Goniometry in Joint Measurement

Testing the Muscles of the Upper Extremity

• Topic: Testing the muscles of the upper extremity.
• Presenter: Prof. Dr. Amir N Wadee

Shoulder Joint

• Components: Brachial nerves, joint capsule, synovium, cartilage, acromion, coracoid process, head of humerus, glenoid fossa, shaft of humerus, scapula.
• Images provide anatomical details and descriptions.

Shoulder Flexion

• Muscles:
  • Anterior Deltoid
  • Coracobrachialis
• Images show the muscles' roles in shoulder flexion.
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Shoulder Goniometry

• Definition: a technique to measure the angles created by the bones at joints using a goniometer instrument comprising a moving arm, a stationary arm, and a fulcrum.

Introduction

• Definition of goniometry: Measuring angles created by bones at joints using a goniometer.
• Goniometer components: moving arm, stationary arm, fulcrum
• Placement: Fulcrum over the joint being measured, stationary arm aligned with non-moving part, moving arm placed on the moving part.
• Example: Knee flexion (stationary arm aligned along the greater trochanter of the femur, moving arm along the midline of the leg).

Introduction - Continued

• Alignments for specific tests, e.g., knee joint or lateral epicondyle of the femur.
• Importance: joint mobility is significant for diagnosing and determining the presence/absence of dysfunction/disorders (example - rheumatoid arthritis progression).
• Usage: evaluating improvements/lacks of progression during rehab.
• Purpose: Assessing effectiveness of treatment.

Flexion

• Range of Motion (ROM): 0 - 180 degrees.
• Patient instructions:
  • Align the goniometer correctly.
  • Upward arm movement like raising a hand to ask a question.
  • Palm facing the body.

Starting Position

• Patient position: Supine, arm at side, palm facing the body.
• Goniometer placement: Fulcrum over acromion process.
• Alignment: Stationary and moving arms with the midline of the humerus/lateral epicondyle.

Ending Position

• Moving arm's alignment: Remains in line with the lateral epicondyle and midline of the humerus.
• Examiner position: Supporting the patient's extremity.
• Stationary arm position: Remains in its initial alignment against the thorax's midline.
• Normal glenohumeral flexion range: 160-180 degrees (The diagram shows 180 degrees).

Muscles Contributing to Shoulder Flexion: Anterior Deltoid

• Origin: Anterior lateral third of the clavicle.
• Insertion: Deltoid tuberosity on the lateral humerus.
• Action: Shoulder flexion.
• Nerve supply: Axillary nerve C5-C6.
• Palpation site: Inferior to the lateral third of the clavicle.

Muscles Contributing to Shoulder Flexion: Coracobrachialis

• Origin: Coracoid process of the scapula.
• Insertion: Middle 1/3 of the medial surface of the humerus.
• Action: Shoulder flexion.
• Nerve supply: Musculocutaneous nerve C5-C7.
• Palpation site: In the axilla, under inferior border of the pectoralis major muscle.

Secondary Movers

• Muscles: Middle deltoid, Pectoralis major, biceps brachii.

Normal and Good

• Position: Sitting, arm at side, slightly flexed elbow.
• Stabilization: Stabilize scapula.
• Palpation: Between lateral clavicle & coracoid process.
• Desired motion: Arm flexion to 90° (palm down).
• Subject directive: Hold arm up, prevent downward resistance.
• Resistance point: Above the elbow.
• Not allowing arm rotation/horizontal adduction/abduction.

Fair

• Technique: Same as normal and good, but without resistance.
• Image (diagram): depicts this technique.

Poor

• Position: Patient sitting, arm at side, elbow slightly flexed, supported by board/examiner.
• Stabilization: Stabilize scapula.
• Palpation: Between lateral clavicle and coracoid process
• Desired motion: Bring the arm forward for 90° of flexion.

Trace & Zero

• Position: Lying on back.
• Palpation: Examine fibers of anterior Deltoid on the shoulder joint; site: inferior to the lateral third of the clavicle.
• Palpation: Coracobrachialis fibers. Site: In the axilla, under the inferior border of the pectoralis major.

Substitutions

• Biceps brachii substitution: Arm flexion with initial external rotation.
• Substitutions with upper Trapezius or Pectoralis major: causes additional shoulder elevation or horizontal adduction; leaning backward or shoulder girdle elevation to assist in flexion.

Notes

• Range of motion: 0-180 and 0-40/60 degrees (from neutral).
• Limiting factors: Joint stiffness, latissimus dorsi tension, posterior deltoid and teres major tension, trapezius & serratus anterior muscle contraction.

Substitution

• Scapular elevation (Upper trapezius).
• Horizontal adduction (Pectoralis major).
• Lateral rotation (Biceps brachii).

Shoulder Extension

• Muscles: Latissimus dorsi, Teres Major, Teres Minor.
• Diagrams of muscles are given.

Extension

• ROM: 0-180 degrees, 0-40/60 degrees (from neutral).
• Patient instructions: Lifting the arm off the table as far as possible.

Starting Position

• Patient position: Prone, arm at side, palm facing body, slightly flexed elbow.
• Alignment: Fulcrum over the acromion process; stationary & moving arms aligned with the lateral humerus midline/lateral epicondyle.

Ending Position

• Moving arm: In line with the lateral epicondyle and midline of the humerus.
• Stationary arm: In alignment with the thorax's midline.
• Glenohumeral range of extension: 40-60 degrees(image shows 61°).

Muscles Contributing to Shoulder Extension: Latissimus Dorsi

• Origin: Spines of lower 6 thoracic and lumbar vertebrae, posterior sacrum, crest of ileum, lower 3-4 ribs
• Insertion: Intertubercular groove of the humerus.
• Action: Shoulder extension.
• Nerve supply: Thoracodorsal nerve C6-C8.
• Palpation: Along midaxillary line on the trunk.

Muscles Contributing to Shoulder Extension: Posterior deltoid

• Origin: Posterior border of scapular spine.
• Insertion: Deltoid tuberosity on the lateral humerus.
• Nerve supply: Axillary nerve C5-C6.
• Palpation: Inferior & lateral to spine of scapula.

Muscles Contributing to Shoulder Extension: Teres Major

• Origin: Lower 1/3 of axillary border of scapula.
• Insertion: Medial lip of intertubercular groove of humerus.
• Action: Shoulder extension.
• Nerve supply: Subscapular nerve C5-C6.
• Palpation: Lateral to inferior angle of scapula.

Muscles Contributing to Shoulder Extension: Teres Minor

• Origin: Posterior scapula (upper & middle aspect of lateral border).
• Insertion: Greater tubercle of humerus.
• Action: Shoulder extension, external rotation.
• Nerve supply: Axillary nerve C5, C6.
• Palpation: Lateral scapula border, superior to inferior angle.

Secondary Movers

• Long head of the triceps brachii.

Normal & Good

• Position: Prone, arm medially rotated & abducted (palm up).
• Stabilization: Stabilize scapula.
• Motion: Patient extends arm through ROM.
• Subject directive: "Lift your arm toward ceiling, don't let me push down."
• Resistance: Proximal to the elbow.

Fair

• Position: Prone, arm at side.
• Stabilization: Stabilize scapula.
• Motion: Patient extends arm through ROM.
• Subject directive: "Lift your arm toward the ceiling, don't let me push it down."

Poor

• Position: Sideling, arm flexed, supported by a board/examiner.
• Stabilization: Stabilize scapula.
• Motion: Patient extends arm in position of medial rotation.

Trace & Zero

• Position: Prone.
• Palpation: Teres major fibers (lower part of axillary border of scapula), Latissimus dorsi (slightly below).

The Latissimus Dorsi

• Palpation: Along midaxillary line on the trunk, inferior & lateral to the scapula's lower angle.
• Action: Shoulder extension.

Note

• ROM: 180 to 0 degrees, 40-60 degrees (from neutral).
• Factors limiting motion: Shoulder flexor muscle tension, greater tubercle of humerus contacting acromion posteriorly.
• Fixation: Rhomboideous major & minor and trapezius muscle contraction, trunk weight.

Substitution

• Trunk lifting/rotation.
• Shoulder shrugging (scapular adduction), downward motion (rotation).

Effect of Weakness

• Latissimus dorsi weakness: Decreased shoulder extension & lateral trunk flexion.
• Posterior deltoid weakness: Decreased shoulder extension & internal rotation.
• Teres major weakness: Decreased shoulder extension.

N.B.

• Latissimus dorsi: Powerful shoulder extensor, important in climbing, walking with crutches, and between parallel bars.
• Activity: Involved in swimming, rowing/paddling, and chopping movements.
• Accessory muscle: Respiratory support.
• Teres major: Also called "little latissimus," pulls the humerus downward during abduction.

Shoulder Horizontal Abduction

• Muscle: Deltoid (posterior portion).

Range of motion (ROM)

• 0–45 degrees (from neutral).
• 0-135 degrees (from complete horizontal abduction to complete horizontal adduction).

Preferred Starting Position

• Sitting, shoulder in neutral rotation, abducted to 90 degrees, elbow flexed to 90 degrees.

End Position

• Shoulder in maximal horizontal abduction, scapula fully adducted.

Goniometric Alignment

• Axis: Superior aspect of acromion process through the humerus head.
• Stationary arm: Along the shoulder's midline, close to the neck base.
• Moving arm: Along the humeral shaft midline, close to the lateral epicondyle.

Stabilization

• Stabilize the thorax against a chair to prevent trunk rotation.

Substitutions

• Subject attempts for trunk rotation to increase movement.
• Elbow extension & scapular elevation.

Muscles Contributing to Shoulder Horizontal Abduction: Deltoid (posterior portion)

• Origin: Inferior edge of scapular spine.
• Insertion: Deltoid tuberosity on humerus.
• Action: Shoulder horizontal abduction.
• Nerve supply: Axillary nerve C5-C6.
• Palpation: Inferior and lateral to the spine of the scapula.

Secondary Movers

• Long head of the triceps brachii.

Normal & Good

• Position: Prone, shoulder abducted to 90°, upper arm on table, lower arm vertically over the edge.
• Stabilization: Scapula in adduction.
• Motion: Horizontal abduction of humerus to table level (90°).
• Subject directive: "Lift elbow toward ceiling, don't let me push down."
• Resistance: Proximal to the elbow.
• Motion primarily at glenohumeral joint, not between scapula & thorax.

Fair

• Position: Prone, shoulder abducted to 90°, upper arm on table, lower arm vertically over the edge.
• Stabilization: Stabilize scapula.
• Motion: Patient abducts upper arm through ROM.
• Subject directive: "Lift elbow toward ceiling, don't let me push down."

Poor

• Position: Sitting, arm supported in 90° of flexion.
• Stabilization: Stabilize scapula.
• Motion: Patient horizontally abducts arm through ROM.

Trace & Zero

• Palpation: Posterior Deltoid fibers on the posterior shoulder joint.

Note

• Factors limiting motion: Anterior capsule, pectoralis major & anterior deltoid tension.
• Fixation: Rhomboids major & minor, trapezius (primarily middle & lower fibers).
• Substitutions: Scapula adduction with trapezius, long head of triceps, teres major, latissimus dorsi.

Explore the essential concepts of goniometry and its applications in measuring joint motion. This quiz covers key aspects such as positioning, arm alignment, and the significance of tracking joint mobility in patients with chronic conditions. Test your knowledge on the proper techniques and purposes of joint measurement.