Stanbridge - T4 - TMT - W7 (Part 2/2) - Elbow & Forearm

• Therapeutic Measurement and Testing focuses on the elbow and forearm.

Elbow and Forearm Overview

• A musculoskeletal review involves bone landmarks, joint motions, and ligaments.

Elbow and Forearm Bones

• Radioulnar joints include superior and inferior connections.
• Other key anatomical features are the radial head, radial notch, and annular ligament.
• Additional components consist of the quadrate ligament, oblique cord, radius, and ulna.

Elbow and Forearm Joints

• Key features are the Coronoid and radial fossa on the anterior humerus
• The lateral epicondyle is a key landmark on the posterior elbow joint
• The capitulum and trochlea are important condyles that articulate with the radius and Ulna
• The Humeroradial joint, the olecranon process and the humeroulnar joint allow pivotment and flexation/extension

Forearm Ligaments

• The Annular ligament and the lateral collateral ligament offer support to the elbow joint
• The Medial collateral ligament is critical to stabilization and is located on the medial aspect of the joint

Elbow Goniometry: Landmarks (Anterior View)

• Landmarks for goniometry on the anterior elbow include the lateral epicondyle of the humerus, radial styloid process, and ulnar styloid process.

Elbow Goniometry: Landmarks (Posterior View)

• On the posterior side the acromion process of the scapula, the lateral epicondyle of the humerus and the radial head are key bony landmarks for goniometry alignment.

Elbow Flexion ROM

• Elbow flexion normally ranges from 0-150 degrees
• Optimal patient positioning is supine with the shoulder at 0 flexion, extension, abduction, and rotation plus with a towel under the distal humerus
• Therapist position is best when seated
• Key stabilizers are the distal humerus, in place to stabilize the joint
• You place the fulcrum on the lateral epicondyle
• Key alignments are the Stationary Arm, parallel against the lateral midline of humerus and then the Movable Arm parallel to radius’ lateral midline
• End feel is soft tissue approximation

Elbow Extension ROM

• Extension is measured at 0 degrees
• For a seated therapist, make sure the patient remains supine, shoulder at 0 degrees flexion, extension, abduction and rotation
• For consistent stabilization, maintain the proximal humerus to prevent anterior translation, or shifting of the humeral head
• Place the fulcrum is on the lateral epicondyle, arm parallels the lateral midline of humerus to the reference of the acromion process
• The moveable arm is best when parallel to the radius’ lateral midline, marking the radial midline
• End feel: bony/hard

Forearm Supination ROM

• Supination ranges from  0-80 degrees.
• Your patient remains seated
• The distal hummerus allows shoulder stabilization, and prevents shoulder ER and adduction while maintaining elbow flexion
• Position the  fulcrum medially and proximally to the ulnar styloid
• Key goniometer alignments parallel the anterior midline of humerus and the styloid processes
• End feel: capsular/firm

Forearm Pronation ROM

• Pronation ranges from 0-80 degrees
• Same positioning and stabilization as supination measurement
• The fulcrum is laterally and proximal to the ulnar styloid process
• Stationary arm parallels the anterior midline of humerus.
• Movable arm is best when against dorsal forearm proximal to the styloid processes.
• End feel: hard/bony or capsular/firm

Functional Application

• Good function of the entire UE requires both strength and range of motion
• A strength rating of at least 3/5 is an essential requirement for good function but if tasks involve holding a utensil or performing a more challenging task, then more is required.
• Eating and bringing food is an example requiring more forearm supination and elbow flexion.
• Activities like lower body dressing need more elbow extension.

Humeroulnar Joint Flexion

• The muscles that flex the humeroulnar joint should be known.

Biceps and Brachialis MMT

• The procedure involves the patient seated or supine, elbow flexed to 90, and supinated, while the elbow should be supported
• Key points include elbow stabilization and resistance applied on the forearm, testing for elbow flexion
• Inability to flex elbow indicates weakness.
• When performed against gravity, the patient is side-lying with UE supported and could use a towel or pillow
• Reduced elbow strength is a cause for concern

Brachioradialis MMT

• Brachioradialis is tested against gravity with the patient seated or supine, elbow flexed to 90, thumb up with elbow supported
• Resistance applies to the elbow during flexion
• Key indicators are looking and feeling fir muscle belly firings with elbow flexion

Humeroulnar Extension

• A key indicator to evaluate for is identifying to ensure the presence of certain muscles

Triceps and Anconeus MMT

• Patient remains supine, shoulder flexed to 90, with a slightly less less than full extension
• Key actions include elbow stabilizations. elbow extension, and how it responds to elbow flexion (testing against gravity)
• Keep in mind that the belly is below the elbow joint

Forearm Supination Muscle

• Review the muscles associated with supination

Supinator and Biceps Brachii MMT

• Key factors involves the patient sitting, elbow at/or below a 90 degree angle, forearm supports
• Start with patient moving from pronation into supination
• Always stabilize the elbow and prevent injury
• Look at hand placement and resist the forearm in an appropriate setting
• Expect reduced supination (must support the are)

Forearm Pronation

• Determine the muscles associated with forearm pronation

Pronator Teres and Quadratus MMT

• During the test, the patient should remain seated, upper arm supported against the side, start with supination and move into pronation
• Stabilization during procedure involves ensuring the elbow and arm as supported
• Resistance is placed into supinstion, with pressure above the wrist
• Expect reduced ability to pronate (avoid pressure in the wrist when performing)

Pronator Quadratus (Kendall)

• Test and actions begins with the patient supine
• Always start in supination and guide the patient into pronation
• Place key stabilizers next to the body
• Place resistance above the wrist
• A key find is noticing a reduced ability to pronate

Wrist MMT

• Anatomical bones and structure should remain on the minds f the practitioners

Wrist Ligaments

• Radioulnar Joints and movements, and key ligaments, tendons and anatomical structures should he reviewed

Forearm Bones

• Radioulnar movements, and bony landmarks should be readily reviewed

Wrist Goniometry

• A clear understanding of the procedure remains crucial

Wrist Flexion

• Flexion normally ranges from 0-80 degrees
• Maintain sitting position with a 90-degree flexion,  palm facing the ground with upper extremity supported by a table
• Place the  therapist to the side for the patient
• Key stabilizers include the radius/ulna that prevent  finger flexion, wrist deviation and the fulcrum at lateral wrist
• Key Goniometer Alignments mark against the midline of the ulna and  5th metacarpal
• End feel: capsular/firm.

Wrist Extension

• Extension should remain at 0-70 degrees
• Therapist actions include stabilizing the wrist, prevent it from moving ulnarly and radially with finger extension. Wrist also should remain fixed
• End feel: capsular/firm

Wrist Radial Deviation

• Should be measured between 0-20 degrees with patient seated
• Key placements are on the patients forearm, and stabilized to avoid supination/pronation
• Also, make sure their is not interference with wrist extension/flexion
• The focus should remain on keeping the ulna stable as the radius moves laterally
• Stabilize at radius and ulna to avoid forearm rotation, and place resistance on the third metacarpal
• The patient should remain consistent and without issues when asked to stabilize the ulna with radial emphasis
• End feel: capsular or may be bony

Wrist Ulnar Deviation

• Measure deviation 0-30 degrees.
• Be aware of stabilizing by preventing wrist flexing and extending to get optimal reading
• Key stabilizer actions include  radius and ulna; avoid wrist flexion, extension, and rotation
•  Fulcrum should stay on the capitate while Stationary arm and Movable arms aligns against midline of forearm
•  Expect a capsular/firm End Feel.

Wrist Capsular Pattern

• Flexion and extension should be about equal

Wrist Functional Ranges

• Know the functional ranges when measuring

Wrist MMT

• Be aware of one primary rule/substitution: flexion for wrist extension with specific details

Wrist Muscles

• Know the muscles that flex the wrist

Flexor Carpi Radialis MMT

• Patient seated to supine, less than full elbow extension with forearm held up
• Stabilizing includes the forearm when its supported on table or while preformed by examiner
• Wrist flexion radial side, and apply resistant against the thener eminence
• Make sure the flexors don't engage or take over (watch for substitutions)

Flexor Carpi Ulnaris MMT

• Similar to FCR, except there will be some minor tweaks
• Involve stabilization, wrist extension test with wrist flexion, key resistance and weakness to look for when engaging and analyzing test
• Key substitutions and test, specifically in the hands should be looked out for and always be noted

The Next Set Of Questions

• What is considered for the test for all other MMT test
• What muscles extend the wrist?

Extensor Carpi Radialis MMT

• Procedure includes MMT that opposes gravity with full stabilization of joint and wrist
• Always be familiar with resistance placements and key areas for the wrist to avoid injury
• The examiner places the patient's forearm in about a 30 degree extension while stabilizing elbow as per the procedure
• Check for ulnar deviations and common substitutions

Extensor Carpi Radialis Longus Longus and Brevis MMT

• You use gravity/non-gravity when testing with key stabilization points for the elbow
• Make sure the patient does not over extend (or fully extend shoulder), or ulnarly deviate for risk of substitution with key stabilizing points

Forearm Flexion

• Key muscles to evaluate

Extensor Carpi Ulnaris MMT

• To ensure key focus, the examiner guides patient to stabilize over the table and stabilizes over examiner
• Resists radial deviation, wrist extension
• Watch out for the use of forearm flexors who may tend to substitute and use the wrist's extensors

Deep Tendon Reflex Testing

• Key components should include a relaxed patient who fully understand the test
• The muscles should be placed on a slight stretch
• A reflex hammer should be used
• Follow through with a strike to the target tendon or joint, and deliver a strike in a controlled manner (comparing left and right hands is an optional comparison

Upper Extremity DTR

• Bicep at C5/6 levels
• The muscles of the brachioradialis are at the same C5/6 level of the body
• Expect the Tricep at C6/7

DTR Grading

• 0 is no response
• "I" is a diminished response
• 2+ indicates an active response, in the normal range
• 3+ or 4+ are marked as exaggerated
• 4+ is a brisk action/exaggerated

Therapeutic Measurement and Testing (TMT) Documentation for the elbow, forearm, and wrist:

• Always perform goniomety test correctly
• Test using MMT
• Keep track of sensory details
• Always record patients response and ensure a sensory grading

Explore the musculoskeletal structure of the elbow and forearm, including bone landmarks, joint motions, and ligaments. Key anatomical features such as the radioulnar joints, radial head, and annular ligament. Learn about the ligaments critical for elbow joint support.