Upper Extremities, Joint Movements, Range of Motion & Muscle Testing Notes

Upper Extremities & Joint Movements

• Anatomy & Kinesiology: Module B Lab

Body Planes & Directional Terms

• Body Planes:
  • Coronal (frontal): Divides the body into anterior and posterior parts.
  • Sagittal: Divides the body into left and right parts.
  • Transverse: Divides the body into superior and inferior parts.
• Directional Terms:
  • Proximal: Nearer to the trunk of the body.
  • Distal: Farther from the trunk of the body.
  • Superior (cephalad): Toward the head.
  • Inferior (caudad): Toward the tail or feet.
  • Medial: Toward the midline of the body.
  • Lateral: Away from the midline of the body.
  • Anterior: Toward the front of the body.
  • Posterior: Toward the back of the body.
  • Mandibular

Spine & Scapula Movements

• Spine:
  • Lateral bending (lateral flexion) to the left.
• Scapula:
  • Adduction (retraction): Movement of the scapula toward the midline.
  • Abduction (protraction): Movement of the scapula away from the midline.
  • Elevation: Raising the scapula.
  • Depression: Lowering the scapula.
  • Upward rotation: The inferior angle of the scapula rotates away from the midline.
  • Downward rotation: The inferior angle of the scapula rotates toward the midline.
  • "Winging" the scapula.

Shoulder (Glenohumeral Joint) Movements

• Flexion: Bending the shoulder forward.
• Extension: Straightening the shoulder.
• Hyperextension: Extending the shoulder beyond the normal range.
• Abduction: Moving the arm away from the midline of the body.
• Adduction: Moving the arm toward the midline of the body.
• External (outward) rotation: Rotating the arm outward.
• Internal (inward) rotation: Rotating the arm inward.
• Circumduction: Circular movement of the shoulder.
• Hyperabduction: Abduction of the shoulder beyond 90^{\circ}, involves rotation of the scapula.

Elbow Movement

• Flexion

Shoulder & Arm Joint Actions

• Shoulder:
  • Flexion
  • Extension
  • Horizontal Abduction
  • Abduction
  • Adduction
  • Lateral Rotation
  • Medial Rotation
• Scapula:
  • Elevation
  • Depression
  • Adduction
  • Abduction
  • Upward Rotation
  • Downward Rotation

Joint Movements & Range of Motion

• Communication with the client is essential during testing and intervention.
  • Give the client the power to ask questions.
  • Allow the client to alter treatment.
  • Allow the client to stop the session if needed.
• Explain the pain scale:
  • Use a 0-10 numerical rating scale.
    • 0 is no pain.
    • 10 is the worst pain imaginable.
  • For children, use a 0-5 pain scale.
  • Encourage them to use words like "none," "mild," "moderate," or "severe."
• Check for non-verbal cues (wincing, twitching, eyebrows, jaw clenching).

Contraindications for Joint Assessments

• Do NOT perform assessments if contraindications exist, including:
  • Joint and disk dysfunction
  • Acute pain
  • Recent trauma
  • Inflammation

Sequence for Joint Assessment (from MFTM p. 471-472)

• History (Information from the Client Intake Form MMNOPQRST)
• Observation (deformity, swollen, edema, discoloration, compare)
• Palpation (types of tissue, texture, superficial or deep?)
• Range of Motion (AROM, AAROM, ARROM, PROM)
• Manual Muscle Testing (more in WCM)
• Specific Orthopedic Tests (learning soon in WCM)

Types of Joint Movement Methods

• Active (AROM) – the client moves the area without any interaction
• Active Assisted (AAROM) – client moves with the massage therapist helps and the action remains within a comfortable limit
• Active Resisted (ARROM) – the massage therapist instructs the client to push slowly against a stabilizing hand or arm while the therapist moves the joint through its entire ROM
• Passive (PROM) – the client relaxes the joint area, while the massage therapist slowly moves the joint through a comfortable ROM

Types of Joint End-Feel (from MFTM p.468)

• Normal End-Feel
  • Soft tissue approximation: Full ROM only restricted by normal muscle bulk; painless and soft.
  • Muscular (tissue stretch): Occurs at extremes of stretch; increasing tension, springiness or elasticity.
  • Capsular (leathery): Painless, has the sensation of stretching a piece of leather (i.e., g/h joint).
  • Bony (hard): Bone contacts bone (i.e., elbow); feels abrupt and hard.
• Abnormal End-Feel
  • Empty: No physical restriction but painful to the client.
  • Muscle spasm: Passive movement stops abruptly because of pain, may act springy or reflexive.
  • Boggy: Effusion or edema is present, the feeling is mushy or soft quality.
  • Springy block (internal derangement): Springy or rebounds; loose cartilage or tissue within joint.
  • Capsular stretch (leathery): Occurs before normal ROM, capsular fibrosis with no inflammation.
  • Bony (hard): Occurs before normal ROM, indicates bony changes, joint disease or malunion.

Examples of Visual Assessment during Client's Active Joint Movements and Range of Motion

• Examples:
  • Shoulder abduction: 170^{\circ}
  • Lateral trunk flexion: 30^{\circ}
  • Leg extension: 25^{\circ}
  • Hip adductor: 30^{\circ}
  • Hip flexion: 90^{\circ}
  • Dorsiflexion: 10^{\circ}

Assessment of Shoulder Using Passive Joint Movement

• Examples:
  • Flexion glenohumeral joint only.
  • Full flexion shoulder complex including glenohumeral joint and scapular movement.
  • Horizontal abduction.
  • Horizontal adduction.
  • Internal/medial rotation.
  • External/lateral rotation.

Muscle Testing – Movement Patterns

• Testing individual movement patterns, normal function and possible dysfunction.
  1. Visual assessment for variations in position and symmetry (is one shoulder higher?).
  2. Check if the shoulder or scapula at rest (is the scapula “winging?”).
  3. Isolate the specified movement patterns on each side of your partner.
  4. Assess for normal function by applying gentle pressure opposite the action of the isolation position. Make sure the body is stabilized, so only the isolated area is moving.

Scapular Elevation

• Assesses: strength and endurance in the isolation position and tension or shortening in the scapular depression pattern
• Muscles Involved: Trapezius (upper fibers), Levator scapulae, Rhomboideus major and rhomboideus minor
• Range of Motion: 0 to 40 degrees
• Position of Client: Seated, with legs over side of table and arms relaxed
• Isolation and Assessment: Client lifts shoulders toward ears, as in shrugging, while examiner applies resistance to push the shoulders down.

Scapular Upward Rotation with Abduction

• Assesses: strength and endurance in the isolation position and tension or shortening in the scapular downward rotation pattern
• Muscles Involved: Upper and lower trapezius, Anterior serratus, Pectoralis minor
• Range of Motion: Reliable values are not available.
• Position of Client: Seated, with legs over side of table, arms resting at sides
• Isolation and Assessment: Client flexes shoulder forward to 120 degrees with no rotation or horizontal movement while examiner applies resistance to arm just above elbow to push it down.

Scapular Abduction (Protraction)

• Assesses: strength and endurance in the isolation position and tension or shortening in the scapular adduction pattern
• Muscles Involved: Serratus anterior, Pectoralis minor
• Range of Motion: 0 to 15 degrees
• Position of Client: Seated, with legs over end or side of table, and hands at sides on top of table
• Isolation and Assessment: Client flexes the straight arm to approximately 130 degrees and reaches forward to protract the scapula. The examiner palpates the medial border of the scapula and applies resistance to the arm.

Scapular Adduction (Retraction)

• Assesses: strength and endurance in the isolation position and tension or shortening in the scapular abduction pattern
• Muscles Involved: Trapezius (middle fibers), Rhomboideus major and rhomboideus minor, Latissimus dorsi
• Range of Motion: 0 to 20 degrees
• Position of Client: Seated with legs over edge of table, Shoulder abducted to 90 degrees and externally rotated, Elbow flexed to a right angle and held at shoulder level
• Isolation and Assessment: Client horizontally abducts arm to adduct the scapula while examiner applies resistance to the posterior arm above the elbow to push the arm into horizontal adduction.

Scapular Depression with Adduction and Downward Rotation

• Assesses: strength and endurance in the isolation position and tension or shortening in the scapular elevation and upward rotation pattern
• Muscles Involved: Lower trapezius, Lower anterior serratus, Levator scapula, Rhomboideus major and rhomboideus minor, Latissimus dorsi
• Range of Motion: Reliable values are not available.
• Position of Client: Prone, Head may be turned to either side for comfort. Internally rotate shoulder, flex elbow, and adduct arm across back. Hand rests on low back near waist.
• Isolation and Assessment: Client further adducts arm by attempting to touch the opposite side. Examiner applies resistance to the medial side of upper arm to pull it away from the body.

Shoulder Flexion

• Assesses: strength and endurance in the isolation position and tension or shortening in the shoulder extension and adduction pattern
• Muscles Involved: Deltoid (anterior and middle), Supraspinatus, Pectoralis major (upper), Coracobrachialis, Biceps brachii, Subscapularis
• Range of Motion: 0 to 180 degrees (including scapular movement)
• Position of Client: Seated with knees bent off table, arms at sides, elbows slightly flexed, and forearm pronated
• Isolation and Assessment: Client flexes shoulder to 90 degrees without rotation or horizontal movement while examiner applies resistance to upper arm above elbow to push arm down.

Shoulder Extension

• Assesses: strength and endurance in the isolation position and tension or shortening in the shoulder flexion pattern
• Muscles Involved: Latissimus dorsi, Deltoid (posterior), Teres major, Triceps brachii (long head)
• Range of Motion: 0 to 45 degrees
• Position of Client: Prone, with arms at sides and shoulder internally rotated (palm up), Elbow remains extended throughout isolation
• Isolation and Assessment: Client lifts arm off table and holds while examiner applies resistance to posterior arm above elbow to push it down.

Shoulder Horizontal Abduction

• Assesses: strength and endurance in the isolation position and tension or shortening in the shoulder horizontal adduction pattern
• Muscles Involved: Deltoid (posterior fibers), Infraspinatus, Teres minor
• Range of Motion: 0 to 90 degrees (beginning at 90 degrees flexion)
• Position of Client: Prone with shoulder abducted to 90 degrees, elbow flexed, upper arm supported on table, and forearm off edge of table
• Isolation and Assessment: Client horizontally (posteriorly) abducts shoulder (lifts elbow toward ceiling) while examiner applies resistance to the posterior arm above elbow to push arm down.

Shoulder Horizontal Adduction

• Assesses: strength and endurance in the isolation position and tension or shortening in the shoulder horizontal abduction pattern
• Muscles Involved: Pectoralis major, Deltoid (anterior fibers)
• Range of Motion: 0 to 40 degrees when starting from a position of 90 degrees of forward flexion
• Position of Client: Supine, Shoulder abducted to 90 degrees, upper arm supported on table, and elbow flexed to 90 degrees
• Isolation and Assessment: Client horizontally adducts arm to move it across the chest while examiner applies resistance to medial side of upper arm above elbow to push it down.

Shoulder External (or Lateral) Rotation

• Assesses: strength and endurance in the isolation position and tension or shortening in the shoulder internal or medial rotation pattern
• Muscles Involved: Infraspinatus, Teres minor, Deltoid (posterior)
• Range of Motion: 0 to 90 degrees
• Position of Client: Prone, with head turned toward test side, Shoulder is abducted to 90 degrees with upper arm fully supported on table, elbow flexed, and forearm hanging over edge of table
• Isolation and Assessment: Client moves forearm upward toward the level of the table, keeping upper arm on table, while examiner applies resistance to distal forearm above wrist to push it down.

Shoulder Internal (or Medial) Rotation

• Assesses: strength and endurance in the isolation position and tension or shortening in the shoulder external or lateral rotation pattern
• Muscles Involved: Subscapularis, Pectoralis major, Latissimus dorsi, Teres major, Deltoid (anterior)
• Range of Motion: 0 to 80 degrees
• Position of Client: Prone with shoulder abducted to 90 degrees, upper arm supported on table, elbow flexed, and forearm hanging over edge of table. Examiner stabilizes upper arm
• Isolation and Assessment: Client moves forearm through internal rotation (backward and upward) while examiner applies resistance to forearm above wrist to push it down.

Muscle Testing: Strength and Neuromuscular

Procedure for Strength Testing

• Isolate muscle or muscle group as specifically as possible
• Apply counterpressure to pull or press muscle out of its isolated position while client holds or maintains contracted position
• Sufficient force must be used to recruit a full response but not enough to recruit other muscles in the body
• The most common testing scale grades on a scale of 1 (only a flicker of movement) to 5 (normal strength)

Muscle Strength Testing Scale (Oxford Scale) Medical Research Council (MRC) grading scale

• 5- Normal: Complete ROM against gravity with full resistance
• 4- Good: Complete ROM against gravity with some resistance; Full ROM with decreased strength
• 3- Fair: Complete ROM against gravity with no resistance; active ROM
• 2-Poor: Complete ROM with some assistance and gravity eliminated
• 1-Trace: Evidence of slight muscular contraction, no joint motion evident
• 0-Zero: No evidence of muscle contraction or NT: Not testable

Muscle testing

• Medial Deltoid
• Biceps Brachii

Neurological Muscle Testing

• Neurological muscle testing focuses more on the patterns of muscle communication
• An efficient muscle pattern is one in which the muscles contract evenly, without jerking and without a lot of synergistic (helper muscle) activity
• The same isolation of muscle groups is used as in strength muscle testing: the client holds the contraction and the massage therapist provides light pressure against the muscle
• Different neurological interactions can be assessed:
  • muscle group interactions
  • muscle activation sequences and firing patterns
  • postural(stabilizer) and phasic (mover) muscle interactions

Assessing Common Muscle Activation Sequence & Muscle Firing Pattern - Knee Flexion

• Normal firing pattern
  • Hamstrings
  • Gastrocnemius
• Assessment
  • Place the client in the prone position.
  • Place your fingers on the hamstring and the gastrocnemius.
  • Instruct the client to flex the knee.
• Altered firing pattern
  • Weak agonist-hamstrings
  • Overactive synergist-gastrocnemius
• Symptoms
  • Pain behind the knee
  • Achilles tendinitis

Assessing Common Muscle Activation Sequence & Muscle Firing Pattern - Shoulder Abduction

• Normal firing pattern
  • Supraspinatus
  • Deltoid
  • Infraspinatus
  • Middle and lower trapezius
  • Contralateral lumbar area
• Assessment
  • Place the client in the seated position. Stand behind the client, and put one hand on the client's shoulder and the other on the contralateral quadratus area.
  • Instruct the client to abduct the shoulder to 90 degrees.
• Altered firing pattern
  • Weak agonist-levator scapulae
  • Overactive agonist-upper trapezius
  • Overactive stabilizer-ipsilateral quadratus lumborum
• Symptoms
  • Shoulder tension
  • Headache at the base of the skull
  • Upper chest breathing
  • Low back pain

Intervention for Altered Muscle Firing Patterns

• Use appropriate massage applications to inhibit the dominant muscle and then strengthen the weak muscles.