12390543 Measurement of Joint Motion a Guide to Goniometry

Measurement of Joint Motion

A Guide to Goniometry

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Cynthia C. Norkin, EdD, PTFormer Associate Professor and DirectorSchool of Physical TherapyCollege of Health and Human ServicesOhio UniversityAthens, Ohio

D. Joyce White, DSc, PTAssociate Professor of Physical TherapyCollege of Health ProfessionsUniversity of Massachusetts LowellLowell, Massachusetts

Measurement of Joint Motion

A Guide to GoniometryTHIRD EDITION

Photographs by Jocelyn Greene Molleur and Lucia Grochowska Littlefield

Illustrations by Timothy Wayne Malone

Additional illustrations provided by Jennifer Daniell and Meredith Taylor Stelling

F. A. Davis Company • Philadelphia

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F.A. Davis Company1915 Arch StreetPhiladelphia, PA 10103www.fadavis.com

Copyright © 2003 by F.A. Davis Company

Copyright © 2003 by F.A. Davis Company. All rights reserved. This book is protected by copyright. No part of it maybe reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photo-copying, recording, or otherwise, without written permission from the publisher.

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As new scientific information becomes available through basic and clinical research, recommended treatments anddrug therapies undergo changes. The author(s) and publisher have done everything possible to make this book accu-rate, up to date, and in accord with accepted standards at the time of publication. The author(s), editors, and publisherare not responsible for errors or omissions or for consequences from application of the book, and make no warranty,expressed or implied, in regard to the contents of the book. Any practice described in this book should be applied bythe reader in accordance with professional standards of care used in regard to the unique circumstances that may applyin each situation. The reader is advised always to check product information (package inserts) for changes and newinformation regarding dose and contraindications before administering any drug. Caution is especially urged whenusing new or infrequently ordered drugs.

Library of Congress Cataloging-in-Publication Data

Norkin, Cynthia C.Measurement of joint motion : a guide to goniometry / Cynthia C. Norkin,D. Joyce White ; photographs by Jocelyn Greene and Lucia GrochowskaLittlefield ; illustrations by Timothy Wayne Malone ; additionalillustrations provided by Jennifer Daniell and Meredith Taylor Stelling.—3rd ed.

p. cm.Includes bibliographical references and index.ISBN 0-8036-0972-8

1. Joints—Range of motion—Measurement. I. White, D. Joyce. II. Title.RD734.N67 2003612.7′5–dc21

2003046244

Authorization to photocopy items for internal or personal use, or the internal or personal use of specific clients, isgranted by F. A. Davis Company for users registered with the Copyright Clearance Center (CCC) TransactionalReporting Service, provided that the fee of $.10 per copy is paid directly to CCC, 222 Rosewood Drive, Danvers,MA 01923. For those organizations that have been granted a photocopy license by CCC, a separate system of paymenthas been arranged. The fee code for users of the Transactional Reporting Service is : 8036-0972/03 0 + $.10

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To Alexandra, Taylor, and Kimberly.CCN

To Jonathan, Alexander, and Ethan.DJW

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The measurement of joint motion is an importantcomponent of a thorough physical examination of theextremities and spine, one which helps health profession-als identify impairments and assess rehabilitative status.The need for a comprehensive text with sufficient writtendetail and photographs to allow for the standardizationof goniometric measurement methods—both for thepurposes of teaching and clinical practice led to thedevelopment of the first edition of the Measurement ofJoint Motion: A Guide to Goniometry in 1985. Ourapproach included a discussion and illustration of testingposition, stabilization, end-feel, and goniometer align-ment for each measurable joint in the body. The resultingtext was extremely well received by a variety of healthprofessional educational programs and was used as areference in many clinical settings.

In the years following initial publication, a consider-able amount of research on the measurement of jointmotion appeared in the literature. Consequently, in thesecond edition, which was published in 1995, we createda new chapter on the reliability and validity of jointmeasurement and added joint-specific research sectionsto existing chapters. We also expanded the text by addingstructure, osteokinematics, arthrokinematics, capsularand noncapsular patterns of limitation, and functionalranges of motion for each joint.

The expanded third edition includes new researchfindings to help clarify normative range of motion valuesfor various age and gender groups, as well as the rangeof motion needed to perform common functional tasks.We added current information on the effects of subjectcharacteristics, such as body mass, occupational andrecreational activities, and the effects of the testingprocess, such as the testing position and type of measur-ing instrument, on range of motion. New to the thirdedition is the inclusion of muscle length testing at jointswhere muscle length is often a factor affecting range ofmotion. This addition integrates the measurement proce-dures used in this book with the American PhysicalTherapy Association’s Guide to Physical TherapyPractice. Inclinometer techniques for measuring range of

motion of the spine are also added to coincide withcurrent practice in some clinical settings. We introduceillustrations to accompany anatomical descriptions sothat the reader will have a visual reminder of the jointstructures involved in range of motion. New illustrationsof bony anatomical landmarks and photographs ofsurface anatomy will help the reader align the goniome-ter accurately. In addition, over 180 new photographsreplace many of the older, dated photographs.

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

Chapter 2 takes the reader through a step-by-stepprocess to master the techniques of goniometric evalua-tion, including: positioning, stabilization, instrumentsused for measurement, goniometer alignment, and therecording 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 ofmeasurement. The results of validity and reliability stud-ies on the measurement of joint motion are summarizedto help the reader focus on ways of improving and inter-preting goniometric measurements. Mathematical meth-ods of evaluating reliability are shown along withexamples and exercises so that the readers can assesstheir reliability in taking measurements.

Chapters 4 to 13 present detailed information ongoniometric testing procedures for the upper and lowerextremities, spine, and temporomandibular joint. Whenappropriate, muscle length testing procedures are alsoincluded. The text presents the anatomical landmarks,

Preface

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testing position, stabilization, testing motion, normal end-feel, 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 captionseliminates the need for repeated demonstrations by aninstructor and provides the reader with a permanentreference for visualizing the procedures. Also includedis information on joint structure, osteokinematic andarthrokinematic motion, and capsular patterns of restric-tions. A review of current literature regarding normalrange of motion values; the effects of age, gender, andother factors; functional range of motion; and reliabilityand validity is also presented for each body region toassist the reader to comply with evidence-based practice.

We hope this book makes the teaching and learning ofgoniometry easier and improves the standardization andthus the reliability of this assessment tool. We believethat the third edition provides a comprehensive coverageof 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 inevaluation. We encourage our readers to provide us withfeedback on our current efforts to bring you a high-quality, user-friendly text.

CCN

DJW

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We are very grateful for the contributions of the manypeople who were involved in the development andproduction of this text. Photographer Jocelyn Molleurapplied her skill and patience during many sessions atthe physical therapy laboratory at the University ofMassachusetts Lowell to produce the high-quality photo-graphs that appear in this third edition. Her effortscombined with those of Lucia Grochowska Littlefield,who took the photographs for the first edition, areresponsible for an important feature of the book.Timothy Malone, an artist from Ohio, used his talents,knowledge of anatomy, and good humor to create theexcellent illustrations that appear in this edition. We alsooffer our thanks to Jessica Bouffard, Alexander White,and Claudia Van Bibber who graciously agreed to besubjects 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 CreativeDevelopment, for their encouragement, ingenuity, andcommitment to excellence. Thanks are also extended toSam 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 aregrateful to the numerous students, faculty, and clinicianswho over the years have used the book or formallyreviewed portions of the manuscript and offered insight-ful comments and helpful suggestions.

Finally, we wish to thank our families: Cynthia’sdaughter, 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.

Acknowledgments

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Reviewers

Suzanne Robben Brown, MPH, PTAssociate Professor & ChairDepartment of Physical TherapyArizona School of Health SciencesMesa, AZ

Larry Chinnock, PT, EdDInstructor/Academic CoordinatorDepartment of Physical TherapyLoma Linda UniversitySchool of Allied Health ProfessionsLoma Linda, CA

Robyn Colleen Davies, BHSCPT, MAPPSC, PTLecturerDepartment of Physical TherapyUniversity of TorontoToronto, Canada

Jodi Gootkin, PTSite CoordinatorPhysical Therapy Assistant ProgramBroward Community CollegeFt. Myers, FL

Deidre Lever-Dunn, PhD, ATCAssistant ProfessorDepartment of Health SciencesProgram DirectorAthletic Training EducationUniversity of AlabamaTuscaloosa, AL

John T. Myers, PT, MBAInstructor/Program DirectorPhysical Therapy Assistant ProgramLorain County Community CollegeElyria, OH

James R. Roush, PhD, PT, ATCAssociate ProfessorDepartment of Physical TherapyArizona School of Health ScienceMesa, AZ

Sharon D. Yap, PTA, BPSAcademic Coordinator of Clinical EducationPhysical Therapy Assistant ProgramIndian River Community CollegeFort Pierce, FL

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P A R T IIntroduction to Goniometry ............1

C H A P T E R 1Basic Concepts ............................................3

GONIOMETRYJOINT MOTION

ArthrokinematicsOsteokinematics

RANGE OF MOTIONActive Range of MotionPassive Range of MotionHypomobilityHypermobilityFactors Affecting Range of Motion

MUSCLE LENGTH TESTING

C H A P T E R 2Procedures ................................................17

POSITIONINGSTABILIZATION

EXERCISE 1: Determining the End of the Range ofMotion and End-feel

MEASUREMENT INSTRUMENTSUniversal GoniometerGravity-dependent Goniometers (Inclinometers)ElectrogoniometersVisual EstimationEXERCISE 2: The Universal Goniometer

ALIGNMENTEXERCISE 3: Goniometer Alignment for Elbow

FlexionRECORDING

Numerical TablesPictorial ChartsSagittal-frontal-transverse-rotation MethodAmerican Medical Association Guide to Evaluation

MethodPROCEDURES

Explanation ProcedureTesting Procedure

EXERCISE 4: Explanation of GoniometryEXERCISE 5: Testing Procedure for Goniometric

Evaluation of Elbow Flexion

C H A P T E R 3Validity and Reliability ..............................39

VALIDITYFace ValidityContent ValidityCriterion-related ValidityConstruct Validity

RELIABILITYSummary of Goniometric Reliability StudiesStatistical Methods of Evaluating Measurement

ReliabilityExercises to Evaluate ReliabilityEXERCISE 6: Intratester ReliabilityEXERCISE 7: Intertester Reliability

P A R T I IUpper-Extremity Testing ................55

C H A P T E R 4The Shoulder ............................................57

STRUCTURE AND FUNCTIONGlenohumeral JointSternoclavicular JointAcromioclavicular JointScalpulothoracic Joint

RESEARCH FINDINGSEffects of Age, Gender, and Other FactorsFunctional Range of MotionReliability and Validity

RANGE OF MOTION TESTING PROCEDURES: THESHOULDER

LANDMARKS FOR GONIOMETER ALIGNMENTFlexionExtension

Contents

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AbductionAdductionMedial (Internal) RotationLateral (External) Rotation

C H A P T E R 5The Elbow and Forearm............................91

STRUCTURE AND FUNCTIONHumeroulnar and Humeroradial JointsSuperior and Inferior Radioulnar Joints


RANGE OF MOTION TESTING PROCEDURES: ELBOW ANDFOREARM

LANDMARKS FOR GONIOMETER ALIGNMENTFlexionExtensionPronationSupination

MUSCLE LENGTH TESTING PROCEDURES: ELBOW ANDFOREARMBiceps BrachiiTriceps Brachii

C H A P T E R 6The Wrist ................................................111

STRUCTURE AND FUNCTIONRadiocarpal and Midcarpal Joints


RANGE OF MOTION TESTING PROCEDURES: WRISTLANDMARKS FOR GONIOMETRIC ALIGNMENT: THE

WRISTFlexionExtensionRadial DeviationUlnar Deviation

MUSCLE LENGTH TESTING PROCEDURES: WRISTFlexor Digitorum Profundus and Flexor Digitorum

SuperficialisExtensor Digitorum, Extensor Indicis, and Extensor

Digiti Minimi

C H A P T E R 7The Hand ................................................137

STRUCTURE AND FUNCTIONFingers: Metacarpophalangeal JointsFingers: Proximal Interphalangeal and Distal

Interphalangeal JointsThumb: Carpometacarpal JointThumb: Metacarpophalangeal JointThumb: Interphalangeal Joint


RANGE OF MOTION TESTING PROCEDURES: FINGERSLANDMARKS FOR GONIOMETER ALIGNMENT

Metacarpophalangeal FlexionMetacarpophalangeal ExtensionMetacarpophalangeal AbductionMetacarpophalangeal AdductionProximal Interphalangeal FlexionProximal Interphalangeal ExtensionDistal Interphalangeal FlexionDistal Interphalangeal Extension

RANGE OF MOTION TESTING PROCEDURES: THUMBLANDMARKS FOR GONIOMETER ALIGNMENT

Carpometacarpal FlexionCarpometacarpal ExtensionCarpometacarpal AbductionCarpometacarpal AdductionCarpometacarpal OppositionMetacarpophalangeal FlexionMetacarpophalangeal ExtensionInterphalangeal FlexionInterphalangeal Extension

MUSCLE LENGTH TESTING PROCEDURES: FINGERSLumbricals, Palmar and Dorsal Interossei

P A R T I I ILower-Extremity Testing ..............181

C H A P T E R 8The Hip ....................................................183

STRUCTURE AND FUNCTIONIliofemoral Joint


RANGE OF MOTION TESTING PROCEDURES: HIPLANDMARKS FOR GONIOMETER ALIGNMENT

FlexionExtensionAbductionAdductionMedial (Internal) RotationLateral (External) Rotation

MUSCLE LENGTH TESTING PROCEDURESHip Flexors (Thomas Test)The Hamstrings: Semitendinous, Semimembranosus,

and Biceps Femoris (Straight Leg Test)Tensor Fascia Latae (Ober Test)

C H A P T E R 9The Knee..................................................221

STRUCTURE AND FUNCTIONTibiofemoral and Patellofemoral Joints

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RANGE OF MOTION TESTING PROCEDURES: KNEELANDMARKS FOR GONIOMETER ALIGNMENT

FlexionExtension

MUSCLE LENGTH TESTING PROCEDURES: KNEERectus Femoris: Ely TestHamstring Muscles: Semitendinosus, Semimembranosus,

and Biceps Femoris: Distal Hamstring Length Test

C H A P T E R 1 0The Ankle and Foot ................................241

STRUCTURE AND FUNCTIONProximal and Distal Tibiofibular JointsTalocrural JointSubtalar JointTransverse Tarsal (Midtarsal) JointTarsometatarsal JointsMetatarsophalangeal JointsInterphalangeal Joints


RANGE OF MOTION TESTING PROCEDURES: ANKLEAND FOOT

LANDMARKS FOR GONIOMETER ALIGNMENT:TALOCRURAL JOINTDorsiflexion: Talocrural JointPlantarflexion: Talocrural Joint

LANDMARKS FOR GONIOMETER ALIGNMENT: TARSALJOINTSInversion: Tarsal JointsEversion: Tarsal Joints

LANDMARKS FOR GONIOMETER ALIGNMENT: SUBTALARJOINT (REARFOOT)Inversion: Subtalar Joint (Rearfoot)Eversion: Subtalar Joint (Rearfoot)Inversion: Transverse Tarsal JointEversion: Transverse Tarsal Joint

LANDMARKS FOR GONIOMETER ALIGNMENT:METATARSOPHALANGEAL JOINTFlexion: Metatarsophalangeal JointExtension: Metatarsophalangeal JointAbduction: Metatarsophalangeal JointAdduction and Metatarsophalangeal JointFlexion: Interphalangeal Joint of the First Toe and

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

Proximal Interphalangeal Joints of the Four Lesser ToesFlexion: Distal Interphalangeal Joints of the Four Lesser

ToesExtension: Distal Interphalangeal Joints of the Four

Lesser ToesMUSCLE LENGTH TESTING PROCEDURES:

Gastrocnemius

P A R T I VTesting of the Spine andTemporomandibular Joint ............293

C H A P T E R 1 1The Cervical Spine ..................................295

STRUCTURE AND FUNCTIONAtlanto-occipital and Atlantoaxial JointsIntervertebral and Zygapophyseal Joints


RANGE OF MOTION TESTING PROCEDURES:CERVICAL SPINE

LANDMARKS FOR GONIOMETER ALIGNMENTFlexionExtensionLateral FlexionRotation

C H A P T E R 1 2The Thoracic and Lumbar Spine ............331

STRUCTURE AND FUNCTIONThoracic SpineLumbar Spine


RANGE OF MOTION TESTING PROCEDURESANATOMICAL LANDMARKS: FOR TAPE MEASURE

ALIGNMENTThoracic and Lumbar FlexionLumbar FlexionThoracic and Lumbar ExtensionLumbar ExtensionThoracic and Lumbar Lateral FlexionThoracic and Lumbar Rotation

C H A P T E R 1 3The Temporomandibular Joint................365

STRUCTURE AND FUNCTIONTemporomandibular Joint

RESEARCH FINDINGSEffects of Age, Gender, and Other FactorsReliability and Validity

RANGE OF MOTION TESTING PROCEDURES:TEMPOROMANDIBULAR JOINT

LANDMARKS FOR RULER ALIGNMENT MEASURINGDepression of the Mandible (Mouth Opening)Protrusion of the MandibleLateral Deviation of the Mandible

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A P P E N D I X ANormative Range of MotionValues ......................................................375

A P P E N D I X BJoint Measurements by BodyPosition....................................................381

A P P E N D I X CGoniometer Price Lists ............................383

A P P E N D I X DNumerical Recording Forms ..................387Index........................................................393

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91C H A P T E R 5 T H E E L B O W A N D F O R E A R M

Humerus

Olecranonprocess

Medialepicondyle

Humeroulnarjoint

UlnaRadius

Radial head

Humeroradialjoint

Lateral epicondyle

Olecranon fossa

FIGURE 5–2 A posterior view of the elbow showing thehumeroulnar and humeroradial joints.

Structure and Function

Humeroulnar and Humeroradial Joints

AnatomyThe humeroulnar and humeroradial joints between theupper arm and the forearm are considered to be a hingedcompound synovial joint (Figs. 5–1 and 5–2). The proxi-mal joint surface of the humeroulnar joint consists of theconvex trochlea located on the anterior medial surface ofthe distal humerus. The distal joint surface is the concavetrochlear notch on the proximal ulna.

The proximal joint surface of the humeroradial joint isthe convex capitulum located on the anterior lateralsurface of the distal humerus. The concave radial head onthe proximal end of the radius is the opposing jointsurface.

The joints are enclosed in a large, loose, weak jointcapsule that also encloses the superior radioulnar joint.Medial and lateral collateral ligaments reinforce the sidesof the capsule and help to provide medial-lateral stability(Figs. 5–3 and 5–4).1

When the arm is in the anatomical position, the longaxes of the humerus and the forearm form an acute angle

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C H A P T E R 5

The Elbow and Forearm

Coronoid fossa

Radial fossa

Lateral epicondyle

Capitulum

Humeroradialjoint

Radial head

Radius Ulna

Coronoid process

Humeroulnar joint

Trochlea

Medial epicondyle

Humerus

FIGURE 5–1 An anterior view of the elbow showing thehumeroulnar and humeroradial joints.

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92 P A R T I I U P P E R - E X T R E M I T Y T E S T I N G

at the elbow. The angle is called the “carrying angle.”This angle is about 5 degrees in men and approximately10 to 15 degrees in women.2 An angle that is greater(more acute) than average is called “cubitus valgus.” Anangle that is less than average is called “cubitus varus.”

OsteokinematicsThe humeroulnar and humeroradial joints have 1 degreeof freedom; flexion-extension occurs in the sagittal planearound a medial-lateral (coronal) axis. In elbow flexionand extension, the axis of rotation lies approximatelythrough the center of the trochlea.3

ArthrokinematicsAt the humeroulnar joint, posterior sliding of the concavetrochlear notch of the ulna on the convex trochlea of thehumerus continues during extension until the ulnarolecranon process enters the humeral olecranon fossa. Inflexion, the ulna slides anteriorly along the humerus untilthe coronoid process of the ulna reaches the floor of the

coronoid fossa of the humerus or until soft tissue in theanterior aspect of the elbow blocks further flexion.

At the humeroradial joint, the concave radial headslides posteriorly on the convex surface of the capitulumduring extension. In flexion, the radial head slides anteri-orly until the rim of the radial head enters the radial fossaof the humerus.

Capsular PatternThe capsular pattern is variable, but usually the range ofmotion (ROM) in flexion is more limited than in exten-sion. For example, 30 degrees of limitation in flexionwould correspond to 10 degrees of limitation in exten-sion.4

Superior and Inferior Radioulnar Joints

AnatomyThe ulnar portion of the superior radioulnar jointincludes both the radial notch located on the lateralaspect of the proximal ulna and the annular ligament(Fig. 5–5). The radial notch and the annular ligament

Humerus

Annular ligament

Radius

Ulna

Medialcollateralligament

Jointcapsule

Medial epicondyle

Joint capule

Lateral collateral ligament Ulna

Radius

Annular ligament

Humerus

Lateralepicondyle

FIGURE 5–4 A lateral view of the elbow showing the lateral(radial) collateral ligament, annular ligament, and joint capsule.

FIGURE 5–5 Anterior view of the superior and inferiorradioulnar joints.

Superior radioulnar joint

Radial head

Radius

Ulnar notch

Radial styloid process

Inferior radioulnar joint

Ulnar styloidprocess

Ulnar head

Ulna

Radial notch

FIGURE 5–3 A medial view of the elbow showing the medial(ulnar) collateral ligament, annular ligament, and joint capsule.

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Annularligament

Oblique cord

Radius

Interosseousmembrane

Articular disc

Anterior radioulnar ligament

Ulna

Quadrate ligament


FIGURE 5–6 Anterior view of the superior and inferiorradioulnar joints showing the annular ligament, quadrate liga-ment, oblique cord, interosseous membrane, anterior radioul-nar ligament, and articular disc.

form a concave joint surface. The radial aspect of thejoint is the convex head of the radius.

The ulnar component of the inferior radioulnar joint isthe convex ulnar head (see Fig. 5–5). The opposing artic-ular surface is the ulnar notch of the radius.

The interosseous membrane, a broad sheet of collage-nous tissue linking the radius and ulna, provides stabilityfor both joints (Fig. 5–6). The following three structuresprovide stability for the superior radioulnar joint: theannular and quadrate ligaments and the oblique cord.Stability of the inferior radioulnar joint is provided by thearticular disc and the anterior and posterior radioulnarligaments (Fig. 5–7).1

OsteokinematicsThe superior and inferior radioulnar joints are mechani-cally linked. Therefore, motion at one joint is alwaysaccompanied by motion at the other joint. The axis formotion is a longitudinal axis extending from the radial

Posterior radioulnarligament

Articular disc

Head of ulna

Radial styloidprocess

Anterior radioulnarligament

Ulnar notchof radius

Ulnar styloid process

head to the ulnar head. The mechanically linked joint isa synovial pivot joint with 1 degree of freedom. Themotions permitted are pronation and supination. Inpronation the radius crosses over the ulna, whereas insupination the radius and ulna lie parallel to one another.

ArthrokinematicsAt the superior radioulnar joint the convex rim of thehead of the radius spins within the annular ligament andthe concave radial notch during pronation and supina-tion. The articular surface on the head of the radius spinsposteriorly during pronation and anteriorly duringsupination.

At the inferior radioulnar joint the concave surface ofthe 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 pronationand slides posteriorly (in the same direction as the hand)during supination.

Capsular PatternAccording to Cyriax and Cyriax,4 Kaltenborn,5 andMagee,6 the capsular pattern is equal limitation ofpronation and supination.

FIGURE 5–7 Distal aspect of the inferior radioulnar jointshowing the\ articular disc and radioulnar ligaments.

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Research Findings

Effects of Age, Gender, and Other Factors

Table 5–1 shows the mean values of ROM for variousmotions at the elbow. The age, gender, and number ofsubjects that were measured to obtain the valuesreported by the American Academy of OrthopaedicSurgeons (AAOS)7,8 and the American MedicalAssociation (AMA)9 in Table 5–1 were not noted. Booneand Azen,10 using a universal goniometer, measuredactive ROM in 109 males between the ages of 18 monthsand 54 years. Greene and Wolf11 measured active ROMwith a universal goniometer in 10 males and 10 femalesaged 18 to 55 years. Petherick and associates12 measuredactive ROM with a universal goniometer in 10 males and20 females with a mean age of 24.0 years. In addition tothe sources listed in Table 5–1, Goodwin and cowork-ers13 found mean active elbow flexion to be 148.9degrees when measured with a universal goniometer in23 females between 18 and 31 years of age.

AgeA comparison of cross-sectional studies of normativeROM values for various age groups suggests that elbowand forearm ROM decreases slightly with age. Tables5–2 and 5–3 summarize the effects of age on ROM of the


elbow and forearm. The male and female infantsreported in the study by Wanatabe and colleagues14 hadmore ROM in flexion, pronation, and supination thanthe older males in studies by Boone15 and by Walker andcoworkers.16 However, it can be difficult to comparevalues obtained from various studies because subjectselection and measurement methods can differ.

Within one study of 109 males ranging in age from 18months to 54 years, Boone and Azen10 noted a significantdifference in elbow flexion and supination betweensubjects less than or equal to 19 years of age and thosegreater than 19 years of age. Further analyses found thatthe group between 6 and 12 years of age had more elbowflexion and extension than other age groups. Theyoungest group (between 18 months and 5 years) had asignificantly greater amount of pronation and supinationthan other age groups. However, the greatest differencesbetween 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.15

Older persons appear to have difficulty fully extendingtheir elbows to 0 degrees. Walker and associates16 foundthat the older men and women (between 60 and 84 yearsof age) in their study were unable to extend their elbowsto 0 degrees to attain a neutral starting position for flex-ion. The mean value for the starting position was 6degrees in men and 1 degree in women. Boone and

TABLE 5–2 Effects of Age on Elbow and Forearm Motion: Mean Values in Degrees for Newborns,Children, and Adolescents 2 Weeks to 19 Years of Age

Wanatabe et al14 Boone15

2 wks–2 yrs 18 mos–5 yrs 6–12 yrs 13–19 yrsn � 45 n � 19 n � 17 n � 17

Motion Range of Means Mean (SD) Mean (SD) Mean (SD)

Flexion 148–158 144.9 (5.7) 146.5 (4.0) 144.9 (6.0)Extension 0.4 (3.4) 2.1 (3.2) 0.1 (3.8)Pronation 90–96 78.9 (4.4) 76.9 (3.6) 74.1 (5.3)Supination 81–93 84.5 (3.8) 82.9 (2.7) 81.8 (3.2)

TABLE 5–1 Elbow and Forearm Motion: Mean Values in Degrees from Selected Sources

AAOS7,8 AMA9 Boone Greene Petherick& Azen10 & Wolf11 et al12

n � 109* n � 20† n � 30‡

Motion Mean (SD) Mean (SD) Mean (SD)

Flexion 150 140 142.9 (5.6) 145.3 (1.2) 145.8 (6.3)Extension 0 0 0.6 (3.1)Pronation 80 80 75.8 (5.1) 84.4 (2.2)Supination 80 80 82.1 (3.8) 76.9 (2.1)

* Values are for males 18 months to 54 years of age.† Values are for 10 males and 10 females, 18 to 55 years of age.‡ Values are for 10 males and 20 females, with a mean age of 24.0 years.

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Azen10 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 and37 men aged 79 years, found that 11 percent had flexioncontractures of the right elbow greater than 5 degrees,and 7 percent had bilateral flexion contractures.

Gender

Studies seem to concur that gender differences exist forelbow flexion and extension ROM but these studies areunclear concerning forearm supination and pronationROM. Bell and Hoshizaki,18 using a LeightonFlexometer, studied the ROM of 124 females and 66males between the ages of 18 and 88 years. Females hadsignificantly more elbow flexion than males.Extrapolating from a graph, the mean differencesbetween males and females ranged from 14 degrees insubjects aged 32 to 44 years, to 2 degrees in subjectsolder than 75 years. Although females had greatersupination-pronation ROM than males, this increase wasnot significant. Fairbanks, Pynsent, and Phillips,19 in astudy of 446 normal adolescents, found that females hadsignificantly more elbow extension (8 degrees) than males(5 degrees) when measured on the extensor aspect with auniversal goniometer. It is unclear from the method usedwhether hyperextension of the elbow or the carryingangle was measured. Salter and Darcus,20 measuringforearm supination-pronation with a specializedarthrometer in 20 males and 5 females between the agesof 16 and 29 years, found that the females had an aver-age of 8 degrees more forearm rotation than males,although the difference was not statistically significant.Thirty older females and 30 older males, aged 60 to 84years, were included in a study by Walker and cowork-ers.16 Females had significantly more flexion ROM (1 to148 degrees) than males (5 to 139 degrees), but maleshad significantly more supination (83 degrees) thanfemales (65 degrees). Females had more pronation ROMthan males, but the difference was not significant.

Escalante, Lichenstein, and Hazuda,21in a study of 695community-dwelling older subjects between 65 and 74years of age, found that females had an average of 4degrees more elbow flexion than males.

Body-Mass IndexBody-mass index (BMI) was found by Escalante,Lichenstein, and Hazuda21 to be inversely associatedwith elbow flexion in 695 older subjects. Each unitincrease in BMI (kg/m2) was significantly associated witha 0.22 decrease in degrees of elbow flexion.

Right versus Left SideComparisons between the right and the left or betweenthe dominant and the nondominant limbs have found noclinically relevant differences in elbow and forearmROM. Boone and Azen10 studied 109 males between theages of 18 months and 54 years, who were subdividedinto six age groups. They found no significant differencesbetween right and left elbow flexion, extension, supina-tion, and pronation, except for the age group of subjectsbetween 20 and 29 years of age, whose flexion ROM wasgreater on the left than on the right. This one significantfinding was attributed to chance. Escalante, Lichenstein,and Hazudal,21 in a study of 695 older subjects, foundsignificantly greater elbow flexion on the left than on theright, but the difference averaged only 2 degrees. Chang,Buschbacher, and Edlich22 studied 10 power lifters and10 age-matched nonlifters, all of whom were righthanded, and found no differences between sides in elbowand forearm ROM.

SportsIt appears that the frequent use of the upper extremitiesin 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 30female national and international tennis players, foundsignificantly less active pronation and supination ROMin the playing arms of all subjects. Male players also

TABLE 5–3 Effects of Age on Elbow and Forearm Motion: Mean Values in Degrees for Adults 20 to 85Years of Age

Boone15 Walker et al16

20–29 yrs 30–39 yrs 40–54 yrs 60–85 yrsn � 19 n � 18 n � 19 n � 30

Motion Mean (SD) Mean (SD) Mean (SD) Mean (SD)

Flexion 140.1 (5.2) 141.7 (3.2) 139.7 (5.8) 139.0 (14.0)Extension 0.7 (3.2) 0.7 (1.7) �0.4* (3.0) �6.0* (5.0)Pronation 76.2 (3.9) 73.6 (4.3) 75.0 (7.0) 68.0 (9.0)Supination 80.1 (3.7) 81.7 (4.2) 81.4 (4.0) 83.0 (11.0)

* The minus sign indicates flexion.

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demonstrated a significant decrease (4.1 degrees) inelbow extension in the playing arm versus the nonplayingarm. Chang, Buschbacher, and Edlich22 studied 10 powerlifters and 10 age-matched nonlifters and found signifi-cantly less active elbow flexion in the power lifters thanin the nonlifters. No significant differences were foundbetween the two groups for supination and pronationROM.

Functional Range of Motion

The amount of elbow and forearm motion that occursduring activities of daily living has been studied byseveral investigators. Table 5–4 has been adapted fromthe works of Morrey and associates,24 Packer andcolleagues,25 and Safaee-Rad and coworkers.26 Morreyand associates24 used a triaxial electrogoniometer tomeasure elbow and forearm motion in 33 normalsubjects during performance of 15 activities. Theyconcluded that most of activities of daily living that werestudied required a total arc of about 100 degrees ofelbow flexion (between 30 and 130 degrees) and 100degrees of rotation (50 degrees of supination and 50degrees of pronation). Using a telephone necessitated thegreatest total ROM. The greatest amount of flexion wasrequired 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 degreesof 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). Amongthe tasks studied, the greatest amount of supination wasneeded for eating with a fork. Reading a newspaper (Fig.5–10), pouring from a pitcher, and cutting with a kniferequired the most pronation.

Five healthy subjects participated in a study by Packerand colleagues,25 which examined elbow ROM duringthree functional tasks. A uniaxial electrogoniometer wasused to determine ROM required for using a telephone,for rising from a chair to a standing position, and foreating with a spoon. A range of 15 to 140 degrees of flex-ion was needed for these three activities. This ROM isslightly greater than the arc reported by Morrey andassociates, but the activities that required the minimaland maximal flexion angles did not differ. The authorssuggest that the height of the chair, the type of chair arms,and the positioning of the telephone could account forthe different ranges found in the studies.

Safaee-Rad and coworkers26 used a three-dimensionalvideo system to measure ROM during three feedingactivities: eating with a spoon, eating with a fork, anddrinking from a handled cup. Ten healthy males partici-pated in the study. The feeding activities required approx-imately 70 to 130 degrees of elbow flexion, 40 degrees ofpronation, and 60 degrees of supination. Drinking with acup required the greatest arc of elbow flexion (58degrees) of the three activities, whereas eating with aspoon required the least (22 degrees). Eating with a forkrequired the greatest arc of pronation-supination (97degrees), whereas drinking from a cup required the least(28 degrees). Maximum ROM values during feedingtasks were comparable with those reported by Morreyand associates. However, minimum values varied, possi-bly owing to the different chair and table heights used inthe two studies.

Several investigators have taken a different approachin determining the amount of elbow and forearm motionneeded for activities of daily living. Vasen and associ-ates27 studied the ability of 50 healthy adults to comfort-ably complete 12 activities of daily living while their

TABLE 5–4 Elbow and Forearm Motion During Functional Activities: Mean Values in Degrees

Activity Flexion Pronation Supination Source

Min Max Arc Max Max Arc

Use telephone 42.8 135.6 92.8 40.9 22.6 63.5 Morrey24

75 140 65 Packer25

Rise from chair 20.3 94.5 74.2 33.8 �9.5* 24.3 Morrey15 100 85 Packer

Open door 24.0 57.4 33.4 35.4 23.4 58.8 MorreyRead newspaper 77.9 104.3 26.4 48.8 �7.3* 41.5 MorreyPour pitcher 35.6 58.3 22.7 42.9 21.9 64.8 MorreyPut glass to mouth 44.8 130.0 85.2 10.1 13.4 23.5 MorreyDrink from cup 71.5 129.2 57.7 �3.4† 31.2 27.8 Safaee-Rad26

Cut with knife 89.2 106.7 17.5 41.9 �26.9* 15.0 MorreyEat with fork 85.1 128.3 43.2 10.4 51.8 62.2 Morrey

93.8 122.3 28.5 38.2 58.8 97.0 Safaee-RadEat with spoon 101.2 123.2 22.0 22.9 58.7 81.6 Safaee-Rad

70 115 45 Packer

* The minus sign indicates pronation.† The minus sign indicates supination.

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elbows were restricted in an adjustable Bledsoe brace.Forty-nine subjects were able to complete all of the taskswith the elbow motion limited to between 75 and 120degrees of flexion. Subjects used compensatory motionsat adjacent normal joints to complete the activities.Cooper and colleagues28 studied upper extremity motionin subjects during three feeding tasks, with the elbowunrestricted and then fixed in 110 degrees of flexion witha splint. The 19 subjects were assessed with a video-based, 3-dimensional motion analysis system while theywere drinking with a handled cup, eating with a fork, andeating with a spoon. Compensatory motions to accom-modate the fixed elbow occurred to a large extent at theshoulder and to a lesser extent at the wrist.

Reliability and Validity

Many studies have focused on the reliability of gonio-metric measurement of elbow ROM. Most researchershave found intratester and intertester reliability of meas-uring elbow motions with a universal goniometer to behigh. Comparisons between ROM measurement takenwith different devices have also been conducted. Fewerstudies have examined the reliability and concurrentvalidity of measuring forearm supination and pronationROM.

In a study published in 1949 by Hellebrandt, Duvall,and Moore,29 one therapist repeatedly measured 13active upper extremity motions, including elbow flexionand extension and forearm pronation and supination, in77 patients. The differences between the means of twotrials ranged from 0.10 degrees for elbow extension to1.53 degrees for supination. A significant differencebetween the measurements was noted for elbow flexion,although the difference between the means was only 1.0degrees. Significant differences were also noted betweenmeasurements taken with a universal goniometer andthose obtained by means of specialized devices, leadingthe author to conclude that different measuring devicescould not be used interchangeably. The universalgoniometer was generally found to be the more reliabledevice.

Boone and colleagues30 examined the reliability ofmeasuring six passive motions, including elbow exten-sion-flexion. Four physical therapists used universalgoniometers to measure these motions in 12 normalmales weekly for 4 weeks. They found that intratesterreliability (r�0.94) was slightly higher than intertesterreliability (r�0.88).

Rothstein, Miller, and Roettger31 found high intra-tester and intertester reliability for passive ROM of

FIGURE 5–8 Drinking from a cup requires about 130 degreesof elbow flexion.

FIGURE 5–9 Studies report that rising from a chair using theupper extremities requires a large amount of elbow and wristextension.

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elbow flexion and extension. Their study involved 12testers who used three different commonly used universalgoniometers (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 flexionand extension ROM, whereas intraclass correlation coef-ficient (ICC) values ranged from 0.85 to 0.95.

Fish and Wingate32 found that the standard deviationof passive elbow ROM goniometric measurements (2.4to 3.4 degrees) was larger than the standard deviationfrom photographic measurements (0.7 to 1.1 degrees).These authors postulated that measurement error wasdue to improper identification of bony landmarks, inac-curate alignment of the goniometer, and variations in theamount of torque applied by the tester.

Grohmann,33 in a study involving 40 testers and onesubject, found that no significant differences existedbetween elbow measurements obtained by an over-the-joint method for goniometer alignment and the tradi-tional lateral method. Differences between the means ofthe measurements were less than 2 degrees. The elbowwas held in two fixed positions (an acute and an obtuseangle) by a plywood stabilizing device.

Petherick and associates,12 in a study in which twotesters measured 30 healthy subjects, found thatintertester reliability for measuring active elbow ROMwith a fluid-based goniometer was higher than with auniversal goniometer. The Pearson product momentcorrelation between the two devices was 0.83. A signifi-cant difference was found between the two devices. Theauthors concluded that no concurrent validity existedbetween the fluid-based and the universal goniometersand that these instruments could not be used inter-changeably.

Greene and Wolf11 compared the reliability of theOrtho Ranger, an electronic pendulum goniometer, withthe reliability of a universal goniometer for active upperextremity motions in 20 healthy adults. Elbow flexionand extension were measured three times for each instru-

ment during each session. The three sessions wereconducted by one physical therapist during a 2-weekperiod. Within-session reliability was higher for theuniversal goniometer, as indicated by ICC values and 95percent confidence intervals. Measurements taken withthe Ortho Ranger correlated poorly with those takenwith the universal goniometer (r � 0.11 to 0.21), andthere was a significant difference in measurementsbetween the two devices.

Goodwin and coworkers13 evaluated the reliability ofa universal goniometer, a fluid goniometer, and an elec-trogoniometer for measuring active elbow ROM in 23healthy women. Three testers took three consecutivereadings using each type of goniometer on two occasionsthat were 4 weeks apart. Significant differences werefound between types of goniometers, testers, and repli-cations. Measurements taken with the universal and fluidgoniometers correlated the best (r � 0.90), whereas theelectrogoniometer correlated poorly with the universalgoniometer (r � 0.51) and fluid goniometer (r � 0.33).Intratester and intertester reliability was high during eachoccasion, with correlation coefficients greater than 0.98and 0.90, respectively. Intratester reliability betweenoccasions was highest for the universal goniometer.ICC values ranged from 0.61 to 0.92 for the universalgoniometer, 0.53 to 0.85 for the fluid goniometer, and0.00 to 0.61 for the electrogoniometer. Similar to otherresearchers, the authors do not advise the interchange-able use of different types of goniometers in the clinicalsetting.

Armstrong and associates34 examined the intratester,intertester, and interdevice reliability of active ROMmeasurements of the elbow and forearm in 38 patients.Five testers measured each motion twice with each of thethree devices: a universal goniometer, an electrogoniome-ter, and a mechanical rotation measuring device.Intratester reliability was high (r values generally greaterthan 0.90) for all three devices and all motions.Intertester reliability was high for pronation and supina-tion with all three devices. Intertester reliability for elbowflexion and extension was high for the electrogoniometerand moderate for the universal goniometer.Measurements taken with different devices varied widely,with 95 percent confidence intervals for mean devicedifferences of more than 30 degrees for most measures.The authors concluded that meaningful changes in intrat-ester ROM taken with a universal goniometer occur with95 percent confidence if they are greater than 6 degreesfor flexion, 7 degrees for extension, and 8 degrees forpronation and supination. Meaningful changes inintertester ROM taken with a universal goniometer occurif they are greater than 10 degrees for flexion, extension,and pronation, and greater than 11 degrees for supina-tion.

FIGURE 5–10 Approximately 50 degrees of pronation occurduring the action of reading a newspaper.

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Acromion processof scapula Humerus

Lateral epicondyle of humerus

Radial head

Radius

Radialstyloidprocess

Ulnar styloidprocess

UlnaOlecranonprocess

Scapula

FIGURE 5–14 Posterior view of the right upper extremityshowing anatomical landmarks for goniometer alignmentduring the measurement of elbow and forearm ROM.

FIGURE 5–13 Posterior view of the right upper extremityshowing surface anatomy landmarks for goniometer align-ment during the measurement of elbow and forearm ROM.

Radial styloid process

Ulnar styloid process

Lateral epicondyleof humerus

FIGURE 5–12 Anterior view of the right upper extremityshowing bony anatomical landmarks for goniometer align-ment during the measurement of elbow and forearm ROM.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.


Range of Motion Testing Procedures: Elbow and Forearm

Landmarks for Goniometer Alignment: Elbow and Forearm

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FIGURE 5–15 The end of elbow flexion ROM. The examiner’s hand stabilizes the humerus, but it mustbe positioned so it does not limit the motion.

tance to further motion is felt and attempts to overcomethe resistance cause flexion of the shoulder.

Normal End-feelUsually the end-feel is soft because of compression of themuscle bulk of the anterior forearm with that of the ante-rior upper arm. If the muscle bulk is small, the end-feelmay be hard because of contact between the coronoidprocess of the ulna and the coronoid fossa of the humerusand because of contact between the head of the radiusand the radial fossa of the humerus. The end-feel may befirm because of tension in the posterior joint capsule, thelateral and medial heads of the triceps muscle, and theanconeus muscle.

Goniometer Alignment See Figures 5–16 and 5–17.

1. Center the fulcrum of the goniometer over thelateral epicondyle of the humerus.

2. Align the proximal arm with the lateral midline ofthe humerus, using the center of the acromionprocess for reference.

3. Align the distal arm with the lateral midline of theradius, using the radial head and radial styloidprocess for reference.

FLEXION

Motion occurs in the sagittal plane around a medial-lateral axis. Mean elbow flexion ROM ranges from 140degrees according to the AMA9 to 150 degrees accordingto the AAOS.7,8 See Tables 5–1 to 5–3 for additionalinformation. See Figures 5–11 to 5–14.

Testing PositionPosition the subject supine, with the shoulder in 0 degreesof flexion, extension, and abduction so that the arm isclose to the side of the body. Place a pad under the distalend of the humerus to allow full elbow extension.Position the forearm in full supination with the palm ofthe hand facing the ceiling.

StabilizationStabilize the humerus to prevent flexion of the shoulder.The pad under the distal humerus and the examiningtable 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-

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FIGURE 5–16 The alignment of the goniometer at the beginning of elbow flexion ROM. A towel isplaced under the distal humerus to ensure that the supporting surface does not prevent full elbow exten-sion. As can be seen in this photograph, the subject’s elbow is in about 5 degrees of hyperextension.

FIGURE 5–17 The alignment of the goniometer at the end of elbow flexion ROM. The proximal anddistal arms of the goniometer have been switched from the starting position so that the ROM can be readfrom the pointer on the body of this 180-degree goniometer.

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occurs when resistance to further motion is felt andattempts to overcome the resistance cause medial rota-tion and abduction of the shoulder.

Normal End-feelThe end-feel may be hard because of contact between theulna and the radius, or it may be firm because of tensionin the dorsal radioulnar ligament of the inferior radioul-nar joint, the interosseous membrane, and the supinatormuscle.

FIGURE 5–18 End of pronation ROM. The subject is sittingon the edge of a table and the examiner is standing facing thesubject. The examiner uses one hand to hold the elbow close tothe subject’s body and in 90 degrees of elbow flexion, helpingto prevent both medial rotation and abduction of the shoulder.The examiner’s other hand pushes on the radius rather than onthe subject’s hand. If the examiner pushes on the subject’s hand,movement of the wrist may be mistaken for movement at theradioulnar joints.

EXTENSION

Motion occurs in the sagittal plane around a medial-lateral axis. Elbow extension ROM is not usually meas-ured and recorded separately because it is the return tothe starting position from the end of elbow flexion ROM.

Testing Position, Stabilization, and GoniometerAlignmentThe testing position, stabilization, and alignment are thesame as those used for elbow flexion.

Testing MotionExtend the elbow by moving the hand dorsally towardthe examining table. Maintain the forearm in supinationduring the motion. The end of extension ROM occurswhen resistance to further motion is felt and attempts toovercome the resistance cause extension of the shoulder.

Normal End-feelUsually the end-feel is hard because of contact betweenthe olecranon process of the ulna and the olecranon fossaof the humerus. Sometimes the end-feel is firm because oftension in the anterior joint capsule, the collateral liga-ments, and the brachialis muscle.

PRONATION

Motion occurs in the transverse plane around a verticalaxis when the subject is in the anatomical position. Whenthe subject is in the testing position, the motion occurs inthe frontal plane around an anterior-posterior axis. Meanpronation ROM is 76 degrees according to Boone andAzen,10 and 84 degrees according to Greene and Wolf.11

Both the AMA9 and the AAOS7,8 state that pronationROM is 80 degrees. See Tables 5–1 to 5–3 for additionalROM information.

Testing PositionPosition the subject sitting, with the shoulder in 0 degreesof flexion, extension, abduction, adduction, and rotationso that the upper arm is close to the side of the body.Flex the elbow to 90 degrees, and support the forearm.Initially position the forearm midway between supinationand pronation so that the thumb points toward theceiling.

StabilizationStabilize the distal end of the humerus to prevent medialrotation and abduction of the shoulder.

Testing MotionPronate the forearm by moving the distal radius in avolar direction so that the palm of the hand faces thefloor. See Figure 5–18. The end of pronation ROM

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Goniometer Alignment See Figures 5–19 and 5–20.

1. Center the fulcrum of the goniometer laterally andproximally to the ulnar styloid process.

2. Align the proximal arm parallel to the anteriormidline of the humerus.

3. Place the distal arm across the dorsal aspect of theforearm, just proximal to the styloid processes ofthe radius and ulna, where the forearm is most leveland free of muscle bulk. The distal arm of thegoniometer should be parallel to the styloidprocesses of the radius and ulna.

FIGURE 5–20 Alignment of the goniometer at the end ofpronation ROM. The examiner uses one hand to hold theproximal arm of the goniometer parallel to the anteriormidline of the humerus. The examiner’s other hand supportsthe forearm and assists in placing the distal arm of thegoniometer across the dorsum of the forearm just proximal tothe radial and ulnar styloid process. The fulcrum of thegoniometer is proximal and lateral to the ulnar styloidprocess.

FIGURE 5–19 The alignment of the goniometer in the begin-ning of pronation ROM. The goniometer is placed laterally tothe distal radioulnar joint. The arms of the goniometer arealigned parallel to the anterior midline of the humerus.

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the elbow to 90 degrees, and support the forearm.Initially position the forearm midway between supinationand pronation so that the thumb points toward the ceil-ing.

StabilizationStabilize the distal end of the humerus to prevent lateralrotation and adduction of the shoulder.

Testing Motion Supinate the forearm by moving the distal radius in adorsal direction so that the palm of the hand faces theceiling. See Figure 5–21. The end of supination ROMoccurs when resistance to further motion is felt andattempts to overcome the resistance cause lateral rotationand adduction of the shoulder.

SUPINATION

Motion occurs in the transverse plane around a longitu-dinal axis when the subject is in the anatomical position.When the subject is in the testing position, the motionoccurs in the frontal plane around an anterior-posterioraxis. Mean supination ROM is 82 degrees according toBoone and Azen,10 and 77 degrees according to Greeneand Wolf.11 Both the AMA9 and the AAOS7,8 state thatsupination ROM is 80 degrees. See Tables 5–1 to 5–3 foradditional ROM information.

Testing PositionPosition the subject sitting, with the shoulder in 0 degreesof flexion, extension, abduction, adduction, and rotationso that the upper arm is close to the side of the body. Flex

FIGURE 5–21 End of supination ROM. The examiner usesone hand to hold the elbow close to the subject’s body and in90 degrees of elbow flexion, preventing lateral rotation andadduction of the shoulder. The examiner’s other hand pushes onthe distal radius while supporting the forearm.

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Normal End-feelThe end-feel is firm because of tension in the palmarradioulnar ligament of the inferior radioulnar joint,oblique cord, interosseous membrane, and pronator teresand pronator quadratus muscles.

Goniometer AlignmentSee Figures 5–22 and 5–23.

1. Center the goniometer medially and proximally tothe ulnar styloid process.

2. Align the proximal arm parallel to the anteriormidline of the humerus.

3. Place the distal arm across the ventral aspect of theforearm, just proximal to the styloid processes,where the forearm is most level and free of musclebulk. The distal arm of the goniometer should beparallel to the styloid processes of the radius andulna.

FIGURE 5–22 Alignment of the goniometer at the beginning ofsupination ROM. The body of the goniometer is medial to thedistal radioulnar joint, and the arms of the goniometer areparallel to the anterior midline of the humerus.

FIGURE 5–23 The alignment of the goniometer at the end ofsupination ROM. The examiner uses one hand to hold theproximal arm of the goniometer parallel to the anterior midlineof the humerus. The examiner’s other hand supports the fore-arm while holding the distal arm of the goniometer across thevolar surface of the forearm just proximal to the radial andulnar styloid process. The fulcrum of the goniometer is proxi-mal and medial to the ulnar styloid process.

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the forearm in pronation. If the biceps brachii is short, itlimits elbow extension when the shoulder is positioned infull extension.

If elbow extension is limited regardless of shoulderposition, the limitation is caused by abnormalities of thejoint surfaces, shortening of the anterior joint capsule,and collateral ligaments, or by muscles that cross only theelbow, such as the brachialis and brachioradialis.

Starting PositionPosition the subject supine at the edge of the examiningtable. See Figure 5–25. Flex the elbow and position theshoulder in full extension and 0 degrees of abduction,adduction, and rotation.

Muscle Length Testing Procedures:Elbow and Forearm

BICEPS BRACHII

The biceps brachii muscle crosses the glenohumeral,humeroulnar, humeroradial, and superior radioulnarjoints. The short head of the biceps brachii originatesproximally from the coracoid process of the scapula (Fig.5–24). The long head originates from the supraglenoidtubercle of the scapula. The biceps brachii attachesdistally to the radial tuberosity.

When it contracts it flexes the elbow and shoulder andsupinates the forearm. The muscle is passively lengthenedby placing the shoulder and elbow in full extension and

Supra Glendoid Tubercle

Glenoid FossaCoracoid Process

Acromion Process

Long Head of the Biceps

Radial Tuberosity

Radius

Ulna

Short Head ofthe Biceps

FIGURE 5–24 A lateral view of the upper extremity showingthe origins and insertion of the biceps brachii while beingstretched over the glenohumeral, elbow, and superior radioul-nar joints.

FIGURE 5–25 The starting position for testing the length ofthe biceps brachii.

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StabilizationThe examiner stabilizes the subject’s humerus. The exam-ining table and passive tension in the serratus anteriormuscle help to stabilize the scapula.

Testing motionExtend the elbow while holding the forearm in prona-tion. See Figures 5–26 and 5–25. The end of the testingmotion occurs when resistance is felt and additionalelbow extension causes shoulder flexion.

Normal End-feelThe end-feel is firm because of tension in the bicepsbrachii muscle.

FIGURE 5–26 The end of the testing motion for the length ofthe biceps brachii. The examiner uses one hand to stabilize thehumerus in full shoulder extension while the other hand holdsthe forearm in pronation and moves the elbow into extension.

FIGURE 5–27 The alignment of the goniometer at the end oftesting the length of the biceps brachii. The examiner releasesthe stabilization of the humerus and now uses her hand to posi-tion the goniometer.

Goniometer AlignmentSee Figure 5–27.



3. Align the distal arm with the lateral midline of theulna, using the ulna styloid process for reference.

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contracts, it extends the shoulder and elbow. The longhead of the triceps brachii is passively lengthened by plac-ing the shoulder and elbow in full flexion. If the longhead of the triceps brachii is short, it limits elbow flexionwhen the shoulder is positioned in full flexion.

If elbow flexion is limited regardless of shoulder posi-tion, the limitation is due to abnormalities of the jointsurfaces, shortening of the posterior capsule or musclesthat cross only the elbow, such as the anconeus and thelateral and medial heads of the triceps brachii.

Starting PositionPosition the subject supine, close to the edge of the exam-ining table. Extend the elbow and position the shoulderin full flexion and 0 degrees of abduction, adduction, androtation. Supinate the forearm (Fig. 5–29).

StabilizationThe examiner stabilizes the subject’s humerus. Theweight of the subject’s trunk on the examining table andthe passive tension in the latissumus dorsi, pectoralisminor, and rhomboid major and minor muscles help tostabilize the scapula.

TRICEPS BRACHII

The triceps brachii muscle crosses the glenohumeral andhumeroulnar joints. The long head of the triceps brachiimuscle originates proximally from the infraglenoid tuber-cle of the scapula (Fig. 5–28). The lateral head of thetriceps brachii originates from the posterior and lateralsurfaces of the humerus, whereas the medial head origi-nates from the posterior and medial surfaces of thehumerus. All parts of the triceps brachii insert distally onthe olecranon process of the ulna. When this muscle

Medial headof triceps

Lond head of triceps

Infra glenoidtubercle

Scapula

Head ofhumerus

Lateral headof triceps

Olecranonprocess

Radius

Ulna

FIGURE 5–28 A lateral view of the upper extremity showingthe origins and insertions of the triceps brachii while beingstretched over the glenohumeral and elbow joints.

FIGURE 5–29 The startingposition for testing the lengthof the triceps brachii.

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Testing MotionFlex the elbow by moving the hand closer to the shoul-der. See Figures 5–30 and 5–28. The end of the testingmotion occurs when resistance is felt and additionalelbow flexion causes shoulder extension.

Normal End-feelThe end-feel is firm because of tension in the long headof the triceps brachii muscle.

Goniometer AlignmentSee Figure 5–31.



3. Align the distal arm with the lateral midline of theradius, using the radial styloid process for refer-ence.

FIGURE 5–30 The end of the testing motion for the length ofthe triceps brachii. The examiner uses one hand to stabilize thehumerus in full shoulder flexion and the other hand to move theelbow into flexion.

FIGURE 5–31 The alignment of the goniometer at the end oftesting the length of the triceps brachii. The examiner uses onehand to continue to stabilize the humerus and align the proxi-mal arm of the goniometer. The examiner’s other hand holdsthe elbow in flexion and aligns the distal arm of the goniometerwith the radius.

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12390543 Measurement of Joint Motion a Guide to Goniometry