OTR 704 3.1 Palpation, Screening, & ROM

Anatomical palpation

Method of physical examination using tactile touch with fingers and hands to assess skin, bony landmarks, and soft tissues; palpate from superficial to deep (light pressure gradually increased) and check for:

• Temperature, tone, edema, mobility of skin, scar tissue

• Crepitus, nodules, spasms, trigger points, tissue consistency

Functional Movement Screening (ROM Screening)

Assesses basic ability to produce volitional movement and typically begins with AROM against gravity

• Occurs at onset of evaluation and throughout plan of care; informs need for further ROM assessment (PROM & goniometry)

• Looks for evidence of: abnormal limb posturing, deviations in trunk alignment, compensatory movement patterns, weakness, inability to selectively control joints, discoordination of movement timing and/or multi-joint movements

How does muscle tissue influence ROM?

Often associated with decreased flexibility in concert with their respective tendons and fascia

• Increasing flexibility relies on elastic properties of muscle

• Length can be changed over time

• Muscle strength may also impact ROM due to size, type, and length-tension relationship

How does connective tissue influence ROM?

Ligaments and joint capsules, while possessing some elastic properties, can lose their elasticity during periods of disuse and immobilization; may also be loose or lax

Connective tissue composition

• Collagen: strong, flexible, inelastic structure that holds connective tissue together; enables tissue to resist mechanical deformation

• Elastin: extensible; allows elongation then return to normal length

• Reticulin: fine fibers

• Ground substance: material between fibers functioning to decrease friction; nutrient transport

Fibrous connective tissue

• Dense (regular & irregular): tendons, ligaments, joint capsules, aponeurosis, periosteum — highly organized, greater cross links creating more dense tissue

• Areolar (loose): adipose, fascia associated with skin, muscle fibers, nerves — unorganized, increased space between the individual fibers

Cartilage

Rigid connective tissue composed of chondrocytes within a collagen, elastin, ground substance matrix

• Types: hyaline, fibrocartilage, and elastic

Reticular connective tissue

Supports structural walls of organs

Elastic connective tissue

Composed of elastic fibers and found in blood vessels, airways, and hollow organs

How do bony structures/joint structures influence ROM?

Can limit end point range, can also stop movement at normal end points in the range

• Ligaments, capsule integrity, and joint surface all influence overall ROM

How does adipose tissue influence ROM

Can act as a “wedge” between lever arms; restricts movement wherever it is found

How does skin influence ROM?

Injury or surgical procedure may alter skin, resulting in tightness & scar tissue formation (e.g., burns)

• Stretching can improve ROM to varying degress

How does neural tissue influence ROM?

Develops tightness as a result of compression, chronic repetitive microtrauma, muscle imbalances, joint dysfunction, or poor posture

How do demographic/personal factors influence ROM?

• Age: increased age = decreased ROM

• Sex: hormonal & anatomical differences impact ROM

• Pre-existing conditions & diagnoses: conditions like arthritis and SCI influence ROM

End-feel

The resistance in a joint that is felt at the end ranges of passive limits of motion

• An abnormal end-feel may indicate a comorbidity or complication

Hard end-feel

Bone-to-bone; stop in movement as bony surfaces meet

• Ex: elbow extension, knee extension

Soft end-feel

Soft-tissue approximation; stop in movement due to soft tissues (e.g., muscles)

• Ex: elbow flexion, knee flexion, shoulder adduction

Firm end-feel

Capsular end-feel; stop in movement that feels somewhat firm or leathery but has some “give” at the end-range

• Ex: shoulder & hip rotation, shoulder abduction

Active ROM (AROM)

Available ROM of a specific joint when the client is volitionally moving the body part/joint

• Often the focus of evaluation

Active-assisted ROM (AAROM)

Available ROM of a specific joint when the practitioner or supportive device aids the client in moving

• Client’s body part/joint is still volitionally participating

• Often used in treatment

Passive ROM (PROM)

Available ROM of a specific joint when the practitioner or client passively moves the body part/joint

• Often used in addition to AROM or if AROM is not possible

Goniometry

ROM assessment that provides an objective measure of ROM

• Universal goniometer is most commonly used device

Passive and active insufficiency

Can occur with muscles that cross more than one joint simultaneously

• Passive: reaches maximum ability to elongate; prevents full ROM

• Active: simultaneous movement at all the joints, reaches its shortest length and is unable to produce effective tension/force

Optimal sufficiency

Balance between the soft tissue structures surrounding the joint; balance between the agonist and antagonist musculature (length & tension) allowing for simultaneous stabilization across muscle joints

ROM assessment precautions

• Healing fractures

• Muscular or tendinous injury

• Significant pain or discomfort

• Known or chronic heterotrophic ossification (ectopic ossification)

• Hypermobility of a joint

• Infection or inflammatory condition

• Marked osteoporosis

ROM assessment contraindications

• Subluxation or dislocation of a joint

• Acute myositis ossificans or ectopic ossification

• Hematoma of a joint

• Known DVTs

ROM assessment client positioning

• Start in anatomical/neutral position (most joints are considered “in neutral" or 0 degrees)

• Maintain consistent start position with trials & re-assessment

• Consider age, HPI/injury, comfort, observation abilities

• Allow movement through full arc of motion

ROM general procedures

1. Position client appropriately and support/stabilize as needed

2. Explain procedure and demonstrate (as needed)

3. Palpate & locate bony landmarks → place goniometer

4. Client performs AROM to best of ability (ASK: “Is that as far as you can go?”)

5. Observe for any compensations

6. Read goniometer & record degrees achieved

***ROM screening performed prior to formal measurements

Parts of the goniometer

What is occurring if PROM > AROM?

• Muscle weakness

• Neuromotor deficits

• Pain with volitional movement

What is occurring if AROM > PROM?

• Guarding

• Assessor error

What is occurring if AROM = PROM but both are below normal limits?

• Soft tissue tightness

• Hypertonicity

• Abnormal end feels (especially abnormal hard end feels)

Effects of immobilization on connective/soft tissue

Even without injury, connective tissue is consistently remodeling, therefore if movement through ROM does not occur over time, motion will be lost due to shortening of soft tissue; general soft tissue changes include:

• Reduced ground substance & increased collagen cross-links,

• Contracted fiber meshwork & wound contraction

• Fibrosis and replacement of tissue with collagen

• Weakness

Effects of immobilization on muscle

• Decreased muscle fiber size & reduced number of myofibrils

• Reduced oxidative capacity & force production

• Increase in fibrous & fatty tissue in the muscle

• Reduced intramuscular capillary density

• Atrophy can be seen in two weeks

• With prolonged immobilization, the normal neural feedback system of movement is lost

• Histological changes: decreased ATP, creatine phosphate, & glycogen

Effects of immobilization on articular cartilage

Changes depend on position of immobilization, duration of immobilization,and weight-bearing status of joint

• Less matrix organization

• Necrosis of areas of constant pressure

• Increased fibrofatty tissue within the joint that becomes scar tissue

• Irreversible damage occurs with continued immobilization

Effects of immobilization on periarticular connective tissue

Periarticular connective tissue = soft tissue surrounding the joint, such as ligaments, the joint capsule, fascia, tendons, and synovial membranes

• Connective tissue becomes thick and fibrosis

• Clinical results = decreased ROM

Effects of re-mobilization

Enhances recovery; resolves abnormal collagen cross-link formation and increases fluid content in the extracellular matrix of connective tissue

• Muscle fibers: early mobilization increases hematoma absorption, tensile strength, and myofiber regeneration & orientation; minimizes adhesions

• Articular cartilage: early controlled loading stimulates proteoglycan & chondrocyte production = promotes healthy function of tissue

• Periarticular cartilage: early mobility decreases excessive collagen fiber cross-linking and maintains fluid content of the extracellular matrix; reduced changes of tissue becoming thick & fibrous

Shoulder flexion normal ROM

0-170°

Shoulder flexion goniometry

• Axis: Center of humeral head, distal to acromion process on lateral aspect of humerus

• Stationary arm: Parallel to the trunk

• Movable arm: Parallel to the humerus, aligned with the sagittal plane

• End-feel: Firm

Shoulder extension normal ROM

0-60°

Shoulder extension goniometry

• Axis: Center of humeral head, distal to acromion process on lateral aspect of humerus

• Stationary arm: Parallel to the trunk

• Movable arm: Parallel to the humerus, aligned with the sagittal plane

• End-feel: Firm

Shoulder abduction normal ROM

0-170°

Shoulder abduction goniometry

• Axis: Below the acromion process on the posterior surface of the shoulder, in line with the joint center at the humeral head

• Stationary arm: Parallel to the trunk

• Movable arm: Parallel to the humerus, pointing at the lateral epicondyle of the elbow

• End-feel: Firm

Shoulder internal rotation (against gravity; shoulder abducted) normal ROM

0-70°

Shoulder internal rotation (against gravity; shoulder abducted) goniometry

• Axis: Olecranon process

• Stationary arm: Horizontal position

• Movable arm: Parallel to the forearm, aligned with the ulna

• End-feel: Firm

Shoulder internal rotation (gravity-reduced; shoulder adducted) normal ROM

0-40°

Shoulder internal rotation (gravity-reduced; shoulder abducted) goniometry

• Axis: Olecranon process

• Stationary arm: Horizontal and pointed forward in the sagittal plane

• Movable arm: Parallel to the forearm, follows the arc of movement in a horizontal plane

• End-feel: Firm

Shoulder external rotation (against gravity; shoulder abducted) normal ROM

0-90°

Shoulder external rotation (against gravity; shoulder abducted) goniometry

• Axis: Olecranon process

• Stationary arm: Horizontal in neutral, parallel to the forearm

• Movable arm: Follows forearm in vertical arc in sagittal plane

• End-feel: Firm

Shoulder external rotation (gravity-reduced; shoulder adducted) normal ROM

0-60°

Shoulder external rotation (gravity-reduced; shoulder adducted) goniometry

• Axis: Aligned with and below the olecranon process

• Stationary arm: Parallel to the forearm

• Movable arm: Parallel to the forearm, follows the forearm in lateral arc towards the abdomen

• End-feel: Firm

Shoulder horizontal adduction normal ROM

0-130°

Shoulder horizontal adduction goniometry

• Axis: Over acromion process

• Stationary arm: Parallel to the line between the left and right acromion, over the shoulder toward the neck

• Movable arm: Parallel to the humerus on the superior aspect

• End-feel: Firm or soft

Shoulder horizontal abduction normal ROM

0-40°

Shoulder horizontal abduction goniometry

• Axis: Over acromion process

• Stationary arm: Parallel to the line between the left and right acromion, over the shoulder toward the neck

• Movable arm: Parallel to the humerus on the superior aspect

• End-feel: Firm or soft

Elbow flexion normal ROM

0 to 135-150°

Elbow flexion goniometry

• Axis: Lateral epicondyle at end of elbow crease

• Stationary arm: Parallel to midline of humerus or aimed at humeral head

• Movable arm: Parallel to radius

• End-feel: Soft, hard, or firm

Elbow extension normal ROM

0°

Elbow extension goniometry

• Axis: Lateral epicondyle at end of elbow crease

• Stationary arm: Parallel to midline of humerus or aimed at humeral head

• Movable arm: Parallel to radius

• End-feel: Hard or firm

Forearm supination normal ROM

0 to 80-90°

Forearm supination goniometry

• Axis: Ulnar border of the volar aspect of the wrist, just proximal to ulnar styloid

• Stationary arm: Vertical, perpendicular to floor

• Movable arm: Resting against volar aspect of wrist

• End-feel: Firm

Forearm pronation normal ROM

0 to 80-90°

Forearm pronation goniometry

• Axis: Ulnar border of dorsal aspect of wrist, just proximal to ulnar styloid

• Stationary arm: Perpendicular to floor

• Movable arm: Squarely across center of dorsum of distal end of forearm between the styloids

• End-feel: Hard

Wrist flexion normal ROM

0-80°

Wrist flexion goniometry

• Axis: Lateral wrist just distal to radial styloid in anatomical snuffbox

• Stationary arm: Parallel to the radius

• Movable arm: Parallel to 2^nd metacarpal (index finger)

• End-feel: Firm

Wrist extension normal ROM

0-70°

Wrist extension goniometry

• Axis: Lateral wrist just distal to radial styloid in anatomical snuffbox

• Stationary arm: Parallel to the radius

• Movable arm: Parallel to 2^nd metacarpal (index finger)

• End-feel: Firm or hard

Wrist radial deviation normal ROM

0-20°

Wrist radial deviation goniometry

• Axis: Dorsum of wrist at base of 3^rd metacarpal in a hollow over the capitate

• Stationary arm: Follows the midline of the dorsal aspect of the forearm

• Movable arm: Parallel to the 3^rd metacarpal aligned with the third MCP joint

• End-feel: Firm

Wrist ulnar deviation normal ROM

0-30°

Wrist ulnar deviation goniometry

• Axis: Dorsum of wrist at base of 3^rd metacarpal in a hollow over the capitate

• Stationary arm: Follows the midline of the dorsal aspect of the forearm

• Movable arm: Parallel to the 3^rd metacarpal aligned with the third MCP joint

• End-feel: Firm or hard

MCP flexion normal ROM

0-90°

MCP flexion goniometry

• Axis: Dorsal aspect of MCP joint

• Stationary arm: Dorsal surface of hand following metacarpal

• Movable arm: Dorsal surface of proximal phalanx

• End-feel: Hard or firm

MCP extension normal ROM

0-45°

MCP extension goniometry

• Axis: Lateral aspect of MCP joint

• Stationary arm: Parallel to the metacarpal

• Movable arm: Parallel to the proximal phalanx

• End-feel: Firm

MCP abduction normal ROM

0-25°

MCP abduction goniometry

• Axis: Over MCP

• Stationary arm: Over corresponding metacarpal

• Movable arm: Over proximal phalanx

• End-feel: Firm

PIP flexion normal ROM

0-110°

PIP flexion goniometry

• Axis: Lateral surface of PIP

• Stationary arm: Lateral side of proximal phalanx

• Movable arm: Follows middle phalanx

• End-feel: Usually hard

PIP extension normal ROM

0°

PIP extension goniometry

• Axis: Lateral surface of PIP

• Stationary arm: Lateral side of proximal phalanx

• Movable arm: Follows middle phalanx

• End-feel: Usually hard

DIP flexion normal ROM

0-80°

DIP flexion goniometry

• Axis: Dorsal surface of DIP

• Stationary arm: Over middle phalanx

• Movable arm: Over distal phalanx

• End-feel: Soft or firm

1st CMC extension (radial abduction) normal ROM

0-50°

1st CMC extension (radial abduction) goniometry

• Axis: Dorsal surface of CMC at the base of the thumb metacarpal, in the anatomical snuffbox

• Stationary arm: Parallel to the radius

• Movable arm: Aligned with the 1^st metacarpal of the thumb

• End-feel: Firm

1st CMC abduction (palmar abduction) normal ROM

0-50°

1st CMC abduction (palmar abduction) goniometry

• Axis: Junction of thumb and index finger metacarpals, in the anatomical snuffbox

• Stationary arm: Over the radius

• Movable arm: Parallel to the 1^st metacarpal of the thumb

• End-feel: Firm

1st MCP flexion normal ROM

0-50°

1st MCP flexion goniometry

• Axis: Parallel to the dorsal surface of the MCP

• Stationary arm: Over the thumb metacarpal

• Movable arm: Over the proximal phalanx

• End-feel: Hard or firm

1st MCP extension normal ROM

0°

1st MCP extension goniometry

• Axis: Parallel to the dorsal surface of the MCP

• Stationary arm: Over the thumb metacarpal

• Movable arm: Over the proximal phalanx

• End-feel: Firm

1st IP flexion normal ROM

0 to 80-90°

1st IP flexion goniometry

• Axis: Over the dorsal surface of the IP

• Stationary arm: Over the proximal phalanx

• Movable arm: Over the distal phalanx

• End-feel: Firm

1st IP extension normal ROM

0 to 20-30°

1st IP extension goniometry

• Axis: Over the dorsal surface of the IP

• Stationary arm: Over the proximal phalanx

• Movable arm: Over the distal phalanx

• End-feel: Firm

Thumb to 5th digit opposition normal ROM

0 (if pads of thumb and 5^th digit can touch)

Thumb to 5th digit opposition goniometry

• Measure the distance between centers of the pads of the thumb and 5^th digit

• End-feel: Soft or firm

Hip flexion normal ROM

0-120°

Hip flexion goniometry

• Axis: Greater trochanter

• Stationary arm: Middle of lateral aspect of pelvis at greater trochanter, parallel to the trunk

• Movable arm: Parallel to the long axis of the femur on the midline of the lateral aspect of the thigh

• End-feel: Soft

Knee flexion normal ROM

0-135°