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Bandy for both Physical Therapy and Occupational Therapy professionals, this book describes in detail the reliability and validity of each technique. A new companion web site features video clips demonstrating over measurement techniques! Full-color design clearly demonstrates various techniques and landmarks.

Clear technique template allows you to quickly and easily identify the information you need. Simple anatomic illustrations clearly depict the various techniques and landmarks for each joint. Coverage of range of motion and muscle length testing includes important, must-know information. Bony landmarks for g o n i o m e t e r a l i g n m e n t lateral aspect of a c r o m i o n process, lateral humeral epicondyle, radial styloid process indicated by orange dots.

Patient position: Supine with upper extremity in anatomical position see Note , elbow extended as far as possible, folded towel under distal humerus, proximal to humeral condyles Fig. Stabilization: None needed. Examiner action: Determine if elbow is extended as far as possible by either: a asking patient to straighten elbow as far as possible if measuring active ROM ; or, b providing pressure across the elbow in the direction of extension if measuring passive ROM Fig. End of elbow extension ROM, showing proper hand placement for stabilizing humerus and extending elbow.


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Bony landmarks for goniometer alignment lateral aspect of acromion process, lateral humeral epicondyle, radial styloid process indicated by orange dots. Goniometer alignment for measurement of elbow extension. Read scale of Documentation: Note: goniometer Fig. Record patient's amount of elbow extension. Alternative patient position: Patient's forearm should be completely supinated at beginning of ROM, or beginning reading of goniometer will be inaccurate and make patient appear to lack full elbow extension.

Seated or sidelying; towel not needed; goniometer alignment remains same. Starting position for measurement of forearm supination. Bony landmarks for goniometer alignment anterior midline of humerus and ulnar styloid process indicated by orange line and dot. Patient position: Seated or standing with shoulder completely adducted, elbow flexed to 90 degrees, forearm in neutral rotation Fig. Stabilization: Over lateral aspect of distal humerus, maintaining 0 degrees shoulder adduction Fig.

Examiner action: After instructing patient in motion desired, supinate patient's forearm through available ROM, avoiding lateral rotation of shoulder or shoulder adduction past 0 degrees see Note. Parallel with anterior midline of humerus. On volar surface of wrist, in line with styloid process of ulna.

Stationary arm: Axis: Moving arm: Read scale of goniometer. End of forearm supination ROM, s h o w i n g proper hand placement for stabilizing h u m e r u s against thorax and supinating forea r m. Bony landmark for goniometer alignment anterior midline of humerus indicated by orange line. Starting position for measurement of forearm supination, demonstrating proper initial alignment of goniometer.

C o n f i r m a t i o n of Repalpate landmarks and confirm proper goniometric alignment at end of ROM, correcting alignment as necessary see Note. Note: No adduction or lateral rotation of shoulder should be allowed during measurement of forearm supination, to prevent artificial inflation of ROM measurements. By end of supination ROM, axis of goniometer will have moved to a position superior and medial to ulnar styloid see Fig.

Alignment of arms, and not axis, of goniometer is most critical element in this measurement. Starting position for measurement of forearm pronation. Bony landmarks for goniometer alignment anterior m i d l i n e of humerus and ulnar styloid process indicated by orange line and dot. Stabilization: Over lateral aspect of distal humerus, maintaining shoulder adduction Fig.

Examiner action: After instructing patient in motion desired, pronate patient's forearm through available ROM, avoiding shoulder abduction and medial rotation see Note. In line with, and just proximal to, styloid process of ulna. End of f o r e a r m pronation ROM, s h o w i n g proper hand placement for stabilizing h u m e r u s against thorax and pronating forea r m.

Bony landmark for goniometer a l i g n m e n t anterior midline of humerus indicated by orange line. Starting position for measurement of forearm pronation, demonstrating proper initial a l i g n m e n t of goniometer. Note: No abduction or medial rotation of shoulder should be allowed during measurement of forearm pronation, to prevent artificial inflation of ROM measurements.

By end of pronation ROM, axis of goniometer will have moved to a position superior and lateral to ulnar styloid see Fig. End of forearm pronation ROM, demonstrating proper alignment of goniometer at end of range. J Orthop Res ; New York, Churchill Livingstone, London JT: Kinematics of the elbow. J Bone Joint Surg ;63A The radiocarpal joint consists of the articulation between the distal end of the radius and the radioulnar disk proximally, and the proximal row of carpal bones distally.

The articulation between the proximal and distal rows of carpal bones makes up the midcarpal joint. Movement at both joints is necessary to achieve the full range of motion ROM of the wrist, which has been classified as a condyloid joint. Motions present at the wrist include flexion, extension, abduction radial deviation , and adduction ulnar deviation.

Thus, the end-feel for passive flexion and extension of the wrist is firm. However, if the fingers are not free to move and are flexed, the position of the fingers will limit wrist flexion secondary to passive tension in the extrinsic finger extensors. Conversely, extension of the fingers will limit wrist extension owing to passive tension in the extrinsic finger flexors. Wrist adduction is limited by ligamentous structures radial collateral ligament and is associated with a capsular end-feel, whereas wrist abduction is limited by bony contact between the radial styloid process and and the trapezium, producing a bony end-feel at the limit of wrist abduction.

Information regarding normal ranges of motion for all movements of the wrist is found in Appendix C. Wrist abduction and adduction are measured using the standard technique of positioning the goniometer over the dorsal surface of the j o i n t. This joint is classified as a saddle joint and is formed by the articulation between the trapezium and the base of the first metacarpal bone.

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Motions occurring at the 1st CMC joint include flexion, extension, abduction, adduction, rotation, and opposition. From the anatomical position, CMC flexion and extension occur in a plane parallel to the palm of the hand frontal plane , whereas abduction and adduction occur in a plane positioned perpendicular to the palm sagittal plane. Rotation occurs as a result of rotation of the metacarpal around its longitudinal axis during flexion and extension of the 1st CMC joint and is normally not measured clinically.

Opposition is a combination of flexion, medial rotation, and abduction of the 1st CMC joint. Carpometacarpal joint flexion may be limited by contact between the thenar muscle mass and the soft tissue of the palm, thereby producing a soft end-feel to the motion. When muscle mass of the thenar eminence is not well developed, limitation of CMC joint flexion is caused by tension in the extensor pollicis brevis and abductor pollicis brevis muscles as well as by tension in the dorsal aspect of the CMC joint capsule, causing the end-feel to be firm.

Extension of the 1st CMC joint is limited primarily by tension in muscles adductor pollicis, flexor pollicis brevis, 1st dorsal interosseous, opponens pollicis as well as by tension in the anterior aspect of the CMC joint capsule, thus producing a firm end-feel to the motion. A firm end-feel also is present at the limits of CMC abduction owing to tension in the adductor pollicis and 1st dorsal interosseous muscles and secondary to stretch of the skin and connective tissue of the web space. Both opposition and adduction of the 1st CMC joint are limited by soft-tissue approximation, the former between the pad of the thumb and the base of the fifth digit, and the latter between the side of the thumb and the tissue overlying the second m e t a c a r p a l.

The majority of techniques used in this text are based on motions of the CMC joint as defined in Gray's Anatomy and are similar to those techniques demonstrated in other goniometry t e x t s. Measurement of 1st CMC joint opposition, as described in other goniometry texts, involves the measurement of motions occurring at the 1st and 5th CMC joints, as well as motion occurring in at least one other joint of the 1st or 5th d i g i t s.

The AAOS technique examines opposition by measuring the linear distance from the tip of the thumb to the base of the 5th metacarpal, stating that "opposition is usually considered complete when the tip of the thumb touches the base of the fifth finger. The technique for examining opposition recommended by the AMA involves measuring the linear distance from the flexor crease of the thumb IP joint to the distal palmar crease over the 3rd metacarpal, without allowing flexion at the MCP or IP joints of the thumb. While the flexor crease of the thumb IP joint provides a more reproducible landmark than the tip of the thumb, the distal palmar crease runs obliquely across the 3rd metacarpal, allowing a variety of points along which the distal end of the ruler may be placed during measurement Fig.

Such a variety of possible placements could lend inconsistency to the results obtained when measuring opposition according to the AMA technique. In an effort to use a technique that: 1 measures only opposition occurring at the 1st CMC joint; and 2 uses reproducible landmarks for both the proximal and the distal ends of the ruler, a technique that combines the best of the AAOS and AMA techniques is described in this text.

The technique described herein examines 1st CMC joint opposition by measuring the linear distance between the flexor crease of the IP joint of the 1st digit thumb and 4 3,11 3,11 5 1 5 1 5 Fig. Volar palmar surface of hand, d e m o n strating distal palmar crease tip of arrows. Note oblique angle at w h i c h distal palmar crease crosses 3rd metacarpal.

Unfortunately, no standards for normal ROM are as yet available for this technique of measuring opposition. Motions available at these joints are flexion, extension, abduction, and adduction. Some variation exists between the MCP joints of digits 2 through 5 and the 1st MCP joint in the thumb , causing the range of abduction and adduction of the 1st MCP joint to be severely restricted.

Nine interphalangeal IP joints are present in the digits of the hand. Each finger possesses two IP joints: a proximal interphalangeal joint PIP , which consists of the articulation of the convex head of the proximal phalanx with the concave base of the middle phalanx, and a distal interphalangeal joint DIP , which consists of the articulation of the convex head of the middle phalanx with the concave base of the distal phalanx. The thumb possesses only a single IP joint, formed by the articulation of the convex head of the proximal phalanx with the concave base of the distal phalanx.

Each of the IP joints of the hand is classified as a hinge joint and is thus able to perform the motions of flexion and extension. Thus, depending on the particular individual, the end-feel for MCP joint flexion can be capsular or bony. Limitation of MCP joint extension is produced by tension in the anterior joint capsule and volar plate, producing a capsular end-feel to the motion. The range of MCP joint abduction is most pronounced in the 2nd and 5th digits, with less motion available in the 3rd and 4th digits and even less motion available in the 1st MCP joint in the thumb.

Owing to tightness of the collateral ligaments when the MCP joints are flexed, MCP abduction is least restricted when the MCP joints are extended and is severely limited-to-absent when the joints are flexed. The end-feel for MCP joint abduction is capsular, owing to tension produced by the collateral ligaments and the skin of the interdigital web spaces. Since MCP joint adduction is restricted primarily by soft-tissue contact with the adjacent digit, the end-feel for this motion is s o f t. Limitation of IP joint flexion depends on the joint being moved.

Flexion at the IP thumb and DIP fingers joints and occasionally flexion at the PIP joints of the fingers is limited by tension in the posterior joint capsule and collateral ligaments, resulting in a capsular end-feel for IP thumb and DIP fingers flexion. Extension of all IP joints is limited by tension in the anterior joint capsule and volar plate of the joint being moved; thus, a capsular end-feel results.

Conversely, extension of the more proximal joints causes tension on the extrinsic finger flexors, which in turn restricts the amount of extension that can be obtained at more distal joints. Therefore, care should be taken to maintain the proximal joints of the wrist and hand in a neutral position during measurement of flexion and extension of the MCP and IP joints.

The standard technique for measuring MCP and IP joint flexion is with the goniometer positioned over the dorsal surface of the joint being examined. However, the soft tissue over the volar surface of the MCP joints may interfere with alignment of the goniometer during measurement of MCP extension using the volar positioning technique. Starting position for measurement of wrist flexion using dorsal alignment technique. Bony landmarks for goniometer alignment lateral epicondyle of h u m e r u s , lunate, dorsal midline of 3rd metacarpal indicated by orange line and dots.

Patient position: Seated, with shoulder abducted 90 degrees; elbow flexed 90 degrees; forearm pronated; arm and forearm supported on table; hand off table with wrist in neutral position Fig. Stabilization: Over dorsal surface of forearm Fig. Examiner action: After instructing patient in motion desired, flex patient's wrist through available ROM see Note. Return wrist to neutral position. Dorsal midline of forearm toward lateral epicondyle of humerus.

Stationary arm: Axis: Moving arm: Dorsal midline of 3rd metacarpal. End of wrist flexion ROM, s h o w i n g proper hand placement for stabilizing forearm and flexing wrist. Bony landmarks for goniometer alignment lateral epicondyle of humerus, lunate, dorsal midline of 3rd metacarpal indicated by orange line and dots. Starting position for measurement of wrist flexion, demonstrating proper initial alignment of goniometer. C o n f i r m a t i o n of alignment: Repalpate landmarks and confirm proper goniometric alignment at end of ROM, correcting alignment as necessary.

Note: Flexion of fingers should be avoided during measurement of wrist flexion to prevent limitation of motion by tension in extrinsic finger extensors. Alternative patient position: Patients unable to achieve 90 degrees of shoulder abduction may be positioned with shoulder adducted for this measurement.

In such a case, stationary arm of goniometer should be aligned with dorsal midline of forearm toward bicipital tendon at elbow. Measurement may also be made with forearm in neutral rotation. End of wrist flexion ROM, d e m o n s t r a t i n g proper alignment of goniometer at end of range. Starting position for measurement of wrist flexion using lateral alignment technique. Bony landmarks for goniometer alignment olecranon process of ulna, t r i q u e t r u m , lateral midline of 5th metacarpal indicated by orange line and dots.

Lateral midline of ulna toward olecranon process. Stationary arm: Axis: Moving arm: Lateral midline of 5th metacarpal. C o n f i r m a t i o n of Repalpate landmarks and confirm proper goniometric alignment at end of ROM, correcting alignment as necessary. Alternative patient position: Patients unable to achieve 90 degrees of shoulder abduction may be positioned with shoulder adducted. In such a case, a dorsal alignment technique should be used, and the measurement also may be made with forearm in neutral rotation.

Stationary arm of the goniometer should be aligned with the dorsal midline of the forearm toward the bicipital tendon at the elbow. Starting position for measurement of wrist extension using volar alignment technique. Bony landmarks for g o n i o m e t e r alignment bicepital t e n d o n at elbow, lunate, volar m i d line of 3rd metacarpal indicated by orange line and dots. Patient position: Seated, with shoulder adducted; elbow flexed 90 degrees; forearm supinated and supported on table; wrist and hand off table with wrist in neutral position Fig. Stabilization: Over ventral surface of forearm Fig.

Examiner action: After instructing patient in motion desired, extend patient's wrist through available ROM see Note. End of wrist extension ROM, showing proper hand placement for stabilizing forearm and extending wrist. Bony landmarks for goniometer alignment bicipital t e n d o n at elbow, lunate, volar m i d line of 3rd metacarpal indicated by orange line and dots.

Goniometer alignment: Stationary arm: Axis: Moving arm: Palpate the following landmarks shown in Fig. Volar midline of forearm toward bicipital tendon at elbow. Volar midline of 3rd metacarpal. Note: Extension of fingers should be avoided during measurement of wrist extension to prevent limitation of motion by tension in extrinsic finger flexors.

Alternative patient position: Measurement also may be made with forearm in neutral rotation. End of wrist extension ROM, demonstrating proper alignment of goniometer at end of range. Starting position for m e a s u r e m e n t of w r i s t extension using lateral a l i g n m e n t technique. Bony landmarks for g o n i o m e t e r a l i g n m e n t olecranon process of ulna, t r i q u e t r u m , lateral m i d l i n e of 5th metacarpal indicated by orange line and dots.

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Bony landmarks for goniometer alignment olecranon process of ulna, triquetrum, lateral midline of 5th metacarpal indicated by orange line and dots. In such a case, goniometer should be placed over volar surface of wrist with stationary arm aligned with midline of forearm toward bicipital tendon, axis over lunate, and moving arm aligned with volar midline of 3rd metacarpal.

Bony landmarks for g o n i o m e t e r a l i g n m e n t lateral epicondyle of h u m e r u s , capitate, dorsal midline of 3rd metacarpal indicated by orange line and dots. Patient position: Seated, with shoulder abducted 90 degrees; elbow flexed 90 degrees; forearm pronated; upper extremity UE supported on table; wrist and hand in neutral position Fig.

Stabilization: Over dorsal surface of distal forearm Fig. Examiner action: After instructing patient in motion desired, adduct patient's wrist through available ROM. End of wrist adduction ROM, showing proper hand placement for stabilizing forearm and adducting wrist. Bony landmarks for goniometer alignment lateral epicondyle of humerus, capitate, dorsal midline of 3rd metacarpal indicated by orange line and dots.

Starting position for measurement of wrist adduction, demonstrating proper initial a l i g n m e n t of goniometer. Dorsal midline of 3rd metacarpal. Alternative patient position: Patients unable to achieve 90 degrees of shoulder adduction may be positioned with shoulder adducted for this measurement. End of wrist adduction ROM, demonstrating proper a l i g n m e n t of goniometer at end of range. Starting position for measurement of wrist abduction. Landmarks for goniometer alignment lateral epicondyle of humerus, capitate, dorsal midline of 3rd metacarpal indicated by orange line and dots.

Patient position: Seated, with shoulder abducted 90 degrees; elbow flexed 90 degrees; forearm pronated; UE supported on table; wrist and hand in neutral position Fig. Examiner action: After instructing patient in motion desired, abduct patient's wrist through available ROM. Performing passive movement provides an estimate of the ROM and demonstrates to patient exact motion desired Fig.

End of wrist abduction ROM, showing proper hand placement for stabilizing f o r e a r m and adducting wrist. Landmarks for g o n i o m e t e r a l i g n m e n t lateral epicondyle of humerus, capitate, dorsal midline of 3rd metacarpal indicated by orange line and dots. Starting position for measurement of w r i s t abduction, demonstrating proper initial a l i g n m e n t of goniometer. End of wrist abduction ROM, demonstrating proper alignment of goniometer at end of range. Patient position: Seated, with forearm pronated; UE supported on table; wrist and hand in neutral position Fig.

Stabilization: Over metacarpals Fig. Return finger to neutral position. Starting position for measurement of MCP abduction, demonstrating proper initial a l i g n m e n t of goniometer. Dorsal midline of metacarpal. Dorsum of MCP joint. Dorsal midline of proximal phalanx. Record patient's ROM. Starting position for measurement of MCP flexion. Landmarks for goniometer a l i g n m e n t dorsal midline of metacarpal, dorsum of MCP joint, dorsal midline of proximal phalanx indicated by orange lines and dot.

Measurement of 2nd MCP joint shown. Stabilization: Over more proximal bone of joint in this case, stabilization of a metacarpals is shown Fig. Examiner action: After instructing patient in motion desired, flex joint to be examined through available ROM. Landmarks for goniometer alignment dorsal midline of metacarpal, dorsum of MCP joint, dorsal midline of proximal phalanx indicated by orange lines and dot.

Starting position for measurement of MCP flexion, demonstrating proper initial alignment of goniometer. Dorsal midline of more proximal bone of joint in this case, a metacarpal. Dorsum of joint being examined in this case, MCP joint. Dorsal midline of more distal bone joint in this case, a proximal phalanx.

The figures shown here depict the measurement of MCP flexion of the 2nd digit index finger. Starting position for m e a s u r e m e n t of MCP extension. Over more proximal bone of joint being examined in this case, stabilization of metacarpals is shown Fig. Starting position for measurement of MCP extension, demonstrating proper initial a l i g n m e n t of goniometer.

Dorsal midline of more distal bone of joint in this case, a proximal phalanx. The figures shown here depict the measurement of MCP extension of the 2nd digit index finger. Starting position for measurement of 1st CMC abduction. Note that thumb is positioned alongside volar surface of 2nd metacarpal. Landmarks for goniometer alignment lateral midline of 2nd metacarpal, radial styloid process, dorsal midline of 1st metacarpal indicated by orange lines and dot. Patient position: Seated, with forearm neutral; UE supported on table; wrist and hand in neutral position; thumb positioned along volar surface of 2nd metacarpal Fig.

Stabilization: Over 2nd metacarpal Fig. Examiner action: After instructing patient in motion desired, abduct 1st CMC joint by grasping 1st metacarpal and moving thumb perpendicularly away from palm. Return thumb to starting position. Lateral midline of 2nd metacarpal. Radial styloid process. Dorsal midline of 1st metacarpal. Stationary arm: Axis: Moving arm: Read scale of goniometer see Note. C o n f i r m a t i o n of Repalpate landmarks and confirm proper goniometric alignment at end of ROM, correcting alignment as necessary Fig. Read scale of goniometer see Note.

Note: Goniometer will not read 0 degrees at beginning of 1st CMC abduction. However, this initial reading should be translated as 0 degrees starting position. Number of degrees of abduction through which joint moves is calculated by subtracting initial goniometer reading from final reading. Motion is then recorded as 0 degrees to X degrees 1st CMC abduction. Note that t h u m b is positioned alongside lateral surface of 2nd metacarpal.

Landmarks for g o n i o m e t e r a l i g n m e n t radial head, ventral surface of 1st CMC joint, ventral midline of 1st metacarpal indicated by orange line and dots. Patient position: Seated, with forearm supinated; UE supported on table; wrist and hand in neutral position; thumb positioned along lateral side of 2nd metacarpal Fig. Stabilization: Over ventral surface of wrist Fig.

Examiner action: After instructing patient in motion desired, flex 1st CMC joint by grasping 1st metacarpal and moving thumb across palm. Ventral midline of radius toward radial head. Ventral surface of 1st CMC joint. Ventral midline of 1st metacarpal. Landmarks for g o n i o m e t e r alignment radial head, ventral surface of 1st CMC joint, ventral midline of 1st metacarpal indicated by orange line and dots.

Starting position for measurement of 1st CMC flexion, demonstrating proper initial a l i g n m e n t of goniometer. Note: Goniometer will not read 0 degrees at beginning of 1st CMC flexion. Number of degrees of flexion through which joint moves is calculated by subtracting final goniometer reading from initial reading. Motion is then recorded as 0 degrees to X degrees 1st CMC flexion. Starting position for m e a s u r e m e n t of 1st CMC extension.

Patient p o s i t i o n : Seated, with forearm supinated; UE supported on table; wrist and hand in neutral position, thumb positioned along lateral side of 2nd metacarpal Fig. Examiner action: After instructing patient in motion desired, extend 1st CMC joint by grasping 1st metacarpal and moving thumb away from, but parallel to, palm. Landmarks for goniometer alignment radial head, ventral surface of 1st CMC joint, ventral midline of 1st metacarpal indicated by orange line and dots. Starting position for measurement of 1st CMC extension, demonstrating proper initial alignment of goniometer.

C o n f i r m a t i o n of alignment: Repalpate landmarks and confirm proper goniometric alignment at end of ROM, correcting alignment as necessary Fig. Note: Goniometer will not read 0 degrees at beginning of 1st CMC extension. Number of degrees of extension through which joint moves is calculated by subtracting initial goniometer reading from final reading.

Motion is then recorded as 0 degrees to X degrees 1st CMC extension. Landmarks for a l i g n m e n t of ruler palmar digital crease of 5th digit, flexor crease of IP j o i n t of t h u m b indicated by orange lines. Patient position: Seated, with forearm supinated; UE supported on table, wrist and hand in neutral position, thumb positioned along lateral side of 2nd metacarpal Fig.

Examiner action: After instructing patient in motion desired, move 1st CMC joint into opposition by bringing flexor crease of IP joint of patient's thumb toward palmar digital crease of 5th digit. End of 1st CMC opposition ROM, s h o w i n g proper hand placement for stabilizing digits 2 t h r o u g h 5 and m o v i n g t h u m b into opposition toward 5th digit. Landmarks for goniometer alignment palmar digital crease of 5th digit, flexor crease of IP joint of t h u m b indicated by orange lines. Measurement is made of distance between flexor crease of IP joint of thumb and palmar digital crease of 5th digit.

Instrument alignment: Place end of ruler at palmar digital crease of 5th digit Fig. Measurement of motion: Measure distance between flexor crease of IP joint of patient's thumb and palmar digital crease of 5th digit, keeping end of ruler in contact with palmar digital crease see Fig. Documentation: Record distance as measured. Starting position for measurement of 1st MCP flexion thumb. Note that CMC joint of t h u m b is positioned in slight abduct i o n. Landmarks for goniometer alignment dorsal midline of 1st metacarpal, d o r s u m of 1st MCP joint, dorsal midline of p r o x i m a l phalanx indicated by orange lines and dot.

Measurement of 1st MCP joint shown. In this case, stabilization of 1st MCP is shown Fig. Landmarks for goniometer alignment dorsal midline of 1st metacarpal, d o r s u m of 1st MCP joint, dorsal midline of proximal phalanx indicated by orange lines and dot. Starting position for measurement of 1st MCP flexion, demonstrating proper initial a l i g n m e n t of goniometer. Examiner action: After instructing patient in motion desired, flex joint through available ROM. Return thumb to neutral position. The figures shown here depict the measurement of MCP flexion of the thumb.

Starting position for measurement of IP extension thumb. Note that CMC joint of t h u m b is positioned in slight abduction. Landmarks for goniometer alignment dorsal midline of proximal phalanx, dorsum of IP joint, dorsal midline of distal phalanx indicated by orange lines and dot. Measurement of IP joint shown. In this case, stabilization of proximal phalanx is shown Fig. Examiner action: After instructing patient in motion desired, extend joint through available ROM.

Landmarks for g o n i o m e t e r alignment dorsal m i d l i n e of p r o x i m a l phalanx, d o r s u m of IP joint, dorsal m i d l i n e of distal phalanx indicated by orange lines and dot. The figures shown here depict the measurement of IP flexion of the thumb.

American Medical Association, New York, Churchill Livingston, J Hand Surg ;16A Moreover, very little research has been conducted on the reliability of the tests described in the literature. The purpose of this section is to describe some early tests suggested in the literature for measurement of muscle length of the upper extremity and the rationale for not including these tests in this chapter on upper extremity muscle length measurement techniques. Additionally, nine tests for the examination of upper extremity muscle length are presented.

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Apley's Scratch Test In , a physical education text published by Scott and French introduced a test for upper extremity flexibility called the "opposite arm across the back" test. Hoppenfeld later referred to this test as "Apley's scratch test. One part involves asking the individual being tested to place the palm of the hand on the back by reaching behind the head and down between the shoulder blades as far as possible Fig. Hoppenfeld suggested that this maneuver was a measurement of shoulder lateral rotation and abduction, and Sullivan and Hawkins suggested that the test was a measurement for shoulder lateral rotation.

The second part of Apley's scratch test consists of asking the subject to place the dorsum of the hand against the back and to reach behind the back and up the spine as far as possible see Fig. Hoppenfeld suggested that this maneuver measured shoulder medial rotation and adduction; Sullivan and Hawkins suggested that the test examined shoulder medial rotation; and Mallon et al.

Techniques for documentation of the measurement have varied. Scott and French suggested measuring the distance between the tips of the fingers of both hands when the two parts of the test are performed simultaneously. Goldstein suggested performing the test one upper extremity at a time and recording the distance between the spinous process of C7 and the tip of the fingers.

Finally, an alternative measurement presented by Magee is to have the individual perform the test one extremity at a time and to record the levels of the vertebrae that the fingers most closely approximate. Philadelphia, WB Saunders, , with permission , a composite test measuring multiple motions and muscles that is not included in this chapter. As suggested by the variety of interpretations of Apley's scratch test, the movement that takes place during the testing is poorly defined, and the actual muscles being examined for flexibility are not known.

Therefore, the opposite arm across the back test, Apley's scratch test, is not included in the flexibility tests for the upper extremity presented in this chapter. Shoulder and Wrist Elevation Test In a text on flexibility written in , Johnson described the shoulder and wrist elevation test to measure shoulder flexibility. The test requires the individual to lift a stick or broom handle until the upper extremities are fully elevated overhead while lying in a prone position with the chin on a stable surface Fig.

The individual raises the stick upward as high as possible by flexion at the shoulders. Two methods have been described for documenting the amount of shoulder elevation achieved in this test. The first is simply to measure the distance from the stable surface to the stick. In the second, which takes into consideration the length of the individual's upper extremity, the length of the upper extremity is measured, and the test score is determined by 4 1 Fig. Shoulder and wrist elevation test, a composite test measuring multiple motions and muscles that is not included in this chapter.

End ROM for latissimus dorsi muscle length. Bony landmarks lateral midline of trunk; shoulder, lateral to acromion; lateral epicondyle of humerus indicated by orange line and dots. Patient position: Supine, upper extremities at side with elbows extended; lumbar spine flat against support surface. Examiner action: After instructing patient in motion desired, examiner flexes shoulder through available range of motion ROM while maintaining elbow in full extension and keeping arms close to head; lumbar spine should remain flat against support surface.

Note: Examiner ordinarily would perform this task standing on same side as extremity being flexed. Examiner is standing on opposite side in photo so landmarks can be seen. This passive movement allows an estimate of ROM available and demonstrates to patient exact motion required Fig. Examiner must ensure that elbow remains extended and lumbar spine remains flat against support surface see Fig. Goniometer method: Palpate bony landmarks shown in Fig.

Patient position for measurement of latissimus dorsi muscle length using goniometer. Patient position for measurement of latissimus dorsi muscle length using tape measure. Stationary arm: Axis: Moving arm: Aligned with lateral midline of trunk. Shoulder, lateral to acromion. Maintaining proper goniometric alignment, note amount of shoulder flexion Fig. Tape measure method: Using tape measure or ruler, measure distance inches or centimeters between lateral epicondyle of humerus and support surface Fig.

Documentation: Record patient's amount of shoulder flexion or distance from lateral epicondyle of humerus to support surface. Starting position for measurement of pectoralis major muscle length. Patient position for measurement of pectoralis major muscle length using tape measure. Tape measure alignment: Using tape measure or ruler, measure distance inches or centimeters between olecranon process of humerus and support surface Fig. Documentation: Record distance from support surface to olecranon process.

Starting position for measurement of lower portion of pectoralis major muscle length. Patient position: Supine, with shoulder laterally rotated and abducted to degrees; elbow fully extended, and forearm supinated; lumbar spine flat against support surface Fig. Examiner must ensure that patient maintains lumbar spine flat against support surface and does not allow trunk rotation especially to side of extremity being measured see Fig.

Patient position for measurement of lower portion of pectoralis major muscle length using goniometer. Goniometer aligned with bony landmarks parallel to support surface, lateral tip of acromion, midline of humerus toward lateral epicondyle. Patient position for measurement of lower portion of pectoralis major muscle length using tape measure. Goniometer method: Stationary arm: Axis: Moving arm: Palpate bony landmarks and align goniometer accordingly Fig.

Parallel to support surface. Lateral tip of acromion. Along midline of humerus toward lateral epicondyle. Maintaining proper goniometric alignment, note amount of shoulder horizontal abduction Fig. Documentation: Record patient's ROM or distance from support surface and lateral epicondyle of humerus.

Note: Figure 6 - 1 1 illustrates patient with excessive length in lower portion of pectoralis major muscle, which is not uncommon. Example of excessive length in lower portion of pectoralis major muscle. Starting position for measurement of upper portion of pectoralis major muscle length. Patient position: Supine, with shoulder laterally rotated and abducted to 90 degrees; elbow fully extended; forearm supinated; lumbar spine flat against support surface Fig. Patient position for measurement of upper portion of pectoralis major muscle length using goniometer.

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Patient position for measurement of upper portion of pectoralis major muscle length using tape measure. Tape measure method: Using tape measure, measure distance inches or centimeters between lateral epicondyle of humerus and support surface Fig. Note: Figure 6 - 1 5 illustrates patient with excessive length in upper portion of pectoralis major muscle, which is not uncommon.

Example of excessive length in upper portion of pectoralis major muscle. Starting position for measurement of pectoralis minor muscle length. Bony landmark posterior acromial border for tape measure alignment indicated by orange dot. Patient position for measurement of pectoralis minor muscle length using tape measure. Bony landmark posterior acromial border indicated by orange dot.

Tape measure alignment: Palpate posterior acromial border see Fig. Using tape measure or ruler, measure distance inches or centimeters between posterior border of acromion process and support surface Fig. Documentation: Record distance from posterior border of acromion process and support surface. Starting position for measurement of triceps muscle length. Bony landmarks humeral head, lateral epicondyle of humerus, radial styloid process indicated by orange dots.

Patient position: Sitting, with shoulder in full flexion; elbow extended; forearm supinated Fig. Examiner action: After instructing patient in motion desired, examiner flexes elbow through available ROM while maintaining full flexion of shoulder. End ROM of triceps muscle length. Patient position and goniometer alignment at end of triceps muscle length. Starting position for measurement of biceps muscle length. Bony landmarks lateral midline of thorax, lateral aspect of acromion process, lateral epicondyle of humerus indicated by orange line and dots.

Patient position: Supine, with shoulder at edge of plinth; elbow extended; forearm pronated Fig. Examiner action: After instructing patient in motion desired, examiner extends shoulder through available ROM while maintaining elbow in full extension. End ROM of biceps muscle length. Patient position and goniometer alignment at end of biceps muscle length. Starting position for measurement of length of forearm flexor muscles.

Landmarks insertion of biceps muscle, lunate, volar midline of 3rd metacarpal indicated by orange line and dots. Patient position: Supine, with shoulder abducted 70 to 90 degrees; elbow extended; forearm supinated; fingers extended Fig. Examiner action: After instructing patient in motion desired, examiner extends patient's wrist through available ROM while maintaining elbow and fingers in extension Fig.

This passive movement allows an estimate of ROM available and demonstrates to patient exact motion required.

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Goniometer alignment: Palpate following landmarks shown in Fig. End ROM of forearm flexor muscle length. Stationary arm: Axis: Moving arm: Insertion of biceps muscle. Maintaining proper goniometric alignment, read scale of goniometer see Fig. Note: Elbow must be maintained in full extension. Documentation: Fig. Patient position and goniometer alignment at end of forearm flexor muscle length. Record patient's maximum amount of wrist extension. Starting position for measurement of length of forearm extensor muscles.

Bony landmarks lateral epicondyle of humerus, lunate, dorsal midline of 3rd metacarpal indicated by orange line and dots. Patient position: Supine, with shoulder abducted 70 to 90 degrees; elbow extended; forearm pronated; fingers flexed Fig. Examiner action: After instructing patient in motion desired, examiner flexes patient's wrist through available ROM while maintaining elbow in extension and fingers in flexion Fig. Patient position and goniometer alignment at end of forearm extensor muscle length.

Record patient's maximum amount of wrist flexion. Corbin CB: Flexibility. Clin Sports Med ; Gaithersburg, Md, Aspen Publications, Portland, Tex, Brown and Littleman, Myers H: Range of motion and flexibility. Measurement and Evaluation in Physical Education. Dubuque, Iowa, Wm. Brown, New York: Churchill Livingstone, Research regarding reliability and validity of joint range of motion techniques is presented in this chapter no studies examining reliability of upper extremity muscle length testing were found. Only those studies providing information as to both relative and absolute reliability or validity are included.

More detailed information regarding appropriate analysis of reliability and validity is presented in Chapter 2. The reliability of passive shoulder flexion and extension goniometry was studied by Riddle et al. This group of investigators examined both intrarater and inter-rater reliability of passive shoulder flexion and extension range of motion in a group of adult patients aged 19 to 77 years.

The investigators used no standardized goniometric technique or patient positioning in this study. In an effort to determine whether the size of the goniometer used made a difference in the reliability obtained, two different sizes of universal goniometers were employed for the study. Intraclass correlation coefficients ICCs were calculated both within and between raters for each type of goniometer used. Intrarater reliability did not vary and inter-rater reliability varied only slightly with the type of goniometer used to measure both shoulder flexion and extension.

However, while intrarater reliabilities for shoulder flexion and extension were good. Unfortunately, all these investigators have chosen to focus on intrarater reliability, and no studies providing reliability coefficients between raters for active shoulder flexion or extension were found. In a study designed to compare reliability of the Ortho Ranger an electronic, computerized goniometer and the universal goniometer, Greene and Wolf examined intrarater reliability of active shoulder flexion and extension goniometry, in addition to 12 other motions of the upper extremity, in 20 healthy adults.

Measurements of shoulder flexion and extension were each taken three times per session across three testing sessions by the same examiner.


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Intrarater reliability for the measurements was analyzed using an ICC. Results revealed high reliability for the universal goniometer. In a study designed to determine the normal active range of motion of 26 movements of the upper and lower extremities in older adults, measurements were taken in 60 persons aged 60 to 84 years. Prior to data collection, intrarater reliability was determined using four subjects. Although the exact number of motions measured to determine reliability was unclear from the authors' description of their methods, they reported Pearson product moment correlation coefficients Pearson's r for intrarater reliability "above.

In a report published in , a group of investigators performed a study designed to determine whether intrarater reliability of measurements of active and passive shoulder flexion and abduction changed when the subjects were placed in a seated as compared with a supine position Sabari et al.

Two measurements were taken of each motion in each position in 30 adult subjects, aged 17 to 92 years. Data were analyzed using ICCs, which ranged from. However, paired t tests between goniometric readings taken in trial 1 compared with trial 2 revealed a significant difference p 15 Shoulder A b d u c t i o n Active Intrarater reliability of active shoulder abduction has been examined by three groups of investigators whose studies have been described previously Greene and Wolf, Sabari et al.

All three studies were performed in healthy adult subjects. Greene and Wolf and Sabari et al. Sabari et al. Greene and Wolf analyzed their data using the ICC and reported intrarater reliability of. Walker et al. However, follow-up paired t tests between goniometric readings taken in trial 1 compared with trial 2 in the study by Sabari et al. Riddle et al. Both intrarater and inter-rater reliabilities have been reported for passive shoulder abduction measurements in children.

Pandya et al. Intraclass correlation coefficients were used to analyze the data, and reliability was reported as. Inter-rater reliability of passive shoulder abduction in a subgroup of 21 children with Duchenne's muscular dystrophy also was examined, and reliability of. Range of motion was measured in patients aged 19 to 77 years without the use of standardized measuring or positioning techniques.

Intrarater reliability ICC for passive shoulder rotation ranged from. Reliability between raters for lateral rotation remained high and was reported as. However, inter-rater reliability for passive shoulder medial rotation was fairly low, equaling. MacDermid et al. In a study of 34 patients older than 55 years with shoulder pathology, MacDermid and colleagues measured passive lateral rotation of the shoulder while the patient was supine with the shoulder abducted 20 to 30 degrees.

Both intrarater and inter-rater reliabilities were calculated using ICCs. Intrarater reliability was reported as. Inter-rater reliability was. Active More groups have examined active shoulder rotation goniometry than have examined passive rotation goniometry. Greene and Wolf and Walker et al. The study by Walker et al. Four different examiners with varied experience in goniometry performed the measurements using AAOS measurement techniques.

Measurements were taken once per week for 4 weeks by each of the four examiners. Average intrarater reliability was. However, although average inter-rater reliability was. The majority of studies regarding the reliability of measuring elbow flexion range of motion involve measurements of active elbow flexion, the exception being a study by Rothstein and colleagues. In contrast, reports of reliability of elbow extension goniometry include about equal numbers of measurements of active and passive joint motion.

Each of the subjects had undergone a surgical procedure for an injury to the elbow, the forearm, or the wrist a minimum of 6 months prior to measurement. Standardized measuring techniques and patient positioning were used during the testing, in which three different instruments were employed to assess range of motion. The instruments used for the study included a universal goniometer, a computerized goniometer, and "a mechanical rotation measuring device.

Active elbow flexion and extension range of motion were measured twice for each instrument on all subjects. Five different examiners, who possessed varied amounts of experience in performing goniometry, measured the amount of elbow flexion and extension in each subject. Both intrarater and inter-rater reliability were analyzed using ICCs.

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Intrarater reliability for active elbow flexion using the universal goniometer ranged from. Similar intrarater reliability levels were obtained for active elbow extension, ranging from. Ninety-five percent CIs within raters averaged 6 degrees for elbow flexion and 7 degrees for elbow extension. Inter-rater reliability for elbow flexion using the universal goniometer was reported as. Levels of interrater reliability reported by Armstrong et al.

Elbow extension inter-rater reliability using the universal goniometer was reported as. Ninety-five percent CIs between raters averaged 10 degrees for both elbow flexion and extension. Goodwin and colleagues also used a variety of examiners and instruments in their study of the reliability of measurements of active elbow flexion range of motion. These investigators compared the reliability of the universal goniometer, of a fluid goniometer, and of an electrogoniometer using three experienced examiners measuring a group of 24 healthy females, aged 18 to 31 years.

Active elbow flexion was measured in each subject by all three examiners using each of the three instruments on two separate occasions. Standardized measurement techniques and patient positioning were employed by all three examiners in all subjects. Test-retest reliability for each examiner using each type of measuring device was calculated using both Pearson's r and the ICC. Reliabilities for the universal goniometer ranged from. Several other groups of researchers whose studies have been described previously have investigated the reliability of measurements of active elbow flexion and extension.

Reliability was analyzed using either Pearson's r Walker et al. Greene and Wolf reported reliability of. The reliability intrarater and inter-rater of goniometric measurements of active elbow flexion range of motion was examined by Boone and colleagues in a group of 12 healthy males aged 26 to 54 years. Measuring techniques advocated by the AAOS were used in the study. Although average inter-rater reliability was.

One other group of researchers examined the reliability of active elbow flexion goniometry, but this group confined their investigation to inter-rater reliability of this motion. Petherick and colleagues compared the inter-rater reliability of active elbow flexion measurements taken with the universal goniometer with those taken with the fluid-based goniometer in a group of 30 healthy subjects with a mean age of 24 years.

Two examiners measured active elbow flexion three times with both instruments on each subject. Standardized measuring techniques and patient positioning were used during the testing procedure. The mean of the three measurements was used to calculate the ICC for each instrument. Intrarater reliability was not reported for either of the two examiners. Inter-rater reliability using the universal goniometer to measure active elbow flexion was reported as. The reliability level using the universal goniometer was similar to that reported by Armstrong et al.

Rothstein and colleagues measured passive elbow flexion and extension in 12 patients of unstated age using three different, commonly used, goniometers. Twelve different examiners performed the measurements, although any one patient was measured by only two different examiners. Data were analyzed using both Pearson's r and the ICC.

Intrarater reliability ranged from. Inter-rater reliability ranged from. In the case of both intrarater and inter-rater reliability levels, values obtained were dependent on the type of goniometer used and the type of statistical analysis performed. Additionally, inter-rater reliability levels were dependent on which measurement was used for comparison purposes first measurement, second measurement, or mean. Reliability of passive elbow extension, but not of flexion, was investigated in a pediatric population by Pandya and colleagues. American Academy of Orthopaedic Surgeons' techniques were used to measure passive elbow extension with the universal goniometer.

In this group of children with muscular dystrophy intrarater reliability was. Although no studies were discovered that examined the reliability of measurements of passive forearm motion, three separate groups have investigated the reliability of measurements of active forearm motion. Both Greene and Wolf and Walker et al. Data were analyzed using the ICC, and intrarater reliability was. Ninety-five percent CIs were reported for forearm pronation and supination, and were 9. Both intrarater and inter-rater reliability of active forearm pronation and supination were investigated by Armstrong and her colleagues in a group of 38 subjects aged 14 to 72 years.

Each subject had undergone a surgical procedure to the upper extremity a minimum of six months prior to measurement. Intrarater reliability for the universal goniometer ranged from. Interrater reliability was slightly lower for the two measurements, with reliability coefficients reported as.

Ninety-five percent CIs within raters averaged 8 degrees for both forearm pronation and supination, whereas CIs between raters averaged 10 degrees for pronation and 11 degrees for supination. One hundred forty patients, aged 6 to 81 years, from eight different clinical sites around the United States, were recruited for the study.

Thirty-two examiners from the eight clinics performed the goniometric measurements. In each of the clinics participating in the study, examiners were randomly paired for purposes of determining inter-rater reliability. Passive wrist flexion and extension were measured twice in each subject by each member of the randomly chosen pair of examiners, using three different measuring techniques. The three techniques used for measuring passive wrist motion included positioning the goniometer: 1 along the radial side of the forearm, with the stationary arm aligned with the "radial midline of the forearm" and the moving arm aligned with the "longitudinal axis of the second metacarpal"; 2 along the ulnar side of the forearm, with the stationary arm aligned with the "longitudinal midline of the ulna toward the olecranon" and the moving arm aligned with the "longitudinal axis of the third metacarpal"; and 3 along the dorsal for flexion or volar for extension surface of the wrist, with the stationary arm aligned with the dorsal or volar surface of the forearm and the moving arm aligned with the "longitudinal axis of the third metacarpal.

The SEMm for wrist flexion within examiners ranged from 5. For wrist extension, the SEMm within examiners ranged from 6. The SEMm for wrist flexion between examiners ranged from 4. For wrist extension, the SEMm between examiners ranged from 6. As was the case for the SEMm within examiners, variations in the SEMm were dependent on the clinic in which the measurements were taken.

Thirteen examiners, with a range of experience of 2 months to 17 years, participated in the study Forty-eight patients, whose ages ranged from 18 to 71 years, had both active and passive wrist motions measured twice each by two randomly paired examiners. No specific method of patient positioning or measuring technique was used during the study.

The ICC was used to analyze the data, and results are reported in Tables 7 - 1 1 and 7 - 1 2. Intrarater reliability was high. The SEMm within raters was 3. Levels of inter-rater reliability were slightly lower. The SEMm between raters for passive wrist motions was 7. For active motion, the SEMm between raters was 7. A third group of investigators, whose work has been described previously see the preceding Shoulder Abduction section , examined the reliability of goniometric measurements of passive wrist motion, but this group measured wrist extension and not flexion Pandya et al.

Both intrarater and interrater reliability of goniometric measurements of passive wrist extension were investigated in groups of and 21 patients, respectively, with Duchenne's muscular dystrophy. Techniques advocated by the AAOS were used in the study, and intrarater reliability was. Both Walker et al. Intrarater reliability levels reported by Walker et al. Horger used patients as subjects in her study and employed 13 examiners who measured both active and passive wrist motions without the use of a standardized technique.

On the other hand, Boone et al. Horger reported intrarater reliability coefficients greater than or equal to. The SEMm within raters reported in the Horger study ranged from 2. Intrarater reliability for goniometric measurements of active wrist adduction were higher in the Horger study than in the study by Boone et al.

While inter-rater reliability for measurements of active wrist adduction was similar between the two studies Table 7 - 1 4 , the ANOVA reported by Boone et al. The SEMm between examiners reported by Horger ranged from 3. Greene and Wolf reported intrarater reliability of. No studies that used inferential statistics to analyze the reliability of goniometric measurements of the thumb were evident in the literature. Only a single group of investigators has used the correlation coefficient to report reliability of discrete motion of any digit. Flowers and LaStayo examined the intrarater reliability of goniometric measurements of passive extension of the proximal interphalangeal PIP joint in 20 fused PIP joints from seven patients.

This examination of reliability was part of a larger study that investigated the correlation between the time spent in serial casting and the change in range of motion in PIP joints of the fingers. The measurement of passive motion in both studies involved placement of the goniometer over the dorsal surface of the joint while a predetermined, controlled extension torque was applied across the PIP joint. After the torque had been applied for 20 seconds, the goniometer was read, and the range of motion was recorded.

Intrarater reliability of this so-called "torque passive range of motion t e s t " - was reported as. Breger-Lee et al.