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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
m
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
Published by
Jitendar P Vij
Jaypee Brothers Medical Publishers (P) Ltd
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*
To Alexandra, Taylor, and Kimberly.
CCN
To Jonathan, Alexander, and Ethan.
DJW
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Preface
it
it
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
v;..
Acknowledgments
;.'■:'■'--".".■: : ' Vj """ "'
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
ill
I
(intents
i
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
I
hi;:
:,
^4
:■■■■■;■:■■■
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
■
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
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4 tb
char
able.
Ic
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shou
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wer
mea
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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.
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CHAPTER 1
BASIC CONCEPTS
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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
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in a clinical setting. Phys Ther 63:1611, 1983.
Ekstrand, J, et al: Lower extremity goniometric measurements: A
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1982
3. Ball, P, and Johnson, GR: Reliability of hindfoot goniometry when 21.
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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.
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(ed): Therapeutic Exercise, ed 3, Williams & Wilkins, Baltimore,
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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.
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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.
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metric study of knee motion in normal gait. J Bone Joint Surg Am
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17. Krmtzen, KM, Bates, BT, and Hamill, J: Electrogoniometry of post-
surgical knee bracing in running. Am J Phys Med Rehabil 62:172,
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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-
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Low, JL: The reliability of joint measurement. Physiotherapy
62:227, 1976.
Moore, ML: The measurement of joint motion. Part I: Introductory
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Salter, N: Methods of measurement of muscle and joint function, j
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Greene, WB, and Heckman JD (eds): The Clinical Measurement of
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Gerhardt, jj, and Russe, OA; International SFTR. Method of
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■ ■ -^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
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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
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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
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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
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87.', White, Dj, et al: Reliability of three clinical methods of measttr-
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■■'i'/l Ther 67:759, 1987.
88.':: Mayer, RS, et a!: Variance in the measurement of sagittal lumbar
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89, r.Chen, SP, et al: Reliability of the lumbar sagittal motion meas-
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90. Breum, J, Wilberg, J, and Bolton, JE: Reliability and concurrent
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92. Dawson-Saunders, B, and Trapp, RG: Basic and Clinical
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93. Francis. K: Computer communication: Reliability. Phvs Ther
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94. Blesh, TE: Measurement in Physical Education, ed 2. Ronald
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97. Shout, PE, and Fleiss, JL: Inrraclass correlations: Uses in assess-
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98. Krebs, DE: Computer communication: Intraclass correlation
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104. Bartko, JJ: Rationale for reporting standard deviations rather
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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
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o
§
—
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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
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)-■
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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
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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.
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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_'.
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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.
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OS
ear
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5
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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.
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in:
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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
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4. Kalrenborn, FM: Manual Mobilization of the Extremity Joints,
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5. American Academy of Orthopaedic Surgeons: Joint Motion:
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8. Greene, BL, and Wolf, ST.: Upper extremity joint movement:
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9. Soderberg, GL: Kinesiology: Application to Pathological Motion.
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10. Doody, SG, Freedman, L, and Waterland, JC: Shoulder move-
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Rehabil 51:595, 1970.
1 1. Poppen, NK, and Walker, PS: Forces at the glenohumeral joint in
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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
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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.
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Kihk-r, Wb, er al: Shoulder range of motion in cine tennis play-
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Chang. DF. buschbaeker. LP. and Fdtich, RF: Limited joint
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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
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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
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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.
Rai
shi
me
EEC
stia
mei
■CU* 1. -U-
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.
■s
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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.
s
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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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104
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
St
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the dh«iv\ Ui Yl) ik-mvo, and *uppi-«*J tlu ' '"'"'•■'■irm.
Inin.ilK pcfeiiHtn the Um-mn inklwa> k-fww" supination
and pnimuuMi *• »*«« lh '- ,bu,nb '"""'" tmv '"' d ll,t ' umU
inji.
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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dis
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^ in |jj
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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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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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108
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
:|
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
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a
c
c
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b
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1
ul
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V:
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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;
Ryu
t
<
j
t
c
c
f
1
c
e
f
c
i
1
s;
o
M
C;
b
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 iyrisc EQM.
third
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Lateral
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Olecranon
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Ulnar stycoid process
FIGURE 6-8 Posterior view of the upper extremity showing bony anatomical landmarks for goniometer
alignment during the measurement of wrist ROM.
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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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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.
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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
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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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PART II UPPER-EXTREMITY TESTING
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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.
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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.
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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.
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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.
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PART II UPPER-EXTREMITY TESTING
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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
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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
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Ritt, M, et al: Rotational stability of the carpus relative to the
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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
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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.
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13.
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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
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■ '■"%£"-'■ ' ■
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.
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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
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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
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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\
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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.
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PART II UPPER-EXTREMITY TESTING
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METACARPOPHALANGEAL ABDUCTION
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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.
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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
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PART II UPPER-EXTREMITY TESTING
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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.
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PART II UPPER-EXTREMITY TESTING
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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.
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CHAPTER 7 THE HAND
15S
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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.
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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.
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Distal
phalanx
1st
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Metacarpal
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FIGURE 7-29 Anterior (palmar) view of the hand showing:
bony anatomical landmarks for goniometer alignment:
during the measurement of thumb range of motion.
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FIGURE 7-31 Posterior view of the hand showing bony
anatomical landmarks for goniometer alignment during the
measurement of thumb range of motion.
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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.
■
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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.
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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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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.
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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 ,
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;rees
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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.
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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.
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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.
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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
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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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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
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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
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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
_
D
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eu
a
z
p
in
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o
5
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—
o
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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
LU
Z
I/) 'si
SIS'- 1
■Q-l
UJ./-I
U :; 1
0|
~ l!
: (j: y4 '
z
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.
^;,^i^l ~* "-J.:...:-...;..;-:.'.-:--- '■■' ,-: '""
rl m
lu
at
D
a
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
en
H
O
o
u
z
<
as
| 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.
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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
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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.
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PART I!! LOWES-EXTREMITY TESTING
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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
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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.
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PART lit LOWER-EXTREMITY TESTING
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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
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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.
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CHAPTER 8 THE HIP
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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.
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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
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resistance cause lateral pelvic tilting, pelvic rotation
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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.
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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.
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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.
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PART III LOWER-EXTREMITY TESTING
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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.
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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.
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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
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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.
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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.
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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
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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.
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'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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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 -
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lata
Psoas major
Sartorius
Anterior superior iliac
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Anterior iliac
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Rectus
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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.
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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.
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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.
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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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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.
-*-- /■"
m
m
the
FIGURE 8-38 The starting position for testing the length of the hamstring muscles.
1
a.
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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
J&\
Or "
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.
c/
■m
isot
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.
CL
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U-i
Of
D
Q
UJ
U
O
as
a.
Z
in
X
z
•JJ
lit
-J
u
in
^)
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
«.
*
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
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Comprehensive Analysis, ed 3. FA Davis, Philadelphia, 2001.
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3. Greene, WB, and Heckman, JD (eds): American Academy of
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4. American Medical Association: Guides to The Evaluation of
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6. Svenningsen, S, et al: Hip motion related to age and sex. Acta
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7. Roach, K£, and Miles, TP: Normal hip and knee active range of
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8. Waugh, KG, cr al: Measurement of selected hip, knee and ankle
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9. Schwarze, DJ, and Denton, JR: Normal values of neonatal limbs:
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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
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12. Wanatabe, H, er al: The range of joint motions of the extremities
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13. Walker, JM: Musculoskeletal development: A review. Phys Ther
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15. Forero, N, Okamura, LA, and Larson, MA: Normal ranges of hip
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16. Nonaka, H, et air Age-related changes in the interactive mobility
of the hip and knee joints: A geometrical analysis. Gait Posture
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17. Kozic, S, et al: Femoral anteversion related to side differences in
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18. Ellison, JB, Rose, SJ, and Sahrman, SA: Patterns of hip rotation:
A comparison between healthy subjects and patients with low
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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
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(Unpublished supplement to Boone, DC, and Azen, SP: Normal
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21. Allander, E, et al: Normal range of joint movements in shoulder,
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23. Boone, DC, Walker, JM, and Perry, J: Age and sex differences in
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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
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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
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36. Striilifcns. MPM. ct al: Range ol motion and disability in patients
with osteoarthritis ot the knee or hip. Rheumatology 39:955,
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37. BeissiKT, K! , Oiiinis, IF, and Holmes, i I; Muscle torce and range
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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-
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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,
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lg-
tld
ing
hip
iller
rapy;
ichos
mical :
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;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
Q
■ UJ
■ U
o
■a"
.;Z;;
In
: ? j4 '
Z^ ;
"^
■'.It?
o
<
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.
LU
—
z
■jj
OL
D
Q:.-
U4
Us
O
a. .
O
2
or
UJ
H-"
I
H
U
z:
u 5
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
■
LU
LU
7
.
^
**
'■-';■" '■■:■.
t/5
LJJ
■ at
3 ;
O
LU
.,-■
U
o
..
as
a.
C
■?c
Z
■'■:■.■.■-■-.-.
". f— *•
ttV-
UW
■■:-■■-:■■■
LU
Jifii:
>;;■;■;■ ■
X
'■;'■.■,
h-
a
;
z
LU
— 1
Wf
LU
■:iP:
-_i-
■ : ■
<. ■.:.:■ -
U
</i
D
m
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
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The ['.ithok t:it siiiliio v Service and Physical Therapy Departments
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fluid-based and universal goniometers for active knee flexion
Phys Ther tiS;lo-(,, l'»SK. ' §j
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ing hamstring muse
1993.
niiparison ot tour clinical tests for asst&v-
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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.
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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
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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.
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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.
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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
w^
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v
v
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.
J-
i
x-
M
■ ■;::;■
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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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.
.:
:,X~f:
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I ■
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-
!
I
;
I
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.
16
HnHPP
tSIl
JBllliill
i'ilS:
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If
W
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
iHfe
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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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^ ;
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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.
■ M
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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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
e
if
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is:
h
■n
I-
■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.
Ol 268
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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)
f 7
mm
m
;'
"^"•"■■"^«;:.?;*:;3i
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
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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
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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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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.
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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.
.
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CHAPTER 10 THE ANKLE AND FOOT
275
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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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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.
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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
* i-
andmarks for Goniometer AHgnment: Metatarsophalangeat Joint
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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.
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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
■i s
Lateral
bead of
gastrocnemius
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.
v -
■m¥
i
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.
V
J
FIGURE; 10-62 Goniometer alignment at the end of the testing motion for the length of the gastrocne-
mius muscle.
;;;,
1
■ 1
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.
'■i
i
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.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
i
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1
1 - ". ^.. ™
IPllKgS*: 2j
w
v
■ s
"I
*" / ft
AM
•
•
^P: ''■■■' r\
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.
i
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■:kZWwli[!:i& :
v^'..::-:':. : .':/:;-: '
^:-:^:-^i;-i:.X.^;"'V:. :
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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as
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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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o
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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.
I
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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
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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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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
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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
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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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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.
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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:-'
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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.
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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,
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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
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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.
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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
-■.
fit
re
w
co
I,
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
wSSm
SHI
FIGURE 12-12 Inclinometer alignment at the end of thoracic and lumbar flexion range of motion.
z
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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
:-■'■:- ,•■"■'>:■■%■
■■■■',:■%*■
:/:■.:■--■■':■& .-
■-■■-- . . .* /.-' - « ■■
:■•■•'■• 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
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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_
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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
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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.
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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,
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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.
■
-
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; ^
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.
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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 -. ...... ..•■.,-, ■...■-■
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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
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1 I
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■ V.^^^^-l^ .
w
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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
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Lundberg, G, and Gerdle, B: Correlations between joint and
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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
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/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
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| Landmarks for Ruler Alignment Measuring
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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).
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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.
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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
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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
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2. Boone, DC, and Azcn, SP: Normal range of motion of joints in
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3. Greene, BL, and Wolf, St.: Upper extremity joint movement:
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4. Walker, JM, et al: Active mobility of the extremities m older
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5. Downey, PA, Fiebert, I, and Stackpole-Brown, JB: Shoulder range
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7. American Medical Association: Guides to the Evaluation of
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8. Ellcnbecker, TS, et al: Glenohumeral joint internal and external
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9. Boon, AJ, and Smith, J: Manual scapular stabilization: Its effect on
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10. Lannan, D, Lehman, T, and Toland, M: Establishment of norma-
tive data for the range of motion of the glenohumeral joint. Master
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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,
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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
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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
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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
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35. Walker, N, Bohannon. R\V, Cameron, D: Validity of temporo-
mandibular joust range of (notion measurements ohtaiued with a
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36. Phillips. DJ, et al: Guide to evaluation of permanent impairment
ol the temporomandibular joint. | Craniomandibular Pract
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37. llighie, I\j, ct al: Effect of head position on vertical mandibular
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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 motio 
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