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Fundamental Concepts 215 Section 1: Range of Motion: Gross Screen INTRODUCTION TABLE 9-1 Factors That Can Affect Range With more than 200 joints, the human body was designed to of Motion move! Movement is central to funct...

Fundamental Concepts 215 Section 1: Range of Motion: Gross Screen INTRODUCTION TABLE 9-1 Factors That Can Affect Range With more than 200 joints, the human body was designed to of Motion move! Movement is central to function, and lack of move- ment, or lack of efficient movement, is one of the most com- Age In children less than 2 years old, mean values differ mon patient problems encountered in physical therapy. A considerably compared to published means for adults. screening assessment of the quantity and quality of move- In the elderly, it is common to note a slow but ments demonstrated by patients is a key component of most progressive loss of available joint motion. physical therapy examinations, regardless of diagnosis or Gender condition. As with many other tests and measures, this Females tend to have greater tissue extensibility and assessment can be global, regional, or local. For some condi- slightly greater joint ROM compared to age-matched males. tions, a gross screen of range of motion (ROM) will be ade- quate, while for others it is important to formally quantify Body Mass Index ROM measures with a goniometer (or other device). This Excessive soft tissue (muscle or adipose) may impede a joint from reaching its full available range. section describes concepts and methods of gross screening assessments of active and passive ROM, which is the first Disease step in determining if more detailed measurement should Many diseases can cause degeneration or inflammation of the joint surfaces, which has a occur. The following section provides a detailed descrip- negative effect on joint motion (e.g., rheumatoid tion of the principles and techniques related to goniometric arthritis, ankylosing spondylitis, psoriatic arthritis, measurement of joint ROM. osteoarthritis). Occupation/Recreation © Mandy Godbehear/Shutterstock Repetitive motions may lead to body adaptations over time that will affect ROM (e.g., a factory worker who repetitively rotates the trunk to the left may present with greater left trunk rotation than observed toward the right). Frequent stretching of soft tissue structures may lead to excessive ROM (e.g., a baseball pitcher may develop external rotation ROM on the pitching arm well beyond the expected range). Culture Certain cultural practices may affect joint ROM (e.g., in some cultures, sitting cross-legged on the floor or maintaining a prolonged squatting position is more common than sitting in a chair). Data from Reese N, Bandy W. Joint Range of Motion and Muscle Length Testing. 2nd ed. St. Louis, MO: Saunders Elsevier; 2010; Several sources provide an accepted normal ROM and Norkin D, White D. Measurement of Joint Motion: A Guide to for each joint that is capable of being assessed.4,5 Realize Goniometry. 4th ed. Philadelphia, PA: F.A. Davis; 2009. that the amount of joint movement an individual needs is relative to his or her desired activities. This relative normal should be considered when determining interventional the muscles that cross the joint.6 TABLE 9-1 lists other factors needs for each patient. For example, a baseball pitcher will that can affect joint motion. Active range of motion, which require movement well beyond the published ROM norms is movement performed solely by the patient with no exter- for shoulder external rotation on the pitching arm to be nal assistance, also relies heavily on the force production successful at delivering a variety of pitches. On the other of the muscles that surround the joint. Therefore, ROM, hand, a retiree whose desired activities include daily walks, muscle length, and muscle strength are all intricately related playing cards, and building birdhouses may need far less and often need to be considered together during a patient than the published ROM norms for unlimited function. If examination. What follows in this section is a discussion of a patient has dysfunction only on one side, then the unaf- active range of motion (AROM), passive range of motion fected side should be the comparative reference. If the dys- (PROM), and joint end feels. function is bilateral, the accepted norms, in conjunction with the patient’s functional requirements, should serve as FUNDAMENTAL CONCEPTS the reference. The degree to which any joint can move through its Active Range of Motion available range depends on a number of factors, including Observation of a patient’s AROM provides information the congruency of the joint surfaces, the pliability of the joint about the patient’s willingness to move, coordination and capsule and surrounding ligaments, and the extensibility of motor control, muscular force production, and potential 216 CHAPTER 9 Musculoskeletal Examination limiting factors (such as pain or a structural restriction). tissue itself, the musculotendinous junction, the tendon, If a patient demonstrates pain-free, unrestricted AROM and the bone-tendon junction. The presence of inflamma- within the expected range (considering published norms tion or injury within any of these structures may lead to pain or the patient’s functional requirements), further assessment upon contraction, which, in turn, may limit active motion. of that joint motion is likely not necessary. Any motion that In theory, if painful contractile tissues are the limiting fac- is limited or reproduces the patient’s symptoms requires tor during AROM, moving the limb through the range further investigation. without the muscles’ contracting (PROM) should allow for It should be noted that typical assessment of ROM, greater, or even full, motion. Much depends on how irritable whether active or passive, grossly or via goniometry, is or acute the patient’s condition is; highly inflamed tissues done using planar motions. For example, shoulder flexion may be quite painful whether motion is active or passive. and extension occur in the sagittal plane, shoulder abduc- Irritated noncontractile tissues, including ligament, joint tion and adduction occur in the frontal plane, and shoulder capsule, cartilage, neural tissue, bursa, fascia, and skin, may internal and external rotation (in standard anatomical posi- also be stretched or pinched during active motion. tion) occur in the transverse plane (see FIGURE 9-1). Func- If a patient reports pain during active motion, asking tional motion, however, typically involves a combination of for a description of the pain may help determine its source. motion in all three planes. For example, the simple action of In addition, it is imperative to determine if the pain felt dur- reaching the hand to touch the opposite shoulder involves ing the active motion was a reproduction of the patient’s a combination of shoulder flexion, adduction, and internal typical pain or something different. For example, a patient rotation. It is possible that motion is relatively normal when being seen for left-sided “sharp and deep” lower back pain assessed using planar motions, but abnormal (painful or may report that both left and right lateral flexion of the limited) during multiplanar motion. trunk are painful during AROM assessment. An error com- mon to novice physical therapy students is to assume that Limited Active Range of Motion both motions reproduced the patient’s symptoms. Asking Pain that limits AROM may be due to several factors. Active the patient to describe the pain, however, might reveal that motion requires contraction of one or more muscles. At lateral flexion to the left reproduced the sharp and deep pain times, multiple muscles are called upon, either in the role on the left, while lateral flexion to the right caused a pain- of the prime mover or in the role of the joint stabilizer. 6 ful pulling sensation in the left-sided lower back muscles When a muscle contracts, stress is placed on the muscle (see FIGURE 9-2). From this information, an experienced Medial Dorsal Lateral Lateral Ventral Sagittal plane Cranial Coronal plane Proximal Transverse plane Distal Proximal Distal Caudal FIGURE 9-1 Standard planes of human motion.  Fundamental Concepts 217 for any given motion. In most joints and for most motions, greater PROM can be expected compared to AROM. This is because there is a small degree of available motion out- side of volitional control.7 If a limitation is noted during AROM, passive assessment of that motion should occur. Passive motion requires that the patient be as relaxed as pos- sible and avoid assisting with the movement. To achieve and maintain this relaxed state, especially when the patient is in pain, he or she must have considerable trust in you to per- form the motion. Much of this trust is gained when a patient is able to sense gentle but confident handling and support through the clinician’s hands. This takes a great deal of prac- tice to develop. Although practicing on classmates, friends, Pulling or family is certainly helpful, it is not until you have worked pain with real patients (who have real pain and real limitations) Sharp that this experience will be gained. pain Sometimes PROM can be performed in the same posi- tion that AROM was assessed. This is joint and symptom dependent. For example, AROM of ankle (subtalar) inver- sion may be grossly assessed with the patient seated on an examination table. If a limitation in AROM is observed, you can ask the patient to return the ankle to the resting posi- tion, gently grasp the lateral aspect of the foot (with your opposite hand stabilizing at the distal tibia), ask the patient FIGURE 9-2 Differentiating the type of pain felt with each motion is important in determining the source of to relax and avoid assisting, then slowly move the ankle pain or dysfunction. into inversion. With many passive motions, especially in the presence of pain, it may be helpful to have the patient lie down (usually in supine). This helps with patient relaxation clinician might hypothesize the left lateral flexion caused as well as clinician support of the body part. For example, compression of irritated articular structures on the left gross AROM of shoulder abduction often is assessed with while the pain felt during right lateral flexion may have been the patient seated. If this motion is limited and quite pain- caused by left-sided muscular tightness that developed from ful, it may be very difficult for the patient to maintain a protective guarding. The focus of the remaining portion relaxed state if you attempt PROM in the same position. of the exam would then be on the hypothesized source of Moving the patient to supine, where the trunk and head are symptoms (articular structures on the left) with secondary fully supported, may allow for greater patient relaxation and attention paid to the left-sided muscular tightness that may more accurate assessment of PROM. This is especially true have developed as a result of the articular dysfunction. for PROM assessment of the cervical spine; “letting go” of Factors other than pain also can limit range of motion. the neck is quite challenging for most patients in a seated These include intra-articular blocks (such as a bone frag- position. ment, cartilage flap, or a bony malformation), joint effusion, Greater ROM can be expected for a number of motions edema, capsular tightness, lack of muscle length, excessive when patients are supine versus seated,8,9 and this should muscular or adipose tissue, and inadequate force produc- be kept in mind in the clinical decision-making process. tion of the prime movers. Each of these problems will feel Regardless of the position in which PROM is performed, it different to a patient and will appear different upon obser- should be carried out with caution and with close attention vation. It is therefore crucial that you continually seek infor- to the patient’s words, facial expressions, muscular resis- mation from the patient and critically evaluate the patient’s tance (intentional or reflexive), and quality of motion felt movements in the presence of limitations. By paying close through your hands. attention to the patient’s history, how the patient describes As with AROM, if a limitation in PROM is found, the the limitation, and observing the quality of movement and patient should be asked what he or she feels is limiting the movement patterns, it is usually possible to narrow the motion. Assumptions about the presence, location, or type potential sources of the limitation. With a narrowed list, of pain should be avoided. Consider the following example: more focused testing can provide additional data. A patient has sought physical therapy examination for Ⓡ Passive Range of Motion anterior knee pain. She describes intense pain in the patellar Passive range of motion can provide information about the area when going up stairs or when running. Visual observa- integrity of joint surfaces; the extensibility of the capsule, tion shows that the Ⓡ knee is moderately effused (swollen). ligaments, and muscle surrounding the joint; the irritabil- During AROM assessment of Ⓡ knee flexion, the patient ity of local tissues; and the full excursion allowed by a joint reports onset of her typical anterior knee pain and stops the 218 CHAPTER 9 Musculoskeletal Examination motion at approximately 75% of the expected normal range. system13 is most descriptive of both normal and pathologi- When the clinician performs PROM of knee flexion, the cal end feels and is described in TABLE 9-2. patient asks that the motion be stopped at nearly full range Even in healthy joints, the “feel” of the end feel will dif- because of pain. However, when asked, the patient reports fer from person to person for any given motion. Individuals her pain to be primarily in the posterior aspect of the knee who are naturally hypermobile may have considerably more (likely due to the effusion). Had the patient not been asked, give at the end range of a joint as compared to someone the clinician might have assumed that both AROM and PROM reproduced the patient’s anterior knee pain. who is naturally hypomobile. Because of these differences, performing an end feel assessment on a patient’s uninvolved Joint End Feel side can provide helpful information about that patient’s Joint end feel can be described as the quality of resistance own “normal” end feel. to movement felt by the examiner while passively mov- For efficiency and to avoid the possibility of invok- ing a joint to its end range. Assessment of joint end feels ing pain twice, you should assess end feel at the same time can help the clinician narrow the type of pathology pres- PROM is performed. If the end range of PROM is not pain- ent, determine the severity or acuity of the condition, and ful, you will be able to apply a moderate amount of force, hypothesize about the patient’s prognosis.10 While several or overpressure, to assess the true end point of motion. classification systems have been published,11,12 the Cyriax However, in the presence of pain, you must proceed with TABLE 9-2 Normal and Abnormal End Feels* End Feel Name and Description Example Normal End Feels Bone-to-Bone Elbow extension A hard, painless sensation with no “give.” Soft Tissue Approximation Elbow or knee flexion A mushy, forgiving sensation that stops further motion. Tissue Stretch Elastic (soft): wrist flexion, shoulder internal rotation The most common type of normal end feel, felt when the Capsular (hard): knee extension primary restraints for further movement are ligament or capsule. May be further divided into elastic (soft) in which there is significant spring or “give” at the end range, or capsular (hard) in which a definite end point is felt. Abnormal End Feels Bone-to-Bone Elbow flexion in the presence of excess bone formation Similar to the feel of the normal bone-to-bone end feel but (heterotopic ossification) following a fracture of the often painful and occurs before the normal expected ROM or coronoid process in joints where a bone-to-bone end feel is not expected. Springy Block Knee extension in the presence of a meniscus tear A forgiving (rebound) feeling, similar to a tissue stretch (extension is limited or blocked by the tear) but often is painful and felt before the normal end ROM is achieved or in joints where this end feel is not expected. Typically found in the knee joint and often indicative of a meniscus tear. Capsular Shoulder abduction in the presence of adhesive capsulitis Feels similar to a capsular tissue stretch end feel but can (frozen shoulder) invoke pain and occurs before the normal end ROM is achieved or in joints where this end feel is not expected. Muscle Spasm Cervical lateral flexion following a whiplash injury Involves a brief, involuntary muscle spasm that occurs in response to pain; is the body’s attempt to protect injured or inflamed tissues. Empty Shoulder flexion or abduction in the presence of acute Involves no sensation of resistance felt by the examiner, but subacromial bursitis the patient indicates (verbally or through facial expression) that motion must stop due to intense pain. Data from Cyriax J. Textbook of Orthopaedic Medicine: Diagnosis of Soft Tissue Lesions. 8th ed. London, England: Bailliere Tindall; 1982; and Magee D. Principles and concepts. In: Orthopaedic Physical Assessment. 6th ed. St. Louis, MO: Saunders Elsevier; 2014:2–70. *It should be noted that these end feel descriptions typically do not apply to the restricted joint motions seen in individuals with neurological conditions. Spasticity, which is further described in Chapter 10, is the result of an upper motor neuron lesion and describes a constant state of increased muscle tone. This tone often restricts available joint ROM, and mild to strong resistance is felt by the clinician when attempting to lengthen the muscle. In these cases, different terminology is used to describe the limited motion. From Bohannon R, Smith M. Interrater reliability of a modified Ashworth Scale of muscle spasticity. Phys Ther. 1987;67(2):206–207.  Fundamental Concepts 219 great caution. Once the patient has experienced pain with list. Measurement may occur on another visit, but the initial passive motion, whether or not any resistance to motion is visit would be as brief and streamlined as possible to move felt, it is quite probable that adding overpressure will further toward intervention and pain reduction. increase the pain. Expert clinicians who have worked with Clinically what often occurs is that formal measure- numerous patients develop the ability to know when it is ment will take place with patients who are being seen fol- and is not appropriate to attempt moving a patient’s limb lowing a surgical procedure on an extremity (e.g., rotator beyond a point of pain. As a novice, it is suggested that you cuff repair or total knee arthroplasty), if a condition or first learn how to skillfully perform PROM and learn the injury affects only one or two joints (e.g., an acute ankle subtleties of the different end feels before you attempt to sprain or following cast removal post elbow fracture), or make these more advanced decisions. if increasing range of motion in a specific joint will be the A classic example of how PROM and end feel can be primary focus of the physical therapy plan of care (e.g., used to assist clinicians in determining the type of pathology adhesive capsulitis). This practice may vary depending on is in differentiation between a rotator cuff tear and adhe- the region of the country, clinical setting, clinician training, sive capsulitis. In both of these conditions, the clinician may practice philosophy, and patient-specific variables. observe a 50% AROM limitation when a patient attempts to elevate the affected shoulder into flexion or abduction. The Documenting Estimated ROM patterns of substitution or compensation (such as hiking the Two popular texts17,18 that outline the guidelines and pro- shoulder or leaning the trunk toward the contralateral side) cedures for measuring joint range of motion acknowledge might also be quite similar in these two conditions. How- that visual estimation is often done clinically, but both dis- ever, a patient with adhesive capsulitis would likely demon- courage this practice. Neither text offers an option for docu- strate similar limitations in both AROM and PROM and the menting motions that are not measured. As stated earlier, end feel would be “hard capsular.” A patient with a rotator you are encouraged to perform a goniometric (or other) cuff tear, on the other hand, might allow nearly full PROM. measurement of motion when a ROM limitation is identi- This is because the factor that limits this patient’s AROM fied and when measuring is appropriate. Clinically, however, (torn muscle) does not affect passive motion. The end feel measurement does not occur on every motion assessed. for this condition would vary depending on the degree of Thus, a means to document the motions that are not for- tissue inflammation, but it would not be “hard capsular.” mally measured is needed. Documenting a visual estimate of a patient’s motion indicates that this motion was at least Quantifying Gross AROM and informally assessed and is certainly preferable to not docu- menting anything at all. PROM A discussion on the use of the terms “within normal Performing a measurement of limited joint motion typi- limits” (WNL) and “within functional limits” (WFL) could cally provides a more accurate and objective description generate many opinions, as well as controversy. Although than visual estimation.14–16 Thus, learning principles and not well defined, these terms are used in several health care techniques of joint measurement, specifically goniometry, documentation textbooks.19,20 Both terms are also com- are important. There are many times when formal mea- monly used in a multitude of clinical settings.21 However, surement of joint ROM is appropriate, such as following there are some sources that suggest these terms provide only a joint-specific surgical procedure or when lack of joint a subjective description, not objective data, and should not motion is a primary limiting factor for a patient’s function. be used in physical therapy documentation.22 While these Having a formal measurement also can assist in more accu- terms do imply that some opinion-based assessment is rate goal writing and assessment of progress or outcomes. required, it should be noted that much of what is tradition- In the clinical setting, however, it is not always practical or ally considered to be objective testing in physical therapy necessary to measure every identified ROM limitation. One involves some degree of subjective assessment. For example, example is a patient who has limitations in multiple motions evaluation of posture and gait, unless performed with equip- through multiple joints. If this patient is seen in a hospital ment to electronically digitize positions and movements, is setting, the clinician’s priority is determining if the patient moderately subjective in nature. In addition, variations in has adequate motion to perform bed mobility, accomplish normal from person to person are quite common; there- various transfers, and ambulate safely. The ROM assess- fore, the term “normal” must inherently have a bit of leeway. ment for this patient can be accomplished through visual The terms WNL and WFL are described here, but you are assessment and does not require measurement. If this same encouraged to follow documentation guidelines of the clini- patient is being seen in an outpatient clinic, the time allotted cal facility in which you study or practice, follow the lead for the initial examination may not allow for measurement of your clinical instructors, and make your own decisions of each of these joints in addition to the other, more critical about whether these terms are clinically appropriate. tests and measures that may need to be performed. Another example is a patient who is being seen for severe acute cer- Within normal limits (WNL). This term can be used to vical pain sustained following a fall on ice. In this case, the indicate that the patient was able to demonstrate joint patient’s pain may be so intense that specific measures of the movement within the typical or expected range for that limited cervical motions drop off the clinician’s “priority” motion. 220 CHAPTER 9 Musculoskeletal Examination Within functional limits (WFL). This term can be Quantification Based on Estimated Percentage of used to indicate that the patient was able to demon- Range strate joint movement that did not reach the typical Another option for documenting estimated ROM is to or expected range, but the available range does not indicate the percent of normal or percent of expected range compromise the patient’s ability to function as desired. achieved by the patient. An informal survey of 71 second- An example would be an elderly woman who demon- and third-year doctor of physical therapy (DPT) students strates pain-free bilateral knee flexion to approximately reporting on 137 clinical experiences found that, for 71 120° with no reported functional difficulties with her (52%) of these experiences, clinical instructors expected daily tasks (e.g., sitting, getting in and out of a car or students to primarily use estimated ROM during patient bathtub, negotiating stairs). In this case, the range is examinations, and on 38 (28%) of those experiences, stu- not within the expected range (135°–145°)17,18 but dents were instructed to document a percent-of-normal within her functional range. Another example is an estimate.21 Using Figure 9-3 again, it can be seen that the individual who has considerable muscle bulk in the individual is demonstrating roughly 75% of the expected upper extremities. Because of approximation of soft 180° of abduction motion. In this case, sample documenta- tissue (muscle), he is only able to achieve roughly 120° tion would be “Ⓛ shoulder abd AROM estimated at 75% of of elbow flexion but reports no functional deficits. His normal” or “visual estimation Ⓛ shoulder abd AROM 75% range is not within the expected range of 140°–150°17,18 of normal.” As mentioned earlier, larger joints or joints with but is still quite functional for his needs. easily visualized angles are easier to estimate. Quantification Based on Estimated Numerical Quantification Based on Descriptors Range Use of the terms “severely limited,” “moderately limited,” If a visual estimation is made of a patient’s ROM, whether and “slightly limited” may also be common in various clini- active or passive, it should be clearly noted in your docu- cal settings. Some electronic documentation systems use mentation that the degrees of motion written are based on these (or similar) terms in drop-down menus for clinicians an estimate. An example of documentation for the AROM to designate ROM limitations. When descriptor terms are depicted in FIGURE 9-3 would be “Ⓡ shoulder abd AROM used, each facility should have a clear definition of what is 0°–135° (estimation)” or “visual estimation Ⓡ shoulder abd meant by severely, moderately, and slightly. ROM less than AROM 0°–135°.” This estimation of a numerical degree is 50% of normal might be considered a severe limitation; not difficult to see in joints such as the shoulder or the knee between 50% and 75%, a moderate limitation; and greater where visualization of a right angle (90°) can be made. This than 75% (but less than normal), a slight limitation. becomes much more challenging with motions such as ankle inversion or wrist radial deviation where identifica- PROCEDURE tion of a 90° reference angle is more difficult. Gross range of motion assessment should involve as few positional changes from the patient as possible. Multiple position changes during an examination may increase a patient’s pain, lead to undue energy expenditure, cause unwanted physiological changes (such as a rapid drop in blood pressure), and risk annoying the patient. This will require you to plan ahead and may necessitate mental or written notes to yourself about motions that need further examination in a different position. For example, a patient may demonstrate painful and limited shoulder flexion and abduction during a screening AROM assessment when seated. To assess these motions passively, or to perform a goniometric measure, the patient should be moved to supine. However, you should complete any other tests and measures while the patient is seated before moving the patient to supine to avoid unnecessary repositioning. When the patient has an affected and an unaffected side, it is recommended that the unaffected side be assessed first, followed by the affected side. Sometimes, for the sake of time and to allow direct comparison, motions may be carried out on both sides simultaneously during the screen- ing examination. This works well for most joints except the hips, where simultaneous right and left motion is often dif- FIGURE 9-3 Limited AROM for right shoulder abduction. Actual shoulder abduction AROM = 135°, which equates to ficult or impossible. For example, when evaluating shoulder 75% of normal/expected AROM. AROM, you can ask the patient to move both arms into  Procedure 221 flexion at the same time. This will allow a visual compari- joints. For example, when examining a patient who was son of ROM available on the affected side compared to the recently hospitalized with Guillain Barré syndrome, a full unaffected side. body ROM assessment may be necessary. However, assess- For each motion, the flow chart in FIGURE 9-4 provides ing major functional motions would be most appropriate; a systematic approach to the decision-making process when eliminating motions that are less necessary to function, such limited ROM is found. As mentioned, when a patient dem- as shoulder abduction, wrist ulnar and radial deviation, hip onstrates a limited active or passive motion, it is impera- internal rotation, and ankle inversion and eversion, can be tive that you ask the patient’s opinion of why the motion is justified. limited. Coupled with the patient’s history, this can provide Ensuring the patient is in the best possible postural you with very valuable information when attempting to alignment is essential when performing a screening exam- determine the reason for the limitation. A patient stating ining of AROM, especially for the upper quarter. A typical that a joint simply “won’t go any farther” might indicate slouched posture places the joints of the cervical spine and that there is a structural restriction (such as joint capsule) or shoulder in poor alignment, which diminishes the available muscle weakness present. If a patient reports motion to be ROM.6 restricted by a “pulling” sensation, this might be indicative of soft tissue tightness. If “pain” is reported as the limiting Try This! Sit in a chair or on a table in a very slouched position. factor, inflamed contractile or noncontractile tissues may Now attempt to raise your arms into flexion. Compare your ROM be the cause. in this posture versus one in which you are seated straight. You The number of motions you should assess will vary likely achieved much greater ROM and felt much less resistance to depending on the patient’s condition and the suspected motion. Comparing available cervical rotation or lateral flexion in source of dysfunction. For patients being seen for joint-spe- the slouched versus straight positions will give you similar results. cific conditions, such as knee pain or post shoulder disloca- This highlights the importance of ensuring your patients are in the tion, you should, at minimum, perform a ROM screen of best possible alignment prior to any ROM assessment. the affected joint, as well as the joint above (proximal) and below (distal). Other patients with conditions that affect the It is vital that the patient understand what you are ask- body more globally may require a ROM screen of a num- ing him or her to do during the AROM assessment. This ber of joints, but possibly not every motion within those is most easily accomplished if you perform the desired Active motion: within normal or functional range and pain free? Yes No If clinically meaningful, Perform passive motion in Document AROM; no further perform PROM and end feel appropriate position; determine assessment needed assessment, for comparative joint end feel at end of purposes passive range Within normal range? Yes No Perform goniometric Perform goniometric Document PROM and measurement of measurement of limited end feel limited AROM if AROM and PROM necessary/appropriate if necessary/appropriate FIGURE 9-4 The decision-making process for range of motion assessment. 222 CHAPTER 9 Musculoskeletal Examination motion standing directly in front of the patient while ver- mimic the motions you perform, you will only confuse them bally describing the motion. The patient can then mirror if you use words they do not understand. your motion to the best of his or her ability. If you use this TABLE 9-3 and TABLE 9-4 list the motions com- method, make sure you complete the full range yourself monly assessed during a screening examination of AROM, and/or use the phrase “move as far as you can.” If you only along with the typical position in which each is assessed demonstrate part of the range with no verbal instructions, (see FIGURES 9-5 through 9-44). Modifications of these some patients may complete only the limited range they positions may need to occur to accommodate setting- and observed, although they may be capable of more. You must patient-specific variables. Patients should be made aware of also avoid using medical terminology when describing the purpose of the ROM assessment, what they can expect motions. Most patients are not familiar with terms such as throughout the testing, and that you should be told of dif- “abduct,” “dorsiflex,” or “pronate.” Even though patients may ficulty or discomfort experienced with any motion. TABLE 9-3 Upper Quarter Active Range of Motion Assessment (Part 1) Joint/Segment Tested Motion Patient Position Additional Information Cervical Ensure that upper body posture is in the best possible alignment for all cervical and shoulder motions. See Figure 9-5 Flexion Seated See Figure 9-6 Extension Seated See Figure 9-7 Lateral flexion Seated See Figure 9-8 Rotation Seated Upper Quarter Active Range of Motion Assessment (Part 2) Joint/Segment Tested Motion Patient Position Additional Information Shoulder See Figure 9-9 Flexion Seated See Figure 9-10 Extension Seated See Figure 9-11 Abduction Seated Adduction Seated Adduction is the normal anatomical position; rarely needs to be assessed. See Figure 9-12 Horizontal adduction Seated Optional. FIGURE 9-5 AROM cervical flexion. FIGURE 9-6 AROM cervical extension.  Procedure 233 © Bocos Benedict/ShutterStock, Inc. PRIORITY OR POINTLESS? When gross range of motion is a PRIORITY minimum, assessment should extend to the joint above to assess: and joint below the identified dysfunctional joints), or Range of motion is essential to function, but can be more global for conditions that affect multiple body limited by many conditions, disease processes, or inju- regions. ries. Observing and analyzing a patient’s ROM, both actively and passively, can provide you with information When range of motion is POINTLESS to that will lead you to the next test or measure and aid in assess: hypothesizing about the patient’s dysfunction. Therefore, It would rarely be pointless to assess a patient’s range of you should perform a range of motion assessment on motion (locally, regionally, or globally). If a patient is not every patient on the first visit. If AROM is limited, you capable of producing active motion, then passive motion must determine why that limitation exists (by asking should be assessed. If motion at a joint is prohibited by the patient and formulating your own hypotheses) and physician order or other means, it would be appropriate then assess PROM and end feel. ROM assessment can to assess ROM of the closest proximal and distal joint in be focused for conditions affecting one or two joints (at which motion is allowed. © Bocos Benedict/ShutterStock, Inc. CASE EXAMPLE #1 Your new inpatient is an 85-year-old man referred to physical was able to take a short walk without the use of an assistive therapy following an emergency splenectomy yesterday. He is device. in good spirits, although he reports a great deal of soreness in the abdominal area. The goals of the first session are to initi- Documentation for Case Example #1 ate ambulation and determine if the patient needs an assistive device for walking. During your AROM assessment of the Subjective: Pt reports mod to significant soreness in the patient’s major upper extremity motions, Ⓑ shoulder flexion, abdominal area post splenectomy. wrist flexion, and wrist extension are limited to about 75% of Objective: AROM: All major UE and LE motions are WFL or normal range, but within the range he needs for function. In the WNL for necessary bed mobility, TRs, and gait. lower extremities, hip flexion, knee flexion and extension, and ankle dorsiflexion and plantar flexion are all slightly limited Assessment: Pt recovering well from surg. No concerns about Ⓑ but within the range needed for unrestricted function. The ROM or mobility at this time. patient’s ROM did not impede his ability to move from supine to seated on the edge of the bed and then to standing, and he Plan: Will cont c‒ gait and functional assessment to allow for D/C to home later this pm.  Fundamental Concepts 235 Section 2: Range of Motion: Goniometry joint is studied. In addition, intra-rater reliability is consis- INTRODUCTION tently higher than inter-rater reliability23,27,28—this becomes Goniometry is simply a formal measure of active and/or important, for example, when one clinician measures ROM passive ROM. Therefore, the underlying concepts of gross on a patient’s initial visit but another clinician conducts the of ROM and goniometric assessment of ROM are the same. same measure during subsequent visits. Most studies have Gross screens of AROM and PROM may provide a clinician been conducted on joints that have the most identifiable with considerable information, including an estimate of the landmarks and the least variability of motion excursion quantity of motion for any given movement. Following an (such as knee and elbow flexion and extension), and most arthroscopic procedure on the shoulder, a clinician might have also been conducted on young, healthy individuals. be able to determine that a patient has approximately 50% Goniometric measurement becomes much more challeng- of expected shoulder flexion and abduction AROM based ing in the presence of pain, when there is substantial muscle on known norms. Depending on the circumstance, includ- or adipose tissue, or when a standard testing position can- ing a patient’s condition, outcome goals, available time, not be achieved. and other influencing factors, an estimated range may be There are several types of goniometers, all of which sufficient in the presence of AROM limitations. However, accomplish the primary task—measuring joint angles. Some obtaining a goniometric measure of both active and passive are made of metal, and others are made of plastic. They ROM may be important to establish a more accurate and come in various sizes and shapes to accommodate differ- objective baseline23,24 that can then be used for assessment ent body areas. Most commonly, clinics utilize clear plastic of progress as the intervention plan proceeds. goniometers imprinted with several different measurement The extent to which goniometry is used in clinical set- scales to allow for a variety of starting positions. tings varies considerably. As stated in the previous section, FIGURE 9-54 shows a standard 12" plastic goniometer. a survey of DPT students on clinical rotations found that, As can be seen, the body of the device (the round portion) of the 137 rotations reported, respondents indicated that contains three measurement scales. The outer scale has two 71 (52%) of the clinical instructors expected students 0° points and four 0°–90° scales. The middle scale has one to primarily use an estimated ROM, 37 (27%) expected 0° point and two 0°–180° scales. Finally, the inner scale has goniometric measures, and 29 (21%) expected equal use of no 0° point, but two 180°–360° scales. Although this may estimates and goniometry.21 Thus, you should have a good seem confusing at first, these different scales provide several understanding of both methods and learn to recognize options that will accommodate various starting positions. when it’s clinically appropriate to use each. Another important part of the body is the center of the cir- cle. This point is positioned at the center of a joint’s axis of FUNDAMENTAL CONCEPTS rotation, referred to as the fulcum (or axis). The other standard parts of a goniometer include Goniometric Devices two arms. The stationary arm is an extension of the body Although several tools are available to measure joint ROM of the goniometer while the movement arm is attached to (see FIGURE 9-53), the goniometer is the most common the body with a rivet or hinge that allows free motion in a tool used by physical therapists in the clinical setting. circular pattern. Standard practice has the stationary arm Goniometry has been shown to be generally reliable and aligned with a nonmoving reference point (sometimes valid,25,26 but results vary considerably depending on what aligned with a bony landmark, sometimes aligned parallel Fulcrum (or Axis) Body Stationary Arm Movement Arm FIGURE 9-53 Various types of devices that can measure joint range of motion. FIGURE 9-54 Parts of a standard plastic 12" goniometer. 236 CHAPTER 9 Musculoskeletal Examination (a) (b) FIGURE 9-55 (a) Starting and (b) ending position of a goniometer when measuring wrist ulnar deviation. or perpendicular to the direction of gravity). The movement maintaining the prone position. The standard testing posi- arm is then aligned with the portion of the body that moves. tion for measuring shoulder extension is in prone. Should FIGURE 9-55 shows an example of the starting and ending a patient be uncomfortable in prone, it may be more appro- positions of a goniometer when measuring joint motion (in priate to perform the measurement with the patient seated, this case, ulnar deviation of the wrist). documenting the altered position. Similarly, the standard Once you have a good understanding of the parts of testing position for hip extension is also prone. If it will take a goniometer and the various scales it contains, you will considerable effort and time for a patient to achieve this be able to use any of the wide variety of devices available, position, it may be prudent to determine if the patient can whether plastic or metal, small or large, or full- or half-circle achieve adequate hip extension via other means, such as by body. performing a bridge while in supine or asking the patient to assume a stagger stance in standing. Clinicians should Goniometric Techniques always have a reason why a particular measure is necessary Goniometric measures quickly become intuitive once the and should also always have a “plan B” if a standard assess- basic concepts are understood and you have a good grasp ment will not work. of anatomy/landmarks. Common procedural techniques Two very important and related concepts when per- include standardized patient positions (specific to whole forming goniometry are (1) the initial alignment of the body position as well as the position of the joint being mea- device with the joint of interest and (2) the determination sured), accurate identification of landmarks for alignment of which measurement scale should be used for the given of the goniometer, and avoidance of substitutions or com- measure. Initial placement of the goniometer requires align- pensatory motions by the patient. ment of the fulcrum, the stationary arm, and the movement Many goniometric measurements are performed in arm. These three alignment points are identical at the begin- supine or prone so as to maximize support and stability of ning and the end of the motion, although the landmarks the body regions that should remain stationary. Some mea- sometimes shift under soft tissue during movement. If your sures have several acceptable patient positions, although it alignment is off, either at the beginning or at the end of the is important to realize that very few of the testing positions measure, this could lead to considerable measurement error. correspond to functional positions. Sometimes it’s impor- Therefore, you are encouraged to practice locating land- tant to make a clinical decision either to alter the standard marks on a variety of body types in a variety of positions. measurement position or to forego a formal measure. For Determining which measurement scale to use and example, many individuals have difficulty achieving or then finding the “zero” point on the device are also vital.  Fundamental Concepts 237 BOX 9-1 Visual Estimation of ROM to Guide Measurement Accuracy One way to avoid a measurement error is to visually estimate of what each joint angle is. For example, FIGURE 9-57 shows a patient performing knee flexion. This should visually appear to be greater than 90° but less than 110° degrees. When a goniometer is placed appropriately, the reference line on the movement arm sits at 101°. If the visual estimate was not performed, an error could be made in thinking that the angle is 81°. Thus, FIGURE 9-56 Hypothetical starting point for measure- doing a rough estimate first will help to guide ment of elbow ROM. Note that the middle (correct) you to the correct number, even if you forget number on the scale reads 16°, while the inner and outer to first establish your zero point. (incorrect) scales read 344° and 74° respectively. Visualize the goniometer when it is positioned at the start- observation that available range is less than what is consid- ing point, then identify which scale corresponds to the zero ered “typical” or when a patient can’t perform desired func- point of the measure. FIGURE 9-56 shows a hypothetical tional activities because of a range of motion restriction. starting point for a measurement of elbow ROM. On the Many times a ROM limitation is due to pain, so it is impera- middle scale, the goniometer reads 16°. The reading on the tive that end-range measurements are taken as quickly as innermost scale is 344° and that on the outmost scale is 74°, possible while maintaining a high degree of accuracy. If both of which should be ignored. Thus, when performing accuracy is sacrificed, then the time spent doing the mea- the final reading of the elbow ROM measure, you should sure is wasted. Performing goniometric measures quickly focus only on the middle scale. If you do not initially deter- is often quite challenging for students, as there are many mine which scale you are referencing for any given motion, factors on which to focus simultaneously. Thus, even when the likelihood of making an error increases. practicing on classmates or friends, always be cognizant of One final error to avoid is neglecting to look squarely how much time each measure takes. As you get more prac- at the scale of the goniometer when determining the joint tice, your efficiency will improve. angle. Attempting to read the scale when looking at it from Goniometric measurement can be used to assess both above, from below, or from the side can skew the visual per- active and passive ROM, although for some motions it is spective and lead to measurement errors. not common to incorporate a passive measurement. These Formal measurement of joint motion is typically done include cervical motions (because of challenges in posi- for the purposes of documenting limitations. This includes tioning the goniometer with the patient in supine) and (a) (b) FIGURE 9-57 (a) Visual estimation should indicate the knee is flexed to greater than 90°. (b) The accurate (101°) and inaccurate (81°) goniometric reading. 238 CHAPTER 9 Musculoskeletal Examination thoracolumbar motions. For many joints, it takes a great Functional Range of Motion deal of practice and excellent handling skills to be able to Understanding the amount of range of motion needed to both passively move a joint through its available range and perform various functional activities is equally if not more accurately position a goniometer to obtain a measurement. important than knowing maximal expected ranges. For Thus, it is sometimes necessary to use a clinical assistant for example, determining that a patient can only achieve 85° of passive goniometric measures, particularly when the move- elbow flexion is the technical component of range-of-motion ment is painful for the patient. assessment. Clinically, it is imperative to then understanding Nearly all measures begin with the patient in the ana- how this limitation will affect the patient’s ability to perform tomical position with a “0°” starting point. The principal essential functional activities, such as combing her hair, eating exception to this is the carpometacarpal joint of the thumb with a fork or spoon, and washing under the opposite axilla. (described in TABLE 9-5). Even if a joint does not rest at Many authors have attempted to determine average the 0° point, as long as it can actively move through the ranges required for common functional activities. How- 0° point, then 0° is the starting measurement that should ever, these ranges vary considerable from study to study. be documented. For example, most individuals demon- For example, the reported minimal elbow flexion range of strate a resting position of plantarflexion at the ankle in motion needed to drink from a glass ranges from 45° to either standard testing position (short sitting or supine). 78°.29,30 Similarly, the reported minimal hip flexion range of However, measurement of both plantar flexion and dor- motion needed to descend stairs ranges from 49° to 66°.31,32 siflexion require a 0° starting point. If the patient can The lack agreement about how much range of motion is actively achieve neutral (0°) then that is where the initial needed for various activities is not at all surprising consider- goniometric measure should start. When documenting, it ing the number of factors that contribute to human motion. is important to include both the starting measure and the Consider the following: ending measure; unless explicitly documented, it cannot be assumed that a patient was able to reach the standard Limb length. Tall individuals require less hip and knee starting position. flexion to ascend stairs as compared to those who are The clinical decision-making process (Figure 9-4) for short (FIGURE 9-58). when to perform goniometric measurement indicates that, Soft tissue bulk. Persons with excessive muscle bulk or in the presence of an affected and an unaffected limb, the adipose tissue in the upper extremity may have lim- unaffected side should not require formal measurement ited elbow flexion range and may thus alter shoulder if demonstrated range is within normal limits. There are or wrist mechanics to accomplish a task. times, however, when a patient’s unaffected side falls outside Cultural or learned patterns of movement. An individ- the expected range of “normal” yet this range is quite func- ual may have learned to squat keeping the feet flat on tional for the patient. In this case, measurement of the unaf- the ground, while another may have learned to squat fected side will provide a helpful reference number when with the ankle in plantar flexion and weight through setting goals and planning for interventions. Consider the the forefoot and toes (FIGURE 9-59). The first method following examples: requires greater dorsiflexion and hip flexion compared to the latter method. 1. A 22-year-old female patient is being seen 2 days post Personal preference. Some individuals prefer to use a ACL reconstruction. She demonstrates very limited spoon or fork with the forearm pronated while others pre- active and passive ROM for both flexion and extension fer the forearm supinated, and this preference will likely on the surgical limb. When assessing the nonsurgical affect the shoulder and wrist mechanics during eating. knee, the physical therapist notes that the patient has Thus, when making clinical decisions about a patient’s notable hyperextension. A valid clinical assumption is available range of motion and the effect that any limitation that both knees had relatively equal ROM prior to the may have on function, numerous factors should be taken surgery, so it will be important to obtain a measure of into consideration. Instead of making assumptions about the degree of hyperextension on the nonsurgical knee to a patient’s ability to perform functional tasks, it can be know what the ROM goal should be for the surgical knee. extremely helpful to observe the patient attempt to accom- 2. A 78-year-old man is being evaluated following surgery plish such tasks when deciding how concerning any given to repair a torn rotator cuff. The patient reports no pain limitation may be. or functional difficulty with the nonsurgical shoulder, but the physical therapist notes that both internal and external rotation AROM are roughly 50% of expected PROCEDURE normal. Thus, the physical therapist should formally Many of the principles discussed in the section describing measure and document the rotation ranges for the non- gross ROM assessment also apply to goniometric assess- surgical shoulder. In addition, long-term AROM goals ment. You should plan ahead in order to minimize position for the surgical shoulder may aim for numbers closer changes for the patient. For example, screening assessment to the unaffected side instead of published expected of shoulder flexion and abduction are typically performed norms. while a patient is seated. If limitations in these motions are  Procedure 239 identified, you should plan to perform PROM and end feel flexion), it is often easier to relocate the landmarks and assessment, as well as obtain goniometric measures of the reposition the goniometer. limited active motion. However, the PROM, end feel, and Performing passive goniometric assessment, as pre- goniometric assessments are all performed with the patient viously mentioned, can be quite challenging, particularly in supine. Thus, all other appropriate assessments should be when pain is present during or at the end of motion. In completed with the patient in sitting prior to moving him some instances, PROM is the only measurement taken— or her to supine. this occurs when the patient is unable, unwilling, or not Patient positioning and alignment are essential. For permitted to actively move. Typically, gross PROM and end goniometry, the standard testing position often maximizes feel assessment are performed prior to formally measuring, stabilization of the body, but you should always ensure that but with planning and skill, a goniometric measure can be the patient does not perform compensatory motions in an done at the same time (avoiding repeated, painful motions). effort to achieve (or appear to achieve) more range. This Performing both passive range and goniometric measure- may require verbal cues, manual stabilization, or both. ment simultaneously, when both skills are new to a student Assessment begins with the patient in the recom- physical therapist, is often not wise. Practicing on class- mended testing position unless he or she is unable to achieve mates, friends, or family members is suggested so challenges this position (in which case an alternate position may be are realized when stakes are not high. When working with used, as long as that position is documented). Active and real patients, however, the priority should always consider passive motion screens should already have been assessed, the patient’s comfort, so it is imperative that maneuvering so you likely have some idea of the patient’s ability to achieve a limb to obtain a measure is not prioritized over avoiding any given range. As mentioned previously, these estimated prolonged positions of pain or discomfort. ranges can be very helpful when determining the actual At times, use of a standard goniometer is not the ideal degree of motion if you forget which scale should be used choice for obtaining an objective measure. This occurs pri- on the goniometer. marily when attempting to assess motion in the thoraco- The next step is palpating the patient’s bony landmarks lumbar spine, particularly flexion, extension, and rotation. specific to the motion being assessed and then aligning the For these motions, the use of a tape measure can provide goniometer with these landmarks. Once the goniometer is adequate objective information. Specifics about the use of a aligned, the starting measurement is noted. The patient is tape measure for these motions are provided in TABLE 9-6 then asked to move through the specified range of motion, and demonstrated in the corresponding figures. as far as he or she is able, at which time the goniometer is What follows are tables that contains information about repositioned (ensuring landmark alignment) and the end- the standard patient position; starting body position and ing measure is recorded. Sometimes it is easier to keep the limb/joint position; landmarks for the fulcrum, station- goniometer in place (maintain the position of the fulcrum ary arm, and movement arm; any special considerations and the stationary arm over their respective landmarks) and for each measurement; and the normal expected AROM. then adjust the movement arm while the limb is moving. FIGURES 9-60 through 9-96 illustrate the positions and Examples include elbow flexion and hip abduction. Other techniques described in the tables. FIGURES 9-97 through times, particularly when the fulcrum and stationary land- 9-100 demonstrate examples of how a goniometer can be marks shift under soft tissue (e.g., shoulder flexion, knee used to measure PROM for select motions. (a) (b) FIGURE 9-58 Compare the amount of hip and knee flexion necessary for a tall (a) and a short (b) person to ascend stairs.  Procedure 263 © Bocos Benedict/ShutterStock, Inc. PRIORITY OR POINTLESS? When goniometric range of motion is a When range of motion is POINTLESS to PRIORITY to assess: assess: A formal measure of active and passive range of motion Goniometric measurement is not always necessary in the can be helpful to objectify a baseline, or starting point, if presence motion limitations, such as when AROM does part of the intervention plan (and goal setting) will focus not fall within normal or expected limits but allows a on specific improvement of the measured ranges. In addi- patient full function. In addition, there are instances in tion, determining a patient’s available range of motion which multi-joint limitations are present, such as with a may offer insight as to why certain functional limitations frail elderly individual, where focus on specific degrees may be present and may then assist in setting functional, of any given joint is not a priority. There are also times ROM-related goals. Goniometric measurements are when taking time for a formal measure would decrease almost always taken following a joint-related surgical the efficiency of an examination, particularly when spe- procedure, such as a total knee arthroplasty, rotator cuff cific ROM goals will not be set. repair, or open-reduction internal-fixation of the ankle. © Bocos Benedict/ShutterStock, Inc. CASE EXAMPLE #1 (IDENTICAL TO CASE #1 IN ROM-GROSS SCREEN SECTION WITH GONIOMETRIC MEASURES ADDED) Your patient has directly sought physical therapy examina- is limited by sharp pain at about 90% of the expected normal tion with a chief complaint of Ⓡ shoulder pain described as range (both measured at 0–160°). The end feel during passive deep, sharp, and localized to the shoulder. She rates her current flexion was empty (the patient grimaced and asked you to stop pain at 7/10 (0–10 scale). Reaching to upper kitchen shelves, before you felt resistance), and the end feel for abduction was driving, and lifting grocery bags out of her car cause the most spasm (you felt the patient’s muscles contract in an attempt to pain. Observation indicates that this patient’s habitual posture stop further motion). Passive internal rotation ROM at 90° is that of forward head, forward shoulders, and moderately abduction did not differ from the patient’s AROM (0–63°) with pronounced thoracic kyphosis. AROM: All motions in the a report of “deep pain,” and the end feel was “spasm.” neck and the Ⓡ elbow are pain free and within the expected range. When you ask the patient to demonstrate Ⓑ shoulder Documentation for Case Example #1 flexion, abduction, extension, internal rotation, and external rotation, all motions on the Ⓛ are pain free and within the Subjective: Pt states Ⓡ shoulder pain is deep and sharp. Rates normal ranges. She is able to place her Ⓛ hand behind her back current pain at 7/10 (0–10 scale; 10 = worst pain). Overhead (functional internal rotation) to the level of T8, and Ⓛ hand reaching, driving, and carrying groceries are most painful. behind her head (functional external rotation) without pain or Objective: All cervical, Ⓛ UE, and Ⓡ elbow motions WNL difficulty. With the Ⓡ shoulder, the patient can achieve about and pain free. See chart below for AROM, PROM, and end 75% of the expected normal range for flexion and abduction feel information. (both measured at 0–135° with a goniometer) with “sharp pain” as the limiting factor. She can achieve approximately 90% of Assessment: Pt c‒ limited and painful AROM and PROM on the expected normal range for internal rotation (measured at the Ⓡ shoulder c‒ abnormal end feels during flex, abd, and 0–63°) and reports “pain and stiffness” as the limiting factors. IR. AROM and PROM into shoulder elevation may be com- The motion of Ⓡ hand behind the back is to the L1 vertebra pressing inflamed soft tissue structures in subacromial space with “achy pain and stiffness” reported. Extension, external resulting in painful and limited motion. rotation, and hand on back of head are equal to that of the Ⓛ and do not cause pain. PROM and End Feel: You opt to per- Plan: Will focus early Rx on ↓ing inflammation to allow for form PROM in supine for the limited motions of Ⓡ shoulder ↑ ROM. Will also address UQ posture to optimize alignment flexion, abduction, and internal rotation, assessing end feels for shoulder elevated activities. at the same time. With both flexion and abduction, the range  Fundamental Concepts 265 Section 3: Muscle Length dorsiflexors do not have the strength to overcome this, she INTRODUCTION may eventually develop a compensatory gait pattern to clear Because muscles cross every joint in the body, and because her foot from the ground while walking. Luckily muscles joints rely solely on muscular force production for move- that are both tight and weak can be improved through the ment, joint ROM and muscle performance (length and proper intervention. strength) can rarely be considered separately. Abnormal muscle length can lead to a number of problems, including diminished joint active and passive ROM, abnormal move- FUNDAMENTAL CONCEPTS ment patterns, development of compensatory postures or Prediction of abnormal muscle length based on posture or motions, and pain. As discussed in the section on posture, activity is relatively easy when considering muscles that only prolonged or habitual positions can lead to shortening or cross one joint, such as the pectoralis major (crosses only lengthening of muscles. If a muscle’s resting length is lon- the shoulder joint), iliopsoas (crosses only the hip joint), ger than optimal, stretch weakness may develop that can and the soleus (crosses only the ankle joint). Prediction of contribute to inefficient movement patterns, diminished abnormal muscle length for muscles that cross two joints postural support, and pain. If a muscle’s resting length is may be more difficult, especially when the muscle tends to shorter than optimal, adaptive shortening may develop that lengthen over one joint while it shortens over another joint. can contribute to restricted joint ROM, poor skeletal align- Examples include the rectus femoris (seated, will shorten ment, and pain.10,33,34 at the hip and lengthen at the knee) and the hamstrings Predictions can be made regarding whether certain (seated, will shorten at the knee and lengthen at the hip). muscles will be longer or shorter than normal based on a Not all muscles can fall cleanly into a one- or two-joint cat- postural or activity assessment. For example, an individual egorization.33 However, with a strong foundational knowl- who wears high-heeled shoes and sits at a desk all day is edge of muscle origin, insertion, and action, formulating likely to have shortened hip flexors (iliopsoas), knee flexors, hypotheses about muscles being abnormally shortened or and ankle plantar flexors. She also will likely have length- lengthened should become routine during your postural ened and weak hip extensors (gluteus maximus) and ankle and movement examinations. dorsiflexors (see FIGURE 9-101). If this individual devel- Prediction of muscle length based on a muscle’s pri- ops chronic tightness in the ankle plantar flexors, and her mary function also has been suggested. Janda6,7 has clas- sified certain muscles into categories of tonic and phasic. Tonic muscles are those primarily responsible for helping us to maintain an upright posture (thus, they are also termed “postural” muscles). They often are two-joint muscles with a low tendency toward atrophy (higher percentage of slow- twitch muscle fibers), but a higher tendency to become tight or hypertonic. Phasic muscles are frequently one- joint muscles that are more suited to movement and have a higher propensity to atrophy (have a higher percentage of fast-twitch muscle fibers). Phasic muscles fatigue easily and have a higher tendency toward inhibition and weak- ness. TABLE 9-7 lists muscles commonly associated with the tonic and phasic categories. Muscles not listed are con- sidered neutral.35 Assessment of muscle length, and in turn whether a muscle is short and strong or long and weak, will lead to interventions that address these impairments. In addition to training and education to correct faulty postures, muscles that are weak should be strengthened and muscles that are short (tight) should be stretched. This section will focus pri- marily on muscles that are short, and thus in need of exer- cises to increase the muscle length (stretching). The next section, Gross Muscle Strength, will describe assessment of muscles that may be in need of strengthening. These two FIGURE 9-101 Lower extremity position of a female when categories of intervention cannot be considered in isolation sitting wearing high-heeled shoes. Prolonged sitting in this position will likely lead to long (and weak) ankle dor- as they often have a mutually dependent relationship. Con- siflexors and gluteus maximus and shortened gastrocne- sider the example of a patient with a posture consisting of mius and hamstrings. forward and internally rounded shoulders and abducted/ 266 CHAPTER 9 Musculoskeletal Examination TABLE 9-7 Muscle Group Divisions (Tonic and Phasic) Tonic (Postural) Muscles Phasic Muscles Suboccipitals Deep cervical flexors Scalenes Extensors of the upper limb Sternocleidomastoid Supraspinatus and infraspinatus Levator scapulae Lower trapezius Upper trapezius Rhomboids Flexors of the upper limb Serratus anterior Pectoralis major Thoracic erector spinae Cervical erector spinae External oblique Quadratus lumborum Transversus abdominis Lumbar erector spinae Rectus abdominis Piriformis Gluteus maximus Tensor fasciae latae Gluteus medius and minimus Iliopsoas Vastus medialis and lateralis Rectus femoris Tibialis anterior Hamstrings Peroneals Short hip adductors Tibialis posterior Gastrocnemius Soleus Data from Jull G, Janda V. Muscle and motor control in low back pain. In: Twomey L, Taylor J, eds. Physical Therapy for the Low Back: Clinics in Physical Therapy. New York: Churchill Livingstone; 2002:253–278. protracted scapulae. Prediction (and experience) tells us document any of these findings, even if a formal measure- that the pectoralis major and minor will be short (and ment is not possible. likely strong), whereas the middle and lower trapezius and It is important to keep in mind that elongation of one rhomboids will be long and weak. Stretching of the anterior muscle often will elongate others, and it is sometimes very pectoral muscles might allow the shoulder to achieve a more difficult to isolate one muscle when attempting to put it on ideal alignment, but without concurrent strengthening of maximal stretch. This highlights the importance of asking the posterior musculature (scapular adductors/retractors), your patients where a stretch is felt. At times this can help the patient will not be able to maintain this improved posi- you tease out the specific muscle being elongated in the test tion for any period of time. position. Sometimes, because of muscular overlap and simi- Objectifying a muscle’s length can be challenging; lar lines of pull, it will not be possible to isolate one muscle, studies of the reliability of muscle length assessment show and additional forms of assessment, such as palpation, may great variability.36–41 For some muscles or muscle groups, it be required. is possible to measure and document a joint angle or limb position at the muscle’s maximal length. Muscles that pri- PROCEDURE marily cause motion in one plane at a given joint, such as Although several standardized muscle length testing posi- the hamstrings at the knee or the triceps at the elbow, are tions have been published,17,18,33,42 there are very few reports good examples. Standard testing positions and measure- of what the “normal” length should be for any particular ment techniques have been developed for these and other muscle. Therefore, the best assessment tools clinicians have muscles.17,18,33 may essentially be a patient’s report and a good working What is typically more difficult to objectively assess are knowledge of the known or suspected pathology. Asking muscles that, upon contraction, cause multiplanar motions. patients whether lengthening of a muscle feels different The upper trapezius, which contributes to ipsilateral lateral (e.g., more intense, painful) on one side versus the other flexion, contralateral rotation, and extension of the cervi- can provide valuable information. Visible and palpable cal spine, as well as elevation of the shoulder complex, is side-to-side differences can also add weight to a working a prime example. While standardized tests have not been hypothesis. developed for these muscles—and there are many—the For many muscles, an active or a passive length assess- importance of assessing their length cannot be overstated. ment can be performed. If an active assessment is made, Assessing a muscle’s available length requires maximal sepa- the patient will perform the motion independently follow- ration of the origin and insertion along its line of pull. If a ing your guidance for specific movements or positioning muscle is capable of being maximally elongated, it is pos- with no overpressure provided (by you or the patient). If sible to determine if that position causes the patient dis- a passive assessment is made, you will position the patient comfort or reproduces the patient’s primary symptoms, if and then provide overpressure until no additional give is the end position is different from side to side, or if the end felt or until the patient asks you to stop. Sometimes know- point of the stretched muscle has a different amount of pas- ing the active muscle length is helpful, such as how far the sive “give” as compared to the opposite side. It is essential to triceps will stretch to allow an individual to reach overhead  Procedure 267 to scratch the upper back. Sometimes it is more helpful to method exists, it is included in the description. Otherwise, know the passive muscle length, such as how far the ankle you will need to rely on the patient’s description of what is can be pushed into dorsiflexion to determine if there is felt and your own analysis of the tissue resistance encoun- adequate motion for descending stairs. Whether active or tered when overpressure is applied. One benefit of knowing passive assessment is used, your technique should be accu- these positions is that many can be used as a patient exercise rately documented. should muscular tightness be determined as an impairment. TABLES 9-8 and 9-9 outline and describe the testing Prior to initia