Positions and Procedure for Joint Measurements

Procedure for measuring ROM

• 1.) Position appropriately

• 2.) Stables proximal segment

• 3.) Move the distal segment through ROM

• 4.) Make a visual estimate of the ROM

• Return the distal segment to the starting point

• Palpate the anatomical bony landmarks

• Align the goniometer and measure the starting point

• Stabilize the proximal segment and move through the available ROM (be sure to instruct if it is either AROM or PROM)

• Realign goniometer using bony landmarks

• Read and record ROM

Documentation of ROM

Includes:

• Joint

• Motion

• Side of body

• AROM or PROM

• Position

• Time (before or after Rx)

Ex. R knee AROM flexion (supine) before treatment 20-100^o

Contraindications for ROM measuring

• Unstable fractures

• Unexpected increase in pain

• Movement is contraindicated

• End ROM that could cause damage to the joint

Precautions for ROM testing

• Increased pain

• Impaired mentation

• Impaired sensation

• Acute injury

Shoulder (complex) and glenohumeral flexion

• Supine (unless contraindicated), stabilize at the ribs, hand thumb up

• Fulcrum: Lateral aspect of the greater tubercle

• Proximal arm: parallel to the midaxillary line of the thorax (rib cage)

• Distal arm: lateral midline of the humerus

• Motion stop indication (complex)look for movement of the rib cage

• Motion stop indication (GH iso): look for movement of the lateral border of the scapula

Shoulder extension

• Prone, towel under shoulder, elbow HAS to be flexed

• Fulcrum: lateral aspect of the greater tubercle

• Proximal arm: parallel to the midaxillary line of the thorax

• Distal arm: lateral midline of the humerus, use lateral epicondyle

• Motion stop indication: upward movement of the rib cage

Shoulder (complex) and glenohumeral abduction

• Supine scooted away from the therapist so their arm could slide on the table with palm up

• Fulcrum: anterior aspect of the acromion process

• Proximal arm: parallel to the midline of the anterior aspect of the sternum

• Distal arm: anterior midline of the humerus

• Motion stop indication (shoulder complex): flaring of the rib cage laterally

• Motion stop indication (glenohumeral abduction): feel and watch for lateral movement of the scapula

• AROM is taken in sitting

Shoulder External and Internal rotation (only glenohumeral)

• Position: supine, shoulder adducted to 90dgs, elbow flexed, off the table, and on a towel

• Fulcrum: olecranon process

• Proximal arm: perpendicular to or parallel to the floor

• Distal arm ulna (align between the olecranon and ulnar styloid)

• Motion stop indication: the chest moving on ER and shoulder lifting on IR

Shoulder Horizontal Abduction and Adduction (shoulder complex)

• Position: supine, arm parallel to floor, elbow flexed, arm moves posterior towards the floor (arm moves anterior during adduction)

• Fulcrum: superior aspect of acromion process

• Proximal arm: perpendicular to the floor

• Distal arm: midline of humerus toward lateral humeral epicondyle

Elbow Flexion and Extension

• Position: Supine, back of upper arm laying on a rolled towel (to pull elbow off the table) to allow for full elbow extension and flexion

• Fulcrum: lateral epicondyle of the humerus

• Proximal arm: lateral midline of the humerus, reference center of the acromion process

• Distal arm: lateral midline of the radius, reference radial head, and radial styloid

• Motion stop indication: extend until hard end-feel for extension and flex until soft end-feel for flexion

• *Might have to hover goniometer away from joint and “eyeball” the alignment because the towel and carrying angle of the arm will be in the way

• The towel does not need to be as high during flexion but the humerus should be parallel to the table

Forearm Supination and Pronation

• Position: Sitting with the forearm midway between supination and pronation, elbow flexed at 90dgs, support wrist

• Fulcrum: laterally and proximally to the ulnar styloid process

• Proximal arm: parallel to the anterior midline of the humerus

• Distal arm: across the dorsal aspect, just proximal to the styloid processes of the radius and ulna

• Motion stop indication: normal end feel for sup and pro

Wrist Flexion and Extension

Position: sitting with wrist off the table able to go into full flexion

Fulcrum: lateral aspect of the wrist over the triquetrum

Proximal arm: lateral midline of the ulna, using olecranon and styloid for reference

Distal arm: lateral midline of the 5th MC (pinky)

Motion stop indication: normal end feels for both motions

*Fingers need to be relaxed for both motions to prevent muscle length problems

Radial and Ulnar Deviation

Position: sitting with arm, wrist, and hand on the table palm down

Fulcrum: dorsal aspect of the wrist over the capitate

Proximal arm: dorsal midline of the forearm

Distal arm: dorsal midline of the 3rd MC

Motion stop indication: normal end-feels for both motions

MCP Flexion and Extension

Position: sitting with arm, wrist, and hand on the table, the hand is on its side (pinky side)

Fulcrum: dorsal aspect of the MCP joint

Proximal arm: dorsal midline of the MC

Distal arm: dorsal midline of the proximal phalanx

MCP Abduction

Position: sitting with arm, wrist, and hand on the table palm down

Fulcrum: dorsal aspect of the MCP joint

Proximal arm: dorsal midline of the MC

Distal arm: dorsal midline of the proximal phalanx

PIP Flexion and Extension

Position: sitting with arm, wrist, and hand on the table and the hand on its side

Fulcrum: dorsal aspect of the PIP joint (or DIP)

Proximal arm: dorsal midline of the proximal phalanx (middle phalanx)

Distal arm: dorsal midline of the middle phalanx (distal phalanx)

*Parenthesis are adjustments for DIP joint measurements

Thumb CMC Flexion and Extension

Position: sitting with hand on the table palm up

Fulcrum: palmar aspect of the 1st CMC joint

Proximal arm: imaginary line between the palmar surface of the trapezium and the pisiform

Distal arm ventral midline of the 1st MC

Thumb CMC Abduction

Position: sitting with hand on the table on its side

Fulcrum: lateral aspect of the radial styloid process

Proximal arm: lateral midline of the 2nd MC, using the center of the 2nd MCP joint for reference

Distal arm: lateral midline of the 1st MC, using the center of the 1st MCP joint for reference

Thumb MCP Flexion

Position: sitting with hand on the table palm up

Fulcrum: dorsal aspect of the MCP (IP joint)

Proximal arm: dorsal midline of the MC (proximal phalanx)

Distal arm: dorsal midline of the proximal phalanx (distal phalanx)

*Parenthesis are the adjustments for thumb IP flexion

Pec major (muscle length testing)

• Supine

• Hands behind head, elbows flared out

• Trying to rest elbow on the table

• Measure form elbow to table

Pec minor (muscle length testing)

• Supine, arms at sides

• Measure from the lateral posterior acromion process to the table

Biceps brachii (muscle length testing)

• Supine, shoulder, and one arm hanging off the table

• Wrist in pronation, elbow flexed, and shoulder extended

• Extend the elbow while keeping the wrist in pronation and the shoulder in extension - stop when you feel wrist turning into supination

• Measure the angle (goniometer at lateral epicondyle to radial styloid) and subtract from 0dgs (which is normal ROM for full elbow extension)

Wrist extensor and flexor (muscle length testing)

• Sitting, wrist and half of forearm off the table

• For extension, have them extend their fingers and push them into extension - measure the angle at the ulnar styloid

• For flexion, press down on the back of the hand while they have a closed fist then measure the angle at the ulnar styloid

Hip Flexion

• Position: supine

• Fulcrum: lateral aspect of the greater trochanter

• Proximal arm: lateral midline of the pelvis (going towards the rib cage)

• Distal arm: lateral midline of the femur, using the lateral epicondyle for reference

• Keep contralateral leg extended (if possible)

• Stabilize the pelvis so that it remain neutral

Hip Extension

• Position: prone

• Fulcrum: lateral aspect of the greater trochanter

• Proximal arm: lateral midline of the pelvis (going towards the rib cage)

• Distal arm: lateral midline of the femur, using the lateral epicondyle for reference

• PROM will require assistance

• Prevent anterior tilt of the pelvis

• KNEE STAYS IN EXTENSION

Hip Abduction

• Position: supine, stabilize at the iliac crest

• Fulcrum: ASIS of the hip

• Proximal arm: horizontal line from ASIS to ASIS

• Distal arm: anterior midline of the femur, using the patella for reference

• Don’t allow lateral rotation or flexion of the femur

• Don’t allow lateral trunk flexion

• Adduction is the same but the opposite direction

Hip Medial/Lateral Rotation

• Position: prone (or sitting on EOB)

• Fulcrum: anterior aspect of the patella

• Proximal arm: perpendicular to the floor

• Distal arm: anterior midline of the lower leg, using the crest of tibia and middle point between two malleoli for reference

• Femur needs to stay in the horizontal plane

• Prevent rotation of the pelvis

Knee Extension/Flexion

• Position: supine, place towel under ankle for ext.

• Fulcrum: lat epicondyle of femur

• Proximal arm: shaft of femur even with greater trochanter

• Distal arm: shaft of fibula to the lay malleolus

Thomas Test (hip flexors)

• Tests one and two joint muscle that flex the hip ( the iliopsoas, rectus femoris, sartorius, TFL, pectineus, add longus and brevis)

• Steps

  • Have pt sit close to the edge of the table and lean back with both knees to the chest

  • Pt lets one leg hang down as far as it can go while holing behind the knee on other leg

  • Look and see if the thigh (upper leg) is flat - if so, measure the knee

  • If the knee is equal to or greater than 80dgs, the test is negative

  • If the either the thigh is not flat or the knee is less than 80dgs flexion, the test is positive

Straight Leg Test

• Supine, non-testing leg straight

• Testing the hamstrings (semitendinosus, semimembranosus, and biceps femoris)

• Between 70-80 dgs is considered normal

• Careful with someone who has acute lumbar or hip pathology

90/90 Test (distal hamstring or popliteal)

• Supine

• Hip and knee of one leg flexed to 90 dgs

• While stabilizing the thigh, extend the knee until this pelvis or spine start (pelvis posterior rotation, or spine lumbar flexion, or both)

• Measure the knee extension and document how far from 180 it is

Ober Test

• Tests the TFL and Iliotibial band

• NEUTRAL (starting position) is 0 dgs (leg is level while in sidelying)

• 3 steps:

  • Have the patient in side-lying facing away from therapist and relax their top leg

  • Support the leg and go into hip flexion then raise the leg with into abduction (all while the knee is flexed)

  • Pull the leg back (while knee is stilled flexed) and line the lateral midline of the thigh/femur with the greater trochanter then lower the leg until you feel pull from the IT band

• The thigh has to drop below 10 dgs horizontally for the test to be considered negative

Ely Test

• Patient in prone and test the RECTUS FEMORIS

• Same procedure as the knee flexion ROM test

• Anterior pelvic/hip flexion is when the muscle is at the end of its length

• 90 dgs of flexion or more is considered normal

Ankle Dorsiflexion/Plantar Flexion

• Position: sitting

• Fulcrum: lateral aspect of the lateral malleolus

• Proximal arm: Lateral midline of the fibula, using the head of the fibula as a reference

• Distal arm: above and parallel lateral aspect of 5th metatarsal

• The knee HAS TO BE IN FLEXION so that gastrocnemius is slack

Ankle Inversion/Eversion

• Position: sitting

• Fulcrum: anterior aspect of the ankle midway between the malleoli (needs a flexible goniometer)

• Proximal arm: anterior midline of the lower leg, using tibial tuberosity for reference

• Distal arm: anterior midline of the second metatarsal

Ankle Rearfoot Inversion/Eversion

• Position: prone, feet hanging off the table

• Fulcrum: posterior aspect of the ankle midway between the malleoli

• Proximal arm: posterior midline of the lower leg

• Distal arm: posterior midline of the calcaneus

MTP Flexion/Extension

• Position: supine or sitting

• Fulcrum: dorsal aspect of the MTP joint

• Proximal arm: dorsal midline of the metatarsal

• Distal arm: dorsal midline of the proximal phalanx

MTP Abduction

• Position: supine with knee bent or sitting

• Fulcrum: dorsal aspect of the MTP joint

• Proximal arm: dorsal midline of the metatarsal

• Distal arm: dorsal midline of proximal phalanx

IP Flexion ( basically same for PIP or DIP flexion)

• Position: supine or sitting

• Fulcrum: dorsal aspect of the IP joint

• Proximal arm: dorsal midline of the proximal phalanx

• Distal arm: dorsal midline of the phalanx distal to the joint being tested

Cervical flexion

• Position: sitting upright with feet flat and back straight (very important)

• Procedure: Palpate between C7 and T1 (movement of T1 indicated when the motions should be stopped)

• Goniometer fulcrum goes over the ear with one arm vertical and one arm lined up with the base of the nose

• An inclinometer can be used as well over C8-T1 and the top of the head

Cervical Extension

• Position: sitting upright with feet flat

• Indication to stop: when cervical extension causes thoracic extension

• Goniometer placement:

  • Fulcrum: over the ear hole

  • Proximal arm: vertical

  • Distal arm: line up with the base of the nose

Cervical rotation

• Position: sitting upright with feet flat and back straight

• Indication to stop: when further rotation cause rotation of the trunk and shoulders

• Goniometer placement:

  • Fulcrum: centered over the head (on a vertical axis)

  • Proximal arm: facing directly forward in line with the nose (or the imaginary lining up the the acromion?)

  • Distal arm: same as proximal but follows the head as it rotates

Cervical side bending

• Pt position: sitting while being supported

• Indication to stop: when further lateral flexion causes lateral flexion of the trunk or shoulders - prevent substitution by rotation

• Goniometer placement:

  • Fulcrum: over C7

  • Proximal arm: vertically down the spine

  • Distal arm: vertical to the occipital protuberance and then follows the head as it bends

Thoracolumbar flexion

• Pt position: standing, feet flat and upright - then bend forward

• Indication to stop: when the patient cannot flex without the pelvis anteriorly tilting

• Tape measure placement: top hand at T1-T2 (make a mark) and bottom hand at S2 (level with the PSIS for ref)

• INCLINOMETERS: same placement as tape measurer

Thoracolumbar extension

• Pt position: standing, feet flat and upright

• Indication to stop: when the pt cannot extend without posteriorly tilting the pelvis

• Tape measure placement: same as flexion

Thoracolumbar lateral flexion

• Pt position: standing upright with feet flat

• Indication to stop: when pt must flex, extend or rotate to go farther

• Tape measure placement and procedure: marks at the tip of the longest finger with arm straight and then another mark using the same finger after pt has laterally flexed