Measurement of Joint Motion - A Guide to Goniometry PDF

 Fifth Edition MEASUREMENT OF JOINT MOTION...

 Fifth Edition MEASUREMENT OF JOINT MOTION A GUIDE TO GONIOMETRY Cynthia C. Norkin, PT, EdD Associate Professor Emerita Division of Physical Therapy College of Health Sciences and Professions Ohio University Athens, Ohio D. Joyce White, PT, DSc Associate Professor Department of Physical Therapy College of Health Sciences University of Massachusetts Lowell Lowell, Massachusetts Photographs by Jason Torres, Jocelyn Greene Molleur, and Lucia Grochowska Littlefield Illustrations by Timothy Wayne Malone and Graphic World Illustration Services F. A. DAVIS COMPANY Philadelphia 4566_Norkin_FM.indd i 14/10/16 9:46  F. A. Davis Company 1915 Arch Street Philadelphia, PA 19103 www.fadavis.com Copyright © 2016 by F. A. Davis Company Copyright © 2016 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. Printed in the United States of America Last digit indicates print number: 10 9 8 7 6 5 4 3 2 1 Senior Acquisitions Editor: Melissa Duffield Editor in Chief: Margaret Biblis Director of Content Development: George W. Lang Developmental Editor: Laura S. Horowitz, York Content Development Art and Design Manager: Carolyn O’Brien 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 information (package inserts) for changes and new information regarding dose and contraindications before administering any drug. Caution is especially urged when using new or infrequently ordered drugs. Library of Congress Cataloging-in-Publication Data Names: Norkin, Cynthia C., author. | White, D. Joyce, author. Title: Measurement of joint motion : a guide to goniometry / Cynthia C. Norkin, D. Joyce White; photographs by Jason Torres, Jocelyn Greene Molleur, and Lucia Grochowska Littlefield; technical advisor, George Kalem, III ; illustrations by Timothy Wayne Malone. Description: Fifth edition. | Philadelphia : F.A. Davis Company, | Includes bibliographical references and index. Identifiers: LCCN 2016026126 | ISBN 9780803645660 | ISBN 080364566X Subjects: | MESH: Arthrometry, Articular—methods | Joints—physiology | Joint Diseases—diagnosis Classification: LCC RD734 | NLM WE 300 | DDC 612.7/5—dc23 LC record available at https://lccn.loc.gov/2016026126 Authorization to photocopy items for internal or personal use, or the internal or personal use of specific clients, is granted by F. A. Davis Company for users registered with the Copyright Clearance Center (CCC) Transactional Reporting Service, provided that the fee of $.25 per copy is paid directly to CCC, 222 Rosewood Drive, Danvers, MA 01923. For those organizations that have been granted a photocopy license by CCC, a separate system of payment has been arranged. The fee code for users of the Transactional Reporting Service is: 8036-2066/09 0 + $.25. 4566_Norkin_FM.indd ii 14/10/16 9:46  Preface The measurement of joint motion is an important compo- provided and updated with each edition. Current evidence of nent of a thorough physical examination of the extremities the effects on range of motion of an individual’s characteris- and spine, one which helps health professionals determine tics such as age, gender, body mass, and recreational/occupa- function, identify impairments, and assess rehabilitative sta- tional activities, as well as the effects of the testing process tus. The need for a comprehensive text with sufficient writ- such as testing position and type of measuring instrument ten detail and photographs to allow for the standardization of have been consistently included in each edition. In this man- goniometric measurement methods—both for the purposes of ner, clinicians have been supported in their efforts to integrate teaching and clinical practice—led to the development of the evidence-based practice as they determine an individual’s first edition of the Measurement of Joint Motion: A Guide to impairments and set rehabilitative goals. Goniometry in 1985. Our approach included a discussion and We have made some changes in the fifth edition as part photographs of testing position, stabilization, end-feel, and of our ongoing search for ways to present current informa- goniometer alignment for each measurable joint in the body. tion in an easily accessible format. New tables and text have The resulting text was extremely well received by a variety of been added that summarize up-to-date research findings on health professional educational programs and was used as a the reliability of the assessment of joint motion with universal reference in many clinical settings and research studies. goniometers and, where appropriate, inclinometers and smart Subsequent editions were expanded to include muscle phone applications. For the first time, these tables include length testing at joints where muscle length is often a fac- absolute measures of reliability such as standard error of tor affecting range of motion. This addition integrated the measurement (SEM) and minimal detectable change (MDC) measurement procedures used in this book with the Ameri- that allow clinicians to estimate their measurement error to can Physical Therapy Association’s Guide to Physical Ther- decide whether changes in range of motion values reflect real apy Practice. Illustrations and anatomical descriptions were changes in their patients. Two exercises have been added to added so that the reader had a visual reminder of the joint Chapter 3 that will help the reader understand and apply these structures and muscles involved in range of motion. Informa- statistical tests. Extensive new tables have been included that tion on osteokinematics, arthrokinematics, and capsular and make it easy to find current research results on joint motions noncapsular patterns of limitation was included. Illustrations needed to perform a wide variety of functional tasks. Sum- of bony anatomical landmarks and photographs of surface mary Guides for each joint that include essential information anatomy were added to help the reader align the goniometer about testing positions, stabilization, and goniometer and/ accurately. Inclinometer techniques for measuring range of or inclinometer placement can be quickly located in a new motion of the spine and some alternative positions and align- Appendix B. In addition, readers will benefit from the more ments for goniometric measurement of the range of motion of than 80 new photographs and illustrations that are included to certain extremity joints were presented to coincide with cur- better explain concepts and enhance learning. rent practice in some clinical settings. In spite of the many changes over the years, this book In the years following initial publication, a consider- continues to present goniometry logically and clearly. Chap- able amount of research on the measurement of joint motion ter 1 discusses basic concepts regarding the use of goniom- appeared in the literature. Consequently, later editions have etry to assess range of motion and muscle length in patient included a chapter on the reliability and validity of joint mea- evaluation. Arthrokinematic and osteokinematic movements, surement, as well as joint-specific research sections in each elements of active and passive range of motion, hypomo- chapter that focus on measurement procedures. Research bility, hypermobility, and factors affecting joint motion are findings to establish normative range-of-motion values and included. The inclusion of end-feels and capsular and noncap- the motion needed for a variety of functional tasks have been sular patterns of joint limitation introduces readers to current iii 4566_Norkin_FM.indd iii 14/10/16 9:46  iv Preface concepts in orthopedic manual therapy and encourages them position, stabilization, testing motion, normal end-feel, and to consider joint structure and muscle length while measuring goniometer alignment for each joint and motion follows in joint motion. a format that reinforces a consistent approach to evaluation. Chapter 2 takes the reader through a step-by-step process The extensive use of photographs, illustrations, and captions to master the techniques of goniometric evaluation including eliminates the need for repeated demonstrations by an instruc- positioning, stabilization, instruments used for measurement, tor and provides the reader with a permanent reference for goniometer alignment, and the recording of results. Exercises visualizing the procedures. At the end of each chapter there that help develop necessary psychomotor skills and demon- is a review of current literature regarding normal range of strate direct application of theoretical concepts facilitate motion values; the effects of age, gender, and other factors learning. on range of motion; functional range of motion; and the reli- Chapter 3 discusses the validity and reliability of mea- ability and validity of measurement procedures. This structure surement. The results of the most contemporary validity and makes it easy for readers who are focused on learning mea- reliability studies on the measurement of joint motion are surement techniques, as well as readers who are focused on summarized to help the reader focus on ways of improving reviewing the research literature for evidence-based practice, and interpreting goniometric measurements. Mathematical to find what they are seeking. methods of evaluating reliability are shown along with exam- We believe that the fifth edition provides a comprehen- ples and exercises so that the reader can assess their reliability sive coverage of the clinical measurement of joint motion and in taking measurements. muscle length that supports evidence-based practice. We hope Chapters 4 through 13 present detailed information on that this book will make the teaching and learning of goni- goniometric testing procedures for the upper and lower extrem- ometry easier and improve the standardization and thus the ities, spine, and temporomandibular joint. When appropriate, reliability and validity of this examination tool. Readers are muscle length testing procedures are also included. In each encouraged to provide us with feedback on our current efforts chapter, a logical sequence progresses from an overview of to bring you a high-quality, user-friendly text. joint structures, osteokinematic and arthrokinematic motions, and capsular patterns of limitation to specific measurement CCN procedures. Information on anatomical landmarks, testing DJW 4566_Norkin_FM.indd iv 14/10/16 9:46  Contributing Authors Erin Hartigan, PT, DPT, PhD, OCS, ATC David A. Scalzitti, PT, PhD Associate Professor Assistant Professor Physical Therapy Department Program in Physical Therapy University of New England George Washington University Portland, Maine Washington, DC Reviewers Becca D. Jordre, PT, DPT, GCS Mary T. Marchetti, PT, PhD, GCS Associate Professor Assistant Professor Physical Therapy Department Physical Therapy Department The University of South Dakota Duquesne University Vermillion, South Dakota Pittsburgh, Pennsylvania Heather MacKrell, PT, PhD Rebecca A Reisch, PT, PhD, DPT, OCS Physical Therapist Assistant Program Director Associate Professor Health Sciences Department Physical Therapy Department Calhoun Community College Pacific University Tanner, Alabama Hillsboro, Oregon Jill Manners, MS, MPT, LAT, ATC, PT Kimberly Varnado, PT, DPT, OCS, FAAOMPT Program Director and Professor Assistant Professor Athletic Training Education Program Physical Therapy Department Western Carolina University Midwestern University Cullowhee, North Carolina Glendale, Arizona v 4566_Norkin_FM.indd v 14/10/16 9:46 4566_Norkin_FM.indd vi 14/10/16 9:46  Acknowledgments We are very grateful for the contributions of the many people the photographs or provided painstaking research support for who were involved in the development and production of Mea- the fifth edition. surement of Joint Motion. We wish to thank David Scalzitti We wish to express our appreciation to these dedicated and Erin Hartigan who added their considerable expertise as professionals at F. A. Davis: Margaret Biblis, Editor in Chief, researchers and educators to update Chapter 3: Validity and Melissa Duffield, Senior Acquisitions Editor, and Laura Reliability of Goniometric Measurement, and Chapter 8: Horowitz, Developmental Editor, for their encouragement The Hip, respectively. Photographer Jason Torres of J. Tor- and commitment to excellence. Our thanks are also extended res Photography in New York used his skills and experience to George Lang, Director of Content Development; Jennifer to produce the new high-quality photographs that appear in Pine, Manager of Developmental Editing; Cindy Breuninger, this fifth edition. We are appreciative of the access provided Managing Editor; Sharon Lee, Production Manager; Caro- by the University of Massachusetts Lowell to take these pho- lyn O’Brien, Manager of Art and Design; Daniel Domzalski, tographs in the teaching laboratories of the Department of Illustration Coordinator; Elizabeth Stepchin, Project Editor; Physical Therapy. The late Jocelyn Molleur, who assiduously Nichole Liccio, Administrative Assistant; and Marsha Hall, took the photographs for the third and fourth editions, and Project Manager, Progressive Publishing Services. We are Lucia Grochowska Littlefield, who produced the photographs very grateful to the numerous, faculty, students, and clini- for the first and second editions, are also responsible for this cians who over the years have used the book or formally important feature of the book. Timothy Malone, an artist from reviewed portions of the manuscript and offered insight- Ohio, used his talents and knowledge of anatomy to create ful comments and helpful suggestions that have improved the excellent illustrations that appear in this as well as past this text. editions. We also offer our thanks to colleagues Erika Lewis Finally, we wish to thank our families: Cynthia’s daugh- and Kyle Coffey, as well as Jessica LeBlanc, Conor Norden- ter, Alexandra, and her daughters, Taylor and Kimberly; and gren, Samantha Rollings, Rachel Blakeslee, Chris Fournier, Joyce’s husband, Jonathan, and sons, Alexander and Ethan, Colleen DeCotret, Rebecca D’Amour, Alexander White, and for their continuing encouragement and support. We will Claudia Van Bibber, who graciously agreed to participate in always be appreciative. vii 4566_Norkin_FM.indd vii 14/10/16 9:46 4566_Norkin_FM.indd viii 14/10/16 9:46  About the Authors Dr. Cynthia C. Norkin is Dr. D. Joyce White is Associate Professor Emerita, Associate Professor, Depart- School of Physical Therapy, ment of Physical Therapy, Ohio University. She holds University of Massachusetts a Doctorate of Education Lowell. She holds a Doctor- degree and an Advanced ate of Science degree in Epi- Master of Science in Phys- demiology and an Advanced ical Therapy degree from Master of Science degree in Boston University, a Bach- Physical Therapy from Bos- elor of Science degree from ton University, and a Bach- Tufts University, and Cer- elor of Science degree in tificate in Physical Ther- Physical Therapy from the apy from the Bouvé-Boston University of Connecticut. School. She founded the School of Physical Therapy at Ohio Dr. White’s research, teaching, and clinical experience have University and served as Director for 11 years. Previously, predominantly focused on the assessment, treatment, and con- she spent 10 years at Boston University as an Assistant Pro- tributing causes of musculoskeletal conditions of the upper fessor of Physical Therapy, Sargent College, where she and and lower extremities. She has authored research articles and Dr. White initially wrote Measurement of Joint Motion: A book chapters, and presented numerous conference papers in Guide to Goniometry. Dr. Norkin is the co-editor and contrib- these areas. The American Physical Therapy Association has uting author of the book Joint Structure and Function: A Com- presented her with the Dorothy Briggs Memorial Scientific prehensive Analysis, currently in its fifth edition. Inquiry Award. Dr. White is a recipient of the University of Massachusetts Lowell Award for Teaching Excellence where she has taught for over 25 years. She has also held academic appointments at Boston University, Sargent College. ix 4566_Norkin_FM.indd ix 14/10/16 9:46 4566_Norkin_FM.indd x 14/10/16 9:46  Brief Contents PART I INTRODUCTION TO PART IV TESTING OF THE SPINE GONIOMETRY AND MUSCLE LENGTH AND TEMPOROMANDIBULAR TESTING, 1 JOINT, 409 Chapter 1 Basic Concepts, 3 Chapter 11 The Cervical Spine, 411 Chapter 2 Procedures, 19 Chapter 12 The Thoracic and Lumbar Spine, 469 Chapter 3 Validity and Reliability of Goniometric Measurement, 43 Chapter 13 The Temporomandibular Joint, 519 PART II UPPER-EXTREMITY TESTING, 65 APPENDIXES Chapter 4 The Shoulder, 66 A: Normative Range of Motion Values, 537 Chapter 5 The Elbow and Forearm, 115 B: Summary Guides for Measuring Range of Motion, 543 Chapter 6 The Wrist, 149 C: Joint Measurements by Body Position, 553 Chapter 7 The Hand, 187 D: Numerical Recording Forms, 555 PART III LOWER-EXTREMITY TESTING, 253 Index, 561 Chapter 8 The Hip, 255 Chapter 9 The Knee, 315 Chapter 10 The Ankle and Foot, 345 xi 4566_Norkin_FM.indd xi 14/10/16 9:46 4566_Norkin_FM.indd xii 14/10/16 9:46  Contents PART I INTRODUCTION TO Gravity-Dependent Goniometers GONIOMETRY AND MUSCLE LENGTH (Inclinometers), 31 TESTING, 1 EXERCISE 4: Inclinometers, 33 EXERCISE 5: Inclinometer Alignment for Chapter 1 Basic Concepts, 3 Cervical Rotation, 33 D. Joyce White, PT, DSc; Cynthia C. Norkin, PT, EdD Electrogoniometers, 34 Goniometry, 3 Radiography, 34 Kinematics, 4 Photography, 34 Arthrokinematics, 4 Smartphones, 34 Osteokinematics, 5 Visual Estimation, 34 Planes and Axes, 6 Recording, 35 Range of Motion, 7 Numerical Tables, 36 Active Range of Motion, 8 Pictorial Charts, 37 Passive Range of Motion, 8 Sagittal–Frontal–Transverse–Rotation (SFTR) Hypomobility, 10 Method of Recording, 37 Hypermobility, 12 American Medical Association Guides to Factors Affecting Range of Motion, 13 Evaluation of Permanent Impairment Muscle Length Testing, 14 Method, 38 Procedures, 38 Chapter 2 Procedures, 19 Precautions to Range of Motion and Muscle Cynthia C. Norkin, PT, EdD; D. Joyce White, PT, DSc Length, 38 Positioning, 19 Preparation for Testing, 38 Stabilization, 22 Explanation of Procedure, 39 EXERCISE 1: Determining the End of the Testing Procedure, 39 Range of Motion and End-Feel, 23 EXERCISE 6: Explanation of Goniometric Measurement Instruments, 24 Testing Procedure, 40 Universal Goniometer, 24 EXERCISE 7: Testing Procedure for EXERCISE 2: The Universal Goniometer, 30 Goniometric Measurement of Elbow EXERCISE 3: Goniometer Alignment for Flexion ROM, 40 Elbow Flexion, 30 xiii 4566_Norkin_FM.indd xiii 14/10/16 9:46  xiv Contents Chapter 3 Validity and Reliability of Research Findings, 92 Goniometric Measurement, 43 Effects of Age, Gender, and Other David A. Scalzitti, PT, PhD; D. Joyce White, PT, DSc Factors, 92 Validity, 43 Functional Range of Motion, 97 Face Validity, 43 Reliability and Validity, 100 Content Validity, 43 Chapter 5 The Elbow and Forearm, 115 Criterion-Related Validity, 43 D. Joyce White, PT, DSc; Cynthia C. Norkin, PT, EdD Construct Validity, 45 Structure and Function, 115 Reliability, 45 Humeroulnar and Humeroradial Joints, 115 Summary of Goniometric Reliability Studies, 45 Superior and Inferior Radioulnar Joints, 116 Statistical Methods of Evaluating Range of Motion Testing Procedures, 118 Measurement Reliability, 47 Landmarks for Testing Procedures, 118 Exercises to Evaluate Reliability, 54 Elbow Flexion, 120 EXERCISE 8: Intratester Reliability, 54 Elbow Extension, 122 EXERCISE 9: Intertester Reliability, 56 Forearm Pronation, 122 EXERCISE 10: Calculation of the Standard Forearm Supination, 124 Error of Measurement and Minimal Muscle Length Testing Procedures, 126 Detectable Change, 58 Landmarks for Testing Procedures, 126 EXERCISE 11: Calculation of the Pearson Elbow Flexors, 126 Product-Moment Correlation Coefficient, Biceps Brachii Muscle Length Test, 127 Standard Error of Measurement, and Elbow Extensors, 128 Minimal Detectable Change, 60 Long Head of the Triceps Brachii Muscle Length Test, 128 PART II UPPER-EXTREMITY Research Findings, 130 TESTING, 65 Effects of Age, Gender, and Other Factors, 130 Chapter 4 The Shoulder, 66 Functional Range of Motion, 133 D. Joyce White, PT, DSc Reliability and Validity, 137 Structure and Function, 66 Shoulder Complex, 66 Chapter 6 The Wrist, 149 Glenohumeral Joint, 66 D. Joyce White, PT, DSc Sternoclavicular Joint, 67 Structure and Function, 149 Acromioclavicular Joint, 68 Radiocarpal and Midcarpal Joints, 149 Scapulothoracic Joint, 69 Range of Motion Testing Procedures, 151 Range of Motion Testing Procedures, 70 Landmarks for Testing Procedures, 151 Landmarks for Testing Procedure, 70 Wrist Flexion, 153 Flexion, 72 Wrist Extension, 156 Extension, 76 Wrist Radial Deviation, 159 Abduction, 80 Wrist Ulnar Deviation, 161 Adduction, 84 Muscle Length Testing Procedures, 163 Medial (Internal) Rotation, 84 Landmarks for Testing Procedures, 163 Lateral (External) Rotation, 88 Wrist Flexors, 163 4566_Norkin_FM.indd xiv 14/10/16 9:46  Contents xv The Flexor Digitorum Profundus and Flexor Thumb: Metacarpophalangeal Flexion, 222 Digitorum Superficialis Muscle Thumb: Metacarpophalangeal Extension, 224 Length Test, 164 Thumb: Interphalangeal Flexion, 225 Wrist Extensors, 167 Thumb: Interphalangeal Extension, 227 The Extensor Digitorum, Extensor Indicis, Muscle Length Testing Procedures: and Extensor Digiti Minimi Muscle Length Fingers, 228 Test, 168 Landmarks for Testing Procedures, 228 Research Findings, 170 Metacarpophalangeal Flexors, 228 Effects of Age, Gender, and Other Factors, 170 Lumbricals, Palmar Interossei, and Dorsal Functional Range of Motion, 173 Interossei Muscle Length Test, 230 Reliability and Validity, 178 Research Findings, 233 Effects of Age, Gender, and Other Chapter 7 The Hand, 187 Factors, 233 D. Joyce White, PT, DSc Functional Range of Motion, 236 Structure and Function, 187 Reliability and Validity, 239 Fingers: Metacarpophalangeal Joints, 187 Fingers: Proximal Interphalangeal and Distal PART III LOWER-EXTREMITY Interphalangeal Joints, 188 TESTING, 253 Thumb: Carpometacarpal Joint, 188 Thumb: Metacarpophalangeal Joint, 189 Chapter 8 The Hip, 255 Thumb: Interphalangeal Joint, 190 Erin Hartigan, PT, DPT, PhD, OCS, ATC; D. Joyce White, PT, DSc Range of Motion Testing Procedures: Structure and Function, 255 Fingers, 191 Iliofemoral Joint, 255 Landmarks for Testing Procedures, 191 Range of Motion Testing Procedures, 256 Fingers: Metacarpophalangeal (MCP) Landmarks for Testing Procedures, 256 Flexion, 192 Hip Flexion, 258 Fingers: Metacarpophalangeal Extension, 194 Hip Extension, 260 Fingers: Metacarpophalangeal Abduction, 197 Hip Abduction, 262 Fingers: Metacarpophalangeal Adduction, 199 Hip Adduction, 264 Fingers: Proximal Interphalangeal Flexion, 199 Hip Medial (Internal) Rotation, 266 Fingers: Proximal Interphalangeal Extension, 201 Hip Lateral (External) Rotation, 268 Fingers: Distal Interphalangeal Flexion, 202 Muscle Length Testing Procedures, 270 Fingers: Distal Interphalangeal Extension, 204 Landmarks for Testing Procedures, 270 Fingers: Composite Flexion of the MCP, PIP, Hip Flexors, 270 and DIP Joints, 205 Thomas Test, 272 Range of Motion Testing Procedures: Hip Extensors, 278 Thumb, 206 Straight Leg Raising (SLR) Test, 279 Landmarks for Testing Procedures, 206 Hip Abductors, 283 Thumb: Carpometacarpal Flexion, 208 Ober Test, 283 Thumb: Carpometacarpal Extension, 211 Modified Ober Test, 287 Thumb: Carpometacarpal Abduction, 214 Research Findings, 288 Thumb: Carpometacarpal Adduction, 216 Effects of Age, Gender, and Other Factors, 288 Thumb: Carpometacarpal Opposition, 216 Functional Range of Motion, 294 4566_Norkin_FM.indd xv 14/10/16 9:46  xvi Contents Reliability and Validity of Hip Range of Talocrural Joint: Dorsiflexion, 352 Motion Measurements, 296 Talocrural Joint: Plantarflexion, 355 Reliability and Validity of Muscle Length Landmarks for Testing Procedures: Tarsal Testing, 303 Joints, 357 Tarsal Joints: Inversion, 358 Chapter 9 The Knee, 315 Tarsal Joints: Eversion, 360 Cynthia C. Norkin, PT, EdD Landmarks for Testing Procedures: Subtalar Structure and Function, 315 Joint (Rearfoot), 363 Tibiofemoral and Patellofemoral Joints, 315 Subtalar Joint (Rearfoot): Inversion, 364 Range of Motion Testing Procedures, 317 Subtalar Joint (Rearfoot): Eversion, 366 Landmarks for Testing Procedures, 317 Transverse Tarsal (Midtarsal) Joint: Inversion, 368 Knee Flexion, 318 Transverse Tarsal (Midtarsal) Joint: Eversion, 370 Knee Extension, 320 Landmarks for Testing Procedures: Knee Rotation, 320 Metatarsophalangeal and Interphalangeal Muscle Length Testing Procedures, 321 Joints, 372 Landmarks for Testing Procedures, 321 Metatarsophalangeal Joint: Flexion, 374 Knee Extensors, 321 Metatarsophalangeal Joint: Extension, 376 Ely Test, 322 Metatarsophalangeal Joint: Abduction, 378 Knee Flexors, 325 Metatarsophalangeal Joint: Adduction, 379 Distal Hamstring Length Test, 326 Interphalangeal Joint of the First Toe and Research Findings, 329 Proximal Interphalangeal Joints of the Effects of Age, Gender, and Other Factors, 329 Four Lesser Toes: Flexion, 380 Functional Range of Motion, 332 Interphalangeal Joint of the First Toe and Reliability and Validity of Range of Motion Proximal Interphalangeal Joints of the Measurement, 335 Four Lesser Toes: Extension, 380 Reliability and Validity of Muscle Length Distal Interphalangeal Joints of the Four Testing, 341 Lesser Toes: Flexion, 381 Distal Interphalangeal Joints of the Four Chapter 10 The Ankle and Foot, 345 Lesser Toes: Extension, 381 D. Joyce White, PT, DSc Muscle Length Testing Procedures, 382 Structure and Function, 345 Landmarks for Testing Procedures, 382 Proximal and Distal Tibiofibular Joints, 345 Ankle Plantarflexors, 382 Talocrural Joint, 345 Gastrocnemius Muscle Length Test: Supine Subtalar Joint, 347 Non-Weight-Bearing, 382 Transverse Tarsal (Midtarsal) Joint, 348 Gastrocnemius Muscle Length Test: Standing Tarsometatarsal Joints, 349 Weight-Bearing, 385 Metatarsophalangeal Joints, 349 Research Findings, 387 Interphalangeal Joints, 350 Effects of Age, Gender, and Other Factors, 387 Range of Motion Testing Procedures, 351 Functional Range of Motion, 393 Landmarks for Testing Procedures: Talocrural Reliability and Validity, 396 Joint, 351 4566_Norkin_FM.indd xvi 14/10/16 9:46  Contents xvii PART IV TESTING OF THE SPINE Chapter 12 The Thoracic and Lumbar AND TEMPOROMANDIBULAR Spine, 469 JOINT, 409 Cynthia C. Norkin, PT, EdD Structure and Function, 469 Chapter 11 The Cervical Spine, 411 Thoracic Spine, 469 Cynthia C. Norkin, PT, EdD Lumbar Spine, 470 Structure and Function, 411 Range of Motion Testing Procedures, 472 Atlanto-Occipital and Atlantoaxial Landmarks for Testing Procedures, 472 Joints, 411 Thoracolumbar Flexion, 473 Intervertebral and Zygapophyseal (Facet) Thoracolumbar Flexion: Tape Measure, 474 Joints, 413 Thoracolumbar Flexion: Fingertip-to-Floor, 475 Range of Motion Testing Procedures, 415 Thoracolumbar Flexion: Double Landmarks for Testing Procedures, 415 Inclinometers, 476 Cervical Flexion: Universal Goniometer, 418 Thoracolumbar Extension, 477 Cervical Flexion: Tape Measure, 420 Thoracolumbar Extension: Tape Measure, 478 Cervical Flexion: Double Inclinometers, 422 Thoracolumbar Extension: Prone Push-Up, 479 Cervical Flexion: Single Inclinometer, 423 Thoracolumbar Extension: Double Cervical Flexion: Cervical Range of Motion Inclinometers, 480 Device, 424 Thoracolumbar Lateral Flexion, 481 Cervical Extension: Universal Goniometer, 426 Thoracolumbar Lateral Flexion: Universal Cervical Extension: Tape Measure, 428 Goniometer, 482 Cervical Extension: Double Inclinometers, 429 Thoracolumbar Lateral Flexion: Cervical Extension: Single Inclinometer, 430 Fingertip-to-Floor, 483 Cervical Extension: CROM Device, 432 Thoracolumbar Lateral Flexion: Cervical Lateral Flexion: Universal Fingertip-to-Thigh, 484 Goniometer, 434 Thoracolumbar Lateral Flexion: Double Cervical Lateral Flexion: Tape Measure, 436 Inclinometers, 486 Cervical Lateral Flexion: Double Thoracolumbar Rotation, 487 Inclinometers, 437 Thoracolumbar Rotation: Universal Cervical Lateral Flexion: Single Goniometer, 487 Inclinometer, 438 Thoracolumbar Rotation: Double Cervical Lateral Flexion: CROM Device, 439 Inclinometers, 489 Cervical Rotation: Universal Goniometer, 440 Lumbar Flexion, 490 Cervical Rotation: Tape Measure, 442 Lumbar Flexion: Modified-Modified Cervical Rotation: Single Inclinometer, 442 Schober Test (MMST) or Simplified Skin Cervical Rotation: CROM Device, 444 Distraction Test, 490 Research Findings, 445 Lumbar Flexion: Double Inclinometers, 492 Effects of Age, Gender, and Other Lumbar Flexion: Single Inclinometer, 493 Factors, 445 Lumbar Extension, 495 Functional Range of Motion, 452 Lumbar Extension: Modified-Modified Reliability and Validity, 454 Schober Test or Simplified Skin Attraction Test, 495 4566_Norkin_FM.indd xvii 14/10/16 9:46  xviii Contents Lumbar Extension: Double Inclinometers, 496 Overbite, 526 Lumbar Extension: Single Inclinometer, 497 Protrusion of the Mandible, 527 Lumbar Lateral Flexion, 499 Lateral Excursion of the Mandible, 528 Lumbar Lateral Flexion: Double Research Findings, 530 Inclinometers, 500 Effects of Age, Gender, and Other Lumbar Lateral Flexion: Single Factors, 530 Inclinometer, 501 Reliability and Validity, 533 Research Findings, 503 Effects of Age, Gender, and Other Factors, 503 APPENDIXES Functional Range of Motion, 507 Reliability and Validity, 509 A: Normative Range of Motion Values, 537 Chapter 13 The Temporomandibular B: Summary Guides for Measuring Range Joint, 519 of Motion, 543 Cynthia C. Norkin, PT, EdD C: Joint Measurements by Body Position, 553 Structure and Function, 519 Temporomandibular Joint, 519 D: Numerical Recording Forms, 555 Range of Motion Testing Procedures, 522 Landmarks for Testing Procedures, 522 Depression of the Mandible (Mouth Index, 561 Opening), 522 4566_Norkin_FM.indd xviii 14/10/16 9:46  I PA R T INTRODUCTION TO GONIOMETRY AND MUSCLE LENGTH TESTING This book is designed to serve as a guide for learning how to instruments such as goniometers and inclinometers are intro- assess range of motion and muscle length. Part I presents the duced so that examiners become competent in their use. The background information on the principles and procedures nec- validity and reliability of goniometric measurements are essary for understanding goniometry. Practice exercises are explored to encourage thoughtful and appropriate use of these included at appropriate intervals to help the examiner apply techniques in clinical practice. Parts II through IV present the this information and develop the psychomotor skills neces- procedures for the examination of joint range of motion and sary for competency in measuring joint motion and muscle muscle length testing of the upper and lower extremities, the length. Different types of joint range-of-motion measuring spine, and temporomandibular joints. OBJECTIVES After completion of Part I, which includes chapters soft, firm, and hard end-feels on Basic Concepts, Procedures, and Validity and hypomobility and hypermobility Reliability, you will be able to: capsular and noncapsular patterns of restricted motion 1. Define: goniometer and inclinometer goniometry reliability and validity kinematics intratester and intertester reliability arthrokinematics face, content, criterion-related, and construct osteokinematics validity range of motion end-feel 4. Explain the importance of: muscle length testing testing positions reliability stabilization validity clinical estimates of range of motion palpation of bony landmarks 2. Identify the appropriate planes and axes for each recording starting and ending positions of the following motions: flexion–extension, abduction–adduction, and 5. Perform an evaluation of elbow joint motion, rotation including: a clear explanation of the procedure 3. Compare: proper placement of the individual in the active, active assistive, and passive ranges of recommended testing position motion adequate stabilization of the proximal joint arthrokinematic and osteokinematic motions component 4566_Norkin_Ch01_001_018.indd 1 10/8/16 12:50 PM  correct determination of the end of the range of 6. Give an example of a muscle length test. motion correct identification of the end-feel 7. Perform and interpret intratester and intertester palpation of the appropriate bony landmarks reliability tests, including standard deviation, accurate alignment of the goniometer coefficient of variation, correlation coefficients, correct reading of both the goniometer and the standard error of measurement, and minimal inclinometer, and recording of the measurements detectable change. 4566_Norkin_Ch01_001_018.indd 2 10/8/16 12:50 PM  1 CHAPTER Basic Concepts D. Joyce White, PT, DSc Cynthia C. Norkin, PT, EdD Goniometry Goniometry is an important part of a comprehensive examination of joints and surrounding soft tissue. A compre- hensive examination typically begins by interviewing the indi- The term goniometry is derived from two Greek words: vidual and reviewing records to obtain an accurate description gonia, meaning “angle,” and metron, meaning “measure.” of current symptoms; functional abilities and activities of daily Therefore, goniometry refers to the measurement of angles, in living; occupational, social, and recreational activities; and particular the measurement of angles created at human joints medical history. Observation of the individual’s body to assess by the bones of the body. The examiner obtains these mea- bone and soft tissue contour, as well as skin and nail condi- surements by placing the parts of the measuring instrument, tion, usually follows the interview. Gentle palpation is used to called a goniometer, along the bones immediately proximal determine skin temperature and the quality of soft tissue defor- and distal to the joint being evaluated. Goniometry may be mities and to locate pain symptoms in relation to anatomical used to determine both a particular joint position and the total structures. Anthropometric measurements such as leg length, amount of motion available at a joint. leg circumference, and body volume may be indicated. The performance of active joint motions by the individ- Example: The elbow joint is evaluated by placing the ual during the examination allows the examiner to screen for parts of the measuring instrument on the humerus abnormal movements and gain information about the indi- (proximal segment) and the forearm (distal segment) vidual’s willingness to move. If abnormal active motions and measuring either a specific joint position or the are found, the examiner performs passive joint motions in an total arc of motion (Fig. 1.1). attempt to determine reasons for joint limitation. Performing t FIGURE 1.1 The left upper en gm extremity of an individual in 145˚ ls e sta the supine position is shown. Di The parts of the measuring instrument have been placed along the proximal (humerus) and distal (radius) body segments and centered over the axis of the elbow joint. When the distal Proximal segment segment has been moved toward the proximal segment (elbow flexion), a measurement of the arc of motion can be obtained. 3 4566_Norkin_Ch01_001_018.indd 3 10/8/16 12:50 PM  4 PART I Introduction to Goniometry and Muscle Length Testing passive joint motions enables the examiner to assess the tissue a translatory motion, is the sliding of one joint surface over that is limiting the motion, detect pain, and make an estimate another, as when a braked wheel skids (Fig. 1.2). A spin of the amount of motion. Goniometry is used to measure and is a rotary motion, similar to the spinning of a toy top. All document the amount of active and passive joint motion as points on the moving joint surface rotate around a fixed axis well as abnormal fixed joint positions. of motion (Fig. 1.3). A roll is also a rotary motion, similar to Following the examination of active and passive range of the rolling of the bottom of a rocking chair on the floor or the motion, resisted isometric muscle contractions, joint integrity rolling of a tire on the road (Fig. 1.4). and mobility tests, and special tests for specific body regions In the human body, slides, spins, and rolls usually occur are used in conjunction with goniometry to help identify the in combination with one another and result in angular move- injured anatomical structures. Tests to assess muscle perfor- ment of the shafts of the bones. The combination of the sliding mance and neurological function are often included. Diagnos- and rolling is referred to as roll-gliding or roll-sliding4 and tic imaging procedures and laboratory tests may be needed. allows for increased motion at a joint by postponing the joint Functional outcome measures are often required for Medi- care, Medicaid, and health insurance documentation. Goniometric data used in conjunction with other informa- tion can provide a basis for the following: Determining the presence, absence, or change in impairment1 Establishing a diagnosis Developing a prognosis, treatment goals, and plan of care Evaluating progress or lack of progress toward rehabilita- tive goals Modifying treatment Motivating the individual Researching the effectiveness of therapeutic techniques or regimens (for example, measuring outcomes following exercises, medications, and surgical procedures) Fabricating orthotics and adaptive equipment FIGURE 1.2 A slide (glide) is a translatory motion in which the same point on the moving joint surface comes in Kinematics contact with new points on the opposing surface, and all the points on the moving surface travel the same amount of distance. Kinematics is the study of motion without regard for the forces that are creating the motion. When referring to the human body, kinematics describes the motion of bony segments including the type, direction, and magnitude of motion; loca- tion of the bony segment in space; and the rate of change or velocity of the segment. The three types of motion that a bony segment can undergo are translatory (linear displacement), Axis rotary (angular displacement), or more often a combination of translatory and rotary motion.2 In translatory motion, all points on a segment move in the same direction at the same time. In rotary motion, the bone spins around a fixed point. These three types of motion will be explained in more detail in the following subdivisions of kinematics: arthrokinematics and osteokinematics. In arthrokinematics, the focus is on how joint surfaces move and interact, whereas in osteokinematics, the focus is on movements of the shafts of bones. Arthrokinematics Motion at a joint occurs as the result of movement of one joint surface in relation to another joint surface. Arthroki- FIGURE 1.3 A spin is a rotary motion in which all the points on the moving surface rotate around a fixed central axis. nematics is the term used to refer to the movement of joint The points on the moving joint surface that are closer to the surfaces.3,4 The movements of joint surfaces are described as axis of motion will travel a smaller distance than the points slides (or glides), spins, and rolls. A slide (glide), which is farther from the axis. 4566_Norkin_Ch01_001_018.indd 4 10/8/16 12:50 PM  CHAPTER 1 Basic Concepts 5 TABLE 1.1 Arthrokinematic (Accessory/Joint Play) Joint Motion Grades Grade Joint Status 0 Ankylosed Axis Axis 1 Considerable hypomobility 2 Slight hypomobility 3 Normal 4 Slight hypermobility 5 Considerable hypermobility 6 Unstable FIGURE 1.4 A roll is a rotary motion in which new points on the moving joint surface come in contact with new points on the opposing surface. The axis of rotation has also moved, in this case to the right. subjectively compared with the same motion on the contra- lateral side of the body or with an examiner’s past experience testing people of similar age and gender as the individual. compression and separation that would occur at either side of An ordinal grading scale of 0 to 6 is often used to describe the joint during a pure roll. The direction of the rolling and the amount of arthrokinematic motions6 (Table 1.1). These sliding components of a roll-slide will vary depending on the motions are also called accessory or joint play motions. shape of the moving joint surface. If a convex joint surface is moving, the convex surface will roll in the same direction as the angular motion of the shaft of the bone but will slide Osteokinematics in the opposite direction (Fig. 1.5A). If a concave joint sur- Osteokinematics refers to the gross movement of the shafts face is moving, the concave surface will roll and slide in the of bony segments rather than the movement of joint surfaces. same direction as the angular motion of the shaft of the bone The movements of the shafts of bones are usually described (Fig. 1.5B). in terms of the rotary or angular motion produced, as if the Arthrokinematic motions are examined for amount of movement occurs around a fixed axis of motion. Goniometry motion, tissue resistance at the end of the motion, and effect measures the angles created by the rotary motion of the shafts on the individual’s symptoms.5 The ranges of arthrokinematic of the bones. Some translatory shifting of the axis of motion motions are very small and cannot be measured with a goni- usually occurs during movement; however, most clinicians ometer or standard ruler. Instead, arthrokinematic motions are find the description of osteokinematic movement in terms of A B Angular motion Angular motion Roll Roll Slide Slide FIGURE 1.5 (A) If the joint surface of the moving bone is convex, sliding is in the opposite direction to the rolling and angular movement of the bone. (B) If the joint surface of the moving bone is concave, sliding is in the same direction as the rolling and angular movement of the bone. 4566_Norkin_Ch01_001_018.indd 5 10/8/16 12:50 PM  6 PART I Introduction to Goniometry and Muscle Length Testing just rotary motion to be sufficiently accurate and use goniom- to the other. This axis is called a medial–lateral axis. All etry to measure osteokinematic movements. motions in the sagittal plane take place around a medial– lateral axis. Planes and Axes The frontal plane proceeds from one side of the body to the other and divides the body into front and back halves. Osteokinematic motions are classically described as tak- The motions that occur in the frontal plane are abduction and ing place in one of the three cardinal planes of the body adduction (Fig. 1.7). The axis around which the motions of (sagittal, frontal, transverse) around three corresponding abduction and adduction take place is an anterior–posterior axes (medial–lateral, anterior–posterior, vertical). The three axis. This axis lies at right angles to the frontal plane and pro- planes lie at right angles to one another, whereas the three ceeds from the anterior to the posterior aspect of the body. axes lie at right angles both to one another and to their corre- Therefore, the anterior–posterior axis lies in the sagittal plane. sponding planes. The transverse plane is horizontal and divides the body The sagittal plane proceeds from the anterior to the into upper and lower portions. The motion of rotation occurs posterior aspect of the body. The median sagittal plane in the transverse plane around a vertical axis (Fig. 1.8). The divides the body into right and left halves.7 The motions of vertical axis lies at right angles to the transverse plane and flexion and extension occur in the sagittal plane (Fig. 1.6). proceeds in a cranial to caudal direction. The axis around which the motions of flexion and exten- The osteokinematic motions described previously are sion occur may be envisioned as a line that is perpendicular considered to occur in a single plane around a single axis. to the sagittal plane and proceeds from one side of the body Combination motions such as circumduction (flexion– abduction–extension–adduction) are possible at many joints, but because of the limitations imposed by the uniaxial design of the measuring instrument, only motion occurring in a sin- gle plane can be measured in goniometry. Anterior– Medial– posterior lateral axis axis Sagittal plane Frontal plane FIGURE 1.6 The shaded areas indicate the sagittal plane. FIGURE 1.7 The frontal plane, indicated by the shaded area, This plane proceeds from the anterior aspect of the body to proceeds from one side of the body to the other. Motions the posterior aspect. Motions in this plane, such as flexion in this plane, such as abduction and adduction of the upper and extension of the upper and lower extremities, take place and lower extremities, take place around an anterior– around a medial–lateral axis. posterior axis. 4566_Norkin_Ch01_001_018.indd 6 10/8/16 12:50 PM  CHAPTER 1 Basic Concepts 7 in three planes around three axes: flexion and extension in the sagittal plane around a medial–lateral axis, abduction and adduction in the frontal plane around an anterior–posterior axis, and medial and lateral rotation in the transverse plane around a vertical axis. The glenohumeral joint has three degrees of freedom of motion. The planes and axes for each joint and joint motion to be measured are presented in Chapters 4 through 13. Range of Motion Range of motion (ROM) is the arc of motion in degrees between the beginning and the end of a motion in a specific plane.1 The arc of motion may occur either at a single joint or at a series of joints.5 The starting position for measuring all ROM is either the anatomical or neutral position. The ana- tomical position is described in the 41st edition of Gray’s Anatomy as a posture in which the upper limbs are by the person’s side and the palms of the hands are facing forward with the fingers extended7 (Fig. 1.9A). The lower limbs are together and facing forward. The neutral position, which is used to measure rotation ROM in the transverse plane, places the upper extremity joints halfway between medial and lateral rotation, and supination and pronation (Fig. 1.9B). FIGURE 1.8 The transverse plane is indicated by the shaded area. Movements in this plane take place around a vertical axis. These motions include rotation of the shoulder (A), head (B), and hip, as well as pronation and supination of the forearm. The type of motion that is available at a joint varies according to the structure of the joint. Some joints, such as Anatomical Neutral position position the interphalangeal joints of the digits, permit a large amount of motion in only one plane around a single axis: flexion and extension in the sagittal plane around a medial–lateral axis. A B A joint that allows motion in only one plane is described as FIGURE 1.9 (A) In the anatomical position, the forearm is having one degree of freedom of motion. The interphalan- supinated so that the palms of the hands face anteriorly. geal joints of the digits have one degree of freedom of motion. (B) When the forearm is in a neutral position (with respect to Other joints, such as the glenohumeral joint, permit motion rotation), the palm of the hand faces the side of the body. 4566_Norkin_Ch01_001_018.indd 7 10/20/16 12:16 PM  8 PART I Introduction to Goniometry and Muscle Length Testing The three notation systems used to define ROM are the 0- to 180-degree system, the 180- to 0-degree system, and the 360-degree system. In the 0- to 180-degree notation system, the upper- and lower-extremity joints are at 0 degrees for flexion–extension and abduction–adduction when the body is in the anatomical position, and at 0 degrees for rotation when the body is in the neutral position (see Fig. 1.9). Normally, a ROM begins at 0 degrees and proceeds in an arc toward 180 degrees. This 0- to 180-degree system of notation, also called the neutral zero method, is widely used throughout the world. First described by Silver8 in 1923, its use has been supported by many authorities, including Cave and Roberts,9 Moore,10 the American Academy of Orthopaedic Surgeons,11,12 and the American Medical Association.1 zero Example: The ROM for shoulder flexion, which begins zero n to with the shoulder in the anatomical position (0 degrees) om s io and ends with the arm overhead in full flexion n fr te n (180 degrees), is expressed as 0 to 180 degrees. xio Ex Fle In the preceding example, the portion of the extension ROM from full shoulder flexion back to the zero starting Extension from position does not need to be measured because this ROM rep- zero resents the same arc of motion that was measured in flexion. However, the portion of the extension ROM that is available beyond the zero starting position must be measured (Fig. 1.10). Flexion to zero Documentation of extension ROM usually incorporates only the extension that occurs beyond the zero starting position. FIGURE 1.10 Flexion and extension of the shoulder begin The term hyperextension is used to describe a greater than with the shoulder in the anatomical position. The ROM in normal extension ROM. flexion proceeds anteriorly from the zero position through Two other systems of notation have been described. The an arc toward 180 degrees. The long, bold arrow shows 180- to 0-degree notation system, first described by Clark, the ROM in flexion, which is measured in goniometry. The ROM in extension proceeds posteriorly from the zero defines the anatomical position as 180 degrees.13 The ROM position through an arc toward 180 degrees. The short, bold begins at 180 degrees and proceeds in an arc toward 0 degrees. arrow shows the ROM in extension, which is measured in The 360-degree notation system, first described by West, goniometry. also defines the anatomical position as 180 degrees.14 The motions of flexion and abduction begin at 180 degrees and proceed in an arc toward 0 degrees. The motions of exten- further testing of that motion probably is not needed. If, how- sion and adduction begin at 180 degrees and proceed in an arc ever, active ROM is limited, painful, or awkward, the physical toward 360 degrees.15 These two notation systems are more examination should include an examination of passive ROM difficult to interpret than the 0- to 180-degree notation system and additional testing to clarify the problem. and are infrequently used. Therefore, we have not included Active assistive ROM is the arc of motion produced by them in this text. the individual’s muscle contraction assisted by an external force. During the examination process the external force is Active Range of Motion provided by the examiner. In other instances the external force may be provided by an unimpaired region of the individual’s Active ROM is the arc of motion produced by the individual’s body, or by a mechanical device. voluntary unassisted muscle contraction. Having an individ- ual perform active ROM provides the examiner with informa- tion about the individual’s willingness to move, coordination, Passive Range of Motion muscle strength, and joint ROM. If pain occurs during active Passive ROM is the arc of motion produced by the appli- ROM, it may be due to contracting or stretching of “contrac- cation of an external force by the examiner. The individual tile” tissues, such as muscles, tendons, and their attachments remains relaxed and plays no active role in producing the to bone. Pain may also be due to stretching or pinching of motion. Normally, passive ROM is slightly greater than noncontractile (inert) tissues, such as ligaments, joint cap- active ROM16–18 because each joint has a small amount of sules, bursa, fascia, and skin. Testing active ROM is a good motion that is not under voluntary control. The additional screening technique to help focus a physical examination. If passive ROM that is available at the end of the normal an individual can complete active ROM easily and painlessly, active ROM is due to the stretch of tissues surrounding 4566_Norkin_Ch01_001_018.indd 8 10/8/16 12:50 PM  CHAPTER 1 Basic Concepts 9 the joint and the reduced bulk of relaxed muscles compared with contracting muscles. This additional passive ROM TABLE 1.2 Normal End-Feels helps to protect joint structures because it allows the joint End-Feel Description Example to absorb extrinsic forces. Testing passive ROM provides the examiner with Soft Soft tissue Knee flexion (contact information about the integrity of the joint surfaces and the approximation between soft tissue of posterior leg and extensibility of the joint capsule and associated ligaments, posterior thigh) muscles, fascia, and skin. Comparisons between passive ROM and active ROM provide information about the amount Firm Muscular stretch Hip flexion with the of motion permitted by the associated joint structures (pas- knee straight (passive sive ROM) relative to the individual’s ability to produce tension of hamstring muscles) motion at a joint (active ROM). In cases of impairment such as muscle weakness, passive ROM and active ROM may Capsular stretch Extension of vary considerably. metacarpophalangeal joints of fingers Example: An examiner may find that an individual with (tension in the anterior a muscle paralysis has full passive ROM but no active capsule) ROM at the same joint. In this instance, the joint sur- Ligamentous Forearm supination faces and the extensibility of the joint capsule, liga- stretch (tension in the palmar ments, muscles, tendons, fascia, and skin are sufficient radioulnar ligament of to allow full passive ROM. The lack of muscle strength the inferior radioulnar prevents active motion at the joint. joint, interosseous membrane, oblique If pain occurs during passive ROM, it is often due to cord) moving, stretching, or pinching of noncontractile (inert) struc- tures. Pain occurring at the end of passive ROM may be due Hard Bone contacting Elbow extension (contact bone between the olecranon to stretching of contractile structures as well as noncontrac- process of the ulna tile structures.19 Pain during passive ROM is not due to active and the olecranon shortening (contracting) of contractile tissues. By comparing fossa of the humerus) which motions (active versus passive) cause pain and noting the location of the pain, the examiner can begin to determine which injured tissues are involved. Careful consideration of the end-feel and location of tissue tension and pain during and abnormal (pathological) end-feels. Table 1.2, which passive ROM also adds information about structures that are describes normal end-feels, and Table 1.3, which describes limiting ROM. abnormal end-feels, have been adapted from the works of End-Feel these authors but are most similar to those presented by The amount of passive ROM is determined by the unique Kaltenborn.6 structure of the joint being tested. Some joints are structured Only recently have researchers begun to conduct studies so that the joint capsules limit the end of the ROM in a par- to determine the validity and reliability of end-feels. Petersen ticular direction, whereas other joints are structured so that and Hayes investigated Cyriax’s theory that abnormal end- ligaments limit the end of a particular ROM. Other normal feels are significantly more painful than normal end-feels. limitations to motion include passive tension in soft tissue The authors found partial confirmation of Cyriax’s theory in such as muscles, fascia, and skin; soft tissue approximation; that some abnormal end-feels were significantly more pain- and contact of joint surfaces. ful than normal end-feels at the two joints (knee and shoul- The type of structure that limits a ROM has a characteris- der) included in their study.21 Hayes and Petersen found that, tic feel that may be detected by the examiner who is perform- generally, end-feel identification reliability was considered ing the passive ROM when slight overpressure is applied at to be good when the same examiner made the identification the end of the motion. This feeling, which is experienced by of Cyriax’s three normal and six abnormal end-feels at the an examiner as a barrier to further motion, is called the end- knee and shoulder.22 However, the ability of different exam- feel.6,19,20 Developing the ability to determine the character of iners to agree on the same end-feels was poor. Manning et al23 the end-feel requires practice and sensitivity. Determination conducted a study to evaluate the reliability of end-feel iden- of the end-feel must be carried out slowly and carefully to tification, pain provocation, and hypomobility at each cervi- detect the end of the ROM and to distinguish among the vari- cal joint from C2–C3 to C6–C7 in symptomatic individuals. ous normal and abnormal end-feels. The ability to distinguish Clinically acceptable reliability was found primarily for among the various end-feels helps the examiner identify the assessment of joint hypomobility and end-feel in the lower type of limiting structure. Cyriax,19 Kaltenborn,6 and Paris20 cervical disc segment of the less painful side but not in the have described a variety of types of normal (physiological) more painful side. 4566_Norkin_Ch01_001_018.indd 9 10/8/16 12:50 PM  10 PART I Introduction to Goniometry and Muscle Length Testing TABLE 1.3 Abnormal End-Feels End-Feel Description Example Soft Occurs sooner or later in the ROM than is usual or Soft tissue edema in a joint that normally has a firm or hard end-feel. Synovitis Feels boggy. Firm Occurs sooner or later in the ROM than is usual or in Increased muscular tonus a joint that normally has a soft or hard end-feel. Capsular, muscular, ligamentous, and fascial shortening Hard Occurs sooner or later in