil Med 18:5, 1986. ' 41 

Solveborn, SA, and Olerud, C: Radial epicondyialgia (tennis 

elbow): Measurement of range of motion of the wrist and the 

elbow, j Orthop Sports Phys Thcr 23:251, 1996. 

Stubbs, NB, Fernandez, JE, and Glenn, WM: Normative data on 42. 

joint ranges of motion of 25- to 54-year-old males. International 

Journal of Industrial Ergonomics 12; 265, 1993. 

Walker, JM, et al: Active mobility of the extremities in older 43 

subjects. Phys Ther 64:919, 1984. 

Chaparro, A, et al: Range of motion of the wrist: Implications for 44 

designing computer input devices for the elderly. Disabil Rehabil 

22:633:2000. 

Wanatabe, H, et al: The range of joint motions of the extremities 45 

in healthy Japanese people: The difference according to age. 

Nippon Seikeigeka Gokkai Zasshi 53:275, 1979. (Cited in 4^ 

Walker, JM: Musculoskeletal development: A review. Phys Ther 

71:878,1991.) 47, 

Boone, DC: Techniques of measurement of joint motion. 

(Unpublished supplement to Boone, DC, and Azen, SP: Normal 43, 

range of motion in male subjects. J Bone Joint Surg (Am) 6 1 :756, 

1979.) 49. 

Hewitt, D: The range of active motion at the wrist of women, j 
Bone Joint Surg (Br) 26:775, 1928. 

Allander, E, et al: Normal range of joint movements in shoulder, $q 
hip, wrist and thumb with special reference to side: A comparison 
between two populations. Int J Epidemiol 3:253, 1974. 



1. 

2. 
3. 
4. 
5. 

6. 

7. 

8. 

9. 
10. 
11. 

12. 
13. 
14. 

15. 
16. 

17. 



19. 
20. 

21. 

22. 

23. 
24. 



Belt, KD, anil I foshi/aki, IB: Relationships ol .1(41; and sex with 
range oi morion of seventeen join! action* in humans. Can J Appl 
Sp; Sti 6:202, mi. 

Cclit:, HM: file range ot active minion of tile wrist of white 
adulrs. J Born- joint Sun; (Br) 26:763, 1928. 

Chang, DL, Buschbachcr, LP, and F.dhch, RF: Limited joint mobil. 
try in power lifters, Am j Sports Med 16:2S.ft, 1988. 
Spilman, HW, and Pinksion, D: Relation of test positions to ratfia] 
and ulnar deviation. Phys Ther 49;S37, 1969. 
Marshall, MM, Morxall, JR. and Shc.ily, JF: The eifects of 
complex wrist and forearm posture oil wrist range of motion 
Human Factors, 41:205, 1999. ) 

Hrumlicld, RH, and Champoux, J A: A biomechanics) study of 
norma! functional wrist motion. Clin Orthop 187:23, 1984. 
Sataee-Rad, R, er al: Norma! functional range of motion of upper 
limb joints during perfromance of three feeding tasks. Arch Phys 
Med Rehabil 71:505, 1990. 

Cooper, JL, a al: Flhow joint restriction: Lffeet on functional : 
upper limb motion during performance of three feeding tasks 
Arch Phys Med Rehabil 74:805, 1993. 

Palmer, AK, et al: Functional wrist motion; A biomechanics! 
study. J Hand Surg 10A:39, 1985. 

Nelson, DL: Functional wrist motion. Hand Clin 1:3:83:, !997. 
hstil!, CL\ and Kroemcr, KH: Fvaluunori oi supermarket bagging- 
using a wrist motion monitor. Plum Factors 40:624, 1998. 
Marras, WS, et al: Quantification of wrist motion during scan- : 
ning. Hum Factors 37:4 1 2, 1995. 

Wagner, CH; The pianist's hand: Anthropometry and biomechan- ''■'■■ 
ics. Ergonomics 3 1:97, 1988. 

Marras, WS, and Schoenmarklin, RW: Wrist motions in industry. ■ 
Ergonomics 36:34 1 , 1995. 

Vecger, DHF.J, et al: Wrist motion in handrim wheelchair propul-^ 
mm. J Rehabil Res Dev 35:305, 1998. 

Bonmger, ML, et al: Wrist biomechanics during two speeds of« 
wheelchair propulsion: An analvsis using a local coordinated 
system. Arch Phys Med Rehab:! 78:564, 1997, 
Ohuiishi, N, et al: Analysis of wrist motion during basketball^ 
shooting. In Nakamiira, RL, Linscheid, RL, and Miura, T (cdi'l: : 
Wrist Disorder: Current Concepts and Challenges. New York,:; 
Springer- Verlng, 1 992. 

Bernard, BP fed): Musculoskeletal disorders and Workplace 
factors. Cincinnati. Oh.: National Institute of Occupational Safe"/ 1 
and Health. 1997. 

Armstrong, I'j, et al: Frgonomic considerations in hand and wrist 
tendinitis. J Hand Surg." 12 A: 830, 1982. 

Hellebrandt, FA, Duvall, FN, and Moore, ML: The measurement-:! 
of joint motion. Part 111: Reliability of goniometrv. Physical..: 
Therapy Review 29:302, 1949. 

Low, JL: The reliabihtv of joint measurement. Physiotherapy 
62:227, 19-6. 

Boone, DC, et al: Reliability of goniometric measurcmeins. Phy^S 
Ther 5S:li55, 19-8. '. 

Bird, FIA, and Stowe, ]: The wrist. Clinics in Rheumatic Disc.".' 
8:559, 1982. 

Horger, MM: The reliability of goniometric measurements 0« ; . : 
active and passive wrist morions. Am | Occup Ther 4-4:342, 19 >■ 
L.aSrayo, PC, and Wheeler. DL: Reliability of passive wrist flexiqaV: 
and extension measurements: A mulricenter studv. I'livs Theft 
74:162, 1994 fl 

Flower, KR: Invited Commentary. Phys Ther 74:174, 1994. : ;1| 



I 



al' 
:s. 



CHAPTER 7 



The Hand 




of 
?.te 



M Structure and Function 

Fingers; Metacarpophalangeal joints 

Anatomy 

The metacarpophalangeal (MCP) joints of the fingers are 
composed of the convex distal end of each metacarpal 
and the concave base of each proximal phalanx (Fig. 
7-1}. The joints are enclosed in fibrous capsules (Figs. 
7-2 and 7-3). The anterior portion of each capsule has a 
fibrocartilaginous thickening called the palmar plate 



(palmar ligament), which is firmly attached to the prox- 
imal phalanx. 1 Ligamentous support is provided by 
collateral and deep transverse metacarpal ligaments. 

Osteokinematks 

The MCP joints are biaxial condyloid joints that have 2 
degrees of freedom, allowing flexion-extension in the 
sagittal plane and abduction-adduction in the frontal 
plane. Abduction-adduction is possible with the MCP 
joints positioned in extension, but limited with the MCP 



; of 

w. 

:ion 
"her 



. Distal interphalangeal 
joints 

Proximat 
interphalangeal -j St 
joints 



Metacarpophalangeal 
joints 



2nd 



3rd 




5th 

Distal 

phalanx 

5th 
Middle 
phalanx 



5th 

Proximal 
phalanx 



5th 
Metacarpal 



FIGURE 7-1 An anterior (palmar) view of the hand showing 
metacarpophalangeal, proximal interphalangeal, and distal 
werphalangeal joints. 



Palmar 
plates 




Joint 
capules 



Deep 

transverse metacarpal 
ligament 



FIGURE 7-2 An anterior (palmar) view of the hand showing 
joint capsules and palmar plates of the metacarpophalangeal, 
proximal interphalangeal, and distal interphalangeal joints, as 
well as the deep transverse metacarpal ligament. 

137 



138 



PART II UPPER-EXTREMITY TESTING 






;i 





Joint ^_^- 






capsules \ 


J jS Collaieral 

Wi[ ligaments 


Joinl . 


fh ligament 


capsule 


Wm 



:;K 



FIGURE 7-3 A lateral view of a finger showing joinr capsules 
and collateral ligaments of the metacarpophalangeal, proximal 
interphalangeal, and distal interphalangeal joints. 



joints in flexion because of tightening of the collateral 
ligaments. 2 A small amount of passive axial rotation has 
been reported at the MCP joints, 2,3 but this motion is not 
usually measured in the clinical setting. 

Arthrokinematics 

The concave base of the phalanx glides over the convex 
head of the metacarpal in the same direction as the shaft 
of the phalanx. In flexion, the base of the phalanx glides 
toward the palm, whereas, in extension, the base glides 
dorsally on the metacarpal head. In abduction, the base 
of the phalanx glides in the same direction as the move- 
ment of the finger. 

Capsular Pattern 

Cyriax and Cyriax 4 report that the capsular pattern is an 
equal restriction of flexion and extension. Knltenborn 5 
notes that all motions are restricted with more limitation 
in flexion. 



Fingers: Proximal Interphalangeal and Distal 
Interphalangeal Joints 

Anatomy 

The structure of both the proximal interphalangeal (PIP) 
and the distal interphalangeal (DIP) joints is very similar 
(see Fig. 7-1). Each phalanx has a concave base and a 
convex head. The joint surfaces comprise the head of the 



more proximal phalanx and the hast- ot the adjacent, 
more distal phalanx. Each joint is supported by ,i joint 
capsule, a palmar plate, and two collateral ligaments (see 
Figs, 7-2 and 7-3), 

Osteokinematics 

The I'll' and DIP joints of the fingers are classified as 

synovial lunge joints with I decree of freedom; flexion- 
extension in the sagittal plane. 

Arthrokinematics 

Motion ot the joint surfaces includes a sliding ot the 
Concave base ot the more distal phalanx on the convex 
head of the proximal phalanx. Sliding of the base of the 
moving phalanx occurs in the same direction as the 
movement ot the shaft. For example, in PIP flexion, the 
base of the middle phalanx slides toward the palm. In 
1'IP extension, the base of the middle phalanx slides 
toward the dorsum of the hand. 

Capsular Pattern 

The capsular partem is an equal restriction of both flex- 
ion and extension, according to C'yriax and C'yriax, 
KaltcnhoriC notes that all motions are restricted with 

more limitation in flexion. 

Thumb: Carpometacarpal joint 
Anatomy 

The carpometacarpal (CMC) joint of the thumb is the 
articulation between the trapezium and the base of the 
first metacarpal (big. ~-4). The saddle-shaped trapezium 
is concave in the sagittal plane and convex in the frontal 
plane. The base of the first metacarpal has a reciprocal 
shape that conforms to that of the trapezium. The joint 
capsule is thick but lax and is reinforced by radial, ulnar, 
palmar, and dorsal ligaments (big. /->). 

Osteokinematics 

The first CMC joint is a saddle joint with 2 degrees of , ; 
freedom; flexion-extension in the frontal plane parallel., 
to the palm and abduction-adduction in the sagittal ■; 
plane perpendicular to the palm. 1 The laxity of the joint ] 
capsule also permits some axial rotation. This rotation:; 
allows the thumb to move into position for contact with! 
the fingers during opposition. The sequence ot motions j 
that combines with rotation and results in opposition! 
is as follows: abduction, flexion, and adduction.'^ 
Reposition returns the rhumb to the starting position. 

A rthrokinematics 

The concave portion of the first metacarpal slides on the . 
convex portion ot the trapezium in the same direction as 
the metacarpal shaft to produce flexion-extension. 
During flexion, the base of the metacarpal slides in a n 
ulnar direction. During extension, it slides in a radial 




CHAPTER 7 THE HAND 



139 



x- 
x. 

th 



■ii 



the 
the 

ura 
ital 
jcal 
Dint 
liar, 



;sof 
•alle! 
iittal 
joint 
atton 
with 
■tions 
sinon 
;tion. 

30- 



mi the 
ion as 

asion. 
in an 
radial 



1st 

Dista! 

phalanx 



1st 

Proximal 
phalanx 



.. 1st 
Metacarpal 



Trapezium 




interphalangeal 
joint 



Metacarpophalangeal 

joint 



Sesamoid 
bones 



Carpometacarpal 

joint 



FIGURE 7-4 An anterior (palmar) view of the thumb showing 
carpometacarpal, metacarpophalangeal, and inrerphalangal 

joints 



direction. The convex portion of the first metacarpal base 
slides on the concave portion of the trapezium in a direc- 
tion opposite to the shaft of the metacarpal to produce 
abduction-adduction. The base of the first metacarpal 
slides toward the dorsal surface of the hand in abduction 
and toward the palmar surface of the hand in adduction. 

Capsular Pattern 

The capsular pattern is a limitation of abduction accord- 
ing to Cyriax and Cyriax. 4 Kaltenborn 5 reports limita- 
tion in abduction and extension. 

Thumb: Metacarpophalangeal joint 

Anatomy 

The MCP joint of the thumb is the articulation between 
the convex head of the first metacarpal and the concave 
base of the first proximal phalanx (see Fig. 7-4). The 
joint is reinforced by a joint capsule, palmar plate, two 
sesamoid bones on the palmar surface, two intersesamoid 
ligaments (cruciate ligaments), and two collateral liga- 
ments (see Fig. 7-5). 

[Osteokinematics 

The MCP joint is a condyloid joint with 2 degrees of 
freedom. 1,6 The motions permitted are flexion-extension 
and a minimal amount of abduction-adduction. Motions 
at this joint are more restricted than at the MCP joints of 



the fingers. Extension beyond neutral is not usually pres- 
ent. 

Arthrokinematics 

At the MCP joint the concave base of the first phalanx 
glides on the convex head of the first metacarpal in the 
same direction as the shaft. The base of the proximal 
phalanx moves toward the palmar surface of the thumb 
in flexion and toward the dorsal surface of the thumb in 
extension. 

Capsular Pattern 

The capsular pattern for the MCP joint is a restriction of 
motion in all directions, but flexion is more limited than 



extension 



*4 



Thumb: Interphalangeal Joint 

Anatomy 

The interphalangeal joint of the thumb is identical in 
structure to the IP joints of the fingers. The head of the 
proximal phalanx is convex and the base of the distal 
phalanx is concave (see Fig. 7-4). The joint is supported 
by a joint capsule, a palmar plate, and two lateral collat- 
eral ligaments (see Fig. 7-5). 







Collateral 
ligaments 


Palmar plaie a 


jm , 


1 — Capsule 


Sesamoid if 
bones ^n^wji; 




Cruciate 
l^*^ ligaments 


Palmar plate *V 


^W:V 


jj,'] Collateral 

&M~-~^~^ ligaments 



■ Capsule 



FIGURE 7-5 An anterior (palmar) view of the thumb showing 
joint capsules, collateral ligaments, palmar plates, and cruciate 
(intersesamoid) ligaments. 




140 



PART II UPPER-EXTREMITY TESTING 



Osteokinematics 

The IP joint is a synovial hinge joint with 1 degree of free- 
dom: flexion-extension in the sagittal plane. 

Arth rokinematics 

At the IP joint the concave base of the distal phalanx 
glides on the convex head of the proximal phalanx, in 

the same direction as the shaft of the bone. The base 
of the distal phalanx moves toward the palmar surface 
of the thumb in flexion and toward the dorsal surface of 
the thumb in extension. 

Capsular Pattern 

The capsular pattern is an equal restriction in both flex- 
ion and extension according to Cyriax. 4 Kaltenborn 

notes that all motions are restricted with more limitation 
in flexion. 

W Research Findings 

Effects of Age, Gender, and Other Factors 

Table 7-1 provides a summary of range of motion 
(ROM) values for the MCP, PIP, and DIP joints of the 
fingers. Although the values reported by the different 
sources in Table 7-1 vary, certain trends are evident. The 
PIP joints, followed by the MCP and DIP joints, have the 
greatest amount of flexion. The MCP joints have the 
greatest amount of extension, whereas the PIP joints have 
the least amount of extension. Total active motion (TAM) 
is the sum of flexion and extension ROM of the MCP, 
PIP, and DIP joints of a digit. The mean TAM varies from 
290 to 310 degrees for the fingers. 

The age, gender, and number of subjects used to 
obtain the values reported by the AAOS 7 and the AMA 8 
in Table 7-1 are not noted. Hume and coworkers 9 meas- 
ured active finger motions in 35 men by means of a 



goniometer on the Literal aspect of both hands. Mallon, 
Brown, and Nun ley measured active finger motions in 
60 men and 60 women with n special digital goniometer 
on the dorsal surface ot both hands. Skvarilova and 
Plcvkova" used a metallic slide goniometer to measure 
active finger motions on the dorsal aspect of both hands 
of 100 men and KM) women. 

Mallon, Brown, and Nunley 10 and Skvarilova and 
Plcvkova 11 also assessed passive and active joint motion 
in individual fingers. Table 7-2 presents passive ROM 
values for the joints of individual fingers. Some differ- 
ences in ROM values are noted between the fingers. 
Flexion ROM at the MCP joints increases linearly in an 
ulnar direction from the index finger to the little 
finger. 1 "'" Mallon, Brown, and Nunley 1 " report that 
extension at the MCP joints is approximately equal for 
all fingers. However, Skvarilova and Plevkova 1 ' note that 
the little finger has the greatest amount of MCP exten- 
sion, PIP flexion and extension and IMP flexion are 
generally equal for all fingers. 1 " Some passive extension 
beyond neutral is possible at the DIP joints, with a minor 
increase in a radial direction from the little finger toward 
the index finger. 

Only the MCP joints of the fingers have a considerable 
amount of abduction-adduction. The amount of abduc- 
tion-adduction varies with the position of the MCP joint. 
Abduction-adduction RO.V1 is greatest in extension and 
least in full flexion. The collateral ligaments of the MCP 
joints are slack and allow full abduction in extension. 
However, the collateral ligaments tighten and restrict 
abduction in the fully flexed position. 1 - 1 - The index and 
little fingers have ;i greater ROM in abduction-adduction 
than the middle and ring fingers. 1 

Table 7-3 presents ROM values for the CMC, MCP, 
and IP joints of the rhumb, flexion is greatest at the IP 
joint and least at the CMC joint. The greatest amount of 
extension is reported at the IP and CMC joints. The age, 



ge 
re, 
Je. 
thi 

CO 

col 



table 7-1 Finger Motion: Mean Values in Degrees from Selected Sources 



jokii 



sMotfon 



M§¥ 



mm a 



Hume* 9 (active) Mallon? 10 (active) : Skvarilova* n (active).;": 



'Meam'(SD) 



B 



MCP 


Flexion 


90 


90 


100 




Extension 


45 


20 





PIP 


Flexion 


100 


100 


105 




Extension 











DIP 


Flexion 


90 


70 


S5 




Extension 











Total active motion 








290 



95 


91.0(6.2) 


20 


25.8 (6.7) 


105 


107.9(5.6) 


7 




68 


84.5 (7.9) 


8 




303 


309.2 (6.6) 



CM 



AAOS = American Association of Orthopaedic Surgeons; AMA = American Medical Association; DIP - distal interphalangeal; MCP = metacar- 
pophalangeal; PIP = proximal interphalangeal; (SO) = standard deviation. 

* Values are for 35 maies aged 26 to 28 years, 

f Values are for 60 males and 60 females, aged 18 to 35 years. Values were recalculated to include both genders and all fingers. 

'Values are for 100 males and 100 females, aged 20 to 25 years. Values were recalculated to include both genders, both hands, all fingers, 
and converted from a 360-degree to a 180-degree recording system. 



con 



CHAPTER 7 THE HAND 



141 



table 7-2 Individual Passive Finger Motion: Mean Values in Degrees from Selected Sources 



}:A>v: 



Motion 



— .— : ;-, - "■'.■■" . ' T- 

MaUon* 10 



Index 



MH \ 



SIJHJtflfif 



MCP 

PIP 

DIP 



Flexion 

Extension 

Flexion 

Extension 

Flexion 

Extension 



94 

29 

106 

n: 

75 
22 



95 
56 
107 
19 
75 
24 



Middle 



MCP 

PIP 

DIP 



Flexion 

Extension 

Flexion 

Extension 

Flexion 

Extension 



98 

:34 

TIG 

10 
80 
19 



100 
54 

112 
20 
79 
23 



Male 



97 

55 

115 

87 



102 

48 

115 

87 



"-: 97->'-, 

: -56-:7 
117 : 

Mtllll 

9SVA 



104. .- 

48 

■ -. /■■.■- 

118 



9$: 



P 
>f 



King 



MCP 

P!P 

DIP 



Flexion 

Extension 

Flexion 

Extension 

Ftexion 

Extension 



102 
29 

no 

14 
74 

17 



103 
60 

108 
20 
76 
18 



uttie 



MCP 

pip 

DIP 



Flexion 

Extension 

F|exion 

Extension 

Flexion 

■Extension 



107 
48 

m 

13 
72 

15 



107 
62 

IIP 
21 

72 
21 



104 

48 

115 

83 



107 
63 

1 11 

89 



102".. 
,49 
1 19 :■ 

92 . 



1.04. 
65 r 

113; 

Tol 



DIP = Distal interphalangeal; MCP = metacarpophalangeal; PIP = proximal interphalangeal. 

'Values are for 60 males and 60 females, aged 18 to 35 years. Flexion values were measured with the contiguous proximal joint extended, 

except for DIP flexion in which the PIP joint was flexed. Extension values were measured with the contiguous proximal joint flexed. These 

contiguous proximal joint positions resulted in the greatest ROM values in the measured joint. 
'Values are for 100 males and 100 females, aged 20 to 25. Values were converted from a 360-degree to a 180-degree recording system. 



gender, and number of subjects used to obtain the values 
reported by the AAOS 7 and the AMA 8 are not noted. 
Jenkins and associates 13 measured active motions of both 
thumbs in 69 females and 50 males by means of a 
computerized Greenleaf goniometer. DeSmet and 
colleagues 14 measured ROM with a goniometer applied 



to the dorsal aspect of both thumbs in 58 females and 
43 males. Skvarilova and Plevkova 11 used a metallic slide 
goniometer to measure active and passive motions on the 

dorsal aspect of both thumbs of 100 men and 100 
women. 



table 7-3 Thumb Motion: Mean Values in Degrees from Selected Sources 





"' . ' Wi-')M: 


- AAOS 7 




fentfns^ 


&eSmei> u 


. SkvarBw 


^^JH^S^^B 










(active),/ ■ :. 




■■■■ (adfre)- '..-■■■ ■■■ 


(passive} . 


■Mnt V,. 


Motion 






Mean (SD) 


Mean.(SD) 


-.= : ' Mean (SO) >■;/.,« 




Meon,(SDy:\ 


CMC 


Abduction. 
Flexion- : 


'"-■'.■ 70 
' ■ 15 














Extension 


20 


50 










MCP 


Flexion 


50 


60 


59(11) 


.54.0(13.7) :;.. 


57.0 (10.7) 


67.0 (9.0) 




Extension 


."-0 








13.7 (10.5) 


22.6 (10.9) 


:'P : 


Flexion 


. 80 


80 


67 (11) 


79.8(10.2) 


79,1 (8.7) 


85.8 (8.3) 




.Extension; 


20 ' 








■ :';.■■ -t J +<t \l 3- J ) ■■■■■■..■■.■.■■■:■.■. 

. .-I"-- P.\y--.- ,■',-.■.■: -.v--." 


.34.7(133) 



CMC = Carpometacarpal; IP = interphalangeal; MCP = metacarpophalangeal; (SD) = standard deviation. 
'Values are for active ROM in 69 females and 50 males, aged 16 to 72 years. 

Values are for 58 females and 43 males, aged 16 to 83 years. 

Values are for 100 males and 100 females, aged 20 to 25 years. Values were recalculated to include both thumbs for both genders and 

converted from a 360-degree to a 1 80-degree recording system. 



142 



PART M UPPER-EXTREMITY TESTING 



I 



i i 



Age 

Goniometric studies focusing on the effects of age on 
ROM typically exclude the joints of the fingers and 
thumb; therefore, not much information is available on 
these joints. DeSmet and colleagues' 4 found a significant 
correlation between decreasing MCP and IP flexion of 
the thumb and increasing age. The 58 females and 43 
males who were included in the study ranged in age from 
16 to 83 years. Beighton, Solomon, and Soskolne 15 used 
passive opposition of the thumb (with wrist flexion) to 
the anterior aspect of the forearm and passive hyperex- 
tension of the MCP joint of the fifth finger beyond 90 
degrees as indicators of hypermobility in a study of 456 
men and 625 women in an African village. They found 
that joint laxity decreased with age. However, Allander 
and associates 16 found that active flexion and passive 
extension of the MCP joint of the thumb demonstrated 
no consistent pattern of age-related effects in a study of 
517 women and 208 men (between 33 and 70 years of 
age). These authors stated that the typical reduction in 
mobility with age resulting from degenerative arthritis 
found in other joints may be exceeded by an accumula- 
tion of ligamentous ruptures that lessen the stability of 
the first MCP joint. 

Gender 

Studies that examined the effect of gender on the ROM 
of the fingers reported varying results. Mallon, Brown, 
and Nunley 10 found no significant effect of gender on the 
amount of flexion in any joints of the fingers. However, 
in this study women genetatty had more extension at 
all joints of the fingers than men. Skvarilova and 
Plevkova 11 found that PIP flexion, DIP flexion, and MCP 
extension of the fingers were greater in women than in 
men, whereas MCP flexion of the fingers was greater in 
men. 

Several studies have found no significant differences 
between males and females in the ROM of the thumb, 
whereas other studies have reported more mobility in 
females. Joseph 17 used radiographs to examine MCP and 
IP flexion ROiM of the thumb in 90 males and 54 
females; no significant differences were found between 
the two groups. He found two general shapes of MCP 
joints, round and flat, with the round MCP joints having 
greater range of flexion. Shaw and Morris' 8 noted no 
differences in MCP and IP flexion ROM between 199 
males and 149 females aged 16 to 86 years. Likewise, 
DeSmet and colleagues, 14 as well as Jenkins and associ- 
ates, 13 found no differences in MCP and IP flexion of the 
thumb owing to gender. 

Allander and associates 16 found that, in some age 
groups, females showed more mobility in the MCP joint 
of the thumb than their male counterparts. Skvarilova 
and Plevkova 11 noted that MCP flexion and extension of 
the thumb were greater in females, whereas differences 
owing to gender were small and unimportant at the IP 



joint, Beighton. Solomon, and Soskolne, in a studv of 
456 men and 625 women of an African village, and 
Fairhank, Pynsctr, and Phillips, in a study of 227 male 
and 2 1 L ^ female adolescents, measured passive opposition 
of the rhumb toward the anterior surface of the forearm 
and hyperex tension of the MCP joints of the fifth or I 
middle fingers. Both studies reported an increase in laxity;;; 
in females compared with males. 

Right versus Left Sides 

The few studies that have compared ROM in the right! 
and left joints of the fingers have generally found JS 
significant difference between sides. Mallon, Brown, amfe 
Nunley,'" in a study in which half of the 120 subjects!? 
were right-handed and the other half left-handed, noted! 
no difference between sides in finger motions at the MCPl 
I'll', and DIP |oinrs. Skvarilova and Plevkova" reported! 
only small right-left differences in the majority of thill 
joints of the fingers and thumb in 200 subjects. Otdjj 
MCP extension of the fingers and thumb and IP flexib|l 
of the rhumb seemed to have greater ROM values ontlfj 
left. 

Similar to findings tn studies of the fingers, moststtjol 
ies have reported no difference in ROM between therighf 
and left thumbs. Joseph 1 and Shaw and Morris,' 8 igj 
study of 1 44 and 2-1 8 subjects, respectively, found Tiff 
significant difference between sides in MCP and IP flex? 
ion ROM of the thumb. DeSmet and colleagues' 4 ex^g 
ined 10! healthy subjects and reported no differeiicli 
between sides for the MCP and IP joints of the thumb| 
No difference between sides in IP flexion of the thuiDlg 
was found by Jenkins and associates in a study of Mm 
subjects. A statistically significant greater amount Oi 
.MCP flexion was reported for the right thumb: than; 
the left; however, this difference was only 2 degi3| 
Allander and associates" 1 also found no different*^ 
attributed to side in MCP motions of the thumb in 72M 
subjects. .'■: if 

Testing Position 

Mallon, Brown, and NunSey," 1 in addition to estabiisj 
normative ROM values for the fingers, also 
passive joint ROM while positioning the next mostpf.. ._. 
ima! joint in maximal flexion and extension. The Bfej 
joint had significantly more flexion ( 18 degrees) w|e 
PIP joint was flexed than when the PIP jointL. 
extended. This finding has been cited as an indication '•[ 
abnormal tightness of the oblique retinacular 'i?*^^ 
(I.andsmeer's Ligament).- However, the resiil^p 
Mallon, Brown, and Nunley's study suggest ^SH 
finding is normal. The MCP joint had about 6 
more flexion when the wrist was extended than Wfl|^ 
wrist was flexed, although this difference was no||| 
ticaily significant. The extensor digitorum, extensor J 
cis, and extensor digiti minimi were more slack tfjjm 
greater flexion of the MCP joint when the wri|| 




CHAPTER 7 THE HAND 143 



extended than when flexed. There was no effect on PIP 
motion with changes in MCP joint position. 

Knutson and associates -1 examined eight subjects to 
study the effect of seven wrist positions on the torque 
required to passively move the MCP joint of the index 
finger. The findings indicated that in many wrist posi- 
tions, extrinsic tissues (chose that cross more than one 
joint) such as the extensor digitorum, extensor indicis, 
flexor digitorum superficialis, and flexor digitorum 
■profundus muscles offered greater restraint to MCP flex- 
ion and extension than intrinsic tissues (those that cross 
only one joint). Intrinsic tissues offered greater resistance 
to passive moment at the MCP joint when the wrist was 
flexed or extended enough to slacken the extrinsic 
tissues. 

■ 

Functional Range of Motion 

joint motion, muscular strength and control, sensation, 
adequate finger length, and sufficient palm width and 
depth are necessary for a hand that is capable of perform- 
ing functional, occupational, and recreational activities. 
Numerous classification systems and terms for describing 
functional hand patterns have been proposed. 2,22 ~ 25 
Some common patterns include (1) finger-thumb prehen- 
sion such as tip (Fig. 7-6), pulp, lateral, and three-point 
pinch (Fig. 7-7); (2) full-hand prehension, also called a 
power grip or cylindrical grip (Fig. 7-8); (3) nonprehen- 
sion, which requires parts of the hand to be used as an 
extension of the upper extremity; and (4) bilateral 
prehension, which requires use of the palmar surfaces of 
both hands. 23 Texts by Stanley and Tribuzi, 26 Hunter and 
coworkers," 7 and the American Society of Hand 
Therapists 28 have reviewed many functional patterns and 
tests for the hand. 

Table 7-4 summarizes the active ROM of the domi- 
nant fingers and thumb during 1 1 activities of daily living 




f 



FIGURE 7-6 Picking up a coin is an example of finger-thumb 
prehension that requires use of the tips or pulps of the digits. In 
'his photograph the pulp of the thumb and the tip of the index 
finger are being employed. 




FIGURE 7-7 Writing usually requires finger-thumb prehension 
in the form of a three-point pinch. 



that require various rypes of finger-thumb prehension or 
full-hand prehension. Hume and coworkers used an 

elcctrogoniometer and a universal goniometer to study 
35 right-handed men aged 26 to 28 years during 
performance of these 1 1 tasks. Of the tasks that were 
included, holding a soda can required the least amount of 




FIGURE 7-8 Holding a cylinder such as a cup requires 
full-hand prehension (power grip). The amount of metacar- 
pophalangeal and proximal interphalangeal flexion varies, 
depending on the diameter of the cylinder. 



144 



PART II UPPER-EXTREMITY TESTING 



%\ 



\ 



finger and thumb motion, whereas holding a toothbrush 
required the most motion. Joint ROM during other tasks, 
such as holding a telephone, holding a fork, turning a 
key, and printing with a pen, were clustered around the 
means listed in Table 7—4. 

Lee and Rim 29 examined the amount of motion 
required at the joints of the fingers to grip five different- 
size cylinders. Data were collected from four subjects by 
means of markers and multi-camera photogrammetry. As 
cylinder diameter decreased, the amount of flexion of the 
MCP and PIP joints increased. However, DIP joint flex- 
ion remained constant with all cylinder sizes. 

Sperling and Jacobson-Sollerman 30 used movie film in 
their study of the grip pattern of 15 men and 15 women 
aged 19 to 56 years during serving, eating, and drinking 
activities. The use of different digits, types of grips, 
contact surfaces of the hand, and relative position of the 
digits was reported; however, ROM values were not 
included. 

Reliability and Validity 

Several studies have been conducted to assess the relia- 
bility and validity of goniometric measurements in the 
hand. Most studies found that ROM measurements of 
the fingers and thumb that were taken with universal 
goniometers and finger goniometers were highly reliable. 
Measurements taken over the dorsal surface of the digits 
appear to be similar to those taken laterally. Consistent 
with other regions of the body, measurements of finger 
and thumb ROM taken by one examiner are more reli- 
able than measurements taken by several examiners. 
Research studies support the opinions of Bear-Lehman 
and Abreu 31 and Adams, Greene, and Topoozian, 32 that 
the margin of error is generally accepted to be 5 degrees 
for goniometric measurement of joints in the hand, 
provided that measurements are taken by the same exam- 
iner and that standardized techniques are employed. 

Hamilton and Lachenbruch 33 had seven testers take 
measurements of MCP, PIP, and DIP flexion in one 



table 7-4 Finger and Thumb Motions During 
1 1 Functional Activities: Values in Degrees 9 



! --■■-"■;. .- ■r.vn.v--.- ^ -■■■;:: ■■ -.■■-'-■■^■- -j 


:■-.■■ .-:.-.->■ '■ - ■ -^" 


" -.,::. -.-"■->-:,: _.■:■> -~--^: '■-.. 


■ '■"%£"-'■ ' ■ 




P>4otion 


Range 


Mean 


;-m i 




Finger MCP flexion 


33-73 


.61 


iv!2 




PIP flexion ■ 


36-86 ■ 


60 


12 




IP flexion T 


20-61 


39 


14 




Thumb MCP flexion : 


10-32 


21 


5 




IP flexion , . ... 


2-43 


18 ^ :«, 


,/:■$-: 





IP = Interphalangeal; MCP = metacarpophalangeal; PIP = proximal 

interphalangeal; (SD) = standard deviation. 
The 1 1 functional activities include: holding a telephone, can, fork, 
scissors, toothbrush, and hammer; using a zipper and comb; turn- 
ing a key; printing with a pen; and unscrewing a jar. 



subject whose lingers were held in a fixed position. The 
daily measurements were taken for 4 days with three 
types of goniometers. These authors found imcrtester 
reliability was lower than intratcsrer reliability. No signif- 
icant differences existed between measurements taken 
with a dorsal (over-the-joint) finger goniometer, a univer- 
sal goniometer, or a pendulum goniometer. 

Groth and coworkers'"' had 39 therapists measure the 
PIP and DIP joints of the index and middle fingers of one 
patient, both dorsally and laterally, using either a six-inch 
plastic universal goniometer or a DeVore metal finger 
goniometer. No significant difference in measurements 
was found between the two instruments. No differences 
were found between die dorsal and lateral measurement 
methods for seven of the eight joint motions, with mean 
differences ranging from 2 to degrees. In a subset of six 
therapists, intertester reliability was high for both meth- 
ods, with intraclass correlation coefficients (ICCs) rang- 
ing from 0.86 for lateral methods to 0.99 for dorsal 
methods. In terms of concurrent validity, there were 
significant differences in measurements obtained from 
radiographs versus those from goniometers excepting 
laterally measured index PIP extension and flexion. 
Differences between radiographic and goniometric meas- 
urements ranged from I to 10 degrees, bur these differ- 
ences may have been due to variations in procedures and 
positioning. 

Weiss and associates ' compared measurements of 
index finger MGP, PIP, and DIP joint positions taken by 
a dorsa! metal finger goniometer with those taken by the 
Exos llandmaster, a Ha 1 1 -effect instrumented exoskele- 
ton. Twelve subjects were measured with each device 
during one session by one examiner, and again within 2 
weeks of the initial session. Test-retest reliability was high 
for both devices, with ICCs ranging from 0.98 to 0.99. 
Mean differences between sessions for each instrument 
were statistically significant but less than 1 degree. 
Measurements taken by the finger goniometer and those 
taken by the Exos llandmaster were significantly. differ- 
ent {mean difference — 7 degrees) but highly correlated 
(r = 0.89 to 0.94). 

Ellis, Bruton, and Goddard Jft placed one subject in 
two splints while a total of 40 therapists measured the 
MCP, PIP, and DIP joints of the middle finger by means 
of a dorsal finger goniometer and a wire tracing. Each 
therapist measured each joint three times with each 
device. The goniometer consistently produced smaller 
ranges and smaller standard deviations than the wire 
tracing, indicating better reliability for the goniometer. 
The 95 percent confidence limit for the difference 
between measurements ranged from 3.8 to 9.9 degrees 
for the goniometer and 8.9 to 13.2 degrees for the wire 
tracing. Borh methods had more variability when distal 
joints were measured, possibly because of the shorter 
levers used to align the goniometer or wire. Intratestef 
reliability was always higher than intertester reliability. 






CHAPTER 7 THE HAND 



145 



Brown and colleagues 37 evaluated the ROM of the 
j^ICP, PIP, and DIP joints of two fingers in 30 patients to 
calculate total active motion (TAMJ by means of the 
dorsal finger goniometer and the computerized Dexter 
Hand Evaluation and Treatment System. Three therapists 
(pleasured each finger three times with each device during 
one session. Intratester and intertester reliability was high 
for both methods, with iCCs ranging from 0.97 to 0.99. 
The mean difference between methods ranged from 0.1 
degrees to 2.4 degrees. 

The distance between the fingertip pulp and distal 
palmar crease has been suggested as a simple and quick 
method of estimating total finger flexion ROM at the 
MCP, PIP, and DIP joints. 32 ' 38 MacDermid and cowork- 
ers 39 studied the validity of using the pulp-to-palm 
distance versus total finger flexion to predict disability as 



measured by an upper extremity disability score (DASH). 
active MCP, PIP, and DIP flexion was measured in 50 
patients by one examiner who used a dorsally placed 
electrogoniometer NK Hand Assessment System. A ruler 
was used to measure pulp-to-palm distance in the same 
patients. The correlation between pulp-to-palm distance 
and total active flexion was -0.46 to -0.51, indicating 
that the measures were not interchangeable. The rela- 
tionship between DASH scores and total active flexion 
was stronger (r — 0.45) than the relationship between 
DASH scores and pulp-to-pa!m distances (r = 0.21 to 
0.30). The authors suggested that total active motion is a 
more functional measure than pulp-to-palm distance, 
and that pulp-to-palm distance "should only be used to 
monitor individual patient progress and not to compare 
outcomes between patients or groups of patients." 



Range of Motion Testing Procedures: Fingers 



deluded in this section are the common clinical tech- 
niques for measuring motions of the fingers and thumb. 
These techniques are appropriate for evaluating these 
motions in the majority of people. However, swelling and 
bony deformities sometimes require that the examiner 



either measure the MCP and IP joints from the lateral 
aspect or create alternative evaluation techniques- 
Photocopies, photographs, and tracings of the hand at 
the beginning and end of the ROM may be helpful. 






5th Distal 
phalanx 

5th Middle 
phalanx 



5th Proximal 
phalanx 



5th Metacarpal 



FIGURE 6-9 Posterior view of the hand showing surface 
anatomy landmarks for goniometer alignment during meas- 
urement of finger range of motion. 



. 

FIGURK6-10 Posterior view of the hand showing bony 
anatomical landmarks for goniometer alignment during: the 
measurement of finger range of motion. The index, middle, 
ring, and Htde fingers each have a metacarpal and a proxi- 
mal, middle, and distal phalanx. 




-T- rr > ~ ^-* '" ~^~- 






ISi 
LU 

fifi 
Q 

UJ 

U 

O 

a. 
U 

z 

LU 



o 



LU 

z 

2 



146 



PART II UPPER-EXTREMITY TESTING 



METACARPOPHALANGEAL FLEXION 



Motion occurs in the sagittal plane around a mediai- 
lateral axis. Mean finger flexion ROM values are 90 
degrees according to the AAOS 7 and the AMA, 8 and 100 
degrees according to Hume and coworkers. 9 MCP flex- 
ion appears to increase slightly in an ulnar direction from 
the index finger to the little finger. See Tables 7-1 and 
7-2 for additional information. 

Jesting Position 

Place the subject sitting, with the forearm and hand rest- 
ing on a supporting surface. Place the forearm midway 
between pronation and supination, the wrist in degrees 
of flexion, extension, and radial and ulnar deviation; and 
the MCP joint in a neutral position relative to abduction 
and adduction. Avoid extreme flexion of the PIP and DIP 
joints of the finger being examined. 

Stabilization 

Stabilize the metacarpal to prevent wrist motion. Do not 

hold the MCP joints of the other fingers in extension 
because tension in the transverse metacarpal ligament 
will restrict the motion. 



Testing Motion 

Flex the MCP joint by pushing on the dorsal surface of 
the proximal phalanx, moving the finger toward the 
palm {Fig. 7-11). Maintain the MCP joint in a neutral 
position relative to abduction and adduction. The end of 
flexion ROM occurs when resistance to further motion is 
felt and attempts to overcome the resistance cause the 
wrist to flex. 

Normal End- feel 

The end-feel may be hard because of contact between the 
palmar aspect of the proximal phalanx and the 
metacarpal, or it may be firm because of tension in the 
dorsal joint capsule and the collateral ligaments. 

Goniometer Alignment 

See Figures 7-12 and 7-13. 

1. Center the fulcrum of the goniometer over the 
dorsal aspect of the MCP joint. 

2. Align the proximal arm over the dorsal midline of 
the metacarpal. 

3. Align the distal arm over the dorsal midline of the 
proximal phalanx. 




« 




■ 



. 



■'8 







FIGURE 7-1 1 During flexion of the metacarpophalangeal joint, the examiner uses one hand to stabilize 

the subject's metacarpal and to maintain the wrist in a neutral position. The index finger and the thumb 
of the examiner's other hand grasp the subject's proximal phalanx to move it into flexion. 



* I 




CHAPTER 7 THE HAND 



147 






■i 



.e;:| 






.ie 
of 

he: 



■fM^&i&Ji&i 








FIGURE 7-12 The alignment of the goniometer at the beginning of metacarpophalangeal flexion range 
of motion (ROM), In this photograph, the examiner is using a 6-inch plastic goniometer in which the 
arms have been trimmed to approximately 2 inches to make it easier to align over the small joints of the 
hand. Most examiners use goniometers with arms that are 6 inches or shorter when measuring ROM in 
the hand. 



mm 

- 




FIGURE 7-13 At the end of metacarpophalangeal (MCP) flexion range of motion, the examiner uses one 
hand to hold the proximal goniometer arm in alignment and to stabilize the subject's metacarpal. The 
examiner's other hand maintains the proximal phalanx in MCP flexion and aligns the distal goniometer 
arm. Note that the goniometer arms make direct contact with the dorsal surfaces of the metacarpal and 
proximal phalanx, causing the fulcrum of the goniometer to lie somewhat distal and dorsal to the MCP 
joint. 



PART II UPPER-EXTREMITY TESTING 




en 

— 

Q 

LLi 

u 

O 

cs 

0.'.'; 

,\ MM ; / 

h- 



Motion occurs in the sagittal plane around a medial- 
lateral axis. Mean MCP finger extension ROM is 20 
degrees according to the AMA 8 and 45 degrees according 
to the AAOS. 7 Passive MCP extension ROM is greater 
than active extension. Mallon, Brown, and Nunley 10 
report that extension ROM at the MCP joints is similar 
across all fingers, whereas Skvarilova and Plevkova 11 
note that the little finger has the greatest amount of MCP 
extension. See Tables 7-1 and 7-2 for additional infor- 



I! manon. 



SI 

° 

m 



Testing Position 

Position the subject sitting, with the forearm and hand 
resting on a supporting surface. Place the forearm 
midway between pronation and supination; the wrist in 
degrees of flexion, extension, and radial and ulnar devia- 
tion; and the MCP joint in a neutral position relative to 
abduction and adduction. Avoid extension or extreme 
I flexion of the PIP and DIP joints of the finger being 
I tested. (If the PIP and DIP joints are positioned in exten- 
| sion, tension in the flexor digitorum superficialis and 
I profundus muscles may restrict the motion. If the PIP and 
■1 DIP joints are positioned in full flexion, tension in the 
J lumbricalis and interossei muscles will restrict the 
J motion.) 

I Stabilization 

I Stabilize the metacarpal to prevent wrist motion. Do not 

5 hold the MCP joints of the other fingers in full flexion 

| because tension in the transverse metacarpal ligament 

I will restrict the motion. 



Testing Motion 

hxtcTul the MCP joint by pushing on [lie palmar surface 
of the proximal phalanx, moving the finger away from 
(he palm (Fig. 7-14). Maintain the MCI* joint in a 
neutral position relative to abduction and adduction. 
The end of flexion ROM occurs when resistance to 
further morion is felt and attempts to overcome resist- 
ance cause the wrist to extend. 

Normal End-feel 

The etui-feel is firm because of tension in the palmar 
joint capsule and in the palmar plate. 



Goniometer Alignment 

See figures 7-15 and 7-16 for alignment of the 

goniometer over the dorsal aspect ot the fingers. 

1. Center the iulcrum of the goniometer over the 
dorsal aspect of the MCP joint. 

2. Align the proximal arm over the dorsal midline of 
the metacarpal. 

3. Align the distal arm over the dorsal midline of the 
proximal phalanx. 

Alternative Goniometer Alignment 

See Figure 7- j 7 for alignment of the goniometer over the : 
palmar aspect of the finger. This alignment should nor be 1 
used it swelling or hypertrophy is present in the palm of 
the hand. 

1. Center the fulcrum of the goniometer over the;; 
palmar aspect of the MCP joint. 

2. Align the proximal arm over the palmar midline of 
the metacarpal. 

3. Align the distal arm over the palmar midline of the 
proximal phalanx. 







X\ 



\ \ 






mi 



FIGURE 7-14 During metacarpophalangeal extension, the examiner uses her index finger aiul thumb to 
grasp the subject's proximal phalanx and to move the phalanx dorsally. The examiner's other hand main- 
tains the subject's wrist in the neutral position, stabilizing the metacarpal. 



I 
'4 







CHAPTER 7 



THE HAND 



149 



FIGURE 7-15 A full-circle, 6-inch plastic goniometer 
is being used to measure the beginning range of motion 
for metacarpophalangeal extension. The proximal 
arm of the goniometer is slightly longer than necessary 
for optimal alignment. If a goniometer of the right size 
is not available, the examiner can cut the arms of a 
plastic model to a suitable length. 



FIGURE 7-16 The alignment of the goniometer at the 
end of metacarpophalangeal (MCP) extension. The 
body of the goniometer is aligned over the dorsal 
aspect of the MCP joint, whereas the goniometer arms 
are aligned over the dorsal aspect of the metacarpal 
and proximal phalanx. 



FIGURE 7-17 An alternative alignment of a finger 
goniometer over the palmar aspect of the proximal 
phalanx, the metacarpophalangeal joint, and the 
metacarpal. The shorter goniometer arm must be used 
over the palmar aspect of the proximal phalanx so that 
the proximal interphalangeal and distal interpha- 
langeal joints are allowed to relax in flexion. 






T 



j ■ 



i • ■'■; 






en 

a. 
lu 

u 

z 



150 



PART II UPPER-EXTREMITY TESTING 






LU 

z 
< 

a: 



METACARPOPHALANGEAL ABDUCTION 



LU 

cc 
O 

UJ 

U 

o 

a. 
U 

z 

Z 

g 
§ 



Motion occurs in the frontal plane around an anterior- 
posterior axis. No sources were found for MCP abduc- 
tion ROM values. 

Testing Position 

Position the subject sitting, with the forearm and hand 
resting on a supporting surface. Place the wrist in 
degrees of flexion, extension, and radial and ulnar devi- 
ation; the forearm fully pronated so that the palm 
of the hand faces the ground; and the MCP joint in 
degrees of flexion and extension. 

Stabilization 

Stabilize the metacarpal to prevent wrist motions. 

Testing Motion 

Abduct the MCP joint by pushing on the medial surface 
of the proximal phalanx, moving the finger away from 

the midline of the hand (Fig. 7-18), Maintain the MCP 



joint in a neutral position relative to flexion and exten- 
sion. The end of flexion ROM occurs when resistance to 
further motion is felt and attempts to overcome the resis- 
tance cause the wrist to move into radial or ulnar devia- 
tion. 

Normal End-feel 

The end-feel is firm because of tension in the collateral 
ligaments of the MCP joints, the fascia of the web space 
between the fingers, and the palmar interossei muscles. 

Goniometer Alignment 

See Figures 7-19 and 7-20. 

1. Center the fulcrum of the goniometer over the 
dorsal aspect of the MCP joint. 

2. Align the proximal arm over the dorsal midline of 
the metacarpal. 

3. Align the distal arm over the dorsal midline of the 
proximal phalanx. 














FIGURE 7-18 During metacarpophalangeal (MCP) abduction, the examiner uses the index finger of one 
hand to press against the subject's metacarpal and prevent radial deviation at the wrist. With the other 

index finger and thumb holding the distal end of the proximal phalanx, the examiner moves the subject's 
second MCP joint into abduction. 



CHAPTER 7 THE HAND 151 




FIGURE 7-19 The alignment of the goniometer at the beginning of metacarpophalangeal abduction 
range of motion. 



: i ': 




'i J .- : -:^f^m 



\ 



"1 






'. 




FIGURE 7-20 At the end of metacarpophalangeal abduction, the examiner aligns the arms of the 
goniometer with the dorsal midline of the metacarpal and proximal phalanx rather than with the contour 
of the hand and finger. 



Vi-i 

LU 

u 

2;: 



152 



PART II UPPER-EXTREMITY TESTING 



■ i t 

■ az 
U 

O. 

ur 

2 1 

f- I 
— i 

2 

O;: 

O 



METACARPOPHALANGEAL ADDUCTION 



Motion occurs in the frontal plane around an anterior- 
posterior axis. MCP adduction is not usually measured 
and recorded because it is the return from full abduction 
to the starting position. There is very little adduction 
ROM beyond the starting position. No sources were 
found for MCP adduction ROM values. 



PROXIMAL INTERPHALANGEAL FLEXION 



■ 2S 
< 



Motion occurs in the sagittal plane around a medial- 
lateral axis. Mean PIP finger flexion ROM values are 100 
degrees according to the AAOS 7 and the AMA K and 105 
degrees according to Hume and coworkers 9 and Mallon, 
Brown, and Nunley. 10 PIP flexion is similar between the 
fingers. 10 See Tables 7-1 and 7-2 for additional informa- 
tion. 

Testing Position 

Place the subject sitting, with the forearm and hand rest- 
ing on a supporting surface. Position the forearm in 
degrees of supination and pronation; the wrist in 
degrees of flexion, extension, and radial and ulnar devia- 
tion; and the MCP joint in degrees of flexion, exten- 
sion, abduction, and adduction. (If the wrist and MCP 
joints are positioned in full flexion, tension in the exten- 
sor digitorum communis, extensor indicis, or extensor 
digiti minimi muscles will restrict the motion. If the MCP 
joint is positioned in full extension, tension in the lumbri- 
calis and interossei muscles will restrict the motion.) 



Stabilization 

Stabilize the proximal phalanx to prevent motion of the 
wrist and the MCP joint. 

Testing Motion 

Flex the PIP joint by pushing on the dorsal surface of the 
middle phalanx, moving the finger toward the palm (I'ig. 
7-21). The end of flexion ROM occurs when resistance 
to further motion is felt and attempts to overcome the 
resistance cause the MCP joint to flex. 

Normal End-feel 

Usually, the end-feel is hard because of contact between 
the palmar aspect of the middle phalanx and the proxi- 
mal phalanx. In some individuals, the end-feel may he 
soft because of compression of soft tissue between the 
palmar aspect of the middle and proximal phalanges. In 
other individuals, the end-feel may be firm because of 
tension in the dorsal joint capsule and the collateral liga- 
ments. 

Goniometer Alignment 
See Figures 7-22 and 7-23. 

1. Center the fulcrum of the goniometer over the 
dorsal aspect of the PIP joint. 

2. Align the proximal arm over the dorsal midline of 
the proximal phalanx. 

3. Align the distal arm over the dorsal midline of the 
middle phalanx. 



.. 






P 

i. 





FIGURE 7-21 During proximal interphalangeal (PIP) flexion, the examiner stabilizes the subject's prox- 
imal phalanx with her thumb and index finger. The examiner uses her other thumb and index finger to 
move the subject's PIP joint into full flexion. 










CHAPTER 7 THE HAND 153 



- 





FIGURE 7-22 The alignment of the goniometer at the beginning of proximal interphalangea! flexion 
range of motion. 




FIGURE 7-23 At the end of proximal interphalangeal (PIP) flexion, the examiner continues to stabilize 
and align the proximal goniometer arm over the dorsal midline of the proximal phalange with one hand. 
The examiner's other hand maintains the PIP joint in flexion and aligns the distal goniometer arm with 
the dotsal middline of the middle phalanx. 



t/1 

DC 
LU 

o 



154 



PART II UPPER-EXTREMITY TESTING 



LU 

DS 
Q 

LU 

u 

o 

si 
0. 

o 
z 

LU 

I— 
Z 

g 
o 

LL. 

o 

LU 
(J 

<: 



PROXIMAL INTERPHALANGEAL 
EXTENSION 



Motion occurs in the sagittal plane around a medial- 
lateral axis. Mean PIP finger extension ROM values are 
degrees according to the AAOS 7 and the AMA. 8 Data 
from Mallon, Brown, and Nunley 10 indicate a mean of 7 
degrees of active PIP extension and 16 degrees of passive 
PIP extension. PIP extension is generally equal for all 
fingers. 10 See Tables 7-1 and 7-2 for additional informa- 
i tiort. 

Testing Position 

Place the subject sitting, with the forearm and hand rest- 
ing on a supporting surface. Position the forearm in 
degrees of supination and pronation, the wrist in 
degrees of flexion, extension, and radial and ulnar devia- 

I tion, and the MCP joint in degrees of flexion, exten- 
sion, abduction, and adduction. (If the MCP joint and 
wrist are extended, tension in the flexor digitorum super- 
ficialis and profundus muscles will restrict the motion.) 



Stabilization 

Stabilize the proximal phalanx to prevent motion of the 
wrist and the MCP joint. 

Testing Motion 

Extend the PIP joint by pushing on the palmar surface of 
the middle phalanx, moving the finger away from the 
palm. The end of extension ROM occurs when resistance 
to further motion is felt and attempts to overcome the 
resistance cause the MCP joint to extend. 

Normal End-feel 

The end-feel is firm because of tension in the palmar joint 
capsule and palmar plate (palmar ligament). 

Goniometer Alignment 

1. Center the fulcrum of the goniometer over the 
dorsal aspect of the PIP joint. 

2. Align the proximal arm over the dorsal midline of 
the proximal phalanx. 

3. Align the distal arm over the dorsal midline of the 
middle phalanx. 



: ; 



V'S ■ 



: : 



■ 






CHAPTER 7 THE HAND 



15S 



of the 



ace of 
m the 
stance 
ie the 



r joint 

er the 
line of 

of the 



DISTAL INTERPHALANCEAL FLEXION 



Motion occurs in the sagittal plane around a medial- 
lateral axis. DIP finger flexion ROM values are 90 
degrees according to the AAOS 7 and 70 degrees accord- 
ing to the AMA. 8 Hume and coworkers 9 and Skvarilova 
and Plevkova 11 report a mean of 85 degrees of active DIP 
flexion. DIP flexion is generally equal for all fingers. 10 
See Tables 7-1 and 7-2 for additional information. 

Testing Position 

Position the subject sitting, with the forearm and hand 
resting on a supporting surface. Place the forearm in 
degrees of supination and pronation; the wrist in 
degrees of flexion, extension, and radial and ulnar devi- 
ation; and the MCP joint in degrees of flexion, exten- 
sion, abduction, and adduction; Place the PIP joint in 



approximately 70 to 90 degrees of flexion. (If the wrist 
and the MCP and PIP joints are fully flexed, tension in 
the extensor digitorum communis, extensor indicis, or 
extensor digiti minimi muscles may restrict DIP flexion. 
If the PIP joint is extended, tension in the oblique reti- 
nacular ligament may restrict DIP flexion.) 

Stabiiization 

Stabilize the middle and proximal phalanx to prevent 
further flexion of the wrist, MCP joints, and PIP joints. 

Testing Motion 

Flex the DIP joint by pushing on the dorsal surface of the 
distal phalanx, moving the finger toward the palm (Fig. 
7-24). The end of flexion ROM occurs when resistance 
to further motion is felt and attempts to overcome the 
resistance cause the PIP joint to flex. 




FIGURE 7-24 During distal interphalangeal (DIP) flexion, the examiner uses one hand to stabilize the 
middle phalanx and keep the proximal interphalangeal joint in 70 to 90 degrees of flexion. The exam- 
iner's other hand pushes on the distal phalanx to flex the DIP joint. 




■ 



156 PART II UPPER-EXTREMITY TESTING 






!;jB 1 Normal End- feel 

." I 

uj 1 The end-feel is firm because of tension in rhe dorsal joint 

33 I capsule, collateral ligaments, and oblique retinacular 

Q 1 ligament. 

u 1 

O I C oniometer A lignment 

See Figures 7-25 to 7-27. 



1. Center the fulcrum of the goniometer over rhe 
dorsal aspect of the DIP joint, 

2. Align the proximal arm over the dorsal midline of 
the middle phalanx. 

3. Align the distal arm over the dorsal midline of the 
distal phalanx. 



■ ■; ■ 



> 




FIGURE 7-25 Measurement of the beginning of distal interphalangcal (DIP) flexion range of morion is 

being conducted by means of a half-circle plastic goniometer with 6-inch arms that have been trimmed to 
accommodate the small size of the DIP joint. 



M 



CHAPTER 7 THE HAND 



157 




S* 




FIGURE 7-26 The alignment of the goniometer at the end of distal interphalangeal flexion range of 
motion. Note that the fulcrum of the goniometer lies distal and dorsal to the proximal interphalangeal 
joint axis so that the arms of the goniometer stay in direct contact with the dorsal surfaces of the middle 
and distal phalanges . 






: 




FIGURE 7-27 Distal interphalangeal flexion range of motion also can be measured by using a finger 
goniometer that is placed on the dorsal surface of the middle and distal phalanges. This type of goniome- 
ter is appropriate for measuring the small joints of the fingers, thumb, and toes. 



158 



PART II UPPER-EXTREMITY TESTING 




DISTAL INTERPHALANGEAL EXTENSION 



Motion occurs in rhe sagittal plane around a medial- 
lateral axis. Most references, such as the AAOS 7 and the 
AMA, 8 report DIP finger extension ROM values to be 
degrees. However, Mallon, Brown, and Nunley 10 report 
a mean of 8 degrees of active DIP extension and 20 
degrees of passive DIP extension. DIP extension is gener- 
ally equal for all fingers. 10 See Tables 7-1 and 7-2 for 
additional information. 

Testing Position 

Position the subject sitting, with the forearm and hand 
resting on a supporting surface. Place the forearm in 
degrees of supination and pronation; the wrist in 
degrees of flexion, extension, and radial and ulnar devi- 
ation; and the MCP joint in degrees of flexion, exten- 
sion, abduction, and adduction. Position the PIP joint in 
approximately 70 to 90 degrees of flexion. (If the PIP 
joint, MCP joint, and wrist are fully extended, tension in 
the flexor digitorum profundus muscle may restrict DIP 
extension.) 



Stabilization 

Stabilize the middle and proximal phalanx to prevent: 
extension of the wrist, MCP joints, and PIP joints. 

Testing Motion 

Extend the DIP joint by pushing on the palmar surface of 
the distal phalanx, moving the finger away from the 
palm. The end of extension ROM occurs when resistance 
to further motion is felt and attempts to overcome the 
resistance cause the PIP joint to extend. 

Normal End-feel 

The end-feel is firm because of tension in the palmar 
joint capsule and the palmar plate (palmar ligament). 

Goniometer Alignment 

1. Center the fulcrum of the goniometer over the 
dorsal aspect of the DIP joint. 

2. Align the proximal arm over the dorsal midline of 
the middle phalanx. 

3. Align the distal arm over the dorsal midline of the 
distal phalanx. 






::■ 



■ 



3 

..■-...-.-. 

A 
.... 



■ 





:nt 



of 
he 
<ce 



lat- 
he 
of 
he : : 






■s*i 






flange Of Motion Testing Procedures: Thumb 



CHAPTER 7 THE HAND 



159 





FIGURE 7-28 Anterior (palmar) view of the hand showing 
surface anatomy landmarks for goniometer alignment 
during the measurement of thumb range of motion. 




FIGURE 7-30 Posterior view of the hand showing surface 
anatomy landmarks for goniometer alignment during the 
^measurement: of thumb range of motion. 




ft 

H 

m 



1st 

Distal 
phalanx 

1st 
proximal 
phalanx 

1st 
Metacarpal 



Trapezium 



Scaphoid 

Radial styloid 
process 



FIGURE 7-29 Anterior (palmar) view of the hand showing: 
bony anatomical landmarks for goniometer alignment: 
during the measurement of thumb range of motion. 



1st 


/jSjrN. 


Distal 

phalanx 


\\*VV 


1st Proximal 

phalanx 




1st Metacarpal — \\ 




Trapezium 




Scaphoid ' 




Radial styloid 
process 



■ 



tfc 



FIGURE 7-31 Posterior view of the hand showing bony 
anatomical landmarks for goniometer alignment during the 
measurement of thumb range of motion. 



;./.'; 



CO 

2 

D 
X 
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LU 

U 

O 

OS 

=- 

U 

z 

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160 PART tl UPPER-EXTREMITY TESTING 

Range of Motion Testing 
Procedures: Thumb 



CARPOMETACARPAL FLEXION 



Motion occurs in the plane of the hand. When the 

subject is in the anatomical position, the motion occurs 
in the frontal plane around an anterior-posterior axis. 
Mean CMC thumb flexion ROM is 15 degrees, accord- 
ing to the AAOS. 7 

Testing Position 

Position the subject sitting, with the forearm and hand 
resting on a supporting surface. Place the forearm in full 
supination; the wrist in degrees of flexion, extension, 
and radial and ulnar deviation; and the CMC joint of the 
thumb in degrees of abduction. The MCP and IP joints 
of the thumb are relaxed in a position of slight flexion. 
(If the MCP and IP joints of the thumb are positioned in 
full flexion, tension in the extensor potlicis longus and 
brevis muscles may restrict the motion.) 

Stabilization 

Stabilize the carpais, radius, and ulna to prevent wrist 
motions. 

Testing Motion 

Flex the CMC joint of the thumb by pushing on the 
dorsal surface of the metacarpal, moving the thumb 
toward the ulnar aspect of the hand {Fig. 7-32). 



Maintain the CMC |nini in degrees of abduction. The 

end of flexion ROM occurs when resistance to further 
motion is felt and attempts to overcome the resistance 
cause the wrist ro deviate ulnarly. 

Normal End -feel 

The end-feel may be soft because of contact between 
muscle bulk of the thenar eminence and the palm of the 
hand, or it may he firm because of tension in the dorsal 
joint capsule and the extensor pollicis brevis and abduc- 
tor pollicis brevis muscles. 

Goniometer Alignment 
See figures 7-33 and 7-34. 

1. Center the fulcrum of the goniometer over the 
palmar aspect of the firsr CMC joint. 

2. Align the proximal arm with the ventral midline of 
the radius using the ventral surface of die radial 
head and radial srytoid process for reference. 

3. Align the distal arm wirh rhe ventral midline of the 
first metacarpal. 

in rhe beginning positions for flexion and extension, 
the goniometer may indicate approximately 50 to 50 
degrees rather than degrees, depending on the shape of 
the hand and wrist position. The end-position degrees 
should be subtracted from rhe beginning-position 
degrees. A measurement that begins at 35 degrees and 

1,5 degrees. 






■ 

■ 







■;. 




FIGURE 7-32 During carpometacarpal (CMC) flexion, the examiner uses the index finger and thumb of 

one hand to stabilize the carpais, radius, and ulna to prevent ulnar deviation of the wrist. The examiner's 
the other index finger and thumb flex rhe CMC joint by moving the first metacarpal medially. 








irther 

tancel 



ine of 
radiat:; 

of the 



CHAPTER 7 THE HAND 




FIGURE 7-33 The alignment of the goniometer at the beginning of carpometacarpal flexion range of 
motion of the thumb. Note that the goniometer does not read degrees. 




FIGURE 7-34 At the end of carpometacarpal {CMC} flexion range of motion, the examiner uses the 
hand chat was stabilizing the wrist to align the proximal arm of the goniometer with the radius. The 
examiner's other hand maintains CMC flexion and aligns the distal arm of the goniometer with the first 
metacarpal. During the measurement, the examiner must be careful not to move the subject's wrist further 
into ulnar deviation or the goniometer reading will be incorrect (too high). 



161 




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X 
H* 

<>i 

LP 

Z> 

;q ; . 

LU 

;u 
O 

OS 

a. 

:Q 

■Z. 

in 

LU 

f- 

z 
2 

u_ 

o 

LU 

o 

Z 



162 



PART II UPPER-EXTREMITY TESTING 



1 



CARPOMETACARPAL EXTENSION 



Motion occurs in the plane of the hand. When the subject 

is in the anatomical position, the motion occurs in the 
frontal plane around an anterior-posterior axis. Reported 
values for CMC thumb extension ROM are 50 degrees, 
according to the AMA, S and vary trom 20 degrees 7 to 
80 degrees, ,s according to the AAOS. However, the 
measurement methods used by the AAOS and the AMA 
appear to differ from the method suggested here. This 
motion is also called radial abduction. 

Testing Position 

Position the subject sitting, with the forearm and hand 
resting on a supporting surface. Place the forearm in full 
supination; the wrist in degrees of flexion, extension, 
and radial and ulnar deviation; and the CMC joint of the 
thumb in degrees of abduction. The MCP and IP joints 
of the thumb are relaxed in a position of slight flexion. (If 
the MCP and IP joints of the thumb are positioned in full 
extension, tension in the flexor pollicis longus muscle 
may restrict the motion.) 

Stabilization 

Stabilize the carpals, radius, and ulna to prevent wrist 
motions. 

Testing Motion 

Extend the CMC joint of the thumb by pushing on the 

palmar surface of the metacarpal, moving the thumb 



toward the radial aspect of the hand I Fig. ^-35). 
Maintain the CMC joint hi degrees of abduction. The 
end of extension ROM occurs when resistance to further 

motion is felt and attempts to overcome che resistance 
cause the wrist to deviate radially. 

Normal End-feel 

The end-feel is firm because of tension in the anterior 

joint capsule and the flexor pollicis brevis, adductor 
pollicis, opponens pollicis, and first dorsal interossei 
muscles. 

Goniometer Alignment 

Sec Figures 7-36 and 7-37. 

1. Center the fulcrum of the goniometer over the 
palmar aspect of the first CMC joint. 

2. Align the proximal arm with the ventral midline of 
the radius, using the ventral surface of the radial 

head and the radial styloid process for reference. 

3. Align the distal arm with the ventral midline of the 
first metacarpal. 

In the beginning positions for flexion and extension, 
the goniometer may indicate approximately 30 to 50 
degrees rather than degrees, depending on the shape of 
the hand and wrist position. The end-position degrees 
should be subtracted from the beginning-position 
degrees. A measurement that begins at 35 degrees and 
ends at 55 degrees should be recorded as to 20 degrees. 



'M 



'-- 







FIGURE 7-35 During carpometacarpal extension of the thumb, the examiner uses one hand to stabilize 
the carpals, radius, and ulnar thereby preventing radial deviation of the subject's wrist; the examiner's 
other hand is used to pull the first metacarpal laterally into extension. 







CHAPTER 7 THE HAND 



163 



the , 



>e of 
;rees 
,uon: 
and 
rees./ 




FIGURE 7-36 The goniometer alignment for measuring the beginning of carpometacarpal (CMC) exten- 
sion range of motion is the same as for measuring the beginning of CMC flexion. 



§111 




FIGURE 7-37 The alignment of the goniometer at the end of carpometacarpal (CMC) extension range 
of motion of the thumb. The examiner must be careful to move only the CMC joint into extension and 
not to change the position of the wrist during the measurement. 



. 



Is 






&: 









' 



CO 1 

x 



UJ 

ad. 

Q 

u-i 
U 


Q 

(A: 

UJ 

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o 

H 

o 

5 



UJ 

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< 
as 



164 



PART II UPPER-EXTREMITY TESTING 




CARPOMETACARPAL ABDUCTION 



Motion occurs at a right angle to the paim of the hand. 
When the subject is in the anatomical position, the 
motion occurs in the sagittal plane around a medial- 
lateral axis. Abduction ROM is 70 degrees, according to 
the AAOS; 10 however, the measurement method appears 
to differ from the method suggested here. This motion is 
also called palmar abduction. 

Testing Position 

Position the subject sitting, with the forearm and hand 
resting on a supporting surface. Place the forearm 
midway between supination and pronation; the wrist in 
degrees of flexion, extension, and radial and ulnar devia- 
tion; and the CMC, MCP, and IP joints of the thumb in 
degrees of flexion and extension. 

Stabilization 

Stabilize the carpals and the second metacarpal to 

I prevent wrist motions. 
I 
I Testing Motion 

ii Abduct the CMC joint by moving the metacarpal away 
j from the palm of the hand (Fig. 7-38). The end of abduc- 



tion ROM occurs when resistance to further motion i s 
felt and attempts to overcome the resistance cause the 
wrist to flex. 

Normal End-feel 

The end-feel is firm because of tension in the fascia and 
the skin of the web space between the thumb and the 
index finger. Tension in the adductor pollicis and first 
dorsal interossei muscles also contributes to the firm end- 
feel. 

Goniometer Alignment 

See Figures 7-39 and 7-40. 

1. Center the fulcrum of the goniometer over the 
lateral aspect of the radial styloid process. 

2. Align the proximal arm with the lateral midline of 
the second metacarpal, using the center of the 
second MCP joint for reference. 

3. Align the distal arm with the lateral midline of the 
first metacarpal, using the center of the first MCP 
joint for reference. 






■: 




FIGURE 7-38 During carpometacarpal abduction, the examiner uses one hand to stabilize the subject's 
second metacarpal. Her other hand grasps the subject's first metacarpal just proximal to the metacar- 
pophalangeal joint to move it away from the palm and into abduction. 




CHAPTER 7 THE HAND 165 







FIGURE 7-39 At the beginning of carpometacarpal abduction range of motion, the subject's first and 
second metacarpals are in firm contact with each other. However, when the arms of the goniometer are 
aligned with the first and second metacarpals, the goniometer will not be at degrees. 




FIGURE 7-40 The alignment of the goniometer at the end of carpometacarpal abduction range of 
motion. 



a 

D 

I 

UJ 

a: 

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Q... 

U 

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C£ 

u ; 

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UJ 

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§ 

u. 

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Off 



166 



PART I! UPPER-EXTREMITY TESTING 



CARPOMETACARPAL ADDUCTION 



Motion occurs at a right angle to the palm of the hand. 
When the subject is in the anatomical position, the 
motion occurs in the sagittal plane around a medial- 
lateral axis. Adduction of the CiVIC joint of the thumb is 
not usually measured and recorded because it is the 
return to the starting position from full abduction. 



CARPOMETACARPAL OPPOSITION 



Motion is a combination of abduction, flexion, medial 
axial rotation (pronation), and adduction at the CMC 
joints of the thumb. Contact between the tip of the 
thumb and the tip of the little finger is usually possible, 
providing that opposition at the CMC joint of the little 
finger and slight flexion at the MCP joints are allowed. 
Alternately, contact between the tip of the thumb and the 
base of the little finger is usually possible, providing that 
slight flexion of the MCP and IP joints of the thumb is 
allowed. 



Testing Position 

Position the subject sitting with the forearm and hand 
resting on a supporting surface. Place the forearm in full 
supination; the wrist in degrees of flexion, extension 
and radial and ulnar deviation; and the IP joints of the 
thumb and little finger in degrees of flexion and exten- 
sion. 

Stabilization 

Stabilize the fifth metacarpal to prevent wrist motions. 

Testing Motion 

Move the first metacarpal away from the pafm of the 
hand and then in an ulnar direction toward the little 
finger, allowing the first metacarpal to rotate (Figs. 7-41 
and 7-42). Move the fifth metacarpal in a palmar and 
radial direction toward the thumb. The end of opposition 
ROM occurs when resistance to further motion is felt 
and attempts to overcome the resistance cause the wrist 
to deviate or the forearm to pronate. 






1 

1 



■■■ 




V 



CHAPTER 7 THE HAND 167 




FIGURE 7-41 At the beginning of the range of motion in opposition, the examiner grasps the first and 
hfth metacarpals. The subject's hand is supported by the table. 






Ss. 





w 



FIGURE 7-42 During opposition, the first and fifth metacarpals are moved toward each other by pla 
ing pressure on their dorsal surfaces. This subject's hand docs not have full range of i 



motion. 



■(/IK 
gjj 168 PART II UPPER-EXTREMITY TESTING 

m. 

iT 1 Normal End-feel 

ass 
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The end-feel may be soft because of contact between the 
muscle bulk of the thenar eminence and the palm; or it 
may be firm because of tension in the CMC joint 
capsule, fascia, and skin of the web space between the 
thumb and the index finger; and in the adductor pollicis, 
first dorsal interossei, extensor pollicis brevis, and exten- 
sor pollicis longus muscles; and in the transverse 
metacarpal ligament (which affects the little finger). 

Goniometer Alignment 

The goniometer is not commonly used to measure the 
range of opposition. Instead, a ruler is often used to 



measure the distance between the tip of the thumb and 
the tip of the little finger (Fig. 7-43). Alternatively, a 
ruler may be used to measure the distance between the 
tip of the thumb and the base of the little finger at the 
palmar digital crease or the distal palmar crease. 40 

The AMA Guides to the Evaluation of Permanent 
Impairment* recommends measuring the longest 
distance from the flexion crease of the thumb IP joint to 
the distal palmar crease directly over the third MCP joint 
(Fig. 7-44). However, this measurement method seems 
more consistent with the measurement of CMC abduc- 
tion. 




FIGURE 7-43 The range of motion (ROM) in opposition is determined by measuring the distance 
between the lateral tips of the subject's thumb and the little finger. The examiner is using the arm of the 
goniometer to measure, but any ruler would suffice. The photograph does not show the complete ROM 
of opposition because its purpose is to demonstrate how the ROM is measured. When full ROM in oppo- 
sition is reached, the tips of the little finger and the thumb are touching. 



CHAPTER 7 THE HAND 



169 



- ■■:■■■ 
'■' •'•&■' 




FIGURE 7-44 In an alternative method of measuring thumb opposition, the examiner uses a ruler to find 
the longest possible distance between the distal palmar crease directly over the metacarpophalangeal joint 
of the middle finger and the flexion crease of the thumb interphalangeal joint. (From Stanley, BG, and 
Tribuzi, SM: Concepts in Hand Rehabilitation. FA Davis, Philadelphia, 1992, p 546, with permission.) 



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170 



PART II 



UPPER-EXTREMITY TESTING 



METACARPOPHALANGEAL FLEXION 



I Morion occurs in the frontal plane around an anterior- 
I posterior axis when the subject is in the anatomical posi- 
| tion. Mean flexion ROM values are 50 degrees according 
I to the AAOS, 7 60 degrees according to the AMA, S and 
J 55 degrees according to DeSmet and colleagues. 1 ' 1 See 
1 Table 7-3 for more information. 



rz i Testing Position 



in 



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O 
p 

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: 

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< 



| Position the subject sitting, with the forearm and hand 
I resting on a supporting surface. Place the forearm in full 
| supination; the wrist in degrees of flexion, extension, 
1 and radial and ulnar deviation; the CMC joint of the 
1 thumb in degrees of flexion, extension, abduction, 
I adduction, and opposition; and the IP joint of the thumb 
1 is in degrees of flexion and extension. {If the wrist and 
I IP joint of the thumb are positioned in full flexion, 
I tension in the extensor pollicis longus muscle will restrict 
| the motion.) 

| Stabilization 

| Stabilize the first metacarpal to prevent wrist motion and 
m flexion of the CMC joint of the thumb. 



:;i-- '■■«:■ 



,v'- 



Testing Motion 

Flex the MCP joint by pushing on the dorsal aspect of the 
proximal phalanx, moving the thumb toward the ulnar 
aspect of the hand (Fig. 7-45), The end of flexion ROM 
occurs when resistance to further motion is felt and 
attempts to overcome the resistance cause the CMC joint 
to flex. 



Normal End- fee} 

The end-feel may be hard because of contact between the 
palmar aspect of the proximal phalanx and the first 
metacarpal, or it may be firm because of tension in the ' 
dorsal joint capsule, the collateral ligaments, and the 
extensor pollicis brevis muscle. 

Goniometer Alignment 

See Figures 7-46 and 7-47. 

1. Center the fulcrum of the goniometer over the 
dorsal aspect of the MCP joint. 

2. Align the proximal arm over the dorsal midline of 
the metacarpal. 

3. Align the distal arm with the dorsal midline of the; | 
proximal phalanx. 





FIGURE 7—45 During metacarpophalangeal flexion of the thumb, the examiner uses the index finger and 
thumb of one hand to stabilize the subject's first metacarpal and maintain the wrist in a neutral position. 
The examiner's other index finger and thumb grasp rhe subject's proximal phalanx to move it into flex- 




CHAPTER 7 THE HAND 









-:-r. : " :■■■ '■•'■r^c:;.^: . 

■.■■:.::,:■■ 











FIGURE 7-46 The alignment of the goniometer on the dorsal surfaces of the first metacarpal and prox- 
imal phalanx at the beginning of metacarpophalangeal flexion range of motion of the thumb. If a bony 
deformity or swelling is present, the goniometer may be aligned with the lateral surface of these bones. 



171 



- 








.' -Y - 




FIGURE 7—47 At the end of metacarpophalangeal flexion, the examiner uses one hand to stabilize the 
subject's first metacarpal and align the proximal arm of the goniometer. The examiner uses her other 
hand to maintain the proximal phalanx in flexion and align the distal arm of the goniometer. 



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172 



PART II UPPER-EXTREMITY TESTING 



METACARPOPHALANGEAL EXTENSION 



Motion occurs in the frontal plane around an anterior- 
posterior axis when the subject is in the anatomical posi- 
tion. Mean extension ROM values are degrees 
according to the AAOS, 7 and 14 degrees (actively) and 23 
degrees (passively) according to Skvarilova and 
Plevkova. 11 

Testing Position 

Position the subject sitting, with the forearm and hand 
resting on a supporting surface. Place the forearm in full 
supination; the wrist in degrees of flexion, extension, 
and radial and ulnar deviation; the CMC joint of the 
thumb in degrees of flexion, extension, abduction, and 
opposition; and the IP joint of the thumb in degrees of 
flexion and extension. (If the wrist and the IP joint of the 
thumb are positioned in full extension, tension in the 
flexor pollicis longus muscle may restrict the motion.) 

Stabilization 

Stabilize the first metacarpal to prevent motion at the 

wrist and at the CMC joint of the thumb. 



Testing Motion 

Extend the MCP joint by pushing on the palmar surface 
of the proximal phalanx, moving the thumb toward the 
radial aspect of the hand. The end of extension ROM 
occurs when resistance to further motion is felt and 
attempts to overcome the resistance cause the CMC joint 
to extend. 

Normal End-feel 

The end-feel is firm because of tension in the palmar 
joint capsule, palmar plate (palmar ligament), inter- 
sesamoid (cruciate) ligaments, and flexor pollicis brevis 
muscle. 

Goniometer Alignment 

1. Center the fulcrum of the goniometer over the 
dorsal aspect of the MCP joint. 

2. Align the proximal arm over the dorsal midline of 
the metacarpal. 

3. Align the distal arm with the dorsal midline of the 
proximal phalanx. 



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CHAPTER 7 THE HAND 



173 



■NTERPHALANGEAL FLEXION 



irfacc I Motion occurs in the frontal plane around an anterior- 
d the i posterior axis when the subject is in the anatomical posi- 
t-OM jl don. Mean IP flexion ROM of the thumb is 67 degrees, 
a nd 1 according to Jenkins and associates, 13 and 80 degrees, 
joint § according to DeSmet and colleagues, 14 and Skvarilova 
and Plevkova. 11 See Table 7-3 for more information. 

Jesting Position 

>lmar ] position the subject sitting, with the forearm and hand 

inter- J testing on a supporting surface. Place the forearm in full 

>revis I supination; the wrist in degrees of flexion, extension, 

-Ml and radial and ulnar deviation; the CMC joint in 

f <feg rees or " flexion, extension, abduction, and opposition; 

K and the MCP joint of the thumb in degrees of flexion 

r the ] and extension. (If the wrist and MCP joint of the thumb 

; are flexed, tension in the extensor pollicis longus muscle 

ine of I may restrict the motion. If the MCP joint of the thumb is 

ffj fully extended, tension in the abductor pollicis brevis and 

af the =1 the oblique fibers of the adductor pollicis may restrict the 

i flj motion through their insertion into the extensor mecha- 

I nism.) 

Stabilization 

Stabilize the proximal phalanx to prevent flexion or 
extension of the MCP joint. 



Testing Motion 

Flex the IP joint by pushing on the distal phalanx, 
moving the tip of the thumb toward the ulnar aspect of 
the hand (Fig. 7-48). The end of flexion ROM occurs 
when resistance to further motion is felt and attempts to 
overcome the resistance cause the MCP joint to flex. 

Normal End-feel 

Usually, the end-feel is firm because of tension in the 
collateral ligaments and the dorsal joint capsule. In some 
individuals, the end-feel may be hard because of contact 
between the palmar aspect of the distal phalanx, the 
palmar plate, and the proximal phalanx. 

Goniometer Alignment 

See Figures 7-49 and 7-50. 

1. Center the fulcrum of the goniometer over the 
dorsal surface of the IP joint. 

2. Align the proximal arm with the dorsal midline of 
the proximal phalanx. 

3. Align the distal arm with the dorsal midline of the 
distal phalanx. 




FIGURE 7-48 During interphalangeal flexion of the thumb, the examiner uses one hand to stabilize the 
proximal phalanx and keep the metacarpophalangeal joint in degrees of flexion and the 
carpometacarpal joint in degrees of flexion, abduction, and opposition. The examiner uses her other 
index finger and thumb to flex the distal phalanx. 



LLi 

Z 



in 

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174 



PART 11 UPPER-EXTREMITY TESTING 







FIGURE 7^49 The alignment of the gors-iometer at the beginning of intcrphalangeal flexion tange of 
motion. The arms of the goniometer are placed on the dorsal surfaces of the proximal and distal 
phalanges. However, the arms of the goniometer could instead be placed on the lateral surfaces of the 
proximal and distal phalanges if the nail protruded or if there was a bony prominence or swelling. 




-■-.-■ 






p 



5i*te 



X 





. . ■ 



«f"«.-..-?.«S»- 



FIGURE 7-50 The alignment of the gon-iometer at the end of intcrphalangeal flexion range of motion. 
The examiner holds the arms of the goniometer so that they maintain close contact with the dorsal 
surfaces of the proximal and distal phalanges. 



CHAPTER 7 THE HAND 



175 



i 



1NTERPHALANCEAL EXTENSION 



Motion occurs in the frontal plane around an anterior- 
posterior axis when the subject is in the anatomical posi- 
tion. Mean extension ROM at the IP joint of the thumb 
is 20 degrees, according to the AAOS 7 , and 23 degrees 
(actively) and 35 degrees (passively) according to 
Skvarilova and Plevkova.' 1 

Testing Position 

Position the subject sitting, with the forearm and hand 
resting on a supporting surface forearm. Place the fore- 
arm in full supination; the wrist in degrees of flexion, 
extension, and radial and ulnar deviation; the CMC joint 
"of the thumb in degrees of flexion, extension, abduc- 
tion, and opposition; and the MCP joint of the thumb in 
degrees of flexion and extension. (If the wrist and MCP 
joint of the thumb are extended, tension in the flexor 
pollicis longus muscle may restrict the motion.) 

Stabilization 

Stabilize the proximal phalanx to prevent extension or 
flexion of the MCP joint. 



Testing Motion 

Extend the IP joint by pushing on the palmar surface of 
the distal phalanx, moving the thumb toward the radial 
aspect of the hand. The end of extension ROM occurs 
when resistance to further motion is felt and attempts to 
overcome the resistance cause the MCP joint to extend. 

Normal End-feel 

The end-feel is firm because of tension in the palmar joint 
capsule and the palmar plate (palmar ligament). 

Goniometer Alignment 

1. Center the fulcrum of the goniometer over the 
dorsal surface of the IP joint. 

2. Align the proximal arm with the dorsal midline of 
the proximal phalanx. 

3. Align the distal arm with the dorsal midline of the 
distal phalanx. 



176 PART II UPPER-EXTREMITY TESTING 

Muscle Length Testing Procedures: 

Fingers 



LUMBRICALS, PALMAR AND DORSAL 
INTEROSSEI 



The lumbrical, palmar, and dorsal interossei muscles 
cross the MCP, PIP, and DIP joints. The first and second 
lumbricals originate proximally from the radial sides of 
the tendons of the flexor digitorum profundus of the 
index and middle fingers, respectively (Fig. 7-51). The 
third lumbrical originates on the ulnar side of the tendon 
of the flexor digitorum profundus of the middle finger 
and the radial side of the tendon of the ring finger. The 
fourth lumbrical originates on the ulnar side of the 
tendon of the flexor digitorum profundus of the ring 
finger, and the radial side of the tendon of the little finger. 
Each lumbrical passes to the radial side of the correspon- 
ding finger and inserts distally into the extensor mecha- 
nism of the extensor digitorum profundus. 

The first palmar interossei muscle originates proxi- 
mally from the ulnar side of the metacarpal of the index 
finger and inserts distally into the ulnar side of the prox- 
imal phalanx, and the extensor mechanism of the exten- 



§ 3rd Lumbrical 



4th Lumbrical 




Flexor digitorum 
profundus 



FIGURE 7-51 An anterior (palmar) view of the hand showing 
the proximal attachments of the lumbricals. The lumbricals 
insert distally into the extensor digitorum on the posterior 
surface of the hand. 



sor digitorum profundus of the same linger (Fig, 7-52.) 
The second and third palmar interossei muscles originate 
proximally from the ulnar sides of the metacarpal of the I 
ring and little fingers, respectively, and insert distally into Is 
the ulnar side of the proximal phalanx and the extensor -M 
mechanism of the extensor digitorum profundus of the I 
same fingers. 

The four dorsal interossei arc bipenniform muscles 
that originate proximally from two adjacent metacarpals --I 
(Fig. 7-53): the first dorsal interossei from the ■" 
metacarpals of the rhumb and index finger, the second:;-^ 
from the metacarpals ot the index and middle fingers, the '■% 
third from the metacarpals of the middle and ring fingers '■ 
and the fourth from the metacarpals of the ring and little 
fingers. The dorsal interossei insert distally into the bases 
of the proximal phalanges and the extensor mechanism 
of the extensor digitorum profundus of the same fingers. -? 

When these muscles contract, they flex the MCP joints 
and extend the PIP and DIP joints. These muscles are 
passively lengthened by placing the MCP joints in exten- ..:■■■ 
sion and the PIP and DIP joints in full flexion. If the' : -i| 



1st Palmar interossei 




■ 



- 






FIGURE 7-52 An anterior (palmar) view of the hand showing.;; 
the proximal and distal attachments of the palmar interossei. : 
The palmar interossei also attach distally to the extensor dig 1 ' 
torum on the posterior surface of the hand. 



CHAPTER 7 THE HAND 



177 



gi^rjparsai 
interossei 




Extensor indicts 



Extensor 
digilojwn 

FIGURE 7-53 A posterior view of the hand showing the prox- 
imal attachments of the dorsal interossei on the metacarpals, 
and the distal attachments into the extensor mechanism of the 
extensor digitorum, extensor indicts, and extensor digiti minimi 

muscles. 



lumbricals and the palmar and dorsal interossei are short, 
they will limit MCP extension when the PIP and DIP 
joints are positioned in full flexion. 

If MCP flexion is limited regardless of the position of 
the PIP and DIP joints, the limitation is due to abnor- 
malities of the joint surfaces of the MCP joint or short- 
ening of the palmar joint capsule and the palmar plate. 

Starting Position 

Position the subject sitting, with the forearm and hand 
resting on a supporting surface. Place the forearm 
midway between pronation and supination; and the wrist 
in degrees of flexion, extension, and radial and ulnar 
deviation. Flex the MCP, PIP, and DIP joints (Fig. 7-54). 
The MCP joints should be in a neutral position relative to 
abduction and adduction. 



showing 
terossei. 
jof dig'' 




FIGURE 7-54 The starting position for testing the length of the lumbricals and the palmar and dorsal 

interossei. The examiner uses one hand to stabilize the subject's wrist, and the other hand to position the 
subject's metacarpophalangeal, proximal interphalangeal, and distal interphalangeal joints in full flexion. 



uv 

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I/) 'si 

SIS'- 1 

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UJ./-I 

U :; 1 

0| 

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: (j: y4 ' 



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178 



PART II UPPER-EXTREMITY TESTING 



Stabilization 

Stabilize the metacarpals and the carpal bones to prevent 
wrist motion. 

Testing Motion 

Hold the PIP and DIP joints in full flexion while extend- 
ing the iVICP joint (Figs. 7-55 and 7-56). All of the 
fingers may be screened together, but if abnormalities arc 
found, testing should be conducted on individual fingers. 
The end of flexion ROM occurs when resistance to 
further motion is felt and attempts to overcome the resis- 
tance cause the PIP, DIP, or wrist joints to extend. 



Normal End-feel 

The end-feel is firm because of tension in the lumbrical 
palmar and dorsal interossei muscles. 

Goniometer Alignment 

See Figure 7-57. 

1. Center the fulcrum of the goniometer over the 
dorsal aspect of the MCP joint. 

2. Align the proximal arm over the dorsal midline of 
the metacarpal. 

3. Align the distal arm over the dorsal midline of the 
proximal phalanx. 



U 





FIGURE 7-55 The end of the motion for testing the length of the iumbricals and the palmar and dorsal 
interossei. The examiner holds the subject's proximal interphalangeal and distal interphalangeal joints in 
full flexion while moving the metacarpophalangeal joint into extension. 



CHAPTER 7 THE HAND 179 



1st Lumbrical 







yff. 



Extensor digitorum 



1st Dorsal interossei 



FIGURE 7-56 A lateral view of the hand showing the first lumbrical and the first dorsal interossei 

muscles being stretched over the metacarpophalangeal, proximal interphalangeal, and distal interpha- 
langeal joints. 




■• ' - : - .. 



;■■■ 



i^^l 








FIGURE 7-57 The alignment of the goniometer at the end of testing rhe length of the iumbricals and the 
palmar and dorsal interossei muscles. The arms of the goniometer are placed on the dorsal midline of the 
metacarpal and proximal phalanx of the finger being tested. 




180 



PART II UPPER-EXTREMITY TESTING 



REFERENCES 

1. Lcvangie, PL, and Norkin, CC: Joint Structure and Function: A 
Comprehensive Analysis, ed 3. FA Davis, Philadelphia, 2001. 

2. Tubiana, R: Architecture and functions of the hand. In Tubiana, R, 
Thomine, JM, and Mackin, E (eds): Examination of the Hand and 
Upper Limb. \VB Sounder*, Philadelphia, 1984. 

3. Krishnan, !, and Chipehase, L; Passive axiai rotation ol the 
metacarpophalangeal join;. J Hand Surg 22B:270, 2000. 

4. Cyriax, JH, and Cyriax, PJ: Illustrated Manual of Orthopaedic 
Medicine. Buitcrworths, London, 1983. 

5. Kalrenborn, FM: Manual Mobilization of the Joints: The 
Extremities, ed 5. Olaf Noriis Bokhandel, Oslo, Norway, 1999. 

6. Ranncy, D: The hand as a concept: Digital differences and their 
importance. Clin Anat 8:281, 1995. 

1, American Academy of Orthopaedic Surgeons: Joinr Motion: 
Methods of Measuring and Recording. AAOS, Chicago, 1965. 

8. American Medical Association: Guides to the Evaluation of 
Permanent Impairment, ed 3. AMA, Chicago, 1990. 

9. Hume, M, et a I: Functional range of motion of the joints of the 
hand. J Hand Surg (Am) 15:240, 1990. 

10. Malta:), WJ, Brown, HR, and Nunley, JA: Digital ranges of motion: 
Normal values in young adults. J Hand Surg (Am) 16:882, 1991. 

1 1 . Skvarilova, 8, and Plevkova, A: Ranges of joint motion of the adult 
hand. Acta Chir Plast 38:67, 1996. 

12. Kisncr, C, and Colby, LA: Therapeutic Exercise: Foundations and 
Techniques, ed 4. FA Davis, Philadelphia, 2002. 

13. Jenkins, M, et al: Thumb joint motion: What is normal? J Hand 
Surg (Br) 23:796, 1998. 

14. DeSmet, L, et a!: Metacarpophalangeal and inrcrphalnngeal flexion 
of the thumb: Influence of sex and age, relation to ligamentous 
injury. Acta Orthop Belg 59:357, [993. 

15. Beighton, P, Solomon, L, and Soskolne, CL: Articular mobility in an 
African population. Ann Rheum Dis 32:413, 1973. 

16. Allander, E, et al: Normal range of joint movements in shoulder, 
hip, wrist and thumb with special reference to side: A comparison 
between two populations. Int J Epidemiol 3:253, 1974. 

17. Joseph, j: Further studies of the metacarpophalangeal and inter- 
phalangeal joints of the thumb. J Anat 85:221, 1951. 

18. Shaw, Sj, and Morris, MA: The range of motion of the metacar- 
pophalangeal' joint of the thumb and its relationship to injury. J 
Hand Surg (Br) 17:164, 1992. 

19. Fairhank, JCT, Pynsett, PB, and Phillips, H-. Quantitative measure- 
ments of joint mobility in adolescents. Ann Rheum Dis 43:288, 
1984. 

20. Nicholson, B: Clinical evaluation. In Stanley, BG, and Tribtizi, SM: 
Concepts in Hand Rehabilitation. FA Davis, Philadelphia, 1992. 

21. Knutson, JS, et al: Intrinsic and extrinsic contributions to the 
passive moment at the metacarpophalangeal joint. J Biomcch 
33:1675,2000. 



22. C.iv.i:i.->va. JS, and Crimen. BK: Adult prehension: Patterns and.:! 
nomenclature kit pinches. J Hand 1 her 2:231. 19SV, 

23. Mil.iii, J: Rheumatic hl-n-jr-i": Occupation Therapy ant j< 
RehamtautMi, ed 2. 1 A ftavW. Philadelphia, i'flii. 

24. Sv.auson, Ate Evaluation n( disabilities and record keeping. In* 
Sw.iriMjn. Aft: Flexible Implant Knectiufi Arthroplasty in the Fland^ 
and Ixucimties. CV Moshy. St Louis. !V73. 

25. Napier, Jl<: Prehensile muvcliwiHt "I the human hand, j Anat,! 
S»:5t>4, W5-V 

26. Toticn. PA. and Hum Wagner, S: hillv.iion.il evaluation of ttit haudj 
In Stanley, I'.d, and Tnhii/i, SM ledsi: { ...'Kepis m Hand 
Rehabilitation, FA Davis, ilnl.uieipl.ia, I W2. 

2 7 . F Imiter, |M. et al: Rehabilitation < ■ I the I land: Surgery and Therapy,?: 
ed ;. CV Mushy, S; I r.uss. I'i'«i. 

28. American Society ut Hand Therapists; t litsic.si Assessment 
Recommendations, ed 2. AM IT. Clu<. ago. l*.W2, 

2 l >. Lee. |W. and Rim, K: Measurement i>( linger imiii .ingles and maxi-1 
mum linger forces during cylinder grip activity. J Kiomcd Eng 4 
13:152. l"«l. 

30. Sperling. L. and Jacohsoii-SiiHcrmaii. I': The grip paiiern of the:'; 
healthy hand during eatmg. Sc.ind j Rehabil Med "■': 1 1 5, 1977. ij 

31. Bear-I chm.in, j. and Abreu. BC: Evaluating the hand: Issues in reli-^ 
ability and validity I'hys Ther 69:1025, l l W>. 

32. Adams, LS. Greene. L\V, and 'Inpuii/i.iH, F: Range til motion. InS 
American Society <it Hand Therapists: t lineal Assessment. 
Recommendations, ed 2. ASI II. t .luc.igo. t l|t '2. 

.53. Hamilton. GK and Lachenbruch, I'A: Reliability or goniometers in ? 
assessing linger joint angle. Plus Ther 49:465., IV6V. 

34. Groth. G. et al: Gi>minnctr\ o! the proximal and distal iitterpha-.; 
langeai lomts. Par: II: Placement prelcreticcs, mterrater reliability,:, 
and concurrent vaiidtry. J I land Thvf 14:23, 2001, '.v. 

35. Weiss, I'l , et .il: Using the l : ,\Os Bandmaster to measure digital':^ 
range of motion: Reliability and yatidky. Med hng 1'hv.s 1 6;.523,. : 
hW4. 

56. Kllis, li. Bruton, A, and Coddard, jR: Joint angle measurement: As 
comparative sriki'. of the reliability of gomometry and wire tracing^ 
tor the hand. Clin Rehab. I I l:3!4, 1997, 

37. Brown, A, e; al: Validity and reliability oj the Dexter Hand: 
I. valuation and Therapy System in hand attuned patients. J Hand; 
Ther 1 ?:37, 2Q0U. 

38. Greene, W!J, and i leckmaft. (1) (edsh The Clinical Measurement of 
Joint Miituiii. American Academy or Orthopaedy Surgeons,;' 
Roiemom, 111.. 1994. 

39. M.tcDermid, JC, et ill: Validity of pulp-to-pjlm distance as a meas^| 
tire or linger flexion. J Fland Surg 2611:432, 2001. 

40. Cambridge. CA: R.inge-ofinotion measurements of the hand. Ins 
Flunter, JM, et al iedsi: Rehabilitation of the Hand: Surgery andl 
Therapy, ed 3. CV Mosby, St Louis, 1990. 




>* 
Ik 
In 






Lower- Ext re m i ty 
Testing 



■■'-'■'} ; :-'-"-'-'- 



iSSfegi 









Objectives 



m 

A 
>8 

si: 

of 



to 



1 1 



.:■. 



ON COMPLETION OF PART III, THE READER WILL BE 

1. Identify: 

appropriate planes and axes for each lower- 
extremity joint motion 

structures that limit the end of the range of 
motion at each lower-extremity joint 

expected normal end-feel 

2. Describe: 

testing positions used for each lower-extremity 
joint motion and muscle length test 

goniometer alignment 

capsular pattern of limitation 

range of motion necessary for selected func- 
tional activities at each major lower-extrem- 
ity joint 

3. Explain: 

how age, gender, and other variables may 

affect the range of motion 
how sources of error in measurement may 

affect testing results 

4. Perform a goniometric measurement of any 
lower-extremity joint, including: 

a clear explanation of the testing procedure 
proper positioning of the subject 
adequate stabilization of the proximal joint 
component 



ABLE TO: 

use of appropriate testing motion 

correct determination of the end of the range 
of motion 

correct identification of the end-feel 
.palpation of the appropriate bony landmarks 

accurate alignment of the goniometer and 
correct reading and recording of goniomet- 
ric measurements 

5. Plan goniometric measurements of the hip, 
knee, ankle, and foot that are organized by 
body position 

6. Assess the intratester and intertester reliability 
of goniometric measurements of the lower- 
extremity joints using methods described in 
Chapter3. 

7. Perform tests of muscle length at the hip, 
knee, and ankle, including: 

a clear explanation of the testing procedure 
proper placement of the subject in the starting 

position 
adequate stabilization 
use of appropriate testing motion 
correct identification of end-feel 
accurate alignment of the goniometer and 

correct reading and recording 



The testing positions, stabilization techniques, testing motions, end-feels, and goniometer alignment for 
the joints of the lower extremities are presented in Chapters 8 through 10. The goniometric evaluation 
should follow the 12-step sequence that was presented in Exercise 5 in Chapter 2. 




The Hip 




M, Structure and Function 

Iliofemoral Joint 

Anatomy 

The hip joint, or coxa, links the lower extremity with the 
trunk. The proximal joint surface is the acetabulum, 
■ which is formed superiorly by the ilium, posteroinferiorly 
by the ischium, and anteroinferiorly by the pubis (Fig. 
; 8-1). The concave acetabulum faces laterally, inferiorly, 
...and anteriorly and is deepened by a fibrocartilaginous 
^acetabular labrum. The distal joint surface is the convex 



head of the femur. The joint is enclosed by a strong, thick 
capsule, which is reinforced anteriorly by the iliofemoral 
and pubofemoral ligaments (Fig. 8-2) and posteriorly by 
the ischiofemoral ligament (Fig. 8-3). 

Osteokinematics 

The hip is a synovial ball-and-socket joint with 3 degrees 
of freedom. Motions permitted at the joint are flexion- 
extension in the sagittal plane around a medial-lateral 
axis, abduction-adduccion in the frontal plane around an 
anterior-posterior axis, and medial and lateral rotation 
in the transverse plane around a vertical or longitudinal 



ilium 



Head of femur 





Pubis 



ischium 
FIGURE 8-1 An anterior view of the hip joint. 



Iliofemoral 
ligament 




Pubofemoral 
ligamenl 

FIGURE 8-2 An anterior view of the hip joint showing the 
iliofemoral and pubofemoral ligaments. 

183 



184 



PART III LOWER-EXTREMITY TESTING 




Ischiofemoral 
ligament 



FIGURE 8-3 A posterior view of the hip joint showing the 
ischiofemoral ligament. 



axis. 1 The axis of motion goes through the center of the 
femoral head. 

Arthrokinematics 

In an open kinematic (non-weight-bearing) chain, the 
convex femoral head slides on the concave acetabulum in 
a direction opposite to the movement of the shaft of the 
bone. In flexion, the femoral head slides posteriorly and 
inferioriy on the acetabulum, whereas in extension, the 
femoral head slides anteriorly and superiorly. In medial 



table 8~i Hip Motion: Values in Degrees 




rotation, the femoral head slides posteriorly on the 
acetabulum. During lateral rotation, the femoral head 
slides anteriorly. In abduction, the femoral head slides 
inferioriy. In adduction, the femoral head slides superi- 
orly. 

Capsular Pattern 

The capsular pattern is characterized by a marked restric- 
tion of medial rotation accompanied by limitations in; 
flexion and abduction. A slight limitation may he present 
in extension, but no limitation is present in either lateral 
rotation or adduction." 



2^ Research Findings 

Effects of Age, Gender, and Other Factors 

Table 8- 1 shows hip range of motion (RO.Mi values from 
various sources. The age, gender, measurement instru- 
ment used, and number or subjects measured to obtain 
the AAOS" and AMA values were nor reported. Boone 
and Azcfi,'* 1 Svenningsen and associates," and Roach and 
Miles used a universal goniometer. Svenningsen and 
associates" measured passive ROM in both males and 
females, whereas Roach and Miles measured active 
ROM. Boone and Azen 5 also measured active ROM but 
only in males. 

Age 

Researchers tend to agree that age affects hip ROM 8 " 22 
and that the effects are motion specific and gender 
specific. Table S-2 shows passive ROM values for 
neonates as reported in five studies. s " ! " All values 
presented in Table S-2 were obtained by means of a 
universal goniometer. A comparison or the neonate's 
passive ROM values shown in Table 8-2 with the values 
of older children and adults shown in Table 8-1 reveals 




Flexion 


120 


Extension 


20 


Abduction 




Adduction 




Medial rotation 


45 


Lateral rotation 


45 



100 
30 
40 
20 

40* 

■■ 50*; ;; 



122.3(6.1) 
9.8 (6.8) 
45.9 (9.3) 
26.9(4.1) 
47.3 (6.0) 
47.2 (6,3) 



137 
23 

40 

29 

38 

43' 



141 
26 

42 
30 
52 

41 



121.0 (13.0) 

19.0 (8.0) 

42.0 (11.0) 

32.0 (8.0). 

32.0 (9.0) 



(5D) = Standard deviation. 

* Measurements taken with subjects in the supine position. 









■'. 



^ - 






CHAPTER 8 THE HIP 



table 8-2 Effects of Age on Hip Motion in Neonates 6 Hours to 4;Weeks of Age: Mean Values 
in Degrees . :/■;. ■"•'■;'• ... ._■■■■- -■).-.■ , .... ,. 



185 




6~6Shrs 
n => 40 






,: ■ ,1^3 dayi . 
,.' n~ WOO 



Broughton efaf 

? -7 days 
, n-- S? . 



Wanatcibe ei 
n = 62 



of 1 



Mean (SO) 



Mean 



Mean (SO) 



I hmm 



Flexion 

Extension* 46.3 (8.2)* 

Ruction 

Adduction 

:MJedial Rotation 

^Lateral Rotation 

(SE>) ~ Standard deviation. 

* All values in this row represent the magnitude of the extension limitation 

'Tested with subjects in the supine poskion. 

'Tested with subjects in the side-lying position. 



28.3 (6.0)* 


20.0 


55.5 (9.5)' 


: 78.0* 


6.4 (3.9)' 


15.0* 


79.8 (9.3) r 


58.0 


113.7(10.4)+ 


80.0 



34.1 (6.3) 



---—■"' .-■:■■: ■■■■■.■: ... .:i-: ■■..■■ .:■■■-■..: . 



1 38.0 
12.0 

A- ^-° 'b. 

24.0 
66.0 



that the neonates studied have larger passive ROM in 
most hip motions except for extension, which is limited. 
The neonate's ROM in hip lateral and media! rotation 
and abduction is much larger than the ROM values of 
adults and older children for the same motions. Also, the 
relationship between hip lateral rotation and medial 
rotation appears to differ from that found in a majority 
of older children and adults. Hip lateral rotation values 
for the neonates are considerably greater than the values 
for medial rotation, whereas in children and adults the 
lateral rotation values are either about the same or less 
than the values for medial rotation. 15 Kozic and 
colleagues, 17 in a study of passive medial and lateral 
rotation in 1140 children aged 8 to 9 years, found that 
90 percent of the children had less than 10 degrees differ- 
ence between lateral and medial rotation. Ellison and 
coworkers, 18 in a study of 100 healthy adults and 50 
patients with back problems found that only 27 percent 
of healthy subjects compared with 48 percent of patients 
had greater lateral rotation than medial rotation. The 
large number of patients who had greater lateral than 
medial rotation suggests a rotational imbalance that may 
be related to back problems. 

However, as seen in Table 8-2 the most dramatic 
effect of age is on hip extension ROM. Newborns and 
infants are unable to extend the hip from full flexion to 



the neutral position (returning to degrees from the end 
of the flexion ROM). s ~ 15 Waugh and associates 8 found 
that all 40 infants tested lacked complete hip extension, 
with limitations ranging from 21.7 degrees to 68.3 
degrees. Schwarze and Denton 9 found mean limitations 
of 19 degrees for boys and 21 degrees for girts, and 
Broughton, Wright, and Menelaus 10 found a mean hip 
extension limitation of 34.1 degrees in 57 boys and girls. 
Forero, Okamura, and Larson 15 found that all 60 
healthy full-term neonates studied had hip extension 
limitations. 

Limitations in hip extension found in the very young 
are considered to be normal and to decrease with age as 
seen in Table 8-3. The term "physiological limitation of 
motion" has been used by Waugh and associates 8 and 
Walker 13 to describe the normal extension limitation of 
motion in infants. According to Walker, 13 movement 
into extension evolves without the need for intervention 
and should not be considered pathological in newborns 
and infants. Usually, a return from flexion to the neutral 
position is attained in children by 2 years of age. 
Extension ROM beginning at the neutral position 
usually approaches adult values by early adolescence. 
Broughton, Wright, and Menelaus 10 found that by 6 
months of age, mean hip extension limitations in infants 
had decreased to 7.5 degrees, and 27 of 57 subjects had 






p 



table 8-3 Hip Extension Limitations in Infants and Young Children 4 Weeks to 5 Years of Age: Mean 
Values in Degrees 




Standard deviation 



186 



PART lit LOWER-EXTREMITY TESTING 



Svennfhasen 



Boone 20 



"Roach and Miles 7 





Female ' ... 


Male;. ' 


;-;o" : :; >Mqles 






Mates and Females 






-.4 yrs . 


[ 4yrs 


6-12 yrs 


T3-19yrs- 


25-39 yrs 


40-59 yrs 


60-74 yrsJ 




n - 52 


.. n .'-■'^^ 


n- 17 


= 17 


n ^ 433 


rt ■= 727 


■;..,. n ~ 523; 


■YtOtfon 


* v ; 


M$m^y|E 


Mean (SO) 


Mean (SO) 


Mean (SD) 
122.0 (12) 


Mean (SD) 
120.0 (14) 


Mean (SO) 


Flexion 


151 


149 


124 .4 (5.9) 


122.6(5.2) 


118.0 (13) 


Extension 


29 


28 


10.4 (7.5) 


11.6(5.0) 


22.0 (8) 


18.0 (7) 


1 7.0 (8) 


Abduction 


55 


53 


48.1 (6.3) 


46.8 (6.0) 


44.0 (11) 


42.0 (11) 


39.0 (12) 


Adduction 


30 


30 


27.6 (3.8) 


26.3(2.9) 








Medial rotation 


60 


SI 


48.4 (4.8) 


47.1 (5.2) 


33.0 (7) 


31.0 (8) 


30.0 (7) 


Lateral rotation 


44 


48 


47.5 (3.2) 


47.4 (5.2) 


34.0 (8) 


32.0 (8) 


29.0 (9) 



(SD) = Standard deviation. 



no limitation. 9 Phelps, Smith, and Half urn 1 '' found that 

100 percent of the 9- and 12-month-old infants tested {n 
= 50} had some degree of hip extension limitation. At 18 
months of age, 89 percent of infants had limitations, and 
at 24 months, 72 percent still had limitations. 

The values in Table 8-4 supplied by Svenningsen and 
associates 6 were obtained by means of a universal 
goniometer from measurements of passive ROM, 
whereas the values supplied by the other authors 7,20 
were obtained by means of a universal goniometer from 
measurements of active ROM. Very little difference is 
evident between the ROM values for hip flexion and hip 
abduction across the life span of 4 to 74 years in contrast 
to hip medial and lateral rotation, which have the great- 
est decrease in ROM. Roach and Miles 7 have suggested 
that differences in active ROM representing less than 10 
percent of the arc of motion arc of little clinical signifi- 
cance, and that any substantia! loss of mobility in indi- 
viduals between 25 and 74 years of age should be viewed 
as abnormal and not attributable to aging. In the data 
from Roach and Miles 7 hip extension was the only 
motion in which the difference between the youngest and 
the oldest groups constituted a decrease of more than 20 
percent of the available arc of motion. 

Other authors who have investigated age or gender 
effects on the hip include Allander and colleagues; 21 
Walker and colleagues; 22 Boone, Walker, and Perry; 23 
James and Parker; 24 Mollinger and Steffan; 25 and 
Svenningsen and associates. 6 Allander and colleagues 21 
measured the ROM of different joints (i.e., shoulder, hip, 
wrist, and thumb metacarpophalangeal joints) in a popu- 
lation of 517 females and 203 males between 33 and 70 
years of age. These authors found that older groups had 
significantly less hip rotation ROM than younger 
groups. Walker and colleagues 22 measured 28 active 
motions (including all hip motions) in 30 women and 30 
men ranging from 60 to 84 years of age. Although 
Walker and colleagues 22 found no differences in hip 
ROM between the group aged 60 to 69 years and the 
group aged 75 to 84 years, both age groups demon- 



strated a reduced ability fn attain a neutral starting posi- 
tion for hip flexion. I he mean starting position for both 
groups for mcitMsremt'iUs of flexion ROM was 11 
degrees instead of degrees. The mean ROM values 
obtained for both age groups tor hip rotation, abduction, 
and adduction were 14 to 25 degrees less than the aver- 
age values published by the AAOS. ' This finding 
provides stmng support for the use ot age-appropriate 
norms. 

James and I'arkcr"" measured active and passive 
ROM at the hip, knee, and ankle in 80 healthy men and 
women ranging from ~(J year* to L, 2 years, of age. 
Measurements ot hip abduction ROM were taken with a 
universal goniometer. All other measurements were 
taken with a l.dghton tlexomctcr. Systematic decreases 
in both active and passive ROM were found itt subjects 
between 70 and 92 years of age. Hip abduction 
decreased the iww with age and was 33.4 percent less in 
the oldest group ot men and women (those aged 85 to 92 
years) compared with the youngest group (those aged 70 
to 74 years). Media! and lateral rotation aiso decreased 
considerably, but the decrease was not as great as that 
seen in abduction. In contrast, hip flexion with the knee 
either extended or flexed was ieast affected by age, with 
a significant reduction occurring only in those older than 
85 years ot age. Passive ROM was greater than active 
ROM for all joint motions tested, with the largest differ- 
ence (7 degrees) occurring in hip flexion with the knee 
flexed. 

Although Svenningsen and associates'' studied hip 
ROM in fairly young subjects (761 males and females 
aged 4 to 28 years), these authors found that even in this 
limited age span, the ROM for most' hip motions showed 
A decrease with increasing age. However, the reductions 
in ROM varied according to the motion. Decreases in 
flexion, abduction, medial rotation, and total rotation 
were greater than decreases in extension, adduction, and 
lateral rotation. 

N'onaka and associates,"' in a study of 77 healthy 
male volunteers aged 15 to 73 years, found that passive 




CHAPTER 8 THE HIP 



187 



; : 



- ■ 



r 



d 






es :' 
lis ; 
-A 

ns 

„ 









hip ROM decreased progressively with increasing age, 
but no change was observed in knee ROM in the same 
population. 

Gender 

The effects of gender on ROM are usually age specific 

and motion specific and account for only a relatively 
small amount of total variance in measurement. Boone 
and coworkers 2j found significant differences for most 
hip motions when gender comparisons were made for 
three age groupings of males and females. Female chil- 
dren {1 to 9 years of age), young adult females (21 to 29 
years of age) and older adult females (61 to 69 years of 
age) had significantly more hip flexion than their male 
counterparts. However, female children and young adult 
females had less hip adduction and lateral rotation than 
males in comparison groups. Both young adult females 
and older adult females had less hip extension ROM than 
males. Allander and colleagues" 1 found that in five of 
eight age groups tested, females had a greater amount of 
hip rotation than males. Walker and colleagues 22 found 
that 30 females aged 60 to 84 years had 14 degrees more 
ROM in hip medial rotation than their male counter- 
parts. Simoneau and coworkers 26 found that females 
(with a mean age of 21.8 years) had higher mean values 
in both medial and lateral rotation than age-matched 
male subjects. The authors used a universal metal 
goniometer to measure active ROM of hip rotation in 39 
females and 21 males. In contrast to Walker and 
colleagues 22 and Simoneau and coworkers, 26 Phelps, 
Smith, and Halium 14 found no gender differences in hip 
rotation in 86 infants and young children (aged 9 to 24 
months). 

:.:■:■■■ Svenningsen and associates 6 measured the passive 
ROM of 1552 hips in 761 healthy males and females 
between 4 years of age and 28 years of age. Females of all 
age groups in this study had greater passive ROM than 
males for total passive ROM, total rotation, medial rota- 
tion, and abduction. Female children in the 1 1-year-old 
age group and the 15-year-old age group and female 
adults had greater passive ROM in hip flexion and 
adduction than males in the same age groups. Males had 
greater passive ROM in hip lateral rotation than females 
in the 4-year-old group and the 6-year-old group and 
in adults. This finding is in agreement with that of 
Boone. 20 

James and Parker 2 ' 1 found that women were signifi- 
cantly more mobile than men in 7 of the 10 motions 
tested at the hip, knee, and ankle. At the hip, women had 
greater mobility than men in all hip motions except 
abduction. This finding is in agreement with that of 
Boone but opposite to the findings of Svenningsen and 
associates. 6 xMen and women had similar mean values in 
hip flexion ROM, both with the knee flexed and with the 
™ee extended in the group aged 70 to 74 years, but in 
the group between 70 and S5-p]us years of age, me;: had 



an approximate 25 percent decrease in ROM, whereas 
women had a decrease of only about 11 percent. 

Body- Mass Index 

Kettunen and colleagues 27 found that former elite 
athletes with a high body-mass index (BM1) had lower 
total amount of hip passive ROM compared with former 
elite athletes with a low BMI, Subjects in the study 
included 117 former elite athletes between the ages of 45 
and 68 years. Measurements were taken by means of a 
Myrin goniometer, with the subjects in the prone posi- 
tion. Escalante and coworkers 28 determined that there 
was a loss of at least one degree of passive range of 
motion in hip flexion for each unit increase in BMI in a 
group of 687 community-dwelling elders (those who 
were 65 years of age to 78 years of age). Severely obese 
subjects had an average of 18 degrees less hip flexion 
than nonobese subjects as measured in the supine posi- 
tion with an inclinometer. BMI explained a higher 
proportion of the variance in hip flexion ROM than any 
other variable examined by the authors. Lichtenstcin and 
associates" 9 studied interrelationships among the vari- 
ables in the study by Escalante and coworkers 28 and 
concluded that BMI could be considered a primary direct 
determinant of hip flexion passive ROM. 

On the other hand, Bennell and associates 89 found no 
effect of BMI on active ROM in hip rotation in a study 
comparing 77 novice ballet dancers and 49 age-matched 
controls between the ages of 8 and 11 years. The control 
subjects, who had a higher BMI than the dancers, also 
had a significantly greater range of lateral and medial hip 
rotation. 

Testing Position 

Simoneau and coworkers -6 found that measurement 

position (sitting versus prone) had little effect on active 
hip medial rotation in 60 healthy male and female college 
students (aged 18 to 21 years), but that position had a 
significant effect on lateral rotation ROM. Lateral rota- 
tion measured with a universal goniometer on subjects in 
the sitting position was statistically less (mean, 36 
degrees) than it was when measured on subjects in the 
prone position (mean, 45 degrees). Bierma-Zeinstra and 
associates 30 found that both lateral and medial rotation 
ROMs were significantly less when measured in subjects 
in the sitting and supine positions compared with those in 
the prone position. However, Schwarze and Denton y 
found no difference in hip medial and lateral rotation 
passive ROM measurements taken in subjects in the 
prone position than in measurements taken in 1000 
neonates in the supine position. 

Van Dillen and coworkers 31 compared the effects of 
knee and hip position on passive hip extension ROM in 
10 patients (mean age, 33 years) with low back pain and 
35 healthy subjects (mean age, 31 years). Both groups 
had less hip extension when the hip was in neutral abduc- 



- 



188 



PART III LOWER-EXTREMITY TESTING 



table 8-5 Effects: of Position on Hip ROM: Mean Values jn Degrees: 



Motion 



Seated 



Position 



Prone 



Mean (SD) 



Mean (SD) 



Supine: 



Meart;. 



Simoneau et al 2s 



Bierma-Zeinstra et al 30 



Lateral rotation* 
Mediaf rotation* 
Total rotation* 
Lateral rotation* 
Medial rotation* 
Lateral rotation* 
Medial rotation* 

(SD) = Standard deviation. 

* Active ROM measured with a universal goniometer. 

T Passive ROM measured with a universal goniometer. 

tion than when the hip was fully abducted. Both groups 
also displayed less hip extension ROM when the knee 
was flexed to 80 degrees than when the knee was fully 
extended (Table 8-5), This finding lends support for 
Kendall, McCreary, and Provance, 32 who maintain that 
changing the knee joint angle during the Thomas test for 
hip flexor length can affect the passive ROM in hip 
extension (see Muscle Length Testing Procedures Section 
later in this chapter for information on the Thomas test). 

Arts and Sports 

A sampling of articles related to the effects of ballet, ice 

hockey, and running on ROM are presented in the 
following paragraphs. As expected, the effects of the 
activity on ROM vary with the activity and involve 
motions that are specific to the particular activity. 
Gilbert, Gross, and Klug 33 conducted a study of 20 
female ballet dancers (aged 11 to 14 years) to determine 
the relationship between the dancer's ROM in hip lateral 
rotation and the turnout angle. An ideal turnout angle is 
a position in which the longitudinal axes of the feet are 
rotated 180 degrees from each other. The authors found 
that turnout angles were significantly greater (between 13 
and 17 degrees) than measurements of hip lateral rota- 
tion ROM. This finding indicates that the dancers were 
using excessive movements at the knee and ankle 
to attain an acceptable degree of turnout. According 
to the authors, the use of compensatory motions at the 
knee and ankle predisposes the dancers to injury. The 
dancers had had 3 years of classical ballet training and 
still had not been able to attain the degree of hip lateral 
rotation that would give a 180-degree turnout angle. 
Consequently, the authors suggest that hip ROM may be 
genetically determined. 

Bennell and associates 19 determined that age-matched 
control subjects had significantly greater active ROM in 
hip lateral and medial rotation than a group of 77 ballet 
dancers (aged 8 to 11 years), although there was no 
significant difference in the degree of turnout between the 
two groups. The amount of non-hip lateral rotation was 
significantly greater in the dancers than in the control 



36 


(7) 


33 


(7) 


69 


(9) 


33.9 




33.6 




37.6 




36.8 





45 


00) 


36 


(9) 


81 


(12) 


47.0 




46.3 




51.9 




53.2 





33.1 
36.0 
34.2 
39.9 



subjects. Non-hip lateral rotation as .1 percentage of 
active hip ROM was 40 percent in dancers compared 
with 20 percent in control subjects. The increased 
torsional forces on the media! aspect of the knee, ankle, 
and toot in the young dancers puts this group at high risk 
of injury. Similar to the findings of Gilbert, Gross, and 
King," the authors found no relationship between 
number of years of training and lateral rotation ROM, 
which again suggests a genetic component of ROM. The 
authors did nor offer an explanation for the fact that the 
control subjects had a greater ROM in lateral motion 
than the dancers; instead, they hypothesized that a short- 
ening of the hip extensors (resulting from constant use) 
and the dancers' avoidance of full hip medial rotation 
might account for the fact that the dancers had less hip 
media! rotation than the control subjects. 

Tyler and colleagues'' 1 found that a group of 25 profes- 
sional male ice hockey piayers had about 10 degrees less 
hip extension ROM than a group of 25 matched control 
subjects. The authors postnlarcd that rhe loss of hip 
extension in the hockey players was probably due to tight 
anterior hip capsule structures and tight iliopsoas 
muscles. The flexed hip and knee posture assumed by the 
players during skating probably contributed to the 
muscle shortness and loss of hip extension ROM. Van 
Meehelen and colleagues"' used goniometry to measure 
hip ROM in 16 male runners who had sustained running 
injuries during the year but who were fit at the time of 
the study. No right-left differences in hip ROM were 
found either in the previously injured group or in a 
control group of runners who had nor sustained an 
injury. However, hip ROM in the injured group was 
on average 59.4 degrees or about 10 degrees less than 
the average ROM of 68.1 degrees in runners without 
injuries. 

Disability 

Steultjens and associates'" used a universal goniometer to 

measure bitareral active assistive ROM at the hip and 

knee in 198 patients with osteoarthritis (OA) of the hip 
or knee. These authors found that generally a decrease in 






CHAPTER 8 THE HIP 



189 



■ 



m- 



kjp ROM was associated with an increase in disability, 
but that association was motion specific. Flexion contrac- 
tures of either hip or knee or both were found in 72.5 
percent of the patients. Hip flexion contractures were 
present in 15 percent of the patients, whereas contrac- 
ture 5 at the knee were found in 31.5 percent of the 
patients. Hip extension and lateral rotation showed 
significant relationships with disability in patients with 
knee OA, whereas knee flexion ROM was associated 
with disability in hip OA patients. Twenty-five percent of 
the variation in disability levels was accounted for by 
differences in ROM. 
, Molltnger and Steffan,~ 5 in a study of 111 nursing 
Horne residents, found a mean hip extension of only 4 
degrees (measured with the residents in the supine posi- 
tion with the leg off the side of the table and the 
contralateral knee flexed). Beissner, Collins, and 
Holmes 37 found that lower-extremity passive ROM and 
lipper-extremity muscle force are important predictors of 
function for elderly individuals living in assisted living 
residences or skilled nursing facilities. Conversely, upper 
extremity ROM and age are the strongest predictors of 
function in elderly individuals residing in independent 
living situations. 

Functional Range of Motion 

Table 8-6 shows the hip flexion ROM necessary for 
selected functional activities as reported in several 
sources. An adequate ROM at the hip is important for 
meeting mobility demands such as walking, stairclimbing 
(Fig. 8—4), and performing many activities of daily living 
that require sitting and bending. According to Magee, 38 
ideal functional ranges are 120 degrees of flexion, 
degrees of abduction, and 20 degrees of lateral rotation. 
However, as can be seen in Table 8-6, considerably less 
ROM is necessary for gait on level surfaces. 39 Livingston, 
Stevenson, and Olney 40 studied ascent and descent on 
stairs of different dimensions, using 15 female subjects 
between 19 years of age and 26 years of age. McFayden 
and Winter 41 also studied stairclimbing; however, these 
authors used eight repeated trials of one subject. 
: In a study to determine the effects of age-related ROM 
on functional activity, Oberg, Krazinia, and Oberg 42 




«*£§! 



FIGURE 8-4 Ascending stairs requires between 47 and 66 
degrees of hip flexion depending on stair dimensions. 40 



measured hip and knee active ROM with an electrogo- 
niometer during gait in 240 healthy male and female indi- 
viduals aged 10 to 79 years of age. Age-related changes 
were slightly more pronounced at slow gait speeds than 
at fast speeds, but the rate of changes was less than 1 
degree per decade, and no distinct pattern was evident, 



TA8LE8-6 Hip Flexion Range of Motion Required for Functional Activities: Values in Degrees 
from Selected Sources 



Uvingston et at 4 



Ranches Los Amigos Medical Center 39 



McFayden and Winter 41 



to 
nd 
hip 



I|||cifi8lnpfalrl: ; 4ifii 



Range 



Mean (SO) 



0-30 

■■i-o^ee- 

1-0-45 



■ 0-3.0 -■. 



60 



H5) 
(0.1) 



190 



PART 111 



LOWER-EXTREMITY TESTING 



except that hip flexion-extension appeared to be affected 
less than other motions. 

Other functional and self-care activities require a 
larger ROM at the hip. For example, sitting requires at 
least 90 to 112 degrees of hip flexion with the knee 
flexed (Fig. 8-5). Additional flexion ROM (120 degrees) 
is necessary for putting on socks (Fig. 8-6), squatting 
(1 15 degrees), and stooping (125 degrees). 38 

Reliability and Validity 

Studies of the reliability of hip measurements have 
included both active and passive motion and different 

types of measuring instruments. Therefore, comparisons 
among studies are difficult. Boone and associates 4 - 1 and 
Clapper and Wolf' 4 investigated the reliability of meas- 
urements of active ROM. Ekstrand and associates, 4 '' 
Pandya and colleagues, 46 Ellison and coworkers, 18 Van 
Mechelen and colleagues, 35 Van Dillcn and coworkers, 31 
Croft and associates, 4 ' Cibulka and colleagues, 48 and 
Cadenhead and coworkers 49 studied passive motion. 
Bierma-Zeinsrra and associates 30 studied the reliability 





FIGURE 8-5 Sitting in a chair with an average seat height 
requires 112 degrees of hip flexion. 38 



HGURE-! S-6 Kunmi' on s"t*fo require* 110 dc£m$ nf flexion, 

211 demees ot ahiluetion .ini.1 20 decrees oi' I.Ult.iI rotation. is 



of both active and passive ROM, Tabic S-* 7 provides a 
sampling of mtraicstcr and intertestcr reliability studies. 

Boone and associates 4 '' conducted a study in which 
tour physical therapists used a universal goniometer to 
measure active ROM of three upper-extremity morions 
and three lower-extremity morions in 12 male volunteers 
aged 2f> to 54 years. One of the motions tested was hip 
abduction. Three measurements were taken by each 
tester at each oi tour sessions scheduled on a weekly 
basis for 4 weeks. Intratester reliability for hip abduction 
was c = 0.75, with a total standard deviation between 
measurements of 4 degrees taken by the same testers. 
Intertester reliability for hip abduction was r = 0.55, 
with a rota! standard deviation of 5.2 degree* between 
measurements taken by different testers. 

Clapper and Wolf 44 compared the reliability of the 
Orrhorangcr (Orchotomies, Daytona Beach, Ida.), an 
electronic computed pendulum goniometer, with that of 
the universal goniometer in a study of active hip motion 




CHAPTER 8 THE HIP 



191 



TABLE 8-7 Intratester Reliability 



ZAuthaf: 



S&mpfe 



Positiar, 



Motion 



ICC: 



Van Ditlen et al JI 



35 



Healthy subjects 



Ellison etal' 8 
Cadenhead et al 19 



22 



Healthy subjects 

Aduits with cerebral palsy 



'■":"' 



Supine: Hip in neutraf and Extension Right hip 0,70 

Knee in 80 degrees flexion. Left hip 0.89 

Hip in neutral and Extension Right hip 0.72 

Knee in full extension. Left hip 0.76 

Hip in full abduction and Extension Right hip 0.87 

Knee in 80 degrees flexion Left hip 0.76 

Hip in full abduction flexion and Extension Right hip, 0.96.: 

Knee in full extension Left hip 0:90 

Prone: hip in neutral: position Medial rotation Right hip 0.99- 

and knee flexed to 90degrees Lateral rotation Right hip Q<?6 

Supine Abduction Right hip 0.99, 

Prone Extension Right hip 0:98 

ne Lateral rotation Right hip 0,79 



ICC = Intraclass correlation coefficient. 




W 
m 

iff 



involving 10 mates and 10 females between the ages of 23 
and 40 years. The authors found that the universal 
goniometer showed significantly less variation within 

sessions than the Orthoranger, except for measurements 
of hip adduction and lateral rotation. The authors 
concluded that the universal goniometer was a more reli- 

. able instrument than the Orthoranger. The poor correla- 
tion between the Orthoranger and the universal 
goniometer for measurement of hip adduction and 
abduction ROM values demonstrated that the two 
instruments could not be used interchangeably. 

Ekstrand and associates 4 ^ measured the passive ROM 
of hip flexion, extension, and abduction in 22 healthy 
men aged 20 to 30 years. They used a specially 
constructed goniometer to measure hip abduction and a 
flexometer to measure hip flexion and extension in two 
testing series. In the first series, the testing procedures 
were not controlled. In the second series, procedures 
were standardized and anatomical landmarks were indi- 
cated. The intratester coefficient of variation was lower 

: : than the intertester coefficient of variation for both 



table 8-8 Intertester Reliability 



series. Standardization of procedures improved reliability 
considerably. The intertester coefficient of variation was 
significantly lower in the second series than in the first 

when the procedures were not standardized. 

In a study by Pandya and colleagues, 46 five physical 
therapists using universal goniometers measured passive 
joint motions including hip extension in the upper and 
lower extremities of 105 children and adolescents, aged 1 
to 20 years, who had Duchenne muscular dystrophy. 
Intratester reliability was high for all measurements; the 
intraclass correlation coefficient (ICC) ranged from 0.81 
to 0.94. The intratester reliability for measurements of 
hip extension was good (ICC = 0.85). The overall ICC 
for intertester reliability for all measurements ranged 
from 0.25 to 0.91. Intertester reliability for measure- 
ments of hip extension was fair (ICC = 0.74). The results 
indicated the need for the same examiner to take meas- 
urements for long-term follow-up and to assess the 
results of therapeutic intervention. 

Ellison and coworkers 18 compared passive ROM 
measurements of hip rotation taken with an inclinometer 



Atithm 



'^Sample 



Position 



Motion 



tec: 



Simoneau et ai 2 * 60 



Ellison et al ia 



22 



15 



Healthy subjects 
(18-27 yrs) 



Healthy subjects 
(20-41 yrs) 



Adults with back pain 
(23-61 yrs) 



Prone Medial rotation 

Seated Medial rotation 

Prone Lateral rotation 

Seated Lateral rotation 

Prone Left medial rotation : 

Prone Left lateral rotation 

. Prone Right medial rotation 

Prone Right lateral rotation 

Prone Left medial rotation 

Prone Left lateral rotation 

Prone /Right medial rotation 

Prone : : .Right lateral rotation 



fts» 



0.82, 0.96, 0.97 

0.89, 0.85, 0.93 

0.89,0.79,0.98 

0.90, 0.76, 0.95 

0.98 

0.97 

0.99 

0.96 

0.97 

0.95 

0.96 

0.95 



ICC = Intraclass correlation coefficient. 



192 



PART III 



I. O W ER-UTREMl T Y T E S T I N C 



and a universal goniometer and found no significant 

ctittercncch between the means. Both instruments were 
found to be reliable, but the authors preferred the incli- 
nometer because it was easier to use. Croft and associ- 
ates' 1 used a fluid-tilled inclinometer called a Plurimeter 
to determine the interrester reliability ol passive hip flex- 
ion and rotation ROM measurements taken by sin clini- 
cians. The clinicians took ROM measurements of both 
hips in six patients with osteoarthritis involving only one 
hip |oint. Flexion was measured with the patient in the 
supine position either to maximum flexion or to the 
point when further motion was restricted by pain. Flic 
results showed no difference between the measurements 
taken by one examiner and those taken by other exam- 
iners, but the decree of agreement was greatest for meas- 
urements of Sn'p flexion. Cibulka and colleagues, ,h in a 



Range of Motion Testing Procedures: 
Landmarks for Goniometer Alignment 



study of passive ROM in medial and lateral hip rotation 
in 100 patients with tow back pain, determined chat fo r 
this group of patients, measurements of rotation taken in 
the prone position were more reliable than those taken in 
the sitting position. Bierma/.einstra and associates 10 
compared the reliability of hip ROM measurements 
taken by means of an electronic inclinometer with those 
taken by means of a universal goniometer. The two 
instruments showed equal intratesrer reliability for both 
active and passive hip ROM in general; however, the 
intratesrer reliability of the inclinometer was higher than 
that of the goniometer for passive hip rotation. The incli- 
nometer also had higher intertester reliability for active 
medial rotation than the goniometer, and the authors 
cautioned that the instruments should not be used inter- 
changeably. 



Hip 



'■'■'-•:':■'' ' . Vv . . :■::■'.■ ■..■■■■ • ■■■■.: / '.■■■ ' ■ -:7. '■ ::■:■ ■ " . ::. 



-'" ^, 



'^SjJUWp^" " 





FIGURE 8-7 A lateral view of the hip showing surface anatomy landmarks For aligning the goniometer 
for measuring hip flexion and extension. 



Greater trochanter 

femur 



Lateral epicondyle 
femur 




>■ 









■', _ - 









HCiURh S-S A lateral view of the hip showing bony anatomical landmarks for aligning the goniometer. 






CHAPTER 8 THE HIP 193 



■ 



i ! 



i ■ 



< ■■ 



■ 

":■ 




Anterior superior 
iliac spine > 



Paislia 



FIGURE 8-9 An anterior view of the hip showing surface 
anatomy landmarks for aligning the goniometer. 



FIGURE 8-7 An anterior view of the pelvis showing the 
anatomical landmarks for aligning the goniometer for meas- 
uring abduction and adduction. 



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PART III LOWER-EXTREMITY TESTING 



FLEXION 



uj.| Motion occurs in the sagittal plane around a medial* 
q I lateral axis. The mean hip flexion ROM for adults is 100 
- 1 degrees according to the AM A *' and 121 degrees accord- 
ing to the study by Roach and Miles. 7 See Tables 8-1, 



U 



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H 



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| 8-2, and 8-5 for additional ROM information. 

I Testing Position 

I 

I Place the subject in the supine position, with the knees 

| extended and both hips in degrees of abduction, adduc- 

1 tion, and rotation. 

t Stabilization 

i 

1 Stabilize the pelvis with one hand to prevent posterior 

I tilting or rotation. Keep the contralateral lower extremity 

I flat on the table in the neutral position to provide addi- 

I tional stabilization. 

J Testing Motion 

' : J Flex the hip by lifting the thigh off the table. Allow the 
J knee to flex passively during the motion to lessen tension 



in the hamstring muscles. Maintain the extremity in 
neutral rotation and abduction and adduction through- 
out the motion (Fig. 8-11). The end of the ROM occurs 
when resistance to further motion is felt and attempts at 
overcoming the resistance cause posterior tilting of the 
pelvis. 

Normal End- feel 

The end-feel is usually soft because of contact between 

the muscle bulk of the anterior thigh and the lower 
abdomen. However, the end-feel may he firm because of 
tension in the posterior joint capsule and the gluteus 
maximus muscle. 

Goniometer Alignment 

See Figures 8-12 and 8-13. 

1. Center the fulcrum of the goniometer over the 

lateral aspect of the hip joint, using the greater 
trochanter of the femur for reference. 

2. Align the proximal arm with the lateral midline of 
the pelvis. 

3. Align the distal arm with the lateral midline of the 
femur, using the lateral epicondyle as a reference. 






f 




FIGURE 8-11 The end of hip flexion passive ROM. The placement of the examiner's hand on the pelvis 

allows the examiner to stabilize the pelvis and to detect any pelvic motion. 









'■%■ 



CHAPTER S THE HIP 195 



S 

it 
te 



:n 
er 

of 

us 



of 










FIGURE 8-12 Goniometer alignment in the supine starting position for measuring hip flexion ROM. 




FIGURE 8-13 At the end of the left hip flexion ROM, the examiner uses one hand to align the distal 
goniometer arm and to maintain the hip in flexion. The examiner's other hand shifts from the pelvis to 
hold the proximal goniometer arm aligned with the lateral midline of the subject's pelvis. 



— 



=/!! 196 



PART I!! LOWES-EXTREMITY TESTING 



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EXTENSION 



I Motion occurs in a sagittal plane around a medial-lateral 

| axis. The mean hip extension ROM for adults is 19 

| degrees according to Roach and Miles' and 30 degrees 

I according to the AMA.' 1 See Tables 8-1, 8-2, 8-4, and 

| 8-5 for additional ROM information. 

I Testing Position 

1 Place the subject in the prone position, with both knees 
I extended and the hip to be tested in degrees of abduc- 
I tion, adduction, and rotation. A pillow may be placed 
I under the abdomen for comfort, but no pillow should be 
1 placed under the head. 

I Stabilization 

I Hold the pelvis with one hand to prevent an anterior tilt. 
I Keep the contralateral extremity flat on the table to 
I provide additional pelvic stabilization 

| Testing Motion 

I Extend the hip by raising the lower extremity from the 
| table (Figure 8—14). Maintain the knee in extension 
| throughout the movement to ensure that tension in the 



two-joint rectus femoris muscle does not limit the hip 
extension ROM. The end of the ROM occurs when 
resistance to further motion of the femur is felt and 
attempts at overcoming the resistance causes anterior 
tilting of the pelvis and/or extension of the lumbar spine. 

Normal End-feel 

The end-feel is firm because of tension in the anterior 
joint capsule and the iliofemoral ligament, and, to a 
lesser extent, the ischiofemoral and pubofemoral liga- 
ments. Tension in various muscles that flex the hip, such 
as the iliopsoas, sartorius, tensor fasciae latae, gracilis, 
and adductor longus, may contribute to the firm end- 
feel. 

Goniometer Alignment 

See Figures 8-15 and 8-16. 

1. Center the fulcrum of the goniometer over the 
lateral aspect of the hip joint, using the greater 
trochanter of the femur for reference. 

2. Align the proximal arm with the lateral midline of 
the pelvis. 

3. Align the distal arm with the lateral midline of the 
femur, using the lateral epicondyle as a reference. 




FIGURE S— 14 The subject's right lower extremity at the end of hip extension ROM. The examiner uses 
one hand to support the distal femur and maintain the hip in extension while her other hand grasps the 
pelvis at the level of the anterior superior iliac spine. Because the examiner's hand is on the subject's pelvis 
the examiner is able to detect pelvic tilting. 



aitip 



CHAPTER 8 THE HIP 197 




-.---; 



I / 





: ■ -' 



FIGURE 8-15 Goniometer alignment in the prone starting position for measuring hip extension ROM. 









FIGURE 8-16 At the end of hip extension ROM, the examiner uses one hand to hold the proximal 

goniometer arm in alignment. The examiner's other hand supports the subject's femur and keeps the distal 
goniometer arm in alignment. 



p 



.5Ei 198 



PART lit LOWER-EXTREMITY TESTING 



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■ .'>.■ LU 
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I']-; os. 



ABDUCTION 



Motion occurs in the frontal plane around an anterior- 
posterior axis. The mean ROM in abduction is 40 
degrees according to the AMA 4 and 42 degrees according 
to Roach and Miles. 7 (Sec Tables 8-1, 8-2, and 8-5 for 

additional ROM information.) 

1 Testing Position 

;| Place the subject in the supine position, with the knees 

:| extended and the hips in degrees of flexion, extension, 
: | and rotation. 

I Stabilization 

I Keep a hand on the pelvis to prevent lateral tilting and 
il rotation. Watch the trunk for lateral trunk flexion. 

I Testing Motion 

-§ Abduct the hip by sliding the lower extremity laterally 

;| (Fig. 8—17), Do not allow lateral rotation or flexion of 

1 the hip. The end of the ROM occurs when resistance to 
1 

I 



further motion of the femur is felt and attempts to over- 
come the resistance causes lateral pelvic tilting, pelvic 
rotation, or lateral flexion of the trunk. 

Normal End- feel 

The end-fed is firm because of tension in the inferior 

(medial) joint capsule, pubofemoral ligament, 
ischiofemoral ligament, and inferior hand of the 
iliofemoral ligament. 1'assive tension in the adductor 
magnus, adductor longus, adductor brevis, pecrineus, 
and gracilis muscles may contribute to the firm end-feel. 

Goniometer Alignment 
See Figures S-1S and &-W. 

1. Center the fulcrum of the goniometer over the ante- 
rior Superior iliac spine (ASIS) of the extremity 
being measured. 

2. Align the proximal arm with an imaginary hori- 
zontal line extending from one ASIS to the other. 

3. Align the distal arm with the anterior midline of the 
femur, using the midline of the patella for reference. 










FIGURE 8-17 The left lower extremity at the end of 
the iup abduction ROM. The examiner uses one hand 

to pull the subject's ieg into abduction. (The examiner's 
i^rip on the ankle is designed to prevent lateral rotation 

ot the hip.) The examiner's other hand not only stabi- 
lizes the pelvis but also is used to delect pelvic motion. 



m 






CHAPTER 8 THE HIP 



199 



itc- 
isty 

ivi- 
r. 

the 
ice. 



MM: 



'S 



-■ 



cl of 
i.ind 
ner's 
tion 
ra bi- 
:ion. 





FIGURE 8-18 In the starting position for measuring hip abduction ROM, the goniometer is at 90 
degrees. This position is considered to be the 0-degrec starting position. Therefore, the examiner must 
transpose her reading from 90 degrees to degrees. For example, an actual reading of 90-120 degrees on 
the goniometer is recorded as 0-30 degrees. 




FIGURE 8-19 Goniometer alignment at the end of the abduction ROM. The examiner has determined 
the end-feel and has moved her tight hand from stabilizing the pelvis in order to hold the goniometer in 
correct alignment. 



0- 

r 

t/i 

ac 

DS 
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Si 

a. 

z 

LU 

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g 

6 

LU 

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OS 



200 



PART II! LOWER-EXTREMITY TESTING 



ADDUCTION 



Motion occurs in a frontal plane around an anterior- 
posterior axis. The mean ROM in adduction for adults is 
20 degrees according to the AMA 4 and 30 degrees 
according to the AAOS. 3 See Tables 8-1, 8-2, and 8-5 
for additional ROM information. 

Testing Position 

Place the subject in the supine position, with both knees 
extended and the hip being tested in degrees of flexion, 
extension, and rotation. Abduct the contralateral extrem- 
ity to provide sufficient space to complete the full ROM 
in adducrion. 






Stabilization 

Stabilize the pelvis to prevent lateral tilting. 

Testing Motion 

Adduct the hip by sliding the lower extremity medially 
toward the contralateral lower extremity (Fig. S-20). 
Place one hand at the knee to move the extremity ■-"■- 
adduction and to maintain the hip in neutral flexion 
rotation, "['he end ot the ROM occurs when resistant 

l-iirf lii.r- >w \ .-I I I -f kmi if (-nth -i n I \ ■ir»l^rt^^\re F*t /iiMn-nmg 



into 
and 

- - - — -• .— anceto 

further adduction is felt and attempts to overcome the 
resistance cause lateral pelvic tilting, pelvic rotation 

irii /nr -in-n rrmiL tl'vinn ,- 



and/or lateral trunk flexion. 





FIGURE 8-20 At the end (if the hip adduction ROM, the 
examiner maintains che hip in adduction with one hand and 
stabilizes the pelvis with her other hand. 





:dialty 
3-20). 
y into 
» 0$ 
nee to 
ne t(ip 
tation. 



CHAPTER 8 THE H!P 



201 



prmal End-feel 

He end-feel is firm because of tension in the superior 
(lateral) joint capsule and the superior band of the 
iliofemoral ligament. Tension in the gluteus medius and 
primus and the tensor fasciae latae muscles may also 
contribute to the firm end-feel. 



Goniometer Alignment 

See Figures 8-21 and 8-22. 

1. Center the fulcrum of the goniometer over the 
ASIS of the extremiry being measured. 

2. Align the proximal arm with an imaginary hori- 
zontal line extending from one ASIS to the other. 

3. Align the distal arm with the anterior midline of 
the femur, using the midline of the patella for refer- 
ence. 



1 



LOM, the 
hand and' 




vfRGURE 8-21 The alignment of the goniometer is at 90 
J%ees. Therefore, when the examiner records the measure- 
vj^nt, she will have to transpose the reading so that 90 degrees 
js equivalent to degrees. For example, an actual reading of 90 

=|p(( degrees is recorded as 0-30 degrees. 



FIGURE 8-22 At the end of the hip adduction ROM, the 
examiner uses one hand to hold the goniometer body over the 
subject's anterior superior iliac spine. The examiner prevents 
hip rotation by maintaining a firm grasp at rhe subject's knee 
with her other hand. 



2= 
X 



= 1 202 



PART III LOWER-EXTREMITY TESTING 



tu I 

0£ ■: 

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MEDIAL (INTERNAL) ROTATION 



Motion occurs in a transverse plane around a vertical 
axis when the subject is in anatomical position. The 
mean adult values for the ROM in media! rotation are 
32 degrees according Roach and Miles and 40 degrees 
according to the AMA. 4 See Tables 8-1, 8-2, 8-3, and 
8-5 for additional ROM information. 



Z 1 



Testing Position 

Seat the subject on a supporting surface, with the knees 
flexed to 90 degrees over the edge of the surface. Place 
the hip in degrees of abduction and adduction and in 

90 degrees of flexion. Place a towel roll under the distal 
end of the femur to maintain the femur in a horizontal 

plane. 



Stabilization 

Stabilize the distal end of the femur to prevent abduc- 
tion, adduction, or further flexion of the hip. Avoid rota- 
tions unci lateral tilting of the pelvis. 

Testing Motion 

Place one hand at the distal femur to provide stabiliza- 
tion and use the other hand at the distal tibia to move the 
lower leg laterally. The hand performing the motion also 
holds the lower leg in a neutral position to prevent rota- 
tion at the knee joint (Fig. 8-23). The end of the ROM 
occurs when attempts at resistance are felt and attempts 
ar further motion cause tilting of the pelvis or lateral 
flexion of the trunk. 





h 



RGURE S-23 The kit lower extremity ,u the end of the ROM 

of hip medial mutton. One of die examiner's hands is placed on 
the subject's distal femur to prevent hip flexion and abduction. 
Her other hand pel 1 Is the lower leg laterally. 




CHAPTER 8 THE HIP 



203 



c- 
a- 



: 



; 



Normal End-feel 

The end-feel is firm because of tension in the posterior 
joint capsule and the ischiofemoral ligament. Tension in 
the following muscles may also contribute to the firm 
end-feel: piriformis, obturatorii (internus and externus), 
gemelli (superior and inferior), quadratus femoris, 
gluteus medius (posterior fibers), and gluteus maximus. 




Goniometer Alignment 
See Figures 8-24 and 8-25. 

1. Center the fulcrum of the goniometer over the 

anterior aspect of the patella. 

2. Align the proximal arm so that it is perpendicular 
to the floor or parallel to the supporting surface. 

3. Align the distal arm with the anterior midline of 
the lower leg, using the crest of the tibia and a 
point midway between the two malleoli for refer- 
ence. 



e ROM 

.Kid on 
juction. 





. - 




FIGURE S-25 At the end of hip medial rotation ROM, the 
proximal arm of the goniometer hangs freely so that it is 
perpendicular to the floor. 



juGURE 8-24 tn the starting position for measuring hip 
i medial rotation, the fulcrum of the goniometer is placed over 
|.&e patella. Both arms of the instrument are together. 



f 



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m 204 



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PART III 



LOWER-EXTREMITY TESTING 



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LATERAL (EXTERNALS ROTATION 



Motion occurs in a transverse plane around a longitudi- 
nal axis when the subject is in anatomical position. The 
mean ROM values for lateral rotation are 32 degrees 
according to Roach and Miles 7 and 50 degrees according 
to the AMA. 4 See Tables 8-1, 8-2, 8-3, and 8-5 for addi- 
tional ROM information. 

Testing Position 

Seat the subject on a supporting surface with knees flexed 
to 90 degrees over the edge of the surface. Place the hip 
in degrees of abduction and adduction and in 90 
degrees of flexion. Flex the contralateral knee beyond 90 
degrees to allow the hip being measured to complete its 
full range of lateral rotation. 



Stabilization 

Stabilize the distal end ol the femur to prevent abduction-' 
or further flexion of she Kip. Avoid rotation and lateral 
tilting of the pelvis. 

Testing Motion 

Place one hand ai the distal femur to provide stabilization 

ami place the order hand on the distal fibula to move the 
lower teg medially [-Fig, 8-26). The hand on the fibula 
also prevents rotation at the knee joint. The end of the 
motion occurs when resistance is felt and attempts at 
overcoming the resistance cause tilting of the pelvis or 
trunk lateral flexion. 





FIGURE 8-26 The left lower extremity is at tile end of the 
ROM ot hip lateral rotation. The examiner places one hand on 
the subject's distal femur lo prevent both hip flexion and hip 
abduction. I'he %uh|cci assists with stabilization bv placing her 
hands on the support tup surface and shifting her weight over 
her left hip. The subject flexes her ri^lu knee ro allow the left 
lower extremity to complete the ROM. 




CHAPTER 8 THE HIP 



205 



m 
le 
la 
he 
at 
or 



Normal End- feel 

The end-feel is firm because of tension in the anterior 
joint capsule, iliofemoral ligament, and pubofemoral 
ligament. Tension in the anterior portion of the gluteus 
medius, gluteus minimus, adductor magnus, adductor 
longus, pectineus, and piriformis muscles also may 
contribute to the firm end-feel. 



Goniometer Alignment 

See Figures 8-27 and 8-28. 

1. Center the fulcrum of the goniometer over the ante- 
rior aspect of the patella. 

2. Align the proximal arm so that it is perpendicular 
to the floor or parallel to the supporting surface. 

3. Align the distal arm with the anterior midline of the 
lower leg, using the crest of the tibia and a point 
midway between the two malleoli for reference. 





hi the- 
ind off;;; 
lid hip:? 
,ngli er : 
if <» er 
the left 





it' 




ipGURE 8-27 Goniometer alignment in the starting position 
'Or measuring hip lateral rotation. 




FIGURE 8-28 At the end of hip lateral rotation ROM the 
examiner uses one hand to support the subject's leg and to 
maintain alignment of the distal goniometer arm. 






' 



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206 



PART III LOWER-EXTREMITY TESTING 



Muscle Length Testing Procedures: 

Hip 



HIP FLEXORS (THOMAS TEST! 



The iliacus and psoas major muscles flex the hip in the 
sagittal plane of motion. Other muscles, because of their 
attachments, create hip flexion in combination with other 
motions. The rectus femoris flexes the hip and extends 
the knee. The sartorius flexes, abducts, and laterally 
rotates the hip while flexing the knee. The tensor fasciae 
latae abducts, flexes, and medially rotates the hip and 
extends the knee. Several muscles that primarily adduce 
the hip, such as the pectineus, adductor longus, and 
adductor brevis, also lie anterior to the axis of the hip 
joint and can contribute to hip flexion. Short muscles 
that flex the hip limit hip extension ROM. Hip extension 
can also be limited by abnormalities of the joint surfaces, 
shortness of the anterior joint capsule, and short 
iliofemoral and ischiofemoral ligaments. 

The anatomy of the major muscles that flex the hip is 
illustrated in Figure 8-29A and B. The iliacus originates 
proximally from the upper two thirds of the iliac fossa, 
the inner iip of the iliac crest, the lateral aspect (ata) of 
the sacrum, and the sacroiliac and iliolumbar ligaments. 
It inserts distally on the lesser trochanter of the femur. 
The psoas major originates proximally from the sides of 
the vertebral bodies and intervertebral discs of T12-L5, 
and the transverse processes of L1-L5. It inserts distally 
on the lesser trochanter of the femur. These two muscles 
are commonly referred to as the iliopsoas. If the iliopsoas 
is short, it limits hip extension without pulling the hip in 
another direction of motion; the thigh remains in the 
sagittal plane. Knee position does not affect the length of 
the iliopsoas muscle. 

The rectus femoris arises proximally from two 
tendons: the anterior tendon from the anterior inferior 
iliac spine, and the posterior tendon from a groove supe- 
rior to the brim of the acetabulum. It inserts distally into 
the base of the patella and into the tibial tuberosity via 
the patellar ligament. A short rectus femoris limits hip 
extension and knee flexion. If the rectus femoris is short, 
and hip extension is attempted, the knee passively moves 
into extension to accommodate the shortened muscle. 
Sometimes, when the rectus femoris is shortened and hip 
extension is attempted, the knee remains flexed but hip 
extension is limited. 

The sartorius arises proximally from the ASIS and the 
upper aspect of the iliac notch. It inserts distally into the 
proximal aspect of the medial tibia. If the sartorius is 
short it limits hip extension, hip adduction, and knee 
extension. If the sartorius is short and hip extension is 
attempted, the hip passively moves into hip abduction 
and knee flexion to accommodate the short muscle. 



Iliacus 



Tensor - 

fascia 
lata 




Psoas major 



Sartorius 



Anterior superior iliac 

spine 



Anterior iliac 

spine 



Rectus 

femoris 



Patella 



Patellar 
ligament 



B 







FIGURE 8-29 An anterior view of the hip flexor muscles. 



CHAPTER 8 THE HIP 



207 















The tensor fasciae iatae arises proximally from the 
anterior aspect of the outer lip of the iliac crest and the 
lateral surface of the ASIS and iliac notch. It inserts 
distally into the iliotibial band of the fascia lata about 
one-third of the distance down the thigh. The iliotibial 
band inserts into the lateral anterior surface of the prox- 
imal tibia. A short tensor fascia larae can limit hip adduc- 
tion, extension and lateral rotation, and knee flexion. If 
hip extension is attempted, the hip passively moves into 
abduction and medial rotation to accommodate the short 
muscle. 

The pectineus originates from the pectineal line of the 
pubis, and inserts in a line from the lesser trochanter to 
the tinea aspera of the femur. The adductor longus arises 
proximally from the anterior aspect of the pubis and 
inserts distally into the linea aspera of the femur. The 
adductor brevis originates from the inferior ramus of the 
pubis. It inserts into a line that extends from the lesser 
trochanter to the linea aspera and the proximal part of 
the linea aspera just posterior to the pectineus and prox- 
imal part of the adductor longus. Shortness of these 
muscles limits hip abduction and extension. If these 



muscles are short and hip extension is attempted, the hip 
passively moves into adduction to accommodate the 
shortened muscles. 



Starting Position 

Place the subject in the sitting position at the end of the 
examining table, with the lower thighs, knees, and legs 
off the table. Assist the subject into the supine position 
by supporting the subject's back and flexing the hips and 
knees (Fig. 8-30). This sequence is used to avoid placing 
a strain on the subject's Sower back while the starting test 
position is being assumed. Once the subject is supine, flex 
the hips by bringing the knees toward the chest just 
enough to flatten the low back and pelvis against the 
table (Fig. 8-31). In this position, the pelvis is in about 10 
degrees of posterior pelvic tilt. Avoid pulling the knees 
too far toward the chest because this will cause the low 
back to go into excessive flexion and the pelvis to go into 
an exaggerated posterior tilt. This low back and pelvis 
position gives the appearance of tightness in the hip flex- 
ors when, in fact, no tightness is present. 






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FIGURE 8-30 The examiner assists the subject into the starting position for testing the length of the hip 
flexors. Ordinarily the examiner stands on the same side as the hip being tested to visualize the hip region 

and take measurements, but the examiner is standing on the contralateral side for the photograph. 



a. 

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208 PART Hi LOWER-EXTREMITY TESTING 



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FIGURE 8-31 The starting position for testing the length of the hip flexors. Both knees and hips are 
flexed so that the low back and pelvis are flat on the examining table. 



j Stabilization 

1 Either the examiner or the subject holds the hip not being 

I tested in flexion (knee toward the chest) to maintain the 

I low back and pelvis flat against the examining table. 

I Testing Motion 

:| Information as to which muscles are short can be gained 

I by varying the position of the knee and carefully observ- 

| ing passive motions of the hip and knee while hip exten- 

I sion is attempted. Extend the hip being tested by 



lowering the thigh toward the examining table. The knee 
is relaxed in approximately 80 degrees of flexion. The 
lower extremity should remain in the sagittal plane. 

If the thigh lies flat on the examining table and the 
knee remains in 80 degrees of flexion, the iliopsoas and 
rectus femoris muscles are of normal length 32 (Figs. 8-32 
and 8-33). At the end of the test, the hip is in 10 degrees 
of extension because the pelvis is being held in 10 degrees 
of posterior tilt. At this point, the test would be 
concluded. 



v 




CHAPTER 8 THE HIP 209 



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FIGURE 8-32 The end of the motion For testing the length of the hip flexors. The subject has normal 
length of the right hip flexors; the hip is able to extend to 10 degrees (thigh is flat on table), the knee 
remains in 80 degrees of flexion, and the lower extremity remains in the sagittal plane. 



•32. 
ees 
ees 
be 



1 




FIGURE 8-33 A lateral view of the hip showing the hip flexors at the end of the Thomas test. 



210 



PART 111 LOWER-EXTREMITY TESTING 



If the thigh does not lie flat on the table, hip extension 
is limited, and further testing is needed to determine the 
cause (Fig. 8-34), Repeat the starting portion by flexing 
the hips and bringing the knee toward the chest. Extend 
the hip by lowering the thigh toward the examining table, 
but this time support the knee in extension (Fig. 8-35). 
When the knee is held in extension, the rectus femoris is 
slack over the knee joint. If the hip extends with the knee 
held in extension so that thigh is able to lie on the exam- 
ining table, the rectus femoris can be ascertained to have 
been short. If the hip cannot extend with the knee held in 
extension and the thigh does not lie on the examining 
table, the iliopsoas, anterior joint capsule, iliofemoral 
ligament, and ischiofemoral ligament may be short. 

When the hip is extending toward the examining table, 
observe carefully to see if the lower extremity stays in the 
sagittal plane. If the hip moves into lateral rotation and 
abduction, the sartorius muscle may be short. If the hip 
moves into media! rotation and abduction, the tensor 
fasciae latae may be short. The Ober test can be used 
specifically to check the length of the tensor fasciae latae. 
If the hip moves into adduction, the pectineus, adductor 
longus, and adductor brevis may be short. Hip abduction 
ROM can be measured to test more specifically for the 
length of the hip adductors. 




Normal End-feel 

When the knee remains flexed at the end of hip extension 
ROM, the end-feel is firm owing to tension in the rectus 
femoris. When the knee is extended at the end of hip 
extension ROM, the end-feel is firm owing to tension in 
the anterior joint capsule, iliofemoral ligament, 
ischiofemoral ligament, and iliopsoas muscle. If one or 
more of the following muscles are shortened they may 
also contribute to a firm end-feel: sartorius, tensor fasciae 
latae, pectineus, adductor longus, and adductor brevis. 

Goniometer Alignment 
See Figure 8-36. 

1. Center the fulcrum of the goniometer over the 
lateral aspect of the hip joint, using the greater 
trochanter of the femur for reference. 

2. Align the proximal arm with the lateral midline of 
the pelvis. 

3. Align the distal arm with the lateral midline of the 
femur, using the lateral epicondyle for reference. 











FIGURE 8-34 This subject has restricted hip extension. Her thigh is unable to lie on the table with the 
knee flexed to 80 degrees. Further testing is needed to determine which structures are short. 



CHAPTER 8 THE HIP 



211 



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FIGURE 8-35 Because the subject had restricted hip extension at the end of the testing motion (see Fig. 
8-34), the testing motion needs to be modified and repeated. This time, the knee is held in extension when 
the extremity is lowered toward the table. At the end of the test, the hip extends to 10 degrees, and the 
thigh lies flat on the table. Therefore, one may conclude that the rectus f'emoris is short and that the iliop- 
soas, anterior joint capsule, and iliofemoral and ischiofemoral ligaments are of normal length. 











FIGURE 8-36 Goniometer alignment for measuring the length of the hip flexors. 



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212 



PART II 



LOWER-EXTREMITY TESTING 



.THE HAMSTRINGS: SEMITENDINOSUS, 
■ SEMIMEMBRANOSUS, AND BICEPS 
1 FEMORIS (STRAIGHT LEG TEST) 



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The hamstring muscles, composed of the semitendinosus, 
semimembranosus, and biceps femoris, cross two 
joints — the hip and the knee. When they contract, they 
extend the hip and flex the knee. The semitendinosus 
originates proximaliy from the ischial tuberosity and 
inserts distally on the proximal aspect of the medial 
surface of the tibia (Fig. 8-37/1), The semimembranosus 
originates from the ischial tuberosity and inserts on the 
posterior medial aspect of the medial condyle of the tibia 
(Fig. 8-37B). The long head of the biceps femoris origi- 
nates from the ischial tuberosity and the sacrotuberous 
ligament, whereas the short head of the biceps femoris 
originates proximaliy from the lateral lip of the linea 
aspera, the lateral supracondylar line, and the lateral 
intermuscular septum (Fig. 8-37A). The biceps femoris 
inserts onto the head of the fibula with a small portion 
extending to the lateral condyle of the tibia and the 
lateral collateral ligament. 

Because the hamstrings are two-joint muscles, short- 
ness can limit hip flexion and knee extension. If 
hamstrings are short and the knee is held in full exten- 
sion, hip flexion is limited. However, if hip flexion is 
limited when the knee is flexed, abnormalities of the joint 
surfaces, shortness of the posterior joint capsule, or a 
short gluteus maximus may be present. 

Starting Position 

Place the subject in the supine position, with both knees 
extended and hips in degrees of flexion, extension, 
abduction, adduction, and rotation {Fig. 8-38). If possi- 
ble remove clothing covering the ilium and low back so 
the pelvis and lumbar spine can be observed during the 
test. 



Semitendinosus 



Semimembranosus 







Biceps femoris 
(long head) 



Bieeos 'emoris 
(short head) 




Semimembranosus 



B 



FIGURE 8-37 A posterior view of the hip showing rhe 
hamstring muscles (A and B). 



■--W-' ' 



CHAPTER 8 THE HIP 



213 



Stabilization 

Hold the knee of the lower extremity being tested in full 
extension. Keep the other lower extremity flat on the 
examining table to stabilize the pelvis and prevent exces- 
sive amounts of posterior pelvic tilt and lumbar flexion. 
Usually the weight of the lower extremity provides 
adequate stabilization, but a strap securing the thigh to 
the examining table can be added if necessary. 

Testing Motion 

Flex the hip by lifting the lower extremity off the table 
(Figs. 8-39 and 8-40). Keep the knee in full extension by 
applying firm pressure to the anterior thigh. As the hip 
flexes, the pelvis and low back should flatten against the 
examining table. The end of the testing motion occurs 
when resistance is felt from tension in the posterior thigh 
and further flexion of the hip causes knee flexion, poste- 
rior pelvic tilt, or lumbar flexion. If the hip can flex to 
between 70 and 80 degrees with the knee extended, 
the test indicates normal length of the hamstring 
muscles. 32 

Shortness of muscles in the hip and lumbar region 
influences the results of the straight leg raising test. If the 
subject has short hip flexors on the side that is not being 
tested, the pelvis is held in an anterior tilt when that 



lower extremity is lying on the examining table. An ante- 
rior pelvic tilt decreases the distance that the leg being 
tested can lift off the examining table, thus giving the 
appearance of less hamstring length than is actually pres- 
ent. To remedy this situation, have the subject flex the 
hip not being tested by resting the foot on the table or 
by supporting the thigh with a pillow (Fig. 8—41). This 
position slackens the short hip flexors and allows the 
low back and pelvis to flatten against the examining 
table. Be careful to avoid an excessive amount of poste- 
rior pelvic tilt and lumbar flexion. 

If the subject has short lumbar extensors, the low 
back has an excessive lordotic curve and the pelvis is in 
an anterior tilt. The distance that the leg can lift off the 
examining table is decreased if the pelvis is in an anterior 
tilt. This gives the appearance of less hamstring length 
than is actually present. In this case, the examiner needs 
to carefully align the proximal arm of the goniometer 
with the lateral midline of the pelvis when measuring hip 
flexion ROM, not being misled by the height of the 
lower extremity from the examining table. 

Normal End- feel 

The end-feel is firm owing to tension in the semimem- 
branosus, semitendinosus, and biceps femoris muscles. 





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FIGURE 8-38 The starting position for testing the length of the hamstring muscles. 



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— ;I 214 PART III LOWER-EXTREMITY TESTING 



Goniometer Alignment 

See Figure 8—42. 

1. Center che fulcrum of the goniometer over the 
lateral aspect of the hip joint, using the greater 
trochanter of the femur for reference. 



vA 



2. Align the proximal arm with the lateral midline of 
the pelvis. 

3. Align the distal arm with the lateral midline of the 
femur, using the lateral epicondyle for reference. 




tjr- 




FIGURE 8-39 The end of the testing motion for the length of the hamstring muscles. The subject has 
normal length of the hamstrings: the hip can be passively flexed to 70 to 80 degrees with the knee held in 
full extension. This test is also called the straight leg raise test. 




■r 






FIGURE 8-40 A lateral view of the hip showing the biceps femoris at the end of the testing motion for 
the length of the hamstrings. 



CHAPTER, 8 THE HiP 21S 





FIGURE 8—41 If the subject has shortness of the contralateral hip flexors, flex the contralateral hip to 
prevent an anterior pelvic tilt. 







FIGURE 8—42 Goniometer alignment for measuring the length of the hamstring muscles. Another exam- 
iner will need to take the measurement while the first examiner supports the leg being tested. 



,. 



El 216 



PART III LOWER-EXTREMITY TESTING 



TENSOR FASCIAE LATAE fOBER TEST} 50 



The tensor fasciae latae crosses two joints — the hip and 
knee. When this muscle contracts, it abducts, flexes, and 
medially rotates the hip and extends the knee. The tensor 
fascia latae arises proximally from the anterior aspect of 

the outer lip of the iliac crest, and the lateral surface of 
the ASIS and the iliac notch (Fig. 8-43}. It attaches 
distally into the iliotibial band of the fascia latae about 
one third of the way down the thigh. The iliotibial band 
inserts into the lateral anterior surface of the proximal 
tibia. If the tensor fascia latae is short it limits hip adduc- 
tion and, to a lesser extent, hip extension, hip lateral 
rotation, and knee flexion. 

Starting Position 

Place the subject in the sidelying position, with the hip 
being tested uppermost. Position the subject near the 
edge of the examining table, so that the examiner can 
stand directly behind the subject. Initially, extend the 
uppermost knee and place the hip in degrees of flexion, 
extension, adduction, abduction, and roration. The 
patient flexes the bottom hip and knee to stabilize the 
trunk, flatten the lumbar curve, and keep the pelvis in a 
slight posterior tilt. 



Stabilization 

Place one hand on the iliac crest to stabilize the pelvis. 
Firm pressure is usually required to prevent the pelvis 
from laterally tilting during the testing motion. Having 
the patient flex the bottom hip and knee can also help to 
stabilize the trunk and pelvis. 

Testing Motion 

Support the leg being tested by holding the medial aspect 
of the knee and the lower leg. Flex the hip and the knee 
to 90 degrees (Fig. 8-44). Keep the knee flexed and move 
the hip into abduction and extension to position the 
tensor fasciae latae over the greater trochanter of the 
femur (Fig. 8-45). Test the length of the tensor fasciae 
latae by lowering the leg into hip adduction, bringing it 
toward the examining table (Figs. 8-46 and 8-47). Do 
not allow the pelvis to tilt laterally or the hip to flex 
because these motions slacken the muscle. Keep the knee 
flexed to control medial rotation of the hip and to main- 
tain the stretch of the muscle. If the thigh drops to slightly 
below horizontal (10 degrees of hip adduction), the test 
is negative and the tensor fasciae latae is of normal 
length. 32 If the thigh remains above horizontal in hip 
abduction, the tensor fasciae latae is tight. 






FIGURE 8^»3 A lateral view of the hip showing the tensor 
fasciae iatae and iliotibial band. 



CHAPTER 8 THE HIP 217 









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FIGURE 8—44 The first step in the testing motion for the length of the tensor fasciae latae is to flex the 
hip and knee. 







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FIGURE 8-45 The next step in the testing motion for the length of the tensor fasciae latae is to abduct 
and extend the hip. These first rwo steps in the testing motion will help position the tensor fasciae latae 
over the greater trochanter of the femur. 



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218 



PART 111 LOWER-EXTREMITY TESTING 



Some authors have stated that the tensor fasciae latae 
is of norma! length when the hip adduces to the examin- 
ing table. 51 ' 52 However, stabilization of the pelvis to 
prevent a lateral tilt and avoidance of hip flexion and 
medial rotation limit hip adduction to 10 degrees during 
the testing motion, causing the thigh to drop slightly 
below the horizontal position. 32 Even more conservative 
hip adduction values have been reported as normal by 
Cade and associates, 53 who found that only 7 of 50 
young female subjects had normal {or not short) bent leg 
Ober test values when the horizontal leg position was 
used as the test parameter. 

Note that at least degrees of hip extension is needed 
to perform length testing of the tensor fascia lata. If the 
iliopsoas is tight, it prevents the proper positioning of the 
tensor fascia lata over the greater trochanter. If the rectus 
femoris is short, the knee may be extended during the 



test, 32 but extreme care must be taken to avoid medial 
rotation of the hip as the leg is lowered into adduction 
This change in test position is called a modified Ober test 

Normal End-fee! 

The end-feel is firm owing to tension in the tensor fascia 
lata. 

Goniometer Alignment 

See Figure 8-48. 

1 . Center the fulcrum of the goniometer over the ASIS 
of the extremity being measured. 

2. Align the proximal arm with an imaginary line 
extending from one ASIS to the other. 

3. Align the distal arm with the anterior midline of the 
femur, using the midline of the patella for reference. 




ligjiii. 



■ ■ ;■■■■ : . 







' 






A'VATSr 




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FIGURE 8-46 The end of the testing motion for the length of the tensor fasciae latae. The examiner is 
firmly holding the iliac crest to prevent a lateral tilt of the pelvis while the hip is lowered into adduction. 
No flexion or media! rotation of the hip is allowed. The subject has a normal length of the tensor fasciae 
latae; the thigh drops to slightly below horizontal. 



CHAPTER 8 THE HIP 219 




FIGURE 8-47 An anterior view of the hip showing the tensor fasciae latac at the end of the Ober test. 





FIGURE 8^*8 Goniometer alignment for measuring the length of the tensor fasciae latae. The examiner 
stabilizes the pelvis and positions the leg being tested white another examiner takes the measurement. If 
another examiner is not available, a visual estimate will have to be made. 



220 



PART III LOWER-EXTREMITY TESTING 



REFERENCES 

1. Levangic, PK, and Norkin, CC: Joinr Structure and Function: A 
Comprehensive Analysis, ed 3. FA Davis, Philadelphia, 2001. 

2. Cyriax, JH, and Cyriax, PJ: Illustrated Manual of Orthopaedic 
Medicine. Butterworths, London, 1983. 

3. Greene, WB, and Heckman, JD (eds): American Academy of 
Orthopaedic Surgeons: The Clinical Measurement of Joint 
Motion: AAOS, Chicago, 1994. 

4. American Medical Association: Guides to The Evaluation of 
Permanent Impairment, ed 3. AM A, Chicago, 1990. 

5. Boone, DC, and Azen, SP: Normal range of morion of joints in 
male subjects. J Bone Joint Surg Am 61:756, 1979. 

6. Svenningsen, S, et al: Hip motion related to age and sex. Acta 
Orrhop Scand 60:97, 1 989. 

7. Roach, K£, and Miles, TP: Normal hip and knee active range of 
motion: The relationship to age. Phys Thcr 71:656, 1991. 

8. Waugh, KG, cr al: Measurement of selected hip, knee and ankle 
joinr motions in newborns. PhysTher 63:1616, 1983. 

9. Schwarze, DJ, and Denton, JR: Normal values of neonatal limbs: 
An evaluation of 1000 neonares. J Pediatr Orthop 13:758, 1993. 

10. Broughion, NS, Wright, j, and Menelaus, MB: Range of knee 
motion in normal neonates, J Pediatr Orthop 13:263, 1993. 

ft. Drews, JE, Vraciu, JK, and Pellino, G: Range of motion of the 
joints of the lower exrremitics of newborns. Phys Occup Ther 
Pediatr 4:49, 1984. 

12. Wanatabe, H, er al: The range of joint motions of the extremities 
in healthy Japanese people: The difference according ro age. Cited 
in Walker, JM: Musculoskeletal development: A review. Phys Ther 
71:878, 1991. 

13. Walker, JM: Musculoskeletal development: A review. Phys Ther 
71:878,1991. 

14. Phelps, E, Smith, Lj, and Hallum, A: Normal' range of hip motion 
of infants between 9 and 24 months of age. Dev Med Child 
Neurol 27:785, 1985. 

15. Forero, N, Okamura, LA, and Larson, MA: Normal ranges of hip 
motion in neonates. J Pediatr Orthop 9:391, 1989. 

16. Nonaka, H, et air Age-related changes in the interactive mobility 
of the hip and knee joints: A geometrical analysis. Gait Posture 
15:236,2002. 

17. Kozic, S, et al: Femoral anteversion related to side differences in 
hip rotation. Passive rotation in 1140 children aged 8-9 years. 
Acta Orthop Scand 68:533, 1997. 

18. Ellison, JB, Rose, SJ, and Sahrman, SA: Patterns of hip rotation: 
A comparison between healthy subjects and patients with low 
back pain. Phys Ther 70:537, 1990. 

19. Bennell, K, et al: Hip and ankle range of motion and hip muscle 
strength in young novice female ballet dancers and controls. Br J 
Sports Med 33:340, 1999. 

20. Boone, DC: Techniques of measurement of joint motion. 
(Unpublished supplement to Boone, DC, and Azen, SP: Normal 
range of motion in male subjects. J Bone Joint Surg Am 61:756, 
1979.) 

21. Allander, E, et al: Normal range of joint movements in shoulder, 
hip, wrist and thumb with special reference to side: A comparison 
between two populations. Int J Epidemiol 3:253, 1974. 

22. Walker, JM, et al: Active mobility of the extremities in older 
subjects. PhysTher 64:919, 1984. 

23. Boone, DC, Walker, JM, and Perry, J: Age and sex differences in 
lower extremity joint motion. Presented ar the National 
Conference of the American Physical Therapy Association, 
Washington, DC, 1981. 

24. James, B, and Parker, AW: Active and passive mobility of lower 
limb joints in elderly men and women. Am J Phys Med Rchabil 
68:162, 1989. 

25. Motlingcc, LA, and Steffan, TM: Knee flexion contractures in 
institutionalized elderly: Prevalence, severity, stability and related 
variables. Phys Ther 73:437, 1993. 

26. Simoneau, GG, cr al: influence of hip position and gender on 
active hip internal and external rotation. J Orthop Sports Phys 
Ther 28:158, 1998. 

27. Kettunen, j, et al: Factors associated with hip joint rotation in 
former elite athletes. Br J Sports Med 34:44, 2000. 

28. Escuhinte, A, et al: Determinants of hip and knee flexion range: 



Results from the San Anionic I oiigitudisi.il Study of Agine ' 
Arthritis Care Res I2:S, I9HW, j 

29. I tchieristctti, MJ, e! ,ii: Modeling impairment: I'sini; the disable-—' 
incut process as a framework to evaluate determinants ol hip ^nd : 
knee i'lwoos. Aging (.Milan) 1-2:208, 2SM.H). 

30. bicrma-Zcinstra, SMA, et al: Comparison between two devices 
lor measuring hip |i.nn; motions. Clin Kehabii 12:497, 1998. 

31 . Van DilU-ii. l.K. et al: Effect or knee and hip position on hip exten- 
sion range ol motion in individuals with and without low back 
ruin. J Orthop Sports Phys [her tth iO~, 2<K>0. 

32. Kendall, IP, McCre.iry. L.K, and Provancc. PC. Muscles Testing 
md Function, ed. 4. Williams :>: Wilkms Philadelphia, 1993. 

33. dilhcrt, I P., Cross. Ml, and King. KB : Relationship between hip 
external rotation and turnout angle tor the five classical baliet 
positions,.! Orthop Sports Phys Ther 27:339. 1998. 

34. Tyler. T, et al: A new pelvic tilt detection device: Rocntgeno- 
gr.tphie validation and application to assessment or hip motion in 
professional hockey players. J Orthop Sports I'hvs Ther 24:303 
199-6, 

25. Van Mechcieu, W, et al: Is range ol motion of the hip and ankle ' 
joint related to running injuries? A case control study, hit | Sporrs 
Med 1 jrf.06, I '»92. 

36. Striilifcns. MPM. ct al: Range ol motion and disability in patients 
with osteoarthritis ot the knee or hip. Rheumatology 39:955, 
2fliH). 

37. BeissiKT, K! , Oiiinis, IF, and Holmes, i I; Muscle torce and range 
ol moium .is predictors ot function in older adults. Phys Ther 

MJ:55&, 2iH)0 

38. Magce, DJ: Orthopedic Physical Assessment, cd 4. WB Saunders, 

Philadelphia, 20u2. 

39. The i'athokinesioliigy Service and the Physical therapy 
Department; Observational Clair Analysis Handbook. Ranchos 
I .os Ainigos Medical ('enter, Downey, CaL, 5989, 

40. Livingston, LA, Stevenson, JM, and Oluey, SJ: Stairelimbing kine- 
matics on stairs or diitering dimensions. Arch Phys Med Rehabil 
"2:398, 199 J. 

41. Mcl-'ayden, BJ. and Winter, DA: An integrated hioiucchantcal 
analysis of normal stair ascent and descent. J Kiorrtech. 21:733, 
|9KS. 

42. Ohcrg 1, Krayiin.t. A. and Olxrg, K: Joint angle parameters in 
gait: Reference data tor normal subjects 10-79 years of age. J 
Rchabil Res IH-v 31:199, 1994. 

43. Boone. DC, et al: Reliability oS gouiometric measurements. Phys 
Their 58:1355. [978. 

44. Clapper, MP, and Wolf, SL: Comparison of the reliability of the 
Orthoranger arid the standard goniometer tor assessing active 
lower extremity range of motion. Phys Ther 68:214, 1988. 

45. Ekstr.md, J, et al: Lower extremity gomometric measurements: A 
study to determine their reliability. Arch i'hvs Med Rehabil 
u.Vl/t. 1982. 

46. Pandya, S, et al: Reliability ol goiiiometric measurements in 
patieiirs with Diichemie muscular dystrophy. Phys Ther 65:1339, 
1 9B5. 

47. (droit, PR, et al: Interobservcr reliability in measuring flexion, 
internal rotation ami external rotation ol [he hip using a 
pleurimcter. Ann Rheum Dis 55:320, 1996. 

48. Cibtilka. MT, et at: Unilateral hip rotation range of motion asym- 
metry in patients with sacroiliac joint regional pain. Spine 
23:1009, 1498.46. 

49. C.idenhead, SI.., McEwcn, IK, and Thompson, DM; Effect of 
passive range ol motion exercises on lower extremity gonometric 
measurements of adults with cerebral palsy: A single subject study 
design. Phys Ther 82:658, 2002. 

50. ( >hcr, FR: flu- role of the ihotibial band and fascia lata as a factor 
in the causation ol low-back disabilities and sciatica. I Bone Joint 
Surg IK: Ills. I'Tsr,. 

51. Hoppentekl, S: Physical Examination ol the Spine and 
Extremities. Appleton-Ccntury-l rofts. New York, l k .'~6, p 167 

52. Cose. |C, and Schwei/cr. ft lhotibi.it band tightness. J Orthop 
Sports Phys Ther 10:599, 19R9, 

5i. Cade, Dl„ el al: Indirectly measuring length of the ihotibial band 
and related hip structures: A correlational analysis of four adduc- 
tion lests. Abstract Platform Presentation at APIA Mid-Wimer. 
Tcs J Orthop Sports Phys Ther 3 l:A22, 2001. 




lg- 



tld 



ing 

hip 
iller 



rapy; 
ichos 



mical : 
:733, 



;Phys| 



asym-'.. 
Spin«g 



CHAPTER 9 



The Knee 



SS Structure and Function 
Tibiofemoral and Patellofemoral Joints 

1 Anatomy 

: 'i The knee is composed of two distinct articulations 
| enclosed within a single joint capsule: the tibiofemoral 
4 joint and the patellofemoral joint. At the tibiofemoral 



Femur 



Ifaterai 
fSohdyle 



^Lateral 
vcortdyfe 



e anil 

■ 16: ,■:■ 

3rth0 M 

ilban|| 

adci-X- 

Wtnwgi 



F ibula 




Patella 
Medial condyle 

Tibiofemoral joint 
Medial condyle 



Intercondylar 
tubercles 



Tibia 



• 'RE 9-1 An anterior view of a right knee showing the 
*ofemoral joint. 




joint, the proximal joint surfaces are the convex medial 
and the lateral condyles of the distal femur (Fig. 9-1). 
Posteriorly and inferiorly, the longer medial condyle is 
separated from the lateral condyle by a deep groove 
called the intercondylar notch. Anteriorly, the condyles 
are separated by a shallow area of bone called the 
femoral patellar surface. The distal articulating surfaces 
are the two shallow concave medial and lateral condyles 
on the proximal end of the tibia. Two bony spines called 
the intercondylar tubercles separate the medial condyle 
from the lateral condyle. Two joint discs called menisci 
are attached to the articulating surfaces on the tibial 
condyles (Fig. 9-2). At the patellofemoral joint, the artic- 



Anteriorcruciale iigament 

Posterior cruciate ligament 
Femur 



Latere! epicondyle 

Lateral condyle 

Lateral meniscus 



Lateral (fibular) 
collateral ligament 



Fibula 




Medial epicondyie 
Medial condyle 
Medial meniscus 



Medial (tibial) 
collateral ligament 



FIGURE 9-2 An anterior view of a right knee in the flexed 
position showing femoral and tibial condyles, medial and 
lateral menisci, and cruciate and collateral ligaments. 

221 



222 



PART Itl LOWER-EXTREMITY TESTING 



ulating surfaces are the posterior surface of the patella 
and the femoral patellar surface (Fig. 9-3). 

The joint capsule that encloses both joints is large, 
loose, and reinforced by tendons and expansions from 
the surrounding muscles and ligaments. The quadriceps 
tendon, patellar ligament, and expansions from the 
extensor muscles provide anterior stability (see Fig. 9-3). 
The lateral and medial collateral ligaments, iliotibial 
band, and pes anserinus help to provide medial-lateral 
stability, and the knee flexors help to provide posterior 
stability. In addition, the tibiofemoral joint is reinforced 
by the anterior and posterior cruciate ligaments, which 
are located within the joint (see Fig. 9-2). 

Osteokinematics 

The tibiofemoral joint is a double condyloid joint with 2 
degrees of freedom. Flexion-extension occurs in the 
sagittal plane around a medial-lateral axis; rotation 
occurs in the transverse plane around a vertical (longitu- 
dinal) axis. 1 The incongruence and asymmetry of the 
tibiofemoral joint surfaces combined with muscle activ- 
ity and ligamentous restraints produce an automatic 
rotation. This automatic rotation is involuntary and 
occurs primarily at the extreme of extension when 
motion stops on the shorter lateral condyle but continues 
on the longer medial condylar surface. During the last 



Femur 



Patellar 
quadriceps 

tendon 



Patella 



Patellar 
ligament 




Semiiendinosjs 



Graciiis 



Sartorius 



Tibial 
tuberosity 



Pes anserinus 



FIGURE 9-3 A view of a right knee showing the medial aspect, 
where the cut tendons of the three muscles that insert into the 
anterotnedial aspect of the tibia make up the pes anserinus. Also 
included are the patdtofemoral joint, the patellar ligament, and 
the patellar tendon. 




portion of the active extension range of motion (ROM) 
automatic rotation produces what is referred to as either 
the screw-home mechanism, or "locking," of the knee, 
Tti begin flexion, the knee must be unlocked by rotation 
in the opposite direction, For example, during 
non-wcight-bearing active knee extension, lateral rota- 
tion of the tibia occurs during the last 10 to 15 degrees 
of extension to lock the knee." Fo unlock the knee, the 
tibia rotates medially. This rotation is not under volun- 
tary control and should not be contused with the volun- 
tary rotation movement possible at the joint. 

Passive ROM in flexion is generally considered to be 
between 130 and 140 degrees. The range of extension 
beyond degrees is about 5 to 10 degrees in young chil- 
dren, whereas degrees is considered to be within 
normal limits for adults.' The greatest range of volun- 
tary knee rotation occurs at 40 degrees of flexion; at this 
point, about 45 degrees of lateral rotation and 15 
degrees of media! rotation are possible. 

Arthokinematics 

The incongruence of the tibiofemoral joint and the fact 
that the femoral articulating surfaces are larger than the 
tibial articulating surfaces, dictates that when the 
femora! condyles are moving on the tibial condyles (in a 
weight-hearing situation), the femoral condyles must roll: 
and slide to remain on the tibia. In weight-bearing flex:-, 
ion, the femoral condyles roll posteriorly and slide ante- 
riorly. The menisci follow the roil of the condyles by 
distorring posteriorly in flexion. In extension, the 
femoral condyles roll anteriorly and slide posteriorly. 1 In 
the last portion of extension, motion stops at the lateral 
femoral condyle, but sliding continues on the media! 
femoral condyle to produce locking of the knee. 

In non-weight-bearing active motion, the concave 
tibial articulating surfaces slide on the convex femoral 
condyles in the same direction as the movement of the 
shaft of the tibia. The tibial condyles slide posteriorly on 
the femoral condyles during flexion. During extension 
from full flexion, the tibial condyles slide anteriorly on 
the femoral condyles. 

The patella slides superiorly in extension and interi- 
orly in flexion. Some patellar rotation and tilting accom- 
pany the sliding during flexion and extension.' 

Capsular Pattern 

The capsular pattern at the knee is characterized by a 
smaller limitation of extension than of flexion and no 
restriction of rotations.'* 1 ' 1 Fritz and associates" found 
that patients with a capsular pattern defined as a ratio or 
extension loss to flexion loss between 0.03 and 0.i"> 
were 3.2 times more likely to have arthritis or arthroses 
of the knee. Hayes reported a mean ratio of extension 
loss to flexion loss of 0.40 in a study of 79 patients with;- y.. 
osteoarthritis. lS 



CHAPTER 9 THE KNEE 223 



:hec 
nee. 
tion 
ring 
'ota- 

»the 

>lun- 
>!uri- : 



table 9-1 Knee Flexion Range of Motion: Values in Degrees 




Scone 

,J_$:mc&-5'4 yn 



'2S-?4yn 
ff = 1683 



::s»?««n<SCi): 



iMean.CSD) 



142.5(5.4) 



132.0(10.0) 



(SD) = Standard deviation. 



ision 
chil- 
fithJn 

blun- 
tthis 
d IS 

ieiact ■ 
in the 
a : the 
s (in a 
1st roll 
gflex- 
i ante- 
des by 
n, the 
rly. 1 In 
lateral 
medial 

is .: 

:oncave 
iemora! 
I of the 
iorly on 
tension 
iorly on 

i inferi- 
■ accom-. 



$ Research Findings 

Table 9-1 provides knee ROM values from selected 
sources. The number, age, and gender of the subjects 
measured to obtain the AMA 9 values are unknown. 
Boone and Azen 10 used a universal goniometer to meas- 
ure active ROM on male subjects. Roach and Miles" 
also used a universal goniometer to measure active 
ROM, but their measurements were obtained from both 
males and females. 

Effects of Age, Gender, and Other Factors 

Limitations of knee extension at birth are normal and 
similar to extension limitations found at birth at the hip 
joint. We have chosen to use the term "extension limita- 
tion" rather than "flexion contracture" because contrac- 
ture refers to an abnormal condition caused by fixed 
muscle shortness, which may be permanent. 12 Knee 
J extension limitations in the neonate gradually disappear, 
i and extension, instead of being limited, may become 
I excessive in the toddler. Waugh and colleagues 13 and 
| Drews and coworkers 14 found that newborns tacked 
approximately 15 to 20 degrees of knee extension. 
[ Sdiwarze and Denton, 15 in a study of 1000 neonates 
I ^fgirls and 473 boys) in the first 3 days of life, found 
I * Mean extension limitation of 15 degrees. These findings 
agree with the findings of Wanatabe and associates, 16 



who found that newborns lacked 14 degrees of knee 
extension. The extension limitation gradually disappears 

as shown by comparing Tables 9-2 and 9-3. Broughton, 
Wright, and Menelaus 17 measured extension limitations 
in normal neonates at birth and again at 3 months and 6 
months. At birth, 53 of the 57 (93 percent) neonates had 
extension limitations of 15 degrees or greater, whereas 
only 30 of 57 (53 percent) infants had extension limita- 
tions at 6 months of age. The mean reduction in exten- 
sion limitations was 3.5 degrees per month from birth to 
3 months, and 2.8 degrees between 3 and 6 months (see 
Table 9-3). The 2-year-olds in the study conducted by 
Wanatabe and associates 16 (see Table 9-3) had no 
evidence of a knee extension limitation. 

Extension beyond degrees at the knee is a normal 
finding in young children but is not usually observed in 
adults, 3 who may have slightly less than full knee exten- 
sion. Wanatabe and associates 16 found that the two-year- 
olds had up to 5 degrees of extension. This finding is 
similar to the mean of 5.4 degrees of extension noted by 
Boone 18 for the group of children between 1 year and 5 
years of age. Beighton, Solomon, and Soskolne, 19 in a 
study of joint laxity in 1081 males and females, found 
that joint laxity decreased rapidly throughout childhood 
in both genders and decreased at a slower rate during 
adulthood. The authors used a ROM of greater than 10 
degrees of knee extension as one of the criteria of joint 
laxity. Cheng and colleagues, 20 in a study of 2360 
Chinese children, found that the average of 16 degrees of 
knee extension ROM in children of 3 years of age 



:ed by a 
. and no 
5 s found- 
t ratio of; 
nd 0,50, 
irthroses 
:X tension 



;nts vro 



ith 



table 9-2 Knee Extension Limitations in Neonates 6 Hours to 7 Days of Age: Mean Values 
in Degrees 



Mean<SD) 



(SD> 




iMean 



15.3: (9.9) 



20.4 (6.7) 



15-0 



^.flstan;. limitation 

. M=-. Standard deviation, 
"""sHies were obtained from passive range of motion measurements with use of a universal goniometer. 



1 



21.4(7.7) 



224 



PART III LOWER-EXTREMITY TESTING 



table 9-3 Knee Range of Motion in Infants and Young Children to 12 Years of Age: Mean 
Values in Degrees 




6moi 



Wanatabe et at 

0-2 yrs 

n={09 



,,!«. 



Boone™ 



1-Syn 
n= 79 



6~?2 yrs ■■■ ,.\ 



Motion 



Miaan(SDJ 



Mean (3D) 



Range of means 



Mean (SD) 



Mean {SpJ|| 



Flexion 
Extension 



145.5 (5.3) 
10.7 <5;1)* 



141.7(6.3) 
3.3 (4.3)" 



•n&i&£ia£3tt&. 



(5D) = Standard deviation. 

* Indicates extension limitations. 

f Indicates extension beyond degrees. 



decreased to 7 degrees by the time the children reached 9 
years of age. A comparison of the knee extension mean 
values for the group aged 13 to 19 years in Table 9—4 
with the extension values for the group aged 1 to 5 years 
in Table 9-3 demonstrates the decrease in extension that 
occurs in childhood. 

In Table 9-4, the mean values obtained by Boone 18 are 
from male subjects, whereas the values obtained by 
Roach and Miles 11 are from both genders. If values 
presented for the oldest groups (those aged 40 to 74 
years) in both studies are compared with the values for 
the youngest group (those aged 13 to 19 years), it can be 
seen that the oldest groups have smaller mean values of 
flexion. However, with a SD of 11 in the oldest groups, 
the difference between the youngest and the oldest 
groups is not more than 1 SD. Roach and Miles" 
concluded that, at least in individuals up to 74 years of 
age, any substantial loss (greater than 10 percent of the 
arc of motion) in joint mobility should be viewed as 
abnormal and not attributable to the aging process. The 
flexion values obtained by these authors were consider- 
ably smaller than the 150-degree average value published 
by the AMA 9 . 

Walker and colleagues 21 included the knee in a study 
of active ROM of the extremity joints in 30 men and 30 
women ranging in age from 60 to 84 years. The men and 
women in the study were selected from recreational 



148-159 



141.7 (6.2) 
5.4 (3.1) f 



147.1 (3.5) 
0.4 (0.9) 



centers. No differences were found in knee ROM 
between the group aged 60 to 69 years and a group aged 
75 to 84 years. However, average values indicated that Sj| 

the sublets had a limitation in extension (inability td'rSf. 
attain a neutral 0-degrec starting position). This finding, 
was similar ro the loss of extension noted at the hip,- 
elbow, and first metatarsophalangeal (MTPi joints. The 
2 -degree extension limitation found at the knee was ■ 
much smaller than that found at the hip joint. Using fjX 
two liirgc studies of adult males as the basis for their 
conclusions, the American Association of Orthopaedic ..A 
Surgeons (AAOSl I landbook' states that extension limi- 
tations of 2 degrees (SD = .5} are considered to be normal 
in adults. 

Extension limitations greater than 5 degrees in adults 
may be considered as knee flexion contractures. These 
contractures often occur in the elderly because of disease, 
sedentary lifestyles, and the effects ol the aging process -. 
on connective tissues. Moliinger and Steffan" used a 
universal goniometer to assess knee ROM among 112 
nursing home residents with an average age of S3 years. 
The authors found that only 1.5 percent of the subjects 
had full (0 degrees) passive knee extension bilaterally. 
Thirty-seven of the I 12 subjects (3.s percent) had bilat- '-.". 
era I knee extension limitations of 5 degrees or less bilac- 
erally. Forty-seven subjects (42 percent) had greater than 
10 degrees of limitations in extension (flexion corttrac- 



:■■;.: v 



table 9-4 Effects of Age on Knee Motion in Individuals 13-74 Years of Age: Mean. Values' 
In Degrees 




,fed/*e**: ; 



Roach arid Miles 



13-1 9 yrs 



20-29 yrs 



40-45 yrs 

n/= 19 



40-59 yrs 

n= 727 



60-^74 vr*""^ 
n = 52 | 



lftfl#fl8K 



Mean (SD) : .- ; 



.Mean (SD) 



Mean (SD) 



Mean (SD) 



Mean ,(SD| 



Flexion 
Extension 



142.9 (3.7) 

6.p (o.o) 



140.2 (5.2) 
0.4 (0,9) 



142.6 (5.6) 
1.6 (2.4) 



132.0 (11.0) 



131.0 (11-0) 



(SD) = Standard deviation. 



CHAPTER 9 THE KNEE 



225 



I 



i : 



DM 

ged 
that 
/ to 

ding 
hip, 
The 

was 
(sing . 
their ■ 
ledic 
limi- 
rmal 

dults 

rhese 

;ease t 

ocess 

»ed a 

§Uji 

years. 

bjects 

orally. 

biiat- 

bilat- 

r than 

ntrac- 



Qi®i 



tures). Residents with a 30-degree loss of knee extension 
Iliad an increase in resistance to passive motion and a loss 

of ambulation. Steultjens and coworkers 23 found knee 
iflexion contractures in 31.5 percent of 198 patients with 
^osteoarthritis of the knee or hip. Generally a decrease in 
active assistive ROM was associated with an increase in 
disability but was action specific. The motions that had 
the strongest relationship with disability were knee flex- 
ion, hip extension, and lateral rotation. A surprising find- 
ing of this study was the strong relationship between 
flexion ROM of the left knee with flexion ROM of the 
right knee. 

lH Despite the knee flexion contractures found in the 

^elderly by Mollinger and Steffan, 22 many elderly individ- 

||als appear to have at least a functional flexion ROM. 

Escalante and coworkers 24 used a universal goniometer 

to measure knee flexion passive ROM in 687 commu- 

ruty-dwelling elderly subjects between the ages of 65 and 

79 years. More than 90 degrees of knee flexion was 

found in 619 (90.1 percent) of the subjects. The authors 

used a cutoff value of 124 degrees of flexion as being 

within normal limits. Subjects who failed to reach 124 

vdegrees of flexion were classified as having an abnormal 

.ROM. Using this criterion, 76 (11 percent) right knees 

:?ahd 63 (9 percent) left knees had abnormal (limited) 

passive ROM in flexion. 

Gender 

Beighton, Solomon, and Soskolne' 9 used more than 10 
degrees of knee extension from (hyperextension) as one 
of their criteria in a study of joint laxity in 1081 males 
and females. They determined that females had more 
laxity than males at any age. Loudon, Goist, and 
Loudon 25 operationally defined knee hyperextension 

,§f|enu recurvatum) as more than 5 degrees of extension 

"fern 0. Clinically, the authors had observed that not only 
was hyperextension more common in females than males, 
but that the condition might be associated with func- 
tional deficits in muscle strength, instability, and poor 
proprioceptive control of terminal knee extension. The 
authors cautioned that the female athlete with hyperex- 
Jended knees may be at risk for anterior cruciate ligament 
injury. Hall and colleagues 26 found that 10 female 
patients diagnosed with hypermobility syndrome had 

: . alterations in proprioceptive acuity at the knee compared 
with an age-matched and gender-matched control group. 

ftf^James and Parker 27 studied knee flexion ROM in 80 
-Oren and women who were aged 70 years to older than 
W_ years. Women in this group had greater ROM in both 
active and passive knee flexion than men. Overall knee 
'fexion values were lower than expected for both 
Insiders, possibly owing to the fact that the subjects were 
pleasured in the prone position, where the two-joint 
. : ^ctus femoris muscle may have limited the ROM. In 
Sfrittast to the findings of James and Parker, 27 Escalante 
|P coworkers 24 found that female subjects had reduced 



passive knee flexion ROM compared with males of the 
same age. However, the women had on average only 2 
degrees less knee flexion than the men. The women also 
had a higher body-mass index (BMI) than the men, which 
may have contributed to their reduced knee flexion. 
Schwarze and Denton 15 observed no differences owing to 
gender in a study of 527 girls and 473 boys aged 1 to 3 
days. 

Body- Mass Index 

Lichtenstein and associates 28 found that among 647 
community-dwelling elderly subjects (aged 64 to 78 
years), those with high BMI had lower knee ROM than 
their counterparts with low BMI. Severely obese elderly 
subjects had an average loss of 13 degrees of knee flexion 
ROM compared with nonobese counterparts. The 
authors determined that a loss of knee ROM of at least 1 
degree occurred for each unit increase in BMI. Escalante 
and coworkers" 4 found that obesity was significantly 
associated with a decreased passive knee flexion ROM. 
Sobti and colleagues 29 found that obesity was signifi- 
cantly associated with the risk of pain or stiffness at the 
knee or hip in a survey of 5042 Post Office pensioners. 

Functional Range of Motion 

Table 9-5 provides knee ROM values required for vari- 
ous functional activities. Figures 9-4 to 9-6 show a vari- 
ety of functional activities requiring different amounts of 
knee flexion. Among the activities measured by Jevesar 
and coworkers 30 (stair ascent and descent, gait, and rising 
from a chair), stair ascent required the greatest range of 
knee motion. 

Livingston and associates 31 used three testing stair- 
cases with different dimensions. Shorter subjects had a 
greater maximum mean knee flexion range (92 to 105 
degrees) for stair ascent in comparison with taller 
subjects (83 to 96 degrees). Laubenthal, Smidt, and 
Kettlekamp 33 used an electrogoniometric method to 
measure knee motion in three planes (sagittal, coronal, 
and transverse). Stair dimensions used by McFayden and 
Winter 34 were 22 cm for stair height and 28 cm for stair 
tread. The Rancho Los Amigos Medical Center's 35 values 
for knee motion in gait are presented in Table 9-5 
because these values are used as norms by many physical 
therapists. However, specific information about the 
population from which the values were derived was not 
supplied by the authors. 

Oberg, Karsznia, and Oberg 3 * used electrogoniome- 
ters to measure knee joint motion in midstance and swing 
phases of gait in 233 healthy males and females aged 10 
to 79 years. Only minor changes were attributable to 
age, and the authors determined that an increase in knee 
angle of about 0.5 degrees per decade occurred at 
midstance and a decrease of 0.5 to 0.8 degrees in knee 
angle in swing phase. 



226 



PART III LOWER-EXTREMITY TESTING 



table 9-s Knee flexion Range of Motion Necessary for Functional Activities: Values 
in Degrees 



sUsi^lisgs 



-.'/e&evor 



fiitpiari 



Lauh&itifat 

eta? 33 



McFoydeh 
and Winter*** 



Roncho £os Amj^^i 
Medical i Center?* 5 ■■■ 



Motion 



Mean (SD) 



Mean range 



Mean range (SD) . Mean, range 



Mean ranged 



Walk ohlevel surfaces 

Ascend stairs . 

Descend stairs 

Rise from chair 

Sit in chair 

fie shoes 

Lift object from floor 



63.1 (7.7) 

92S (9.4) 

,86.9 (5.7) 

:?0.1: (9:8) 



5-60.0 



is2rr405,0 

iiio7.o 



0-83.0 

0-83.0 



(8.4) 
(8.2) 



10-100.0 
20-100.0 



.0-93.0(10.3) 

: 0-1 06.0 (9.3) 

0-117.0 (13.1) 



(SD) = Standard deviation. 

* Sample consisted of a control group of 1 1 healthy subjects (6 males and 5 females) with a mean age of 53 years. 

f Sample consisted of 1 5 healthy women aged 1 9 to 26 years. 

* Sample consisted of 30 healthy men with a mean age of 25 years. 
4 Sample consisted of 1 subject measured during eight trials. 

1 "Large Sample" data collected over a number of years. 









FIGURE 9-5 Rising from a chair requires a mean range oi 
knee flexion of 90. 1 degrees.' 30 



FIGURE 9-4 Descending stairs requires between 86.9 30 and 
107 31 degrees of knee flexion depending on the stair dimen- 
sions. 




CHAPTER 9 THE KNEE 



227 






FIGURE 9-6 Putting on socks requires approximately 117 
degrees of knee flexion. 32 



Reliability and Validity 

Reliability studies of active and passive range of knee 
motion have been conducted in healthy subjects 37 ^ 11 and 
in patient populations. 42 ' 45 Boone and associates, 17 in a 
study in which four testers using universal goniometers 
measured active knee flexion and extension ROM at four 
weekly sessions, found that intratester reliability was 
higher than intertester reliability. The total intratester SD 
for measurements at the knee was 4 degrees, whereas the 
intertester SD was 5.9 degrees. The authors recom- 
mended that when more than one tester measures the 
range of knee motion, changes in ROM should exceed 6 
degrees to show that a real change has occurred. 

Gogia and colleagues 38 measured knee joint angles 
between and 120 degrees of flexion. These measure- 
ments were immediately followed by radiographs. 
Intertester reliability was high (Table 9-6). The intraclass 
correlation coefficients {ICC} for validity also was high, 
0.99. The authors concluded that the knee angle meas- 
urements taken with a universal goniometer were both 
reliable and valid. 

Rheault and coworkers 39 investigated intertester relia- 
bility and concurrent validity of a universal goniometer 
and a fluid-based goniometer for measurements of active 
knee flexion. These investigators found good intertester 
reliability for the universal goniometer (Table 9-6), and 
the fluid-based goniometer (r = 0.83). However, signifi- 
cant differences were found between the instruments. 
Therefore, the authors concluded that although the 



table 9-6 Intratester and Intertester Reliability: Knee Range of Motion Measured with a Universal 
Goniometer 



range 



of 




Boone et at i7 
Rheault et at " 
Gogia et at ** 
Drews et.al- 14 
Rothstein et al * 2 

Watkinsetal 41 

Pandya et at** 



: Mollinger and Steffan " 10 
Beissner et at * 5 



AROM = Active range of motion; 
Correlation Coefficient, 



12 


.. , AROM 




■'P Flexion 


20 


AROM 




Flexion 


30 


PROM 




Flexion 


9 


PROM 


24 


PROM 




Flexion 




Extension 


43 


PROM 




Flexion 




Extension 


150 


PROM 


21 


Extension 


10 


Extension 


10 


PROM 




Flexion 




Extension 


otion; 


ICC = intraclass 



(lntra)KC (Inter) ICC (Intro) r (Fnter)r 



Healthy adult males (25-54 yrs) 
Healthy adults (mean age (24.8 yrs) 
Healthy adults (20-60 yrs) 
Healthy infants (1 2 hrs-6 days) 
Patients (ages not reported) 

Patients (mean age 39.5 yrs) 



Duchenne muscular dystrophy 
(younger than 1 yr-20 yrs) 

Nursing home residents 
Nursing home and Independent 
living Residents (mean age 81 .0 yrs) 



0.87 



0.50 



0.99 



0.97-0.99 


0.91-0.99 


0.91-0.97 


0.64-0.71 


0.99 


0.90 


0.98 


0.86 


0.93 






0,73 


0.99 


0.97 



0.70-0.93 



0.87 
0.98 

0.69:ieft 

0.89 fight 

0.88-0.91 
063-0.70 



correlation coefficient; PROM = passive range of motion; r = Pearson Product Moment 



228 



PART 111 LOWER-EXTREMITY TESTING 



universal and fluid-based goniometers each appeared to 
have good reliability and validity, they should not be used 
interchangeably in the clinical setting. Bartholomy, 
Chandler, and Kaplan" 10 had similar findings. These 
authors compared measurements of passive knee flexion 
ROM taken with a universal goniometer with measure- 
ments taken with a fluid goniometer and an Optotrak 
motion analysis system. Subjects for the study were 80 
individuals aged 22 to 43 years. Ail subjects were tested 
in the prone position, and a hand-held dynamometer was 
used to apply 10 pounds of force on the distal tibia. 
Individually, the universal goniometer and the fluid 
goniometer were found to be reliable instruments for 
measuring knee flexion passive ROM. ICCs for the 
universal goniometer were 0.97 and for the fluid 
goniometer 0.98. However, there were significant differ- 
ences among the three devices used, and the authors 
caution that these instruments should not be used inter- 
changeably. 

Enwemeka 41 compared the measurements of six knee 
joint positions (0, 15, 30, 45, 60, and 90 degrees) taken 
with a universal goniometer with bone angle measure- 
ments provided by radiographs. The measurements were 
taken on 10 healthy adult volunteers {four women and 
six men) between 21 and 35 years of age. The mean 
differences ranged from 0.52 to 3.81 degrees between 
goniometric and radiographic measurements taken 
between 30 and 90 degrees of flexion. However, mean 
differences were higher (4.59 degrees) between gonio- 
metric and radiographic measurements of the angles 
between and 15 degrees. 

Rothstein, Miller, and Roettger 42 investigated intra- 
tester, intertester, and interdevice reliability in a study 
involving 24 patients referred for physical therapy. 
Intratester reliability for passive ROM measurements for 
flexion and extension was high. Intertester reliability also 
was high among the 12 testers for passive ROM meas- 
urements for flexion, but was relatively poor for knee 



extension measurements (see Table 9-6). Intertester relia- 
bility was not improved by repeated measurements, but 
was improved when testers used the miiiic patient posi- 
tioning. Interdevice reliability was high tor all measure- 
ments. Neither the composition of the universal 
goniometer (metal or plastic) nor the si/.e (large or small) 
had a significant effect on the measurements. 

Mollinger and Stet'tan" collected intratester reliability 
data on measurement at knee extension made by two 
testers using a universal goniometer. ICCs for knee exten- 
sion repeated measurements were high I. see Table 9-6) 
with differences between repeated measurements averag- 
ing i degree. Panciya and colleagues' 1 ' 1 studied intratester 
and sntertester reliability of passive knee extension meas- 
urements in 150 children aged 1 to 20 years, who had a 
diagnosis of Duchenne muscular dystrophy. Intratester 
reliability with use ut the universal goniometer was 
high, but intertester reliability was only fair (see Table 
9-6), 

Wat kins and associates' 11 compared passive ROM 
measurements of the knees of 43 patients made by 14 
physical therapists who used a universal goniometer and 
visual estimates. These authors found that intratester reli- 
ability with the universal goniometer was high for both 
knee flexion and knee extension. Intertester reliability for 
goniometric measurements also was high for knee flexion 
but only good for knee extension (see Table 9-6). 
Intratester and intertester reliability were lower for visual 
estimation than for goniometric measurement. The 
authors suggested that therapists should not substitute 
visual estimates for goniometric measurements when 
assessing a patient's range ot knee motion because of the 
additional error that is introduced with use of visual esti- 
mation. A patient's diagnosis did not appear to affect reli- 
ability, except in the case of below-knee amputees. 
However, the small number ot amputees in the patient 
sample prevented the authors from making any conclu- 
sions about reliability in this type of patient. 



%: 



-:! 



L 



■ 








CHAPTER 9 THE KNEE 229 



I 

it 



I 

k 

14 
Eld 
:!i 

Sh- 
ir 

I- 

oaf 
Je 
utv 
i§n 
ie- 



Range of Motion Testing Procedures: Knee 




FIGURE 9-8 A lateral view of the. subject's right lower eitreniity showing surface anatomy landmarks 
for goniometer alignment. 



;'es. 
11 



Greater trochanter 
;; of femur 



Laferatfernpral 
epicondyfe ■ 



Lateral malleolus 
of fibula 




FIGURE 9-^8 A lateral view or the subject's rightlower extremity; showing bony anatomical landmarks 
for goniometer alignment for measuring knee flexion ROM. 



S 




1X1 

Z 

on 

OS 

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■ U 

o 

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.;Z;; 

In 

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Z^ ; 

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< 



230 



PART I I I 



LOWER-EXTREMSTY TESTING 



FLEXION 



Motion occurs in the sagittai plane around a medial- 
iaterai axis. The range of motion for flexion ranges from 
132.0 degrees (Roach and Miles 51 ) to 142.5 degrees 
(Boone and Azen 10 ) to 150.0 degrees (AMA 9 ). Please 
refer to Tables 9-1 through 9-4 for additional ROM 
information. 

Testing Position 

Place the subject supine, with the knee in extension. 
Position the hip in degrees of extension, abduction, and 
adduction. Place a towel roll under the ankle to allow the 
knee to extend as much as possible. 

Stabilization 

Stabilize the femur to prevent rotation, abduction, and 
adduction of the hip. 

Testing Motion 

Hold the subject's ankie in one hand and move the poste- 
rior thigh with the other hand. Move the subject's thigh 
to approximately 90 degrees of hip flexion and move the 



knee into flexion (Fig. 9-9). Stabilize the thigh to prevent 
further motion and guide the lower leg into knee flexion 
The end of the range of knee flexion occurs when resist- 
ance is felt and attempts to overcome the resistance cause 
additional hip flexion. 

Normal End-feel 

Usually, the end-feel is soft because of contact between 
the muscle bulk of the posterior calf and the thigh or 
between the heel and the buttocks. The end-feel may be 
firm because of tension in the vastus medialis, vastus 1 
lateralis, and vastus intermedialis muscles. 

Goniometer Alignment 

Sec Figures 9-10 and 9-11. 

1. Center the fulcrum of the goniometer over the 
lateral epicondyle of the femur. 

2. Align the proximal arm with the lateral midline of 
the femur, using the greater trochanter for refer- 
ence. 

3. Align the distal arm with the lateral midline of the 
fibula, using the lateral malleolus and fibular head 
for reference. 







lifi; 






FIGURE 9-9 The right lower extremity at the end of knee flexion ROM. The examiner uses one hand to 
move the subject's thigh to approximately 90 degrees of hip flexion and then stabilizes the femur to 
prevent further flexion. The examiner's other hand guides the subject's lower leg through full knee flex- 
ion ROM. 



; 
j 



CHAPTER 9 THE KNEE 231 








FIGURE 9-10 In the starting position for measuring knee flexion ROM, the subject is supine with the 
upper thigh exposed so that the greater trochanter can be visualized and palpated. The examiner either 
kneels or sits on a stool to align and read the goniometer at eye level. 






m 



FIGURE 9-11 At the end of the knee flexion ROM, the examiner uses one hand to maintain knee flex- 
ion and also to keep the distal arm of the goniometer aligned with the lateral midline of the leg. 



■■■■ • ;- 



■-^. a — ;*---- . 



232 



PART ill LOWER-EXTREMITY TESTING 



X~ 



EXTENSION 



Motion occurs in the sagittal plane around a medial- 
lateral axis. Extension is not usually measured and 
recorded because it is a return to the starting position 
from the end of the knee flexion ROM. 

Normal End -feel 

The end-fee! is firm because of tension in the posterior 
joint capsule, the oblique and arcuate popliteal ligaments, 
the collateral ligaments, and the anterior and posterior 
cruciate ligaments. 



Muscle Length Testing Procedures: 
Knee 



RECTUS FEMORIS: ELY TEST 



The rectus femoris is one of the four muscles that make 
up the muscle group called the quadriceps femoris. The 
rectus femoris is the only one of the four muscles that 
crosses both the hip and the knee joints. The muscle 
arises proximally from two tendons: an anterior tendon 
from the anterior inferior iliac spine, and a posterior 
tendon from a groove superior to the brim of the acetab- 
ulum. Distally, the muscle attaches to the base of the 
patella by way of the thick, flat quadriceps tendon and 
attaches to the tibial tuberosity by way of the patellar 
ligament (Fig. 9-12). 



Goniometer Alignment 

1. Center the fulcrum of the goniometer over the 
lateral epicondyle of the femur. 

2. Align the proximal arm with the lateral midline of 
the femur, using the greater trochanter for refer- 
ence. 

3. Align the distal arm with the lateral midline of the 
fibula, using the lateral malleolus and fibular head 
for reference. 






When the rectus femoris muscle contracts, it flexes the 
hip and extends the knee. If the rectus femoris is short 
knee flexion is limited when the hip is maintained in a 

neurral position. It knee flexion is limited when the hip is 
in a flexed position, the limitation is not owing to a short 
rectus femoris muscle but to abnormalities of joint struc- 
tures or short one-joint knee extensor muscles. 

Starting Position 

Place the subject prone, with both feet off the end of the 
examining table. Extend the knees and position the hips 
in degrees of flexion, extension, abduction, adduction, 
and rotation (Fig. 9-13). 

Stabilization 

Stabilize the hip to maintain the neutral position. Do not 
allow the hip to flex. 












CHAPTER 9 THE KNEE 233 



the 

-'of 
fer- 
tile 
ead 



i the 
tort, 
in a 
ip is 
hort 

TUC- 



f the 

hips 
cion. 



d not 



Tibial tuberosity 




Anterior inferior 
iliac spine 



Rectus femoris 



Patella 



Patellar 
ligament 



FIGURE 9-12 An anterior view of the left lower extremity showing the attachments of the rectus femoris 
muscle. 




FIGURE 9-13 The subject is shown in the prone starting position for testing the length of the rectus 
femoris muscle. Ideally, the feet should be extended over the edge of the table. 



234 PART 111 LOWER-EXTREMITY TESTING 



o i 



a 

z... 

— * ■ 



i 





FIGURE 9-14 A lateral view of the subject at the end of the testing motion for the length of the left rectus 
femoris muscle. 






FIGURE 9-15 A lateral view of the left rectus femoris muscle being stretched over the hip and knee joints 
at the end of the testing motion. 




CHAPTER 9 THE KNEE 



235 




0n9 Motion 

f he knee ^ ''ft' n 8 tne lower leg off the table. The 

A f the ROM occurs when resistance is felt from 

*"•• n in the anterior thigh and further knee flexion 

t ^a»s the hip to flex. If the knee can be flexed to at least 

art tteerees w ; t h c he hip in the neutral position, the length 
fthe teems femoris is normal (Figs. 9-14 and 9-15). 



Goniometer Alignment 

See Figure 9-16. 

1. Center the fulcrum of the goniometer over the 
lateral epicondyle of the femur. 

2. Align the proximal arm with the lateral midline of 
the femur, using the greater trochanter as a refer- 
ence. 

3. Align the distal arm with the lateral midline of the 
fibula, using the lateral malleolus and the fibular 
head for reference. 




FIGURE 9-16 Goniometer alignment for measuring the position of the knee. 




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236 



PART III LOWER-EXTREMITY TESTING 



HAMSTRING MUSCLES: 
SEMITENDINOSUS, SEMIMEMBRANOSUS, 
AND BICEPS FEMORIS: DISTAL 
HAMSTRING LENGTH TEST 



The hamstring muscles are composed of the semitendi- 
nosus, semimembranosus and biceps femoris. The semi- 
tendinosus and semimembranosus as well as the long 
head of the biceps femoris cross both the hip and the knee 
joints. The proximal attachment of the semitendinosus is 
on the ischial tuberosity and the distal attachment is on 
the proximal aspect of the media! surface of the tibia (Fig. 
9-1 7 A). The proximal attachment of the semimembra- 
nosus is on the ischial tuberosity and the distal attach- 
ment is on the medial aspect of the medial tibia! condyle. 
(Fig. 9-1 7B) The biceps femoris muscle arises from two 
heads; the long head attaches to the ischial tuberosity and 
the sacrotuberous ligament, whereas the short head 
attaches along the lateral lip linear aspera, the lateral 



supracondylar line, and the lateral intermuscular septum. 
The distal attachments of the biceps femoris are on the 
head of the fibula, with a small portion attaching to the 
lateral tibial condyle and the lateral collateral ligament 
(see Fig. 9-17A). 

When the hamstring muscles contract, they extend the 
hip and flex the knee. In the following test, the hip i s 
maintained in 90 degrees of flexion while the knee is 
extended to determine whether the muscles are of normal 
length. If the hamstrings are short, the muscles limit knee 
extension ROM when the hip is positioned at 90 degrees 
of flexion. 

Gajdosik and associates, 46 in a study of 30 healthy 
males aged 18 to 40 years found a mean value of 31 
degrees (SD = 7.5) for knee flexion during this test. 
Values for knee flexion ranged from 17 to 45 degrees. 
Examiners reported that end-feel was firm and easily 
identified. 




; 



1 
1 



[ft 

i 

! 

•It' 



Semifendmosus 



Biceps femoris 
(long head) 



Sct r-r-mbrarosus 



Tibia 




Biceps lemons 
(short iHcid) 



Heac c! 
fibula 



A 



Tibia 





Semimembranosus 



Head cl 
fibula 



B 



FIGURE 9-17 (A). A posterior view of the thigh showing the attachments of the semitendinosus and the 
biceps femoris muscles. (B). A posterior view of the thigh showing the attachments of the semimembra- 
nosus muscle which lies under the two hamstring muscles shown in Figure 9-17A. 



. 




CHAPTER 9 THE KNEE 



237 






lie 



oat 

ies-v 

31 
test. 



Stflrt/n^f Position 

Position the subject supine with the hip on the side being 
tested in 90 degrees of flexion and degrees of abduc- 
tion, adduction, and rotation (Fig. 9-18). Initially, the 
knee being tested is allowed to relax in flexion. The lower 
extremity that is not being tested rests on the examining 
table with the knee fully extended and the hip in 
j f „ rees of flexion, extension, abduction, adduction, and 
rotation. 

Stabilization 

Stabilize the femur to prevent rotation, abduction, and 
adduction at the hip and to maintain the hip in 90 
degrees of flexion. 



'::.■'■■-:' ■ ■ 



HIS 




"rfAvi^I;.*^ 





m 



- 



FIGURE 9-18 The starting position for measuring the length of the hamstring muscles. 



1 



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LU 




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t/5 




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238 



PART III LOWER-EXTREMITY TESTING 



Testing Motion 

Extend the knee to the end of the ROM. The end of the 
testing motion occurs when resistance is felt from tension 
in the posterior thigh and further knee extension causes 
the hip to move toward extension (Figs. 9-19 and 9-20). 



Normal End-feel 

The end-feel is firm owing to tension in the semimem- 
branosus, semitendinosus, and biceps femoris muscles. 





m> 






' 



FIGURE 9-19 The end of the testing motion for the length of the right hamstring muscles. 





FIGURE 9-20 A lateral view of the right lower extremity shows the hamstring muscles being stretched 
over the hip and knee joints at the end of the testing motion. 



CHAPTER 9 THE KNEE 



239 



Goniometer Alignment 

See Figure 9-21. 

1, Center the fulcrum of the goniometer over the 
lateral epicondyle of the femur. 



2. Align the proximal arm with the lateral midline of 
the femur, using the greater trochanter for a refer- 
ence. 

3. Align the distal arm with the lateral midline of the 
fibula, using the lateral malleolus and fibular head 
for reference. 







FIGURE 9-21 Goniometer alignment for measuring knee position. 



240 



PART Ml LOWER-EXTREMITY TE5TINC 



REFERENCES 



9. 

so. 
11. 
12. 
13. 
14. 

15. 

16. 

17. 
18. 

19. 
20. 
21. 
22. 

23. 

24. 



25. 

Levangie, PK, and Norkin, CC: Joint Structure and Function: A 26. 

Comprehensive Analysis, ed 3. FA Davis, Philadelphia, 2Q0I. 

Williams, PI. fed): Gray's Anatomy, cd 38, Churchill Livingstone, ly 

New York, 1995. 

Greene, WB, and Heckman, JD (eds): The Clinical Measurement 

of Joint Morion. American Academy of Orthopaedic Surgeons, ig 

Chicago, 1994. 

Kaltenborn, FM: Mobilization of the Extremity joints, ed 5. Olaf 

Norlis Bokhnndel, Oslo, 1999. 29. 

Cyriax, JH, and Cyriax, PJ: Illustrated Manual of Orthopaedic 

Medicine. Butterwotths, London, 1983. 

Fritz, JM, cc al: An examination of the selective tissue tension 30 

scheme, with evidence for the concept of a capsular pattern of the 

knee. Phys Ther 78:1046, 1998. 

Hayes, KW: Invited commentary. Phys Ther 78:1057, 1998. 3 ] . 

Hayes KW, Petersen C, and Falcone, J: An examination of 

Cvriax's passive motion tests with patients having ostcoarthirks 

of the knee, Phys Ther 74:697, 1994. 32. 

American Medical Association: Guides to the Evaluation of 

Permanent Impairment, ed 3 (revised). AMA. Chicago, 1990. 

Boone, DC, and Azen, SP: Norma! range of motion of joints in 33 

male subjects. J Bone joint Surg Am 61:756, 1979. 

Roach, KE, and Miles, TP: Normal hip and knee active range of 

motion: The relationship to age. Phys Ther 71:656, 1991. 34 

Rothstein, JM, Roy, SH, and Wolf, SL: The Rehabilitation 

Specialist's Handbook, ed 2. FA Davis, Philadelphia, 1998. 

Waugh, KG, et ah Measurement of selected hip, knee, and ankle 35, 

joint motions in newborns. Phys Ther 63:1616, 1983. 

Drews, JE, Vraciu, JK, and Pcllino, G: Range of motion of the 

lower extremities of newborns. Phys Occup Ther Pediatr 4:49, 

1984. 3 6 . 

Schwarze, DJ, and Denton, JR: Normal values of neonatal limbs: 

An evaluation of 1000 neonates. J Pediatr Orthop 13:758, 1993. 

Wanatabe, H, et ai: The range of joint motions of the extremities 37 

in healthy Japanese people: The difference according to age, 

Nippon Seikeigeka Gakkai Zasshi 53: 275, 1979 (Cited by 3s 

Walker, JM: Musculoskeletal development: A review. Phys Ther 

71:878, 1991.) 39. 

Broughron NS, Wright J, and Menebus, MB: Range of knee 

motion in normal neonates. J Pediatr Orthop 13:263, 1993. 

Boone, DC: Techniques of measurement of joint motion. 4Q 

(Unpublished supplement to Boone, DC, and Azen, SP: Normal 

range of motion in male subjects. J Bone joint Surg Am 61:756, 

1979.) 41, 

Beighton, P, Solomon, L, and Soskolne, CL: Articular mobihry in 

an African population. Ann Rheum Dis 32:23, 1973. 42. 

Cheng, JC, Chan, PS, and Hui, PW: Joint laxity in children. J 

Pediatr Orthop 11: 752, 1991. 43 

Walker, JM, et al: Active mobility of the extremities in older 

subjects. Phys Ther 64:919, 1984. 

Mollinger, LA, and Stcffan, TM: Knee flexion contractures in 44 

institutionalized elderly: Prevalence, severity, stability and related 

variables. Phys Ther 73:437, 1993. 

Steultjens, MPM, et al: Range of motion and disability in patients 43 

with osteoarthritis of rhe knee or hip. Rheumatology 39:955, 

2000. 

Escalante, A, et al: Determinants of hip and knee flexion range: 4(, 

Results from the San Antonio Longitudinal Srudy of Aging. 

Arthritis Care Res 12:8, 1999. 



Loudon. jK. (loisi, III, .md Loudon, KL: Genu recurvat ^- 

syndrome. | Orthop Sports Phy* Ther 27:361. h>98. Ul ^| 

Hall, Md. el al: The e/tct'l ot hyperiliohrlity syndrome on kn"8 

joint proprkictprmii. Br j Rheumatol 34:121, l 1 >95. 

Jaiim, B. and Parker. AW: Active and passive mobility of ih'S 

lower titnh limits in elderly men and ttftittli-n. Am | f'hys Med a H 

Rrh.ih Midf.2. |9!v9>. ' M ?| 

Lichiciistem, Mj, et al: Modeling iiiip.urineiil: using the disahtJP 

mem proctsx as a framework m evaluate determinants of hinariif^ 

kiiee thxum. Aging iMilaiioi I2:2(«5, 2000. 

Sobtl, A, et al: Occupational physical actuary and long term rist?: 

of musculoskeletal symptoms: A national survey of post officii'' 

pensioners. Am J Indust Med 32:76, lv l >~. 

Jevseear, DS, e! .1!; Knee kinematics and kinetics during locomoi? 

t<ir activities or daily living in subjects with knee arthroplasty wj 

in healthy control subjects. Phys Ther 73:229, 199,3. 

Livingston, LA, Stevenson, JM, ami Olney, SJ: SiatrdiinhingkineJft 

iiKHiLs nn stairs ot dillering dimensions. Arch Phys Med RehabiP 

72:398, 19 1 >I. 

Clarksoii, MM: Musctiloskeiet.it Assessment: Joint Range of-' 

Motion and Manual Muscle Strength, ed 2. t.ippincott Williams 

es: Wilkuis, Philadelphia. 2000. 

Laubcnthal. KN, Sino.lt. CI , and kelt'ekamp. [>B: A quantitative- 

analysis ot ktscc motion during activities 01 daily living. PhysThef 

>2:J4, 1972. 

Mcl-ayden, B|. and Winter, DA: An integrated biomechanics!' 

analysis oi normal si.ur ascent and descent. I Riomech 21:733". 

l l >.SS. ' 

The ['.ithok t:it siiiliio v Service and Physical Therapy Departments 

Observational Gait Analysis, ed. 4. Los Anngos Research aoj- ' 

Education Institute. Inc. Rancho Los Amigos National 

Rehabilitation Center, Downey, C'A. 2001, 

Oners', I. Kars/nia, A. and Ohcrg, K: joint angle parameters ir};- 

gait: Reference data for normal subtests. 10-79 years of age. J 

Kehaiul Ke, Dcv »J:19<», 1994. 

Boone, DC, er at: Reliability ot goiunmetric measurements, PhyC 

Ther 58:1355. IWS. 

Gugia, PP. et al: Reliability and validity of goniomerric measurer; 

meiits at the knee. Phys Ther ts~:142, 1^X7. 

Rheault. W, et al: lntertester reliability and concurrent validity 0? 

fluid-based and universal goniometers for active knee flexion 

Phys Ther tiS;lo-(,, l'»SK. ' §j 

Banholomy. JK, Chandler, RF, and Kaplan, SE: Validity analysis. 

of thud goniometer measurements ot knee flexion. [AbstrJ Pay's'-. 

Ther 80*16, 2000. 

bnwciiicka. CS: Radiographic venficarion of knee goniomeuv.. 

Scand J Rchabil Med 18:47, 19&6. >-. 

Roilistem. JM, Miller. P|, and Roetiger, RE: Goniometric rcliabilv 

icy in a clinical setting. Phys [her ftarffrl I, 19X3. 

Watkms. MA. et at: Reliability ot gomonietric measurements and 

visu.il estiinaies of knee range ot motion obtained in a clinic|t: 

setting. Phys Ther 7 1:90. I W|. .. 

Paiulya. S. ei al: Reliability ot goniometric measurements at 

patients with Duchctine muscular dystrophy. Phys fher 65:1333, 

1985. ;lf 

Iteissner K, Collins JK and Holmes H: Muscle force and «il{*™ ; 

motion as predictors csr luuciion in older adults. Phys tn» 

S0:55(>, 2000. 

Gajdosik et al: Comparison ot tour 

ing hamstring muse 

1993. 




niiparison ot tour clinical tests for asst&v- 
le length. J Orthop Sport Phys Ther 18: 6W>; 



iK& 



■tat 
and . 



fttsk if 
fee - 

f.and : '- : v"' 

ikine- - 
sbabit 

& of ■ 
lliams 

itaiive ;i, 

§S$erf| 

;i:733,.\ .■ 

ctmcnc 
eh and 

«ets in | 

i age. J 

ts. Phys ■ 

rieasurc-: 

ilidity of , 
Sexiote 

analysis 
strlPhyte 

liometry. 

c/reliabi| 3 i 

aents and 
a ciinicai 

!ments iii 
65:1339. 

i range of 
>hys The; 

or aswss- 
r 18; 614, 



©HAPTER ID 



The Ankle and Foot 




M Structure and Function 

Proximal and Distal Tibiofibular Joints 

Anatomy 

The proximal tibiofibular joint is formed by a slightly 
convex tibial facet and a slightly concave fibular facet 
and is surrounded by a joint capsule that is reinforced by 
anterior and posterior ligaments. The distal tibiofibular 
joint is formed by a fibrous union between a concave 
facet on the lateral aspect of the distal tibia and a convex 
facet on the distal fibula. (Fig. 10-1A) Both joints are 
supported by the interosseous membrane, which is 
located between the tibia and the fibula (Fig. 10-1 B) The 
distal joint does not have a joint capsule but is supported 
by anterior and posterior ligaments and the crural 
interosseous tibiofibular ligament. (Fig. 10-lC). 

Qsteokinematics 

The proximal and distal tibiofibular joints are anatomi- 
cally distinct from the talocrural joint but function to 
serve the ankle. The proximal joint is a plane synovia! 
joint that allows a smalt amount of superior and inferior 
sliding of the fibula on the tibia and a slight amount of 
rotation. The distal joint is a syndesmosis, or fibrous 
union, but it also allows a small amount of motion. 

Arthrokinematics 

During dorsiflexion of the ankle, the fibula moves proxi- 

foally and slightly posteriorly (lateral rotation) away 
from the tibia. During plantarflexion, the fibula glides 
oistally and slightly anteriorly toward the tibia. 

Capsular Pattern 

The capsular pattern is not defined for the tibiofibular 

ipints. 



Talocrural Joint 

Anatomy 

The talocrural joint comprises the articulations between 
the talus and the distal tibia and fibula. Proximally, the 
joint is formed by the concave surfaces of the distal tibia 
and the tibial and fibular malleoli. Distally, the joint 
surface is the convex dome of the talus. The joint capsule 
is thin and weak anteriorly and posteriorly, and the joint 
is reinforced by lateral and medial ligaments. Anterior 
and posterior talofibular ligaments and the calcaneofibu- 
lar ligament provide lateral support for the capsule and 
joint (Fig. 10-2A and 8). The deltoid ligament provides 
medial support (Fig. 10-3). 

Osteokinematics 

The talocrural joint is a synovial hinge joint with 1 
degree of freedom. The motions available are dorsiflex- 
ion and plantarflexion. These motions occur around an 
oblique axis and thus do not occur purely in the sagittal 
plane. The motions cross three planes and therefore are 
considered to be tripianar. Dorsiflexion of the ankle 
brings the foot up and slightly lateral, whereas plan- 
tarflexion brings the foot down and slightly medial. The 
ankle is considered to be in the 0-degree neutral position 
when the foot is at a right angle to the tibia. 

Arthrokinematics 

In dorsiflexion in the non-weight-bearing position, the 
talus moves posteriorly. In plantarflexion, the talus 
moves anteriorly. In dorsiflexion, in the weight-bearing 
position, the tibia moves anteriorly. In plantarflexion, 
the tibia moves posteriorly. 

Capsular Pattern 

The pattern is a greater limitation in plantarflexion than 
in dorsiflexion. 

241 



242 PART II! LOWER-EXTREMITY TESTING 



Proximal tibiofibular 
ligament 



Fibula 



Distal tibiofibular 
[oint 




Anterior 

ligament 

of fibular 

head 



Tibia 



Anterior 

tibiofibular 

ligament 




interosseous 
membrane 




Posterior ligament of 
fibular head 



Posterior tibiofibular 
Hgament 



FIGURE 10-1 {A) The anterior aspect of the proximal and distal tibiofibular joints of a right lower 
extremity. (B) The anterior tibiofibular ligaments and the interosseous membrane. (C) The posterior 
aspect of the tibiofibular joints and the posterior tibiofibular ligaments of a right lower extremity. 



Fibula 



Fibula 



Talocrural 
joint 




Tibia 



Posterior 
talofibular 
ligament 

Calcaneofibular 
ligament 



Calcaneus 



Cuboid 



Posterior 
tibiofibular 
ligament 



Calcaneofibular 
iigament 



B 




Talus 

Talocrural 
joint 



Posterior talofibuiar 
ligament 



Calcaneus 



FIGURE 10-2 (A) A lateral view of a left talocrural joint with the anterior and posterior talofibular liga- 
ments and the calcaneofibular ligament (B) A posterior view of a left talocrural joint shows the posterior 
talofibular ligament and the calcaneofibular ligament. 



CHAPTER 10 THE ANKLE AND FOOT 243 



Posterior tibsotatar 
Tibiocalcaneal 
Anterior tibiotalar 
Tibionavicular 




Deltoid 
ligament 



FIGURE 10-3 The deltoid ligament in a medial view of a left talocrural joint. 






Subtalar Joint 

Anatomy 

;The subtalar (talocalcaneai) joint is composed of three 

■ separate plane articulations: the posterior, anterior, and 
middle articulations between the talus and the calcaneus. 

iThe posterior articulation, which is the largest, includes a 

■^concave facet on the inferior surface of the talus and a 
convex facet on the body of the calcaneus. The anterior 
and middle articulations are formed by two convex facets 

■on the talus and two concave facets on the calcaneus. The 
anterior and middle articulations share a joint capsule 
with the talonavicular joint; the posterior articulation has 

■its own capsule. The subtalar joint is reinforced by ante- 
rior, posterior, lateral, and medial talocalcaneai ligaments 
and the interosseus talocalcaneai ligament. (Figs. 10-4 

lad 10-5). 



Osteokinematics 

The motions permitted at the joint are inversion and 
eversion, which occur around an oblique axis. These 
motions are composite motions consisting of abduction- 
adduction, flexion-extension, and supination-pronation. 1 
In non— weight-bearing inversion, the calcaneus adducts 
around an anterior-posterior axis, supinates around a 
longitudinal axis, and plantar flexes around a medial- 
lateral axis. In eversion, the calcaneus abducts, pronates, 
and dorsi flexes. 



Arth rokin etna tics 

The alternating convex and concave facets limit mobility 
and create a twisting motion of the calcaneus on the 



Talus 



talofibular 



js 



Talus 



i 



Subtalar 

joint 



|. : Interosseus 

;| biocalcanea! — 

■ ligament 





Lateral talocalcaneai 

ligament 



Calcaneus 



: | 'IGURE 10-4, The interosseus talocalcaneai and lateral talo- 
I Calcaneal ligaments in a lateral view of a left subtalar joint. 



Posterior 

talocaneal 

ligament 




Subtalar 
joint 



Calcaneus Medial talocalcaneai 

ligament 

FIGURE 10-5 The medial and posterior talocalcaneai liga- 
ments in a medial view of a left subtalar joint. 



244 



PART Ml LOWER-EXTREMITY TESTING 



talus. In inversion of the foot, the calcaneus slides later- 
ally on a fixed talus. In eversion, the calcaneus slides 
medially on the talus. 

Capsular Pattern 

The capsular pattern consists of a greater limitation in 

inversion. 3 



Transverse Tarsal (Midtarsal) Joint 

Anatomy 

The transverse tarsal, or midtarsal, joint is a compound 
joint formed by the talonavicular and calcaneocuboid 
joints (Fig. 10-6/1). The talonavicular joint is composed 
of the large convex head of the talus and the concave 
posterior portion of the navicular bone. The concavity is 
enlarged by the plantar calcaneonavicular ligament 
(spring ligament). The joint shares a capsule with the 



anterior and middle portions of the subtalar joint and is 
reinforced by the spring, bifurcate (calcaneocuboid and 
calcaneonavicular), and dorsal Talonavicular ligaments 
(big. 10-6/1). 

The calcaneocuboid joint is composed of the shallow 
convex-concave surfaces on the anterior calcaneus and 
the convex-concave surfaces on live posterior cuboid. The 
joint is enclosed in a capsule that is reinforced by the 
bifurcate (calcaneocuboid and calcaneonavicular), dorsal 
calcaneocuboid, plantar calcaneocuboid, and long plan- 
tar ligaments (Fig. I0-6Q. 

Osteokinematics 

The joint is considered to have two axes, one longitudi- 
nal and one oblique. Motions around both axes are 
tnplanar and consist of inversion ami eversion. The 
transverse tarsal joint is the transitional link between the 

hindfoot and the forefoot. 



Talus 



^ 



i 



Navicular 




: 



::^ 



Talonavicular joint 



Calcaneocuboid join! 



.. Transverse tarsal 

(midtarsal) joint 



Fifth' 7 ' 
metatarsal 



Dorsal talonavicular ligament 



Talus 



Cuboid 



Navicular 



Calcaneus 

Dorsal talonavicular ligament 

Navicular 



Calcaneonavicular 
ligament 








Calcaneocuboid 
ligament 






Dorsal calcaneocuboid 
ligament 



Calcaneus 



Plantar calcaneonavicular ligament 
(spring ligament) 



First metatarsal 



C Long plantar ligament 



FIGURE 10-6 (A) The two joints that make up the transverse tarsal joinr arc shown in ,i Literal view of 
a left ankle. {B) The dorsal talonavicular ligament, the bifurcate ligament {calcaneonavicular and calca- 
neocuboid ligaments), and the dorsal calcaneocuboid ligament in a lateral view of a left ankle. (O The 
long plantar ligament, the plancat calcaneonavicular ligament, and the dorsal talonavicular ligament in a 
media! view. 




CHAPTER 10 THE ANKLE AND FOOT 



245 



Arthrokinematics 

In inversion, the concave navicular slides medially and 
dorsally on the convex talus. The calcaneus slides medi- 
ally and toward the plantar surface. In eversion, the 
navicular slides laterally and toward the plantar surface, 
on the talus the calcaneus slides laterally toward the 
dorsal surface. 

Capsular Pattern 

The capsular pattern consists of a limitation in inversion 

(adduction and supination). Other motions are full. 

Tarsometatarsal Joints 

Anatomy 

The five tarsometatarsal (TMT) joints link the distal 
tarsals with the bases of the five metatarsals (Fig. 10-7). 
The concave base of the first metatarsal articulates with 
the convex surface of the medial cuneiform. The base of 
the second metatarsal articulates with the mortise formed 
; by the intermediate cuneiform and the sides of the medial 
and lateral cuneiforms. The base of the third metatarsal 
articulates with the lateral cuneiform, and the base of the 
fourth metatarsal articulates with the lateral cunieform 



Metatarsals 
.: : (1 thru 5) 



Lateral 

cuneiform 



Cuboid 




Tarsometatarsal 
joint 



Medial 
cuneiform 



Navicular 



Intermediate 
cuneiform 



Transverse 

tarsal 

joint 



T-m. 



FIGURE 10-7 The tarsometatarsal joints and transverse tarsal 
joint in a dorsal view of a left foot. 



and the cuboid. The fifth metatarsal articulates with the 
cuboid. The first joint has its own capsule, whereas the 
second and third joints and the fourth and fifth joints 
share capsules. Each joint is reinforced by numerous 
dorsal, plantar, and interosseous ligaments. 

Osteokinematics 

The TMT joints are plane synovial joints that permit 
gliding motions, including flexion-extension, a minimal 
amount of abduction-adduction, and rotation. The type 
and amount of motion vary at each joint. For example, at 
the third TMT joint, the predominant motion is flexion- 
extension. The combination of motions at the various 
joints contributes to the hollowing and flattening of the 
foot, which helps the foot conform to a supporting 
surface. 

A rthrokinematics 

The distal joint surfaces glide in the same direction as the 
shafts of the metatarsals. 

Metatarsophalangeal Joints 

Anatomy 

The five metatarsophalangeal (MTP) joints are formed 
proximally by the convex heads of the five metatarsals 
and distally by the concave bases of the proximal 
phalanges (Fig. 10-8^4). The first MTP joint has two 
sesamoid bones that lie in two grooves on the plantar 
surface of the distal metatarsal. The four lesser toes are 
interconnected on the plantar surface by the deep trans- 
verse metatarsal ligament {Fig. 10-SB). The plantar 
aponeurosis helps to provide stability and limits exten- 
sion. 

Osteokinematics 

The five MTP joints are condyloid synovial joints with 2 
degrees of freedom, permitting flexion-extension and 
abduction-adduction. The axis for flexion-extension is 
oblique and is referred to as the metatarsal break. The 
range of motion (ROM) in extension is greater than in 
flexion, but the total ROM varies according to the rela- 
tive lengths of the metatarsals and the weight-bearing 
status. 

A rthrokinematics 

In flexion, the bases of the phalanges slide in a plantar 
direction on the heads of the metatarsals. In abduction, 
the concave bases of the phalanges slide on the convex 
heads of the metatarsals in a lateral direction away from 
the second toe. In adduction, the bases of the phalanges 
slide in a medial direction toward the second toe. 

Capsular Pattern 

The pattern at the first MTP joint is gross limitation; of 
extension and slight limitation of flexion. At the other 




246 



PART 



LOWER-EXTREMITY TESTING 



Distai interphalangeai joints 



Distat phalanx 
Middle phalanx 

Proximai phalanx 
Metatarsal 



Deep transverse 
metatarsal ligaments 




Interphalangeai 
joint 



Metatarso- 
phalangeal 
joint 



Plantar ligaments 
(plates) 



B 

FIGURE 10-8 (A) The metatarsophalangeal, interphalangeai, 
and distal interphalangeai joints in a dorsal view of a left foot. 
(B) The deep transverse metatarsal ligaments and the plantar 
plates in a plantar view of a left foot. 



table io-i Ankle Motion: Values in 
Degrees from Selected Sources 



joints (second to fifth), the limitation is more restriction 
of flexion than extension.' 

interphalangeai joints 

Anatomy 

The structure of the interphalangeai (IP) joints of the feet 
is identical to that of the IP joints of the lingers. bach IP 
joint is composed of the concave base or a distal phalanx 
and the convex head of a proximal phalanx (see Fig. 
10-8 A). 

Osteokinematics 

The IP joints are synovial hinge joints with S degree of 
freedom. The motions permitted are flexion and exten- 
sion in the sagittal plane, bach jomt is enclosed in a 
capsule and reinforced with collateral ligaments. 

Arthrokinematics 

The concave base of the distal phalanx siides on the 
convex head of the proximal phalanx in the same direc- 
tion as the shaft of the distal bone. The concave base, 
slides toward the plantar surface of the foot during flex- 
ion and toward the dorsum of the foot during extension. 



I Research Findings 

Tables 10-1 and 10-2 provide ankle and toe ROM values. 
from various sources. Hie age, gender, and number of the;; 
subjects who were measured to obtain the values; 
reported by the American Association o! Orthopaedic;. 
Surgeons (AAOS) 2 (published in 1965) and the American: 
Medical Association (AMA)' 1 are unknown. The 1994; 
AAOS' edition includes ROM values from various-:: 
research studies, including the same values from Boone ;: 
and A/en" that are included in I'able 10-i as well as a; ; 
few values from the 1965 edition. Boone and Azen, ; 



table 10-2 Toe Motion: Values in 
Degrees from Seiected Sources 



f.<ls i.ii-r 



Flexion 



AAO& AAOS? AMA* BoomandAzer?* 



joint 



bW<?- 



AAOS 1 



'» 




Motion :: \::y-- :{ -' : - 








:Medn (SD)r '■: 


MTP 1 


50 


70 


30 


45;t 




=-=—^ — 








* 2 


40 


40 


30 


40 - 








Dorsfflexion 


.;H^/0;: ;:/;;; :'^ 


20 


20 


12.6 


3 


30 


40 


20 


40. ,;, 


on 


50 


50 


:,->v40:- : ':';- : .:.- 


m:S6.20Mi&:'M 


4 


20 


40 


10 


40 2 


Forefoot inversion 


■i35'-.:,^ 




■ K-30*; .f: 


.. i ■ :. .. 


5 


10 


40 


10 


40 2 


Forefoot eversion 


■■■■is- -■.-■ 




,:■:::■ 26*; : "; 


20.7 


IP 1 






30 


90S 


Rearfoot inversion 


--.!:: 5->'f :-.,■; 








PIP 2-5 








35;> 


Rearfoot 


-MfelS 








DIP 2-5 








60.;: 



AMA = American Medical Association; AAOS = American 

Association of Orthopaedic Surgeons; (SD) = standard deviation. 
•Values represent visual estimation of arc of motion. 
f Subjects were 1 09 males 1 to 54 years of age. 



AMA ■■■■ American Medical Association; AAOS American 
Association of Orthopaedic Surgeons; DIP dislal interpha- 
langeai; IP ~ interphalangeai; MTP ■■■■ metatarsophalangeal; PIP : 
proximal interphalangeai. 



CHAPTER 10 THE ANKLE AND FOOT 



247 



' 






fable io-3 Effects of Age on Ankle Motion in Newborns and Children Aged 6 to 12 Years: 
Mean Values in Degrees 




Dorsltexion 
Plantarflewon 

Standard deviation 



(SO) 




r 



the?:; 
ties 
die 
;an 

Iff 
oiis ' 
one 



using a universal goniometer, measured active ROM on 
male subjects. 

Effects of Age, Gender and Other Factors 

A study of Table 10-3 shows that newborns, infants, and 
2-year-olds have a larger dorsiflexion ROM than older 
children. The mean values for dorsiflexion in the 
youngest age groups are more than double the average 
adult values presented in Tables 10-1 and 10-4. 
However, between 1 and 5 years of age, dorsiflexion 
values decrease to within adult ranges (Table 10-3). 
Newborns also have less plantarflexion ROM than 
adults, but they attain adult values in the first few weeks 
of life. According to Walker, 10 the persistence in infants 
of a limited ROM in plantarflexion may indicate pathol- 
ogy- 

Tabic 10—4, provides evidence that decreases in both 
dorsiflexion and plantarflexion ROM occur with 
increases in age. However, the difference between dorsi- 
flexion values in the oldest and those in the youngest 
groups constitutes less than 1 standard deviation (SD). 
Oti: the other hand, plantarflexion values in the oldest 
group are slightly more than 1 SD less than values for the 
youngest group. 

James and Parker 12 found a consistent reduction in 

both active and passive ROM with increasing age in all 

: ankle joint motions in a group of 80 active men and 



women ranging from 70 to 92 years of age. The most 
rapid reduction in ROM occurred for individuals in the 
ninth decade. Ankle dorsiflexion measured with the knee 
extended (a test of the length of the gastrocnemius 
muscle) showed the most marked change. The investiga- 
tors suggested that shorteness of the plantarflexor 
muscle-tendon unit was due to connective tissue changes 
associated with the aging process. In another study that 
examined the effects of aging on dorsiflexion ROM, 
Gajdosik, VanderLinden, and Williams 13 used an isoki- 
netic dynamometer to passively stretch the calf muscles in 
74 females (aged 20 to 84 years). The older women (aged 
60 to 84 years) had a significantly smaller mean dorsi- 
flexion angle of 15.4 degrees than the younger women 
(aged 20 to 39 years), who had a mean of 25.8 degrees, 
and the middle-aged women, who had a mean of 22.8 
degrees. The decrease in dorsiflexion in the older women 
was associated with a decrease in plantarflexor muscle- 
tendon unit extensibility. 

Nigg and associates 14 found that age-related changes 
in ankle ROM were motion specific and differed between 
males and females. The authors measured active ROM in 
121 subjects (61 males and 60 females) between the ages 
of 20 and 79 years. For the whole group of subjects, 
decreases in active ROM with increases in age occurred 
in plantarflexion, inversion, abduction, and adduction 
but not in eversion and dorsiflexion (tested in the sifting 
position with the knee flexed). Plantarflexion decreased 
about 8 degrees from the youngest to the oldest group. 



PIP % 
- 



table io-4 Effects of Age on Active Ankle Motion for Individuals 1 3 to 69 Years of Age: Mean 
Values in Degrees . 




"*yrj 
n ¥ 19 



61-^9 yrs 



n(SD) 



Meati(SD^ 



Me^V<SDV ? 



S^eao (SD) 



DoEifffexion 

Wan^ffiexion: 

w)~ Standard deviation. 



10.6(3.7) 


12.1 (3.4) 


12-2(4.3) 


12.4(4.7) 


8.2 (4.6) 


55.5(5.7) 


55.4(3.6) ■ 


; ;s; ; 54.6(6.0) 


■ 52.9(7.6) 


,.46.2.(7.7) 



?.3? 



248 



PART III LOWE R- EXTREMITY TESTING 



table 10-s Effects of Age and Gender on Dorsiflexion Range of Motion in Males and Females 
Aged 40 to 85 Years: Mean Values in Degrees 



•:'-■:. ■ ; 



NiggetairH/ 



Mates Femafp-s 

40-59 yrs 



h = 15 



h = 15. 



>M3t'esl 



qFe|tttn)w 



n = 15 ' n^V5l 



Mates 1 



Vandfirvoort et al ni 

..■ Malei-f 



Females 



Females 



55-60 yrs 
n = 20 n=16 



■ 81-85 yrs ; 
n = 18 n = 17 



■ 



jMean<SD) 



Mean (SB) 



Meart(SD) " : Mean (SO),, 



Mean(SD) Mean(SD) Mean (SD) Meart(SD) jp 



25.0 (7.0) 



26.0 (6.4) 



26.4(4.7) 



185 (4.8) 



15.4 (4.3) 



19.3 (3.2) 



13.1 (3.5) 



12.1 (5.5) 



ROM = Range of motion; (SD) = standard deviation. 

* A laboratory coordinate system ROM instrument was used to measure active ROM in subject silting with the knee flexed. 

'An electric computer- con trolled torque motor system was used to produce passive ROM in subjects positioned prone with the knee flexed. 



: ■ 



Gender 

Gender effects on ROM are joint specific and motion 
specific and are often related to age. Nigg and associ- 
ates 14 found gender differences in ankle motion but 
determined that the differences changed with increasing 

age. Only in the oldest group, did women have 8 degrees 
more plantarflexion than men (Table 10-5}. The only 
gender differences noted by Boone, Walker, and Perry 11 
were that females in the 1 -year-old to 9-year-old group 
and those in the 61 -year-old to 69-year-old group had 
significantly more ROM in plantarflexion than their male 
counterparts. Three other studies also found that women 
had more plantarflexion than men. Bell and Hoshizaki 16 
studied 17 joint motions in 124 females and 66 males 
ranging in age from 18 to 88 years. Females berween 17 
and 30 years of age had a greater ROM in plantarflexion 
as well as dorsiflexion than males in the same age groups. 
Walker and colleagues 17 studied active ROM in 30 men 
and 30 women ranging in age from 60 to 84 years. 
Women had 11 degrees more ankle plantarflexion than 



men. James and Parker,'" 1 who measured both active and 
passive ROM, found that the only motion rhai showed a 

significant difference between the genders was ankle 
plantarflexion measured with the knee extended. Women 
and men had similar mean values in the group berween 
70 and 74 years of age, but the reduction in ROM over 
the entire age range was greater for men (25.2 percent) 
that) tor women (I 1.3 percent). High-heeled shoe wear 
has been proposed by Nigg and associates 1 " as one reason | 
why women have a greater ROM in plantarflexion than 
men. 

In contrast to the findings that women have greater 
ROM than men in plantarflexion, a few investigators 
have found that females have less active and passive 
dorsiflexion ROM than males. ' J ' In a study by Nigg 
and associates, 1 '' males in the oldest group had a greater 
acme range of motion in dorsiflexion (S degrees) meas- 
ured with the knee flexed than females in the same age. 
group (Table 10-5). Females showed a significant: 
decrease in active dorsiflexion ROM with increasing age, 
from 26.0 degrees in the youngest group to 18.5 degrees 



■ 



.v'iS 



table io-6 Dorsiflexion Range of Motion Measured in ' :: Nbh4V^1ght-6earihg>P6sitiohs'wi'th' 
the Knee Extended in Male and Female Subjects Aged 20 to 85 Years: Mean Values in Degrees 



Cajdosik et al" n 



\ 20-24 yrs - 40-59 yrs 60-84 yrs - 

; n = >A .•-, •■•■.■.ri=:24^..v" : ; • n 33 



Moseteyetci 1 ' 

15-34 yrs 

n .-. 2<V- 



fonsonand Gross?? 

■'■;■' 18-30 yrs 
■:'■;, :'n = 57 ■■ >' : - : 



Vandetvoort et at 1 ' 1 ,- 



55-60 p 
n = .-* 



30-85 yrs 
n '--iW 



3n(SD) : 



Mean (50).; 



: Mean (SEtjK* 



MeanfSD; 



Mean(SD) 



Mean. (5D) : 



Mean. (5p)V 



25.83 (5.5) 



22.8 (4.4) 



15.4(5.8) 



18.1 (6.9) 



16.2(3.7) 



203 (4.6) 



11.8(5.2) 



ROM = Range of motion; (SD) = standard deviation. 

* All measurements are of passive ROM in female subjects taken in the supine position with t i universal goniometer. 

* All measurements are of passive ROM in both genders taken in the pron<" position with use of ii protractor and with the application of 12.0 

Nm of torque. 

* All measurements are of active assistive ROM in the prone position. 

5 All measurements are of active ROM in the prone position with use of a footplate and a potentiometer. 



■■7; 



CHAPTER 10 THE ANKLE AND FOOT 



249 



Si' 



m 



m 

ft 
& 



table 10-7 Comparison Between Dorsiflexion Range of Motion Measurements Taken with 
the Knee Flexed and Extended in Subjects Aged 8 to 87 Years: Mean Values in Degrees 



Berindi Ut al"" 



Skstrand et al u 



MePoil and Cornv,ciF ,} Mecagni et of 74 1 



-11 yrs. 



8.2-11 yrs 

n - 



2CW>\r\ 

r. = 10 



22-30 yrs 

n = T2 






64-57 yrs 

n - 34- • 



Mean (SDJ: 



Mean(- 



Mea&tSO) .' MsanJjgp); 



Mean (50)^ 



Ivtea'ri ■(£&>'■ 



Knee flexed 
Knee extended 



31.9(6.8) 
25.0 (7.6) 



29.2 (6.4) 
25.4 (8.5) 



26,6(2.5) 
22.9 (2.5) 



24.9(0.8) 
22.5 (0.7) 



16;2 (3.2) 
10.1 (2.2) 



10.9 (4.2) 
8.5 (3.1) 



ROM = Range of motion; (SD) = standard deviation. 

'Ail measurements were taken in weight-bearing positions with use of an inclinometer. 

'All measurements were taken in weight-bearing positions with use of a Leighton Flexometer (a type of gravity inclinometer). The flexed-knee 
testing position was greater than 90 degrees. 

* All measurements were taken by one tester using a masked goniometer. The testing position was not reported, but in the flexed-knee posi- 
tion, the knee was flexed to 90 degrees. 

s All measurements were taken in non-weight-bearing positions with use of an active assistive ROM technique 



in the oldest group. Females a}^$showed a significant 
decrease in eversion of 5.8 de^rfces with increasing age. 
Males, on the other hand, had'Jmtie or no change in either 
active dorsiflexion or eversion R'OM from the youngest 
to the oldest group. Vandervoort and coworkers 15 expe- 
rienced similar findings in a study measuring passive 
dorsiflexion ROM with the knee flexed. The end of the 
ROM was defined as the maximum degree of dorsiflex- 

. ion possible before muscle contraction occurred, or when 
the subject felt discomfort, or when the heel lifted from a 
floor plate. Females in the study showed a decrease in 
passive dorsiflexion ROM, from a high of 19.3 degrees in 
the youngest group {aged 55 to 60 years} to a low of 12.1 
degrees in the oldest group (aged 81 to 85 years) (Table 
10-5). In comparison, male subjects showed a decrease 
of only 2.3 degrees in dorsiflexion from the youngest 
group (mean = 15.4 degrees) to the oldest group (mean 

■',= 13.1 degrees). Males had greater passive elastic stiff- 
ness than females, with 10 degrees of dorsiflexion. 

Grimston and associates 18 measured active ROM in 
120 subjects (58 males and 62 females) ranging in age 
from 9 to 20 years. These authors found that females 
generally had a greater ROM in all ankle motions than 
males. Both males and females showed a consistent trend 
toward decreasing ROM with increasing age, but females 

■ had a larger decrease than males. 

testing Position 

A variety of positions are used to measure dorsiflexion 
ROM, including sitting with the knee flexed, supine with 
the knee either flexed or extended, prone with the knee 
either flexed or extended, and standing with the knee 
either flexed or extended. Positions in which the knee is 



flexed are used to relax the gastrocnemius muscle so that 
its effect on the measurement of dorsiflexion ROM is 
reduced. Positions in which the knee is extended gener- 
ally are used for testing the length of the gastrocnemius 
muscle (Table 10-6). Dorsiflexion measurements taken 
with the knee flexed generally are larger than measure- 
ments taken with the knee in the extended position (Table 
10-7). Dorsiflexion measurements taken in the weight- 
bearing position are usually greater than measurements 
taken in the non-weight-bearing position 25 (Tables 10—6 
and 10-7). 

McPoil and Cornwall 23 compared dorsiflexion ROM 
measurements taken with the knee flexed with measure- 
ments taken with the knee extended in 27 healthy young 
adults. As might be expected, the mean dorsiflexion 
ROM (16.2 degrees) with the knee flexed was greater 
than the mean (10.1 degrees) with the knee extended 
(Table 10-7). Baggett and Young 25 compared measure- 
ments of dorsiflexion ROM taken in the non-weight- 
bearing supine position with those taken in the standing 
weight-bearing position in 10 males and 20 female 
patients, aged 18 to 66 years. Both supine and standing 
measurements were taken with the knees extended. The 
average dorsiflexion ROM in the supine position was 8.3 
degrees, whereas the average dorsiflexion ROM in the 
standing position was 20.9 degrees. Little correlation was 
found between measurements taken in the non-weight- 
bearing position with those taken in the weight-bearing 
position. Consequently, the authors recommended that 
examiners not use the non-weight-bearing and weight- 
bearing positions interchangeably. 

Lattanza, Gray, and Kanter 26 measured subtalar joint 
eversion in weight-bearing and non-weight-bearing 



250 



PART ttl LOWER-EXTREMITY TESTING 



postures in 15 females and 2 males . Measurements of 
subtalar joint eversion in a weight-bearing posture were 

found to be significantly greater than those in a 
non-weight-bearing posture. The authors advocated 
measurement in both positions. 

Nowoczenski, Baumjauer, and Umberger 27 measured 
active and passive extension ROM of the MTP joint of 
the first toe in different positions in 14 women and 19 
men between the ages of 20 and 54 years. Active and 
passive toe extension measurements were taken with the 
subject standing on a platform with toes extending over 
the edge. Passive measurements were taken in the 
non-weight-bearing seated position and during heel rise 
in standing. Mean values in the weight-bearing position 
were 37.0 degrees for passive MTP extension and 44.0 
degrees for active extension compared with a mean value 
of 57.0 degrees obtained in the non-weight-bearing 
seated position and 58 degrees during heel rise in the 
standing position. Similar to the effects of different test- 
ing positions on ankle ROM, the results showed that the 
positions could not be used interchangeably, with the 
exception of the heel rise and seated non-weight-bearing 
positions. 

Injury/Disease 

Wilson and Gansneder 28 measured physical impairment 
measures (loss of passive ankle dorsiflexion, plantarflex- 
ion ROM, and swelling), functional limitations, and 
disability duration in 21 athletes with acute ankle 
sprains. Passive ROM measurements were taken with a 
universal goniometer, and ROM loss was obtained by 
subtracting the ROM total of the affected ankle from the 
passive ROM measurements taken on the unaffected 
ankle. The authors found that the combination of ROM 
loss and swelling predicted an acceptable estimate of 
disability duration, accounting for one-third of the vari- 
ance. Functional limitation measures alone provided a 
better estimate of disability duration, accounting for 67 
percent of the variance in the number of days the athletes 
were unable to work after the acute ankle sprain. 
Kaufman and associates 29 tracked 449 trainees at a 
Naval Special Warfare Training Center to determine 
whether an association existed between foot structure 
and the development of musculoskeletal overuse injuries 
of the lower extremities. Restricted dorsiflexion ROM 
was one of the five risk factors associated with overuse 
injury. 

Chesworth and Vandervoort 30 measured dorsiflexion 
ROM after ankle fracture. They found that large differ- 
ences occurred in the maximum passive dorsiflexion 
ROM between fractured ankles and the contralateral 
uninvolved ankles. Maximum passive dorsiflexion was 
defined as that point just prior to the initiation of muscle 
activity in the plantarflexor muscles. The authors hypoth- 
esized that the reflex length-tension relationship was 



altered in the fractured ankles and that this reflex activ- 
ity acted as a protective mechanism to prevent over- 
stretching of the plantarflexors. after a period of 
immohili* uion. Reynolds and colleague '' found that in 
rats, f> weeks ol immobilization of a healthy hind limb 
resulted in a significant (70 percent) loss of dorsiflexion 
ROM when a fixed torque was applied. The authors 
suggested that loss of extensibility of the musculotendi- 
nous unit was probably caused by tissue remodeling that 
occurred during extended immobilization. 

Hastings and coworkers 1 " studied a single patient with 
diabetes mellitus who had received a tendo-achilles 
lengthening procedure. The operation resulted in art; 
increase in dorsitiexion ROM with the knee extended 
from a preoperative level of degrees to a 7 month post 
operative level of 18 degrees. Plantar pressure during gait 
was considerably reduced by 55 percent when the patient 
was wearing shoes and the patient's scores on the 
performance of a number at functional tasks was 
improved by 24 percent. 

Salich, Mueller, and Sahrmann ' * found rhat patients 
with diabetes mellitus and peripheral neuropathy demon- 
strated less dorsiflexion ROM (extensibility of the 
musculotendinous unit] than a group of age matched 
control subjects, Salich, Brown, and Mueller'"' found that 
there was a positive relationship between body size and 
passive plantar flexor muscle stiffness. The lack of a 
correlation between stiffness (change in torque per unit 
change in joint angle) and a decrease in ROM ted the 
authors to caution examiners about using the term "stiff- 
ness" to describe limited joint motion. Limitations in- 
joint ROM may be caused by tension exerted by a fully 
lengthened muscle at the end ot its end-range which is 
different than muscle stiffness. The authors suggested 
that older patients who complain of stiffness may actu- 
ally be experiencing stretch intolerance which may halt 
motion early in the ROM measurement. 



Functional Range of Motion 

An adequate ROM at the ankle, foot, and toes is neces- 
sary for normal gait. At least 10 degrees of dorsiflexion 

is necessary in the stance phase of gait so that tibia 
can advance over the foot (Table 10-8) and at least 15 
degrees of plantarflexion is necessary in preswing. 
Five degrees of eversion is necessary at loading response 
to unlock the midtarsal joint for shock absorption, 
When the midtarsal joint is unlocked the foot is able to 
accommodate to various surfaces by tilting medially and 
laterally. In normal walking the first toe extends at every 
step and it has been estimated that this MTP extension 
occurs about 900 rimes in walking a mile.'"' About 30 
degrees of extension is required at the M7 P joints in the 
terminal stance phase of gait. In pre-swing, extension at 
the MTP joints reaches a maximum of approximately o" 




. 




CHAPTER 10 THE ANKLE AND FOOT 251 



c 


.3 


t 


| 


t 
e 


i 
.1 


5 


1 


:s 


■:';s 


<e 




id 




at : 


■jl 



id 

a 
lit 
he 
ff- 

I 
IS 

:ed 
tu- 
llt 





FIGURE 10-9 Standing on tiptoe requires a full range of 

motion in plantarflexion and 58 to 60 degtees of extension 27 at 
the first metatarsophalangeal joint. 



FIGURE 10-10 Descending staits requires an average of 21 to 

36 degrees of dorsiflexion. 37 



;es- 
ion 
ibia 
:15 

)fltse 

n. 3i 
e to 
.and 
very 
sipn 
t 30 
i the 

y.60 



degrees when the toes maintain contact with the floor 
after heel rise {Fig. 10-9). If the ROM at the MTP joints 
is limited it will interfere with forward progression, and 
the step length of the contralateral leg will be 
decreased. 35 

Running requires to 20 degrees of dorsiflcxion and 



to 30 degrees of plantarflexion,'" these ROMs are simi- 
lar to the amount of motion required for stair ascent and 
descent as shown in table 10-8. Descending stairs 
requires a maximum of between 21 and 36 degrees of 
dorsiflcxion (Fig. 10-10). Another activity requiring 
maximum dorsiflcxion is rising from a chair (Fig. 10-11). 



table 10-8 Range of Ankle Motion Necessary for Functional Locomotor Activities: Values 
in Degrees 




ISsiftexibrt 



10 (Murray) 36 

0-10 (Rancho Los Amigos) 3s 

0-15(Ostroskyetal) 39 

15-30 (Murray)* 3S 

0-15 (Rancho Los Amigos). 35 

0-31(Ostroskyetal) 3 * 

*Range of maximum mean angles observed during the activity. 



P&ntarfiexion 



14-27 (Livingston et a!)* 37 
15-25 (McFayden and Winter)* 35 

23-30 (Livingston et af)* 
15-25 (McFayden and Winter)* 



21-36 (Livingston et at)* : 



24-31 (Livingston et ag*; 




252 PART III LOWER-EXTREMITY TESTING 



! : 



.■■■... 
■ 



i 

: H 






■■■ i; 



r 



1 



; : 




FIGURE 10-11 Getting out of a chair may require a full 
dorsiflcxion range of motion (ROM), depending on the height 
of the chair seat. The lower the seat, the greater the ROM 

required. 



Mecagni and colleagues 24 suggested that decreases 
in dorsiflexion ROM constituted a risk factor for 
decreased balance and alteration of movement patterns 
and Hastings and coworkers 32 identified limited dorsi- 
flexion ROM as a risk factor for increased plantar pres- 
sures during walking and decreased functional 
performance. 

Torburn, Perry, and Gronley 42 found that when 
subjects assumed a relaxed, one-legged standing position 
in three trials, they stood with the rearfoot in approxi- 
mately the same everted position {mean of 9.8 degrees). 
The authors suggested that the position of the rearfoot 
during one-legged standing could be used as an indica- 
tion of the maximum eversion ROM needed for the 
single support phase of gait. Garbalosa and associates 4 - 3 



measured iorefoot-rearfoot frontal plane relationships in 
234 feet ( 1 20 healthy males and females with a mean age 
of 28.1 years). Approximately S T percent of the meas- 
ured feet had forefoot varus, 8.8 percent had forefoot 
valgus and 4. ft percent had a neutral forefoot-rcarfoot 
relationship. 

Reliability and Validity 

Reliability studies involving one or more motions at the 
ankle have been conducted on healthy subjects 44 "" 
and on patient populations. ■ Also, motions of the 
subtalar joint, the subtalar joint neutral position, and the i 
forefoot position have been investigated. ■ ''^"'" , 

Some joints and motions can be measured more reli- 
ably than others. Boone and associates found that 
intratester reliability for selected motions at the ankle 
was better than that obtained for hip and wrist motions, 
but not as good as that obtained tor selected motions at.. 
the shoulder, elbow, and knee. 

Clapper and Wolf 4> found that both the universal 
goniometer and the Orthoranger (Orthotronics, Daytona 
Beach, HI.) were reliable instruments for measuring dorsi- 
flexion and plantarflexion but that the intraclass correla- 
tion coefficients (ICCs) were higher for the universal 
goniometer. The ICC for measurements of active dorsi- 
flexion for the universal goniometer was 0.92 in compar- 
ison with 0.80 for the Orthoranger. The ICC for the 
goniometer for plantarflexion was 0.96, whereas the ICC 
for the Orthoranger was 0.93. Considering the fact that 
the Orthoranger, a type of pendulum goniometer, costs 
considerably more than the universal goniometer, the 
authors concluded that the additional cost involved in 
purchasing an Orthoranger to measure ROM could not 
be justified. 

Bohannon, Tiberio, and Waters,' 1 " in a study involving 
I I males and I i females aged 21 to 43 years, investigated 
passive ROM for ankle dorsiflexion by means of differ- 
ent goniometer alignments. In one alignment, the arms of 
the goniometer were arranged parallel with the fibula 
and the heel. The second alignment used the fibula and a 
line parallel to the fifth metatarsal. These authors found 
that passive ROM measurements for dorsiflexion 
differed significantly according to which landmarks were 
used. 

Benneil and colleagues' 1 * conducted a study to deter- 
mine intertester and intratester reliability using the 
weight-bearing lunge method for measuring dorsiflexion. 
Four examiners used an inclinometer to measure the 
angle between the anterior border and the vertical border 
of the tibia and a tape measure to determine the distance 
of the lunging toe from the wall. Intratester and 
intertester reliability was extremely high (ICC' = 0.97 to 
0.99) for the four examiners with both methods of assess- 
ment. Refer to Tables 10-7 and 10-9, 



\m\ 



CHAPTER 1 



THE ANKLE AND FOOT 



253 



■ge 

Ik 



3 le io-9 Intratester and intertester Reliability: Dorsiflexion 



fie 
Hie 



fat 

pe 

>iis, 
||t 

jsal 
6na ■ 

SESt- 

eia- 

sal 

fei-' 

gar- 
Kthe 
ICC 
Ithat 
^ists 

"the 
# in 

[ving 
jated 
tffer- 

itsof 
ibula 
mda 
ound 
;xion 
were 

feter- 

j the 
goon, 
e.the 




Sample 



PosMwif 



(tntm) ICC (inter) ICC 55 



gjhrieH et al 



Operand Wolfe 45 20 
: gtf<&wiCorrwa\\ i ' i 27 



jonson and Gross J 
Saistcnetai; 1 

Civeru et al 50 

^Yoiidas et al 5 '- 



18 

34 

43 
38 



Healthy adults (mean age 18.8 yrs) 

Healthy adults (20-36 yrs) 
Healthy adults (mean age 26.1 yrs) 

Healthy adults (1 8-30 yrs) 
One-half healthy/one-hatf with 

diabetes mellitus (59-63 yrs) 
Patients with orthopedic or neurological 

problems (1 2-81 yrs) 
Patients with orthopedic problems 

(13^71 yrs) 



Weight bearing lunge- 


0.98 


i.r 


knee fiexed 


0.92 


0.97 1 A' 


Knee flexed to 90 a 


0.97 




Knee extended 


0.98 




Knee extended— prone position 


0.74 


0.65 


Knee extended— prone position 


0.95 




Passive ROM— no standard 


0.90 


0.50 


position used 






Active ROM— no standard 


0.78-0.96 


0.28 


position used* 







iCC = Intertester or intertester correlation coefficient, as noted; ROM = range of motion; SEM = sample evaluation method. 

•Knee was extended in 87.7 percent of measurement sessions. 



Hopson, McPoil, and Cornwall 49 conducted four 
static clinical tests to measure extension of the first MTP 
joint in 20 healthy adult subjects between 21 and 45 
years of age. Alt measurement techniques were found to 
be reliable but not interchangeable. Nowoczenski, 
Baurnjauer, and Umberger 27 also used four clinical tests 
to measure the first MTP joint extension: active and 
passive ROM and heel rise in the weight-bearing posi- 
tion, and passive ROM in the non-weight-bearing posi- 
tion. Test values were compared with measurements of 
MTP extension during normal walking. Active ROM in 
the weight-bearing position (44 degrees) and extension 
measured during heel rise {58 degrees) had the strongest 
correlations with motion of the MTP joint (42 degrees) 
during normal walking (r = 0.80 and 0.87, respectively). 

Elveru and associates 50 employed 12 physical thera- 
pists using universal goniometers to measure the passive 
ankle ROM in 43 patients with either neurological or 
orthopedic problems. The ICCs for intratester reliability 
for inversion and eversion were 0.74 and 0.75, respec- 
tively, and intertester reliability was poor (see Tables 
10-9, 10-10, and 10-11). Intertester reliability also was 
poor for dorsiflexion, and patient diagnosis affected the 
reliability of dorsiflexion measurements. Sources of error 
were identified as variable amounts of force being 
exerted by the therapist, resistance to movement in 
neurological patients, and difficulties encountered by the 



examiner in maintaining the foot and ankle in the desired 
position while holding the goniometer. 

Youdas, Bogard, and Suman 51 used 10 examiners in a 
study to determine the intratester and intertester reliabil- 
ity for active ROM in dorsiflexion and plantarflexion. 
The authors compared measurements made by a univer- 
sal goniometer and those obtained by visual estimation 
on 38 patients with orthopedic problems. A considerable 
measurement error was found to exist when two or more 
therapists made either repeated goniometric or visual 
estimates of the ankle ROM on the same patient (Tables 
10-9 and 10-10). The authors suggested that a single 
therapist should use a goniometer when making repeated 
measurements of ankle ROM. 

The subtalar joint neutral position, which has been the 
subject of numerous studies, is not the same as the 
starting position for the subtalar joint as used in this 
book and many others, including those of the AAOS, 2 the 
AMA, 4 and Clarkson. 55 The subtalar joint neutral posi- 
tion is defined as one in which the calcaneus inverts twice 
as many degrees as it everts. According to Elveru and 
associates, 52 this position can be found when the head of 
the talus either cannot be palpated or is equally extended 
at the medial and lateral borders of the talonavicular 
joint. This is the position usually used in the casting of 
foot orthotics, but it also has been used for measurement 
of joint motion. However, Elveru, Rothstein, and Lamb 50 



table 10-10 Intratester and Intertester Reliability: Plantarflexion 



j&nce 

and 
97 to 

ssess- 



Clapper and Wolfe 4S 20 
Elveru et al so 43 

ftudas et al 5 ' 38 



Healthy adults (20-36 yrs) 

Patients with orthopedic or neurological problems (12-81 yrs) 

Patients with orthopedic problems (13-71 yrs) 



Active ROM 


0.96 




PassiveROM 


0.86 


0.72 


Active ROM 


0.64-0.08 .;,, 


0.25 



JCC = intertester or intratester coefficient; ROM = range of motion. 



■■/ : ;-r*j 



254 PART III LOWER-EXTREMITY TESTING 



table 10-11 Intratester and Intertester Reliability: Inversion and Eversion 



nor 



Sample 



McPoil and Cornwall 21 27 

Torbum et a\ A2 42 

Elveru etal so 43 



Healthy adults (mean age 26.1 yrs) 

■:-■■■■=■■■"■■■:■■':■. ■•■■- - ;-:. -'.-■■"■■:>.. 

Patients with orthopedic and neurological problems 



ICC = Intertester and intratester correlation coefficient as noted. 
* Referenced to subtalar joint neutral. 
f Not referenced to subtalar joint neutral. 



found that referencing passive ROM measurements for 
inversion and eversion to the subtalar joint neutral posi- 
tion consistently reduced reliability {see Table 10-11). 
Based on the study of Elveru, Rothstein, and Lamb so and 
information from the following studies, vvc have decided 
not to use the subtalar neutral position as defined by 
Elveru and associates 52 in this text. 

Bailey, Perillo, and Forman i3 used tomography to 
study the subtalar joint neutral position in 2 female and 
13 male volunteers aged 20 to 30 years. These authors 
found that the neutral subtalar joint position was quite 
variable in relation to the total ROM, and that it was not 
always found at one-third of the total ROM from the 
maximally everted position. Furthermore, the neutral 
position varied not only from subject to subject but also 
between right and left sides of each subject. 

Picciano, Rowlands, and Worrell 54 conducted a study 
to determine the intratester and intertester reliability of 
measurements of open-chain and closed-chain subtalar 
joint neutral positions. Both ankles of 15 volunteer 
subjects (with a mean age of 27 years} were measured by 
two inexperienced physical therapy students. The 
students had a 2-hour training session using a universal 
goniometer prior to data collection. The method of 
taking measurements was based on the work of Elveru 
and associates. 52 Intratester reliability of open-chain 



Motion 


(Intra) ICC 


Inversion 


0.95 


Eversion 


0.96 


Inversion 




Eversion 




Inversion 


0.62' 




0.74* 


Eversion 


0.59* 




0.75 f 



0.3?3 

0,39^ 

0.15*: 

032*- 

0.1^ 

0.171: 



measurements of the subtalar joint neutral position was-i 
ICC -■- 0.27 for one tester and ICC ■ 0.06 for the;;; 
other tester. Intertester reliability was 0.00. Intra- 
tester and intertester reliability also were poor tor 
closed kinematic-chain measurements. Picciano^l 
Rowlands, and WorrclP" concluded that subtalar joints 
neutral measurements taken by inexperienced testers:, 
were unreliable; they recommended rluu clinicians should: 
practice taking measurements and performing repeated ■ 
measurements to determine their own reliability for these . 
measurements. However, Torburn, Perry, and Gronley 42 : 
suggested that inaccuracy of measurement technique with 
use of a universal goniometer rather rhan the ability of 
examiners to position the subtalar joint in the neutral 
position might be responsible for poor reliability findings 
for subtalar joint neutral positioning. The ICC for 
intertester reliability for 3 examiners was (ICC = 0.76) 
for positioning the subtalar joint in the neutral position. 
In this study, the examiners palpated the head of the talus 
in 10 subjects lying in the prone position while an elec- 
trogoniometer was used to record the position. 

In contrast to the low reliability found in the afore- 
mentioned Studies, McPoil and Cornwall"' found high 
intratester reliability for both subtalar invasion and 
eversion measurements taken by two testers (see Table 
10-11). 









m 




37 
39 
15* 

12*' 



ii was 
>r the 
Intra- 
)r for 
riano, 
: joint 
testers 
should 
pea ted 
r these 
)nley 42 
le with 
ility of 
neutral 
indings 

SC m 

| 0.76) 
osition. 
he talus 
an elec- 

e afore- 
nd high 
on and, 
;e Table 



CHAPTER 10 THE ANKLE AND FOOT 255 



Range of Motion Testing Procedures: Ankle and Foot 
uimarks for Goniometer Alignment: Talocrural Joint 







FIGURE 10-12 The subject's right lower extremity showing surface anatomy landmarks for goniometer 
alignment in measurement of dorsiflexion and plantarflexion range of motion. 



Head of fibula 




Fifth metarsai 



FIGURE 10-13 The subject's right lower extremity shows the bony anatomical landmarks for goniome- 
ter alignment for measurement of dorsiflexion and plantarflexion range of motion. 



-v 

J 



S3 

o 

_ 

Q 
Z 
< 

UJ 

_j 
it 
Z 
< 

H I 

D 

Q 

m 

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'a 
z 

H 

z 

o 



o 



256 



PART III LOWER-EXTREMITY TESTING 



DORSIFLEXION: TALOCRURAL JOINT 



I Motion occurs in the sagittal plane around a medial- 
I lateral axis. The mean dorsiflexion ROM according to 
I the both the AAOS 5 and the AMA 4 is 20 degrees. The 
:\ mean active dorsiflexion ROM in the non-weight-bear- 
I ing position is 12,6 degrees according to Boone and 
I Azen. 6 Refer to Tables 10-1 through 10-7 for additional 
1 information. 

Dorsiflexion ROM is affected by the testing position 
I (knee flexed or extended) and by whether the measure- 
1 ment is taken in the weight-bearing or non-weight-bear- 
I ing position. Dorsiflexion ROM measured with the knee 
1 flexed is usually greater than that measured with the knee 
1 extended. Knee flexion slackens the gastrocnemius 
1 muscles so passive tension in the muscle does not inter- 
§ fere with dorsiflexion. Knee extension stretches the 
| gastrocnemius muscle, and ROM measured in this posi- 
| tion represents the length of the muscle. Weight-bearing 



dorsiflexion ROM is usually greater than non-weighr- 
bearing measurements, and these positions should not be 
used interchangeably. 

Testing Position 

Place the subject sitting, with the knee flexed to 90 

degrees position. The foot in degrees of inversion and 
eversion, 

Stabilization 

Stabilize the tibia and fibula to prevent knee motion and 
hip rotation. 

Testing Motion 

Use one hand to move the foot into dorsiflexion by push- 
ing on the bottom of the foot (fig. 10-14). Avoid pres- 
sure on the lateral border of the foot under the fifth 
metatarsal and the toes. A considerable amount of force 
is necessary to overcome the passive tension in the soleus 





■iS» 




I 






FIGURE 10-14 The subject's left ankle at the end of dorsi- 
flexion range of motion, She examiner holds the distal 
portion of the lower leg with one hand to prevent knee 
motion and uses her other hand to push on the palmar 
surface of the foot to maintain dorsiflexion. 



m 



r 



?.'■ 



sir 



CHAPTER 10 THE ANKLE AND FOOT 



257 



ht- 



90 



ind 

l 



|h- 
;es- 
fth 

ice 
eiis 



i ajid Achilles musculotendinous unit. Often, a compari- 
son of the active and passive ROMs for a particular indi- 
vidual helps to determine the amount of upward force 
necessary to complete the passive ROM in dorsiflexion. 
The end of the ROM occurs when resistance to further 
motion is felt and attempts to produce additional motion 
cause knee extension. 

formal End-feel 

;;The end-fee! is firm because of tension in the posterior 
joint capsule, the soleus muscle, the Achilles tendon, the 
posterior portion of the deltoid ligament, the posterior 
talofibular ligament, and the calcaneofibular ligament. 

Goniometer Alignment 

:See Figures 10-15 and 10-16. 

1. Center the fulcrum of the goniometer over the 
lateral aspect of the lateral malleolus. 



2. Align the proximal arm with the lateral midline of 
the fibula, using the head of the fibula for refer- 
ence. 

3. Align the distal arm parallel to the lateral aspect of 
the fifth metatarsal. Although it is usually easier to 
palpate and align the distal arm parallel to the fifth 
metatarsal, an alternative method is to align the 
distal arm parallel to the inferior aspect of the 
calcaneus. However, if the latter landmark is used, 
the total ROM in the sagittal plane (dorsiflexion 
plus plantarflexion) may be similar to the total 
ROM of the preferred technique, but the separate 
ROM values for dorsiflexion and plantarflexion 
will differ considerably. 



irss- 
istal 
crtec 
mar 




FIGURE 10-15 In the starting position for measuring 
dorsiflexion range of motion the ankle is positioned so that 
the goniometer is at 90 degrees. This goniometer reading is 
transposed and recorded as degrees. The examiner sits on 
a stool or kneels in order to align the goniometer and 
perform the readings at eye level. 



o. 

,0/. 

u. 

Q 
Z 
< 



■^4 
< I 

■■:'■■* 3 

t/i I 

UJ I 

^ I 

Q I 
U I 

Of 
e. 1 

« 1 

:Z I 

..si 

u. i 
o 

LU 

o I 



258 



PART III LOWER-EXTREMITY TESTING 



Three Alternative Positions for Measuring 
Dorsiflexion ROM 

The supine and prone positions are two alternative 
non-weight-bearing positions that can be used to meas- 
ure dorsiflexion ROM. Standing is an alternative weight- 
bearing position for this measurement. Measurements 
taken in different non-weight-bearing positions may not 
be the same; therefore, these positions should not be 
used interchangeably. Also, measurements taken in the 
weight-bearing position differ considerably from those 
taken in non-weight-bearing positions and therefore 
should not be used interchangeably. Measurements taken 
in the weight-bearing position compared with those 
taken in the non-weight-bearing position may be able to 
provide the examiner with information that is more rele- 
vant to the performance of functional activities such as 
walking. However, it may be difficult to control substi- 
tute motions of the hindfoot and forefoot in the weight- 
bearing position. Also, some subjects may not have the 




strength and balance necessary to assume the weight- 
bearing position. 

Alternative Position for Measuring Dorsiflexion ROM" 
Supine 

Place the subject in supine with the knee flexed to 3Q 

degrees and supported by a pillow. Goniometer align- 
ment is the same as that for the seated position. 

Alternative Position for Measuring Dorsiflexion ROM: 
Prone 

Position the subject prone with the knee on the side 

being tested flexed to 90 degrees. Position the foot in 
degrees of inversion and eversion {big. 10-17). 

Alternative Position for Measuring Dorsiflexion ROM: 
Standing 

Position the subject standing on the leg to be rested with 
the knee flexed (Fig. 10-18). 









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FIGURE 10-16 At the end of dorsiflexion range of 

morion, the examiner uses one hand to align the proximal 
goniometer arm while the other hand maintains dorsiflex- 
ion and alignment of the distal goniometer arm 




- 



CHAPTER 10 THE ANKLE AND FOOT 259 



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FIGURE 10-17 Goniometer alignment at the end of dorsi- 
flexion range of motion. The subject is in an alternative 
prone position with the knee flexed to 90 degrees. 



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FIGURE 10-18 Goniometer alignment at the end of dorst- 
flexion range of motion. The subject is in an alternative 
weight-bearing position with the knee flexed. 




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260 



PART III LOWER-EXTREMITY TESTING 



PLANTARFLEXION: TALOCRURAL JOINT 



I Motion occurs in the sagittal plane around a medial- 

1 lateral axis. The ROM is 50 degrees according to the 

AAOS, 2 40 degrees according to the AMA,' 1 and 56.1 

according to Boone and Azen. 6 The ROM is affected by 

the testing position (knee flexed or extended} and 
whether or not the measurement is taken in a 
non-weight-bearing versus a weight-bearing position. 
Please refer to Tables 10-1 through 10^4 for addi- 
1 tional information regarding effects of age and gender. 

I Testing Position 

| Place the subject sirring with the knee flexed to 90 
| degrees. Position the foot in degrees of inversion and 
i eversion. 



Stabilization 

Stabilize the tibia and fibula to prevent knee flexion and 
hip rotation. 

Testing Motion 

Push downward with one hand on the dorsum of the 
subject's foot to produce plantarflexion (Fig. 10-19). Do 
not exert any force on the subject's toes and be careful to 
avoid pushing the ankle into inversion or eversion. The 
end of the ROM is reached when resistance is felt and 
attempts to produce additional plantarflexion result in 
knee flexion. 






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FIGURE 10-19 The subject's left ankle at the end of plantarflexion range of motion. 




CHAPTER 10 THE ANKLE AND FOOT 



261 



formal End-feel 

Usually, the end-feet is firm because of tension in the 
anterior joint capsule; the anterior portion of the deltoid 
jigament; the anterior Talofibular ligament; and the 
tibial' 5 anterior, extensor hallucis longus, and extensor 
digitorum longus muscles. The end-feel may be hard 
because of contact between the posterior tubercles of the 
talus and the posterior margin of the tibia. 



Goniometer Alignment 
See Figures 10-20 and 10-21. 

1. Center the fulcrum of the goniometer over the 
lateral aspect of the lateral malleolus. 

2. Align the proximal arm with the lateral midline of 
the fibula, using the head of the fibula for refer- 
ence. 



m 





FIGURE 10-20 Goniometer alignment in the starting position for measuring plantarflexion range of 
motion. 



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262 PART 111 LOWER-EXTREMITY TESTING 

3. Align the distal arm parallel to the lateral aspect of 
rhc fifth metatarsal. Although it is usually easier to 
palpate and align the distal arm parallel to the fifth 
metatarsal, as an alternative, the distal arm can be 
aligned parallel to the inferior aspect of the calca- 
neus. If the alternative landmark is used, the total 
ROM in the sagittal plane (dorsiflexion plus plan- 



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tarflexion) may be similar to the total ROM of the 
preferred technique, but the separate ROM values 
for dorsiflexion and plantarflexion will differ 
considerably. Measurements taken with the alter- 
native landmark should not be used interchange- 
ably with those taken using the fifth metatarsal 
landmark. 





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FIGURE 10-21 At the end of the plantarflexion range of motion, the examiner uses one hand to main- 
tain plantarflexion and to align the distal goniometer arm. The examiner holds the dorsum and sides of 
the subject's foot to avoid exerting pressure on the toes. She uses her other hand to stabilize the tibia and 
align the proximal arm of the goniometer. 






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CHAPTER 10 THE ANKLE AND FOOT 263 



Landmarks for Goniometer^ Alignment: Tarsal Joints 



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FIGURE I0--22 An anterior view of the sub ject's left ankle 
with surface anatomy landmarks to indicate goniometer 
alignment for measuring inversion and eversion range of 
.motion."'' " 



Tibial 

tuberosity 



Medial 
malleolus 



2nd 

metatarsal 




Lateral 
malleolus 



: An anterior view of the subject's left ankle 
with bony anatomical landmarks to. indicate goniometer 

alignment for measuring: inversion and eversion range of 
motion. 





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264 



PART III LOWER-EXTREMITY TESTING 



INVERSION: TARSAL JOINTS 



This motion is a combination of supination, adduction, 
and piantarflexion occurring in varying degrees at the 
subtalar, transverse tarsal (talocalcaneonavicular and 
calcaneocuboid), cuboideonavicular, cuneonavicular, 

intercuneiform, cuneocuboid, tarsometarsal (TMT), and 
intermetatarsal joints. The functional ability of the foot 
to adapt to the ground and to absorb contact forces 
depends on the combined movement of all of these joints. 
Because of the uniaxial limitations of the goniometer, 
inversion is measured in the frontal plane around an 
anterior-posterior axis. Methods for measuring inversion 
of the rearfoot and forefoot are included in the sections 
on the subtalar and transverse tarsal joints. 

Testing Position 

Place the subject in the sitting position, with the knee 
flexed to 90 degrees and the lower leg over the edge of 



£ 




the supporting surface. 1'nMtion the hip in degrees of 

rotation, adduction, ,ind ahdu^iion. Alternatively, it ! s 
possible to place the subject in the supine position, with 
the loot over the edge oi the supporting surface. 

Stabilization 

Stabilize the tibia and the fibula to prevent medial rota- 
tion and extension of ihe knee and lateral rotation and 
abduction of the hip 

Testing Motion 

Push the forefoot downward into plantai 'flexion, medi- 
ally into adduction, and turn the sole of the loot medi- 
ally into supination to produce inversion (I'tg. 10-24). 
The end of the ROM occurs when resistance is felt and 
attempts at further morion produce medial rotation of 
the knee and/or lateral rotation and abduction at the hip. 





FIGURE 10-24 The subject's left foot and ankle at the end of 
inversion range of motion. Ihe examiner uses one hand on the 
subject's distal lower leg to prevent knee and hip motion while 
her other band maintains inversion. 




:7^ ; 









. 



CHAPTER 10 THE ANKLE AND FOOT 



265 






Normal End -feel 

The end-feel is firm because of tension in the joint 
capsule the anterior and posterior talofibular ligament; 
the calcaneofibular ligament; the anterior, posterior, 
'■ lateral, and interosseous talocalcancal ligaments; the 
dorsal calcaneal ligaments; the dorsal calcaneocuboid 
ligament; the dorsal talonavicular ligament; the lateral 
band of the bifurcate ligament; the transverse metatarsal 
ligament; and various dorsal, plantar, and interosseous 
ligaments of the cuboideonavicular, cuneonavicular, 
intercuneiform, cuneocuboid, TMT, and intermetatarsal 
joints; and the peroneus longus and brcvis muscles. 



Goniometer Alignment 

See Figures 10-25 and 10-26. 

1 . Center the fulcrum of the goniometer over the ante- 
rior aspect of the ankle midway between the malle- 
oli. (The flexibility of a plastic goniometer makes 

this instrument easier to use for measuring inver- 
sion than a metal goniometer.) 

2. Align the proximal arm of the goniometer with the 
anterior midline of the lower leg, using the tibial 
tuberosity for reference. 

3. Align the distal arm with the anterior midline of the 
second metatarsal. 









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FIGURE 10-25 Goniometer alignment in rhe starting position 
for measuring inversion range of motion. 




■ 




FIGURE 10-26 At the end of the range of motion, the exam- 
iner uses her one hand to maintain inversion and to align the 
distal goniometer arm, 



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266 



PART !!l LOWER-EXTREMITY TESTING 



EVERSION: TARSAL JOINTS 



This motion is a combination of pronation, abduction, 
and dorsiflexion occurring in varying degrees at the 
subtalar, transverse tarsal (talocalcaneonavicular and 
calcaneocuboid}, cuboideonavicuiar, cuneonavicular, 
intercuneiform, cuneocuboid, TMT, and intermetatarsal 
joints. The functional ability of the foot to adapt to the 
ground and to absorb contact forces depends on the 
combined movement of all of these joints. Because of the 
uniaxial limitations of the goniometer, this motion is 
measured in the frontal plane around an anterior-poste- 
rior axis. Methods for measuring eversion isolated to the 
rearfoot and the forefoot are included in the sections on 
the subtalar and transverse tarsal joints. 



Testing Position 

Place the subject in the sitting position, with the knee- 
flexed to 90 degrees and the lower leg over the edge of' 
the supporting surface. Position the hip in degrees of-' 
rotation, adduction, and abduction. Alternatively, it j|S 
possible to place the subject in the supine position, wirfit 
the foot over the edge of the supporting surface. 

Stabilization 

Stabilize the tibia and fibula to prevent lateral rotation! 
and flexion of the knee and medial rotation and adduc- 
tion of the hip. 




| FIGURE 10-27 The left ankle and foot at the end of the range of motion in eversion. The examiner uses one hand on the subjects- 
I distal lower leg to prevent knee flexion and lateral rotation. The examiner's other hand maintains eversion. 



CHAPTER 10 THE ANKLE AND FOOT 



267 



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■festing Motion 

pull the forefoot laterally into abduction and upward 
j n to dorsiflexion, turning the forefoot into pronation so 
that the lateral side of the foot is higher than the medial 
side to produce eversion (Fig, 10-27). The end of the 
ROM occurs when resistance is felt and attempts at 
further morion cause lateral rotation at the knee and/or 
medial rotation and adduction at the hip. 

Normal End-feel 

The end-feel may be hard because of contact between the 
calcaneus and the floor of the sinus tarsi. In some cases, 
tjie end- feel may be firm because of tension in the joint 
capsules; the deltoid ligament; the medial talocalcaneal 
ligament; the plantar calcaneonavicular and calca- 
neocuboid ligaments; the dorsal talonavicular ligament; 
the medial band of the bifurcated ligament; the transverse 



metatarsal ligament; various dorsal, plantar, and 
interosseous ligaments of the cuboideonavicular, cuneo- 
navicular, intercuneiform, cuneocuboid, TMT, and inter- 
metatarsal joints; and the tibialis posterior muscle. 

Goniometer Alignment 

Sec Figures 10-28 and 10-29. 

1 . Center the fulcrum of the goniometer over the ante- 
rior aspect of the ankle midway between the malle- 
oli. (The flexibility of a plastic goniometer makes 
this instrument easier to use than a metal goniome- 
ter for measuring inversion.) 

2. Align the proximal arm of the goniometer with the 
anterior midline of the lower leg, using the tibial 
tuberosity for reference. 

3. Align the distal arm with the anterior midline of the 
second metatarsal. 



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FIGURE 10-28 Goniometer alignment in the starting position for measuring eversion range of motion. 



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PART Ml LOWER-EXTREMITY TESTING 




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FIGURE 10-29 At the end of the eversion range of motion, the examiner's left hand maintains eversion 
and keeps the distal goniometer arm aligned with the subject's second metatarsal. 



CHAPTER 10 THE ANKLE AND FOOT 269 






Landma rks for Gontorneter Alignment; Subtalar joint (Rearfoot) 




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m 



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WGURE 10-30 Surface anatomy landmarks indicate 
Sompmeter alignment for measuring rearfoot inversion and 
Version; range of motion in a posterior view of a subject's 

'W lower leg and foot. 



Lateral 
ma:lac!us 




Medial 
malleolus 



Calcaneus 



FIGURE 10-31 Bony anatomical landmarks for measuring 
subtalar (rearfoot) inversion and eversiort range of motion in 
a posterior view of the subject's left lower leg and foot. 






270 



PART IM LOWER-EXTREMITY TESTING 



INVERSION: SUBTALAR JOINT 
(REARFOOT) 



Morion is a combination of supination, adduction, and 
plantarflexion. Because of the uniaxial limitations of che 
goniometer, this motion is measured in the frontal plane 
around an anterior-posterior axis. The ROM is about 5 
degrees. 2 

Testing Position 

Place the subject in the prone position, with the hip in 
degtces of flexion, extension, abduction, adduction, and 
rotation. Position the knee in degrees of flexion and 
extension. Position the foot over the edge of the support- 
ing surface. 



Stablization 

Stabilize the rihia ant! tibuia to prevent lateral hip a nt i 
knee rotation and Kip adduction. 

Testing Motion 

Hold the subject's lower leg with one ham! and use the- 
other hand to puii the subject's calcaneus medially into 
adduction and to rotate it into supination, thereby 
producing rcarfoot subtalar inversion (Fig. 10-321 
Avoid pushing on the forefoot. The end of the ROM |$ 
reached when resistance to further morion is felt and 
attempts at overcoming the resistance produce lateral 
rotation at the hip or knee. 





1 : 





FIGURE 10-32 The left lower cxtrcmiry at the cud of subtalar 
rcarfoot inversion range of motion. 




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CHAPTER 10 THE ANKLE AND FOOT 



271 



j Normal End-feel 

I The end-fed is firm because of tension in the lateral joint 
:|. ■■■■'.: capsule; the anterior and posterior talofibular ligaments; 

■ J the calcaneofibuiar ligament; antfthe lateral, posterior, 

] anterior, and interosseous talocalcaneal ligaments. 

i Goniometer Alignment 

] See Figures 10-33 and 10-34. 



1. Center the fulcrum of the goniometer over the 
posterior aspect of the ankle midway between the 
malleoli. 

2. Align the proximal arm with the posterior midline 
of the lower leg. 

3. Align the distal arm with the posterior midline of 
the calcaneus. 




ilar 



v;FIGURE 10-33 Goniometer alignment in the starting position 
for measuring subtalar rearfoot inversion range of motion. 
Normally, the examiner's hand would be holding the distal 

^goniometer arm, but for the purpose of this photograph, she 
removed her hand. 



FIGURE 10-34 At the end of subtalar (rearfoot) inversion, the 
examiner's hand maintains inversion and keeps the distal 
goniometer arm in alignment. 



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272 



PART 111 LOWER-EXTREMITY TESTING 



=11 EVERSION: SUBTALAR JOINT 
fREARFOOTI v ^ ^ 



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Motion is a combination of pronation, abduction, and 
dorsiflexion. Because of the uniaxial limitations of the 
goniometer, this motion is measured in the frontal plane 
around an anterior-posterior axis. The ROM is about 5 
degrees." 

Testing Position 

Place the subject prone, with the hip in degrees of flex- 
ion, extension, abduction, adduction, and rotation. 



Position the knee in degrees ot flexion and extension 
Place the foot over the fcdge ot the supporting surface. 

Stabilization 

Stabilize the tibia and fibula to prevent media! hip and 
knee rotation and hip abduction. 

Testing Motion 

Pull the calcaneus laterally into alnftictioti and rotate it 
into pronation to produce subtalar eversion fl-'tg, 1 ((—351 

The end of the KO.YI occurs when resistance to further 



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FIGURE 10-35 The left lower extremity Lit die eiul of subtalar ; 
(reartoot) eversion range of morion. One can observe rhaf this 
subject's eversion is iHiift limited, ['he examiner's hand main- 
tains subtalar eversion by pulling the calcaneus laterally. 



CHAPTER 10 THE ANKLE AND FOOT 273 



movement is felt and additional attempts to move the 
calcaneus result in medial hip or knee rotation. 

Normal End-feel 

The end-feel may be hard because of contact between the 
calcaneus and the floor of the sinus tarsi, or it may be 
firm because of tension in the deltoid ligament, the 
medial taiocalcaneal ligament, and the tibialis posterior 
muscle. 



Goniometer Alignment 

Sec Figures 10-36 and 10-37. 

1. Center the fulcrum of the goniometer over the 
posterior aspect of the ankle midway between the 
malleoli. 

2. Align the proximal arm with the posterior midline 
of the lower leg. 

3. Align the distal arm with the posterior midline of 
the calcaneus. 



.alar 
this 
t.iift- 



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FIGURE 10-36 Goniometer alignment in the starting position 
for measuring subtalar (rearfoot) cversion. 



FIGURE 10-37 At the end of subtalar cversion, the examiner's 
hand maintains cversion and keeps the distal goniometer arm 
aligned. 



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274 



PART Ml 



LOWER-EXTREMITY TESTING 



i 



INVERSION: TRANSVERSE TARSAL JOINT 



Most of the morion in the midfoot and forefoot occurs at 
the talonavicular and calcaneocuboid joints. Some addi- 
tional motion occurs at the cubotdeonavicuiar, cuneo- 
navicular, intercuneiform, cuneocuboid, and TMT joints. 
Morion is a combination of supination, adduction, 
and plantarflexion. Because of the uniaxial limitation of 
the goniometer, this motion is measured in the frontal 
plane around an anterior-posterior axis. The normal 
ROM ranges from 30 to 37 degrees for the forefoot. 4,6 

Testing Position 

Place the subject sitting, with the knee flexed ro 90 
degrees and the lower leg over the edge of the supporting 
surface. The hip is in degrees of rotation, adduction, 
and abduction, and the subtalar joint is placed in the 
starting position. Alternatively, it is possible to place the 
subject in the supine position, with the foot over the edge 
of the supporting surface. 

Stabilization 

Stabilize the calcaneus to prevent dorsiflexion of the 
ankle and inversion of the subtalar joint. 

Testing Motion 

Grasp the metatarsals rather than the toes and push the 
forefoot slightly into plantarflexion and medially into 
adduction. Turn the sole of foot medially into supination, 
being careful not to dorsiflex the ankle (Fig. 10-38). The 
end of the ROM occurs when resistance is felt and 
attempts at further motion cause dorsiflexion and/or 
subtalar enversion. 

Normal End-feel 

The end-feel is firm because of tension in the joint 
capsules; the dorsal calcaneocuboid ligament; the dorsal 
talonavicular ligament; the lateral band of the bifurcated 
ligament; the transverse metatarsal ligament; various 
dorsal, plantar, and interosseous ligaments of the 
cuboideonavicular, cuneonavicular, intercuneiform, 
cuneocuboid, TMT, and intermetatarsal joints; and the 
peroneus longus and brevis muscles. 



Goniometer Alignment 
See Figures 10-39 and 10-40, 

1. Center the fulcrum of tin: goniometer over the 
anterior aspect of the ankle slightly distal to a 
point midway between the malleoli. 

2. Align the proximal arm with the anterior midline 
of the lower leg, using the tibial tuberosity for 
reference. 

3. Align the distal arm with the anterior midline of 
the second metatarsal. 

Alternative Goniometer Alignment 

See Figures 10-41 and 10-42. 

i. Place the hilcrum of the goniometer at tile lateral 
aspect of the fifth metatarsal head. 

2. Align the proximal arm parallel ro the anterior 
midline of the lower leg. 

3. Align the distal arm with the plantar aspect of the 
first through the fifth metatarsal heads. 



'•■■ 




FIGURE 10-38 The left lower extremity at the end of trans- 
verse tarsal inversion range of motion (ROM). The examiner's 

hand stabilizes the calcaneus to prevent subtalar inversion. 
Notice that the ROM for the transverse tarsal joint is less than 
that of all of the tarsal joints combined. 



. 



■ 




CHAPTER 10 THE ANKLE AND FOOT 



275 



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niner's 
.■rsiott. 

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FIGURE 10-39 Goniometer alignment in the starting position 

: for measuring transverse tarsal inversion. 




FIGURE 10-40 At the end of transverse tarsal inversion, one 

of the examiner's hands releases the calcaneus and aligns the 
proximal goniometer arm with the lower leg. The examiner's 

other hand maintains inversion and holds the distal goniometer 
arm aligned with the second metatarsal. 



i HGURE 10-41 Goniometer alignment in the alternative start- 

i m K position for measuring transverse tarsal inversion range of 

I amotion places the goniometer at 90 degrees, which is the 

i starting position. Therefore, the goniometer reading should be 

transposed and recorded as starting at degrees. 




FIGURE 10-42 At the end of the transverse tarsal inversion 

range of motion, the examiner uses her hand to maintain inver- 
sion and to keep the distal goniometer arm aligned. 



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276 



PART It! LOWER-EXTREMITY TESTING 



EVERStON: TRANSVERSE TARSAL JOINT 



Motion is a combination of pronation, abduction, and 
dorsiflexion. Because of the uniaxial limitations of the 
goniometer, this motion is measured in the frontal plane 
around an anterior-posterior axis. The normal ROM for 
forefoot eversion ranges from 15 to 21 degrees. 4, 6 

Testing Position 

Place the subject sitting, with the knee flexed to 90 
degrees and the lower leg over the edge of the supporting 
surface. Position the hip in degrees of rotation, adduc- 
tion, and abduction, and the subtalar joint in the start- 
ing position. Alternatively, it is possible to place the 



subject in the supifi« position, with the toot over the edge 
of the supporting surface. 

Stabilization 

Stabilize the calcaneus and talus to prevent plantarflcx- 

ion of the ankle and eversion of the subtalar joint. 

Testing Motion 

Pull the forefoot laterally into ahduction and upward 
into dorsiflcNion. 'Turn the forefoot into pronation so 
thai the lateral side of the foot is higher than the medial 
side (l ; ig. 10-43), The end of the ROM occurs when 
resistance is felt and attempts to produce additional 
motion cause pSantarflexion and/or subtalar eversion. 




.-■-■<-- 





= . 









■ ■■:• 




" 



FIGURE 10— M The end of transverse tarsal eversion range of 
motion. The examiners hand stabilizes the calcaneus to prevent 

subtalar eversion. As can he seen in the photograph, owf * 

small amount of motion is available at the Transverse tarsa 
joint 111 this subject. 




CHAPTER 10 THE ANKLE AND FOOT 



277 



Normal End-feel 

The end-feel is firm because of tension in rhe joint 
capsules; the deltoid ligament; the plantar calcaneonavic- 
ular and calcaneocuboid ligaments; the dorsal talonavic- 
ular ligament; the medial band of the bifurcated 
ligament; the transverse metatarsal ligament; various 
dorsal, plantar, and interosseous ligaments of the 
cuboideonavicular, cuneonavicular, intercuneiform, 
cuneocuboid, TMT, and intermetatarsa! joints; and the 
tibialis posterior muscle. 



Goniometer Alignment 

See Figures 10-44 and 10-45. 

1. Center the fulcrum of the goniometer over the ante- 
rior aspect of the ankle slightly distal to a point 

midway between the malleoli. 

2. Align the proximal arm with the anterior midline 
of the lower teg, using the tibia! tuberosity for 
reference. 

3. Align the distal arm with the anterior midline of the 
second metatarsal. 





FIGURE 10-44 Goniometer alignment in the starting position 
tor measuring transverse tarsal eversion range of motion. 



sail! 



FIGURE 10—45 At the end of the transverse tarsal eversion 

range of motion, one of the examiner's hands releases the calca- 
neus and aligns the proximal goniometer arm with the lower 
leg. The examiner's other hand maintains eversion and align- 
ment of the distal goniometer arm. 



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1 278 PART 111 LOWER-EXTREMITY TESTING 

I 

| Alternative Goniometer Alignment 

| Sec Figures 1CM16 and 10-47. 

1. Place rhe fulcrum of the goniometer at the medial 
aspect of the first metatarsal head. 






2. Align rhe proximal arm parallel to the anterior 
midline of the lower leg, 

3. Align rhe distal arm with the plantar aspect from 
the first to the fifth metatarsal heads. 





FIGURE 10-46 Goniometer alignment in the alternative start- 
t ing position for measuring transverse tarsal cversion range of 



motion. 



FIGURE 10—17 At the end of the range of motion, the exam- 
iner uses one hand to maintain cversion while her other hand 
aligns rhe goniometer. Because the subject is sitting on a table, 
the examiner sits on a low stool ro align the goniometer and to 
read the measurements at eye level. 



CHAPTER 10 THE ANKLE AND FOOT 279 



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andmarks for Goniometer AHgnment: Metatarsophalangeat Joint 



^0^ 




Distal phalanx . 



Proximal phalanx 



1st metatarsal 




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FIGURE 10-48 {A) Surface anatomy landmarks for measuring flexion and extension at die first metatar- 
sophalangeal (MTP) joint and first intcrphalangeal (IP) joint in a medial view of the subject's left foot. (B) 
Bony anatomical landmarks for measuring flexion and extension at the first MTP and IP joints. 



1 



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and 
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1st metatarsal 



Proximal phalanx 



. Distal phalanx 



B 

FIGURE 10-49 M) Surface anatomy landmarks for goniometer alignment for measuring flexion and 
extension range of motion at the first and second MTP and IP joints and abduction and adduction at the 
first MTP joint. (B) Bony anatomical landmarks for flexion and extension at the first and second MTP 
and IP joints and abduction and adduction at the first MTP joint. 




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PART III LOWER - EXTR EM I TY TESTING 



FLEXION: METATARSOPHALANGEAL 

joint ';.■;. 



Motion occurs in the sagittal plane around a medial- 
lateral axis. Flexion ROM at the fist MTP joint ranges 
between 30 degrees" 1 and 45 degrees/ See Table 10-2 for 

additional information. 

Testing Position 

Place the subject in the supine or sitting position, with the 
ankle and foot in degrees of dorsiflexion, plantarflex- 
ion, inversion, and eversion. Position the MTP joint in 
degrees of abduction and adduction and the IP joints in 
degrees of flexion and extension. (If the ankle is plan- 
tarftexed and the IP joints of the toe being tested are 
flexed, tension in the extensor haliucis longus or extensor 
digitorum iongus muscle will restrict the motion.) 

Stabilization 

Stabilize the metatarsal to prevent plantarflexion of the 
ankle and inversion or eversion of the foot. Do not hold 
the MTP joints of the other toes in extension, because 
tension in the transverse metatarsal ligament will restrict 
the motion. 

Testing Motion 

Pull the great toe downward toward the plantar surface 
into flexion (Fig. 10-50). Avoid pushing on the distal 



phalanx and causing interphalangeai flexion. The end of 

the KO.M i% reached when resistance is lelt ami attempts 
at further motion cause plantarflexion at the ankle. 

Normal End-feel 

The end-feel is firm because of tension in the dorsal joint 

capsule and the collateral ligaments. Tension in die 
extensor digitorum brevis muscle may contribute to the 

firm end -feci. 

Goniometer Alignment 

See Figures 10-51 and 10-52. 

1. Center the fulcrum of the goniometer over the 
dorsal aspect of the MTP joint. 

2. Align the proximal arm over the dorsal midline of 
the metatarsal. 

2i. Align the distal arm over the dorsal midline of the 
proximal phalanx. 

Alternative Goniometer Alignment for First 
Metatarsophalangeal joint 

1. Center the fulcrum of the goniometer over the 
medial aspect of the first MTP joint. 

2. Align the proximal arm with the medial midline of 
the first metatarsal. 

.?. Align the distal arm with the medial midline of the 
proximal phalanx of the first toe. 



:■■:■ 








FIGURE 10-50 The left first metatarsophalangeal (MTP) joint at the end of the flexion range of motion. 

The subject is supine, with her foot and ankle placed over the edge of the supporting surface, i iowever, 
the subject's foot could rest on the supporting surface. The examiner uses her thumb across the 
metatarsals to prevent ankle plantarflexion. The examiner's other hand maintains the first MTP joint in 
flexion. 



CHAPTER 10 THE ANKLE AND FOOT 281 









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FIGURE 10-51 Goniometer alignment in the starting position for measuring metatarsophalangeal flex- 
ion range of motion. The arms of this goniometer have been cut short to accommodate the relative short- 
ness of the proximal and distal joint segments 




FIGURE 10-52 At the end of the range of motion, the examiner uses one hand to align the goniometer 
while her other hand maintains metatarsophalangeal flexion. 



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PART ill LOWER-EXTREMITY TESTING 




EXTENSION: METATARSOPHALANGEAL 
JOINT 



is felt and attempts at further motion cause dorsiflexion 
at the ankle. 



Motion occurs in the sagittal plane around a medial- Normal End-feel 



lateral axis. The ROM ranges between SO degrees and 
70 degrees. 2 See Table 10-2 for additional information. 

j Testing Position 

f. The testing position is the same as that for measuring 
| flexion of the MTP joint. (If the ankle is dorsiflexed and 
j the IP joints of the toe being tested are extended, tension 

iin the flexor hallucis longus or flexor digitorum longus 
muscle will restrict the motion. If the IP joints of tiie toe 
, being tested are in extreme flexion, tension in the lumbri- 
1 calis and interosseus muscles may restrict the motion.) 

1 Stabilization 

1 Stabilize the metatarsal to prevent dorsiflexion of the 
I ankle and inversion or eversion of the foot. Do not hold 
| the MTP joints of the other toes in extreme flexion, 

because tension in the transverse metatarsal ligament will 

restrict the motion. 

Testing Motion 

Push the proximal phalanx toward the dorsum of the 
foot, moving the MTP joint into extension (Fig. 10-53). 
Avoid pushing on the distal phalanx, which causes IP 
extension. The end of the motion occurs when resistance 



The end-feel is firm because of tension in the plantar 
joint capsule, the plantar pad (plantar fibrocartilaginous 
plate), and the flexor hallucis brevis, flexor digitorum 
brevis, and flexor digiti minimi muscles. 

Goniometer Alignment 

See Figures 10-54 and 10-55. 

1. Center the fulcrum of the goniometer over the 
dorsal aspect of the MTP joint. 

2. Align the proximal arm over the dorsal midline of 
the metatarsal. 

3. Align the distal arm over the dorsal midline of the 
proximal phalanx. 

Alternative Goniometer Alignment for Extension 
at the First Metatarsophalangeal Joint 

1. Center the fulcrum of the goniometer over the 

medial aspect of the first MTP joint. 

2. Align the proximal arm with the medial midline of 
the first metatarsal. 

3. Align the distal arm with the medial midline of the 
proximal phalanx of the first toe. 








FIGURE 10-53 The left first metatarsophalangeal joint at the end of extension range of motion. The 
examiner places her digits on the dorsum of the subject's foot to prevent dorsiflexion and uses the thumb 
on her other hand to push the proximal phalanx into extension. 





CHAPTER 10 THE ANKLE AND FOOT 



283 




FIGURE 10-54 Goniometer alignment in the starting position for measuring extension at the first 
metatarsophalangeal joint. 




FIGURE 10-55 At the end of metatarsophalangeal extension, the examiner maintains goniometer align- 
ment with one hand while using her the index finger of her other hand to maintain extension. 



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PART 111 LOWER-EXTREMITY TESTING 



ABDUCTION: METATARSOPHALANGEAL 



Motion occurs in the transverse plane around a vertical 
axis when the subject is in anatomical position. 

Testing Position 

Place the subject supine or sitting, with the foot in 
degrees of inversion and eversion. Position the MTP and 
IP joints in degrees of flexion and extension. 

Stabilization 

Stabilize the metatarsal to prevent inversion or eversion 
of the foot. 



Testing Motion 

Pull the proximal phalanx of (Ik- tot laterally away from 

the midline ol the foot into abduction (Pig. 10-56). 
Avoid pushing on the distal phalanx, which places a 
strain on the IP joint. The end of the ROM occurs when 
resistance is felt and attempts at further mot! on cause 
either inversion or aversion at the foot. 

Normal End -feel 

I he end-feel is tinn because nt tension in the joint 
capsule, the collateral ligaments, the fascia of the web 

space between the toes, and die adductor hallucis and 
plantar interosscus muscles. 




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abduction range of motion. The examiner uses one thumb to 
prevent transverse tarsal inversion. She use-, the index finger 
and thumb of her other hand to pull the proximal phalanx into 
abduction. 



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CHAPTER 10 THE ANKLE AND fOOT 



285 



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Goniometer Alignment 

See Figures 10-57 and 10-58. 

1. Center the fulcrum of the goniometer over the 
dorsal aspect of the MTP joint. 



2. Align the proximal arm with the dorsal midline of 
the metatarsal. 

3. Align the distal arm with the dorsal midline of the 
proximal phalanx. 



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FIGURE 10-57 Goniometer alignment in the starting position 
for measuring metatarsophalangeal abduction range of motion. 



FIGURE 10-58 At the end of metatarsophalangeal (MTP) 
abduction, the examiner's hand maintains alignment of the 
distal goniometer arm while keeping the MTP in abduction. 







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PART Ml LOWER-EXTREMITY TESTING 



ADDUCTION: METATARSOPHALANGEAL 
JOINT 



Motion occurs in the transverse plane around a vertical 
axis when the subject is in anatomical position. 
Adduction is the return from abduction to the starting 
position and is not usually measured. 



FLEXION: INTERPHALANCEAL JOINT OF 
THE FIRST TOE AND PROXIMAL 
INTERPHALANGEAL JOINTS OF THE 
FOUR LESSER TOES 



Motion occurs in the sagittal plane around a medial- 
lateral axis. The ROM is between 30 degrees 4 and 90 
degrees for the first toe 2 and 35 degrees and 65 degrees 
for the four iesser toes. 2 

Testing Position 

Place the subject supine or sitting, with the ankle and foot 
in degrees of dorsiflexion, plantarflexion, inversion, 
and eversion. Position the MTP joint in degrees of flex- 
ion, extension, abduction, and adduction. (If the ankle is 
positioned in plantarflexion and the MTP joint is flexed, 
tension in the extensor hallucis longus or extensor digi- 
torum longus muscles will restrict the motion. If the MTP 
joint is positioned in full extension, tension in the lumbri- 
calis and interosseus muscles may restrict the motion.) 



Stabilization 

Stabilize the metatarsal and proximal phalanx to prevent 
dorsiflexion or plantarflexion of the ankle and inversion 
or eversion of the foor. Avoid flexion and extension of 
the MTP joint. 

Testing Motion 

Pull the distal phalanx of the first toe or the middle 
phalanx of the lesser toes down toward the plantar 
surface of the foot. The end of the ROM occurs when 
resistance is felt and attempts at further flexion cause 
plantarflexion of the ankle or flexion at the MTP joint. 

Normal End-feel 

The end-teel lor flexion of the IP joint of the big toe and 
the proximal intcrphalangeal (PIP) joints of the smaller 
toes may be soft because of compression of soft tissues 
between the plantar surfaces of the phalanges. 
Sometimes, the end-teel is firm because of tension in the 
dorsal joint capsule artel the collateral ligaments.. 

Goniometer Alignment 

1. Center the fulcrum of the goniometer over the 
dorsal aspect of the interphalangeal joint being 
tested. 

2. Align the proximal arm over the dorsal midline of 
the proximal phalanx. 

3. Align the distal arm over the dorsal midline of the 
phalanx distal to the joint being tested. 




CHAPTER 10 THE ANKLE AND FOOT 



287 




EXTENSION: INTERPHALANGEAL JOINT 
OF THE FIRST TOE AND PROXIMAL 
INTERPHALANGEAL JOINTS OF THE 
FOUR LESSER TOES 



Motion occurs in the sagittal plane around a medial 
lateral axis. Usually this motion is not measured because 
it is a return from flexion to the zero starting position. 



FLEXION: DISTAL INTERPHALANGEAL 
JOINTS OF THE FOUR LESSER TOES 



Motion occurs in the sagittal plane around a medial- 
lateral axis. Flexion ROM is to 30 degrees. 5 

Testing Position 

Place the subject supine or sitting, with the ankle and foot 
in degrees of dorsiflexion, plantarflexion, inversion, 
and eversion. Position the MTP and PIP joints in 
degrees of flexion, extension, abduction, and adduction. 

Stabilization 

Stabilize the metatarsal, proximal, and middle phalanx to 
prevent dorsiflexion or plantarflexion of the ankle and 
inversion or eversion of the foot. Avoid flexion and 
extension of the MTP and PIP joints of the toe being 
tested. 

Testing Motion 

Push the distal phalanx toward the plantar surface of the 
foot. The end of the motion occurs when resistance is felt 
and attempts to produce further flexion cause flexion at 
the MTP and PIP joints and/or plantarflexion of the 
ankle. 



Normal End- feel 

The end-fee! is firm because of tension in the dorsal joint 
capsule, the collateral ligaments, and the oblique retinac- 
ular ligament. 

Goniometer Alignment 

1. Center the fulcrum of the goniometer over the 
dorsal aspect of the distal interphalangeal (DIP) 
joint. 

2. Align the proximal arm over the dorsal midline of 
the middle phalanx. 

3. Align the distal arm over the dorsal midline of the 
distal phalanx. 



EXTENSION: DISTAL INTERPHALANGEAL 
JOINTS OF THE FOUR LESSER TOES 



Motion occurs in the sagittal plane around a medial- 
lateral axis. Usually this motion not measured becuase it 
is returned from flexion to the zero starting position. 



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288 PART ill LOWER-EXTREMITY TESTING 

Muscle Length Testing Procedures: 
The Ankle and Foot 



GASTROCNEMIUS 



The gastrocnemius muscle is a two-joint muscle that 
crosses the ankle and knee. The medial head of the 
gastrocnemius originates proximalfy from the posterior 
aspect of the medial condyle of the femur, whereas the 
lateral head of the gastrocnemius originates from the 
posterior lateral aspect of the lateral condyle {Fig. 
10-59). Both heads join with the tendon of the soleus 
muscle to form the tendocalcaneus (Achilles) tendon 
which inserts distally into the posterior surface of the 
calcaneus. When the gastrocnemius contracts, it plan- 
tarflexes the ankle and flexes the knee. 

A short gastrocnemius can limit ankle dorsiflexion and 
knee extension. During the test for the length of the 
gastrocnemius the knee is held in full extension. A short 
gastrocnemius results in a decrease in ankic dorsiflexion 
ROM when the knee is extended. If, however, ankle 
dorsiflexion ROM is decreased with the knee in a flexed 



position, die dorsiflexion limitation is due to short ness of 
the one-joint soleus muscle or other joint structures. 

Normal values for durst flexion of the ankle with the 
knee in extension vary (sec Tables !0-6 and 10-7). 

Starting Position 

Place the subject supine, with the knee extended and the 
foot in degrees of inversion and cersion. 

Stabilization 

Hold the knee in full extension. Usually, the weight of the 
limb and hand pressure on the .interior leg can maintain 
an extended knee position. 




Medial 

head of 

gaslronomius 



Achiiles 
tendon 



Calcaneus 



Femoral 
condyles 




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bead of 

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FIGURE 10-59 A posterior view of a right lower extremity, 
shows the attachments of the BasrrocMemius muscle. 



jesting Motion 
Ijwjjflex the ankle to the end of the ROM by pushing 
latjward a cross the plantar surface of the metatarsal heads 
fell 10-60 and Fig. 10-61). Do not allow the foot to 
JKrotate and move into inversion or eversion. The end of 
S t he testing motion occurs when considerable resistance is 



CHAPTER 10 THE ANKLE AND FOOT 



289 



felt from tension in the posterior calf and knee and 
further ankle dorsiflexion causes the knee to flex. 



Normal End-feel 

The end-feel is firm owing to tension in the gastrocne- 
mius muscle. 






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FIGURE 10-60 The subject's right ankle at the end of the testing motion for the length of the gastroc- 
nemius muscle. 




FIGURE 10-61 The gastrocnemius muscle is stretched over the extended knee and dorsiflexed ankle. 



290 



PART III LOWER- EXTREMITY TESTING 



Goniometer Alignment 
See Figure 10-62. 

1. Center the fulcrum of the goniometer over the 
lateral aspect of the lateral malleolus, 

2. Align the proximal arm with the lateral midline of 
the fibula, using the head of the fibula for refer- 
ence. 

3. Align the distal arm parallel to the lateral aspect of 
the fifth metatarsal. 

Alternative Testing Position: Standing 

Place the subject in the standing position, with the knee 
extended and the foot in degrees of inversion and ever- 
sion. The foot is in line (sagittal plane) with the lower leg 
and knee. The subject stands facing a wall or examining 
table, which can be used for balance and support. 

Stabilization 

Maintain the knee in full extension, and the heel remains 
in total contact with the floor. The examiner may hold 
the heel in contact with the floor. 



Testing Motion 

The patient dorsi flexes the ankle by leaning the body 

forward (Fig. 10-63). The end of the testing motion 

occurs when the patient feels tension in the posterior calf 

and knee and further ankle dorsiftexion causes the knee 

to flex. 

Goniometer Alignment 

See Figure 10-64. 

1. Center the fulcrum of the goniometer over the 
lateral aspect of the lateral malleolus. 

2. Align the proximal arm with the lateral midline of 
the fibula, using the head of the fibula for refer- 
ence. 

3. Align the distal arm parallel to the lateral aspect of 
the fifth metatarsal. 





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FIGURE; 10-62 Goniometer alignment at the end of the testing motion for the length of the gastrocne- 
mius muscle. 



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CHAPTER 10 THE ANKLE AND FOOT 291 







m 



V 






FIGURE 10-63 The subject's right ankle at the end of the 

weight-bearing testing motion for the length of the gastrocne- 
mius muscle. 



\::.-.'-'^:. '.-::■■.-:;-. ■::.::-. :■::;;',:: .:;v/'/o%f:; t .;.^';|.^ 



FIGURE 10-64 Goniometer alignment in the alternative test- 
ing position. 



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REFERENCES 

!. Lcvangie, PK, and Norkin, CC: joint Structure and Function: A 
Comprehensive Analysis, cd 3. FA Davis, Philadelphia, 2001. 

2. American Academy of Orthopaedic Surgeons: Joint Motion: 
Method of Measuring and Recording. AAOS, Chicago, 1965 

3. Cyriax, JM, and Cyriax, PJ: Illustrated Manual of Orthopaedic 
Medicine, Butterwonhs, London, 1983, 

4. American Medical Association: Guides to the Evaluation of 
Permanent Impairment, ed 3 (revised). AMA, Chicago, 1988. 

5. Greene, WB, and Heck man, J D (Eds): The Clinical Measurement 
of Joinr Morion: American Academy of Orthopaedic Surgeons, 
Chicago, 1994. 

6. Boone, DC, and Ar.en, SP: Normal range of motion of joints in 
male subjects. J Bone Joint Surg Am 61:756, 1979. 



10. 



II. 



Waugh, KG, et ah Measurement of selected hip, knee and ankle 

joint motions in newborns. Phys Ther 63:1616, 1983. 

Wanatabe, H, et al: The range of joint motion of the extremities 

in healthy Japanese people: The differences according to age. 

Nippon Seikeigeka Gakkai Zasshi 53:275, 1979. (Cited in 

Walker, JM: Musculoskeletal development: A review Phys Ther 

71:878, 1991.) 

Boone, DC: Techniques of measurement of joint motion. 

(Unpublished supplement to Boone, DC, and Azcn, SP: Normal 

range of motion in male subjects. J Bone Joint Surg Am 61:756, 

1979.) 

Walker, JM: Musculoskeletal development: A review. Phys Ther 

71:878, 1991. 

Boone, DC, Walker, JM, and Perry, J: Age and sex differences in 

lower extremity joint motion. Presented at the National 



.--^t^-^.^.^^^^.^^.^^...,.. 



292 



PART 111 LOWER-EXTREMITY TESTING 



Conference, American Physical Therapy Association, 
Washington, DC, 1981. 

12. James, B, and Parker, AW: Active and passive mohiFity of lower 54. 

limb joints in elderlv men and women, Am J Phvs Med Rehabil 

68:162, 1989. 
1 .5. Gajdosik Rl., VanderLinden, DW, and Williams. AK: Influence of 

age on length and passive elastic stiffness: Characteristics of the 35. 

calf muscle-tendon unit of women. Phys Titer 79:827, 1999. 

14. Nigg, BM, et al: Range of motion of the foot as a function of age. 
Foot Ankle 613:336, 1991. 3*. 

15. Vaudervoort, AA, et aS: Age and sex effects on the mobility of the 
human ankle, j Gerontol 476:M 1 7, 1 992. 37. 

16. Bell, RD, and Hoshizaki, TB: Relationships of age and sex with 
range of motion of seventeen joint actions in humans. Can J Appl 
Sport Sci, 6:202, 1981. 38. 

17. Walker, JM, et at: Active mobility of the extremities of older 
subjects. Phys Ther 64:919, 1984. ' 

18. Grimston, SK, et al: Differences in ankle joint complex range of 39, 
motion as a function of age. Foot Ankle 14:215, 1993. 

19. Most ley, AN, Crosbic, J, and Adams, R: Normative data for 40. 
passive plantartlexion-dorsiffexion flexibility. Clin Biomech 41. 
(Bristol, Avon) 16: 514,2001. 

20. Jonson, SR, and Gross, MT: Inttaexaminer reliability, interexam- 
iner reliability and mean values for nine lower extremity skeletal 
measures in healthy midshipmen. J Orthop Sports Phys Ther -12, 
25:25.3, 1997. 

21. Beimcll, K, et at: Hip and ankle range of motion and hip muscle 
strength in young female ballet dancers and controls. Br J Sports 4.5. 
Med 33:340, 1999. 

22. F.kstrand, MD, et al: Lower extremity goniometric measurements: 
A study to determine their reliability. Arch Phys Med Rch.ibil 44 
63:171, 1982. 

23. McPoil, TG, and Cornwall, MW: The relationship between static 45. 
lower extremity measurements and rearfoot motion during walk- 
ing, j Orthop Sports Phys Ther 24: 309, 1996. 

24. Mecagni, C, et al : Balance and ankle range of motion in conimu- 46, 
tiitv-dwelling women aged 64-S7 vears: A correlational study. 
Phys Ther 80: 1 004, 2000. 

25. Baggett, BD, and Young, G: Ankle joint dorsiflexion. 47. Ro 
Establishment of a normal range. J Am Podiatr Med Assoc 
83:251, 1993. 

26. Lattanza, L, Gray, GW, and Ranter, RM: Closed versus open kitie- 4S'. 
matic chain measurements of subtalar joint eversion: implications 
for clinical practice, j Orthop Sports Phys Ther 9:310, 1988. 

27. Nawoczenski, DA, Baumhauer, JF, and Umberger, BR: 49. 
Relationship between clinical measurements and motion of the 
first metatarsophalangeal joint durim; gait. J Bone Joint Surg 
8f:370, 1999. 50. 

28. Wilson, RW, and Gansneder, BM: Measures of functional limita- 
tion as predictors of disablement in athletes with acute ankle 
sprains. J Orthop Sports Phys Ther 30:528, 2000. 5 1 . 

29. Kaufman, KR, et al: The effect of foot structure and range of 
motion on musculoskeletal overuse injuries. Am | Sports Med 27: 
5S5, 1999. 

30. Chesveorrh, BM, and Vandervoort, AA: Comparison of passive 52. 
stiffness variables and range of motion in uninvolved and involved 
ankle joints of patients following ankle fractures. Phys Ther 55. 
75:233, 1995. 

31. Reynolds, CA, ct al: The effect of nontraumatic immobilization 54. 
on ankle dorsiflexion stiffness in rats. J Orthop Sports Phys Ther 
23: 27, 1996. 

32. Hastings, MK, et al: F.ffects of a tendo-achilles lengthening proct- 5>. 
dure on muscle function and gait characteristics in a patient with 
diabetes ntellitus. J Orthop Spons Phys Ther 30:S5, 2000. 

33. Salsich, Gil, Mueller, MJ, and Sahrmann, SA: Passive ankle stiff- 



ms< us subiect". wsrii thjlhiei and peripheral jieifrojuiln ''efsiisan 

.u;e iuaictivd lontJiafrMtii group. I "J s y ■— liiei :-<<>: !s2. 2iWu. 

s.tUtL-k. iA\. Ri-imu. V!. and Mtiellvr. Ml; Rriafaniviup klwten 

pl.iiiiarlk'vir smtvere vMtTticv.. •.Tretigtri and ramre oi motion in 

■rttf»|e,.t\ with diabetes; jiertjilteral Siporop, 1 1 re, compared u> ,iw. 

matched con; roU. I i irtlmp Sj'nris Pin-, I her '.0: 4" s. 2000. 

t'.itiiiil.i:ie>ii>fii;;-, V-rvice ami J'ir.sjcai Htcrap) Depp 

Observational (..u: An.tlv-!-.. uti 4, S.AKf'l. Rjiurun l-i>-> Amigos 

N.i!;..ii.m |<el:.d'ii;tJi!on ( enter, Dtvwtu-y. ( A. 2s«>l. 

Murray. MP: d-t«! a-, a sou! pattern >»i iinwemem. Am | Phvs \-ted 

Rehalni 4(.:2"o, |>>f>~. 

1 ivt'igstott. I. A. V;". ;■;!-.. .n. JM. ,huI i HiH-y. s|: Mairclintbing kine- ' 

mattes nil s;.iu^ n! difSeruig dsHieiivHHf,. Arch Phvs Med Rehabil 

~2:i'»S. IWt. 

Mel aydtri, I'jJ. .nn! \\ ltitei. I>\. An integrated biottiech.tnical 

analysts ul norma! -a.i:r a-ci-in and tU-wciw, I lUnmech 21:733 

I"Ss:. 

IKtnisk}, KM: A coiUjianMjii <■! i;.ii: ih.it. icteristus in lining and 

old *uhf.vt*. Ptn<* riier '"-!:>• r. |*«4. 

( ailfici. R: Foul and Ankle, ed i. FA I 'law-.. Philadelphia, 1997. 

Nkl'oit. I'd. and Cornwall. \I\V: Applied -.tHirt* biomechanics in 

ivIubiltt-ttttiM rtMitHiH*. hi /.i-.h.i/e'.se-.ki, (f., M.igee, Hi, and 

Owilen. NX'S iF-iKi: Athletic lrtiurie-. and Rehabilitation., WB 

Sautulers, I'hii.ruelpha, 1 "***«■. 

Turburn, 1 . Pert;. I. and <• «nmle>. |-AK: Av«rv»num! ■■! rearioot 

inotUfHt P.'vave juisttttiiimg, one-legged Ma-:dmg, i:.H!. Finn Ankle 

hll l**:<iSK, |»»«M4. 

Cirbatuva, I'- . et al: I hi irnnr.il plane rel.isuiti-.lup Hi the forefoot 

»i rite reartmw ib .its a->i)ui % it>ttMtH pitjiilatiou. I (>a hup Sports 

I'h-.-. Iher 20:20»i. I-W4. 

{Wfse. IK . ei ,il: Reli.thilui o> iyinii>n!ttr>v nsejviir-mefit*. Phys 

I her ((S;I.is5, \"-f~!i. 

CJ.ii.H't. MP. and Wolf, sl : t oitrpartsr.:! <>• she rekvhiUty of the 

Orthorasiger and the %:."i;d.tri! goiimnieie? i"E avs-iMOg active 

lower e\tren:ir. ra:i-,;e o, ::n»t:ori. P)i\^ 1 her u*:l I 4. 1 V 'SS. 

Bi«h,tii(«in, !i\\. liK.no, 1 ' . and Vi.iier>. d: M.iIumi measured. 

ironi loretoMt and liin,l!oo: landmark-, djinrig jvv«!»c ankle dorsi- ; 

i.exio!-, r.iuue its mtitttm, I t)r!hn|> Spuria ISiy* Tiier 13:20, 1991. 



k. jrivj ( niVie... 



tjbihii Mikiv oi ;he universal-' 



goniometer, llun! goniuiiieie!. ,»su! elc.trn;;omnnieUT (or the 
;ue.iMiFeHieit! ill ankW ,ioriillexMt!!. iooi Aiikle hit 1":2.S. 1 "'96. 
SVsHSeil. K. ei al: iaterraser .lttd imraratei reliability ul a weight- 
Ivafiug lunge uie.iMiiv u! ,it:kle liorNiilex-on. Ais'-i I'iiv-iothcr 
•14:l~5, | "VS. 
lh.p>o::. MM. MJ'oii. "It,, ami Csirnwail. MW: Motion of the 

lit-.! ItseSJMtsopiiaiaiige.i: i ;. Keliahiliiv a!ie! validity ul four 

mv.!iur«n,iK tcciuiiouev J Am 1'odiatr Med Wn, Svl'iS, 1995, 
i ivet'ii, KA, Ri.rhj.tem, I, .i::j l.iiiiK lil : t iot;!on: ; trie reliability 
ill .1 ehni.a! *e!lmg: Sui'i.jl.n and ankle toiirt mca'viircmemv Phys) 
Tisef !*>".'. 1"SS. 

YosuI.In. |Vi'. l'...;.;.i:J. t 1 . ,!\>.j Smii,;:i, \ j: KchabtlH) of gonio- 
sial e-'imate-- »•! atikle |i»tM range of 



T,v> 



her, 
v:i:t me.'.sure- 



meiri. mv-tsuremriiio am 

mnnou obi. mied in a .iiuteai settin.4 Mb-.ir. 

~2iNiippl-:M i I. 14*12, 

I I'.eru. RA, el ,ii: Meshm.:-, !..r taking .',ii>:.:i.ii 

llient^: A .iniiv.i! report. I'hv, ! fur riS:h~S, IVSS. 

lUiley. Ds. IVisiio. j 1. and format!, M: Stilqjt.tr |i«»tn neuiral: A 
stirdi iiMI!;; toltisigiaphv. I Am PoJi.io.U-.ov ""-J:>", l l 'S4. 
IViUno. AM, RinviatKK, Ms, ,, m ) Worrell. I: Rehabihiv of open 

am! closed kinetic chain subtalar louil neutral po-.it ion-, and u.ivic- 
id.it drop teM. J t 'ithop Sporu I'iv. v Iher lS;>5i. [»''.», 
t l.ukMiu. I INI: M'.ivc iiio-.kelel.il .-Weivmeiii: loun K.mge ot 
Mono., an.! Manna! Muwiv strength, ed, 2. lappiiKotr Williams 
Cv. W:ikiti%. I'iiil.ideiiihi.i, 1'XHl 



_:,^M 







mpo.ro its an 





Objectives 



ON COMPLETION OF PART 111, THE READER WILL BE 

1. Identify: 

appropriate planes and axes for each spinal 

and jaw motion 
expected normal end-feels 
structures that limit the end of the range of 

motion 

2. Describe: 

testing positions for motions of the spine and 
jaw 

goniometer alignments 

capsular patterns of restrictions 

range of motion necessary for functional tasks 

3. Explain: 

how age and gender may affect the range of 

motion 
how sources of error in measurement may 

affect testing results 

4. Perform an assessment of the cervical, 
thoracic, and lumbar spine, using a universal 
goniometer including: 

a clear explanation of the testing procedure 
placement of the subject in the appropriate 
testing position 



ABLE TO: 

adequate stabilization of the proximal joint 

component 
correct determination of the end of the range 

of motion 
correct identification of the end-feel 
palpation of che correct bony landmarks 
accurate alignment of the goniometer 
correct reading and recording 

5. Perform an assessment of the range of motion 

of the cervical spine, using each of the follow- 
ing methods: a tape measure, dual inclinome- 
ters, and the cervical range of morion 
(CROM) device. 

6. Perform an assessment of the range of motion 
of the thoracic and lumbar spine, using a tape 
measure and dual inclinometers 

7. Perform an evaluation of the temporo- 
mandibular joint using a ruler 

S. Assess the intratester and intertester reliability 
of measurements of the spine and temporo- 
mandibular joint 



Chapters 11 through 13 present common clinical techniques. for, measuring gross motions of the cervi- 
cal, thoracic, and lumbar spine and the temporomandibular joint. Evaluation of. the range of motion 
and end-feels of individual facet joints of the spine are not included. 



293 



CHAPTER II 



The Cervical S 




■* 



':■ 



I" 



'M. Structure and Function 
Atlanto-occipital and Atlantoaxial joints 

Anatomy 

The aclanto-occipital joint is composed of the right and 
left slightly concave superior facets of the atlas (Cl) that 
articulate 'with the right and left convex occipital 
condyles of the skull (Fig. L 1—1). 

The atlantoaxial joint is composed of three separate 
articulations: the median atlantoaxial and two lateral 
joints. The median atlantoaxial joint consists of an ante- 
rior facet on the dens (the odontoid process of C2) that 



Occipital condyle 




Occipital 

bone 



Spinous process 



Superior atlantal 

articular process 



Transverse process 



FIGURE 11-1 A lateral view of a portion of the atlanto-occip- 
ital joint shows the superior atlantai articular process of the 
atlas (Cl) and the corresponding occipital condyle. The joint 
space has been widened to show the articular processes. 



articulates with a facet on the internal surface of the atlas 
(Cl). The two lateral joints are composed of the right and 
left superior facets of the axis (C2) that articulate with 
the right and left slightly convex inferior facets on the 
atlas (Cl) (Fig. 11-2). 

The atlanto-occipital and atlantoaxial joints are rein- 
forced by the posterior and anterior atlantoaxial liga- 
ments, the transverse band of the cruciate ligament, the 
alar ligaments, and the tectorial membrane. 

Osteokinematics 

The atlanto-occipital joint is a plane synovia! joint that 
permits flexion-extension, some axial rotation, and 
lateral flexion. Flexion-extension takes place in the sagit- 
tal plane around a medial-lateral axis. Axial rotation 
takes place in the transverse plane around a vertical axis 



Superior band 
cruciate ligament 




Transverse cruciate band iigament 



Superior articular 

facet 



Lateral atlantoaxial 
joint 
Interior articular 

facet 
Median atlantoaxial 
joint 

Inferior band 
cruciate ligament 



FIGURE 1 1-2 A posterior view of the atlantoaxial joint and the 
superior, inferior, and transverse bands of the cruciate ligamenc. 

295 



296 



PART IV TESTING OF THE SPINE AND TEMPOROMANDIBULAR JOINT 



__Jf|i 

- 1 - . 
Tiflli 

■ 



'Q 



mm 

ill 
ten 

ik*-::-- 



111 



and lateral flexion takes place in the frontal plane around 
an anterior-posterior axis. Flexion is limited by osseous 
contact of the anterior ring of the foramen magnum with 
the dens and by tension in the tectorial membrane. 
Extension is limited by the anterior atlantoaxial ligament. 
Combined flexion-extension is reported to be between 20 
degrees' and 30 degrees 2 and is usually described as the 
amount of motion that occurs during nodding of the 
head. However, according to Cailliet, 5 the range of 
motion (ROM) in flexion is 10 degrees and the range in 
extension is 30 degrees. Maximum rotation at the 
atlanto-occipital joint is between approximately 2.5 
percent and 5 percent of the total cervical spine rota- 
tion. 4 ^ Lateral flexion is approximately 10 degrees. 1 

The two lateral atlantoaxial joints are plane synovial 
joints that allow flexion-extension, lateral flexion, 
and rotation. The median atlantoaxial joint is a 
synovial trochoid (pivot) joint that permits rotation. 
Approximately 55 percent of the total cervical range of 
rotation occurs at the atlantoaxial joint. Rotation at the 
median atlantoaxial joint is limited by the two alar liga- 
ments. About 45 degrees of rotation to the right and left 
sides are available. The motions permitted at the three 
atlantoaxial articulations are flexion-extension, lateral 
flexion, and rotation. 

Arthokinematics 

At the atlanto-occipital joint, the inferior convex 
condyles of the occiput articulate with the two superior 
concave zygapophyseal articular facets of the lateral 

bodies of the atlas. When the head moves on the atlas 



Intervertebral 
joints 



Zygapophyseal 
joints 




Intervertebral 
disc 



the 

w 



1 
(convex surfaces moving on concave surfaces), the occinJ 
ital condyles glide in the direction opposite to the mov I 
merit of the top of th* head. In flexion, the condyles riu 

posteriorly on tin.- arias articular surfaces. In extension ' 

ie occipital condyles glide anteriorly on the atlas' 1 - 

hcrcas the back ot the head moves posteriorly. 

.\, ,1,.. I., ,..-..! -,,[.,.,,. ..,,..;.,! ;..:.,,., „l ..." 



icreas trie nacK ot tne neati moves posteriorly. 

At the larera! atlantoaxial joints the inferior 
zygapophyseal articular facets ol the atlas are convex and 
articulate with the superior concave articular facets of the 
axis. At the median joint the atlas forms a ring with the I 
transverse ligament (band) ot the cruciate ligament, artd : 
this ring rotates around the dens (odontoid process);- 
which serves as a pivot for rotation. The dens articulates 
with a small facet in the centra! area of the anterior arch' 
or the atlas. '% 



Capsular Pattern 



FIGURE 11-3 A lateral view of the cervical spine shows the 
intervertebral and zygapophyseal joints from C3 to C7. 



The capsular pattern for the atlanto-occipital joint is an 
equal restriction of extension and lateral flexion^ 
Rotation and flexion are not affected. 1 

Intervertebral and Zygapophyseal joints 

Anatomy 

The intervertebral joints are composed of the superior 
and interior surfaces of the vertebral bodies and the adja-4 
cent intervertebral discs (big. i 1-3). The joints are rein- 
forced anteriorly by the anterior longitudinal ligament, 
which limits extension, and posteriorly by the posterior 
longitudinal ligament, ligamentum nuehae, and ligamen- 
tum flavum, which help to limit flexion. 

The zygapophyseal joints arc formed by the right and 
left superior articular facets (processes) of one vertebra 
and tile right and left inferior articular facers of an adja- 
cent superior vertebra (Fig. 1 1-^1). Each joint has its own 
capsule and capsular ligaments, which are iax and permit 
a relatively large ROM. The ligamentum flavum helps to 
reinforce the joint capsules. 

Osteokinematics 

According to White and Punjabi,' 1 one vertebra can move 
in relation to an adjacent vertebra in six different direc- 
tions (three translations and three rotations) along and 
around three axes. The compound effects of sliding and 
tilting at a series of vertebrae produce a large ROM for 
the column as a whole, including flexion-extension, 
lateral flexion, and rotation. Some motions in the verte- 
bral column are coupled with other motions; this 
coupling varies from region to region. A coupled motion 
is one in which one motion around one axis is consis- 
tently associated with another motion or motions around 
a different axis or axes. For example, left lateral flexion 
from C.l to C5 is accompanied by rotation to the left 
(spinous processes move to the right) and forward flex- 
ion. In the cervical region from C2 to C7, flexion and 
extension are the only motions that arc not coupled. 



m 



CHAPTER 11 THE CERVICAL SPINE 



297 



Uncinate processes 



Inferior articular 
.facet 



Superior 

articular 

facet 




Zygapophyseal 
joint 



FIGURE 11-4 An anterior view of the right and left 
zygapophyseal joints between two cervical vertebrae. The verte- 
brae have been separated to provide a clear view of the inferior 
articular facets of the superior vertebra and the superior articu- 
lar facets of the adjacent inferior vertebra. 



The intervertebral joints are cartilaginous joints of the 
symphysis type. The zygapophyseal joints are synovial 
plane joints. In the cervical region, the facets are oriented 
at 45 degrees to the transverse plane. The inferior facets 

; of the superior vertebrae face anteriorly and inferiorly. 
:;The superior facets of the inferior vertebrae face posteri- 
orly and superiorly. The orientation of the articular 
facets, which varies from region to region, determines the 
direction of the tilting and sliding of the vertebra, 
whereas the size of the disc determines the amount of 
motion. In addition, passive tension in a number of soft 

^tissues and bony contacts controls and limits motions of 

::the vertebral column. In general, although regional vari- 
ations exist, the soft tissues that control and limit 
extremes of motion in forward flexion include the 
supraspinous and interspinous ligaments, zygapophyseal 
joint capsules, ligamentum flavum, posterior longitudinal 
ligament, posterior fibers of the annulus fibrosus of the 
intervertebral disc, and back extensors. 

■■■v Extension is limited by bony contact of the spinous 
processes and by passive tension in the zygapophyseal 
joint capsules, anterior fibers of the annulus fibrosus, 
anterior longitudinal ligament, and anterior trunk 
muscles. Lateral flexion is limited by the intertransverse 
ligaments, by passive tension in the annulus fibrosus on 
the side opposite the motion on the convexity of the 
curve, and by the uncinate processes. Rotation is limited 
by fibers of the annulus fibrosus. 

Arthrok'mematics 

The intervertebral joints permit a small amount of sliding 
and tilting of one vertebra on another. In all of the 
motions at the intervertebral joints, the nucleus pulposus 



of the intervertebral disc acts as a pivot for the tilting and 
sliding motions of the vertebrae. Flexion is a result of 
anterior sliding and tilting of a superior vertebra on the 
interposed disc of an adjacent inferior vertebra. 
Extension is the result of posterior sliding and tilting. 

The zygapophyseal joints permit small amounts of 
sliding of the right and left inferior facets on the right and 
left superior facets of an adjacent inferior vertebra. In 
flexion, the inferior facets of the superior vertebrae slide 
anteriorly and superiorly on the superior facets of the 
inferior vertebrae. In extension, the inferior facets of the 
superior vertebrae slide posteriorly and inferiorly on the 
superior facets of the inferior vertebrae. In lateral flexion 
and rotation, one inferior facet of the superior vertebra 
slides inferiorly and posteriorly on the superior facet of 
the inferior vertebra on the side to which the spine is 
laterally flexed. The opposite inferior facet of the supe- 
rior vertebra slides superiorly and anteriorly on the supe- 
rior facet of the adjacent inferior vertebra. 

Capsular Pattern 

The capsular pattern for C2 to C7 is recognizable by pain 
and equal limitation of all motions except flexion, which 
is usually minimally restricted. The capsular pattern for 
unilateral facet involvement is a greater restriction of 
movement in lateral flexion to the opposite side and in 
rotation to the same side. For example, if the right artic- 
ular facet joint capsule is involved, lateral flexion to the 
left and rotation to the right are the motions most 
restricted. 7 

SK Research Findings 

Effects of Age, Gender, and Other Factors 

Measurement of the cervical spine ROM is complicated 
by the region's multiple joint structure, lack of well 
defined landmarks, lack of an accurate and workable 
definition of the neutral position, and the lack of a stan- 
dardized method of stabilization to isolate cervical 
motion from thoracic spine motion. The search for 
instruments and methods that are capable of providing 
accurate and affordable measurements of the cervical 
spine ROM is ongoing, and the following sections 
provide a sampling of studies that have investigated 
cervical ROM. Tables 11-1 and 11-2 provide cervical 
spine ROM values from various sources and with use of 
a variety of methods. 

Age 

A large number of researchers have investigated the 
effects of age on cervical ROM,' 4-25 but differences 
between the populations tested and the wide variety of 
instruments and procedures employed in these studies 
make it difficult to compare results. Generally, 
researchers agree that a tendency exists for cervical ROM 






298 



PART IV TESTING OF THE SPINE AND TEMPO-ROM A l 



O i N 




Table 11-1 Cervical Spine Range of Motion: Mean Valuesin Degrees 



Motion 



Flexion: 'v.:;- - 
j Extension:-., ^y^- 
Right lateral flexion 
Left lateral flexion 
Right rotation 
Left rotation 



■ Luniz, Chen, a.nd Bti'ch**] 
Mean age ■ = 20-39 'yrs 



■AMA fi 



CapuamO'Pucci et af 10 

Mean age- 23. S yrs 
: ';v/:r. rV=20. /- 



'Mean. (SB) 



Mean ($0} 



60 (8) 

,56 (11) 

43 (8) 

41 (?) 

72 (7) 

73 (6) 



50 

.60 
45 
45 
80 

80 



CROM = Cervical Range of Motion device; ROM - range of motion; (SD; 

■ Values for active ROM were obtained with use of the CA-6000 spine motior 

' Values obtained using an inclinometer. 

' Values obtained using the CROM device. 

* Values for active ROM obtained using a universal goniometer. 





5t 


(9) 




70 


("■>) 




44 


(8) 




71 


(5) 


mill -;: • !■.■■.:. 


'.■,:; 




wty/er. 







Yottdasiet afi u 

Manage ~ 59..J^ 
.: n^20-\ £ 



Mean (SO) 



40 (12) 

50 (14) 
22 (8) 
22 (7) 

51 (!1) 

-19 (9) 



:£ 



i 



i 






to decrease with increasing age. The only exception is 
axial rotation (occurring primarily at the atlantoaxial 
joint), which has been shown either to stay the same or 

to increase with age to compensate for an age-related 
decrease in rotation in the lower cervical Spine. l7 *- s Age 
may nor account for a large amount of the variance in 

ROM, hut age appears to have a stronger effect than 
gender. O'Driscoll and Tomenson''' studied cervical 
ROM across age groups. These investigators used a spirit 
inclinometer (a hydrogoniometer that works on a pendu- 
lum principle) for their measurements. They measured 79 
females and SO males ranging in age from to 79 years. 
ROM decreased with increasing age, and differences 



tablmi-2; Gervical Spine Range of Motion < 
Measured with a Tape Measure: Mean Values 
in Centimeters 



.'■' ^S'v" ,^:ir-iCI" 'A': 



siehondYeung-" Bologunetalt^ 
if}— it 



ri- 1:1 
Tester M 



■Tester : M 



Nation. 



-Mean (SD) 'Mean (SD) 



lean (SD) 



Flexion, 
Extension 

Right lateral flexion 
Left lateral flexion 
Right Rotation 1 
Left Rotation 



1.0 (1.68) 
22.4 (1.56) 

11.0 (1.92) 
10.7 (1.87) 
11.6 (1.73) 
(1.88) 



11.2 



1.8(1.60) 

20.8 (2.36) 

11.5 (2.10) 

■11.1 (2.07) 

,12.6(2.52) 

1 3.2 (2.37) 



4.3 (2.0) 

18.5 (2.0) 

12.9 (2.4) 

12.8 (2.5) 

11.0 (2.5) 

11.0 (2.5) 



CI = Confidence interval; r = Pearson product moment correlation 

coefficient; (SD) = standard deviation. 
*99 percent confidence interval of measurement error ranged from 

1.4 cm to 2.55 cm for tester 1 (experienced). CI ranged from 1.91 

cm to 3.30 em for tester 2 (inexperienced). 
+ r values ranged from 0.26 to 0.88 for intratester reliability and from 

0.30 to 0.92 for intertester reliability. 



existed luiwecn inak-s and females. A nisiliipfe regression! 
.lu.ifyM* showed that age alone c-cptalijcd a significant^ 
aiijmmi u? the variation, nut regression line-, tor males 
and females were .signiticanrh dtricrcm. 

Table I l-o shows rhi- eftects t»l age on cervical spine 
ROM. Values presented in Tabic M~i were obtained 
tfuni ii™ iie.ii[l!\ volunteers ;l _ i females and \66~ 
maicv. 1 he subjects were measured using the cervical . 
range < -t morion -;( ROM;, de'.tec; therefore, the values: 
presented in rkx t.ihles should he tiseei for reference 
imiy si examiners are using a (ROM device for their 
measuring sustruniciir. However, the t. shies .tie useful in 
thai they show rhe effects of age on cervical ROM.. 
Ideally, the examiner should use norms rhai are appro- 
priate to the method o! measurement and the age and 
gender ol the individuals being examined. In Table 1 1-3,. 
the mean values tor active neck flexion in the two oldest 
groups oi males and females arc less than the mean values 
obtained in the youngest group. Highly- to ninety-year- 
old subjects show about -'■' degrees less motion than LI 
ro i L > year old subjects. 

I'cliachia and Bithannoii" found that the mean values 
far later, 1 .! flexion us subjects younger than .U) years of 
age exceeded 42 degrees, whereas mean values for lateral 
tlc\ioi! in subjects older rh.ttt TV years of age were less 
than IS degrees. Nikson, (Jurn'ig^cti, and ('hristciiseii, 
in a study of 9(! healthv men and women aged 20 to 60 
years, concluded that rhe decrease in cervical passive 
ROM with, increasing age could lie explained by using a 
simple linear regression of ROM as a function of age. 
t hen and colleagues," * in a detailed review of the litera- 
ture regarding the effects ol aging on cervical spine 
ROM, concluded thai active ROM decreased by 4 
degrees per decade, f his finding is very close to the >■ 
degree decrease found by Youdtis and associates.'" 

Other investigators have found some evidence that rhe 



CHAPTER 1 1 



THE CERVICAL SPINE 



299 



TABLE 11-3 Effects of Age on Active Cervical Flexion Range of Motion in Mates and Females 
Aged 1 1 to 89 Years: Mean Values in Degrees* 






20-29 yn 

n=42 



"3fc~39~yr. 
rs = 41 



40-49 yi:, 
n-- 4Z 



■n=40 



n = 4^ 



JVjHWWMatBHI 



7:6-79 yrs 
n ~ 40 



; ,.. ...... . . .... ..... 

89-89 jitter 



mean(Sp) 



MeaKfSB). 



Mean (SD) 



Mean (SO) 



Wean (SO) 



Mean (SB) 



Mean(SQi 



Mean (S& 



M 






iffi ■ 



64 (9) 



54.(9) 



47(10) 



50 VM 



46(9) 



41 (8) 



mm 



40 (9) ■ 



;(SD) = Standard deviation. 

Adapted from Youdas, [W, et al 14 : Reprinted from Physical Therapy with the permission of the American Physical Therapy Association. 
"Measurements were obtained with use of a Cervical Range of Motion (CROM) device. 



effects of age on ROM may be motion specific and age 
specific; however, the evidence appears to be somewhat 
controversial. Trott and colleagues 21 found a significant 
decrease in the means of all motions (flexion-extension, 
lateral flexion, and axial rotation) with increasing age, 
but they determined that most coupled motions were not 
affected by age. Pearson and Walmsley 18 and Walmsley, 
Kimber, and Culham 20 were the only authors to include 
the cervical spine motions of retraction and protraction 
in their studies. Pearson and Walmsley 13 found that the 
older age groups had less ROM in retraction, but that 
they showed no age difference in the neutral resting posi- 
tion. In contrast to Pearson and Walmsley's 18 findings. 
Walmsley, Kimber, and Culham 20 found age-related 
decreases in both protraction and retraction. Lantz, 
Chen, and Buch, s in a- study of 52 matched males and 
females, found a significant age effect, with subjects in 
the third decade having greater ROM in rotation and 
flexion-extension than subjects in the fourth decade. 
Dvorak and associates 1 ' determined that the most 
dramatic decrease in ROM in 150 healthy men and 
women (aged 20 to 60 years and older) occurred between 
the 30-year-old group and the 40-year-old group. In 
contrast to the findings of Dvorak and associates, 1 ' Trott 



and colleagues" 1 found that the greatest decrease in flex- 
ion-extension ROM in 60 healthy men and women (aged 
20 to 59 years) occurred between the 20-year-old group 
and the 30-year-old group. 

Gender 

Many of the same researchers who looked at the effects 
of age on cervical ROM also studied the effects of gender, 
but the results of these studies appear to be more incon- 
sistent than the results of the age studies. In some studies, 
the trend for women to have a greater ROM than men 
was apparent, although differences were small and gener- 
ally not significant. Also, in some instances, the effects of 
gender appeared to be motion specific and age specific in 
that some motions at some ages were affected more than 
others. 

Castro 25 was one of the authors who found significant 
gender differences in cervical ROM, but these authors 
noted that the differences occurred primarily in the 
motions of lateral flexion and flexion-extension in 
subjects between the ages of 70 and 79 years (Tables 
1 1 — 4, 11-5, and 11-6). Women older than 70 years of 
age were on the average more mobile in flexion- 
extension than men of the same age. Nilsson, Harrvigsen, 



table n-4 Effects of Age and Gender on Cervical Lateral Flexion Range of Motion in Males and 
Females Aged 20 to 80 Years and Olden MeanValues in Degrees* 



Nilsson etaf* 19 

Males '.y. \ 
n - 37 



Dvorak et a/" 7 
Males 



Castro etafi" 

Males 
n= 71 



Nilsson et dt'* : 

Females 



Dvorak et al": 

Females 
n = 64 



Age Groups 


Mean(SD) /.;■■: 


Mean(SD) 


20-29 yr 


122 (4) 


101 (13) 


j 30-39 yr 


111(12) 


95(10) 


40-49 yr 


102(15) 


84(14) 


• 50-59 yr 


104(12) 


88 (29) 


60-69 yr 




74(14) 


70-79 yr 






80+ yr 




:■■-. ''',■■■':'■ 



Mean 



Mean (SD) 



Mean (SD) 



92(14) 116(18) 100 (9) 

89(23) 108(14) 106(18) 

74(15) 99(11) 88(16) 

70(12) .97 (7) 76(10) 

65(14) 80(18) 
47(12) 

(SD) = Standard deviation. 

* The values in this table represent the combined total of right and left lateral flexion range of motion. 

f Nilsson et al. used the Cervical Range of Motion (CROM) device to measure passive range of motion. 

* Dvorak et al. used the CA 6000 spinal motion analy2er to measure passive range of motion. 

5 Castro et al. used an ultasound-based coordinate measuring system, the CMS SO, to measure active range of motion 



Castro etaf? 

... Females 
n = 86 



Mean (SO) 



90(13) 
86 (18) 
77(12) 
69(15) 
68(12"-; 
70 (14) 
50(18) 



300 



PART ! V 



TESTING OF THE S P i N £ AND T f M P O R O M A N D i B U L A R |01NT 



% 



table 11-5 Effects of Age and Gender on Cervical Flexion/Extension Range of Motion in Mates and 
Females Aged;20 to $0 Years and Older: Mean Values in Degrees* 





Nilsson et at" ? 


Dvorak et aP 7 


Castro et ol i ^ s 


Nilsson et al" 


Dvorak et al" 


Castro et of" 






Mates 


Males 


Males 


Females 


Females 


Females 




;. v - 


n« 3J 


n~86 


n^ 71 


n = S9 


n= 64 


n=86 i; 




. Age Groups vy 


Mean (SO) 


Mean (SD) 


Mean (SD) 


Mean(SD) 


Mean (SD) 


' 

Mean(SD) | 




I 20-29 yrs 


129(6) 


153 (20) 


149(13) 


128(12} 


149 (12) 


152 (15) 


, 


30-39 yrs 


1 20 (8) 


141 (11) 


135 (26) 


120(12) 


156(23) 


141 (132) ■ 


' = 


40-49 yrs 


110(6) 


131 (19) 


129(21) 


114(10) 


1 40 (1 3) 


1 25 (13) 




1 50-59 yrs 


1 1 1(8) 


i Jo{"6) 


116(H) 


117(19) 


127(15) 


124 (24) 




60-69 yrs 




116(19) 


110(16) 




133 (8) 


117 (15) 




70-79 yrs 






102(13) 






121 (21) : 




80+ yrs 












98 (11) 


f 


(SD) Standard deviation. 












: 


' The values in this 
' Nilsson et ill. used 


tiible represent the 
the Cervical Ranq< 


combined total of fte 
of Motion device (CF 


ciofi and extension 

tOM) to measure p 


range of m-ottort. 
iissi'.'t: raivoe erf motion. 









: Dvorak et at used list- CA-6000 spinal motion analyzer to measure passive ROW 

'•Castro et al. used an uka sound -based coordinate measuring system, '.be CMS 50, to measure active range o! motion. 



and Cihristcnsen 1 " found a difference between genders m 
lateral flexion ROM. The differences were significant, 

but, iti this study, males were more mobile than females 
(Table i 1-4}. LaiHZ, (.hen, and Buck* studied a total of 
56 healthy men aiul women aged 20 to .39 years. The 
authors found no difference between genders m total 
combined left and right lateral flexion, but women had 
greater ranges of active and passive axial rotation and 
flexion-extension than men of the same age. Women had 
an average of 12.7 degrees more active flexion-extension 
and an average of 6. 50 degrees more active axial rotation 
than men of the same age. Women also had greater 
passive ROM in all cervical motions. Dvorak and associ- 
ates 1 found that women between 40 and 49 years of age- 
had greater ROM in all motions than men in the same 



age group. I lowever, within each ot the oilier age groups 
20 to 2'> years, oil to fr l) years. 70 to "9 year*, and 80 to 
SM sears, no differences in cervical ROM were found 
between gender-,. 

lables 11-7 .im.\ 1I-S contam information from a 
study by Youdas and associates 1 " showing that females in 
almost all age groups appear to have greater mean values 
tor active cervical motion than males. Youdas and asso- 
ciates' 1, found a significant gender effect in all motions 
except flexion s.»i.\ determined that males and females 
lose about s degrees of active extension and 3 degrees of 
active lateral flexion and rotation with each 10-year 
increase in age. Ii the measurements using the CR.OM 
device are valid, one can expect to find approximately 15 
decrees to 20 decrees less active neck extension in a 



TABLE 11-6 Effects of Age and Gender on Cervicat Rotation Range of Motion in Males and Fema 
Aged 20 to 80 Years and Older: Mean Values in Degrees* 



Nilsson et a!*' 9 
Males 

n •-- 31 



Dvorak et at Sf 
Males 
n - 86 



Castro et ai& s 
Males 
n ^ 71 



Nilsson et al ls> 
Females 
n = 59 



Dvorak et al' 7 
Females 
n= 64 



Age Croups 



Mean (SD) 



Mean (SD) 






Mean (SD) 



Mean (SD) 



Mean (SD) 



Castro etaf s 
Females 
n^86 



Mean (SD) 



20-29yrs 174(13) 18-1(12) 161(16) 174(13) 182(10) 160(14) 

30-39 yrs 166(12) 175(10) 156(32) 167(13) 186(10) 150(15) 

40-49yrs 161(21) 157(20) 141(15) 170(10) 169(14) 142(15) 

50-59yrs 158(10) 166(14) 145(11) 163(!2) 152(16) 139(19) 

60-69 yrs 146(13) 136(18) 154(15) 126(14) 

70-79 yrs 121 (14) 135(16) 

80+ yrs 113(21) 

(SD) =■■ Standard deviation. 

" The values in this table represent the combined total of right and left rotation range of motion. 

T Nilsson et al used the Cervical Range of Motion device (CROM) to measure passive range of motion. 

* Dvorak et al used the CA 6000 spinal motion analyzer to measure passive ROM. 

* Castro et a! used an ultasound-based coordinate measuring system, the CMS 50, to measure active range of motion. 



' mm 

■II 



CHAPTER 11 THE CERVICAL SPINE 



301 



table n-7 Effects of Age and Gender on Active Cervical Spine Motion in Males and Females 
Aged 11 to 49 Years: Mean Values in Degrees* 



Extension 

Right lateral flexion 
Left lateral flexion 
Right rotation 

; Left rotation 



Mates ' 



Females 



Mates 



Mates 



Fe, 





■ n^ 2Q - _ n=20 


20-29 yn '-- ■ 
„ = 20 n-20 


- 3(W 

. n.= 20 _ 


9 yrs\ ■: ; 
n~21 -. . 


■ ■ 40-49 yrs ~S/ :i a 
n = 2Q ■ n~-22 


pjom 


. Mean (SB) ■ . Mean- (SO) 


Mean (SO). Mean (SO) 


Me&p($t>) 


Mean (SO) 


Mean. (SO) Mean (SO) : 

_; : _^J — l-J : 1^___ 



86(12) 


84(15) 


« (8) 


49 (7) 


46- (?) 


47 (?) 


74 (8) 


75(10) 


72 (7) 


71(10) 



77(13) 
45 (7) 
41 (7) 
70 (6) 
69 (7) 



86(11) 
46 (7) 
43 (5) 
75 (6) 
72 (6) 



68 (1 3) 


78 (14) 


63(12) 


78(13) 


43 (?) 


47 (8) 


38(11) 


42 (9) 


41 (10) 


44 (8) 


36 (8) 


41 (9) 


67 (7) 


72 (6) 


65 (10) 


70 (7) 


6S (9) 


66 (8) 


62 (8) 


64 (8) 



(SD) = Standard deviation. 

Adapted from Youdas, |W, et al 16 : Reprinted from Physical Therapy with the permission of the American Physical Therapy Association. 

•Measurements were obtained using the Cervical Range of Motion device (CROM). 



healthy 60-year-old individual compared with a healthy 
20-year-old individual of the same gender. 

In contrast to the preceding studies, the following 
investigators concluded chat gender had no effect on 
cervical ROM, Feipel and coworkers,*" 4 in a study involv- 
ing 250 subjects between the ages of 17 and 70 years, 
concluded that gender had no effect on cervical ROM, 
. Watmsley, Kimber, and Culham 20 found no differences in 
axial rotation that were attributable to gender. Trott and 
colleagues, 21 in a study of 120 men and women between 
20 and 59 years of age, also found that gender did not 
have a significant effect either on coupled motions or on 
ROM. However, age-related effects were different 
between males and females. Ordway and associates 2 '' 
found a nonsignificant gender effect, and Petlachia and 
Bohannon," in a study of 135 subjects aged 15 to 95 
years with a history of neck pain, concluded that neither 
neck pain nor gender had any effect on ROM. 

Testing Position 

The lack of a well-defined neutral cervical spine position 
is thought to be responsible for the lower reliability of 
cervical spine motions starting in the neutral position 



(half-cycle motions) compared with those starting at the 
end of one ROM and continuing to the end of another 
ROM (full-cycle motions). Studies that have attempted to 
better define the neutral position have used either radi- 
ographs 26,27 or motion analysis systems. 28,2 ''' In the radi- 
ographic study conducted by Ordway and associates, 26 
the authors determined that when the cervical spine is in 
the neutral position, the upper segments are in flexion 
and the lower segments have progressively less flexion; 
therefore, at C6 to C7, the spine is in a considerable 
amount of extension. Miller, Polissar, and Haas,"' in the 
other radiographic study, found that the cervical spine is 
in the neutral position when the hard palate is in the hori- 
zontal plane. Although these findings arc of considerable 
interest, they provide little help to the average clinician, 
who does not have access to radiographs for patient posi- 
tioning. 

Two studies that are more clinically relevant used the 
CA-6000 Spine Analyzer. 251,29 This motion analysis 
system is capable of giving the location of neutral posi- 
tion as coordinates in three dimensions corresponding to 
the three planes of motion, Christensen and Nilsson 28 
found that the ability of 38 healthy subjects to reproduce 



table n-8 Effects of Age and Gender on Active Cervical Spine Motion in Males and Females 
Aged 50 to 89 Years: Mean Values in Degrees* 



Moiei 



Females 



Males 



Females 



Males 



Females 



Males 



Females ■ 



S0-S9 yn 
20 --■=-- 20 



60-69 yrs. 
20 n = 20 



■nwm-i" -: h =^ 20 



80-89 yrs 
n = 20 rt= JS 



-.Motion 



Mean (SO) Mean (SO) 



Mean (SD) Medti (SD) Mean (SD) Mean (SD) . 



Mean(SD) Meari($D)\ 



Extension 60(10) 65(16) 57(11) 65(13) 54(14) 55(10) 49(11) 50(15). 

Right lateral flexion 36 (5) 37 (7) 30 (5) 33(10) 26 (7) 28 (7) 24 (6) 26 (6) 

Left lateral flexion 3S (7) 35 (6) 30 (5) 34 (8) 25 (8) 27 (7) 24 (7) 23 (7); 

Right rotation 61 (8) 61 (9) 54 (7) 65(10) 50(10) 53 (9) 46 (8) 53(11)" 

: Left rotation 58 (9) 63 (8) 57 (7) 60 (?) 50 (9) 53 (9) 47 (9) 51 (11) 

(SD) s= Standard deviation. 

Adapted from Youdas, |W, et al 16 : Reprinted from Physical Therapy with the permission of the American Physical Therapy Association. 

"Measurements were obtained using the Cervical Range of Motion device (CROM). 



302 



PART IV TESTING Of THE SPINE AND Tlls<lPOROMAND!3UtAR ] O i N 



the neutral spine position with eyes and mouth closed 
was very good. The mean difference from neutral in 
three motion planes was 2.7 degrees in the sagittal plane, 
1.0 degree in the horizontal plane, and 0.65 degrees in 
the frontal plane. Possibly, patients may be able to find 
the neutral position on their own, but the subjects in this 
study were healthy individuals, and the ability of patients 
to reproduce the neutral position is unknown. Solinger, 
Chen, and Lantz 29 attempted to standardize a neutral 
head position when measuring cervical motion in 20 
subjects. For flexion and extension, the authors described 
a neutral position as one in which the corner of the eye 
was aligned with the upper angle of the ear, at the point 
where it meets the scalp. For lateral flexion, neutral was 
defined as the point at which the axis of the head was 
perceived to be vertically aligned. Compared with data 
collected using a less stringent head positioning, Solinger, 
Chen, and Lantz~ y demonstrated that by standardizing 
head position they obtained increases in reliability of 3 
percent to 15 percent for rotation and lateral flexion but 
showed a decrease in reliability of up to 14 percent for 
flexion-extension. In a study using (the 3-Space Isocrak 
System) Pearson and Walmsley is found a significant 
difference in the neutral resting position (it became more 
retracted) after repeated neck retractions performed by 
30 healthy subjects. 

Another potential positional problem that testers need 
to be aware of has been identified by Lantz, Chen, and 
Buch. h These authors found that ROM measurements of 
the cervical spine taken in the seated position were 
consistently about 2.6 degrees greater than measurements 
taken in the standing position in all planes of motion. 
Greater differences occurred between seated and standing 
positions when flexion and extension were measured as 
half-cycle motions starting in the neutral position as 
opposed to measurement of full-cycle motions. 

Body Size 

Castro" 3 found that obese patients were not as mobile as 
nonobese patients. Mean values for motions in all planes 
decreased with increasing body weight. Chibnall, 
Duckro, and Baumer, j0 in a study of 42 male and female 
subjects, found that body size reflected by distances 
between specific anatomic landmarks (e.g., between the 
chin and the acromial process) influenced ROM meas- 
urements taken with a tape measure. Any variation in 
body size among subjects resulted in an underestimation 
of ROM for subjects with large distances between land- 
marks and an overestimation of ROM for subjects with 
small distances between landmarks. The authors 
concluded that the use of proportion of distance (POD) 
should be used when comparing testing results among 
subjects. The use of POD (calculated by dividing the 
distance between the at-rest value and the end-of-range 
value by the at-rest value) helps to eliminate the effect of 
body size on ROM values obtained with a tape measure. 



Obviously, calculation oi POD is Etot necessary if fh c 

progress oi only one subject is measured. 

Functional Range of Motion 

Motion of (he cervical spine is necessary lor most activi- - 
lies of daiiy living ;is well .is most recreational and occu- ' 
pniional activities. Relatively small amounts of flexion 
extension, and rotation are required lor eating, reading . : ; 
writing, and using a computer. Drinking requires more *-i 
cervical extension ROM than eating, and star-gazing or ■ 
simply looking up at the ceiling requires a full ROM in '% 
extension (Fig. I 1-5). Using a telephone requires lateral I 
flexion as well as rotation. Considerably more motion is 
required for bathing and grooming. Sports ncm ities such 
as serving a tennis bait, catching or batting, a baseball ■ 
canoeing, iw.\ kayaking may require a full ROM in all 




FIGURE I 1-5 One needs al least 40 to 50 degrees of cervical 
extension range ol moiion (ROM) to took up ai the ceiling. >' 
cervical extension ROM ts limited, ilu- person must extend the 
entire spine in an e'tort to place the head in a position whereby 
the eyes can look up at the ceiling, 



■:' 



■ 



:■ ■■■:<;: 



CHAPTER 11 THE CERVICAL SPINE 



303 




FIGURE 11-6 One needs a minimum of 60 to 70 degrees of cervical rotation to took over the shoulder. 1 
If cervical rotation range of motion is limited, the person has to rotate the entire trunk to position the 
head to check for oncoming traffic. 



planes. Guth 3! compared cervical rotation ROM in a 
group of 40 swimmers with that in 40 nonathletic volun- 
teers. The swimmers aged 14 to 17 years had a mean 
total rotation ROM that was 9 degrees greater than the 
ROM of those aged 14 to 17 years in the control group. 
■Occupational activities such as house painting or wallpa- 
pering require a full range of cervical extension and, 
possibly, a full range of flexion. A full ROM in cervical 
: rotation is essential for safe driving of cars or trucks (Fig. 
:.il~6). 



to obtain a true validation of cervical ROM measure- 
ments because radiographic measurement has not been 
subjected to reliability and validity studies. Therefore, no 
valid gold standard exists. The only options available for 
investigators at the present time are to conduct concur- 
rent validity studies to obtain agreement between instru- 
ments and procedures. Some of the studies that have been 
conducted to assess reliability or validity (or both) of the 
various instruments and methods are reviewed in the 
following section. 



Reliability and Validity- 
Many different methods and instruments have been 
employed to assess motion of the head and neck. Similar 
to other areas of the body, intratester reliability generally 
is better than intertester reliability, no matter what instru- 
ment is used. Also, some motions seems to be more reli- 
ably measured than others. For example, the total 
(combined) ranges of flexion-extension and right-left 
lateral flexion appear to be more reliably measured than 
single motions such as flexion or extension measured 
troEn the neutral position. This finding may be owed to 
the variability of the neutral position and the lack of a 
standardized method that an examiner can use for plac- 
ing a subject in the neutral position. 

According to Chen and colleagues, 23 it is not possible 



Universal Goniometer and Gravity Goniometer 

Tucci and coworkers^- compared the intratester and 
intertester reliability of cervical spine motions measured 
with both a universal goniometer and a gravity goniome- 
ter. Intraclass correlation coefficients (ICCs) for 
intertester reliability ranged from -0.08 for flexion to 
0.82 for extension, for measurements taken with the 
universal goniometer by two experienced testers on 10 
volunteer subjects. ICCs for intertester reliability ranged 
from 0.80 for right rotation to 0.91 for left rotation, for 
measurements taken with the gravity goniometer by one 
experienced and one novice tester on 11 different volun- 
teers. The authors concluded that the gravity goniometer 
that they had developed had good intertester reliability 
and was an accurate and reliable instrument. ■ 



304 



P ART i 



TESTING Of THE SPiMt AND TEMPOROMANDIBULAR JOINT 



table 11-9 Cervical Range of Motion (CROM) Device Intratester and Intertester Reliability 



Author 



Tester a: Subject n 



Meartpge ; Sample 



Motions 



(Intra) (Inter) (Intra) (Inter) ri 



ICC = intraclass correlation coefficient, r = Pearson product moment correlation coefficient; SEM = standard error of measurement. 

* Nilsson measured passive ROM. 

f 95 percent O for single subject measurement (mean of S measurements). 

' Represents intersubject SEM. 





Cupuano- 


2 


20 


23.5 yrs 


Healthy 


Flexion 














Pucci el at' 




(4 males, 

16 femafes) 






Tester 1 

Tester 2 
Extension 

Tester 1 

Tester 2 
Right lateral ffexion 

Tester 1 

Tester 2 
Right rotation 

Tester 1 

Tester 2 






0.63 
0.91 

0.90 
0.82 

0.79 

0.89 

0.85 
0.62 


0.84 
0.84 






Youdaset al ,h 


S 


6 (Intratester) 


27.2 yrs 


Healthy 


Flexion 


0.88 


0.83 








':■ 






20 (Intertester) 


33.0 yrs 




Extension 

Right lateral flexion 
Right rotation 


0.94 
0.88 
0.82 


0.90 
0.87 
0.82 










Garrett et af" 


7 


40 


59.1 yrs 




Forward head 
posture 


0.93 


0.83 








1 


Nilsson*' 4 


2 

(1 experi- 
enced; 1 no 
experience) 


14 


20-45 yfs 


Healthy 


Flexion 

Extension 

Right lateral flexion 

Right rotation 






0.76 
0.85 

0.61 

0.75 


0.71 
0.47 
0.58 

0.66 


6 5 ' 
5° 
5" 

6" 




Nilsson et al" 3i 


2 


35 


20-28 yri 


Healthy 


Flexion 

Extension 




0.65 

0.54 




0.70 

0.55 




"';-■■ 












Right lateral flexion 
Right rotation 
Flexion-extension 
Right-feft lateral 

flexion 
Right-left rotation 




0.64 
0.41 
0.60 
0.69 

0.88 




0.70 
0.41 
0.61 

0.71 

0.88 






Rheault et al 5li 




22 


37.4 yrs 


Hxof 

cervical 


Flexion 

Extension 




0.76 

0.98 


















spine 
pathology 


Right laterai flexion 
Right rotation 




0.87 
0.81 








1 


Olson et al" 


■; 


12 


34 yrs 


Neck pain 


Flexion 
Extension 

Right lateral flexion 
Right rotation 


0.88 
0.99 
0.98 
0.99 


0.58 
0.97 
0.96 
0.96 






4°* 

3° 

r 
y 


I 


Youdas et al" 


i 1 


20 
20 


55.9 yrs 
60.7 yrs 


Orthopedic 
disorders 


Flexion 

Extension 

Right lateral flexion 


0.95 

0.90 
0.92 


0.86 
0.86 
0.88 








\. 






20 


60.8 yrs 




Left lateral flexion 


0.93 


0.92 









Universal Goniometer, Visual Estimation, and the 
CROM Device 

Youdas, Carey, and Garrett " used the following three 
methods to determine active cervical ROM: visual esti- 
mation, a universal goniometer, and the cervical ROM 
device. Prior to testing, the therapists had 1 hour of 
instruction and practice using standardized measurement 
procedures for each instrument. Intratester and 



intertester reliability varied among the motions tested, 
but. generally, intratester reliability using either the 
universal goniometer or the CROM device were good 
(ICCs greater than 0.HO). ICCs for intertester reliability 
ol borh the universal goniometer and visual estimates 
wltl- less than O.S'O. Intertester ICCs tor visual estimation 
were lower than those of the universal goniometer for 
all morions except rotation. Intertester reliability f° r 




CHAPTER 11 THE CERVICAL SPINE 



305 



the CROM device was good. ICCs were poor to fair for 
interdevice comparisons among the three methods 
(visual estimation, universal goniometer, and CROM 
device) for all cervical motions. The authors concluded 
that, because of poor interdevice reliability, the three 
methods should not be used interchangeably. The fact 
that intertester reliability was higher with the CROM 
device than with the universal goniometer suggests that 
use of the CROM device for measuring cervical ROM is 
preferable to use of either the universal goniometer or 
visual estimation when different therapists take measure- 
ments on a particular patient. 

CROM Device 

Capuano-Pucci and coworkers 10 studied intratester and 
intertester reliability using the CROM device and 
concluded that the instrument had acceptable reliability. 
Intertester reliability was slightly higher than intratester 
reliability, a finding attributed to the fact that the time 
interval between testers was only minutes, whereas the 
time interval between the first and the second trials by 
one tester was 2 days. See Table 11-9 for more detailed 
information about this study and other studies in this 
section. 

Youdas and associates 16 determined the intratester 
reliability of cervical ROM measurements during 
repeated testing on six healthy subjects. The testers 
followed a written protocol and were given a 30-minute 
training session using the CROM device prior to 
testing. Intertester reliability was determined based on 
measurements of 20 healthy volunteers (11 females and 
9 males) between 22 and 50 years of age. Each subject's 
active ROM in six cervical motions was measured 
independently by three testers within moments of each 
other. 

Nilsson 34 found that intratester reliability for passive 
ROM with use of the CROM device was moderately reli- 
able, but intertester reliability was less than acceptable. 
In a follow-up study, Nilsson, Christensen, and 
Hartvigsen 35 found that both intratester and intertester 
reliability was unacceptable if motions were started in 
the neutral position. Measurement of total ROM 
(combining the motions of flexion and extension by 
measuring from a position of full flexion to a position of 
full extension) improved intratester reliability to an 
acceptable level. Rheault and colleagues 36 found small 
mean differences ranging from 0.5 degrees to 3.6 degrees 
between two testers who measured extension with the 
CROM device. See Table 11-9. 

CROM Device, 3-D-Space System and 
Radiographs 

Ordway and associates 38 compared measurements of 20 
volunteers' combined flexion-extension taken with a 
CROM device with those taken with the 3-D-Space 
System (an internally referenced computed tracking 



system with 6 degrees of freedom) and with radiographic 
measurements. The authors determined that flexion- 
extension could be measured reliably by all three meth- 
ods but that there was no measurement consistency 
between the methods. However, the CROM device's 
advantages over the 3-D Space System were lower cost 
and ease of use. 

Tousignant, 39 using radiographs to determine crite- 
rion validity of the CROM device, found that the meas- 
urements of flexion and extension in 31 healthy 
participants aged 18 to 25 years were highly correlated. 
One drawback of this study was the fact that the neutral 
position was not defined. 

CA-6000 Spine Motion Analyzer 

The CA-6000 Spine Motion Analyzer, which consists of 
6 potentiometers linked by a series of hinged rods, is a 
very expensive piece of equipment used primarily for 
research purposes. Christensen and Nilsson - " 1 found 
good intratester and intertester reliability for measure- 
ments of active cervical ROM in 40 individuals tested by 
2 examiners. Intratester reliability was also good for 
passive ROM, but intertester reliability was good only 
for passive ROM of combined motions. Lantz, Chen, 
and Buch 8 determined the validity of the CA-6000 Spine 
Motion Analyzer concurrent with the dual inclinometer 
by demonstrating almost identical mean values for flex- 
ion/extension and lateral flexion. Full-cycle ROM had 
less variability than ROM measured from neutral and 
axial rotation, and lateral flexion measurements had 
greater reliability than flexion-extension measurements. 
Intertester and intratester reliability was high for total 
active motion, and reliability values were consistently- 
higher for active motion than for passive motion. 
Solinger, Chen, and Lantz,~ <; in a study of cervical ROM 
in 20 healthy men and women volunteers aged 20 to 40 
years, also found that reliability values were consistently 
lower for measurements beginning in the neutral posi- 
tion compared with those taken at full-cycle ROM. The 
range of intertester and intratester reliability values 
(ICCs) for full-cycle motions of left and right rotation 
and left and right lateral flexion were 0,93 to 0.97 
compared with the single motions starting in the neutral 
position whose range was 0.83 to 0.95. Flexion from the 
neutral position was the least reliable measurement, even 
when taken by a single examiner. 

Pendulum Goniometer 

Defibaugh -5 ' used a pendulum goniometer with an 
attached mouthpiece to measure cervical motion. The 30 
male subjects in this study ranged in age from 20 to 40 
years. The author found coefficients of 0.90 to 0.71 for 

intratester reliability and coefficients of correlations of 
0.94 to 0.66 for intertester reliability. Unlike the major- 
ity of other researchers, the author found that intertester 
reliability was higher than intratester reliability for some 






- 



306 



PART IV TESTING OF THE SPINE AND TfMPORO M A N I B U L A R ] O I N T 



motions. However, 1 to 7 days elapsed between the first 
and the second measurements taken by the same tester, 
whereas only 2 hours elapsed between one tester's meas- 
urements and those taken by another tester. The higher 
intertester reliability was attributed to the short lapse of 
time between measurements. 

Herrmann 42 took radiographic measurements of 
passive ROM of neck flexion-extension in 16 individuals 
aged 2 to 68 years. The radiographic measurements were 
compared with those obtained by means of a pendulum 
goniometer, ICCs of 0.98 indicated a good agreement 
between the two methods. 

Gravity Goniometer and Tape Measure 

Balogun and coworkers, 1 " 5 in a study that employed three 
testers and 21 healthy subjects, compared the reliability 
of measurements obtained with a Myrin Gravity- 
Reference Goniometer (Inclinometer) (OB Rehab AB, 
Soina, Sweden) with measurements taken by a tape meas- 
ure. Intratester reliability coefficients for both the incli- 
nometer and the tape measure were moderately high for 
all motions except flexion. Intertester reliability was 
slightly higher for the tape measure method than for the 
Myrin goniometric method. However, intertester reliabil- 
ity of flexion measurements was poor for both methods. 
See Table 11-2 for additional information. 

In a reliability study of the tape measure method, by 
Hsieh and Yeung, 12 an experienced tester (tester 1) and 
an inexperienced tester (tester 2) measured active cervical 
motion. Tester 1 measured 17 subjects and tester 2 meas- 
ured a different group of 17 subjects. Intratester reliabil- 
ity coefficients (Pearson's r) ranged from 0.80 to 0.95 for 
tester 1 and 0.78 to 0.91 for tester 2. See Table 11-2 for 
measurement error. 

Visual Estimation 

The reliability of visual estimates has been studied by 
Viikari-Juntura 43 in a neurological patient population 
and by Youdas, Carey, and Garrett 11 in an orthopedic 
patient population. In the study by Viikari-Juntura, 43 the 
subjects were 52 male and female neurological patients 
ranging in age from 13 to 66 years, who had been 
referred for cervical myelography. Intertester reliability 
between two testers of visual estimates of cervical ROM 
was determined by the authors to be fair. The weighted 



kappa reliability coefficient tor intratester agreeincnt in 
can-nones of norma! limited, or markedly limited ROM 
ranged from 0.50 to 0.5f>. 

hi the study by Youdas, Carey, and Garrett, M rhe 
subjects were 60 orthopedic patients ranging in age from 
2] to S4 years. Intertester reliability for visual estimates 
ot both active flexion and extension was poor (ICC = 
0.42). Intertester reliability for visual estimates of active 
neck lateral flexion ROM was fair. 'The ICC for left 
lateral flexion was 0.6.3; for right lateral flexion it was 
0.70. I he intertester reliability for visual estimates of 
rotation was poor for left rotation (ICC = 0.69) and 
good for rie,ht rotation (ICC : 0.S2). 

Flexible Ruler 

Rbeault and colleagues'" fotmd that intertester reliability 
with a flexible ruler was good (r :; 0.S0) tor obtaining 
measurements ot the neutral cervical spine position and 
high (r :: 0.90) tor obtaining measurements of cervical 
spine fiexion,. Measurements were taken on 20 healthy 
subjects ( 14 women and 6 men). 

Summary 

bach ot the techniques for measuring cervical ROM 
discussed in this chapter has certain advantages and 
disadvantages, flic universal goniometer, tape measure, 
and flexible ruler are the least inexpensive and easiest to 
obtain, transport, and tise. Reliability tends to be morion 
specific, and, generally, intratester reliability is better 
than intertester reliability. Therefore, if these methods are 
used to determine a patient's progress, measurements 
should be taken by a single therapist. 

In consideration of the cost and availability of the vari- 
ous instruments for measuring cervical ROM, and 
because ot the fact that the intratester reliability of the 
universal goniometer and tape measure appears compa- 
rable with that of measurements taken with other instru- 
ments, we decided to retain the universal goniometer and 
tape measure methods in this edition, but we added the 
double inclinometer and the GROM device, If the tape 
measure is hem;.; used to compare ROM among subjects, 
calculation of POD should help to eliminate the effects of 
different body sizes on measurements. '" 



CHAPTER 11 THE CERVICAL SPINE 307 



Range of Motion Testing Procedures: Cervical Spine 

tsgrtment 




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FIGURE 11-7 Surface anatomy landmarks for 
goniometer alignment and tape measure alignment for 
measuring cervical motions. 






Base of 
nares 




Auditory 
meatus 



FIGURE 11-8 Bony anatomical landmarks for 
goniometer alignment for measuring cervical 
flexion and extension. 












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308 



PARI IV T E S 1 ! N C f f H f. SPINE AN "I f M f J O R O M AND! B U L A R | O I N I 




HGURaV, 1 1 -9 Surface anatomy landmarks 
used to measure cervical motion with a rape 
measure: tip of the chin, sternal notch, and 
acromion process. The mastoid process, 
which is used to measure lateral flexion, is 
included in Figure 1 1-8. 



Tip of nose 



Acromion 
process 




i 



HCiL'lU-. 11-10 Bony anatomical land- 
marks for measuring cervical spine 
range or motion with a tape measure. 



CHAPTER 11 



THE CERVICAL SPINE 



309 




FIGURE ll-.lt A posterior view of the subject's head and 
cervical spine shows the surface anatomy landmarks used 
for measuring lateral flexion with a goniometer and flexion., 
and extension with dual inclinometers. 



Occipital 

bor&'iM 




Acromion 
process 



FIGURE 11-12 Bony anatomical landmarks used to align 

ne r ,>- -• s cervical range of 

■ motion-de vice','. Ail -of' 1 these- .instrumen t,s use ; the ■ spinous ■' 

a as a landmark for 
the measuremdntof at least one cervical motion.' '■■ . 



Spine of scapula 



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310 



PART IV TESTING OF THE SPINE AND TEMPOROMANDIBULAR |OIN! 



FLEXION 



p Motion occurs in the sagittal plane around a medial- 

| lateral axis. The mean cervical flexion ROM measured 

I with a universal goniometer is 40 degrees (SD = 12) 

I degrees." See Table 11-1. 

1 

| Testing Position 

I Place the subject in the sitting position, with the thoracic 
| and lumbar spine well supported by the back of a chair. 
| Position the cervical spine in degrees of rotation and 

lateral flexion. A tongue depressor can be held between 

the teeth for reference. 

Stabilization 

I Stabilize the shoulder girdle either by a strap or by the 
| examiner's arm to prevent flexion of the thoracic and 
lumbar spine. 



Testing Motion 

I'm mil.' hand on the hack ot the subject's head and, wich 
the other hand, hold the subject's chin. Push gently but 
firmly cm the hack of the subject's head ro move the- head 
anteriorly. Pull the subject's chin in toward the chest to 
move the subject through flexion ROM (Fig. I 1-13), The 
end of the ROM occurs when resistance to further 
motion is felt and further attempts at flexion cause 
forward flexion of the trunk. 

Normal End-feel 

file normal cud-feel is firm owing to stretching of the 
posterior ligaments (supraspinous, inlraspinous, ligamen- 
tuni flavtim, and ligametitum tuichaei, posterior fibers of 
the annulus fibrosus in the intervertebral disks, and the 
zygapopbyseal joint capsules; and because of impaction 
ot the submandibular tissues against the throat and 
passive tension in the following muscles; iliocostals 




FIGURE 1 1-13 The subject ar the end of cervical flexion range 

of motion. 



FIGURE 11-14 In the starting position for measuring cervi- 
cal flexion range of motion, the goniometer reads 90 degrees. 

This reading should he transposed and recorded as degrees. 



'■*■! 



CHAPTER 11 THE CERVICAL SPINE 



311 



, : ?>t 



ccrvicis, iongissimus capitis, Iongissimus cervicis, 
obliquus capitis superior, rectus capitis posterior major, 
rectus capitis posterior minor, semispinaiis capitis, semi- 
spinalis cervicis, splenius cervicis, splenius capitis, 
spinalis capitis, spinalis cervicis, and upper trapezius. 

Goniometer Alignment 

See Figures 11-14 and 11-15. 

1. Center the fulcrum of the goniometer over the 

external auditory meatus. 

2. Align the proximal arm so that it is either perpen- 
dicular or parallel to the ground. 

3. Align the distal arm with the base of the nares. If a 
tongue depressor is used, align the arm of the 
goniometer parallel to the longitudinal axis of the 
tongue depressor. 



Alternative Measurement Method for Flexion: Tape 
Measure 

The mean cervical flexion ROM obtained with a tape 
measure ranges from 1.0 to 4.3 cm 12-13 (see Table 1 1-2). 
Measure the distance between the tip of the chin and the 

lower edge of the sternal notch at the end of the ROM. 
Make sure that the subject's mouth remains closed (Fig. 
11-16}. 



m 




FIGURE 11-15 The goniometer reads 130 degrees at the end 
of the range of motion (ROM), but the ROM should be 
recorded as to 40 degrees because the goniometer reads 90 
degrees in the starting position. The tongue depressor that the 
subject is holding between her teeth may be used as an alterna- 
tive landmark for the alignment of the distal goniometer arm. 







FIGURE 11-16 In the alternative method for measuring cervi- 
cal flexion, the examiner uses a tape measure to determine the 

distance from the tip of the chin to the sternal notch. 



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312 



PART ( V TESTING OF THE SPINE AND TEMPOROMANDIBULAR ! O I N T 



Alternative Measurement Method for Flexion: 
Double Inclinometers 

Both inclinometers must be zeroed after they are posi- 
tioned on the subject and prior to the beginning of the 
measurement. To zero the inclinometer, adjust the rotat- 
ing dial so the bubble or pointer is at on the scale. 

Inclinometer Alignment 

1. Place one inclinometer directly over the spinous 
process of the C-7 vertebra, making sure that the 
inclinometer is adjusted to 0. 

2. Place the second inclinometer firmly on the poste- 
rior aspect of the head, making sure that the incli- 
nometer is adjusted to (Fig. 11-17). 

Testing Motion 

Instruct the subject to bring the head forward into flex- 
ion while keeping the trunk straight, (Fig. 11-18). (Note 
that active ROM is being measured. 



%.;::,. 



At the end ot the motion, read and record the infor- 
mation mi the dials (if each inclinometer. The R< )\! is the 
difference between the readings uf the two instruments. 

Alternative Measurement Method for Flexion: 
CROM Device 

The mean flexion ROM for the CROM device ranges 
from 64 degrees in subjects aged I 1 to IV years to 40 
degrees in subjects aged SO to fi9 years. "' Refer to Tables 

I 1-1 and I 1-3 tor additional information. 

bamiliari/c yourself with the CROM device prior to 
beginning the measurement The CROM device consists 
of a headpiece that supports two gravity inclinometers 
and a compass inclinometer. The gravity inclinometers 
arc used to measure flexion, extension, and lateral flex- 
ion, [he compass goniometer is used to measure rota- 
tion. A neckpiece containing two strong magnets is worn 
to ensure the accuracy ot the compass inclinometer. 



:M 



. ■. 

Am 



■ . 



I 



:, 




| FIGURE 11-17 Inclinometer alignment in the starting position 
for measuring cervical flexion range of motion. 



FIGURF 11-18 Inclinometer alignment at the end of cervical 
flexion range ot motion. 



\:Wi 




I 






CHAPTER 11 TH£ CERVICAL SPiNE 



313 



1 



The CROM device should fir comfortably over the 
bridge of the subject's nose. A Velcro strap chat goes 

around the back of the head can be adjusted to make a 
snug fie One size instrument fits all, and it is relatively 
easy for an examiner to fit the device to a subject 

CROM Device Alignment 4 " 1 

t. Place the CROM device carefully on the subject's 

head so that the nosepicce is on the bridge of the 



nose and the band fits snugly across the back of the 
subject's head (Fig. 1 1-19). 
2. Position the subject's head so that the inclinometer 
on the side of the head reads 0. 

Testing Motion 

Push gently but firmly on the back of the subject's head 
to move it anteriorly and infcriorly through flexion ROM 
(Fig. 1 1-20). At the end of the motion, read rhe dial on 
the inclinometer on the side of the head. 







FIGURE 11-19 The CROM positioned on the subject's head in 
the starting position for measuring cervical flexion range of 
motion. The dial on the gravity inclinometer located on the side 
of the subjects head is at degrees. 




FIGURE 11-20 The examiner is shown stabilizing the trunk 
with one hand and maintaining the end of the flexion range of 
motion with her other hand. 



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314 



PART IV TESTING OF THE SPINE AND TtMPOROMANDI 8 U 1 A R | O I N i 



EXTENSION 



Morion occurs in the sagittal plane around a medial- 
lateral axis. Mean cervical extension ROM measured 
with a universal goniometer is 50 degrees (SD = 14 
degrees). 11 Refer to Table 11-1 for additional informa- 
tion. 

Testing Position 

Place the subject in the sitting position, with the thoracic 
and lumbar spine well supported by the back of a chair. 
Position the cervical spine in degrees of rotation and 
lateral flexion. A tongue depressor can be held between 
the teeth for reference. 

Stabilization 

Stabilize the shoulder girdle to prevent extension of the 
thoracic and lumbar spine. Usually, the stabilization is 
achieved through the cooperation of the patient and 



I 




FIGURE 11-21 The end of the cervical extension range of 
|| motion. The examiner prevents both cervical rotation and 
f I lateral flexion by holding the subject's chin with one hand and 

the back of the subject's head with her other hand. The back of 
i;| the chair (not visible) helps to prevent thoracic and lumbar 

extension. 



support from the back of tin- chair. A strap placed around 
the chest and the back of the chair also may be used. 

Testing Motion 

I'm one hand on the back of the subject's Head and, with 
the other hand, hold the subnet's chin. Push gently but 
firmly upward and. posteriorly on the chin to move the 
head through the ROM in extension (Fig. I 1-2!), The" 
end of the ROM occurs when resistance to further.' 
morion is felt and further attempts at extension cause i 
extension of the trunk. 

Normal End-feel 

The normal end-feel is firm owing to the passive tension - : 
developed by stretching of the (inferior longitudinal iiga- : ■ 
merit, anterior fibers of the annul us tibrosus, /.ygapophy-v; 
seal joint capsules, and the following muscles:! 
sternocleidomastoid, longus capitis, longus colli, rectus:, 
capitis anterior and scalenus anterior. I'.xtrcmcs of extem-i 






M 



FIGURE 11-22 In the starting position for measuring cervi- 
cal extension range ol motion the tromometer reads 9Q degrees. 
This reading should be transposed and recorded as degrees. 




CHAPTER 11 



THE CERVICAL SPINE 



315 



sion rnay be limited by contact between the spinous 
processes. 

Coniometer Alignment 

See Figures 1 1-22 and 1 1-23. 

1. Center the fulcrum of the goniometer over the 
external auditory meatus. 

2. Align the proximal arm so that it is either perpen- 
dicular or parallel to the ground. 

3. Align the distal arm with the base of the nares. If a 
tongue depressor is used, align the arm of the 
goniometer parallel to the longitudinal axis of the 
tongue depressor. 



Alternative Measurement Method for Extension: 
Tape Measure 

The mean cervical extension ROM measured with a tape 
measure ranges from 18.5 to 22.4 cm. 12 ' 13 See Table 
11-2 for additional information. 

A tape measure can be used to measure the distance 
between the tip of the chin and the sternal notch (Fig. 
1 1-24). The distance between the two points of reference 
is recorded in centimeters at the end of the ROM. Be sure 
that the subject's mouth remains closed during the meas- 
urement. 







1. 



FIGURE 1 1-23 At the end of cervical extension, the examiner 
maintains the perpendicular alignment of the proximal 
goniometer arm with one hand. With her other hand, she aligns 

the distal arm with the base of the nares. The tongue depressor 
between the subject's teeth also can be used to align the distal 
arm. 



FIGURE 1 1-24 In the alternative method for measuring cervi- 
cal extension, one end of the tape measure is placed on the tip 
of the subject's chin; the other end is placed at the subject's ster- 
nal notch. 



316 



PART IV TESTING OF THE SPINE AND T E M P O !'. u M •"■ N L ■ : !■; U 1 -, S OIN 



0. 
</V 
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LU 

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LU 

Q 

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O 

a* 



Alternative Measurement Method for Extension: 
Double Inclinometers 

Inclinometer Alignment 

1 . Place one inclinometer directly over the spine of the 
scapula. Adjust the dial of the inclinometer so that 
it reads 0. (If the inclinometer is placed over the 
seventh cervical vertebra it may impact the other 
inclinometer in full extension.) 

2. Place the second inclinometer firmly on the poste- 
rior aspect of the head, making sure that the incli- 
nometer reads (Fig. 11-25). 




FIGURE 1 1-25 Inclinometer alignment in the starting position 
for measuring cervical extension ROM. The examiner has 
zeroed both inclinometers prior to beginning the motion. 



Testing Motion 

insirua the subject to move the head into extension while 

keeping the trunk straight il : ig. 1 l-.2(i). (Note that active 
ROM is hi.-:!!;', measured), At (he nul or the motion, read 
and I'lx'i.ird the information mi the dims of each incli- 
nometer, i he K< >M is the difference between the reading 
ol [he rvvi> instruments. 

Alternative Measurement Method for Extension: 
CROM Device 

I he mean cervical ROM m extension measured with the 
(ROM ranges from .So degrees in males aged II to 19 










;■ '■.":.:. 








FIGURE 1 1-26 Inclinometer alignment ar die end of cervical 
extension r:iii"e ot motion. 




CHAPTER 11 THE CERVICAL SPINE 



years and to 49 degrees in males aged SO to 89 years. 16 
Refer to Tables 11-1, 11-7, and 11-8 for additional 
^information. 

CROM Device Alignment 44 

■- 1. Place rhe CROM device carefully on the subject's 
head so that the nosepiece is on the bridge of the 
nose and the band fits snugly across the back of the 
subject's head (Fig. U-27}. 



317 



2. Position the subject's head so that the gravity incli- 
nometer on the side of the head reads 0. 

Testing Motion 

Guide the subject's head posteriorly and interiorly 
through extension ROM (Fig. 11-28). At the end of the 
motion read the dial on the inclinometer on the side of 
the head. 




FIGURE 11-27 The subject is positioned in the starting posi- 
tion with the CROM device in place. The gravity inclinometer 
located at the side of the subject's head is at prior to begin- 
ning the motion. 




HGURE 11-28 At the end of cervical extension range of 
motion (ROM), the examiner is stabilizing the trunk with one 
hand and maintaining the end of the ROM with her other hand 
on top of the subject's head. Note that this subject's passive- 
ROM in extension is much greater than his active ROM in 
extension as shown in Fig. I 1-26. 



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318 



PART tV TESTING OF THE SPINE AND TEMPOROMANDIBULAR | O I N T 



LATERAL FLEXION 



Motion occurs in the frontal plane around an anterior- 
posterior axis. The mean cervical lateral flexion ROM to 
one side, measured with a universal goniometer, is 22 
degrees (SD = 7 to 8 degrees). Refer to Table 1 1-1 for 
additional information. 

Testing Position 

Place the subject sitting, with the thoracic and lumbar 
spine well supported by the back of a chair. Position the 
cervical spine in degrees of flexion, extension, and rota- 
tion. 

Stabilization 

Stabilize the shoulder girdle to prevent lateral flexion of 
the thoracic and lumbar spine. 

Testing Motion 

Grasp the subject's head at the top and side (opposite to 
the direction of the motion). Pull the head toward the 
shoulder. Do not allow the head to rotate, forward flex, 



or extend during the- motion (Fig. 1 1-29). The end of the 
motion occurs when resistance to motion is felt and 
attempts to produce additional motion cause lateral 
trunk flexion. 

Normal End '- feel 

The normal end-feel is hrm owing to the passive tension 
developed in the intertransverse ligaments, the lateral 
annulus fibrostis fibers, and the following contralateral 
muscles: longus capitis, longus colli, scalenus anterior 
and sternocleidomastoid. 

Goniometer Alignment 

See Figures I 1-30 and 1 1-31. 

1 . Center the fulcrum of the goniometer over the spin- 
ous process of the (17 vertebra. 

2. Align the proximal arm with the spinous processes : 
of the thoracic vertebrae so that the arm is perpen-; 
dicular to the ground. 

3. Align the distal arm with the dorsal midline of the : 
head, rising the occipital protuberance for refer- 
ence. 




FIGURE I 1-29 The end of the cervical lateral flexion 
range of motion. I'lie examiner's hand holds the subject's, 
left shoulder to prevent lateral flexion of the thoracic and 
lumbar spine. The examiners other hand maintains cervi- 
cal lateral flexion by pulling the subject's head laterally. 



CHAPTER 11 



THE CERVICAL SPINE 



319 



iS::: 




FIGURE 11-30 In the starting position for measuring 
cervical lateral flexion range of motion, the proximal 
goniometer arm is perpendicular to the floor. 



FIGURE 11-31 At the end of the lateral flexion range of motion, 
the examiner maintains alignment of the proximal goniometer 
arm with one hand. In practice, the examiner would have one 
hand on the subject's head to maintain lateral flexion; the exam- 
iner is using only one hand so that the goniometer alignment is 
visible. 



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PART IV TESTING OF THE SPINE AND TEMPOROMANDIBULAR JOINT 






i ■ - • ■ ; 



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Bsases 



M': :: ' : 



^Hf 





FIGURE 11-32 in the alternative method for measuring cervical lateral flexion, the subject holds a 
tongue depressor between her teeth (in this photograph the tongue depressor is almost completely hidden 
by the goniometer arm). The proximal arm is perpendicular to the floor. 




FIGURE 11-33 At the end of lateral flexion, the examiner maintains 
arm with one hand while holding the fulcrum of the instrument with 



alignment of the distal goniometer 
icr other hand. 




CHAPTER 11 THE CERVICAL SPINE 



321 



Alternative Goniometer Alignment 

place a tongue depressor between the upper and the 
lower teeth of both sides of the subject's mouth. 

1. Center the fulcrum of the goniometer near one end 
of the tongue depressor {Fig. 11-32). 

2. Align the proximal arm so that it is either perpen- 
dicular or parallel to the ground. 

3. Align the distal arm with the longitudinal axis of 
the tongue depressor (Fig. 11-33), 



Alternative Measurement Method for Lateral 
Flexion: Tape Measure 

The mean cervical lateral flexion ROM measured with a 
tape measure ranges from 10.7 to 12.9 cm. Refer to Table 
1 1-2 for additional information. 

A tape measure can be used to measure the distance 
between the mastoid process and the lateral tip of the 
acromial process (Fig. 11-34). The examiner measures 
the distance between the subject's mastoid process and 
the acromial process, at the end of" the ROM. 



S i 




FIGURE 11-34 The subject is shown at the end of cervical lateral flexion range of motion. 



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PART IV TESTING OF THE SPINE AND Tf M J ■• O R O 



O i ■ 



I Alternative Measurement Method for Lateral 
1 Flexion: Double Inclinometers 

| Inclinometer Alignment 

| 1. Position one inclinometer directly over the spinous 
I process of the seventh cervical vertebra. Adjust the 

rotating dial so that the bubble is at on the scale. 
2. Place the second inclinometer firmly on the top of 

the subject's head and adjust the dial so that it 

reads (Fig. 11-35). 




tearing Motion 

instruct [he subject io mow the head into later;! I flexion 
while keeping the trunk straight (Fig. I i-36'j, (Note that 
active ROM i.s being measured.) The ROM is the differ- 
ence between tiie two instruments. 

Alternative Measurement Method for Lateral 
Flexion: CROM Device 

The mean ROM Literal flexion using the cervical ROM 
device ranges trom a mean ot 45 degrees itt subjects aged 




FIGURE 11-35 In the starting position for measuring cervical 
lateral flexion range of motion, one inclinometer is positioned 
at the level of the spinous process of the seventh cervical verte- 
bra. A piece of tape has been placed at that level to help align 
the inclinometer. The examiner has zeroed both inclinometers 
prior to beginning the motion. 



HGURli 1 i —3 6 Inclinometer alignment at the end of lateral 
flexion range of motion. At the end of the motion, the examiner 
i'e;uls and records the information (in die dials ot each incli- 
nometer, file range of motion is the difference between the 
readttics of die two instruments. 




1 



mm 



CHAPTER 11 THE CERVICAL SPINE 



323 



to 19 years to 23 degrees in subjects aged 80 to 89 
;Vears. t6 See Tables 11-1, 11-7, and 1.1.-0 for additional 
information. 

GROM Device Alignment 44 

1, Place the CROM device on the subject's head so 
;|';: that the nosepiece is on the bridge of the nose and 
the band fits snugly across the back of the subject's 
W< : : head. 



2. Position the subject in the testing position so that 
the gravity inclinometer on the front of the CROM 
device reads degree (Fig. 11-37). 

Testing Motion 

Guide the subject's head lateral. At the end of the motion, 
read the dial located in front of the forehead. 



■II 



: mil 





FIGURE 11-37 The subject is placed in the starting position 
for measuring cervical lateral flexion range of motion so that 
,f|e inclinometer located in front of the subject's forehead is 
.zeroed before starting the motion. 



FIGURE 11-38 At the end of lateral flexion range of motion 
(ROM), the examiner is stabilizing the subject's shoulder with 
one hand and maintaining the end of the ROM with her other 
hand on the subject's head. 



I 324 PART ! V TESTING OF THE SPINE AND TH-IPOilOM A N D i B U LAR J O i N T 



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ROTATION 



Motion occurs in the transverse plane around a vertical 
axis. The mean cervical ROM in rotation with use of a 
universal goniometer is 49 degrees to the left (SD = 9 
degrees) and 51 degrees to the right (SD =11 degrees). 11 
See Table 11-1. Magee ! reports that the range of motion 
in rotation is between 70 and 90 degrees but cautions 
that cervical rotation past 50 degrees may lead to kinking 
of the contralateral vertebral artery. The ipsilatera! artery 
may kink at 45 degrees of rotation. 1 

Testing Position 

Place the subject sitting, with the thoracic and lumbar 
spine well supported by the back of the chair. Position the 
cervical spine in degrees of flexion, extension, and 
lateral flexion. The subject may hold a tongue depressor 
between the front teeth for reference. 

Stabilization 

Stabilize the shoulder girdle to prevent rotation of the 
thoracic and lumbar spine. 

Testing Motion 

Grasp the subject's chin and rotate the head by moving 
the head toward the shoulder as shown in Figure 11-39. 
The end of the ROM occurs when resistance to move- 
ment is felt and further movement causes rotation of the 
trunk. 



Normal End-feet 

Fhti normal end-lccl is linn owing to stretching of the 
alar ligament, the fibers of the /ygapophvscal joint 
capsules, and ilk' following contralateral muscles: longus 
capitis, kjrtgit-S colli, and scalenus anterior. Passive tension 
in the ipsilateral sternocleidomastoid may limit extremes 
of rotation. 

Goniometer Alignment 

See Figures' 1 1-40 and I 1-41. 

1. Center the fulcrum of the goniometer over the 
center of the cranial aspect of the head. 

2. Align the proximal arm parallel to an imaginary 
Sine between the two acromial processes. 

.). Align the distal arm with the tip of the nose, if a 
tongue depressor is used, align the arm of the 
goniometer parallel to the longitudinal axis of the 
tongue depressor. 






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l-i'GURE I 1-39 I he end of the cervical rotation range of 
mutioii. One of the examiner's hands maintains rotation and 
prevents cervical flexion and extension. The examiner's other 
hand is placed on the subject's left shoulder to prevent rotation 
of the thoracic ami lumbar spine. 



CHAPTER 11 THE CERVICAL SPINE 325 




FIGURE 11-40 To align the goniometer ac the starting position for measuring cervical rotation range of 
motion, the examiner stands in back of the subject, who is seated in a low chair. 




FIGURE 11—41 At the end of the range of right cervical rotation, one of the the examiner's hands main- 
tains alignment of the distal goniometer arm with the rip of the street's nose and with the tip of the 
tongue depressor. The examiner's other hand keeps the proximal arm aligned parallel to the imaginary 
line bcrween the acromial processes. 



LU 

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Z:;| 326 PART IV TESTING OF THE SPINE AND TEMPOROMANDIBULAR JOINT 



Alternative Measurement Method for Rotation: 
Tape Measure 

The mean cervical rotation ROM to the left measured 
with a tape measure ranges from 11.0 to 13.2 centime- 
ters 12,13 . Measure the distance between the tip of the chin 
and the acromial process at the end of the motion (Fig. 
11-42). 




wmSi 









tsmm 






FIGURE 11^12 At the end of the right cervical range of motion, the examiner is using a rape measure to 
determine the distance between the tip of the subject's chin and her right acromial process. 



Alternative Measurement Method for Rotation: 
Inclinometer 

Testing Position 

Place the subject supine with the head in neutral rotation, 
lateral flexion, flexion, and extension. 

Inclinometer Alignment 

1. Place the inclinometer in the middle of the subject's 
forehead, and zero the inclinometer (Fig. 11^43). 

2. Hold the inclinometer firmly while the subject's 
head moves through rotation ROM (Fig. 11-44). 

Testing Motion 

Instruct the subject to roll the head into rotation. The 
ROM can be read on the inclinometer at the end of the 
ROM. 




CHAPTER 11 THE CERVICAL SPINE 327 









■;q.' ■■-,.:: 



.::■-;. 



FIGURE 11-43 Inclinometer alignment in the starting position for measuring cervical rotation range of 
motion. Only one inclinometer is used fot this measurement. 




t .... 



FIGURE 11-44 Inclinometer alignment at the end of cervical rotation range of motion (ROM). The 
number of degrees on the dial of the inclinometer equals the ROM in rotation. 



'Si:-' 

..ur 
a 



328 



PART IV TESTING OF THE SPINE AND TEMPOROMANDIBULAR JOINT 



Alternative Measurement Method for Rotation: 
CROM Device 

The mean cervical ROM in rotation with use of the 
CROM varies from IS degrees in subjects aged 11 to 19 
years to 46 degrees in subjects aged 80 years. 16 Refer to 
Tables 11-1 and 11-7 and 11-8 for additional informa- 
tion regarding rotation ROM using the CROM device. 

CROM Device Alignment 44 

1. Place the CROM device on the subject's head so 
that the nosepiece is on the bridge of the nose and 
the band fits snugly across the back of the subject's 




FIGURE 11—45 The compass inclinometer on the top of the 
CROM device has been leveled so that the examiner is able to 
zero it prior to the beginning of the motion. 



head. The arrow on die magnetic yoke should be 

pointing north (Tig. I 1-45). 
2. To ensure that the- compass inclinometer is level 

adjust the position of the subject's head so that 

both gravity inclinometers read (Fig, 1 1-46). 
A After leveling the compass inclinometer, turn the 

rotation meter on the compass inclinometer until 

the pointer is at 0. 

Testing Motion 

Guide the subjects head into rotation and read the incli- 
nometer at the end of the ROM. 




'~^}i^?M 









sssS 

it 

BUI 



n 

it 



■""'"■Si 



FIGURE I 1-46 At the end of right rotation range of motion 
(ROM), the examiner is stabilizing the subject's shoulder with 
one hand and maintaining the end of rotation ROM with the 
other hand. The examiner will read the dial of the inclinometer 
on the fop of the CROM device. Rotation ROM will be the 
number o) degrees on the dial at the end of the ROM. 



CHAPTER 11 THE CERVICAL SPINE 



329 



■ 






REFERENCES 

1. Magee, DJ: Orthopedic Physical Assessment, ed 4. WB Saunders, 
Philadelphia, Elsevier Science USA, 2002. 

2. Goel, VK: Moment-rotation relationships of the ligamentous 
occipito-atlanto-axial complex, j Biomech 8:673, 1988. 

3. Caillie, R: Soft Tissue Pain and Disability,, cd 3. FA Davis, 
Philadelphia, 1991. 

4. Crisco, JJ, Panjabi, MM, and Dvorak, J: A m<)dcl of the alar liga- 
ments of the upper cervical spine in axial rotation. J Biomech 
24:607,1991. 

5. Dumas, JL, et ah Rotation of the cervical spinal column. A 
computed tomography in vivo study. Surg Radiol Anat 15:33, 
1993. 

6. White, AA, and Punjabi, MM: Clinical Biomechanics of the Spine, 
ed 2. JB Lippincoir, Philadelphia, 1990. 

7. Herrling, D, and Kessler, RM: Management of Common 
Musculoskeletal Disorders, cd 3. JB Lippincort, Philadelphia, 
1996 

8. Lanrz, CA, Chen, J, and Buch, D: Clinical validity and stability of 
active and passive Cervical range of motion with regard to total 
and unilateral uniplanar motion. Spine 1 1:1082, 1999. 

9. American Medical Association: Guides to the Evaluation of 
Permanent Impairment, ed 3. AMA, Chicago, 1988. 

10. Capuano-Pucci, D, et at: Intratestcr and intcrtester reliability of 
the cervical range of motion device. Arch Phys Med Rehabil 
72:338, 1991. 

11. Youdas, JW, Carey, JR, and Garrett, TR: Reliability of measure- 
ments of cervical spine range of motion: Comparison of three 
methods. Phys Titer? 1:2, 1991. 

12. Hsieh, C-Y, and Yeung, BW: Active neck motion measurements 
with a tape measure. J Orthop Sports Phys Ther S:8S, 1986. 

■13. Balogun, JA, et ah Inter- and intratester reliability of measuring 
neck motions with tape measure and Myrin gravity-reference 
goniometer. J Orthop Sports Phys Ther jan:248, 1989. 

14. O'Driscoll, SL, and Tonlenson, J: The cervical spine. Clin Rheum 
Dis 8:617, 1982. 

15. Keskc, J, Johnson, G, and Ellingham, C: A reliability srudy of 
cervical range of motion of young and elderly subjects using an 
clccrromagncric range of morion system (EN ROM) (abstract). 
Phys Ther 71 :S94, 1991. 

16. Youdas, JW, et ah Normal range of motion of the cervical spine: 
An initial goniometric study. Phys Ther 72:770, 1992. 

17. Dvorak, j, et al: Age and gender related normal motion of the 
cervical spine. Spine 17:S-393, 1992. 

18. Pearson, ND, and Walmslcy, RP: Trial into the effects of repeated 
neck retractions in normal subjects- Spine 20:1245, 1995. 

19. Nilsson, N, Hartvigscn, J, and Christcnsen, HW: Normal ranges 
of passive cervical morion for women and men 20-60 years old. J 
Manipulative Physiol Ther 19:306, 1996. 

20. Walmsley, RP, Kimber, P, and Culham, E: The effect of initial head 
position on active cervical axial rotation range of motion in two 
age populations. Spine 21:24335, 1996 

21. Trott, PH, et al: Three dimensional analysis of active cervical 
motion: The effect of age and gender. Clin Biomech 1 1:201, 1996. 

22. Pellachia, GL, and Bohannon, RW: Active lateral neck flexion 
range of motion measurements obtained with a modified 
goniometer: Reliability and estimates of normal. J Manipulative 
Physiol Ther 21:443, 1998. 

23. Chen, J, et al: Meta-analysis of normative cervical motion. Spine 
24:1571, 1999. 



24. Fcipcl, V, et al: Normal global motion of the cervical spine: An 
electrogoniometric study. Clin Biomech {Bristol, Avon) 14:462, 
1999. 

25. Castro, WHM: Noninvasive three-dimensional analysis of cervi- 
.^ea1~5pine motion in normal subjects in relation to age and sex. 

Spine 25:445, 2000. 

26. Ordway, NR, et al: Cervical flexion, extension, protrusion and 
retraction. A radiographic tegmenta! analysis. Spine 24:240, 
1999. 

27. Miller, JS, Polissar, NL, and Haas, M: A radiographic comparison 
of neutral cervical posture with cervical flexion and extension 
ranges of motion, j Manipulative Physiol Ther 19:296, 1996. 

28. Christiansen, HW, and Nilsson, N: The ability to reproduce the 
neutral zero position of the head. J Manipulative Physiol Ther 
22:26,1999. 

29. Solinger, AB, Chen, j, and Lantz, CA: Standardized initial head 
position in cervical range-of-motion assessment: Reliability and 
error analysis. J Manipulative Physiol 23:20, 2000. 

30. Chibnall, JT, Duckro, PN, and Baumcr, K. The influence of body 
size on linear measurements used to reflect cervical range of 
motion. Phys Ther 74:1 134, 1994. 

31. Guth, EH: A comparison of cervical rotation in age-matched 
adolescent competitive swimmers and healthy males. J Orthop 
Sports Phys Ther 21:21, 1995. 

32. Tucci, SM, et al: Cervical motion assessment: A new, simple and 
accurate method. Arch Phys Med Rehabil 67:225, 1986. 

33. Garrett, TR, Youdas, JW, and Madson, TJ: Reliability of measur- 
ing the forward head posture in patients (abstract). Phys Ther 
7t:S54, 1991. 

34. Nilsson N: Measuring passive cervical motion: A study of relia- 
bility. J Manipulative Physiol Ther 18:293, 1995 

35. Nilsson N, Christcnsen, HW, and Hartvigsen, j: The intercxam- 
incr reliability of measuring passive cervical range of motion, f 
Manipulative Physiol Ther 19:302, 1996. 

36. Rheault, W, et al: Intertester reliability of the flexible ruler for the 
cervical spine. J Orthop Sports Phys Ther jan:254, 1989. 

37. Olson, SL, et al: Tender point sensitivity, range of motion, and 
perceived disability in subjects with neck pain, j Orthop Sports 
Phys Ther 30:13, 2000. 

38. Ordway, NR, er al: Cervical sagittal range of motion. Analysis 
using three methods: Cervical range-of-motion device. 3. Space 
and radiography. Spine 22:501, 1997. 

iS. Tousignant, MA: Criterion validity of the cervical range of motion 
(CROM) goniometer for cervical flexion and extension. Spine 
25:324, 2000. 

40. Chrisrensen, HW, and Nilsson, N: The reliability of measuring 
active and passive cervical range of motion: An observer blinded 
and randomized repeated measures design.} Manipulative Physiol 
Ther 21:341, 1998. 

41. Defibaugh, JJ: Measurement of head motion. Part II: An experi- 
mental study of head motion in adult males. Phys Ther 44:163, 
1964. 

42. Herrmann, DB: Validity study of head and neck flexion-extension 
motion comparing measurements of a pendulum goniometer and 
roentgenograms, j Orthop Sports Phys Ther 11:414, 1990. 

43. Viikari-Juntura, E: Interexaminer reliability of observations in 
physical examination of the neck. Phys Ther 67:1526, 1987. 

44. CROM Procedure Manual: Procedure for Measuring Neck 
Motion with the CROM. Performance Attainment Assoc., St 
Paul. 



WW?*' 



H AFTER 12 



The Thoracic and 
lumbar Spine 




; 






pS, Structure and Function 
^Thoracic Spine 

iAnatomy 

The 12 vertebrae of the thoracic spine form a curve that 
is convex posteriorly (Fig. 12— 1 A). These vertebrae have 
a number of unique features. Spinous processes slope 
iaferiorly from Tl to TlO and overlap from T5 to TS. 
The spinous processes of Til and T12 take on the hori- 
zontal orientation of the spinous processes in lumbar 
vertebrae. The transverse processes from the Tl to the 
TlO area are large, with thickened ends that support 
paired costal facers for articulation with the ribs. The 
vertebral bodies from T2 to T9 have paired demifacets 
(superior and inferior costovertebral facets} on the 
posterolateral corners. The intervertebral and 
zygapophyseal joints in the thoracic region have essen- 
tially the same structure as described for the cervical 
region, except that the superior articular zygapophyseal 
facets face posteriorly, slightly laterally, and cranially. 
The superior articular facet surfaces are slightly convex, 
whereas the inferior articular facet surfaces are slightly 
concave. The inferior articular facets face anteriorly and 
slightly medially and caudatly. In addition, the joint 
capsules are tighter than those in the cervical region. 

The costovertebral joints are formed by slightly 
yonvex costal superior and inferior demifacets (costover- 
tebral facets) on the head of a rib and corresponding 
demifacets on the vertebral bodies of a superior and an 
inferior vertebra (Fig. 12-1B). From T2 to T8, the 
costovertebral facets articulate with concave demifacets 
located on the inferior body of one vertebra and on the 




superior aspect of the adjacent inferior vertebral body. 
Some of the costovertebral facets also articulate with the 
interposed intervertebral disc, whereas the 1st, 1 1th, and 
12th ribs articulate with only one vertebra. A thin, 
fibrous capsule, which is strengthened by radiate liga- 
ments and the posterior longitudinal ligament, surrounds 
the costovertebral joints. An intra-articular ligament lies 
within the capsule and holds the head of the rib to the 
annulus pulposus. 

The costotransverse joints are the articulations 
between the costal tubercles of the 1st to the 10th ribs 
and the costal facets on the transverse processes of the 
1st to the 10th thoracic vertebrae. The costal tubercles of 
the 1st to the 7th ribs are slightly convex, and the costal 
facets on the corresponding transverse processes are 
slightly concave (see Fig. 12-1B). The articular surfaces 
of the costal and vertebral facets are quite flat from 
about T7 to TlO. The costotransverse joint capsules are 
strengthened by the medial, lateral, and superior costo- 
transverse ligaments. 

Osteokinematics 

The zygapophyseal articular facets lie in the frontal plane 
from Tl to 16 and therefore limit flexion and extension 
in this region. The articular facers in the lower thoracic 
region arc oriented more in the sagittal plane and thus 
permit somewhat more flexion and extension. The ribs 
and costal joints restrict lateral flexion in the upper and 
middle thoracic region, but in the lower thoracic 
segments, lateral flexion and rotation are relatively free 
because these segments are not limited by the ribs. In 
general, the thoracic region is less flexible than the cervi- 



■ -™ 



332 



PART IV TESTING OF THE SPINE AND TEMPOROMANDIBULAR JOINT 



Transverse process 

Spinous process 
Coslal facets 

Zygapcphysea 

joints 



Superior and 

inferior costovertebral 

facets 

Vertebral body 




Costotransverse 
ligament 



Superior articular processes (facets) 



Lateral costotransverse Spin0US pr0C8SS 

ligament 

B 

FIGURE 12-1 (A) A lateral view of the thoracic spine shows 
the costal facets on the enlarged ends of the transverse processes 
from Tl to T10 and the costovertebral facets on the lateral 

edges of the superior and inferior aspects of the vertebral 
bodies. The zygapophyseal joints are shown between the infe- 
rior articular facets of the superior vertebrae and the superior 
articular facets of the adjacent inferior vertebra. (£} A superior 
view of a thoracic vertebra shows the articulations between the 
vertebra and the ribs: the left and right costovertebral joints, the 
costotransverse joints between the costal facets on the left and 
right transverse processes, and the costal tubercles on the corre- 
sponding ribs. 



cal spine because of the limitations on movement 
imposed by the overlapping spinous processes, the tighter 
joint capsules, and the rib cage. 

Arthrokinematics 

In flexion, the body of the superior vertebra tilts anteri- 
orly, translates anteriorly and rotates slightly on the adja- 
cent inferior vertebra. At the zygapophyseal joints, the 
inferior articular facets of the superior vertebra slide 



upwards on the superior articular facets of the adjacent 

interior vertebra, lit extension, the opposite motions 
occur: tlie superior vertebra tilts and translates posteri- 
orly and the inferior articular facets glide downward on 
the superior articular facets of the adjacent inferior verte- 
bra. 

In lateral flexion to the right, the right inferior articu- 
lar facets of the superior vertebra glide downward on the 
right superior articular facets of the inferior vertebra. On 
die contralateral side, the left inferior articular facets of 
the superior vertebra glide upward on the left superior 
articular facets of the adjacent inferior vertebra. 

In axial rotation, the superior vertebra rotates on the 
interior vertebra, and the inferior articular surfaces of the 
superior vertebra impact on the superior articular 
surfaces of the adjacent interior vertebra, for example, in 
rotation to the left, the right inferior articular facet 
impacts on the right superior articular facet of the adja- 
cent inferior vertebra. Rotation and gliding motions 
occur between the ribs and the vertebral bodies at the 
costovertebral joints. A slight amount of rotation is 
possible between the joint surfaces of the ribs and the 
transverse processes at the upper costotransverse joints, 
and more rotation is allowed tn the gliding that occurs at 
the lower joints fT7 to Tl 0). The movements at the costal 
joints are primarily for ventilation of the lungs but also 
allow some flexibility of the thoracic region. 

Capsular Pattern 

I he capsular pattern for the thoracic spine is a greater 

limitation of extension, lateral flexion, and rotation than 

of forward flexion. 



Lumbar Spine 

Anatomy 

The bodies of the five lumbar vertebrae are more massive 

than those in the other regions of the spine. Spinous 
processes are broad and thick and extend horizontally 
[Fig. 12— 2r\). Surfaces of the superior articular facets at 
the zygapophyseal joints are concave and face medially 
and posteriorly. Inferior articular facer surfaces are 
convex and face laterally and anteriorly. The fifth lumbar 
vertebra differs from the other four vertebrae in having a 
wedge-shaped body, with the anterior height greater than 
the posterior height. The inferior articular facers of the 
fifth vertebra are widely spaced for articulation with the 
sacrum. 

joint capsules are strong and ligaments of the region 
are essentially the same as those for the thoracic region, 
except for the addition of the iliolumbar and thora- 
columbar fascia. The supraspinous ligament is well devel- 
oped only in the upper lumbar spine. The interspinous 
ligaments connect one spinous process to another. The 
iliolumbar ligament helps to stabilize the lumbosacral 
joint and prevent anterior displacement. The intertratts- 



i 



llll 



i 



CHAPTER 12 THE THORACIC AND LUMBAR SPINE 



333 



Spinous process 



to-;:--- 

m 




Transverse process 



Sacrum 



Anterior longitudinal 
ligament 



Interspinous 
ligament 

Supraspinous 
ligament 



B 



FIGURE 12-2 (A) A lateral view of the lumbar spine shows the 
broad, thick, horizontally oriented spinous processes and large 
vertebral bodies. (B) A lateral view of the lumbar spine shows 
the anterior longitudinal, supraspinous, and interspinous liga- 
ments. 

verse ligament is well developed in the lumbar area, and 
the anterior longitudinal ligament is strongest in this area 
(see Fig. 12-2B). The posterior longitudinal ligament is 
not well developed in the lumbar area. 

Osteokinematics 

The zygapophyseal articular facets of LI to L4 lie prima- 
rily in the sagittal plane, which favors flexion and exten- 
sion and limits lateral flexion and rotation. Flexion of the 
lumbar spine is more limited than extension. During 



combined flexion and extension, the greatest mobility 
takes place between L4 and L5. The greatest amount of 
flexion takes place at the lumbosacral joint, L5-S1. 
Lateral flexion and rotation are greatest in the upper 
lumbar region, and little or no lateral flexion is present at 
the lumbosacral joint because of the orientation of the 
facets. 

Arthrokinema tics 

According to Bogduk, 1 flexion at the intervertebral joints 
consistently involves a combination of 8 to 13 degrees of 
anterior rotation (tilting), 1 to 3 mm of anterior transla- 
tion (sliding), and some axial rotation. The superior 
vertebral body rotates, tilts, and translates (slides) anteri- 
orly on the adjacent inferior vertebral body. During flex- 
ion at the zygapophyseal joints, the inferior articular 
facets of the superior vertebra slide upward on the supe- 
rior articular facets of the adjacent inferior vertebra. In 
extension, the opposite motions occur: The vertebral 
body of the superior vertebra tilts and slides posteriorly 
on the adjacent inferior vertebra, and the inferior articu- 
lar facets of the superior vertebra slide downward on the 
superior articular facets of the adjacent inferior vertebra. 
In lateral flexion, the superior vertebra tilts and translates 
laterally on the adjacent vertebra below. 

In lateral flexion to the right, the right inferior articu- 
lar facets of the superior vertebra slide downward on the 
right superior facets of the adjacent inferior vertebra. The 
left inferior articular facets of the superior vertebra slide 
upward on the left superior facets of the adjacent inferior 
vertebra. In axial rotation, the superior vertebra rotates 
on the inferior vertebra, and the inferior articular 
surfaces of the superior vertebra impact on the superior 
articular facet surfaces of the adjacent inferior vertebra. 
In rotation to the left, the right inferior articular facet 
impacts on the right superior facet of the adjacent infe- 
rior vertebra. 

Capsular Pattern 

The capsular pattern for the lumbar spine is a marked 
and equal restriction of lateral flexion followed by 
restriction of flexion and extension. 2 



3H Research Findings 

Table 12-1 shows thoracolumbar spine range of motion 
(ROM) values from the American Academy of 
Orthopaedic Surgeons (AAOS) 3 and lumbar spine ROM 

values from the American Medical Association (AMA). 



Effects of Age, Gender, and Other Factors 

Age 

A wide range of instruments and methods have been used 
to determine the range of thoracic, thoracolumbar, and 




334 



PART IV TESTING OF THE SPINE AND TEMPOROMANDIBULAR JOINT 



table 12-1 Thoracic and Lumbar Spine 
Motion: Values in Inches and Degrees from 
Selected Sources 



Motion 



AAOS* 



AMA* 4 



Ffexion 4 60 

Extension 20-30 25 

Right lateral flexion 35 25 

Left lateral flexion 35 25 

Right rotation 45 30 

AAOS = American Association of Orthopaedic Surgeons; AMA = 
American Medical Association. 

•Values represent thoracolumbar motion. Flexion measurement in 
inches was obtained with a tape measure with use of the spinous 
processes of C7 and S1 as reference points. The remaining 
motions were measured with a universal goniometer and are in 
degrees. 

f Lumbosacral motion was measured from midsacrum to T12 with 
use of a two-inclinometer method (values in degrees). 



lumbar motion. Therefore, comparisons between studies 
are difficult. As is true for other regions of the body, 
conflicting evidence exists regarding the effects of age on 
ROM. However, most studies indicate that age-related 
changes in the ROM occur and that these changes may 
affect certain motions more than others at the same joint 
or region. 5-11 

In one of the earlier studies, Loebl used an incli- 
nometer to measure active ROM of the thoracic and 
lumbar spine of 126 males and females berween 15 and 
84 years of age. He found age-related effects for both 
males and females and concluded that both genders 
should expect a loss of about 8 degrees of spinal ROM 
per decade with increases in age. In a more recent study, 
Sullivan, Dickinson and Troup 6 used double inclinome- 
ters to measure sagittal plane lumbar motion in 1126 
healthy male and female subjects. These authors found 
that when gender was controlled, flexion, extension, and 
total ROM decreased with increasing age. The authors 
suggested that the ROM thresholds that determine 
impairment ratings should take age into consideration. 

Different measurement methods were used in each of 
the following three studies to assess the effects of age on 
lumbar sagittal plane ROM. In each instance, the inves- 
tigators found decreases in ROM with increases in age. 
Macrae and Wright, 7 using a modification of the 
Schober technique to measure forward flexion in 195 
women and 147 men (18 to 71 years of age), found that 
active flexion ROM decreased with age. Moll and 
Wright used skin markings and a plumb line to measure 
the range of lumbar extension in a study involving 237 
subjects (119 men and 118 women) aged 20 to 90 years. 
These authors found a wide variation in normal values 
but detected a gradual decrease in lumbar extension in 
subjects between 35 and 90 years of age. Anderson and 



Sweetman" employed a device th.it combined ,l flexible 
rule and a hydrogoniometer to measure the ROM of 432 
working men aged 20 to i9 years. Increasing age was 
associated with a lower iota! lumbar spine ROM (flexion 
and extension}, I'rom a total of 74 men who had less than 
50 degrees combined flexion-extension, >2 were in the 
category of Miyear-old to >9-y*-ar-ok! subjects, 
compared with V in the group ol 20 -year-old to 29-year- 
old subjects. Ol the 162 men who had more than 60 
degrees total ROM, 22 were in the ^0-year-old to 59- 
year-oid group and 6(1 were in the 20 year-old to 29-ycar- 
old category. 

One of the following two studies investigated segmen- 
tal mobility, whereas the other investigated lumbar spine 
morion in all plants. Segmental and motion-specific 
changes were found with increasing age. Gnicovetsky 
and associates'" found a significant difference berween 
young ,\\\d old in a group of 40 subjects aged I 4 ' to 64 
years. Older subjects had decreased segmental mobility in 
the lower lumbar spine compared with younger subjects. 
To compensate for the decrease in mobility, the older 
subjects increased the contribution of the peK is to flexion 
arid extension. McGregor, McCarthy, and Hughes" 
found that although age had a significant effect on all 
planes of motion, the effect varied for each motion, and 
age accounted for only a small portion of the variability 
seen in the 203 normal subjects studied. Maximum 
extension was the most affected motion, with significant 
decreases between each decade. Lateral flexion decreased 
alter age 40 and each decade thereafter, flexion 
decreased initially alter age 30 years but stayed the same 
until an additional decrease alter age 50 years. No simi- 
lar decreases or trends were found in axial rotation. 

The results of a study by I'it/gerald and associates. 
are presented in Table 12-2. The authors investigated 
effects of age on thoracolumbar ROM. A review of the 
values in Table 12-2 shows that the oldest group had 
considerably less motion than the youngest group in all 
motions except for flexion. The coefficients of variation 
indicated that a greater amount of variability existed in 
the ROM in the oldest groups. 

Gender 

Investigations of the effects of gender on lumbar spine 
ROM indicate that they may be morion specific and 
possibly age specific, but controversy still exists about 

which motions are affected, and some authors report that 
gender has no effects. The fact that investigators used 
different instruments and methods makes comparisons 
between studies difficult, for example, the research cited 
in the following paragraph was carried our by means ol 
tape measures, inclinometers, and plumb lines. 

Macrae and Wright found that females had signifi- 
cantly less forward flexion than males across all age 
groups. Sullivan, Dickinson, and Troup" found that when 
age was controlled, mean flexion ROM was greater in 



I 



1 



CHAPTER 12 THE THORACIC AND LUMBAR SPINE 



335 



table 12-2 Effects of Age on Lumbar and Thoracolumbar Spine Motion: Mean Values in Degrees 



K: \ ' ■ : _ r . -^ .: -^ -i 


20-29ynl> ! 


- 30-Z9yn " 
-■- it = 42 




SO-S^yrs 
n = -43 


■ 60^69 -yfi :■'_:■ 
,:■ n= 26 ; 


70-79 yn 

;.. n~9 


Virion " '' 


Mean (SD) 


- Mean (SO) 


Mean (SD) 


Mean (SB) 


Mean (SB) 


Mean (SD) -v. 


Flexion* 

Extension 

Right lateral flexion 

Left lateral flexion 


3.7 (0.7) 
41.2 (9.6) 

37.6 (5.8) 

38.7 (5.7) 


3.9 (1.0) 
40.0 (8.8) 
35.3 (6.5) 

36,5 (6.0); .;■; 


3.1 (0.8) 
31.1 (8.9) 
27.1 (6.S) 
28.5 (5,2) 


3.0 (1.1) 
27.4 (8.0) 
25.3 (6.2) 
26.8 (6.4) 


2A (0,7) 
17.4 (7.5) 

20.2 (4.8) 

20.3 (5.3) 


2.2 (0.6) 
16.6 (8,8) 
18.0 (4.7) 

':'::. 18.9 (6.0) : 



(SD) = Standard deviation. 

Adapted from Fitzgerald, GK, et al: Objective assessment with establishment of normal values for lumbar spine range of motion. Phys Ther 

63:1 776, 1 983. With the permission of the American Physical Therapy Association. 
* Flexion measurements were obtained with use of the Schober method and are reported in centimeters. All other measurements were 

obtained with use of a universal goniometer and are reported in degrees. Subjects were 172 volunteer patients without current back pain. 



males, but mean extension ROM and total ROM were 
significantly greater in females. Subjects in the study were 
1126 healthy male and female volunteers aged 15 to 65 
years. The authors noted that although female total 
ROM was significantly greater than male total ROM, the 
difference of 1.5 degrees was not clinically relevant. Age 
and gender combined accounted for only 14 percent of 
the variance in flexion, 25 percent in extension and 20 
percent of the variance in total ROM. Measurements of 
lumbar spine motion were taken with an inclinometer. 
Flexion was measured in the sitting position and exten- 
sion in the prone position (Table 12-3). Moll and 
Wright's 8 findings regarding lumbar spine extension are 
directly opposite to the findings of Sullivan, Dickinson, 
and Troup 6 in that Moll and Wright 8 determined that 
male mobility in extension significantly exceeded female 
mobility by 7 percent. Differences in findings between 
studies may have resulted from the fact that Moll and 
Wright did not control for age. These authors used skin 
markings and a plumb line to measure the range of 
lumbar extension in a study involving 237 subjects (119 
males and 118 females) aged 15 to 90 years, who were 
clinically and radiologically normal relatives of patients 
with psoriatic arthritis (Tables 12-4 and 12-5). 

In contrast to the preceding authors, the following two 



studies reported no significant effects for gender on 
lumbar spine ROM. Loebl 5 found no significant gender 
differences between the 126 males and females aged 15 to 
84 years of age for measurements of lumbar flexion and 
extension. Bookstein and associates 15 used a tape meas- 
ure to measure the lumbar extension ROM in 75 elemen- 
tary school children aged 6 to 11 years. The authors 
found no differences for age or gender, but they found a 
significant difference for age-gender interaction in the 6- 
year-old group. Girls aged 6 years had a mean range of 
extension of 4.1 cm in contrast to the 6-year-old boys, 
who had a mean range of extension of 2.1 cm. 

Occupation and Lifestyle 

Researchers have investigated the following factors 
among others in relation to their effects on lumbar ROM: 
occupation, lifestyle, 11,14 " 16 time of day, 17 and disabil- 
ity, 6, 18 ~ 22 Similar to the findings related to age and 
gender, the results have been controversial. 

Sughara and colleagues, 14 using a device called a spin- 
ometer, studied age-related and occupation-related 
changes in thoracolumbar active ROM in 1071 men and 
1243 women aged 20 to 60 years. The subjects were 
selected from three occupational groups: fishermen, 
farmers, and industrial workers. Although both flexion 



TABLE 12-3 

Degrees * 



Effects of Age and Gender on Lumbar Motion in Individuals 15-65 years: Mean Values in 



Mate 

"024'ya- 



femak 
}£-24yn 



?S#&|e; . 
2^34 yrs 
:n=29$: 



yti 



Mate:. 
is-6s~0: 

n =269i 



femate; '. 
3S~6Syh 

. n = t3S: 



Motion 



:Mean{SD) 



-^eqtt(SD) 



Mem (SO) 



Mem(Sij) 



Mean (SD) 



: Mean(SDJ : . 



flexion 
Extension 



33 (9) 
54 (10) 



26(9) 
63(9) 



3H8) 

52 (9) 



24 (8) 
60(10) 



27(8) 
47(9) 



22(8) 
53 (9) 



(SD) = Standard deviation. 

Adapted from Sullivan, MS, Dickinson, CE, and Troup, (DC: The influence of age and gender on lumbar spine sagittal plane range of motion: 

A study of 1126 healthy subjects. Spine 19:682, 1994. 
* ROM values obtained with a fluid filled inclinometer. 



336 



PART IV TESTING OF THE SPINE AND TEMPOROMANDIBULAR JOINT 



table 12-4 Effects of Age and Gender on Lumbar and Thoracolumbar Motion in Individuals Age 
15-44 years: Mean Values in Centimeters 



;■:,:■ ^:- -r^M:-.^ ^--v^y; Mag; 



"ftfflafe: 



Male 



Female 



Male 



15-24 yn 
n = 21 n = 10 



25-34ycs 

s«= J 3 %- n=;U 



35-44 yrs 
n= 14 . n= is 



rfotfon" ; 



m 



Wmm. < : 



Mean' (i -'• " Mean (SD) 



"Mean (SD) 



"Mean : . (SB) 



Mean (SB) 



Flexion* 
Extension* 
Right lateral flexion* 
Left lateral flexion 1 ' 



7.23 (0.92) 

4.21 (1.64) 

5.43 (1.30) 

5.06 (1.40) 



6.66 (1.03) 

4.34 (1.52) 

6.85 (1.46) 

7.20 (1.66) 



7.48 (0.82) 

5.05 (1 .-11) 

5.34 (1.06) 

5.93 (1.07) 



6.69 (1.09) 
476 (1.53) 
6.32 (1.93) 
6.13 (1.42) 



6.88 (0.88) 

3.73 (1.47) 

4.83 (1.34) 

4.83 (0.99) 



6.29 (1.04) 

3.09 (1.31) 

5.30 (1.61) 
5.48 (1.30). 



Adapted from Moll, |MH, and Wright, V: Normal range of spinal mobility: An objective clinical study. Ann Rheum Dis 30:381, 1971. The 

authors used skin markings and a plumb line on the thorax for lateral flexion. 
(SD) = Standard deviation. 
•Lumbar motion 
*Thoracolumbar motion 



and extension were found to decrease with increasing 
age, decreases in the extension ROM were greater than 
decreases in flexion. Decreases in active extension ROM 
were less in the group of fishermen and their wives than 
in the farmers and industrial worker groups and their 
wives. The authors concluded that because the fisher- 
men's wives, like the fishermen, had more extension than 
other groups, variables other than the physical demands 
of fishing were affecting the maintenance of extension 
ROM in the fisherman group. 

Sjolie' 6 compared low-back strength and low-back 
and hip mobility between a group of 38 adolescents 
living in a community without access to pedestrian roads 
and a group of 50 adolescents with excellent access to 
pedestrian roads. Low-back mobility was measured by 
means of the modified Schober technique. The results 
showed that adolescents living in rural areas without easy 
access to pedestrian roads had less low-back extension 
and hamstring flexibility than their counterparts in urban 
areas. The hypothesis that negative associations would 



twist between school bus use and physical performance 
was confirmed. Tht distance traveled by the school bus 
was inversely associated with hamstring flexibility and 
other hip motions bur not with low-back flexion. 
Walking or bicycling to leisure activities was positively 
associated with low-hack strength, low-back extension 
ROM and hip flexion and extension. 

f'reidrich and colleagues s conducted a comprehensive 
examination of spinal posture tluring stooped walking in 
22 male sewer workers aged 24 to 49 years. Working in 
a stooped posture lias been identified as one of the risk 
factors associated with spinal disorders, bivc posture 
levels corresponding to standardized sewer heights rang- 
ing from 150 to 105 cm were taped by a video-based 
motion analysis system. The results showed that the 
lumbar spme abruptly changed from the usual lordotic 
position in normal upright walking to a kyphotic posi- 
tion in mild. 1 50-cm headroom restriction. As ceiling 
height decreased, the neck progressively assumed a more 
extended lordotic position, the thoracic spine extended 



table 12-s Effects of Age and Gender on Lumbar and Thoracolumbar Motion in Individuals Aged 
45-74 years: Mean Values in Centimeters 




Mate ■■ 



Female 



"Male 



Wemale-- 



1 



. 55-64 yrs 
34 n 



30: 



65-74 yrs 



o= 14 



14 



'• MotMn 



^Mmn fSp} 



jtfean (Sp) 



§fian (SD) 



Mean (SO) 



Mean (SO)-, 



Mean (Sm 



Flexion*.. . 
Extension* 
Right lateral flexion 1. 
Left lateral flexion* 



7,17 (1.20) 

3:88 (1.19) 

4.71 (1,35) 

*55 <0.94) 



6.02 (1.32) 

3-12 (1.36) 

5.37 (1.54) 

5.14 (1.54) 



6.87 (0.89) 

'3,56 (1.28) 

5.05 (1.30) 

4.94 (1.22) 



6.08 (1.32) 
3.57 (1.32) 
5.10 (1.85) 
4.88 (1.61) 



5.67 (1.31) 

3.41 (1.56) 

4.44 (1.03) 

4.38 (0.98) 



4.93 (0-90) 

272 (0.95)S 

5.56 (2.04)/ 

5.55 (2.16); 



Adapted from Moll, JMH, and Wright, V: Normal range of spinal mobility: An objective clinical study. Ann Rheum Dis 30:381, 1971. The 

authors used skin markings and a plumb line on the thorax for lateral flexion. 
(SD) = Standard deviation. 
•Lumbar Motion 
■•Thoracolumbar Motion 



'v^M 





CHAPTER 12 THE THORACIC AND LUMBAR SPINE 



337 






mi 



and flattened, becoming less kyphotic, and the lumbar 
spine became more kyphotic. As expected, the older 
workers showed decreased segmental mobility in the 
lumbar spine and an increase in cervical lordosis with 
decreasing ceiling height. 

Disability 

Sullivan, Dickinson, and Troup 6 used dual inclinometers 
to measure lumbar spine sagittal motion in 1126 healthy 
individuals. The authors found a large variation in meas- 
urements and suggested that detection of ROM impair- 
ments might be difficult because 95 percent confidence 
intervals yielded up to a 36-degree spread in normal 
ROM values. Sullivan, Shoaf, and Riddle ls examined the 
relationship between impairment of active lumbar flexion 
ROM and disability. The authors used normative data to 
determine when an impairment in flexion ROM was 
present, and used the judgement of physical therapists to 
determine whether flexion ROM impairment was rele- 
vant to the patient's disability. Low correlations between 
■lumbar ROM and disability were found, and the authors 
; concluded that active lumbar ROM measurements 
should not be used as treatment goals. 

Lundberg and Gerdle 1 '' investigated spinal and periph- 
eral joint mobility and spinal posture in 607 female 
employees (mean age = 40.5 years) working at least 50 
percent part time as homecare personnel. Lumbar sagit- 
tal hypomobiiity atone was associated with higher 
disability, and a combination of positive pain provoca- 
tion tests and lumbar sagittal hypomobiiity was associ- 
ated with particularly high disability levels. Peripheral 
joint mobility, spinal sagittal posture, and thoracic sagit- 
tal mobility showed low correlations with disability. 

Kujala and coworkers 20 conducted a 3-year longitudi- 
nal study of lumbar mobility and occurrence of low-back 
pain in 98 adolescents. The subjects included 33 nonath- 
letes (16 males and 17 females), 34 male athletes, and 31 
female athletes. Participation in sports and low maxima! 
lumbar flexion predicted low-back pain during the 
follow-up in males but accounted for only 16 percent of 
the variance between groups with and without low-back 
pain. A decreased ROM in the lower lumbar segments, 
low maximal ROM in extension and high body weight 
were predictive of low-back pain in females and 
accounted for 31 percent of the variability between 
groups. 

Natrass and associates -1 used a long-arm goniometer 
and dual inclinometers to measure low-back ROM in 34 
patients with chronic low-back pain. ROM for all 
subjects was compared with their ratings on commonly 
used impairment and disability indexes. The investigators 
found no relationship between the ROM measurements 
and the impairment ratings as determined by the tests. 
The authors concluded that the instruments and methods 
of measurement had poor validity. 

Shirley and colleagues 22 compared lumbar ROM 



values obtained with three different instruments in 44 
patients with chronic low-back pain whose mean age was 
38 years. Measurements obtained with the SPINETRAK 
(Motion Analysis Corp., Santa Rosa, Cai.) were signifi- 
cantly correlated (r = .62} with ROM determined by 
liquid inclinometers, but only mildly correlated with the 
MedX (lumbar extension testing and exercise machine) 
ROM measurements. T-test results showed that measure- 
ments taken with the SPINETRAK were significantly 
lower than those taken with either the liquid inclinome- 
ter or the MedX. The SPINETRAK measurements also 
were about 12 to 16 degrees lower than the values set by 
the AMA guide for determining disability. 

Functional Range of Motion 

Hsieh and Pringle 23 used a CA-6000 Spinal Motion 

Analyzer (Orthopedic Systems, Inc., Hayward, Cal.) to 
measure the amount of lumbar motion required for 
selected activities of daily living performed by 48 healthy 
subjects with a mean age of 26.5 years. Activities 
included stand to sit, sit to stand, putting on socks, and 
picking up an object from the floor. The individual's peak 
flexion angles for the activities were normalized to the 
subject's own peak flexion angle in erect standing. Stand 
to sit and sit to stand (Fig. 12-3) required approximately 
56 percent to 66 percent of lumbar flexion. The mean 




FIGURE 12-3 Sit to stand requires an average of 35 degrees of . 
lumbar flexion. J3 



338 



PART IV TESTING OF THE SPINE AND TEMPOROMAN I B U LAfi 101 N T 




Inclinometer 

l.<K'hY' has stated that the only reliable technique for 
measuring iumhar spine motion is radiography. However 
radiography is expensive and poses a health risk to the 
subject; moreover, the validity ot radiographic assessment 
of ROM is unreported. Therefore, researchers have used 
many different instruments and mcrhods in a search for 
reliable and valid measures of lumbar spine motion. 
LoebP used an inclinometer to measure flexion and 
extension m nine subjects, lie fotmtl that in five repeated 
active measurements, the ROM varied by 5 degrees in the 
most consistent subject and by - .i degrees m the most 
inconsistent subject. Variability decreased when measure- 
ments were taken on an hourly basis rather than on a 
daily basis. Patch' 14 who used the double-inclinometer 
method to measure lumbar tiexioti on 25 subjects aged 
21 to .17 years, found intratestcr reliability to be high (r 

- 0,9 1} but intertester reliability to be only moderate (r 

- 0,68]. 



FIGURE 12-4 Putting on socks requires an average of 56 
degrees of lumbar flexion. 23 



m ■ 



was 34.6 degrees (SD = 14 degrees) for sit to stand. The 
mean was 41.8 degrees (SD = 14.2 degrees) for stand to 
sit. Putting on socks (Fig. 12-4) required 90 percent of 
lumbar flexion (mean = 56.4 degrees and the SD - 15), 
and picking up an object from the floor (Fig. 12-5) 
required 95 percent of lumbar flexion (mean = 60.4 
degrees). In view of these findings, one can understand 
how limitations in lumbar RChVt may affect an individ- 
ual's ability to independently carry out dressing and other 
activities of daily living. 

Reliability and Validity 

The following section on reliability and validity has been 
divided according to the instruments and methods used 
to obtain the measurements. Some overlap occurs 
between the sections because several investigators have 
compared different methods and instruments within one 
study. 



MM. 








HGURE 12-5 Picking tip an object from the floor requires an 
average of 60 degrees of lumbar flexion. ~' 



CHAPTER 12 THE THORACIC AND LUMBAR SPINE 



339 



The AMA Guides to the Evaluation of Permanent 
Impairment* states that "measurement techniques using 
inclinometers are necessary to obtain reliable spinal 
mobility measurements." However, in a study by 
Williams and coworkers""' that compared the measure- 
ments of the inclinometer with those of the tape measure, 
the authors found that the double-inclinometer technique 
had questionable reliability (Table 12-6). 

Mayer and associates -6 compared repeated measure- 
ments of lumbar ROM of IS healthy subjects taken by 14 
different examiners using three different instruments: a 
fluid-filled inclinometer, the kyphometer, and the electri- 
cal inclinometer. The three instruments were found to be 
equally reliable, but significant differences were found 
between examiners. Poor intertester reliability was the 
most significant source of variance. The authors identi- 
fied sources of error as being caused by differences in 
instrument placement among examiners and inability to 
locate the necessary landmarks. 

Saur and colleagues 27 used Pleurimeter V inclinome- 
ters to measure lumbar ROM in 54 patients with chronic 
low- back pain who were between 18 and 60 years of age. 
: Measurements were taken with and without radiographic 
.verification of the T12 and SI landmarks used for posi- 
tioning the inclinometers. Also, correlation of radi- 



ographic ROM measurements with inclinometer ROM 
measurements demonstrated an almost linear correlation 
for flexion (r — 0.98} and total lumbar flexion/extension 
ROM (r = 0.97, but extension did not correlate as well 

(r = 0.75). Intertester reliability of the inclinometry tech- 
nique for total ROM in a subgroup of 48 patients was 
high ( r= 0.94), and flexion was good (r=0.8S), but 
extension was poor (r = 0.42). The authors concluded 
that the Pleurimeter V was a reliable and valid method 
for measuring lumbar ROM and that with use of this 
instrument it was possible to differentiate lumbar spine 
movements from hip movements. 

In contrast to the findings of Saur and colleagues, 27 a 
number of authors 28-31 have reported poor criterion 
validity and poor intertester and intratestcr reliability 
with use of inclinometers. Samo and coworkers 28 
compared radiographic measurements of lumbar ROM 
in 30 subjects with measurements taken with the follow- 
ing three instruments: a Pleurimeter V (double incli- 
nometer), a carpenter's double inclinometer, and a 
computed single-sensor inclinometer. All ICCs between 
radiographs and for each method were below 0.90 and 
therefore judged by the authors to have poor criterion 
validity. Chen and associates 29 investigated intertester 
and intratester reliability using three health professionals 



table u-6 Intratester and Intertester Reliability for Thoracolumbar and Lumbar ROM 



Subject n 



instrument 



\Moikw$i 



slCC 



Inter ICC intra r inter r 



Fitzgerald 1 



Breum et a! i2 



.Madsonetal 33 



Petersen et al 47 



Williams et al is 



iNitsctike et al 31 



17 



4? 



40 



21 



25 



34 



Healthy 


Tape Measure* 
(Schober) 
Universal 
Goniometer* 


Flexion 

Extension 
R. lat. Flex. 
L. (atJtex. 








Healthy 


BROM II* 


Flexion 


.91 


.77 




(18-38 yrs) 




Extension 


.63 


.35 








R. lat.Ffex, 


.89 


.89 








R. Rotation 


.57 


.35 




Healthy 


BROM* 


Flexion 


.67 






(20-40 yrs) 




Extension 

R. lat. Flex. 
R. Rotation 


.78 
.95 
.93 






Healthy 


OSI- 


Flexion 


■90 


.85 




(10-79 yrs) 


CA 6000 * 


Extension 


.96 


.96 








R. lat Flex. 


.89 


.85 








R, Rotation 


.95 


.90 




Back pain 


Tape Measure 


Flexion 




.72 


.78-.S9 


(25-53 yrs) 


(MMS)* 


Extension 




.76 


.69-.91 




Dual Inclinometers* 


Flexion 




.60 


.13-.87 




. ..■■ 


Extension 




.48 


.28-.66 


Back pain 


Universal 


Flexion 


92 


.84 




(20-65yrs) 


Goniometer ^ 


Extension 


.81 


.63 








R. fat.Flex 


.76 


.62 






Dual 


Flexion 


.90 


,52 






Inclinometers * 


Extension 


.70 


.35 








R. lat Flex. 


.90 


.18 





BROM 11= Back Range of Motion Device; OSI CA 6000 = Spine Motion Analyzer; MMS- Modified Modified Schober 

* Lumbar ROM 

+ Thoracolumbar ROM 



1.0 

.88 

.76 
.91 



■ -1 



340 



PART IV 



TESTING OF THE SPINE AND TEMPOROMANDIBULAR JOINT 



co measure lumbar ROM with the same instruments used 
in the study by Samo and coworkers -8 Intertester relia- 
bility was poor, with all ICCs below 0.75, and with a 
single exception, intratester reliability was below 0.90. 
The authors determined that the largest source of meas- 
urement error was attributable to the examiners and 
associated factors and concluded that these three surface 
methods had only limited clinical usefulness. 

Mayer and colleagues' used a Cybex EDI-320 
(Lumex, Ron Konkoma, NY), a computed inclinometer 
with a single sensor, to measure lumbar ROM in 38 
healthy individuals. Total sagittal ROM was the most 
accurate measurement and extension was the least accu- 
rate. Errors in locating T12 and SI, improper instruction 
of patients, lack of firm placement of the inclinometer, 
device error, and human variability contributed to a lack 
of measurement accuracy. Clinical utility of lumbar sagit- 
tal plane ROM measurement appeared to be highly sensi- 
tive to the training of the test administrator in aspects of 
the process such as locating bony landmarks and main- 
taining inclinometer placement without rocking on the 
sacrum. The authors determined that device error was 
negligible relative to the error associated with the test 
process itself and that practice was the most significant 
factor in eliminating the largest source of error when 
inexperienced examiners were used. 

Nitschke and colleagues - ' 1 compared the following 
measurement methods in a study involving 34 male and 
female subjects with chronic low-back pain and two 
examiners: dual inclinometers for lumbar spine ROM 
(flexion, extension, and lateral flexion) and a plastic long 
arm goniometer for thoracolumbar ROM (flexion, exten- 
sion, lateral flexion, and rotation). 

Intertester reliability was poor for all measurements 
except for flexion taken with the long arm goniometer 
(Table 12-6). The dual inclinometer method had no 
systematic error, but there was a large random error for 
all measurements. The authors concluded that the stan- 
dard error of measurement might be a better indicator of 
reliability than the ICC. 

Back Range of Motion Device 

The back range of motion (BROM) II device 
(Performance Attainment Associates, Roseville, Minn.) 
has been used to measure lumbar spine motion. It is rela- 
tively expensive (see Appendix B), and we are not 
convinced that its measurements are better than less 
expensive measurement methods. Two groups of 
researchers investigating the reliability of the BROM H 
device agreed that the instrument had high reliability for 
measuring lumbar lateral flexion and low reliability for 
measuring extension. However, the two groups differed 
regarding the reliability of the BROM II device for meas- 
uring flexion and rotation. Breum, Wiberg, and Bolton 32 
concluded that the BROM II device could measure flex- 
ion and rotation reliably, whereas Madson, Youdas, and 



Sunian'* determined that rotation but not flexion could 
be reliably measured (see fable l2-(>). Potential sources 
n( error identified by Madson. Youdas, and Suman'' 
included slippage of the device over the sacrum during 
flexion and extension and variations in the identification 
of landmarks from one measurement to another. 

Tape Measure Methods 

Macrae and Wright, rested the validity ol both the orig- 
inal two-mark Schober technique and a three-mark modi- 
fication of the Schober technique (modified Schober). 
I he authors found a linear relationship between meas- 
urements of lumbar flexion obtained by these methods 
and measurements taken radiographically. The correla- 
tion coefficient was 0.90 between the Schober technique 
and radiographs (x-rays) with a standard error of 6.2 
degrees. The correlation coefficient was 0.97 between the 
modified Schober measurement and the radiographic 
measurements, with a standard error of 5,25 degrees. 
Clinical identification of the lumbosacral junction was 
nor easv, and faulty placemen! of skin marks seriously 
impaired the accuracy of the unmodified Schober tech- 
nique. Placement or marks 2 cm loo low led K' an over- 
estimate of 14 degrees. Marks placed 2 cm too high led 
to an underestimate of 15 degrees. In the modified 
Schober technique, the same errors in placement led to 
overestimates and underestimates of 5 and 3 degrees, 
respectively. 

Reynolds" compared intratester and intertester relia- 
bility with use of a spondylometer, a plumb line anil skin 
distraction, and an inclinometer. Subjects were 30 volun- 
teers with a mean age of 38. i years. Intertester error was 
calculated by comparing the results of two testers raking 
10 repeated measurements of lumbar flexion, extension, 
and lateral flexion on 30 volunteers with a mean age of 
38. 1 years. Highly significant positive correlations were 
found between flexion-extension ROM measured with 
the inclinometer and that measured with the spondy- 
lometer. Lumbar flexion measurements correlated well 
with skm distraction and the inclinometer. The incli- 
nometer had acceptable intertester reliability, but the skin 
distraction method had acceptable intertester reliability 
only for extension. The highest intratester reliability was 
found for inclinometer measurement of lateral flexion to 
the right. 

Miller and colleagues compared the following four 
methods for measuring thoracolumbar mobility: the 
fingcrrip- to- floor method, the modified Schober tech- 
nique, the OB Myrin gravity goniometer (I.IC Rehab, 
Sweden), and a skin contraction 10-cm-segment method 
with a tape measure, four testers using all four methods 
measured four subjects (one healthy subject and three 
patients with ankylosing spondylitis). Intertester error 
was nor found to be a significant source of variation. The 
lO-cm-segmcnt method was found to be the most sensi- 
tive in detecting a loss of spinal mobility in the upper and 



i 
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fit 

re 

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Pi- 
ca 

ex 



CHAPTER 12 THE THORACIC AND LUMBAR SPINE 



341 



fertile 10-cm segments. The fingertip-to-floor method 
Was the next sensitive, followed by the 10-cm-segment 
: ftechn><3 ue f° r tne lower 10-cm segment, and the modified 
ISchober technique. The least sensitive was the OB Myrin 
Izoniornetric measurement. The testers rated the fingertip- 
Ifg-floor method as the most convenient, followed by the 

modified Schober technique, the 10-cm-segment method, 
f-jiid the OB Myrin goniometric technique. 

; Porte k and colleagues 36 compared the modified 
f^hpber method and two other clinical methods with 
Svgach other and with radiographs. These authors found 
.little correlation either among the measurements 

obtained by two testers using three clinical techniques to 
gjqeasure lumbar flexion in 1 1 subjects or among the three 
-clinical techniques and radiographs. A Pearson's reliabil- 
ity coefficient of 0.43 was found between the modified 

Schober technique and the radiographic measurement. 
FFhe intertester error for the modified Schober method for 

lumbar flexion showed significant differences between 

testers according to paired t-tests. However, intertester 
lector was calculated between 10 measurements on 10 
Ixjjfferent days, and the authors attributed the error to 
^difficulties in reestablishing a neutral starting position 
Kfnd the mobility of the skin over the landmarks. 
||K, Gill and coworkers 37 compared the reliability of four 
^methods of measurement including fingertip-to-floor 
.distance, the modified Schober technique, the two-incli- 
i'nometer method, and a photometric technique. The 
|;subjects of the study were 10 volunteers (five men and 
:|five women), aged 24 to 34 years. Repeatability of the 
: ; :fingertip-to-floor method was poor (CV = 14.1 percent). 
^Repeatability of the inclinometer for the measurement of 
: : fu!l flexion was also poor (CV = 33.9 percent). However, 
athe modified Schober technique yielded a CV of 0.9 

percent for full flexion and a CV of 2.8 percent for exten- 
sion. 
% i ; - Fitzgerald and associates' 2 used the Schober technique 

to measure forward lumbar flexion and the universal 
igoniometer to measure thoracolumbar lateral flexion and 
^extension, Intertester reliability was calculated from 
^measurements taken by two testers on 1.7 physical ther- 
§gpy student volunteers. Pearson reliability coefficients 

were calculated on paired results of the two testers (see 

Tahle 12-6}. 

: v: Williams and coworkers 2 " 1 measured flexion and 
-.extension on 15 patient volunteers (eight females and 
;:Seven males) with a mean age of 35.7 years who had 
^chronic low-back pain. The authors compared the modi- 
iied-modified Schober technique (MMS), 3S which is also 

referred to as the simplified skin distraction method, 39 

With the double-inclinometer method. Intratestcr Pearson 
correlation coefficients for the MMS were 0.89 for tester 
fjj 0.78 for tester 2, and 0.83 for tester 3, Intertester 
parson correlation coefficients between the three physi- 
cal therapist testers were 0.72 for flexion and 0.77 for 

extension with use of the MMS. The therapists under- 



went training in the use of standardized procedures for 
each method prior to testing. According to the testers, the 
MMS was easier and quicker to use than the double-incli- 
nometer method. The only disadvantage to using the 
MMS method is that norms have not been established for 
all age groups. 

Flexible Ruler 

The flexible ruler has been investigated as a possible 
instrument for measuring lumbar spine ROM as well as 
fixed postures. 41 *"" 44 Measurements taken with the ruler 
must be calculated, and Youdas, Suman, and Garrett'' ! 
determined that two commonly used methods for calcu- 
lating measurements can be used interchangeably. ICCs 
for each motion and calculation method in this study 
were in the good (0.80 to 0.90) to high (0.90 to 0.99) 
range. Lindahl 4a described the flexible ruler as providing 
a "fairly accurate" method of measuring flexion and 
extension compared with the fingertip-to-floor method. 
Lovell, Rothstein, and Personius, 44 in a study involving 
80 subjects, found that the intratestcr reliability for meas- 
uring lumbar lordosis ranged from 0.73 to 0.94. 
However, intertester reliability was poor. Bryan and 
colleagues 43 measured lumbar lordosis in 45 subjects and 
found a poor correlation between measurements taken 
with the flexible ruler and radiographs. Based upon a 
lack of norms and the fact that the flexible ruler has been 
used only for measuring flexion and extension, we 
decided not to include this instrument in the procedures 
section of the book. 

Functional Axial Rotation Device 

Schenkman and coworkers 45 developed a device and a 
measurement technique for quantifying axial rotation of 
the spine. The functional axial rotation (FAR) device 
consists of a 1-m-diameter circular hoop that is 
suspended by tripods at the eye level of a seated subject . 
It is designed to measure functional movements of the 
neck and trunk such as those that occur when one rotates 
the body to look at children in the back seat of a car. 
Axial motion is quantified by the distance that the head 
is moved in relation to the pelvis. In a study of 17 
subjects aged 20 to 74 years, test retest reliability was 
high (ICC greater than 0.90) and intertester reliability 
was also high (ICC = 0.97). In a subsequent study by 
Schenkman and associates 46 involving 15 patients with 
Parkinson's disease, ranging from 64 to 84 years of age, 
the ICC for test retest reliability was 0.89. 

Motion Analysis Systems 

A number of researchers have investigated the reliability 
of motion analysis systems including, among others, the 
CA-6000 Spine Motion Analyzer, "• !2 - 47 the SPINE- 
TRAK, 4S and the FASTRAK (Polhemus, Colchester, 
Vt.). 49 Two research groups found that intratester relia- 
bility for measuring lumbar flexion was very high with 



342 



PART IV TESTING OF THE SPINE AND TEMPOROMANDIBULAR fOiNT 



use of the CA-6000. 11 ' 2 - 5 In one of the studies, both 
intratester and intertester reliability ranged from good to 
high for lumbar forward flexion and extension, but 
intratester and intertester reliability were poor for rota- 
tion. 11 In a study using the SPINETRAK, 48 ICCs were 
0.89 or greater for intratester reliability. ICCs for 
intertester reliability ranged from 0.77 for thoracolumbar 
flexion to 0.95 for thoracolumbopelvic flexion. Steffan 
and colleagues 4 '' 1 used the FASTRAK system to measure 
segmental motion in forward lumbar flexion by tracking 
sensors attached to Kirschner wires that had been 
inserted into the spinous processes of L3 and L4 in 16 



healthy men. Segmental forward flexion showed large 
intersubject variation. 

Summary 

The sampling of studies reviewed in this chapter reflects 
the amount of effort that has been directed toward find- 
ing a reliable and valid method for measuring spinal 
motion. Each method reviewed has advantages and 
disadvantages, and clinicians should first select a method 
that appears to be appropriate for their particular clinical 
situation and then determine its reliability. 




CHAPTER 12 THE THORACIC AND LUMBAR SPINE 



343 



Range of Motion Testing Procedures 

tThe testing procedures that are presented in the next 
Section include the universal goniometer, the tape meas- 
: ure method, the modified Schober technique as described 
: by Macrae and Wright, 7 the MMS technique or simpli- 
■fiecl skin distraction method, and the double-inclinome- 
iter method. The first four methods were selected because 
\ they were inexpensive, were relatively easy to use, and 
had reliability and validity comparable with other meth- 



ods. The inclinometer method has been included in this 
edition because examiners may find these instruments 
being used in the clinical setting. We hope that by the 
time the next edition of this textbook is being prepared, 
more norms will have been published for the simplified 
skin distraction method and that additional evidence 
regarding the reliability and validity of methods of meas- 
uring spinal ROM will be available. 






• • • 





FIGURE 12-6 Surface anatomy landmark's for tape meas- 
ure and inclinometer alignment for measuring the thoracic 

i^cTlumbat spine mptioruThe-dataare. -located: over spinous ; 
processes of C7, Tl, TU, LI, U, and S2 as well as over the . 
■nght iv.d left posterior superior iliac opines (PSLS}, 



!#Mici 

FIGURE 12-7 Bony anatomical landmarks for tape meas- 
VnreVarjiihcfo 

■■-<;„.-... 6 . 



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344 PART IV TESTING OF THE SPINE AND TEMPOROMANDIBULAR |0!NT 



THORACIC AND LUfc B> £ FLEXION 



| Motion occurs in the sagittal plane around a medial- 

I lateral axis. 

I 

| Testing Position 

Place the subject standing, with the cervical, thoracic, 
and lumbar spine in degrees of lateral flexion and rota- 
tion. 

Stabilization 

Stabilize the pelvis to prevent anterior tilting. 

Testing Motion 

Direct the subject to bend forward gradually while keep- 
ing the arms relaxed (Fig. 12-8). The end of the motion 
occurs when resistance to additional flexion is experi- 



enced by the subject and the examiner feels the pelvis 
start to tip anteriorly. 

Normal End-feel 

The normal end-feel is firm owing to the stretching of the 
posterior longitudinal ligament (in the thoracic region) 
the ligamentum flavum, the supraspinous and inter- 
spinous ligaments, and the posterior fibers of the annulus 
pulposus of the intervertebral discs and the zygapophy- 
seal joint capsules. Passive tension in the thoracolumbar 
fascia and the following muscles may contribute to the 
end-feel: spinalis thoracis, semispinalis thoracis, ilio- 
cosralis lumborum and iliocostalis thoracis, interspinals, 
intertransversarii, longissimus thoracis, and multificlus. 
The orientation of the zygapophyseal facets from T 1 to 
T6 restrict flexion in the upper thoracic spine. 




FIGURE 12-8 The subject is shown at the end of combined thoracic and lumbar flexion range of motion. 
The examiner is shown stabilizing the subject's pelvis to prevent anterior pelvic tilting. 



CHAPTER 12 THE THORACIC AND LUMBAR SPINE 



345 



Measurement Method for Thoracic and Lumbar 
flexion: Tape Measure 

Four inches is considered to be an average measurement 
for healthy adults. 3 

1. Use a skin-marking pencil to mark the spinous 
processes of C7 and SI. 

2. Align the tape measure between the two processes 
and note the distance (Fig. 12-9). 

3. Hold the tape measure in place as the subject 
performs flexion ROM, (Allow the tape measure to 
unwind and accommodate the motion,} 

4. Record the distance at the end of the ROM (Fig. 
12-10). The difference between the first and the 
second measurements indicates the amount of 
thoracic and lumbar flexion that is present. 



Alternative Measurement Method for Thoracic and 

Lumbar Flexion: Fingertip-to-Floor 

In this method the subject is asked to bend forward as far 
as possible in an attempt to touch the floor with the 
fingers while keeping knees extended. No stabilization is 
provided by the examiner. 

At the end of flexion ROM, measure the distance 
between the tip of the subject's middle finger and the 
floor. Tiiis test combines spinal flexion and hip flexion, 
making it impossible to isolate and measure either 
morion. Therefore, this test is not recommended for 
measuring thoracic and lumbar flexion, but it can be used 
to assess general body flexibility. 50 " 52 



m 




FIGURE 12-9 Tape measure alignment in the starring position 
for measuring thoracic and lumbar flexion range of morion. 



I 



FIGURE 12-10 Tape measure alignment at the end of thoracic 
and lumbar flexion range of motion. The metal tape measure 
case (not visible in the photo) is in the examiner's right hand. 




346 



PART 



TESTING OF THE SPINE AND TEMPOROMANDIBULAR (OINT 



Alternative Measurement Method for Thoracic and 

Lumbar Flexion: Double inclinometer 



1. 



■=■ i 2 



Use a skin-marking pencil to mark the midline of 
the midsacrum and the spinous process of the 
seventh cervical vertebra with the subject in the 
upright starting position. 

Position one inclinometer over the midsacrum. 
Position the other inclinometer over the spinous 



process of the seventh cervical vertebra, and zero 
both instruments prior to beginning the motion 

(Fig. 12-11). 
3. At the end of the motion, read and note the infor- 
mation on both inclinometers (Fig. 12-12). The 
difference between the two inclinometers indicates 
the amount of thoracic and lumbar flexion ROM. 



■'".;■; , 



§U 




'"? 






m& 



m : >A 



FIGURE 12-11 The starting position for measuring thoracic and lumbar flexion with both inclinometers 
aligned and zeroed. 



CHAPTER 12 THE THORACIC AND LUMBAR SPINE 



347 






JM 



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SHI 








FIGURE 12-12 Inclinometer alignment at the end of thoracic and lumbar flexion range of motion. 



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348 



PART IV TESTING OF THE SPINE AND TEMPOROMANDIBULAR JOINT 



LUMBAR FLEXION 



| Testing Position 

§ Place the subject standing, with the cervical, thoracic, 
1 and lumbar spine in degrees of lateral flexion and rora- 
I tion. 

I 

; Stabilization 

I 

I Stabilize the pelvis to prevent anterior tilting 

I Testing Motion 

f Ask the subject to bend forward as far as possible while 

| keeping the knees straight. 

Normal End-feel 

I The end feel is firm owing to stretching of the ligamen- 
I turn flavuni, posterior fibers of the annulus fibrosus and 
| zygapophyseal joint capsules, thoracolumbar fascia, 
* iliolumbar ligaments and the multifidus, quadratus 
lumborum, iliocostalis lumborum, and longissimus 
thoracis muscles. The location of the following muscles 



■-; 




FIGURE12-13 A line is drawn between the two posterior 
superior iliac spines and the point at which the lower end of the 
tape measure should be positioned. The location of the 15cm 
mark shows that all five of the lumbar vertebrae in this subject 

arc included. 



suggests that they may limit flexion, but the actual 
actions of the interspinales and the intertransversarii 

medialcs and latcralcs are unknown. 1 

Measurement Method for Lumbar Flexion: 
Modified-Modified Scbober Test 25,38 or Simplified 
Skin Distraction Method 39 

In the original Schoher method, the examiner made onlv 
two marks on the subject's back. The first mark was 

made at the lumbosacral junction and the second 10 cm 
above the first mark on the spine. Macrae and Wright 7 
decided to modify the Schober method because they 

believed skin movement was a problem in the original 
method and that the skin was more firmly attached in the 




:-:>-- '' 



SM 



-m * 




FIGURE 12-14 The tape measure is aligned between the upper 
and the lower landmarks .it the beginning of lumbar flexion 
range of motion. Paper tape was placed over the skin marking 
pencil dots (o improve visibility of landmarks for the photo- 
graph. 









CHAPTER 12 THE THORACIC AND LUMBAR SPSNE 



349 



region below the lumbosacral junction. However, begin- 
ning the measurement 5 cm below the lumbosacral junc- 
tion places the most superior mark at L2 or L3; therefore, 
the measurement in Macrae and Wright's 7 modified 
method does not include the entire lumbar spine. 
^Furthermore, examiners experienced difficulties in accu- 
rately locating the lumbosacral junction. Macrae and 
Wright's method is presented in this text as an alternative 
measurement method following the Modified-Modified 
>Schober Test (MMST)- 38 or the simplified skin distraction 
.method, 39 which is presented in the next paragraph. 
5v: The MMST uses two marks, one over the spine on a 
line connecting the two posterior-superior iliac spines 
(PSIS) and the other over the spine 15 cm superior to the 
"first mark. This technique was proposed by van 
: Adrichem and van der Korsr 38 to eliminate errors in iden- 
tification of the lumbosacral junction and to make sure 
that the entire lumbar spine was included. 
;: Van Adrichem and van der Korst, 38 using the MMST, 
found a mean of 6.7 cm (SD = 1.0 cm) in male subjects 



between 15 and 18 years of age and a mean of 5.8 cm 
(SD = 0.9 cm) in female subjects in the same age group. 

Tape measure alignment: MMST 

1. Use a skin-marking pencil to mark the subject's two 
posterior superior iliac spines. Use a ruler to locate 
and mark a midline point on the sacrum that is on 
a level with the iliac spines. Make a mark on the 
lumbar spine that is 15 cm above the midline sacra! 
mark (Fig. 12-13). 

2. Align the tape measure between the superior and 
the inferior marks. (Fig. 12—14) Ask the subject to 
bend forward as far as possible while keeping the 
knees straight. 

3. Maintain the tape measure against the subject's 
back during the movement but the allow the tape 
measure to unwind to accomodate the motion. At 
the end of the flexion ROM, note the distance 
between the two marks (Fig. 12-15), The ROM is 
the difference between 15 cm and the length meas- 
ured at the end of the motion. 



Sfe 








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■-■■-- . . .* /.-' - « ■■ 
:■•■•'■• J ■ ■;■ : -,'■••'■ 




FIGURE 12-15 The tape measure is stretched between the upper and the lower landmarks at 
lumbar flexion range of motion. 



■ ■■.■■ 

the end of 



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350 



PART IV TESTING OF THE SPINE AND TEMPOROMANDIBULAR JOINT 



Alternative Measurement Method for Lumbar 
Flexion: Modified Schober Technique 7 

Macrae and Wright found an average of 6.3 cm 7 of flex- 
ion in healthy adults, and Battie and coworkers 53 found 
an average of 6.9 cm in a similar group of subjects. 

1. Use a skin-marking pencil to place a mark at the 
lumbosacral junction. Place a second mark 10 
centimeters above the first (measure to the nearest 
millimeter). Place a third mark 5 centimeters below 
the first (lumbosacral junction). 



Align the tape measure between the most superior 
and the most inferior marks. Ask the subject to 
bend forward as far as possible while keeping the 
knees straight. 

Maintain the tape measure against the subject's 
back during the movement and note the distance 
between the most superior and the most inferior 
marks at the end of the ROM. The ROM is the 
difference between IS cm and the length measured 
at the end of the motion. 




FIGURE 12-16 The starting position for measurement of lumbar flexion range of motion, with incli- 
nometers aligned and zeroed. 




CHAPTER 12 THE THORACIC AND LUMBAR SPINE 



351 



Alternative Measurement Method for Lumbar 
flexion: Double inclinometer 

The ROM in flexion is 60 degrees according to the 
AMA 4 and to 66 degrees (for males 15 to 30 years of 
a ge) according to Loebl/ 

1. Use a skin-marking pencil to place a mark in the 
midline of the midsacrum and a second mark over 
the spinous process of T12. 

2. Place one inclinometer over the spinous process of 
T12 and the other over the midsacrum. (Fig. 
12-16). 



Zero both inclinometers, and ask the subject to 
bend forward as far as possible while keeping the 
knees straight. 

Note the information on the inclinometers at the 
end of the flexion ROM (Fig. 12-17). Calculate 
lumbar flexion ROM by subtracting the degrees 
from the dial of the sacra! inclinometer from those 
on the dial on the T12 inclinometer. The degrees on 
the sacral inclinometer are supposed to represent 
hip flexion ROM. 19 





/ 






FIGURE 12-17 The end of lumbar flexion range of motion, with inclinometers aligned over the spinous 
processes of T12 and SI. 




"Ji 



352 PART fV TESTING OF THE SPINE AND TEMPOROMANDIBULAR JOINT 



a. s 
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— * 1 

C 1 

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THORACIC AND LUMBAR EXTENSION 



Motion occurs in the sagittal plane around a medial- 
lateral axis. 

Testing Position 

Place the subject standing, with the cervical, thoracic, 
and lumbar spine in degrees of lateral flexion and rota- 
tion. 

Stabilization 

Stabilize the pelvis to prevent posterior tilting. 



Testing Motion 

Ask the subject to extend the spine as far as possible (t-ig, 
12-18). The end of the extension ROM occurs when the 
pelvis begins to tilt posteriorly. 

Normal End-feel 

The end feel is firm owing to stretching of the zygapophy- 
seal joint capsules, anterior fibers of the annulus fibrosus, 
anterior longitudinal ligament, rectus abdominis, and 
external and internal oblique abdominals. The end-feel 
also may be hard owing to contact by the spinous 
processes and the zygapophyseaf facets. 




FIGURE 12-18 At the end of thoracic and lumbar extension range of motion, the examiner uses one 
hand on the subject's anterior pelvis and her other hand on the posterior pelvis to prevent posterior pelvic 
tilting. If the subject has balance problems or muscle weakness in the lower extremities, the measurement 
can be taken in either the prone or side-lying position. 




CHAPTER 12 THE THORACIC AND LUMBAR SPINE 



353 



Measurement Method for Thoracic and Lumbar 

Extension: Tape Measure 

1. Use a skin-marking pencil to mark the spinous 
. j;: processes of C7 and SI. 

2. Align the tape measure between the two marks and 
record the measurement (Fig. 12-19). 



Keep the tape measure aligned during the motion 

and record the measurement at the end of the 
ROM (Fig. 12-20). The difference between the 
measurement taken at the beginning of the motion 
and that taken at the end indicates the amount of 
thoracic and lumbar extension that is present. 





FIGURE 12-19 Tape measure alignment in the starting posi- 
tion for measurement of thoracic and lumbar extension range 
of motion. When the subject moves into extension, rhe tape 
slides into the tape measure case in the examiner's hand. 



FIGURE 12-20 At the end of thoracic and lumbar extension 
range of motion, the distance between the two landmarks is less 
than it was in the starting position. 



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354 



PART [V TESTING OF THE SPINE AND TEMPOROMANDIBULAR JOINT 



LUMBAR EXTENSION 



Testing Position 

Place the subject standing, with the cervical, thoracic, 
and iumbar spine in degrees of lateral flexion and rota- 
tion. 

Stabilization 

Stabilize the pelvis to prevent posterior tilting. 

Testing Motion 

Ask the subject to extend the spine as far as possible. The 
end of the extension ROM occurs when the pelvis begins 
to tilt posteriorly. 



Normal End-feel 

The end feel is firm owing to stretching of the anterior 
longitudinal ligament, anterior fibers of the annulus 
fibrosus, zygapophyseal joint capsules, rectus abdominis 
and external and internal oblique muscles. The end-feel 
may also be hard owing to contact between the spinous 
processes. 

Measurement Method for Lumbar Extension: 
Modified Modified-Schober or Simplified Skin 
Distraction 

1. Use a skin-marking pencil to place marks on the 
right and left posterior superior iliac spines. Use a 



o. 

u_ 
■ O 

■<■ 

EC 




FIGURE 12-21 Tape measure alignment in the starting position for measurement of lumbar extension 
range of morion with use of rhe simplified skin distraction method (modified-modified Schober method). 



CHAPTER 12 THE THORACIC AND LUMBAR S P t hJ E 



355 



3 



I 



ruler to locate and mark a midline point on the 
sacrum that is on a level with the posterior superior 
iliac spines. Make a mark on the lumbar spine that 
is 15 cm above the mark on the sacrum. 

2. Align the tape measure between the superior and 
the inferior marks on the spine, (Fig, 12-21), and 
ask the subject to bend backward as far as possible. 

3. At the end of the ROM, note the distance between 
the superior and the inferior marks (Fig. 12-22). 
The ROM is the difference between 15 cm and the 
length measured at the end of the motion. 

Alternative Measurement Method for Lumbar 
Extension: Modified Schober Technique 

Battie and coworkers 5 found a mean of 1.6 cm in 100 

healthy adults. 



Use a skin-marking pencil to place a mark at the 
lumbosacral junction. Place a second mark 10 cm 
above the first mark (measure to the nearest 
millimeter). Place a third mark 5 cm below the first 
mark (lumbosacral junction). 
Align the tape measure between the most superior 
and the most inferior marks. Ask the subject to put 
the hands on the buttocks and to bend backward as 
far as possible. 

Note the distance between the most superior and 
the most inferior marks at the end of the ROM and 
subtract the final measurement from the initial 15 
cm. The ROM is the difference between 15 cm and 
the length measured at the end of the motion 



-j 



i : 



Eg 



■ S 



. 






- 
j. 



m 

1 







r 





1 



FIGURE. 12-22 Tape measure alignment at the end of lumbar extension range of motion, with use of the 
simplified skin distraction method. 



i 






356 PART !V TESTING OF THE SPINE AND TEMPOROMANDIBULAR JOINT 



THORACIC AND LUMBAR LATERAL 
FLEXION ; y- .----. 



ROM ranges from 18 to 38 degrees with use of a 
goniometer 12 and from 5 to 7 cm with use of a tape meas- 



ure.' 



Testing Position 

Place the subject standing, with the cervical, thoracic, 
and lumbar spine in degrees of flexion, extension, and 
rotation. 



Stabilization 

Stabilize the pelvis to prevent lateral tilting. 

Testing Motion 

Ask the subject to bend the trunk to one side while keep- 
ing the arms in a relaxed position at the sides of the body. 
Keep botii feet flat on the floor with the knees extended 
(Fig. 12-23). The end of the motion occurs when the heel 
begins to rise on the foot opposite to the side of the 
motion and the pelvis begins to tilt laterally. 




FIGURE 12-23 The end of thoracic and lumbar lateral flexion range of motion. The examiner places 
both hands on the subject's pelvis to prevent lateral pelvic tilting. 



CHAPTER 12 THE THORACIC AND LUMBAR SPiNE 



357 



1 






T' : 



formal End-feet 

The end-feel is firm owing to the stretching of the 
contralateral fibers of the annulus fibrosus, zygapophy- 
seal joint capsules, intertransverse ligaments, thora- 
columbar fascia, and the following muscles: external and 
oblique abdominals, longissimus thoracis, iliocostalis 
lurrtborum and thoracis lumborum, quadratus lumbo- 
rum, multifidus, spinalis thoracis, and serratus posterior 
inferior. The end-feel may also be hard owing to impact 
of the ipsilateral zygapophyseal facets (right facets when 
bending to the right) and the restrictions imposed by the 
ribs and costal joints in the upper thoracic spine. 

Measurement Method for Thoracic and Lumbar 
Lateral Flexion: Universal Goniometer 

Fitzgerald and associates 12 found that lateral flexion 
measured with a goniometer ranged from a mean of 37.6 




FIGURE 12-24 The subject is shown with the goniometer 

aligned in the starting position for measurement of thoracic and 
lumbar lateral flexion. 




degrees (in a group 20 to 29 years old) to 18.0 degrees 
(in a group 70 to 79 years old). See Table 12-2 for addi- 
tional information. 12 According to Sahrmann/ 5 more 
than three-quarters of thoracic and lumbar lateral flexion 
ROM takes place in the thoracic spine. 

1. Use a skin-marking pencil to mark the spinous 
processes of C7 and SI. 

2. Center the fulcrum of the goniometer over the 
posterior aspect of the spinous process of SI. 

3. Align the proximal arm so that it is perpendicular 
to the ground. 

4. Align the distal arm with the posterior aspect of the 
spinous process of C7 (Figs. 12-24 and 12-2.5). 




FIGURE 12-25 At the end of thoracic and lumbar lateral flex- 
ion, the examiner keeps the distal goniometer arm aligned with 
the subject's seventh cervical vertebra. The examiner makes no 
attempt to align the distal arm with the subject's vertebral 
column. As can be seen in the photograph, the lower thoracic 
and upper lumbar spisie become convex to the left during right 
lateral flexion. 



U-l 

Z 

=_ 
</> 

OS ■_ 
CO . 

s.i 



358 



PART IV TESTING OF THE SPINE AND TEMl'OBO M A \ \) i R u S. A R j i \ 



Alternative Measurement of Thoracic and Lumbar 
Lateral Flexion: Fingertip-to-Floor Method 

1. Place the subject in the erect standing position, 
with the arms hanging freely at the sides of the 
body. Ask the subject to bend to the side as far as 
possible while keeping both feet flat on the ground 
and the knees extended. 

2. At the end of the ROM, make a mark on the leg 
level with the tip of the middle finger. Use a tape 
measure to measure the distance between the mark 
on the leg and that on the floor (Fig. 12-26). One 
problem with this method is that it may be affected 
by the subject's body proportions. Therefore, it 
should be used only to compare repeated measure- 
ments for a single subject and not for comparing 
one subject with another subject. 

a variation of the fingertip-to-floor method, 



z ; : 
| 

en 

O 
X 

H 

(/> 

tu 

Off./ 

LU 

§ 

o- 

O s 

Z 1 designed to account for differences in body size, Meliin 
H I 

UJ 

I- 

Z 

O 

.Si 

o 

O 

z 
< 

0C 



In 



suggests that a mark should he mack- on the thigh, whe 
the up ot tlu- ilurd linger rests in the starting position A 
second mark should he made on the leg ar the noim 
where the (ip of the third finger rests at tlu- end of th e 
lateral flexion KOM. The distance between the two 
marks is tht; thoracolumbar ROM. In a study involving 
\ l > healthy subjects, .Vlelltii ft hi si d thai the mean ROM 
in lateral flexion using tins technique was 22 cm (SD = 
5.4 cm). 





FIGURE 12-26 At the end ol thoracic and lumbar lateral flex- 
ion range ot motion, the examiner is using a tape measure to 
determine the distance Ironi the tip ol the subject's third finger 
to the floor. Lateral pelvic lilting should be avoided. 



■ 

- 






lit! 



; ^ 




CHAPTER 12 THE THORACIC AND LUMBAR SPINE 



359 



Alternative Measurement Method for Thoracic and 

Lumbar Lateral Flexion: Double Inclinometer 

According to the AMA, the ROM is 25 degrees to each 
side of the body. 4 

1. Use a skin-marking pencil to identify locations on 
the spinous processes of SI and Tl. 

2. Place one inclinometer over the SI spinous process 
and the other over that of Tl and then zero both 
inclinometers (Fig. 12—27). 



Ask the subject to bend to the side as far as possi- 
ble while keeping both knees straight and both feet 

firmly on the ground (Fig. 12-28). 
At the end of the ROM, note the information on 
the dials of both inclinometers. Calculate lateral 
flexion ROM by subtracting the reading on the 
sacral inclinometer from that on the dial of the 
thoracic inclinometer. Repeat the entire measure- 
ment process to measure lateral flexion on the 
other side. 



I 










FIGURE 12-27 The subject is in the starting position for meas- 
urement of thoracic and lumbar lateral flexion with both incli- 
nometers aligned and zeroed. 



FIGURE 12-28 Inclinometer alignment at the end of thoracic 

and lumbar lateral flexion range of motion. 



■ 



LU 

z 

a. 
t« 

< 

Q 

:Z 
< 

u 
< 

O 

X 

(/5 

jj 
ds 
D 
Q 

UJ 

U 

O 

OS 

O 

UJ 

z 
g 

p! 

o 

u. 

o 

UJ 

o 

z 

<■■■ 



360 



PART iV TESTING OF THE SPINE AND TEMPOROMANDIBULAR JOINT 



THORACIC AND LUMBAR ROTATION 



Motion occurs in the transverse plane around a vertical 

axis. 

Testing Position 

Place the subject sitting, with the feet on the floor to help 
stabilize the pelvis. A seat without a back support is 
preferred so that rotation of the spine can occur freely. 
The cervical, thoracic, and lumbar spine are in degrees 
of flexion, extension, and lateral flexion. 

Stabilization 

Stabilize the pelvis to prevent rotation. Avoid flexion, 
extension, and lateral flexion of the spine. 

Testing Motion 

Ask the subject to turn his body to one side as far as 
possible keeping his trunk erect and feet flat on the floor 
(Fig. 12-29). The end of the motion occurs when the 
examiner feels the pelvis start to rotate. 

Normal End- feel 

The end-feel is firm owing to stretching of the fibers of 
the contralateral annulus fibrosus and zygapophysea! 
joint capsules; costotransverse and costovertebral joint 



capsules; supraspinous, intcrspmotis. And iliolumbar liga- 
ments and the following muscles: rectus abdominis 
external and internal obliques and multilidus. and semi- 
^pm.iiis thoracis .inj rotatores. I he end-feel may also be 
hard owing to contact between the /.ygapopbyseal facets. 

Measurement Method for Thoracic and Lumbar 
Rotation: Universal Goniometer 

See Figures 12-3(1 and 12-31. 

1. Center the fulcrum ot the goniometer over the 
center of the cranial aspect ol the subject's head. 

2. Align the proximal arm parallel to an imaginary 
line between the two prominent tubercles on the 
iliac crests. 

3. Align the distal arm with an imaginary line 
between the two acromial processes. 




FIGURE 



iij <>t tlic thoracic 



and lumbar rotation range ul morion. The sub|eci is seated on 
a tow stoul without a hack rest so that spinal movement can 

occur without interference. The ex.immcr positions her hands 
On the subject's iliac crests to prevent pelvic rotation. 






CHAPTER 12 THE THORACIC AND LUMBAR SPINE 



361 



illiliife- 










as 






FIGURE 12-30 In the starting position for measurement of rotation range of motion, the examiner 

stands behind the seated subject. Tile examiner positions the fulcrum of the goniometer on the superior 
aspect of the subject's head. One of the examiner's hands is holding both arms of the goniometer aligned 
with the subject's acromion processes. The subject should be positioned so that the acromion processes 
are aligned directly over the iliac tubercles. 






liijl 

I I 
ill . 



i ' 



I 




FIGURE 12-31 At the end of rotation, one of the examiner's hands keeps the proximal goniometer arm 

aligned with the subject's iliac tubercles while keeping the distal goniometer arm aligned with the subject's 
right acromion process. 



LU 

z 



362 



PART IV TESTING OF THE SPINE AND TEMPOROMANDIBULAR JOINT 



S/5 

< 

3 



Alternative Measurement Method for Thoracic and 

Lumbar Rotation: Double Inclinometer 

According to the AMA, 4 rotation ROM measured with 
use of inclinometers is 30 degrees to each side. 

1. Use a skin-marking pencil to place a mark over the 
spinous processes of SI and the seventh cervical 
vertebra. 

2. Place the subject in a forward-flexed standing posi- 
tion so that the subject's back is parallel to the 
ground. 



3. Place one inclinometer at SI and the other over the 

spinous process of the seventh cervical vertebra and 
zero both inclinometers (Fig. 12-32}, 

4. Ask the subject to rotate the trunk as far as possi- 
ble without moving into extension. (Fig. 12-33). 

Note the degrees shown on the inclinometers at the 
end of the motion. The difference between the incli- 
nometer readings is the rotation ROM. 



ly 



■- . _**- '■■ .■. .-■.■.-. - H -. ...... ..•■.,-, ■...■-■ 







y °.' : W 



^ 



**&* 







1 





FIGURE 12-32 The subject is in the starting position for measurement of thoracic and lumbar rotation, 
with inclinometers aligned and zeroed. 






I 

I 



CHAPTER 12 THE THORACIC AND LUMBAR SPINE 363 



■ 



1 I 




< ■.■ :;,; 



■ V.^^^^-l^ . 



w 

! 








':"." 



FIGURE 12-33 The subject is shown with the inclinometers aligned at the end of thoracic and lumbar 
rotation range of motion. 



364 



PART IV TESTING OF THE SPINE AND TEMPOROMAMDIBUI AS JOINT 



REFERENCES 29. 

Bogduk, N: Clinical Anatomy of rhe Lumbar Spine and Sacrum, 
ed 3. Churchill Livingstone, New York, 1997. 30 

Cyriax, JH, and Cyriax, I': Illustrated Manual of Orthopaedic 
Medicine. ISutterworrhs, London, 1983. 31, 

American Academy of Orthopaedic Surgeons: joint Motion: 
Method of Measuring and Recording, AAOS, Chicago, 196.5. 
American Medical Association: Guides to the Evaluation of 
Permanent Impairment, ed 3, AMA, Chicago, 1988. 37. 

Loebl, WY: Measurement of spinal posture and range of spinal 
movement. Ann Phys Med 9:103, 1967. 

Sullivan, MS, Dickinson, CE, and Troup, JDG: The influence of 33 
age and gender on lumbar spine range of motion. A study of 1 i 26 
healthy subjects. Spine 19:682, 1994. 

Macrae, IF, and Wright, V: Measurement of back movement. Ann 34 
Rheum Dis 28:584, 1969. 

Moll, JMH, and Wright, V: Normal range of spinal mobility: An 35 
objective clinical study. Ann Rheum Dis 30:381, 1971. 
Anderson, JAD, and Sweetman, BJ: A combined flexi-rule hydro- 
goniometer for measurement of lumbar spine and its sagittal 3^ 

movement. Rheumatol Rchabil 14:173, 1975, 
Gracovetsky, S, et at: A database for estimating normal spinal 
motion derived from non-invasive measurements. Spine 20:1036, 37 

199%" 

McGregor, A II, McCarthy, D and Hughes SP: Motion character- 3$ 
isrics of the lumbar spine in the norma! population. Spine 
20:2421, 1995. 

Fitzgerald, OK, et al: Objective assessment with establishment of 39, 
normal values for lumbar spine range of motion. Phys Ther 
63:1776, 1983, 

Bookstcin, NA, et al: Lumbar extension range of motion in 49 
elementary school children. Abstr Phys Ther 72:S35, 1992. 
Sughara, M, et al: Epidemiological study on the change of mobil- 4 ] _ 
ity of the thoracolumbar spine and body height with age as 
indites for senility. J Hum Ergo! (Tokyo) 10:49, 1981. 
Freidrich, M, et al: Spinal posture during stooped walking under 42. 
vertical space constraints. Spine 25:1 1 18, 2000. 
Sjolie, AN: Access to pedestrian roads, daily activities and physi- 
cal performance of adolescents. Spine 25:1965, 2000. 43 
Ensink, FB, et a I: Lumbar range of morion. Influence of time of 
day and individuals factors on measurements. Spine 21:1339, 
19%. 44 _ 
Sullivan, MS, Sboaf, l.D, and Riddle, DL: The relationship of 
lumbar flexion to disability in patients with low back pain. Phys 
Ther 80:240, 2000. 45 
Lundberg, G, and Gerdle, B: Correlations between joint and 
spinal mobility, spinal sagittal configuration, segmental mobility, 4^ 
segmental pain symptoms and disabilities in female hoirtecarc 
personnel. Scand j Rehab Med 32:124, 2000. 

Kujala UM, er al: Lumbar mobility and low back pain during 47 
adolescence. A longitudinal three-year follow-up study in athletes 
and controls. Am J Sports Med 25:363, 1 997. 
Nattrass, CL, et al: Lumbar spine range of motion as a measure 
of physical and functional impairment: An investigation of valid- 43 
ity (abstract!. Clin Rchabil 13:211, 1999. 

Shirley, FR, et al: Comparison of lumbar range of motion using 
three measurement devices in patients with chronic low back 49 
pain. Spine 19:779, 1994. 

Hsich, CY, and Pringle, RK: Range of motion of the lumbar spine 
required for four activities of daily living. J Manipulative Physiol jq 
Ther 17:353, 1994. 

Patel, RS: Intratester and intertester reliability of the inclinometer ci_ 

in measuring lumbar flexion. Phys Ther 72:S44, 1992. 
Williams, R, et a!: Reliability of the modified-modified Schobcr c>. 

and double inclinometer methods for measuring lumbar flexion 
and extension. Phys Ther 73:26, 1993. 53 

Mayer, RS, et al: Variance in the measurement of sagittal lumbar 
range of motion among examiners, subjects, and instruments. 54 

Spine 20:1489, 1995. 

Saur, PMM, et al: Lumbar range of motion: Reliability and valid- ^^ 

ity of the inclinometer technique in the clinical measurement of 
trunk flexibility. Spine 2 !: 1 332, 1996. 

Samo, DG, et a!: Validity of three lumbar sagittal motion meas- 
urement methods: Surface inclinometers compared with radi- 
ographs, j Occup Environ Med 39:209, 1997. 



1. 

2. 
3. 

4. 
5. 

6. 

7. 
8. 
9. 

10, 

II. 

12. 

13. 

14, 

15. 
16. 
17. 



19. 



20. 



21. 



23. 

24. 
25. 

26. 

27. 

28. 



(.hen. SI', el a I: Reliability nl rhe 1 urn bar sagittal runt run measure- 
ment method-.; Surface Inclinometers, j (Jcchtj Environ Med 
'.9:2 I ". 1997. 

Mayer, TG, et al: Spina) range ni motion. Accuracy and sources 
ii) error with mclmomctrie measurement. Spine 22:1976, 1997. 
Nnschkje, JK. el al: Reliability o! the American Medical 
Association (nudes' Model lor Measuring Spina! Range of 
Motion. Its implication tor whole person impairment ratings. 
Spine 24:262, 199'*. 

Breiim, j, Wiherg, J, and Bolton, JH: Reliability and concurrent 
validity ol the BRUM II tor measuring lumbar mobilitv. J 
Manipulative Physiol (her 18:497. IWS. 

Madsun, I J, Yuudas, JVC-', and Simian, VJ: Reproducibility of 
lumbar spine range of motion measurements using the back range 
of morion device. J Ortlmp Sports I'liys Ther 29:470, 1999, 
Reynolds, I'MCi; Measurement ol spinal mobility: A comparison 
of three methods. Rheumatol Rchabil 14:180, 1975. 
Miller, MM, et al: Measurement ol spinal mobility 111 the sagittal 
plane: New skin distraction technique Compared with established 
methods.] Rheumatol I 1:4, 1984. 

S'oriek, 1, et al: Correlation between radiographic and clinical 
measurement ol lumbar spine niovemeiil. P>r | Rheumatol 22:197, 
198 !. 

OIL, k.etal: Repeatability ol four clinical methods lor assessment 
nl lumbar spina! motion. Spine I3;sif, l*-JS8. 

Van Adrichem, JAM, and van tier korst, |K: Assessment ot the 
(legibility ot the lumbar spine. A pilot stud; 1 in children and 
adolescents. Scam! J Rheumatol 2:S 7 , 1 97,!. 
Greene. \V"B. and Hcckmaii. ID (edsi: The Clinical Measurement 
til Joint Motion. American Academy oi ( 'rtiiopaedic Surgeons. 
Kosetnont. Hi. 1994. 

I ittdahl, O: Determination i>t the sagittal mobility ol the lumbar 
spine. Acta Onhup Scand 37:241, !%(i. 

Voudas, |\V, Sum. 111, V'J and Garrett, IK: Reliability <>: measure- 
ments of lumbar spine sagittal mobility obtained w tilt the flexible 
curve. J Orthop Sports Phys Ther 21.-1 >. 1V*>5. 
Kat/man, VC H, (..utter, KA, and Ash. HA: Difference* in reliability 
of the flexible ruler lor rhe experienced and novice tester. Abstract 
Feb. 2000. J Orthop Spoils Phys Titer 50-.A9. 20tlU, 
Bryan. |M, el al: Investigation ot the llc-xible ruler as .1 noninva- 
sive measure of lumbar lordosis 111 black and white adult female 
sample populations. | Orthop Sports Phys Ther II:!. I''H9, 
l.ovcll. IW, Rot hstcin, JM, and I'ersonnis. \Y|: Reliability ot clin- 
ical measurements ol lumbar lordosis taken with a flexible rufe. 
1'hys Ther 69 ; 9(,, I9K9. 

Seheukm.in, M, et al: A clinical too) lor measuring limctiona) 
axial rotation. Phys Ther 75:151, I99.S. 

Schetikuiaii, M, et al: Spinal movement and performance of a 
standing reach task in participants with and without Parkinson 
disease. Phys I her SI: 1400, 2001, 

Petersen, CM, et al: Iniraohservcr and imcrohserver reliability of 
asymptomatic subject's thoracolumbar range ot morion using the 
OS 1 CA 6000 Spine Morion Anabvcr, | Onliop Sports Phys ther 
220:207, 19S7. 

Robinson, MR, et al: Inirastlbiect reliability oi spinal range of 
motion and velocity determined In video motion analysis. Phys 
Titer 73:626, 199.1,' 

Stctf.in, T, et al: A new technique for measuring lumbar segmen- 
tal motion in vivo; method, accuracy and preliminary results. 
Spine 22:l5li, I 1 ' 1 '". 

Kraus. 1 1, and I lirschlatid, RP: Minimum muscular fitness tests in 
school children. Res (J Exert Sport 25:I 7 H, 19$+. 
Nicholas, JA: Risk factors, sports medicine and the orth.ipedic 
system: An overview, j Sports Med 3:243, I 97s. 
Brodie, DA, Bird, ilA. ami Wright, V: |oinr laxity in selected 
athletic populations. Med Sci Sports Exert I4:i9». |9S2. 
Battle, MC. et al: The role of spinal flexibility in back pain 
complaints 111 industry. A prospective suidy. Spine I5i7it>8, [990. 
Melliu, GP: Accuracy of measuring lateral flexion of the spine 
with a tape. Clin Biomcch 1:85. |9H(> 

Sahrm.inn, SA: Diagnosis and Treatment 01 Movement 
Impairment Syndromes. Moshy. St Louis, 2002. 



fffi 



; 



■1 



1 
'■■I 

i 
j 




CHAPTER 13 




The Temporomandibular 
Joint 



'SS, Structure and Function 

Temporomandibular Joint 

Anatomy 

The temporomandibular joint (TMj) is the articula- 
tion between the mandible, the articular disc, and the 
temporal bone of the skull (Fig. 13— 1A). The disc divides 
the joint into two distinct parts, which are referred to 
as the upper and lower joints. The larger upper joint 
consists of the convex articular eminence and concave 
mandibular fossa of the temporal bone and the superior 
surface of the disc. The lower joint consists of the convex 
surface of the mandibular condyle and the concave infe- 
rior surface of the disc. 1-3 The articular disc helps the 
convex mandible conform to the convex articular surface 
of the temporal bone (Fig. 13— IB). 2 

The TMJ capsule is described as being thin and loose 
above the disc but taut below the disc in the lower joint. 
Short capsular fibers surround the joint and extend 
between the mandibular condyle and the articular 
disc and between the disc and the temporal eminence. 3 
Longer capsular fibers extend from the temporal bone to 
the mandible. 

The primary ligaments associated with the TMJ are 
the temporomandibular, the stylomandibular and the 
sphenomandibular ligaments (Fig. 13-2). The muscles 
associated with the TMJ are the medial and lateral ptery- 
goids, temporalis, masseter, digastric, stylohyoid, mylo- 
hyoid and geniohyoid. 

Osteokinematics 

The upper joint is an amphiarthrodial gliding joint. The 
lower joint is a hinge joint. The TMJ as a whole allows 



Maxilla . 





Zy 


gomatic arch 


r 


n^ Articular 


.... j 




\s eminence of 
j/\ temporal bone 


-■■•-' s~~7 






L- Mandibular 


/' / 


^■^r 


jjs^ 


fossa 


■ / 


/S> 


r 


^ Mastoid 




S" 


-J^jl process 

"""""- Mandibular condyloid 
process 
Styloid process 


Mandibular 










Joint capule 

B 

FIGURE 13-1 (A) Lateral view of the skull showing the 
temporomandibular joint (TMJ) and surrounding structures. 
(B) A lateral view of the TMj showing the articular disc and a 
portion of the joint capsule. 

365 



366 



PART IV TESTING OF THE SPINE AND TEMPOROMANDIBULAR )OINT 



Spheno- 

mandibular 

ligament 



Stylomancii 
ligament 



B 




Fibrous 
capsule 



Tempormandibular 
ligament 



Joint capsuie 



Sphenomandibular 
ligament 



FIGURE 13-2A (A) A lateral view of the temporomandibular 
joint showing the oblique fibers of the temporomandibular liga- 
ment and the stylomandibular and .sphenomandibular liga- 
ments. (B) A medial view of the temporomandibular joint 
showing the medial portion of the joint capsule and the stylo- 
mandibular and sphenomandibular ligaments. 



motions in three planes around three axes. All of the 
motions except mouth closing begin from the resting 
position of the joint in which the teeth are slightly sepa- 
rated (freeway space). 3 ' 4 The amount of freeway space, 
which usually varies from 2 mm to 4 mm, allows free 
anterior, posterior, and lateral movement of the 
mandible. The functional motions permitted are 
mandibular elevation (mouth closing) and depression 
(mouth opening), protrusion (anterior translation) and 
retrusion (posterior translation), and right and left lateral 
deviation (excursion). Maximal contact of the teeth in 
mouth closing is called centric occlusion. 

The oblique portion of the temporomandibular liga- 
ment limits mandibular depression, retrusion, and rota- 
tion of the condyle during mouth opening. The 
horizontal portion of the temporomandibular ligament 
limits posterior translation of the mandibular condyle in 
retrusion and lateral deviation of the mandible. The func- 
tions of the stylomandibular and sphenomandibular liga- 
ments are controversial. According to Magee, 5 the 
ligaments keep the condyle, disc, and temporal bone in 
close approximation. These ligaments also may prevent 



excessive protrusion, but their exact function has not 
been verified. 

The diagasrric and lateral pterygoid muscles produce 
mandibular depression. ^ "1 be mylohyoid and geniohy- 
oid muscles assist in the motion, especially against resis- 
tance/'^ Mandibular elevation is produced by the 
temporalis, masseter, ami medial pterygoid muscles, '•'" 5 
A'hich are responsible for maintaining the freeway space. 

:tion of 
id 



which are responsible tor maintaining the freeway space. 
Mandibular protrusion is a result of bilateral action of 
the masseter, 1 ' 1 medial, "''"■"' tod lateral'" pterygoid 
muscles. The mylohyoid, stylohyoid, and digastric 
muscles may assist. 1 Retrusion ts brought about by bilat- 
eral action of the posterior fibers of the temporalis 
muscles 1 " 1 '; by the di agastric, "^ middle, and deep 
fibers of the masseter * l> ; and by the stylohyoid , mylohy- 
oid,'"'' and geniohyoid 1 ' 1 ' 1 muscics. Mandibular devia- 
tion is produced by a unilateral contraction of the- medial 
and lateral pterygoid muscles. A unilateral contraction 
of the temporalis muscle causes deviation to the same 
side. 

Cervical spine muscles may be activated in conjunc- 
tion with l.MJ muscles because a close functional rela- 
tionship exists between the head and the neck. l,4 ~ tJ 
Coordinated ami parallel movements at the T.Y1J arti 



V AA^I VllllullLLl vMIU j'UUIiai I ! 1 I I , K- : 1 1 \_ ! U T) .It 

cervical spine joints have been observed in some studies 
1 researchers suggest thai prcprogramme 



:cl neural 
.Is may simultaneously activate both jaw and 



ant 

commands m 
neck muscles 

Arthrokinematics 

Mandibular depression (mouth opening) occurs in the 
sagittal plane and is accomplished by rotation and sliding 
of the mandibular condyles. Condylar rotation is 
combined with anterior and inferior sliding of the 
conchies on the interior surface of the discs, which also 
slide anteriorly (translate) along the temporal articular 
eminences. Mandibular elevation (mouth closing) is 
accomplished by rotation of the mandibular condyles on 
the discs and sliding of the discs with the condyles poste- 
riorly and superiorly on the temporal articular 
eminences. 

In protrusion, the bilateral condyles and discs translate 
together anteriorly and interiorly along the temporal 
articular eminences. The movement takes place at the 
upper joint, and no rotation occurs during this motion. In 
lateral deviation, one mandibular condyle and disc slide 
interiorly, anteriorly, and medially along the articular 
eminence. The other mandibular condyle rotates about a 
vertical axis and slides medially within the mandibular 
tossa. i ; or example, in left lateral deviation, the left 
condyle spins and the right slides anteriorly. 

Capsular Pattern 

In the capsular pattern, mandibular depression is limited 
to 1 cm, with deviation toward the restricted side.'' 
Protrusion is limited and accompanied by deviation 



. 



CHAPTER 13 THE TEMPOROMANDIBULAR JOINT 



367 



■ 



table .13-1 Mouth Opening Range of Motion in Subjects 18 to 61 Years of Age: Mean Linear 
Distance in Millimeters . 



Trovers 




lewis et al' 



'9 >vs 
IBM 



. H;ylifceial t,s . 

\S~S4yn 
h = ZQM wid 20F 



Wc'fc. ttaP 



21-61 yn 
n = if arid MM 



Cavisii et al*'* 

15-16 yn 

«=■ 248 



Meem 



(SO) 



Mem) (SD) 



■Mean (S&p 



46.6 



46.0 



52.1 



44.5 (5.3) 

..-." 1.: .. 



43.5 .,(6.1) 51.6 (6.2) 



F = Females; M = males; (5D) = standard deviation. 

• Measurements were obtained with an Optotrak jaw-tracking system. 

* Measurements were obtained with a millimeter ruler. 
*The instrument that was used was not reported. 



toward the restricted side. 5 Lateral deviation is limited on 
the side opposite the restriction. 4 

91 Research Findings 

The normal range of motion (ROM} for mouth opening 
is considered to be a distance sufficient for the subject to 
place two or three flexed proximal interphalangeal joints 
within the opening. That distance may range from 35 
mm to 50 mm and is considered to be a measure of func- 
tional opening, although an opening of only 25 mm to 35 
mm is needed for norma! activities. 5 A definition of 
normal range of mouth opening as 40 mm to 50 mm was 
arrived at by consensus judgements made at a 1995 
Permanent Impairment Conference by representatives of 
all major societies and academies whose members treat 
TMJ disorders. 10 Similar mean ROMs for mouth open- 
ing, from a low of 43.5 mm to a high of 52.1 mm, are 
presented in Table 13-1. The linear distances for protru- 
sion and lateral deviation are presented from three 
sources in Table 13-2. 



Dijkstra and coworkers 17 investigated the relationship 
between vertical and horizontal mandibular ROM in 91 
healthy subjects (59 women and 32 men) with a mean 
age of 27.2 years. A mean ratio was found ranging from 
6.0:1 to 6.6:1 between vertical and horizontal ROM. 
Individual ratios ranged from 3.6 to 15.5, and correla- 
tions between the vertical and the horizontal ROM 
measurements were weak. Therefore, based on the results 
of this study, the authors concluded that the 4:1 ratio 
between vertical and horizontal ROM that has been used 
in the past IS should be replaced by the approximately 6:1 
ratio found in this study. However, the authors found 
that the ratio has poor predictive value. A review of 
values in Tables 13-1 and 13-2 indicates that the ratio 
between mandibular depression (vertical ROM) and 
lateral deviation (horizontal ROM) is between 4:1 and 
5:1. Dijkstra and coworkers' 17 measurements of incisal 
linear distance during mouth opening included the over- 
bite measurement, and this addition may account for 
some of the differences between these authors' ratios and 
the ratios shown in the tables. 



table 13-2 Protrusion and Lateral Deviation 
(Deviation) Range of Motion: Mean Linear 
Distance in Millimeters 



.,;.T*ta^' 



-fttagee** -. 




Protrusion 
L. Deviation 
R. Deviation 



9.3 

n.o 
n:5 



7;1 (2.3) 

8.6 (2.1) 
9.2 (2.6) 



(SD) = Standard deviation; F = female; M = male 

* Measurements were obtained with an Optotrak jaw tracking 

system. 
f Measurements were obtained with a millimeter ruler. 
'The instrument that was used to obtain measurements is unknown. 
5 Normal values may vary depending upon the degree of overbite 

(greater movement) and underbite (lesser movement). 



Effects of Age, Gender, and Other Factors 

Age 

Thurnwald 19 found that the ROM in all active TMJ 
motions except retrusion decreased with increasing age. 
Mouth opening decreased from a mean of 59.4 mm in the 
younger group to 54.3 mm in the older group. The study 
involved 50 males and 50 females ranging from 17 to 65 
years of age. The author also found a decrease in the 
quality of six passive accessory movements with increas- 
ing age. Resistance to passive accessory movement and 
crepirus increased in the older group. A number of other 
studies have investigated populations of children, adoles- 
cents, and elderly individuals to determine the prevalence 
of TMJ disorders in these age groups. 20 "" 4 

Gender 

Studies investigating the effects of gender on temporo- 
mandibular function in a healthy population are scarce. 



I 

i; 



368 



PART IV TESTING OF THE SPINE ANO TEMPOROMANDIBULAR JOINT 



Thurnwald 19 determined that the subject's gender signif- 
icantly affected mouth opening and lateral deviation. 
The SO males in the study had a greater mean range of 
mouth opening (59.4 mm) than the 50 females (54.0 
mm). The males also had a greater mean ROM in right 
lateral deviation, but the difference berween genders in 
this instance was small. No effect of gender was appar- 
ent on passive accessory motions. Lewis, Buschang, and 
Throck-morton M found that males had significantly 
greater mouth opening ROM (mean = 52.1 mm) than 
females (mean = 46.0 mm) in the study (see Table 13-1). 
In contrast to the findings of Lewis, Buschang, and 
Throckmorton, 1 "' Westling and Helkimo 25 found that 
the angular displacement of the mandible in relation to 
the cranium (angle of mouth opening) in maximal jaw 
opening in adolescents was slightly larger in females than 
in males. This finding might have been influenced by the 
fact that females generally reach adult ROM values by 
10 years of age, whereas males do not reach an adult 
ROM values until 1.5 years of age. 2<; 

Mandibular Length 

Dijkstra and colleagues, 27 in a study of mouth opening 
in 13 females and 15 males, found that the linear 
distance berween the upper and the lower incisors during 
mandibular depression was significantly influenced by 
mandibular length. In a more recent study, Dijkstra and 
associates 28 investigated the relationship between incisor 
distances, mandibular length, and angle of mouth open- 
ing in 91 healthy subjects (59 women and 32 men) rang- 
ing from 13 to 56 years of age (mean 27.2 years). Mouth 
opening was influenced by both mandibular length and 
angle of mouth opening. Therefore, it is possible that 
subjects with the same mouth opening distance may 
differ from each other in regard to TMJ mobility. Lewis, 
Buschang, and Throckmorton 54 found that mandibular 
length accounted for some of the gender differences in 
mouth opening and for most of the gender differences in 
condylar translation in mouth opening. Westling and 
Helkimo 2 ■ , found that passive ROM as measured by 
mouth opening was strongly correlated to mandibular 
length. 

To adjust for mandibular length, Miller and cowork- 
ers 29 conducted a study to determine whether a "mouth 
opening index" developed by the authors might be able 
to differentiate between TMJ disorders of arthrogenous 
origin and those of myogenous origin. Forty-seven 
patients and 27 healthy control subjects were included in 
the study. The temporomandibular opening index (TOI) 
was determined by employing the following formula: 
TOI = (PO - MVO/ PO + MVO) x 100. "PO" in the 
formula refers to passive opening and "MVO" refers to 
maximal voluntary opening. A significant difference was 
found between the mean TOI between the two groups of 
patients and between the myogenous and the control 
groups but not between the arthrogenous group and the 



control group. The authors suggested that the TOI might 
be a better measure than simple linear distance measures 
for mouth opening. In a subsequent study. Miller and 
associates' compared the TOI in I I patients with a 
disorder with the TOI in a control group of t 1 individu- 
als without TMJ disorders. Based on the results of the 
study, the authors concluded that the TOI appears to be 
independent of age, gender, and mandibular length. 

Head and Neck Positions 

1 lighie and associates 11 investigated the effects of head 
position (forward, neutral, and retracted) on mouth 
opening in 20 healthy males and 20 healthy females 
between 18 and 54 years of age. Mouth opening ROM 
measured with a millimeter ruler was significantly differ- 
ent among the three positions. Mouth opening was great- 
est in the forward head position (mean = 44.5, SD = 
53), less in the neutral head position (mean = 41.5, SD 
=■ 4.S), and least in the retracted head position (mean = 
36.2, SI) -- 4.5}. Day-to-day reliability was found to vary 
from 0.90 to 0.97, depending on head position, and the 
standard error of measurement (SfcM) ranged from 0.77 
to 1.69 mm, also depending on head position. As a result 
of the findings, the authors concluded that the head posi- 
tion should be controlled when mouth opening measure- 
ments are taken. However, the authors found that an 
error of I mm to 2 mm occurred regardless of the posi- 
tion in which the head was placed. 

Temporomandibular Disorders 

The structure of the TMJs and the fact that these joints 
get so much use predisposes the joints, associated liga- 
ments, and musculature to injury, mechanical problems, 
and degenerative changes. For example, the articular disc 
may become entrapped, deformed, or torn; the capsule 
may become thickened; the ligaments may become short- 
ened or lengthened; and the muscles may become 
inflamed, contracted, and hypertrophic^]. These problems 
may give rise to a variety of symptoms and signs that are 
included in the temporomandibular disorder (T.VID) clas- 
sification. Restricted mouth opening ROM is considered 
to be one of the important signs of TMD."'' Popping or 
clicking noises (or both) in the joint during mouth open- 
ing and/or closing and deviation of the mandible during 
mouth opening and closing may be present. 16 *"™ 
Other signs and symptoms include facial pain, muscular 
pain,* ' and tenderness in the region of the TMJ, either 
unilaterally or bilaterally, headaches, and stiffness of the 
neck. TMDs appear to be more prevalent in females of all 
ages after puberty, although the actual percentages of 
women affected varies among investigators. "■'' 2 ''''''~ , " f The 
reason lor this gender preference has been attributed a 
number of factors including, among others, greater stress 
levels in women,'-' hormonal influences/ -1 and habits of 
adolescent girls that arc extremely harmful to the 
temporomandibular joints (e.g., intensive gum chewing, 



i 






CHAPTER 13 THE TEMPOROMANDIBULAR JOINT 



369 



i-,6 

ft 



continuous arm leaning, ice crushing, nail hiring, biting 
foteign objects, jaw play, clenching, and bruxism). 16,22 

Reliability and Validity 

Most of the following studies agree that TMj ROM 
measurements of the distance between the upper and the 
lower incisors are reliable. The validity of these ROM 
measurements is more controversial. Walker, Bohannon, 
and Cameron 11 found chat measurements of incisor 
distances for mouth opening had construct validity. 
However, some authors question how differences in the 
length and size of the mandible affect linear distance 
measurements. 

Walker, Bohannon, and Cameron 11 determined that 
six TMJ motions measured with a millimeter ruler were 
reliable. Measurements were taken by two testers ac three 
sessions, each of which were separated by a week. The 30 
subjects who were measured included 15 patients with a 
TMJ disorder (13 females and 2 males with a mean age 
of 35.2 years) and 15 subjects without a TMJ disorder 
(12 females and 3 males with a mean age of 42.9 years). 
The intratester reliability intraclass correlation coeffi- 
cients (ICCs) for tester one ranged from 0.82 to 0.99, and 
the intratester reliability for tester two ranged from 0,70 
to 0.90. Intertester reliability ranged from good to excel- 
lent (ICC = 0.90 to 1,0). However, only mouth opening 
measurements had construct validity and were useful for 
discriminating between subjects with and without TMJ 
disorders. The technical error of measurement (difference 
between measurements that would have to be exceeded if 
the measurements were to be truly different) was 2.5 mm 
for mouth opening measurement in subjects without a 
TMJ disorder. Higbie and associates l> also found that 
ROM measurements of mouth opening were highly reli- 
able with use of a millimeter ruler. Twenty males and 20 
females with a mean age of 32.9 years were measured by 
two examiners. Intratester, intertester, and test-retesc reli- 
ability ICCs ranged from 0.90 to 0.97, depending on 
head position. SEM values indicated that an error of 1 
mm to 2 mm existed for the measurement technique used 
in the study. Kxopmans and colleagues' 5 found similar 
high reliability in a study of mouth opening involving 5 
male and 20 female patients with painfully restricted 



TMJs. Intratester, intertester, and test-rerest reliability 
varied between 0.90 and 0.96. However, in contrast to 
the findings of Walker, Bohannon, and Cameron 11 and 
those of Higbie and associates, ts the authors found that 
the smallest detectable difference of maximal mouth 
opening in this group of subjects varied from 9 mm to 6 
mm. Based on these results, a clinician would have to 
measure at least 9 mm of improvement in maximal 
mouth opening in this group of patients to say that 
improvement had occurred. 

The following studies investigated incisor distances as 
a measure of mandibular condylar movements. Buschang 
and associates, 12 in a sample of 27 healthy females 23 to 
25 years of age, found that measurements of incisor 
motion during protrusion and lateral deviation provided 
moderately reliable measures of condylar translation. 
The linear distances that the incisors moved during 
lateral deviation provided the best measure of contralat- 
eral condylar translation. Travers and coworkers, 13 in a 
study involving 27 females, determined that the incisor 
linear distance in maximal mouth opening does not 
provide reliable information about condylar translation, 
because normal individuals perform mouth opening with 
highly variable amounts of condylar translation. Dijkstra 
and colleagues, 2 ' in a. study of 28 healthy volunteers (13 
females and 15 males) between 21 and 41 years of age, 
found thar linear distance between the central incisors in 
maximal mouth opening was only weakly related to 
condylar movement. Lewis, Buschang, and Throck- 
morton, 14 who studied incisor movements in mouth 
opening in 29 men and 27 women, concluded that inci- 
sor movements should not be used as an indicator of 
condylar translation. 

The influence of mandibular length on incisor distance 
measurements in mouth opening has been well docu- 
mented. H,25,27>28 The TOI mouth opening index was 
developed by Miller and coworkers 29 and Miller and 
associates. 30 According to these authors, the index is 
independent of mandibular length as well as gender and 
age. If additional research supports the authors' claims, 
use of the TOI would increase the validity of incisor 
measurements of mouth opening. Additional information 
about the TOI is presented in the section on mandibular 
length. 



f- 



370 PART IV TESTING OF THE SPINE AND TEMPOROMANDIBULAR JOINT 



< 

_ 

z 

< 

o 

O 

Q. 
LU 

DC 
D 
Q 

LU 
U 

o 

O 

z 

LU 



o 



j Range of Motion Testing Procedures: Temporomandibular joint 
| Landmarks for Ruler Alignment Measuring 



LU 

u 

Z 

< 




Maxilla 



Canines 




Lateral incisor 



Central incisors 



' Mandible 

FIGURE 13-3 The adult has between 28 and 32 permanent teeth including 8 incisors, 4 canines, 8 
premolars, and 8 to 12 molars. The central and iateral incisors and canines serve as landmarks for ruler 
placement. 



DEGRESSION 01 Vv. MAI U^i » 



j Motion occurs in the sagittal plane around a mcdial- 

j lateral axis. Functionally, the mandible is able to depress 

| approximately 35 mm to 50 mm so that the subject's 

| three fingers or two knuckles can be placed between the 

| upper and die lower central incisor teeth.' According to 

j the consensus judgements or the Permanent Impairment 

| Conference, the normal ROM for mouth opening ranges 

| between 40 mm and 50 mm. 1 " The mean ROM in Table 

| 13-1 shows ranges from 43.5 mm to 52.1 mm. 

| Testing Position 

| Place the subject sitting, with the cervical spine in 
| degrees of flexion, extension, lateral flexion, and rotation. 

| Stabilization 

| Stabilize the posterior aspect of the subject's head and 
| neck to prevent flexion, extension, lateral flexion, and 
j rotation of the cervical spine. 

| Testing Motion 

| Grasp the mandible so that it fits between the thumb and 
| the index finger and pull the mandible inferiorly (Fig. 



13-4). The subject may assist with the motion by open- 
ing the mouth as far as possible. The end of the motion 
occurs when resistance is felt and attempts to produce 
additional motion cause the head to nod forward (cervi- 
cal flexion). 

Normal End- feel 

The end-feel is firm owing to stretching' of the joint 
capsule, retrodiscal tissue, and the temporomandibular 
ligament, as well as the masseter, temporalis, and medial 
pterygoid muscles."'' 1 

Measurement Method 

Measure the distance between the upper and the lower 
central incisor teeth with a ruler (Fig. 13-5). In normal 
active movement, no lateral deviation occurs during 
depression. If lateral deviation does occur, it may take the 
form of either a Oshap.ec! or an S-shapcd curve. With a 
C-shaped curve, the deviation is to one side and should 
be noted on tSie recording form. With an S-shaped curve, 
the deviation occurs first to one side and then to the 
opposite side.' A description of the deviations should be 
included on the recording form (Fig. \3~-6). 



CHAPTER 13 THE TEMPOROMANDIBULAR JOINT 



371 



m 

H 




: FIGURE 13-4 At the end of mandibular depression, one of the 
examiner's hands maintains the end of the range of motion by 
pulling the jaw inferiorly. The examiner's other hand holds the 
back of the subject's head to prevent cervical motion. 



FIGURE 13-5 At the end of mandibular depression range of 
motion, the examiner uses the arm of a plastic goniometer to 
measure the distance between the subject's upper and lower 
central incisors. 



rcliiiimnjiiiiiiiuJLiimiti[miinii[ 






R himluilimtuii iiiiiiiitjimiuul L 



RIihhiiiiIiiiiniii liinimlnmuiit|_ 



/! 



4 cm 



A B 

FIGURE 13-6 Examples of recording deviations in temporomandibular motions. {A) Deviation R and L 
on opening; maximum opening, 4 cm; lateral deviation equal (1 cm each direction); protrusion on func- 
tional opening (dashed lines). (B) Capsule-iigamentous pattern: opening limited to 1 cm; lateral deviation 
greater to R than to L; deviation to L on opening. (C) Protrusion is 1 cm; lateral deviation to R on protru- 
sion (indicates weak lateral pterygoid on opposite side). (Magee, Dj: Orthopedic Physical Assessment, ed 
3. \VB Saunders, Philadelphia, 1997, p. 165, with permission). 



J 




8ft- 



FIGURE 13-4 At the end of mandibular depression, one of the 
examiner's hands maintains the end of the range of motion by 
pulling the jaw inferiorly. The examiner's other hand holds the 
back of the subject's head to prevent cervical motion. 



FIGURE 13-5 At the end of mandibular depression range of 
motion, the examiner uses the arm of a plastic goniometer to 
measure the distance between the subject's upper and lower 
central incisors. 



ft Liuiuujmmte uaitialttaatui i 



p) limit. iiliimn 



UUli I 



RilmiiMlhllinill 



/i 



muni JiiiiiiiiiI^ 



4 cm 



A B C 

FIGURE 13-6 Examples of recording deviations in temporomandibular motions. {A) Deviation R and L 
on opening; maximum opening, 4 cm; lateral deviation equal (1 cm each direction); protrusion on func- 
tional opening {dashed lines). (B) Capsule-ligamentous pattern: opening limited to 1 cm; lateral deviation 
greater to R than to L; deviation to L on opening. (C) Protrusion is 1 cm; lateral deviation to R on protru- 
sion (indicates weak iateral pterygoid on opposite side). (Magee, Dj: Orthopedic Physical Assessment, ed 
3. WB Saunders, Philadelphia, 1997, p. 165, with permission). 



z 


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-J 

S3 
5 

z 
..< 

o 
o 

c 

LU 

S£ 

D" 

O 

LL) 
U 


=s 
c 

U 

Z 



372 PART IV TESTING OF THE SPINE AND TEMPOROMANDIBULAR |OINT 



PROTRUSION OF THE MANDIBLE 



This translator)' motion occurs in the transverse plane. 
Normally, the lower central incisor teeth are able to 
protrude 6 mm to 9 mm beyond the upper central incisor 
teeth. However the distance may range from 3 mm 5 to 10 

mm."' See Table 13-2 for additional information. 



Z 

o 

§ 

: 

: LLJ 

o 
z 
< 



Testing Position 

Place the subject sitting, with the cervical spine in 
degrees of flexion, extension, lateral flexion, and rota- 
tion. The TMj is opened slightly. 

Stabilization 

I Stabilize the posterior aspect of the head and neck to 
I prevent flexion, extension, lateral flexion, and rotation of 
| the cervical spine. 

| Testing Motion 

I Grasp the mandible between the thumb and the fingers 
from underneath the chin. The subject may assist with 



a 




mKKKSm 



JH@h=' ' : 









■■■ ^ 



FIGURE 13~7 At the end of mandibular protrusion range of 
motion, the examiner uses one hand to stabilize the posterior 
aspect of the subject's head while her other hand moves the 
mandible into protrusion. 



the movement by pushing the chin anteriorly as far as 
possible. The end of the motion occurs when resistance is 
felt and attempts at additional morion cause anterior 
motion of the head (Fig. 13-7). 

Normal End-feel 

The end-feel is firm owing to stretching of rhe joint 
capsule, temporomandibular, stylomandibular and sphe- 
nomandibular ligaments, as well as the temporalis, 
masseter, digastric, stylohyoid, mylohyoid and geniohy- 
oid muscles.'"' 

Measurement Method 

Measure the distance between the lower central incisor 
and the upper central incisor teeth with a rape measure or 
ruler (Fig. 13-8}, Alternatively, two vertical lines drawn 
on the upper and lower canines or lateral incisors may be 
used as the landmarks for measurement.' ' 




t 



FIGURE- 13-S At the em) of protrusion range of motion, the 
examiner uses the end of a plastic goniometer to measure the 
distance between the subject's upper and lower central incisors. 
The subject maintains the position. 






CHAPTER 13 THE TEMPOROMANDIBULAR JOINT 



373 



LATERAL DEVIATION OF THE MANDIBLE 



This translatory motion occurs in the transverse plane. 
i'The amount of lateral movement to the right and left 

sides should be similar, between 10 mm and 12 mm 2 but 
imay range from 6 mm to 15 mm. 5 According to the 

consensus judgement of the Permanent Impairment 

Conference, the normal ROM is between 8 mm and 12 
f mm- 10 See Table 13-2 for additional information. 

Jesting Position 

Place the subject sitting, with the cervical spine in 
degrees of flexion, extension, lateral flexion, and rota- 
tion. The TMJ is opened slightly so that the subject's 
upper and lower teeth are not touching prior to the start 
of the motion. 

Stabilization 

Stabilize the posterior aspect of the head and neck to 
prevent flexion, extension, lateral flexion, and rotation of 
the cervical spine. 



Testing Motion 

Grasp the mandible between the fingers and the thumb 
and move it to the side. The end of the motion occurs 
when resistance is felt and attempts to produce additional 
motion cause lateral cervical flexion (be careful to avoid 
depression, elevation, and protrusion and retrusion 
during the movement) (Fig. 13-9). 

Normal End- feel 

The normal end-feel is firm owing to stretching of the 
joint capsule and temporomandibular ligaments, as well 
as the temporalis, medial, and lateral pterygoid muscles. 

Measurement Method 

Measure the distance between the most lateral points of 
the lower and the upper cuspid or the first bicuspid teeth 
with a tape measure or ruler (Fig. 13-10). Alternatively, 
two vertical lines drawn on the upper and lower central 
incisors may be used as landmarks for measurement. 




FIGURE 13-9 At the end of mandibular lateral deviation range 
of motion, the examiner uses one hand to prevent cervical 
motion and the other hand to maintain a lateral pull on the 
mandible. 



FIGURE 13-10 The examiner uses the end of a plastic 
goniometer to measure the distance between the upper and the 
Sower canines. 



374 PART IV TESTING OF THE SPINE AND TEMPOROMANDIBULAR JOINT 



REFERENCES 

1. Perry, JF: The temporomandibular joint. In Levangie, PK, and 
Norkin, CC (eds): joint Structure and Function: A Comprehensive 
Analysts, ed 3. FA Davis, Philadelphia, 2001. 

2. Igliirsh, ZA, and Synder-Mackler, L: The temporomandibular 
joint and the cervical spine. In Richardson, JK, and Iglarsh, ZA 
(eds): Clinical Orthopaedic Physical Therapy. WB Saunders, 
Philadelphia, 199.1. 

3. Williams, PL: Gray's Anatomy, ed 38. Churchill Livingstone, New 
York, 1995. 

4. Harrison, AL: The temporomandibular joint. In Malone, TR, 
McPoil, T, and Nit/., AJ (eds): Orthopedic and Sports Physical 
Therapy, ed 3. CV Mosby, St Louis, 1997. 

5. Magce, DJ: Orthopedic Physical Assessment, ed 3. WB Saunders, 
Philadelphia, 1997. 

6. Caillier, R: Soft Tissue Pain and Disability, ed 3. FA Davis, 
Philadelphia, 1996. 

7. Zafar, H, Nordh, E, and F.riksson, PO: Temporal coordination 
between mandibular and head-neck movements during jaw open- 
ing-closing tasks in man. Arch Oral Biol 45:675, 2000. 

S. Zafar, H: Integrated jaw and neck function in man. Studies of 
mandibular and head-neck movements during jaw opening-clos- 
ing tasks. Swed Dent j !43(Suppl):l, 2000. 

9. Eriksson, PO, et at: Co-ordinated mandibular and head-neck 
movements during rhythmic jaw activities in man. J Dent Res 
79:1378,2000. 

10. Phillips, DJ, et al: Cmide to evaluation of permanent impairment 
of the temporomandibular joint, J Craniomandibukir Pract 
15:170, 1997. 

1 1. Walker, N, Bohannon, R\V, and Cameron, D: Discriminant valid- 
ity of temporomandibular joint range of motion measurements 
obtained with a ruler. J Orthop Sports Phys Ther 30:484, 2000. 

12; Busehang, PH, et al: Incisor and mandibular condylar movements 
of young adult females during maximum protrusion and latera- 
rrusion of the jaw. Arch Oral Biol 46:39, 2001. 

13. Travers, KH, et al: Associations between incisor and mandibular 
condylar movements during maximum mouth opening in 
humans. Arch Oral Biol 45:267, 2000. 

14. Lewis, RP, Buschang, PH, and Throckmorton, GS: Sex differences 
in mandibular movements during opening and closing. Am j 
Orthod Dentofaeia! Orthop 120:294, 2001. 

15. Higbie, Ej, et al: Effect of head position on vertical mandibular 
opening. J Orthop Sports Phys Ther 29:127, 1999. 

16. Gavish, A, er al: Oral habits and their association with signs and 
symptoms of temporomandibular disorders in adolescent girls, j 
Oral Rehabil 27:22, 2000. 

17. Dijkstra, PU, et al: Ratio between vertical and horizontal 
mandibular range of motion, j Oral Rehabil 25:353, 199S. 



Hockstedlcr. JL, Allen. |D, and I'ol'mar, MA: Temporomandi- 
bular joint range >>' rmmorua ratio nf mtcrcisai opening to excur- 
sive movement in .1 healthy population. Cranio I4:2'*f>, 1996. 
1 hltflKvaUi, PA: The effect or age and gender on normal temporo- 
mandibular jtHin mtrtton. Physiother Theory I'ract 7:'2(W, 1991, 
Sottmrt, H, el al: Prevalence ot temporomandibular dysfunction 
111 Turkish children with mixed ami permanent dentition. \ Oral 
Kehabil 2S:2KO, 2(101 

Alatnoiidi, N, e( al: Temporomandibular disorders among school 
children. | C.I111 I'ediatr Dent 22: 52 1, I99X. 

Wuiocur, I., et al: Oral habits among adolescent girls and their 
association with svmpmms nl temporomandibular disorders. J 
Oral Kehabil IX: o24, 2001. 
23. ( lilnmcu, is. el ,il: Prevalence i>! signs of temporomandibular 
disorders among elderly inhabitants eit Helsinki. Finland. Acta 
Odontol Scand 5 1x20, 1995. 



IS. 

19. 

20. 

21. 
■>■> 



24. 
25. 
26. 
27. 

2S. 
29. 
30. 

31. 
32. 

n. 
34. 
is. 



k.iuhab, K, 



, et al: facial pain and temporomandibular disorders: 
an epiJeuinilogic.il study, 

W'estling, I., and llclkimo, I.: Maximum jaw opening capacity in 
adolescents in relation to general [mat mobility. 19:4&5. 1992. 
VC 'Vight, DM, and Mottat, BC, Jr: The postnatal development of 
the human temporomandibular ji >u: t . Am j Anal 141:215, 1974. 
Dijkstra, PS !, et al: Temporomandibular |«in! mobility assessment: 
A comparison between four methods. J Oral Kehabil 22:439, 
I'Wi. 
Di|ksira, PL', et al: luNiierue ol mandibular length oil mouth 

.peiimg. I ( lr.il Kehabil 2t>: I I", :' 

Miller, VJ. ei al: A month opening index (or patients with 
temporomandibular disorders. I Oral Kehabil 2(>: * 54, 1999. 
Milter, VJ. v! .ll: The temporomandibular opeiuttg index [TOl'i in 
patients with closed luck and ,1 control group with no temporo- 
mandibular disorders (TMD): .11! initial study. J Oral Rehabil 
2~:8 1>", 20(H). 

Fsposito, CJ, Panucci, PJ. and larmati, AC: Associations in 425 
patients having temporomandibular disorders. J Kentucky Med 
Assoc 9«:21 3/20i)l. 

Le Resche, I.: Epidemiology of temporomandibular disorders: 
implications (or the invcstigaiion ot etiologic factors'. Grit Rev 
Oral BSol Med X: 291, 1997. 

kutilla, M, et al: TMD treatment need iti relation to age, gender, 
stress and diagnostic subgroup, j Orotac Pain 12:67, 1998, 
Warren, MP, and Fried, JL: leinporomandibular disorders and 
hormones m women. Cells Tissues Organs I6 1 >:1!>", 2000. 
SsTopmans, I, cc al: Smallest detectable diflerence of maxima! 
mouth opening in patients with painfully restricted temporo- 
mandibular joint function. Fur J Oral Sci iOX:9, 2000. 



■ 

■-■■: 

i 



.% 
1 



APPENDIX A 



»; 



Normative Range of 
Motion Values 




table A-i Shoulder, Elbow, Forearm, and Wrist Motion: Mean Values in Degrees 



ft?<-t,.>" 



Wonatabeetaf'BooheandAzen * Green and Wolf* 
0-2yis US4yci IB-SSyrs 

fades) nOM,WF) 



156 





SHOULDER COMPLEX 






|M 


/■ Flexion 


172^-180 


167 


Jt 


Extension 


78-89 


62 




Abduction 


177-181 


184 




Medial rotation 


72-90 


69 




Lateral rotation 


118-134 


. 104 




ELSOW AND FOREARM 








Flexion 


148-1 5S 


143 




Extension 




1 




Pronation 


90-96 


76 




Supination 


81-93 


82 




WRIST 








Flexion 


88-96 


?6 




Extension 


82-89 


75 




Radial deviation 




22 




Ulnar deviation 




36 



168 
49 
84 

145 

84 
77 



Walker etal* 

6&-8Syts 

n~ 60 

(30M,30F) 



165 

44 
165 

62 
81 

143 

-4* 
71 
74 



Downrf el al f 

61-93 yrs 

n -- J06 

(60 M, 140Fihaulderx) 



A40J * AMA 



165 

158 
65 
81 



73 64 

65 63 

25 \.-;'T9 ..>;., 

39 im:m&:: 

AAOS = American Association of Orthopaedic Surgeons; AMA = American Medical Association; M 
Values obtained with a universal goniometer. 
* Minus sign indicates flexed position. 



males; F = females. 



180 
60 

180 
70 
90 

150 



80 

80 

80 
70 
20 
30 



m 



ISO, 
50 

i8o : : 

90: 

9<J :? 

140 


80 
80 

60 
605 
20: 
30 



375 



376 



APPENDIX A 



! 



table A-2 Glenohurheral Motion: Mean Values in Degrees 



^ ; sffw; - ' """'•■"■''■r : .'-..i : '; 


Bknbecker-et al s 


Eltenbeckeretat" t r V;:: 


|ilp§; Boon & ini/I/i ' 


■ Ltmson 'et&M 


^ri 


''.'':£ 


; - 


U-Uyn -' 


j;-77yrs 


f^-JS y« 


■ : 21-40 ?ts 


*4 


•''.'' '.''^ 


■■- •:: 


.■■'.-.- : ■-■:■'«■= Jli :■:•■- 


n = 90 


n - SO 


n = 60 


'J* 




Motion y- 


m 


ffi> 


(18M/32F) 


(2QM,4QF} 


Si 


J 


GLENOHUMERAL 










J 


Flexion 








106 






Extension 








20 






Abduction 








129 




| 


Medial rotation 


51 


56 


63 


49 






Lateral rotation 


103 


105 


10S 


94 


:- 


: 



M males; F = females. 

Values obtained witii a universal goniometer. 



TABLE A-3 


Finger Motions: Mean Values in Degrees 


9s r J^^^^^^0\^^'-i ■■'": '■ ' -'■*•&£% ' *'^Wg$$8BsB3i 




SttajitovQ & Pl&tkwa* T! 


HumeetaP™ 


Matfonetal*" 


: AAOS* 


AMaW$ 




2Q-2Syrs 


26-28 yrs 


18-3Syn 






:„", ■■■:•', . ' ■■: : ■ 


ti = 200 


n= 35 


a = 120 






: MOftop >; :;■;:.: ' 


(10B ', , ■ F) 


i m ... 


..;,. (6QM,6Q.F}[ 




^'.^' "■■"..'. /.-■! 


FINGER MCP 












Flexion 


91 


100 


95 


90 


90 ■■;3 


Extension 


26 




20 


45 


20.V-A 


FINGER PIP 












Flexion 


108 


105 


105 


100 


TOO 


Extension 







7 





0: 


FINGER DIP 












Flexion 


85 


85 


68 


90 


70 .. 


Extension 







8 





0:: f fl 



DIP • Distal interphalangeai; MCP =■ metacarpophalangeal; PIP = proximal interphatangeal. 
AAOS - American Association ol Orthopaedic Surgeons; AMA * American Medical Association; M 
* Values obtained with a metallic slide goniometer on dorsal aspect. 
'Values obtained with a universal goniometer on lateral aspect. 
'Values obtained with a digital goniometer on dorsal aspect. 



Males; F females. 



APPENDIX A NORMATIVE RANGE OF MOTION VALUES 



377 



table a-4 Thumb Motions: Mean Values in Degrees 



: :-l ' 


■ - . : ;. ;■-. 


Skaril" Ove* f T 


Siarltova and Plevkava*? 1 


jehltir.s et oF ''* 


DeSmet etaf " 




|;K; 


20~2S:y^. ■ 


2Q~2S;yn 


16-72 yn 


■ '".-■ 16-83 yrs: ■ 






t = 2ca 


n = 200 


■ n~-119: -■■ . 


«=■ J« '.-.■■ 






(100 M, J OOF) 


^tQOM t 100f) 


(SO Si, 69 F) 


(43M,SSF) 


; i 


iAfatfon - 


Active:^ -■':. 


\ Passive v.." -: , ■■■■■■ 


: -^ : 'Active y'/ 




fti- 


THUMB CMC 

Abduction 












Flexion 
Extension 

THUMB MCP 










v| ■■: 


Flexion 


57 


67 


59 


54 


: 


Extension 


14 


23 







A405* MM ; 



THUMB IP 

Flexion 79 86 

Extension 23 35 

CMC = carpometacarpal; F = females; IP = interphalangeal; M = males; MCP 
'Values obtained with a metallic slide goniometer on dorsal aspect. 
'Values obtained with a computerized Greenleaf goniometer. 
* Values obtained with a gonimeter applied to the dorsal aspect. 



67 



metacarpophalangeal. 



80 



70 




15 




20 


50 


50 


6& 





o- 


80 


80 


20 


10 



table A»5 Hip and Knee Motions: Mean Values in Degrees 



.Motion 



Waugh Drews . 

etal™ :•';'-" etoP* 
6-65 hn 12brs-6days 
n ■ 40 n^ S4 

.28 f) 



: "Schwarze-drtd 
Denton iB 
1 3 days 
- #? = 1000 

(4?3M r S2rt) 



Wanatabe 
etal' 

: 8-12/mbs:> 



Phelps 
etal'* 

24 m 

(M and Fl : 



and teen 3 
1-54 yrs 

i: '■'(?■=. 109 ■-. 



■ apdiMlles:^- 
2S~74yrs 
»= 7<S83 



MOS 6 AMA> 



Xt09M) (82 TM, 862 F) 



HIP 

Flexion 
Extension 
Abduction 
Adduction 
Medial rotation 
Lateral rotation 

KNEE 

Flexion 
Extension 



46* 



15* 



28* 

55 

6 

80 



20* 



M = males; F = females. 

* Values refer to extension limitations. 

*A 1994 AAOS value. 



20* 

78 

15 

58 

80 

150 
15* 



38 
79 

148-159 



52 
47 



122 
10 

46 

27 

47 

142 



121 
19 
42 

32 
32 



132 



120 


100 


20 T 


30 


45 


40 


30 


20; 


45 


50? 


45 


50 


135 


150 


10 





378 



APPENDIX A 



table A-6 Ankle and Foot Motions: Mean Values in Degrees 



Wation 



Wattghetal* 1 
6-65 hri 
v> ■■ 40 

as m. 22 n 



Wanatabe et ai 1 

- 4-3 moi 

n = S4 



59 
26 



51 

60 



Boone and Azeit* 

1-54 yn 

n 109 

(M) 



n 

56 
37 
21 



McPoif and Cornwall 23 
x = 26. 1 yes. 

n=27 
(9M, 18 F) 



ANKLE 
Dorsiflexion 
Plantar flexion 
Inversion 
Eversion 

FIRST MTP 

Flexion 
Extension 

F = females; M -•= males. 

Ail range of motion values in the table obtained with a universal goniometer. 



16 

19 (Subtalar) 
12 (Subtalar) 



66 



tgnl etal 21 

64rS7yn 

n = 34 
(F) 



AAOS* AMA r - 



11 

64 

26 

17 



20 

50 
35 
15 

45 

70 



20 
40 
30 
20 

30 

50 



table A-7 Cervical Spine Motions: Mean Values in Centimeters and Degrees 









Youdasetal*^ 1 : 






tantzetaP™. 
>20-39 yn 


Hslehand Young**? 
14-31 yrs 


Balogun et afi '** 
18-26 yrs 


AAOS 6 


AMA 7 


:'V- ,: -v-v. V" ' "v " 


:, 11- 


19 yn 


30-39 yrs 


70-79 yn 


- ■-■■■■■ ;r<?ism 


■'-. '■' -'■ '■':'■■■'. ■■ ■■' ' . " '. '"'■ , - : '. 


tt* 


*:4&M$X 


'><:■■■■■ n = 


-41 


.?,:■■: n = 


40 


n r 


63 


n-- 34 


; £. n- 21 ": 




-;=?^ 




(20 M. 20 F) 


(20 M, 211 


(20 M, 


?9M 






<27M./f} 


(1SM,6F) 




i'VSlltit 


- 

' Matlw ■■-..'■' 


;e ? ; w. 


F ■;■ 


M 


F 


mjfc-^: 


^'■■f* 


Acr 


Pais 










CERVICAL SPINE 






















Flexion 


64 




47 




39 




60 


74 


01 cm 


0.4 cm 32 


45 


so 


Extension 


86 


84 


68 


78 


54 


55 


56 


53 


22 cm 


19 cm 64 


45 


60 


Right lateral flexion 


45 


49 


43 


47 


26 


23 


-43 


48 


11 cm 


13 cm 41 


45 


45 


Right rotation 


74 


75 


61 


72 


50 


S3 


72 


79 


12 cm 


1 1 cm 64 


60 


80 



AAOS = American Association of Orthopaedic Surgeons; AMA = American Medical Association; F = female; M = male. 

* Values in degrees were obtained for active range of motion using the cervical range of motion (CROM) instrument. 

f Values in degrees were obtained for active (Act) and passive (Pass) range of motion with use of the OSI CA-6000 Spinal Motion Analyzer. 

* Values in centimeters were obtained with a tape measure. 

* Values in centimeters obtained with a tape measure appear in the first column, whereas values in degrees obtained with a Myrin gravity- 

referenced goniometer appear in the second column. 
NB; AMA values in degrees were obtained with use oi a universal goniometer and AAOS values in degrees were obtained with use of an incli- 
nometer. 



i 



APPENDIX A NORMATIVE RANGE OF MOTION VALUES 



379 



■ ■ 
i 



TABLE A-8 


Thoracic and Lumbar Spine Motions: Mean Values in Centimeters and Degrees 




p\ - 


Holey MoO and 

etal* 2 * Wright*™ 

5-9 yrs 15-75 yrs 

n±282 n^237 

{140% (119M,7WF) 


VanAdrlchemi 
and van derKarst? 3 ' 

(34M,32F) 


Breurn . McGregor 
eta?* 3 etaf" 
18-38 S0-S9 yrs 

(27*4,20?) - (21 M, 26 F) 


Fitzgerald AAOl 
ctai** 4 
- '20-S2ys 
n~172 
(168 M, 4 F) 


?&i<f^&^& '■. $ 


Motion 


""■'■' ■:■<■'■■'■■'■ 


M f 


M F 




. 



6^7 cm 



5-7 cm 



7 cm 6 cm 



56* 54* 55 


60 




80 


60 


22 21 21 


18 


16-41 


25 


25 


33 31 30 


30 


18-38 


35 


25 


8 8 26 


26 




45 


30 


cal Association; F = female; M 


= male 







Flexion 
Extension 

Right lateral flexion 
Right rotation 

AAOS = American Association of Orthopaedic Surgeons; AMA • 

* Lumbar values obtained with use of the modified Schober method, 

f Lumbar values obtained using the modified-modified 5chober (simplified skin distraction) method 

* Lumbar values in the first column were obtained with the BROM II. Lumbar values in the second column were obtained with double 

inclinometers. 

4 Lumbar values obtained with the OSI CA-6000. 

1 Lumbar values for thoracolumbar extension and lateral flexion were obtained with a universal goniometer. Lower values are for ages 70-79 
years and higher values are for ages 20-29 years. 

NE: AAOS values for thoracolumbar motions were obtained with a universal goniometer. AMA values were obtained with use of the two- 
inclinometer method for lumbar motions of flexion, extension, and lateral flexion. The value for rotation is for the thoracolumbar spine. 



.; 

J 
Is 

::; 



Y 



table a-9 Temporomandibular Motions: Mean Values in Millimeters 





Walker, Bohannon, and Cameron* ss 


Phillips el of * 


Hig%teetar*? 


^^SfS^^ttHuiiwai^f 




21-61 yrs 




18-54 yrs Jfi| 


17-25 yrs 


"-■'Sfcfcyn/. 




n = 15 




. n « 40 


WSiii?^ so 


n~SQ . - 




M 12 F) 




. (2Q*A s 2t}F) 
Read PosHforu 


(2SM,25F) 


(25 M.2SF) 










■Motion : ■., 






Fwd Ntut Retract 


M F 


M 



Opening 

Left lateral Deviation 
Right lateral Deviation 
Protrusion 



43 
9 
9 
7 



40-50 
8-12 



45 42 



36 



5 



61 


55 


58 


51 


9 


8 


8 


6. 


10 


9 


7 


9 


5 


5 


5 


4 



Fwd = Forward; Neut = neutral; Retract = retracted. 

* Values were obtained for active range of motion (ROM) with an 1 1-cm plastic ruier marked in millimeters. 

* Values represent consensus judgments of normal ROM made at the Permanent Impairment Conference. 

* Values were obtained for active ROM with a ruler. 

s Values were obtained for active ROM with Vernier calipers as the measuring instrument 






380 



APPENDIX A 



I! 



:■■-. 



■ 






m 



REFERENCES 

1. Wanatabe, H, ct al: The range of joint motion of the extremities in 
healthy Japanese people: The differences according to age. (Cited 
in Walker, JM: Musculoskeletal development: A review, Phys Thcr 
71:878, 1991.} 

2. Boone, DC, and Azcn, SP: Normal range of motion of joints in 
male subjects. J Bone Joint Surg 61:756, 1979. 

3. Greene, BL, and Wolf, St.: Upper extremity joint movement: 
Comparison of two measurement devices. Arch Phvs Med Rehabil 
70:288, 1989. 

4. Walker, JM, et al: Active mobility of the extremities m older 
subjects. Phys Ther 4:919, 1984. 

5. Downey, PA, Fiebert, I, and Stackpole-Brown, JB: Shoulder range 
of motion in persons aged sixtv and older, {abstract). Phys Ther 
71:S75, 1991. 

6. American Academy of Orthopaedic Surgeons: Joint Motion: 
Method of measuring and recording. American Academy of 
Orthopaedic Surgeons, Chicago, 1965. 

7. American Medical Association: Guides to the Evaluation of 
Permanent Impairment, ed 3. AMA, Chicago 1988. 

8. Ellcnbecker, TS, et al: Glenohumeral joint internal and external 
rotation range of motion in elite junior tennis players. J Orthop 
Sports Phys Ther 24:336, 1996. 

9. Boon, AJ, and Smith, J: Manual scapular stabilization: Its effect on 
shoulder rotational range of motion. Arch Phys Med Rehabil 
81:978,2000. 

10. Lannan, D, Lehman, T, and Toland, M: Establishment of norma- 
tive data for the range of motion of the glenohumeral joint. Master 
of Science thesis, University of Massachusetts, Lowell, 1996, 

11. Skarilova, B, and Plevkova, A: Ranges of joint motion of the adult 
hand. Acta Chir Plast 38:67, I9M 

12. Hume, M, et al: Functional range of motion of the joints of the 
hand, J Hand Surg 15A;240, 1990. 

13. Malion, WJ, Brown, HR, and Nunley J A; Digital ranges of 
motion: Normal values in young adults. J Hand Surg 16A:882, 
1991. 

14. Jenkins, M, et al: Thumb joint motion: What is normal? J Hand 
Surg 2315:796, 1998. 

15. DeSmett, L, et al: Metacarpophalangeal and interphatnngeal flex- 
ion of the thumb: Influence of sex and age, relation to ligamentous 
injury. Acta Orhtop Belg 59:37, 1993. 

16. Waugh, KG, et al: Measurement of selected hip, knee and ankle 
joint motions in newborns. Phys Ther 63:1616, 1983. 

17. Drews, JE, Vraciu, JK, and Peliino, G: Range of motion of the 
lower extremities of newborns. Phvs Occup Ther Pediatr 4:49, 
1884. 

18. Schwarze, DJ, and Denton, JR; normal values of neonatal limbs: 
An evaluation of 1000 neonates. J Pediatr Orthop 13:758, 1993. 

19. Phelps, V,, Smith, LJ, and Hailum, A: Normal ranges of hip motion 



of infants between 9 
Neurol 27:785, 1985. 



and 24 months of age. Dev Med Child 



20. Roach, KK, and Miles, 'IT: Normal hip and knee active range of 
motion: The relationship of age. Phys Ther 71: 656, 1991. 

21. Greene, WB, and ileckman, |[.) (edsi: The Clinical Measurement 
of joint Motion. American Academy of Orthopaedic Surgeons 
Koscmnnt. til. 1994. 

22. Mecagni, C, et al: Balance and ankle range of [notion in commu- 
nity dwelling women aged 6-1-87 years: A correlational study. 
Phys Ther 80:1004, 200(1. 

23. McPoil, TG, and Cornwall, M\V: The relationship between static 
lower extremity measurement 1 , and rcarloot motion during walk- 
nig. PhysTher'24:309, 1996. 

24. Youdas, J, et al: Norma! range ol motion ot the cervical spine: An 
initial gomometric study. Phys Ther 72:770, 1992. 

25. Lint/., CA, Chen, J. and Bueh. I): Clinical validity and stability of 
active and passive Cervical range ol motion with regard to total 
and imiplanar motion. Spine 24:1082, 19 1 J9. 

26. Msieh, C-Y and Yeung, BVC': Active neck motion measurements 
with a tape measure. J Orthop Sports Phys Ther K:K8, I9S6. 

27. Balogun, jA, et al: Inter-and intratester reliability of measuring 
neck motions with tape measure and Myrin Gravity-Reference 
Goniometer, j Orthop Sports Phys Ther 9:248, 1989. 

28. American Medical Association: Guides to the [.valuation of 
Permanent Impairment, ed 4. AMA, Chicago, 1993. 

29. I laley, 5.M, Tula, \XL, (Jarniichaei, KM: Spinal mobility in young 
children. Phys Thcr (M:1697, |9W. 

30. Moll, JMH, and Wright, V: Normal range ol spinal mobility: An 
objective clinical study. Ann Rheum Dis 30:381, 1971. 

31. van Adrichem, JAM, and van der Korst, JK: Assessment of flexi- 
bility of the lumbar spine. A pilot study in children and adoles- 
cents. Scant! j Rheumatol 2:87, 1973, 

32. S5rcmn, J, Vt'iherg, J, and Bolton, JM: Reliability and concurrent 
validity of the- BROM II for measuring lumbar mobility. J 
Manipulative Physiol Ther 18:497, 1995. 

ii. Mcgregor, All, MacCarfhy, ID, and Hughes, SP: Motion charac- 
teristics of the lumbar spine in the normal population. Spine 
20:242!, 1995. 

34. Fitzgerald, CK, et a!: Objective assessment with establishment of 
normal values for lumbar spine range of motion. Phys Ther 
63:1776, 1983. 

35. Walker, N, Bohannon. R\V, Cameron, D: Validity of temporo- 
mandibular joust range of (notion measurements ohtaiued with a 
ruler. J Orthop Sports Phys Thcr 30:484, 2000. 

36. Phillips. DJ, et al: Guide to evaluation of permanent impairment 
ol the temporomandibular joint. | Craniomandibular Pract 
15:170. 1997. 

37. llighie, I\j, ct al: Effect of head position on vertical mandibular 
opening. J Orthop Sports Phys Thcr 29; 1 27. 1999. 

33. Thuruwald, PA: The effect of age and gender on normal temporo- 
mandibular joint movement. Phvsioiher Theory Pract 7:209, 
1991. 



m 



I 

i 

m 



:•.»;:■' 




T> T7 XT T^ T Y XI 



Joint Measurements 
by Body Position 




Shoulder 



Elbow 
Forearm 

Wrist 



Hand 
Hip 



Knee 

Ankle and foot 



Toes 
Cervical spine 



Thoracic and lumbar spine 



Temporomandibular joint 



Extension 


Flexion 
Abduction 
Medial rotation 
Lateral rotation 
Flexion 


Pronation 
Supination 
Flexion 
Extension 
Radial deviation 
Ulnar deviation 
All motions 




Extension 


Flexion 


Medial rotation 






Abduction 


Lateral rotation 






Adduction 








Flexion 






Subtalar inversion 


Dorsiflexion 


Dorsiflexion 




Subtalar eversion 


Plantar flexion 


Plantar flexion 






Inversion 


Inversion 






Eversion 


Eversion 






Midtarsal inversion 


Midtarsal inversion 






Midtarsa! eversion 


Midtarsal eversion 






All motions 


All motions 
Flexion 
Extension 
Lateral flexion 
Rotation 








Rotation 


Flexion 

Extension 

Lateral flexion ; 






Depression 








Anterior protrusion 








Lateral deviation 





381 



APPENDIX C 




Goniometer Price Lists 






i 



table c-1 Plastic Goniometers 



Jjpe 



:]Ske (in) 



5c?i&(degr£i3y 



increnieeti {degrees} Cos^tf. 5,. 



ErZ ReadjAMAR Full Circle 12V 2 

^international Goniometer 127., 
fiSOM (STER) Goniometer Full Circle 12 

Baseline ISOM 12 



0-1 80 and 0-360 

0-360 

0-360 



0-360 



ISOM Full Circle 



8 



0-360 



Full Circle 

::FuH Circle 

Full Circle 

International Goniometer 
E-Z Read JAMAR Half Circle 
Half Circle 
E-Z Read JAMAR Full Circle 



8 


0-90 and 0-180 


8 


0-90 degrees and 0-180 


8 


0-180 


77 8 


0-180 


6V4 


0-180 


6% 


0-180 


6 


0-180 



islSOM Full Circle 



0-360 



Pocket Goniometer 

Devore Pocket Finger Goniometer 

Royian Finger Goniometer 
: Roylan Finger/Toe Goniometer 
sDigit Goniometer 



0-180 
4x2'/e 0-180 

30 of hyperextension to 129 of flexion 
30 of hyperextension to 1 20 of flexion 

Measures 1 1 p of flexion and 40 of hyperextension 



19.95* 
17.95* 
18,49* 

17.95 s 
22.95 1 



8.99* 

10.00 s 

9.95 1 



Md 



5;95* 
8.95* 
11.95* 
10.95* 
7.95* 
3.95* 
9.95* 

7.49* 

?;95i 

*8:00 s 



m 



4.49* 
17.50* 
10,29** 
20.49" 
25.99* 



All prices are from 2002 catalogs except those for Sammons-Preston and Best Priced Products, which are from 2001 catalogs. 
*Sammons Preston 1-800-323-5547. 

* North Coast Medical 1-800-821-9391. 

* Best Priced Products 1-800-824-2939. 
5 Pro-Med Products 1-800-542-9297. 
''American 3-B Scientific 1-888-326-6335. 
" Smith-Nephew 1-800-558-8633, 



1 

1 ' 
»1 i 



383 



384 



APPENDIX C 




Size (in) Scale (degrees) 



Increment f (degrees) 



Full Circle Stainless Steel Goniometer 


14 


0-360, 0-180, and 180-0 


1 (thumb knob varies tension in arms) 


31.99* 


Haif Circle Stainless Steel Goniometer 


14 


0-180, and 180-0 


1 (nonlocking friction arm) 


35.95? 
27.99* 

34,95* 


Full Circle Stainless Steel Goniometer 
Black Aluminum X-Ray Goniometer 
Haif Circle Stainless Steel Goniometer 


14 
14 
8 


0-360, 0-180, 180-0 
0-180 and 180-0 
0-180 and 180-0 


1 (knob varies tension in arms and locks) 

2V2 {white radiopaque markings) 

1 (thumb knob varies tension in arms) 


39.95* 
35.99* 

15.99* ; 


Stainless Steel Metal Goniometer 


8 


0-180 


1 (thumb knob varies tension in arms and locks) 


20.95* '■ 
22.50* 1 


Black Aluminum X-Ray Goniometer 


8 


0-180 and 180-0 


2V2 (white radiopaque markings) 


27.99* 



Robinson Pocket Goniometer 



7 0-180 

7.25 0-180 

6 0-180 



15.95* 
13.95* 
17.95 5 
11.99* 



Standard Stainless Steei Finger Goniometer 6 

Deluxe Stainless Steel Finger Goniometer 6 

Deluxe Small Joint Stainless Steel Goniometer 5V2 



0-180 and 180-0 

0-180 and 180-0 
0-150 



23.99* 
27.95* 
31,99* 
32.95* 



Stainless Steel Finger Goniometer 



57a 



25.9S 5 

34.50* 
45.99' 



Stainless Steel Finger Goniometer 
Small Stainless Steel Finger Goniometer 

"Sammons Preston 1-800-323-5547. 
f Flag House 1-800-793-7900. 
♦North Coast Medical 1-800-821-9319. 
^Best Priced Products 1-800-824-2939. 
1 Smith-Nephew 1-800-558-8633. 



0-150 



3'/2 



29.95* 
23.99* 



'-1 



APPENDIX C GONIOMETER PRICE LIST 



385 



f TABLE C-3 Inclinometers 


'■'■.. ^-->^.. 




JW 


Features'.; M- -;;"■' 


......... 

Cost (U.S. $) . 


Universal Inclinometer (fluid based) 

Universal Inclinometer (fluid based) 


A^ftitfbie with clip or headband 
Available with two interchangeable bases 


59 S&M&5M 
69.99 1 ;: 


Baseline Bubble Inclinometer 


Size 4" x 3" with 360-degree rotating dial 


59.99* 
79.00* 

99.Q0 5 


■MIE Inclinometer (Bubble Inclinometer) 


Si2e 4" x 3" with 360-degree rotating dial 


95.00 1 
105.00" 
129.9S n 


PROsupmator Gravity Based fluid inclinometer 


Measures supination and pronation and ulnar 
and radial deviation on a 5-degree, 360 scale 


64.95" 
49.95 s 


Umlevel Dual Scale Inclinometer 
Baseline Digital Inclinometer 


1 -degree increments on one side and 2-degree 
increments on the other side 


1 1 5.00 1 
239.00* 


■Saunders Digital Inclinometer (methods, 
guides and protocol) 


Arch attachment for measuring irregular surfaces 
and ruler for radiographs and sacral base angles. 

On/off, alternate 0, and hold buttons 


299.99* 
319.95 n 


CROM (Cervical Range of Motion Instrument) includes 
!~ storage case and a manual with normal values 


Measures flexion/extension, rotation, lateral tilt, 
and protraction/retraction 


379.95 n 

349.99* 



BROM (lumbar range of motion instrument) 

* Best Priced Products 1-800-824-2939 

*The Saunders Group 1-800-966-3138 

* American 3B Scientific 1-888-326-6335 
1 ProMed products 1-800-542-9297 

5 North Coast Medical 1-800-821-9319 

"FlagHouse 1-800-793-7900 

" Sammons Preston 1-800-323-5547 



Measures lumbar range of motion 



475.95 n 



lip: 



.'■'■ 



m 



■ :.:(Si ; .= : . ,:.A^Hi.'i. 



\-: : --;"^W$£r¥^- 



APPENDIX D 




Numerical Recording 



Patient's 


Range of Motion — TMJ and Spine 
Name Date of Birth 




Left Right 








Date 














Examiner's Initials 














Temporomandibular Joint 














Depression 














Anterior Protrusion 














Lateral Deviation — Right 














Lateral Deviation — Left 














Comments: 














Cervical Spine 














Flexion 














Extension 














Lateral Flexion — Right 














Lateral Flexion — Left 














Rotation — Right 














Rotation — Left 














Comments: 














Thoracolumbar Spine 














Flexion 














Extension 














Lateral Flexion — Right 














Lateral Flexion — Left 














Rotation — Right 














Rotation — Left 














Comments: 














Lumbar Spine 














Flexion 














Extension 














Comments: 









> 






387 



388 



APPENDIX D 



Patient's 


Range of Motion — Upper Extremity 
Name P* 


te of Birth 






Left 


Right 








Date 














Examiner's Initials 














Shoulder Complex 














Flexion 














Extension 














Abduction 














Medial Rotation 














Lateral Rotation 














Comments: 














Glenohumcral 














Flexion 














Extension 














Abduction 














Medial Rotation 














Lateral Rotation 














Comments: 














Elbow and Forearm 














Flexion 














Supination 














Pronation 














Comments: 














Wrist 














Flexion 














Extension 














Ulnar Deviation 














Radial Deviation 














Comments: 









APPENDIX D NUMERICAL RECORDING FORMS 



389 



Patient's 


Range of Motion — Hand 


e of Birth 






Left 


Right 








Date 














Examiner's Initials 














Thumb 














CMC Flexion 














CMC Extension 














CMC Abduction 














CMC Opposition 














MCP Flexion 














IP Flexion 














IP Extension 














Index Finger 














MCP Flexion 














MCP Extension 














MCP Abduction 














PIP Flexion 














DIP Flexion 














Middle Finger 














MCP Flexion 














MCP Extension 














MCP Radial Abduction 














MCP Ulnar Abduction 














PIP Flexion 














DIP Flexion 














Ring Finger 














MCP Flexion 














MCP Extension 














MCP Abduction 














PIP Flexion 














DIP Flexion 














Little Finger 














MCP Flexion 














MCP Extension 














xVICP Abduction 














PIP Flexion 














DIP Flexion 














Comments: 












390 



APPENDIX D 



Patient's 


Range of Motion — Lower Extremity 

Nnmc Hn 


te of Birth 






Left 


Right 








Date 














Examiner's Initials 














Hip 














Flexion 














Extension 














Abduction 














Adduction 














Media! Rotation 














Lateral Rotation 














Knee 














Flexion 














Ankle 














Dorsifiexion 














Plantarflexiun 














Inversion — Tarsal 














F, version — Tarsal 














Inversion — Subtalar 














Eversion — Subtalar 














Inversion — Midtarsal 














Eversion — Midtarsal 














Great Toe 














MTP Flexion 














MTP Extension 














MTP Abduction 














IP Flexion 














Toe 














MTP Flexion 














MTP Extension 














MTP Abduction 














PIP Flexion 














DIP Flexion 














DIP Extension 














Comments: 









APPENDIX D NUMERICAL RECORDING FORMS 391 






Patient's 


Muscle Length 

Nnmp Da! 


e of Birth 






Left 


Right 








Date 














Examiner's Initials 














Upper Extremity 














Biceps Brachii 














Triceps Brachii 














Flexor Digitorum Profundus &C Superficial 














Extensor Digitorum 














Lumbricals 














Comments: 














Lower Extremity 














Hip Flexors — Thomas Test 














Rectus Femoris — Ely Test 














Hamstrings — SLR 














Hamstrings — Distal Hamstring Length Test 














Tensor Fascia Lata — Ober Test 














Gastrocnemius 














Comments: 









i 



■■. ■#;- 



index 



m - 



A *b" following a page number indicates a box; an *f" indicates a figure, and a "t" indicates a tabic. 



Abduction. Sec specific joints 
Achilles tendon 

anatomy of, 288, 288f 
Acromioclavicular joint 
anatomy of, 59, 59f 
arthrokinematics of, 60 
osteokinematics of, 59-60 
Active range of motion. See also Range of 
motion 
defined, 6-7 
testing of, 7 
Activities of daily living 
functional range of motion in 
ankle and foot, 250-252, 251f-252f, 2511 
cervical spine, 302f-303f, 302-303 
elbow, 96t, 96-97, 97f-98f 
hand, 143f, 143-144, 144t 
hip, 189f-190f, 189t, 189-192 
knee, 225, 226f-227f, 226t 
shoulder, 63, 64f-65f, 64 1 
thoracic/lumbar spine, 337f~338f, 

337-338 
wrist, 115t-116t, 115-117, U6f-117f 
Adduction. Sec specific joints 
Adductor longus and brevis muscles 
anatomy of, 207 

in Thomas test, 206f-211f, 206-211 
Adolescents 
low-back pain in, 337 
range of motion in 
ankle and foot, 247t 
cervical spine, 298t-299t 
elbow, 94, 94t 
hip, 184t, 186t 
knee, 224, 224t 
shoulder, 61, 61t 
thoracic and lumbar spine, 334, 

335t-336t, 336 
wrist, 113r, 113-114 
temporomandibular joint disorders in, 

368-369 
urban versus rural, 336 
Adults 
range of motion in, 11 
ankle and foot, 247t-248t, 247-248 



cervical spine, 298t-299t, 298-299 

elbow, 94-95, 95t 

hand, 142 

hip, 184t, 184-187, 186t 

knee, 223t-224t, 224-225 

shoulder, 6 It, 61-62 

temporomandibular joint, 367, 367t 

thoracic and lumbar spine, 334, 
335t-336t 

wrist, 113t, 113-114 
Age 

range of motion and, 11-12 

ankle and foot, 247, 247t~249t 

cervical spine, 297-299, 298t~299t 

elbow, 94t-95t, 94-95 

hand, 141 

hip, 184-187, 185t-186t 

knee, 223t-224t, 223-225 

shoulder, 61t, 61-62 

temporomandibular joint, 367, 367t 

thoracic and lumbar spine, 333-334, 
335t-336t 

wrist, 11 2f, 112-113 
Alignment 

in ankle and foot testing 

for toe abduction, 285, 285f 

anatomical landmarks for, 255f, 263f, 
269f, 279f 

for dorsiflexion, 257f-259f, 257-258 

for eversion, 267, 267f-268f, 273, 273f, 
277f-278f, 277-278 

for toe extension, 282, 283f 

for toe flexion, 280, 281 f, 286-287 

for inversion, 265, 2631, 271, 271 f, 274, 
275 f 

for muscle length, 290, 290f 

for plantarflexion, 261, 262f 
in cervical spine testing 

anatomical landmarks for, 307f-309f 

for extension, 314f-317f, 315-317 

for flexion, 310f-313f, 311-313, 

for lateral flexion, 318, 319f-323f, 
321-323 

for rotation, 324, 325f-328f, 326, 328 
in elbow testing 

anatomical landmarks for, 99, 99f 



for extension, 102 

for flexion, 100, lOlf 

of muscle length, 107, 107f, 109, 109f 

for pronation, 103, 1031" 

for supination, 105, 105f 
general procedures for, 27f-29f, 27-30 

exercise for, 30 
in hand testing 

for abduction, 150, 151f, 164, 165f 

for adduction, 152, 153f 

anatomical landmarks for, 145f 

for extension, 148, 149f, 154, 158, 162, 
163f, 172, 175 

for flexion, 146, 147f, 156, 156f-157f, 
160, 161f, 170, 171f, 173, 174f 

for muscle length, 178, 179f 

for opposition, 168, 168f-169f 
in hip testing 

for abduction, 198, 199f 

for adduction, 201, 201 f 

anatomical landmarks for, 192f-193f 

for extension, 196, 197f 

for flexion, 194, 195f 

for lateral rotation, 205, 205f 

for medial rotation, 203, 203f 

for muscle length, 210, 2Uf, 214, 215f, 
218, 219f 
in knee testing 

anatomical landmarks for, 229f 

for extension, 232 

for flexion, 230, 231f 

for muscle length, 232, 235, 235f, 239, 
239f 
in shoulder testing, 68, 68f-69f 

for abduction, 80, 80f-81f 

anatomical landmarks for, 68f-69f 

for extension, 76, 76f-77f 

for flexion, 72, 72f-73f 

for lateral rotation, 88, 88f-89f 

for medial rotation, 84, 84f~85f 
in temporomandibular joint testing 

anatomicm landmarks far, 370f 

for depression, 370, 371f 

for lateral deviation, 373, 373f 

for protrusion, 372, 372f 
in thoracic and lumbar spine testing 

393 



394 



INDEX 



Alignment (Continued) 

anatomical landmarks for, 343f 

for extension, 357f-359f, 357-359 

for flexion, 346, 346f-347f, 350f-351f, 
350-351 

for rotation, 360, 361f-363f, 362 
in wrist testing 

anatomical landmarks for, 119f 

for extension, 122, 123f 

for flexion, 120, 121f 

of muscle length, 131, !31f, 135, 
135f 

for radial deviation, 124, 125f 

for ulnar deviation, 126, I27f 
American Academy of Orthopaedic 
Surgeons 
range of motion findings of 

ankle, 246, 246t, 378t 

elbow, 94, 94t, 375t 

foot, 246, 246t, 378t 

hand, 140t, 140-141, 376t-377t 

hip, 1S4, 184t,377t 

knee, 224, 377t 

shoulder, 60, 60t, 375t 

spine, 333, 334t, 378t-379t 

wrist, 112t, 112-113, 375t 
American Medical Association 
range of motion findings of 

ankle, 246, 246t, 378t 

elbow, 94, 94 1, 375t 

foot, 246, 246t, 378t 

hand, 140t, 140-141, 376t-377t 

hip, 184, 184t, 377t 

knee, 223t, 223-224, 377t 

shoulder, 60, 60t, 375t 

spine, 298t, 333, 334t, 378t-379l 

wrist, U2t, 112-113, 375t 
recording guide of, 34 
Anatomical landmarks 
goniometer alignment using, 27, 27f 

ankle, 255f, 263f, 269 f 

cervical spine, 307f-309f 

elbow, 99, 99f 

foot, 255f, 263f, 269f, 279f 

hand, 145f, 159f 

hip, 192f-193f 

knee, 229f 

shoulder, 68f-69f 

temporomandibular joint, 370f 

thoracic and lumbar spine, 343f 

wrist, 119f 
Anatomy 
ankle and foot, 241, 242f-246f, 243-245 
cervical spine, 295f-297f, 295-296 
elbow, 91 f-93f, 91-93 
hand, 137f-139f, 137-139 
hip, 183f-184f, 183-184 
knee, 221f-222f, 221-222 
shoulder, 57-60, 5Sf-59f 
(emporomandibular joint, 365, 365f~366f 
thoracic and lumbar spine, 331-333, 

332f-333f 
wrist, lllf~112f, 111-112 
Ankle. See also Foot 
anatomical landmarks of, 255f, 263f, 269f 
anatomy of, 241-244, 242f-244f 
arthrokinematics of, 241, 243-245 



capsular pattern in, 241 
dorsifiexion of 

end-fee! determinations and, 20 

functional range of motion in, 250-252, 
25tf-252f, 251 1 

reliability of testing of, 253, 253t 

research findings in, 248t-249t, 248-249 

talocrural testing of, 256f-259f, 256-259 
eversion of 

reliability of testing of, 253, 254t 

Subtalar testing of, 272f-273f, 272-273 

tarsal testing of, 266f-268f, 266-268 
inversion of 

reliability of testing of, 253, 254t 

subtalar testing of, 270f-271f, 270-271 

tarsal testing of, 264f-265f, 264-265 
osteokinematics of, 241, 243-244 
plantarflexion of 

functional range of moiion in, 250-252, 
251f, 251 1 

reliability of testing of, 253, 253t 

talocrural testing of, 260f-262f, 260-262 
range of motion of 

age and, 247, 247f 

disease and, 250 

functional, 250-252, 251f-252f, 251t 

gender and, 248t, 248-249 

injury and, 250 

normative values for, 378t 

numerical recording form for, 390f 

reliability and validity in testing of, 
252-254, 253t-254t 

research findings in, 246t-248t, 246-247 
subtalar eversion of 

testing of, 272f-273f, 272-273 
subtalar inversion of 

testing of, 270f-271f, 270-271 
talocrural dorsifiexion of 

testing of, 256f-259f, 256-239 
talocrural plantarflexion of 

testing of, 260f-262f, 260-262 
tarsal eversion of 

testing of, 266f-268f, 266-268 
tarsal inversion of 

testing of, 264f-265f, 264-265 
Ankylosis 
sagittal-frontal-transverse-rota tion 

method of recording, 34 
Anterior-posterior axis 

defined, 4, 5f 
Arm. See also specific joints; Upper- 
extremity testing 
muscle length testing in, 106f-109f, 

106-107 
range of motion of, 99f-105, 99-105 
structure and function of, 91f-93f, 91-93, 

106f, 108f 
Arthrokinematics 
of acromioclavicular joint, 60 
of atlanto-occipital and atlantoaxial joints, 

296 
of carpometacarpal joint, 138-139 
defined, 4 

of glenohumeral joint, 57-58 
of humeroulnar and humeroradial joints, 

92 
of iliofemoral joint, 184 



of interphalangeal joints 

toes, 246 

fingers, 138 

thumb, 140 
of intervertebral and zygapophysenl 

joints, 297 
of lumbar spine, 333 
of melacarpGphalangeal joints, 138-139 
of metatarsophalangeal joints, 245 
of midtarsal joint, 245 
of radioulnar joints, 93 
of scapulothoracic joint, 60 
of sternoclavicular joint, 59 
of subtalar joint, 243-244 
of talocrural joint, 241 
of tarsometatarsal joints, 245 
of temporomandibular joint, 366 
of thoracic spine, 332 
of tibiofemoral and patellofemoral joints, 

??? 

of tibiofibular joints, 241 

of wrist, 112 
Ascending stairs 

range of motion necessary for 
ankle and foot, 251, 251f, 25lt 
hip, 189, lS9f, lS9t 
knee, 225, 226f, 226t 
Athletes 

ankle sprains in, 250 

low-back pain in, 337 
Atlantoaxial joint. See also Cervical spine 

anatomy of, 295, 295f 

arthrokinematics of, 296 

osteokinematics of, 295-296 
Atlanto-occipital joint. See also Cervical 

spine 

anatomy of, 295, 295f 

arthrokinematics of, 296 

capsular pattern in, 296 

osteokinematics of, 295-296 
Axes 

in osteokinematics, 4. 5f 



B 

Back Range of Motion Device 

price of, 385t 

reliability of, 339t, 340 
Ballet 

range of motion of hip and, 18S 
Baseball players 

shoulder rotation in, 62-63 
Basic concepts, 3-14 
Beighton hypermobility score, 10, lit 
Benign joint hypermobility syndrome 

defined, 10 
Biceps brachii muscle 

muscle length testing of, 106f-107f, 
106-107 
Biceps femoris muscle 

anatomy of, 212, 2I2f, 236, 236f 

in distal hamstring length test, 236f-239f, 
236-239 

in straight leg test, 212f-215f, 212-215 
Biological variation 

standard deviation indicating, 44, 44t 
Body position 



■ ; ) 






,\ 



■ 



'..; 



■;.< 



INDEX 



395 



■ : 



■/<m 



m. 









joint measurements and, 381t 
Body size 
range of motion and 
ankle and foot, 230 
cervical spine, 302 
Body-mass index 
range of motion and 
elbow, 95 
hip, 187 
knee, 225 
shoulder, 62 
Bubble goniometers, 24-25, 25f 



CA-6000 Spine Motion Analyzer 
in cervical spine testing 
reliability of, 305 

testing position and, 301-302 
in thoracic and lumbar spine testing 

of functional activities, 337 

reliability of, 339t, 341-342 
Calcaneus 

anatomy of, 288, 288f 
Capsular fibrosis 

capsular pattern in, 10 
Capsular pattern of restricted motion 
of atlanto-occipitaf and atlantoaxial joints, 

296 
of carpometacarpal joint, 139 
defined, 9 
example of, 9b 
of glenohumeral joint, 58 
of humeroulnar and humeroradial joinls, 

92 
of iliofemoral joint, 184 
of interphalangeal joints 

fingers, 138 

thumb, 140 
of intervertebral and zygapophyseal 

joints, 297 
of lumbar spine, 333 
of metacarpophalangeal joints, 138-139 
of metatarsophalangeal joints, 245-246 
of midtarsal joint, 245 
of radioulnar joints, 93 
in range of motion testing, 9t, 9-10 
of subtalar joint, 244 
of talocrural joint, 241 
of temporomandibular joint, 366-367 
of thoracic spine, 332 
of tibiofemoral and patellofemoral joints, 

222 
of tibiofibular joints, 241 
of wrist, 112 
Carpal tunnel syndrome 
wrist position and, 117 
Carpometacarpal joints. Sec alio Hand 
anatomy of, 137f, 138 
arthrokinematics of, 138-139 
capsular pattern of, 1 39 
osteokinematics of, 1 38 
range of motion of, 140-141, 141t 

normative values for, 377t 
Carrying angle 
elbow, 91-92 
Cervical Range of Motion Device 



in cervical spine testing 
of extension, 316-317, 317f 
of flexion, 312-313, 313f 
of lateral flexion, 322-323, 323f 
reliability of, 304t, 304-306 
research findings in, 298, 299t 
of rotation, 328, 32Sf 

price of, 385t 
Cervical spine, 295-328 

anatomical landmarks of, 307f-309f 

anatomy of, 295f-297f, 295-297 

arthrokinematics of, 296-297 

capsular pattern in, 296-297 

extension of 
age and, 299-301, 300t-301t 
testing of, 314f-317f, 314-317 

flexion of 
age and, 2991-301 1, 299-300 
testing of, 310f-313f, 310-313 

lateral flexion of 
testing of, 318f-323f, 318-323 

osteokinematics of, 295-297 

range of motion of 
age and, 297-299, 299t-301t 
body size and, 302 
functional, 302f-303f, 302-303 
gender and, 299t-301t, 299-301 
normative values for, 378t 
numerical recording form for, 387f 
reliability and validity of testing of, 

303-306, 304t 
research findings in, 297, 298t 
testing position and, 301-302, 381t 

rotation of 
ageand,300,300t-301i 
testing of, 324f-328f, 324-328 
Children 

range of morion in, 11 

ankle and foot, 247t, 247-248 
cervical spine, 299t 
elbow, 94, 94t 
hip, 184t-186t, 184-186 
knee, 223t-224t, 223-224 
shoulder, 61, 61t 
wrist, 113, 113t 
Clavicle 

as shoulder anatomical landmark, 68f 
Coefficients 

correlation, 45-47, 46t 
inrraclass, 46-47 

of variation 

in reliability evaluation, 45 
of replication, 45 
Collateral ligaments 

elbow, 91, 92f 
Concurrent validity 

criterion-related validity and, 39 
Construct validity 

applications of, 40-41 

defined, 40 
Content validity 

defined, 39 
Correlation coefficients 

intraclass, 46-47 

Pearson product moment, 46, 46t 

in reliability evaluation, 45-47, 46t 
Criterion-related validity, 39-40 



of extremity joint studies, 40 
of spinal studies, 40 
Cup holding 

range of motion necessary for 
hand, 143, 143f 
Cybex inclinometer 

in thoracic and lumbar spine testing, 
340 



Degrees of freedom of motion 

defined, 6 
Depression 

testing of mandibular, 370, 371 f 
Descending stairs 
range of motion necessary for 
ankle and foot, 251, 251 f, 251t 
hip, 189, 189f, 189t 
knee, 225, 226f, 226t 
Deviation. See specific joints 
Devore goniometer 
price of, 383t 
reliability of, 144 
Dexter Hand Evaluation and Treatment 
System 

reliability of, 145 
Diabetes mellitus 

ankle and foot range of motion in, 250 
Disability 
range of motion and 
hip, 188-189 

thoracic and lumbar spine, 337 
Disorders. Sec also specific conditions 
ankle and foot, 250 
temporomandibular joint, 368-369 
Distal goniometer arm 

defined, 28-29, 29f 
Distal hamstring length test, 236f-239f, 

236-239 
Distal interphalangeal joints. Sec 

Interphalangeal joints 
Distal tibiofibular joint. See Tibiofibular 

joints 
Doorknob turning 
range of motion necessary for 
wrist, 115, I15t, 116f 
Dorsal interossei muscles 
muscle length testing in, 176f-179f, 
176-179 
Dorsiflexton. Set - Ankle; Foot 
Double inclinometers 
in cervical spine testing 
of extension, 316, 316f 
of flexion, 312, 312f 
of lateral flexion, 322, 322f 
of rotation, 326, 327f 
in thoracic and lumbar spine testing 
age and, 334 
disability and, 334 
of flexion, 346, 346f-347f, 351, 351 f 
of lateral flexion, 35", 359f 
reliability of, 339 1, 339-340 
of rotation, 362, 362f-363f 
Down syndrome 

hypermobility in, 10 
Drinking 



396 



INDEX 



range of motion necessary for 

cervical spine, 302 
elbow, 96t, 96-97, 97f 
hand, 144 

shoulder, 63, 64t, 65f 
wrist, 115t, 116-117 
Driving 
range of motion necessary for 
cervical spine, 303, 303f 
Duchenne's muscular dystrophy 

testing reliability in, 65 
Dynamometers 

potentiometers and, 25 



Eating 

range of motion necessary for 

cervical spine, 302 

elbow, 96t, 96-97 

hand, 144 

shoulder, 63, 64t, 65 f 

wrist, 115t, 116-117 
Elbow. See (?/so specific joints 
anatomical landmarks of, 99, 99f 
anatomy of, 91f-93f, 91-93 
arthrokinematics of, 92-93 
capsular pattern in, 92-93 
carrying angle of, 91-92 
extension of 

end-feel determinations and, 21 

recording of, 31-32, 32f 

testing of, 102 
flexion of 

end-feel determinations and, 20 

exercise for, 30 

goniometer alignment for, 27f-2Sf, 
30 

recording of, 31, 31 f, 34b 

reliability studies of, 41 

testing of, 36, 100, lOOf 
hype rex tension of 

recording of, 31-32, 32f 
ligaments of, 91, 92f 
muscle length testing in, 106f-109f, 

106-109 
osteokinemattcs of, 92-93 
pronation of 

testing of, I02f-103f, 102-103 
range of motion 

testing position and, 381t 
range of motion of, 99M05f, 99-105 

age and, 94t-95t, 94-95 

body-mass index and, 95 

example of, 12b, 13f, 14b, 14f 

functional, 96t, 96-97, 97f-9Sf 

gender and, 95 

normative values for, 375t 

numerical recording form for, 3S8f 

reliability and validity in testing of, 
97-98' 

research findings in, 94t-95t, 94-96 

right versus left side and, 95 

sports and, 95-96 
supination of 

testing of, 104f-105f, 104-105 
Elderly ad tills 



range of motion in, 11 

ankle and foot, 247t-248t, 247-248 

cervical spine, 289-299, 299t 

elbow, 95, 95t 

hip, 184t, 186t, 186-187 

knee, 223t-224t, 224-225 

shoulder, 6! 

thoracic and lumbar spine, 334, 
335t-336t 

wrist, 113 
Electrogoniometers 
in elbow testing, 98 
overview of, 25-26 
Ely test 
of rectus femoris muscle length, 232-235, 

233f-235f 
End-feels 
abnormal, 8t 
in ankle and foot 

abduction of, 284 

dorsiflexion of, 20, 257 

aversion of, 267, 273, 277 

extension of, 282 

flexion of, 280, 286-287 

inversion of, 265, 271, 274 

muscle length testing in, 289 

plantarflexion of, 261 
in cervical spine 

extension of, 314-315 

flexion of, 310 

lateral flexion of, 318 

rotation of, 324 
defined, S 
in elbow 

extension of, 21, 102 

flexion of, 20, 100 

muscle length testing in, 107, 109 

pronation of, 102 

supination of, 105 
in hand 

abduction of, 150, 164 

adduction of, 152 

extension of, 148, 154, 158, 162, 172, 175 

flexion of, 146, 156, 160, 170, 173 

muscle length testing in, 176, 178 

opposition of, 1 68 
in hip 

abduction of, 198 

adduction of, 201 

extension of, 196 

flexion of, 194 

muscle length testing in, 210, 213-214, 
218 

rotation of, 203, 205 
in knee 

extension of, 232 

flexion of, 230 

muscle length testing in, 238 
normal, 8t 

in ankle and foot testing, 257, 261, 
265, 267, 271, 273-274, 277, 280, 282, 
284 

in cervical spine testing, 310-311, 
314-315,318,324 

in elbow testing, 100, 102, 105, 107, 
109 

in hand testing, 146, 148, 150, 152, 154, 



156, 160, 162, 164, 168, 170, 172-173 




in hip testing, 194, 196, 198, 201, 203, 


i 


205,210,213,218 


: 


in knee testing, 230, 232, 238 


j 


in shoulder testing, 72, 76, 80, 84, 88 


i 


in temporomandibular joint testing. 


1 


370, 371-373 


\ 


in thoracic and lumbar spine testing. 




344, 348, 352, 354, 357, 360 


y 


in wrist testing, 120, 122, 126 


: 


in range of motion testing, 8, 8t 


1 


general procedures for, 20-21 


1 


in shoulder 


i 


abduction of, 80 


1 


extension of, 76 


! 


flexion of, 72 




lateral rotation of, 88 


■ 1 


medial rotation of, 84 


i 


in temporomandibular joint 


. | 


depression of, 370 


;| 


lateral deviation of, 373 


protrusion of, 372 


; 3 


in thoracic and lumbar spine 


v'i 


extension of, 352, 354 


i 'j , ji 


flexion of, 344 


■-_".! 


lateral flexion of, 348, 357 


>:| 


rotation of, 360 


if 


in wrist 




extension of, 122 


r,j 


flexion of, 120 


: [■■::' 


muscle length testing in, 130, 133 


-v1 


radial deviation of, 124 




ulnar deviation of, 126 


ri-'-i 


Errors 


ft: 


measurement, 29, 4], 43 




Eversion. See Ankle; Foot 


'■-'=-' m 


Exos Handmaster 


: s? 


reliability- of, 144 




Explanation procedures, 34-35 


■ £: 1 


example of, 34-35 


ffi;| 


exercise for, 36 




Extension. See specific joints 




Extensor digiti minimi muscle 


■ Wi 


muscle length testing of, 132M35, 


/'■'■''$%■'■ 


132-135 


;..■;/■;; 


Extensor digitorum muscle 


'-:&,'. 


muscle length testing of, 132f-135, 




132-135 


Extensor indicis muscle 


m 


muscle length testing of, 132M35, 


■:'^ 


132-135 


.'['My. 


Extremity joint studies 


M 


criterion-related validity of, 40 


■^ i 



Face validity 


: :-::-™l'^ 


types of, 39 
FASTRAK system 




in thoracic and lumbar spine testing, 
341-342 


'HI 


Finger. See also Hand 
anatomy of, 137f-139f, 137-139 

arthrokinematics of, 138 


'■::■' ■'■"■ 


capsular pattern in, 138 

osteokinematics of, 137-138 




range of molion of, 140, 140t-141t 


':;::-;|||: 







INDEX 



397 



functional, 145-144, 144t 

normative values for, 376t 

numerical recording form for, 389f 
Fingertip-to-floor method 

in thoracic and lumbar spine testing 

of flexion, 345 

of lateral flexion, 358, 358f 

reliability of, 340-341 
Fishermen 

lumbar and thoracic spine testing in, 

335-336 
Flexible rulers 

in cervical spine testing 

reliability of, 306 
in thoracic and lumbar spine testing 

age and, 334 

reliability of, 341 
Flexion. See specific joints 
Flexor digitorum muscles 
muscle length testing in, 128f-131f, 

128-131 
Flexor muscles of hip 
anatomy of, 206f, 206-207 
muscle length testing in, 206f-2Hf, 

206-211 
Fluid goniometers, 24-25, 25f 
reliability of 

in elbow testing, 98 

in knee testing, 228 
Foot. See also Ankle 

anatomical landmarks of, 255f, 263f, 269f, 

279f 
anatomy of, 241-245, 242f-245f 
arthrokinematics of, 245 
dorsiflexion of 

functional range of motion in, 250-252, 
251 f 

reliability of testing of, 253, 253t 
eversion of 

reliability of testing of, 253, 254t 

transverse tarsal testing of, 276f-278f, 
276-278 
interphalangeal extension of 

testing of, 287 
interphalangeal flexion of 

testing of, 287 
inversion of 

reliability of testing of, 253, 254t 

transverse tarsal testing of, 274f-275f, 
274-275 
metatarsophalangeal abduction of 

testing of, 284f-285f, 284-285 
metatarsophalangeal adduction of 

testing of, 286 
metatarsophalangeal extension of- 

testing of, 282f-283f, 282-283 
metatarsophalangeal flexion of 

testing of, 280f-281f, 280-281 
osteokinematics of, 245-246 
plantarflexion of 

functional range of motion in, 250, 
251f 

reliability of testing of, 253, 253t 
range of motion of 

age and, 247, 247f 

disease and, 250 

functional, 250-252, 251f 



gender and, 248t, 248-249 

injury and, 250 

normative values for, 378 1 

numerical recording form for, 390f 

reliability and validity in testing of, 
252-254, 253t-254t 

research findings in, 246t, 246-247 

testing position and, 249t, 249-250, 
381 1 
transverse tarsal eversion of 

testing of, 276f-278f, 276-278 
transverse tarsal inversion of 

testing of, 274f-275f, 274-275 
Forearm, 91-109. Sec also Elbow 
anatomical landmarks of, 99, 99f 
range of motion 

testing position and, 381 1 
range of motion of, 99f-105f, 99-105 

normative values for, 375 1 

numerical recording form for, 388f 
structure and function of, 91f~93f, 91-92 
Forefoot. See also Foot 
in transverse tarsal eversion testing, 

276f-278f, 276-278 
in transverse tarsal inversion testing, 

274f-275f, 274-275 
Freedom of motion degrees 

defined, 6 
Frontal plane 

defined, 4, 5f 
Fulcrum 

in goniometer alignment, 29 
Functional axial rotation device 

in thoracic and lumbar spine testing, 

341 
Functional range of motion 
ankle and foot, 250-252, 251f~252f, 251 1 
cervical spine, 302f-303f, 302-303 
elbow, 96t, 96-97, 97f-98f 
hand, 143f, 143-144, 144t 
hip, 189f-190f, 189t, 189-192 
knee, 225, 226f-227f, 226t 
shoulder, 63, 64 f-65f, 64t 
thoracic and lumbar spine, 337f-338f, 

337-338 
wrist, 115t-116t, 115-117, 116f-117f 



Gastrocnemius muscle 
anatomy of, 288, 288f 
muscle length testing in, 288f-291f, 
288-291 
Gender 

range of motion and, 12 

ankle and foot, 248t, 248-249 
cervical spine, 299t-300t, 299-301 
elbow, 95 
hand, 141, 141t 
hip, 186t, 187 
knee, 225 

shoulder, 60t, 61-62 
temporomandibular joint, 367-368 
thoracic and lumbar spine, 334—335, 

335t-336t 
wrist, 114 
Glenohurneral joint 



anatomy of, 57, 57f-58f 
arthrokinematics of, 57-58 
capsular pattern of, 58 
osteokinematics of, 57 
range of motion of 

abduction in, 78, 79f, 80 

extension in, 74, 75f, 76 

flexion in, 70, 71f,72 

lateral rotation in, 86, 87f, 88 

medial rotation in, 82, 83f, 84 

normative values for, 376t 

numerical recording form for, 388f 

research findings in, 60t, 60-61 
Goniometers, 21-27, 22f-25f. See also 
specific types of instruments 
alignment of, 27f~29f, 27-29. See also 

Alignment 
electrogoniometers as, 25-26 
fluid (bubble), 24-25, 25f 
gravity-dependent, 24-25, 25f 
measurement errors with, 29 
metal, 22 

pendulum, 24, 25f 
plastic, 22 

price lists for, 383t-385t 
proximal and distal arms of, 28-29, 29f 
recording of measurements with, 29-34, 

31f-33f 
reliability of, 41-43, 43t 

in ankle and foot testing, 252-254, 
253t-254t 

in cervical spine testing, 303-306, 304t 

in elbow testing, 98 

in hand testing, 144-145 

in hip testing, 190-192, 1916 

in knee testing, 227t, 227-228 

in shoulder testing, 66-67 

in temporomandibular joint testing, 
369 

in thoracic and lumbar spine testing, 
338-342, 339t 

in wrist testing, 117-119 
universal, 21-24, 22f-24f. See also 

Universal goniometer 
visual estimation versus, 26-27 
Goniometry 
basic concepts in, 3f, 3-14, 5f-7f, 8t-9t, 

lit, 13f-14f 
basic objectives in, 1 
defined, 3 
example of, 3b, 3f 
explanation procedure for, 34-36 
indications for, 4 
testing procedures in, 35-36 
Gravity-dependent goniometers 
overview of, 24-25, 25f 
reliability of 

in cervical spine testing, 303, 306 

in thoracic and lumbar spine testing, 
340-341 
Gripping 

range of motion necessary for 

hand, 143f, 143-144 
Grooming. See Personal care activities ..■■. 
Guides to the Evaluation of Permanent 
Impairment, 34 



398 



INDEX 



Hamstrings 
muscle length testing in, 212f-215f, 

212-215 

distal, 236f-239f, 236-239 
Hand, 137-179 
anatomical landmarks of, 1451, 159f 
anatomy of, 137f-139f, 137-139 
arthrokinematics of, 138-140 
capsular partem in, 138-140 
carpometacarpal abduction of 

testing of, 164, 164f-165f 
carpometacarpal adduction of 

testing of, 166 
carpometacarpal extension of 

testing of, 162, 162f-163f 
carpometacarpal flexion of 

testing of, 160, I60f-161f 
carpometacarpal opposition of, 166, 

167f-169f, 168 
inlerphalangeal extension of 

testing of, 154, 158,175 
inlerphalangeal flexion of 

testing of, 152, 152f-153f, 155, 

155f-157f, 173, 173f-174f 

metacarpophalangeal abduction of 

testing of, 150, 150f-I51f 
metacarpophalangeal adduction of 

testing of, 152 
metacarpophalangeal extension of 

testing of, 148, 148f-149f, 172 
metacarpophalangeal flexion of 

testing of, 146, I46f-147f, 170, 
170M7U 
muscle length testing in, 176f-179f, 

176-179 
osteokinematics of, 137-140 
range of motion of, 140-175 

age and, 140-142 

functional, 143f, 143-144, 144t 

gender and, 140-142, 141t 

normative values for, 376t-377t 

numerical recording form for, 389f 

reliability and validity in testing of, 
144-145 

research findings in, 140t-141t, 
140-144, I43f, 144t 

right versus left sides and, 142 

testing position and, 142-143, 
381 1 
Head. Sec also Cervical spine; 
Temporomandibular joint 
temporomandibular joint and position of, 

368 
Hereditary disorders 

hypermobility in, 10 
Hip 
abduction of 

testing of, 198, 198f-199f 
adduction of 

testing of, 200, 200f-20 If 
anatomical landmarks of, 192f-193f 
anatomy of, 183f-184f, 183-184 
arthrokinematics of, 184 
capsular pattern in, 184 
extension of 

testing of, 195, 196f-197f 



flexion of 

recordings of, 33f 

testing of, 194, 194f-195f 
lateral rotation of 

testing of, 204, 204f-205f 
medial rotation of 

testing of, 202, 202f-203f 
muscle length testing in 

of flexors, 206f-211f, 206-211 

of hamstrings, 212f-215f, 212-215 

Ober test in, 216f-219f, 216-219 

straight leg test in, 212f-215f, 
212-215 

of tensor fasciae latae, 216f-219f, 
216-219 

Thomas test in, 206f-211f, 206-211 
osteokinematics of, 183-184 
positioning of 

example of, 18b, 19f 
range of motion of 

age and, 184t-186t, 184-187 

ballet and, 188 

body-mass index and, 187 

disability and, 188-189 

example of, 12b, 13f 

functional, 189f-190f, 189t, 189-190 

gender and, 187 

normative values for, 377t 

numerical recording form for, 390f 

reliability and validity in testing of, 
190-192, 191 1 

research findings in, 184t~186t, 184-189 

sagittal-frontal-transverse- rotation 
method of recording, 33b-34b 

sports and, 188 

testing position and, 187-188, 188t,381t 
House painting 
range of motion necessary for 

cervical spine, 303 
Humeroradial joint. See also Elbow 
anatomy of, 91f-92f, 91-92 
arthrokinemotics of, 92 
osteokinematics of, 92 
Humeroulnar joint. See also Elbow 
anatomy of, 91f-92f, 91-92 
nrlhrokinematics of, 92 
osteokinematics of, 92 
Humerus 

as shoulder anatomical landmark, 68f-69f 
Hydrogoniometers 
in shoulder testing, 67 
in thoracic and lumbar spine testing 

age and, 334 
Hypermobility 
causes of, 10 
defined, 10 

in range of morion testing, 10, lit 
Hypermobility syndrome 

defined, 10 
Hypomobility 
causes of, 9 
defined, 8-9 

in range of motion testing, 8-10, 9t 
sagittal-frontal- transverse- rotation 

method of recording, 34 



I 
Iliacus muscle 
anatomy of, 206, 206f 
in Thomas test, 206f-21lf, 206-211 
Iliofemoral joint 
anatomy of, 183f-184f, 183-184 
arthrokinematics of, 184 
capsular pattern in, 184 
osteokinematics of, 183-1S4 
Iliotibial band 
anatomy of, 216, 216f 
Ober test, 216f-219f, 216-219 
Inclinometers 
in cervical spine testing 

of extension, 316, 316f 

of flexion, 312, 312f 

of lateral flexion, 322, 322f 

of rotation, 326, 327f 
overview of, 24-25, 25f 
price list for, 385t 
reliability of, 42 

in ankle and foo! testing, 252 

in hip testing, 192 

in shoulder testing, 67 

in thoracic and lumbar spine testing, 
338-340, 339t 
in thoracic and lumbar spine testing 

age and, 334 

disability and, 334 

of flexion, 346, 346f-347f, 351, 351 f 

of lateral flexion, 359, 359f 

of rotation, 362, 362f-363f 
Index finger. See also Hand 
range of motion of, 14 It 

numerical recording form for, 389f 
Infants. See also Children 
range of motion in, 11 
Injury 
ankle and foot, 250 
repetitive wrist, 117 
Instruments, 21-27, 22f-25f. See also specific 
instruments 

electrogoniomelcrs as, 25-26 
grnvitv-dependent goniometers as, 24-25, 

25f 
universal goniometer as, 21-24, 22f-24f, 

26 
visual estimation versus, 26-27 
Interossei muscles 
muscle length testing in, 176f-179f, 

176-179 
Interphaiangeal joints 
foot. See also Poot 

anatomy of, 246, 246f 

arthrokinematics of, 246 

extension of, 287 

flexion of, 287 

osteokinematics of, 246 
hand. See also Hand 

anatomy of, 137f-139f, 138-139 

arthrokinematics of, 138, 140 

capsular pattern of, 138, 140 

extension of, 154, 158, 175 

flexion of, 152, 152f-153f, 155, 
155f-157f, 173, 173f-174f 

osteokinematics of, 138, 140 

range of motion of, 140, 140t-141t, 



% 



. 



m 



/-:■- 



INDEX 



399 



if 



:■. ■■.■■■ 



142 
range of motion of 
normative values for, 376t-377t 
Intertester reliability 
evaluation of, 42 

in ankle and foot testing, 252-254, 

253t-254t 
in cervical spine testing, 303-306, 304 1 
in elbow testing, 98 
exercise for, 50-51 
in hand testing, 144 
in hip testing, 19 It, 191-192 
in knee testing, 227t, 227-228 
in shoulder testing, 63, 65 
in temporomandibular joint testing, 369 
in thoracic and lumbar spine testing, 

338-342, 339t 
in wrist testing, ttS-119 
Intervertebral joints. See also Cervical spine 
anatomy of, 296, 296f 
arthrokinematics of, 297 
capsular pattern in, 297 
osteokinematics of, 296-297 
Intraclass correlation coefficient 
in reliability evaluation, 46-47 
Intratester reliability 
evaluation of, 42 
in ankle and foot testing, 252-254, 

253t-254t 
in cervical spine testing, 303-306, 304t 
in elbow testing, 98 
exercise for, 48-49 
in hip testing, 190-191, 191t 
in knee testing, 227t, 227-223 
in shoulder testing, 63, 65 
in temporomandibular joint testing, 369 
in thoracic and lumbar spine testing, 

338-342, 339t 
in wrist testing, 118-119 
Inversion. See Ankle; Foot 



I 

Jaw. Sec Temporomandibular joint 

Joint effusions 

capsular pattern in, 10 

Joint measurements 
body position and, 38 It 

Joint motion testing 
basic concepts in, 4-6, 5f 
body position and, 18t 
criterion-related validity of, 40 
reliability studies of, 41-43 



Knee 
anatomical landmarks of, 229f 
anatomy of, 221f, 221-222 
arthrokinematics of, 222 
capsular pattern in, 222 
extension of 

testing of, 232 
flexion of 

testing of, 230, 230f-231f 
goniometer for 

example of, 24b, 24f 



muscle length testing in 
distal hamstring length test in, 

236f-239f, 236-239 
Ely test in, 232-235, 233f-235f 

osteokinematics of, 222 

range of motion of 
age and, 223t-224t, 223-225 
body-mass index and, 225 
functional, 225, 226f, 226t-227f 
gender and, 225 
normative values for, 377t 
numerical recording form for, 390f 
reliability and validity in testing of, 

227t, 227-228 
research findings in, 223t-224t, 223-225 
testing position for, 18b, 381 1 
Kyphometers 

in thoracic and lumbar spine testing, 339 
Kyphosis 

occupational, 336-337 



Landmarks 
anatomical. See Anatomical landmarks 

Lifestyle 

in temporomandibular joint disorders, 

368-369 
thoracic and lumbar spine range of 
motion and, 335-337 
Ligaments 
elbow, 91, 92f 
wrist, lllf-112f, 111-112 
Little finger. See also Hand 
range of motion of, I4tt 

numerical recording form for, 3S9f 
Looking upward 
range of motion necessary for 
cervical spine, 302, 302f 
Lordosis 

occupational, 336-337 
Low-back pain 

range of motion and, 337 
Lower-extremity testing, 181-291. See also 
specific structures 
ankle and foot in, 241-291 
hip in, 183-219 
knee in, 221-239 

numerical recording forms for, 390f-391f 
objectives in, 181 
reliability studies of, 41-42 
Lumbar spine 
anatomical landmarks of, 343f 
anatomy of, 332-333, 333f 
arthrokinematics of, 333 
capsular pattern in, 333 
extension of 

testing of, 352f-355f, 352-355 
flexion of 

testing of, 344f-35if, 344-351 
lateral flexion of 

testing of, 356f-359f, 356-359 
osteokinematics of, 333 
range of motion 

testing position and, 381 1 
range of motion of 
age and, 333-334, 335t-336t 



disability and, 337 
functional, 337f-338f, 337-338 
gender and, 334-335, 335t-336t 
lifestyle and, 335-337 
normative values for, 379t 
numerical recording form for, 387f 
occupation and, 335-337 
reliability and validity of testing of, 

338-342, 339t 
research findings in, 333-337, 334t-336t 
rotation of 

testing of, 360f-363f, 360-363 
Lumbrical muscles 
muscle length testing in, 176M79f, 
176-179 



M 

Mandibular length. Sire also 
Temporomandibular joint 
range of motion and, 368-369 
Mean 
defined, 43 
standard error of, 47 
Measurement 

standard error of, 47-48 
Measurement errors 
defined, 43 

goniometer-related, 29 
reliability and, 41 

standard deviation indicating, 44-45, 
45t 
Measurement instruments, 21-27, 22f~25f. 
See also Goniometers; Instruments; other 
instruments 
Medial-lateral axis 

defined, 4, 5f 
Men. See Adults; Gender 
Metacarpophalangeal joints. See also Hand 
anatomy of, 137, 137f-139f, 139 
arthrokinematics of, 138-139 
capsular pattern of, 138-139 
osteokinematics of, 137-139 
range of morion of, 140, I40t-141t 
age and, 11, 12, 142 
gender and, 142 
normative values for, 376t-377t 
testing position and, 142-143 
Metal goniometers 
price list for, 384t 
Metatarsals 

in transverse tarsal eversion testing, 

276f-278f, 276-278 
in transverse tarsal inversion testing, 
274f-275f, 274-275 
Metatarsophalangeal joints. Sir also Foot 
abduction of 

testing of, 2S4f-285f, 284-285 
adduction of 

testing of, 286 
anatomical landmarks of, 279f 
anatomy of, 245, 246f 
arthrokinematics of, 245 
capsular pattern in, 245-246 
extension of 
normative values for, 378t 
testing of, 282f-283f, 282-283 



400 



INDEX 



flexion of 
normative values for, 378t 
testing of, 280f-281f, 280-281 

osteokinematics of, 245 

Midcarpal joint. See also Wrist 
anatomy of, lllf-112f, 111-112 
arthrokinematics of, 112 
osteokinematics of, 112 
Middle finger. See also Hand 
range of motion of, 141 1 
numerical recording form for, 389f 
Midtarsal joint. See also Ankle 
anatomy of, 244, 244f 
arthrokinematics of, 245 
capsular pattern in, 245 
osteokinematics of, 244 
Modified Schober test 
in thoracic and lumbar spine testing 
of extension, 355 
of flexion. 350, 350f 
reliability of, 340-341 
Modified-modified Schober test 

in thoracic and lumbar spine testing 
of extension, 354f, 354-355 
of flexion, 348f-349f, 348-349 
procedure for, 343 
Motion 
range of. See Range of motion; specific 

joints 
testing. Set' Testing motion 
Mouth opening 
in temporomandibular joint 
disorders of, 368-369 
head and neck positions and, 368 
mandibular length and, 368-369 
testing of, 370, 371 f 
Muscle length 
defined, 12 

testing of, 12-14, I3f-14f 
of biceps brachii, 106f-107f, 

106-107 
examples of, 12b, 13f, 14, 14f 
of extensor digitorum, indicis, and 
digiti minimi, 132f-135f, 132-135 
of flexor digitorum muscles, 128f-131f, 

128-131 
of gastrocnemius, 288f-291f, 288-291 
of hamstrings, 212f-215f, 212-215, 

236f-239f, 236-239 
of lumbricals and interossei, 176f-179f, 

176-179 
numerical recording form for, 

391f 
of rectus femoris, 232-235, 233f-235f 
of tensor fasciae latae, 216f-219f, 

216-219 
of triceps brachii, 108f-109f, 108-109 
Myrin OB Goniometer, 25 



N 

Neck. See also Cervical spine; 

Temporomandibular joint 

temporomandibular joint and position of, 
368 
Neutral zero method 



in range of motion testing, 6, 6f-7f 
NK Hand Assessment System 

reliability of, 145 
Noncapsular pattern of restricted motion 
defined, 10 
example of, 10b 
in range of motion testing, 10 
Normative values 
range of motion 

ankle and foot, 378t 

cervical spine, 378t 

elbow and forearm, 375t 

finger, 376t 

glenohumera! joint, 376t 

hip, 377t 

knee, 377t 

shouider, 375t 

temporomandibular joint, 379t 

thoracic and lumbar spine, 379t 

thumb, 377t 

wrist, 375t 
Numerical recording forms 
instructions for completing, 32, 32f 
for muscle length, 391 f 
for range of motion, 387f-391f 

of ankle and foot, 390f 

of elbow and forearm, 388f 

of hand, 389f 

of hip, 390f 

of knee, 390f 

of shoulder, 388f 

of spine, 387f 

of temporomandibular joint, 387f 

of wrist, 388f 



OD Myrin gravity goniometer 

in thoracic and lumbar spine testing 
reliability of, 340-341 
Ober test 

of tensor fasciae latae muscle length, 
216f-219f, 216-219 
Occupation 
range of motion and 
cervical spine, 303 
thoracic and lumbar spine, 335-337 
Opposition 

thumb, 166, 167f-169f, 168 
Optotrak motion analysis system 

in knee testing, 228 
Orthoranger goniometer 
reliability of 

in ankle and foot testing, 252 
in elbow testing, 98 
in hip testing, 190-191 
in shoulder testing, 66 
in wrist testing, 118 
Osteokinematics 
of acromioclavicular joint, 59-60 
of attanto-occipital and atlantoaxial joints, 

295-295 
of carpometacarpal joint, 138 
defined, 4 

of glenohumeral joint, 57 
of humeroulnar and humeroradial joints, 



92 
of iliofemoral joint, 183-184 
of interphalangcal joints 

foot, 246 

hand, 138 

thumb, 140 
of intervertebral and zygapophyseal 

joints, 296-197 
of lumbar spine, 333 
of metacarpophalangeal joints, 137-139 
of metatarsophalangeal joints, 245 
of midtarsal joint, 244 
planes and axes in, 4—6, 5f 
of radioulnar joints, 93 
of scapulothoracic joint, 60 
of sternoclavicular joint, 58 
of subtalar joint, 243 
of talocrural joint, 241 
of tarsometatarsal joints, 245 
of temporomandibular joint, 365-366 
of thoracic spine, 331-332 
of tibiofemoral and pateSlofemoral joints, 

222 
of tibiofibular joints, 241 
of wrist, 112 



Pain 
causes in passive range of motion of, 

7-8 
low-back, 337 
Palmar interossei muscles 
muscle length testing in, 176f-t79f, 
176-179 
Passive insufficiency 

defined, 12 
Passive range of motion. Sec also Range of 
motion 
defined, 7 
testing of, 7-8 
example of, 7b 
Pearson product moment correlation 
coefficient 

in reliability evaluation, 46, 46t 
Pectineus muscle 
anatomy of, 207 

in Thomas test, 206f-211f, 206-211 
Pendulum goniometers, 24, 25f 
reliability of 

in cervical spine testing, 305-306 
in elbow testing, 98 
Peripheral neuropathy 

ankle and foot range of motion in, 250 
Personal care activities 
range of motion necessary for 
cervical spine, 302 
shoulder, 63, 64f, 64t 
wrist, 116t, 116-117, U7f 
Picking up coin 
range of motion necessary for 
hand, 143, 143f 
Picking up object from the floor 
range of motion necessary for 
lumbar, 338, 338f 
Pictorial charts 






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INDEX 



401 






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J 






in goniometry recordings, 32, 33f 
Planes 

in osteokinematics, 4-6, 5f 
Plantarflexion. Sve Ankle; Foot 
Plastic goniometers 

price list for, 3B3t 
Plcurimcter inclinometer 

reliability of 
in hip testing, 192 

in thoracic and lumbar spine testing, 
339 
Plumb line and skin markings 

in thoracic and lumbar spine testing 
age and, 334 
reliability of, 340 
Positioning. See also Testing positions 

general procedures for, 17—18, 18t 
example of, 17 

importance of, 17 

joint measurements and, 381 1 

in range of motion testing, 18t 

reliability and, 43t 
Positions 

testing. Sir Positioning; Testing positions 
Posture 

spinal 

disability and, 337 
effects of stooped, 336-337 
Potentiometers, 25-26 
Pouring from pitcher 

range of motion necessary for 
wrist, 115t, 116 
Power lifters 

elbow range of motion in, 96 

shoulder rotation in, 63 
Price lists 

goniometer, 3S3t~385t 
Procedures, 17-36 

for alignment, 27f-29f, 27-30 

for end-feel testing, 20-21 

explanation of, 34-36 

instruments in, 21-27, 22f-25f. Sob ntsa 
Goniometers; Instruments; other 
instruments 

for positioning, 17-18, 18t 

for range of motion testing, 20-21. See also 
specific joints and structures 

for recording, 29-34, 31f-33f 

reliability and, 42 

for stabilization, 18-19, 19f 

testing, 35-36 
Pronation. See Elbow 
Protrusion 

testing of mandibular, 372, 372f 
Proximal goniometer arm 

defined, 28, 29f 
Proximal interphalangeal joints. See 

Interphalangeal joints 
Proximal tibiofibular joint. Sec Tibiofibular 

joints 
Psoas major muscle 

anatomy of, 206, 206f 

in Thomas test, 206f-211f, 206-211 
Putting on socks 

range of motion necessary for 
hip, 190, 190f 



knee, 227f 

lumbar, 338, 338f 



Radiocarpal joint. See also Wrist 
anatomy of, lllf-112f, 111-112 
arthrokincmatics of, 112 
osteokinematics of, 112 
Radiography 

in knee testing, 228 
Radioulnar joint See also Elbow 
anatomy of, 92f-93f, 92-93 
arthrokinematics of, 93 
osteokinematics of, 93 
Range of motion. See alio specific joints 
active, 6-7 

basic concepts in, 6-12 
defined, 6 
end-feels in, 8, 8t 
factors affecting, 10-12 
functional. See Functional range of 

motion 
hypermobility in, 10, lit 
hypomobility in, 8-10, 9t 
neutral zero method of testing, 6, 

6f-7f 

example of, 6b 
normative values for, 375t-379t 
notation systems for, 6 
numerical recording forms for, 

387f-391f 
passive, 7-8 

recording of, 29-34, 31f-33f 
reliability studies of, 41-43 

exercises for, 48-52 

statistical methods in, 43— IS 
testing procedures for, 20-21 
validity studies of, 40 
Reaching 

range of motion necessary for 

elbow, 96, 96t 

shoulder, 63, 64f-65f, 64t 

wrist, 116t, 116-117, H7f 
Reading a newspaper 
range of motion necessary for 

elbow, 96, 96t, 98f 
Rearfoot. See Subtalar joint 
Recordings 
numerical forms for, 387f-391f 

instructions for, 32, 32f 
procedures for, 29-34, 31f-33f 

AMA guides in, 34 

numerical forms in, 32, 32f 

pictorial charts in, 32, 33f 

sagittal-frontal-transverse-rotation 
method in, 33-34 
Rectus femoris muscle 
anatomy of, 206, 206f, 232, 233f 
in Ely test, 232-235, 233f-235f 
in Thomas test, 206f-211f, 206-211 
Reliability, 41-51 
of ankle and foot testing, 252-254, 

253t-254t 
of cervical spine testing, 303-306, 304t 
defined, 41 



of elbow testing, 97-98 
evaluation of, 43-51 

coefficient of variation in, 45 

correlation coefficients in, 45-47, 46t 

exercises for, 48-51 

intertester, 50-51 

intratester, 48-49 

standard deviation in, 43-45, 44t-45t 

standard error of measurement in, 
47-48 
goniometric study summary of, 31—13 
of hand testing, 144-145 
of hip testing, 190-192, 191 1 
of knee testing, 2271, 227-228 
recommendations for improving, 32-43, 

43t 
of shoulder testing, 63, 65-67 
of temporomandibular joint testing, 

369 
of thoracic and lumbar spine testing, 

338-342, 339t 
of wrist testing, 117-119 
Repetitive injury 

wrist, 117 
Replication 

coefficient of variation of, 45 
Right versus left side 
range of motion and 

elbow, 95 

hand, 141 

shoulder, 62-63 

wrist, 114 
Ring finger. See also Hand 
range of motion of, 14 It 

numerical recording form for, 389f 
Rising from chair 

range of motion necessary for 

ankle and foot, 251, 252f 

elbow, 96, 96t, 97f 

knee, 226f, 226t 

wrist, 115t, 116 
Rotation. See also specific joints 
sagittal-frontal-transverse-rotation 

method of recording, 33 
Rulers 
flexible. See Flexible rulers 
in temporomandibular joint testing 

of lateral deviation, 373, 373f 

of mouth opening, 370, 371 f 

of protrusion, 372, 372f 

reliability