C. C. Norkin, J. White, T. W. Malone - Measurement of Joint Motion - A Guide To Goniometry, Fourth Edition - F.A. Davis Company (2009) PDF
C. C. Norkin, J. White, T. W. Malone - Measurement of Joint Motion - A Guide To Goniometry, Fourth Edition - F.A. Davis Company (2009) PDF
C. C. Norkin, J. White, T. W. Malone - Measurement of Joint Motion - A Guide To Goniometry, Fourth Edition - F.A. Davis Company (2009) PDF
Measurement of
Joint Motion
A Guide to Goniometry
fourth edition
i
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F. A. Davis Company
1915 Arch Street
Philadelphia, PA 19103
www.fadavis.com
Copyright © 2009 by F. A. Davis Company. All rights reserved. This product is protected by copyright. No part
of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic,
mechanical, photocopying, recording, or otherwise, without written permission from the publisher.
As new scientific information becomes available through basic and clinical research, recommended treatments
and drug therapies undergo changes. The author(s) and publisher have done everything possible to make this
book accurate, up to date, and in accord with accepted standards at the time of publication. The author(s),
editors, and publisher are not responsible for errors or omissions or for consequences from application of the
book, and make no warranty, expressed or implied, in regard to the contents of the book. Any practice described
in this book should be applied by the reader in accordance with professional standards of care used in regard to
the unique circumstances that may apply in each situation. The reader is advised always to check product infor-
mation (package inserts) for changes and new information regarding dose and contraindications before adminis-
tering any drug. Caution is especially urged when using new or infrequently ordered drugs.
Norkin, Cynthia C.
Measurement of joint motion : a guide to goniometry / Cynthia C. Norkin, D. Joyce White ; photographs by Jocelyn
Greene Molleur and Lucia Grochowska Littlefield ; illustrations by Timothy Wayne Malone. -- 4th ed.
p. ; cm.
Includes bibliographical references and index.
ISBN-13: 978-0-8036-2066-7
ISBN-10: 0-8036-2066-7
1. Joints--Range of motion--Measurement. I. White, D. Joyce. II. Title.
[DNLM: 1. Arthrometry, Articular--methods. 2. Joint Diseases--diagnosis. 3. Joints--physiology.
WE 300 N841m 2009]
RD734.N67 2009
612.7'5--dc22
2008036707
Authorization to photocopy items for internal or personal use, or the internal or personal use of specific clients, is
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Preface
The measurement of joint motion is an important component anatomical descriptions of joint structures and landmarks
of a thorough physical examination of the extremities and used in goniometer alignment directly to the measurement
spine, one which helps health professionals identify impair- procedures. Information summarizing research findings now
ments and assess rehabilitative status. The need for a compre- follows, rather than precedes, the measurement procedures.
hensive text with sufficient written detail and photographs to This restructuring makes it easier for readers that are focused
allow for the standardization of goniometric measurement on learning measurement technique, as well as readers that are
methods—both for the purposes of teaching and clinical prac- focused on reviewing the research literature for evidence-
tice led to the development of the first edition of the Measure- based practice, to find what they are seeking. Similar to earlier
ment of Joint Motion: A Guide to Goniometry in 1985. Our editions we have incorporated new information on normative
approach included a discussion and illustration of testing range of motion values for various age and gender groups, as
position, stabilization, end-feel, and goniometer alignment for well as the range of motion needed to perform common func-
each measurable joint in the body. The resulting text was tional tasks. We added current information on the effects of
extremely well received by a variety of health professional subject characteristics, such as body mass, occupational and
educational programs and was used as a reference in many recreational activities, and the effects of the testing process,
clinical settings. such as the testing position and type of measuring instrument,
In the years following initial publication, a considerable on range of motion. In the fourth edition we added and re-
amount of research on the measurement of joint motion structured more measurement techniques to the spine chapters
appeared in the literature. Consequently, a second edition, and added several commonly used methods to assess finger
published in 1995, included a chapter on the reliability and and thumb range of motion. The TMJ chapter was enhanced
validity of joint measurement as well as joint-specific re- with clear photographs and illustrations of measurement tech-
search sections in each existing chapter. We also expanded the niques. In addition, over 90 new photographs and illustrations
text by adding structure, osteokinematics, arthrokinematics, replaced many of the older, dated art work.
capsular and noncapsular patterns of limitation, and func- This book continues to present goniometry logically
tional ranges of motion for each joint. and clearly. Chapter 1 discusses basic concepts regarding
The third edition included extensive new research find- the use of goniometry to assess range of motion and muscle
ings related to joint motion. New to the third edition was the length in patient evaluation. Arthrokinematic and osteokine-
inclusion of muscle length testing at joints where muscle matic movements, elements of active and passive range of
length is often a factor affecting range of motion. This addi- motion, hypomobility, hypermobility, and factors affecting
tion integrated the measurement procedures used in this book joint motion are included. The inclusion of end-feels and
with the American Physical Therapy Association’s Guide to capsular and noncapsular patterns of joint limitation intro-
Physical Therapy Practice. Inclinometer techniques for mea- duces readers to current concepts in orthopedic manual ther-
suring range of motion of the spine were added to coincide apy and encourages them to consider joint structure while
with current practice in some clinical settings. Illustrations measuring joint motion.
were included to accompany anatomical descriptions so that Chapter 2 takes the reader through a step-by-step process
the reader had a visual reminder of the joint structures in- to master the techniques of goniometric evaluation, including:
volved in range of motion. New illustrations of bony anatom- positioning, stabilization, instruments used for measurement,
ical landmarks and photographs of surface anatomy were goniometer alignment, and the recording of results. Exercises
added to help the reader align the goniometer accurately. that help develop necessary psychomotor skills and demon-
In the fourth edition we reorganized the content in strate direct application of theoretical concepts facilitate
Chapters 4 to 13 to create a more logical progression from learning.
v
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vi Preface
Chapter 3 discusses the validity and reliability of mea- arthrokinematic motion, and capsular patterns of restrictions.
surement. The results of validity and reliability studies on the A review of current literature regarding normal range of
measurement of joint motion are summarized to help the motion values; the effects of age, gender, and other factors
reader focus on ways of improving and interpreting goniomet- on range of motion; functional range of motion; and reliabil-
ric measurements. Mathematical methods of evaluating relia- ity and validity of measurement procedures are also presented
bility are shown along with examples and exercises so that the for each body region to assist the reader to comply with
readers can assess their reliability in taking measurements. evidence-based practice.
Chapters 4 to 13 present detailed information on gonio- We hope this book makes the teaching and learning
metric testing procedures for the upper and lower extremities, of goniometry easier and improves the standardization and
spine, and temporomandibular joint. When appropriate, mus- thus the reliability and validity of this examination tool.
cle length testing procedures are also included. The text We believe that the fourth edition provides a comprehensive
presents the anatomical landmarks, testing position, stabiliza- coverage of the clinical measurement of joint motion and
tion, testing motion, normal end-feel, and goniometer align- muscle length. We hope that the additions will motivate health
ment for each joint and motion, in a format that reinforces a professionals to conduct research and to use research results
consistent approach to evaluation. The extensive use of pho- in evaluation. We encourage our readers to provide us with
tographs and captions eliminates the need for repeated feedback on our current efforts to bring you a high-quality,
demonstrations by an instructor and provides the reader with user-friendly text.
a permanent reference for visualizing the procedures. Also CCN
included is information on joint structure, osteokinematic and DJW
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Acknowledgments
We are very grateful for the contributions of the many peo- Melissa Duffield, Acquisitions Editor, for their encouragement
ple who were involved in the development and production and commitment to excellence. Our thanks are also extended
of this text. Photographer Jocelyn Molleur applied her skill to George Lang, Manager of Content Development; David
and patience during many sessions at the physical therapy Orzechowski, Managing Editor; Robert Butler, Production
laboratory at the University of Massachusetts Lowell to Manager; Karen Carter, Developmental Editor; Carolyn
produce the high-quality photographs that appear in both O'Brien, Manager of Art and Design; Katharine L. Margeson,
the third and fourth editions. Her efforts combined with Illustration Coordinator; Elizabeth Stepchin, Developmental
those of Lucia Grochowska Littlefield, who took the pho- Associate; Stephanie Casey, Administrative Assistant; and
tographs for the first edition, are responsible for an impor- Jean-Francois Vilain, Former Publisher for the first and second
tant feature of the book. Timothy Malone, an artist from editions. We are very grateful to the numerous students, fac-
Ohio, used his talents, knowledge of anatomy, and good ulty, and clinicians who over the years have used the book or
humor to create the excellent illustrations that appear in formally reviewed portions of the manuscript and offered in-
this edition. We also offer our thanks to Colleen DeCotret, sightful comments and helpful suggestions that have improved
Alexander White, Claudia Van Bibber, and University of this text.
Massachusetts Lowell physical therapy students: Rachel Finally, we wish to thank our families: Cynthia’s daugh-
Blakeslee, Rebecca D'Amour, and Chris Fournier who gra- ter, Alexandra, and her daughters, Taylor and Kimberly; and
ciously agreed to be subjects for the new photographs and Joyce’s husband, Jonathan, sons, Alexander and Ethan, and
provided painstaking research support for the fourth edition. parents, Dorothy and Emerson, for their continuing encour-
We wish to express our appreciation to these dedicated agement and support. We will always be appreciative.
professionals at F. A. Davis: Margaret Biblis, Publisher, and
vii
vii
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Reviewers
Joni Goldwasser Barry, PT, DPT, NCS Liz L. Harrison, DPT, BPT, MSc, PhD
Assistant Professor Professor and Associate Dean
School of Health Professions School of Physical Therapy
Maryville University University of Saskatchewan
St. Louis, Missouri Saskatoon, Saskatchewan, Canada
viii
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Contents
PART I INTRODUCTION TO Alignment, 27
GONIOMETRY, 1 EXERCISE 3: Goniometer Alignment for
Elbow Flexion, 30
Chapter 1 Basic Concepts, 3 Recording, 31
Goniometry, 3 Numerical Tables, 32
Joint Motion, 4 Pictorial Charts, 32
Arthrokinematics, 4 Sagittal-Frontal-Transverse-Rotation
Osteokinematics, 5 Method, 33
Planes and Axes, 5 American Medical Association Guides to
Range of Motion, 6 Evaluation Method, 34
Active Range of Motion, 8 Procedures, 34
Passive Range of Motion, 8 Explanation Procedure, 35
Hypomobility, 9 Testing Procedure, 35
Hypermobility, 11 EXERCISE 4: Explanation of
Factors Affecting Range of Motion, 12 Goniometric Testing Procedure, 36
Muscle Length Testing, 13 EXERCISE 5: Testing Procedure for
Goniometric Evaluation of Elbow
Chapter 2 Procedures, 19 Flexion ROM, 36
Positioning, 19
Stabilization, 20 Chapter 3 Validity and Reliability, 39
Measurement Instruments, 21 Validity, 39
Universal Goniometer, 21 Face Validity, 39
EXERCISE 1: Determining the End Content Validity, 39
of the Range of Motion and End-Feel, 22 Criterion-Related Validity, 39
Gravity-Dependent Goniometers Construct Validity, 40
(Inclinometers), 25 Reliability, 41
Electrogoniometers, 26 Summary of Goniometric Reliability
Visual Estimation, 26 Studies, 41
EXERCISE 2: The Universal Statistical Methods of Evaluating
Goniometer, 27 Measurement Reliability, 43
ix
ix
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x Contents
Contents xi
xii Contents
Contents xiii
I
INTRODUCTION TO
GONIOMETRY
On completion of Part I, the reader will be able to: • Clinical estimates of range of motion
• Palpating bony landmarks
1. Define: • Recording starting and ending positions
• Goniometry
• Planes and axes 5. Describe the parts of universal, fluid, and
• Range of motion pendulum goniometers
• End-feel
• Muscle length testing 6. List:
• Reliability • Six-step explanation sequence
• Validity • 12-step testing sequence
• 10 items included in recording
2. Identify the appropriate planes and axes for each
of the following motions: 7. Perform a goniometric evaluation of the elbow
Flexion–extension, abduction–adduction, and joint including:
rotation • Clear explanation of the procedure
• Positioning of a subject in the testing position
3. Compare: • Adequate stabilization of the proximal joint com-
• Active and passive ranges of motion ponent
• Arthrokinematic and osteokinematic motions • Correct determination of the end of the range of
• Soft, firm, and hard end-feels motion
• Hypomobility and hypermobility • Correct identification of the end-feel
• Capsular and noncapsular patterns of restricted • Palpation of the correct bony landmarks
motion • Accurate alignment of the goniometer
• One-joint, two-joint, and multijoint muscles • Correct reading of the goniometer and recording
• Reliability and validity of the measurement
• Intratester and intertester reliability
8. Perform and interpret intratester and intertester
4. Explain the importance of: reliability tests including standard deviation,
• Testing positions coefficient of variation, correlation coefficients,
• Stabilization and standard error of measurement.
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1
Basic Concepts
This book is designed to serve as a guide to learning the tech- the measurement of angles created at human joints by the bones
nique of human joint measurement called goniometry. Back- of the body. The examiner obtains these measurements by plac-
ground information on principles and procedures necessary for ing the parts of the measuring instrument, called a goniometer,
an understanding of goniometry is found in Part 1. Practice along the bones immediately proximal and distal to the joint
exercises are included at appropriate intervals to help the exam- being evaluated. Goniometry may be used to determine both a
iner apply this information and develop the psychomotor skills particular joint position and the total amount of motion avail-
necessary for competency in goniometry. The validity and reli- able at a joint.
ability of goniometric measurements are explored to encourage
Example: The elbow joint is evaluated by placing the
thoughtful and appropriate use of these techniques in clinical
parts of the measuring instrument on the humerus
practice. Procedures for the goniometric examination of joint
(proximal segment) and the forearm (distal segment)
range of motion and muscle length testing of the upper extrem-
and measuring either a specific joint position or the
ity, lower extremity, and spine and temporomandibular joint are
total arc of motion (Fig. 1.1).
presented in Parts II, III, and IV, respectively.
Goniometry is an important part of a comprehensive
examination of joints and surrounding soft tissue. A compre-
hensive examination typically begins by interviewing the sub-
Goniometry ject and reviewing records to obtain an accurate description of
current symptoms; functional abilities; occupational, social,
The term goniometry is derived from two Greek words, gonia, and recreational activities; and medical history. Observation
meaning angle, and metron, meaning measure. Therefore, of the body to assess bone and soft tissue contour, as well as
goniometry refers to the measurement of angles, in particular skin and nail condition, usually follows the interview. Gentle
3
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Axis
• Determining the presence or absence of impairment
• Establishing a diagnosis
• Developing a prognosis, treatment goals, and plan of care
• Evaluating progress or lack of progress toward
rehabilitative goals
• Modifying treatment
• Motivating the subject
• Researching the effectiveness of therapeutic techniques or
regimens (for example, measuring outcomes following
exercises, medications, and surgical procedures)
• Fabricating orthoses and adaptive equipment
A B
Angular
motion
Angular
motion
Roll
Roll
Slide
Slide
Anterior–
posterior
axis
Medial–
lateral
axis
Frontal
plane
Sagittal
plane
A Vertical axis
Anatomical Neutral
position position
Transverse
plane A B
zero
additional passive ROM helps to protect joint structures because
zero
n to it allows the joint to absorb extrinsic forces.
om
Testing passive ROM provides the examiner with informa-
sio
n fr
te n
tion about the integrity of the joint surfaces and the extensibility
xio
Ex
and skin. To focus on these issues, passive ROM rather than ac-
Extension tive ROM should be tested in goniometry. Unlike active ROM,
from
zero passive ROM does not depend on the subject’s muscle strength
and coordination. Comparisons between passive ROMs and
active ROMs provide information about the amount of motion
Flexion
permitted by the associated joint structures (passive ROM) rela-
to zero
tive to the subject’s ability to produce motion at a joint (active
FIGURE 1.10 Flexion and extension of the shoulder begin ROM). In cases of impairment such as muscle weakness, pas-
with the shoulder in the anatomical position. The ROM in sive ROMs and active ROMs may vary considerably.
flexion proceeds anteriorly from the zero position through
an arc toward 180 degrees. The long, bold arrow shows the Example: An examiner may find that a subject with a
ROM in flexion, which is measured in goniometry. The ROM muscle paralysis has a full passive ROM but no active
in extension proceeds posteriorly from the zero position ROM at the same joint. In this instance, the joint sur-
through an arc toward 180 degrees. The short, bold arrow
faces and the extensibility of the joint capsule, liga-
shows the ROM in extension, which is measured in
goniometry. ments, muscles, tendons, fascia, and skin are sufficient
to allow full passive ROM. The lack of muscle strength
prevents active motion at the joint.
toward 0 degrees. The motions of extension and adduction
The examiner should test passive ROM prior to perform-
begin at 180 degrees and proceed in an arc toward 360 degrees.
ing a manual muscle test of muscle strength because the grad-
These two notation systems are more difficult to interpret than
ing of manual muscle tests is based on completion of the joint
the 0 to 180 degree notation system and are infrequently used.
ROM. An examiner must know the extent of the passive ROM
Therefore, we have not included them in this text.
before initiating a manual muscle test.
If pain occurs during passive ROM, it is often due to
Active Range of Motion moving, stretching, or pinching of noncontractile (inert)
Active range of motion (AROM) is the arc of motion structures. Pain occurring at the end of passive ROM may be
attained by a subject during unassisted voluntary joint motion. due to stretching of contractile structures as well as noncon-
Having a subject perform active ROM provides the examiner tractile structures. Pain during passive ROM is not due to
with information about the subject’s willingness to move, active shortening (contracting) of contractile tissues. By com-
coordination, muscle strength, and joint ROM. If pain occurs paring which motions (active versus passive) cause pain and
during active ROM, it may be due to contracting or stretching noting the location of the pain, the examiner can begin to
of “contractile” tissues, such as muscles, tendons, and their determine which injured tissues are involved. Having the sub-
attachments to bone. Pain may also be due to stretching or ject perform resisted isometric muscle contractions midway
pinching of noncontractile (inert) tissues, such as ligaments, through the ROM, so that no tissues are being stretched, can
joint capsules, bursa, fascia, and skin. Testing active ROM is help to isolate contractile structures. Having the examiner
a good screening technique to help focus a physical examina- perform joint play mobility and joint integrity tests on the
tion. If a subject can complete active ROM easily and pain- subject can help determine which noncontractile structures
lessly, further testing of that motion is probably not needed. are involved. Careful consideration of the end-feel and
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location of tissue tension and pain during passive ROM also Examiners should practice trying to distinguish among
adds information about structures that are limiting ROM. the end-feels. In Chapter 2, Exercise 1 is included for this pur-
pose. However, some additional topics regarding positioning
End-Feel
and stabilization must be addressed before this exercise can
The amount of passive ROM is determined by the unique struc-
be completed.
ture of the joint being tested. Some joints are structured so that
the joint capsules limit the end of the ROM in a particular direc-
tion, whereas other joints are so structured that ligaments limit
Hypomobility
the end of a particular ROM. Other normal limitations to motion The term hypomobility refers to a decrease in passive ROM
include passive tension in soft tissue such as muscles, fascia, and that is substantially less than normal values for that joint, given
skin; soft tissue approximation; and contact of joint surfaces. the subject’s age and gender. The end-feel occurs early in the
The type of structure that limits a ROM has a character- ROM and may be different in quality from what is
istic feel that may be detected by the examiner who is per- expected. The limitation in passive ROM may be due to a
forming the passive ROM. This feeling, which is experienced variety of causes including abnormalities of the joint surfaces;
by an examiner as a barrier to further motion at the end of a passive shortening of joint capsules, ligaments, muscles,
passive ROM, is called the end-feel. Developing the ability to fascia, and skin; and inflammation of these structures. Hypomo-
determine the character of the end-feel requires practice and bility has been associated with many orthopedic conditions such
sensitivity. Determination of the end-feel must be carried out as osteoarthritis,29,30 rheumatoid arthritis,31 adhesive capsuli-
slowly and carefully to detect the end of the ROM and to dis- tis,32,33 and spinal disorders.34, 35 Decreased ROM is a common
tinguish among the various normal and abnormal end-feels. consequence of immobilization after fractures36,37 and scar
The ability to detect the end of the ROM is critical to the safe development after burns.38,39 Neurological conditions such as
and accurate performance of goniometry. The ability to distin- stroke, head trauma, cerebral palsy, and complex regional pain
guish among the various end-feels helps the examiner identify syndrome40 can also result in hypomobility owing to loss of vol-
the type of limiting structure. Cyriax,18 Kaltenborn,3 and untary movement, increased muscle tone, immobilization, and
Paris19 have described a variety of normal (physiological) and pain. In addition, metabolic conditions such as diabetes have
abnormal (pathological) end-feels. Table 1.1, which describes been associated with limited joint motion.41–43
normal end-feels, and Table 1.2, which describes abnormal
Capsular Patterns of Restricted Motion
end-feels, have been adapted from the works of these authors.
Cyriax18 has proposed that pathological conditions involving
In Chapters 4 through 13 we describe what we believe are
the entire joint capsule cause a particular pattern of restriction
the normal end-feels and the structures that limit the ROM for
involving all or most of the passive motions of the joint. This
each joint and motion. Because of the paucity of specific liter-
pattern of restriction is called a capsular pattern. The restric-
ature in this area, these descriptions are based on our experi-
tions do not involve a fixed number of degrees for each
ence in evaluating joint motion and on information obtained
motion, but rather a fixed proportion of one motion relative to
from established anatomy20,21 and biomechanics texts.22–28 Con-
another motion.
siderable controversy exists among experts concerning the
structures that limit the ROM in some parts of the body. Also, Example: The capsular pattern for the elbow joint is
normal individual variations in body structure may cause a greater limitation of flexion than of extension. The
instances in which the end-feel differs from our description. elbow joint normally has a passive flexion ROM of
Soft Soft tissue approximation Knee flexion (contact between soft tissue of posterior leg and
posterior thigh)
Firm Muscular stretch Hip flexion with the knee straight (passive elastic tension of
hamstring muscles)
Capsular stretch Extension of metacarpophalangeal joints of fingers (tension in
the anterior capsule)
Ligamentous stretch Forearm supination (tension in the palmar radioulnar ligament
of the inferior radioulnar joint, interosseous membrane,
oblique cord)
Hard Bone contacting bone Elbow extension (contact between the olecranon process of
the ulna and the olecranon fossa of the humerus)
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0 to 150 degrees. If the capsular involvement is mild, which there is considerable joint effusion or synovial inflam-
the subject might lose the last 15 degrees of flexion mation, and (2) conditions in which there is relative capsular
and the last 5 degrees of extension so that the pas- fibrosis.
sive flexion ROM is 5 to 135 degrees. If the capsular Joint effusion and synovial inflammation accompany
involvement is more severe, the subject might lose conditions such as traumatic arthritis, infectious arthritis,
the last 30 degrees of flexion and the first 10 degrees acute rheumatoid arthritis, and gout. In these conditions the
of extension so that the passive flexion ROM is 10 to joint capsule is distended by excessive intra-articular synovial
120 degrees. fluid, causing the joint to maintain a position that allows the
greatest intra-articular joint volume. Pain triggered by stretch-
Capsular patterns vary from joint to joint (Table 1.3). The
ing the capsule and muscle spasms that protect the capsule
capsular patterns for each joint, as presented by Cyriax18 and
from further insult inhibit movement and cause a capsular pat-
Kaltenborn,3 are listed in the beginning of Chapters 4 through
tern of restriction.
13. Studies are needed to test the hypotheses regarding the
Relative capsular fibrosis often occurs during chronic low-
cause of capsular patterns and to determine the capsular pat-
grade capsular inflammation, immobilization of a joint, and the
tern for each joint. Several studies44–46 have examined the con-
resolution of acute capsular inflammation. These conditions
struct validity of Cyriax’s capsular pattern in patients with
increase the relative proportion of collagen compared with that
arthritis or arthrosis of the knee. Although differing opinions
of mucopolysaccharide in the joint capsule, or they change the
exist, the findings seem to support the concept of a capsular
structure of the collagen. The resulting decrease in extensibility
pattern of restriction for the knee but with more liberal inter-
of the entire capsule causes a capsular pattern of restriction.
pretation of the proportions of limitation than suggested by
Cyriax.18 Two studies46,47 examining capsular patterns for the Noncapsular Patterns of Restricted Motion
hip found decreases in all hip motions in osteoarthritic hips as A limitation of passive motion that is not proportioned similarly
compared to nonosteoarthritic hips, but raised questions con- to a capsular pattern is called a noncapsular pattern of
cerning specific patterns of limitation proposed by restricted motion.18,48 A noncapsular pattern is usually caused by
Kaltenborn3 and Cyriax.18 a condition involving structures other than the entire joint cap-
Hertling and Kessler48 have thoughtfully extended Cyr- sule. Internal joint derangement, adhesion of a part of a joint
iax’s concepts on causes of capsular patterns. They suggest capsule, ligament shortening, muscle strains, and muscle
that conditions resulting in a capsular pattern of restriction contractures are examples of conditions that typically result in
can be classified into two general categories: (1) conditions in noncapsular patterns of restriction. Noncapsular patterns usually
2066_Ch01_001-018.qxd 5/21/09 5:04 PM Page 11
Glenohumeral joint Greatest loss of lateral rotation, moderate loss of abduction, minimal
loss of medial rotation.
Elbow complex (humeroulnar, Loss of flexion greater than loss of extension. Rotations full and painless
humeroradial, proximal radioulnar except in advanced cases.
joints)
Forearm (proximal and distal radioulnar Equal loss of supination and pronation, only occurring if elbow has
joints) marked restrictions of flexion and extension.
Wrist (radiocarpal and midcarpal joints) Equal loss of flexion and extension, slight loss of ulnar and radial
deviation (Cyriax).
Equal loss of all motions (Kaltenborn).
Hand
Carpometacarpal joint—digit 1 Loss of abduction (Cyriax). Loss of abduction greater than extension
(Kaltenborn).
Carpometacarpal joint—digits 2–5 Equal loss of all motions.
Metacarpophalangeal and Equal loss of flexion and extension (Cyriax).
interphalangeal joints
Restricted in all motions, but loss of flexion greater than loss of other
motions (Kaltenborn).
Hip Greatest loss of medial rotation and flexion, some loss of abduction,
slight loss of extension. Little or no loss of adduction and lateral
rotation (Cyriax).
Greatest loss of medial rotation, followed by less restriction of
extension, abduction, flexion, and lateral rotation (Kaltenborn).
Knee (tibiofemoral joint) Loss of flexion greater than extension.
Ankle (talocrural joint) Loss of plantarflexion greater than dorsiflexion.
Subtalar joint Loss of inversion (varus).
Midtarsal joint Loss of inversion (adduction and medial rotation); other motions full.
Foot
Metatarsophalangeal joint—digit 1 Loss of extension greater than flexion.
Metatarsophalangeal joint—digits 2–5 Loss of flexion greater than extension.
Interphalangeal joints Loss of extension greater than flexion.
Reproduced with permission from Dyrek, DA: Assessment and treatment planning strategies for musculoskeletal
deficits. In O’Sullivan, SB, and Schmitz, TJ (eds): Physical Rehabilitation: Assessment and Treatment, ed 3. FA Davis,
Philadelphia, 1994.
Capsular patterns are from Cyriax18 and Kaltenborn.3
involve only one or two motions of a joint, in contrast to capsu- extension at the elbow joint is about 0 degrees.10 A ROM mea-
lar patterns, which involve all or most motions of a joint.3,18 surement of 30 degrees or more of extension at the elbow is
well beyond normal ROM and is indicative of a hypermobile
Example: A strain of the biceps muscle may result in
joint in an adult. Children have some normally occurring spe-
pain and restriction at the end of the range of passive
cific instances of increased ROM as compared with adults.
elbow extension. The passive motion of elbow flexion
For example, neonates 6 to 72 hours old have been found to
would not be affected.
have a mean ankle dorsiflexion passive ROM of 59 degrees,50
which contrasts with mean adult ROM values of between 12
Hypermobility and 20 degrees.9,51 The increased motion that is present in
The term hypermobility refers to an increase in passive ROM these children is normal for their age. If the increased motion
that exceeds normal values for that joint, given the subject’s persists beyond the expected age range, it would be consid-
age and gender. For example, in adults the normal ROM for ered abnormal and hypermobility would be present.
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Hypermobility is due to the laxity of soft tissue structures According to Grahame,53 the following joint motions should
such as ligaments, capsules, and muscles that normally prevent also be considered: shoulder lateral rotation greater than
excessive motion at a joint. In some instances the hypermobil- 90 degrees, cervical spine lateral flexion greater than 60
ity may be due to abnormalities of the joint surfaces. A frequent degrees, distal interphalangeal joint hyperextension greater
cause of hypermobility is trauma to a joint. Hypermobility also than 60 degrees, and first metatarsophalangeal joint extension
occurs in serious hereditary disorders of connective tissue such greater than 90 degrees.
as Ehlers-Danlos syndrome, Marfan syndrome, rheumatic dis-
eases, and osteogenesis imperfecta. One of the typical physical Factors Affecting Range of Motion
abnormalities of Down syndrome is hypermobility. In this
ROM varies among individuals and is influenced by factors
instance generalized hypotonia is thought to be an important
such as age, gender, and whether the motion is performed
contributing factor to the hypermobility.
actively or passively. A fairly extensive amount of research on
Hypermobility syndrome (HMS) or benign joint hyper-
the effects of age and gender on ROM has been conducted for
mobility syndrome (BJHS) is used to describe otherwise-
the upper and lower extremities as well as the spine. Other
healthy individuals who have generalized hypermobility
factors relating to subject characteristics such as body mass
accompanied by musculoskeletal symptoms.52,53 An inherited
index (BMI), occupational activities, and recreational activi-
abnormality in collagen and regular physical exercise are
ties may affect ROM, but have not been as extensively
thought to be responsible for the joint laxity in these individ-
researched as age and gender. In addition, factors relating to
uals.54,55 Traditionally, the diagnosis of HMS involves the ex-
the testing process, such as the testing position, type of instru-
clusion of other conditions, a score of at least “4” on the
ment employed, experience of the examiner, and even time of
Beighton scale (Table 1-4), and arthralgia for longer than
day have been identified as affecting ROM measurements. A
3 months in four or more joints.56–58 Some researchers have
brief summary of research findings that examine age and gen-
noted that these criteria are inadequate for children because
der effects on ROM is presented later in this chapter. To assist
scores greater than “4” on the Beighton scale have been found
the examiner, more detailed information about the effects of
in 65 percent of a sample of 1120 children ages 4 to 7 years
age and gender on the featured joints is presented at the
in Brazil.55 Other criteria have also been proposed, includ-
end of Chapters 4 through 13. Information on the effects of
ing additional joint motions and extra-articular signs.53,54,58
subject characteristics and the testing process is included if
available.
Ideally, to determine whether a ROM is impaired, the
value of the ROM of the joint under consideration should be
TABLE 1.4 Beighton Hypermobility Score compared with ROM values from people of the same age and
gender and from studies that used the same method of mea-
surement. Often such comparisons are not possible because
The Ability to Points age-related and gender-related norms have not been estab-
Passively appose thumb to forearm
lished for all groups. In such situations the ROM of the joint
should be compared with the same joint of the individual’s
Right 1
contralateral extremity, providing that the contralateral
Left 1 extremity is not impaired or used selectively in athletic or
Passively extend fifth MCP joint occupational activities. Most studies have found little differ-
more than 90 degrees ence between the ROM of the right and left extremi-
Right 1 ties.29,51,59–65 A few studies16,66–68 have found slightly less ROM
Left 1 in some joints of the upper extremity on the dominant or right
Hyperextend elbow more side as compared with the contralateral side, which Allender
than 10 degrees and coworkers66 attribute to increased exposure to stress. If
Right 1
the contralateral extremity is inappropriate for comparison,
the individual’s ROM may be compared with average ROM
Left 1
values in handbooks of the American Academy of
Hyperextend knee more than Orthopaedic Surgeons9,10 and other standard texts.11,69–73 How-
10 degrees ever, in many of these texts, the populations from which the
Right 1 values were derived, as well as the testing positions and type
Left 1 of measuring instruments used, are not identified.
Place palms on floor by flexing trunk 1 Mean ROM values published in several standard texts
with knees straight and studies are summarized at the beginning of the Range of
Total Beighton Score = sum of points. 0–9 Motion Testing Procedures for each motion and in tables at
the end of Chapters 4 through 13. The ROM values presented
Adapted from Beighton, P, Solomon, L, and Soskolne, CL: Articular should serve as only a general guide to identifying normal
mobility in an African population. Ann Rheum Dis 32:23, 1973. versus impaired ROM. Considerable differences in mean
2066_Ch01_001-018.qxd 5/21/09 5:04 PM Page 13
ROM values are sometimes noted between the various of active motion in neck extension and 3 degrees in lateral
references. flexion and rotation. Chen and colleagues,84 in a review of the
literature regarding the effects of aging on cervical spine
Age
ROM, concluded that active cervical ROM decreased by
Numerous studies have been conducted to determine the
4 degrees per decade, which is similar to the findings of
effects of age on ROM of the extremities and spine. General
Youdas and associates.
agreement exists among investigators regarding the age-
related effects on the ROM of the extremity joints of new- Gender
borns, infants, and young children up to about 2 years of The effects of gender on the ROM of the extremities and spine
age.50,74–78 These age effects are joint and motion specific but also appear to be joint and motion specific. If gender differ-
do not seem to be affected by gender; both males and females ences in the amount of ROM are found, females are more
are affected similarly. The youngest age groups have more hip often reported to have slightly greater ROM than males. In
flexion, hip abduction, hip lateral rotation, ankle dorsiflexion, general, gender differences appear to be more prevalent in
and elbow motion as compared to adults. Limitations in hip adults than in young children.
extension, knee extension, and plantar flexion are considered Bell and Hoshizaki85 found that females across an age
to be normal for these youngest age groups. Mean values for range of 18 to 88 years had more flexibility than males in
these age groups differ by more than 2 standard deviations 14 of 17 joint motions tested. Beighton, Solomon, and
from mean values for adults published by the American Acad- Soskolne,56 in a study of an African population, found that
emy of Orthopaedic Surgeons,9 the American Medical Associ- females between 0 and 80 years of age were more mobile than
ation,11 and Boone and Azen.51 Therefore, age-appropriate their male counterparts. Walker and coworkers,86 in a study of
norms should be used whenever possible for newborns, 28 joint motions in 60 to 84 year olds, reported that 8 motions
infants, and young children up to 2 years of age. were greater in females and 4 motions were greater in males,
Most investigators who have studied a wide range of age whereas the other motions showed little gender difference.
groups have found that older adult groups have somewhat less Kalscheur and associates87 measured 24 upper-extremity and
ROM of the extremities than younger adult groups. These age- cervical motions in men and women between the ages of
related changes in the ROM of older adults also are joint and 63 and 86 years. Gender differences were noted for 14 of the
motion specific and may affect males and females differently. motions, and in all cases the older women had greater active
Allander and associates66 found that wrist flexion–extension, hip ROM than the older men. Looking at the thoracolumbar
rotation, and shoulder rotation ROM decreased with increasing spine, Moll and Wright80 found that female left lateral flexion
age, whereas flexion ROM in the metacarpophalangeal (MCP) exceeded male left lateral flexion by 11 percent. However,
joint of the thumb showed no consistent loss of motion. Roach male mobility exceeded female mobility in thoracolumbar
and Miles79 generally found a small decrease (3 to 5 degrees) in flexion and extension.
mean active hip and knee motions between the youngest age
group (25 to 39 years) and the oldest age group (60 to 74 years).
Except for hip extension ROM, these decreases represented less
than 15 percent of the arc of motion. Stubbs, Fernandez, and
Muscle Length Testing
Glenn67 found a decrease of between 4 percent and 30 percent
in 11 of 23 joints studied in men between the ages of 25 and Maximal muscle length is the greatest extensibility of a muscle-
54 years. James and Parker15 found systematic decreases in tendon unit.5 It is the maximal distance between the proximal
10 active and passive lower-extremity motions in subjects who and the distal attachments of a muscle to bone. Clinically, mus-
were between 70 and 92 years of age. cle length is not measured directly; instead, it is measured
As with the extremities, age-related effects on spinal indirectly by determining the maximal passive ROM of the
ROM appear to be motion specific. Investigators have reached joint(s) crossed by the muscle.88–90 Muscle length, in addition
varying conclusions regarding how large a decrease in ROM to the integrity of the joint surfaces and the extensibility of the
occurs with increasing age. Moll and Wright80 found an initial capsule, ligaments, fascia, and skin, affects the amount of pas-
increase in thoracolumbar spinal mobility (flexion, extension, sive ROM of a joint. The purpose of testing muscle length is
lateral flexion) in subjects from 15 to 34 years of age, fol- to ascertain whether hypomobility or hypermobility is caused
lowed by a progressive decrease with increasing age. These by the length of the inactive antagonist muscle or other struc-
authors concluded that age alone may decrease spinal mobility tures. By ascertaining which structures are involved, the
from 25 percent to 52 percent by the seventh decade, depend- health professional can choose more specific and more effec-
ing on the motion. Loebl81 found that thoracolumbar spinal tive treatment procedures.
mobility (flexion–extension) decreases with age an average of Muscles can be categorized by the number of joints they
8 degrees per decade. Fitzgerald and colleagues82 found a sys- cross from their proximal to their distal attachments. One-
tematic decrease in lateral flexion and extension of the lumbar joint muscles cross and therefore influence the motion of
spine at 20-year intervals but no differences in rotation and only one joint. Two-joint muscles cross and influence the
forward flexion. Youdas and associates83 found that with each motion of two joints, whereas multi-joint muscles cross and
decade both females and males lose approximately 5 degrees influence multiple joints.
2066_Ch01_001-018.qxd 5/21/09 5:04 PM Page 14
No difference exists between the indirect measurement of muscle crosses a joint the examiner is assessing for ROM, the
the length of a one-joint muscle and the measurement of pas- subject must be positioned so that passive tension in the mus-
sive joint ROM in the direction opposite to the muscle’s cle does not limit the joint’s ROM. To allow full ROM at the
active motion. Usually, one-joint muscles have sufficient joint under consideration and to ensure sufficient length in the
length to allow full passive ROM at the joint they cross. If a muscle, the muscle must be put on slack at all of the joints the
one-joint muscle is shorter than normal, passive ROM in the muscle crosses that are not being assessed. A muscle is put on
direction opposite to the muscle’s action is decreased and slack by passively approximating the origin and insertion of
the end-feel is firm owing to a muscular stretch. At the end of the muscle.
the ROM the examiner may be able to palpate tension within
Example: The triceps is a two-joint muscle that
the muscle-tendon unit if the structures are superficial. In
extends the elbow and shoulder. The triceps is pas-
addition, the subject may complain of pain in the region of the
sively insufficient during full shoulder flexion and full
tight muscle and tendon. These signs and symptoms help to
elbow flexion. When an examiner assesses elbow
confirm muscle shortness as the cause of the joint limitation.
flexion ROM, the shoulder must be in a neutral posi-
If a one-joint muscle is abnormally lax, passive tension in
tion so there is sufficient length in the triceps to allow
the capsule and ligaments may initially maintain a normal
full flexion at the elbow (Fig. 1.12).
ROM. However, with time, these joint structures often
lengthen as well and passive ROM at the joint increases. Be- To assess the length of a two-joint muscle, the subject is
cause the indirect measurement of the length of one-joint positioned so that the muscle is lengthened over the proximal
muscles is the same as the measurement of passive joint or distal joint that the muscle crosses. One joint is held in po-
ROM, we have not presented specific muscle length tests for sition while the examiner attempts to further lengthen the
one-joint muscles. muscle by moving the second joint through full ROM. The
end-feel in this situation is firm owing to the development of
Example: The length of one-joint hip adductors such
passive tension in the stretched muscle. The length of the two-
as the adductor longus, adductor magnus, and adduc-
joint muscle is indirectly assessed by measuring the passive
tor brevis is assessed by measuring passive hip abduc-
ROM in the direction opposite to the muscle’s action at the
tion ROM. The indirect measurement of the length of
second joint.
these hip adductor muscles is identical to the mea-
surement of passive hip abduction ROM (Fig. 1.11). Example: To assess the length of a two-joint muscle
such as the triceps, the shoulder is positioned and
In contrast to one-joint muscles, the length of two-joint
held in full flexion. The elbow is flexed until tension
and multi-joint muscles is usually not sufficient to allow full
is felt in the triceps, creating a firm end-feel. The
passive ROM to occur simultaneously at all joints crossed by
length of the triceps is determined by measuring
these muscles.91 This inability of a muscle to lengthen and
passive ROM of elbow flexion with the shoulder in
allow full ROM at all of the joints the muscle crosses is
flexion (Fig. 1.13).
termed passive insufficiency. If a two-joint or multi-joint
FIGURE 1.11 The indirect measurement of the muscle length of one-joint hip
adductors is the same as measurement of passive hip abduction ROM.
2066_Ch01_001-018.qxd 5/21/09 5:04 PM Page 15
35. Hermann, KM, and Reese, CS: Relationship among selected measures of
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2
Procedures
Competency in goniometry requires that the examiner acquire knee is extended, hip flexion is prematurely limited
the following knowledge and develop the following skills. by tension in the hamstring muscles.
The examiner must have knowledge of the following for
It is important that examiners use the same testing posi-
each joint and motion:
tion during successive measurements of a joint ROM so that
1. Joint structure and function the relative amounts of tension in the soft tissue structures are
2. Normal end-feels the same as in previous measurements. In this manner, a com-
3. Testing positions parison of ROM measurements taken in the same position
4. Stabilization required should yield similar results. When different testing positions
5. Anatomical bony landmarks are used for successive measurements of a joint ROM, more
6. Instrument alignment variability is added to the measurement1–10 and no basis for
comparison exists. If testing positions vary, it is difficult to
The examiner must have the skill to perform the follow-
determine if differences in successive measurements are the
ing for each joint and motion:
result of changes in the testing position or a true change in
1. Position and stabilize correctly joint ROM.
2. Move a body part through the appropriate range of Testing positions refer to the positions of the body that
motion (ROM) we recommend for obtaining goniometric measurements. The
3. Determine the end of the ROM and end-feel series of testing positions that are presented in this text are
4. Palpate the appropriate bony landmarks designed to do the following:
5. Align the measuring instrument with landmarks
1. Place the joint in a starting position of 0 degrees
6. Read the measuring instrument
2. Permit a complete ROM
7. Record measurements correctly
3. Provide stabilization for the proximal joint segment
If a testing position cannot be attained because of
Positioning restrictions imposed by the environment or limitations of
the subject, the examiner must use creativity to decide how
to obtain a particular joint measurement. The alternative
Positioning is an important part of goniometry because it is
testing position that is created must serve the same three
used to place the joints in a zero starting position and helps to
functions as the recommended testing position. The exam-
stabilize the proximal joint segment. Positioning affects the
iner must describe the position precisely in the subject’s
amount of tension in soft tissue structures (capsule, ligaments,
records so that the same position can be used for all subse-
muscles) surrounding a joint. A testing position in which one
quent measurements.
or more of these soft tissue structures become taut results in a
Testing positions involve a variety of body positions
more limited ROM than a position in which the same struc-
such as supine, prone, sitting, and standing. When an exam-
tures become lax. As can be seen in the following example,
iner intends to test several joints and motions during one test-
the use of different testing positions alters the ROM obtained
ing session, the goniometric examination should be planned
for hip flexion.
to avoid moving the subject unnecessarily. For example, if
Example: A testing position in which the knee is the subject is prone, all possible measurements in this posi-
flexed yields a greater hip flexion ROM than a testing tion should be taken before the subject is moved into another
position in which the knee is extended. When the position. Table 2.1, which lists joint measurements by body
19
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position, has been designed to help the examiner plan a a series of joints. Positional stabilization may be supple-
goniometric examination. mented by manual stabilization provided by the examiner.
Example: Measurement of medial rotation of the hip
joint is performed with the subject in a sitting posi-
Stabilization tion (Fig. 2.1A). The pelvis (proximal segment) is par-
tially stabilized by the body weight, but the subject is
The testing position helps to stabilize the subject’s body and moving her trunk and pelvis during hip rotation.
proximal joint segment so that a motion can be isolated to the Additional stabilization should be provided by the
joint being examined. Isolating the motion to one joint helps examiner and the subject (Fig. 2.1B). The examiner
to ensure that a true measurement of the motion is obtained, provides manual stabilization for the pelvis by exert-
rather than a measurement of combined motions that occur at ing a downward pressure on the iliac crest of the side
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CHAPTER 2 Procedures 21
FIGURE 2.1 (A) The consequences of inadequate stabilization. The examiner has failed to stabilize the subject’s
pelvis and trunk; therefore, a lateral tilt of the pelvis and lateral flexion of the trunk accompany the motion of
hip medial rotation. The range of medial rotation appears greater than it actually is because of the added
motion from the pelvis and trunk. (B) The use of proper stabilization. The examiner uses her right hand to
stabilize the pelvis (keeping the pelvis from raising off the table) during the passive range of motion (ROM). The
subject assists in stabilizing the pelvis by placing her body weight on the left side. The subject keeps her trunk
straight by placing both hands on the table.
Exercise 1
Determining the End of the Range of Motion and End-Feel
This exercise is designed to help the examiner determine the end of the ROM and to differentiate
among the three normal end-feels: soft, firm, and hard.
ELBOW FLEXION: Soft End-Feel
ACTIVITIES: See Figure 5.13 in Chapter 5.
1. Select a subject.
2. Position the subject supine with the arm placed close to the side of the body. A towel roll is
placed under the distal end of the humerus to allow space for full elbow extension. The forearm is
placed in full supination with the palm of the hand facing the ceiling.
3. With one hand, stabilize the distal end of the humerus (proximal joint segment) to prevent flexion
of the shoulder.
4. With the other hand, slowly move the forearm through the full passive range of elbow flexion
until you feel resistance limiting the motion.
5. Gently push against the resistance until no further flexion can be achieved. Carefully note the
quality of the resistance. This soft end-feel is caused by compression of the muscle bulk of the
anterior forearm with that of the anterior upper arm.
6. Compare this soft end-feel with the soft end-feel found in knee flexion (see ROM Testing
Procedures for Knee Flexion and Figure 9.6 in Chapter 9).
ANKLE DORSIFLEXION: Firm End-Feel
ACTIVITIES: See Figure 10.11 in Chapter 10.
1. Select a subject.
2. Place the subject sitting so that the lower leg is over the edge of the supporting surface and the
knee is flexed at least 30 degrees.
3. With one hand, stabilize the distal end of the tibia and fibula to prevent knee extension and hip
motions.
4. With the other hand on the plantar surface of the metatarsals, slowly move the foot through the
full passive range of ankle dorsiflexion until you feel resistance limiting the motion.
5. Push against the resistance until no further dorsiflexion can be achieved. Carefully note the
quality of the resistance. This firm end-feel is caused by tension in the Achilles tendon, the
posterior portion of the deltoid ligament, the posterior talofibular ligament, the calcaneo-fibular
ligament, the posterior joint capsule, and the wedging of the talus into the mortise formed by the
tibia and fibula.
6. Compare this firm end-feel with the firm end-feel found in metacarpophalangeal (MCP) extension
of the fingers (see ROM Testing Procedures for Fingers MCP Extension and Figure 7.12 in
Chapter 7).
ELBOW EXTENSION: Hard End-Feel
ACTIVITIES:
1. Select a subject.
2. Position the subject supine with the arm placed close to the side of the body. A small towel roll is
placed under the distal end of the humerus to allow full elbow extension. The forearm is placed in
full supination with the palm of the hand facing the ceiling.
3. With one hand resting on the towel roll and holding the posterior, distal end of the humerus,
stabilize the humerus (proximal joint segment) to prevent extension of the shoulder.
4. With the other hand, slowly move the forearm through the full passive range of elbow extension
until you feel resistance limiting the motion.
5. Gently push against the resistance until no further extension can be attained. Carefully note the
quality of the resistance. When the end-feel is hard, it has no give to it. This hard end-feel is caused
by contact between the olecranon process of the ulna and the olecranon fossa of the humerus.
6. Compare this hard end-feel with the hard end-feel usually found in radial deviation of the wrist
(see ROM Testing Procedures for Radial Deviation and Figure 6.12 in Chapter 6).
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CHAPTER 2 Procedures 23
FIGURE 2.2 Plastic universal goniometers are available in different shapes and sizes.
Some goniometers have full-circle bodies (A,B,C,E), whereas others have half-circle
bodies (D). The 14-inch goniometer (A) is used to measure large joints such as the hip,
knee, and shoulder. Six- to 8-inch goniometers (B,C,D) are used to assess midsized joints
such as the wrist and ankle. The small goniometer (E) has been cut in length from a 6-inch
goniometer (C) to make it easier to measure the fingers and toes.
FIGURE 2.3 These metal goniometers are of different sizes but all have half-circle
bodies. Metal goniometers with full-circle bodies are also available. The smallest
goniometer (D) is specifically designed to lie on the dorsal or ventral surface of the
fingers and toes while measuring joint motion. Goniometers A and B have a cut-out
portion on the moving arm, whereas goniometers C and D have pointers on the
moving arm to enable the reading of the scale on the bodies.
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and shapes but adhere to the same basic design. Typically the Increments on the scales may vary from 1 to 10 degrees, but
design includes a body and two thin extensions called arms— 1- and 5-degree increments are the most common.
a stationary arm and a moving arm (Fig. 2.4). Traditionally, the arms of a universal goniometer are des-
The body of a universal goniometer resembles a protractor ignated as moving or stationary according to how they are
and may form a half circle or a full circle (Fig. 2.5). The scales attached to the body of the goniometer (Fig. 2.4). The station-
on a half-circle goniometer read from 0 to 180 degrees and from ary arm is a structural part of the body of the goniometer and
180 to 0 degrees. The scales on a full-circle instrument may read cannot be moved independently from the body. The moving
either from 0 to 180 degrees and from 180 to 0 degrees, or from arm is attached to the center of the body of most plastic go-
0 to 360 degrees and from 360 to 0 degrees. Sometimes full- niometers by a rivet that permits the arm to move freely on the
circle instruments have both 180-degree and 360-degree scales. body. The moving arm may have one or more of the follow-
ing features: a pointed end, a black or white line extending the
length of the arm, or a cut-out portion (window). Goniometers
that are used to measure ROM on radiographs have an opaque
white line extending the length of the arms and opaque mark-
ings on the body. These features help the examiner to read the
scales.
The length of the arms varies among instruments from
approximately 1 to 14 inches. These variations in length rep-
resent an attempt on the part of the manufacturers to adapt the
size of the instrument to the size of the joints.
Example: A universal goniometer with 14-inch arms is
appropriate for measuring motion at the knee joint
because the arms are long enough to permit align-
ment with the greater trochanter of the femur and
the lateral malleolus of the tibia (Fig. 2.6A). A univer-
sal goniometer with short arms would be difficult to
FIGURE 2.4 The body of this universal goniometer forms a use because the arms do not extend a sufficient
half circle. The stationary arm is an integral part of the body
of the goniometer. The moving arm is attached to the body distance along the femur and tibia to permit
by a rivet so that it can be moved independently from the alignment with the bony landmarks (Fig. 2.6B). A
body. In this example, a cut-out portion, sometimes referred goniometer with long arms would be awkward for
to as a “window,” is found in the center and at the end of measuring the MCP joints of the hand.
the moving arm. The windows permit the examiner to read
the scale on the body of the goniometer.
Half-circle
body
CHAPTER 2 Procedures 25
FIGURE 2.6 Selecting the right-sized goniometer makes it easier to measure joint motion.
(A) The examiner is using a full-circle instrument with long arms to measure knee flexion
ROM. The arms of the goniometer extend along the distal and proximal segments of the
joint to within a few inches of the bony landmarks (black dots) that are used to align the
arms. The proximity of the ends of the arms to the landmarks makes alignment easy and
helps ensure that the arms are aligned accurately. (B) The small half-circle metal goniometer
is a poor choice for measuring knee flexion ROM because the landmarks are so far from the
ends of the goniometer’s arms that accurate alignment is difficult.
motion device (CROM) use a pendulum needle that reacts to A potentiometer is connected to the two arms. Changes in
gravity to measure motions in the frontal and sagittal planes joint position cause the resistance in the potentiometer to
and use a compass needle that reacts to the earth’s magnetic vary. The resulting change in voltage can be used to indicate
field to measure motions in the horizontal plane. A fairly large the amount of joint motion. Potentiometers measuring angu-
selection of manual inclinometers and a few digital incli- lar displacement have also been integrated with strain
nometers are commercially available. Generally these instru- gauges26,27 and isokinetic dynamometers28 for measuring resis-
ments are more expensive than universal goniometers. tive torque. Flexible electrogoniometers with two plastic end-
Inclinometers are either attached to or held on the distal blocks connected by a flexible strain gauge have been
segment of the joint being measured. The angle between the designed to measure angular displacement between the end-
long axis of the distal segment and the line of gravity is noted. blocks in one or two planes of motion.19,29
Inclinometers may be easier to use in certain situations than Some electrogoniometers resemble pendulum goniome-
universal goniometers because they do not have to be aligned ters.30,31 Changes in joint position cause a change in contact
with bony landmarks or centered over the axis of motion. between the pendulum and the small resistors. Contact with
However, it is critical that the proximal segment of the joint the resistors produces a change in electric current, which is
being measured be positioned vertically or horizontally to used to indicate the amount of joint motion.
obtain accurate measurements; otherwise, adjustments must Electrogoniometers are expensive and take time to cali-
be made in determining the measurement.12,15 Inclinometers brate accurately and attach to the subject. Given these draw-
are also difficult to use on small joints16 and where there is backs, electrogoniometers are used more often in research
soft tissue deformity or edema.12,15 than in clinical settings. Radiographs, photographs, film,
Although universal and gravity-dependent goniometers videotapes, and computer-assisted video motion analysis
may be available within a clinical setting, they should not be systems are other joint measurement methods used more
used interchangeably.17–20 For example, an examiner should commonly in research settings.
not use a universal goniometer on Tuesday and an inclinome-
ter on Wednesday to measure a subject’s knee ROM. The two Visual Estimation
instruments may provide slightly different results, making
Although some examiners make visual estimates of joint
comparisons for judging changes in ROM inappropriate.
position and motion rather than use a measuring instrument,
we do not recommend this practice. Several authors suggest
Electrogoniometers the use of visual estimates in situations in which the subject
Electrogoniometers, introduced by Karpovich and Karpovich21 has excessive soft tissue covering physical landmarks.32,33
in 1959, are used primarily in research to obtain dynamic joint Most authorities report more accurate and reliable measure-
measurements. Most devices have two arms, similar to those ments with a goniometer than with visual estimates.34–40 Even
of the universal goniometer, which are attached to the when produced by a skilled examiner, visual estimates yield
proximal and distal segments of the joint being measured.22–25 only subjective information in contrast to goniometric
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CHAPTER 2 Procedures 27
measurements, which yield objective information. However, to more accurately visualize the joint segments. These land-
estimates are useful in the learning process. Visual estimates marks, which have been identified for all joint measurements,
made prior to goniometric measurements help to reduce should be exposed so that they may be identified easily and also
errors attributable to incorrect reading of the goniometer. If palpated (Fig. 2.8). The landmarks should be learned and
the goniometric measurement is not in the same quadrant as adhered to when taking all measurements. The careful visual-
the estimate, the examiner is alerted to the possibility that the ization, palpation, and alignment of the arms of the goniometer
wrong scale is being read. with the landmarks improve the accuracy and consistency of
After the examiner has read and studied this section on the measurements.
measurement instruments, Exercise 2 should be completed. The stationary arm is often aligned parallel to the longi-
Given the adaptability and widespread use of the universal tudinal axis of the proximal segment of the joint, and the
goniometer in the clinical setting, this book focuses on teach- moving arm is aligned parallel to the longitudinal axis of the
ing the measurement of joint motion using a universal distal segment of the joint (Fig. 2.9). In some situations,
goniometer. because of limitations imposed by either the goniometer or
the subject (Fig. 2.10A), it may be necessary to reverse the
alignment of the two arms so that the moving arm is aligned
Alignment with the proximal part and the stationary arm is aligned with
Goniometer alignment refers to the alignment of the arms of the distal part (Fig. 2.10B). Therefore, we have decided to use
the goniometer with the proximal and distal segments of the the term proximal arm to refer to the arm of the goniometer
joint being evaluated. Instead of depending on soft tissue that is aligned with the proximal segment of the joint. The
contour, the examiner should use bony anatomical landmarks term distal arm refers to the arm aligned with the distal
Exercise 2
The Universal Goniometer
The following activities are designed to help the examiner become familiar with the universal
goniometer.
EQUIPMENT: Full-circle and half-circle universal goniometers made of plastic and metal.
ACTIVITIES:
1. Select a goniometer.
2. Identify the type of goniometer selected (full-circle or half-circle) by noting the shape of the
body.
3. Differentiate between the moving and the stationary arms of the goniometer. (Remember that the
stationary arm is an integral part of the body of the goniometer.)
4. Observe the moving arm to see if it has a cut-out portion.
5. Find the line in the middle of the moving arm and follow it to a number on the scale.
6. Study the body of the goniometer and answer the following questions:
a. Is the scale located on one or both sides?
b. Is it possible to read the scale through the body of the goniometer?
c. What intervals are used?
d. Does the body contain one, two, or more scales?
7. Hold the goniometer in both hands. Position the arms so that they form a continuous straight
line. When the arms are in this position, find the scale that reads 0 degrees.
8. Keep the stationary arm fixed in place and shift the moving arm while watching the numbers on
the scale, either at the tip of the moving arm or in the cut-out portion. Shift the moving arm from
0 to 45, 90, 150, and 180 degrees.
9. Keep the stationary arm fixed and shift the moving arm from 0 degrees through an estimated
45-degree arc of motion. Compare the visual estimate with the actual arc of motion by reading
the scale on the goniometer. Try to estimate other arcs of motion and compare the estimates with
the actual arc of motion.
10. Keep the moving arm fixed in place and move the stationary arm through different arcs of
motion.
11. Repeat steps 2 to 10 using different goniometers.
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FIGURE 2.8 The examiner is using a grease pencil to mark the location of the subject’s left acromion
process. Note that the patient’s clothing has been removed so that the bony landmark can be easily
visualized. The examiner is using the index and middle fingers of her left hand to palpate the bony
landmark.
CHAPTER 2 Procedures 29
FIGURE 2.10 (A) When the examiner uses a half-circle goniometer to measure left elbow flexion,
aligning the moving arm with the subject’s forearm causes the pointer to move beyond the
goniometer body, which makes it impossible to read the scale. (B) Reversing the arms of the
instrument so that the stationary arm is aligned parallel to the distal part and the moving arm is
aligned parallel to the proximal part causes the pointer to remain on the body of the
goniometer, enabling the examiner to read the scale along the pointer.
will be obvious. Another source of error is misinterpretation case the examiner would incorrectly read 91 degrees instead
of the intervals on the scale. For example, the smallest of 95 degrees.
interval of a particular goniometer may be 5 degrees, but an After the examiner has read this section on alignment,
examiner may believe the interval represents 1 degree. In this Exercise 3 should be completed.
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FIGURE 2.11 Throughout the book we use the term “proximal arm” to indicate the arm
of the goniometer that is aligned with the proximal segment of the joint being examined.
The term “distal arm” is used to indicate the arm of the goniometer that is aligned with
the distal segment of the joint. During the measurement of elbow flexion, the proximal
arm is aligned with the humerus, and the distal arm is aligned with the forearm.
Exercise 3
Goniometer Alignment for Elbow Flexion
The following activities are designed to help the examiner learn how to align and read the goniometer.
EQUIPMENT: Full-circle and half-circle universal goniometers of plastic and metal in various sizes
and a skin-marking pencil.
ACTIVITIES: See Figures 5.9 to 5.15 in Chapter 5.
1. Select a goniometer and a subject.
2. Position the subject so that he or she is supine. The subject’s right arm should be positioned so that it
is close to the side of the body with the forearm in supination (palm of hand faces the ceiling). A
towel roll placed under the distal humerus helps to ensure that the elbow is fully extended.
3. Locate and mark each of the following landmarks with the pencil: acromion process, lateral
epicondyle of the humerus, radial head, and radial styloid process.
4. Align the proximal arm of the goniometer along the longitudinal axis of the humerus, using the
acromion process and the lateral epicondyle as reference landmarks. Make sure that you are
positioned so that the goniometer is at eye level during the alignment process.
5. Align the distal arm of the goniometer along the longitudinal axis of the radius, using the radial
head and the radial styloid process as reference landmarks.
6. The fulcrum should be close to the lateral epicondyle. Check to make sure that the body of the
goniometer is not being deflected by the supporting surface.
7. Recheck the alignment of the arms and readjust the alignment as necessary.
8. Read the scale on the goniometer.
9. Remove the goniometer from the subject’s arm and place it nearby so it is handy for measuring
the next joint position.
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CHAPTER 2 Procedures 31
10. Move the subject’s forearm into various positions in the flexion ROM, including the end of the
flexion ROM. At each joint position, align and read the goniometer. Remember that you must
support the subject’s forearm while aligning the goniometer.
11. Repeat steps 3 to 10 on the subject’s left upper extremity.
12. Repeat steps 4 to 10 using goniometers of different sizes and shapes.
13. Answer the following questions:
a. Did the length of the goniometer arms affect the accuracy of the alignment? Explain.
b. What length goniometer arms would you recommend as being the most appropriate for this
measurement? Why?
c. Did the type of goniometer used (full-circle or half-circle) affect either joint alignment or the
reading of the scale? Explain.
d. Did the side of the body that you were testing make a difference in your ability to align the
goniometer? Why?
0˚–50˚
20˚–70˚
FIGURE 2.12 A recording of ROM should
include the beginning of the range as well as
the end. (A) In this illustration, the motion
begins at 0 degrees and ends at 50 degrees
so that the total ROM is 50 degrees. (B) In this
illustration, the motion begins at 20 degrees of
flexion and ends at 70 degrees, so that the
total ROM is 50 degrees. For both subjects,
the total ROM is the same, 50 degrees, even
though the arcs of motion are different.
on the authority consulted. To avoid confusion, we have noted at the top of the measurement columns. Subsequent
omitted the use of plus and minus signs. A ROM that does measurements are recorded on the same form and identified
not start with 0 degrees or ends prematurely indicates hypo- by the examiner’s initials and the date at the top of the
mobility. The addition of zero, representing the usual start- appropriate measurement column. This format makes it
ing position within the ROM, indicates hypermobility. easy to compare a series of measurements to identify
problem motions and then to track rehabilitative response
Numerical Tables over time.
Numerical tables typically list joint motions in a column
down the center of the form (Fig. 2.14). Space to the left of
Pictorial Charts
the central column is reserved for measurements taken on Pictorial charts may be used in isolation or combined with
the left side of the subject’s body; space to the right is numerical tables to record ROM measurements. Pictorial
reserved for measurements taken on the right side of the charts usually include a diagram of the normal starting and
body. The examiner’s initials and the date of testing are ending positions of the motion (Fig. 2.15).
20˚–0˚– 140˚
CHAPTER 2 Procedures 33
Paul Jones 57 M
JW JW JW
FIGURE 2.14 This numerical table records the results of ROM measurements of a subject’s
left and right hips. The examiner has recorded her initials and the date of testing at the
top of each column of ROM measurements. Note that the right hip was tested once, on
March 18, 2008, and the left hip was tested twice, once on March 18, 2008, and again on
April 1, 2008.
3/18/08 4/1/08
3/18/08
FIGURE 2.15 This pictorial chart records the results of flexion ROM measurements of a subject’s
left hip. For measurements taken on March 18, 2008, note the 0 to 73 degrees of left hip flexion;
for measurements taken on April 1, 2008, note the 0 to 98 degrees of left hip flexion. (Adapted
with permission from Range of Motion Test, New York University Medical Center, Rusk Institute of
Rehabilitation Medicine.)
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number indicates the starting position, which would be 0 in Example: An elbow fixed in 40 degrees of flexion
normal motion. would be recorded: Elbow S: 0–40 degrees.
In the sagittal plane, represented by S, the first number
indicates the end of the extension ROM, the middle number American Medical Association
indicates the starting position, and the last number indicates
the end of the flexion ROM.
Guides to Evaluation Method
Another system of recording restricted motion has been
Example: If a subject has 50 degrees of shoulder
described by the American Medical Association in the Guides
extension and 170 degrees of shoulder flexion,
to the Evaluation of Permanent Impairment.43 This book pro-
these motions would be recorded: Shoulder S:
vides ratings of permanent impairment for all major body sys-
50–0–170 degrees.
tems, including the respiratory, cardiovascular, digestive, and
In the frontal plane, represented by F, the first number visual systems. The longest chapter focuses on impairment
indicates the end of the abduction ROM, the middle number evaluation of the extremities, spine, and pelvis. Restricted
indicates the starting position, and the last number indicates active motion, ankylosis, amputation, sensory loss, vascular
the end of the adduction ROM. The ends of spinal ROM in the changes, loss of strength, pain, joint crepitation, joint
frontal plane (lateral flexion) are listed to the left first and to swelling, joint instability, and deformity are measured and
the right last. converted to percentage of impairment for the body part. The
total percentage of impairment for the body part is converted
Example: If a subject has 45 degrees of hip abduc-
to the percentage of impairment for the extremity and, finally,
tion and 15 degrees of hip adduction, these motions
to a percentage of impairment for the entire body. Often these
would be recorded: Hip F: 45–0–15 degrees.
permanent impairment ratings are used, along with other
In the transverse plane, represented by T, the first num- information, to determine the patient’s level of disability and
ber indicates the end of the horizontal abduction ROM, the the amount of monetary compensation to be expected from
middle number indicates the starting position, and the last the employer or the insurer. Physicians and therapists work-
number indicates the end of the horizontal adduction ROM. ing with patients with permanent impairments who are seek-
ing compensation for their disabilities should refer to this
Example: If a subject has 30 degrees of shoulder hor-
book for more detail.
izontal abduction and 135 degrees of shoulder hori-
The system of recording restricted motion found in the
zontal adduction, these motions would be recorded:
Guides to the Evaluation of Permanent Impairment also uses
Shoulder T: 30–0–135 degrees.
the 0 to 180 degree notation method. The neutral starting po-
Rotation is represented by R. Lateral rotation ROM, in- sition is recorded as 0 degrees with motions progressing to-
cluding supination and eversion, is listed first; medial rotation ward 180 degrees. However, the recording system proposed in
ROM, including pronation and inversion, is listed last. Rotation the Guides to the Evaluation of Permanent Impairment does
ROM of the spine to the left is listed first; rotation ROM to the differ from other recording systems described in our text. In
right is listed last. Limb position during measurement is noted if this system, when extension exceeds the neutral starting posi-
it varies from anatomical position. “F90” would indicate that a tion, it is referred to as hyperextension and is expressed with
measurement was taken with the limb positioned in 90 degrees the plus (⫹) symbol. For example, motion at the metacar-
of flexion. pophalangeal (MCP) joint of a finger from 15 degrees of
hyperextension to 45 degrees of flexion would be recorded as
Example: If a subject has 35 degrees of lateral
⫹15 to 45 degrees. The plus (⫹) symbol is used to emphasize
rotation ROM of the hip and 45 degrees of medial
the fact that the joint has hyperextension.
rotation ROM of the hip, and these motions were
In this system, the minus (–) symbol is used to emphasize
measured with the hip in 90 degrees of flexion,
the fact that a joint has an extension limitation. When the neu-
these motions would be recorded: Hip R: (F90)
tral (zero) starting position cannot be attained, an extension
35–0–45 degrees.
limitation exists and is expressed with the minus symbol. For
Hypomobility is noted by the lack of 0 as the middle example, motion at the MCP joint of a finger from 15 degrees
number or by less-than-normal values for the first and last of flexion to 45 degrees of flexion would be recorded as –15
numbers, which indicate the ends of the ROM. to 45 degrees. It should be noted that the American Academy
of Orthopaedic Surgeons40 does not use the minus (–) symbol
Example: If elbow flexion ROM was limited and
to indicate an extension limitation or hypomobility.
a subject could move only between 20 and 90 degrees
of flexion, it would be recorded: Elbow S: 0–20–90
degrees. The starting position is 20 degrees of flex-
ion, and the end of the ROM is 90 degrees of flexion. Procedures
A fixed-joint limitation, ankylosis is indicated by the use
of only two numbers. The zero starting position is included to Prior to beginning a goniometric evaluation, the examiner
clarify in which motion the fixed position occurs. must do the following:
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CHAPTER 2 Procedures 35
• Determine which joints and motions need to be tested have to ask you to remove certain articles of clothing,
• Organize the testing sequence by body position such as your shirt. Also, to locate some of the land-
• Gather the necessary equipment, such as goniometers, marks, I may have to press my fingers against your skin.
towel rolls, and recording forms Demonstration: The examiner shows the subject an
• Prepare an explanation of the procedure for the subject easily identified anatomical landmark such as the
radial styloid process.
Explanation Procedure 4. Explain and Demonstrate Recommended Testing
Positions
The listed steps and the example that follow provide the
Explanation: Certain testing positions have been
examiner with a suggested format for explaining the gonio-
established to help make joint measurements easier
metric testing procedure to a subject.
and more accurate. Whenever possible, I would like
Steps you to assume these positions. If you need some help
1. Introduce self and explain purpose in getting into a particular position, I will be happy to
2. Explain and demonstrate goniometer assist you. Please let me know if you need assistance.
3. Explain and demonstrate anatomical landmarks Demonstration: The sitting or supine positions.
4. Explain and demonstrate testing position 5. Explain and Demonstrate Examiner’s and
5. Explain and demonstrate examiner’s and subject’s roles Subject’s Roles During Active Motion
6. Confirm subject’s understanding Explanation: I will ask you to move your arm in
exactly the same way that I move your arm.
Lay rather than technical terms are used in the example
Demonstration: The examiner takes the subject’s arm
so that the subject can understand the procedure. During the
through a passive ROM and then asks the subject to
explanation, the examiner should try to establish a good rap-
perform the same motion.
port with the subject and enlist the subject’s participation in
6. Explain and Demonstrate Examiner’s and
the evaluation process. After reading the example, the exam-
Subject’s Roles During Passive Motion
iner should practice Exercise 4 on page 36.
Explanation: I will move your arm and take a mea-
Example: Explanation of Goniometric Testing Proce- surement. You should relax and let me do all of the
dure for Measuring Elbow Flexion work. These measurements should not cause discom-
1. Introduce Self and Explain Purpose fort. Please let me know if you have any discomfort
Introduction: My name is ______________. I am a and I will stop moving your arm.
(occupational title). Demonstration: The examiner moves the subject’s arm
Explanation: I understand that you have been hav- gently and slowly through the range of elbow flexion.
ing some difficulty moving your elbow. I am going 7. Confirm Subject’s Understanding
to measure the amount of motion that you have at Explanation: Do you have any questions? Are you
your elbow joint to see if it is equal to, less than, ready to begin?
or greater than normal. I will use this information
to plan a treatment program and assess its
Testing Procedure
effectiveness.
Demonstration: The examiner flexes and extends his The testing procedure is initiated after the explanation has
or her own elbow so that the subject is able to been given and the examiner is assured that the subject under-
observe a joint motion. stands the nature of the testing process. The testing procedure
2. Explain and Demonstrate Goniometer consists of the following 12-step sequence of activities.
Explanation: The instrument that I will be using to
Steps
obtain the measurements is called a goniometer. It is
1. Place the subject in the testing position.
similar to a protractor, but it has two extensions
2. Stabilize the proximal joint segment.
called arms. It is placed on the outside of your body,
3. Move the distal joint segment to the zero starting position.
next to your elbow.
If the joint cannot be moved to the zero starting position,
Demonstration: The examiner shows the goniometer
it should be moved as close as possible to the zero starting
to the subject and encourages the subject to ask
position. Slowly move the distal joint segment to the end
questions. The examiner shows the subject how the
of the passive ROM and determine the end-feel. Ask the
goniometer is used by holding it next to his or her
subject if there was any discomfort during the motion.
own elbow.
4. Make a visual estimate of the ROM.
3. Explain and Demonstrate Anatomical Landmarks
5. Return the distal joint segment to the starting position.
Explanation: To obtain accurate measurements, I will
6. Palpate the bony anatomical landmarks.
need to identify some anatomical landmarks. These
7. Align the goniometer.
landmarks help me to align the arms of the goniome-
8. Read and record the starting position. Remove the
ter. Because these landmarks are important, I may
goniometer.
2066_Ch02_019-038.qxd 5/21/09 4:44 PM Page 36
9. Stabilize the proximal joint segment. Exercise 5, which is based on the 12-step sequence,
10. Move the distal segment through the full ROM. affords the examiner an opportunity to use the testing proce-
11. Replace and realign the goniometer. Palpate the dure for an evaluation of the elbow joint. This exercise should
anatomical landmarks again if necessary. be practiced until the examiner is able to perform the activi-
12. Read and record the ROM. ties sequentially without reference to the exercise.
Exercise 4
Explanation of Goniometric Testing Procedure
EQUIPMENT: A universal goniometer.
ACTIVITIES: Practice the following six steps with a subject.
1. Introduce yourself and explain the purpose of goniometric testing. Demonstrate a joint ROM on
yourself.
2. Show the goniometer to your subject and demonstrate how it is used to measure a joint ROM.
3. Explain why bony landmarks must be located and palpated. Demonstrate how you would locate a
bony landmark on yourself, and explain why clothing may have to be removed.
4. Explain and demonstrate why changes in position may be required.
5. Explain the subject’s role in the procedure. Explain and demonstrate your role in the procedure.
6. Obtain confirmation of the subject’s understanding of your explanation.
Exercise 5
Testing Procedure for Goniometric Measurement of Elbow Flexion ROM
EQUIPMENT: A universal goniometer, skin-marking pencil, recording form, and pencil.
ACTIVITIES: See Figures 5.9 to 5.15 in Chapter 5.
1. Place the subject in a supine position, with the arm to be tested positioned close to the side of
the body. Place a towel roll under the distal end of the humerus to allow full elbow extension.
Position the forearm in full supination, with the palm of the hand facing the ceiling.
2. Stabilize the distal end of the humerus to prevent flexion of the shoulder.
3. Move the forearm to the zero starting position and determine whether there is any motion
(extension) beyond zero. Move to the end of the passive range of flexion. Evaluate the end-feel.
Usually the end-feel is soft because of compression of the muscle bulk on the anterior forearm
in conjunction with that on the anterior humerus. Ask the subject if there was any discomfort
during the motion. Refer to Figure 5.13.
4. Make a visual estimate of the beginning and end of the ROM.
5. Return the forearm to the starting position.
6. Palpate the bony anatomical landmarks (acromion process, lateral epicondyle of the humerus,
radial head, and radial styloid process) and mark with a skin pencil. Refer to Figures 5.9 to 5.12.
7. Align the arms and the fulcrum of the goniometer. Align the proximal arm with the lateral
midline of the humerus, using the acromion process and lateral epicondyle for reference. Align
the distal arm along the lateral midline of the radius, using the radial head and the radial styloid
process for reference. The fulcrum should be close to the lateral epicondyle of the humerus.
8. Read the goniometer and record the starting position. Refer to Figure 5.14. Remove the goniometer.
9. Stabilize the proximal joint segment (humerus).
10. Perform the passive ROM, making sure that you complete the available range.
11. When the end of the ROM has been attained, replace and realign the goniometer. Palpate the
anatomical landmarks again if necessary. Refer to Figure 5.15.
12. Read the goniometer and record your reading. Compare your reading with your visual estimate
to make sure that you are reading the correct scale on the goniometer.
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CHAPTER 2 Procedures 37
3
VALIDITY
AND RELIABILITY
Validity opinion. However, face validity is the most basic and elemen-
tary form of validity, whereas content validity involves more
rigorous and careful consideration. Gajdosik and Bohannon6
For goniometry to provide meaningful information, measure- state, “Physical therapists judge the validity of most ROM
ments must be valid and reliable. Currier1 states that validity measurements based on their anatomical knowledge and their
is “the degree to which an instrument measures what it is pur- applied skills of visual inspection, palpation of bony land-
ported to measure; the extent to which it fulfills its purpose.” marks, and accurate alignment of the goniometer. Generally,
Stated in another way, the validity of a measurement refers to the accurate application of knowledge and skills, combined
how well the measurement represents the true value of the with interpreting the results as measurement of ROM only,
variable of interest. The purpose of goniometry is to measure provide sufficient evidence to ensure content validity.”
the angle created at a joint by the adjacent bones of the body.
Therefore, a valid goniometric measurement is one that truly Criterion-Related Validity
represents the actual joint angle. The joint angle is used to
describe a specific joint position or, if a beginning and ending Criterion-related validity justifies the validity of the measuring
joint position are compared, a range of motion (ROM). instrument by comparing measurements made with the instru-
ment to a well-established gold standard of measurement—the
Face Validity criterion.2–5 If the measurements made with the instrument and
criterion are taken at approximately the same time, concurrent
There are four main types of validity: face validity, content validity is tested. Concurrent validity is a type of criterion-
validity, criterion-related validity, and construct validity.2–5 related validity.3,7 Criterion-related validity can be assessed
Most support for the validity of goniometry is in the form of objectively with statistical methods. In terms of goniometry, an
face, content, and criterion-related validity. Face validity examiner may question the construction of a particular
indicates that the instrument generally appears to measure goniometer on a very basic level and consider whether the
what it proposes to measure—that it is plausible.2–5 Much of degree units of the goniometer accurately represent the degree
the literature on goniometric measurement does not specifi- units of a circle. The angles of the goniometer can be compared
cally address the issue of validity; rather, it assumes that the with known angles of a protractor—the criterion. Usually the
angle created by aligning the arms of a universal goniometer construction of goniometers is adequate, and the issue of valid-
with bony landmarks truly represents the angle created by the ity focuses on whether the goniometer accurately measures the
proximal and distal bones composing the joint. One infers angle of joint position and ROM in a subject.
that changes in goniometer alignment reflect changes in joint
angle and represent a range of joint motion. Portney and Criterion-Related Validity Studies
Watkins3 report that face validity is easily established for of Extremity Joints
some tests, such as the measurement of ROM, because the The best gold standard used to establish criterion-related
instrument measures the variable of interest through direct validity of goniometric measurements of joint position and
observation. ROM is radiography. Several studies that examined extremity
joints for the concurrent validity of goniometric and radi-
ographic measurements are discussed below. When available,
Content Validity summaries of additional studies comparing goniometry to
Content validity is determined by judging whether or not radiographs and/or photographs are included in the Research
an instrument adequately measures and represents the Findings sections of Chapters 4 to 13. Gogia and associates8
domain of content—the substance—of the variable of inter- measured the knee position of 30 subjects with radiography
est.2–5 Both content and face validity are based on subjective and with a universal goniometer. Knee positions ranged from
39
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0 to 120 degrees. High correlation (correlation coefficient [r] and the radiographs were 0.97 (standard error ⫽ 3.3 degrees).
⫽ 0.97) and agreement (intraclass correlation coefficient Portek and associates,17 in a study of 11 males, found no signif-
[ICC] ⫽ 0.98) were found between the two types of measure- icant difference between lumbar flexion and extension ROM
ments. Therefore goniometric measurement of knee joint measurement taken with a skin distraction method and single
position was considered to be valid. Enwemeka9 studied the inclinometer compared with radiographic evidence, but correla-
validity of measuring knee ROM with a universal goniometer by tion coefficients were low (0.42 to 0.57). Comparisons may have
comparing the goniometric measurements taken on 10 subjects been inappropriate because measurements were made sequen-
with radiographs. No significant differences were found tially rather than concurrently, with subjects in varying testing
between the two types of measurements when ROM was within positions. Radiographs and skin distraction methods were per-
30 to 90 degrees of flexion (mean difference between the formed on standing subjects, whereas inclinometer measure-
two measurements ranged from 0.5 to 3.8 degrees). However, a ments were performed in subjects sitting for flexion and prone
significant difference was found when ROM was within 0 to for extension.
15 degrees of flexion (mean difference 4.6 degrees). Ahlback Burdett, Brown, and Fall,18 in a study of 27 subjects,
and Lindahl10 found that a joint-specific goniometer used to found a fair correlation between measurements taken with a
measure hip flexion and extension in 14 subjects closely agreed single inclinometer and radiographs for lumbar flexion (r ⫽
with radiographic measurements. Kato and coworkers11 com- 0.73) and a very poor correlation for lumbar extension (r ⫽
pared the accuracy of three types of goniometers aligned on the 0.15). Mayer and coworkers19 measured lumbar flexion and
lateral and dorsal surfaces of the proximal interphalangeal joints extension in 12 patients with a single inclinometer, double
of the 16 fixated fingers to radiographs. Mean differences inclinometer, and radiographs. No significant difference was
between the goniometers and radiographs ranged from 0.5 to noted between measurements. Saur and colleagues,20 in a
3.3 degrees. study of 54 patients, found lumbar flexion ROM measurement
taken with two inclinometers correlated highly with radi-
Criterion-Related Validity Studies ographs (r ⫽ 0.98). Extension ROM measurement correlated
of the Spine with radiographs to a fair degree (r ⫽ 0.75). Samo and asso-
Various instruments used to measure ROM of the spine have ciates21 used double inclinometers and radiographs to
also been compared with a radiographic criterion, although measure 30 subjects held in a position of flexion and exten-
some researchers question the use of radiographs as the gold sion. Radiographs resulted in flexion values that were 11 to
standard given the variability of ROM measurement taken from 15 degrees greater than those found with inclinometers and
spinal radiographs.12 Three studies that contrasted cervical extension values that were 4 to 5 degrees less than those
range of motion measurements taken with gravity-dependent found with inclinometers.
goniometers with those recorded on radiographs found concur-
rent validity to be high. Herrmann,13 in a study of 11 subjects,
noted a high correlation (r ⫽ 0.97) and agreement (ICC ⫽
Construct Validity
0.98) between radiographic measures and pendulum goniome- Construct validity is the ability of an instrument to measure
ter measures of head and neck flexion–extension. Ordway and an abstract concept (construct)3 or to be used to make an
colleagues14 simultaneously measured cervical flexion and inferred interpretation.7 There is a movement within rehabili-
extension in 20 healthy subjects with a cervical range of motion tative medicine to develop and validate measurement tools to
device (CROM), a computerized tracking system, and radi- identify functional limitations and predict disability.22 Joint
ographs. There were no significant differences between mea- ROM may be one such measurement tool. In Chapters
surements taken with the CROM and radiographic angles 4 through 13 on measurement procedures, we have included
determined by an occipital line and a vertical line, although the results of research studies that report joint ROM observed
there were differences between the CROM and the radi- during functional tasks. These findings begin to quantify the
ographic angles between the occiput and C-7. Tousignant and joint motion needed to avoid functional limitations. Several
coworkers15 measured cervical flexion and extension in 31 sub- researchers have artificially restricted joint motion with
jects with a CROM goniometer and radiographs that included splints or braces and examined the effect on function.23–25 It
cervical and upper thoracic motion. They found a high correla- appears that many functional tasks can be completed with
tion between the two measurements (r ⫽ 0.97). severely restricted elbow or wrist ROM, providing other adja-
Studies that compared clinical ROM measurement methods cent joints are able to compensate.
for the lumbar spine with radiographic results report high to low Some studies have measured the correlation between ROM
validity. Macrae and Wright16 measured lumbar flexion in values and the ability to perform functional tasks in patient pop-
342 subjects by using a tape measure, according to the Schober ulations. A study by Hermann and Reese26 examined the
and modified Schober method, and compared these results with relationship among impairments, functional limitations, and dis-
those shown in radiographs. Their findings support the validity ability in 80 patients with cervical spine disorders. The highest
of these measures: correlation coefficient values between the correlation (r ⫽ 0.82) occurred between impairment measures
Schober method and the radiographic evidence were 0.90 (stan- and functional limitation measures, with ROM contributing
dard error ⫽ 6.2 degrees) and between the modified Schober more to the relationship than the other two impairment measures
2066_Ch03_039-054.qxd 5/21/09 5:35 PM Page 41
of cervical muscle force and pain. Triffitt27 found significant ROM. Studies that measured a fixed joint position usually
correlations between the amount of shoulder ROM and the abil- have reported higher reliability values than studies that mea-
ity to perform nine functional activities in 125 patients with sured ROM.8,13,32,33 This finding is expected because more
shoulder symptoms. Wagner and colleagues28 measured passive sources of variation and error are present in measuring ROM
ROM of wrist flexion, extension, radial and ulnar deviation, and than in measuring a fixed joint position. Additional sources of
the strength of the wrist extensor and flexor muscles in 18 boys error in measuring ROM include movement of the joint
with Duchenne muscular dystrophy. A highly significant nega- axis, variations in manual force applied by the examiner dur-
tive correlation was found between difficulty performing func- ing passive ROM, and variations in a subject’s effort during
tional hand tasks and radial deviation ROM (r ⫽ ⫺0.76 to active ROM.
⫺0.86) and between difficulty performing functional hand tasks The reliability of goniometric ROM measurements varies
and wrist extensor strength (r ⫽ ⫺0.61 to ⫺0.83). somewhat depending on the joint and motion. ROM measure-
ments of upper-extremity joints have been found by several
researchers to be more reliable than ROM measurements of
Reliability lower-extremity joints,34,35 although opposing results have
also been reported.36 Even within the upper or lower extremi-
The reliability of a measurement refers to the amount of ties there are differences in reliability between joints and
consistency between successive measurements of the same motions. For example, Hellebrandt, Duvall, and Moore,37 in a
variable on the same subject under the same conditions. A study of upper-extremity joints, noted that measurements of
goniometric measurement is highly reliable if successive wrist flexion, medial rotation of the shoulder, and abduction
measurements of a joint angle or ROM, on the same subject of the shoulder were less reliable than measurements of other
and under the same conditions, yield the same results. A motions of the upper extremity. Low38 found ROM measure-
highly reliable measurement contains little measurement ments of wrist extension to be less reliable than measure-
error. Assuming that a measurement is valid and highly reli- ments of elbow flexion. Greene and Wolf39 reported ROM
able, an examiner can confidently use its results to determine measurements of shoulder rotation and wrist motions to be
a true absence, presence, or change in dysfunction. For exam- more variable than elbow motion and other shoulder motions.
ple, a highly reliable goniometric measurement could be used Reliability studies on ROM measurement of the cervical and
to determine the presence of joint ROM limitation, to evalu- thoracic spine in which a universal goniometer was used have
ate patient progress toward rehabilitative goals, and to assess generally reported lower reliability values than studies of the
the effectiveness of therapeutic interventions. extremity joints.18,40–43 Many devices and techniques have
A measurement with poor reliability contains a large been developed to try to improve the reliability of measuring
amount of measurement error. An unreliable measurement is spinal motions. Gajdosik and Bohannon6 suggested that the
inconsistent and does not produce the same results when the reliability of measuring certain joints and motions might be
same variable is measured on the same subject under the same adversely affected by the complexity of the joint. Measure-
conditions. A measurement that has poor reliability is not ment of motions that are influenced by movement of adjacent
dependable and should not be used in the clinical decision- joints or multijoint muscles may be less reliable than mea-
making process. surement of motions of simple hinge joints. Difficulty palpat-
ing bony landmarks and passively moving heavy body parts
Summary of Goniometric may also play a role in reducing the reliability of measuring
ROM of the lower extremity and spine.6,34
Reliability Studies Many studies of joint measurement methods have found
The reliability of goniometric measurement has been the intratester reliability to be higher than intertester reliabil-
focus of many research studies. Given the variety of study ity.18,32–38,40,41,43–63 Reliability was higher when successive
designs and measurement techniques, it is difficult to compare measurements were taken by the same examiner than when
the results of many of these studies. However, some findings successive measurements were taken by different examiners.
noted in several studies can be summarized. An overview of This is true for studies that measured joint position and ROM
such findings is presented here. More information on reliabil- of the extremities and spine with universal goniometers and
ity studies that pertain to the featured joint is reviewed in other devices such as joint-specific goniometers, pendulum
Chapters 4 through 13. Readers may also wish to refer to sev- goniometers, tape measures, and flexible rulers. Only a few
eral review articles and book chapters on this topic.6,29–31 studies found intertester reliability to be higher than intra-
The measurement of joint position and ROM of the tester reliability.64–67 In most of these studies, the time interval
extremities with a universal goniometer has generally been between repeated measurements by the same examiner was
found to have good-to-excellent reliability. Numerous relia- considerably greater than the time interval between measure-
bility studies have been conducted on joints of the upper and ments by different examiners.
lower extremities. Some studies have examined the reliability The reliability of goniometric measurements is affected
of measuring joints held in a fixed position, whereas others by the measurement procedure. Several studies found that
have examined the reliability of measuring passive or active intertester reliability improved when all the examiners used
2066_Ch03_039-054.qxd 5/21/09 5:35 PM Page 42
consistent, well-defined testing positions and measurement take repeated measurements on a subject with the same type
methods.45,47,48,68 Intertester reliability was lower if examiners of measurement device. For example, an examiner should
used a variety of positions and measurement methods. take all repeated measurements of a ROM with a universal
Several investigators have examined the reliability of goniometer, rather than taking the first measurement with a
using the mean (average) of several goniometric measure- universal goniometer and the second measurement with an
ments compared with using one measurement. Low38 recom- inclinometer. We believe most examiners find it easier and
mends using the mean of several measurements made with the more accurate to use a large universal goniometer when
goniometer to increase reliability over one measurement. measuring joints with large body segments and a small
Early studies by Cobe69 and Hewitt70 also used the mean of goniometer when measuring joints with small body seg-
several measurements. However, Boone and associates34 ments. Inexperienced examiners may wish to take several
found no significant difference between repeated measure- measurements and record the mean (average) of those mea-
ments made by the same examiner during one session and surements to improve reliability, but one measurement is usu-
suggested that one measurement taken by an examiner is as ally sufficient for more experienced examiners using good
reliable as the mean of repeated measurements. Rothstein, technique. Finally, it is important to remember that successive
Miller, and Roettger,48 in a study on knee and elbow ROM, measurements are more reliable if taken by the same exam-
found that intertester reliability determined from the means of iner rather than by different examiners.
two measurements improved only slightly from the intertester The mean standard deviation of repeated ROM measure-
reliability determined from single measurements. ment of extremity joints taken by one examiner using a
The authors of some texts on goniometric methods sug- universal goniometer has been found to range from 4 to
gest the use of universal goniometers with longer arms to 5 degrees.34,36 Therefore, to show improvement or worsening
measure joints with large body segments such as the hip and of a joint motion measured by the same examiner, a difference
shoulder.29,71,72 Goniometers with shorter arms are recom- of about 5 degrees (1 standard deviation) to 10 degrees
mended to measure joints with small body segments such as (2 standard deviations) is necessary. The mean standard devi-
the wrist and fingers. Robson,73 using a mathematical model, ation increased to 5 to 6 degrees for repeated measurements
determined that goniometers with longer arms are more accu- taken by different examiners,34,36 so that a difference of about
rate in measuring an angle than goniometers with shorter 6 (1 standard deviation) to 12 degrees (2 standard deviations)
arms. Goniometers with longer arms reduce the effects of is necessary to show true change in this situation. These val-
errors in the placement of the goniometer axis. However, ues serve as a general guideline only and will vary depending
Rothstein, Miller, and Roettger48 found no difference in relia- on the joint and motion being tested, the examiners and
bility among large plastic, large metal, and small plastic procedures used, and the individual being tested. Refer to the
universal goniometers used to measure knee and elbow ROM. Research Findings section of Chapters 4 to 13 for more joint-
Riddle, Rothstein, and Lamb46 also reported no difference in specific information on reliability.
reliability between large and small plastic universal goniome-
ters used to measure shoulder ROM.
Numerous studies have compared the measurement
values and reliability of different types of devices used to TABLE 3.1 Recommendations for
measure joint ROM. Universal, pendulum, and fluid goniome- Improving the Reliability
ters; joint-specific devices; tape measures; and wire tracing are of Goniometric Measurements
some of the devices that have been compared. Studies compar-
• Use consistent, well-defined positions.
ing clinical measurement devices have been conducted on the
shoulder,37,39 elbow,32,37,39,57,74,75 wrist,32,39 hand,33,60,76,77 hip,78,79 • Use consistent, well-defined, and carefully palpated
anatomical landmarks to align the goniometer.
knee,48,78,80,81 ankle,78,82 cervical spine,40,41,65,83 and thoracolum-
bar spine.17,21,42,63,84–91 Many studies have found differences in • Use the same amount of manual force to move
values and reliability between measurement devices, whereas subject’s body part during successive measurements
of passive ROM.
some studies have reported no differences.
In conclusion, on the basis of reliability studies and our • Urge subject to exert the same effort to move the body
clinical experience, we recommend the following procedures part during successive measurements of active ROM.
to improve the reliability of goniometric measurements • Use the same device to take successive measurements.
(Table 3.1). Examiners should use consistent, well-defined • Use a goniometer that is suitable in size to the joint
testing positions and carefully palpated anatomical land- being measured.
marks to align the arms of the goniometer. During successive • If examiner is less experienced, record the mean of
measurements of passive ROM, examiners should strive to several measurements rather than a single
apply the same amount of manual force to move the subject’s measurement.
body. During successive measurements of active ROM, the • Have the same examiner, rather than a different
subject should be urged to exert the same effort to perform a examiner, take successive measurements.
motion. To reduce measurement variability, it is prudent to
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Statistical Methods of Evaluating definitional formula is easier to understand, but the computa-
tional formula is easier to calculate.
Measurement Reliability
Σ (x − −x )
Clinical measurements are prone to three main sources of 2
variation: (1) true biological variation, (2) temporal variation, Standard deviation = SD =
and (3) measurement error.92 True biological variation refers n − 1
to variation in measurements from one individual to another,
caused by factors such as age, sex, race, genetics, medical his- ( Σx ) 2
Σ (x ) 2 −
tory, and condition. Temporal variation refers to variation in n
SD =
measurements made on the same individual at different times, n − 1
caused by changes in factors such as a subject’s medical
(physical) condition, activity level, emotional state, and circa- The standard deviation has the same units as the original
dian rhythms. Measurement error refers to variation in data observations. If the data observations have a normal
measurements made on the same individual under the same (bell-shaped) frequency distribution, 1 standard deviation
conditions at different times, caused by factors such as the above and below the mean includes about 68 percent of all the
examiners (testers), measuring instruments, and procedural observations, and 2 standard deviations above and below the
methods. For example, the skill level and experience of the mean include about 95 percent of the observations.
examiners, the accuracy of the measurement instruments, and It is important to note that several standard deviations
the standardization of the measurement methods affect the may be determined from a single study and represent differ-
amount of measurement error. Reliability reflects the degree to ent sources of variation.92 Two of these standard deviations
which a measurement is free of measurement error; therefore, are discussed here. One standard deviation that can be deter-
highly reliable measurements have little measurement error. mined represents mainly intersubject variation around the
Statistics can be used to assess variation in numerical data mean of measurements taken of a group of subjects, indicat-
and hence to assess measurement reliability.92,93 A digression ing biological variation. This standard deviation may be of
into statistical methods of testing and expressing reliability is interest in deciding whether a subject has an abnormal ROM
included to assist the examiner in correctly interpreting gonio- in comparison with other people of the same age and gender.
metric measurements and in understanding the literature on Another standard deviation that can be determined represents
joint measurement. Several statistics—the standard deviation, intrasubject variation around the mean of measurements
coefficient of variation, Pearson product moment correlation taken of an individual, indicating measurement error. This is
coefficient, intraclass correlation coefficient, and standard the standard deviation of interest to indicate measurement
error of measurement—are discussed. Examples that show the reliability.
calculation of these statistical tests are presented. For addi- An example of how to determine these two standard devi-
tional information, including the assumptions underlying the ations is provided. Table 3.2 presents ROM measurements
use of these statistical tests, the reader is referred to the cited taken on five subjects. Three repeated measurements (observa-
references. tions) were taken on each subject by the same examiner.
At the end of this chapter, two exercises are included for The standard deviation indicating biological variation
examiners to assess their reliability in obtaining goniometric (intersubject variation) is determined by first calculating the
measurements. Many authors recommend that clinicians con- mean ROM measurement for each subject. The mean ROM
duct their own studies to determine reliability among their measurement for each of the five subjects is found in the last
staff and patient population. Miller30 has presented a step-by- column of Table 3.2. The grand mean of the mean ROM mea-
step procedure for conducting such studies. surement for each of the five subjects equals 56 degrees. The
Standard Deviation grand mean is symbolized by X̄ . The standard deviation is
In the medical literature, the statistic most frequently used to determined by finding the differences between each of the five
indicate variation is the standard deviation.92,93 The standard subjects’ means and the grand mean. The differences are
deviation is the square root of the mean of the squares of the squared and added together. The sum is used in the defini-
deviations from the data mean. The standard deviation is sym- tional formula for the standard deviation. Calculation of
bolized as SD, s, or sd. If we denote each data observation as the standard deviation indicating biological variation is found
x and the number of observations as n, and the summation in Table 3.3.
notation ⌺ is used, then the mean that is denoted by x̄, is as In the example, the standard deviation indicating biological
follows: variation equals 13.6 degrees. This standard deviation denotes
primarily intersubject variation. Knowledge of intersubject vari-
Σx
mean ⫽ x̄ ⫽ ation may be helpful in deciding whether a subject has an abnor-
n mal ROM in comparison with other people of the same age and
Two formulas for the standard deviation are given below. gender. If a normal distribution of the measurements is assumed,
The first is the definitional formula; the second is the compu- one way of interpreting this standard deviation is to predict that
tational formula. Both formulas give the same result. The about 68 percent of all the subjects’ mean ROM measurements
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TABLE 3.2 Three Repeated ROM Measurements (in Degrees) Taken on Five Subjects
1 57 55 65 177 59
2 66 65 70 201 67
3 66 70 74 210 70
4 35 40 42 117 39
5 45 48 42 135 45
(59 ⫹ 67 ⫹ 70 ⫹ 39 ⫹ 45)
Grand mean (X̄) ⫽ ⫽ 56 degrees.
5
TABLE 3.3 Calculation of the Standard Deviation Indicating Biological Variation in Degrees
2
Subject Mean of Three Measurements (x̄) Grand Mean (X̄) (x̄ ⫺ X̄) (x̄ ⫺ X̄)
1 59 56 3 9
2 67 56 11 121
3 70 56 14 196
4 39 56 ⫺17 289
5 45 56 ⫺11 121
− Σ (x− X− 2
736
Σ(x− − X )2 = 9 + 121 + 196 + 289 + 121 = 736 degrees; SD = = = 13.6 degrees.
(n − 1) (5 − 1)
would fall between 42.4 degrees and 69.6 degrees (plus or standard deviation for subject 3 ⫽ 4.0 degrees, the standard
minus 1 standard deviation around the grand mean of deviation for subject 4 ⫽ 3.6 degrees, and the standard devi-
56 degrees). We would expect that about 95 percent of all ation for subject 5 ⫽ 3.0 degrees. The mean standard devia-
the subjects’ mean ROM measurements would fall between tion for all of the subjects combined is determined by
28.8 degrees and 83.2 degrees (plus or minus 2 standard
deviations around the grand mean of 56 degrees).
The standard deviation indicating measurement error
(intrasubject variation) also is determined by first calculating TABLE 3.4 Calculation of the Standard
the mean ROM measurement for each subject. However, this Deviation Indicating
standard deviation is determined by finding the differences Measurement Error in Degrees
between each of the three repeated measurements taken on a for Subject 1
subject and the mean of that subject’s measurements. The dif- 2
ferences are squared and added together. The sum is used in Measurements (x) Mean (x̄) (x ⫺ x̄) (x ⫺ x̄)
the definitional formula for the standard deviation. Using the 57 59 ⫺2 4
information on subject 1 in the example, the calculation of
55 59 ⫺4 16
the standard deviation indicating measurement error is shown
in Table 3.4. 65 59 6 36
Referring to Table 3.2 for information on the each of the
Σ( x − −
x )2 56
other subjects and using the same procedure as shown in SD = = = 5.3 degrees
Table 3.4, the standard deviation for subject 1 ⫽ 5.3 degrees, ( n − 1) 2
the standard deviation for subject 2 ⫽ 2.6 degrees, the
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summing the five subjects’ standard deviations and dividing This statistic is especially useful in comparing the reliability
by the number of subjects, which is 5: of two or more variables that have different units of measure-
ment (for example, comparing ROM measurement methods
5.3 ⫹ 2.6 ⫹ 4.0 ⫹ 3.6 ⫹ 3.0 18.5
SD ⫽ ⫽ ⫽ 3.7 degrees recorded in inches versus degrees).
5 5
Correlation Coefficients
In the example, the standard deviation indicating intra-
Correlation coefficients are traditionally used to measure the
subject variation equals 3.7 degrees. This standard deviation
relationship between two variables. They result in a number
is appropriate for indicating measurement error, especially if
from ⫺1 to ⫹1, which indicates how well an equation can pre-
the repeated measurements on each subject were taken within
dict one variable from another variable.2–4,92 A ⫹1 describes a
a short period of time. Note that in this example the standard
perfect positive linear (straight-line) relationship, whereas a
deviation indicating measurement error (3.7 degrees) is much
⫺1 describes a perfect negative linear relationship. A correla-
smaller than the standard deviation indicating biological vari-
tion coefficient of 0 indicates that there is no linear relationship
ation (13.6 degrees). One way of interpreting the standard
between the two variables. Correlation coefficients are used to
deviation for measurement error is to predict that about
indicate measurement reliability because it is assumed that two
68 percent of the repeated measurements on a subject would
repeated measurements should be highly correlated and
fall within 3.7 degrees (1 standard deviation) above and below
approach ⫹1. One interpretation of correlation coefficients
the mean of the repeated measurements of a subject because
used to indicate reliability is that 0.90 to 0.99 equals high reli-
of measurement error. We would expect that about 95 percent
ability, 0.80 to 0.89 equals good reliability, 0.70 to 0.79 equals
of the repeated measurements on a subject would fall within
fair reliability, and 0.69 and below equals poor reliability.95
7.4 degrees (2 standard deviations) above and below the mean
Another interpretation offered by Portney and Watkins3 states
of the repeated measurements of a subject, again because of
that correlation coefficients higher than 0.75 indicate good
measurement error. The smaller the standard deviation, the
reliability, whereas those less than 0.75 indicate poor to mod-
less the measurement error and the better the reliability.
erate reliability.
Coefficient of Variation
Sometimes it is helpful to consider the percentage of variation Pearson Product Moment Correlation
rather than the standard deviation, which is expressed in the Coefficient
units of the data observation (measurement). The coefficient Because goniometric measurements produce ratio level data,
of variation is a measure of variation that is relative to the the Pearson product moment correlation coefficient has
mean and standardized so that the variations of different vari- been the correlation coefficient usually calculated to indicate
ables can be compared. The coefficient of variation is the reliability of pairs of goniometric measurements. The
the standard deviation divided by the mean and multiplied by Pearson product moment correlation coefficient is symbolized
100 percent. It is a percentage and is not expressed in the units by r, and its formula is presented following this paragraph. If
of the original observation. The coefficient of variation is this statistic is used to indicate reliability, x symbolizes the
symbolized by CV and the formula is as follows: first measurement and y symbolizes the second measurement.
SD Σ(x − − x )(y − −
y)
coefficient of variation ⫽ CV ⫽ (100)% r=
x̄ −
Σ (x − x ) 2
Σ (y − −
y )2
For the example presented in Table 3.2, the coefficient of
variation indicating biological variation uses the standard devia- Referring to the example in Table 3.2, the Pearson corre-
tion for biological variation (standard deviation ⫽ 13.6 degrees). lation coefficient can be used to determine the relationship
between the first and the second ROM measurements on the
SD 13.6 five subjects. Calculation of the Pearson product moment cor-
CV ⫽ (100)% ⫽ (100)% ⫽ 24.3%
x̄ 56 relation coefficient for this example is found in Table 3.5. The
The coefficient of variation indicating measurement error uses resulting value of r ⫽ 0.98 indicates a highly positive linear
the standard deviation for measurement error (standard devi- relationship between the first and the second measurements.
ation ⫽ 3.7 degrees). In other words, the two measurements are highly correlated.
57 ⫹ 66 ⫹ 66 ⫹ 35 ⫹ 45 55 ⫹ 65 ⫹ 70 ⫹ 40 ⫹ 48
x̄ ⫽ ⫽ 53.8 degrees; ȳ ⫽ ⫽ 55.6 degrees.
5 5
measurements are identical, the equation of the straight line This statistic is determined from an analysis of variance
best representing the relationship should be determined. If the model, which compares different sources of variation. The
equation of the straight line representing the relationship ICC is conceptually expressed as the ratio of the variance
includes a slope b equal to 1 and an intercept a equal to 0, associated with the subjects, divided by the sum of the vari-
then an r value that approaches ⫹1 also indicates that the two ance associated with the subjects plus error variance.97 The
measurements are identical. The equation of a straight line is theoretical limits of the ICC are between 0 and ⫹1; ⫹1 indi-
y ⫽ a ⫹ bx, with x symbolizing the first measurement, y the cates perfect agreement (no error variance), whereas 0 indi-
second measurement, a the intercept, and b the slope. The cates no agreement (large amount of error variance).
equation for a slope is There are six different formulas for determining ICC val-
ues based on the design of the study, the purpose of the study,
Σ (x - x̄) (y - ȳ)
slope ⫽ b ⫽ and the type of measurement.3,97,98 Three models have been
Σ (x - x̄)2
described, each with two different forms. In Model l, each
The equation for an intercept is intercept ⫽ a ⫽ ȳ - b x̄ subject is tested by a different set of testers, and the testers are
For our example, the slope and intercept are calculated as considered representative of a larger population of testers—to
follows: allow the results to be generalized to other testers. In Model
Σ (x - x̄) (y - ȳ) 650.6 2, each subject is tested by the same set of testers, and again
b⫽ ⫽ ⫽ 0.88 the testers are considered representative of a larger population
Σ (x - x̄)2 738.8
intercept ⫽ a ⫽ ȳ - b x̄ ⫽ 55.6 ⫺ 0.88(53.8) ⫽ 8.26 of testers. In Model 3, each subject is tested by the same set
of testers, but the testers are the only testers of interest—the
The equation of the straight line best representing the rela- results are not intended to be generalized to other testers. The
tionship between the first and the second measurements in the first form of all three models is used when single measure-
example is y ⫽ 8.26 ⫹ 0.88x. Although the r value indicates ments (1) are compared, whereas the second form is used
high correlation, the two measurements are not identical when the means of multiple measurements (k) are compared.
given the linear equation. The different formulas for the ICC are identified by two num-
One concern in interpreting correlation coefficients is bers enclosed by parentheses. The first number indicates the
that the value of the correlation coefficient is markedly influ- model, and the second number indicates the form. For further
enced by the range of the measurements.3,93,96 The greater the discussion, examples, and formulas, the reader is urged to
biological variation between individuals for the measurement, refer to the referenced texts3 and articles.97–99
the more extreme the r value, so that r is closer to ⫺1 or ⫹1. In our example, a repeated measures analysis of variance
Another limitation is the fact that the Pearson product was conducted and the ICC (3,1) was calculated as 0.94. This
moment correlation coefficient can evaluate the relationship ICC model was used because each measurement was taken by
between only two variables or measurements at a time. the same tester, there was only an interest in applying the
Intraclass Correlation Coefficient results to this tester, and single measurements were compared
To avoid the need for calculating and interpreting both the rather than the means of several measurements. This ICC
correlation coefficient and a linear equation, some investiga- value indicates a high reliability between the three repeated
tors use the intraclass correlation coefficient (ICC) to eval- measurements. However, this value is slightly lower than the
uate reliability. The ICC also allows the comparison of two or Pearson product moment correlation coefficient, perhaps due
more measurements at a time; one can think of it as an aver- to the variability added by the third measurement on each
age correlation among all possible pairs of measurements.96 subject.
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Like the Pearson product moment correlation coefficient, standard deviation of the repeated measurements or the stan-
the ICC is also influenced by the range of measurements dard error of measurement are the appropriate statistical tests
between the subjects. As the group of subjects becomes more to use.105
homogeneous, the ability of the ICC to detect agreement is Let us return to the example and calculate the standard
reduced and the ICC can erroneously indicate poor reliabil- error of the measurement. The value for the ICC is 0.94. The
ity.3,97,100 Because correlation coefficients are sensitive to the value for SDx, the standard deviation indicating biological
range of the measurements and do not provide an index of variation among the 5 subjects, is 13.6.
reliability in the units of the measurement, some experts pre-
fer the use of the standard deviation of the repeated measure-
ments (intrasubject standard deviation) or the standard error
of measurement to assess reliability.4,100,101
Standard Error of Measurement Likewise, if we use the results of the repeated measures
The standard error of measurement is the final statistic that we analysis of variance to calculate the SEM, the SEM equals
review here to evaluate reliability. It has received support the square root of the mean square of the error ⫽ √10.9 ⫽
because of its practical interpretation in estimating measure- 3.3 degrees. In this example, about two-thirds of the time
ment error in the same units as the measurement. According the true measurement would be within 3.3 degrees of the
to DuBois,102 “The standard error of measurement is the observed measurement.
likely standard deviation of the error made in predicting true
scores when we have knowledge only of the obtained scores.” Exercises to Evaluate Reliability
The true scores (measurements) are forever unknown, but Exercises 6 and 7 have been included to help examiners
several formulas have been developed to estimate this statis- assess their reliability in obtaining goniometric measure-
tic. The standard error of measurement is symbolized as ments. Calculations of the standard deviation and coefficient
SEM, SEmeas, or Smeas. If the standard deviation indicating of variation are included in the belief that understanding is
biological variation is denoted SDx, a correlation coefficient reinforced by practical application. Exercise 6 examines
such as the intraclass correlation coefficient is denoted ICC, intratester reliability. Intratester reliability refers to the
and the Pearson product moment correlation coefficient is amount of agreement between repeated measurements of the
denoted r, the formulas for the SEM are as follows: same joint position or ROM by the same examiner (tester). An
SEM = SD x 1 − ICC intratester reliability study answers the question: How accu-
rately can an examiner reproduce his or her own measure-
ments? Exercise 7 examines intertester reliability. Intertester
or
reliability refers to the amount of agreement between repeated
measurements of the same joint position or ROM by different
SEM = SD x 1− r examiners (testers). An intertester reliability study answers
The SEM can also be determined from a repeated mea- the question: How accurately can one examiner reproduce
sures analysis of variance model. The SEM is equivalent to measurements taken by other examiners?
the square root of the mean square of the error.103,104 Because
the SEM is a special case of the standard deviation, 1 standard
error of measurement above and below the observed measure-
ment includes the true measurement 68 percent of the time.
Two standard errors of measurement above and below the
observed measurement include the true measurement 95 per-
cent of the time.
It is important to note that another statistic, the standard
error of the mean, is often confused with the standard error of
measurement. The standard error of the mean is symbolized
as SEM, SEM, SE x̄, or S x̄. 2,4,92,93 The use of the same or simi-
lar symbols to represent different statistics has added much
confusion to the reliability literature. These two statistics are
not equivalent, nor do they have the same interpretation. The
standard error of the mean is the standard deviation of a dis-
tribution of means taken from samples of a population.1,2,93 It
describes how much variation can be expected in the means
from future samples of the same size. Because we are inter-
ested in the variation of individual measurements when
evaluating reliability rather than the variation of means, the
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Exercise 6
Intratester Reliability
1. Select a subject and a universal goniometer.
2. Measure elbow flexion ROM on your subject three times, following the steps outlined in
Chapter 2, Exercise 5.
3. Record each measurement on the recording form (see opposite page) in the column labeled x.
A measurement is denoted by x.
4. Compare the measurements. If a discrepancy of more than 5 degrees exists between
measurements, recheck each step in the procedure to make sure that you are performing the steps
correctly, and then repeat this exercise.
5. Continue practicing until you have obtained three successive measurements that are within
5 degrees of each other.
6. To gain an understanding of several of the statistics used to evaluate intratester reliability,
calculate the standard deviation and coefficient of variation by completing the following steps.
a. Add the three measurements together to determine the sum of the measurements. ⌺ is the
symbol for summation. Record the sum at the bottom of the column labeled x.
b. To determine the mean, divide this sum by 3, which is the number of measurements. The
number of measurements is denoted by n. The mean is denoted by x̄. Space to calculate the
mean is provided on the recording form.
c. To continue the process of calculating the standard deviation, subtract the mean from each of
the three measurements and record the results in the column labeled x ⫺ x̄. Space to calculate
the standard deviation is provided on the recording form.
d. Square each of the numbers in the column labeled x ⫺ x̄, and record the results in the column
labeled (x ⫺ x̄)2.
e. Add the three numbers in column (x ⫺ x̄)2 to determine the sum of the squares. Record the
results at the bottom of the column labeled (x ⫺ x̄)2.
f. Divide this sum by 2, which is the number of measurements minus 1 (n ⫺ 1). Then find the
square root of this number.
g. To determine the coefficient of variation, divide the standard deviation by the mean. Multiply
this number by 100 percent. Space to calculate the coefficient of variation is provided on the
recording form.
7. Repeat this procedure with other joints and motions after you have learned the testing procedures.
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Measurement x x – x̄ (x – x̄ )2 x2
1
2
3
n⫽3 Σx ⫽ Σ(x ⫺ x̄ )2 ⫽ Σx2 ⫽
Σx
Mean of the three measurements ⫽ x̄ ⫽ n ⫽
Σ (x − x−)2
Standard deviation = ⫽
n−1
( Σx )2
Σx 2 −
or use SD = n
n −1
SD
Coefficient of variation ⫽ (100)% ⫽
x̄
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Exercise 7
Intertester Reliability
1. Select a subject and a universal goniometer.
2. Measure elbow flexion ROM on your subject once, following the steps outlined in Chapter 2,
Exercise 5.
3. Ask two other examiners to measure the same elbow flexion ROM on your subject, using your
goniometer and following the steps outlined in Chapter 2, Exercise 5.
4. Record each measurement on the recording form (see opposite page) in the column labeled x. A
measurement is denoted by x.
5. Compare the measurements. If a discrepancy of more than 5 degrees exists between
measurements, repeat this exercise. The examiners should observe one another’s measurements to
discover differences in technique that might account for variability, such as faulty alignment, lack
of stabilization, or reading the wrong scale.
6. To gain an understanding of several of the statistics used to evaluate intertester reliability,
calculate the mean deviation, standard deviation, and coefficient of variation by completing the
following steps.
a. Add the three measurements together to determine the sum of the measurements. ⌺ is the
symbol for summation. Record the sum at the bottom of the column labeled x.
b. To determine the mean, divide this sum by 3, which is the number of measurements. The
number of measurements is denoted by n. The mean is denoted by x̄ . Space to calculate the
mean is provided on the recording form.
c. To continue the process of calculating the standard deviation, subtract the mean from each of
the three measurements, and record the results in the column labeled x ⫺ x̄. Space to calculate
the standard deviation is provided on the recording form.
d. Square each of the numbers in the column labeled x ⫺ x̄, and record the results in the column
labeled (x ⫺ x̄)2.
e. Add the three numbers in column (x ⫺ x)2 to determine the sum of the squares. Record the
results at the bottom of column (x ⫺ x̄)2.
f. Divide this sum by 2, which is the number of measurements minus 1 (n ⫺ 1). Then find the
square root of this number.
g. To determine the coefficient of variation, divide the standard deviation by the mean. Multiply
this number by 100 percent. Space to calculate the coefficient of variation is provided on the
recording form.
7. Repeat this exercise with other joints and motions after you have learned the testing procedures.
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Measurement x x – x̄ (x – x̄ )2 x2
1
2
3
n⫽3 Σx ⫽ Σ(x ⫺ x̄ )2 ⫽ Σx2 ⫽
Σx
Mean of the three measurements ⫽ x̄ ⫽ ⫽
n
Σ (x − x−)2
Standard deviation =
n−1
( Σx )2
Σx 2 −
or use SD = n
n −1
SD
Coefficient of variation ⫽ (100)% ⫽
x̄
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30. Miller, PJ: Assessment of joint motion. In Rothstein, JM (ed): Measure- ble inclinometer methods for measuring lumbar flexion and extension.
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64. Defibaugh, JJ: Measurement of head motion. Part II: An experimental 85. Miller, MH, et al: Measurement of spinal mobility in the sagittal plane:
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J Orthop Sports Phys Ther 10:248, 1989. lumbar spinal motion. Spine 13:50, 1988.
66. Capuano-Pucci, D, et al: Intratester and intertester reliability of the cervi- 87. Lindahl, O: Determination of the sagittal mobility of the lumbar spine.
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67. LaStayo, PC, and Wheeler, DL: Reliability of passive wrist flexion and 88. White, DJ, et al: Reliability of three clinical methods of measuring lat-
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74:162, 1994. 1987.
68. Mayer, TG, et al: Spinal range of motion. Spine 22:1976, 1997. 89. Mayer, RS, et al: Variance in the measurement of sagittal lumbar range
69. Cobe, HM: The range of active motion at the wrist of white adults. J Bone of motion among examiners, subjects, and instruments. Spine 20:1489,
Joint Surg Br 10:763, 1928. 1995.
70. Hewitt, D: The range of active motion at the wrist of women. J Bone Joint 90. Chen, SP, et al: Reliability of the lumbar sagittal motion measurement
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74. Goodwin, J, et al: Clinical methods of goniometry: A comparative study. 94. Francis, K: Computer communication: Reliability. Phys Ther 66:1140,
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75. Petherick, M, et al: Concurrent validity and intertester reliability of uni- 95. Blesh, TE: Measurement in Physical Education, ed 2. Ronald Press,
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78. Clapper, MP, and Wolf, SL: Comparison of the reliability of the Ortho- 98. Shout, PE, and Fleiss, JL: Intraclass correlations: Uses in assessing rater
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II
UPPER-EXTREMITY
TESTING
ON COMPLETION OF PART II, THE READER WILL BE • Adequate stabilization of the proximal joint
ABLE TO: component
• Correct determination of the end of the range of
1. Identify: motion
• Appropriate planes and axes for each upper- • Correct identification of the end-feel
extremity joint motion • Palpation of the appropriate bony landmarks
• Structures that limit the end of the range of • Accurate alignment of the goniometer and
motion correct reading and recording
• Expected normal end-feels
5. Plan goniometric measurements of the shoulder,
2. Describe: elbow, wrist, and hand that are organized by
• Testing positions used for each upper-extremity body position.
joint motion and muscle length test
6. Assess intratester and intertester reliability of
• Goniometer alignment
goniometric measurements of the upper-
• Capsular pattern of restricted motion
extremity joints using methods described in
• Range of motion necessary for selected functional
Chapter 3.
activities
7. Perform tests of muscle length at the shoulder,
3. Explain:
elbow, wrist, and hand including:
• How age, gender, and other factors can affect the
• A clear explanation of the testing procedure
range of motion
• Proper positioning of the subject in the starting
• How sources of error in measurement can affect
position
testing results
• Adequate stabilization
4. Perform a goniometric measurement of any • Use of appropriate testing motion
upper-extremity joint including: • Correct identification of the end-feel
• Accurate alignment of the goniometer and
• A clear explanation of the testing procedure
correct reading and recording
• Proper positioning of the subject
The testing positions, stabilization techniques, end-feels, and goniometer alignment for the joints of the upper
extremities are presented in Chapters 4 through 7. The goniometric evaluation should follow the 12-step sequence
presented in Exercise 5 in Chapter 2.
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4
The Shoulder
Structure and Function rotation and flexion, the surface of the humeral head slides
posteriorly and rolls anteriorly.4,5 In lateral rotation and exten-
sion, the surface of the humeral head slides anteriorly and
Glenohumeral Joint rolls posteriorly on the glenoid fossa.4,5 Arthrokinematic
Anatomy motions during flexion and extension have also been
The glenohumeral joint is a synovial ball-and-socket joint. described as a spin.3
The ball is the convex head of the humerus, which faces
medially, superiorly, and posteriorly with respect to the shaft
of the humerus (Fig. 4.1).1,2 The socket is formed by the con- Coracoid process
Glenoid fossa
cave glenoid fossa of the scapula and faces laterally, superi- Acromion
process
orly, and anteriorly. The socket is shallow and smaller than
the humeral head but is deepened and enlarged by the fibro- Head of
humerus
cartilaginous glenoid labrum. The joint capsule is thin and lax,
Greater
blends with the glenoid labrum, and is reinforced by the tendons tubercle
of the rotator cuff muscles and by the glenohumeral (superior,
Lesser
middle, inferior) and coracohumeral ligaments (Fig. 4.2). tubercle
Osteokinematics
The glenohumeral joint has 3 degrees of freedom. The
motions permitted at the joint are flexion–extension, abduction–
Scapula
adduction, and medial–lateral rotation.1,2 In addition, horizon-
tal abduction and horizontal adduction are functional motions
performed at the level of the shoulder and are created by com-
bining abduction and extension, and adduction and flexion,
Glenohumeral Humerus
respectively. Full range of motion (ROM) of the shoulder joint
requires humeral, scapular, and clavicular motion at the
glenohumeral, sternoclavicular, acromioclavicular, and scapu-
lothoracic joints.
Arthrokinematics
Motion at the glenohumeral joint occurs as a rolling and slid-
ing of the head of the humerus on the glenoid fossa. The
convex joint surface of the head of the humerus slides in the
opposite direction and rolls in the same direction as the
osteokinematic movements of the shaft of the humerus.2,3 The
sliding motions help to maintain contact between the head of
the humerus and the glenoid fossa of the scapular during the
rolling motions and reduce translational movement of the axis
of rotation in the humerus. During abduction the surface of
the humeral head slides inferiorly while rolling superiorly.2–5
The opposite motions occur during adduction. In medial FIGURE 4.1 An anterior view of the left glenohumeral joint.
57
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Acromioclavicular Joint
Anatomy
The acromioclavicular (AC) joint is a synovial joint linking
the scapula and the clavicle. The scapular joint surface is a
Clavicle
Sternoclavicular joint
Articular
Capsular Pattern disc
1st rib
Anatomy
The sternoclavicular (SC) joint is a synovial joint linking the Interclavicular ligament
medial end of the clavicle with the sternum and the cartilage
of the first rib (Fig. 4.3A). The joint surfaces are saddle-
shaped.1,2 The clavicular joint surface is convex cephalocau-
dally and concave anteroposteriorly. The opposing joint
Costoclavicular
surface, located at the notch formed by the manubrium of the ligament
sternum and the first costal cartilage, is concave cephalocau-
dally and convex anteroposteriorly. An articular disc divides
the joint into two separate compartments.
The associated joint capsule is strong and reinforced by Anterior sternoclavicular
anterior and posterior sternoclavicular ligaments (Fig. 4.3B). B ligament
These ligaments limit anterior–posterior movement of the
FIGURE 4.3 (A) An anterior view of the sternoclavicular joint
medial end of the clavicle. The costoclavicular ligament, showing the bone structures and articular disc. (B) An anterior
which extends from the inferior surface of the medial end of view of the SC joint showing the interclavicular, sternoclavicu-
the clavicle to the first rib, limits clavicular elevation and lar, and costoclavicular ligaments.
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shallow concave facet located on the medial aspect of the Coracoclavicular ligament
acromion of the scapula (Fig. 4.4).4,5 The clavicular joint sur-
face is a slightly convex facet located on the lateral end of the Acromioclavicular ligament
Clavicle
clavicle. However, in some individuals the joint surfaces may
be flat or the reverse pattern of convex–concave shapes.1 The
joint contains a fibrocartilaginous disc and is surrounded by a
Coracoacromial
weak joint capsule. The superior and inferior acromioclavicu- ligament
lar ligaments reinforce the capsule (Fig. 4.5). The coracocla-
vicular ligament, which extends between the clavicle and the
scapular coracoid process, provides additional stability.
Osteokinematics
The AC joint has 3 degrees of freedom and permits movement
of the scapula on the clavicle in three planes.2 Numerous
terms have been used to describe these motions. Tilting (tip-
ping) is movement of the scapula in the sagittal plane around
a coronal axis. During anterior tilting the superior border of
the scapula and glenoid fossa move anteriorly, whereas the
inferior angle moves posteriorly. During posterior tilting
(tipping) the superior border of the scapula and glenoid
fossa move posteriorly, whereas the inferior angle moves FIGURE 4.5 An anterior view of the left acromioclavicular
anteriorly. joint showing the coracoclavicular, acromioclavicular, and
Upward and downward rotations of the scapula occur coracoacromial ligaments.
in the frontal plane around an anterior–posterior axis.
During upward rotation the glenoid fossa moves cranially,
whereas during downward rotation the glenoid fossa moves Protraction and retraction of the scapula occur in the
caudally. transverse plane around a vertical axis. During protraction
(also termed medial rotation, or winging) the glenoid fossa
moves medially and anteriorly, whereas the vertebral border
Clavicle of the scapula moves away from the spine. During retraction
(also termed lateral rotation) the glenoid fossa moves laterally
and posteriorly, whereas the vertebral border of the scapula
moves toward the spine. The terms abduction–adduction have
Acromioclavicular joint been used by various authors to indicate the motions of
upward rotation–downward rotation as well as protraction–
retraction.5,7
Arthrokinematics
If the acromial facet is concave in shape, the acromial facet
Acromion
will slide and roll on the lateral end of the clavicle in the same
process
direction as osteokinematic movement of the scapula.5
Scapulothoracic Joint
Anatomy
The scapulothoracic joint is considered to be a functional
rather than an anatomical joint. The joint surfaces are the
Scapula
anterior surface of the scapula and the posterior surface of the
thorax.
Osteokinematics
The motions that occur at the scapulothoracic joint are caused
by the independent or combined motions of the sternoclavic-
ular and acromioclavicular joints. These motions include
scapular elevation–depression, upward–downward rotation,
anterior–posterior tilting, protraction–retraction, and medial–
lateral rotation.1,2
FIGURE 4.4 A posterior–superior view of the left Arthrokinematics
acromioclavicular joint. Motion consists of a sliding of the scapula on the thorax.
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RANGE OF MOTION TESTING PROCEDURES: motion throughout the shoulder complex, making
isolation of glenohumeral motion difficult. Certain
Shoulder studies have begun establishing some normative
values (Table 4.2 in Research Findings) and assessing
Full ROM of the shoulder requires movement at the
the reliability of this glenohumeral measurement
glenohumeral, SC, AC, and scapulothoracic joints. To
method.
make measurements more informative, we suggest
The second method measures full motion of the
using two methods of measuring the ROM of the
shoulder complex and is useful in evaluating the func-
shoulder. One method measures passive motion pri-
tional ROM of the shoulder. This more traditional
marily at the glenohumeral joint. The other method
method of assessing shoulder motion incorporates
measures passive ROM at all the joints included in the
the stabilization of the thoracic spine and rib cage.
shoulder complex.
Tissue resistance to further motion is typically due to
We have found the method that measures primar-
the stretch of structures connecting the clavicle to the
ily glenohumeral motion is helpful in identifying
sternum, and the scapula to the ribs and spine. ROM
glenohumeral joint problems within the shoulder com-
values for shoulder complex motion are presented in
plex. The ability to differentiate and quantify ROM at
Tables 4.1, 4.3, and 4.4 in Research Findings. Both
the glenohumeral joint from other joints in the shoul-
methods of measuring the ROM of the shoulder are
der complex is important in diagnosing and treating
presented in the following discussions of stabilization
many shoulder conditions. This method of measuring
techniques and end-feels. However, the alignment of
glenohumeral motion requires the use of passive
the goniometer is the same for measuring gleno-
motion and careful stabilization of the scapula. Active
humeral and shoulder complex motions.
motion is avoided because it results in synchronous
Clavicle
Coracoid process
Scapula
Acromion
Greater
tubercle
Sternum
Humerus
Lateral
epicondyle
Medial
epicondyle
FIGURE 4.6 An anterior view of the humerus, clavicle, ster- FIGURE 4.7 An anterior view of the humerus, clavicle, ster-
num, and scapula showing surface anatomy landmarks for num, and scapula showing bony anatomical landmarks for
aligning the goniometer. aligning the goniometer.
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FIGURE 4.8 A lateral view of the upper arm showing surface anatomy landmarks for
aligning the goniometer.
Greater
Lateral tubercle
Olecranon
epicondyle of humerus
FIGURE 4.9 A lateral view of the upper arm showing bony anatomical landmarks for
aligning the goniometer.
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Stabilization
Glenohumeral Flexion
Stabilize the scapula to prevent posterior tilting,
upward rotation, and elevation of the scapula.
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FIGURE 4.11 The end of shoulder complex flexion ROM. The examiner stabilizes the subject’s trunk
and ribs with her hand. The examiner is able to determine that the end of the ROM has been
reached because any attempt to move the extremity into additional flexion causes extension of the
spine and movement of the ribs.
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FIGURE 4.12 The alignment of the goniometer at the beginning of glenohumeral and shoulder complex
flexion ROM.
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FIGURE 4.14 The alignment of the goniometer at the end of shoulder complex flexion ROM. More
motion is noted during shoulder complex flexion than in glenohumeral flexion.
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FIGURE 4.16 The end shoulder complex extension ROM. The examiner stabilizes the subject’s
trunk and ribs with her hand. The examiner is able to determine that the end of the ROM has
been reached because any attempt to move the extremity into additional extension causes
flexion and rotation of the spine.
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FIGURE 4.17 The alignment of the goniometer at the beginning of glenohumeral and shoulder
complex extension ROM.
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FIGURE 4.19 The alignment of the goniometer at the end of shoulder complex extension ROM. The
examiner’s hand that formerly stabilized the subject’s trunk now positions the goniometer.
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Stabilization
Glenohumeral Abduction
Stabilize the scapula to prevent upward rotation and
elevation of the scapula.
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ADDUCTION Stabilization
Motion occurs in the frontal plane around an anterior- Glenohumeral Medial Rotation
posterior axis. Adduction is not usually measured and In the beginning of the ROM, stabilization is often
recorded because it is the return to the zero starting needed at the distal end of the humerus to keep the
position from full abduction. shoulder in 90 degrees of abduction. Toward the end
of the ROM, the clavicle and corocoid and acromion
processes of the scapula are stabilized to prevent
MEDIAL (INTERNAL) ROTATION anterior tilting and protraction of the scapula.
When the subject is in anatomical position, the
motion occurs in the transverse plane around a verti-
cal axis. When the subject is in the testing position,
Shoulder Complex Medial Rotation
Stabilization is often needed at the distal end of the
the motion occurs in the sagittal plane around a
humerus to keep the shoulder in 90 degrees of abduc-
medial-lateral (coronal) axis. Normal shoulder complex
tion. The thorax may be stabilized by the weight of the
medial rotation for adults is 67 degrees according to
subject’s trunk or with the examiner’s hand to prevent
Boone and Azen,11 70 degrees according to the
flexion or rotation of the spine.
AAOS,8 and 90 degrees according to the AMA.10
Normal glenohumeral medial rotation for adults is 49
degrees according to Lannan, Lehman, and Toland,12
Testing Motion
Medially rotate the shoulder by moving the forearm an-
and for older childern it is 54 degrees according to
teriorly, bringing the palm of the hand toward the floor.
Ellenbecker14 and 63 degrees according to Boon and
Maintain the shoulder in 90 degrees of abduction and
Smith.15 See Tables 4.1 to 4.4 in Research Findings for
the elbow in 90 degrees of flexion during the motion.
additional normal ROM values by age and gender.
FIGURE 4.26 The end of shoulder complex medial (internal) rotation ROM. The examiner stabilizes
the distal end of the humerus to maintain the shoulder in 90 degrees of abduction and the elbow in
90 degrees of flexion during the motion. Resistance is noted at the end of medial rotation of the
shoulder complex because attempts to move the extremity into further motion cause the spine to
flex or rotate. The clavicle and scapula are allowed to move as they participate in shoulder complex
motions.
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FIGURE 4.27 The alignment of the goniometer at the beginning of medial rotation ROM of the gleno-
humeral and shoulder complex.
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FIGURE 4.29 The alignment of the goniometer at the end medial rotation ROM of the shoulder
complex.
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FIGURE 4.31 The end of lateral rotation ROM of the shoulder complex. The examiner stabilizes the
distal humerus to prevent shoulder abduction beyond 90 degrees. The elbow is maintained in
90 degrees of flexion during the motion.
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FIGURE 4.32 The alignment of the goniometer at the beginning of lateral rotation ROM of the
glenohumeral joint and shoulder complex.
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FIGURE 4.34 The alignment of the goniometer at the end of lateral rotation ROM of the shoulder
complex.
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Research Findings More studies are needed to establish normative values for
glenohumeral ROM, especially in older adults.
TABLE 4.1 Shoulder Complex Motion: Normal Values for Adults in Degrees From Selected Sources
TABLE 4.2 Glenohumeral Motion: Normal Values in Degrees From Selected Sources
TABLE 4.3 Effects of Age on Shoulder Complex Motions for Newborns Through Adolescents:
Normal Values in Degrees
Wanatabe et al21 Boone22
0–2 yrs 1–5 yrs 6–12 yrs 13–19 yrs
n = 45 n = 19 n = 17 n = 17
Males and Females Males Males Males
Motion Range of Means Mean (SD) Mean (SD) Mean (SD)
Flexion 172–180 168.8 (3.7) 169.0 (3.5) 167.4 (3.9)
Extension 79–89 68.9 (6.6) 69.6 (7.0) 64.0 (9.3)
Medial rotation 72–90 71.2 (3.6) 70.0 (4.7) 70.3 (5.3)
Lateral rotation 118–134 110.0 (10.0) 107.4 (3.6) 106.3 (6.1)
Abduction 177–187 186.3 (2.6) 184.7 (3.8) 185.1 (4.3)
TABLE 4.4 Effects of Age on Shoulder Complex Motion in Adults 20 to 93 Years of Age:
Normal Values in Degrees
Boone22 Walker et al23 Downey et al24
61–93 yrs
20–29 yrs 30–39 yrs 40–54 yrs 60–85 yrs n = 140
n = 19 n = 18 n = 19 n = 30 Female and
Males Males Males Males 60 Male Shoulders
Motion Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD)
Flexion 164.5 (5.9) 165.4 (3.8) 165.1 (5.2) 160.0 (11.0) 165.0 (10.7)
Extension 58.3 (8.3) 57.5 (8.5) 56.1 (7.9) 38.0 (11.0) — —
Medial rotation 65.9 (4.0) 67.1 (4.2) 68.3 (3.8) 59.0 (16.0) 65.0 (11.7)
Lateral rotation 100.0 (7.2) 101.5 (6.9) 97.5 (8.5) 76.0 (13.0) 80.6 (11.0)
Abduction 182.6 (9.8) 182.8 (7.7) 182.6 (9.8) 155.0 (22.0) 157.9 (17.4)
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and women tennis players aged 14 to 50 years, found a signif- aged-matched male nonlifters were included in the study. The
icant decrease in active medial rotation ROM of the shoulder authors suggest that athletic training programs that emphasize
complex in the playing versus the nonplaying arm (mean dif- muscle-strengthening exercise without stretching exercise
ference = 6.8 degrees in males, 11.9 degrees in females). Men may cause progressive loss of ROM.
also had a significant increase in lateral rotation ROM in the
playing compared with the nonplaying arm. A study by Kibler
and colleagues34 of 39 members of the U. S. Tennis Associa-
Functional Range of Motion
tion National Tennis Team and touring professional program, Numerous activities of daily living (ADL) require adequate
found a decrease in passive glenohumeral medial rotation shoulder ROM. Tiffitt,36 in a study of 25 patients, found a sig-
ROM, an increase in glenohumeral lateral rotation ROM, and nificant correlation between the amount of specific shoulder
a decrease in total rotation ROM in the playing versus the complex motions and the ability to perform activities such as
nonplaying arm. The differences in medial rotation ROM combing the hair, putting on a coat, washing the back, wash-
increased with age and years of tournament play. A study by ing the contralateral axilla, using the toilet, reaching a high
Ellenbecker and associates14 of 203 junior elite tennis players shelf, lifting above the shoulder level, pulling, and sleeping on
aged 11 to 17 years reported a significant decrease in active the affected side. Flexion and adduction ROM correlated best
medial rotation ROM and total rotation ROM of the gleno- with the ability to comb the hair, whereas medial and lateral
humeral joint in the playing versus the nonplaying arm. The rotation ROM correlated best with the ability to wash the back.
average differences in medial rotation ROM were 11 degrees Several studies37–39 have examined the ROM that occurs
in the 113 males and 8 degrees in the 90 females. There were during certain functional tasks (Table 4.5). A large amount of
no significant differences in glenohumeral lateral rotation abduction (112 degrees) and lateral rotation is required to
ROM between playing and nonplaying arms. reach behind the head for activities such as grooming the hair
Power lifters were found to have decreased ROM in (Fig 4.35), positioning a necktie, and fastening a dress zipper.
shoulder complex flexion, extension, and medial and lateral Maximal flexion (148 degrees) is needed to reach a high shelf
rotation compared with nonlifters in a study by Chang, (Fig. 4.36), whereas less flexion (36 to 52 degrees) is needed
Buschbacker, and Edlich.35 Ten male power lifters and 10 for self-feeding tasks (Fig 4.37). To reach behind the back for
TABLE 4.5 Maximal Shoulder Complex Motion Necessary for Functional Activities:
Mean Values in Degrees
Activity Motion Mean (SD) Source
Eating Flexion 52 (8) Matsen*37
Flexion 36 (14) Safaee-Rad et al†38
Abduction 22 (7) Safaee-Rad et al
Medial rotation 18 (10) Safaee-Rad et al
Horizontal adduction‡ 87 (29) Matsen
Drinking with a cup Flexion 43 (16) Safaee-Rad et al
Abduction 31 (9) Safaee-Rad et al
Medial rotation 23 (12) Safaee-Rad et al
Washing axilla Flexion 52 (14) Matsen
Combing hair Horizontal adduction 104 (12) Matsen
Abduction 112 (10) Matsen
Horizontal adduction 54 (27) Matsen
Maximal elevation Flexion/abduction 148 (11) Matsen
Maximal reaching up back Horizontal adduction 55 (17) Matsen
Extension 56 (13) Matsen
Horizontal abduction ‡
69 (11) Matsen
Reaching perineum Extension 38 (10) Matsen
Horizontal abduction 86 (13) Matsen
* Eight normal subjects were assessed with electromagnetic sensors on the humerus.
†
Ten normal male subjects were assessed with a three-dimensional video recording system.
‡
The 0-degree starting position for measuring horizontal adduction and horizontal abduction was in 90 degrees of abduction.
2066_Ch04_055-090.qxd 5/21/09 4:45 PM Page 86
sessions that occurred over a 2-week period. Both instruments Boon and Smith15 studied 50 high school athletes to de-
demonstrated high intrasession correlations (ICCs ranged termine the reliability of measuring passive shoulder rotation
from 0.98 to 0.87), but correlations were higher and 95 per- ROM with and without manual stabilization of the scapula.
cent confidence levels were much lower for the universal Four experienced physical therapists working in pairs took
goniometer. Measurements of medial rotation and lateral goniometric measurements with the shoulder in 90 degrees of
rotation were less reliable than measurements of flexion, abduction and repeated those measurements 5 days later.
extension, abduction, and adduction. There were significant Scapular stabilization, which resulted in more isolated gleno-
differences between measurements taken with the Ortho humeral motion, produced significantly smaller ROM values
Ranger and the universal goniometer. Interestingly, there were than when the scapula was not stabilized. According to the
significant differences in measurements between sessions for authors, intratester reliability for medial rotation was poor for
both instruments. The authors noted that the daily variations nonstabilized motion (ICC ⫽ 0.23, SEM ⫽ 20.2 degrees) and
that were found might have been caused by normal fluctuation good for stabilized motion (ICC ⫽ 0.60, SEM ⫽ 8.0). The
in ROM, as suggested by Boone and colleagues,41 or by daily authors state that intratester reliability for lateral rotation was
differences in subjects’ efforts while performing active ROM. good for both nonstabilized (ICC ⫽ 0.79, SEM ⫽ 5.6) and
Bovens and associates,44 in a study of the variability and stabilized motion (ICC ⫽ 0.53, SEM ⫽ 9.1). Intertester
reliability of nine joint motions throughout the body, used a reliability for medial rotation improved from nonstabilized
universal goniometer to examine active lateral rotation ROM motion (ICC ⫽ 0.13, SEM ⫽ 21.5) to stabilized motion (ICC
of the shoulder complex with the arm at the side. Three physi- ⫽ 0.38, SEM ⫽ 10.0) and was comparable for both nonstabi-
cian testers and eight healthy subjects participated in the lized and stabilized lateral rotation (ICC ⫽ 0.84, SEM ⫽ 4.9
study. Intratester reliability coefficients for lateral rotation of and ICC ⫽ 0.78, SEM ⫽ 6.6), respectively.
the shoulder ranged from 0.76 to 0.83, whereas the intertester Hayes and coworkers46 measured the intratester reliabil-
reliability coefficient was 0.63. Mean intratester standard ity of active shoulder flexion, abduction, and lateral rotation
deviations for the measurements taken on each subject ranged ROM in nine patients using one tester, and the intertester re-
from 5.0 to 6.6 degrees, whereas the mean intertester standard liability of active shoulder motion in eight patients using four
deviation was 7.4 degrees. The measurement of lateral rota- testers. A universal goniometer was aligned with the humerus
tion ROM of the shoulder was more reliable than ROM mea- and various planes of motion with the subjects in sitting for
surements of the forearm and wrist. Mean standard deviations flexion and abduction and in supine for lateral rotation. Intra-
between repeated measurement of shoulder lateral rotation tester reliability ICC values for the universal goniometer
ROM were similar to those of the forearm and larger than ranged from 0.53 to 0.65, and SEM values ranged from 14 to
those of the wrist. 23 degrees. Intertester reliability ICC values for the universal
Sabari and associates30 examined intrarater reliability in goniometer ranged from 0.64 to 0.69, and SEM values ranged
the measurement of active and passive shoulder complex flex- from 14 to 25 degrees. The reliability of using visual estima-
ion and abduction ROM when 30 adults were positioned in tion and still photography to measure shoulder ROM was also
supine and sitting positions. The ICCs between two trials by studied and produced similar results. However, the use of a
the same tester for each procedure ranged in value from 0.94 tape measure to note distance between T1 and the thumb dur-
to 0.99, indicating high intratester reliability, regardless of ing reaching behind the back produced even worse ICC val-
whether the measurements were active or passive or whether ues of 0.39 and SEM values of 6 centimeters.
they were taken with the subject in the supine or the sitting The reliability of measurement devices other than a
position. ICCs between measurements taken in supine com- universal goniometer for assessing shoulder ROM has also
pared with those taken in sitting positions ranged from 0.64 to been studied and is briefly mentioned here. Intratester and
0.81. There were no significant differences between compara- intertester reliability for the different motions and methods
ble flexion measurements taken in supine and sitting posi- varied widely. Green and associates47 investigated the reliabil-
tions. However, significantly greater abduction ROM was ity of measuring active shoulder complex ROM with a
found in the supine than in the sitting position. Plurimeter-V inclinometer in six patients with shoulder pain
In a study by MacDermid and colleagues,45 two experi- and stiffness. Tiffitt, Wildin, and Hajioff48 studied the reliabil-
enced physical therapists measured passive shoulder complex ity of using an inclinometer to measure active shoulder com-
rotation ROM in 34 patients with a variety of shoulder plex motions in 36 patients with shoulder disorders. Valentine
pathologies. A universal goniometer was used to measure lat- and Lewis49 included 45 subjects with and without shoulder
eral rotation with the shoulder in 20 to 30 degrees of abduc- symptoms in a study of the intratester reliability of shoulder
tion. Intratester ICCs (0.88 and 0.93) and intertester ICCs flexion and abduction using a gravity dependent inclinometer,
(0.85 and 0.80) were high. Intratester standard errors of mea- lateral rotation using a tape measure, and medial rotation
surement (SEMs; 4.9 and 7.0 degrees) and intertester SEMs using visual estimation. Bower50 and Clarke and coworkers26
(7.5 and 8.0 degrees) also indicated good reliability. The examined the reliability of measuring passive glenohumeral
SEMs indicate that differences of 5 to 7 degrees could be at- motions with a hydrogoniometer. Croft and colleagues51
tributed to measurement error when the same tester repeats a investigated the reliability of observing shoulder complex
measurement and about 8 degrees could be attributed to mea- flexion and lateral rotation, and sketching the ROMs onto
surement error when different testers take a measurement. diagrams that were then measured with a protractor.
2066_Ch04_055-090.qxd 5/21/09 4:45 PM Page 89
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and thumb with special reference to side: A comparison between two
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2. Ludewig, PM, and Borstead, JD: The shoulder complex. In Levangie, P, 28. Escalante, A, Lichenstein, MJ, and Hazuda, HP: Determinants of shoul-
and Norkin, C (eds): Joint Structure and Function: A Comprehensive der and elbow flexion range: Results from the San Antonio longitudinal
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Measuring and Recording. AAOS, Chicago, 1965. 33. Chinn, CJ, Priest, JD, and Kent, BA: Upper extremity range of motion,
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11. Boone, DC, and Azen, SP: Normal range of motion in male subjects. 36. Tiffitt, PD: The relationship between motion of the shoulder and the
J Bone Joint Surg Am 61:756, 1979. stated ability to perform activities of daily living. J Bone Joint Surg
12. Lannan, D, Lehman, T, and Toland, M: Establishment of normative data 80:41, 1998.
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Thesis, University of Massachusetts, Lowell, MA, 1996 WB Saunders, Philadelphia, 1994.
13. Rundquist, PJ, et al: Shoulder kinematics in subjects with frozen shoul- 38. Safaee-Rad, R, et al: Normal functional range of motion of upper limb
der. Arch Phys Med Rehabil 84:1473, 2003. joints during performance of three feeding activities. Arch Phys Med
14. Ellenbecker, TS, et al: Glenohumeral joint internal and external rotation Rehabil 71:505, 1990.
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24:336, 1996. tional tasks. Gait Posture (2007), doi:10.1016/j.gaitpost 2007.03.002.
15. Boon, AJ, and Smith, J: Manual scapular stabilization: Its effect on shoul- 40. Hellebrandt, FA, Duvall, EN, and Moore, ML: The measurement of joint
der rotational range of motion. Arch Phys Med Rehabil 81:978, 2000. motion. Part III: Reliability of goniometry. Phys Ther Rev 29:302, 1949.
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83:1229, 2002. 46. Hayes, K, et al: Reliability of five methods for assessing shoulder range
21. Wanatabe, H, et al: The range of joint motions of the extremities in of motion. Australian J Physiother 47:289, 2001.
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Seikeigeka Gakkai Zasshi 53:275, 1979. Cited by Walker, JM: Muscu- movement of the shoulder using the Plurimeter-V inclinometer and
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supplement to Boone, DC, and Azen, SP: Normal range of motion in 48. Tiffitt, PD, Wildin, C, and Hajioff, D: The reproducibility of measure-
male subjects. J Bone Joint Surg Am 61:756, 1979.) ment of shoulder movement. Acta Orthop Scand 70:322, 1999.
23. Walker, JM, et al: Active mobility of the extremities in older subjects. 49. Valentine, RE, and Lewis, JS: Intraobserver reliability of 4 physiologic
Phys Ther 64:919, 1984. movements of the shoulder in subjects with and without symptoms. Arch
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1991. motion. Aust J Physiother 28:12, 1982.
25. West, CC: Measurement of joint motion. Arch Phys Med Rehabil 26:414, 51. Croft, P, et al: Observer variability in measuring elevation and external
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26. Clarke, GR, et al: Preliminary studies in measuring range of motion in
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5
The Elbow
and Forearm
Structure and Function The joints are enclosed in a large, loose, weak joint capsule
that also encloses the superior radioulnar joint. Medial and lat-
eral collateral ligaments reinforce the sides of the capsule and
Humeroulnar and Humeroradial help to provide medial–lateral stability (Figs. 5.3 and 5.4).1
Joints When the arm is in the anatomical position of full elbow ex-
tension and supination, the long axes of the humerus and the
Anatomy forearm form an acute angle at the elbow. This angle is called
The humeroulnar and humeroradial joints between the upper the “carrying angle” (Fig. 5.5) and is approximately 10 to
arm and the forearm are considered to be a hinged compound 12 degrees in men and 13 to 17 degrees in women.2,3 The
synovial joint (Figs. 5.1 and 5.2). The proximal joint surface carrying angle of the dominant arm is reported to be slightly
of the humeroulnar joint consists of the convex trochlea greater (1.5 degrees) than the nondominant arm and slightly
located on the anterior medial surface of the distal humerus. greater (2 degrees) in adults than in children.4 An angle that
The distal joint surface is the concave trochlear notch on the is greater (more acute) than average is called “cubitus valgus.” 5
proximal ulna. An angle that is less than average is called “cubitus varus.”
The proximal joint surface of the humeroradial joint is
the convex capitulum located on the anterior lateral surface of Osteokinematics
the distal humerus. The concave radial head on the proximal The humeroulnar and humeroradial joints have 1 degree of
end of the radius is the opposing joint surface. freedom; flexion–extension occurs in the sagittal plane
Coronoid fossa
Humerus
Humerus
Radial fossa
Medial epicondyle
Olecranon fossa
Olecranon
Lateral epicondyle
process
Lateral epicondyle
Capitulum
Trochlea
Medial
epicondyle Humeroradial
Humeroradial
joint joint
Humeroulnar joint
Radial head
Humeroulnar
joint
Coronoid process
Radial head
Radius
Radius Ulna
Ulna
FIGURE 5.1 An anterior view of the right elbow showing the FIGURE 5.2 A posterior view of the right elbow showing the
humeroulnar and humeroradial joints. humeroulnar and humeroradial joints.
91
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Humerus
Medial epicondyle
Annular ligament
Joint
Radius capsule
Medial
collateral
ligament
Ulna
Radial head
Radial notch
Annular
ligament
Quadrate ligament
Oblique cord
Radius Ulna
Radius Ulna
Interosseous
membrane
Ulnar styloid
Radial styloid process process
Articular disc
Inferior radioulnar joint
FIGURE 5.7 Anterior view of the superior and inferior
FIGURE 5.6 Anterior view of the superior and inferior radioulnar joints showing the annular ligament, quadrate
radioulnar joints of the right forearm. ligament, oblique cord, interosseous membrane, anterior
radioulnar ligament, and articular disc.
the inferior radioulnar joint is provided by the articular
disc and the anterior and posterior radioulnar ligaments posteriorly (in the same direction as the hand) during
(Fig. 5.8).1 supination.
Osteokinematics Capsular Pattern
The superior and inferior radioulnar joints are mechanically The capsular pattern is an equal limitation of supination and
linked. Therefore, motion at one joint is always accompanied pronation according to Cyriax and Cyriax7 and Kaltenborn.8
by motion at the other joint. The axis for motion is a longitu-
dinal axis extending from the radial head to the ulnar head.
The mechanically linked joint is a synovial pivot joint with 1 Posterior radioulnar
Articular disc
Lateral epicondyle
Radial styloid process of humerus
Acromion process
of scapula
Humerus
Lateral epicondyle of humerus
Radial head
Radial
styloid
Radius process
Scapula
Ulna
Olecranon Ulnar styloid
process process
FIGURE 5.13 End of elbow flexion ROM. The examiner’s hand stabilizes the humerus, but it must be positioned so it does not
limit the motion.
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FIGURE 5.15 Alignment of the goniometer at the end of elbow flexion ROM. The proximal and distal arms of the goniometer
have been switched from the starting position so that the ROM can be read from the pointer on the body of this 180-degree
goniometer.
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Testing Motion
Extend the elbow by moving the hand dorsally toward
the examining table. Maintain the forearm in supina-
tion during the motion. The end of extension ROM
occurs when resistance to further motion is felt and
attempts to overcome the resistance cause extension
of the shoulder.
Normal End-Feel
Usually the end-feel is hard because of contact
between the olecranon process of the ulna and the
olecranon fossa of the humerus. Sometimes the end-
feel is firm because of tension in the anterior joint cap-
sule, the collateral ligaments, and the brachialis muscle.
FOREARM PRONATION
Motion occurs in the transverse plane around a verti-
cal axis when the subject is in the anatomical position.
When the subject is in the testing position, the
motion occurs in the frontal plane around an anterior–
posterior axis. Normal ROM values for adults are
76 degrees according to Boone and Azen13 and
84 degrees according to Greene and Wolf.14 Both the
AMA12 and the AAOS10,11 state that normal pronation
ROM is 80 degrees. See Research Findings and
Tables 5.1 to 5.3 for additional normal ROM values by
age and gender.
Testing Position
Position the subject sitting, with the shoulder in
0 degrees of flexion, extension, abduction, adduction,
and rotation so that the upper arm is close to the side
FIGURE 5.16 End of pronation ROM. The subject is sitting
of the body. Flex the elbow to 90 degrees, and sup- on the edge of a table, and the examiner is standing facing
port the forearm. Initially position the forearm midway the subject. The examiner uses one hand to hold the elbow
between supination and pronation so that the thumb close to the subject’s body and in 90 degrees of elbow
points toward the ceiling. flexion, helping to prevent both medial rotation and
abduction of the shoulder. The examiner’s other hand
pushes on the radius rather than on the subject’s hand. If
Stabilization the examiner pushes on the subject’s hand, movement of
Stabilize the distal end of the humerus to prevent the wrist may be mistaken for movement at the radioulnar
medial rotation and abduction of the shoulder. joints.
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because of tension in the dorsal radioulnar ligament 2. Align proximal arm parallel to the anterior midline
FIGURE 5.17 Alignment of the goniometer in the beginning FIGURE 5.18 Alignment of the goniometer at the end of
of pronation ROM. The goniometer is placed laterally to the pronation ROM. The examiner uses one hand to hold the
distal radioulnar joint. The arms of the goniometer are proximal arm of the goniometer parallel to the anterior
aligned parallel to the anterior midline of the humerus. midline of the humerus. The examiner’s other hand supports
the forearm and assists in placing the distal arm of the
goniometer across the dorsum of the forearm just proximal
to the radial and ulnar styloid process. The fulcrum of the
goniometer is proximal and lateral to the ulnar styloid
process.
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MUSCLE LENGTH TESTING PROCEDURES: extension when the shoulder is positioned in full
extension.
Elbow and Forearm If elbow extension is limited regardless of shoul-
der position, the limitation is caused by abnormalities
BICEPS BRACHII of the joint surfaces, by shortening of the anterior
The biceps brachii muscle crosses the glenohumeral, joint capsule and collateral ligaments, or by muscles
humeroulnar, humeroradial, and superior radioulnar that cross only the elbow such as the brachialis and
joints. The short head of the biceps brachii originates brachioradialis.
proximally from the coracoid process of the scapula
(Fig. 5.22). The long head originates from the supra- Starting Position
glenoid tubercle of the scapula. The biceps brachii Position the subject supine at the edge of the examin-
attaches distally to the radial tuberosity. ing table. See Figure 5.23. Flex the elbow and posi-
When the biceps brachii contracts, it flexes the tion the shoulder in full extension and 0 degrees of
elbow and shoulder and supinates the forearm. The abduction, adduction, and rotation.
muscle is passively lengthened by placing the shoul-
der and elbow in full extension and the forearm in
pronation. If the biceps brachii is short, it limits elbow
Supraglenoid tubercle
Coracoid process
Glenoid fossa
Acromion process
Radial tuberosity
Ulna
Radius
Stabilization
Normal End-Feel
The end-feel is firm because of tension in the biceps
brachii muscle.
FIGURE 5.24 End of the testing motion for the length of the FIGURE 5.25 Alignment of the goniometer at the end of
biceps brachii. The examiner uses one hand to stabilize the testing the length of the biceps brachii. The examiner
humerus in full shoulder extension while the other hand releases the stabilization of the humerus and now uses her
holds the forearm in pronation and moves the elbow into hand to position the goniometer.
extension.
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Stabilization
The examiner stabilizes the subject’s humerus. The
Lateral head
of triceps weight of the subject’s trunk on the examining table
and the passive tension in the latissumus dorsi,
Head of
humerus pectoralis minor, and rhomboid major and minor mus-
Scapula
cles help to stabilize the scapula.
FIGURE 5.26 A lateral view of the left upper extremity
showing the origins and insertions of the triceps brachii
while being stretched over the glenohumeral and elbow
joints.
Testing Motion
FIGURE 5.28 End of the testing motion for the length of the FIGURE 5.29 Alignment of the goniometer at the end of
triceps brachii. The examiner uses one hand to stabilize the testing the length of the triceps brachii. The examiner uses
humerus in full shoulder flexion and the other hand to move one hand to continue to stabilize the humerus and align the
the elbow into flexion. proximal arm of the goniometer. The examiner’s other hand
holds the elbow in flexion and aligns the distal arm of the
goniometer with the radius.
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Research Findings age 19 years or younger and those older than 19 years. Further
analyses found that the group between 6 and 12 years of age
had more elbow flexion and extension than other age groups.
Effects of Age, Gender, The youngest group (between 18 months and 5 years) had a
and Other Factors significantly greater amount of pronation and supination than
other age groups. However, the greatest differences between
Table 5.1 provides normal elbow and forearm ROM values the age groups were small: 6.8 degrees of flexion, 4.4 degrees
for adults.10–15 In addition to the sources listed in Table 5.1, of supination, 3.9 degrees of pronation, and 2.5 degrees of
Goodwin and coworkers16 found mean active elbow flexion to extension.22
be 148.9 degrees in 23 females between 18 and 31 years Older persons appear to have difficulty fully extending
of age. Petherick and associates17 found mean active elbow their elbows to 0 degrees. Walker and associates23 found that
flexion to be 145.8 degrees in 10 males and 20 females with a the older men and women (between 60 and 84 years of age)
mean age of 24.0 years. Sanya and Chinyelu18 studied in their study were unable to extend their elbows to 0 degrees
50 healthy adults (27 females and 23 males) between 20 and to attain a neutral starting position for flexion. The mean value
71 years of age and found mean active elbow flexion to be for the starting position was 6 degrees in men and 1 degree in
137.8 degrees. All of these sources used universal goniome- women. Boone and Azen13 also found that the oldest subjects
ters to obtain measurements. Fiebert, Fuhri, and New19 mea- in their study (between 40 and 54 years of age) had lost elbow
sured elbow flexion and forearm motions with the Ortho extension and began flexion from a slightly flexed position.
Ranger (electronic inclinometer) and elbow extension with a Bergstrom and colleagues,24 in a study of 52 women and
universal goniometer in 124 men and women, 60 to 99 years 37 men aged 79 years, found that 11 percent had flexion con-
of age. They found mean passive elbow flexion ROM to be tractures of the right elbow greater than 5 degrees, and
147 degrees, elbow extension –1 degree, pronation 84 degrees, 7 percent had bilateral flexion contractures.
and supination 85 degrees. Kalscheur and associates25 examined the effects of age in a
study of 61 older women aged 63 to 83 years and the effects of
Age
age and gender in the same sample of 61 older women and
A comparison of cross-sectional studies of normal ROM values
25 older men aged 66 to 86 years.26 Depending on the linear
for various age groups suggests that elbow and forearm ROM
regression models used, they found that elbow flexion declined
decreases slightly with increasing age. The elbow and forearm
about 0.1 to 0.2 degrees per year from age 65 to 85 years; prona-
ROM values in infants reported by Wanatabe and colleagues20
tion declined about 0.1 to 0.4 degrees per year, and supination
and in young male children aged 1 to 7 years reported by Hacker
declined about 0.0 to 1.0 degrees per year. It was projected that
and coworkers21 as noted in Table 5.2 are generally greater than
over a 20-year period elbow flexion could be expected to decline
the normal values for adult males found in Tables 5.1 and 5.3.
approximately 3 degrees, pronation 4 degrees, and right supina-
However, it can be difficult to compare values obtained from
tion 6 degrees.26 Only declines in right supination and pronation
various studies because subject selection and measurement
ROM were statistically significant.
methods can differ.
Within one study of 109 males ranging in age from Gender
18 months to 54 years, Boone and Azen13 noted a significant Studies seem to concur that females have more elbow flexion
difference in elbow flexion and supination between subjects and extension ROM than males, but results are unclear
TABLE 5.1 Normal Elbow and Forearm ROM Values for Adults in Degrees From Selected Sources
AAOS10,11 AMA12 Boone & Azen13 Greene & Wolf14 Gunal et al15
20–54 yrs* 18–55 yrs* 18–22 yrs†
n ⫽ 56 n ⫽ 20 n ⫽ 1000
Males Males and Females Males
Motion Mean (SD) Mean (SD) Mean (SD)
Flexion 150 140 140.5 (4.9) 145.3 (1.2) 144.2 (5.8)
Extension 0 0 0.3 (2.7) 4.9 (11.1)
Pronation 80 80 75.0 (5.3) 84.4 (2.2)
Supination 80 80 81.1 (4.0) 76.9 (2.1) 91.7 (9.6)
SD ⫽ standard deviation.
* Values are for active ROM measured with a universal goniometer.
†
Values are for passive ROM measured with a universal goniometer. Values are extrapolated from tables.
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TABLE 5.2 Effects of Age on Elbow and Forearm Motion: Normal Values in Degrees
for Newborns, Children, and Adolescents
Wanatabe et al20 Hacker er al21 Boone22
2 wks–2 yrs* 1–7 yrs 18 mos–5 yrs †
6–12 yrs† 13–19 yrs†
n = 45 n = 72 n = 19 n = 17 n = 17
Males and Females Males Males Males Males
Motion Range of Means Mean (SD) Mean (SD) Mean (SD) Mean (SD)
Flexion 148–158 151.4 (1.8) 144.9 (5.7) 146.5 (4.0) 144.9 (6.0)
Extension 1.1 (3.9) 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)
SD = standard deviation.
* Values are for passive ROM.
†
Values are for active ROM measured with a universal goniometer.
concerning gender effects on forearm supination and prona- Thirty older females and 30 older males, aged 60 to 84
tion ROM. years, were included in a study by Walker and coworkers.23
Bell and Hoshizaki,27 using a Leighton Flexometer, stud- Females had significantly more flexion ROM (1–148 degrees)
ied the ROM of 124 females and 66 males between the ages of than males (5–139 degrees), but males had significantly more
18 and 88 years. Females had significantly more elbow flexion supination (83 degrees) than females (65 degrees). Females
than males. Extrapolating from a graph, the mean differences had more pronation ROM than males, but the difference was
between males and females ranged from 14 degrees in subjects not significant.
aged 32 to 44 years to 2 degrees in subjects older than 75 years. Kalscheru and coworkers26 found that older women had
Although females had greater supination–pronation ROM than more elbow and forearm ROM than older men in a study of a
males, this increase was not statistically significant. 61 women and 25 men ranging in age from 63 to 86 years.
Salter and Darcus,28 measuring forearm supination– These gender differences were statistically significant for
pronation with a specialized arthrometer in 20 males and elbow flexion and pronation with mean differences of 6.2 and
5 females between the ages of 16 and 29 years, found that the 4.9 degrees, respectively. There was no significant difference
females had an average of 8 degrees more forearm rotation than in supination ROM between the men and women.
males, although the difference was not statistically significant.
Escalante, Lichenstein, and Hazuda,29 in a study of Body Mass Index
695 community-dwelling older subjects between 65 and Body mass index (BMI) was found by Escalante, Lichenstein,
74 years of age, found that females had an average of 4 degrees and Hazuda29 to be inversely associated with elbow flexion in
more elbow flexion than males. 695 older subjects. Each unit increase in BMI (kg/m2) was
TABLE 5.3 Effects of Age on Active Elbow and Forearm Motion: Normal Values in Degrees
for Adult Males 20 to 85 Years of Age
Boone22 Walker et al23
SD ⫽ standard deviation.
* The minus sign indicates flexion.
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significantly associated with a 0.22 decrease in degrees of elbow extension ROM and 5.5 degrees for elbow flexion
elbow flexion. Hacker and coworkers21 also found an associa- ROM in the dominant versus the nondominant arm of 33 pro-
tion between increased BMI and decreased elbow ROM in fessional pitchers. No significant differences were noted be-
72 healthy boys ages 1 to 7 years. tween the dominant and nondominant sides for supination and
pronation ROM.
Right Versus Left Side
Studies comparing ROM between the right and left sides or Functional Range of Motion
between the dominant and nondominant limbs have generally
found no clinically relevant differences in elbow and forearm The amount of elbow and forearm motion that occurs during
ROM. Studies that had large numbers of subjects had the sta- activities of daily living has been studied by several investiga-
tistical power to find differences of 2 to 3 degrees to be sig- tors. Table 5.4 has been adapted from the works of Morrey
nificant. If differences were found, the left or nondominant and associates,33 Packer and colleagues,34 and Safaee-Rad and
side had more motion. coworkers.35 Morrey and associates33 used a triaxial electro-
Boone and Azen13 studied 109 males between the ages of goniometer to measure elbow and forearm motion in
18 months and 54 years who were subdivided into six age 33 normal subjects during performance of 15 activities. They
groups. They found no significant differences between right concluded that most of the activities of daily living that were
and left elbow flexion, extension, supination, and pronation, studied required a total arc of about 100 degrees of elbow
except for the age group of subjects between 20 and 29 years flexion (between 30 and 130 degrees) and 100 degrees of
of age, whose elbow flexion ROM was greater on the left than rotation (50 degrees of supination and 50 degrees of prona-
on the right. This one significant finding was attributed to tion). Using a telephone necessitated the greatest total ROM.
chance. Hacker and colleagues21 found no significant differ- The greatest amount of flexion was required to reach the back
ence between sides for elbow ROM in 72 healthy boys aged of the head (144 degrees), whereas feeding tasks such as
1 to 7 years. Gunal and coworkers,15 in a study of 1000 males drinking from a cup (Fig. 5.30) and eating with a fork
between 18 to 22 years of age, found significantly greater required about 130 degrees of flexion. Reaching the shoes and
elbow flexion, extension, and supination ROM on the left as rising from a chair (Fig. 5.31) required the greatest amount of
compared to the right; mean differences were 2.6 degrees, extension. Among the tasks studied, the greatest amount of
2.0 degrees, and 2.2 degrees, respectively. Chang, Buschbacher, supination was needed for eating with a fork. Reading a news-
and Edlich30 studied 10 power lifters and 10 age-matched non- paper (Fig. 5.32), pouring from a pitcher, and cutting with a
lifters, all of whom were right handed, and found no differences knife required the most pronation.
between sides in elbow and forearm ROM. Five healthy subjects participated in a study by Packer
Studies on older subjects have noted similar results. and colleagues,34 which examined elbow ROM during three
Escalante, Lichenstein, and Hazudal,29 in a study of 695 older functional tasks. A uniaxial electrogoniometer was used to
subjects, found significantly greater elbow flexion on the left determine ROM required for using a telephone, for rising
than on the right, but the difference averaged only 2 degrees. from a chair to a standing position, and for eating with a
Kalscheur and coworkers25 reported no significant differences spoon. A range of 15 to 140 degrees of flexion was needed for
between sides for elbow flexion and pronation ROM in a these three activities. This ROM is slightly greater than the
study of 61 older women. A statistically significant difference arc reported by Morrey and associates, but the activities that
between sides was noted for pronation ROM, with the left required the minimal and maximal flexion angles did not dif-
side being an average of 3.0 degrees greater than the right. fer. The authors suggest that the height of the chair, the type
of chair arms, and the positioning of the telephone could
Sports account for the different ranges found in the studies.
It appears that the frequent use of the upper extremities in Safaee-Rad and coworkers35 used a three-dimensional
sport activities may reduce elbow and forearm ROM. Possible video system to measure ROM during three feeding activi-
causes for this association include muscle hypertrophy, mus- ties: eating with a spoon, eating with a fork, and drinking
cle tightness, and joint trauma from overuse. from a handled cup. Ten healthy males participated in the
Chinn, Priest, and Kent,31 in a study of 53 male and study. The feeding activities required approximately 70 to
30 female national and international tennis players, found sig- 130 degrees of elbow flexion, 40 degrees of pronation, and
nificantly less active ROM in pronation (mean difference ⫽ 60 degrees of supination. Drinking with a cup required the
5.8 degrees) and supination (4.6 degrees) in the playing arms greatest arc of elbow flexion (58 degrees) of the three activ-
of all subjects. Male players also demonstrated a significant ities, whereas eating with a spoon required the least
decrease (4.1 degrees) in elbow extension in the playing arm (22 degrees). Eating with a fork required the greatest arc of
versus the nonplaying arm. Chang, Buschbacher, and Edlich30 pronation–supination (97 degrees), whereas drinking from a
studied 10 power lifters and 10 age-matched nonlifters and cup required the least (28 degrees). Maximum ROM values
found less active elbow flexion in the power lifters than in the during feeding tasks were comparable with those reported
nonlifters. No significant differences were found between the by Morrey and associates. However, minimum values var-
two groups for supination and pronation ROM. Wright and ied, possibly owing to the different chair and table heights
colleagues32 noted an average decrease of 7.9 degrees for used in the two studies.
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TABLE 5.4 Elbow and Forearm Motion During Functional Activities: Mean Values in Degrees
FIGURE 5.31 Studies report that rising from a chair using the
FIGURE 5.30 Drinking from a cup requires about 130 degrees upper extremities requires a large amount of elbow and
of elbow flexion. wrist extension.
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for the universal goniometer, as indicated by ICC values and ranged from 0.57 to 0.84 for flexion, 0.66 to 0.92 for elbow
95 percent confidence intervals. Measurements taken with the extension, and 0.85 to 0.94 for supination. The authors
Ortho Ranger correlated poorly with those taken with the uni- concluded that random error, followed by observer and
versal goniometer (r = 0.11 to 0.21), and there was a signifi- patient–observer interaction were the most important sources of
cant difference in measurements between the two devices. variation in these patients with reflex sympathetic dystrophy.
Goodwin and coworkers16 evaluated the reliability of a uni- A study by Gajdosik45 of 31 healthy subjects compared
versal goniometer, a fluid goniometer, and an electrogoniometer three methods of measuring active ROM for supination and
for measuring active elbow ROM in 23 healthy women. Three pronation. All three methods aligned the stationary arm of a
testers took three consecutive readings using each type of universal goniometer parallel to the humerus. However,
goniometer, on two occasions that were 4 weeks apart. Signifi- Method I aligned the movable arm of the goniometer with a
cant differences were found between types of goniometers, pencil held in the hand. Method II placed the movable arm of
testers, and replications. Measurements taken with the universal the goniometer over the anterior or posterior surface of the
and fluid goniometers correlated the best (r ⫽ 0.90), whereas distal forearm, and Method III aligned the movable arm of the
the electrogoniometer correlated poorly with the universal goniometer parallel to a visualized line connecting the distal
goniometer (r ⫽ 0.51) and fluid goniometer (r ⫽ 0.33). Intra- radius and ulna. There was a significant difference in values
tester and intertester reliability was high during each occasion, between the three methods, with Method I having the greatest
with correlation coefficients greater than 0.98 and 0.90, respec- amount of supination and the least amount of pronation. All
tively. Intratester reliability between occasions was highest methods were highly reliable with ICC values ranging from
for the universal goniometer. ICC values ranged from 0.61 to 0.81 to 0.97 for three trials by one tester in one session and
0.92 for the universal goniometer, 0.53 to 0.85 for the fluid from 0.86 to 0.96 for two sessions conducted 30 minutes
goniometer, and 0.00 to 0.61 for the electrogoniometer. Similar apart. The author noted that Method I was the most reliable
to other researchers, the authors do not advise the interchange- but was confounded during supination by movement of the
able use of different types of goniometers in the clinical setting. fourth and fifth metacarpals. Methods II and III were recom-
Armstrong and associates43 examined the intratester, mended as reliable and more valid for clinical use but should
intertester, and interdevice reliability of active ROM measure- not be used interchangeably.
ments of the elbow and forearm in 38 surgical patients. Five Flower and associates46 measured passive supination and
testers measured each motion twice with each of the three pronation ROM in 30 orthopedic patients (31 wrists) with a
devices: a universal goniometer, an electrogoniometer, and a traditional 6-inch universal goniometer aligned with the
mechanical rotation measuring device. Intratester reliability was humerus and placed on the distal forearm and a new offset
high (r values generally greater than 0.90) for all three devices goniometer with a tubular handle and plumbline design.
and all motions. Intertester reliability was high for pronation and Three therapists measured each motion with each device once
supination with all three devices. Intertester reliability for elbow per session and repeated the session 20 minutes later. Intra-
flexion and extension was high for the electrogoniometer and class correlation coefficients for supination were 0.95 for both
moderate for the universal goniometer. Measurements taken the universal and new goniometer and 0.79 and 0.87 for
with different devices varied widely. The authors concluded that pronation with the universal and new goniometer, respec-
meaningful changes in intratester ROM taken with a universal tively. Average standard error of the measurement for supina-
goniometer occur with 95 percent confidence if they are greater tion was 3.7 degrees for both the universal and new
than 6 degrees for flexion, 7 degrees for extension, and 8 degrees goniometer and 7.0 and 6.2 degrees for pronation with the
for pronation and supination. Meaningful changes in intertester universal and new goniometer, respectively. The authors
ROM taken with a universal goniometer occur if they are greater stated that the difference in reliability between the two meth-
than 10 degrees for flexion, extension, and pronation and greater ods is probably not clinically significant.
than 11 degrees for supination. Karagiannopoulos, Sitler, and Michlovitz47 assessed the
Two examiners measured the active ROM of several reliability of two methods of measuring a functional combina-
upper-extremity joints in 29 patients with reflex sympathetic tion of active forearm and wrist rotation in 20 injured and
dystrophy with either an inclinometer or universal goniometer in 20 noninjured subjects. One method placed the stationary arm
a study by Geertzen and coworkers.44 Each examiner measured of a universal goniometer vertically and aligned the movable
the motions of each patient once per session, and the session arm with a pencil held in the hand. The second method uti-
was repeated 30 minutes later. The smallest detectable differ- lized an investigator-constructed tubular handle attached to a
ence, defined as the smallest amount of change in a variable that single-arm plumbline goniometer. Measurements were taken
can be measured with statistical significance, for elbow flexion three times with each method by the two examiners during
and extension with a universal goniometer was 9.6 and one session. Reliability was high and error was low for both
12.1 degrees on the affected side and 7.1 and 12.1 degrees on the methods and subject groups. Intratester and intertester ICC
nonaffected side, respectively. The smallest detectable differ- values ranged from 0.86 to 0.98 and from 0.91 to 0.96,
ence for supination measured with an inclinometer was 19.3 respectively. Intratester SEM values ranged from 1.4 to
degrees on the affected side and 16.5 degrees on the nonaffected 2.1 degrees, whereas intertester SEM values ranged from
side. Correlation coefficients between repeated measurements 2.2 to 3.9 degrees. To assess functional supination and
2066_Ch05_091-114.qxd 5/21/09 8:31 PM Page 112
pronation, the authors recommended the clinical use of the 135 degrees of flexion by a splint. In some cases the land-
handheld pencil method over the slightly more reliable marks were prelabeled, whereas in others the testers had to
plumbline method because of the simplicity and greater avail- palpate and identify the landmarks for goniometer alignment.
ability of the equipment for the handheld pencil method. Measurements were also determined from photographs of the
prelabeled, fixed elbow. In addition, passive elbow flexion
ROM was measured in the unsplinted elbow. There were small
Validity but significant differences (ranging from 0.6 to 5.1 degrees)
We are unaware of any published studies that report criterion- between the means of the goniometric measurements as com-
related validity of elbow and forearm ROM measurements pared to the photographic measurements, except in one case.
taken with a universal goniometer to radiographs. However, The standard deviation of the measurements increased from a
if photographic measurements are accepted as valid, then low of 0.7 to 1.1 degrees with photographic measurements to a
some indication of criterion-related validity may be provided high of 3.4 to 4.2 degrees with passive ROM. The authors pro-
by comparing goniometric and photographic measurements. posed that small systematic errors in alignment of the goniome-
In a study by Fish and Wingate,48 46 physical therapy stu- ter, identification of bony landmarks, and variations in the
dents used plastic and metal universal goniometers to mea- amount of torque applied by the tester may account for these
sure the angle of an elbow fixed in approximately 50 and differences.
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6
The Wrist
Structure and Function convex surface (Fig. 6.1). The radius articulates with the
scaphoid and lunate, whereas the radioulnar disc articulates
with the triquetrum and, to a lesser extent, the lunate. The
Radiocarpal and Midcarpal Joints pisiform, although found in the proximal row of carpal bones,
Anatomy does not participate in the radiocarpal joint. The joint is
The wrist is comprised of two joints, the radiocarpal and mid- enclosed by a strong capsule and is reinforced by the palmar
carpal joints, both of which are important to function. The radiocarpal, ulnocarpal, dorsal radiocarpal, ulnar collateral,
radiocarpal joint lies closer to the forearm, whereas the mid- and radial collateral ligaments and numerous intercarpal liga-
carpal joint is closer to the hand. The proximal joint surface ments (Figs. 6.2 and 6.3).
of the radiocarpal joint consists of the distal radius and The midcarpal joint is distal to the radiocarpal joint. The
radioulnar articular disc (Fig. 6.1; see also Fig. 5.7).1 The disc predominant central and ulnar portions of the midcarpal joint
connects the medial aspect of the distal radius to the distal consist of the concave surfaces of the scaphoid, lunate, and tri-
ulna. The distal radius and the disc form a continuous concave quetrum proximally and the convex surfaces of the capitate and
surface.2,3 The distal joint surface includes three bones from the hamate distally (Fig. 6.1). On the radial side of the midcarpal
proximal carpal row—the scaphoid, lunate, and triquetrum— joint, a smaller convex surface of the scaphoid contacts the
which are connected by interosseous ligaments to form a concave surfaces of the trapezium and trapezoid. The midcarpal
Ulna Radius
FIGURE 6.1 An anterior (palmar) view of the right wrist FIGURE 6.2 An anterior (palmar) view of the right wrist
showing the radiocarpal and midcarpal joints. showing the palmar radiocarpal, ulnocarpal, and collateral
ligaments.
115
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Osteokinematics
The radiocarpal and midcarpal joints are of the condyloid
type, with 2 degrees of freedom.2 The wrist complex (radio-
carpal and midcarpal joints) permits flexion–extension in the
sagittal plane around a medial–lateral axis and radial–ulnar
deviation in the frontal plane around an anterior–posterior
axis. Both joints contribute to these motions.4–6 Some sources
also report that a small amount of supination–pronation
occurs at the wrist complex,7 but this rotation is not usually
measured in the clinical setting.
Arthrokinematics
Motion at the radiocarpal joint occurs because the convex sur-
faces of the proximal row of carpals roll and slide on the con-
cave surfaces of the radius and radioulnar disc. The proximal
row of carpals rolls in the same direction but slides in the
opposite direction to movement of the hand.3,8,9 The carpals
slide dorsally on the radius and disc during wrist flexion and
ventrally toward the palm during wrist extension. During
ulnar deviation, the carpals roll in an ulnar direction and slide
in a radial direction. During radial deviation, they roll in a ra-
dial direction and slide in an ulnar direction.
Motion at the midcarpal joint occurs because the distal
row of carpals rolls and slides on the proximal row of carpals.
The distal joint surface is predominantly convex and rolls in
the same direction and slides in the opposite direction to the
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FIGURE 6.4 Posterior view of the upper extremity showing surface anatomy landmarks
for goniometer alignment during the measurement of wrist ROM.
Capitate
Radius
Third
metacarpal
Fifth metacarpal
Lateral
epicondyle of
humerus Ulna Triquetrum
Olecranon
process
FIGURE 6.5 Posterior view of the upper extremity showing bony anatomical landmarks for
goniometer alignment during the measurement of wrist ROM.
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FIGURE 6.6 The end of wrist flexion ROM. Only about three-quarters of the subject’s
forearm is supported by the examining table so that there is sufficient space for the
hand to complete the motion.
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FIGURE 6.8 At the end of wrist flexion ROM the examiner uses one hand to align the
distal arm of the gonimeter with the fifth metacarpal while maintaining the wrist in
flexion. The examiner exerts pressure on the middle of the dorsum of the subject’s
hand and avoids exerting pressure directly on the fifth metacarpal because such
pressure will distort the goniometer alignment.
Alternative Goniometer Alignment: 1. Center fulcrum over the capitate on the dorsal
Dorsal Aspect aspect of the wrist joint.
This alternative goniometer alignment is recom- 2. Align proximal arm with the dorsal midline of the
mended by LaStoya and Wheeler,16 although edema forearm.
may make accurate alignment over the dorsal surfaces 3. Align distal arm with the dorsal aspect of the third
of the forearm and hand difficult. Intratester reliability metacarpal.
is similar to lateral alignment technique (intraclass cor-
relation coefficient [ICC] ⫽ 0.87 to 0.92).
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Wrist Extension dorsal direction toward the ceiling (Fig. 6.9). Maintain
Motion occurs in the sagittal plane around a the wrist in 0 degrees of radial and ulnar deviation.
medial–lateral axis. Wrist extension is sometimes The end of extension ROM occurs when resistance to
referred to as dorsal flexion. Normal ROM values for further motion is felt and attempts to overcome the
adults are 60 degrees according to the AMA,12 resistance cause the forearm to lift off of the
70 degrees according to the AAOS,13,14 and 74 degrees supporting surface.
according to Boone and Azen.15 See Research Find-
ings and Tables 6.1 to 6.3 for additional normal ROM Normal End-Feel
values by age and gender. Usually the end-feel is firm because of tension
in the palmar radiocarpal ligament, ulnocarpal
Testing Position ligament, and palmar joint capsule. Tension in the
Position the subject sitting next to a supporting surface palmaris longus, flexor carpi radialis, and flexor
with the shoulder abducted to 90 degrees, the elbow carpi ulnaris muscles may also contribute to the
flexed to 90 degrees, and the palm of the hand facing firm end-feel. Sometimes the end-feel is hard
the ground. In this position the forearm will be midway because of contact between the radius and the
between supination and pronation. Rest the forearm on carpal bones.
the supporting surface, but leave the hand free to
move. Avoid radial or ulnar deviation of the wrist and Goniometer Alignment
extension of the fingers. If the fingers are held in exten- See Figures 6.10 and 6.11.
sion, tension in the flexor digitorum superficialis and
profundus muscles will restrict the motion. 1. Center fulcrum on the lateral aspect of the wrist
over the triquetrum.
Stabilization 2. Align proximal arm with the lateral midline of the
Stabilize the radius and ulna to prevent supination or ulna, using the olecranon and ulnar styloid process
pronation of the forearm and motion of the elbow. for reference.
3. Align distal arm with the lateral midline of the fifth
Testing Motion metacarpal. Do not use the soft tissue of the
Extend the wrist by pushing evenly across the palmar hypothenar eminence for reference.
surface of the metacarpals, moving the hand in a
FIGURE 6.9 At the end of the wrist extension ROM, the examiner stabilizes the
subject’s forearm with one hand and uses her other hand to hold the subject’s wrist
in extension. The examiner is careful to distribute pressure equally across the
subject’s metacarpals.
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FIGURE 6.11 At the end of the ROM of wrist extension, the examiner aligns the distal
goniometer arm with the fifth metacarpal while holding the wrist in extension. The examiner
avoids exerting excessive pressure on the fifth metacarpal.
Alternative Goniometer Alignment: 1. Center fulcrum on the palmar surface of the wrist
Palmar Aspect joint at the level of the capitate.
This alternative goniometer alignment is recommended 2. Align proximal arm with the palmar midline of the
by LaStayo and Wheeler,16 although edema may make forearm.
accurate alignment over the palmar surfaces of the 3. Align distal arm with the palmar midline of the
forearm and hand difficult. Intratester reliability is simi- third metacarpal.
lar to lateral alignment technique (ICC = 0.80 to 0.84).
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Wrist Radial Deviation of flexion and extension, and avoid rotating the hand.
Motion occurs in the frontal plane around an anterior– The end of radial deviation ROM occurs when resis-
posterior axis. Radial deviation is sometimes tance to further motion is felt and attempts to over-
referred to as radial flexion or abduction. Normal come the resistance cause the elbow to flex.
ROM values for adults are 20 degrees according to
the AMA12 and AAOS13,14 and 25 degrees according Normal End-Feel
to Greene and Wolf.17 See Research Findings and Usually the end-feel is hard because of contact be-
Tables 6.1 to 6.3 for additional normal ROM values by tween the radial styloid process and the scaphoid, but
age and gender. it may be firm because of tension in the ulnar collat-
eral ligament, the ulnocarpal ligament, and the ulnar
Testing Position portion of the joint capsule. Tension in the extensor
Position the subject sitting next to a supporting sur- carpi ulnaris and flexor carpi ulnaris muscles may also
face with the shoulder abducted to 90 degrees, the contribute to the firm end-feel.
elbow flexed to 90 degrees, and the palm of the hand
facing the ground. In this position the forearm will be Goniometer Alignment
midway between supination and pronation. Rest the See Figures 6.13 and 6.14.
forearm and hand on the supporting surface. 1. Center fulcrum on the dorsal aspect of the wrist
over the capitate.
Stabilization 2. Align proximal arm with the dorsal midline of the
Stabilize the radius and ulna to prevent pronation or forearm. If the shoulder is in 90 degrees of abduc-
supination of the forearm and elbow flexion beyond tion and the elbow is in 90 degrees of flexion, the
90 degrees. lateral epicondyle of the humerus can be used for
reference.
Testing Motion 3. Align distal arm with the dorsal midline of the
Radially deviate the wrist by moving the hand toward third metacarpal. Do not use the third phalanx
the thumb (Fig. 6.12). Maintain the wrist in 0 degrees for reference.
FIGURE 6.12 The examiner stabilizes the subject’s forearm to prevent flexion of the elbow beyond
90 degrees when the wrist is moved into radial deviation. The examiner avoids moving the wrist into
either flexion or extension.
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FIGURE 6.14 The alignment of the goniometer at the end of radial deviation ROM. The examiner
must center the fulcrum over the dorsal surface of the capitate. If the fulcrum shifts to the ulnar side
of the wrist, there will be an incorrect measurement of excessive radial deviation.
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WRIST ULNAR DEVIATION wrist in 0 degrees of flexion and extension, and avoid
Motion occurs in the frontal plane around an rotating the hand. The end of ulnar deviation ROM
anterior–posterior axis. Ulnar deviation is sometimes occurs when resistance to further motion is felt and
referred to as ulnar flexion or adduction. Normal ROM attempts to overcome the resistance cause the elbow
values for adults are 30 degrees according to the to extend.
AMA12 and AAOS13,14 and 39 degrees according to
Greene and Wolf.17 See Research Findings and Normal End-Feel
Tables 6.1 to 6.3 for additional normal ROM values by The end-feel is firm because of tension in the radial
age and gender. collateral ligament and the radial portion of the joint
capsule. Tension in the extensor pollicis brevis and
Testing Position abductor pollicis longus muscles may contribute to
Position the subject sitting next to a supporting the firm end-feel.
surface with the shoulder abducted to 90 degrees,
the elbow flexed to 90 degrees, and the palm of the
Goniometer Alignment
hand facing the ground. In this position the forearm
See Figures 6.16 and 6.17.
will be midway between supination and pronation.
Rest the forearm and hand on the supporting surface. 1. Center fulcrum on the dorsal aspect of the wrist
over the capitate.
Stabilization 2. Align proximal arm with the dorsal midline of the
Stabilize the radius and ulna to prevent pronation or forearm. If the shoulder is in 90 degrees of abduc-
supination of the forearm and less than 90 degrees of tion and the elbow is in 90 degrees of flexion, the
elbow flexion. lateral epicondyle of the humerus can be used for
reference.
Testing Motion 3. Align distal arm with the dorsal midline of the
Deviate the wrist in the ulnar direction by moving the third metacarpal. Do not use the third phalanx for
hand toward the little finger (Fig. 6.15). Maintain the reference.
FIGURE 6.15 The examiner uses one hand to stabilize the subject’s forearm and maintain the elbow in
90 degrees of flexion. The examiner’s other hand moves the wrist into ulnar deviation, being careful
not to flex or extend the wrist.
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FIGURE 6.17 The alignment of the goniometer at the end of the ulnar deviation ROM. The examiner
must center the fulcrum over the dorsal surface of the capitate. If the fulcrum shifts to the radial side
of the wrist, there will be an incorrect measurement of excessive ulnar deviation.
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FIGURE 6.18 An anterior view of the right forearm showing the attachments of the flexor
digitorum profundus muscle.
Medial epicondyle
of humerus Flexor digitorum superficialis
Ulna
Radius
FIGURE 6.19 An anterior view of the right forearm and hand showing the attachments of
the flexor digitorum superficialis muscle.
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FIGURE 6.20 The starting position for testing the length of the flexor digitorum profundus and
flexor digitorum superficialis muscles.
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FIGURE 6.21 The end of the testing motion for the length of the flexor digitorum profundus
and flexor digitorum superficialis muscles. The examiner uses one hand to stabilize the
forearm, while the other hand holds the fingers in extension and moves the wrist into
extension. The examiner has moved her right thumb from the dorsal surface of the fingers to
allow a clearer photograph, but keeping the thumb placed on the dorsal surface would help
to prevent the fingers from flexing at the PIP joints.
Flexor digitorum
Flexor digitorum
profundus
superficialis
(humeral + ulnar heads)
FIGURE 6.22 A lateral view of the right forearm and hand showing the flexor digitorum
profundus and flexor digitorum superficialis being stretched over the elbow, wrist, MCP, PIP,
and DIP joints.
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Goniometer Alignment
FIGURE 6.23 The alignment of the goniometer at the end of testing the length of the flexor
digitorum profundus and flexor digitorum superficialis muscles.
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EXTENSOR DIGITORUM,
EXTENSOR INDICIS, AND
EXTENSOR DIGITI MINIMI
MUSCLE LENGTH
The extensor digitorum, extensor indicis, and exten-
sor digiti minimi muscles cross the elbow; wrist; and
MCP, PIP, and DIP joints. When these muscles con-
tract, they extend the MCP, PIP, and DIP joints of the Extensor
hood
fingers and extend the wrist. These muscles are pas- mechanism
sively lengthened by placing the elbow in extension Distal phalanx
and the wrist, MCP, PIP, and DIP joints in full flexion. Middle phalanx
The extensor digitorum originates proximally
from the lateral epicondyle of the humerus and inserts
distally onto the middle and distal phalanges of the
Proximal phalanx
fingers via the extensor hood (Fig. 6.24). The exten-
sor indicis originates proximally from the posterior
surface of the ulna and the interosseous membrane.
This muscle inserts distally onto the extensor hood of
the index finger. The extensor digiti minimi also orig-
inates proximally from the lateral epicondyle of the
humerus but inserts distally onto the extensor hood of
the little finger.
If the extensor digitorum, extensor indicis, and Ulna
Radius
extensor digiti minimi muscles are short, they will Extensor indicis
limit wrist flexion when the elbow is positioned in
extension and the MCP, PIP, and DIP joints are posi-
tioned in full flexion. If wrist flexion is limited regard- Extensor
Extensor digiti
digitorum
less of the position of the MCP, PIP, and DIP joints, minimi
the limitation is due to abnormalities of joint surfaces
of the wrist or shortening of the dorsal joint capsule,
dorsal radiocarpal ligament, extensor carpi radialis FIGURE 6.24 A posterior view of the right forearm and hand
longus, extensor carpi radialis brevis, or extensor showing the distal attachments of the extensor digitorum,
carpi ulnaris muscles. extensor indicis, and extensor digiti minimi muscles.
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FIGURE 6.25 The starting position for testing the length of the extensor digitorum, extensor
indicis, and extensor digiti minimi muscles. The hand is positioned off the end of the
examining table to allow room for finger and wrist flexion.
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FIGURE 6.26 The end of the testing motion for the length of the extensor digitorum, extensor
indicis, and extensor digiti minimi muscles. One of the examiner’s hands stabilizes the forearm,
while the other hand holds the fingers in full flexion and moves the wrist into flexion.
Ulna
Extensor
indicis
Extensor
Lateral epicondyle digiti
of humerus minimi
Extensor indicis
tendon
FIGURE 6.27 A posterior view of the right forearm and hand showing the extensor
digitorum, extensor indicis, and extensor digiti minimi muscles stretched over the elbow,
wrist, MCP, PIP, and DIP joints.
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Goniometer Alignment 3. Align distal arm with the lateral midline of the
FIGURE 6.28 The alignment of the goniometer at the end of testing the length of the extensor
digitorum, extensor indicis, and extensor digiti minimi muscles.
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Research Findings Table 6.2 provides normative wrist ROM values for new-
borns and children. Although caution must be used in draw-
ing conclusions from comparisons between values obtained
Effects of Age, Gender, by different researchers, the mean flexion and extension
and Other Factors values for infants from Wanatabe and coworkers22 are larger
than values for males aged 18 months to 19 years reported by
Table 6.1 provides normal wrist ROM values for adults as Boone and Azen.15,23 Within the study by Boone and Azen,
reported by the AAOS,12–15,17,18 AMA,12 Boone and Azen,15 wrist flexion and ulnar and radial deviation motions for the
Greene and Wolf,17 and Ryu and associates.18 In general, these youngest age group (18 months to 5 years) were significantly
values range from 60 to 80 degrees for flexion, 60 to 75 degrees larger than the values for other age groups (see Tables 6.2 and
for extension, 20 to 25 degrees for radial deviation, and 30 to 6.3). Wrist extension values were significantly larger for
40 degrees for ulnar deviation. Other studies that provide wrist males 6 to 12 years of age than for those in the other age
ROM data for adults between the ages of 20 to 60 years include groups.
Solgaard and colleagues,19 Solveborn and Olerud,20 and Stubbs Table 6.3 provides wrist ROM values in male adults from
and coworkers.21 20 to 54 years of age. Boone and Azen15,23 found a significant
Age difference in wrist flexion and extension ROM between males
Most studies support a small, gradual decrease in the amount younger than or equal to 19 years of age and those who were
of wrist motion with increasing age. Age-related ROM older. However, the effects of age on wrist motion in adults
changes appear to be most marked in young children and from 20 to 54 years of age appear to be very slight. A study
seniors, whereas changes in young and middle-aged adults by Stubbs and associates21 placed 55 male subjects between
seem minimal. the ages of 25 and 54 years into three age groups. There was
TABLE 6.1 Normal Wrist ROM Values for Adults in Degrees from Selected Sources
AAOS13,14 AMA12 Boone and Azen15 Greene and Wolf17 Ryu et al18
20–54 yrs 18–55 yrs n = 40
n = 56 n = 20 Males and
Males Males and Females Females
Motion Mean (SD) Mean (SD) Mean
Flexion 80 60 74.8 (6.6) 73.3 (2.1) 79.1
Extension 70 60 74.0 (6.6) 64.9 (2.2) 59.3
Radial deviation 20 20 21.1 (4.0) 25.4 (2.0) 21.1
Ulnar deviation 30 30 35.3 (3.8) 39.2 (2.1) 37.7
TABLE 6.2 Effects of Age on Wrist ROM in Newborns, Children, and Adolescents: Normal Values
in Degrees
Wanatabe et al22 Boone and Azen15,23
2 wks–2 yrs 18 mos–5 yrs 6–12 yrs 13–19 yrs
n = 45 n = 19 n = 17 n = 17
Males and Females Males Males Males
Motion Range of Means Mean (SD) Mean (SD) Mean (SD)
Flexion 88–96 82.2 (3.8) 76.3 (5.6) 75.4 (4.5)
Extension 82–89 76.1 (4.9) 78.4 (5.9) 72.9 (6.4)
Radial deviation 24.2 (3.7) 21.3 (4.1) 19.7 (3.0)
Ulnar deviation 38.7 (3.6) 35.4 (2.4) 35.7 (4.2)
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TABLE 6.3 Effects of Age on Wrist ROM in Men 20 to 54 Years Old: Normal Values in Degrees
20–29 yrs 30–39 yrs 40–54 yrs 25–34 yrs 35–44 yrs 45–54 yrs
n = 19 n = 18 n = 19 n = 15 n = 20 n = 20
Motion Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD)
Flexion 76.8 (5.5) 74.9 (4.0) 72.8 (8.9) 70.6 (9.3) 73.5 (10.4) 68.9 (8.4)
Extension 77.5 (5.1) 72.8 (6.9) 71.6 (6.3) 78.3 (11.8) 76.4 (10.4) 76.7 (11.7)
Radial deviation 21.4 (3.6) 20.3 (3.1) 21.6 (5.1) 23.8 (9.5) 22.5 (7.9) 18.9 (7.9)
Ulnar deviation 35.1 (3.8) 36.1 (2.9) 34.7 (4.5) 51.1 (9.0) 49.9 (7.0) 44.1 (4.3)
no significant difference among the age groups for wrist differences in the average amount of active motion in various
flexion, extension, and radial deviation ROM. A significant age groups, but no statistical analyses were performed. Allander
difference in ulnar deviation (7 degrees) was found between and coworkers,28 in a study of 309 Icelandic females, 208
the oldest and the youngest age groups, with the oldest group Swedish females, and 203 Swedish males ranging in age from
having less motion. 33 to 70 years, found that with increasing age there was a
Wrist ROM values in males 60 years of age and older are decrease in flexion and extension ROM at both wrists. Males
presented in Table 6.4. Flexion and extension ROM in these lost an average of 2.2 degrees of motion every 5 years. Bell
older adults, as presented by Walker and associates,24 Chap- and Hoshizaki29 studied 124 females and 66 males ranging in
arro and colleagues,25 and Kalscheur and coworkers26 are less age from 18 to 88 years. A significant negative correlation
than the values for the age groups presented in Table 6.3. was noted between ROM and age for wrist flexion–extension
Chaparro and colleagues25 further subdivided the 62 male and radial–ulnar deviation in females and for wrist
subjects in their study into four age groups: 60 to 69 years of flexion–extension in males. As age increased, wrist motions
age, 70 to 79 years of age, 80 to 89 years of age, and 90 years generally decreased. There was a significant difference
of age and older. They found a trend of decreasing ROM with among the five age groups of females for all wrist motions,
increasing age, with the oldest group having significantly although the difference was not significant for males.
lower wrist flexion and ulnar deviation values than the two Kalscheur and associates,30 in a study of 61 women between
youngest groups. the ages of 63 and 85 years, found a significant linear relation-
Four other studies offer additional information on the ship between age and right wrist flexion and extension with
effects of age on wrist motion. Hewitt,27 in a study of ROM decreasing an average of 0.4 to 0.5 degrees per year in
112 females between 11 and 45 years of age, found slight these older women. The relationships between age and left
wrist motions were not statistically significant.
Gender
TABLE 6.4 Effects of Age on Wrist ROM The following four studies offer evidence of gender effects on
in Men Older Than 60 Years: the wrist joint, with most supporting the belief that women
Normal Values in Degrees have slightly more wrist ROM than men. Cobe,31 in a study of
100 college men and 15 women ranging in age from 20 to
Walker Chaparro Kalscheur
et al24 et al25 et al26 30 years, found that women had a greater active ROM in all
motions at the wrist than men. Allander and coworkers28 com-
60–85 yrs 60–90+ yrs 66–86 yrs pared wrist flexion and extension ROM in 203 Swedish men
n = 30 n = 62 n = 25 and 208 Swedish women between the ages of 45 and more
Motion Mean (SD) Mean (SD) Mean (SD) than 70 years of age and noted that women had significantly
greater motion than men. Both studies measured active
Flexion 62.0 (12.0) 50.8 (13.8) 64.9 (8.7) motion with joint-specific mechanical devices. Walker and as-
Extension 61.0 (6.0) 44.0 (9.9) 58.2 (10.9) sociates,24 in a study of 30 men and 30 women aged 60 to
Radial 20.0 (6.0) 84 years, found that the women had more active wrist exten-
deviation sion and flexion than the men, whereas the men had more
Ulnar 28.0 (7.0) 35.0 (9.5) ulnar and radial deviation than the women. These differences
deviation were statistically significant for wrist extension (4 degrees)
and ulnar deviation (5 degrees). Chaparro and colleagues25
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examined wrist flexion, extension, and ulnar deviation ROM on the left compared with the right. However, mean differ-
in 62 men and 85 women from 60 to more than 90 years ences between sides were only 2 degrees. The authors con-
of age. Women had significantly greater wrist extension curred with Boone and Azen15 that a patient’s healthy limb
(6.4 degrees) and ulnar deviation (3.0 degrees) than men. can be used to establish a norm for comparing with the
Kalscheur and coworkers26 found that women had more wrist affected side.
flexion and extension ROM than men in a study of 61 women Testing Position
and 25 men between the ages of 63 and 86 years. These dif- Several studies have reported differences in wrist ROM
ferences ranged from 1.7 to 5.3 degrees and were statistically depending on the testing position of the forearm during mea-
significant for right wrist flexion (5.0 degrees) and left wrist surement. These findings support the use of consistent fore-
extension (5.3 degrees). arm positions during wrist measurements. Cobe,31 in a study
Right Versus Left Sides of 100 men and 15 women, found that ulnar deviation ROM
Study results vary as to whether there is a difference between was greater in supination, whereas radial deviation was
left and right wrist ROM. Boone and Azen,15 in a study of 109 greater in pronation. It is interesting that the total amount of
normal males between 18 months and 54 years of age, found ulnar and radial deviation combined was similar between the
no significant difference in wrist flexion, extension, and radial two positions. Hewitt27 measured wrist ROM in 112 females
and ulnar deviation between sides. Likewise, Chang, in supination and pronation and found that ulnar deviation
Buschbacher, and Edlich32 found no significant difference was greater in supination, whereas radial deviation, flexion,
between right and left wrist flexion and extension in the and extension were greater in pronation. Werner and
10 power lifters and 10 nonlifters who were their subjects. Plancher,6 in a review article, also stated that ulnar deviation
Solgaard and coworkers19 studied 8 males and 23 females has a greater ROM when the forearm is supinated than when
aged 24 to 65 years. Right and left wrist extension and radial the forearm is pronated. They noted that radial and ulnar
deviation differed significantly, but the differences were small deviation ROMs become minimal when the wrist is fully
and not significant when the total range (i.e., flexion and flexed or extended. No specific references for these observa-
extension) was assessed. The authors stated that the opposite tions were cited.
wrist could be satisfactorily used as a reference. Spilman and Pinkston28 examined the effect of three fre-
In contrast, several studies have found the left wrist to quently used goniometric testing positions on active wrist
have greater ROM than the right wrist. Cobe31 measured radial and ulnar deviation ROM in 100 subjects (63 males,
wrist motions in the positions of pronation and supination in 37 females). In Position One the subject’s arm was at the side,
100 men and 15 women. He found that men had greater ROM with the elbow flexed to 90 degrees and the forearm fully
in their left wrist than in their right for all motions except pronated. In Position Two the shoulder was in 90 degrees of
ulnar deviation measured in pronation. However, he reported flexion, with the elbow extended and the hand prone. In Posi-
that the women had greater wrist motion on the right except tion Three the subject’s shoulder was in 90 degrees of abduc-
for extension in pronation and radial deviation in supination. tion, with the elbow in 90 degrees of flexion and the hand
No statistical tests were conducted in the 1928 study, but prone (in this position the forearm is in neutral pronation).
Allander and associates28 reported that a recalculation of the Ulnar deviation and the total range of radial and ulnar devia-
original data collected by Cobe found a significantly greater tion were significantly greater when measured in Position
ROM on the left in men. Cobe31 suggests that the heavy work Three. Radial deviation was significantly greater when the
that men performed using their right extremities may account subject was in Position Three or Position Two than in Position
for the decrease in right-side motion in comparison with left- One. The differences between the means for the three posi-
side motion. A study by Kalscheur and associates30 found a tions were small—approximately 3 degrees.
significantly greater range of left wrist extension and right Wrist ROM values have also been found to vary if differ-
wrist flexion as compared to the contralateral side in 61 older ent wrist positions are used during testing. It appears that the
women. The mean differences between sides were small, greatest ROM values are obtained with the wrist in a neutral
ranging from 3 to 5 degrees. position. Marshall, Morzall, and Shealy34 evaluated 35 men
Allander and associates,28 in a study subgroup of 309 Ice- and 19 women for wrist ROM in one plane of motion while
landic women aged 34 to 61 years, found no significant the subjects were fixed in secondary wrist and forearm posi-
difference between the right and the left wrists. However, a tions. For example, during the measurement of radial and
subgroup of 208 women and 203 Swedish men in the study ulnar deviation, the wrist was alternatively positioned in
showed significantly smaller ranges of wrist flexion and 0 degrees, 40 degrees of flexion, and 40 degrees of extension.
extension on the right than on the left, independent of gender. During the measurement of flexion and extension the wrist
The authors state that these differences may be due to a higher was positioned in 0 degrees, 15 degrees radial deviation, and
level of exposure to trauma of the right hand in a predominantly 25 degrees ulnar deviation. The effects of the secondary wrist
right-handed society. Solveborn and Olerud20 measured wrist and forearm postures, although statistically significant, were
ROM in 16 healthy subjects in addition to 123 patients with generally small (less than 5 degrees), with most motions hav-
unilateral tennis elbow. Among the healthy subjects a signifi- ing the greatest range with the wrist in neutral. However,
cantly greater ROM was found for wrist flexion and extension radial deviation ROM was greatest when performed in wrist
2066_Ch06_115-142.qxd 5/22/09 7:47 PM Page 137
extension. The authors believed that the changes that occur in activities generally required the least amount of extension
wrist ROM with positional alterations might have been due to (6 to 24 degrees) and the smallest arc of motion (13 to
changes in contact between articular surfaces and tautness of 20 degrees). Using the telephone (Fig. 6.29), turning a
ligaments that span the wrist region. In a study of 10 subjects steering wheel or a doorknob and rising from a chair (see
performing active circumduction, Li and associates35 found Fig. 5.31) required the greatest amounts of extension (40 to
that maximum ROM in flexion and extension occurred with 63 degrees) and arc of motion (43 to 85 degrees). Turning a
the wrist near 0 degrees of radial and ulnar deviation. Like- doorknob (Fig. 6.30) involved the greatest amount of flex-
wise, maximum ROM in radial and ulnar deviation occurred ion (40 degrees). The greatest amounts of ulnar deviation
with the wrist near 0 degrees of flexion and extension. Wrist (27 to 32 degrees) were noted while rising from a chair,
deviation from the neutral position in one plane of motion re- turning a doorknob and steering wheel, and pouring from a
duced wrist ROM in other planes of motions. pitcher.
Table 6.6 provides information on wrist position during
the placement of the hand on the body areas commonly
Functional Range of Motion touched during personal care. The majority of positions
Several investigators have examined the range of motion that required wrist flexion and less overall wrist motion than the
occurs at the wrist during activities of daily living (ADLs) and ADLs presented in Table 6.5. Among the positions studied,
during the placement of the hand on the body areas necessary placing the palm to the front of the chest consistently
for personal care. Tables 6.5 and 6.6 are adapted from the required the greatest amount of wrist flexion, whereas plac-
works of Brumfield and Champoux,36 Ryu and associates,18 ing the palm to the sacrum required the greatest amount of
Safaee-Rad and colleagues,37 and Cooper and coworkers.38 Dif- ulnar deviation.
ferences in ROM values reported for certain functional tasks Brumfield and Champoux36 used a uniaxial electrogo-
were most likely the result of variations in task definitions, niometer to determine the range of wrist flexion and extension
measurement methods, and subject selection. However, in spite during 15 ADLs performed by 12 men and 7 women. They
of the range of values reported, certain trends are evident. determined that ADLs such as eating, drinking, and using a
A review of Table 6.5 shows that the majority of ADLs telephone were accomplished with 5 degrees of flexion to
required wrist extension and ulnar deviation. Drinking 35 degrees of extension. Personal care activities that involved
TABLE 6.5 Wrist ROM During Functional Activities: Mean Values in Degrees
TABLE 6.6 Wrist Motions During Hand Placement Needed for Personal Care Activities:
Mean Values in Degrees
Extension Flexion Ulnar Deviation Radial Deviation
Activity Mean (SD) Mean (SD) Mean (SD) Mean (SD) Source
3 degrees of ulnar deviation to 18 degrees of radial deviation. incidences of injury, studies have been conducted on the wrist
Both studies found that drinking from a cup required less of positions used and the amount and frequency of wrist motions
an arc of wrist motion than eating with a fork or spoon. required during grocery bagging,41 grocery scanning,42 piano
Nelson40 took a different approach to determining the playing,43 industrial work,44 and handrim wheelchair propul-
amount of wrist motion necessary for carrying out functional sion45,46 and in playing sports such as basketball, baseball
tasks. He evaluated the ability of 9 males and 3 females to pitching, and golf.6,47 The reader is advised to refer directly to
perform 123 ADLs with a splint on the dominant wrist that these studies to gain information about the amount of wrist
limited motion to 5 degrees of flexion, 6 degrees of extension, ROM that occurs during these activities. In general, an asso-
7 degrees of radial deviation, and 6 degrees of ulnar deviation. ciation has been noted between activities that require extreme
All 123 activities could be completed with the splint in place, wrist postures and the prevalence of hand/wrist tendinitis.48
with 9 activities having a mean difficulty rating of greater than Tasks that involve repeated wrist flexion and extreme wrist
or equal to 2 (could be done with minimal difficulty or frustra- extension, repetitive work with the hands, and repeated force
tion and with satisfactory outcome). The most difficult activities applied to the base of the palm and wrist have been associated
included putting on/taking off a brassiere (Fig. 6.31), washing with carpal tunnel syndrome.49
legs/back, writing, dusting low surfaces, cutting vegetables,
handling a sharp knife, cutting meat, using a can opener, and
using a manual eggbeater. It should be noted that these sub-
Reliability
jects were pain free and had normal shoulders and elbows to In early studies of wrist motion conducted by Hewitt27 and
compensate for the restricted wrist motions. The ability to Cobe31 in the 1920s, both authors observed considerable dif-
generalize these results to a patient population with pain and ferences in repeated measurements of active wrist motions.
multiply involved joints may be limited. These differences were attributed to a lack of motor control
Repetitive trauma disorders such as carpal tunnel syn- on the part of the subjects in expending maximal effort. Cobe
drome and wrist/hand tendinitis have been noted to occur suggested that only average values have much validity and
more frequently in performing certain types of work, sports, that changes in ROM should exceed 5 degrees to be consid-
and artistic endeavors. To elucidate the cause of these higher ered clinically significant.
Later studies of intratester and intertester reliability were
conducted by numerous researchers. The majority of these
investigators found that intratester reliability was greater than
intertester reliability, that reliability varied according to the
motion being tested, and that different instruments should not
be used interchangeably during joint measurement.
Hellebrandt, Duvall, and Moore50 found that wrist motions
measured with a universal goniometer were more reliable than
those measured with a joint-specific device. Measurements of
wrist flexion and extension were less reliable than measure-
ments of radial and ulnar deviation, although mean differences
between successive measurements taken with a universal
goniometer by a skilled tester were 1.1 degrees for flexion and
0.9 degrees for extension. The mean differences between suc-
cessive measurements increased to 5.4 degrees for flexion and
5.7 degrees for extension when successive measurements were
taken with different instruments.
In a study by Low,51 50 testers using a universal
goniometer visually estimated and then measured the
author’s active wrist extension and elbow flexion. Five
testers also took 10 repeated measurements over the course
of 5 to 10 days. Mean error improved from 12.8 degrees for
visual estimates to 7.8 degrees for goniometric measure-
ment. Intraobserver error was less than interobserver error.
The measurement of wrist extension was less reliable than
the measurement of elbow flexion, with mean errors of
7.8 and 5.0 degrees, respectively.
Boone et al52 conducted a study in which four testers
FIGURE 6.31 A large amount of wrist flexion is needed to using a universal goniometer measured ulnar deviation on
fasten a bra or bathing suit. This is one of the most difficult 12 male volunteers. Measurements were repeated over a
activities to perform if wrist motion is limited. period of 4 weeks. Intratester reliability was found to be
2066_Ch06_115-142.qxd 5/22/09 7:47 PM Page 140
better than intertester reliability. The authors concluded that LaStayo and Wheeler16 studied the intratester and
to determine true change when more than one tester measures intertester reliability of passive ROM measurements of wrist
the same motion, differences in motion should exceed flexion and extension in 120 patients as measured by 32 ran-
5 degrees. domly paired therapists, who used three goniometric align-
In a study by Bird and Stowe,53 two observers repeat- ments (ulnar, radial, and dorsal–volar). The reliability of
edly measured active and passive wrist ROM in three sub- measuring wrist flexion ROM was consistently higher than
jects. They concluded that interobserver error was greatest that of measuring extension ROM. Mean intratester ICCs for
for extension (⫾8 degrees) and least for radial and ulnar wrist flexion were 0.86 for radial, 0.87 for ulnar, and 0.92 for
deviation (⫾2 to 3 degrees). Error during passive ROM dorsal alignment. Mean intratester ICCs for wrist extension
measurements was slightly greater than during active ROM were 0.80 for radial, 0.80 for ulnar, and 0.84 for volar align-
measurements. ment. The authors recommended that these three alignments,
Greene and Wolf17 compared the reliability of the Ortho- although generally having good reliability, should not be used
Ranger, an electronic pendulum goniometer, with a universal interchangeably because there were some significant differ-
goniometer for active upper-extremity motions in 20 healthy ences between the measurements taken with the three align-
adults. Wrist ROM was measured by one therapist three times ments. The authors suggested that the dorsal–volar alignment
with each instrument during each of three sessions over a should be the technique of choice for measuring passive wrist
2-week period. There was a significant difference between flexion and extension, given its higher reliability. In an invited
instruments for wrist extension and ulnar deviation. Within- commentary on this study, Flower55 suggested using the fifth
session reliability was slightly higher for the universal goniome- metacarpal, which is easier to visualize and align with the
ter (ICC = 0.91 to 0.96) than for the OrthoRanger (ICC ⫽ distal arm of the goniometer in the ulnar technique, rather
0.88 to 0.92). The 95 percent confidence level, which represents than the third metacarpal, which was used in the study. Flower
the variability around the mean, ranged from 7.6 to 9.3 degrees noted that the presence and fluctuation of edema on the
for the goniometer and from 18.2 to 25.6 degrees for the Ortho- dorsal surface of the hand may reduce the reliability of the
Ranger. The authors concluded that the OrthoRanger provided dorsal alignment and necessitate the use of the ulnar (fifth
no advantages over the universal goniometer. metacarpal) alignment in the clinical setting.
Solgaard and coworkers19 found intratester standard devi-
ations of 5 to 8 degrees and intertester standard deviations of
6 to 10 degrees in a study of wrist and forearm motions
Validity
involving 31 healthy subjects. Measurements were taken with We are unaware of any published studies that report criterion-
a universal goniometer by four testers on three different occa- related validity of wrist ROM measurements taken with a
sions. The coefficients of variation (percent variation) goniometer to radiographs. However, several studies have
between testers were greater for ulnar and radial deviation examined construct validity between impairment measures,
than for flexion, extension, pronation, and supination. such as wrist ROM, and ratings of functional limitation or dis-
Horger54 conducted a study in which 13 randomly paired ability. A review of 32 published wrist outcome instruments
therapists performed repeated measurements of active and noted that ROM was the most frequently included variable,
passive wrist motions on 48 patients. Therapists were free to present in 82 percent of the outcome instruments.56
select their own method of measurement with a universal Wagner and colleagues57 measured passive ROM of wrist
goniometer. The six specialized hand therapists used an ulnar flexion, extension, radial and ulnar deviation, and the strength
alignment for flexion and extension, whereas the nonspecial- of the wrist extensor and flexor muscles in 18 boys with
ized therapists used a radial goniometer alignment. Intratester Duchenne muscular dystrophy. A highly significant negative
reliability of both active and passive wrist motions were correlation was found between difficulty performing func-
highly reliable (all ICCs higher than 0.90) for all motions. tional hand tasks and radial deviation ROM (r = –0.76 to
Intratester reliability was consistently higher than intertester –0.86) and between difficulty performing functional hand
reliability (ICC 0.66 to 0.91). Standard errors of measure- tasks and wrist extensor strength (r = –0.61 to –0.83).
ments (SEM) ranged from 2.6 to 4.4 for intratester values and The relationship between wrist ROM and activity limita-
from 3.0 to 8.2 for intertester values. Agreement between tion, pain, and disability following wrist fractures has been
measures was better for flexion and extension than for radial examined. Tremayne and associates,58 in a study of 20 patients
and ulnar deviation. Intertester reliability coefficients for with distal radius fractures, found strong, significant correla-
measurements of active motion (ICC = 0.78 to 0.91) were tions (r = –0.51 to –0.76) between grip strength and tasks in
slightly higher than were coefficients for passive motion (ICC the Jebsen Test of Hand Function (JTHF) and weaker correla-
= 0.66 to 0.86) except for radial deviation. Generally, reliabil- tions (r = –0.17 to –0.55) between wrist extenson ROM and
ity was higher for the specialized therapists than for the tasks in the JTHF. In a subset of 11 patients with Colles’ type
nonspecialized therapists. The author determined that the fractures, there were significant correlations (r = –0.74 to
presence of pain reduced the reliability of both active and pas- –0.84) between wrist extension ROM and three of seven tasks
sive measurements, but active measurements were affected (turning cards, stimulated feeding, and lifting large light
more than passive measurements. objects) included in the JTHF.
2066_Ch06_115-142.qxd 5/22/09 7:47 PM Page 141
In a study of 120 patients with distal radius fractures, They concluded that grip strength, followed by wrist exten-
MacDermid and coworkers59 found that higher patient-rated sion and forearm pronation, were the most sensitive clinical
pain and disability scores 6 months post-injury (6-month indicators of return of wrist function. In another report of
Patient-Rated Wrist Evaluation [PRWE] scores) were moder- 31 patients recovering from distal radial fracture, the same
ately associated (r = –0.41) with lower composite ROM authors noted that flexion–extension and pronation–supination
scores. Composite ROM scores were based on wrist flexion, arcs of motion (expressed as percentages of the unaffected
extension, ulnar and radial deviation, supination, pronation, side) were not significantly associated with total PRWE
and finger flexion. scores in a multiple regression model that included grip
Karnezis and Fragkiadakis,60 in a study of 25 patients re- strength, age, gender, presence of high-energy injury, and
covering from distal radial fractures, reported correlations be- intra-articular fracture.61 The possibility that some of the vari-
tween the “Function Score” of the PRWE score and grip ables included in the regression model may be inadvertent
strength (r = 0.80), wrist extension ROM (r = 0.78), pronation markers for diminished ROM values may have affected the
(r = 0.70), supination (r = 0.63), and wrist flexion (r = 0.62). findings.
2066_Ch06_115-142.qxd 5/22/09 7:47 PM Page 142
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adults. Phys Occup Ther Geriatr 22:77, 2003. 59. MacDermid, JC, et al: Patient versus injury factors as predictors of pain
27. Hewitt, D: The range of active motion at the wrist of women. J Bone Joint and disability six months after a distal radius fracture. J Clin Epidemiol
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7
The Hand
Structure and Function Osteokinematics
The MCP joints are biaxial condyloid joints that have 2 degrees
of freedom, allowing flexion–extension in the sagittal plane and
Fingers: Metacarpophalangeal abduction–adduction in the frontal plane. Abduction–adduction
Joints is possible with the MCP joints positioned in extension, but it is
limited with the MCP joints in flexion because of tightening of
Anatomy the collateral ligaments.2 A small amount of passive axial rota-
The metacarpophalangeal (MCP) joints of the fingers are
tion has been reported at the MCP joints,2-4 but this motion is not
composed of the convex distal end of each metacarpal and the
usually measured in the clinical setting.
concave base of each proximal phalanx (Fig. 7.1). The joints
are enclosed in fibrous capsules (Figs. 7.2 and 7.3). The ante- Arthrokinematics
rior portion of each capsule has a fibrocartilaginous thicken- The concave base of the phalanx slides and rolls on the convex
ing called the palmar plate (palmar ligament), which is head of the metacarpal in the same direction as movement of
loosely attached to the metacarpals and firmly attached to the the shaft of the phalanx.5 During flexion the base of the phalanx
proximal phalanx.1,2 Ligamentous support is provided by pal- slides and rolls anteriorly toward the palm, whereas during
mar, collateral, and deep transverse metacarpal ligaments. extension the base of the phalanx slides and rolls dorsally. In
3rd
2nd
4th
Palmar
plates
Distal interphalangeal
joints 5th
Distal
Proximal phalanx Joint
interphalangeal 1st 5th capsules
joints Middle
phalanx
Metacarpophalangeal 5th
joints Proximal
phalanx
5th
Metacarpal
Deep
transverse metacarpal
ligament
Arthrokinematics
The concave joint surface of the first metacarpal slides and
rolls on the convex surface of the trapezium in the same direc-
tion as the metacarpal shaft to produce flexion–extension.5,7
During flexion, the base of the metacarpal slides and rolls in
an ulnar direction. During extension, it slides and rolls in a ra-
dial direction.
To produce abduction–adduction the convex joint surface
of the first metacarpal slides on the concave portion of the
trapezium in the opposite direction to the shaft of the metacarpal
but rolls in the same direction as the shaft of the metacarpal. 5,7
Therefore, the base of the metacarpal slides toward the dorsal
surface of the hand and rolls toward the palmar surface of the
hand during abduction. The base of the first metacarpal slides
toward the palmar surface of the hand and rolls toward the dor-
FIGURE 7.5 The saddle-shaped joint surface of the trapezium sal surface of the hand during adduction.
at the first carpometacarpal (CMC) joint is convex in the frontal
plane (flexion–extension) and concave in the sagittal plane Capsular Pattern
(abduction–adduction). The base of the metacarpal of the The capsular pattern is a limitation of abduction according to
thumb has a shape that is reciprocal to that of the trapezium. Cyriax and Cyriax.6 Kaltenborn7 reports limitations in abduc-
Reproduced with permission from Levangie, PL, and Norkin, tion and extension.
CC: Joint Structure and Function: A Comprehensive Analysis,
ed 4. FA Davis, Philadelphia, 2005.
Thumb: Metacarpophalangeal
Joint
some axial rotation. This rotation allows the thumb to move
Anatomy
into position for contact with the fingers during opposition.
The metacarpophalangeal (MCP) joint of the thumb is the artic-
The sequence of motions that combines with rotation and
ulation between the convex head of the first metacarpal and the
results in opposition is as follows: abduction, flexion, medial
concave base of the first proximal phalanx (see Fig. 7.4). The
axial rotation, and adduction.1,5 Reposition returns the thumb
joint is reinforced by a joint capsule, palmar plate, two sesamoid
to the starting position.
bones on the palmar surface, two intersesamoid ligaments (cru-
ciate ligaments), and two collateral ligaments (see Fig. 7.6).1
Osteokinematics
Collateral
The MCP joint is a condyloid joint with 2 degrees of free-
ligaments dom.1,8 The motions permitted are flexion–extension and a
minimal amount of abduction–adduction. Motions at this
Capsule
joint are more restricted than at the MCP joints of the fingers.
Palmar plate
Arthrokinematics
Cruciate At the MCP joint the concave base of the proximal phalanx
ligaments slides and rolls on the convex head of the first metacarpal in
Sesamoid
bones Capsule the same direction as the shaft of the phalanx.5,7 The base of
Collateral
the proximal phalanx moves toward the palmar surface of the
Palmar plate ligaments thumb in flexion and toward the dorsal surface of the thumb
in extension.
Capsular Pattern
The capsular pattern for the MCP joint is a restriction of
motion in all directions, but flexion is more limited than
extension.6,7
Capsule
capsule, a palmar plate, and two lateral collateral ligaments same direction as the shaft of the phalanx.5,7 The base of the
(see Fig. 7.6). distal phalanx moves toward the palmar surface of the thumb
in flexion and toward the dorsal surface of the thumb in
Osteokinematics
extension.
The IP joint is a synovial hinge joint with 1 degree of free-
dom: flexion–extension.
Capsular Pattern
Arthrokinematics The capsular pattern is an equal restriction in both flexion and
At the IP joint the concave base of the distal phalanx slides extension according to Cyriax.6 Kaltenborn7 notes that all
and rolls on the convex head of the proximal phalanx, in the motions are restricted with more limitation in flexion.
2066_Ch07_143-194.qxd 5/22/09 7:55 PM Page 147
5th Distal
phalanx
5th Middle
phalanx
5th Proximal
phalanx
5th Metacarpal
FIGURE 7.9 During flexion of the metacarpophalangeal (MCP) joint, the examiner uses one hand to
stabilize the subject’s metacarpal and to maintain the wrist in a neutral position. The index finger and
the thumb of the examiner’s other hand grasp the subject’s proximal phalanx to move it into flexion.
2066_Ch07_143-194.qxd 5/22/09 7:55 PM Page 149
FIGURE 7.11 At the end of metacarpophalangeal (MCP) flexion range of motion, the examiner uses
one hand to hold the proximal goniometer arm in alignment and to stabilize the subject’s metacarpal.
The examiner’s other hand maintains the proximal phalanx in MCP flexion and aligns the distal
goniometer arm. Note that the goniometer arms make direct contact with the dorsal surfaces of the
metacarpal and proximal phalanx, causing the fulcrum of the goniometer to lie somewhat distal and
dorsal to the MCP joint.
2066_Ch07_143-194.qxd 5/22/09 7:55 PM Page 150
FINGERS: Stabilization
METACARPOPHALANGEAL Stabilize the metacarpal to prevent wrist motion. Do
not hold the MCP joints of the other fingers in full
EXTENSION flexion because tension in the transverse metacarpal
Motion occurs in the sagittal plane around a medial- ligament will restrict the motion.
lateral axis. Normal ROM values for adults are
20 degrees according to the AMA11 and 45 degrees Testing Motion
according to the AAOS.10 Passive MCP extension Extend the MCP joint by pushing on the palmar
ROM is greater than active extension. Mallon, Brown, surface of the proximal phalanx, moving the
and Nunley13 report that extension ROM at the MCP finger away from the palm (Fig. 7.12). Maintain the
joints is equal across all fingers, whereas Skvarilova MCP joint in a neutral position relative to abduction
and Plevkova14 and Smahel and Klimova15 note that and adduction. The end of extension ROM occurs
the little finger has the greatest amount of MCP ex- when resistance to further motion is felt and
tension. See Research Findings and Tables 7.1 and attempts to overcome resistance cause the wrist
7.2 for additional normal ROM values. to extend.
Testing Position Normal End-Feel
Position the subject sitting, with the forearm and hand
The end-feel is firm because of tension in the palmar
resting on a supporting surface. Place the forearm
joint capsule and in the palmar plate.
midway between pronation and supination; the wrist
in 0 degrees of flexion, extension, and radial and
ulnar deviation; and the MCP joint in a neutral posi-
Goniometer Alignment
See Figures 7.13 and 7.14 for alignment of the
tion relative to abduction and adduction. Avoid exten-
goniometer over the dorsal aspect of the fingers.
sion or extreme flexion of the PIP and DIP joints of
the finger being tested. (If the PIP and DIP joints are 1. Center fulcrum of the goniometer over the dorsal
positioned in extension, tension in the flexor digito- aspect of the MCP joint.
rum superficialis and profundus muscles may restrict 2. Align proximal arm over the dorsal midline of the
the motion. If the PIP and DIP joints are positioned in metacarpal.
full flexion, tension in the lumbricalis and interossei 3. Align distal arm over the dorsal midline of the
muscles will restrict the motion.) proximal phalanx.
FIGURE 7.12 During metacarpophalangeal (MCP) extension, the examiner uses her index
finger and thumb to grasp the subject’s proximal phalanx and to move the phalanx dorsally.
The examiner’s other hand maintains the subject’s wrist in the neutral position, stabilizing the
metacarpal.
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FIGURE 7.14 The alignment of the goniometer at the end of metacarpophalangeal (MCP)
extension. The body of the goniometer is aligned over the dorsal aspect of the MCP joint,
whereas the goniometer arms are aligned over the dorsal aspect of the metacarpal and
proximal phalanx.
2066_Ch07_143-194.qxd 5/22/09 7:55 PM Page 152
Alternative Goniometer Alignment: 1. Center fulcrum of the goniometer over the palmar
Palmar Aspect aspect of the MCP joint.
See Figure 7.15 for alignment of the goniometer over 2. Align proximal arm over the palmar midline of the
the palmar aspect of the finger. This alignment should metacarpal.
not be used if swelling or hypertrophy is present in 3. Align distal arm over the palmar midline of the
the palm of the hand. proximal phalanx.
FIGURE 7.15 An alternative alignment of a finger goniometer over the palmar aspect of the
proximal phalanx, the metacarpophalangeal joint, and the metacarpal. The shorter
goniometer arm must be used over the palmar aspect of the proximal phalanx so that the
proximal interphalangeal and distal interphalangeal joints are allowed to relax in flexion.
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Testing Motion
Abduct the MCP joint by pushing on the medial sur-
face of the proximal phalanx, moving the finger away
FIGURE 7.16 During metacarpophalangeal (MCP) abduction, the examiner uses the index finger of
one hand to press against the subject’s metacarpal and prevent radial deviation at the wrist. With
the other index finger and thumb holding the distal end of the proximal phalanx, the examiner
moves the subject’s second MCP joint into abduction.
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FIGURE 7.17 The alignment of the goniometer at the beginning of metacarpophalangeal abduction
range of motion.
FIGURE 7.18 At the end of metacarpophalangeal (MCP) abduction, the examiner aligns the arms of
the goniometer with the dorsal midline of the metacarpal and proximal phalanx rather than with the
contour of the hand and finger.
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FIGURE 7.19 During proximal interphalangeal (PIP) flexion, the examiner stabilizes the subject’s
proximal phalanx with her thumb and index finger. The examiner uses her other thumb and index
finger to move the subject’s PIP joint into full flexion.
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FIGURE 7.20 The alignment of the goniometer at the beginning of proximal interphalangeal (PIP)
flexion range of motion.
FIGURE 7.21 At the end of proximal interphalangeal (PIP) flexion, the examiner continues to stabilize
and align the proximal goniometer arm over the dorsal midline of the proximal phalange with one
hand. The examiner’s other hand maintains the PIP joint in flexion and aligns the distal goniometer arm
with the dorsal midline of the middle phalanx.
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FIGURE 7.22 During distal interphalangeal (DIP) flexion, the examiner uses one hand to stabilize the
middle phalanx and keep the proximal interphalangeal joint in 70 to 90 degrees of flexion. The
examiner’s other hand pushes on the distal phalanx to flex the DIP joint.
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FIGURE 7.24 The alignment of the goniometer at the end of distal interphalangeal (DIP) flexion
range of motion. Note that the fulcrum of the goniometer lies distal and dorsal to the proximal
interphalangeal joint axis so that the arms of the goniometer stay in direct contact with the dorsal
surfaces of the middle and distal phalanges.
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FIGURE 7.25 Distal interphalangeal flexion range of motion also can be measured by using a finger
goniometer that is placed on the dorsal surface of the middle and distal phalanges. This type of
goniometer is appropriate for measuring the small joints of the fingers, thumb, and toes.
FIGURE 7.26 Composite finger flexion (CFF) is determined by measuring the distance between
the distal palmar crease and the tip of the finger at the end of flexion of the MCP, PIP, and
DIP joints. Normally, the tip of the finger is able to touch the palm at the distal palmar crease.
This subject has limited range of motion.
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Tip
Pulp
Proximal Proximal
digital palmar
crease crease
Distal
palmar
crease Distal
digital
crease
Distal Proximal
wrist digital crease
crease
FIGURE 7.27 A, B Anterior (palmar) view of the right hand showing the digital and palmar creases used for measuring
composite finger flexion and CMC opposition of the thumb.
1st
Distal
phalanx
1st
Proximal
phalanx
1st
Metacarpal
Pisiform Trapezium
Scaphoid
Radial styloid
process
FIGURE 7.28 Anterior (palmar) view of the right hand FIGURE 7.29 Anterior (palmar) view of the right hand show-
showing surface anatomy landmarks for goniometer align- ing bony anatomical landmarks for goniometer alignment
ment during the measurement of thumb range of motion. during the measurement of thumb range of motion.
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2nd
MCP
joint
2nd
Metacarpal
1st
Distal
phalanx
1st Proximal
phalanx
1st MCP joint
1st Metacarpal
Trapezium
Scaphoid
Radial styloid
process
FIGURE 7.32 During carpometacarpal (CMC) flexion, the examiner uses the index finger and thumb
of one hand to stabilize the carpals, radius, and ulna to prevent ulnar deviation of the wrist. The
examiner’s other index finger and thumb flex the CMC joint by moving the first metacarpal medially.
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FIGURE 7.34 At the end of carpometacarpal (CMC) flexion range of motion, the examiner uses the
hand that was stabilizing the wrist to align the proximal arm of the goniometer with the radius. The
examiner’s other hand maintains CMC flexion and aligns the distal arm of the goniometer with the first
metacarpal. During the measurement, the examiner must be careful not to move the subject’s wrist
further into ulnar deviation or the goniometer reading will be incorrect (too high).
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FIGURE 7.37 During carpometacarpal (CMC) extension of the thumb, the examiner uses one hand
to stabilize the carpals, radius, and ulna thereby preventing radial deviation of the subject’s wrist.
The examiner’s other hand is used to pull the first metacarpal laterally into extension.
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FIGURE 7.42 During carpometacarpal (CMC) abduction, the examiner uses one hand to stabilize the
subject’s second metacarpal. Her other hand grasps the subject’s first metacarpal just proximal to the
metacarpophalangeal joint to move it away from the palm and into abduction.
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FIGURE 7.43 At the beginning of carpometacarpal (CMC) abduction range of motion, the
distal end of the subject’s first metacarpal of the thumb lies over the second metacarpal of
the index finger.
FIGURE 7.44 The alignment of the goniometer at the end of carpometacarpal (CMC) abduction
range of motion.
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FIGURE 7.46 At the end of the range of opposition the tip of the subject’s thumb is normally
in contact with the base of the little finger. The thumb has moved through carpometacarpal
(CMC) abduction, flexion, medial rotation, and adduction, while the metacarpophalangeal
(MCP) joint is allowed to flex.
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Normal End-Feel digital crease of the little finger at the end of oppo-
The end-feel may be soft because of contact between sition (Fig. 7.47).10,18
the muscle bulk of the thenar eminence and the palm Alternately, the shortest distance between the
or between the tip of the thumb with the base of the center of the proximal digital crease of the thumb
little finger. In some individuals it may be firm because and the distal palmar crease directly over the fifth
of tension in the CMC joint capsule, fascia, and skin of MCP joint can be measured (Fig. 7.48). In this
the web space between the thumb and the index fin- manner, motion at the MCP and IP joints of the
ger and tension in the adductor pollicis, first dorsal thumb will not affect the measurement of opposition.
interossei, extensor pollicis brevis, and extensor polli- The AMA Guides to the Evaluation of Permanent
cis longus muscles. Impairment11 recommends measuring the longest dis-
tance from the flexion crease of the thumb IP joint
Measurement Method to the distal palmar crease directly over the third
The goniometer is not commonly used to measure the MCP joint (Fig. 7.49). However, this measurement
angular range of opposition. Instead, a ruler is often method seems more consistent with the measurement
used to measure the shortest distance between the of CMC abduction. A distance of less than 8 cm is
tip of the thumb and the center of the proximal considered impaired.11
FIGURE 7.47 The range of motion (ROM) in opposition can be determined by measuring the
shortest distance between the tip of the thumb and the proximal digital crease of the little
finger. The examiner is using the arm of a goniometer to measure, but any ruler would
suffice. This subject’s hand does not have full ROM in opposition.
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FIGURE 7.50 During metacarpophalangeal (MCP) flexion of the thumb, the examiner uses the index
finger and thumb of one hand to stabilize the subject’s first metacarpal and maintain the wrist in a
neutral position. The examiner’s other index finger and thumb grasp the subject’s proximal phalanx
to move it into flexion.
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FIGURE 7.52 At the end of metacarpophalangeal (MCP) flexion, the examiner uses one hand to
stabilize the subject’s first metacarpal and align the proximal arm of the goniometer. The examiner
uses her other hand to maintain the proximal phalanx in flexion and align the distal arm of the
goniometer.
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Stabilization
Stabilize the first metacarpal to prevent motion at the
wrist and at the CMC joint of the thumb.
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THUMB: INTERPHALANGEAL
FIGURE 7.53 During interphalangeal (IP) flexion of the thumb, the examiner uses one hand to stabilize
the proximal phalanx and keep the metacarpophalangeal joint in 0 degrees of flexion and the
carpometacarpal joint in 0 degrees of flexion, abduction, and opposition. The examiner uses her
other index finger and thumb to flex the distal phalanx.
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Goniometer Alignment 3. Align distal arm with the dorsal midline of the dis-
See Figures 7.54 and 7.55. tal phalanx.
1. Center fulcrum of the goniometer over the dorsal
surface of the IP joint.
2. Align proximal arm with the dorsal midline of the
proximal phalanx.
FIGURE 7.54 The alignment of the goniometer at the beginning of interphalangeal (IP) flexion range
of motion. The arms of the goniometer are placed on the dorsal surfaces of the proximal and distal
phalanges. However, the arms of the goniometer could instead be placed on the lateral surfaces of
the proximal and distal phalanges if the nail protruded or if there was a bony prominence or swelling.
FIGURE 7.55 The alignment of the goniometer at the end of interphalangeal (IP) flexion range of
motion. The examiner holds the arms of the goniometer so that they maintain close contact with the
dorsal surfaces of the proximal and distal phalanges.
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THUMB: INTERPHALANGEAL
MUSCLE LENGTH TESTING PROCEDURES: of the extensor digitorum profundus of the same fin-
ger (Fig. 7.57). The second and third palmar interossei
Fingers muscles originate proximally from the radial sides of
the metacarpal of the ring and little fingers, respec-
LUMBRICALS, PALMAR tively, and insert distally into the ulnar side of the
INTEROSSEI, AND DORSAL proximal phalanx and the extensor mechanism of the
extensor digitorum profundus of the same fingers.
INTEROSSEI The four dorsal interossei are bipenniform mus-
The lumbrical, palmar interossei, and dorsal interossei
cles that originate proximally from two adjacent
muscles cross the MCP, PIP, and DIP joints. The first
metacarpals (Fig. 7.58): the first dorsal interossei
and second lumbricals originate proximally from the
from the metacarpals of the thumb and index finger,
radial sides of the tendons of the flexor digitorum
the second from the metacarpals of the index and
profundus of the index and middle fingers, respec-
middle fingers, the third from the metacarpals of the
tively (Fig. 7.56). The third lumbrical originates on the
middle and ring fingers, and the fourth from the
ulnar side of the tendon of the flexor digitorum pro-
metacarpals of the ring and little fingers. The
fundus of the middle finger and the radial side of the
dorsal interossei insert distally into the bases of the
tendon of the ring finger. The fourth lumbrical origi-
proximal phalanges and the extensor mechanism
nates on the ulnar side of the tendon of the flexor
of the extensor digitorum profundus of the same
digitorum profundus of the ring finger and the radial
fingers.
side of the tendon of the little finger. Each lumbrical
When these muscles contract, they flex the MCP
passes to the radial side of the corresponding finger
joints and extend the PIP and DIP joints. These muscles
and inserts distally into the extensor mechanism of
are passively lengthened by placing the MCP joints in
the extensor digitorum profundus.
extension and the PIP and DIP joints in full flexion. If
The first palmar interossei muscle originates
the lumbricals and the palmar and dorsal interossei are
proximally from the ulnar side of the metacarpal of
short, they will limit MCP extension when the PIP and
the index finger and inserts distally into the ulnar side
DIP joints are positioned in full flexion.
of the proximal phalanx and the extensor mechanism
1st
3rd Lumbrical Lumbrical
2nd Palmar
2nd interossei
Lumbrical
4th Lumbrical
3rd Palmar
interossei
Flexor digitorum
profundus
Starting Position
Position the subject sitting, with the forearm and hand
resting on a supporting surface. Place the forearm
4th Dorsal midway between pronation and supination and the
interossei wrist in 0 degrees of flexion, extension, and radial and
2nd Dorsal
ulnar deviation. Flex the MCP, PIP, and DIP joints
interossei 3rd Dorsal (Fig. 7.59). The MCP joints should be in a neutral po-
interossei
sition relative to abduction and adduction.
Abductor
digiti Stabilization
minimi Stabilize the metacarpals and the carpal bones to
1st Dorsal prevent wrist motion.
interossei
Extensor digiti
minimi
Extensor indicis
Extensor
digitorum
FIGURE 7.59 The starting position for testing the length of the lumbricals and the palmar and dorsal
interossei. The examiner uses one hand to stabilize the subject’s wrist and the other hand to
position the subject’s metacarpophalangeal, proximal interphalangeal, and distal interphalangeal
joints in full flexion.
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Normal End-Feel
The end-feel is firm because of tension in the lumbri-
cal, palmar, and dorsal interossei muscles.
FIGURE 7.60 The end of the motion for testing the length of the lumbricals and the palmar and
dorsal interossei. The examiner holds the subject’s proximal interphalangeal and distal interphalangeal
joints in full flexion while moving the metacarpophalangeal joint into extension.
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Extensor digitorum
1st Dorsal interossei
FIGURE 7.61 A lateral view of the right hand showing the first
lumbrical and the first dorsal interossei muscles being stretched
over the metacarpophalangeal, proximal interphalangeal, and
distal interphalangeal joints.
FIGURE 7.62 The alignment of the goniometer at the end of testing the length of the lumbricals and
the palmar and dorsal interossei muscles. The arms of the goniometer are placed on the dorsal
midline of the metacarpal and proximal phalanx of the finger being tested.
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Research Findings Only the MCP joints of the fingers have a considerable
amount of abduction–adduction. The amount of abduction–
adduction varies with the position of the MCP joint. Abduc-
Effects of Age, Gender, tion–adduction ROM is greatest in extension and least in full
and Other Factors flexion. The collateral ligaments of the MCP joints are slack
and allow full abduction in extension. However, the collateral
Table 7.1 provides a summary of ROM values for the MCP, ligaments tighten and restrict abduction in the fully flexed
PIP, and DIP joints of the fingers. Certain trends are evident, position.1,3 Some authors note that the index and little fingers
although the values reported by the sources in Table 7.1 vary. have a greater ROM in abduction–adduction than the middle
The PIP joints, followed by the MCP and DIP joints, have the and ring fingers,1 whereas others report that the little finger
greatest amount of flexion. The MCP joints have the greatest has the greatest MCP abduction.16
amount of extension, whereas the PIP joints have the least Table 7.3 presents ROM values for the joints of the
amount of extension. Total active motion (TAM) is the sum of thumb. The greatest amount of flexion and extension ROM is
flexion and extension ROM of the MCP, PIP, and DIP joints reported at the IP joint.10,11,14,18,22,23,25 Studies by Joseph26 and
of a digit. Normal TAM values range from 290 to 310 degrees Yoshida and coworkers25 have identified two general anatom-
for the fingers. ical shapes of the metacarpal head of the thumb. MCP joints
Mallon, Brown, and Nunley13; Skvarilova and Plevkova14; with a round versus a flat metacarpal head had greater motion
and Smahel and Klimova15,24 also studied joint motion in and may account for some of the variations seen in MCP val-
individual fingers (Table 7.2). Some differences in ROM values ues. Sauseng and coworkers27 and Shaw and Morris28 also
are noted between the fingers. Flexion ROM at the MCP joints present some normative data on MCP and IP flexion of the
seems to increase linearly in an ulnar direction from the index thumb. Very little data are available for normal values of
finger to the little finger.13–15 Mallon, Brown, and Nunley13 motions at the CMC joint.
report that extension at the MCP joints is approximately equal
for all fingers. However, Skvarilova and Plevkova14 and Smahel Age
and Klimova15 note that the little finger has the greatest amount Goniometric studies focusing on the effects of age on ROM typ-
of MCP extension. PIP flexion and extension and DIP flexion ically exclude the joints of the fingers and thumb. However,
are generally equal for all fingers.13 Some passive extension among the limited number of studies that examined aging
beyond neutral is possible at the DIP joints, with a minor effects in the hand there appears to be less finger and thumb
increase in a radial direction from the little finger toward the ROM with increasing age. DeSmet and colleagues22 found a sig-
index finger.13 nificant correlation between decreasing MCP and IP flexion of
TABLE 7.1 Active Finger Motion: Normal Values in Degrees from Selected Sources
AAOS = American Association of Orthopaedic Surgeons; AMA = American Medical Association; DIP = distal interphalangeal;
MCP = metacarpophalangeal; PIP = proximal interphalangeal; SD = standard deviation.
* Values were averaged from both genders and all fingers.
†
Values were averaged from both genders, both hands, and all fingers and were converted from a 360-degree to a 180-degree recording
system.
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TABLE 7.2 Individual Finger Motion: Mean Values in Degrees From Selected Sources
the thumb and increasing age. The 58 females and 43 males who of the thumb (with wrist flexion) to the anterior aspect of the
were included in the study ranged in age from 16 to 83 years. forearm and passive hyperextension of the MCP joint of the
Smahel and Klimova,15,24 in studies of 101 university students, fifth finger beyond 90 degrees as indicators of hypermobility
60 senior citizens, and 52 pianists, found that the senior citizens in a study of 456 men and 625 women in an African village.
had significantly less MCP, PIP, and DIP ranges of motion in the They found that joint laxity decreased with age. Lamari and
fingers than the university students, except for total abduction coworkers,30 in a study that included similar measures of
(ability to spread fingers) of the MCP joints in females. The hypermobility in the thumb/wrist and little finger of 1120
mean age differences were 6.3 degrees for active MCP flexion, healthy Brazilian children between the ages of 4 to 7 years,
6.1 degrees for active MCP extension, 20.4 degrees for passive found that lower hypermobility scores were associated with
MCP extension, 9.1 degrees for active PIP flexion, and increasing age, even within this limited age range. Overall, 76
9.5 degrees for active DIP flexion. The age differences in ROM percent of the children were able to apposition the thumb to
were generally greater in males than in females. the forearm and 53 percent were able to hyperextend the MCP
Measures of hypermobility that include motions of the joint of the little finger beyond 90 degrees. Significant age dif-
thumb and little finger have shown a decrease with age. ferences were present in both genders for thumb apposition
Beighton, Solomon, and Soskolne29 used passive apposition but only in boys for little finger hyperextension.
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TABLE 7.3 Thumb Motion: Mean Values in Degrees from Selected Sources
CMC Abduction 70
Flexion 15
Extension 20, 80 35†
MCP Flexion 50 60 59 (11) 54.0 (13.7) 77 57.0 (10.7) 67.0 (9.0)
Extension 0 40 35 13.7 (10.5) 22.6 (10.9)
IP Flexion 80 80 67 (11) 79.8 (10.2) 81 79.1 (8.7) 85.8 (8.3)
Extension 20 30 33 23.2 (13.3) 34.7 (13.3)
One study by Allander and associates31 found that active two general shapes of MCP joints, round and flat, with the
flexion and passive extension of the MCP joint of the thumb round MCP joints having greater range of flexion. Shaw and
demonstrated no consistent pattern of age-related effects in a Morris28 noted no differences in MCP and IP flexion ROM
study of 517 women and 208 men (between 33 and 70 years between 199 males and 149 females aged 16 to 86 years.
of age). These authors stated that the typical reduction in mo- Likewise, DeSmet and colleagues,22 as well as Jenkins and
bility with age resulting from degenerative arthritis found in associates,23 found no differences in MCP and IP flexion of
other joints may be exceeded by an accumulation of ligamen- the thumb owing to gender.
tous ruptures that reduce the stability of the first MCP joint. Allander and associates31 found that, in some age groups,
females showed more mobility in the MCP joint of the thumb
Gender
than their male counterparts. Skvarilova and Plevkova14 noted
Studies that examined the effect of gender on the ROM of the
that MCP flexion and extension of the thumb were greater in
fingers reported varying results. Mallon, Brown, and Nunley13
females, whereas gender differences were small and unimpor-
found no significant effect of gender on the amount of flexion
tant at the IP joint. Yoshida and associates,25 in a study of
in any joints of the fingers. However, in this study women
51 healthy men, 49 healthy women, and 70 cadavers, identi-
generally had more extension at all joints of the fingers than
fied two general shapes of the metacarpal head: round and
men. Skvarilova and Plevkova14 found that PIP flexion, DIP
flat. The female gender was associated with greater MCP joint
flexion, and MCP extension of the fingers were greater in
ROM and a higher prevalence of a round metacarpal head. No
women than in men, whereas MCP flexion of the fingers was
gender differences were noted in ROM at the IP joint.
greater in men. Smahel and Klimova15 reported that MCP
Beighton, Solomon, and Soskolne29 in a study of 456 men and
extension was significantly greater in women versus men in
625 women of an African village; Fairbank, Pynsett, and
both groups of young and older adults, whereas no gender dif-
Phillips32 in a study of 227 male and 219 female adolescents;
ferences were noted in MCP flexion. In a study of PIP and
and Lamari and coworkers30 in a study of 1120 young Brazil-
DIP joint ROM of the fingers, Smahel and Klimova24 found
ian children measured passive apposition of the thumb toward
that women had greater PIP flexion than men, but they did not
the anterior surface of the forearm and hyperextension of the
differ in DIP flexion (see Table 7.2).
MCP joints of the fifth or middle fingers. All three studies
Several studies have found no significant differences be-
reported an increase in laxity in females as compared with
tween males and females in the ROM of the thumb, whereas
males.
other studies have reported more mobility in females.
Joseph26 used radiographs to examine MCP and IP flexion Right Versus Left Sides
ROM of the thumb in 90 males and 54 females; no significant The studies that have compared ROM in the right and left joints
differences were found between the two groups. He found of the fingers have generally found no significant difference
2066_Ch07_143-194.qxd 5/22/09 7:56 PM Page 189
between sides or only a small increase in motion on the left results of Mallon, Brown, and Nunley’s study13 suggest that
side. Mallon, Brown, and Nunley,13 in a study in which half of this finding is normal. The MCP joint had about 6 degrees
the 120 subjects were right-handed and the other half left- more flexion when the wrist was extended than when the wrist
handed, noted no difference between sides in finger motions was flexed, although this difference was not statistically signifi-
at the MCP, PIP, and DIP joints. Skvarilova and Plevkova14 cant. The extensor digitorum, extensor indicis, and extensor dig-
reported only small right-left differences in the majority of the iti minimi were more slack to allow greater flexion of the MCP
joints of the fingers and thumb in 200 subjects. Only MCP joint when the wrist was extended than when flexed. There was
extension of the fingers and thumb and IP flexion of the thumb no effect on PIP motion with changes in MCP joint position.
seemed to have greater ROM values on the left. Smahel and Knutson and associates34 examined eight subjects to study
Klimova,15,24 in studies of 101 university students, 60 senior cit- the effect of seven wrist positions on the torque required to
izens, and 52 pianists, found that in all three groups MCP joint passively move the MCP joint of the index finger. The findings
ROM of the fingers was greater in the left hand. However, in indicated that in many wrist positions, extrinsic tissues (those
most instances, ROM differences between the left and right that cross more than one joint) such as the extensor digitorum,
hands were not significant for PIP and DIP joints of the fingers. extensor indicis, flexor digitorum superficialis, and flexor dig-
Similar to findings in studies of the fingers, most studies itorum profundus muscles offered greater restraint to MCP
have reported no difference in ROM between the right and left flexion and extension than intrinsic tissues (those that cross
thumbs. Joseph26 and Shaw and Morris,28 in a study of 144 only one joint). Intrinsic tissues offered greater resistance to
and 248 subjects, respectively, found no significant difference passive moment at the MCP joint when the wrist was flexed or
between sides in MCP and IP flexion ROM of the thumb. extended enough to slacken the extrinsic tissues.
DeSmet and colleagues22 examined 101 healthy subjects and
reported no difference between sides for the MCP and IP Functional Range of Motion
joints of the thumb. No difference between sides in IP flexion
Joint motion, muscular strength and control, sensation, ade-
of the thumb was found by Jenkins and associates23 in a study
quate finger length, and sufficient palm width and depth are
of 119 subjects. A statistically significant greater amount of
necessary for a hand that is capable of performing functional,
MCP flexion was reported for the right thumb than for the
occupational, and recreational activities. Numerous classifica-
left; however, this difference was only 2 degrees. Allander and
tion systems and terms for describing functional hand patterns
associates31 also found no differences attributed to side in
have been proposed.23,35–38 Some common patterns include
MCP motions of the thumb in 720 subjects.
(1) finger-thumb prehension such as tip (Fig. 7.63), pulp, lat-
Testing Position eral, and three-point pinch (Fig. 7.64); (2) full-hand prehen-
Mallon, Brown, and Nunley,13 in addition to establishing nor- sion, also called a power grip or cylindrical grip (Fig. 7.65);
mative ROM values for the fingers, also studied passive joint (3) nonprehension, which requires parts of the hand to be used
ROM while positioning the next most proximal joint in max- as an extension of the upper extremity; and (4) bilateral pre-
imal flexion and extension. The DIP joint had significantly hension, which requires use of the palmar surfaces of both
more flexion (18 degrees) when the PIP joint was flexed than hands.36 Texts by Stanley and Tribuzi,39 Mackin and associ-
when the PIP joint was extended. This finding has been cited ates,40 and the American Society of Hand Therapists19 have
as an indication of abnormal tightness of the oblique reviewed many functional patterns and tests for the hand.
retinacular ligament (Landsmeer’s ligament).33 However, the Table 7.4 summarizes the active ROM of the dominant
fingers and thumb during 11 activities of daily living that
ranging from 0.98 to 0.99. Mean differences between sessions The distance between the fingertip pulp and distal palmar
for each instrument were statistically significant but less than crease has been suggested as a simple and quick method of
1 degree. Measurements taken by the finger goniometer and estimating total finger flexion ROM at the MCP, PIP, and DIP
those taken by the Exos Handmaster were significantly differ- joints.18,19 Ellis and Bruton17 examined the intratester and
ent (mean difference 7 degrees) but highly correlated intertester reliability of composite finger flexion (CFF) and
(r 0.89 to 0.94). compared it to dorsal goniometric measures of PIP flexion of
Ellis, Bruton, and Goddard47 placed one subject in two the index, middle, and ring fingers. One hand was splinted in
splints while a total of 40 therapists measured the MCP, PIP, three positions and measured three times by 51 therapists at
and DIP joints of the middle finger by means of a dorsal fin- 18 hospital sites with a ruler and goniometer. Intratester gonio-
ger goniometer and a wire tracing. Each therapist measured metric measurements fell within 4 to 5 degrees of each other
each joint three times with each device. The goniometer con- 95 percent of the time, whereas intertester goniometric mea-
sistently produced smaller ranges and smaller standard devia- surements fell within 7 to 9 degrees of each other 95 percent of
tions than the wire tracing, indicating better reliability for the the time. CFF measures fell within 5 to 6 mm of each other
goniometer. The 95 percent confidence limit for the difference 95 percent of the time for intratester measurements and within
between measurements ranged from 3.8 to 9.9 degrees for the 7 to 9 mm of each other for intertester measurements. After
goniometer and 8.9 to 13.2 degrees for the wire tracing. Both scaling the two methods to allow comparison, the goniometer
methods had more variability when distal joints were mea- provided better reliability than CFF for measurements taken by
sured, possibly because of the shorter levers used to align the the same tester, but both methods were equally reliable for
goniometer or wire. Intratester reliability was always higher measurements taken by different testers. The authors suggested
than intertester reliability. that CFF may be a useful alternative when multiple joint mea-
Brown and colleagues48 evaluated the ROM of the MCP, sures are needed or when goniometry is impractical.
PIP, and DIP joints of two fingers in 30 patients to calculate
total active motion (TAM) by means of the dorsal finger
goniometer and the computerized Dexter Hand Evaluation
Validity
and Treatment System. Three therapists measured each finger Goniometric measurements of the fingers have been compared
three times with each device during one session. Intratester to radiographs, digital photographs, and disability measures in
and intertester reliability were high for both methods, with patient populations. In a study by Groth and coworkers,45
ICCs ranging from 0.97 to 0.99. The mean difference between active ROM of the PIP and DIP joints of the index and mid-
methods ranged from 0.1 degrees to 2.4 degrees. dle fingers of one patient who had sustained a crush injury
Goldsmith and Juzl49 studied the intratester reliability of with multiple fractures was measured by 39 therapists over a
measuring active ROM of the MCP, PIP, and DIP joints of the 3-day period. Measurements were made dorsally and laterally
fingers in 12 healthy subjects and intertester reliability in using either a DeVore metal finger goniometer or a 6-inch
12 patients with hand conditions. A universal goniometer plastic universal goniometer. Prior to the goniometer mea-
adapted for measuring the hand (one short arm) was applied surements, radiographs were taken. In terms of concurrent
over the dorsal surface. The two therapists each took three validity, there were significant differences in measurements
measurements of flexion and extension at each joint in one obtained from radiographs versus those from goniometers
session to assess intratester reliabilty and one measurement of except for laterally measured index finger PIP extension and
flexion and extension at each involved joint in one session to flexion. Differences between radiographic and mean gonio-
assess intertester reliabilty. Both intratester and interester metric measurements ranged from 1 to 2 degrees for laterally
reliability were high with correlation coefficients greater than and dorsally measured index finger PIP motions to 14 degrees
0.99. When agreement was defined as within 3 degrees, the for laterally and dorsally measured middle finger PIP
percent agreement was 93.9 to 94.6 percent for intratester motions. The authors noted that concurrent validity was
reliability and 67.7 percent for interester reliability. When inconclusive because some of these differences may have
agreement was defined as within 5 degrees, the percent agree- been due to variations in the patient instructions for perform-
ment was 99.7 percent to 100 percent for intratester reliabil- ing active motion, patient positioning, and patient fatigue with
ity and 87.1 percent for intertester reliability. multiple active measurements.
Sauseng and coworkers,27 in a study of 50 patients with Kato and coworkers50 compared the accuracy of three
type 1 diabetes mellitus and 44 healthy controls, measured therapists measuring PIP joint angles using three types of uni-
active ROM of the fifth MCP joint, first MCP joint, first IP versal goniometers to lateral x-ray films in 16 fingers fixated
joint, wrist, ankle, and first metatarsal phalangeal joint with with Kirschner wires from four cadavers. Each examiner used
a pocket goniometer. Each motion was measured three a 6-inch plastic goniometer with 6-inch arms, a plastic
times by one tester. The coefficients of variation for the goniometer with a 3.5-inch and a 1-inch arm, and a metal
measurements were between 1.3 percent and 8.2 percent. goniometer with 1.5-inch arms to take measurements on the
The ROM of all tested joints was significantly lower in the lateral and dorsal surfaces of the fingers. Intertester reliability
diabetic versus the control group except for the first IP and was good with Pearson correlation coefficients ranging from
MTP joints. 0.80 to 0.82. The mean angle discrepancies between the
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goniometers and x-rays ranged from 1.2 to 3.3 degrees (SD Field53 studied 100 patients with Colles fractures of the
3.5 to 6.0 degrees) for the lateral method and from 0.5 to wrist for the development of algodystrophy (complex regional
2.9 degrees (SD 3.5 to 6.4 degrees) for the dorsal method. pain syndrome). ROM of the PIP, DIP, and MCP joints of the
There was no difference in angle discrepancies between types fingers was measured at 1, 5, and 9 weeks on the dorsal sur-
of goniometer using the lateral method. However, with two faces with a finger goniometer and summed to generate a
testers using the dorsal method the angle discrepancy was total ROM value for the hand. Pain response to pressure was
greater with the plastic goniometer with 6-inch arms, perhaps assessed with a dolorimeter. Swelling was assessed using a
due to having longer arms than the other two goniometers. water displacement method. Differences between the affected
In a study by Georgeu and associates,51 one therapist and unaffected hands were used in statistical tests. At 9 weeks
measured full active flexion and extension of the MCP, PIP, postfracture, 24 patients were diagnosed with algodystrophy.
and DIP joints of the little or ring finger in 20 patients. A dig- Goniometry ROM measurements at 1 week showed a sensi-
ital camera, aligned with the MCP joint with the hand placed tivity of 96 percent and a specificity of 59 percent in predict-
in a stabilizing device, was integrated with a computer to also ing the development of algodystrophy. The cutoff for a posi-
determine ROM. There was a high correlation between the tive test appeared to be about 70 degrees of ROM loss in the
two methods (r2 0.975). The photograph-computer method affected hand. The combination of dolorimetry and goniome-
averaged 1 degree (95-percent confidence interval 0 to try resulted in a sensitivity of 96 percent and improved speci-
2 degrees, SD 6 degrees) greater than the goniometer ficity to 73 percent.
method but was not significantly different. The 95 percent MacDermid and coworkers54 studied the validity of us-
level of agreement was –11 to 13 degrees. ing fingertip pulp-to-palm distance versus total finger flex-
Goodson and associates52 measured ROM of the wrist, ion (also called composite finger flexion) to predict disabil-
MCP and IP joints of the fingers with goniometers applied to ity as measured by an upper-extremity disability score
the dorsal surface, pinch/grip strength, and pain and disability (Disabilities of the Arm, Shoulder, and Hand, or DASH).
scoring (Cochin Scale) in 10 patients with rheumatoid arthri- Active MCP, PIP, and DIP flexion of the most severely af-
tis, 10 patients with osteoarthritis, and 10 healthy control sub- fected finger was measured in 50 patients by one examiner
jects. ROM and pinch/grip measurements were able to clearly who used a dorsally placed electrogoniometer NK Hand
discriminate between patient groups, which pain and disabil- Assessment System. A micrometer tool was used to measure
ity scales were unable to do. Patients with rheumatoid arthri- pulp-to-palm distance in the same patients. The correlation
tis had the greatest reduction in ROM of the MCP, followed between pulp-to-palm distance and total active flexion was
by wrist and PIP joints. Patients with osteoarthritis had the –0.46 to –0.51, indicating that the measures were related but
greatest reduction in ROM at the DIP followed by the PIP were not interchangeable. The relationship between DASH
joints. In the rheumatoid arthritis group, ROM of the MCP scores and total active flexion was stronger (r 0.45) than the
joints correlated with disability scores (R2 0.31) and time relationship between DASH scores and pulp-to-palm dis-
since initial diagnosis (R2 0.32). Wrist ROM was also tances (r 0.21 to 0.30). The authors suggested that total
related to time since diagnosis (R2 0.37). The authors active motion is a more functional measure than pulp-to-palm
concluded that ROM and pinch/grip strength may more accu- distance and that pulp-to-palm distance “should only be used
rately reflect functional impairment associated with arthritis to monitor individual patient progress and not to compare out-
than pain and disability measures. comes between patients or groups of patients.”
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14. Skvarilova, B, and Plevkova, A: Ranges of joint motion of the adult hand. 41. Lee, JW, and Rim, K: Measurement of finger joint angles and maximum
Acta Chir Plast 38:67, 1996. finger forces during cylinder grip activity. J Biomed Eng 13:152, 1991.
15. Smahel, Z, and Klimova, A: The influence of age and exercise on the 42. Sperling, L, and Jacobson-Sollerman, C: The grip pattern of the healthy
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21. Reese, NB, and Bandy, WD: Joint Range of Motion and Muscle Length using a goniometer for the measurement of finger joints. Br J Hand Ther
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22. DeSmet, L, et al: Metacarpophalangeal and interphalangeal flexion of the 50. Kato, M, et al: The accuracy of goniometric measurements of proximal
thumb: Influence of sex and age, relation to ligamentous injury. Acta interphalangeal joints in fresh cadavers: Comparison between methods of
Orthop Belg 59:357, 1993. measurement, types of goniometers, and fingers. J Hand Ther 20:12,
23. Jenkins, M, et al: Thumb joint motion: What is normal? J Hand Surg (Br) 2007.
23:796, 1998. 51. Georgeu, GA, Mayfield, S, and Logan, AM: Lateral digital photography
24. Smahel, Z, and Klimova, A: The influence of age and exercise on the with computer-aided goniometry versus standard goniometry for record-
mobility of hand joints: 2: Interphalangeal joints of the three-phalangeal ing finger joint angles. J Hand Surg 27B:184, 2002.
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25. Yoshida, R, et al: Motion and morphology of the thumb metacarpopha- tion: Usefulness and reproducibility. Manual Ther 12:144, 2007.
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26. Joseph, J: Further studies of the metacarpophalangeal and interpha- 19:511, 2003.
langeal joints of the thumb. J Anat 85:221, 1951. 54. MacDermid, JC, et al: Validity of pulp-to-palm distance as a measure of
27. Sauseng, S, Kastenbauer, T, and Irsigler, K: Limited joint mobility in finger flexion. J Hand Surg 26B:432, 2001.
selected hand and foot joints in patients with type 1 diabetes mellitus: A
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III
LOWER-EXTREMITY TESTING
ON COMPLETION OF PART III, THE READER WILL BE • Adequate stabilization of the proximal joint
ABLE TO: component
• Use of appropriate testing motion
1. Identify: • Correct determination of the end of the range of
• Appropriate planes and axes for each lower- motion
extremity joint motion • Correct identification of the end-feel
• Structures that limit the end of the range of • Palpation of the appropriate bony landmarks
motion • Accurate alignment of the goniometer and cor-
• Expected normal end-feels rect reading and recording of goniometric
measurements
2. Describe:
• Testing positions used for each lower-extremity 5. Plan goniometric measurements of the hip, knee,
joint motion and muscle length test ankle, and foot that are organized by body
• Goniometer alignment position.
• Capsular pattern of limitation
6. Assess the intratester and intertester reliability of
• Range of motion necessary for selected functional
goniometric measurements of the lower-extremity
activities at each major lower-extremity joint
joints using methods described in Chapter 3.
3. Explain:
7. Perform tests of muscle length at the hip, knee,
• How age, gender, and other variables may affect and ankle, including:
the range of motion
• A clear explanation of the testing procedure
• How sources of error in measurement may affect
• Proper placement of the subject in the starting
testing results
position
4. Perform a goniometric measurement of any • Adequate stabilization
lower-extremity joint, including: • Use of appropriate testing motion
• Correct identification of end-feel
• A clear explanation of the testing procedure
• Accurate alignment of the goniometer and cor-
• Proper positioning of the subject
rect reading and recording
The testing positions, stabilization techniques, testing motions, end-feels, and goniometer alignment for the
joints of the lower extremities are presented in Chapters 8 through 10. The goniometric evaluation should follow
the 12-step sequence that was presented in Exercise 5 in Chapter 2.
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8
The Hip
Structure and Function Osteokinematics
The hip is a synovial ball-and-socket joint with 3 degrees of
freedom. Motions permitted at the joint are flexion–extension in
Iliofemoral Joint the sagittal plane around a medial–lateral axis, abduction–
Anatomy adduction in the frontal plane around an anterior–posterior axis,
The hip joint, or coxa, links the lower extremity with the and medial and lateral rotation in the transverse plane around a
trunk. The proximal joint surface is the acetabulum, which vertical or longitudinal axis.1 The axis of motion goes through
is formed superiorly by the ilium, posteroinferiorly by the the center of the femoral head.
ischium, and anteroinferiorly by the pubis (Fig. 8.1). The Arthrokinematics
concave acetabulum faces laterally, inferiorly, and anteri- In an open kinematic (non–weight-bearing) chain, the convex
orly and is deepened by a fibrocartilaginous acetabular femoral head rolls in the same direction and slides in the
labrum.1 The distal joint surface is the convex head of the opposite direction, to movement of the shaft of the femur. In
femur. The joint is enclosed by a strong, thick capsule, flexion, the femoral head rolls anteriorly and slides posteri-
which is reinforced anteriorly by the iliofemoral and orly and inferiorly on the acetabulum, whereas in extension,
pubofemoral ligaments (Fig. 8.2) and posteriorly by the the femoral head rolls posteriorly and slides anteriorly and
ischiofemoral ligament (Fig. 8.3). superiorly. In medial rotation, the femoral head rolls anteriorly
Ilium
Iliofemoral
Head of femur ligament
Pubis
Pubofemoral
Hip joint ligament
Ischium
FIGURE 8.2 An anterior view of the right hip joint showing
FIGURE 8.1 An anterior view of the right hip joint. the iliofemoral and pubofemoral ligaments.
197
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FIGURE 8.4 A lateral view of the hip showing surface anatomy landmarks for aligning the goniometer
for measuring hip flexion and extension.
Greater trochanter
femur
Lateral epicondyle
femur
FIGURE 8.5 A lateral view of the hip showing bony anatomical landmarks for aligning the goniometer.
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Patella
FIGURE 8.6 An anterior view of the hip showing surface FIGURE 8.7 An anterior view of the pelvis showing the
anatomy landmarks for aligning the goniometer. anatomical landmarks for aligning the goniometer for
measuring abduction and adduction.
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Testing Motion
Flex the hip by lifting the thigh off the table. Allow
the knee to flex passively during the motion to reduce
FIGURE 8.8 The end of hip flexion passive ROM. The placement of the examiner’s hand on the pelvis
allows the examiner to stabilize the pelvis and to detect any pelvic motion.
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FIGURE 8.10 At the end of the left hip flexion ROM, the examiner uses one hand to align the distal
goniometer arm and to maintain the hip in flexion. The examiner’s other hand shifts from the pelvis
to hold the proximal goniometer arm aligned with the lateral midline of the subject’s pelvis.
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Goniometer Alignment
Stabilization See Figures 8.12 and 8.13.
Hold the pelvis with one hand to prevent an anterior
tilt (an assistant could help stabilize the pelvis). Keep 1. Center fulcrum of the goniometer over the lateral
the contralateral extremity flat on the table to provide aspect of the hip joint, using the greater trochanter
additional pelvic stabilization. of the femur for reference.
2. Align proximal arm with the lateral midline of the
Testing Motion pelvis.
Extend the hip by raising the lower extremity from the 3. Align distal arm with the lateral midline of the
table (Fig. 8.11). Maintain the knee in extension femur, using the lateral epicondyle as a reference.
FIGURE 8.11 The subject’s right lower extremity at the end of hip extension ROM. The examiner uses
one hand to support the distal femur and maintain the hip in extension while her other hand grasps
the pelvis at the level of the anterior superior iliac spine. Because the examiner’s hand is on the
subject’s pelvis, the examiner is able to detect pelvic tilting.
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FIGURE 8.13 At the end of hip extension ROM, the examiner uses one hand to hold the proximal
goniometer arm in alignment. The examiner’s other hand supports the subject’s femur and keeps the
distal goniometer arm in alignment.
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FIGURE 8.16 Goniometer alignment at the end of the abduction ROM. The examiner has
determined the end-feel and has moved her right hand from stabilizing the pelvis to hold the
goniometer in correct alignment.
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Normal End-Feel
FIGURE 8.20 The left lower extremity at the end of the ROM
of hip medial rotation. One of the examiner’s hands is
placed on the subject’s distal femur to prevent hip flexion
and abduction. Her other hand pulls the lower leg laterally.
FIGURE 8.21 In the starting position for measuring hip
medial rotation, the fulcrum of the goniometer is placed
over the patella. Both arms of the instrument are together.
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Normal End-Feel
Normal End-Feel
The tensor fascia lata (TFL) arises proximally from the hip passively moves into adduction to accommo-
FIGURE 8.29 The examiner assists the subject into the starting position for testing the length of the
hip flexors. Ordinarily the examiner stands on the same side as the hip being tested to visualize the
hip region and take measurements, but the examiner is standing on the contralateral side for the
photograph.
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FIGURE 8.30 The starting position for testing the length of the hip flexors. Both knees and hips are
flexed so that the low back and pelvis are flat on the examining table.
Rectus
femoris
Iliacus Psoas
FIGURE 8.32 A lateral view of the hip showing the hip flexors at the end of the Thomas test.
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If the thigh does not lie flat on the table, hip measured to test more specifically for the length of
extension is limited and further testing is needed to the hip adductors.
determine the cause (Fig. 8.33). Repeat the starting
portion by flexing the hips and bringing the knee Normal End-Feel
toward the chest. Extend the hip by lowering the When the knee remains flexed at the end of hip
thigh toward the examining table, but this time sup- extension ROM, the end-feel is firm owing to tension
port the knee in extension (Fig. 8.34). When the knee in the rectus femoris. When the knee is extended at
is held in extension, the rectus femoris is slack over the end of hip extension ROM, the end-feel is firm
the knee joint. If the hip extends with the knee held in owing to tension in the anterior joint capsule,
extension so that the thigh is able to lie on the exam- iliofemoral ligament, ischiofemoral ligament, and iliop-
ining table, the rectus femoris can be ascertained as soas muscle. If one or more of the following muscles
being short. If the hip cannot extend with the knee are shortened, they may also contribute to a firm end-
held in extension and the thigh does not lie on the feel: sartorius, tensor fascia lata, pectineus, adductor
examining table, the iliopsoas, anterior joint capsule, longus, and adductor brevis.
iliofemoral ligament, and ischiofemoral ligament may
be short.
Goniometer Alignment
When the hip is extending toward the examining
See Figure 8.35.
table, observe carefully to see if the lower extremity
stays in the sagittal plane. If the hip moves into lateral 1. Center fulcrum of the goniometer over the lateral
rotation and abduction, the sartorius muscle may be aspect of the hip joint, using the greater trochanter
short. If the hip moves into medial rotation and of the femur for reference.
abduction, the tensor fascia lata may be short. The 2. Align proximal arm with the lateral midline of the
Ober test can be used specifically to check the length pelvis.
of the tensor fasciae latae. If the hip moves into ad- 3. Align distal arm with the lateral midline of the
duction, the pectineus, adductor longus, and adduc- femur, using the lateral epicondyle for reference.
tor brevis may be short. Hip abduction ROM can be
FIGURE 8.33 This subject has restricted hip extension. Her thigh is unable to lie on the table with the
knee flexed to 80 degrees. Further testing is needed to determine which structures are short.
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FIGURE 8.35 Goniometer alignment for measuring the length of the hip flexors.
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THE HAMSTRINGS: septum (Fig. 8.36A). The biceps femoris inserts onto
the head of the fibula with a small portion extending
SEMITENDINOSUS, to the lateral condyle of the tibia and the lateral
SEMIMEMBRANOSUS, AND collateral ligament.
BICEPS FEMORIS: STRAIGHT The hamstring muscles cross the hip and knee
joints, and if the hamstrings are short, they can limit
LEG RAISING TEST both hip flexion and knee extension. Hip flexion is
The hamstring muscles, composed of the semitendi-
limited when the hamstrings are short and the knee is
nosus, semimembranosus, and biceps femoris, cross
held in full extension. However, if hip flexion is limited
two joints—the hip and the knee. When they contract,
when the knee is flexed, abnormalities of the joint sur-
they extend the hip and flex the knee. The semitendi-
faces, shortness of the posterior joint capsule, or a
nosus originates proximally from the ischial tuberosity
short gluteus maximus may be present.
and inserts distally on the proximal aspect of the
Hamstring length can be measured using either
medial surface of the tibia (Fig. 8.36A). The semi-
the straight leg raising (SLR) method, wherein the an-
membranosus originates from the ischial tuberosity
gle between the pelvis and the thigh is measured, or
and inserts on the posterior medial aspect of the
by the distal hamstring length method, wherein the
medial condyle of the tibia (Fig. 8.36B). The long
angle between the thigh and the lower leg is mea-
head of the biceps femoris originates from the ischial
sured. The SLR test is presented in the following sec-
tuberosity and the sacrotuberous ligament, whereas
tion, and the distal hamstring length test, also called
the short head of the biceps femoris originates proxi-
the popliteal angle (or PA) test, is covered in the knee
mally from the lateral lip of the linea aspera, the lat-
chapter.
eral supracondylar line, and the lateral intermuscular
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Biceps femoris
Semimembranosus (short head)
Semimembranosus
FIGURE 8.36 A posterior view of the hip showing the hamstring muscles (A and B).
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FIGURE 8.37 The starting position for testing the length of the hamstring muscles with the straight
leg raising test (SLR).
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Biceps femoris
FIGURE 8.39 A lateral view of the hip showing the biceps femoris at the end of the testing
motion for the length of the hamstrings.
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Shortness of muscles in the hip and lumbar region excessive amount of posterior pelvic tilt and lumbar
influences the results of the SLR test. If the subject flexion.
has short hip flexors on the side that is not being If the subject has short lumbar extensors, the low
tested, the pelvis is held in an anterior tilt when that back has an excessive lordotic curve and the pelvis is
lower extremity is lying on the examining table. An in an anterior tilt. The distance that the leg can lift off
anterior pelvic tilt decreases the distance that the leg the examining table is decreased if the pelvis is in an
being tested can lift off the examining table, thus giv- anterior tilt, giving the appearance of less hamstring
ing the appearance of less hamstring length than is length than is actually present. In this case, the exam-
actually present. To remedy this situation, have the iner needs to carefully align the proximal arm of the
subject flex the hip not being tested by resting the goniometer with the lateral midline of the pelvis when
foot on the table or by supporting the thigh with a measuring hip flexion ROM and not be misled by the
pillow (Fig. 8.40). This position slackens the short hip height of the lower extremity from the examining
flexors and allows the low back and pelvis to flatten table.
against the examining table. Be careful to avoid an
FIGURE 8.40 If the subject has shortness of the contralateral hip flexors, flex the contralateral hip to
prevent an anterior pelvic tilt.
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Normal End-Feel
Goniometer Alignment
See Figure 8.41.
1. Center fulcrum of the goniometer over the lateral
aspect of the hip joint, using the greater trochanter
of the femur for reference.
2. Align proximal arm with the lateral midline of the
pelvis.
3. Align distal arm with the lateral midline of the
femur, using the lateral epicondyle for reference.
FIGURE 8.41 Goniometer alignment for measuring the length of the hamstring muscles. Another
examiner will need to take the measurement while the first examiner supports the leg being tested.
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TENSOR FASCIA LATA AND near the edge of the examining table, so that the
examiner can stand directly behind the subject.
ILIOTIBIAL BAND: OBER TEST Initially, extend the uppermost knee and place the
The tensor fascia lata crosses two joints—the hip and
hip in 0 degrees of flexion, extension, adduction,
knee. When this muscle contracts, it abducts, flexes,
abduction, and rotation. The patient flexes the
and medially rotates the hip and extends the knee.
bottom hip and knee to stabilize the trunk, flatten
The tensor fascia lata arises proximally from the ante-
the lumbar curve, and keep the pelvis in a slight
rior aspect of the outer lip of the iliac crest and the
posterior tilt.
lateral surface of the ASIS and the iliac notch
(Fig. 8.42). It attaches distally into the iliotibial band
of the fascia lata about one-third of the way down the Stabilization
thigh. The iliotibial band inserts into the lateral Place one hand on the iliac crest to stabilize the
tuberosity of the tibia, the head of the fibula, the lat- pelvis. Firm pressure is usually required to prevent the
eral condyle of the femur, and the lateral patellar reti- pelvis from laterally tilting during the testing motion.
naculum. If the tensor fascia lata is short, it limits hip Having the patient flex the bottom hip and knee can
adduction and to a lesser extent hip extension, hip also help to stabilize the trunk and pelvis.
lateral rotation, and knee flexion. Shortening of this
structure has been cited as a contributing cause of Testing Motion
low-back pain,8 iliotibial band friction syndrome,9 and Support the leg being tested by holding the medial
patellofemoral pain due to lateral tracking and tilting aspect of the knee and the lower leg. Flex the hip
of the patella.10 and the knee to 90 degrees (Fig. 8.43). Keep the
Some authors have stated that the tensor fasciae knee flexed and move the hip into abduction and
latae is of normal length when the hip adducts to the extension to position the tensor fascia lata over
examining table.11,12 However, according to Kendall the greater trochanter of the femur (Fig. 8.44). Test
and colleagues,6 stabilization of the pelvis to prevent the length of the tensor fascia lata and iliotibial
a lateral tilt and avoidance of hip flexion and medial
rotation will limit hip adduction to 10 degrees during
the testing motion, which causes the thigh to drop
only slightly below the horizontal position. More con-
servative hip adduction values have been reported as
normal by Cade and associates,13 who found that only
7 of 50 young female subjects had normal (or not
short) Ober test values when the horizontal leg posi-
tion or 0 degrees of adduction was used as the test
parameter.
Gajdosik, Sandler, and Marr14 used a universal
goniometer centered at the ipsilateral ASIS to deter-
mine the effects of knee position and gender on Ober
test values for 49 adults aged 20 to 43 years. The
26 women in the study had a range of 3 degrees of
adduction to 16 degrees of abduction, whereas the
23 men had a range of 4 degrees of adduction to
15 degrees of abduction. According to Wang,15 a nor-
mal value for 36 healthy subjects with a mean age of
24.3 years was found to be 17.8 degrees of adduction
measured at the lateral femoral epicondyle at the knee
with an inclinometer. Reese and Bandy16 also used an
inclinometer over the distal femur to measure the hip
adduction position in 61 healthy subjects with a mean
age of 24 years. The authors obtained a mean value of
18.9 degrees of adduction (SD = 7.6 degrees), which is
similar to the value obtained by Wang.
Starting Position
Place the subject in the sidelying position, with the FIGURE 8.42 A lateral view of the left hip showing the
hip being tested uppermost. Position the subject tensor fascia lata muscle (in red) and the iliotibial band.
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FIGURE 8.44 The next step in the testing motion for the length of the tensor fascia lata and
iliotibial band is to abduct and extend the hip.
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band by lowering the leg into hip adduction and Goniometer Alignment
bringing it down toward the examining table See Figure 8.47.
(Figs. 8.45 and 8.46). Do not allow the pelvis to tilt
laterally or the hip to flex because these motions 1. Center fulcrum of the goniometer over the ASIS of
slacken the muscle. Keep the knee flexed to control the extremity being measured.
medial rotation of the hip and to maintain the 2. Align proximal arm with an imaginary line extend-
stretch of the muscle. If the thigh drops to slightly ing from one ASIS to the other.
below horizontal (10 degrees of hip adduction), the 3. Align distal arm with the anterior midline of the fe-
test is negative and the tensor fascia lata and mur, using the midline of the patella for reference.
iliotibial band are of normal length.6 If the thigh Note that at least 0 degrees of hip extension is
remains above horizontal in hip abduction, the ten- needed to perform length testing of the tensor fascia
sor fasciae latae and iliotibial band may be tight. lata and iliotibial band. If the iliopsoas is tight, it pre-
vents the proper positioning of the tensor fascia lata
Normal End-Feel over the greater trochanter. If the rectus femoris is
The end-feel is firm owing to tension in the tensor short, the knee may be extended during the test,6 but
fascia lata. extreme care must be taken to avoid medial rotation of
the hip as the leg is lowered into adduction. This
change in test position is called a Modified Ober test.
FIGURE 8.45 The end of the testing motion for the length of the tensor fascia lata and iliotibial
band. The examiner is firmly holding the iliac crest to prevent a lateral tilt of the pelvis while the hip
is lowered into adduction. No flexion or medial rotation of the hip is allowed. The subject has a
normal length of the tensor fascia lata and iliotibial band; the thigh drops to slightly below
horizontal.
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FIGURE 8.47 Goniometer alignment for measuring the length of the tensor fascia lata and iliotibial
band. The examiner stabilizes the pelvis and positions the leg being tested while another examiner
takes the measurement. If another examiner is not available, a visual estimate will have to be made.
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FIGURE 8.48 The extended position of the knee is shown at the end of the Modified Ober test.
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AAOS3 AMA4 Boone and Azen17 Svenningsen et al18 Roach and Miles5
18 mos – 54 yrs 23 yrs 23 yrs 25 – 47yrs
Males Males Females Males and Females
n = 109 n = 102 n = 104 n = 1683
Motion Mean (SD) Mean Mean Mean (SD)
Flexion 120 100 122.3 (6.1) 137 141 121.0 (13.0)
Extension 20 30 9.8 (6.8) 23 26 19.0 (8.0)
Abduction 40 45.9 (9.3) 40 42 42.0 (11.0)
Adduction 20 26.9 (4.1) 29 30
Medial rotation 45 40* 47.3 (6.0) 38 52 32.0 (8.0)
Lateral rotation 45 50* 47.2 (6.3) 43 41 32.0 (9.0)
SD ⫽ standard deviation.
* Measurements taken with subjects in the supine position.
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TABLE 8.2 Age Effects on Hip Motion in Neonates 6 Hours to 4 Weeks of Age: Normal Values
in Degrees
Schwarze
Waugh et al19 Drews et al22 and Denton20 Broughton et al21 Wanatabe et al23 Forero et al25
SD = standard deviation.
* All values in this row represent the magnitude of the extension limitation.
†
Tested with subjects in the supine position.
‡
Tested with subjects in the side-lying position.
extension ROM beginning at the neutral position usually be viewed as abnormal and not attributable to aging. In the
approaches adult values by early adolescence. data from Roach and Miles,5 hip extension was the only
Broughton, Wright, and Menelaus21 found that by motion in which the difference between the youngest and the
6 months of age, mean hip extension limitations in infants had oldest groups constituted a decrease of more than 20 percent
decreased to 7.5 degrees, and 27 of 57 subjects had no limita- of the available arc of motion.
tion. However, Phelps, Smith, and Hallum24 found that Although Svenningsen and associates18 studied hip ROM
100 percent of the 9- and 12-month-old infants tested (n = 50) in fairly young subjects (761 males and females aged 4 to
had some degree of hip extension limitation. At 18 months of 28 years), these authors found that even in this limited age
age, 89 percent of infants had limitations, and at 24 months, span, the ROM for most hip motions showed a decrease with
72 percent still had limitations. increasing age. However, the reductions in ROM varied
In Table 8.4, very little difference is evident between the according to the motion. Decreases in flexion, abduction,
ROM values for hip flexion and hip abduction across the life medial rotation, and total rotation were greater than decreases
span of 4 to 74 years in contrast to hip medial and lateral in extension, adduction, and lateral rotation.
rotation, which have the greatest decrease in ROM. Roach Nonaka and associates,30 in a study of 77 healthy male
and Miles5 have suggested that differences in active ROM volunteers aged 15 to 73 years, found that passive hip ROM
representing less than 10 percent of the arc of motion are of decreased progressively with increasing age, but no change
little clinical significance and that any substantial loss of was observed in knee ROM in the same population. The
mobility in individuals between 25 and 74 years of age should authors suggested that most activities of daily living can be
TABLE 8.3 Hip Extension Limitations in Infants and Young Children 4 Weeks to 5 Years of Age:
Values in Degrees
Wanatabe et al23 Broughton et al21 Phelps et al24 Boone28
SD = standard deviation.
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TABLE 8.4 Age Effects on Hip Motion in Individuals 4 to 74 Years of Age: Normal
Values in Degrees
Svenningsen18 Boone28 Roach and Miles5
Female Male Males Males and Females
4 yrs 4 yrs 6–12 yrs 13–19 yrs 25–39 yrs 40–59 yrs 60–74 yrs
n = 52 n = 51 n = 17 n = 17 n = 433 n = 727 n = 523
Motion Mean Mean Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD)
Flexion 151 149 124.4 (5.9) 122.6 (5.2) 122.0 (12) 120.0 (14) 118.0 (13)
Extension 29 28 10.4 (7.5) 11.6 (5.0) 22.0 (8) 18.0 (7) 17.0 (8)
Abduction 55 53 48.1 (6.3) 46.8 (6.0) 44.0 (11) 42.0 (11) 39.0 (12)
Adduction 30 30 27.6 (3.8) 26.3 (2.9) — — —
Medial rotation 60 51 48.4 (4.8) 47.1 (5.2) 33.0 (7) 31.0 (8) 30.0 (7)
Lateral rotation 44 48 47.5 (3.2) 47.4 (5.2) 34.0 (8) 32.0 (8) 29.0 (9)
SD ⫽ standard deviation.
performed without maximal lengthening of hip joint muscles. abduction. In contrast, hip flexion with the knee either
Therefore, loss of hip ROM with increasing age may result extended or flexed was least affected by age, with a significant
from shortening of muscles or connective tissue due to reduction occurring only in those older than 85 years of age.
reduced compliance of joint structures and degenerative Passive ROM was greater than active ROM for all joint
changes in spinal alignment as a result of a decrease in phys- motions tested, with the largest difference (7 degrees) occur-
ical activities that stretch the musculature surrounding the hip. ring in hip flexion with the knee flexed.
A number of other researchers have investigated age or In a large study by Steinberg and colleagues,35 passive
gender effects on hip ROM.31–34 Allander and colleagues31 mea- hip ROM was compared in 1320 female dancers aged 8 to
sured hip ROM in a population of 517 females and 203 males 16 years and 223 nondancers of similar age. Hip flexion and
between 33 and 70 years of age. These authors found that older medial and lateral rotation decreased in both groups with
groups had significantly less hip rotation ROM than younger increasing age, whereas hip abduction decreased significantly
groups. with increasing age only in the dancers. Hip extension ROM
Walker and colleagues32 measured all active hip motions was found to increase with age in both groups, but the
in 30 women and 30 men ranging from 60 to 84 years of age. increase was only significant in the dancer group.
Although Walker and colleagues32 found no differences in hip
ROM between the group aged 60 to 69 years and the group Gender
aged 75 to 84 years, both age groups demonstrated a reduced The effects of gender on hip ROM are usually age and motion
ability to attain a neutral starting position for hip flexion. The specific and account for only a relatively small amount of
mean starting position for both groups for measurements of total variance in measurement. Gender effects have been found
flexion ROM was 11 degrees instead of 0 degrees. The mean in both children and adults, but these effects have not been
ROM values obtained for both age groups for hip rotation, found in neonates and infants. Phelps, Smith, and Hallum24
abduction, and adduction were 14 to 25 degrees less than the found no gender differences in hip rotation in 86 infants and
average values published by the AAOS.3 This finding appears young children (aged 9 to 24 months). Forero, Okamura, and
to provide support for the use of age-appropriate norms. Larson25 found no significant gender differences in any of six
James and Parker34 measured active and passive ROM at hip motions in 60 neonates (26 females and 34 males).
the hip, knee, and ankle in 80 healthy men and women rang- Some studies have found that female children and
ing from 70 years to 92 years of age. Measurements of hip adults have greater hip flexion ROM than males.18,33,34
abduction ROM were taken with a universal goniometer. All Boone and coworkers33 found significant differences for
other measurements were taken with a Leighton flexometer. most hip motions when gender comparisons were made for
Systematic decreases in both active and passive ROM were three age groupings of males and females. These findings
found in subjects between 70 and 92 years of age. Hip abduc- were age and motion specific. Female children (1 to 9 years
tion decreased the most with age and was 33.4 percent less in of age), young adult females (21 to 29 years of age), and
the oldest group of men and women (those aged 85 to older adult females (61 to 69 years of age) had significantly
92 years) compared with the youngest group (those aged more hip flexion than their male counterparts. However,
70 to 74 years). Medial and lateral rotation also decreased female children and young adult females had less hip adduc-
considerably, but the decrease was not as great as that seen in tion and lateral rotation than males in comparison groups.
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Both young adult females and older adult females had less between the ages of 45 and 68 years. Measurements were
hip extension ROM than males. taken by means of a Myrin inclinometer with the subjects in
Svenningson and associates18 measured the passive ROM the prone position.
of 1552 hips in 761 healthy females and males between 4 and Escalante and coworkers40 determined that there was a loss
28 years of age. Females of all age groups had greater passive of at least 1 degree of passive range of motion in hip flexion for
ROM than males for total passive ROM, total rotation, medial each unit increase in BMI in a group of 687 community-
rotation, and abduction. The following two findings agreed dwelling elders (those who were 65 to 78 years of age). Sub-
with Boone’s findings: female children in the 11- and jects who were severely obese had an average of 18 degrees
15-year-old age groups and female adults had greater passive less hip flexion than nonobese subjects as measured in the
ROM in hip flexion than males in the same age groups, and supine position with an inclinometer. BMI explained a higher
females in the 4- and 6-year-old groups and female adults had proportion of the variance in hip flexion ROM than any other
less hip lateral rotation than males in the same age groups. variable examined by the authors.
However, females had more hip adduction than males, which Lichtenstein and associates41 studied interrelationships
is opposite to Boone’s findings. among the variables in the study by Escalante and cowork-
Allander and colleagues31 determined that in five of eight ers40 and concluded that BMI could be considered a primary
age groups tested, females had a greater amount of hip rotation direct determinant of hip flexion passive ROM. However,
than males. Walker and colleagues32 found that 30 females Bennell and associates42 found no effect of BMI on active
aged 60 to 84 years had 14 degrees more ROM in hip medial ROM in hip rotation in a study comparing 77 novice ballet
rotation than their male counterparts. Simoneau and cowork- dancers and 49 age-matched controls between the ages of
ers36 discovered that females (with a mean age of 21.8 years) 8 and 11 years. The control subjects, who had a higher BMI
had higher mean values in both medial and lateral rotation than than the dancers, also had a significantly greater range of lat-
age-matched male subjects. The authors used a universal eral and medial hip rotation.
metal goniometer to measure active ROM of hip rotation in
Testing Position
39 females and 21 males.
Simoneau and coworkers36 found that measurement position
James and Parker34 found that women were significantly
(sitting versus prone) had little effect on active hip medial
more mobile than men in 7 of the 10 motions tested at the hip, rotation ROM in 60 healthy male and female college students
knee, and ankle. At the hip, women had greater mobility than (aged 18 to 21 years), but position had a significant effect on
men in all hip motions except abduction. Men and women had lateral rotation ROM. Lateral rotation measured in the sitting
similar mean values in hip flexion ROM, both with the knee position was statistically less (mean ⫽ 36 degrees) than it was
flexed and with the knee extended, in the group aged 70 to when measured on subjects in the prone position (mean ⫽
74 years, but in the group between 70 and 85-plus years of age, 45 degrees). Bierma-Zeinstra and associates43 found that both
men had an approximate 25 percent decrease in ROM, whereas lateral and medial rotation ROMs were significantly less
women had a decrease of only about 11 percent. when measured in two males and seven females aged 21 to
In a study by Youdas and colleagues,7 two testers used a 43 years in the sitting and supine positions compared to mea-
360-degree goniometer to measure hamstring length by two surements taken in the prone position (Table 8.5). However,
methods (straight leg raising and popliteal angle) in 214 adults Schwarze and Denton20 found no difference in passive ROM
(108 women and 106 men) aged 20 to 79 years. A significant measurements of hip medial and lateral rotation with neonates
gender effect was found in both testing methods, with women in the prone position compared to measurements of the
having approximately 8 degrees more motion than men in the 1000 neonates taken in the supine position.
SLR test and 11 degrees more motion than men in the popliteal Van Dillen and coworkers44 compared the effects of knee
angle test. and hip position on passive hip extension ROM in 10 patients
In contrast to the previously mentioned studies, Hu and (mean age = 33 years) with low-back pain and 35 healthy sub-
associates,37 using a photographic method, found no signifi- jects (mean age = 31 years). Both groups had less hip exten-
cant gender differences in all six hip motions in 51 male and sion when the hip was in neutral abduction than when the hip
54 female healthy Chinese subjects between the ages of was fully abducted. Both groups also displayed less hip exten-
65 and 85 years living in Beijing, China. sion ROM when the knee was flexed to 80 degrees than when
Sanya and Obi38 found no significant gender differences the knee was fully extended. This finding lends support for
between 50 male and female patients with diabetes and a con- Kendall and colleagues,6 who maintain that changing the knee
trol group of 50 healthy subjects. Both groups ranged in age
joint angle during the Thomas test for hip flexor length can
from 21 to 71 years.
affect the passive ROM in hip extension.
Body Mass Index Gajdosik, Sandler, and Marr14 found that changing the
Increases in body mass index (BMI) seem to decrease the position from knee flexion in the Ober test to knee extension
ROM at the hip. Kettunen and colleagues39 found that former in the Modified Ober test changed the angle of hip adduction
elite athletes with a high BMI had lower total amounts of hip in 49 subjects (26 women and 23 men). The knee flexed
passive ROM compared with former elite athletes with a low position limited hip adduction more than the knee extended
BMI. Subjects in the study included 117 former elite athletes position.
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SD = standard deviation.
* Active ROM measured with a universal goniometer.
†
Passive ROM measured with a universal goniometer.
Arts and Sports The authors hypothesized that a shortening of the hip exten-
A sampling of articles related to the effects of ballet and other sors (resulting from constant use) and the dancers’ avoidance
forms of dance, ice hockey, and running on ROM are pre- of full hip medial rotation might account for the fact that the
sented in the following paragraphs. As expected, the effects of dancers had less hip medial rotation than the control subjects.
the activity on ROM vary with the activity and involve Tyler and colleagues46 found that a group of 25 profes-
motions that are specific to the particular activity. sional male ice hockey players had about 10 degrees less hip
Gilbert, Gross, and Klug45 conducted a study of 20 female extension ROM than a group of 25 matched control subjects.
ballet dancers (aged 11 to 14 years) to determine the relation- The authors postulated that the loss of hip extension in the
ship between the dancer’s ROM in hip lateral rotation and the hockey players was probably due to tight anterior hip capsule
turnout angle. An ideal turnout angle is a position in which the structures and tight iliopsoas muscles. The flexed hip and
longitudinal axes of the feet are rotated 180 degrees from each knee posture assumed by the players during skating probably
other. The authors found that turnout angles were significantly contributed to the muscle shortness and loss of hip extension
greater (between 13 and 17 degrees) than measurements of ROM.
hip lateral rotation ROM. This finding indicated that the Van Mechelen and colleagues47 used goniometry to mea-
dancers were using excessive movements at the knee and sure hip ROM in 16 male runners who had sustained running
ankle to attain an acceptable degree of turnout. According to injuries during the year but who were fit at the time of the
the authors, the use of compensatory motions at the knee and study. No right–left differences in hip ROM were found either
ankle predisposes the dancers to injury. The dancers had had in the previously injured group or in a control group of run-
3 years of classical ballet training and still had not been able ners who had not sustained an injury. However, hip ROM
to attain the degree of hip lateral rotation that would give a in the injured group was on average 59.4 degrees, or about
180-degree turnout angle. Consequently, the authors suggest 10 degrees less than the average ROM of 68.1 degrees in run-
that hip ROM may be genetically determined. ners without injuries.
Bennell and associates42 determined that age-matched
control subjects had significantly greater active ROM in hip Disability
lateral and medial rotation than a group of 77 ballet dancers Steultjens and associates48 used a universal goniometer to
(aged 8 to 11 years), although there was no significant differ- measure bilateral active assistive ROM at the hip and knee in
ence in the degree of turnout between the two groups. The 198 patients with osteoarthritis (OA) of the hip or knee. Gen-
amount of non-hip lateral rotation was 40 percent in the erally a decrease in hip ROM was associated with an increase
dancers compared to 20 percent in the control subjects. Non- in disability, but that association was motion specific. Hip
hip lateral rotation increases torsional forces on the medial flexion contractures were present in 15 percent of the patients,
aspect of the knee, ankle, and foot in the young dancers and whereas contractures at the knee were found in 31.5 percent
puts this group at high risk of injury. Similar to the findings of of the patients. Twenty-five percent of the variation in disabil-
Gilbert, Gross, and Klug,45 the authors found no relationship ity levels was accounted for by differences in ROM.
between number of years of training and lateral rotation Mollinger and Steffan,49 in a study of 111 nursing home
ROM, which again suggests a genetic component of ROM. residents, found a mean hip extension of only 4 degrees.
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TABLE 8.6 Hip Flexion Range of Motion Required for Functional Activities: Normal Values
in Degrees From Selected Sources
Ranchos Los Amigos McFayden
Livingston, et al53 Medical Center39 and Winter54 Protopapadaki et al55
Activity Range Range Mean (SD) Mean (SD)
Walking on 0–30 0–30 44 (4.5) —
level surfaces
Ascending stairs 1–0–66 — 60 65.1 (7.1)
Descending stairs 1–0–45 — 66 (0.1) 49.0 (7.8)
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Wolf65 investigated the reliability of measurements of active Ekstrand and associates66 measured the passive ROM of hip
ROM, whereas other researchers27,44,47,60,61,66–68 studied passive flexion, extension, and abduction in 22 healthy men aged 20 to
motion. Bierma-Zeinstra and associates43 studied the reliabil- 30 years in two testing series. In the first series, the testing pro-
ity of both active and passive ROM. Table 8.7 and Table 8.8 cedures were not controlled. In the second series, procedures
provide a sampling of intratester and intertester reliability were standardized and anatomical landmarks were indicated.
studies. The intratester coefficient of variation was lower than the
Boone and associates64 conducted a study in which four intertester coefficient of variation for both series, but standard-
physical therapists used a universal goniometer to measure ization of procedures improved reliability considerably.
active hip abduction ROM in 12 healthy male volunteers aged Ellison and coworkers27 compared passive ROM measure-
26 to 54 years. Three measurements were taken by each tester ments of hip rotation taken with an inclinometer and a universal
at each of four sessions scheduled on a weekly basis for goniometer and found no significant differences between the
4 weeks. Intratester reliability for hip abduction was r ⫽ 0.75, means. Both instruments were found to be reliable, but the
with a total standard deviation between measurements of authors preferred the inclinometer because it was easier to use.
4 degrees taken by the same testers. Intertester reliability for Bierma-Zeinstra and associates43 compared the reliability
hip abduction was r = 0.55, with a total standard deviation of of hip ROM measurements taken with an electronic incli-
5.2 degrees between measurements taken by different testers. nometer with those taken by a universal goniometer. The two
Clapper and Wolf65 compared the reliability of the Ortho- instruments showed equal intratester reliability for both active
Ranger (Orthotronics, Daytona Beach, Fla.), an electronic and passive hip ROM in general and passive hip flexion and
computed pendulum goniometer, with that of the universal passive extension ROM. The intratester reliability of the incli-
goniometer in a study of active hip motion involving 10 males nometer was higher than that of the goniometer for passive
and 10 healthy females between the ages of 23 and 40 years. hip lateral rotation and sitting medial rotation. The goniome-
The authors found that the universal goniometer showed ter had higher reliability for active and passive medial rotation
significantly less variation within sessions than the Ortho- in the prone position. The authors concluded that because the
Ranger, except for measurements of hip adduction and lateral inclinometer and goniometer do not result in the same ROM
rotation. The authors concluded that the universal goniometer values, the instruments should not be used interchangeably.
was a more reliable instrument than the OrthoRanger, and, Gajdosik, Sandler, and Marr14 assessed the intratester
due to the poor correlation between the two instruments, the reliability of measurements of hip abduction or adduction
authors cautioned that the instruments should not be used during both the Ober and Modified Ober tests. One therapist
interchangeably administered all of the tests, and an assistant positioned and
Van Dillen et al 44
35 Healthy subjects Supine: Hip in neutral Extension Right hip 0.70
and knee in Left hip 0.89
80 degrees flexion
Hip in neutral and Extension Right hip 0.72
knee in full Left hip 0.76
extension
Hip in full abduction Extension Right hip 0.87
and knee in Left hip 0.76
80 degrees flexion
Hip in full abduction Extension Right hip 0.96
flexion and knee Left hip 0.90
in full extension
Ellison et al27 22 Healthy subjects Prone: hip in neutral Medial rotation Right hip 0.99
position and knee Lateral rotation Right hip 0.96
flexed to 90 degrees
Cadenhead et al68 6 Adults with Supine Abduction Right hip 0.99
cerebral palsy Prone Extension Right hip 0.98
Supine Lateral rotation Right hip 0.79
Simoneau et al 36
60 Healthy subjects (18–27 yrs) Prone Medial rotation 0.82, 0.96, 0.97
Seated Medial rotation 0.89, 0.85, 0.93
Prone Lateral rotation 0.89, 0.79, 0.98
Seated Lateral rotation 0.90, 0.76, 0.95
Ellison et al27 22 Healthy subjects (20–41 yrs) Prone Left medial rotation 0.98
Prone Left lateral rotation 0.97
Prone Right medial rotation 0.99
Prone Right lateral rotation 0.96
15 Adults with back pain (23–61 yrs) Prone Left medial rotation 0.97
Prone Left lateral rotation 0.95
Prone Right medial rotation 0.96
Prone Right lateral rotation 0.95
read the universal goniometer. The intraclass correlation coef- motions including hip extension in 105 children and adoles-
ficients (ICCs) among three trials for women were 0.87 for cents, aged 1 to 20 years, who had Duchenne muscular dys-
the Ober test and 0.92 for the Modified Ober test. The ICCs trophy. The intratester reliability for measurements of hip
for men were slightly lower, with an ICC of 0.83 for the Ober extension was good (ICC ⫽ 0.85), and the intertester reliabil-
test and an ICC of 0.82 for the Modified Ober test. ity for measurements of hip extension was fair (ICC ⫽ 0.74).
Reese and Bandy,16 in a study involving 61 healthy sub- The results indicated the need for the same examiner to take
jects with a mean age of 24 years, used an inclinometer to measurements for long-term follow-up and to assess the
determine the intratester reliability of the repeated measure- results of therapeutic intervention.
ments of the Ober and Modified Ober tests. Intertester relia- McWhirk and Glanzman58 employed two therapists (one
bility was greater than an ICC of 0.90 for both tests using the with 10 years of experience and one with 1 year of experi-
inclinometer. T tests showed a significant difference in hip ence) to measure abduction and extension ROM in both hips
adduction ROM between the Ober test (18.9 degrees) and the of 25 children aged 2 to 18 years with spastic cerebral palsy.
Modified Ober test (23.4 degrees), but the actual difference To achieve the standarized positioning recommended by
between the two tests was 4.5 degrees. Norkin and White, the therapists assisted each other to help
Youdas and associates7 had two experienced testers mea- support and stabilize the limbs. Hip extension was measured
sure hamstring length with a 360-degree goniometer using the using the Thomas test and was the least reliable intertester
passive SLR test in 214 adults (108 women and 106 men measurement with ICC ⫽ 0.58 (95 percent confidence inter-
between the ages of 20 and 79 years. ICCs were 0.97 for the val (CI) for mean absolute difference ⫽ 3.96 ⫾ 1.87 degrees),
right side and 0.98 for the left side. but intertester reliability for hip abduction ROM had an ICC
Piva and colleagues69 determined the intertester reliability of 0.91 (95 percent CI for mean absolute difference ⫽ 3.47 ⫾
of measurements of the length of the hamstrings, tensor fasciae 1.47 degrees). The authors demonstrated that therapists with
latae, and the quadriceps. Two pairs of testers took the measure- differing levels of pediatric experience can achieve moderate
ments with an inclinometer in 30 subjects with a mean age of to high levels of intertester reliability. The effect of a strict
28.1 years. All ICCs were higher than 0.80. (Hamstring length protocol and the use of a second person to either stabilize or
ICC ⫽ 0.92 and tensor fascia latae ICC = 0.97). help hold the test limb in patients with cerebral palsy
Steinberg and associates35 calculated intratester reliability appeared to contribute to the high level of reliability.
coefficients on test-retest ROM measurements on 20 subjects. Kilgour, McNair, and Stott 62 conducted a study in which
Intratester Pearson values ranged from r ⫽ 0.90 for hip medial three testers used a pediatric plastic goniometer with 10-cm
rotation to r ⫽ 0.96 for both hip abduction and hip flexion. moveable arms to measure straight leg raise, popliteal angle,
Predictably, intertester reliability r values were lower, ranging prone hip extension, and hip extension in supine in the
from 0.74 to 0.95. Thomas test and other joints in 25 children with spastic cere-
In a study by Pandya and colleagues,60 five physical ther- bral palsy aged 6 to 17 years and 25 age- and sex-matched
apists using universal goniometers measured passive joint healthy controls. The ICCs for intrasessional measures for
2066_Ch08_195-240.qxd 5/22/09 8:03 PM Page 238
straight leg raise (hip flexion) and for the popliteal angle were made by the single persons when compared to measurements
0.95 and higher in both groups. The ICCs for the Thomas tests made by two people working together, except for internal
were poor for both groups, although there were low median rotation. The authors concluded that to obtain the most accu-
absolute differences. Intersessional variation in both groups rate results, measurements should be performed by two peo-
was high, indicating that the measurement variability was not ple working together. No significant differences were found
influenced by the presence of spasticity. Measurement of a between goniometric measurements and visual estimates or
fixed joint by the three physical therapists was very reliable, between measurements from the first and second sessions for
with a maximum difference of 5 degrees and a between- the same team with the exception of hip abduction. Repro-
sessions difference of 6.5 degrees. Therefore, the authors con- ducibility of meaurements was best for hip flexion.
cluded that a major source of error in the study was difficulty Cliborne and associates70 determined the ROM and intra-
in determining the correct end-range joint positioning. tester reliability of hip flexion in 22 patients with osteoarthritis
Mutlu and associates 63 conducted a study in which pas- of the knee (mean age ⫽ 61.2 years) and 17 subjects without
sive range of motion was measured in 38 patients aged 18 to symptoms. Intratester reliability for hip flexion for two pairs of
108 months with spastic cerebral palsy. Three physical thera- testers using an inclinometer was an ICC of 0.94 (95% CI ⫽
pists used a 360-degree goniometer to measure each child’s 0.89–0.97).
hip ROM once in each session on two different occasions Owen and colleagues71 followed the goniometric proto-
1 week apart. The highest intertester reliability (ICC ⫽ 0.95) cols used by the AAOS to measure 82 children aged 4 to
was for hip extension using the Thomas test, and the lowest 10 years with femoral shaft fractures at 15 and 24 months
(ICC = 0.61) was for hip abduction. Intrareliability and inter- post-fracture. Hip abduction and adduction were measured
reliability was also high for hip flexion with the knee flexed in the supine position, and hip rotation was measured in the
and the opposite leg extended. prone position. Active hip extension was measured using
Croft and associates61 had six clinicians use a fluid-filled the Thomas test. The most reliable measure was for hip
inclinometer called a Plurimeter to take passive hip flexion flexion ROM, but that was low with an ICC of 0.48 (95%
and rotation ROM measurements of both hips in six patients CI ⫽ 0.29–0.63). The authors concluded that standarized
with osteoarthritis involving only one hip joint. The results protocols for hip ROM in this population had low reliabil-
showed that the degree of agreement among testers was great- ity because only when differences in rotation exceeded at
est for measurements of hip flexion. least 30 degrees and ROM in flexion–extension exceeded
Cibulka and colleagues,67 in a study of passive ROM in 50 degrees could clinicians conclude that true change has
medial and lateral hip rotation in 100 patients with low-back occurred.
pain, determined that for this group of patients, measurements In a reliability and validity study by Sprigle and associ-
of rotation taken in the prone position were more reliable than ates,72 radiographs were taken as 10 healthy male subjects sat
those taken in the sitting position. in erect, anterior, and posterior postures. An electromagnetic
Holm and associates59compared the reliability of gonio- tracking device (Flock of Birds) was used to digitize the ante-
metric and visual measurements in 25 patients with hip rior and posterior superior iliac spines as a 6 degree of freedom
osteoarthritis symptoms and a mean age of 64 years. Two sensor was mounted on the thigh and sacrum. The variables
teams consisting of two therapists each and one team consist- were pelvic tilt and hip thigh flexion angle. Intratester reliabil-
ing of a single experienced therapist took passive standard- ity was calculated using nine radiographs and two testers.
ized goniometric measurements using a half-circle metal Intertester reliability was calculated from 30 radiographs and
goniometer. The fourth team was an orthopedic surgeon who two testers. The ICCs for both intratester and intertester
made visual estimates. Each team took measurements on two reliability were 0.98 or higher. Validity was determined by
occasions with a week between sessions. There were highly comparison of Flock of Birds measurements with radiographic
significant differences in degrees between measurements measurements.
2066_Ch08_195-240.qxd 5/22/09 8:03 PM Page 239
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9
The Knee
Structure and Function longer medial condyle is separated from the lateral condyle
by a deep groove called the intercondylar notch. Anteriorly,
the condyles are separated by a shallow area of bone called
Tibiofemoral and Patellofemoral the femoral patellar surface. The distal articulating surfaces
Joints are the two shallow concave medial and lateral condyles on
the proximal end of the tibia. Two bony spines called the
Anatomy intercondylar tubercles separate the medial condyle from the
The knee is composed of two distinct articulations enclosed lateral condyle. Two joint discs called menisci are attached to
within a single joint capsule: the tibiofemoral joint and the the articulating surfaces on the tibial condyles (Fig. 9.2). At
patellofemoral joint. At the tibiofemoral joint, the proximal the patellofemoral joint, the articulating surfaces are the pos-
joint surfaces are the convex medial and the lateral condyles terior surface of the patella and the femoral patellar surface
of the distal femur (Fig. 9.1). Posteriorly and inferiorly, the (Fig. 9.3).
The joint capsule that encloses both joints is large, loose,
and reinforced by tendons and expansions from the surround-
ing muscles and ligaments. The quadriceps tendon, patellar
ligament, and expansions from the extensor muscles provide
anterior stability (see Fig. 9.3). The lateral and medial collat-
eral ligaments, iliotibial band, and pes anserinus help to
Femur provide medial–lateral stability, and the knee flexors help to
Lateral Patella
condyle Medial condyle Lateral epicondyle Medial epicondyle
Tibiofemoral joint
Lateral condyle Medial condyle
Lateral Medial condyle
condyle Lateral meniscus Medial meniscus
Intercondylar
tubercles Lateral (fibular)
collateral ligament Medial (tibial)
collateral ligament
Fibula Tibia
Fibula Tibia
FIGURE 9.4 A lateral view of the subject’s right lower extremity showing surface anatomy landmarks
for goniometer alignment.
Greater trochanter
of femur Lateral femoral
epicondyle Lateral malleolus
of fibula
FIGURE 9.5 A lateral view of the subject’s right lower extremity showing bony anatomical landmarks for
goniometer alignment for measuring knee flexion ROM.
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KNEE FLEXION prevent further motion and guide the lower leg into
Motion occurs in the sagittal plane around a knee flexion. The end of the range of knee flexion oc-
medial–lateral axis. According to the American curs when resistance is felt and attempts to overcome
Medical Association (AMA),9 the normal flexion the resistance cause additional hip flexion.
ROM for adults is 150 degrees. According to Boone
and Azen,10 the mean flexion ROM for males age Normal End-Feel
18 months to 54 years is 142.5 degrees. Roach Usually, the end-feel is soft because of contact
and Miles11 found a mean knee flexion range of between the muscle bulk of the posterior calf and the
132.0 degrees for males and females 25 to 74 years thigh or between the heel and the buttocks. The
of age. Please refer to Tables 9.1 through 9.4 in the end-feel may be firm because of tension in the vastus
Research Findings section for additional normal ROM medialis, vastus lateralis, and vastus intermedialis
values by age and gender. muscles.
Testing Motion
Hold the subject’s ankle in one hand and the posterior
thigh with the other hand. Move the subject’s thigh to
approximately 90 degrees of hip flexion and move
the knee into flexion (Fig. 9.6). Stabilize the thigh to
FIGURE 9.6 The right lower extremity at the end of knee flexion ROM. The examiner uses one hand
to move the subject’s thigh to approximately 90 degrees of hip flexion and then stabilizes the femur
to prevent further flexion. The examiner’s other hand guides the subject’s lower leg through full knee
flexion ROM.
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FIGURE 9.8 At the end of the knee flexion ROM, the examiner uses one hand to maintain knee
flexion and also to keep the distal arm of the goniometer aligned with the lateral midline of
the leg.
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Normal End-Feel
The end-feel is firm because of tension in the poste-
rior joint capsule, the oblique and arcuate popliteal
ligaments, the collateral ligaments, and the anterior
and posterior cruciate ligaments.
Rectus femoris
Patella
Patellar
Tibial tuberosity
ligament
FIGURE 9.10 The subject is shown in the prone starting position for testing the length of the rectus
femoris muscle.
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FIGURE 9.11 A lateral view of the subject at the end of the testing motion for the length of the left
rectus femoris muscle.
FIGURE 9.12 A lateral view of the left rectus femoris muscle being stretched over the hip and knee joints
at the end of the testing motion.
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FIGURE 9.13 Goniometer alignment for measuring the position of the knee.
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HAMSTRING MUSCLES: whereas the short head attaches along the lateral lip
linear aspera, the lateral supracondylar line, and the lat-
SEMITENDINOSUS, eral intermuscular septum. The distal attachments of
SEMIMEMBRANOSUS, the biceps femoris are on the head of the fibula, with a
AND BICEPS FEMORIS: DISTAL small portion attaching to the lateral tibial condyle and
the lateral collateral ligament (see Fig. 9.14A).
HAMSTRING LENGTH TEST When the hamstring muscles contract, they ex-
OR POPLITEAL ANGLE TEST tend the hip and flex the knee. In the following test,
The distal hamstring length test is also called the the hip is maintained in 90 degrees of flexion while
popliteal angle (PA) test because the angle that is the knee is extended to determine whether the mus-
being measured is the popliteal angle between the cles are of normal length. If the hamstrings are short,
femur and the lower leg. The hamstring muscles are the muscles limit knee extension ROM when the hip is
composed of the semitendinosus, semimembranosus, positioned at 90 degrees of flexion.
and biceps femoris. The semitendinosus, semimem- Gajdosik and associates,13 in a study of 30 healthy
branosus, and the long head of the biceps femoris males aged 18 to 40 years, found a mean value of
cross both the hip and the knee joints. The proximal 31 degrees (SD = 7.5 degrees) for passive knee exten-
attachment of the semitendinosus is on the ischial sion during this test with a large range of values from
tuberosity, and the distal attachment is on the proxi- 17 to 45 degrees. Testers noted that knee extension
mal aspect of the medial surface of the tibia end-feel was firm and easily identified. Intrarater reliabil-
(Fig. 9.14A). The proximal attachment of the semi- ity intraclass correlation coefficients (ICCs) for the test
membranosus is on the ischial tuberosity, and the dis- were 0.86 when knee extension was performed actively
tal attachment is on the medial aspect of the medial and 0.90 when performed passively. Some researchers
tibial condyle (Fig. 9.14B). The biceps femoris muscle have reported the supplementary angles to those noted
arises from two heads; the long head attaches to the by Gajdosik and associates. Youdas and colleagues14
ischial tuberosity and the sacrotuberous ligament, used a 360-degree universal goniometer to measure the
Ischial Ischial
tuberosity tuberosity
Semitendinosus
Biceps femoris
(long head)
Semimembranosus
Biceps femoris
Semimembranosus (short head)
Head of Head of
Tibia fibula Tibia fibula
A B
FIGURE 9.14 A: A posterior view of the thigh showing the attachments of the semitendinosus and the biceps femoris
muscles. B: A posterior view of the thigh showing the attachments of the semimembranosus muscle, which lies under
the two hamstring muscles shown in A.
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FIGURE 9.15 Starting position for measuring the length of the hamstring muscles.
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FIGURE 9.16 End of the testing motion for the length of the right hamstring muscles.
FIGURE 9.17 A lateral view of the right lower extremity shows the hamstring muscles being stretched over the
hip and knee joints at the end of the testing motion.
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Goniometer Alignment
TABLE 9.3 Knee Range of Motion in Infants and Young Children 0 to 12 Years of Age:
Normal Values in Degrees
Broughton et al21 Wanatabe et al20 Boone22
In Table 9.4 the mean values obtained by Boone22 are at the knee was much smaller than that found at the hip joint.
from male subjects, whereas the values obtained by Roach According to the American Association of Orthopaedic Sur-
and Miles11 are from both genders. If values presented for the geons (AAOS) handbook,3 extension limitations of 2 degrees are
oldest groups (those aged 40 to 74 years) in both studies are considered to be normal in adults. Extension limitations greater
compared with the values for the youngest group (those aged than 5 degrees in adults may be considered as knee flexion con-
13 to 19 years), it can be seen that the oldest groups have smaller tractures. These contractures often occur in the elderly because
mean values of flexion. However, with a SD of 11 degrees in the of disease, sedentary lifestyles, and the effects of the aging
oldest groups, the difference between the youngest and the old- process on connective tissues.
est groups is not more than 1 SD. Roach and Miles11 concluded Mollinger and Steffan26 used a universal goniometer
that, at least in individuals up to 74 years of age, any substan- (UG) to assess knee ROM among 112 nursing home residents
tial loss (greater than 10 percent of the arc of motion) in joint with an average age of 83 years. The authors found that only
mobility should be viewed as abnormal and not attributable to 13 percent of the subjects had full (0 degrees) passive knee
the aging process. The flexion values obtained by these extension bilaterally. Thirty-seven of the 112 subjects (33 per-
authors were considerably smaller than the 150-degree aver- cent) had bilateral knee extension limitations of 5 degrees or
age value published by the AMA.9 less bilaterally, which the AAOS considers to be normal in
Walker and colleagues25 studied active ROM of the extrem- older adults. Forty-seven subjects (42 percent) had greater
ity joints in 30 men and 30 women (ranging in age from 60 to than 10 degrees of limitations in extension (flexion contrac-
84 years) from recreational centers. No differences were found tures). Residents with a 30-degree loss of knee extension had
in knee ROM between subjects aged 60 to 69 years and subjects an increase in resistance to passive motion and a loss of
aged 75 to 84 years. However, average values indicated that the ambulation.
subjects had an extension limitation (inability to attain a neutral Steultjens and coworkers27 found knee flexion contractures
0-degree starting position). This finding was similar to the loss in 31.5 percent of 198 patients with osteoarthritis of the knee or
of extension noted at the hip, elbow, and first metatarsopha- hip. (It should be noted that these authors considered knee flex-
langeal (MTP) joints. The 2-degree extension limitation found ion contractures as an inability to attain the horizontal 0 position
13–19 yrs 20–29 yrs 40–45 yrs 40–59 yrs 60–74 yrs
n = 17 n = 19 n = 19 n = 727 n = 523
Motion Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD)
Flexion 142.9 (3.7) 140.2 (5.2) 142.6 (5.6) 132.0 (11.0) 131.0 (11.0)
Extension 0.0 (0.0) 0.4 (0.9) 1.6 (2.4)
starting position for measuring flexion.) Flexion contractures of position, where the two-joint rectus femoris muscle may have
the knee or hip or both were found in 73 percent of patients. limited the ROM.
Generally, a decrease in active assistive ROM was associated In contrast to the findings of James and Parker,33
with an increase in disability but was motion specific. The Escalante and coworkers29 found that female subjects had
motions that had the strongest relationship with disability were reduced passive knee flexion ROM compared with males of
knee flexion, hip extension, and lateral rotation. Ersoz and the same age. However, the women had on average only
Ergun28 found that in a group of 44- to 76-year-old patients with 2 degrees less knee flexion than men. The women also had a
primary knee osteoarthritis, 33 out of the 40 knees tested (82.5 higher body mass index (BMI) than the men, which may have
percent) had extension limitations ranging from 1 to 14 degrees. contributed to their reduced knee flexion.
Despite the knee flexion contractures found in the elderly Schwarze and Denton19 observed no differences owing to
by Mollinger and Steffan,26 many elderly individuals appear gender in a study of 527 girls and 473 boys aged 1 to 3 days.
to have at least a functional flexion ROM. Escalante and Likewise, Cleffken and colleagues34 found no gender differ-
coworkers29 used a universal goniometer (UG) to measure ences in active and passive knee flexion and extension ROM
knee flexion passive ROM in 687 community-dwelling el- in 23 male and 19 female healthy volunteers aged 19 to
derly subjects between the ages of 65 and 79 years. More than 27 years.
90 degrees of knee flexion was found in 619 (90.1 percent) of
Body Mass Index
the subjects. The authors used a cutoff value of 124 degrees
Lichtenstein and associates35 found that among 647 community-
of flexion as being within normal limits. Subjects who failed
dwelling elderly subjects (aged 64 to 78 years), those with
to reach 124 degrees of flexion were classified as having an
high BMI had lower knee ROM than their counterparts with
abnormal ROM. Using this criterion, 76 (11 percent) right
low BMI. Elderly subjects who were severely obese had an
knees and 63 (9 percent) left knees were below this value and
average loss of 13 degrees of knee flexion ROM compared
thus had abnormal (limited) passive ROM in flexion.
with their counterparts who were not obese. The authors
Nonaka and colleagues30 examined age-related changes
determined that a loss of knee ROM of at least 1 degree
at the hip and knee in 77 healthy male volunteers aged 15 to
occurred for each unit increase in BMI. Escalante and
73 years. The authors found that passive range of motion
coworkers29 found that obesity was significantly associated
(PROM) of the hip joint decreased with increasing age but the
with a decreased passive knee flexion ROM. Knees of
knee joint PROM remained unchanged. However, interactive
subjects who were overweight had a flexion ROM that was
motion of the hip and knee showed an age-related reduction,
5 degrees less than subjects who were not obese. Sobti and
which the authors attributed to shortening of muscle and
colleagues36 found that obesity was significantly associated
connective tissue.
with the risk of pain or stiffness at the knee or hip in a survey
Gender of 5042 Post Office pensioners. Knees of subjects who were
Beighton, Solomon, and Soskolne23 defined more than overweight had a knee flexion ROM that was 5 degrees less
10 degrees of knee extension beyond 0 as hyperextension than subjects who were not obese.
and included this criterion in a study of joint laxity in 1081
males and females. Females in the study had more joint lax-
ity than males at any age. Loudon, Goist, and Loudon31
Functional Range of Motion
operationally defined knee hyperextension (genu recurva- Table 9.5 provides knee ROM values required for various
tum) as more than 5 degrees of extension beyond the 0 posi- functional activities. Figures 9.19 to 9.21 show a variety of
tion. Clinically, the authors had observed that not only was functional activities requiring different amounts of knee flex-
hyperextension more common in females than males, but ion. Of the activities measured by Jevsevar and coworkers37
that the condition might be associated with functional (stair ascent and descent, gait, and rising from a chair), stair
deficits in muscle strength, instability, and poor propriocep- ascent required the greatest range of knee motion.
tive control of terminal knee extension. The authors Livingston and associates38 used three testing staircases
cautioned that the female athlete with hyperextended knees with different dimensions. Shorter subjects had a greater maxi-
may be at risk for anterior cruciate ligament injury. Hall and mum mean knee flexion range (92 to 105 degrees) for stair
colleagues32 found that 10 female patients diagnosed with ascent in comparison with taller subjects (83 to 96 degrees).
hypermobility syndrome had alterations in proprioceptive Laubenthal, Smidt, and Kettlekamp39 used an electrogoniomet-
acuity at the knee compared with an age-matched and ric method to measure knee motion in three planes (sagittal,
gender-matched control group. coronal, and transverse). Stair dimensions used by McFayden
James and Parker33 studied knee flexion ROM in 80 men and Winter40 were 22 cm for stair height and 28 cm for stair
and women who ranged in age from 70 years to older than tread. Similar dimension stairs were used by Protopapadaki and
85 years. Women in this group had greater ROM in both ac- associates,41who used a rise height of 18 cm and a stair tread
tive and passive knee flexion than men. Overall knee flexion length of 28.5 cm to determine the knee motion during stair
values were lower than expected for both genders, possibly ascent and descent of 33 young healthy male and female sub-
owing to the fact that the subjects were measured in the prone jects ranging in age from 18 to 39 years. The mean knee flexion
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TABLE 9.5 Knee Flexion Range of Motion Necessary for Functional Activities:
Normal Values in Degrees
McFayden
Jevsevar et al*37 Livingston et al38 Laubenthal et al39 and Winter40 Rowe et al42
Healthy Subjects
(6M, 5F) Healthy Women Healthy Men Healthy Male* Normal Elderly
Mean = 53 yrs Range 19-26 yrs Mean = 25 yrs Mean = 67 yrs
n = 11 n = 15 n = 30 n=1 n = 20
Motion Mean (SD) Mean range Mean range (SD) Mean range Mean (SD)
Walk on level 63.1 (7.7) 64.5 (5.9)
surfaces
Ascend stairs 92.9 (9.4) 2–105.0 0–83.0 (8.4) 10–100.0 80.3 (8.1)
Descend stairs 86.9 (5.7) 1–107.0 0–83.0 (8.2) 20–100.0 77.8 (8.3)
Rise from chair 90.1 (9.8) 89.8 (9.4)
Sit in chair 0–93.0 (10.3) 91.0 (11.8)
Tie shoes 0–106.0 (9.3)
Lift object 0–117.0 (13.1)
from floor
measures the range of knee motion, changes in ROM should reliable instruments for measuring passive knee flexion. ICCs
exceed 6 degrees to show that a real change has occurred. for the UG were 0.97, and ICCs for the fluid inclinometer
Rheault and coworkers50 found good intertester reliability were 0.98. However, there were significant differences in the
for the UG (Table 9.6) and the fluid-based inclinometer ROM values obtained among the three devices used, and the
(r ⫽ 0.83) for measurements of active knee flexion. However, authors caution that these instruments should not be used
significant differences in the ROM values were found between interchangeably.
the instruments. Therefore, the authors concluded that, although Mollinger and Steffan26 collected intratester reliability
the universal and fluid-based goniometers each appeared to data on measurement of knee extension made by two testers
have good reliability, they should not be used interchangeably using a UG. ICCs for repeated measurements of knee exten-
in the clinical setting. sion were high (see Table 9.6), with differences between mea-
Bartholomy, Chandler, and Kaplan51 had similar findings. surements averaging 1 degree.
These authors compared measurements of passive knee flex- Brosseau and associates60 used a UG and a parallel
ion ROM taken with a UG with measurements taken with a goniometer (PG) to measure two flexion-angle positions in
fluid-based inclinometer and an Optotrak motion analysis sys- the right knees of 60 healthy subjects (44 females and
tem. Eighty subjects aged 22 to 43 years were measured. 16 males). Intratester reliability of the smaller-angle (about
Individually, the UG and the inclinometer were found to be 20 degrees) and larger-angle (about 100 degrees) positions
TABLE 9.6 Intratester and Intertester Reliability: Knee Range of Motion Measured
with a Universal Goniometer
Author n Sample Motion Intra ICC Inter ICC Intra r Inter r
Boone et al 48
12 Healthy adult AROM 0.87 0.50
males Flexion
(25–54 yrs)
Brosseau et al60 60 Healthy Flexion fixed 0.86–0.97 0.91–0.94
adults (mean angles
age 20.6 yrs)
Rheault et al 50
20 Healthy adults AROM 0.87
(mean age Flexion
24.8 yrs)
Gogia et al 49
30 Healthy adults PROM
(20–60 yrs) Flexion 0.99 0.98
Drews et al 18
9 Healthy infants PROM 0.69 left
(12 hrs–6 days) Flexion 0.89 right
Rothstein et al 53
12 Patients (ages PROM
not reported) Flexion 0.97–0.99 0.84–0.99 0.97–0.99 0.83–0.92
Extension 0.91–0.97 0.59–0.80 0.91–0.96 0.57–0.79
Watkins et al 54
43 Patients (mean PROM
age 39.5 yrs) Flexion 0.99 0.90
Extension 0.98 0.86
Pandya et al 55
150* Duchenne PROM 0.93 0.73
muscular Extension
dystrophy
21† (<1 yr–20 yrs)
Mollinger and 10 Nursing home Extension 0.99 0.97
Steffan 26 residents
Beissner et al 56
10 Nursing home and PROM
Independent Flexion 0.70–0.93
living residents Extension 0.70–0.93
(mean age
81.0 yrs)
AROM ⫽ active range of motion; ICC ⫽ intraclass correlation coefficient; PROM ⫽ passive range of motion;
r ⫽ pearson product moment correlation coefficient.
*150 subjects were used to calculate intratester ICC.
†
21 subjects were used to calculate intertester ICC.
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were good to excellent for the UG and good for the PG. 19.0 degrees difference between the two testers. ICC values
Intertester reliability was lower than intratester reliability for for intertester reliability were highest for active and passive
both positions and goniometers, however, the smaller angle flexion while sitting.
had lower intertester reliability compared to the large angle Kilgour, McNair, and Stott59 had three pediatric physical
(see Table 9.6). therapists measure bilateral knee extension in 25 children
with spastic cerebral palsy ranging in age from 6 to 17 years
Reliability: Universal Goniometer
and 25 age- and sex-matched controls. Intrasessional absolute
in Patient Populations
differences ranged from 0 to 2.7 degrees in the control group
Rothstein, Miller, and Roettger53 investigated intratester,
and 0 to 2.4 degrees in the cerebral palsy (CP) group. Intrases-
intertester, and interdevice reliability in a study involving
sional ICCs were good in the control group (ICC ⫽ 0.79 to
12 patients referred to physical therapy for their knee. Intratester
0.87) and excellent in the CP group (ICC ⫽ 0.97 to 0.99). Inter-
reliability for passive ROM measurements for knee flexion and
sessional ICCs were lower for both the control and CP group,
extension was high. Intertester reliability also was high among
but only the control group had unacceptable ICCs (0.34 to 0.67)
the 12 testers for passive ROM measurements for flexion but
compared to an ICC of 0.89 to 0.92 for the CP group. The
was lower for knee extension measurements (see Table 9.6).
authors concluded that sagittal plane ROM measures have sim-
Intertester reliability was not improved by repeated measure-
ilar levels of reliability in children with spastic CP compared
ments but was improved when testers used the same patient
with healthy controls both within and between sessions.
positioning. Interdevice reliability was high for all measure-
ments. Neither the composition of the UG (metal or plastic) Reliability: Electronic Digital Inclinometer
nor the size (large or small) had a significant effect on the (CYBEX EDI320)
measurements. Cleffken and associates34conducted a study to determine both
Watkins and associates54 compared passive ROM mea- intratester and intertester reproducibility for measurements of
surements of the knees of 43 patients made by 14 physical active and passive knee flexion and extension in 42 healthy
therapists who used a UG and visual estimates. These authors volunteers. Each motion was measured by two testers three
found that intratester reliability with the UG was high for both times in four measurements sessions. Measurements of pas-
knee flexion and knee extension. Intertester reliability for sive maximum flexion of the knee resulted in a smaller
goniometric measurements also was high for knee flexion but detectable difference (SDD ⫽ 0 ⫾ 6.4 degrees) than active
only good for knee extension (see Table 9.6). Both intratester knee flexion (SDD = 0 ⫾ 7.4 degrees) for intertester compar-
and intertester reliability were lower for visual estimation isons. Intratester reliability showed better reproducibility with
than for goniometric measurement. The authors suggested SDDs reduced by 0.4 to 1.9 degrees over intertester values.
that therapists should not substitute visual estimates for
goniometric measurements when assessing a patient’s range Reliability: Electrogoniometer
of knee motion because of the additional error that is intro- Piriyaprasarth and colleagues61 assessed intratester and
duced with use of visual estimation. intertester reliability of measurements using a flexible electro-
Pandya and colleagues55 studied intratester and intertester goniometer of two different fixed flexion angles (45 and
75 degrees) in sitting, supine, and standing positions Thirty-
reliability of passive knee extension measurements in 150 chil-
seven healthy volunteers (mean age 31 years) participated in
dren aged 1 to 20 years who had a diagnosis of Duchenne mus-
the intratester study, and 35 healthy volunteers (mean age
cular dystrophy. Intratester reliability with use of the UG was
30 years) participated in the intertester reliability study. Ten
high, but intertester reliability was only fair (see Table 9.6).
repetitions of joint angles were taken by two testers. Intra-
McWhirk and Glanzman57 had two physical therapists
tester reliability of measurements ranged from fair for supine
measure the knee ROM and the popliteal angle in 46 knees in
(ICC ⫽ 0.75 to 0.76), good in sitting (ICC ⫽ 0.86 to 0.87), to
25 children (aged 2 to 18 years) with spastic cerebral palsy. The
very good in standing (ICC ⫽ 0.87 to 0.88). Intertester relia-
intertester reliability of knee extension measurements was an
bility was poor to fair for supine (ICC ⫽ 0.58 to 0.71), poor
ICC of 0.78 with a 95% confidence interval (CI) ⫽ ⫾1.75, and
to fair for sitting (ICC ⫽ 0.68 to 0.79), and poor to good for
the popliteal angle measurement had an ICC of 0.93 with a
standing (ICC ⫽ 0.57 to 0.80). The sitting position had larger
95% CI ⫽ ⫾1.47. The therapists helped each other during the
ICCs and lower standard errors of measurement (SEMs) for
measurements by having one or the other either provide support
both intratester and intertester reliability compared to the supine
for the test leg or stabilize the other extremity.
position. One drawback of the study was that only angles less
In a study by Lessen and associates,58 two physical ther-
than 90 degrees were measured. The SEM was less than
apists used a long arm UG to measure active and passive knee
1.7 degrees when the same tester repeated the measurements.
flexion and extension in 30 patients within the first 4 days
after total knee arthoplasty. Measurements were taken with Reliability: Inclinometer
the patients supine in a hospital bed and in the sitting position The mean knee flexion ROM for the Ely test was 138.5 degrees
on an examination table. The highest levels of agreement for four testers using an inclinometer in a study by Piva and
between the testers were found for passive flexion and exten- associates.12 Measurements were taken of 30 patients with
sion in the sitting position. The lowest level of agreement was patellofemoral pain syndrome ranging in age from 14 to
found for passive flexion in the supine position with 16.2 to 47 years. The intertester reliability ICC was 0.91.
2066_Ch09_241-262.qxd 5/22/09 10:19 AM Page 261
Validity: Universal Goniometer extension, and medial and lateral rotation taken with a UG
Gogia and colleagues49 measured knee joint angles between and radiographs. For example, limitations in internal rotation
0 and 120 degrees of flexion. These measurements were ROM provided a prediction of advanced disease in the lateral
immediately followed by radiographs. Intertester reliability knee compartment. The authors concluded that measurements
was high (Table 9.6). The ICC for validity also was high of joint ROM were helpful in the determination of the compart-
(0.99). The authors concluded that the knee angle measure- ment or compartments that were affected by the disease process.
ments taken with a UG were both reliable and valid. Brousseau and associates60 measured active knee flexion in
Enwemeka52 compared the measurements of six knee two positions in 60 healthy university students (44 females and
joint positions (0, 15, 30, 45, 60, and 90 degrees) taken with 16 males) with a mean age of 21 years. Two trained testers
a UG with bone angle measurements provided by radio- alternately used either a universal (UG) or a pendulum (PG)
graphs. The measurements were taken on 10 healthy adult goniometer for the measurements. Eight measurements were
volunteers (four women and six men) between 21 and taken with the knee flexed in the supine position and eight with
35 years of age. The mean differences ranged from 0.52 to the knee in the first 20 degrees of flexion in the supine position.
3.81 degrees between goniometric and radiographic measure- A radiograph was taken of each subject in each knee position.
ments taken between 30 and 90 degrees of flexion. However, Criterion validity was determined by calculating Pearson prod-
mean differences were higher (4.59 degrees) between gonio- uct moment correlation coefficients between each goniometric
metric and radiographic measurements of the smaller angles and radiologic measurement. Results showed that both the PGs
between 0 and 15 degrees. and UGs had higher validity when measuring the larger fixed
Ersoz and Ergun28 used a UG with 25-cm arms and knee flexion angle compared to the smaller angle when using
1-degree increments to measure the ROM in both knees of radiographs as the gold standard.
20 patients with bilateral knee osteoarthritis. Radiographs were Rheault and coworkers50 investigated the concurrent
taken of tibiofemoral, lateral tibiofemoral, and patellofemoral validity of a UG and an inclinometer for measurements of
compartments of the same knees. The authors found a clear active knee flexion. Each instrument had good validity, but
relationship between knee ROM measurements of flexion, instruments could not be used interchangeably.
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25. Walker, JM, et al: Active mobility of the extremities in older subjects. estimates of knee range of motion obtained in a clinical setting. Phys
Phys Ther 64:919, 1984. Ther 71:90, 1991.
26. Mollinger, LA, and Steffan, TM: Knee flexion contractures in institution- 55. Pandya, S, et al: Reliability of goniometric measurements in patients with
alized elderly: Prevalence, severity, stability and related variables. Phys Duchenne muscular dystrophy. Phys Ther 65:1339, 1985.
Ther 73:437, 1993. 56. Beissner K, Collins JE, and Holmes H: Muscle force and range of
27. Steultjens, MPM, et al: Range of motion and disability in patients with motion as predictors of function in older adults. Phys Ther 80:556,
osteoarthritis of the knee or hip. Rheumatology 39:955, 2000. 2000.
28. Ersoz, M, and Ergun, S: Relationship between knee range of motion and 57. McWhirk, LB, Glanzman, AM: Within-session inter-rater reliability of
Kellgren-Lawrence radiographic scores in knee osteoarthritis. Am J Phys goniometric measures in patients with spastic cerebral palsy. Paedtr Phys
Med Rehabil 82:110–115, 2003. Ther 18:262–265, 2006.
29. Escalante, A, et al: Determinants of hip and knee flexion range: Results 58. Lessen, AF, van Dam, EM, Crijns, YH, et al: Reproducibility of gonio-
from the San Antonio Longitudinal Study of Aging. Arthritis Care Res metric measurement of the knee in the in-hospital phase following total
12:8, 1999. knee arthroplasty. BMC Musculoskeletal Disord 8:83, 2007.
30. Nonaka, H, Mita, K, Watakabe, M et al: Age-related changes in the inter- 59. Kilgour, G, McNair, PM, Stott, NS: Intrarater reliability of lower limb
active mobility of the hip and knee joints: A geometrical analysis. Gait sagittal range-of-motion measures in children with spastic diplegia. Dev
Posture 15:236–243, 2002. Med Child Neurol 45:391–399, 2003.
31. Loudon, JK, Goist, HL, and Loudon, KL: Genu recurvatum syndrome. 60. Brosseau, L, Tousignant, M, Budd, J, et al: Intratester and intertester
J Orthop Sports Phys Ther 27:361, 1998. reliability and criterion validity of the parallelogram and universal
32. Hall, MG, et al: The effect of hypermobility syndrome on knee joint pro- goniometers for active knee flexion in healthy adults. Physiother Res Int
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33. James, B, and Parker, AW: Active and passive mobility of the lower limb 61. Piriyaprasarth, P, et al: The reliability of knee joint position testing using
joints in elderly men and women. Am J Phys Med Rehab 68:162, 1989. electrogoniometry. BMC Musculoskelet Disord 9:6, 2008.
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10
The Ankle and Foot
Structure and Function tibial and fibular malleoli. Distally, the joint surface is the
convex dome of the talus. The joint capsule is thin and weak
anteriorly and posteriorly, and the joint is reinforced by lateral
Proximal and Distal Tibiofibular and medial ligaments. Anterior and posterior talofibular liga-
Joints ments and the calcaneofibular ligament provide lateral sup-
port for the capsule and joint (Fig. 10.2A and B). The deltoid
Anatomy ligament provides medial support (Fig. 10.3).
The proximal tibiofibular joint is formed by a slightly convex
tibial facet and a slightly concave fibular facet and is sur- Osteokinematics
rounded by a joint capsule that is reinforced by anterior and The talocrural joint is a synovial hinge joint with 1 degree of
posterior ligaments. The distal tibiofibular joint is formed freedom. The motions available are dorsiflexion and plan-
by a fibrous union between a concave facet on the lateral tarflexion. These motions occur around an oblique axis and
aspect of the distal tibia and a convex facet on the distal fibula thus do not occur purely in the sagittal plane. The motions
(Fig. 10.1A). Both joints are supported by the interosseous cross three planes and therefore are considered to be triplanar.
membrane, which is located between the tibia and the fibula Dorsiflexion of the ankle brings the foot up and slightly lat-
(Fig. 10.1B). The distal joint does not have a joint capsule but eral, whereas plantarflexion brings the foot down and slightly
is supported by anterior and posterior ligaments and the crural medial. The ankle is considered to be in the 0-degree neutral
interosseous tibiofibular ligament (Fig. 10.1C). position when the foot is at a right angle to the tibia.
Osteokinematics Arthrokinematics
The proximal and distal tibiofibular joints are anatomically During dorsiflexion in the non–weight-bearing position, the
distinct from the talocrural joint but function to serve the talus moves posteriorly. During plantarflexion, the talus
ankle. The proximal joint is a plane synovial joint that allows moves anteriorly. During dorsiflexion, in the weight-bearing
a small amount of superior and inferior sliding of the fibula on position, the tibia moves anteriorly. During plantarflexion, the
the tibia and a slight amount of rotation. The distal joint is a tibia moves posteriorly.
syndesmosis, or fibrous union, but it also allows a small Capsular Pattern
amount of motion. The pattern is a greater limitation in plantarflexion than in
Arthrokinematics dorsiflexion.
During dorsiflexion of the ankle, the fibula moves proximally
and slightly posteriorly (lateral rotation) away from the tibia. Subtalar Joint
During plantarflexion, the fibula glides distally and slightly
Anatomy
anteriorly toward the tibia.
The subtalar (talocalcaneal) joint is composed of three sepa-
Capsular Pattern rate plane articulations: the posterior, anterior, and middle
The capsular pattern is not defined for the tibiofibular joints. articulations between the talus and the calcaneus. The poste-
rior articulation, which is the largest, includes a concave facet
on the inferior surface of the talus and a convex facet on the
Talocrural Joint body of the calcaneus. The anterior and middle articulations
Anatomy are formed by two convex facets on the talus and two concave
The talocrural joint comprises the articulations between the facets on the calcaneus. The anterior and middle articulations
talus and the distal tibia and fibula. Proximally, the joint is share a joint capsule with the talonavicular joint; the posterior
formed by the concave surfaces of the distal tibia and the articulation has its own capsule. The subtalar joint is
263
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Anterior
ligament
of fibular
head
Interosseous
membrane
Fibula Tibia
Anterior
tibiofibular
ligament
Distal tibiofibular Posterior tibiofibular
joint ligament
A B C
FIGURE 10.1 A: The anterior aspect of the proximal and distal tibiofibular joints of a right lower extremity. B: The anterior
tibiofibular ligaments and the interosseous membrane. C: The posterior aspect of the tibiofibular joints and the posterior
tibiofibular ligaments of a right lower extremity.
Fibula Tibia
Fibula
Tibia
Calcaneus
5th metatarsal Anterior
talofibular Calcaneus
ligament
A Cuboid B
FIGURE 10.2 A: A lateral view of a left talocrural joint with the anterior and posterior talofibular ligaments and the
calcaneofibular ligament. B: A posterior view of a left talocrural joint shows the posterior talofibular ligament and the
calcaneofibular ligament.
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Posterior tibiotalar
Tibiocalcaneal Deltoid
Anterior tibiotalar ligament
Tibia
Tibionavicular
Talocrural
joint
Navicular
Calcaneus
FIGURE 10.3 The deltoid ligament in a medial view of a left talocrural joint.
reinforced by anterior, posterior, lateral, and medial talocal- talus. During eversion, the calcaneus slides medially on
caneal ligaments and the interosseus talocalcaneal ligament the talus.
(Figs. 10.4 and 10.5).
Capsular Pattern
Osteokinematics The capsular pattern consists of a greater limitation in
The motions permitted at the joint are inversion and eversion, inversion.2
which occur around an oblique axis. These motions are
composite motions consisting of abduction–adduction, Transverse Tarsal (Midtarsal) Joint
flexion–extension, and supination–pronation.1 During non–
Anatomy
weight-bearing inversion, the calcaneus adducts around an
The transverse tarsal, or midtarsal, joint is a compound joint
anterior–posterior axis, supinates around a longitudinal axis,
formed by the talonavicular and calcaneocuboid joints
and plantarflexes around a medial–lateral axis. During ever-
(Fig. 10.6A). The talonavicular joint is composed of the large
sion, the calcaneus abducts, pronates, and dorsiflexes.
convex head of the talus and the concave posterior portion of
Arthrokinematics the navicular bone. The concavity is enlarged by the plantar
The alternating convex and concave facets limit mobility and calcaneonavicular ligament (spring ligament). The joint
create a twisting motion of the calcaneus on the talus. During shares a capsule with the anterior and middle portions of
inversion of the foot, the calcaneus slides laterally on a fixed the subtalar joint and is reinforced by the spring, bifurcate
Talus
Talus Subtalar
Subtalar
joint Posterior joint
talocalcaneal
ligament
Lateral talocalcaneal
Interosseus ligament
talocalcaneal
ligament
(calcaneocuboid and calcaneonavicular), and dorsal talona- laterally and toward the plantar surface; the cuboid slides
vicular ligaments (Fig. 10.6B). laterally and toward the dorsal surface.
The calcaneocuboid joint is composed of the shallow
Capsular Pattern
convex–concave surfaces on the anterior calcaneus and the
The capsular pattern consists of a limitation in inversion
convex–concave surfaces on the posterior cuboid. The joint is
(adduction and supination). Other motions are full.
enclosed in a capsule that is reinforced by the bifurcate (calca-
neocuboid and calcaneonavicular), dorsal calcaneocuboid, plan-
tar calcaneocuboid, and long plantar ligaments (Fig. 10.6C).
Tarsometatarsal Joints
Anatomy
Osteokinematics
The five tarsometatarsal (TMT) joints link the distal tarsals
The joint is considered to have two axes, one longitudinal and
with the bases of the five metatarsals (Fig. 10.7). The concave
one oblique. Motions around both axes are triplanar and con-
base of the first metatarsal articulates with the convex surface
sist of inversion and eversion. The transverse tarsal joint is the
of the medial cuneiform. The base of the second metatarsal
transitional link between the hindfoot and the forefoot.
articulates with the mortise formed by the intermediate
Arthrokinematics cuneiform and the sides of the medial and lateral cuneiforms.
During inversion in a non-weight-bearing position, the con- The base of the third metatarsal articulates with the lateral
cave navicular slides medially and dorsally on the convex cuneiform, and the base of the fourth metatarsal articulates
talus. The cuboid slides medially and toward the plantar sur- with the lateral cunieform and the cuboid. The fifth metatarsal
face on the calcaneus. During eversion, the navicular slides articulates with the cuboid. The first joint has its own capsule,
Talus
Navicular
Talonavicular joint
Transverse tarsal
(midtarsal) joint
Calcaneocuboid joint
Fifth
metatarsal
Dorsal talonavicular ligament Talus
Cuboid Navicular Calcaneonavicular
ligament
A Calcaneus
Cuboid
Dorsal calcaneocuboid
B ligament Calcaneus
FIGURE 10.6 A: The two joints that make up the transverse tarsal joint are shown in a lateral view of a left ankle. B: The
dorsal talonavicular ligament, the bifurcate ligament (calcaneonavicular and calcaneocuboid ligaments), and the dorsal
calcaneocuboid ligament in a lateral view of a left ankle. C: The long plantar ligament, the plantar calcaneonavicular
ligament, and the dorsal talonavicular ligament in a medial view.
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whereas the second and third joints and the fourth and fifth deep transverse metatarsal ligament (Fig. 10.8B). The plantar
joints share capsules. Each joint is reinforced by numerous aponeurosis helps to provide stability and limits extension.
dorsal, plantar, and interosseous ligaments.
Osteokinematics
Osteokinematics The five MTP joints are condyloid synovial joints with
The TMT joints are plane synovial joints that permit gliding 2 degrees of freedom, permitting flexion–extension and
motions, including flexion–extension, a minimal amount of abduction–adduction. The axis for flexion–extension is oblique
abduction–adduction, and rotation. The type and amount of and is referred to as the metatarsal break. The range of motion
motion vary at each joint. For example, at the third TMT joint, (ROM) in extension is greater than in flexion, but the total
the predominant motion is flexion–extension. The combina- ROM varies according to the relative lengths of the metatarsals
tion of motions at the various joints contributes to the hollow- and the weight-bearing status.
ing and flattening of the foot, which helps the foot conform to
Arthrokinematics
a supporting surface.
In flexion, the bases of the phalanges slide in a plantar direc-
Arthrokinematics tion on the heads of the metatarsals. In abduction, the concave
The distal joint surfaces glide in the same direction as the bases of the phalanges slide on the convex heads of the
shafts of the metatarsals.
Distal interphalangeal joints
Metatarsophalangeal Joints
Anatomy
The five metatarsophalangeal (MTP) joints are formed proxi-
mally by the convex heads of the five metatarsals and distally
by the concave bases of the proximal phalanges (Fig. 10.8A).
The first MTP joint has two sesamoid bones that lie in two
grooves on the plantar surface of the distal metatarsal. The four Interphalangeal
joint
lesser toes are interconnected on the plantar surface by the
Distal phalanx
Metatarso-
phalangeal
Middle phalanx joint
Proximal phalanx
Metatarsal
A
Metatarsals
Tarsometatarsal
(1 through 5)
joint
Plantar ligaments
(plates)
Medial
cuneiform
Navicular
Lateral
cuneiform Intermediate
cuneiform
Deep transverse
metatarsal ligaments
Transverse
tarsal
Cuboid joint
B
FIGURE 10.8 A: The metatarsophalangeal, interphalangeal,
and distal interphalangeal joints in a dorsal view of a left
FIGURE 10.7 The tarsometatarsal joints and transverse tarsal foot. B: The deep transverse metatarsal ligaments and the
joint in a dorsal view of a left foot. plantar plates in a plantar view of a left foot.
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metatarsals in a lateral direction away from the second toe. In composed of the concave base of a distal phalanx and the con-
adduction, the bases of the phalanges slide in a medial direc- vex head of a proximal phalanx (see Fig. 10.8A).
tion toward the second toe.
Osteokinematics
Capsular Pattern The IP joints are synovial hinge joints with 1 degree of free-
The pattern at the first MTP joint is gross limitation of exten- dom. The motions permitted are flexion and extension in the
sion and slight limitation of flexion. At the other joints sagittal plane. Each joint is enclosed in a capsule and rein-
(second to fifth), the limitation is more restriction of flexion forced with collateral ligaments.
than extension.2
Arthrokinematics
The concave base of the distal phalanx slides on the convex
Interphalangeal Joints head of the proximal phalanx in the same direction as the
Anatomy shaft of the distal bone. The concave base slides toward the
The structure of the interphalangeal (IP) joints of the feet is plantar surface of the foot during flexion and toward the dor-
identical to that of the IP joints of the fingers. Each IP joint is sum of the foot during extension.
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FIGURE 10.9 The subject’s right lower extremity showing surface anatomy landmarks for goniometer
alignment in measurement of dorsiflexion and plantarflexion range of motion.
Head of fibula
Lateral malleolus
Fifth metatarsal
FIGURE 10.10 The subject’s right lower extremity shows the bony anatomical landmarks for goniometer
alignment for measurement of dorsiflexion and plantarflexion range of motion.
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passive ROM in dorsiflexion. The end of the ROM 2. Align proximal arm with the lateral midline of the
Stabilization
Normal End-Feel 3. Align distal arm parallel to the lateral aspect of the
Usually, the end-feel is firm because of tension in the fifth metatarsal. Although it is usually easier to pal-
anterior joint capsule; the anterior portion of the pate and align the distal arm parallel to the fifth
deltoid ligament; the anterior talofibular ligament; metatarsal, as an alternative, the distal arm can be
and the tibialis anterior, extensor hallucis longus, and aligned parallel to the inferior aspect of the calca-
extensor digitorum longus muscles. The end-feel neus. If the alternative landmark is used, full cycle
may be hard because of contact between the poste- ROM in the sagittal plane (dorsiflexion plus plan-
rior tubercles of the talus and the posterior margin tarflexion) may be similar to full cycle ROM
of the tibia. measurement using the fifth metatarsal as a land-
mark, but the single cycle ROM values for dorsiflex-
Goniometer Alignment ion and plantarflexion will differ considerably. Mea-
See Figures 10.17 and 10.18. surements taken with the alternative landmark
should not be used interchangeably with those
1. Center fulcrum of the goniometer over the lateral taken using the fifth metatarsal landmark.
aspect of the lateral malleolus.
2. Align proximal arm with the lateral midline of the
fibula, using the head of the fibula for reference.
FIGURE 10.17 Goniometer alignment in the starting position FIGURE 10.18 At the end of the plantarflexion range of
for measuring plantarflexion range of motion. motion, the examiner uses one hand to maintain plantarflex-
ion and to align the distal goniometer arm. The examiner
holds the dorsum and sides of the subject’s foot to avoid
exerting pressure on the toes. She uses her other hand to
stabilize the tibia and align the proximal arm of the
goniometer.
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Tibial
tuberosity
Medial
malleolus
Lateral
malleolus
2nd
metatarsal
FIGURE 10.19 An anterior view of the subject’s left ankle FIGURE 10.20 An anterior view of the subject’s left ankle
with surface anatomy landmarks to indicate goniometer with bony anatomical landmarks to indicate goniometer
alignment for measuring inversion and eversion range of alignment for measuring inversion and eversion range of
motion. motion.
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INVERSION: TARSAL JOINTS of the supporting surface. Position the hip in 0 degrees
Inversion is a combination of supination, adduction, of rotation, adduction, and abduction. Alternatively, it is
and plantarflexion occurring in varying degrees at the possible to place the subject in the supine position,
subtalar, transverse tarsal (talocalcaneonavicular and with the foot over the edge of the supporting surface.
calcaneocuboid), cuboideonavicular, cuneonavicular,
intercuneiform, cuneocuboid, tarsometarsal (TMT), Stabilization
and intermetatarsal joints. The functional ability of the Stabilize the tibia and the fibula to prevent medial
foot to adapt to the ground and to absorb contact rotation and extension of the knee and lateral rotation
forces depends on the combined movement of all of and abduction of the hip.
these joints. Because of the uniaxial limitations of the
goniometer, inversion is measured in the frontal plane Testing Motion
around an anterior–posterior axis. Push the forefoot downward into plantarflexion,
Menadue and colleagues measured active inver- medially into adduction, and turn the sole of the
sion in both ankles in 30 male and female subjects foot medially into supination to produce inversion
with a mean age of 35 years. Mean values obtained (Fig. 10.21). The end of the ROM occurs when resis-
with a universal goniometer ranged from 30 degrees tance is felt and attempts at further motion produce
to 35.0 degrees.7 medial rotation of the knee and/or lateral rotation
and abduction at the hip.
Testing Position
Place the subject in the sitting position, with the knee
flexed to 90 degrees and the lower leg over the edge
FIGURE 10.21 The subject’s left foot and ankle at the end of
inversion range of motion. The examiner uses one hand on
the subject’s distal lower leg to prevent knee and hip motion
while her other hand maintains inversion.
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Eversion: Tarsal Joints possible to place the subject in the supine position, with
Eversion is a combination of pronation, abduction, and the foot over the edge of the supporting surface.
dorsiflexion occurring in varying degrees at the subtalar,
transverse tarsal (talocalcaneonavicular and calca- Stabilization
neocuboid), cuboideonavicular, cuneonavicular, inter- Stabilize the tibia and fibula to prevent lateral rotation
cuneiform, cuneocuboid, TMT, and intermetatarsal and flexion of the knee and medial rotation and
joints. The functional ability of the foot to adapt to the adduction of the hip.
ground and to absorb contact forces depends on the
combined movement of all of these joints. Because of Testing Motion
the uniaxial limitations of the goniometer, this motion is Pull the forefoot laterally into abduction and upward
measured in the frontal plane around an anterior– into dorsiflexion, turning the forefoot into pronation so
posterior axis. Menadue and colleagues7 measured that the lateral side of the foot is higher than the medial
active eversion in both ankles in 30 male and female side to produce eversion (Fig. 10.24). The end of the
subjects with a mean age of 35 years. Mean values
obtained with a universal goniometer ranged from
11.0 degrees to 12.0 degrees.7 (Methods for measuring
eversion isolated to the rearfoot and the forefoot are
included in the sections on the subtalar and transverse
tarsal joints.)
Testing Position
Place the subject in the sitting position, with the knee
flexed to 90 degrees and the lower leg over the edge
of the supporting surface. Position the hip in 0 degrees
of rotation, adduction, and abduction. Alternatively, it is
FIGURE 10.24 The left ankle and foot at the end of the range
of motion in eversion. The examiner uses one hand on the
subject’s distal lower leg to prevent knee flexion and lateral
rotation. The examiner’s other hand maintains eversion.
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ROM occurs when resistance is felt and attempts at fur- medial talocalcaneal ligament; the plantar calcaneo-
Goniometer Alignment
See Figures 10.25 and 10.26.
1. Center the fulcrum of the goniometer over the
anterior aspect of the ankle midway between the
malleoli. (The flexibility of a plastic goniometer
makes this instrument easier to use than a metal
goniometer for measuring inversion.)
2. Align proximal arm of the goniometer with the
anterior midline of the lower leg, using the tibial
tuberosity for reference.
3. Align distal arm with the anterior midline of the
second metatarsal.
Medial
malleolus
Lateral
malleolus Calcaneus
FIGURE 10.27 Surface anatomy landmarks indicate FIGURE 10.28 Bony anatomical landmarks for measuring
goniometer alignment for measuring rearfoot inversion subtalar (rearfoot) inversion and eversion range of mo-
and eversion range of motion in a posterior view of a tion in a posterior view of the subject’s left lower leg
subject’s left lower leg and foot. and foot.
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Normal End-Feel
EVERSION: SUBTALAR JOINT Position the knee in 0 degrees of flexion and exten-
sion. Place the foot over the edge of the supporting
(REARFOOT) surface.
Eversion is a combination of pronation, abduction,
and dorsiflexion. Because of the uniaxial limitations
Stabilization
of the goniometer, eversion of the subtalar joint is
Stabilize the tibia and fibula to prevent medial hip and
measured in the frontal plane around an anterior–
knee rotation and hip abduction.
posterior axis. The ROM is about 5 degrees according
to the AAOS3 and between 8 and 9 degrees for active
Testing Motion
eversion according to Menadue and colleagues.7
Pull the calcaneus laterally into abduction and rotate it
into pronation to produce subtalar eversion (Fig. 10.32).
Testing Position The end of the ROM occurs when resistance to further
Place the subject prone, with the hip in 0 degrees of
flexion, extension, abduction, adduction, and rotation.
FIGURE 10.36 Goniometer alignment in the starting position FIGURE 10.37 At the end of transverse tarsal inversion, one
for measuring transverse tarsal inversion. of the examiner’s hands releases the calcaneus and aligns
the proximal goniometer arm with the lower leg. The exam-
iner’s other hand maintains inversion and holds the distal
goniometer arm aligned with the second metatarsal.
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EVERSION: TRANSVERSE TARSAL place the subject in the supine position, with the foot
over the edge of the supporting surface.
JOINT
Eversion is a combination of pronation, abduction,
Stabilization
and dorsiflexion. Because of the uniaxial limitations of
Stabilize the calcaneus and talus to prevent plantarflex-
the goniometer, eversion of the transverse tarsal joint
ion of the ankle and eversion of the subtalar joint.
is measured in the frontal plane around an anterior–
posterior axis. The normal ROM for forefoot eversion
Testing Motion
ranges from 15 to 21 degrees.5,6
Pull the forefoot laterally into abduction and upward
into dorsiflexion. Turn the forefoot into pronation so
Testing Position that the lateral side of the foot is higher than the
Place the subject sitting, with the knee flexed to
medial side (Fig. 10.38). The end of the ROM occurs
90 degrees and the lower leg over the edge of the
when resistance is felt and attempts to produce addi-
supporting surface. Position the hip in 0 degrees of ro-
tional motion cause plantarflexion and/or subtalar
tation, adduction, and abduction and the subtalar joint
eversion.
in the 0 starting position. Alternatively, it is possible to
Distal phalanx
Proximal phalanx
1st metatarsal
A B
FIGURE 10.41 A: Surface anatomy landmarks for measuring flexion and extension at the first
metatarsophalangeal (MTP) joint and first interphalangeal (IP) joint in a medial view of the sub-
ject’s left foot. B: Bony anatomical landmarks for measuring flexion and extension at the first
MTP and IP joints.
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1st metatarsal
Proximal phalanx
Distal phalanx
A B
FIGURE 10.42 A: Surface anatomy landmarks for goniometer alignment for measur-
ing flexion and extension range of motion at the first and second MTP and IP joints
and abduction and adduction at the first MTP joint. B: Bony anatomical landmarks
for flexion and extension at the first and second MTP and IP joints and abduction
and adduction at the first MTP joint.
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FIGURE 10.43 The left first metatarsophalangeal (MTP) joint at the end of the flexion range of motion. The
subject is supine, with her foot and ankle placed over the edge of the supporting surface. However, the
subject’s foot could rest on the supporting surface. The examiner uses her thumb across the metatarsals to
prevent ankle plantarflexion. The examiner’s other hand maintains the first MTP joint in flexion.
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FIGURE 10.45 At the end of the range of motion, the examiner uses
one hand to align the goniometer while her other hand maintains
metatarsophalangeal flexion.
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FIGURE 10.46 The left first metatarsophalangeal joint at the end of extension range of motion. The
examiner places her digits on the dorsum of the subject’s foot to prevent dorsiflexion and uses the
thumb on her other hand to push the proximal phalanx into extension.
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Goniometer Alignment 2. Align proximal arm with the dorsal midline of the
FIGURE 10.50 Goniometer alignment in the starting position FIGURE 10.51 At the end of metatarsophalangeal (MTP) ab-
for measuring metatarsophalangeal abduction range of duction, the examiner’s hand maintains alignment of the dis-
motion. tal goniometer arm while keeping the MTP in abduction.
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Normal End-Feel
FLEXION: INTERPHALANGEAL The end-feel for flexion of the IP joint of the big toe
JOINT OF THE FIRST TOE and the proximal interphalangeal (PIP) joints of the
smaller toes may be soft because of compression of
AND PROXIMAL soft tissues between the plantar surfaces of the pha-
INTERPHALANGEAL JOINTS langes. Sometimes, the end-feel is firm because of
OF THE FOUR LESSER TOES tension in the dorsal joint capsule and the collateral
Motion occurs in the sagittal plane around a medial– ligaments.
lateral axis. The ROM is between 30 degrees5 and
90 degrees for the first toe.3 See Table 10.2 in the Goniometer Alignment
Research Findings section for normal ROM values for 1. Center fulcrum of the goniometer over the dorsal
the four lesser toes. aspect of the interphalangeal joint being tested.
2. Align proximal arm over the dorsal midline of the
Testing Position proximal phalanx.
Place the subject supine or sitting, with the ankle and 3. Align distal arm over the dorsal midline of the pha-
foot in 0 degrees of dorsiflexion, plantarflexion, lanx distal to the joint being tested.
inversion, and eversion. Position the MTP joint in
0 degrees of flexion, extension, abduction, and
adduction. (If the ankle is positioned in plantarflexion
and the MTP joint is flexed, tension in the extensor
hallucis longus or extensor digitorum longus muscles
will restrict the motion. If the MTP joint is positioned
in full extension, tension in the lumbricalis and
interosseus muscles may restrict the motion.)
Stabilization
Stabilize the metatarsal and proximal phalanx to pre-
vent dorsiflexion or plantarflexion of the ankle and
inversion or eversion of the foot. Avoid flexion and
extension of the MTP joint.
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EXTENSION: INTERPHALANGEAL
FLEXION: DISTAL
INTERPHALANGEAL JOINTS OF
THE FOUR LESSER TOES
Motion occurs in the sagittal plane around a medial–
lateral axis. Flexion ROM is 0 to 30 degrees.4
Testing Position
Place the subject supine or sitting, with the ankle and
foot in 0 degrees of dorsiflexion, plantarflexion, inver-
sion, and eversion. Position the MTP and PIP joints in
0 degrees of flexion, extension, abduction, and
adduction.
Stabilization
Stabilize the metatarsal, proximal, and middle phalanx
to prevent dorsiflexion or plantarflexion of the ankle
and inversion or eversion of the foot. Avoid flexion
and extension of the MTP and PIP joints of the toe
being tested.
Testing Motion
Push the distal phalanx toward the plantar surface of
the foot. The end of the motion occurs when resis-
tance is felt and attempts to produce further flexion
cause flexion at the MTP and PIP joints and/or plan-
tarflexion of the ankle.
Normal End-Feel
The end-feel is firm because of tension in the dorsal
joint capsule, the collateral ligaments, and the oblique
retinacular ligament.
Goniometer Alignment
1. Center fulcrum of the goniometer over the dorsal
aspect of the distal interphalangeal (DIP) joint.
2. Align proximal arm over the dorsal midline of the
middle phalanx.
3. Align distal arm over the dorsal midline of the dis-
tal phalanx.
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MUSCLE LENGTH TESTING PROCEDURES: Normal values for dorsiflexion of the ankle with
the knee in extension vary. See Tables 10.6 and 10.7
The Ankle and Foot in the Research Findings section for normal ROM val-
ues by age and gender.
GASTROCNEMIUS
The gastrocnemius muscle is a two-joint muscle that Starting Position
crosses both the ankle and knee. The medial head of Place the subject supine, with the knee extended and
the gastrocnemius originates proximally from the pos- the foot in 0 degrees of inversion and eversion.
terior aspect of the medial condyle of the femur,
whereas the lateral head of the gastrocnemius origi- Stabilization
nates from the posterior lateral aspect of the lateral Hold the knee in full extension. Usually, the weight of
condyle (Fig. 10.52). Both heads join with the tendon of the limb and hand pressure on the anterior leg can
the soleus muscle to form the tendocalcaneus (Achilles) maintain an extended knee position.
tendon, which inserts distally into the posterior surface
of the calcaneus. When the gastrocnemius contracts, it
plantarflexes the ankle and flexes the knee.
A short gastrocnemius can limit ankle dorsiflexion
and knee extension. During the test for the length of
the gastrocnemius the knee is held in full extension. A
short gastrocnemius results in a decrease in ankle dor-
siflexion ROM when the knee is extended. If, however,
ankle dorsiflexion ROM is decreased with the knee in Femoral
condyles
a flexed position, the dorsiflexion limitation is due to
shortness of the one-joint soleus muscle or other joint
structures.
Medial
head of Lateral
gastrocnemius head of
gastrocnemius
Achilles
tendon
Calcaneus
Testing Motion
FIGURE 10.53 The subject’s right ankle at the end of the testing motion for the length of the gastrocne-
mius muscle.
FIGURE 10.54 The gastrocnemius muscle is stretched over the extended knee and dorsi-
flexed ankle.
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Goniometer Alignment
See Figure 10.55.
1. Center fulcrum of the goniometer over the lateral
aspect of the lateral malleolus.
2. Align proximal arm with the lateral midline of the
fibula, using the head of the fibula for reference.
3. Align distal arm parallel to the lateral aspect of the
fifth metatarsal.
FIGURE 10.55 Goniometer alignment at the end of the testing motion for the length of the gastrocne-
mius muscle.
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GASTROCNEMIUS LENGTH occurs when the patient feels tension in the posterior
Testing Motion
The patient dorsiflexes the ankle by leaning the body
forward (Fig. 10.56). The end of the testing motion
FIGURE 10.56 The subject’s left ankle at the end of the FIGURE 10.57 Goniometer alignment in the alternative test-
weight-bearing testing motion for the length of the gastroc- ing position.
nemius muscle.
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Research Findings
TABLE 10.2 Toe Motion: Values in Degrees
from Selected Sources
Tables 10.1 and 10.2 provide ankle and toe ROM values from
various sources. The 1994 AAOS4 edition includes ROM val- Extension Flexion
ues from various research studies, including the same values Joint AMA 5
AAOS 3
AMA 5
AAOS3
from Boone and Azen6 that are found in Table 10.1, and a few
values from the 1965 edition. Boone and Azen,6 using a uni- MTP 1 50 70 30 45
versal goniometer, measured active ROM on male subjects. 2 40 40 30 40
3 30 40 20 40
Effects of Age, Gender, 4 20 40 10 40
and Other Factors 5 10 40 10 40
Age IP 1 — — 30 90
Table 10.3 shows that newborns, infants, and 2 year olds have PIP 2–5 — — — 35
a larger dorsiflexion ROM than older children. The mean val- DIP 2–5 — — — 60
ues for dorsiflexion in the youngest age groups are more than
double the average adult values presented in Tables 10.1 and AMA American Medical Association; AAOS American
10.4. However, between 1 and 5 years of age, dorsiflexion val- Associaion of Orthopaedic Surgeons; DIP distal interphalangeal;
ues show a decrease (Table 10.3). Plantarflexion ROM in IP interphalangeal; MTP metatarsophalangeal; PIP proximal
interphalangeal.
newborns is smaller compared to adults, but newborns attain
adult values in the first few weeks of life. According to
Walker,11 the persistence in infants of a limited ROM in plan-
tarflexion may indicate pathology. values also varied widely, ranging from 30 to 80 degrees.
Table 10.4 provides evidence that decreases in both dor- Intraindividual differences of greater than 5 to 10 degrees
siflexion and plantarflexion ROM occur with increases in age. were found between children’s right and left ankles, leading
However, the difference between dorsiflexion values in the the authors to caution testers about using the ROM in one
youngest and oldest groups constitutes less than 1 standard ankle as a normal ROM for the opposite ankle in this young
deviation (SD). Plantarflexion values in the oldest group are age group.
slightly more than 1 SD less than values for the youngest Saxena and Kim14 tested dorsiflexion ROM in 40 high
group. school athletes ages 14 to 17 years. An experienced tester
Alanen and colleagues13 found a wide variation in maxi- used a goniometer to measure ankle dorsiflexion in the supine
mum passive ROM measurements of dorsiflexion and plan- position in both ankles with the knees extended and flexed. In
tarflexion in 245 boys and girls with a mean age of 10 years contrast to the findings of Alenan and colleagues,13 no signif-
and an age range of 7 to 14 years. ROM values varied from icant differences were found between measurements of right
5 to 50 degrees for maximum dorsiflexion with the knee and left ankles or between girls and boys. However, the age
extended in the prone position and from 21 to 61 degrees with groups are considerably different between the two studies.
the knee flexed in the weight-bearing position. Plantarflexion Ankle dorsiflexion in this group of adolescent athletes was
TABLE 10.3 Effects of Age on Ankle Motion in Newborns and Children Aged 6 to 12 Years:
Mean Values in Degrees
Waugh et al8 Wanatabe et al9 Boone10
6–72 hrs 2–4 wks 4–8 mos 2 yrs 1–5 yrs 6–12 yrs
n = 40 n = 57 n = 54 n = 57 n = 19 n = 17
Motion Mean (SD) Mean range Mean (SD) Mean (SD)
Dorsiflexion 58.9 (7.9) 0–53.0 0–51.0 0–41.0 14.5 (5.0) 13.8 (4.4)
Plantarflexion 25.7 (6.3) 0–58.0 0–60.0 0–62.0 59.7 (5.4) 59.6 (4.7)
SD standard deviation.
found to be 0.35 (SD = 2.2) degrees with the knees extended in dorsiflexion in the older women was associated with a de-
and just less than 5 degrees with the knees flexed. These val- crease in plantarflexor muscle-tendon unit extensibility.
ues for dorsiflexion are below the normal values and less than In a subsequent study, Gajdosik and colleagues17 com-
the 10 degrees needed for normal gait. The authors did not pared the passive stretch and release characteristics of the calf
offer any explanation for the limited ROM, but it is possible muscles of 15 healthy older women with a mean age of
that it is related to either developmental changes in this group 79 years with that of 15 healthy young women with a mean age
of adolescents or athletic activities that decreased the extensi- of 24 years. The right ankles of all subjects were stretched from
bility of the gastrocnemius and soleus muscles. plantarflexion to maximal dorsiflexion and then released into
James and Parker15 found a consistent reduction in both plantarflexion. Older women had less calf muscle length exten-
active and passive ROM with increasing age in all ankle joint sibility, less passive resistive force, less stored passive-elastic
motions in a group of 80 active men and women ranging in energy, and less mean maximum passive dorsiflexion ROM
age from 70 to 92 years. The most rapid reduction in ROM (10.3 degrees) compared to younger women (28.0 degrees).
occurred for individuals in the ninth decade. Ankle dorsiflex- Nigg and associates18 found that age-related changes in
ion measured with the knee extended (a test of the length of ankle ROM were motion specific and differed between males
the gastrocnemius muscle) showed the most marked change. and females. The authors measured active ROM in 121 subjects
The investigators suggested that the decrease in extensibility (61 males and 60 females) between the ages of 20 and 79 years.
of the plantarflexor muscle-tendon unit was due to connective For the entire group of subjects, decreases in active ROM with
tissue changes associated with the aging process. In another increases in age occurred in plantarflexion, inversion, abduction,
study that examined the effects of aging on dorsiflexion and adduction but not in eversion and dorsiflexion (tested in the
ROM, Gajdosik, VanderLinden, and Williams16 used an isoki- sitting position with the knee flexed). Plantarflexion decreased
netic dynamometer to passively stretch the calf muscles in about 8 degrees from the youngest to the oldest group.
74 females (aged 20 to 84 years). The older women (aged
60 to 84 years) had a significantly smaller mean dorsiflexion Gender
angle of 15.4 degrees than the younger women (aged 20 to Gender effects on ROM are joint specific and motion specific
39 years), who had a mean of 25.8 degrees, and the middle- and are often related to age. Nigg and associates18 found gender
aged women, who had a mean of 22.8 degrees. The decrease differences in ankle motion but determined that the differences
TABLE 10.4 Effects of Age on Active Ankle Motion for Individuals 13 to 69 Years of Age:
Normal Values in Degrees
Boone10 Boone et al11
13–19 yrs 20–29 yrs 30–39 yrs 40–54 yrs 61–69 yrs
n = 17 n = 19 n = 18 n = 19 n = 10
Motion Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD)
Dorsiflexion 10.6 (3.7) 12.1 (3.4) 12.2 (4.3) 12.4 (4.7) 8.2 (4.6)
Plantarflexion 55.5 (5.7) 55.4 (3.6) 54.6 (6.0) 52.9 (7.6) 46.2 (7.7)
SD standard deviation.
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changed with increasing age. Only in the oldest group did In a study conducted by Baggett and Young22 of 18 to
women have more (8 degrees) plantarflexion than men. The 66 year olds, males compared to females had less dorsiflexion
only gender differences noted by Boone, Walker, and Perry12 ROM in non–weight-bearing and a greater ROM in weight-
were that females in the 1-year-old to 9-year-old group and bearing. However the differences in ROM were small between
those in the 61-year-old to 69-year-old group had significantly the genders and probably not of clinical importance.
more ROM in plantarflexion than their male counterparts. Four Grimston and associates23 measured active ROM in
other studies also found that females had more plantarflexion than 120 subjects (58 males and 62 females) ranging in age from 9 to
males.13,15,19,20 Alanen and colleagues,13 in a study of ankle joint 20 years. These authors found that females generally had a
mobility in 245 children ages 7 to 14 years (mean age 10 years), greater ROM in all ankle motions than males. Both males and
found that girls had a significantly greater range of passive females showed a consistent trend toward decreasing ROM with
plantarflexion compared to the boys in the study. However, increasing age, but females had a larger decrease than males.
according to the authors, the differences were small and proba- In contrast to the findings of the previously mentioned
bly not of clinical inportance. studies, Saxena and Kim14 found no differences in dorsiflex-
Bell and Hoshizaki19 studied 17 joint motions in ion ROM values between 24 boys and 16 girls ages 14 to
124 females and 66 males ranging in age from 18 to 88 years. 17 years. However, the age range in this study was relatively
Females between 17 and 30 years of age had a greater ROM small compared to Grimston’s23 study.
in plantarflexion and dorsiflexion than males in the same age
groups. Walker and colleagues20 studied active ROM in 30 men Testing Position
and 30 women ranging in age from 60 to 84 years. Women A variety of positions are used to measure dorsiflexion ROM,
had 11 degrees more ankle plantarflexion than men. including sitting with the knee flexed, supine with the knee
James and Parker15 found that the only motion that either flexed or extended, prone with the knee either flexed or
showed a significant difference between the genders was extended, and standing with the knee either flexed or
plantarflexion measured with the knee extended. Women and extended. Positions in which the knee is flexed bring the dis-
men had similar mean values in the group between 70 and tal and proximal attachments of the gastrocnemius muscle
74 years of age, but the reduction in active and passive ROM closer together and result in relaxing the muscle so that its
over the entire age range was greater for men (25.2 percent) effect on dorsiflexion ROM is reduced. Positions in which the
than for women (11.3 percent). High-heeled shoe wear has knee is extended generally are used for testing the length of
been proposed by Nigg and associates18 as one reason why the gastrocnemius muscle (Tables 10.6 and 10.7). Dorsiflex-
women have a greater ROM in plantarflexion than men. ion measurements taken in the weight-bearing position are
In contrast to the findings that women have greater ROM usually greater than measurements taken in non–weight-
in plantarflexion than men, a few investigators have found that bearing positions.22
females have less active and passive dorsiflexion ROM than McPoil and Cornwall28 compared dorsiflexion ROM mea-
males.18,20,21 In a study by Nigg and associates,18 males in the surements taken with the knee flexed with measurements taken
oldest group had a greater active ROM in dorsiflexion with the knee extended in 27 healthy young adults. As might
(8 degrees) measured with the knee flexed than females in the be expected, the mean dorsiflexion ROM (16.2 degrees) with
same age group (Table 10.5). Females showed a significant the knee flexed was greater than the mean (10.1 degrees) with
decrease in active dorsiflexion ROM with increasing age, the knee extended (Table 10.7). In a study of dorsiflexion
from 26.0 degrees in the youngest group to 18.5 degrees in the ROM in 7 to 14 year olds, Alanen and colleagues13 found that
oldest group. Females also showed a significant decrease in dorsiflexion measurements taken with the knee flexed to
eversion of 5.8 degrees with increasing age. Males, however, 90 degrees were 10 to 19 degrees greater than measurements
had little or no change in either active dorsiflexion or eversion taken with the knee extended.
ROM from the youngest to the oldest group. Vandervoort and Riemann and coworkers29 measured the resistance to pas-
coworkers21 experienced similar findings in a study measuring sive dorsiflexion from 23 degrees of plantarflexion to 13 degrees
passive dorsiflexion ROM with the knee flexed. The end of of dorsiflexion in 12 physically active men (mean age 22 years)
the ROM was defined as the maximum degree of dorsiflexion and 12 women (mean age 20 years). Passive movements at a
possible before muscle contraction occurred, or when the constant angular velocity were applied using a Biodex System
subject felt discomfort, or when the heel lifted from a floor 2 Isokinetic Dynamometer in passive mode. Significantly higher
plate. Females in the study showed a decrease in passive dor- stiffness values were found in the knee extended position com-
siflexion ROM, from a high of 19.3 degrees in the youngest pared with the knee flexed position. The stiffness values in the
group (aged 55 to 60 years) to a low of 12.1 degrees in the gastrocnemius increased significantly as the ankle moved from
oldest group (aged 81 to 85 years; Table 10.5). In comparison, plantarflexion toward dorsiflexion. Stiffness was defined by the
male subjects showed a decrease of only 2.3 degrees in dorsi- authors as representing the amount of deformation proportional
flexion from the youngest group (mean 15.4 degrees) to the to the load applied.
oldest group (mean 13.1 degrees). Males had greater Moseley, Crosbie, and Adams24 quantified the passive dor-
passive elastic stiffness than females, with 10 degrees of siflexion ROM resulting from a 12-Nm torque applied by a dy-
dorsiflexion. namometer to the soles of both feet of 300 healthy male and
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TABLE 10.5 Effects of Age and Gender on Dorsiflexion Range of Motion in Males and Females
Aged 40 to 85 Years: Normal Values in Degrees
Nigg et al*18 Vandervoort et al†21
40–59 yrs 70–79 yrs 55–60 yrs 81–85 yrs
Males Females Males Females Males Females Males Females
n = 15 n = 15 n = 15 n = 15 n = 20 n = 16 n = 18 n = 17
Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD)
25.0 (7.0) 26.0 (6.4) 26.4 (4.7) 18.5 (4.8) 15.4 (4.3) 19.3 (3.2) 13.1 (3.5) 12.1 (5.5)
TABLE 10.6 Dorsiflexion Range of Motion Measured in Non–Weight-Bearing Positions with the Knee
Extended in Male and Female Subjects Aged 20 to 85 Years: Normal Values in Degrees
Gajdosik et al*16 Moseley et al†24 Jonson and Gross‡25 Vandervoort et al§21
20–24 yrs 40–59 yrs 60–84 yrs 15–34 yrs 18–30 yrs 55–60 yrs 80–85 yrs
n = 24 n = 24 n = 33 n = 298 n = 57 n = 36 n = 35
Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD)
25.83 (5.5) 22.8 (4.4) 15.4 (5.8) 18.1 (6.9) 16.2 (3.7) 20.3 (4.6) 11.8 (5.2)
TABLE 10.7 Comparison Between Dorsiflexion Range of Motion Measurements Taken With the Knee
Flexed and Extended in Subjects Aged 8 to 87 Years: Normal Values in Degrees
Bennell et al*26 Ekstrand et al†27 McPoil and Cornwall‡23 Mecagni et al§24
8–11 yrs 8.2–11 yrs 20–25 yrs 22–30 yrs Mean 26.1 yrs 64–87 yrs
n = 77 n = 49 n = 10 n = 12 n = 56 feet n = 34
Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD)
Knee flexed 31.9 (6.8) 29.2 (6.4) 26.6 (2.5) 24.9 (0.8) 16.2 (3.2) 10.9 (4.2)
Knee extended 25.0 (7.6) 25.4 (8.5) 22.9 (2.5) 22.5 (0.7) 10.1 (2.2) 8.5 (3.1)
female subjects who were in the supine position with the knee results showed that the positions could not be used interchange-
extended. Based on the results, the authors proposed a scheme ably, with the exception of the heel rise and seated non–weight-
in which application of the same Nm torque would classify bearing positions.
passive dorsiflexion ROM less than 4 degrees as hypomobile,
11.2 to 25 degrees as normal, and 32 degrees as hypermobile. Injury/Disease
Baggett and Young22 compared measurements of dorsi- Wilson and Gansneder33 measured physical impairments (loss of
flexion ROM taken in the non–weight-bearing supine position passive ankle dorsiflexion, plantarflexion ROM, and swelling),
with those taken in the standing weight-bearing position in functional limitations, and disability duration in 21 athletes with
10 males and 20 female patients aged 18 to 66 years. Both acute ankle sprains. ROM loss was obtained by subtracting the
supine and standing measurements were taken with the knees passive ROM total of the affected ankle from the passive ROM
extended. The average dorsiflexion ROM in the supine posi- measurements taken on the unaffected ankle. The authors found
tion was 8.3 degrees, whereas the average dorsiflexion ROM that the combination of ROM loss and swelling predicted an ac-
in the standing position was 20.9 degrees. Little correlation ceptable estimate of disability duration, accounting for one third
was found between measurements taken in the non–weight- of the variance. Functional limitation measures alone provided a
bearing position with those taken in the weight-bearing posi- better estimate of disability duration, accounting for 67 percent
tion. Consequently, the authors recommended to examiners of the variance in the number of days the athletes were unable
that the non–weight-bearing and weight-bearing positions to work after the acute ankle sprain.
should not be used interchangeably and that the weight- Morrison and Kaminski34 reviewed the literature for the
bearing position might be more clinically relevant. years 1965 to 2005 for information that identified the risk fac-
Bohannon, Tiberio, and Waters,30 in a study involving tors for acute and chronic ankle inversion injuries and for the
11 males and 11 females aged 21 to 43 years, investigated role that the foot played in these types of injuries.The authors
passive ROM for ankle dorsiflexion by means of different go- found that the most commonly identified risk factors were a
niometer alignments. In one alignment, the arms of the go- high longitudal arch, large foot width, cavovarus foot defor-
niometer were arranged parallel with the fibula and the heel. mity, open chain large calcaneal eversion ROM in women,
The second alignment used the fibula and a line parallel to the subtalar joint instability, and a large ROM in MTP extension.
fifth metatarsal. These authors found that passive ROM mea- However, the authors suggested that a great deal of research
surements for dorsiflexion differed significantly according to was necessary to adequately evaluate these risk factors.
which landmarks were used. Kaufman and associates35 tracked 449 trainees at a Naval
Menadue and colleagues7 compared measurements of Special Warfare Training Center to determine whether an
inversion and eversion in both ankles of 60 male and female association existed between foot structure and the develop-
patients between the ages of 21 and 59 years. Some of the ment of musculoskeletal overuse injuries of the lower extrem-
patients had a past history of a variety of orthopedic ankle ities. Restricted dorsiflexion ROM was one of the five risk
conditions. Three testers used universal goniometers to per- factors associated with overuse injury.
form the measurements in the sitting and prone positions. Full Chesworth and Vandervoort36 measured dorsiflexion
cycle (inversion-eversion) ROM was 43.1 degrees in the sitting ROM after ankle fractures due to snowboarding accidents.
position and 24.2 degrees in the prone position. Naturally, the They found that large differences occurred in the maximum
two positions should not be used interchangeably. passive dorsiflexion ROM between fractured ankles and the
Lattanza, Gray, and Kanter31 measured subtalar joint contralateral uninvolved ankles. Maximum passive dorsiflex-
eversion in weight-bearing and non–weight-bearing postures ion was defined as that point just prior to the initiation of
in 15 females and 2 males. Measurements of subtalar joint muscle activity in the plantarflexor muscles. The authors
eversion in a weight-bearing posture were found to be signif- hypothesized that the reflex length-tension relationship was
icantly greater than those in a non–weight-bearing posture. altered in the fractured ankles and that this reflex activity
The authors advocated measurement in both positions. acted as a protective mechanism to prevent overstretching of
Nawoczenski, Baumjauer, and Umberger32 measured active the fragile plantarflexors after a period of immobilization.
and passive extension ROM of the MTP joint of the first toe in Reynolds and colleagues37 found that in rats, 6 weeks of
different positions in 14 women and 19 men between the ages immobilization of a healthy hind limb resulted in a significant
of 20 and 54 years. Active and passive toe extension measure- (70 percent) loss of dorsiflexion ROM when a fixed torque
ments were taken with the subject standing on a platform with was applied. The authors suggested that loss of extensibility
toes extending over the edge. Passive measurements were taken of the musculotendinous unit was probably caused by tissue
in the non–weight-bearing seated position and during heel rise remodeling that occurred during extended immobilization.
in standing. Mean values in the weight-bearing position were Hastings and coworkers38 studied a single patient with
37.0 degrees for passive MTP extension and 44.0 degrees for diabetes mellitus who had received a tendo-achilles lengthen-
active extension, compared with a mean value of 57.0 degrees ing procedure. The operation resulted in an increase in dorsi-
obtained in the non–weight-bearing seated position and flexion ROM with the knee extended from a preoperative
58 degrees during heel rise in the standing position. Similar to level of 0 degrees to a 7-month postoperative level of
the effects of different testing positions on ankle ROM, the 18 degrees. Plantar pressure during gait was considerably
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TABLE 10.8 Range of Ankle Motion Necessary for Functional Locomotor Activities:
Values in Degrees
Gait Level Surfaces Stair Ascent Stair Descent
Dorsiflexion 0–10 (Murray) 43
14–27 (Livingston et al)* 48
21–36 (Livingston et al)* 48
0–10 (Rancho Los Amigos) 42
15–25 (McFayden and Winter)* 47
21.1 (Protopadaki et al) †49
0–15 (Ostrosky et al) 44
11.2 (Protopadaki et al) † 49
an adequate extension ROM at the MTP joints for normal elderly used 200 percent of their passive dorsiflexion ROM so
gait. If the ROM at the MTP joints is limited, it will interfere that they could spend more time in foot flat to increase their
with forward progression, and the step length of the contralat- stability.
eral leg will be decreased.42 Mecagni and colleagues51 suggested that decreases in
Running requires 0 to 20 degrees of dorsiflexion and 0 to dorsiflexion ROM constituted a risk factor for decreased bal-
30 degrees of plantarflexion.46 These ROMs are similar to the ance and alteration of movement patterns. Hastings and
amount of motion required for stair ascent and descent, as coworkers38 identified limited dorsiflexion ROM as a risk
shown in Table 10.8. Ascending stairs requires between 11 factor for increased plantar pressures during walking and
and 27 degrees of dorsiflexion,47 whereas descending stairs decreased functional performance in patients with diabetes
requires a maximum of between 21 and 36 degrees of dorsi- mellitus.
flexion48 (Fig. 10.59) and between 24 and 40 degrees of plan- Torburn, Perry, and Gronley52 found that when subjects
tarflexion.49 The height of the stair risers will affect the amount assumed a relaxed, one-legged standing position in three
of ROM required. Another activity requiring maximum dorsi- trials, they stood with the rearfoot in approximately the same
flexion is rising from a chair (Fig. 10.60). everted position (mean of 9.8 degrees). This position of the
In a study by Lark and associates,50 six elderly and six rearfoot during one-legged standing could be used as an indi-
young subjects performed a stepping-down task from a range cation of the maximum eversion ROM needed for the single
of stair heights. At all stair heights, the maximum dorsiflexion support phase of gait. Garbalosa and associates53 measured
angle during descent was significantly greater in the elderly forefoot–rearfoot frontal plane relationships in 234 feet (120
than in the younger subjects. The authors determined that the healthy males and females with a mean age of 28.1 years).
FIGURE 10.59 Descending stairs requires an average of FIGURE 10.60 Getting out of a chair may require a full
21 to 36 degrees of dorsiflexion.48 dorsiflexion range of motion (ROM), depending on the
height of the chair seat. The lower the seat, the greater the
ROM required.
2066_Ch10_263-316.qxd 5/22/09 8:06 PM Page 311
Approximately 87 percent of the measured feet had forefoot for measuring dorsiflexion. Four examiners used an incli-
varus, 8.8 percent had forefoot valgus, and 4.6 percent had a nometer to measure the angle between the anterior border and
neutral forefoot–rearfoot relationship. the vertical border of the tibia and a tape measure to deter-
Hemmerich and associates,54 in a study of activities of mine the distance of the lunging toe from the wall. Intratester
daily living in a non-Western culture, found that the largest and intertester reliability was extremely high (ICC = 0.97 to
mean dorsiflexion angle required by 30 Indian subjects was 0.99) for the four examiners with both methods of assessment
39.7 degrees for kneeling with the ankles dorsiflexed. Squat- (Table 10.9).
ting with the heels down required 38.5 degrees of dorsiflex- Three testers in a study by Evans and Scutter60 used
ion. These amounts of dorsiflexion are much larger than visual estimation to assess dorsiflexion ROM in 29 healthy
required for many activities of daily living in Western cul- children ages 4 to 6 years. The estimates were made with chil-
tures, such as getting in and out of a chair or bed or walking dren in the prone position with the knee both flexed and
up and down stairs. Cross-legged sitting on the floor is extended. Intertester reliability of measures in both positions
another common posture assumed in non–Western cultures, was very poor and highly variable between testers.
and that activity was found to require a maximum angle of Alanen and colleagues13 used a universal goniometer to
17 degrees of eversion. Because health-care workers are apt to assess the ROM of the ankle in 245 healthy children ages 7 to
encounter people of many different cultures, it is important 14 years. Passive dorsiflexion was measured in the prone
that they are aware that other cultures may require different position with the knee extended and flexed. Plantarflexion
ROM goals for rehabilitation. was measured in the supine position. Dorsiflexion in the
weight-bearing position was measured from photographs. The
range of ICCs varied from a low of 0.51 for right eversion to
Reliability and Validity
0.88 for weight-bearing dorsiflexion measurements.
Reliability studies involving one or more motions at the ankle
Reliability: Dorsiflexion and Plantarflexion
have been conducted on healthy subjects13,56–60 and on patient
in Patient Populations
populations.66–68 Also, motions of the subtalar joint, the subta-
Allington, Leroy, and Doneux61 had two testers follow a strict
lar joint neutral position, and the forefoot position have been
protocol to assess intratester and intertester reliability and
investigated.
reproducibility of ankle ROM in 24 children ages 3 to 14 years
In 2004 Martin and McPoil55 reviewed the existing ankle
with cerebral palsy. Pearson’s correlation coefficients for
literature and found ample evidence for intratester reliability
intratester and intertester reliability for both the universal
for dorsiflexion and plantarflexion ROM, some evidence for
goniometer and visual estimates were excellent (r >90) for
intertester reliability of dorsiflexion, but little evidence of
dorsiflexion with the knee flexed and extended. The Pearson’s
intertertester reliability for plantarflexion ROM. The authors
correlation coefficients for intratester and intertester reliabil-
also determined that subject diagnosis, with the exception of
ity for plantarflexion for both goniometric and visual esti-
cerebral palsy, did not appear to affect intratester reliability.
mates were in the good category (r >0.80) and in the fair to
Training sessions prior to measurement appeared to have a
good category for inversion and eversion. The SEM for dorsi-
positive effect on intrarater reliability. However, the authors
flexion and plantarflexion was 4 to 5 degrees; the SEM for
concluded that on the basis of the literature review, the
eversion was 6 to 9 degrees; and the SEM for inversion was
responsiveness of ankle measurements was uncertain.
5 to 9 degrees. Even though both goniometric and visual esti-
Reliability: Dorsiflexion and Plantarflexion mates were reliable, the mean measurement error of 5 degrees
in Healthy Populations plus the standard deviation of 5 degrees produced a 0- to
Some joints and motions can be measured more reliably than 10.degree error that would have to be taken into account in
others. Boone and associates56 found that intratester reliabil- clinical decision-making.
ity for selected motions at the ankle was better than that McWhirk and Glanzman62 assessed intertester reliability
obtained for hip and wrist motions, but it was not as good as of measurements of ankle dorsiflexion in 25 children (ages
that obtained for selected motions at the shoulder, elbow, 2 to 18 years) with spastic cerebral palsy. The two therapists
and knee. who took the measurements succesively on the same day
Clapper and Wolf57 found that both the universal goniome- helped each other hold the limbs at end range. Intertester
ter and the OrthoRanger (Orthotronics, Daytona Beach, FL) relaibility was very good, with an ICC 0.87 and a mean
were reliable instruments for measuring dorsiflexion and plan- absolute difference of 3.6 degrees. The 95 percent confidence
tarflexion but that the intraclass correlation coefficients (ICCs) interval around the mean absolute difference was 1.2 degrees.
were higher for the universal goniometer. The ICC for measure- Mutlu, Livanelioglu, and Gunel63 assessed the intratester
ments of active dorsiflexion for the universal goniometer was and intertester reliability of goniometric measurements of
0.92, in comparison with 0.80 for the OrthoRanger. The ICC ankle dorsiflexion that were taken by three therapists in
for the universal goniometer for plantarflexion was 0.96, 38 children (ages 18 to 108 months) with spastic cerebral
whereas the ICC for the OrthoRanger was 0.93. palsy. The therapists used a 360-degree universal goniometer
Bennell and colleagues58 determined intertester and to measure dorsiflexion once in two different sessions a week
intratester reliability using the weight-bearing lunge method apart. Intratester reliability was determined using Pearson’s
2066_Ch10_263-316.qxd 5/22/09 8:06 PM Page 312
Bennell et al 58
13 Healthy adults Weight bearing 0.98 0.97 1.1º (Intra)
(mean age lunge with knee 1.4º (Inter)
18.8 yrs) flexed
Clapper and 20 Healthy adults 0.92
Wolfe56 (20–36 yrs)
McPoil and 27 Healthy adults Knee flexed to 90º 0.97
Cornwall28 (mean age Knee extended 0.98
26.1 yrs)
Jonson and 18 Healthy adults Knee extended— 0.74 0.65
Gross25 (18–30 yrs) prone position
Salsich et al39 34 One-half healthy/ Knee extended— 0.95
one-half with prone position
diabetes
mellitus
(59–63 yrs)
Elveru et al64 43 Patients with Passive ROM— 0.90 0.50
orthopedic or no standard
neurological position used
problems
(12–81 yrs)
Youdas et al65 38 Patients with Active ROM— 0.64–0.96 0.28
orthopedic no standard
problems position used* Median 0.83
(13–71 yrs)
reliability coefficient (r) and ICCs. The r values ranged from movement in neurological patients, and difficulties encoun-
0.65 to 0.81, and ICCs ranged from 0.81 to 0.90, with the tered by the examiner in maintaining the foot and ankle in the
most experienced tester obtaining the highest reliability. desired position while holding the goniometer. It would
Intertester reliability r values ranged from 0.65 to 0.75, and appear that the latter problem could be solved by having
the ICC value was very good (0.88). Based on the findings of another person either maintain the foot and ankle in position
this study and the previous study, it appears to be possible to or hold the goniometer.
obtain reliable goniometric measurements in this population Youdas, Bogard, and Suman65 used 10 examiners in a
of children with spastic cerebral palsy. The authors suggested study to determine the intratester and intertester reliability for
that this study needs to be followed with a validity study. active ROM in dorsiflexion and plantarflexion. The authors
Elveru and associates64 employed 12 physical therapists compared measurements made by a universal goniometer
using universal goniometers to measure the passive ankle with visual estimates on 38 patients with orthopedic prob-
ROM in 43 patients with either neurological or orthopedic lems. Fair to excellent reliability was noted when repeated
problems. The ICCs for intratester reliability for inversion and measurements were made by the same therapist using a
eversion were 0.74 and 0.75, respectively, and intertester goniometer. Reliability was higher using the mean of two
reliability was poor (see Tables 10.9, 10.10, and 10.11). repeated measurements than using one measurement. A
Intertester reliability also was poor for dorsiflexion, and considerable measurement error was found to exist when
patient diagnosis affected the reliability of dorsiflexion mea- two or more therapists made either repeated goniometric or
surements. Sources of error were identified as variable visual estimates of the ankle ROM on the same patient
amounts of force being exerted by the therapist, resistance to (see Tables 10.9 and 10.10). Therapists used various patient
2066_Ch10_263-316.qxd 5/22/09 8:06 PM Page 313
positions and goniometer alignment methods. The authors tently reduced reliability (see Table 10.11). Based on the study
suggested that the same therapist should make two goniomet- of Elveru, Rothstein, and Lamb64 and information from the fol-
ric measurements and record the average value when making lowing studies, we have decided not to use the subtalar neutral
repeated measurements of ankle ROM. position as defined by Elveru and associates67 in this text.
Bailey, Perillo, and Forman68 used tomography to study
Reliability: Eversion and Inversion the subtalar joint neutral position in 2 female and 13 male vol-
The subtalar joint neutral position, which has been the subject unteers aged 20 to 30 years. These authors found that the neu-
of numerous studies, is not the same as the 0 starting position tral subtalar joint position was quite variable in relation to the
for the subtalar joint as used in this book and many others, total ROM and that it was not always found at one third of the
including those of the AAOS,3,4 the AMA,5 and Clarkson.66 The total ROM from the maximally everted position. Furthermore,
subtalar joint neutral position is defined as one in which the the neutral position varied not only from subject to subject but
calcaneus inverts twice as many degrees as it everts. also between right and left sides of each subject.
According to Elveru and associates,67 this position can be Picciano, Rowlands, and Worrell69 conducted a study to de-
found when the head of the talus either cannot be palpated or termine the intratester and intertester reliability of measure-
is equally extended at the medial and lateral borders of the ments of open-chain and closed-chain subtalar joint neutral po-
talonavicular joint. This is the position usually used in the cast- sitions. Both ankles of 15 volunteer subjects (with a mean age
ing of foot orthotics, but it also has been used for measurement of 27 years) were measured by two inexperienced physical ther-
of joint motion. However, Elveru, Rothstein, and Lamb64 apy students. The students had a 2-hour training session using a
found that referencing passive ROM measurements for inver- universal goniometer prior to data collection. The method of
sion and eversion to the subtalar joint neutral position consis- taking measurements was based on the work of Elveru and
associates.67 Intratester reliability of open-chain measurements values measured with a universal goniometer have been
of the subtalar joint neutral position was an ICC of 0.27 for one compared to values taken with another device. Menadue and
tester and ICC of 0.06 for the other tester. Intertester reliability colleagues7 found low correlations between full-cycle active
was 0.00. Intratester and intertester reliability also were poor for inversion and eversion measurements taken with the 3Space
closed-kinematic-chain measurements. The authors69 concluded Fastrak electromagnetic tracking system and the universal
that subtalar joint neutral measurements taken by inexperienced goniometer. Only 18 percent of the variance in Fastrak mea-
testers were unreliable; they recommended that clinicians surements could be explained by the goniometric measure-
should practice taking measurements and performing repeated ments. The discrepancy between the goniometric and Fastrak
measurements to determine their own reliability for these mea- measurements may be partially explained by the fact that the
surements. However, Torburn, Perry, and Gronley52 suggested Fastrak system records motion in all planes, whereas the uni-
that inaccuracy of measurement technique with use of a univer- versal goniometer measures motion in one plane.
sal goniometer, rather than the ability of examiners to position Ankle ROM values have been compared to functional
the subtalar joint in the neutral position, might be responsible for assessment measures. Mecagni and coworkers51 assessed ac-
poor reliability findings for subtalar joint neutral positioning. tive assistive and passive ankle ROM and balance perfor-
The ICC for intertester reliability for three examiners was an mance using the Performance Oriented Mobility Assessment
ICC of 0.76 for positioning the subtalar joint in the neutral po- (POMA) in 34 healthy elderly women ages 64 to 87 years.
sition. In this study, the examiners palpated the head of the talus Correlations between the POMA gait subtest indicated that all
in 10 subjects lying in the prone position while an electrogo- ankle motions contributed to the maintenance of balance dur-
niometer was used to record the position (see Table 10.11). ing gait: inversion (r 0.50), dorsiflexion with knee flexed
already inserted Table 10.11 (r 0.44), plantarflexion (r 0.42), and eversion (r 0.32).
Keenan, App, and Bach70 used a prone measurement posi- Active assistive ROM had higher correlations compared to
tion system described by Elveru et al67 to assess the non–weight- passive ROM. The highest correlation was between active
bearing subtalar neutral position and subtalar inversion and assistive ROM and the POMA gait subtest (r 0.63).
eversion in 24 healthy subjects. Static and dynamic measure-
Reliability: Metatarsophalangeal Extension
ments were made on two different occasions by four experi-
Hopson, McPoil, and Cornwall71 conducted four static clinical
enced clinicians using a universal goniometer. Intertester
tests to measure extension ROM of the first MTP joint in
reliability was poor and so was test-retest reliability for static
20 healthy adult subjects between 21 and 45 years of age. All
measurements. Reliability was also poor for visual assessments
measurement techniques were found to be reliable but not
of dynamic measurements. The most experienced clinician had
interchangeable. Approximately 65 degrees of first MTP exten-
the highest overall reliability, whereas the clinician with only a
sion was required for normal walking as determined from video
year’s experience had the lowest reliability. However, the same
recordings. The values from the four clinical tests of first MTP
trend was not evident in static measurements.
extension ROM exceeded the amount required for walking.
In contrast to the low reliability found in the aforemen-
tioned studies, McPoil and Cornwall46 found high intratester Validity: Metatarsophalangeal Extension
reliability for both subtalar inversion and eversion ROM mea- No studies were noted that examined the concurrent validity of
surements taken by two testers (see Table 10.11). MTP motions measured with a universal goniometer to radio-
Menadue and colleagues7 assessed active inversion and graphs. Construct validity of clinical measures of first MTP
eversion ROM in the prone lying position with the ankle extension ROM to indicate ROM during gait have been initally
over the edge of the table. The 30 subjects in the study had explored.71,32 Nawoczenski, Baumjauer, and Umberger32 used
both ankles measured by three testers using a blinded uni- four clinical tests to measure the first MTP joint extension:
versal goniometer. Test and retest measurements were made active and passive ROM and heel rise in the weight-bearing po-
2 weeks apart. Within-session intratester reliability for sition, and passive ROM in the non–weight-bearing position.
inversion was excellent (ICC 0.94) for all testers, whereas Test values were compared with measurements of MTP exten-
intratester reliability for eversion was slightly lower and sion during normal walking. Active ROM in the weight-bearing
ranged from good (ICC 0.83) to excellent (ICC 0.96) position (44 degrees) and extension measured during heel rise
among the three testers. Intertester reliability ranged from (58 degrees) had the strongest correlations with motion of the
poor (ICC 0.33) to fair (ICC 0.70) for inversion MTP joint (42 degrees) during normal walking (r 0.80 and
and was unacceptable for eversion. Between-sessions mea- 0.87, respectively).
surement error ranged from 4 degrees to 8 degrees. (See
Table 10.11 for additional information.)
Validity: Eversion, Inversion, Dorsiflexion,
and Plantarflexion
We are unaware of any studies that compared ankle and foot
ROM values measured with a universal goniometer to values
measured with radiographs. However, eversion and inversion
2066_Ch10_263-316.qxd 5/22/09 8:06 PM Page 315
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IV
TESTING OF THE SPINE
AND TEMPOROMANDIBULAR
JOINT
ON COMPLETION OF PART IV, THE READER WILL BE Perform a range of motion assessment of the
ABLE TO: thoracic and lumbar spines using the universal
goniometer, tape measure, and inclinometers.
1. Identify: Please include the following in your assessment:
• Appropriate planes and axes for each spinal and • A clear explanation of the testing procedure
jaw motion • Placement of the subject in the appropriate
• Expected normal end-feels testing position
• Structures (contractile and noncontractile) that • Adequate stabilization of the proximal joint
have the potential to limit the end of the range of component
motion • Correct determination of the end of the range
of motion
2. Describe:
• Correct identification of the end-feel
• Testing positions for motions of the spine and jaw • Palpation and marking of the correct bony
• Goniometer, tape measure, and inclinometer landmarks
alignments • Accurate alignment of the goniometer
• Capsular patterns of restrictions • Correct reading and recording
• Range of motion necessary for functional tasks
5. Perform a range of motion assessment of the
3. Explain: temporomandibular joint using a ruler.
• How age, gender, and other factors may affect
the range of motion 6. Assess the intratester and intertester reliability
• How sources of error in measurement may affect of measurements of the spine and
testing results temporomandibular joint.
4. Perform a range of motion assessment of the 7. Discuss the reliability and validity of range
cervical spine using the universal goniometer, of motion measurements using the universal
tape measure, inclinometers (double and single), goniometer, tape measure, inclinometers, CROM
and cervical range of motion (CROM) device. device, and ruler.
Chapters 11 through 13 present common clinical techniques for measuring gross motions of the cervical,
thoracic, and lumbar spine and the temporomandibular joint. Evaluation of the range of motion and end-feels of
individual facet joints of the spine are not included.
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11
The Cervical Spine
Structure and Function (Fig.11.3A) and posteriorly by the posterior atlanto-occipital,
atlantoaxial, and tectorial membranes (Fig.11.3B).
Superior band
Occipital cruciate ligament Transverse band cruciate ligament
Dens
bone
Superior articular
facet
Atlanto-occipital
joint Lateral atlantoaxial
Spinous process joint
Atlas Atlas Inferior articular
(C1) (C1) facet
Superior atlantal Median atlantoaxial
joint
articular process
Anterior aspect
Atlanto-occipital membrane
Posterior aspect
Occipital
bone
Tectorial
membrane
Atlas
(transverse
process)
Posterior
Axis
longitudinal
(transverse
ligament
process)
C3
C4
B
FIGURE 11.3 A: The anterior atlanto-occipital and atlantoaxial membranes help to support the anterior aspect of the atlanto-
occipital and atlantoaxial joints. B: The posterior atlanto-occipital, atlantoaxial, and tectorial membranes help to support the
posterior aspect of the atlanto-occipital and atlantoaxial joints. The tectorial membrane is an extension of the posterior longi-
tudinal ligament.
The two lateral atlantoaxial joints are plane synovial of the top of the head. For example, in flexion, the occipital
joints that allow flexion–extension, lateral flexion, and condyles roll anteriorly and glide posteriorly on the concave
rotation. The median atlantoaxial joint is a synovial trochoid articular surfaces of the atlas. In extension, the occipital
(pivot) joint that permits rotation. Approximately 55 percent condyles roll posteriorly and glide anteriorly on the atlas and
of the total cervical range of rotation occurs at the atlantoaxial the back of the head moves posteriorly.1
joint. Rotation at the median atlantoaxial joint is limited At the lateral atlantoaxial joints the inferior zygapophy-
primarily by the two alar ligaments, with minor restraint seal articular facets of the atlas are convex and articulate with
being provided by the capsules of the lateral atlantoaxial the superior concave articular facets of the axis. At the median
joints.1 About 45 degrees of rotation to the right and left joint the atlas forms a ring with the transverse ligament (band)
sides are available. The motions permitted at the three of the cruciate ligament, and this ring rotates around the dens
atlantoaxial articulations are flexion–extension, lateral flexion, (odontoid process), which serves as a pivot for rotation. The
and rotation.6 dens articulates with a small facet in the central area of the
anterior arch of the atlas.
Arthrokinematics
At the atlanto-occipital joint when the head moves on the Capsular Pattern
atlas (convex surfaces moving on concave surfaces), the The capsular pattern for the atlanto-occipital joint is an equal
occipital condyles roll in the same direction as the top of restriction of extension and lateral flexion. Rotation and
the head and glide in the direction opposite to the movement flexion are not affected.2
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Joints
Anatomy
The intervertebral joints are composed of the superior and
inferior surfaces of the vertebral bodies and the adjacent inter- C3
vertebral discs (Fig. 11.4). The joints are reinforced anteriorly
by the anterior longitudinal ligament, which limits extension C4
(Fig. 11.5), and posteriorly by the posterior longitudinal
ligament, ligamentum nuchae, ligamentum flavum, supraspin- Anterior
C5
ous and interspinous ligaments (Fig. 11.6), and the back longitudinal
ligament
extensors, which help to limit flexion. C6
The zygapophyseal joints are formed by the right and
left superior articular facets (processes) of one vertebra and C7
the right and left inferior articular facets of an adjacent supe-
rior vertebra (Fig. 11.7). Each joint has its own capsule and
capsular ligaments, which are lax and permit a relatively
large ROM. The ligamentum flavum helps to reinforce the
joint capsules.
Osteokinematics FIGURE 11.5 The anterior longitudinal ligament reinforces the
According to White and Punjabi,7 one vertebra can move in anterior portion of the discs and helps to prevent extremes of
relation to an adjacent vertebra in six different directions extension.
(three translations and three rotations) along and around three
axes. The compound effects of sliding and tilting at a series flexion from C2 to C5 is accompanied by rotation to the left
of vertebrae produce a large ROM for the column as a whole, (spinous processes move to the right) and forward flexion. In
including flexion–extension, lateral flexion, and rotation. the cervical region from C2 to C7, flexion and extension are
Some motions in the vertebral column are coupled with other the only motions that are not coupled.7
motions; this coupling varies from region to region. A The intervertebral joints are cartilaginous joints of the
coupled motion is one in which one motion around one axis symphysis type. The zygapophyseal joints are synovial plane
is consistently associated with another motion or motions joints. In the cervical region, the facets are oriented at
around a different axis or axes. For example, left lateral 45 degrees to the transverse plane. The inferior facets of the
Zygapophyseal
joints Lateral aspect
Intervertebral
joints
C3
C3
C4 C4
Posterior
longitudinal
Vertebral C5
ligament
body C
5
C6
C
6 C7
C
7
Intervertebral
disc
FIGURE 11.6 The posterior longitudinal ligament reinforces
FIGURE 11.4 The lateral view of the cervical spine shows the the posterior portion of the discs and helps to prevent
intervertebral and zygapophyseal joints from C3 to C7. extremes of forward flexion.
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Uncinate processes inferior facets of the superior vertebrae slide anteriorly and
superiorly on the superior facets of the inferior vertebrae. In
extension, the inferior facets of the superior vertebrae slide
posteriorly and inferiorly on the superior facets of the inferior
vertebrae. In lateral flexion and rotation, one inferior facet of
Inferior articular
facet the superior vertebra slides inferiorly and posteriorly on the
superior facet of the inferior vertebra on the side to which
the spine is laterally flexed. The opposite inferior facet of the
superior vertebra slides superiorly and anteriorly on the supe-
rior facet of the adjacent inferior vertebra.
Capsular Pattern
The capsular pattern for C2 to C7 is recognizable by pain and
Superior equal limitation of all motions except flexion, which is
articular usually minimally restricted. The capsular pattern for unilat-
Zygapophyseal
facet
joint eral facet involvement is a greater restriction of movement in
lateral flexion to the opposite side and in rotation to the same
FIGURE 11.7 An anterior view of the right and left zygapophy- side. For example, if the right articular facet joint capsule is
seal joints between two cervical vertebrae. The vertebrae involved, lateral flexion to the left and rotation to the right are
have been separated to provide a clear view of the inferior
articular facets of the superior vertebra and the superior the motions most restricted.8
articular facets of the adjacent inferior vertebra. Measurement of the cervical spine ROM is complicated
by the region’s multiple joint structure, lack of well-defined
and standardized landmarks, lack of an accurate and
workable definition of the neutral position, and lack of a
superior vertebrae face anteriorly and inferiorly. The superior
standardized method of stabilization to isolate cervical
facets of the inferior vertebrae face posteriorly and superiorly.
motion from thoracic spine motion. The search for instru-
The orientation of the articular facets, which varies from
ments and methods that are capable of providing accurate
region to region, determines the direction of the tilting and
and affordable measurements of the cervical spine ROM is
sliding of the vertebra, whereas the size of the disc determines
ongoing. Tables 11.1 through 11.4 in the Research Findings
the amount of motion. In addition, passive tension in a num-
Section provide normal cervical spine ROM values from var-
ber of soft tissues and bony contacts controls and limits
ious sources and with use of a variety of methods. Additional
motions of the vertebral column. In general, although regional
tables and text in the Research Findings section provide
variations exist, the soft tissues that control and limit extremes
ROM values by age and gender. This information is followed
of motion in forward flexion include the supraspinous and
by functional ranges of motion and a review of research stud-
interspinous ligaments, zygapophyseal joint capsules, liga-
ies on the reliability and validity of the various instruments
mentum flavum, posterior longitudinal ligament, posterior
used to measure cervical range of motion.
fibers of the annulus fibrosus of the intervertebral disc, and
back extensors.
Extension is limited by bony contact of the spinous
processes and by passive tension in the zygapophyseal joint
capsules, anterior fibers of the annulus fibrosus, anterior lon-
gitudinal ligament, and anterior trunk muscles. Lateral flexion
is limited by the intertransverse ligaments, by passive tension
in the annulus fibrosus on the side opposite the motion on the
convexity of the curve, and by the uncinate processes. Rota-
tion is limited by fibers of the annulus fibrosus.
Arthrokinematics
The intervertebral joints permit a small amount of sliding and
tilting of one vertebra on another. In all of the motions at the
intervertebral joints, the nucleus pulposus of the intervertebral
disc acts as a pivot for the tilting and sliding motions of the
vertebrae. Flexion is a result of anterior sliding and tilting of a
superior vertebra on the interposed disc of an adjacent inferior
vertebra. Extension is the result of posterior sliding and tilting.
The zygapophyseal joints permit small amounts of
sliding of the right and left inferior facets on the right and left
superior facets of an adjacent inferior vertebra. In flexion, the
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Auditory
meatus
Sternal
notch
Acromion
process
2066_Ch11_317-364.qxd 5/21/09 5:19 PM Page 324
Tip of nose
Acromion Acromion
process process
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Top of
head
Occipital
bone
Spine of scapula
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FIGURE 11.15 In the 0 starting position for measuring cervical FIGURE 11.16 The goniometer reads 135 degrees at the end
flexion range of motion, the goniometer reads 90 degrees. of the range of motion (ROM) but the ROM should be
This reading should be transposed and recorded as 0 degrees. recorded as 0-45 degrees.
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FIGURE 11.18 Inclinometer alignment in the starting position FIGURE 11.19 Inclinometer alignment at the end of cervical
for measuring cervical flexion range of motion. flexion range of motion.
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CERVICAL FLEXION: CERVICAL situated over the top of the head in the transverse
plane and is used to measure rotation. A neckpiece
RANGE OF MOTION (CROM) containing two strong magnets is placed around the
DEVICE subject’s neck to ensure the accuracy of the compass
The mean flexion ROM for the CROM device ranges inclinometer.
from 64 degrees in subjects aged 11 to 19 years to The CROM device should fit comfortably over the
40 degrees in subjects aged 80 to 89 years.13 For bridge of the subject’s nose. A Velcro strap that goes
additional ROM values by age and gender, refer to around the back of the head can be adjusted to make
Capuano-Pucci14 and Tousignant15 in Table 11.1 in the a snug fit. One size instrument fits all, and it is rela-
Research Findings section; to Nilsson16 in Tables 11.5, tively easy for an examiner to fit the device to a sub-
11.6, and 11.7; and to Youdas13 in Tables 11.4, 11.8, ject.17 Remember to stabilize the subject’s trunk to
and 11.9. prevent thoracic motion.
Familiarize yourself with the CROM device prior to
beginning the measurement. The CROM device consists CROM Device Alignment17
of a headpiece that supports two gravity inclinometers 1. Place the CROM device carefully on the subject’s
and a compass inclinometer. One gravity inclinometer is head so that the nosepiece is on the bridge of the
located on the side of the head in the sagittal plane and nose and the Velcro strap fits snugly across the
is used to measure flexion and extension. The other back of the subject’s head (Fig. 11.20).
gravity inclinometer is located over the forehead in the 2. Position the subject’s head so that the inclinometer
frontal plane and is used to measure lateral flexion. on the side of the head reads 0 degrees.
The compass inclinometer has a gravity needle and is
FIGURE 11.20 The CROM device positioned on the subject’s FIGURE 11.21 The examiner is shown stabilizing the trunk
head in the starting position for measuring cervical flexion with one hand and maintaining the end of the flexion range
range of motion. The dial on the gravity inclinometer of motion with her other hand.
located on the side of the subjects head is at 0 degrees.
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Testing Position
Place the subject in the sitting position, with the tho-
racic and lumbar spine well supported by the back of
a chair. Position the cervical spine in 0 degrees of
rotation and lateral flexion. A tongue depressor can
be held between the teeth for reference.
Stabilization
Stabilize the shoulder girdle and chest to prevent
extension of the thoracic and lumbar spine. Usually,
the stabilization is achieved through the cooperation
of the patient and support from the back of the chair.
A strap placed around the chest and the back of the
chair also may be used.
Testing Motion
Put one hand on the back of the subject’s head
and, with the other hand, hold the subject’s chin.
Push gently but firmly upward and posteriorly on
the chin to move the head through the ROM in
extension (Fig. 11.22). The end of the ROM occurs
when resistance to further motion is felt and
further attempts at extension cause extension of
the trunk.
Goniometer Alignment 3. Align distal arm with the base of the nares. If a
See Figures 11.23 and 11.24. tongue depressor is used, align the arm of the
goniometer parallel to the longitudinal axis of the
1. Center fulcrum of the goniometer over the external tongue depressor.
auditory meatus.
2. Align proximal arm so that it is either perpendicu- ➧ NOTE: The same testing position, testing
lar or parallel to the ground. motions, and stabilization decribed for measuring
extension with a goniometer should be used for all
of the following alternative measurement methods.
FIGURE 11.23 In the 0 starting position for measuring FIGURE 11.24 At the end of cervical extension, the examiner
cervical extension range of motion the goniometer reads maintains the perpendicular alignment of the proximal
90 degrees. This reading should be transposed and goniometer arm and keeps the distal arm aligned with the
recorded as 0 degrees. base of the nares.
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CERVICAL EXTENSION: TAPE move his or her head posteriorly as far as possible,
FIGURE 11.26 Inclinometer alignment in the starting position FIGURE 11.27 Inclinometer alignment at the end of cervical
for measuring cervical extension range of motion. The extension range of motion.
examiner has zeroed both inclinometers prior to beginning
the motion.
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FIGURE 11.28 The subject is positioned in the starting FIGURE 11.29 At the end of cervical extension range of
position with the CROM device in place. The gravity motion (ROM), the examiner is stabilizing the trunk with one
inclinometer located at the side of the subject’s head is at hand and maintaining the end of the ROM with her other
0 degrees prior to beginning the motion. hand on top of the subject’s head.
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muscles: longus capitis, longus colli, scalenus anterior, ➧ NOTE: The same testing position, testing motion,
FIGURE 11.34 In the starting position for measuring cervical FIGURE 11.35 Inclinometer alignment at the end of lateral
lateral flexion range of motion, one inclinometer is flexion range of motion. At the end of the motion, the
positioned at the level of the spinous process of the first examiner reads and records the information on the dials of
thoracic vertebra. A piece of tape has been placed at that each inclinometer. The range of motion is the difference
level to help align the inclinometer. The examiner has between the readings of the two instruments.
zeroed both inclinometers prior to beginning the motion.
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FIGURE 11.36 The subject is placed in the starting position FIGURE 11.37 At the end of lateral flexion range of motion
for measuring cervical lateral flexion range of motion so that (ROM), the examiner is stabilizing the subject’s shoulder
the inclinometer located in front of the subject’s forehead is with one hand and maintaining the end of the ROM with
zeroed before starting the motion. her other hand on the subject’s head.
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Stabilization
Stabilize the shoulder girdle and chest to prevent
rotation of the thoracic and lumbar spine. A strap
across the chest may be used to keep the trunk from
rotating.
Testing Motion
Grasp the subject’s chin and rotate the head by
moving the head toward the shoulder, as shown in
Figure 11.38. The end of the ROM occurs when
resistance to movement is felt and further movement
causes rotation of the trunk.
FIGURE 11.39 To align the goniometer at the starting position for measuring cervical rotation
range of motion, the examiner stands in back of the subject, who is seated in a low chair.
FIGURE 11.40 At the end of the range of right cervical rotation, one of the the examiner’s hands
maintains alignment of the distal goniometer arm with the tip of the subject’s nose. The
examiner’s other hand keeps the proximal arm aligned parallel to the imaginary line between
the acromial processes.
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FIGURE 11.41 At the end of the right cervical range of motion, the examiner is using a tape measure
to determine the distance between the tip of the subject’s chin and her right acromial process.
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FIGURE 11.43 Inclinometer alignment at the end of cervical rotation range of motion (ROM). The
number of degrees on the dial of the inclinometer equals the ROM in rotation.
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CERVICAL ROTATION: CROM head. The arrow on the magnetic yoke should be
FIGURE 11.44 The compass inclinometer on the top of the FIGURE 11.45 At the end of right rotation range of motion
CROM device has been leveled so that the examiner is able (ROM), the examiner is stabilizing the subject’s shoulder
to zero it prior to the beginning of the motion. with one hand and maintaining the end of rotation ROM
with the other hand. The examiner will read the dial of the
inclinometer on the top of the CROM device. Rotation
ROM will be the number of degrees on the dial at the end
of the ROM.
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Research Findings account for a large amount of the variance in cervical ROM,
but age appears to have a stronger effect than gender.
O’Driscoll and Tomenson20 studied cervical ROM across
Measurement of the cervical spine ROM is complicated by the age groups using a type of inclinometer. They measured
region’s multiple joint structure and lack of well-defined land- 79 females and 80 males ranging in age from 0 to 79 years
marks, a workable definition of the neutral position, and a stan- and found that ROM decreased with increasing age and dif-
dardized method of stabilization to isolate cervical motion from ferences existed between males and females. In another study
thoracic motion. The search for instruments and methods capa- that included a relatively large number of subjects (250) and
ble of providing accurate and affordable measurements of the a large age range (from 14 to 70 years), Feipel and col-
cervical spine is ongoing. At this time the universal goniometer leagues28 found a significant decrease in all cervical motions
appears to be the most commonly used instrument in the clinic, with increasing age. Kulman30 compared the range of motion
although relatively few research studies are available to provide of 42 subjects aged 70 to 90 years and 31 subjects aged 20 to
normative data and to attest to the goniometer’s reliability 30 years and found that the elderly group had significantly
and validity. ROM values from one study are presented in less motion than the younger group for all motions measured,
Table 11.1. The tape measure also is used in the clinical setting including rotation. Sforza and coworkers,35 who studied the
and ROM values can be found in Table 11.2. Single inclinome- effects of age on ROM in 20 male adolescents (mean age
ter values are found in Table 11.3. 16 years), 30 young adult males (mean age 23 years), and
20 middle-aged men (mean age 37 years) also found that all
Effects of Age, Gender, and Other cervical AROMs decreased between the youngest group and
Factors on Cervical Range the oldest group.
Pellachia and Bohannon26 found that the mean values for
of Motion Measurements lateral flexion in subjects younger than 30 years of age
Age exceeded 42 degrees, whereas mean values for lateral flexion in
A large number of researchers have investigated the effects of subjects older than 79 years of age were less than 25 degrees.
age on active cervical ROM,13,16,20–36 but differences between Nilsson, Hartvigsen, and Christensen,16 in a study of 90 healthy
the populations tested and the wide variety of instruments and men and women aged 20 to 60 years, concluded that the
procedures employed in these studies make it difficult to com- decrease in half cycle cervical passive range of motion (PROM)
pare results. Generally, most researchers agree that in adults a with increasing age could be explained by using a simple linear
tendency exists for cervical ROM to decrease with increasing regression of ROM as a function of age. Chen and colleagues,27
age. The only exception that has been found by some authors in a detailed review of the literature regarding the effects of
is that axial rotation (occurring primarily at the atlantoaxial aging on cervical spine ROM, concluded that active cervical
joint) has been shown either to stay the same or to increase ROM decreased by 4 degrees per decade. This finding is
with increasing age to compensate for an age-related decrease very close to the 5-degree decrease found by Youdas and
in rotation in the lower cervical spine.22,29 Age may not associates.13
CROM ⫽ cervical range of motion device; ROM ⫽ range of motion; SD ⫽ standard deviation.
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TABLE 11.2 Cervical Spine Range of Motion Measured With a Tape Measure: Normal Values
in Centimeters
Hsieh and Yeung*10 Balogun et al†11
Ages 14–31 yrs Ages 18–26 yrs
Tester 1 Tester 2
n = 17 n = 17 n = 21
Motion Mean (SD) Mean (SD) Mean (SD)
Flexion 1.0 (1.7) 1.8 (1.6) 4.3 (2.0)
Extension 22.4 (1.6) 20.8 (2.4) 18.5 (2.0)
Right lateral flexion 11.0 (1.9) 11.5 (2.1) 12.9 (2.4)
Left lateral flexion 10.7 (1.9) 11.1 (2.1) 12.8 (2.5)
Right rotation 11.6 (1.7) 12.6 (2.5) 11.0 (2.5)
Left rotation 11.2 (1.9) 13.2 (2.4) 11.0 (2.5)
In Table 11.4 the mean values for active neck flexion in the rotation occurred between 20 and 29 year olds and 30 and
two oldest groups of males and females ages 80 to 90 years have 39 year olds in their study of 84 asymptomatic men and
about 20 degrees less motion than the youngest group of 1 to women. Demaille-Wlodyka,32 in a study of 232 healthy volun-
19 year olds. Both men and women were measured using the teers ranging in age from 15 to 65 years of age or older, found
CROM device; therefore, the values presented in the table that all cervical motions decreased after age 25 and that the
should be used for reference only if the examiners are using the age effect was significant. Nilsson and associates16 measured
CROM as their measuring instrument. Ideally, the examiner PROM using the CROM device in 90 healthy men and
should use norms that are appropriate to the method of measure- women with a mean age of 39 years and an age range of 21 to
ment and the age and gender of the individuals being examined. 60 years. The authors determined that the decrease in PROM
Hole, Cook, and Bolton33 determined that the loss of as age increases could be described by a simple linear regres-
cervical mobility equals to approximately 4 percent per sion. See Tables 11.5, 11.6, and 11.7.
decade in flexion and lateral flexion and 6 to 7 percent for Other investigators have postulated that the effects of age
extension. The decrease in extension, lateral flexion, and on ROM may be motion specific and age specific; however,
TABLE 11.3 Cervical Spine ROM Measured With the Myrin Single Inclinometer: Normal Values
in Degrees
Balogen et al11 Malstrom et al18 Alaranta et al19
Healthy young people Healthy men and women White and blue collar employees
Mean age = 22 yrs Ages 22–58 yrs Ages 35–54 yrs
n = 21 n = 60 n = 508
Motions Mean (SD) Mean (SD) Mean (SD)
Extension 64 (17) 67 (12) 120* (16)
Flexion 32 (13) 65 (8) —
Left lateral flexion 41 (9) 41 (7) 37† (6)
Right lateral flexion 42 (9) 42 (7) —
Left rotation 64 (17) 76 (8) 75 (7)
Right rotation 68 (15) 76 (9) —
TABLE 11.4 Age Effects on Active Cervical Flexion ROM in Males and Females Aged 11 to 89 Years:
Normal Values in Degrees Using the CROM Device
11–19 yrs 20–29 yrs 30–39 yrs 40–49yrs 50–59 yrs 60–69 yrs 70–79 yrs 80–89 yrs
n = 40 n = 42 n = 41 n = 42 n = 40 n = 40 n = 40 n = 38
Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD)
64 (9) 54 (9) 47 (10) 50 (11) 46 (9) 41 (8) 39 (9) 40 (9)
the evidence appears to be somewhat controversial. Trott and Lantz, Chen, and Buch,34 in a study of 52 matched males
colleagues25 found a significant decrease in the means of all and females, found a significant age effect, with subjects in
motions (flexion–extension, lateral flexion, and axial rotation) the third decade having greater ROM in rotation and
with increasing age, but they determined that most coupled flexion–extension than subjects in the fourth decade. Dvorak
motions were not affected by age. In contrast to Trott’s find- and associates22 determined that the most dramatic decrease
ings, Damaille-Wlodyka32 found that lateral flexion, which in ROM in 150 healthy men and women (aged 20 to 60 years
was always coupled with axial rotation, decreased with and older) occurred between the 30-year-old group and the
increasing age, whereas axial rotation increased. In fact, these 40-year-old group. A somewhat similar result was found by
authors found that coupled motions showed a tendency to Peolsson and colleagues,36 who investigated the age effects on
decrease with age in all three planes. cervical motion in 101 volunteers including 51 men ages 25 to
Pearson and Walmsley23 and Walmsley, Kimber, and 63 years and 50 women ages 25 to 60 years. These authors
Culham24 were the only authors to include the cervical spine found that AROM in all planes decreased by about 30 degrees
motions of retraction and protraction in their studies. Pearson from the 25- to 34-year-old group to the 55- to 64-year-old
and Walmsley23 found that the older age groups had less ROM group. The decrease in AROM was statistically significant in
in retraction but that they showed no age difference in the neu- all planes but was most pronounced in extension and least
tral resting position. In contrast to Pearson and Walmsley’s23 evident in flexion (0.3 degrees/year).
findings, Walmsley, Kimber, and Culham24 found age-related In contrast to the findings of Dvorak and associates22 and
decreases in both protraction and retraction. Peolsson and colleagues, 36 Trott and colleagues25 found that
TABLE 11.5 Age and Gender Effects on Cervical Lateral Flexion ROM: Normal Values in Degrees*
Nilsson et al†16 Dvorak et al‡22 Castro et al§29 Nilsson et al16 Dvorak et al22 Castro et al29
SD =standard deviation.
* The values in this table represent the combined total of right and left lateral flexion range of motion.
†
Nilsson et al used the cervical range of motion (CROM) device to measure passive range of motion.
‡
Dvorak et al used the CA-6000 Spine Motion Analyzer to measure passive range of motion.
§
Castro et al used an ultasound-based coordinate measuring system, the CMS 50, to measure active range of
motion.
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TABLE 11.6 Age and Gender Effects on Cervical Flexion–Extension ROM: Normal Values
in Degrees*
Nilsson et al†16 Dvorak et al‡22 Castro et al§29 Nilsson et al16 Dvorak et al22 Castro et al29
SD = standard deviation.
* The values in this table represent the combined total of flexion and extension range of motion.
†
Nilsson et al used the cervical range of motion device (CROM) to measure passive range of motion.
‡
Dvorak et al used the CA-6000 Spine Motion Analyzer to measure passive ROM.
§
Castro et al used an ultasound-based coordinate measuring system, the CMS 50, to measure
active range of motion.
TABLE 11.7 Age and Gender Effects on Cervical Rotation ROM: Normal Values in Degrees*
Nilsson et al†16 Dvorak et al‡22 Castro et al§29 Nilsson et al16 Dvorak et al22 Castro et al29
SD = standard deviation.
* The values in this table represent the combined total of right and left rotation range of motion.
†
Nilsson et al used the cervical range of motion device (CROM) to measure passive range of motion.
‡
Dvorak et al used the CA-6000 Spine Motion Analyzer to measure passive ROM.
§
Castro et al used an ultasound-based coordinate measuring system, the CMS 50, to measure
active range of motion.
2066_Ch11_317-364.qxd 5/21/09 5:19 PM Page 350
appeared to be motion specific and age specific in that some group of 84 healthy men and women 20 to 69 years of age.
motions at some ages were affected more than others. Mannion39 also found no effects of gender in 10 men and
Castro29 was one of the authors who found significant women whose AROM was measured in all cervical motions.
gender differences in cervical ROM, but this author noted that
the differences occurred primarily in the motions of lateral Active Versus Passive ROM
flexion and flexion–extension in subjects between the ages of The AMA’s fifth edition of the Guides to the Evaluation of
70 and 79 years (see Tables 11.5, 11.6, and 11.7). Women Permanent Impairment recommends that AROM be per-
older than 70 years of age were on the average more mobile formed.12 The authors of the Guides are aware that a number
in flexion–extension than men of the same age. Nilsson, of factors may affect a person’s performance of AROM, such
Hartvigsen, and Christensen16 found a significant difference as pain, fear of injury, and motivation; therefore, they stress
between genders in lateral flexion ROM, but, in this study, that a patient must be encouraged to put forth a maximal
males were more mobile than females, as seen in Table 11.6. effort. They also state that AROM is probably much closer
Lantz, Chen, and Buch34 studied a total of 56 healthy men and than PROM to the type of motion that a patient would use
women aged 20 to 39 years. The authors found no difference functionally and therefore is more relevant to impairment.
between genders in total combined left and right lateral flex- Furthermore, PROM is dependent on the amount of force
ion, but women had greater ranges of active and passive axial applied by the examiner, and a patient could be at risk of
rotation and flexion–extension than men of the same age. injury. Also, if a patient can perform a full ROM actively, then
Women had an average of 12.7 degrees more active flexion– there is no reason to perform PROM.12
extension and an average of 6.50 degrees more active axial Other reasons for using AROM rather than PROM have
rotation than men of the same age. Women also had greater pas- been investigated by the following researchers, who have
sive ROM in all cervical motions. Dvorak and associates22 found that AROM is more reliably measured than PROM and
found that women between 40 and 49 years of age had greater has less variability. Assink and coworkers 40 determined that
ROM in all motions than men in the same age group. However, the intraclass correlation coefficients (ICCs) of AROM mea-
within each of the other age groups—20 to 29 years, 60 to surements were higher than the ICCs of PROM measurements
69 years, 70 to 79 years, and 80 to 89 years—no differences in in 30 symptomatic and 30 unsymptomatic volunteers. In
cervical ROM were found between genders. Tables 11.8 and asymptomatic subjects, PROM was generally larger than in
11.9 contain information from a study by Youdas and associ- AROM. In symptomatic subjects, the percentage of paired
ates13 that shows that females in almost all age groups appear observations within 5 degrees varied from a low of 17 percent
to have greater mean values for active cervical motion than for PROM in extension to a high of 60 percent for AROM in
males. Ferrario and associates37 used a digital optoelectronic rotation.
instrument to measure cervical motion in 30 women and Nilsson41 used the CROM device to measure half cycle
30 men and found that the women had greater ROM in PROM in 14 asymptomatic volunteers (seven men and seven
all motions than the men. More support for a gender differ- women between the ages of 23 and 45 years). All motions
ence comes from Demaille-Wlodyka,32 who found that of were measured by two testers from neutral 0, and intratester
232 healthy subjects aged 15 to 79 years, females had greater reliability was found to be acceptable to the author, ranging
range of motion in flexion–extension and lateral flexion than from an r of 0.61 for right lateral flexion to an r of 0.85 for
males but not in axial rotation. extension. Intertester reliability was unacceptable because the
Youdas and associates13 found a significant gender effect in correlation coefficients fell below 0.60 in four out of the six
all motions except flexion and determined that both males and directions, ranging from an r of 0.29 for left rotation to an r of
females lose about 5 degrees of active extension and 3 degrees 0.71 for flexion.
of active lateral flexion and rotation with each 10-year increase Nilsson, Christensen, and Hartvigsen42 conducted a study
in age. If the measurements using the CROM device are valid, to correct any problems with the previous study. More exten-
one can expect to find approximately 15 degrees to 20 degrees sive training was arranged for the testers, and the number of
less active neck extension in a healthy 60-year-old individual subjects was increased from 14 to 35 (17 men and 18 women)
compared with a healthy 20-year-old individual of the same who ranged in age from 20 to 28 years. Intertester reliability
gender. still was unacceptable for half cycle PROM because three out
In contrast to the preceding studies, a number of investi- of six measurements fell below an r of 0.60. Intertester relia-
gators concluded that gender had no effect on cervical bility for full cycle PROM was much better with r values in
ROM.24,25,27,28,33 Ordway and associates38 found a nonsignifi- three planes ranging from 0.61 to 0.88. It appears as if the half
cant gender effect, and Pellachia and Bohannon,26 in a study cycle motions may be contributing more than the passive
of 135 subjects aged 15 to 95 years with a history of neck range of motion to the poor intertester reliability.
pain, concluded that neither neck pain nor gender had any Bergman and associates43 found that the highest variation
effect on ROM. Arbogast and coworkers31 also found no in both 58 subjects in the symptomatic group and the 48 men
effects of gender in the 67 children tested between the ages of and women in the asymptomatic group occurred in PROM
3 and 12. Hole, Cook, and Bolton33 determined that gender testing versus AROM testing. The variation over a 12-week
had no significant effect on cervical range of motion in a period ranged from 20.4 degrees for passive lateral flexion in
TABLE 11.8 Age and Gender Effects on Half Cycle Active Cervical Spine Motion in Males and Females Aged 11 to 49 Years:
Normal Values in Degrees Using the CROM Device
2066_Ch11_317-364.qxd
Ages 11–19 yrs Ages 20–29 yrs Ages 30–39 yrs Ages 40–49 yrs
Motion Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD)
Extension 86 (12) 84 (15) 77 (13) 86 (11) 68 (13) 78 (14) 63 (12) 78 (13)
Right lateral flexion 45 (8) 49 (7) 45 (7) 46 (7) 43 (9) 47 (8) 38 (11) 42 (9)
5:19 PM
Left lateral flexion 46 (7) 47 (7) 41 (7) 43 (5) 41 (10) 44 (8) 36 (8) 41 (9)
Right rotation 74 (8) 75 (10) 70 (6) 75 (6) 67 (7) 72 (6) 65 (10) 70 (7)
Left rotation 72 (7) 71 (10) 69 (7) 72 (6) 65 (9) 66 (8) 62 (8) 64 (8)
Page 351
TABLE 11.9 Age and Gender on Half Cycle Active Cervical Spine Motion in Subjects Aged 50 to 89 Years: Mean Values
in Degrees Using the CROM Device
Ages 50–59 yrs Ages 60–69 yrs Ages 70–79 yrs Ages 80–89 yrs
the asymptomatic group to 85.2 degrees for passive rotation ability to return their heads to a self-defined neutral position
in the symptomatic group. The fact that a substantial amount after performing a cervical ROM. However, Owens,47 who
of variation occurred in PROM measurement prompted the used a computer interface electrogoniometer to measure head
authors to question whether PROM should be used as an out- position in 48 students (36 males and 12 females) with a mean
come measure in intervention studies. Demaille-Wlodyka and age of 28 years, found that active contractions of the posterior
colleagues32 recommended that PROM should not be used neck muscles caused subjects to undershoot their target neu-
because it overestimates a subject’s mobility. tral position by 2.1 degrees. This finding demonstrated that a
recent history of cervical paraspinal muscle contraction can
Testing Position
influence head repositioning in flexion–extension.
The lack of a well-defined neutral cervical spine position is
In a study using the 3Space Isotrak System, Pearson and
thought to be responsible for the lower reliability of cervical
Walmsley23 found a significant difference in the neutral resting
spine motions starting in the neutral position (half cycle
position (it became more retracted) after repeated neck retrac-
motions) compared with those starting at the end of one ROM
tions performed by 30 healthy subjects, but no statistically sig-
and continuing to the end of another ROM (full cycle mo-
nificant difference was found in the neck retraction ROM.
tions). An example of a half cycle motion is flexion, whereas
Another potential positional problem that testers need to
an example of a full cycle motion is flexion-extension.
be aware of has been identified by Lantz, Chen, and Buch.34
Studies that have attempted to better define the neutral
These authors found that ROM measurements of the cervical
position have used either radiographs38,44 or motion analysis
spine taken in the seated position were consistently about
systems.45,46 In the radiographic study conducted by Ordway
2.6 degrees greater than measurements taken in the standing
and associates,38 the authors determined that when the cervi-
position in all planes of motion. Greater differences occurred
cal spine is in the neutral position, the upper segments are in
between seated and standing positions when flexion and
flexion and the lower segments have progressively less flex-
extension were measured as half cycle motions starting in the
ion; therefore, at C6 to C7, the spine is in a considerable
neutral 0 position as opposed to measurement of full cycle
amount of extension. Miller, Polissar, and Haas,44 in the other
motions. For axial rotation there was no significant difference
radiographic study, found that the cervical spine is in the neu-
in half cycle motions between sitting and standing.
tral position when the hard palate is in the horizontal plane.
Although these findings are of considerable interest, they Body Size
provide little help to the average clinician, who does not have Castro29 found that patients who were obese were not as mobile
access to radiographs for patient positioning. as patients who were not obese. Mean values for motions in
Two studies that are more clinically relevant used the all planes decreased with increasing body weight. Chibnall,
CA-6000 Spine Motion Analyzer.45,46 This motion analysis Duckro, and Baumer,48 in a study of 42 male and female sub-
system is capable of giving the location of neutral 0 position jects, found that body size reflected by distances between
as coordinates in three dimensions corresponding to the three specific anatomical landmarks (e.g., between the chin and the
planes of motion. Christensen and Nilsson45 found that the acromial process) influenced ROM measurements taken with a
ability of 38 young (20 to 30 years of age) subjects to repro- tape measure. Any variation in body size among subjects re-
duce the neutral spine position with eyes and mouth closed sulted in an underestimation of ROM for subjects with large
was very good. The mean difference from neutral 0 in three distances between landmarks and an overestimation of ROM for
motion planes was 2.7 degrees in the sagittal plane, 1.0 degrees subjects with small distances between landmarks. The authors
in the horizontal plane, and 0.65 degrees in the frontal plane. concluded that the use of proportion of distance (POD) should
Possibly, patients may be able to find the neutral position be used when comparing testing results among subjects. The use
on their own, but the subjects in this study were healthy indi- of POD (calculated by dividing the distance between the at-rest
viduals, and the ability of patients to reproduce the neutral value and the end-of-range value by the at-rest value) helps to
position is unknown. Solinger, Chen, and Lantz46 attempted to eliminate the effect of body size on ROM values obtained with
standardize a neutral head position when measuring cervical a tape measure. Obviously, calculation of POD is not necessary
motion in 20 subjects. For flexion and extension, the authors if the progress of only one subject is measured. Peolsson and
described a neutral position as one in which the corner of the colleagues36 found no significant correlation between body mass
eye was aligned with the upper angle of the ear, at the point index (BMI) and AROM, with the exception of extension for
where it meets the scalp. For lateral flexion, neutral was both men and women and flexion for men.
defined as the point at which the axis of the head was per-
ceived to be vertically aligned. Compared with data collected
using a less stringent head positioning, Solinger, Chen, and
Functional Range of Motion
Lantz46 demonstrated that by standardizing head position they Motion of the cervical spine is necessary for most activities of
obtained increases in reliability of 3 percent to 15 percent for daily living and for most recreational and occupational activ-
rotation and lateral flexion but showed a decrease in reliability ities. Bennett and asssociates49 used the CROM device to de-
of up to 14 percent for flexion–extension. termine the range of cervical motion required for 13 daily
Demaille-Wlodyka and colleagues32 determined that tasks performed by 28 college students. The greatest amount
neither age nor gender affected the 232 healthy volunteers’ of motion was required by the following activities: backing up
2066_Ch11_317-364.qxd 5/21/09 5:19 PM Page 353
a car, tying shoes, and crossing the street. Relatively small range of flexion. A full ROM in cervical rotation is essential for
amounts of flexion, extension, and rotation are required for safe driving of cars or trucks (Fig. 11.47).
eating, reading, writing, and using a computer. Drinking
requires more cervical extension ROM than eating, and star- Reliability and Validity
gazing or simply looking up at the ceiling requires a full ROM An article by Jordan51 provides an excellent review of reliabil-
in extension (Fig. 11.46). Using a telephone requires lateral ity studies and the instruments and methods used to evaluate
flexion and rotation. Bathing and grooming require a consid- cervical range of motion. The author identifies a number of
erable amount of motion.49 problems with studies, including among others, the lack of an
Sports activities such as serving a tennis ball, catching or adequate sample size, appropriate statistical methods, and
batting a baseball, canoeing, and kayaking may require a full standardized protocols for measurement and for performance
ROM in all planes. Different types of sports activities may have of the motions. These deficits make it difficult to compare
effects on ROM. For example, Guth50 compared cervical rota- studies and to be able to use the data that they generate.
tion ROM in a group of 40 swimmers with that in 40 nonath- Many different methods and instruments have been
letic volunteers. The swimmers, aged 14 to 17 years, had a employed to assess motion of the head and neck. Similar to
mean total rotation ROM that was 9 degrees greater than the other areas of the body, intratester reliability generally is bet-
ROM of those aged 14 to 17 years in the control group. Certain ter than intertester reliability, no matter what instrument is
occupational activities such as house painting or wallpapering used. Also, some motions seems to be more reliably measured
require a full range of cervical extension and, possibly, a full than others. For example, the full cycle motions such as
flexion–extension and right–left lateral flexion measured from
one extreme of the range to the other appear to be more reli-
ably measured than half cycle motions such as flexion mea-
sured from the neutral position.18,32,40–43,52 This finding may be
owed to the variability of the neutral position and the lack of
a standardized method that an examiner can use for placing a
subject’s head in the neutral position. However, the problem
with only measuring full cycle motions is that full cycle mea-
surements do not provide any information about where unilat-
eral limitations in motion occur.
Nilsson41 found that intratester reliability was good when
measuring half cycle motions, but intertester reliability was
poor. Nilsson, Christensen, and Hartvigsen42 found that the
intertester reliability of passive range of motion measurements
of half cycle motions was poor (r ⫽ 0.39 to 0.70), but the
intertester reliability of passive range of motion measurements
of full cycle motions was acceptable (r ⫽ 0.61 to 0.70). Jordan
and colleagues,52 who used the three-dimensional Fastrak sys-
tem to measure cervical ROM, also found that the intertester
reliability of full cycle motions (intraclass correlation coeffi-
cients [ICCs] ⫽ 0.81 to 0.89) was better than the reliability of
half cycle motions (ICCs ⫽ 0.61 to 0.80) in 40 healthy subjects
with two testers. The same was true for intratester reliability in
which the ICCs for full cycle motions ranged from 0.76 to 0.82,
whereas the ICCs for half cycle motions ranged from 0.54 to
0.70 in 32 healthy subjects with one tester on three occasions.
Malstrom and colleagues,18 using both the Zebris ultrasonic
system and the Myrin inclinometer, found that the full cycle
motions showed less variability than the half cycle motions in
60 healthy volunteers (25 men and 35 women) 22 to 58 years of
age. The ICCs ranged from 0.92 to 0.97 for full cycle motions
and from 0.88 to 0.93 for half cycle motions. The full cycle
motions also showed better concurrent validity with the Zebris
than did half cycle measurements.
FIGURE 11.46 One needs at least 40 to 50 degrees of Damaille-Wlodyka,32 in a study of 232 subjects, deter-
cervical extension range of motion (ROM) to look up at the
ceiling.2 If cervical extension ROM is limited, the person mined that full cycle motions had better validity than half
must extend the entire spine in an effort to place the head cycle motions but half cycle motions allow for better assess-
in a position whereby the eyes can look up at the ceiling. ment of unilateral limitations. Piva and associates,53 using a
2066_Ch11_317-364.qxd 5/21/09 5:19 PM Page 354
FIGURE 11.47 One needs a minimum of 60 to 70 degrees of cervical rotation to look over the
shoulder.2 If cervical rotation range of motion is limited, the person has to rotate the entire trunk to
position the head to check for oncoming traffic.
single gravity goniometer to measure half cycle motions in 0.75 indicate good reliability and coefficients of less than
30 patients with neck pain, found that the standard error of 0.75 indicate poor to moderate reliability.
measurement (SEM) ranged from 3.7 degrees for right lateral
flexion to 5.6 degrees for extension. ICCs ranged from 0.78 Reliability: Universal Goniometer
for flexion to 0.91 for axial rotation, and intertester reliability Tucci and coworkers55 found that the ICCs for intertester reli-
was moderate to substantial for measuring active ROM in the ability of cervical spine motion ranged from –0.08 for flexion
sagittal and transverse planes of motion. to 0.82 for extension for measurements taken with the univer-
According to Chen and colleagues,27 it is not possible to sal goniometer by two experienced testers on 10 volunteer
obtain a true validation of cervical ROM measurements subjects.
because radiographic measurement has not been subjected to Youdas, Carey, and Garrett9 measured half cycle AROM
reliability and validity studies. Therefore, no valid gold stan- in 60 patients with orthopedic problems ranging in age from
dard exists. The only option available for investigators at the 21 to 84 years. The patients were divided into three groups of
present time is to conduct concurrent validity studies to obtain 20 people. Each subject performed five repetitions of the
agreement between instruments and procedures.27 However, motion in each plane to increase the compliance of the neck’s
many researchers still consider radiographic measurement to soft tissues. Intratester reliability was good for flexion (ICC ⫽
be the gold standard. 0.83), extension (ICC ⫽ 0.86), right lateral flexion (ICC ⫽
Some of the studies that have been conducted to assess 0.85), left lateral flexion (ICC⫽0.84 and right rotation
reliability or validity (or both) of the various instruments and (ICC⫽0.90). Intratester reliability was fair for left rotation
methods are reviewed in the following section. The terms (ICC⫽0.78). Intertester reliability was fair (ICC⫽0.72 to
high, good, fair, poor, and unacceptable are used to designate 0.79) for extension, left lateral flexion, and right lateral flex-
different degrees of reliability. High reliability refers to ICCs ion. Intertester reliability was poor (ICC ⫽ 0.54 to 0.62) for
of 90 to 99, good reliability refers to ICCs of 80 to 89, fair flexion and left and right rotation.
reliability refers to ICCs of 70 to 79, low or poor reliability is Pile and associates56 used a universal goniometer to mea-
an ICC of 60 to 69, and unacceptable reliability is an ICC sure half cycle lateral flexion and flexion and extension in
of less than 0.60. These definitions of reliability appear to be 10 patients with ankylosing spondylitis with minimal disease
the most commonly used terms in the following studies, al- activity and ranging from 28 to 73 years of age. The testers
though a few authors have used the interpretation by Portney included a rheumatologist, a rheumatology registrar, and three
and Watkins54 in which correlation coefficients higher than physical therapists. For intratester reliability each tester
2066_Ch11_317-364.qxd 5/21/09 5:19 PM Page 355
measured one patient four times. The authors did not present for all three therapists. Intratester reliability for extension was
intratester reliability coefficients. The intertester reliability very good for two therapists and fair for one therapist. The
coefficient for right lateral flexion was 0.74; for left lateral intratester values for left and right rotation ranged from an r
flexion it was 0.68. The landmarks used for the lateral flexion of 0.58 to 0.86. The fact that the interval between the first and
measurement were the sternal notch as the axis and a line second sessions was so long may have had an adverse effect
through the nose and forehead for the proximal arm. Flexion on the intratester values. Intertester values ranged from an r of
and extension were measured in the same way as the 0.35 to 0.90 in Session I and from an r of 0.47 for left lateral
goniometer is used in this text. The intertester reliability coef- flexion to an r of 0.92 for extension in Session II.
ficient for flexion was unacceptable (0.21), whereas the coef- Haywood and associates58 used a plastic tape measure for
ficient for extension was somewhat better (0.59). measuring half cycle AROM in 159 patients with ankylosing
Maksymowych and colleagues57measured full cycle rota- spondylitis. The authors used the tip of the nose and the
tion AROM using a plastic universal goniometer in 44 patients acromioclavicular joint as landmarks to measure right and left
with ankylosing spondylitis with a mean age of 42.7 years. All cervical rotation. The ROM was the difference between the
measurements were taken by two testers (a trained clinical tape measurement in the neutral position and the measure-
nurse and a rheumatologist) in mid-morning to avoid the ment in maximal ipsilateral rotation. Fifty-five patients partic-
effects of early morning stiffness. Intratester reliability was ipated in the reliability study. The intratester reliability (test-
high for two testers (ICC ⫽ 0.98 and 0.97), and intertester retest at 2-week interval) was high (ICC >0.90), but intertester
reliability also was high (ICC ⫽ 0.95). reliability was unacceptable for the neutral starting position.
Maksymowych and coworkers57 measured full cycle rota-
Validity: Universal Goniometer tion AROM on 263 patients with ankylosing spondylitis from
In a search of the literature, no validity studies were found for three different countries. Forty-four of the patients were
the universal goniometer in which radiographs were used as involved in the reliability study. Landmarks used for measur-
the gold standard. ing rotation were the tragus of the right ear and the superster-
nal notch. Measurements were taken with a tape-based tool at
Reliability: Tape Measure
full right rotation (D1) and at full left rotation (D2). Full
The fact that the landmarks used to obtain the measurements
cycle rotation was defined as the distance between the two
varied from study to study diminishes the usefulness of some
measurements (D1-D2). Intratester reliability was good for
of the following information. Landmarks and methods need to
the two testers (ICC ⫽ 0.80 and 0.89); intertester reliability
be standardized to make valid comparisons. The landmarks
also was good (ICC ⫽ 0.82).
and results of studies by the authors10,11 in Table 11.2 and by
Viitanen and associates59 measured cervical lateral flex-
others are described in the following paragraphs.
ion and rotation in a series of 52 male patients with idiopathic
Hsieh and Young10 used two testers (one experienced and
ankylosing spondylitis with a mean age of 45 years. Testing
one inexperienced) to measure half cycle AROM in 34
was done by two physical therapists. Intratester aand
healthy volunteers (27 men and 7 women) with an average
intertester reliability coefficients for tape measurements were
age of 18 years. The landmarks used in the study for flexion
excellent for cervical lateral flexion (ICCs ⫽ 0.96 and ICC ⫽
and extension were the sternal notch and the chin. The land-
0.97, respectively) and for rotation (ICC ⫽ 0.98 and ICC ⫽
marks for rotation were the acromial process and the chin, and
0.97, respectively).
the landmarks for lateral flexion were the acromion process
and the lowest point of the earlobe. One tester measured Validity: Tape Measure
17 subjects, and the other tester measured a different group of Balogun and associates11 compared measurements taken
17 subjects. Intratester reliability coefficents (Pearson’s r) with a tape measure with measurements taken with a Myrin
ranged from 0.80 to 0.95 for the experienced tester and from Reference Goniometer (Inclinometer). The r values of each
0.78 to 0.91 for the inexperienced tester. Measurement error of the three testers were higher for the tape measuring
for the experienced tester at the 99 percent confidence inter- method than for the inclinometer method. Therefore, the au-
val (CI) was approximately ⫾1 cm for sagittal motions and thors recommended that the tape measure method be used
⫾ 2 cm for other motions. The inexperienced tester had a more widely.
higher measurement error of approximately ⫾2 to 3 cm for Viitanen and associates59 compared cervical rotation and
sagittal motions and ⫾3 cm for other motions. lateral flexion tape measurements with radiologic changes
Balogen and associates11 employed three physical thera- such as changes in the apophyseal joints, calcification of
pists to measure half cycle AROM in 21 physical therapy stu- discs, and ossification of spinal ligaments. Cervical rotation
dents. The test-retest interval ranged from 4 to 110 days. The and lateral flexion measurements correlated significantly with
landmarks used to measure cervical flexion were the tip of the cervical radiologic changes and, therefore, according to the
chin and the sternal notch. Landmarks for measuring lateral authors, the tape measure was an appropriate method for
flexion were the anterior dimples in the shoulder to the lowest assessing disease severity and progression.
point of the earlobe. For rotation, the landmarks were the tip Maksymowych and coworkers57 compared measure-
of the chin and the anterior dimples in the shoulder. Intratester ments of cervical AROM taken with a tape measure with mea-
reliability coefficients (r) for measuring neck flexion was poor surements of cervical rotation AROM taken with a plastic
2066_Ch11_317-364.qxd 5/21/09 5:19 PM Page 356
universal goniometer. The authors found that the tape mea- Therefore, only changes greater than these values can be
sure approach was comparable to the universal goniometer, detected beyond measurement error when a single therapist
which the authors used as the gold standard. performs the measurements. The SDD values were higher if
two different raters performed the measurements.
Reliability: Inclinometer
Piva and coworkers53 measured half cycle AROM with a
Viitanen and associates59 used the Myrin Gravity Reference
gravity goniometer (MIE) in 30 patients ages 18 to 75 years
Goniometer to measure AROM in 52 male patients with anky-
of age who had symptoms in their neck, scapula, or head. ICC
losing spondylitis with a mean age of 44.7 years. Two physi-
values ranged from fair to high (ICC ⫽ 0.78 to ICC ⫽ 0.91).
cal therapists measured patients on successive days. Both
The minimal detectable change (MDC) the authors considered
intratester reliability and intertester reliability were high with
to be adequate for clinical use ranged from 9 degrees for left
ICCs of 0.89 to 0.98.
rotation in flexion to 16 degrees for the motions of flexion and
Balogun and coworkers11 employed three testers to use
extension. The SEM was as follows: extension ⫽ 5.6 degrees,
the Myrin Gravity Reference Goniometer to measure the
flexion ⫽ 5.8 degrees, left lateral flexion ⫽ 4.2 degrees, right
AROM of half cycle motions. Twenty-one healthy students
lateral flexion ⫽ 3.7 degrees, left rotation ⫽ 4.1 degrees, and
were measured over a period of several days (between 4 and
right rotation ⫽ 4.8 degrees.
110). Intratester reliability coefficients (r) values for all
Malstrom and associates18 used the Myrin Gravity Refer-
motions ranged from unacceptable (r ⫽ 0.31) for flexion to
ence Goniometer to measure both full and half cycle AROM in
good (r ⫽ 0.86) for extension. Intertester reliability coeffi-
60 “neck healthy” volunteers (35 women and 25 men) ranging
cients across two testing sessions ranged from unacceptable
in age from 22 to 58 years of age (Table 11.10). Intratester re-
(r ⫽ 0.26) for left rotation to good (r ⫽ 0.84) for extension.
liability was high, with ICCs of 0.90 and higher for full
Alaranta and associates19 used a liquid single inclinome-
cycle flexion–extension, lateral flexion, and rotation. Intra-
ter, the MIE (Medical Research Ltd, London), which they
tester reliability was lower for half cycle motions, with the
attached by Velcro to a cloth helmet to the top of the subject’s
ICC ranging from 0.69 for left rotation to 0.89 for extension.
head to measure half cycle AROM flexion and extension and
Bush and associates61 evaluated the reliability of the fol-
lateral flexion. A gravitational inclinometer was attached to
lowing inclinometers: a single inclinometer, double incli-
the helmet, and the subject was placed in a supine position to
nometers, and a single inclinometer with stabilization. Six
measure rotation. Ninety-nine subjects participated in the
Gerhardts Uni-Level pendulum inclinometers were used by
intratester reliability part of the study in which one physio-
34 practicing physical therapists to take half cycle measure-
therapist measured all subjects twice at an interval of 1 year.
ments of AROM of neck motions in three healthy models. The
The correlation coefficient values for half cycle motions were
reliability between the three methods was unacceptable, with
an r of 0.68 for flexion and extension, r of 0.61 for lateral flex-
ICC values of 0.13 for extension, 0.31 for right lateral flexion,
ion, and unacceptable (r ⫽ 0.37) for rotation. Forty-eight sub-
and 0.20 for left lateral flexion.
jects participated in the intertester reliability study in which
two physiotherapists did the testing at a 1-week interval. The Validity: Inclinometer
values for full cycle motions ranged from an r of 0.69 for Herrmann62 took radiographic measurements of passive ROM
flexion-extension to an r of 0.86 for left-right rotation. of neck flexion–extension in 16 individuals aged 2 to 68 years.
Hole, Cook, and Bolton33 also had two testers use an MIE The radiographic measurements were compared with those
single inclinometer to measure AROM in 30 healthy volun- obtained by means of a pendulum goniometer (inclinometer).
teers ages 20 to 69 years. Intratester reliability for flexion- ICCs of 0.98 indicated a good agreement between the two
extension, right lateral flexion, and right rotation was high methods.
(ICC ⫽ 0.93 to 0.94) and intratester reliability for left lateral Lanz, Chen, and Buch 34 compared the double inclinometer
flexion and left rotation was good (ICC ⫽ 0.84 to 0.88). Dualer digital dual inclinometer and the CA-6000 electrogo-
Intertester reliability was good (ICC ⫽ 0.81 to 0.86) for niometer. Simultaneous measurements by the two instruments
flexion-extension, both right and left lateral flexion as well as were performed twice over a 1-week interval. Concurrent valid-
left rotation. However, intertester reliability was only fair for ity of the two instruments showed almost identical mean values
right rotation (ICC ⫽ 0.76). for flexion, extension, and lateral flexion. The ICC for between-
Hoving and associates60 used a Cybex Electronic Digital instrument comparison in the same session was high.
Inclinometer-320 (EDI-320) to measure full cycle AROM in Malstrom and associates18 compared the Myrin Gravity
32 patients 18 to 70 years of age with neck pain, neck stiff- Reference Goniometer with a three-dimensional ultra-
ness, or both. Intratester reliability was high for motions in sound motion device—the Zebris, CMS 30/70P system (Zebris
three planes, with values ranging from an ICC of 0.93 for lat- Medizintechnik GmbH, Isny, Germany). Both instruments were
eral flexion for both raters to an ICC of 0.97 for flexion– used to measure full cycle AROM in 60 healthy volunteers
extension for one rater. Intertester reliability was good to high (35 women and 25 men) ranging in age from 22 to 58 years of
with ICCs of 0.89 and higher. The smallest detectable differ- age. The test and retest ICC was high, greater than 0.90 for
ences (SDDs) based upon intratester agreement results for intradevice reliability. The ICC was greater than 0.93 for con-
one of the testers were 11.1 degrees for flexion–extension, current validity. The authors concluded that their research sup-
10.4 degrees for lateral flexion, and 13.5 degrees for rotation. ports the continued use of the Myrin in routine clinical work.
TABLE 11.10 Cervical Range of Motion (CROM) Device: Intratester and Intertester Reliability
2066_Ch11_317-364.qxd
Tester Subject Mean Sample Motions Intra Inter Intra r Inter r SEM
Author n n Age ICC ICC
14
Pucci et al Tester 1 0.63
Tester 2 0.91
Extension
5:19 PM
Tester 1 0.90
Tester 2 0.82
Right lateral
flexion
Page 357
TABLE 11.10 Cervical Range of Motion (CROM) Device: Intratester and Intertester Reliability––cont’d
Tester Subject Mean Sample Motions Intra Inter Intra r Inter r SEM
2066_Ch11_317-364.qxd
PART IV
flexion
20 60.8 yrs Left lateral 0.93 0.92
flexion
ICC ⫽ intraclass correlation coefficient, r ⫽ Pearson product moment correlation coefficient; SEM ⫽ standard error of measurement.
* 95% confidence interval for single subject measurement.
†
Represents intertester SEM.
2066_Ch11_317-364.qxd 5/21/09 5:19 PM Page 359
Bush and associates61 compared three methods of incli- at 20-minute intervals. Intratester reliability was considered to
nometry measurements of sagittal and frontal plane cervical be acceptable (r ⫽ 0.61 to 0.86). Intertester reliability was
motion with radiographic measurements. Transverse plane unacceptable (r ⫽ 0.29 to 0.66) based on the mean of five
motion measurements were compared with computed tomog- repeated measures and the fact that in four out of six motions
raphy scan measurements. The authors defined validity as the r was less than 0.60.
those inclinometry measurements that fell within ±5 degrees Hole, Cook, and Bolton33 selected 30 of 84 asymptomatic
of radiographic measurements. Using this standard, only the subjects for the reliability portion of a study of full cycle
single and double inclinometer methods were valid for mea- AROM. Intratester reliability was high (ICC ⫽ 0.96) for the
suring flexion; only the single and single stabilization meth- full cycle combined motion of flexion and extension, and
ods were valid for measuring extension. No methods were intertester reliability was good (ICC ⫽ 0.88). Intratester reli-
valid for measuring either lateral flexion or rotation. The sin- ability was high (ICC ⫽ 0.96) for full cycle right-left lateral
gle inclinometer method had the highest validity among the flexion, and intertester reliability was good (ICC ⫽ 0.84).
three methods. Both intratester and intertester reliability were high (ICC ⫽
0.92) for the full cycle motion of left-right rotation.
Reliability: CROM Device Nilsson, Christiansen, and Hartvigsen42 measured half
Capuano-Pucci14 in 1981 conducted one of the earliest studies and full cycle PROM on 17 males and 18 females 20 to
on the CROM device in which two testers took measurements 28 years of age. Subjects were asked to close their eyes and
of each half cycle AROM performed by 20 subjects (16 women position their heads in neutral while the dials on the CROM
and 4 men) with a mean age of 23.5 years. The author found device were set to 0. Intertester reliability was acceptable (r ⫽
good intratester reliability for four out of six half cycle motions 0.61 to 0.88) for full cycle motions, but intertester reliability
for one tester and for five out six motions for the second tester. for measuring single cycle motions was an r of 0.39 to 0.70.
All correlation coefficients were greater than 0.80 for intertester Rheault and colleagues63 found only small mean differences
reliability, which was slightly higher than intratester reliability. ranging from 0.5 degrees to 3.6 degrees between two testers
This unusual finding was attributed to the fact that the time who measured half cycle extension AROM with the CROM
interval between testers was only minutes, whereas the time device.
interval between the first and second trials by one tester was Lindell, Eriksson, and Strender64 compared the perfor-
2 days. More detailed information about this study and other mance of a medically untrained tester with an experienced
studies in the section can be found in Table 11.10. physical therapist using the therapist as the gold standard. The
In the 1991 study by Youdas, Carey, and Garrett,9 11 vol- untrained tester received 4 hours of training and practice in
unteer physical therapists were given a 1-hour training session 10 tests including measurements of half cycle cervical flexion
on the CROM device prior to measuring half cycle AROM in and extension and rotation taken with the CROM device. The
60 patients (39 women and 21 men) with orthopedic disor- subjects in the study included 30 patients with neck and back
ders. The patients, ranging in age from 21 to 84 years, were pain and 20 healthy subjects. In the interrater reliability study,
divided into groups of 20 and were tested twice by two thera- all 50 subjects were tested once by each tester. In the
pists. The results of the testing showed high intratester relia- intertester study, each tester measured neck motions twice in
bility and good intertester reliability for both flexion and 10 of the 20 healthy subjects. Intratester reliability for the
extension. Intratester reliability was good for left neck lateral therapist was good for flexion (ICC ⫽ 0.86) and high for
flexion (ICC ⫽ 0.84) and was high for right lateral flexion extension (ICC ⫽ 0.98), with an SEM of 2 degrees for each
(ICC ⫽ 0.92). Intertester reliability was fair for left lateral measurement. The ICCs for intratester reliabilty for the other
flexion and good for right lateral flexion. Intratester reliability tester were 0.62 for flexion and 0.80 for extension. The ICC
was high for both left and right rotation, and intertester relia- for the therapist for right rotation was high; for left rotation
bility for rotation ranged from good for left rotation to high the ICC was good. The other tester had good ICCs for both
for right rotation. right and left rotation and slightly higher SEMs compared to
Youdas and associates13 used five testers to measure the therapist. Cervical flexion and extension had poor
half cycle AROM in 337 healthy subjects (171 women and 166 intertester reliability, which the authors attributed to the need
men) who were 11 to 97 years of age. Each subject performed for manual stabilization. Other tests that required manual sta-
three repetitions of each motion, and each subject was tested by bilization also had poor intertester reliability, but overall, the
three testers within minutes of each other. Intratester reliability medically untrained tester was able to perform acceptably in
was low for flexion (ICC ⫽ 0.76), high for extension (ICC ⫽ 7 out of 10 tests.
0.94), and good for left and right lateral flexion. Intratester reli-
ability for rotation also was good, with ICCs of 0.84 for left Validity: CROM Device
rotation and 0.80 for right rotation. The intertester reliability of Ordway and coworkers65 simultaneously measured full cycle
all half cycle neck motion measurements was good except for AROM of combined flexion-extension with the CROM
left rotation, which was poor (ICC ⫽ 0.66). device, 3Space system, and radiographs in 20 healthy volun-
Nilsson41 measured half cycle PROM on 14 volunteers teers (11 women and 9 men) between 20 and 49 years of age.
23 to 45 years of age. Each subject was measured three times The authors found no significant difference between CROM
2066_Ch11_317-364.qxd 5/21/09 5:19 PM Page 360
device measurements and the radiographic angle between the between the two instruments when measuring AROM in the
occipital line and the vertical body, nor between the 3Space sagittal and coronal planes, and concurrent validity was sup-
system and radiographic angle between the occipital line and ported for flexion–extension and for right–left lateral flexion,
the C7 vertebral body. However, there was a significant differ- but there was no agreement when measuring rotation in the
ence between flexion and extension measurements taken with transverse plane because, according to the authors, motion was
the CROM device and the 3Space system. Therefore, these consistently overestimated by the MIE.
methods could not be used interchangeably. The authors
determined that full cycle flexion–extension could be reliably Reliability: CA-6000 Electrogoniometer
measured by all three methods but that standardization of Lantz, Chen, and Buch34 measured active and passive half
positioning was required to minimize upper thoracic motion cycle motions in healthy students with the CA-6000. Intra-
with the CROM device. Protraction and retraction measured tester reliability ICC ranged from fair (0.76) to high (0.97) for
with the 3Space system were in agreement with the radio- AROM for full cycle motions and from poor (0.58) to high
graphic measurements but differed significantly from the (0.95) for PROM for full cycle motions. Intertester ICCs for
measurements taken with the CROM device The CROM full cycle AROM were higher, ranging from good (0.84) to
device’s advantages over the 3Space system were lower cost high (0.91), compared to ICCs for full cycle PROM, which
and ease of use. were fair (0.74) to good (0.86).
Tousignant66 used radiographs to determine the criterion Solinger, Chen, and Lantz46 measured half and full cycle
validity of the CROM device for measuring half cycle flexion AROM in 20 healthy volunteer subjects (9 men and 11 women)
and extension on 31 healthy participants who were 18 to ranging in age from 20 to 40 years. Each subject’s ROM was
25 years of age. CROM measurements were highly correlated measured twice by two experienced testers. Intertester and
with measurements obtained by the radiographic method for intratester reliability for full cycle motions of rotation and lat-
extension (r ⫽ 0.98, P ⬍0.001) and flexion (r ⫽ 0.97, eral flexion had high ICCs, ranging from 0.93 to 0.97, whereas
P ⬍0.001) so that the validity of the CROM device for mea- intertester and intratester reliability ICCs for half cycle motions
suring flexion and extension was supported. ranged from good (0.83) to high (0.95). Reliability values were
Tousignant and associates67 determined that the CROM consistently lower for measurements beginning in the neutral
measurements of half cycle AROM of lateral flexion demon- position compared with full cycle motions. The ICCs indicated
strated a very good linear relationship with radiographic mea- that the electrogoniometer performed very reliably for rotation
surements. A physiotherapist who had received 4 hours of and lateral flexion but only at an acceptable level for flexion–
instruction in using the CROM device measured right and left extension (0.75 to 0.93). Flexion from the neutral position was
lateral flexion in 24 patients with neck pain. The measure- the least reliable measurement even when taken by a single
ments of left lateral flexion and right lateral flexion were com- tester.
pared with radiographic measurements as the gold standard. Christensen and Nilsson68 found good intratester and
The correlation between the CROM device and radiographic intertester reliability for measurements of AROM in 40 indi-
measurements was good for both left (r ⫽ 0.82) and right (r ⫽ viduals tested by two testers. Intratester reliability was also
0.84) lateral flexion. Therefore, the criterion validity of the good for PROM, but intertester reliability was good only for
CROM device for measuring lateral flexion was supported. full cycle motions.
Tousignant and associates,15 in another criterion validity Validity: CA-6000 Spine Motion Analyzer
study, compared half cycle AROM measurements taken with Electrogoniometer
the CROM device with measurements taken with the Optotrak Mannion and associates39 compared cervical CROM mea-
(an optoelectronic system). Subjects in the study included surements taken with the CA-6000 Spine Motion Analyzer
34 women (21 to 85 years of age) and 21 men (19 to 80 years with measurements taken with a three-dimensional ultrasound
of age) recruited from the community. The results showed a motion device called the Zebris CMS System. Initial mea-
very strong linear relationship between cervical rotation mea- surements by both systems were taken in 19 healthy volun-
sured with the CROM device and the values obtained with the teers, and the same measurements were taken 3 days later.
Optotrak. Pearson correlation coefficients (r) between CROM Test-retest reliability was good for each instrument, but a
values and Optotrak values were good to excellent for rotation small significant difference (1 to 10 percent) between the val-
and for all other cervical motions. Based on their findings, the ues obtained by each instrument occurred.
authors concluded that the validity of the CROM device was Petersen and coworkers69 determined that there was a
supported for the measurement of half cycle rotation in healthy large difference between the measurements obtained with the
individuals. CA-6000 Spine Motion Analyzer and radiographs.
Hole, Cook, and Bolton33 compared measurements of full
cycle AROM taken with the CROM device to measurements Reliability: Visual Estimation
taken with a single gravity inclinometer (MIE) to determine The reliability of visual estimates has been studied by Viikari-
the reliability and concurrent validity of the two instruments Juntura71 in a neurological patient population and by Youdas,
for measuring cervical motion. Eighty-four asymptomatic sub- Carey, and Garrett 9 in an orthopedic patient population. In the
jects were included in the study. There was good agreement study by Viikari-Juntura,71 the subjects were 52 male and
2066_Ch11_317-364.qxd 5/21/09 5:19 PM Page 361
female neurological patients ranging in age from 13 to Generally, intratester reliability is better than intertester relia-
66 years who had been referred for cervical myelography. bility. Therefore, if these methods are used to determine a
Intertester reliability between two testers of visual estimates patient’s progress, repeated measurements should be taken by
of cervical ROM was determined by the authors to be fair. a single therapist. However, both the universal goniometer
The weighted kappa reliability coefficient for intratester and tape measure require more extensive research to validate
agreement in categories of normal, limited, or markedly lim- their continued use in the clinic.
ited ROM ranged from 0.50 to 0.56. In consideration of the cost and availability of the various
In the study by Youdas, Carey, and Garrett,9 the subjects instruments for measuring cervical ROM, and because of the
were 60 orthopedic patients ranging in age from 21 to fact that the intratester reliability of the universal goniometer
84 years. Intertester reliability for visual estimates of both active and tape measure appears comparable with that of measure-
flexion and extension was poor (ICC ⫽ 0.42). Intertester relia- ments taken with other instruments, we have retained the uni-
bility for visual estimates of active neck lateral flexion ROM versal goniometer and tape measure methods in this edition,
was fair. The ICC for left lateral flexion was 0.63; for right lat- but we added methods using the double inclinometer and the
eral flexion it was 0.70. The intertester reliability for visual esti- CROM device. We included the double inclinometer because
mates of rotation was poor for left rotation (ICC ⫽ 0.69) and this method is advocated for measuring the cervical spine by
good for right rotation (ICC ⫽ 0.82). the American Medical Association, although research on the
reliability and validity of this method is lacking. The reliabil-
Summary ity and validity of the CROM device has been very well
researched, as presented in this section. If the tape measure is
Each of the techniques for measuring cervical ROM discussed
being used to compare ROM among subjects, calculation of
in this chapter has certain advantages and disadvantages. The
proportion of distance (POD) should help to eliminate the
universal goniometer and tape measure are the least inexpen-
effects of different body sizes on measurements (refer to
sive and easiest to obtain, transport, and use, and therefore
Body Size in the Research Findings section).48
may be more acceptable clinically than other instruments.
2066_Ch11_317-364.qxd 5/21/09 5:19 PM Page 362
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12
The Thoracic
and Lumbar Spine
Structure and Function ligament, surrounds the costovertebral joints. An intra-articular
ligament lies within the capsule and holds the head of the rib to
the annulus pulposus.
Thoracic Spine The costotransverse joints are the articulations between
the costal tubercles of the 1st to the 10th ribs and the costal
Anatomy of the Vertebrae
facets on the transverse processes of the 1st to the 10th tho-
The 12 vertebrae of the thoracic spine form a curve that is
racic vertebrae. The costal tubercles of the 1st to the 7th ribs
convex posteriorly (Fig. 12.1A). These vertebrae have a
are slightly convex, and the costal facets on the corresponding
number of unique features. Spinous processes slope inferi-
transverse processes are slightly concave. The articular
orly from T1 to T10 and overlap from T5 to T8, whereas
surfaces of the costal and vertebral facets are quite flat from
the spinous processes of T11 and T12 take on the horizontal
about T7 to T10. The costotransverse joint capsules are
orientation of the lumbar region’s spinous processes. The
strengthened by the medial, lateral, and superior costotrans-
transverse processes from T1 to T10 are large, with thick-
verse ligaments.
ened ends that support paired costal facets for articulation
with the ribs. Paired demifacets (superior and inferior cos- Osteokinematics
tovertebral facets), also for articulation with the ribs, are The zygapophyseal articular facets lie in the frontal plane
located on the posterolateral corners of the vertebral bodies from T1 to T6 and therefore limit flexion and extension in this
from T2 to T9. region. The articular facets in the lower thoracic region are
oriented more in the sagittal plane and thus permit somewhat
Anatomy of the Joints
more flexion and extension. The ribs and costal joints restrict
The intervertebral and zygapophyseal joints in the thoracic
lateral flexion in the upper and middle thoracic region, but in
region have essentially the same structure as described
the lower thoracic segments, lateral flexion and rotation are
for the cervical region, except that the superior articular
relatively free because these segments are not limited by the
zygapophyseal facets face posteriorly, somewhat laterally,
ribs. In general, the thoracic region is less flexible than
and cranially. The superior articular facet surfaces are
the cervical spine because of the limitations on movement
slightly convex, whereas the inferior articular facet surfaces
imposed by the overlapping spinous processes, the tighter
are slightly concave. The inferior articular facets face ante-
joint capsules, and the rib cage.
riorly and slightly medially and caudally. In addition, the
joint capsules are tighter than those in the cervical region. Arthrokinematics
The costovertebral joints are formed by slightly convex In flexion, the body of the superior thoracic vertebra tilts
costal superior and inferior demifacets (costovertebral anteriorly, translates anteriorly, and rotates slightly on the
facets) on the head of a rib and corresponding demifacets on adjacent inferior vertebra. At the zygapophyseal joints,
the vertebral bodies of a superior and an inferior vertebra the inferior articular facets of the superior vertebra slide
(Fig. 12.1B). From T2 to T8, the costovertebral facets artic- upwards on the superior articular facets of the adjacent
ulate with concave demifacets located on the inferior body inferior vertebra. In extension, the opposite motions occur:
of one vertebra and on the superior aspect of the adjacent the superior vertebra tilts and translates posteriorly and the
inferior vertebral body. Some of the costovertebral facets inferior articular facets glide downward on the superior
also articulate with the interposed intervertebral disc, articular facets of the adjacent inferior vertebra.
whereas the 1st, 11th, and 12th ribs articulate with only one In lateral flexion to the right, the right inferior articular
vertebra. A thin, fibrous capsule, which is strengthened by facets of the superior vertebra glide downward on the right
radiate ligaments (see Fig. 12.1B) and the posterior longitudinal superior articular facets of the inferior vertebra. On the
365
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Transverse process rotation is allowed in the gliding that occurs at the lower
joints (T7 to T10). The movements at the costal joints are
Spinous process
T1 primarily for ventilation of the lungs but also allow some
Costal facets flexibility of the thoracic region.
Zygapophyseal Capsular Pattern
joints
The capsular pattern for the thoracic spine is a greater limita-
Superior and tion of extension, lateral flexion, and rotation than of forward
inferior costovertebral
facets flexion.1
Vertebral body
Lumbar Spine
Anatomy of the Vertebrae
The bodies of the five lumbar vertebrae are more massive than
those in the other regions of the spine in order to support the
T12 weight of the trunk. Spinous processes are broad and thick
A and extend almost horizontally (Fig. 12.2A). The fifth lumbar
Vertebral body
vertebra differs from the other four vertebrae in having a
wedge-shaped body, with the anterior height greater than
Radiate ligament
Costovertebral joint the posterior height. The inferior articular facets of the fifth
vertebra are widely spaced for articulation with the sacrum.
Rib Anatomy of the Joints
The surfaces of the superior articular facets at the zygapophy-
Costotransverse Costotransverse joint
seal joints are concave and face medially and posteriorly. The
ligament
inferior articular facet surfaces are convex and face laterally
Rib and anteriorly. Joint capsules are strong and ligaments of the
region are essentially the same as those for the thoracic
region, except for the addition of the iliolumbar ligament and
Superior articular processes (facets)
Joint capsule thoracolumbar fascia and the fact that the posterior longitudi-
Lateral costotransverse
Spinous process nal ligament is not well developed in the lumbar area. The
ligament supraspinous ligament is well developed only in the upper
B lumbar spine. However, the intertransverse ligament is well
FIGURE 12.1 A: A lateral view of the thoracic spine shows developed in the lumbar area, and the anterior longitudinal
the costal facets on the enlarged ends of the transverse ligament is strongest in this area (Fig. 12.2B). The inter-
processes from T1 to T10 and the costovertebral facets on spinous ligaments connect one spinous process to another,
the lateral edges of the superior and inferior aspects of the and the iliolumbar ligament helps to stabilize the lumbosacral
vertebral bodies. The zygapophyseal joints are shown between joint and prevent anterior displacement.
the inferior articular facets of the superior vertebrae and the
superior articular facets of the adjacent inferior vertebra.
B: A superior view of a thoracic vertebra shows the articulations
Osteokinematics
between the vertebra and the ribs: the left and right costover- The zygapophyseal articular facets of L1 to L4 lie primarily
tebral joints, the costotransverse joints between the costal in the sagittal plane, which favors flexion and extension and
facets on the left and right transverse processes, and the costal limits lateral flexion and rotation. However, flexion is more
tubercles on the corresponding ribs. limited than extension. During combined flexion and exten-
sion, the greatest mobility takes place between L4 and L5,
contralateral side, the left inferior articular facets of the whereas the greatest amount of flexion takes place at the lum-
superior vertebra glide upward on the left superior articular bosacral joint, L5-S1. Lateral flexion and rotation are greatest
facets of the adjacent inferior vertebra. in the upper lumbar region, and little or no lateral flexion is
In axial rotation, the superior vertebra rotates on the infe- present at the lumbosacral joint because of the orientation of
rior vertebra, and the inferior articular surfaces of the superior the facets.
vertebra impact on the superior articular surfaces of the adja-
cent inferior vertebra. For example, in rotation to the left, the Arthrokinematics
right inferior articular facet impacts on the right superior According to Bogduk,2 flexion at the lumbar intervertebral
articular facet of the adjacent inferior vertebra. Rotation and joints consistently involves a combination of 8 to 13 degrees
gliding motions occur between the ribs and the vertebral bod- of anterior rotation (tilting), 1 to 3 mm of anterior translation
ies at the costovertebral joints. A slight amount of rotation (sliding), and some axial rotation. The superior vertebral body
is possible between the joint surfaces of the ribs and the trans- rotates, tilts, and translates (slides) anteriorly on the adjacent
verse processes at the upper costotransverse joints, and more inferior vertebral body. During flexion at the zygapophyseal
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Coccyx
A
Interspinous
Anterior longitudinal ligament
ligament
Supraspinous
ligament
B
FIGURE 12.2 A: A lateral view of the lumbar spine shows the
broad, thick, horizontally oriented spinous processes and
large vertebral bodies. B: A lateral view of the lumbar spine
shows the anterior longitudinal, supraspinous, and interspinous
ligaments.
RANGE OF MOTION TESTING PROCEDURES Evaluation of Permanent Impairment4 requires that this
method be used to obtain reliable spinal mobility mea-
Measurement of the thoracic and lumbar spines is com- surements for disability determination. According to
plicated by the regions’ multiple joint structure, lack of the Guides, full ROM is interpreted as no impairment,
well-defined landmarks, and difficulty separating tho- and restriction of movement in one or more directions
racic and lumbar motion from hip motion. These diffi- is interpreted as a degree of impairment.
culties have given rise to the variety of different meth- Normal thoracic and lumbar spine ROM values us-
ods used to measure ROM. The testing procedures ing a variety of instruments are located in the Research
presented in this section include the tape measure Findings section, where Tables 12.1 to 12.5 provide in-
method, the Modified Schober technique (MST) as de- formation about the effects of age and gender on tho-
scribed by Macrae and Wright,3 the Modified–Modified racic and lumber ROM. This information is followed by
Schober Test (MMST), the universal goniometer (UG) functional ranges of motion and a review of research
method, and the double inclinometer method. The first studies on the reliability and validity of the various in-
four methods were selected because they are inexpen- struments and methods used to measure thoracic and
sive, are relatively easy to use, and have acceptable re- lumbar ROM (see Tables 12.6 to 12.8 in the Research
liability. The double inclinometer method has been in- Findings section). Note that in the following testing
cluded in this edition because the fifth edition of the procedures we are measuring active range of motion
American Medical Association’s (AMA) Guides to the (AROM).
C7
T1
T12
L1
L5
PSIS
S2
FIGURE 12.3 Surface anatomy landmarks for tape measure, FIGURE 12.4 Bony anatomical landmarks for tape measure,
universal goniometer, and inclinometer alignment for universal goniometer, and inclinometer alignment for mea-
measuring the thoracolumbar spine motion. The dots are suring thoracolumbar spine motion.
located over spinous processes of C7, T1, T12, L1, L5, and
S2 and over the right and left posterior superior iliac spines
(PSIS).
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THORACOLUMBAR FLEXION
THORACOLUMBAR FLEXION: TAPE identify than the spinous process of S1, and there is
no motion between S1 and S2.
MEASURE 2. Align the tape measure between the two spinous
Four inches (10 cm) is considered to be an average
processes and record the distance at the starting of
measurement for healthy adults.5
the ROM (Fig. 12.6).
3. Hold the tape measure in place as the subject
Procedure performs flexion ROM. (Allow the tape measure to
1. Mark the spinous processes of the C7 and S2 verte-
unwind and accommodate the motion.)
brae using a skin marking pencil, with the subject in
4. Record the distance at the end of the ROM
the standing position. The spinous process of S2 is
(Fig. 12.7). The difference between the first and
on a horizontal level with the posterior superior
the second measurements indicates the amount of
iliac spines [PSIS]. We have chosen to use the spin-
thoracolumbar flexion ROM.
ous process of S2 for a landmark as it is easier to
FIGURE 12.6 Tape measure alignment in the starting posi- FIGURE 12.7 Tape measure alignment at the end of thora-
tion for measuring thoracolumbar flexion ROM. columbar flexion ROM. The metal tape measure case (not
visible in the photo) is in the examiner’s right hand.
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FIGURE 12.8 At the end of trunk and hip flexion the exam-
iner measures the distance between the tip of the subject’s
middle finger and the floor with either a centimeter ruler or
a tape measure.
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FIGURE 12.9 The starting position for measuring thoracolum- FIGURE 12.10 Inclinometer alignment at the end of thora-
bar flexion with both inclinometers aligned and zeroed. columbar flexion ROM.
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THORACOLUMBAR EXTENSION
THORACOLUMBAR EXTENSION: 3. Keep the tape measure aligned during the motion
and record the measurement at the end of the
TAPE MEASURE ROM (Fig. 12.13). The difference between the
Procedure measurement taken at the beginning of the motion
1. Mark the spinous processes of the C7 and S2 verte- and that taken at the end indicates the amount of
brae using a skin marking pencil, with the subject in thoracic and lumbar extension.
the standing positon.
2. Align the tape measure between the two spinous
processes and record the measurement (Fig. 12.12).
FIGURE 12.12 Tape measure alignment in the starting posi- FIGURE 12.13 At the end of thoracolumbar extension ROM,
tion for measurement of thoracolumbar extension. When the distance between the two landmarks is less than it was
the subject moves into extension, the tape slides into the in the starting position.
tape measure case in the examiner’s hand.
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THORACOLUMBAR EXTENSION: 3. At the end of the motion, read and record the val-
FIGURE 12.14 The starting position for measuring thoracolum- FIGURE 12.15 Inclinometer alignment at the end of thora-
bar extension with both inclinometers aligned and zeroed. columbar extension.
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THORACOLUMBAR LATERAL occurs when the heel begins to rise on the foot oppo-
site to the side of the motion and the pelvis begins to
FLEXION tilt laterally.
Testing Position
Place the subject standing with the feet shoulder
width apart and the cervical, thoracic, and lumbar Normal End-Feel
spine in 0 degrees of flexion, extension, and rotation. The end-feel is firm owing to the stretching of the con-
tralateral fibers of the annulus fibrosus, zygapophyseal
Stabilization joint capsules, intertransverse ligaments, thoracolumbar
Stabilize the pelvis to prevent lateral tilting. fascia, and the following muscles: external and oblique
abdominals, longissimus thoracis, iliocostalis lumborum
Testing Motion and thoracis lumborum, quadratus lumborum, multi-
Ask the subject to bend the trunk to one side while fidus, spinalis thoracis, and serratus posterior inferior.
keeping the arms in a relaxed position at the sides of The end-feel may also be hard owing to impact of the
the body. Keep both feet flat on the floor with the ipsilateral zygapophyseal facets (right facets when
knees extended (Fig. 12.16). The end of the motion
FIGURE 12.16 The end of thoracolumbar lateral flexion ROM. The examiner
places both hands on the subject’s pelvis to prevent lateral pelvic tilting.
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bending to the right) and the restrictions imposed by to 29 year olds) to 18.0 degrees (in a group of 70 to 79
THORACOLUMBAR LATERAL 3. Ask the subject to bend to the side as far as possi-
Normal End-Feel
The end-feel is firm owing to stretching of the fibers
of the contralateral annulus fibrosus and zygapophy-
seal joint capsules; costotransverse and costovertebral
joint capsules; supraspinous, interspinous, and iliolum-
bar ligaments; and the following muscles: rectus
abdominis, external and internal obliques and multi-
fidus, and semispinalis thoracis and rotatores. The
end-feel may also be hard owing to contact between
the zygapophyseal facets.
➧ NOTE: Use the same testing position, stabiliza-
tion, testing motion, and normal end-feel described
in the Thoracolumbar Rotation section above for
the following rotation measurement methods
unless changes are noted.
FIGURE 12.27 At the end of rotation, one of the examiner’s hands keeps the proximal goniometer
arm aligned with the subject’s iliac tubercles while keeping the distal goniometer arm aligned with
the subject’s right acromion process.
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THORACOLUMBAR ROTATION: 4. Ask the subject to rotate the trunk as far as possi-
ble without moving into extension (Fig. 12.29). The
DOUBLE INCLINOMETER examiner needs to hold the inclinometers firmly
Procedure against the subject’s back during the motion.
1. Mark the spinous processes of the T1 and S2 verte- 5. Note the degrees shown on the inclinometers at
brae using a skin marking pencil the end of the motion. The difference between
2. Place the subject in a forward flexed standing posi- inclinometer readings is the rotation ROM.
tion so that the subject’s back is parallel to the floor.
3. Place one inclinometer over the spinous process of
T1 and the second inclinometer over the sacrum at
the level of S2. Then zero both inclinometers
(Fig. 12.28).
Procedure
Testing Motion 1. Use a ruler to locate and place a first mark at a
Ask the subject to bend forward as far as possible
midline point on the sacrum that is level with the
while keeping the knees straight.
posterior superior iliac spines (this mark will be over
the spinous process of S2). Make a second mark
Normal End-Feel 15 cm above the midline sacral mark (Fig. 12.30).
The end-feel is firm owing to stretching of the ligamen-
2. Align the tape measure between the superior and
tum flavum; posterior fibers of the annulus fibrosus and
inferior marks (Fig. 12.31). Ask the subject to bend
zygapophyseal joint capsules; thoracolumbar fascia; illio-
forward as far as possible while keeping the knees
lumbar ligaments; and the multifidus, quadratus lumbo-
straight. Maintain the tape measure against the sub-
rum, and iliocostalis lumborum muscles. The location of
ject’s back during the motion, but allow the tape
the following muscles suggests that they may limit flex-
measure to unwind to accommodate the motion.
ion, but the actual actions of the interspinales and inter-
3. At the end of flexion ROM, note the distance
transversaii mediales and laterales are unknown.2
between the two marks (Fig. 12.32). The ROM is
the difference between 15 cm and length measured
LUMBAR FLEXION: at the end of the motion.
MODIFIED–MODIFIED SCHOBER
TEST19,20 OR SIMPLIFIED SKIN
DISTRACTION TEST21
In the original Schober method, the examiner made
only two marks on the subject’s back. The first mark
was made at the lumbosacral junction, and the sec-
ond mark was made 10 cm above the first mark on L1
the spine. Macrae and Wright3 decided to modify the
Schober method (Modified Schober test) because
they found that skin movement was a problem in the 15cm
original method. They believed that the skin was more
firmly attached in the region below the lumbosacral
junction and therefore decided to use three marks—
the first mark at the lumbosacral junction, the second
mark 10 cm above the first mark, and the third mark
5 cm below the lumbosacral junction. The tape mea-
surement is placed between the most superior and PSIS
the most inferior marks. However, difficulty in cor-
rectly identifying the lumbosacral junction led to
another modification of the original Schober test, Sacrum
called the Modified–Modified Schober Test (or MMST),
which was proposed by van Adrichem and van der
Korst.20 The MMST is sometimes referred to as the
simplified skin distraction test21 and is described in
the next paragraph.
The MMST uses two marks: one over the sacral
FIGURE 12.30 A line is drawn between the two posterior
spine on a line connecting the two PSISs and the other superior iliac spines and the point at which the lower end of
mark over the spine 15 cm superior to the first mark. the tape measure should be positioned. The location of the
Because the PSISs are much easier to identify than the 15-cm mark shows that all five of the lumbar vertebrae in
lumbosacral junction, van Adrichem and van der Korst20 this subject are included.
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LUMBAR FLEXION:MODIFIED
FIGURE 12.33 The starting position for measurement of FIGURE 12.34 The end of lumbar flexion range of motion,
lumbar flexion range of motion, with inclinometers aligned with inclinometers aligned over the spinous processes of
and zeroed. T12 and S2.
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LUMBAR EXTENSION: DOUBLE 3. Ask the subject to bend backward as far as possi-
ble. Maintain the inclinometers firmly against the
INCLINOMETER spine during the motion (Fig. 12.38).
The normal ROM values for young-adult males (15 to
4. Read and record the degrees from both inclinome-
30 years) is 38 degrees, whereas the value for middle-
ters at the end of the motion. Subtract the degrees
age males (31 to 60 years) is 35 degrees. In males older
on the sacral inclinometer from the degrees on
than age 60 years the ROM is 33 degrees. In young-
the T12 inclinometer to obtain the lumbar
adult females the ROM is 42 degrees, in middle-aged
extension ROM.
females the ROM is 40 degrees, and in females older
than 60 years the ROM is 36 degrees.23 According to
the AMA,6 the normal ROM for adults is from 207 to
254 degrees; both of these values are considerably less
than the values that were found by Loebl.23
Procedure
1. Mark the spinous processes of the T12 and S2 ver-
tebrae using a skin marking pencil, with the subject
in the standing position.
2. Place one inclinometer over the spinous process of
T12 and the second inclinometer over the midline
of the sacrum at S2. Then zero both inclinometers
(Fig 12.37).
Normal End-Feel
The end-feel is firm owing to stretching of the con-
tralateral band of the iliolumbar ligament, contralat-
eral thoracolumbar fascia, contralateral fibers of the
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LUMBAR LATERAL FLEXION: 3. Ask the subject to bend the trunk laterally while
keeping both feet flat on the ground and the knees
DOUBLE INCLINOMETER straight (Fig. 12.40).
According to the AMA, the ROM value is 25 to
4. Read and record the degrees on both inclinome-
30 degrees to each side.4,7
ters. Subtract the degrees on the sacral inclinome-
ter from the degrees on the T12 inclinometer to
Procedure obtain the lumbar lateral flexion ROM to one side.
1. Mark the spinous processes of the T12 and S2 ver-
5. Repeat the measurement process to measure lumbar
tebrae using a skin marking pencil, with the subject
lateral flexion ROM on the other side.
in the standing position.
2. Position one inclinometer over the T12 spinous
process and the second inclinometer over the
sacrum at the level of S2. Then, zero both incli-
nometers (Fig. 12.39).
FIGURE 12.39 Starting position for measuring lumbar lateral FIGURE 12.40 At the end of lumbar lateral flexion range of
flexion range of motion with double inclinometers placed motion (ROM), read and record the degrees on each incli-
over the spinous processes of T12 and S2. nometer. Subtract the degrees on the sacral inclinometer
from the T12 reading to obtain the ROM.
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TABLE 12.1 Thoracolumbar and Lumbar Spine Motion: Normal Values for Adults in Inches
and Degrees From Selected Sources
Instrument Tape Measure & Double BROM II 3Space Inclinometer
Goniometer Inclinometers isotrak system
Motion Thoracolumbar Lumbar Lumbar Lumbar Lumbar
Authors AAOS*5 AMA† 6 Breum et al70 VanHerp et al 33 Ng et al24
Sample 18–38 years 20–29 years 30 yrs
Motion Mean (SD) Mean (SD) Mean (SD)
Flexion 4 inches 60 degrees 56.3 (1.3) degrees 56.4 (7.1) degrees 52 (90) degrees
Extension 20–30 degrees 25 degrees 21.5 (8.2) degrees 22.5 (7.8) degrees 19 (9) degrees
Right lateral flexion 35 degrees 25 degrees 33.3 (5.9) degrees 26.2 (8.4) degrees 31 (6) degrees
Left lateral flexion 35 degrees 25 degrees 33.6 (6.2) degrees 25.8 (7.8) degrees 30 (6) degrees
Right rotation 45 degrees 14.4 (5.1) degrees 33 (9) degrees
TABLE 12.2 Age Effects on Lumbar and Thoracolumbar Spine Motion in 20- to 79-Year-Old Adults:
Normal Values in Centimeters and Degrees
20–29 yrs 30–39 yrs 40–49 yrs 50–59 yrs 60–69 yrs 70–79 yrs
Sample n = 31 n = 42 n = 16 n = 43 n = 26 n=9
Motion Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD)
Flexion* 3.7 (0.7) 3.9 (1.0) 3.1 (0.8) 3.0 (1.1) 2.4 (0.7) 2.2 (0.6)
Extension 41.2 (9.6) 40.0 (8.8) 31.1 (8.9) 27.4 (8.0) 17.4 (7.5) 16.6 (8.8)
Right lateral flexion 37.6 (5.8) 35.3 (6.5) 27.1 (6.5) 25.3 (6.2) 20.2 (4.8) 18.0 (4.7)
Left lateral flexion 38.7 (5.7) 36.5 (6.0) 28.5 (5.2) 26.8 (6.4) 20.3 (5.3) 18.9 (6.0)
SD = standard deviation.
* Flexion measurements were obtained with use of the Schober method and are reported in centimeters.
All other measurements were obtained with use of a universal goniometer and are reported in degrees.
Adapted from Fitzgerald, GK, et al: Objective assessment with establishment of normal values for lumbar
spine range of motion. Phys Ther 63:1776, 1983.14 With the permission of the American Physical Therapy Association.
decrease in lateral flexion is similar to the findings of McGregor, The following two studies investigated segmental mobility.
McCarthy, and Hughes,29 who found that lateral flexion Gracovetsky and associates28 found a significant difference
showed a slightly higher decrease in ROM (43 percent) than between young and old in a group of 40 subjects aged 19 to
the decrease in forward flexion (40 percent). 64 years. Older subjects had decreased segmental mobility in
In other studies the authors reported that both flexion and the lower lumbar spine compared with younger subjects. To
extension ROM were found to decline with increasing age, compensate for the decrease in mobility, the older subjects
but in some of the studies the motions were full cycle increased the contribution of the pelvis to flexion and extension.
motions, so it is difficult to tell whether the decrease was in Wong and colleagues35 assessed intervertebral lumbar
flexion or in extension. flexion and extension in 100 healthy volunteers (50 males and
In one of the earlier studies, in 1967 Loebl23 used an 50 females) ages 20 to 76 years. The results showed that all
inclinometer to measure active sagittal plane ROM of the segmental lumbar spinal motion profiles within the ROM of
thoracic and lumbar spine of 126 males and females between 10 degrees of extension to 40 degrees of flexion did not
15 and 84 years of age. He found age-related effects for both change as age increased until subjects were 51 years of age or
males and females and concluded that both genders should older. Subjects in the oldest age group had a decrease in max-
expect a loss of about 8 degrees of spinal ROM per decade imum flexion and extension ROM, but an increase in the
with increases in age. slopes of the intervertebral flexion-extension curves at each
In a more recent study, Sullivan, Dickinson, and Troup25 lumbar segment.
used double inclinometers to measure sagittal plane lumbar
motion in 1126 healthy male and female subjects. These Gender
authors found that when gender was controlled, flexion and Investigations of the effects of gender on lumbar spine ROM
extension decreased with increasing age. The authors sug- indicate that the effects may be motion specific and possibly
gested that the ROM thresholds that determine impairment age specific, but controversy still exists concerning which
ratings should take age into consideration. motions are affected, and some authors report that gender has
In 1969 Macrae and Wright3 used a modification of the no effects. The fact that investigators used different instru-
Schober technique to measure forward lumbar flexion in ments and methods makes comparisons between studies diffi-
195 women and 147 men (18 to 71 years of age). The authors cult. However, the following five studies appear to agree that
found that active flexion ROM decreased with age. the ROM in flexion is greater in males than in females, at least
Anderson and Sweetman27 used a device that combined a in subjects 15 to 65 years of age. This difference in flexion
flexible rule and a hydrogoniometer to measure the ROM of ROM between males and females is apparent even in children
432 working men aged 20 to 59 years. Increasing age was between the ages of 5 to 11 years.30 At the other end of the age
associated with a lower total lumbar spine ROM (flexion and spectrum, this difference between the genders in flexion ROM
extension) in this group of subjects. may have evened out by the time men and women were in
The preceding studies are fairly consistent in concluding their 80s.31,32
that both thoracolumbar and lumbar ROM decreases with Macrae and Wright3 found that females had signifi-
increasing age, and that extension and lateral flexion may be cantly less forward flexion than males across all age
affected more than flexion. Axial rotation was not measured groups. Sullivan, Dickinson, and Troup25 also found that
in the majority of studies, but when it was measured, no age- when age was controlled, mean flexion ROM was greater in
related changes in ROM were found. males. However, mean extension ROM and total ROM were
2066_Ch12_365-408.qxd 5/21/09 5:21 PM Page 395
significantly greater in females. Subjects in the study were spine ROM. Loebl23 found no significant gender differences
1126 healthy male and female volunteers aged 15 to 65 years. between the 126 males and females aged 15 to 84 years of age
The authors noted that, although female total ROM was sig- for measurements of lumbar flexion and extension. Bookstein
nificantly greater than male total ROM, the difference of 1.5 and associates34 used a tape measure to measure the lumbar
degrees was not clinically relevant. Age and gender combined extension ROM in 75 elementary school children aged 6 to 11
accounted for only 14 percent of the variance in flexion, 25 years. The authors found no differences for age or gender, but
percent in extension, and 20 percent of the variance in total they found a significant difference for age–gender interaction
ROM (Table 12.3). Alaranta and associates,18 in a study of in the 6-year-old group. Girls aged 6 years had a mean range
508 males and females ages 35 to 45 years, also determined of extension of 4.1 cm, in contrast to the 6-year-old boys, who
that men had greater flexion ROM than women. However, had a mean range of extension of 2.1 cm. Wong and col-
these authors found no difference between the sexes in exten- leagues35 used an electrogoniometer and videofluoroscopy to
sion ROM. Kondratek and associates,30 in a study of 116 girls assess the flexion–extension profile of the lumbar spine in
and 109 boys aged 5 to 11 years of age, found a statistically different genders and age groups. A total of 100 healthy vol-
significant difference between the youngest and oldest sub- unteers (50 females and 50 males) ages 21 to 51 years and
jects in active lumbar flexion in girls and active lumbar lateral older participated in the study, but no statistically significant
flexion and rotation in both girls and boys. The older girls, differences in the pattern of motion were found between the
aged 11 years, consistently demonstrated less motion in genders.
forward flexion and right and left lateral flexion than the boys.
Diurnal Effects
Extension varied very little in either gender. Troke and col-
Ensink and coworkers 36 determined that the average increase
leagues31,32 found that men had greater ROM in flexion at
in height in the morning after 8 hours of bed rest was 2 mm,
16 years than women, but in the final decade (80 to 90 years)
with 40 percent of the increase occurring in the lumbar spine.
men and women were equal.
The increase in height was due to the hydration of the discs
Moll and Wright’s26 findings are directly opposite to the
that occurred during bed rest. Lumbar spine ROM in flexion
findings of the previous three studies in that Moll and Wright
was decreased in the morning but increased during the day as
determined that male mobility in extension significantly
water was squeezed out of the discs. ROM in extension was
exceeded female mobility by 7 percent. Differences in findings
not affected. Consequently, examiners should try to test and
between studies may have resulted from the fact that Moll and
retest lumbar flexion ROM during the same time of day.
Wright26 did not control for age. These authors measured the
range of lumbar extension in a study involving 237 subjects Occupation and Lifestyle
(119 males and 118 females) aged 15 to 90 years, who were Researchers have investigated the following factors among
clinically and radiologically normal relatives of patients with others in relation to their effects on lumbar ROM: occupa-
psoriatic arthritis (Tables 12.4 and 12.5). tion,37 lifestyle,29,37–39 time of day,36 and disability.25,40–44 Simi-
Van Herp and associates,33 in an investigation of lumbar lar to the findings related to age and gender, the results have
range of motion in 100 subjects (50 male and 50 female) 20 to been controversial.
77 years of age, found that females consistently showed greater Sughara and colleagues,37 using a device called a spin-
flexibility than males in lumbar flexion–extension, lateral flex- ometer, studied age-related and occupation-related changes in
ion, and axial rotation throughout the age range. Because flex- thoracolumbar active ROM in 1071 men and 1243 women
ion was not separated from extension, it is difficult to know aged 20 to 60 years. Subjects were selected from three occu-
which motion was responsible for the increase. pational groups: fishermen, farmers, and industrial workers.
In contrast to the preceding authors, the following three Although both flexion and extension were found to decrease
studies reported no significant effects for gender on lumbar with increasing age, decreases in the extension ROM were
TABLE 12.3 Age and Gender Effects on Lumbar Motion in Individuals 15 to 65 Years Old:
Normal Values in Degrees Using a Fluid-Filled Inclinometer
Sample 16-24 yrs 15–24 yrs 25–34 yrs 25–34 yrs 35–65 yrs 35–65 yrs
Male Female Male Female Male Female
n = 122 n = 161 n = 295 n = 143 n = 269 n= 136
Motion Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD)
Flexion 33 (9) 26 (9) 31 (8) 24 (8) 27 (8) 22 (8)
Extension 54 (10) 63 (9) 52 (9) 60 (10) 47 (9) 53 (9)
SD = standard deviation.
Adapted from Sullivan, MS, Dickinson, CE, and Troup, JDG: The influence of age and gender on lumbar spine sagittal plane range of
motion: A study of 1126 healthy subjects. Spine 19:682, 1994.40
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TABLE 12.4 Age and Gender Effects on Lumbar and Thoracolumbar Motion in Individuals
Ages 15 to 44 Years: Normal Values in Centimeters
Sample 15–24 yrs 25–34 yrs 35–44 yrs
Adapted from Moll, JMH, and Wright, V: Normal range of spinal mobility: An objective clinical study. Ann Rheum
Dis 30:381, 1971.26 The authors used skin markings and a plumb line on the thorax for lateral flexion.
SD = standard deviation.
*Lumbar motion.
†
Thoracolumbar motion.
greater than decreases in flexion. Decreases in active exten- exist between school bus use and physical performance was
sion ROM were less in fishermen and their wives than in the confirmed. The distance traveled by the school bus was
other occupational groups in the study. The researchers con- inversely associated with hamstring flexibility and other hip
cluded that because both fishermen and their wives had more motions but not with low-back flexion. Walking or bicycling to
extension than other groups, other variables than the physical leisure activities was positively associated with low-back
demands of fishing were affecting the maintenance of exten- strength, low-back extension ROM, and hip flexion and
sion ROM. extension.
Sjolie39 compared low-back strength and low-back and hip Freidrich and colleagues38 conducted a comprehensive
mobility between a group of 38 adolescents living in a commu- examination of spinal posture during stooped walking in
nity without access to pedestrian roads and a group of 50 ado- 22 male sewer workers aged 24 to 49 years. Working in a
lescents with excellent access to pedestrian roads. Low-back stooped posture has been identified as one of the risk factors
mobility was measured by means of the modified Schober tech- associated with spinal disorders. Five posture levels corre-
nique. The results showed that adolescents living in rural areas sponding to standardized sewer heights ranging in decreasing
without easy access to pedestrian roads had less low-back size from 150 to 105 cm were taped by a video-based motion
extension and hamstring flexibility than their counterparts in analysis system. The results showed that the lumbar spine
urban areas. The hypothesis that negative associations would abruptly changed from the usual lordotic position in normal
TABLE 12.5 Age and Gender Effects on Lumbar and Thoracolumbar Motion in Individuals
Ages 45 to 74 Years: Normal Values in Centimeters
Sample 45–54 yrs 55–64 yrs 65–74 yrs
Adapted from Moll, JMH, and Wright, V: Normal range of spinal mobility: An objective clinical study.
Ann Rheum Dis 30:381, 1971.26 The authors used skin markings and a plumb line on the thorax for lateral flexion.
SD = standard deviation.
*Lumbar motion.
†
Thoracolumbar motion.
2066_Ch12_365-408.qxd 5/21/09 5:21 PM Page 397
upright walking to a kyphotic position in mild, 150-cm head- only 16 percent of the variance between groups with and with-
room restriction. As ceiling height decreased, the neck out low-back pain. A decreased ROM in the lower lumbar seg-
progressively assumed a more extended lordotic position; the ments, low maximal ROM in extension, and high body weight
thoracic spine extended and flattened, becoming less were predictive of low-back pain in females and accounted for
kyphotic; and the lumbar spine became more kyphotic. As 31 percent of the variability between groups.
expected, the older workers showed decreased segmental Alaranta and associates,18 in a study of 508 male and
mobility in the lumbar spine and an increase in cervical lor- female white and blue collar employees ages 35 to 54 years,
dosis with decreasing ceiling height. found that the strongest connections were between trunk lateral
flexion ROM and low-back pain during the preceding year.
Disability
The relationship between ROM findings and disability is a
topic of considerable interest and importance to health profes-
Functional Range of Motion
sionals. Researchers have reported conflicting results, so that Hsieh and Pringle45 used a CA-6000 Spinal Motion Analyzer
there appears to be no clear relationship between range of (Orthopedic Systems, Inc., Hayward, CA) to measure the
motion and disability at the present time. amount of lumbar motion required for selected activities of
Sullivan, Dickinson, and Troup25 used dual inclinometers daily living performed by 48 healthy subjects with a mean age
to measure lumbar spine sagittal motion in 1126 healthy indi- of 26.5 years. Activities included stand to sit, sit to stand,
viduals. The authors found a large variation in measurements putting on socks, and picking up an object from the floor. The
and suggested that detection of ROM impairments might be individual’s peak flexion angles for the activities were
difficult because 95% confidence intervals yielded up to a normalized to the subject’s own peak flexion angle in erect
36-degree spread in normal ROM values. Sullivan, Shoaf, and standing. Stand to sit and sit to stand (Fig. 12.41) required
Riddle40examined the relationship between impairment of approximately 56 percent to 66 percent of lumbar flexion. The
active lumbar flexion ROM and disability. The authors used mean was 34.6 degrees for sit to stand and 41.8 degrees for
normative data to determine when an impairment in flexion stand to sit. Putting on socks (Fig. 12.42) required 90 percent
ROM was present and used the judgment of physical thera- of lumbar flexion ROM (mean 56.4 degrees), and picking up
pists to determine whether flexion ROM impairment was rel- an object from the floor (Fig. 12.43) required 95 percent of
evant to the patient’s disability. Low correlations between lumbar flexion (mean 60.4 degrees). In view of these findings,
lumbar ROM and disability were found, and the authors con- one can understand how limitations in lumbar ROM may
cluded that active lumbar ROM measurements should not be
used as treatment goals.
Nattrass and associates43 used a long-arm goniometer to
measure thoracolumbar ROM and dual inclinometers to mea-
sure low-back ROM in 34 patients aged 20 to 65 years with
chronic low-back pain. ROM for all subjects was compared with
ratings on commonly used impairment and disability
indexes. Only flexion measured with the goniometer demon-
strated greater than 50 percent of the variance in common with
one of the disability measues. The authors concluded that lum-
bar ROM alone is not enough to represent impairment and,
therefore, the AMA Guides to the Evaluation of Permanent
Impairment should not limit impairment ratings to ROM be-
cause ROM seems to represent only one aspect of impairment.
However, Lundberg and Gerdle,41 who investigated
spinal and peripheral joint mobility and spinal posture in
607 female home care employees (mean age 40.5 years),
found that lumbar sagittal hypomobility alone was associated
with higher disability, and a combination of positive pain
provocation tests and lumbar sagittal hypomobility was asso-
ciated with particularly high disability levels. Peripheral joint
mobility, spinal sagittal posture, and thoracic sagittal mobility
showed low correlations with disability.
Kujala and coworkers42 conducted a 3-year longitudinal
study of lumbar mobility and occurrence of low-back pain in
98 adolescents. The subjects included 33 nonathletes (16 males
and 17 females), 34 male athletes, and 31 female athletes. Par-
ticipation in sports and low maximal lumbar flexion predicted FIGURE 12.41 Sit to stand requires an average of 35 degrees
low-back pain during the follow-up in males, but accounted for of lumbar flexion.45
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affect an individual’s ability to independently carry out dress- Littlewood and May47 conducted a systematic review of
ing and other activities of daily living. 86 ROM studies to determine what low tech measurement
Levine and associates46 conducted a study with 20 healthy methods were valid for measuring lumbar spine ROM. Only
women (mean age 23.4 years) from a university student popu- four studies—those by Samo and colleagues,48 Saur and
lation to determine changes in lumbar spine motion in stand- colleagues,49 Williams and colleagues,19 and Tousignant and
ing, walking, and running on a treadmill at three different colleagues50—were found to meet the criteria of English
gradients. According to results obtained from the Vicon language only, evaluated validity by comparison to radiographs,
Motion Analysis System, total lumbar spine ROM was greater included adult subjects with non-specific low back pain, and in-
during running than during walking, and greater walking cluded measurement accuracy to enable judgement on validity.
downhill than walking uphill or on a level surface. However, All failed to meet the criteria of blinding the examiners. Double
the maximum amount of lumbar extension (anterior pelvic tilt) inclinometers were used in three of the four studies, and the
was found in standing at the three gradients. Modified-Modified-Schober Test (MMST) was used in the other
study. Littlewood and May4 performed a qualitative analysis but
did not perform a meta-analysis. In regard to the double incli-
Reliability and Validity nometer method, they concluded that there was only limited
The following section on reliability and validity has been positive supporting evidence for the validity of measuring total
divided according to the instruments and methods used to lumbar ROM in comparison to radiographic analysis; there was
obtain the measurements. However, some overlap occurs conflicting evidence for the validity of measuring lumbar flex-
between the sections because several investigators have com- ion ROM; and there was limited positive evidence for the lack
pared different methods and instruments within one study. of validity of measuring lumbar extenson. In regard to the
2066_Ch12_365-408.qxd 5/21/09 5:21 PM Page 399
MMST they determined that there was limited positive evidence Saur and colleagues49 used Pleurimeter V inclinometers to
for the lack of validity for measuring lumbar flexion ROM. The measure lumbar ROM in 54 patients with chronic low-back
authors concluded that there is a need for scientific evidence on pain who were between 18 and 60 years of age. Measurements
the validity of these measurement procedures. were taken with and without radiographic verification of the
In another review, Essendrop and colleagues51 screened T12 and S1 landmarks used for positioning the inclinometers.
databases from 1980 to 1999 for reliability studies regarding Intertester reliability of the inclinometry technique for full
the measurement of low-back ROM, strength, and endurance. cycle flexion–extension in a subgroup of 48 patients was high
Seventy-nine studies were located, 6 of which met the predeter- (r 0.94) and half cycle flexion was good (r 0.88), but half
mined criteria for a quality study and focused on the measure- cycle extension was poor (r 0.42). The authors concluded
ment of low back ROM. Noting the difficulty in making that the Pleurimeter V was a reliable and valid method for
definite conclusions based on these limited studies, the authors measuring lumbar ROM and that with use of this instrument it
reported that the tape measure was the most reliable instrument was possible to differentiate lumbar spine movements from
for flexion measurements. Reliable extension measurements hip movements.
were difficult to achieve with any of the reviewed instruments. Chen and associates54 investigated intertester and intra-
The tape measure and Cybex EDI 320 goniometer were reliable tester reliability using three health professionals to measure
for trunk lateral flexion when comparing groups but not individ- lumbar ROM using a Pleurimeter V (double inclinometer), a
uals. Trunk rotation measurements were the most unreliable for carpenter’s double inclinometer, and a computed single-
all instruments including the double inclinometer, Myrin incli- sensor inclinometer. Intertester reliability was poor, with all
nometer, tape measure, and universal goniometer. ICCs less than 0.75; with a single exception, intratester relia-
Reliability:Inclinometer bility was less than 0.90. The authors determined that the
The AMA Guides to the Evaluation of Permanent Impairment4 largest source of measurement error was attributable to the
states that “measurement techniques using inclinometers are examiners and associated factors and concluded that these
necessary to obtain reliable spinal mobility measurements.” three surface methods had only limited clinical usefulness.
However, in a study by Williams and coworkers19 that com- Mayer and colleagues55 used a Cybex EDI-320 (Lumex,
pared the measurements of the inclinometer with those of the Ronkonkoma, NY), a computed inclinometer with a single
tape measure, the authors found that the double inclinometer sensor, to measure lumbar ROM in 38 healthy individuals.
technique had questionable intertester reliability (Table 12.6). Full cycle sagittal ROM was the most accurate measurement,
Reliability problems with the use of double inclinometers are and extension was the least accurate. Clinical utility of lum-
often related to difficulty in identifying landmarks and in hold- bar sagittal plane ROM measurement appeared to be highly
ing the inclinometers correctly. Other problems include too sensitive to the training of the test administrator in aspects of
long a time period between test and retest and lack of sufficient the process such as locating bony landmarks of T12 and S1 and
practice to familiarize the examiner with the instruments. maintaining inclinometer placement without rocking on the
Loebl23 has stated that the only reliable technique for sacrum. Device error was negligible relative to the error associ-
measuring lumbar spine motion is radiography. However, ated with the test process itself. The authors found that practice
radiography is expensive and may pose a health risk to the was the most significant factor in eliminating the largest source
subject; moreover, the validity of radiographic assessment of of error when inexperienced examiners were used.
ROM is unreported. Loebl23 used an inclinometer to measure Nitschke and colleagues56 compared the following mea-
flexion and extension in nine subjects. He found that in five surement methods in a study involving 34 male and female
repeated active measurements, the ROM varied by 5 degrees subjects with chronic low-back pain and two examiners:
in the most consistent subject and by 23 degrees in the most dual inclinometers for lumbar spine ROM (flexion, exten-
inconsistent subject. Variability decreased when measure- sion, and lateral flexion) and a plastic long-arm goniometer
ments were taken on an hourly basis rather than on a daily for thoracolumbar ROM (flexion, extension, lateral flexion,
basis. Patel,52 who used the double inclinometer method to and rotation). Intertester reliability was poor for all mea-
measure lumbar flexion on 25 subjects aged 21 to 37 years, surements except for flexion taken with the long-arm
found intratester reliability to be high (r 0.91), but goniometer (Table 12.6). The dual inclinometer method had
intertester reliability was considerably lower (r 0.68). no systematic error, but there was a large random error for
Mayer and associates53 compared repeated measurements all measurements. The authors concluded that the standard
of lumbar ROM of 18 healthy subjects taken by 14 different error of measurement might be a better indicator of reliabil-
examiners using three different instruments: a fluid-filled ity than the ICC.
inclinometer, the kyphometer, and the electrical inclinometer. Reynolds57 compared intratester and intertester reliability
The three instruments were found to be equally reliable, but with use of a spondylometer, a plumb line and skin distraction,
significant differences were found between examiners. Poor and an inclinometer. Intertester error was calculated by com-
intertester reliability was the most significant source of vari- paring the results of two testers taking 10 repeated measure-
ance. The authors identified sources of error as being caused ments of lumbar flexion, extension, and lateral flexion on 30
by differences in instrument placement among examiners and volunteers with a mean age of 38.1 years. Highly significant
inability to locate the necessary landmarks. positive correlations were found between flexion–extension
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TABLE 12.6 Intratester and Intertester Reliability for Thoracolumbar and Lumbar ROM
BROM Back Range of Motion Device; OSI CA-6000 Spine Motion Analyzer.
* Lumbar ROM.
+ Thoracolumbar ROM.
ROM measured with the inclinometer and that measured with In contrast to the findings of Saur and colleagues,49
the spondylometer. The inclinometer had acceptable intertester Samo and coworkers48 reported poor criterion validity with
reliability, with the highest reliability for measurement of lat- the use of inclinometers. Samo and coworkers48 compared
eral flexion to the right. radiographic measurements of lumbar ROM in 30 subjects
with measurements taken with the following three instru-
Validity: Double Inclinometers ments: a Pleurimeter V (double inclinometer), a carpenter’s
Saur and colleagues49 found that the correlation of radiographic double inclinometer, and a computed single-sensor incli-
ROM measurements with inclinometer ROM measurements nometer. All ICCs between radiographs and each method
demonstrated an almost linear correlation for flexion (r 0.98) were less than the 0.90 established by the authors as the cri-
and total lumbar flexion–extension ROM (r 0.97), but exten- terion. Therefore, the authors judged that each method had
sion did not correlate as well (r 0.75). poor validity.
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Reliability: Universal Goniometer reliability was excellent (ICC 0.94) and so was intertester
Nitschke and colleagues56 compared lumbar spine ROM mea- reliability (ICC 0.96).
surements taken with the universal goniometer and the double Jones and associates17 conducted a repeated measures
inclinometer in a study involving 34 males and females with study of 119 children aged 11 to 16 years to assess the mea-
low-back pain. The goniometer was used to measure all surement error associated with spinal mobility measures.
ranges of lumbar spine motion. Intertester reliability was poor Thirty children in the sample reported recurrent low-back
for all measurements for both instruments except for flexion pain, and 89 children were asymptomatic (Table 12.8). The
using the goniometers (see Table 12.6). correlation coefficient for lumbar flexion using the MST was
Fitztgerald and associates14 used the universal goniome- 0.99 for the asymptomatic group and 0.93 for the sympto-
ter to measure thoracolumbar lateral flexion and extension. matic group. Little systematic error was present, but the
Two testers measured half cycle motions in 17 volunteers who 95 percent limits of agreement showed that all measures
were physical therapy students. The intertester reliability was exhibited random error, which was greater in the symptomatic
high for left lateral flexion (r 0.91), good for extension (r group and could affect the reliability of spinal mobility tests
0.88), and fair for right lateral flexion (r 0.76). in children with back pain.
Reynolds57 calculated intertester error by comparing the
Validity: Universal Goniometer results of two testers taking 10 repeated measurements of
Nattrass and coworkers43 compared measurements of the tho- lumbar flexion and extension on 30 volunteers with a mean
racolumbar spine taken with the universal goniometer and age of 38.1 years. The MST had acceptable intertester relia-
measurements of the lumbar spine with the Dualer Electric bility only for extension.
Inclinometer with three measures of impairment. Thirty-four Pile and colleagues60 had five testers (three physical ther-
patients between 20 and 65 years of age with chronic low- apists, a rheumatologist, and a rheumatology registrar) use
back pain were the subjects for the study. The results showed the MST to measure lumbar flexion twice in each of
that only flexion ROM measured with the goniometer demon- 10 patients with ankylosing spondylitis. Intertester reliability
strated greater than 50 percent of the variance in common was fair (r 0.78).
with one of the disability measures. Lindell and coworkers9 conducted a study with one med-
Reliability: Schober Test ically trained physiotherapist and one medically untrained
Fitzgerald and associates14 used the Schober technique to tester (research assistant) using the MST to measure lumbar
measure lumbar flexion and the universal goniometer to flexion in 50 subjects (30 patients with low-back or neck pain,
measure thoracolumbar lateral flexion and extension. In- and 20 healthy participants). The intratester reliability was an
tertester reliability was calculated from measurements taken ICC of 0.87 with a standard error of the measurement (SEM)
by two testers on 17 volunteers who were physical therapy of 0.3 cm for the medically trained tester, and an ICC of 0.79
students. Pearson reliability coefficients were calculated on with a SEM of 0.7 cm for the other tester. Intertester reliabil-
paired results of the two testers (see Table 12.6). Intertester ity ranged from an ICC of 0.94 (SEM0.4 cm) when testing
reliability using the Schober Test was excellent with an patients to an ICC of 0.22 (SEM1.0 cm) when testing
r value of 1.0. healthy participants. The intertester ICC for all subjects was
0.79 (SEM0.7 cm). The authors concluded that reliable
Reliability: Modified Schober Test measurements could be taken by medically untrained testers
Many of the following reliability studies were conducted on using tests like the MST, forward bending fingertip-to-floor
patient populations that usually have lower reliability scores test, and lateral bending fingertip-to-thigh test that did not re-
than healthy populations. However, one can see by looking at quire manual stabilization.
Table 12.7 that some of the intrareliability and interreliability Gill and coworkers37 compared the reliability of four
coefficients for the modified Schober test (MST) are in the methods of measurement including fingertip-to-floor dis-
good to excellent category for patient populations. tance, the Modified Schober technique, the two-inclinometer
Haywood and colleagues58 used the MST to evaluate the method, and a photometric technique. The subjects of the
measurement properties of spinal mobility in 159 patients study were 10 volunteers (5 men and 5 women) aged 24 to
with ankylosing spondylitis (133 males and 26 females, 20 to 34 years. Repeatability of the fingertip-to-floor method
74 years of age). Fifty-one patients participated in the reliabil- was poor (coefficient of variation (CV) 14.1 percent).
ity study in which both intratester (ICC 0.94) and in- Repeatability of the inclinometer for the measurement of
tertester (ICC 0.90) reliability were high. Also, the MST full flexion was also poor (CV 33.9 percent). The MST
had a strong relationship with all mobility measures. yielded a CV of 0.9 percent for full flexion and a CV of
Viitanen and associates59 employed two physical thera- 2.8 percent for extension.
pists to use the MST to measure lumbar flexion ROM in Validity: Schober and Modified Schober Tests
52 patients with ankylosing spondylitis with a mean age of Macrae and Wright3 tested the validity of both the original
45 years. Repeat tests were performed within 72 hours from two-mark Schober technique and a three-mark modification
entry on successive days at the same time of day. Intratester of the Schober technique (modified Schober). The authors
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TABLE 12.7 Reliability of Schober Tests: Modified Schober Test (MST) and Modified–Modified
Schober Test (MMST)
Test MST MST MST MST MMST MMST
Author Lindell Haywood Jones Pile Williams Tousignant
et al9 et al58 et al17 et al60 et al19 et al50
Sample 20 healthy Patients with 89 healthy and Patients Patients Patients
and 30 patients ankylosing 30 patients with with with
with back/neck spondylitis with LBP AS CLBP LBP
pain (AS)
20–63 yrs 18–75 yrs 11–16 yrs 26–73 yrs 25–53 yrs Mean age = 44 yrs
n = 20 n = 50 n = 26 n = 51 n = 30 n = 89 n = 10 n = 15 n = 31
Motion Intra Inter Intra Inter Inter Inter Intra Inter Intra Inter
ICC ICC ICC ICC r r Inter r ICC ICC ICC
Flexion 0.87 0.79 0.90 0.94 0.94 0.94 0.78 0.78 - 0.72 0.95 0.91
0.89
Extension 0.69 - 0.76
0.91
CLBP chronic low-back pain; LBP low-back pain. ICC intraclass correlation coefficient;
r pearson product moment correlation coefficient; Intra intratester reliability; Inter intertester reliability.
found a linear relationship between measurements of lum- faulty placement of skin marks seriously impaired the accu-
bar flexion obtained by these methods and radiographic racy of the unmodified Schober technique. Placement of
measurements. The correlation coefficient was 0.90 be- marks 2 cm too low led to an overestimate of 14 degrees.
tween the Schober technique and radiographs (x-rays), with Marks placed 2 cm too high led to an underestimate of
an SE of 6.2 degrees. The correlation coefficient was 0.97 15 degrees. In the MST, the same errors in placement led
between the modified Schober measurement and the radi- to overestimates and underestimates of 5 and 3 degrees,
ographic measurements, with an SE of 3.25 degrees. Clinical respectively.
identification of the lumbosacral junction was not easy, and
AS ankylosing spondylitis; ICC intraclass correlation coefficient; LBP low-back pain; r Pearson product moment correlation
coefficient; Intra intratester reliability; Inter intertester reliability.
* Some workers had back or neck pain, and some had no pain.
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Viitanen and associates59 found that the MST, thora- authors compared these measurements with measurements
columbar lateral flexion, and fingertip-to-floor test using a calculated on x-rays as the gold standard. The comparison
tape measure had the most significant correlations with thora- showed that the MMST had moderate validity (r 0.67; 95%
columbar changes seen on x-ray (calcifications of discs, ossi- confidence interval 0.44 to 0.84). The minimum metrically
fication of liagments, and changes in the apophyseal joints). detectable change (MMDC) of 1 cm was determined to be
In constrast to the preceding studies, the following two excellent in this group of patients, but because of the moder-
studies did not find good evidence for the validity of the ate validity finding, the authors suggest that further studies
Schober and the MST. Portek and colleagues63 compared the need to perfomed to establish the test’s validity.
MST and two other clinical methods with each other and with
Reliability: Prone Press-Up (for Extension)
radiographs. These authors found little correlation either
Bandy and Reese64 compared the reliability of the prone
among the measurements obtained by two testers using three
press-up to measure lumbar extension under two conditions:
clinical techniques to measure lumbar flexion in 11 subjects
with and without a strap to control pelvic motion. Sixty-three
or among the three clinical techniques and radiographs. A
unimpaired individuals with a mean age of 26 years partici-
Pearson’s reliability coefficient of 0.43 was found between
pated as subjects in the study. Measurements of extension
the MST and the radiographic measurement. The intertester
ROM were taken by an experienced group and a student
error for the MST for lumbar flexion showed significant dif-
group using a tape measure. Intratester reliability was excel-
ferences between testers according to paired t-tests. However,
lent for the experienced group in both the strapped (ICC
intertester error was calculated between 10 measurements on
0.91) and unstrapped (ICC 0.90) conditions and good for
10 different days, and the authors attributed the error to diffi-
the student group. Intertester reliability for both the strapped
culties in reestablishing a neutral starting position and the
and unstrapped conditions was good (ICC 0.87 and ICC
mobility of the skin over the landmarks.
0.85, respectively).
Quack and colleagues,8 in a study involving 112 female
subjects with a mean age of 53 years, compared the MST with Reliability and Validity: Fingertip-to-Floor
magnetic resonance imaging (MRI) findings. The authors did Test (for Forward Flexion)
not find any statistically significant findings between the MST Perret and colleagues10 included 32 patients with low-back pain
and MRI findings. Therefore, the validity for the MST with with a mean age of 52 years in a reliability study. Intratester and
respect to segmental lumbar degeneration was questioned. intertester reliability were excellent (ICC 0.99). Ten patients
with low-back pain (mean age of 42 years) participated in the
Reliability: Modified–Modified Schober Test
validity study. Two lateral radiographs were taken: one of the
Williams and coworkers19 measured flexion and extension on
dorsal spine with the patients in the neutral standing position
15 patient volunteers with a mean age of 36 years who had
and one taken in full trunk flexion. Spearman’s correlation
chronic low-back pain. The authors compared the MMST,20
coefficient for this validity test of trunk flexion was excellent
which is also referred to as the simplified skin distraction
(r 0.96). Seventy-two patients with low-back pain partici-
method,21 with the double inclinometer method. Intratester
pated in the responsiveness study. High values were found for
Pearson correlation coefficients for the MMST were an r of
responsiveness for the fingertip-to-floor method, which showed
0.89 for tester 1, an r of 0.78 for tester 2, and an r of 0.83 for
that the fingertip test has very good sensitivity to change.
tester 3. Intertester Pearson correlation coefficients between
Haywood and colleagues58 also assessed reliability, valid-
the three physical therapist testers were an r of 0.72 for flex-
ity, and responsiveness of the fingertip-to-floor forward flex-
ion and an r of 0.77 for extension with use of the MMST. The
ion test in 77 patients with ankylosing spondylitis. The
therapists underwent training in the use of standardized pro-
authors found both intratester and intertester reliability to be
cedures for each method prior to testing. According to the
excellent, with ICCs between 0.94 and 0.99. Also, the test was
testers, the MMST was easier and quicker to use than the dou-
the most responsive to self-perceived changes in health at
ble inclinometer method. The only disadvantage to using the
6 months. Authors recommended this test for clinical practice
MMST method is that norms have not been established for all
and research.
age groups.
Viitanen and associates59 found that the fingertip-to-floor
Tousignant and associates50 used the MMST to obtain lum-
test had significant correlations with thoracolumbar changes
bar flexion ROM measurements in 31 patients with low-back
seen on x-ray (calcifications of disc, ossification of ligaments,
pain. The authors found excellent intratester reliability (ICC
and changes in apophyseal joints).
0.95) and very good intertester reliability (ICC 0.91).
Pile and associates60 found that the sagittal plane fingertip-
Validity: Modified–Modified Schober Test to-floor test had an excellent intertester reliability (ICC 0.95)
The ease of finding landmarks for measuring lumbar flexion in a study in which three physical therapists, a rheumatologist,
and extension with the MMST appears to make this method a and a rheumatology registrar measured 10 patients twice.
better choice over the Schober and MST; however, more stud- Lindell and coworkers9, in a study of 50 subjects
ies need to be performed to confirm its validity. Tousignant (30 patients with low-back or neck pain, and 20 healthy par-
and associates50 used the MMST to obtain lumbar flexion ticipants), found intratester reliability to be excellent with an
ROM measurements in 31 patients with low-back pain. The ICC 0.95 and SEM0.9 cm for both an experienced
2066_Ch12_365-408.qxd 5/21/09 5:21 PM Page 404
physiotherapist and a medically untrained research assis- Reliability: Back Range of Motion Device
tant. Intertester reliability was also excellent with ICC values Reliability results are inconclusive, and it appears that
greater than 0.95 and SEM values ranging from 0.9 to additional research needs to be done on this method of mea-
1.2 cm. surement to warrant the expenditure involved in purchasing
Gauvin, Riddle, and Rothstein65 used a modified version the back range of motion (BROM) device. The BROM II
of the fingertip-to-floor test by placing subjects on a stool and device (Performance Attainment Associates, Roseville, MN)
then measuring the distance from the tip of the subject’s mid- is a revised and improved version of the original BROM.
dle finger to the stool. Seventy-three patients with low-back Two groups of researchers investigating the reliability of the
pain participated in the study, and both intratester (ICC BROM II device agreed that the instrument had high relia-
0.98) and intertester (ICC 0.95) reliability were excellent. bility for measuring lumbar lateral flexion and low reliabil-
The modified version of the test is supposed to account for the ity for measuring extension. However, the two groups
fact that many people can reach the floor, and in this study differed regarding the reliability of the BROM II device
27 percent of the subjects were able to reach the top of the for measuring flexion and rotation. Breum, Wiberg, and
stool or beyond the top. Bolton66 concluded that the BROM II device could measure
In contrast to the preceding studies, the following study flexion and rotation reliably, whereas Madson, Youdas, and
did not find acceptable retest reliability. Gill and coworkers61 Suman67 determined that rotation but not flexion could be
compared the reliability of four methods of measurement reliably measured (see Table 12.6). Potential sources of
including fingertip-to-floor distance, the Modified Schober error identified by the authors67 included slippage of the
technique, the two-inclinometer method, and a photometric device over the sacrum during flexion and extension and
technique. The subjects of the study were 10 volunteers variations in the identification of landmarks from one mea-
(5 men and 5 women) aged 24 to 34 years. Repeatability of surement to another.
the fingertip-to-floor method was poor (CV 14.1 percent). Kondratek and colleagues30 used the BROM II to conduct
Repeatability of the inclinometer for the measurement of full one of the few studies on lumbar ROM in children. The subjects
flexion was also poor (CV 33.9 percent). were 225 normally developing children ages 5 to 11 years of
age. Two physical therapists experienced working with children
Reliability: Fingertip-to-Thigh Test were trained in the use of the BROM II. Intrarater reliability on
(for Lateral Flexion) 15 childern was good to excellent for one tester for all half
Alaranta and associates,18 in a study involving 508 white and cycle motions except for flexion, which was unacceptable (ICC
blue collar workers between the ages of 35 and 54 years, 0.53). The intratester reliability for the second tester ranged
found that the intertester reliability was high at an interval of from an ICC of 0.71 for flexion and an ICC of 0.76 for right lat-
1 week for the fingertip-to-thigh method of assessing thora- eral flexion, to an ICC of 0.91 for right rotation.
columbar lateral flexion. Intratester reliability at the interval Kachingwe and Phillips68 employed two testers to use the
of 1 year was remarkably good for the large time interval be- BROM to measure lumbar motions in 91 healthy men and
tween tests (see Table 12.8). women with a mean age of 28 years. Intratester reliability for
Jones and colleagues,17 in a study of 119 children ages 11 lateral flexion was good (ICC 0.85 to 0.83), forward flex-
to 16 years (30 children with low-back pain and 89 asympto- ion was good to fair (ICC 0.84 to 0.79), and extension and
matic children), found excellent correlation coefficients for right rotation was fair to poor (ICC 0.76 to 0.58). Intertester
and left lateral flexion in the low-back pain group (r 0.93 to reliability was fair to poor for all lumbar motions and for
0.95) and in the asymptomatic group (r 0.99). Limits of pelvic inclination (ICC 0.76 to 0.58).
agreement, expressed as the mean difference between test and
retest 1.96 SD of the difference between test and retest, Reliability: Motion Analysis Systems
were 0.16 mm ± 6.78 for right lateral flexion for the asympto- A number of researchers have investigated the reliability of
matic children but much larger for the symptomatic group motion analysis systems including, among others, the CA-6000
(0.50 mm 16.93 mm). The authors concluded that there was Spine Motion Analyzer,14,29 the SPINETRAK,71 and the
very little systematic bias but all measures exhibited random FASTRAK (Polhemus, Colchester, VT).69 Two research groups
error, which was larger in the symptomatic group (see Table 12.8). found that intratester reliability for measuring lumbar flexion
Lindell and coworkers9 conducted a study of 50 subjects was very high with use of the CA-6000.29,45 In one of the stud-
(30 patients with low-back or neck pain, and 20 healthy sub- ies, both intratester and intertester reliability ranged from good
jects) who were tested by two examiners. The intratester reli- to high for lumbar forward flexion and extension, but intratester
ability for the fingertip-to-thigh test for lateral bending was and intertester reliability were poor for rotation.29
excellent for the experienced physiotherapist (ICC 0.94- In a study using the SPINETRAK,72 ICCs were 0.89 or
0.99, SEM 0.5-1.0 cm) and fair for the medically untrained greater for intratester reliability. ICCs for intertester reliabil-
tester (ICC 0.73-0.86, SEM 1.4-1.6 cm). Intertester reli- ity ranged from 0.77 for thoracolumbar flexion to 0.95 for
ability was fair to excellent depending on the group and side thoracolumbopelvic flexion. Steffan and colleagues69 used the
tested, with ICCs ranging from 0.79 to 0.98 and SEMs rang- FASTRAK system to measure segmental motion in forward
ing from 0.9 to 1.5 cm. lumbar flexion by tracking sensors attached to Kirschner
2066_Ch12_365-408.qxd 5/21/09 5:21 PM Page 405
wires that had been inserted into the spinous processes of L3 Summary
and L4 in 16 healthy men. Segmental forward flexion showed
large intersubject variation. The sampling of studies reviewed in this chapter reflects the
Van Herp and associates33 used the Polhemus Navigation amount of effort that has been directed toward finding reliable
Sciences 3 Space System to measure ROM in 100 healthy and valid methods for measuring spinal motion. Each method
subjects (50 male and 50 female subjects) ranging in age reviewed has advantages and disadvantages, and clinicians
from 20 to 77 years of age. Recorded ranges of motion should select a method that appears to be appropriate for their
including flexion, extension, lateral flexion and rotation particular clinical situation.
showed a level of agreement with x-ray data indicating good
concurrent validity.
2066_Ch12_365-408.qxd 5/21/09 5:21 PM Page 406
61. Gill, K, et al: Repeatability of four clinical methods for assessment of 67. Madson, TJ, Youdas, JW and Suman,VJ: Reproducibility of lumbar spine
lumbar spinal motion. Spine 13:50, 1988. range of motion measurements using the back range of motion device.
62. Miller, MH, et al: Measurement of spinal mobility in the sagittal plane: J Orthop Sports Phys Ther 29:470, 1999.
New skin distraction technique compared with established methods. 68. Kachingwe, AF, and Phillips, BJ: Inter and Intrarater reliability of a back
J Rheumatol 11:4, 1984. range of motion instrument. Arch Phys Med Rehabil 86:2347, 2005.
63. Portek, I, et al: Correlation between radiographic and clinical measure- 69. Steffan, T, et al: A new technique for measuring lumbar segmental
ment of lumbar spine movement. Br J Rheumatol 22:197, 1983. motion in vivo: Method, accuracy and preliminary results. Spine 22:156,
64. Bandy,WD, and Reese, NB: Strapped versus unstrapped technique of the 1997.
prone press-up for measurement of lumbar extension using a tape mea- 70. Petersen, CM, et al: Intraobserver and interobserver reliability of asymp-
sure: Differences in magnitude and reliability of measurements. Arch tomatic subject’s thoracolumbar range of motion using the OSI CA-6000
Phys Med Rehabil 85:99, 2004. Spine Motion Analyzer. J Orthop Sports Phys Ther 220:207, 1997.
65. Gauvin, MG, Riddle, DL, and Rothstein, JM: Reliability of clinical mea- 71. Robinson, ME, et al: Intrasubject reliability of spinal range of motion and
surements of forward bending using the modified fingertip-to-floor velocity determined by video motion analysis. Phys Ther 73:626, 1993.
method. Phys Ther 70:443, 2000.
66. Breum, J, Wiberg, J, and Bolton, JE: Reliability and concurrent validity
of the BROM II for measuring lumbar mobility. J Manipulative Physiol
Ther 18:497, 1995.
2066_Ch12_365-408.qxd 5/21/09 5:21 PM Page 408
2066_Ch13_409-424.qxd 5/21/09 5:22 PM Page 409
The 13
Temporomandibular
Joint
Structure and Function
Temporomandibular Joint
Zygomatic arch
Anatomy
The temporomandibular joint (TMJ) is the articulation between
the mandible, the articular disc, and the temporal bone of the Articular
skull (Fig. 13.1A, B). The disc divides the joint into two distinct eminence of
temporal bone
parts, which are referred to as the upper and lower joints. The Mandibular
larger upper joint is formed by the convex articular eminence, fossa
concave mandibular fossa of the temporal bone, and the supe- Mastoid
process
rior surface of the disc. The lower joint consists of the convex
surface of the mandibular condyle and the concave inferior sur-
face of the disc.1–3 The articular disc helps the convex mandible Maxilla
Mandibular condyloid
conform to the convex articular surface of the temporal bone.2 process
The TMJ capsule is described as being thin and loose Styloid process
above the disc but taut below the disc in the lower joint. Short
capsular fibers surround the joint and extend between the
mandibular condyle and the articular disc and between the Mandible
409
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Maxilla Maxilla
Mandible Mandible
FIGURE 13.3 Protrusion is an anterior motion of the FIGURE 13.4 Retrusion is a posterior motion of the mandible
mandible in relation to the maxilla. in relation to the maxilla.
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Maxilla Arthrokinematics
Mandibular depression (mouth opening) occurs in the sagittal
plane and is accomplished by rotation and sliding of the
mandibular condyles. Condylar rotation is combined with
anterior and inferior sliding of the condyles on the inferior
surface of the discs, which also slide anteriorly (translate)
along the temporal articular eminences. Mandibular elevation
(mouth closing) is accomplished by rotation of the mandibu-
lar condyles on the discs and sliding of the discs with the
condyles posteriorly and superiorly on the temporal articular
eminences.
In protrusion, the bilateral condyles and discs translate
together anteriorly and inferiorly along the temporal articular
eminences. The movement takes place at the upper joint, and
no rotation occurs during this motion. In lateral excursion, one
Mandible
mandibular condyle and disc slide inferiorly, anteriorly, and
medially along the articular eminence. The other mandibular
FIGURE 13.5 Lateral excursion is a lateral motion of the condyle rotates about a vertical axis and slides medially within
mandible to either side.
the mandibular fossa. For example, in left lateral excursion,
the left condyle spins and the right condyle slides anteriorly.
Capsular Pattern
In the capsular pattern, mandibular depression is limited.7
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Mandible
Normal End-Feel
The end-feel is firm owing to stretching of the joint
capsule; retrodiscal tissue; the temporomandibular
FIGURE 13.10 At the end of passive mandibular depression FIGURE 13.11 Use a millimeter ruler to measure the vertical
(mouth opening), one of the examiner’s hands maintains the distance between the edge of a lower central incisor and
end of the range of motion by pulling the jaw inferiorly. The the edge of the opposing upper central incisor to measure
examiner’s other hand holds the back of the subject’s head mouth opening.
to prevent cervical motion.
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Passive Protrusion
FIGURE 13.14 At the end of passive mandibular protrusion FIGURE 13.15 At the end of mandibular protrusion range of
range of motion, the examiner uses one hand to stabilize motion, the examiner uses the end of a plastic goniometer
the posterior aspect of the subject’s head while her other to measure the distance between the subject’s upper and
hand moves the mandible into protrusion. lower central incisors. The subject maintains the position.
2066_Ch13_409-424.qxd 5/21/09 5:22 PM Page 418
••
FIGURE 13.16 At the end of passive mandibular lateral excursion range of motion, the
examiner uses one hand to prevent cervical motion and the other hand to maintain a lateral
pull on the mandible.
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••
FIGURE 13.18 Note the difference between the alignment of the lower and upper central
incisors in the neutral position compared to alignment of these incisors at the end of lateral
excursion as shown in Figs. 3.16 and 3.17.
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Research Findings 6.6:1 between vertical and horizontal ROM. Therefore, based
on the results of this study, the authors concluded that the 4:1
ratio between vertical and horizontal ROM that has been used
The search for normative ROM values for TMJ joint motions is as a standard in the past19 should be replaced by the approxi-
ongoing and includes various age groups of males and females mately 6:1 ratio found in this study. However, the authors
in different populations and ethnic groups. A sampling of these found that the ratio has poor predictive value.
studies is included in this section and in the sections that follow
on the effects of age and gender on TMJ ROM. Effects of Age, Gender,
In one of the few studies conducted to determine refer-
and Other Factors
ence values for children, Cortese, Oliver, and Biondi16 found
that the normal range of mouth opening in boys and girls with Age
a mean age of 4.6 years was 38.6 mm. For children in the Temporomandibular joint ROM in children tends to show an
study with a mean age of 6.9 years, the ROM was found to be increase in ROM as age increases between the ages of 3 and
42.0 mm.16 Hirsch and colleagues,17 in a study involving chil- 17 years.16,17 Similar to other areas of the body, the ROM in
dren and adolescents 10 to 17 years old, found that the mean adults tends to decrease rather than increase as age increases
ROM for mouth opening was 50.6 mm. from ages 16 or 17 years onward. Also, like other areas of the
Functional mouth opening is a distance sufficient for the body, some TMJ motions appear to be affected by age more
subject to place two or three flexed proximal interphalangeal than other TMJ motions in both adults and children.
joints within the opening. That distance in adults may range Cortese, Oliver, and Biondi16 determined ROM values in
from 35 mm to 50 mm, although an opening of only 25 mm a sample of 212 boys and girls ages 3 to 11 years of age. The
to 35 mm is needed for normal activities.7 A slightly more re- ROM in mouth opening and lateral excursion was found to be
stricted normal range of adult values (40 to 50 mm) was ar- smaller in young children (3 to 4 years) compared to slightly
rived at by consensus judgments made at a 1995 Permanent older children (11 years), but no change in protrusion ROM
Impairment Conference by representatives of all major soci- was observed.
eties and academies whose members treat TMJ disorders.12 In a population-based study involving 1011 German male
Similar normative mean values for adult mouth opening, from and female children and adolescents between the ages of 10 and
a low of 41 mm to a high of 58.6 mm, are presented in 17 years, Hirsch and colleagues17 also found an increase in the
Table 13.1. Normal mean values for the ROM in protrusion ROM of some motions as age increased. A significant difference
and lateral excursive motions are presented from four sources occurred between maximum active mouth opening in the 10- to
in Table 13.2. 13-year-old group and in the 14- to 17-year-old group, with the
Dijkstra and coworkers18 investigated the relationship older adolescent group having a greater range of mouth opening.
between vertical and horizontal mandibular ROM in The authors determined that maximal unassisted mouth opening
91 healthy subjects (59 women and 32 men) with a mean age increased by 0.4 mm per year of age. Lateral excursion and
of 27.2 years. A mean ratio was found ranging from 6.0:1 to protrusion also were influenced by age, with lateral excursion
TABLE 13.1 Maximum Active Mouth Opening ROM in Subjects 10 to 99 Years of Age:
Normal Linear Distance in Millimeters*
Hirsch Marklund and Goulet Celic Gallagher Turp
Author et al17 Wunman20 et al21 et al22 et al23 et al15
Sample Male and Male and Male and Male Males and Male and
female female female Croatian females from female German
German Swedish volunteers dental population dental students
school dental students in Ireland and staff
children students
Mean age Mean age
10–17 yrs 18–48 yrs 29 yrs 19–28 yrs 16–99 yrs 26.1 yrs
Males Females Males Females
n = 1011 n = 371 n = 36 n = 60 n = 657 n = 856 n = 58 n = 83
Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean Mean Mean (SD) Mean (SD)
ROM 50.6 (6.4) 55.3 (6.1) 52.6 (6.3) 50.8 (5.0) 43 41 58.6 (7.1) 54.6 (7.9)
SD = standard deviation;.
* All measurements were obtained with a millimeter ruler, and all measurements include the amount of overbite except for measurements
taken by Gallagher et al.
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TABLE 13.2 Mandibular Protrusion and Lateral Excursion Range of Motion: Normal Linear Distance
in Millimeters*
Author Hirsch et al17 Celic et al22 Walker et al14 Turp et al15
Sample 486 male and Males and 3 males and Male and female
525 female females 12 females students and staff
students Mean age = 26.1 yrs
10–17 yrs 19–28 yrs 21–61 yrs n = 141
n = 1011 n = 60 n = 15 Male Female
Motion Mean (SD) Range Mean (SD) Range Mean (SD) Range Mean (SD) Mean (SD)
Protrusion 8.2 (2.5) 1–22 7.9 (2.5) 3–13 7.1 (2.3) 4–11 —
Left lateral excursion 10.6 (2.3) 3–21 10.1 (3.0) 3–15 8.6 (2.1) 5–12 12.1 (2.3) 11.5 (2.4)
Right lateral excursion 10.2 (2.2) 3–17 10.0 (2.8) 4–15 9.2 (2.6) 6–14 11.0 (2.6) 10.9 (2.1)
SD = standard deviation.
* All measurements were obtained with a millimeter ruler.
increasing 0.1 mm per year of age and protrusion decreasing Thurnwald24 found that the subject’s gender significantly
0.1 mm per year of age. affected both mouth opening and lateral excursion. The
Gallagher and coworkers23 conducted a population-based 50 males in this study had a greater mean range of mouth
study of mouth opening in 1513 Irish adults ages 16 to opening (59.4 mm) than the 50 females (54.0 mm). The males
99 years. Maximum mouth opening showed a decrease in also had a greater mean ROM in right lateral excursion, but the
ROM from 45 mm in the 16- to 24-year-old group of males to difference between genders in this instance was small. The
41 mm in the 65- to 99-year-old group of males. A similar de- healthy 26-year-old males in a study by Turp, Alpaslan,
crease in mouth opening ROM occurred in females from the and Gerds15 had significantly larger maximum ROM in mouth
youngest to the oldest group. Thurnwald24 also found that opening and in both right and left lateral excursion in
mouth opening decreased with increasing age. The decrease comparison to healthy females of the same age (see Table
was about 5 mm from a mean of 59.4 mm in the 17-year-old 13.1). Lewis, Buschang, and Throckmorton26 determined that
group to 54.3 mm in the 65-year-old group. In fact, active males had significantly greater mouth opening ROM (mean =
ROM in all TMJ motions except for retrusion decreased with 52.1 mm) than females (mean = 46.0 mm).
increasing age in the 100 subjects in the study. However, when mouth opening was measured as the an-
In contrast to the preceding studies Hassel, Rammelsberg, gular displacement of the mandible in relation to the cranium
and Schmitter,25 in a comparison of ROM between a group of (angle of mouth opening), Westling and Helkimo27 found that
44 young adults ages 18 to 45 years and a group of 43 elderly maximal jaw opening in adolescents was slightly larger in fe-
patients ages 68 to 96 years, found that mouth opening ROM males than in males. This finding might have been influenced
did not decrease from the youngest to the oldest groups. How- by the fact that females generally reach adult ROM values by
ever, the ROM in protrusion and lateral excursion followed the 10 years of age, whereas males do not reach adult ROM val-
normal pattern and decreased from the youngest to the oldest ues until 15 years of age.28
group.
Mandibular Length
Gender The ROM in mouth opening appears to be related to the length
A definite gender difference appears to be present in adults of the mandible. Dijkstra and colleagues,29 in a study of mouth
16 to 99 years of age, with males having larger ROM in opening in 13 females and 15 males, found that the linear
mouth opening than females.23,24,26 Studies also have found distance between the upper and the lower incisors during
that male adults have a larger ROM in lateral excursion than mandibular depression was significantly influenced by
females.15,24 Furthermore, Hirsch and colleagues17detected a mandibular length. In a subsequent study, Dijkstra and associ-
gender effect in 10 to 17 year olds, with males having a sig- ates30 investigated the relationship between incisor distances,
nificantly larger (1.8 mm) ROM in maximum active mouth mandibular length, and angle of mouth opening in 91 healthy
opening than females. However, according to Cortese, Oliver, subjects (59 women and 32 men) ranging from 13 to 56 years
and Biondi,16 the gender effect on mouth opening does not ap- of age (mean 27.2 years). Mouth opening was influenced by
pear to be present in young children 3 to 11 years of age. both mandibular length and angle of mouth opening. There-
Gallagher and coworkers,23 in a study of mouth opening in fore, it is possible that subjects with the same mouth opening
1513 Irish males and females, determined that the 657 males distance may differ from each other in regard to TMJ mobility.
16 to 99 years of age had greater maximum active mouth Lewis, Buschang, and Throckmorton26 found that mandibular
opening ROM compared to the 856 females in the study. length accounted for some of the gender differences in mouth
2066_Ch13_409-424.qxd 5/21/09 5:22 PM Page 422
opening and for most of the gender differences in condylar musculature to injury, mechanical problems, and degenerative
translation in mouth opening. Westling and Helkimo27 found changes. For example, the articular disc may become entrapped,
that passive mouth opening ROM was strongly correlated to deformed, or torn; the capsule may become thickened; the liga-
mandibular length. ments may become shortened or lengthened; and the muscles
To adjust for mandibular length, Miller and coworkers31 may become inflamed, contracted, and hypertrophied. These
developed a “mouth opening index,” called the temporo- problems may give rise to a variety of symptoms and signs that
mandibular opening index (TOI), which was determined by are included in the TMD classification.
using the following formula: TOI = (PO – MVO/PO + MVO) ⫻ Restricted mouth opening ROM is considered to be one
100. PO is passive opening, and MVO refers to maximal volun- of the important signs of TMD.36 Popping or clicking noises
tary opening. In a subsequent study, Miller and associates32 (or both) in the joint during mouth opening and/or closing and
compared the TOI in patients with a temporomandibular disor- deviation of the mandible during mouth opening and closing
der (TMD) with the TOI in a control group of individuals may be present.36–39 Other signs and symptoms include facial
without TMDs. Based on the results of the study, the authors pain; muscular pain36; tenderness in the region of the TMJ,
concluded that the TOI appeared to be independent of age, gen- either unilaterally or bilaterally; headaches; and stiffness of
der, and mandibular length. Moipolai, Karic, and Miller,33 in a the neck. TMDs appear to be more prevalent in females of all
study of 42 asymptomatic patients, used analysis of covariance ages after puberty, although the actual percentages of women
to assess the association between the TOI and age, gender, affected varies among investigators.36,39–43
ramus length, and gonial angle. No relationship between the A number of studies have investigated TMJ disorders in
variables and the TOI was found. In a more recent study, populations of children, adolescents, and elderly individu-
Miller34 found that the TOI was able to distinquish between two als.17,20,22,25,39,44–46 Celic and colleagues22 investigated the range
groups of patients with myogenous TMD, a finding that should of mandibular movements in a young male population of
make the TOI valuable as a diagnostic tool. 180 patients with TMD disorders and 60 control subjects. A
significant difference was found in maximal active mouth
Head and Neck Positions and Motions
opening and active lateral excursion and protrusion between
Head and neck positions and motions are closely linked with
the controls and patients with TMD, but the authors con-
mouth opening and closing movements. Also, the ROM of
cluded that it was not possible to discriminate among the fol-
mouth opening is affected by the static position of the head
lowing three patient groups: myogenous, disc, and combined
and neck, so examiners need to be aware of the subject’s head
myogenous and disc.
and neck position during measurements of the TMJ. Accord-
Cooper and Kleinberg 47 reviewed the records of 4528 men,
ing to Zafar,9,10 there is a functional linkage between the tem-
women, and children patients between the ages of 11 and
poromandibular and craniocervical regions, with head and
70 years and found that the prevalence of TMDs was highest
neck extension movements being an integral part of natural
between the ages of 21 and 50 years of age. The authors also
active mouth opening and head and neck flexion being an
found a gender difference in that 77 percent of the patients were
integral part of mouth closing.
females.
Higbie and associates35 investigated the effects of static
In a study of 114 males and 194 female university stu-
head positions (forward, neutral, and retracted) on mouth
dents with a mean age of 23 years, Marklund and Wanman20
opening in 20 healthy males and 20 healthy females between
found that the persistence of signs and symptoms over the
18 and 54 years of age. Mouth opening ROM measured with
period of a year was higher in female students. However, the
a millimeter ruler was significantly different among the three
1-year incidence of TMJ signs and symptoms (12 percent)
positions. Mouth opening was greatest (mean = 44.5 mm,
was not significantly different between men and women.
standard deviation [SD] = 5.3) in the forward head position,
Possible reasons for a gender preference have been attrib-
which includes extension of the upper cervical region; it was
uted to a number of factors including, among others, greater
less in the neutral head position (mean = 41.5 mm, SD = 4.8);
stress levels in women,42 hormonal influences,43 and habits of
and it was least (mean = 36.2 mm, SD = 4.5) in the retracted
adolescent girls that are extremely harmful to the temporo-
head position, which includes cervical flexion. Day-to-day
mandibular joints (e.g., intensive gum chewing, continuous
reliability was found to vary from an r value of 0.90 to 0.97,
arm leaning, ice crushing, nail biting, biting foreign objects,
depending on head position, and the standard error of mea-
jaw play, clenching, and bruxism).37,38
surement (SEM) ranged from 0.77 to 1.69 mm, also depend-
ing on head position. As a result of the findings, the authors
concluded that the head position should be controlled when Reliability and Validity
mouth opening measurements are taken. However, the authors
As is the case in other areas of the body, some TMJ motions
found that an error of 1 mm to 2 mm occurred regardless of
appear to be more reliably measured than other motions in
the position in which the head was placed.
both asymptomatic and symptomatic subjects. Mouth open-
Temporomandibular Disorders (TMDs) ing (active and passive) measured with a millimeter ruler as
The structure of the TMJs and the fact that these joints get the vertical distance between the upper and lower central
so much use predisposes the joints, associated ligaments, and incisors has consistently demonstrated good to excellent
2066_Ch13_409-424.qxd 5/21/09 5:22 PM Page 423
reliability (see Table 13.3).14,35,47–50 Measurements of protru- and test-retest reliability varied between 0.90 and 0.96. How-
sion have also shown good reliability, but lateral excursion ever, in contrast to the findings of Walker, Bohannon, and
has consistently shown poor to good reliability.25,48,50–53 Cameron14 and those of Higbie and associates,35 the authors
Walker, Bohannon, and Cameron14 determined that all six found that the smallest detectable difference of maximal
TMJ motions measured with a millimeter ruler were reliable. mouth opening in this group of subjects varied from 9 mm to
Measurements were taken by two testers at three sessions, 6 mm. Based on these results, a clinician would have to mea-
each of which were separated by a week. The 30 subjects who sure at least 9 mm of improvement in maximal mouth open-
were measured included 15 patients with a TMJ disorder ing in this group of patients to say that improvement had
(13 females and 2 males with a mean age of 35.2 years) and occurred.
15 subjects without a TMJ disorder (12 females and 3 males Reliability appears to be improved when examiners par-
with a mean age of 42.9 years). The intratester reliability ticipate in a calibration training program in which examiners
intraclass correlation coefficients (ICCs) for tester 1 ranged are calibrated to a standarized set of examination procedures
from 0.82 to 0.99, and the intratester reliability for tester and criteria, as described by the RDC/TMD. Lobbezoo and
2 ranged from 0.70 to 0.90. However, only mouth opening colleagues52 found that calibration training resulted in good to
measurements had construct validity and were useful for dis- excellent interexaminer reliability of both active and passive
criminating between subjects with and without TMJ disor- mouth opening measurements and protrusion ROM. Only
ders. The technical error of measurement (difference between lateral excursion ROM measurements had fair interexaminer
measurements that would have to be exceeded if the measure- reliability.
ments were to be truly different) was 2.5 mm for mouth open- In a study by Leher and colleagues,51 no significant differ-
ing measurement in subjects without a TMJ disorder. ence was found in the reliability of ROM measurements
Higbie and associates35 also found that ROM measure- between inexperienced dental students and experienced practi-
ments of mouth opening were highly reliable with the use of tioners who had participated in a calibration program. The
a millimeter ruler. Twenty males and 20 females with a mean authors concluded that calibration training was more important
age of 32.9 years were measured by two examiners. Intra- than experience. However, both groups had unacceptable relia-
tester, intertester, and test-retest reliability ICCs ranged from bility scores for lateral excursive motions. Lausten, Glaros, and
0.90 to 0.97, depending on head position. SEM values indi- Williams 53 compared nonexpert and expert examiners’ ability
cated that an error of 1 mm to 2 mm existed for the measure- to measure TMJ ROM following calibration training. The non-
ment technique used in the study. experts were able to measure maximum active mouth opening
Kropmans and colleagues48 found similar high reliability ROM with a high degree of reliability, but, similar to Leher’s
in a study of mouth opening involving 5 male and 20 female results, neither group was able to measure lateral excursive
patients with painfully restricted TMJs. Intratester, intertester, motions reliably.
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cents in relation to general joint mobility. 19:485, 1992.
2066_App-A_425-430.qxd 5/21/09 5:23 PM Page 425
A
Normative Range
of Motion Values
TABLE A.1 Shoulder, Elbow, Forearm, and Wrist Motion: Mean Values in Degrees
425
2066_App-A_425-430.qxd 5/21/09 5:23 PM Page 426
Author Ellenbecker et al8 Ellenbecker et al8 Boon & Smith9 Lannan et al10
M ⫽ males; F ⫽ females.
Values obtained with a universal goniometer.
Author Skarilova & Mallon et al‡, 12 Smahel & Hume et al†,15 AAOS6 AMA7
Plevkova*,11 Klimova*,13,14
Author Skarilova and Skarilova and Jenkins et al†,16 DeSmet et al‡,17 AAOS6 AMA7
Plevkova*,11 Plevkova*,11
20–25 yrs 20–25 yrs 16–72 yrs 16–83 yrs
n = 200 n = 200 n = 119 n = 101
(100 M, 100 F) (100 M, 100 F) (50 M, 69 F) (43 M, 58 F)
Motion Active Passive Active
Thumb CMC
Abduction — — — — 70 —
Flexion — — — — 15 —
Extension — — — — 20, 80 35§
Thumb MCP
Flexion 57 67 59 54 50 60
Extension 14 23 — — 0 40
Thumb IP
Flexion 79 86 67 80 80 80
Extension 23 35 — — 20 30
Author Waugh Drews Schwarze Wanatabe Phelps Boone Roach AAOS6 AMA7
et al18 et al 19 and et al1 et al21 and and
Denton20 Azen2 Miles22
12 hrs–
6–65 hrs 6 days 1–3 days 4 weeks 9 mos 1–54 yrs 25–74 yrs
n = 40 n = 54 n = 1000 n = 62 n = 25 n = 109 n = 1683
Motion (26 M, (473 M, (821 M,
28 F) 527 F) (M and F) (109 M) 862 F)
Hip
Flexion — — — 138 — 122 121 120 100
Extension 46* 28*† 20* 12* 10* 10 19 20 30
Abduction — 55‡ 78‡ 51 — 46 42 40
Adduction — 6‡ 15‡ — — 27 — 20
Medial rotation — 80‡ 58 24 52 47 32 45 50
Lateral rotation — 114‡ 80 66 47 47 32 45 50
Knee
Flexion — — 150 — — 142 132 135 150
Extension 15* 20* 15* — — — — 10 —
6–65 hrs 4–8 mos 1–54 yrs 26.1 yrs 64–87 yrs
n = 40 n = 54 n = 109 n = 27 (54 feet) n = 34
Motion (18 M, 22 F) (M) (9 M, 18 F) (F)
Ankle
Dorsiflexion 59 51 13 16 11 20 20
Plantar flexion 26 60 56 — 64 50 40
Inversion — — 37 19 (Subtalar) 26 35 30
Eversion — — 21 12 (Subtalar) 17 15 20
First MTP
Flexion — — — — — 45 30
Extension — — — 86 — 70 50
TABLE A.7 Cervical Spine Motions: Mean Values in Centimeters and Degrees
TABLE A.8 Thoracic and Lumbar Spine Motions: Mean Values in Centimeters and Degrees
Author Haley Moll and Van Adrichem and Breum McGregor Fitzgerald AAOS6 AMA7
et al*,30 Wright*,31 van der Korst†,32 et al‡,33 et al§,34 et al¶,35
5–9 yrs 15–75 yrs 15–18 yrs 18–38 yrs 50–59 yrs 20–82 yrs
n = 282 n = 237 n = 66 n = 47 n = 41 n = 172
(140 M, (119 M, (34 M, (27 M, (21 M, (168 M,
142 F) 118 F) 32 F) 20 F) 20 F) 4 F)
Motion M F M F M F M F
Flexion 6–7 cm 5–7 cm 7 cm 6 cm 56 54 55 60 — 80 60
Extension — — — — 22 21 21 18 16–41 25 25
Right lateral
flexion — — — — 33 31 30 30 18–38 35 25
Right — — — — 8 8 26 26 — 45 30
rotation
* Values were obtained for active range of motion (ROM) with an 11-cm plastic ruler marked in millimeters.
†
Values were obtained for active ROM with Vernier calipers as the measuring instrument.
2066_App-A_425-430.qxd 5/21/09 5:23 PM Page 430
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son of two measurement devices. Arch Phys Med Rehabil 70:288, 1989. Motion. American Academy of Orthopaedic Surgeons, Rosemont, Ill.
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Phys Ther 4:919, 1984. 24. Mecagni, C, et al: Balance and ankle range of motion in community
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1991. 25. McPoil, TG, and Cornwall, MW: The relationship between static lower
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Chicago 2001. and passive cervical range of motion with regard to total and uniplanar
8. Ellenbecker, TS, et al: Glenohumeral joint internal and external rotation motion. Spine 24:1082, 1999.
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2066_App-B_431-432.qxd 5/21/09 8:41 PM Page 431
B
Joint Measurements
by Body Position
Prone Supine Sitting Standing
431
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2066_App-C_433-438.qxd 5/21/09 5:25 PM Page 433
C
Numerical Recording
Forms
Range of Motion—Temporomandibular Joint and Spine
Left Right
Date
Examiner’s Initials
Temporomandibular Joint
Depression (opening)
Protrusion
Lateral Excursion
Overbite
Comments:
Cervical Spine
Flexion
Extension
Lateral Flexion
Rotation
Comments:
Thoracolumbar Spine
Flexion
Extension
Lateral Flexion
Rotation
Comments:
Lumbar Spine
Flexion
Extension
Lateral Flexion
Comments:
433
2066_App-C_433-438.qxd 5/21/09 5:25 PM Page 434
Left Right
Date
Examiner’s Initials
Shoulder Complex
Flexion
Extension
Abduction
Medial Rotation
Lateral Rotation
Comments:
Glenohumeral
Flexion
Extension
Abduction
Medial Rotation
Lateral Rotation
Comments:
Flexion
Supination
Pronation
Comments:
Wrist
Flexion
Extension
Ulnar Deviation
Radial Deviation
Comments:
2066_App-C_433-438.qxd 5/21/09 5:25 PM Page 435
Range of Motion—Hand
Left Right
Date
Examiner’s Initials
Thumb
CMC Flexion
CMC Extension
CMC Abduction
CMC Opposition
MCP Flexion
IP Flexion
IP Extension
Index Finger
MCP Flexion
MCP Extension
MCP Abduction
PIP Flexion
DIP Flexion
Middle Finger
MCP Flexion
MCP Extension
MCP Radial Abduction
MCP Ulnar Abduction
PIP Flexion
DIP Flexion
Ring Finger
MCP Flexion
MCP Extension
MCP Abduction
PIP Flexion
DIP Flexion
Little Finger
MCP Flexion
MCP Extension
MCP Abduction
PIP Flexion
DIP Flexion
Comments:
2066_App-C_433-438.qxd 5/21/09 5:25 PM Page 436
Left Right
Date
Examiner’s Initials
Hip
Flexion
Extension
Abduction
Adduction
Medial Rotation
Lateral Rotation
Knee
Flexion
Ankle
Dorsiflexion
Plantarflexion
Inversion—Tarsal
Eversion—Tarsal
Inversion—Subtalar
Eversion—Subtalar
Inversion—Midtarsal
Eversion—Midtarsal
Great Toe
MTP Flexion
MTP Extension
MTP Abduction
IP Flexion
Toe _____
MTP Flexion
MTP Extension
MTP Abduction
PIP Flexion
DIP Flexion
Comments:
2066_App-C_433-438.qxd 5/21/09 5:25 PM Page 437
Muscle Length
Left Right
Date
Examiner’s Initials
Upper Extremity
Biceps Brachii
Triceps Brachii
Comments:
Lower Extremity
Hamstrings—SLR
Gastrocnemius
Comments:
2066_App-C_433-438.qxd 5/21/09 5:25 PM Page 438
2066_Ind_439-450.qxd 5/22/09 6:32 PM Page 439
Index
A knee, 255t, 255–256
shoulder, 82, 82t–83t, 84
for pronation, 99, 99f
for supination, 101, 101f
Abduction. See specific joints
temporomandibular joint, 420t–421t, general procedures for, 27–30, 28f–30f
Acromioclavicular joint
430–421 exercise for, 30–31
anatomy of, 58–59, 59f
thoracolumbar, 393–394, 394t–396t in hand testing
arthrokinematics of, 59
wrist, 134t–135t, 134–135 for abduction, 153, 153f, 170, 171f
osteokinematics of, 59
Age anatomical landmarks for, 147f, 162f–163f
Active range of motion. See also Range of motion
range of motion and, 13 for extension, 150, 151f–152f, 152, 157,
defined, 8
ankle and foot, 304t–305t, 304–305, 307t 160, 168f–169f, 168–169, 178
testing of, 8, 8f
cervical spine, 346–349, 347t–349t, 351t for flexion, 148, 149f, 155, 156f, 158,
Activities of daily living
elbow, 106, 106t–107t 159f–160f, 164, 165f–166f, 166
cultural differences and, 235, 258, 311
hand, 186t–188t, 186–188 for muscle length, 184, 185f
functional range of motion in
hip, 229t–231t, 229–231 in hip testing
ankle and foot, 309f–310f, 309t, 309–311
knee, 254t–255t, 254–256 for abduction, 204, 205f
cervical spine, 352–354, 353f–354f
shoulder, 82, 83t, 84 for adduction, 207, 207f
elbow, 108, 109f–110f, 109t, 110
temporomandibular joint, 420t–421t, anatomical landmarks for, 198f–199f
hand, 189–190, 190t
420–421 for extension, 202, 203f
hip, 234f–235f, 234t, 234–235
thoracic and lumbar spine, 393–394, for flexion, 200, 201f
knee, 256, 257f–258f, 257t, 258
394t–396t for lateral rotation, 210f–211f, 211
shoulder, 85t, 85–86, 86f–87f
wrist, 134t–135t, 134–135 for medial rotation, 209, 209f
thoracic and lumbar spine, 397f, 397–398
Algodystrophy for muscle length, 216, 217f, 223, 223f, 226,
wrist, 137t–138t, 137–139, 138f–139f
hand testing for, 192 227f–228f, 228
Adduction. See specific joints
Alignment in knee testing
Adductor longis and brevis muscles
in ankle and foot testing anatomical landmarks for, 243f
anatomy of, 213
for abduction, 297, 297f for flexion, 244, 245f
in Thomas test, 212f–217f, 212–214, 216
anatomical landmarks for, 269f, 281f, for muscle length, 249, 249f, 253, 253f
Adductor longus, magnus, and brevis muscles
290f–291f in shoulder testing
muscle length testing in, 14, 14f
for dorsiflexion, 271f–272f, 271–272 for abduction, 72, 72f–73f
Adolescents
for eversion, 280, 280f, 285, 285f, 289, 289f anatomical landmarks for, 60, 60f–61f
range of motion in, 13
for extension, 294, 295f for extension, 68, 68f–69f
ankle and foot, 304–305, 305t, 307t
for flexion, 292, 293f, 298–299 for flexion, 64, 64f–65f
cervical spine, 346, 348t, 351t
for inversion, 277, 277f, 283, 283f, 287, for lateral rotation, 80, 80f–81f
elbow, 106–107, 107t
287f for medial rotation, 76, 76f–77f
hand, 188t
for muscle length, 302f–303f, 302–303 in temporomandibular joint testing
hip, 229–230, 231t
for plantarflexion, 274, 274f anatomical landmarks for, 412f
knee, 254, 255t
in cervical spine testing in thoracic and lumbar spine testing
shoulder, 82, 83t
anatomical landmarks for, 323f–325f anatomical landmarks for, 368f
temporomandibular joint, 420t–421t,
for extension, 332, 332f, 334f–335f, for extension, 373–375, 373f–375f, 388,
420–422
334–335 389f–390f, 390
thoracolumbar, 395, 395t–396t, 397
for flexion, 327f–330f, 327–330 for flexion, 369–372, 369f–372f, 385,
wrist, 134, 134t
for lateral flexion, 337, 337f, 339f–340f, 385f–387f, 387
Adults
339–340 for lateral flexion, 376–379, 376f–381f, 381,
permanent teeth in, 412f
for rotation, 341, 342f, 343, 344f–345f, 345 391–392, 392f
range of motion in, 13
in elbow testing for rotation, 382, 382f–384f, 384
ankle and foot, 304t–305t, 305, 307t
anatomical landmarks for, 94f–95f in wrist testing
cervical spine, 346t–349t, 346–349, 351t
for extension, 98 anatomical landmarks for, 117f
elbow, 106t–107t, 106–107
for flexion, 27–31, 28f–30f, 96, 96f–97f for extension, 120–121, 121f
hand, 186t–188t, 186–188
of muscle length, 103, 103f, 105, 105f for flexion, 118–119, 119f
hip, 229t, 229–231, 231t
439
439
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of muscle length, 129, 129f, 133, 133f inversion of of subtalar joint, 265
for radial deviation, 122, 123f reliability and validity of testing of, 313t, of tarsometatarsal joints, 267
for ulnar deviation, 124, 125f 313–314 of temporomandibular joint, 411
American Academy of Orthopaedic Surgeons tarsal testing of, 276f–277f, 276–277 of thoracic spine, 365–366
range of motion findings of muscle length testing in, 300f–303f, 300–303 of tibiofibular joints, 263
ankle, 304t, 428t osteokinematics of, 263, 265–268 of wrist, 116
elbow, 106, 106t, 425t plantarflexion of Arts
foot, 304t, 428t age and gender and, 304t–305t, 304–306 range of hip motion and, 233
hand, 186, 186t, 426t–427t reliability and validity of testing of, Ascending stairs
hip, 229, 229t, 427t 311–314, 313t range of motion necessary for
shoulder, 82, 82t, 425t–426t talocrural testing of, 273f–274f, 273–274 ankle and foot, 310
spine, 393t, 428t–429t range of motion of hip, 234, 234f, 234t
wrist, 134, 134t, 425t age and, 304t–305t, 304–305, 307t knee, 256, 257t, 258
American Medical Association functional, 309f–310f, 309t, 309–311 Athletes
range of motion findings of gender and, 305–306, 307t body mass index of, 232
ankle, 304t, 428t injury and, 308–309 Atlantoaxial joint. See also Cervical spine
elbow, 106, 106t, 425t normative values for, 304, 304t, 428t anatomy of, 319, 319f–320f
foot, 304t, 428t numerical recording form for, 436t arthrokinematics of, 320
hand, 186, 186t, 426t–427t reliability and validity in testing of, capsular pattern in, 320
hip, 229, 229t, 427t 311–314, 312t–313t osteokinematics of, 319–320
knee, 254t, 427t research findings in, 304t–305t, 304–314, Atlanto-occipital joint. See also Cervical spine
shoulder, 82, 82t, 425t–426t 307t, 309f–310f, 309t, 312t–313t anatomy of, 319, 319f–320f
spine, 346t, 393t, 428t–429t testing position and, 20t, 306, 308, 431t arthrokinematics of, 320
wrist, 134, 134t, 425t subtalar eversion of capsular pattern in, 320
recording guide of, 34 testing of, 284f–285f, 284–285 osteokinematics of, 319–320
Anatomical landmarks subtalar inversion of Axes
goniometer alignment using, 27–28, 28f–30f testing of, 282f–283f, 282–283 in osteokinematics, 5–6, 6f–7f
ankle, 269f, 275f, 281f talocrural dorsiflexion of
cervical spine, 323f–325f testing of, 270f–272f, 270–272
elbow, 94f–95f talocrural plantarflexion of
B
Back range of motion device
foot, 269f, 281f, 290f–291f testing of, 273f–274f, 273–274
in thoracic and lumbar spine testing
hand, 147f, 162f–163f tarsal eversion of
reliability of, 404
hip, 198f–199f, 212, 212f, 218, 219f testing of, 278f, 278–280, 280f
Ballet
knee, 243f tarsal inversion of
range of hip motion and, 233
shoulder, 60f–61f testing of, 276f–277f, 276–277
Baseball players
temporomandibular joint, 412f Anterior-posterior axis
shoulder range of motion in, 84
thoracic and lumbar spine, 368f defined, 5–6, 6f
Beighton hypermobility score, 12, 12t
wrist, 117f Arm. See also specific joints; Upper–extremity
Benign joint hypermobility syndrome
Anatomical position testing
defined, 12
forearm, 7f structure and function of, 57f–60f, 57–59,
Biceps brachii muscle
Anatomy 91f–95f, 91–93
muscle length testing of, 102f–103, 102–103
cervical spine, 319f–325f, 319–321 Arthralgia
strain of
elbow and forearm, 91f–95f, 91–93 in hypermobility syndrome, 12
example of, 11b
hand, 143f–145f, 143–146, 147f Arthritis
Biceps femoris muscle
hip, 197f–199f, 197–198, 219f capsular patterns in, 10
anatomy of, 218, 219f
knee, 241f–243f, 241–242, 246, 247f, 250, 250f Arthrokinematics
in straight leg raising test, 218, 219f–223f, 220,
lumbar spine, 366, 367f–368f of acromioclavicular joint, 59
222–223
shoulder, 57f–61f, 57–59 of atlanto-occipital and atlantoaxial joints, 320
Biological variation
temporomandibular joint, 409, 409f–412f basic concepts of, 4f–5f, 4–5
standard deviation indicating, 43–44, 44t
thoracic spine, 365, 366f, 368f of carpometacarpal joint, 145
Body mass index
wrist, 115f–117f, 115–116, 126f, 128f, 130, defined, 4
range of motion and
132f of elbow, 92–93
elbow, 107–108
Ankle, 263–314. See also Foot of glenohumeral joint, 58
hip, 232
anatomical landmarks of, 269f, 275f, 281f of hand, 143–146
knee, 256
anatomy of, 263, 264f–266f, 265–267, 269f of iliofemoral joint, 197–198
shoulder, 84
arthrokinematics of, 263, 265–268 of interphalangeal joints
Body position
dorsiflexion of fingers, 144
joint measurements and, 431t
age and gender and, 304t–305t, 304–306, 307t thumb, 146
Body size
end-feel determinations and, 22 toes, 268
cervical spine mobility and, 352
reliability and validity of testing of, of intervertebral and zygapophyseal joints, 322
Bony landmarks. See Anatomical landmarks
311–314, 312t of knee, 242
Bubble goniometers, 25, 26f
talocrural testing of, 270f–272f, 270–272 of lumbar spine, 366–367
testing position and, 306, 308 of metacarpophalangeal joints, 143–145
eversion of of metatarsophalangeal joints, 267–268 C
reliability and validity of testing of, 313t, of midtarsal joint, 266 Calibration training
313–314 of scapulothoracic joint, 59 in temporomandibular joint testing
tarsal testing of, 278f, 278–280, 280f of sternoclavicular joint, 58 reliability and, 423
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442 Index
Index 443
reliability and validity testing and, 190–192 normative values for, 304, 304t, 428t arthrokinematics of, 57–58
right versus left sides and, 188–189 numerical recording form for, 436t capsular pattern in, 58
Fingertip-to-floor test reliability and validity in testing of, osteokinematics of, 57
of thoracolumbar flexion, 371, 371f 311–314, 312t–313t range of motion of
reliability and validity of, 403–404 research findings in, 304t–305t, 304–314, abduction in, 70, 71f–73f, 72
of thoracolumbar lateral flexion, 378, 378f 307t, 309f–310f, 309t, 312t–313t extension in, 66, 67f–69f, 68
Fingertip-to-thigh test testing position and, 20t, 306, 308, 431t flexion in, 62, 63f–65f, 64
of thoracolumbar lateral flexion, 379, transverse tarsal eversion of, 288f–289f, lateral rotation in, 78, 79f–81f, 80
379f–380f 288–289 medial rotation in, 74, 75f–77f, 76
reliability of, 404 transverse tarsal inversion of, 286f–287f, normative values for, 426t
Flexion. See also specific joints 286–287 research findings in, 82, 83t
basic concepts of, 7, 7b, 8f Forearm. See also Elbow testing procedures for, 60f–61f, 60–61
Flexor digitorum muscles anatomical landmarks of, 94f–95f Glide
muscle length testing of, 126f–130f, 126–130 anatomical position of, 7f in arthrokinematics, 4
Flexor muscles of hip neutral position of, 7f Goniometers
anatomy of, 212, 212f range of motion of, 96–101, 96–101f alignment of, 27–31, 28f–30f. See also
muscle length testing in, 212f–217f, 212–214, normative values for, 425t Alignment
216 numerical recording form for, 434t cervical range of motion device as, 25–26
Flock of Birds tracking device testing position for, 20t electrogoniometers as, 26
reliability and validity of structure and function of, 91f–93f, 91–93 fluid (bubble), 25, 26f
in hip testing, 238 Forefoot. See also Foot gravity-dependent, 25–26, 26f
Fluid goniometers, 25, 26f in transverse tarsal eversion testing, 288f–289f, Myrin OB, 25–26
reliability of 288–289 pendulum, 25, 26f
in elbow testing, 110 in transverse tarsal inversion testing, reliability of, 42, 42t
Foot. See also Ankle 286f–287f, 286–287 in cervical spine testing, 354–355, 360
abduction of Freedom of motion degrees in elbow testing, 110–112
metatarsophalangeal testing of, 296f–297f, defined, 6 in hand testing, 190–191
296–297 Frontal plane in hip testing, 236–238
adduction of defined, 5, 6f in knee testing, 258–260
metatarsophalangeal testing of, 298 Fulcrum in shoulder testing, 86–88
anatomical landmarks of, 269f, 281f, in goniometer alignment, 28 in wrist testing, 139–140
290f–291f Functional hand patterns, 189 universal, 21–22, 23f–25f, 24. See also
anatomy of, 263, 264f–267f, 265–268, 269f Functional range of motion Universal goniometer
arthrokinematics of, 263, 265–268 ankle and foot, 309f–310f, 309t, 309–311 validity of
eversion of cervical spine, 352–353, 353f in knee testing, 261
transverse tarsal testing of, 288f–289f, elbow, 108, 109f–110f, 109t, 110 visual estimation versus, 26–27
288–289 hand, 189f–190f, 189–190, 190t Goniometry
extension of hip, 234f–235f, 234t, 234–235 basic concepts in, 3f–8f, 3–15, 9t–12t, 14f–15f
interphalangeal testing of, 299 knee, 256, 257f–258f, 257t, 258 basic objectives in, 1
metatarsophalangeal testing of, 294, shoulder, 85t, 85–86, 86f–87f defined, 3
294f–295f thoracic and lumbar spine, 397f–398f, 397–398 example of, 3b, 3f
flexion of wrist, 137t–138t, 137–139, 138f–139f indications for, 4
interphalangeal testing of, 298–299 instruments in, 21–22, 23f–25f, 24–31, 28f–30f
metatarsophalangeal testing of, 292, skills required for, 19
292f–293f G testing procedures in, 19–36. See also
interphalangeal extension of Gastrocnemius muscle Procedures; specific procedures and
testing of, 299 anatomy of, 300, 300f–301f structures
interphalangeal flexion of muscle length testing in, 300f–303f, 300–303 Gravity-dependent goniometers
testing of, 298–299 Gender overview of, 25–26, 26f
inversion of range of motion and, 13 Great toe
transverse tarsal testing of, 286f–287f, ankle and foot, 305–306, 307t range of motion of
286–287 cervical spine, 348t–349t, 349–350, 351t numerical recording form for, 436t
metatarsophalangeal abduction of elbow, 106t–107t, 106–107 Grip strength
testing of, 296f–297f, 296–297 hand, 186t–188t, 188 post-wrist fracture function and, 141
metatarsophalangeal adduction of hip, 229t–231t, 231–232 Gripping
testing of, 298 knee, 256 range of motion necessary for, 189–190, 190f
metatarsophalangeal extension of shoulder, 82t–83t, 84 Grooming. See Personal care activities
reliability and validity of testing of, 314 temporomandibular joint, 420t–421t, Guides to the Evaluation of Permanent Impairment,
testing of, 294, 294f–295f 421–422 34, 174, 399
metatarsophalangeal flexion of thoracic and lumbar spine, 394t–396t,
testing of, 292, 292f–293f 394–395
osteokinematics of, 263, 265–268 wrist, 134t–135t, 135–136 H
range of motion of Glenohumeral joint Hamstrings
age and, 304t–305t, 304–305, 307t range of motion of anatomy of, 218, 219f
functional, 309f–310f, 309t, 309–311 numerical recording form for, 434t muscle length testing in, 218, 219f–223f,
gender and, 305–306, 307t Glenohumeral joint 222–223
injury and, 308–309 anatomy of, 57, 57f–58f distal, 250f–253f, 250–251, 253
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Hand, 143–192. See also specific joints muscle length testing in Iliotibial band
anatomical landmarks of, 147f, 162f–163f of adductors, 14, 14f anatomy of, 224, 224f
anatomy of, 143f–145f, 143–146, 147f example of, 14, 14f in Ober test, 224, 224f–228f, 226, 228
arthrokinematics of, 143–146 of flexors, 212f–217f, 212–214, 216 Inclinometers
capsular pattern in, 144–146 of hamstrings, 218, 219f–223f, 222–223 in cervical spine testing
carpometacarpal abduction of of iliotibial band, 224, 224f–228f, 226, 228 of extension, 334, 334f
testing of, 170f–171f, 170–171 Ober test in, 224, 224f–228f, 226, 228 of flexion, 329, 329f
carpometacarpal adduction of straight leg raising test in, 218, 219f–223f, of lateral flexion, 339, 339f
testing of, 172 222–223 reliability and validity of, 356, 359
carpometacarpal extension of of tensor fascia lata, 224, 224f–228f, 226, 228 of rotation, 343, 343f–344f
testing of, 167f–169f, 167–169 Thomas test in, 212f–217f, 212–214, 216 overview of, 25–26, 26f
carpometacarpal flexion of osteokinematics of, 197 reliability of
testing of, 164, 164f–166f, 166 range of motion of in cervical spine testing, 356
carpometacarpal opposition of age and, 229t–231t, 229–231 in elbow testing, 111
testing of, 172, 173f–175f, 174 arts and, 233 in hip testing, 237–238
interphalangeal extension of body mass index and, 232 in knee testing, 260
testing of, 157, 160, 181 disability and, 233–234 in shoulder testing, 88
interphalangeal flexion of functional, 234f–235f, 234t, 234–235 in thoracic and lumbar spine testing
testing of, 155, 155f–156f, 158, 158f–160f, gender and, 229t–231t, 231–232 of extension, 375, 375f, 390, 390f
161, 161f, 179, 179f normative values for, 427t of flexion, 372, 372f, 387, 387f
metacarpophalangeal abduction of numerical recording form for, 436t of lateral flexion, 381, 381f
testing of, 153, 153f–154f reliability and validity in testing of, reliability of, 399–400, 400t
metacarpophalangeal adduction of 235–238, 236t–237t of rotation, 384, 384f
testing of, 155 sports and, 233 validity of
metacarpophalangeal extension of testing position and, 20t, 232, 431t in cervical spine testing, 356, 359
testing of, 150, 150f–152f, 152, 178 Hockey players Index finger. See also Hand
metacarpophalangeal flexion of range of hip motion in, 233 range of motion of, 187t
testing of, 148, 148f–149f, 161, 161f, 176, Humeroulnar joint. See also Elbow numerical recording form for, 435t
176f–177f anatomy of, 91, 91f–92f Infants. See also Children
muscle length testing in, 182f–185f, 182–184 arthrokinematics of, 92 range of motion in, 13
osteokinematics of, 143–146 capsular pattern in, 92 ankle and foot, 304, 305t
range of motion of, 147–192 osteokinematics of, 91–92 hip, 229–230, 230t
age and, 186t–188t, 186–188 Humerus knee, 254, 254t–255t
functional, 189f–190f, 189–190, 190t as shoulder anatomical landmark, 60f–61f Injury
gender and, 186t–188t, 188 Hydrogoniometers ankle and foot, 308–309
normative values for, 425t–427t reliability of dance-related, 233
numerical recording form for, 435t in shoulder testing, 88 repetitive wrist, 139
reliability and validity in testing of, 190–192 Hyperextension Instruments, 21, 23f–26f, 24–31, 28f–30f. See
research findings in, 186t–188t, 186–192, defined, 7 also specific instruments
189f–190f, 190t Hypermobility electrogoniometers as, 26
right versus left sides and, 188–189 causes of, 12 gravity-dependent goniometers as, 25–26, 26f
testing position and, 20t, 189, 431t defined, 11 universal goniometer as, 21, 23f–25f, 24
Head. See Cervical spine; Temporomandibular in goniometry recordings, 31–32, 33f visual estimation versus, 26–27
joint in range of motion testing, 11–12, 12t Interossei muscles
Hip, 197–238 Hypermobility syndrome muscle length testing in, 182f–185f, 182–184
abduction of defined, 12 Interphalangeal joints
recordings of, 34b Hypomobility foot. See also Foot
testing of, 204, 204f–205f causes of, 9–11 anatomy of, 267f, 268
adduction of defined, 9 arthrokinematics of, 268
recordings of, 34b in goniometry recordings, 31–32, 32f extension of, 299
testing of, 206f–207f, 206–207 in range of motion testing, 9–11, 11t flexion of, 298–299
anatomical landmarks of, 198f–199f examples of, 9b–11b osteokinematics of, 268
anatomy of, 197f–199f, 197–198, 212, 212f, hand. See also Hand
218, 219f anatomy of, 143f–145f, 144–146
arthrokinematics of, 197–198 I arthrokinematics of, 144, 146
extension of Ice hockey players capsular pattern in, 146
testing of, 202, 202f–203f range of hip motion in, 233 extension of, 155, 156f, 157, 160, 181
flexion of Iliacus muscle flexion of, 158, 158f–160f, 161, 161f,
recordings of, 33f anatomy of, 212, 212f 179f–180f, 179–180
testing of, 200, 200f–201f in Thomas test, 212f–217f, 212–214, 216 osteokinematics of, 144, 146
lateral rotation of Iliofemoral joint. See also Hip range of motion of, 186, 186t–188t
recordings of, 34b anatomy of, 197, 197f–198f Intersubject variation
testing of, 210f–211f, 210–211 arthrokinematics of, 197–198 standard deviation indicating, 43
medial rotation of capsular pattern in, 198 Intertester reliability
example of, 20b–21b, 21f osteokinematics of, 197 defined, 47
recordings of, 34b Iliopsoas muscles evaluation of, 41
testing of, 208f–209f, 208–209 anatomy of, 212, 212f in ankle and foot testing, 311–314, 312t–313t
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in cervical spine testing, 353–356, muscle length testing in osteokinematics of, 366
357t–358t, 359–361 distal hamstring length test in, 250f–253f, range of motion of
in elbow testing, 110–112 250–251, 253 age and, 393–394, 394t–396t
exercise for, 50–51 Ely test in, 246, 247f–249f, 249 disability and, 397
in hand testing, 190–191 osteokinematics of, 242 diurnal effects on, 395
in hip testing, 236–238, 238t range of motion of functional, 397f–398f, 397–398
in knee testing, 258–260, 259t age and, 254t–255t, 254–256 gender and, 394t–396t, 394–395
in shoulder testing, 86–88 body mass index and, 256 normative values for, 393t, 429t
in temporomandibular joint testing, functional, 256, 257f–258f, 257t, 258 numerical recording form for, 433t
423, 423t gender and, 256 occupation and lifestyle and, 395–397
in thoracic and lumbar spine testing, normative values for, 254, 254t, 427t reliability and validity of, 398–405, 400t,
399–404, 400t numerical recording form for, 436t 402t
in wrist testing, 139–140 reliability in testing of, 258–260, 259t research findings in, 393t–396t, 393–405,
Intervertebral joints. See also Cervical research findings in, 254t–255t, 254–261, 397f–398f, 400t, 402t
spine 257f–258f, 257t, 259t testing position and, 20t, 431t
anatomy of, 321, 321f–322f testing position and, 19b, 20t, 244, 431t rotation of
arthrokinematics of, 322 validity in testing of, 261 testing of, 382, 382f–384f, 384
capsular pattern in, 322 Lumbrical muscles
osteokinematics of, 321–322 muscle length testing in, 182f–185f,
Intraclass correlation coefficients L 182–184
in reliability evaluation, 45–47, 46t Landmarks
Intrasubject variation anatomical. See Anatomical landmarks
standard deviation indicating, 43 Lateral excursion M
Intratester reliability mandibular, 410–411, 411f, 414f, 418, 418f–419f Mandibular length. See also Temporomandibular
defined, 47 Lifestyle joint
evaluation of, 41 range of motion and range of motion and
in ankle and foot testing, 311–314, thoracic and lumbar spine, 395–397 temporomandibular joint, 421–422
312t–313t Ligaments Mandibular motions, 410, 410f–411f
in cervical spine testing, 353–356, elbow, 91, 92f–93f Mean
357t–358t, 359–361 hip, 197, 198f–198f defined, 43
in elbow testing, 110–112 shoulder, 58f–60f, 58–59 standard error of, 47
exercise for, 48–49 Little finger. See also Hand Measurement
in hand testing, 190–191 range of motion of, 187t standard error of, 47
in hip testing, 236–238, 237t numerical recording form for, 435t Measurement errors
in knee testing, 258–260, 259t Looking upward defined, 43
in shoulder testing, 86–88 range of motion necessary for goniometer-related, 28–29
in temporomandibular joint testing, 423 cervical spine, 353, 353f reliability and, 41
in thoracic and lumbar spine testing, Lordosis standard deviation indicating, 44t, 44–45
399–404, 400t occupational, 396–397 Measurement instruments, 21, 23f–26f, 24–31,
in wrist testing, 139–140 Low-back pain 28f–30f. See also Goniometers; Instruments;
Inversion. See Ankle; Foot in adolescents, 397 other instruments
range of motion and, 397 Medial-lateral axis
Lower-extremity testing. See also specific defined, 5, 6f
J structures Men. See Adults; Gender
Jaw. See Temporomandibular joint
ankle and foot in, 263–314 Metacarpophalangeal joints. See also Hand
Joint effusions
hip in, 197–238 abduction of
capsular patterns in, 10
knee in, 241–261 testing of, 153, 153f–154f
Joint measurements
numerical recording forms for, 436t–437t adduction of
body position and, 431t
objectives in, 195 testing of, 155
Joint motion testing
reliability studies of, 41–42 arthrokinematics of, 143–145
basic concepts in, 4f–7f, 4–6
Lumbar spine capsular pattern in, 144–145
instruments for, 21–22, 23f–25f, 24–31,
anatomical landmarks of, 368f extension of
28f–30f
anatomy of, 366, 367f–368f testing of, 150, 150f–152f, 152, 178
procedures for, 12–13, 19–21, 20t, 21f
arthrokinematics of, 366–367 flexion of
recording of, 31–34, 32f–33f
capsular pattern in, 367 testing of, 148, 148f–149f, 161, 161f, 176,
extension of 176f–177f
K age and, 394, 394t osteokinematics of, 143, 145
Knee, 241–261 testing of, 373f–375f, 373–375, 388, range of motion of, 186t–188t, 1186
anatomical landmarks of, 243f 389f–390f, 390 age and, 186t–188t, 186–188
anatomy of, 241f–243f, 241–242, 246, 247f, flexion of functional, 189f–190f, 189–190, 190t
250, 250f age and, 393–394, 394t gender and, 186t–188t, 188
arthrokinematics of, 242 testing of, 369f–372f, 369–372, 385, reliability and validity in testing of,
capsular pattern in, 242 385f–387f, 387 190–192
extension of lateral flexion of right versus left sides and, 188–189
testing of, 246 age and, 394, 394t testing position and, 189
flexion of testing of, 376f–381f, 376–379, 381, Metal goniometers
testing of, 244f, 244–245 391–392, 392f universal, 21, 23f, 24
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Metatarsophalangeal joints. See also Foot of lumbricals and interossei, 182f–185f, basic concepts of, 5
abduction of 182–184 of carpometacarpal joint, 144–145
testing of, 296f–297f, 296–297 numerical recording form for, 437t defined, 5
adduction of of popliteal angle, 250f–253f, 250–251, of elbow, 92–93
testing of, 298 253 of glenohumeral joint, 57
anatomical landmarks of, 290f–291f of rectus femoris, 246, 247f–249f, 249 of iliofemoral joint, 197
anatomy of, 267, 267f of tensor fascia lata, 224, 224f–228f, 226, of interphalangeal joints
arthrokinematics of, 267–268 228 fingers, 144
capsular pattern in, 268 of triceps brachii, 104f–105f, 104–105 thumb, 146
extension of Muscle paralysis toes, 268
reliability and validity of testing of, 314 range of motion and of intervertebral and zygapophyseal joints,
testing of, 294, 294f–295f example of, 8b 321–322
flexion of Myrin OB Goniometer, 25, 26f of knee, 242
testing of, 292, 292f–293f of lumbar spine, 366
osteokinematics of, 267 of metacarpophalangeal joints, 143, 145
Midcarpal joint. See also Wrist
N of metatarsophalangeal joints, 267
Neck. See Cervical spine; Temporomandibular
anatomy of, 115f–116f, 115–116 of midtarsal joint, 266
joint
arthrokinematics of, 116 of scapulothoracic joint, 59
Neutral position
osteokinematics of, 116 of sternoclavicular joint, 58
forearm, 7f
Middle finger. See also Hand of subtalar joint, 265
Neutral zero method
range of motion of, 187t of tarsometatarsal joints, 267
in range of motion testing, 7, 7f–8f
numerical recording form for, 435t of temporomandibular joint, 409–410,
Noncapsular pattern of restricted motion
Midtarsal joint. See also Ankle 410f–411f
defined, 10
anatomy of, 265–266, 266f of thoracic spine, 365
example of, 11b
arthrokinematics of, 266 of tibiofibular joints, 263
in range of motion testing, 10–11
capsular pattern of, 266 of wrist, 116
Normative values
osteokinematics of, 266 Overbite
range of motion
Modified Ober test defined, 416
ankle and foot, 304, 304t, 428t
of tensor fascia lata muscle length, 228, 228f testing for, 416, 416f
cervical spine, 346, 346t–347t, 428t
reliability of, 236–237
elbow and forearm, 425t
Modified Schober test
finger, 426t
in thoracic and lumbar spine testing
glenohumeral joint, 426t
P
of extension, 388 Pain
hip, 427t
of flexion, 387, 387f causes in passive range of motion of, 8–9
knee, 254, 254t, 427t
reliability and of, 401–403, 402t Passive insufficiency
shoulder, 425t–426t
Modified-modified Schober test defined, 14
temporomandibular joint, 429t
in thoracic and lumbar spine testing Passive range of motion. See also Range of
thoracic and lumbar spine, 393t, 429t
of extension, 388 motion
thumb, 427t
of flexion, 385, 385f–386f causes of pain during, 8–9
wrist, 425t
procedure for, 385, 388 defined, 8
Numerical recording forms
reliability of, 398, 402t, 403 testing of, 8–9
instructions for completing, 32, 33f
Motion example of, 8b
for muscle length, 437t
range of. See Range of motion; specific joints Patellofemoral joint. See also Knee
for range of motion, 433t–436t
testing. See Testing motion anatomy of, 241–242, 242f
Motion analysis systems Pearson product moment correlation coefficient
in thoracic and lumbar spine testing O in reliability evaluation, 45–46, 46t
reliability of, 404–405 OB Myrin Goniometer, 25, 26f Pectineus muscle
Mouth opening Ober test anatomy of, 213
temporomandibular joint in of tensor fascia lata muscle length, 224, in Thomas test, 212f–217f, 212–214, 216
disorders of, 422 224f–228f, 226, 228 Pelvis
functional motions in, 410f–411f, 410–411 reliability of, 236–237 anatomical landmarks in, 199f
maximum, 420, 420t Obesity. See also Body mass index Pendulum goniometers
testing of, 412–413, 413f–419f, 415–418 cervical spine mobility and, 352 reliability of
Muscle length Occupation in shoulder testing, 87–88
defined, 13 range of motion and Pendulum goniometers, 25, 26f
testing of, 13–15, 14f–15f cervical spine, 352–354 reliability of
of biceps brachii, 102f–103f, 102–103 thoracic and lumbar spine, 395–397 in elbow testing, 110–111
examples of, 14, 14f–15f Opposition in wrist testing, 140
of extensor digitorum muscles, 130f–133f, thumb, 172, 173f–175f, 174 Personal care activities
130–131, 133 Ortho Ranger goniometer range of motion necessary for
of flexor digitorum muscles, 126f–129f, reliability of elbow, 108, 110
126–129 in elbow testing, 110–111 hip, 235, 235f
of gastrocnemius, 300f–303f, 300–303 in hip testing, 236 shoulder, 85t, 85–86, 86f–87
of hamstrings, 218, 219f–223f, 222–223, Osteokinematics wrist, 137–139, 138t, 139f
250f–253f, 250–251, 253 of acromioclavicular joint, 59 Picking up coin
of hip flexors, 212f–217f, 212–214, 216 of atlanto-occipital and atlantoaxial joints, range of motion necessary for
of iliotibial band, 224, 224f–228f, 226, 228 319–320 hand, 189, 189f
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448 Index
Index 449
of lateral flexion, 378f–380f, 378–380 extension of, 294, 294f foot, 20t
reliability of, 401, 402t, 403 flexion of, 292, 292f, 298–299 forearm, 20t
Tarsal joints. See also Ankle; Foot inversion of, 276, 276f, 282, 282f, 286, 286f hand, 20t, 148, 150, 153, 155, 157–158,
anatomical landmarks of, 275f muscle length in, 301, 301f, 303, 303f 160–161, 164, 167, 170, 172, 176, 189
eversion of plantarflexion of, 273, 273f hip, 20t, 200, 202, 204, 206, 208, 210, 232,
testing of, 278f, 278–280, 280f cervical spine 233t
inversion of extension of, 331, 331f, 334f–335f, 334–335 knee, 19b, 20t, 244
testing of, 276f–277f, 276–277 flexion of, 326, 326f, 329, 329f–330f, 331 overview of, 431t
Tarsometatarsal joints. See also Foot lateral flexion of, 336, 336f, 339f–340f, procedures for, 19–21, 20b–21b, 20t, 21f
anatomy of, 266–267 339–340 shoulder, 20t, 62, 66, 70, 74, 78
arthrokinematics of, 267 rotation of, 341, 341f, 343, 345 temporomandibular joint, 20t, 413, 417–418
osteokinematics of, 267 elbow thoracic and lumbar spine, 369, 373, 376, 382,
Teeth extension of, 98 385, 388, 391
permanent, 412f flexion of, 96, 96f thoracolumbar spine, 20t
Telephone use muscle length in, 103, 103f, 105, 105f wrist, 20t, 118, 120, 122, 124, 136–137
range of motion necessary for pronation of, 98 Testing procedures. See Procedures; specific
elbow, 108, 109t supination of, 101 procedures and structures
wrist, 137, 137t, 138f hand Thomas test
Temporal variation abduction of, 153, 153f, 170, 170f of hip flexor muscle length, 212f–217f,
defined, 43 extension of, 150, 150f, 157, 160, 167, 167f, 212–214, 216
Temporomandibular joint, 409–423 178, 181 reliability of, 237–238
anatomical landmarks of, 412f flexion of, 148, 148f, 155, 155f, 158, 158f, Thoracic spine
anatomy of, 409, 409f–412f 161, 164, 164f, 176, 176f, 179 anatomical landmarks of, 368f
arthrokinematics of, 411 muscle length in, 184 anatomy of, 365, 366f, 368f
capsular pattern in, 411 opposition of, 172, 173f arthrokinematics of, 365–366
disorders of, 422 hip capsular pattern in, 366
mandibular depression of, 410f, 410–411 abduction of, 204, 204f extension of
testing of, 412–413, 413f–415f, 415 adduction of, 206, 206f testing of, 373f–375f, 373–375
mandibular lateral excursion of, 410, 411f, extension of, 202, 202f flexion of
414f flexion of, 200, 200f testing of, 369f–372f, 369–372
testing of, 418, 418f–419f lateral rotation of, 210, 210f lateral flexion of
mandibular protrusion of, 410, 410f medial rotation of, 208, 208f testing of, 376f–381f, 376–379, 381
testing of, 417, 417f muscle length in, 214, 215t, 216, 220, osteokinematics of, 365
mandibular retrusion of, 410, 410f 221f–222f, 222, 224, 225f–227f, 226, 228 range of motion of
testing of, 416, 416f knee age and, 393–394, 394t–396t
osteokinematics of, 409–410, 410f–411f flexion of, 244, 244f disability and, 397
overbite of muscle length in, 248f, 249, 251, 252f diurnal effects on, 395
testing for, 416, 416f shoulder functional, 397f–398f, 397–398
range of motion of abduction of, 70, 71f gender and, 394t–396t, 394–395
age and, 420t–421t, 420–421 extension of, 66, 67f normative values for, 393t, 429t
gender and, 420t–421t, 421–422 flexion of, 62, 63f numerical recording form for, 433t
head and neck positions and, 422 lateral rotation of, 78, 79f occupation and lifestyle and, 395–397
mandibular length and, 421–422 medial rotation of, 74, 75f reliability and validity of, 398–405, 400t,
normative values for, 429t temporomandibular joint 402t
numerical recording form for, 433t depression of, 413, 413f–415f, 415 research findings in, 393t–396t, 393–405,
reliability and validity of testing of, 422–423 lateral excursion of, 418, 418f 397f–398f, 400t, 402t
research findings in, 420t–421t, 420–423, protrusion of, 417, 417f testing position and, 20t, 431t
423t thoracic and lumbar spine rotation of
testing position and, 20t, 413, 417, 422, 431t extension of, 373, 373f, 388 testing of, 382, 382f–384f, 384
recording of motions of, 413, 414f flexion of, 369, 369f, 385 Thumb. See also Hand
testing objectives in, 317 lateral flexion of, 376, 376f, 391 anatomical landmarks of, 162f–163f
Temporomandibular ligament rotation of, 382, 382f anatomy of, 144f–145f, 145–146
function of, 410, 410f wrist arthrokinematics of, 145–146
Tendinitis extension of, 120, 120f capsular pattern in, 145–146
wrist, 139 flexion of, 118, 118f carpometacarpal joint testing in, 164,
Tennis players muscle length in, 128, 128f, 131, 131f–132f 164f–171f, 166–172, 173f–175f, 174
elbow range of motion in, 108 radial deviation of, 122, 122f interphalangeal joint testing in, 179f–180f,
shoulder range of motion in, 84–85 ulnar deviation of, 124, 124f 179–180, 181
Tensor fascia lata muscle Testing positions metacarpophalangeal joint testing in, 176,
anatomy of, 212f, 213, 224, 224f ankle, 20t 176f–177f, 178
in Ober test, 224, 224f–228f, 226, 228 ankle and foot, 270, 273, 276, 278, 282, 284, opposition of, 172, 173f–175f, 174
Testing motion 286, 288, 292, 294, 296, 298–299 osteokinematics of, 145–146
ankle and foot cervical spine, 20t, 326, 331, 336, 341, 352 range of motion of, 186, 188t
abduction of, 296, 296f defined, 19 age and, 186t–188t, 186–188
dorsiflexion of, 270f, 270–271 elbow, 20t, 96, 96f, 98, 98f, 99, 99f, 100, 100f, functional, 189–190
eversion of, 278f, 278–279, 284f, 284–285, 102, 102f, 104, 104f gender and, 186t–188t, 188
288, 288f example of, 19b normative values for, 427t
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numerical recording form for, 435t metal, 21, 23f, 24 Visual estimation
reliability and validity testing of, 190–192 plastic, 21, 23f, 24 in cervical spine testing
research findings in, 186t–188t, 186–192, reliability of, 42 reliability of, 360–361
189f–190f, 190t in cervical spine testing, 354–355 goniometer use versus, 26–27
right versus left sides and, 188–189 in elbow testing, 110–112
testing position and, 189
Tibiofemoral joint. See also Knee
in hand testing, 190–191
in hip testing, 236–237
W
Walking
anatomy of, 241f–242f, 241–242 in knee testing, 258–260 range of motion necessary for
arthrokinematics of, 242 in shoulder testing, 86–88 hip, 234t
osteokinematics of, 242 in wrist testing, 139–140 knee, 257t, 258
Tibiofibular joints in thoracic and lumbar spine testing Women. See Adults; Gender
anatomy of, 263, 264f of lateral flexion, 377, 377f Wrist, 115–141. See also specific joints
arthrokinematics of, 263 reliability and validity of, 401 anatomical landmarks of, 117f
capsular pattern in, 263 of rotation, 382, 383f anatomy of, 115f–117f, 115–116, 126f, 128f,
osteokinematics of, 263 uses of, 21 130f, 132f
Toe. See also Foot validity of arthrokinematics of, 116
anatomy of, 267f in cervical spine testing, 355 capsular pattern in, 116
arthrokinematics of, 268 in knee testing, 261 extension of
osteokinematics of, 268 Upper-extremity testing. See also specific reliability studies of, 41
range of motion of structures testing of, 120f–121f, 120–121
interphalangeal testing in, 298–299 elbow and forearm in, 91–112 flexion of
numerical recording form for, 436t hand in, 143–192 reliability studies of, 41
research findings in, 304, 304t numerical recording forms for, 434t–435t, 437t testing of, 118f–119f, 118–119
testing position and, 20t, 431t objectives in, 55 muscle length testing in, 126f–133f, 126–131,
Total active motion reliability studies of, 41–42 133
defined, 186 shoulder in, 57–88 osteokinematics of, 116
Transverse plane wrist in, 115–141 radial deviation of
defined, 6, 7f testing of, 122, 122f–123f
Transverse tarsal joint. See also Ankle; Foot
anatomy of, 265–266, 266f
V range of motion of
Validity, 39–41 age and, 134t–135t, 134–135
arthrokinematics of, 266 of ankle and foot testing, 314 functional, 137t–138t, 137–139,
capsular pattern of, 266 of cervical spine testing, 353–356, 359–361 138f–139f
eversion of concurrent, 39 gender and, 134t–135t, 135–136
testing of, 288f–289f, 288–289 construct, 40–41 normative values for, 425t
inversion of content, 39 numerical recording form for, 434t
testing of, 286f–287f, 286–287 criterion–related, 39–40 reliability in testing of, 139–140
osteokinematics of, 266 defined, 39 research findings in, 134t–135t, 134–141,
Triceps brachii muscle of elbow testing, 112 137t–138t, 138f–139f
muscle length testing of, 104f–105f, 104–105 face, 39 right versus left sides and, 136
example of, 14, 15f of hand testing, 191–192 testing position and, 20t, 136–137, 431t
True biological variation of hip testing, 235–238 validity in testing of, 140–141
defined, 43 of knee testing, 261 repetitive trauma of, 139
Tying shoes of shoulder testing, 86–88 ulnar deviation of
range of motion necessary for of thoracic and lumbar spine testing, testing of, 124, 124f–125f
knee, 257t 398–403 Writing
of wrist testing, 140–141 range of motion necessary for, 189, 189f
U Variation elbow, 110
Universal goniometer, 21, 23f–25f, 24 coefficient of, 45
in cervical spine testing intrasubject and intersubject, 43
of extension, 331f–332f, 331–332 temporal, 43 Z
of flexion, 326f–327f, 326–327 true biological, 43 Zygapophyseal joints. See also Cervical
of lateral flexion, 336f–337f, 336–337 Vertebrae. See also Cervical spine; Lumbar spine; spine
of rotation, 341f–342f, 341–342 Thoracic spine anatomy of, 321, 321f–322f
components of, 23f–24f, 24 anatomy of, 365–366, 366f–367f arthrokinematics of, 322
example of, 24, 25f Vertical axis capsular pattern in, 322
exercise for, 22 defined, 6, 7f osteokinematics of, 321–322
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Testing Procedures
PART II UPPER-EXTREMITY TESTING THUMB: Carpometacarpal Joint
Flexion, 164–166
Chapter 4 The Shoulder Extension, 167–169
Flexion, 62–65 Abduction, 170–171
Extension, 66–69 Adduction, 172
Abduction, 70–73 Opposition, 172–175
Medial (Internal) Rotation, 74–77 THUMB: Metacarpophalangeal Joint
Lateral (External) Rotation, 78–81 Flexion, 176–177
Chapter 5 The Elbow and Forearm Extension, 178
Flexion, 96–97 THUMB: Interphalangeal Joint
Extension, 98 Flexion, 179–180
Pronation, 98–99 Extension, 181
Supination, 100–101 Muscle Length Testing Procedures
Muscle Length Testing Procedures Lumbricals, Palmar Interossei, and Dorsal
Biceps Brachii, 102–103 Interossei, 182–185
Triceps Brachii, 104–105