Week 1: Principles of Joint Motion Assessment & Principles of Muscle Testing

Principles of Joint Motion Assessment

The Basics

Planes & Axes of Motion

  • Sagittal Plane

    • Divides right/left and medial/lateral

    • Flexion & extension

  • Frontal/Coronal Plane

    • Divides anterior/posterior

    • Adduction & abduction

  • Transverse Plane

    • Divides superior/inferior

    • Internal & external rotation

Range of Motion

  • Contraindications

    • In region of dislocation, unhealed fracture

    • Post-surgery if it will disrupt healing process

    • Presence of ossification

  • Precautions

    • Painful conditions, inflamed or infected joints

    • With use of pain medicine or muscle relaxers

    • Fragile bones (e.g. stress fracture (fx), osteoporosis)

    • Hypermobile or subluxed joints

    • Following prolonged immobilization 

Assessing Motion

  • Qualitative

    • On AROM (active), assessing for:

      • Willingness to move

      • Ability to follow instructions/Level of Consciousness (LOC)

      • Coordination

      • Amount of observable motion

      • Pain

      • Strength & functional ability 

    • On PROM (passive), assessing for:

      • Amount of movement possible

      • Factors limiting movement

      • Movements that increase/decrease pain

      • Difference from AROM

      • Capsular vs. non-capsular patterns 

  • Quantitative

    • Measurement implements

      • Goniometer

        • Axis: at point of rotation for movement

        • Stationary arm: along segment that will not move

        • Movement arm: in line with segment that will move

          • Movement arm should be only thing that moves at all during testing

      • Inclinometer

        • Provides ROM reference relative to gravity

          • Requires only movement axis, but must note start position

          • Readily available (e.g. smartphones)

          • Limitations? 

      • Tape measure

    • General Principles

      • Have reference criterion on non-moving segment (or gravity)

      • Have device move with patient through motion until end-range

      • If passive, apply slight over-pressure

      • Read while on patient

      • Compare bilaterally

  • Common Measurement Errors

    • Reading wrong side/not correcting for start position

    • Tendency to read values that end in 0/5

    • Having expectations

    • Not positioning patient correctly/movement of axis/patient compliance

    • Comparing at different points in day

    • Most reliable with same clinician, day/time, tool, position, protocol

Normal End-Feels

  • Firm: Stretching soft tissue

    • Shoulder extension

  • Soft: Soft tissue contracting soft tissue

    • Elbox flexion

  • Hard: Bone contracting bone

    • Elbow extension

Abnormal End-Feels

  • Early soft / Late soft

  • Early firm / Late firm

  • Early hard / Late hard

  • Spasm

    • Patient stops you

  • Empty

    • No end-feel, no resistance

  • Springy block

Capsular Patterns

  • Capsular Pattern: limitation in specific movements that indicate capsule affected

    • E.g. osteophyte (bone spurs), arthritic changes

    • Often inconsistent due to lack of evidence

  • Close-packed position

    • High joint congruity

    • Maximal tautness of capsule & ligament

    • Opposite is loose-packed position

Documentation

  • ROM type

  • Side/Body part

  • Direction

  • Start/end degrees

  • Total ROM

  • Subjective info (pain/discomfort)

  • Objective info (appearance/spasm)

  • Type of device

Principles of Muscle Testing

Muscle Length & 2-Joint Muscles

  • Consider if a muscle will contribute to decreased ROM?

    • When assessing hip flexion, what effect will flexing/extending the knee have?

    • Passive Insufficiency: shortening the muscle of one joint so that it won’t affect the measurement of that joints ROM

Resistive Range of Motion/Manual Muscle Testing

  • RROM is the screening tool - follows physiologic ROM, narrows down muscles needing testing

  • MMT is the scoring tool - requires specific patient positioning, consideration of gravity, assessment through full ROM and break test (for 5/5)

  • What would the patient position be for:

    • Elbow flexion

    • Hip abduction

    • Ankle inversion

    • Shoulder internal rotation

Key Terminology

  • Static vs. Dynamic contractions

    • Isometric

    • Isotonic

    • Isokinetic

  • Concentric vs. Eccentric

  • Agonist

  • Antagonist

  • Synergist

    • Neutralizing/counteracting, conjoint, stabilizing/fixating

MMT Procedure

  • Explanation/instruction to patient

  • Assess first on uninvolved or opposite direction

  • Consider position (gravity dependent/eliminated)

    • Joint supported with bolister/towel

  • Stabilize proximally (hands, straps, body-weight)

  • Resist distally, perform 2-3 reps

    • If 4/5, perform break test to determine 5/5 in mid-ROM

    • Break test: “Hold this position, don’t let me break you”

    • Concentric: “Push/pull against my resistance as far as you can”

    • Eccentric: “Push/pull against my resistance, but let me win”

2-Joint Muscles

  • Can isolate muscle by making supporting muscles actively insufficient

  • Examples:

    • Gastrocnemius + Soleus perform ankle plantarflexion

    • Gastrocnemius crosses the knee, Soleus does not

    • If I flex the knee, the Gastrocnemius is unable to contract as it is already shortened, therefore it is actively insufficient

Injury Evaluation Process (HIPFLINS)

  • Process

    • Must be systematic

    • Must include each step

    • Specific tests may be justifiably included or excluded based on previous findings

  • SOAP Notes

    • Subjective

      • History

    • Objective

      • Observation, Palpation, Functional Assessment, Ligamentous testing, Neurological Testing, Special Testing

    • Assessment

      • Likely diagnosis

      • All pathologies that have not been ruled-out (r/o)

    • Plan

      • Long-term & short-term goals

      • SMART

  1. History

  2. Observation/Inspection

    1. Pain

    2. Asymmetry/atrophy

    3. Deformity

    4. Discoloration

    5. Swelling

      1. Swelling vs Edema vs Effusion

    6. Function

    7. Posture, Biomechanical Alignment

    8. Facial Expressions

    9. Symmetrical & compensatory

    10. Muscle contours

    11. Body proportions

    12. Signs of Inflammation

      1. Redness, heat, pain, swelling, loss of function

  3. Palpation

    1. Tenderness

      1. Point tenderness (TTP)

    2. Tissue Density

      1. Trigger points, knot, or spasm

    3. Deformity

    4. Temperature change

    5. Texture

    6. Crepitus

    7. Hypoesthesia

      1. Decrease sensation

    8. Anaesthesia

      1. No sensation

    9. Hyperesthesia

      1. Overly sensitive

    10. Parestnesia 

      1. Abnormal sensation (tingley)

    11. Move from bony tissue towards soft tissue

    12. Palpate away from the injury site, moves towards the injury

    13. Always compare bilaterally

    14. Document 

      1. R elbow: TTP lat epicondyle

      2. Palpable p! & crepitus L post tib tendon

  4. Functional Assessment (ROM, MMT, Gait/Function)

    1. ROM

      1. Active ROM

        1. Patient voluntarily moves through ROM without assistance

          1. Performed first unless contraindicated

        2. Look proximal, distal, and bilateral

        3. Assessing for:

          1. Willingness to move, coordination, ability to follow instructions (LOC), movements that increase or decrease pain, ability to perform, quantity 

      2. Passive ROM

        1. Clinician or external force moves through ROM

        2. Should yield more ROM than AROM

        3. Can be used to assess muscle length (in specific pattern)

        4. Always compare bilaterally

        5. Assessing for:

          1. Quality of motion, end-feel, pain (compared to AROM), quantity of motion (measurement instrument), capsular vs non-capsular patterns, contractile vs inert injuries

      3. Resisted ROM

        1. Assessing joint ROM against resistance 

          1. Do not perform if unable to achieve AROM

        2. Occurs through physiological ROM

        3. Used to narrow down list of manual muscle tests

          1. Consider all muscles that would contribute to the joint motion

        4. Assessing for:

          1. Difference from ROM, quality of movement (weakness at certain points in ROM0, weakness

      4. Manual Muscle Testing

        1. Typically isolated test of muscle function

          1. Requires specific patient positioning to isolate muscle & manipulate gravity 

        2. Scoring relative to performance relative to gravity

          1. Full ROM vs Break Test

      5. Functional Screening

        1. Squat, lunge, Functional Movement Screen (FMS)

        2. BESS, LESS

  5. Ligament Testing

    1. Joint stress tests (e.g. valgus, varus)

      1. Tests ligamentous integrity

      2. Scored as Firm (I), Soft (II), or Empty (III) end-feels

    2. Joint play assessment

      1. ROM assessed physiologic motion (e.g. flexion/extension; abduction/adduction)

      2. Joint play assessed accessory motion (e.g. glide)

      3. Scored 0-6 scale with 3 as normal

  6. Neurological Testing

    1. Determines if pain, paresthesia, or weakness is caused by peripheral nerve or nerve root injury

      1. Quarter screen tests nerve roots (e.g. C3 or C4 or T1)

      2. Peripheral nerve screen tests peripheral nerve (e.g. median nerve = C5-T1)

    2. Quarter screen assess dermatomes, myotomes, and reflexes 

  7. Tests for Specific Pathologies

    1. Narrows down the pathology

      1. Therefore done last

    2. Note the positive sign required from each test

    3. Can be used to rule in pathologies (high specificity = believe a positive test); or rule out pathologies (high sensitivity = believe a negative test)



Taking a History

General Information

Name? Age?

What sport do you play?

Patient goals

General fitness level

Diet

Mental Health

Occupation

Dominant side/limb

Chief Complaint 

What happened?

Duration

Mechanism of injury

Self Treatment

Limitations/Disability

Pain (PQRST)

Provocation

Quality

Referred, radiating, radicular

Severity

Time

Past Medical History

Previous Injuries

  • When/Outcome

  • What treatment

  • Surgery

  • Immobilized

  • Resolved? 

  • Similar feeling?

Medication

Family History

General Health/Chronic Illness

Opposite side?
Other spots in the kinetic chain?

Changes in Activity

Changes in Training/Season of sport (pre/post season)

Change in Environment

Use of protective equipment (braces, taping, gear, etc.)

Change of Footwear/Insole or Equipment

Changes in ADL (day living)

Change in Technique/Skills


Other Information

Unusual sound/sensations

Dizziness/Lightheaded

Neurological sensations - referral, 

Nausea 

Locking or catching



  • Cultural Competence

    • Explain to the patient

      • Rationale, things they may experience

      • Speak slowly & encourage questions

    • Avoid miscommunications

      • Language

      • Non-verbal

      • Respect

    • Patient-first Language

    • Open-ended questions

  • Sign vs Symptom

  • Pain Differentiation

    • Muscle pain vs Bone pain?

      • What about stress fractures vs fractures

    • Nerve vs Vascular pain?

    • Peripheral Nerve vs Nerve Root vs Sympathetic Nerve

  • Subjective Function

Red Flags

  • Severe, unremitting pain (up at night)

  • Severe chest pain

  • Bilateral neurological problems

  • Bilateral symptoms

  • Female stomach problems

  • Low back pain

  • Unexplained syncope

  • Inability to eat or drink

  • Change in urinary or bowel function