__Measurement_of_Joint_Motion__A_Guide_to_Goniometry_3rd_Edition

Measurement ofJoint Motion A Guide to Goniometry

(, ::/f¥¥5f&tt~\\~ Cynthia C. Norkin, EdO, PT ~.. ~. Former Associate Professor and DIrector 'iF'41\" School of Physical Therapy /D'Iil\\11i' , (,;}!;C~ilege of Health and Human Services ,?!ic)hioUniversity j'Athens, Ohio ,:V,;, ,d. joyce White, OSc, PT ;ro, A~sociate Professor of Physical Therapy College of Health Professions University of Massachusens Lowell Lowell, Massachusetts Measurement ofJoint Motion A Guide to Goniometry THIRD EDITION Photographs by Jocelyn Greene Molleur and Lucia Grochowska Littlefield Illustrations by Timothy Wayne Malone Additional illustrations provided by Jennifer Daniell and Meredith Taylor Stelling + F. A. Dovl' Comp,ny • Phil,d\"phi.

FIRST INDIAN EDITION 2004 84-5 © 2003 by F.A. Davis Company ThiS:.,edltionhas be;en,published in India by arrangement with F.A. Davis Company, 1915 Arch:.:Slreel, Philadelphia, PA 10103. All rights reserved. No part of this publication may be .reproduced, slored· in a retrieval system. or transmitted in any form or by any means, elect~onic, mechanical, photocopying, recording or otherwise, without prior written permission from the publisher. inFor Sale I~~ia. Pakistan, Bangladesh, Burma, Bhutan and Nepal only. Printed In India Published by Jitendar P Vij Jaypee\" Brothers Medical Publishers (P) Ltd EMCA House, 23/238 Ansari Road. Oaryaganj New Del\"i 110002. India Phones: 23272143,23272703,23282021,23245672 Fax: 011·23276490, 23245683 e-mail: [email protected] ViSit our website: www.jaypeebrothers.com Branches • 202 Batavia Chambers, B Kumara Krupa Road. Kumara Park East Ban9alore 560001, Phones: 22285971, 22382956 Tele Fax: 22281761 e-mail: [email protected] • 282 Illrd Flool. Khalaal Shilazi Estate, Fountain Plaza Panlheon Aoad. Chennal 600 008. Phone: 8262665 Fax: 8262331 e-mail: jpmedpub@·md3.vsnl.net.in 4-2-1067/1-3. 1st Floor. Baraji Building, Ramkote Cross Road Hyderabad 500 095, Phones: 55610020, 24758498 Fax: 24758499 a-mail: [email protected] lA Indian Mirror Streel. Wellington Square Kolka!a 700013, Phone: 2451926 Fax: 2456075 a-mail: [email protected] 106 Amit Industrial Estale. 61 Or SS Aao Road, Neal MGM Hospital Parel, Mumbai 400 012, Phones: 24124863, 24104532 Fax: 24160828 a-mail: [email protected] Printed by Gopsons Papers Ltd., Seclor 60. Naida .ij

To Alexandra, Taylor, and Kimberly. CCN To Jonathan, Alexander, and Ethan. DJW

The measurement of joint motion is an important motion of the spine are also added to coincide with component of a thorough physical examination of the current practice in some clinical settings. We introduce extremities and spine, one which helps health profession- illustrations to accompany anatomical descriptions so als identify impairments and assess rehabilitative status. that the reader will have a visual reminder of the joint The need for a comprehensive text with sufficient written structures involved in range of motion. New illustrations detail and photographs to allow for the standardization of bony anatomical landmarks and photographs of of goniometric measurement methods-both for the surface anatomy will help the reader align the goniome- purposes of teaching and clinical practice led to the ter accurately. In addition, over 180 new photographs development of the first edition of the Measurement of replace many of the older, dated photographs. Joint Motion: A Cuide to Coniometry in 1985. Our approach included a discussion and illustration of testing Similar to earlier editions, the book presents goniom- position, stabilization, end-feel, and goniometer align- etry logically and clearly. Chapter 1 discusses basic ment for each measurable joint in the body. The resulting concepts regarding the use of goniometry to assess range text was extremely well received by a variety of health of motion and muscle length in patient evaluation. professional educational programs and was used as a Arrhrokinematic and osteokinematic movements, reference in many cl!nical settings. elements of active and passive range of motion, hypomo- bility, hypermobility, and factors affecting joint motion In the years following inirial publication, a consider- are included. The inclusion of end-feels and capsular and able amount of research on the measurement of joint noncapsular patterns of joint limitation introduces read- motion appeared in the literature. Consequently, in the ers to current concepts in orthopedic manual therapy and second edition, which was published in 1995, we created encourages them to consider joint structure while meas- a new chapter on the reliability and validity of joint uring joint motion. measurement and added joint-specific research sections to existing chapters. We also expanded the text by adding Chapter 2 takes the reader through a step-by-step structure, osteokinematics, arthrokinematics, capsular process to master the techniques of goniometric evalua- and noncapsular patterns of limitation, and functional tion, including: positioning, stabilization, instruments ranges of motion for each joint. used for measurement, goniometer alignment, and the recording of results. Exercises that help develop neces- The expanded third edition includes new research sary psychomotor skills and demonstrate direct applica- findings to help clarify normative range of motion values tion of theoretical concepts facilitate learning. for various age and gender groups, as well as the range of motion needed to perform common functional tasks. Chapter 3 discusses the validity and reliability of We added current information on the effects of subject measurement. The results of validity and reliability stud- characteristics, such as body mass, occupational and ies on the measurement of joint motion are summarized recreational activities, and the effects of the testing to help the reader focus on ways of improving and inter- process, such as the testing position and type of measur- preting goniometric measurements. Mathematical meth- ing instrument, on range of motion. New to the third ods of evaluating reliability are shown along with edition is the inclusion of muscle length testing at joints examples and exercises so that the readers can assess where muscle length is often a factor affecting range of their reliability in taking measurements. motion. This addition integrates the measurement proce- >lures used in this book with the American Physical Chapters 4 to 13 present detailed information on Therapy Association's Cuide to Physical Therapy goniometric testing procedures for the upper and lower Practice. Inclinometer techniques for measuring range of extremities, spine, and temporomandibular joint. When appropriate, muscle length testing procedures are also included. The text presents the anatomical lanIUlllar\"\"

viii PREFACE testing position, stabilization, testing motion, normal end- We hope this book makes the reaching and learning of feel, and goniometer alignment for each joint and motion, goniometey easier and improves the standardization and in a format that reinforces a consistent approach to eval- thus rhe reliabiliry of rhis assessmenr tool. We believe uation. The exrensive use of photographs and caprions thar the rhird edirion provides a comprehensive coverage eliminares the need for repeated demonstrations by an of rhe measurement of joint marion and muscle length. instruc(Qc and provides the reader with a permanent We hope thar rhe addirions will morivate healrh profes- reference for visualizing rhe procedures. Also included sionals (0 conduct research and to use research results in is information on joint structure, osteokinematic and evaluation. We encourage our readers to provide us with arrhrokinematic motion, and capsular patterns of restric- feedback on our currenr efforts ro bring you a high- tions. A review of current literature regarding normal quality, user-friendly rext. range of motion values; rhe effecrs of age, gende~ and other factors; funcrional range of motion; and reliability CCN and validity is also presented for each body region ro assisr rhe reader to comply with evidence-based practice. DJW

We are very grateful for the contributions of the many Publisher, and Susan Rhynet, Manager of Creative people who were involved in the development and Development, for their encouragement, ingenuity, and production of this text, Photographer Jocelyn Molleur commitment to excellence. Thanks are also extended to applied her skill and patience during many sessions at Sam Rondinelli, Production Manager; Jack Brandt, the physical therapy laboratory at the Universiry of Illustration Specialist; Louis Forgione, Design Manager; Massachusetts Lowell to produce the high-qualiry photo- Ona Kosmos, Editorial Associate; Melissa Reed, graphs that appear in this third edition. Her efforts Developmental Associate; Anne Seitz, Freelance Editot; combined with those of Lucia Grochowska Littlefield, and Jean-Francois Vilain, Former Publisher, We are who took the photographs for the fitst edition, are grateful to the numetous students, faculry, and clinicians responsible for an important featute of the book. who over the years have used the book Ot formally Timothy Malone, an artist from Ohio, used his talents, reviewed portions of the manuscript and offered insight- knowledge of anatomy, and good humor to create the ful comments and helpful suggestions. excellent illustrations that appear in this edition. We also offer OUt thanks to Jessica Bouffard, Alexander White, Finally, we wish to thank our families: Cynthia's and Claudia Van Bibber who graciously agreed to be daughter, Alexandta, and Joyce's husband, Jonathan, subjects for some of the photographs. and sons, Alexander and Ethan, fot their encouragement, We wish to exptess our appreciation to these dedi- support, and tolerance of \"time away\" for this endeavor. cated professionals at F. A Davis: Margaret Biblis, We will always be appteciative. ix \\I\"

Suzanne Robben Brown, MPH, PT Deidre Lever-Dunn, PhD, ATC Associate Professor & Chair Assistant Professor Department of Physical Therapy Department of Health Sciences Arizona School of Health Sciences Program Director Mesa, AZ Athletic Training Education University of Alabama Larty Chinnock, PT, EdD Tuscaloosa, AL Instructor!Academic Coordinator Department of Physical Therapy John T. Myers, PT, MBA Lorna Linda University InstrucrorlProgram Director School of Allied Health Professions Physical Therapy Assistant Program Lorna Linda, CA Lorain County Community College Elyria,OH Robyn Colleen Davies, BHSCPT, MAPPSC, PT James R. Roush, PhD, PT, ATC Lecturer Associate Professor Department of Physical Therapy Department of Physical Therapy Arizona School of Healrh Science University of Toronto Mesa, AZ Toronto, Canada Sharon D. Yap, PTA, BPS Jodi Gootkin, PT Academic Coordinator of Clinical Education Site Coordinator Physical Therapy Assistant Program Physical Therapy Assistant Program Indian River Community College Broward Community College Fort Pierce, FL Ft. Myers, FL xi J

PART I 1 EXERCISE 4: Explanation of Gonlometry Introduction to Goniometry EXERCISE 5: Testing Procedure for Gonlometrlc Evaluation of Elbow Flexion CHAPTER 1 3 CHAPTER 3 39 Basic Concepts Validity and Reliability GONIOMETRY VALIDITY JOINT MOTION Face Validity Content Validity Arthrokinematics Criterion-related Validity Osteokinematics Construct Validity RANGE OF MOTION Active Range of Motion RELIABILITY Passive Range of Motion Summary of Goniometric Reliability Studies Hypomobility Statistical Methods of Evaluating Measurement Hypermobility Reliability Factors Affecting Range of Motion Exercises to Evaluate Reliability MUSCLE LENGTH TESTING EXERCISE 6: Intratester Reliability EXERCISE 7: Intertester Reliability CHAPTER 2 17 Procedures POSITIONING PART II 55 STABILIZATION Upper-Extremity Testing 57 EXERCISE 1: Determining the End of the Range of CHAPTER 4 Motion and End-feel The Shoulder MEASUREMENT INSTRUMENTS Universal Goniometer STRUCTURE AND FUNCTION Gravity-dependent Goniometers (Inclinometers) Glenohumeral Joint Electrogoniometers Sternoclavicular Joint Visual Estimation Acromioclavicular Joint EXERCISE 2: The Universal Goniometer Scalpulothoracic Joint ALIGNMENT RESEARCH FINDINGS EXERCISE 3: Goniometer Alignment for Elbow Effects of Age, Gender, and Other Factors Flexion Functional Range of Motion Reliability and Validity RECORDING Numerical Tables RANGE OF MOTION TESTING PROCEDURES: THE Pictorial Charts SHOULDER Sagittal-frontal-transverse-rotation Method American Medical Association Guide to Evaluation LANDMARKS FOR GONIOMETER ALIGNMENT Method Flexion Extension PROCEDURES Explanation Procedure Testing Procedure

xiv CON TEN T S Abduction RESEARCH FINDINGS Adduction Effects of Age, Gender, and Other Factors Medial (Internal) Rotation Functional Range of Motion Lateral (External) Rotation Reliability and Validity CHAPTER 5 91 RANGE OF MOTION TESTING PROCEDURES: FINGERS LANDMARKS FOR GONIOMETER ALIGNMENT The Elbow and Forearm Metacarpophalangeal Flexion STRUCTURE AND FUNCTION Metacarpophalangeal Extension I Humeroulnar and Humeroradial Joints Metacarpophalangeal Abduction Superior and Inferior Radioulnar Joints Metacarpophalangeal Adduction Proximal Interphalangeal Flexion RESEARCH FINDINGS Proximal Interphalangeal Extension Effects of Age, Gender, and Other Factors Distal Interphalangeal Flexion Functional Range of Motion Distal Interphalangeal Extension Reliability and Validity RANGE OF MOTION TESTING PROCEDURES: THUMB LANDMARKS FOR GONIOMETER ALIGNMENT RANGE OF MOTION TESTING PROCEDURES: ELBOW AND Carpometacarpal Flexion FOREARM Carpometacarpal Extension Carpometacarpal Abduction LANDMARKS FOR GONIOMETER ALIGNMENT Carpometacarpal Adduction Flexion Carpometacarpal Opposition Extension Metacarpophalangeal Flexion Pronation Metacarpophalangeal Extension Supination Interphalangeal Flexion Interphalangeal Extension MUSCLE LENGTH TESTING PROCEDURES: ELBOW AND MUSCLE LENGTH TESTING PROCEDURES: FINGERS FOREARM Lumbricals, Palmar and Dorsal Interossei Biceps Brachii Triceps Brachii CHAPTER 6 111 PART III Lower-Extremity Testing The Wrist STRUCTURE AND FUNCTION 181 Radiocarpal and Midcarpal Joints CHAPTER 8 183 RESEARCH FINDINGS Effects of Age, Gender, and Other Factors The Hip Functional Range of Motion Reliability and Validity STRUCTURE AND FUNCTION Iliofemoral joint RANGE OF MOTION TESTING PROCEDURES: WRIST LANDMARKS FOR GONIOMETRIC ALIGNMENT: THE RESEARCH FINDINGS Effects of Age, Gender, and Other Factors WRIST Functional Range of Motion Flexion Reliability and Validity Extension Radial Deviation RANGE OF MOTION TESTING PROCEDURES: HIP Ulnar Deviation LANDMARKS FOR GONIOMETER ALIGNMENT MUSCLE LENGTH TESTING PROCEDURES: WRIST Flexor Digitorum Profundus and Flexor Digitorum Flexion Extension Superficialis Abduction Extensor Digitorum, Extensor Indicis, and Extensor Adduction Medial (Internal) Rotation Digiti Minimi Lateral (External) Rotation MUSCLE LENGTH TESTING PROCEDURES CHAPTER 7 137 Hip Flexors (Thomas Test) The Hamstrings: Semitendinous, Semimembranosus, The Hand and Biceps Femoris (Straight Leg Test) STRUCTURE AND FUNCTION Tensor Fascia Latae (Ober Test) Fingers: Metacarpophalangeal joints Fingers: Proximal Interphalangeal and Distal CHAPTER 9 2 21 Interphalangeal Joints i' Thumb: Carpometacarpal Joint The Knee Thumb: Metacarpophalangeal joint ,_; 'L Thumb: Interphalangeal Joint STRUCTURE AND FUNCTION ; Tibiofemoral and Patellofemoral Joints '.-; L. ,,-.

CONTENTS xv RESEARCH FINDINGS PART IV Effects of Age, Gender, and Other Factors Testing of the Spine and 293 Functional Range of Motion Temporomandibular Joint Reliability and Validity RANGE OF MOTION TESTING PROCEDURES: KNEE LANDMARKS FOR GONIOMETER ALIGNMENT CHAPTER 11 \" \" \" . \" .. 295 Flexion The Cervical Spine \"\"\"\".\" Extension STRUCTURE AND FUNCTION Atlanto-occipital and Atlantoaxial Joints MUSCLE LENGTH TESTING PROCEDURES: KNEE Intervertebral and Zygapophyseal joints Rectus Femoris: Ely Test RESEARCH FINDINGS Hamstring Muscles: Semitendinosus, Semimembranosus, and Biceps Femoris: Distal Hamstring Length Test CHAPTER 10 \" 241 Effects of Age, Gender, and Other Factors Functional Range of Motion The Ankle and Foot Reliability and Validity STRUCTURE AND FUNCTION RANGE OF MOTION TESTING PROCEDURES: Proximal and Distal Tibiofibular joints CERVICAL SPINE Talocrural joint LANDMARKS FOR GONIOMETER ALIGNMENT Subtalar joint Flexion Transverse Tarsal (Midtarsal) joint Extension Tarsometatarsal joints Lateral Flexion Metatarsophalangeal Joints Rotation Interphalangeal Joints RESEARCH FINDINGS Effects of Age, Gender, and Other Factors CHAPTER 12 Functional Range of Motion The Thoracic and Lumbar Spine \"\".\" .. \".331 Reliability and Validity RANGE OF MOTION TESTING PROCEDURES: ANKLE STRUCTURE AND FUNCTiON AND FOOT Thoracic Spine ~1 LANDMARKS FOR GONIOMETER ALIGNMENT: Lumbar Spine RESEARCH FINDINGS TALOCRURAL JOINT Dorsiflexion: Talocrural joint Effects of Age, Gender, and Other Factors Plantarflexion: Talocrural joint Functional Range of Motion Reliability and Validity 83 LANDMARKS FOR GONIOMETER ALIGNMENT: TARSAL JOINTS RANGE OF MOTION TESTING PROCEDURES Inversion: Tarsal Joints ANATOMICAL LANDMARKS: FOR TAPE MEASURE Eversion: Tarsal Joints ALIGNMENT LANDMARKS FOR GONIOMETER ALIGNMENT: SUBTALAR Thoracic and Lumbar Flexion JOINT (REARFOOn lumbar Flexion Inversion: Subtalar Joint (Rearfoot) Thoracic and Lumbar Extension Eversion: Subtalar Joint (Rearfoot) Lumbar Extension Inversion: Transverse Tarsal Joint Thoracic and Lumbar Lateral Flexion Eversion: Transverse Tarsal Joint Thoracic and Lumbar Rotation LANDMARKS FOR GONIOMETER ALIGNMENT: METATARSOPHALANGEAL JOINT Flexion: Metatarsophalangeal joint CHAPTER 13 365 Extension: Metatarsophalangeal joint Abduction: Metatarsophalangeal joint The Temporomandibular Joint Adduction and Metatarsophalangeal joint STRUCTURE AND FUNCTION Flexion: Interphalangeal joint of the First Toe and Temporomandibular Joint Proximal Interphalangeal joints of the Four Lesser Toes RESEARCH FINDINGS Extension: Interphalangeal joint 'of the First Toe and Effects of Age, Gender, and Other Factors Proximal Interphalangeal joints of the Four Lesser Toes Reliability and Validity Flexion: Distal Interphalangeal joints of the Four Lesser RANGE OF MOTION TESTING PROCEDURES: Toes TEMPOROMANDIBULAR JOINT t21 Extension: Distal Interphalangeal Joints of the Four LANDMARKS FOR RULER ALIGNMENT MEASURING Depression of the Mandible (Mouth Opening) Lesser Toes MUSCLE LENGTH TESTING PROCEDURES: Protrusion of the Mandible Lateral Deviation of the Mandible ,. Gastrocnemius \" j J;;;;jx~4.:;/'

xvi CONTENTS APPENDIX C 383 APPENDIX A Goniometer Price Lists 387 .375 393 Normative Range of Motion Values APPENDIX D APPENDIX B Numerical Recording Forms Joint Measurements by Body 381 Index Position i ~.

83 87 ,93 Introduction to Goniometry Objectives ON COMPLETION OF PART 1 THE READER WILL BE ABLE TO: 1. Define: 5. Describe the parts of universal, fluid, and pendulum goniomctcrs goniomerry planes and axes 6. List: range of motion end-feel the six-step explannrion sequence mllscle length testing rhe 12-srcp testing sequence reliability rhe 10 items included in recording validity 7. Perform a goniomcrric evaluation of the 2. Identify the appropriate planes and axes for elbow joint including: each of the following motions: a clear explanation of rhe procedure tlexion-extcnsion, abduction-adduction, and positioning of a subject in the testing position rotation adequate stabilization of the proximal joint 3. Compare: componenr a corn;ct determination oJ the end of the range active and passive ranges of motion arrhrokinematic and osteokinematic motions of motion soit, iirm, and hard end-feels a correct identification of the end-feci hypomobiliry and hypermobility palpation of the correcr bony landmarks capsular and noncapsular pan:erns of accurate alignmclH of rhe goniometer carn::C£ reading of the goniometer and record- rcsrricred motion one·, two-, and multijoinr muscles ing of the measurement rcliabiliry and validiry intratesrer and- intcrrestcr .re[jab.ili[~1 8. Perform and interpret intratestcr and imertcstcr reliability tests including standard .; 4. Explain the importance of: deviation, coefficient of variation, correlation coefficients, and standard crror of mcasure- resting positions ment. stabilization clinical estimates of range of motion recording st~1rting and ending positions

Basic Concepts I This book is designed to serve as a guide to learning the Therefore, goniometry refers to the. measurement of technique of human joint measutement called goniome- angles, inJ'art~cular the meas.urement of angles cteated.\"!.- try,. Background information on principles and proce- human joints by the bones of the body, The examiner dures necessary for an understanding of goniometry is obtains these measurements by placing the parts of the found in Part 1. Ptactice exercises are included at appro- measuring instrument, called a goniometer, along the ptiate intervals to help the examiner apply this informa- bones immediately proximal and distal to the joint being tion and develop the psychomotor skills necessary for evaluated, Goniometry may be used to determine both a competency in goniometry, Procedures for the goniomet- particular joint position and the total amount of motion ric examination of joints and muscle length testing of the available at a joint, upper extremity, lower extremity, and spine and temporomandibular joint are presented in Parts 2, 3, and 4, respectively, • Goniometry The term gQlliometry is derived from two Greek wordSh gonia, meaning angle, a~~~,,~!J...tQ!h., meaning measure. FIGURE I-I The upper left extremity of a subject in the supine position is shown. The pans of the measuring instru- ment have been placed along the proximal (humerus) and distal (radius) components and centered over the axis of the elbow joint, When the distal component has been moved toward the proximal component (elbow flexion), a measurement of the arc of motion can be obtained. 3

r 4 PART I INTRODUCTION TO GONIOMETRY Goniometey is an important part of a comprehensive (glides). spins, ond rolls.' A slide (glide), which is a trans- examination of joints and surrounding soft tissue. A !awr)' motion, is the sliding of one joint surface Over comprehensive examination typically begins by inter- anmher, as \\vhcn a braked wheel skids. A spin is a rotary viewing the subject and reviewing records to obtain an (3ngular) motion, similar ro the spinning of a toy top. All accurate description of current symptoms; functional points on the moving joim surface rotate at a constant abilities; occupational, social and recreational activities; disrance around a fixed axis of motion. A roll is a rotary and medical history. Observation of the body to assess motion similar to the rolling of the bottom of a rocking bone and sofr tissue contour, as well as skin and nail chair on the floor, or the rolling of a tirc on the road. In condition, usually follows the interview. Gentle palpation the human body, glides, spins, and rolls Llsually Occur in is used to determine skin temperature and the quality of combination \\vith each other and result in movement of soft tissue deformities and to locate pain symptoms in the shafts of the bOI1('·s. rdation to anatomical structures. Anthropometric mea- surements such as leg length, circumference, and body Osteokinematics volume may be indicared. Ostcokincmatics refers to the movement of the shafts of ;:'; \" The performance of acrive joint motions by the subject bones father than the movemcnt of joint surfaces. The \":- during the examinacion allows the examiner to screen for movements of the shafts of borll'S are usually described in ), abnormal movements and gain information about the terms of the rorary mOtion produced. as if the movement i subject's willingness to move. If abnormal active motions o~curs around a fixed axis of motion. Goniomctr}· mea- ;i ( 3rc found, the examiner performs passive joint motions SlIfC:'S the angles created by the rotary morion of the shafts in an attempt co determine reasons for joint limitation. of the bones. However, some translatory motion usually ')1 I Performing passive joint motions enables the examiner to accompanies rotary motion and creates a slightly chang- assess the tissue that is limiting the motion, detect pain, ing .lxis of motion during movement. Ncverrheless, most ( and make an estimate of the amount of motion. clinicians find the description of osreokilH.:matic move- ( Goniometry is used to measure and document the ll1em in terms of rotary motion sufficiently accurate and amount of active and passive joint motion as well as lise goniometry ro measure osrcokincmatic movcments. \"~ abnormal fixed joint positions. Resisted isometric muscle contractions, joint integrity and mobility tests, and Planes and Axes special tests for specific body regions are used in conjunc- 3 tion with goniometty to help identify the injured anatom- ical structures. Tests to assess muscle performance and Osteokinematic mOtions arc classically described as neurological function are often included. Diagnostic imaging procedures and laborarory tests may be taking place in one of the three cardinal planes of the required. bod)\" (sagittal, fromal, transverse) around three corre- '\" Goniometric data used in conjunction with other information can provide a basis for: sponding axes {medial-lateral, anterior-posterior, verti- • Determining the presence or absence of impairment col). The three planes lie at right angles to one another, • Establishing a diagnosis 1 • Developing a prognosis, treatment goals, and plan whereas the three axes lic at right angles both to one f- of care • Evaluating progress or lack of progress roward another and to their corresponding planes. , rehabilitarive goals The sagirral plane proceeds from the amerior to the • Modifying treatment • Motivating the subject posterior aspect of the body. The median sagittal plane • Researching the effectiveness of therapeutic tech- divides the body into right and left halves. The motions niques or regimens; for example, exercises, medica- tions, and surgical procedures of flexion and extension occur in the sagirral plane (Fig. • Fabricating orthoses and adaprive equipment 1-2). The axis around which the motions of flexion and • Joint Motion extension occur may be envisioned as a line that is Arthrokinematics perpendicular to the sagittal plane and proceeds from Motion at a joint occurs as the result of movement of one joint surface in relation to another. Arthrokinematics is one side of the body to the other. This axis is called a the term used to refer to the movement of joint surfaces. The movements of joint surfaces are described as slides medial-lateral axis. All mOtions in the sagittal plane take place around a medial-lateral axis. The fro mal plone proceeds from one side of thc body to the other and divides the body into from and back halves. The motions that occur in the frontal plane are abduction and adduction (Fig. 1-3). Thc axis around which the motions of abduction and adduction take place is an amerior-posterior axis. This axis lies at right angles ro the fromal plane and proceeds from the ame- rior to the posterior aspect of the body. Therefore, the anterior-posterior axis lies in the sagittal plane. The transverse plane is horizontal and divides the body into upper and lower portions. The motion of rota-

CHAPTER 1 BASIC CONCEPTS 5 ;- Anterior - posterior axis 'Y II It 'Y 'g n n MediaHateral axis )f Ie n 1,-t ts Iy ,,- FIGURE 1-2 The shaded areas indicate the sagittal plane. This FIGURE 1-3 The frontal plane, indicated by the shaded area, st plane extends from the anterior aspect of the body to the poste- extends from one side of the body ro the other. Motions in this e- rior aspect. Motions in this plane, such as flexion and exten- plane, such as abduction and adduction of the upper and lower sion of the upper and lower extremities, rake place around a extremities, take place around an anterior~posterior axis. medial-lateral axis !ion occurs in the transverse plane around a vertical axis motions such as circumduction (flexion·abduction·exten- 15 (Fig. 1-4A and B). The vertical axis lies at right angles to sion-adducrion) are possible at many joints, but because \\e the transverse plane and proceeds in a cranial to caudal of the limitations imposed by the uniaxial design of the e- direction. measuring instrument, only motions occurring in a single :1- The morions described previously are considered to plane are measured in goniometry. ~r, occur in a single plane around a single axis. Combination The rype of motion that is available at a joint varies Ie Ie Vertical axis Transverse Vertical 1e '\\ plane ' axis 1S f tJ~ FIGURE 1·4 (Aj The trans- verse plane is indicated by the g. A {\"A·· . Id shaded area. Movements in is \\ -';=t m I this plane take place around ;a a (e --tJ.,...--- vertical axis. These motions 1,,,· . Iy include rotation of the heaci I :k (B), shoulder, (Aj, and hip; •• II well as pronation and,,~,~,p(na- re ,I tion of the forearm.' ' .d (e B ot e- Ie •. 1,-e ~ , \\

6 PA RT I INTRODUCTION TO GONIOMETRY according to the structure of the joint. Some joints, such (( .,, as the interphalangeal joints of the digits; permit a large amount of motion in only one plane around a single axis: ~L' 1 flexion and extension in the sagittal plane around a medial-lateral axis. A joint that allows motion in only I F: one plane is described as having 1 degree of freedom of motion. The interphalangeal joints of the digits have 1 ! \"ir degree of freedom of motion. Other joints, such as the glenohumeral joint, permit motion in three planes l ZI around three axes: flexion and extension in the sagittal plane around a medial-lateral axis, abduction and adduc- a, tion in the frontal plane around an anterior~posterior axis, and medial and lateral rotation in the transverse g. plane around a vertical axis. The glenohumeral joint has si three degrees of freedom of motion. a The planes and axes for each joint and joint motion to be measured are presented for the examiner in Chapters \\I 4 through 13. c~ !![Ii; Range of Motion B o o Range of motion (ROM) is the arc of motion that occurs FIGURE 1-5 (A) In the anatomical position, the forearm is at a joint or a series of joints.' The starting position for supinated so that the palms of the hands face anteriorly. (B) t, measuring all ROM, except rotations in the transverse When the forearm is in a neurral position (with respect to rota- plane, is the anatomical position. Three notation systems d have been used to define ROM: the 0- ro 180-degree tion), the palm of the hand faces the side of the body. ti system, the 180- to O-degree system, and the 360-degree a system. measured (Fig. 1-{i). Documentation of extension ROM usually incorporates only the extension that occurs n In the 0- to 180-degree notation system, the upper beyond the zero starting position. The term extension, as and lower extremity joints are at 0 degrees for flexion- it is used in this manual, refers to both the motion that is extension and abduction-adduction when the body is a return from full flexion to the zero starting position in anatomical position (Fig. 1-5A). A body position in and rhe morion· that normally occurs beyond !he zero which the extremity joints are halfway between medial starting position. The term hyperextension is 'used to (internal) and \"lateral (external) rotation is 0 degrees describe a greater than normal extension ROM. for the ROM in rotation (Fig. 1-5B). An ROM normally begins at 0 degrees and proceeds in an arc toward 180 Two other systems of notation have been desctibed. degrees. This 0- to 180-degree system of notation, The 180- to O-degree notation system defines anatomical also called the neutral zero method, is widely used position as 180 degrees. 1O An ROM begins at 180 throughout the world. First described by SilverJ in degrees and proceeds in an arc toward 0 degrees. The 1923, its use has been supported by many authorities, 360-degree notation system also defines anatomical posi- including Cave and Roberts; Moore,\"· the American tion as 180 degrees. ll •l1 The motions of flexion and Academy of Orthopaedic Surgeons,'\" and the American. abduction begin at 180 degrees and proceed in an arc Medical Association! roward 0 degrees. The motions of extension and adduc- tion begin at 180 degrees and proceed in an arc roward In the preceding example, the portion of the exrension 360 degrees. These two notation systems are more diffi- ROM from full shoulder flexion back to rhe zero srarting cult to interpret than the 0- to 180-degree notation position does not need to be measured because rhis ROM system and are infrequently used. Therefore, we have not represents the same arc of motion that was measured in included them in this text. flexion. However, the portion of the extension ROM that is available beyond the zero starting position must be Active Range of Motion Active range of motion is rhe arc of motion attained by a subject during unassisted voluntary joint motion. Having

CHAPTER 1 BASIC CONCEPTS 7 Passive Range of Motion Passive tange of motion is the arc of motion attained by an examinet without assistance from the subject. The subject remains relaxed and plays no active role in producing the motion. Normally passive ROM is slightly greater than active ROM 13.14 because each joint has a small amount of available motion that is not under voluntary control. The additional passive ROM that is available at the end of the normal active ROM is due to the strerch of tissues surrounding the joint and the reduced bulk of relaxed muscles. This additional passive ...0...0 ROM helps to protect joint structures because it allows III the joint to absorb extrinsic forces . III . . Testing passive ROM provides the examiner with 0 E information about the integrity of the articular surfaces - -...0 and the extensibility of the joint capsule, associated liga- c: ments, muscles, fascia, and skin. To focus on these issues, passive ROM rather rhan active ROM should be tesred .2 ->< in goniometry. Unlike active ROM, passive ROM does ~ not depend on the subject's muscle strength and coordi- nation. Comparisons between passive ROMs and active ROMs provide information abour rhe amount of motion permitted by the joint structure (passive ROM) relative to the subject's ability to produce motion at a joint lrm is (active ROM). In cases of impairment such as muscle Iy. (8) ) rota- ,ero.\\\"\",lenSlon weakness, passive ROMs and active ROMs may vary .... Zero ROM considerably. .ccurs \"e~ oO,as :hat is n to zero sition : zero FIGURE 1-6 Shoulder flexion and extension. Flexion begins The examiner should test passive ROM prior to ed to with the shoulder in the anatomical position and the forearm performing a manual muscle test of muscle strength because the grading of manual muscle tests is based on tibed. in the neutral position. The ROM in flexion proceeds from the completion of a joint ROM. An examiner must know the .mical zero position rhrough an arc of 180 degrees. The long, bold extent of the passive ROM before initiating a manual , 180 arrow shows the ROM in flexion, which is measured in muscle test. ;. The goniometry. The shore, bold arrow shows the ROM in exten- I posi- If pain occurs during passive ROM, it is often due to 11 and sion, which is measured in goniometry. moving, stretching, or pinching of noncontractile (inert) LO arc structures. Pain occurring at the end of passive ROM .dduc- a subject perform active ROM provides the examinet may be due to stretching of contractile structures as well with infotmation about the subject's willingness to move, as noncontractile structures. Pain during passive ROM is ~watd cootdination, muscle sttength, and joint ROM. If pain not due to active shorrening (contracting) of contracrile OCcurs during active ROM, it may be due to contracting tissues. By comparing which motions (active versus ! diffi- or stretching of \"contractile\" tissues, such as muscles, passive) cause pain and noting the location of the pain, tendons, and their attachments to bone. Pain may also be the examiner can begin to determine which injured ration due to stretching or pinching of noncontractile (inert) rissues are involved. Having the subject perform resisted isometric muscle contractions midway through the ve not tissues, such as llgaments, joint capsules, bursa, fascia, ROM, so that no tissues are being stretched, can help d by a and skin. Testing active ROM is a good screening tech· to isolate contractile structures. Having the examiner laving nique to help focus a physical examination. If a subject ,;, can complete active ROM easily and painlessly, furthet testing of that motion is probably not needed. If, s1 however, active ROM is limited, painful, or awkward, the physical examination should include additional test- t ing to clatify the problem.

• 8 PART I INTRODUCTION TO GONIOMETRY TABLE 1-1 Normal End-feels ' , ROM; that jo -~~~t1exfQ.~1conta(tb~tween soft ti5s~e ofposterior j'eg and ~~terior thigh) ' H-!~nl~xio~~,-*ItJl the kne.e straighSJpassive elastic tension of hamstring muscles) occur~ '~ht~9~)\"qQ~Sf9i~tacarpophal,an,~~al jo,l,~,is, ,of flnge(~ (tension in the anterior capSUle) .1.· ::f?f~~r,w,~,,~pination in(tteenrossioselloiu~s,Jmhe~m_bpraaln,e~t~_r.roa~dlj(i)quulen~crolrjdg)a'men~-_,ofth-e):'.n' ferior ity fn He;r~dioliln'aRJeint, ' I ROM maliti~ j itboW'.eXt~_rfiion «(oota.ct betweep the olecranon process of the ulna and the n~ joint '; well a ;.'t\\f~to(em~nbrdOssaof the. humerus) has b ~~\"\"':> ._iJ:=--:. -. such, spinal perform Joint mobiliry and JOint integrity tests on the safe and accurate performance of goniometry. The ability conse subject can help determine which noncontractile struc- to distinguish among the various end-feels helps the scar, tures are involved. Careful consideration of the end-feel examiner identify the type of limiting structure. Cyriax) IS dons and locaJion of tissue tension .and pain during passive Kaltenborn,16 and Paris 17 have described a variety of also 1 ROM also adds information about structures that arc normal (physiological) and abnormal (pathological) end- move limiting ROM. feels I ' Table 1-1, which describes normal end-feels, \"nd In ad been End-feel Table 1-2, which describes abnormal end-feels, have been adapted from the works of these amhors. Cap~ The amount of passive ROM is determined by the unique structure of the joint being tested. Some joints arc struc- In Chapters 4 through 13 we describe what we believe Cyri:: tured so that the joint capsules limit the end of the ROM arc the normal end-feels and the structures that limit the invol in a particular direction, whereas other joints are so ROM for each joint and motion. Because of the p311city patte structured that ligaments limit the end of a particular of specific literature in this area, these descriptions ~lrC motii ROM. Other normal limitations to morion include based on our experience in evaluating joint motion nnd a caJ;: passive tension in soft tissue such as muscles, fascia) and on infornl<1tion obtained from established anaromyl9,20 l1uml skin, 50ft tissue approximation, and contact of joint and biomechanics texts 21 -2.7 There is considerable prop surfaces. controversy among experts concerning the strucmrcs that limir the ROM in some parts of the body. Also, The type of structure that limits a ROM has a c~arac­ normal individual variations in body strucmre may cause teristic feel that may be detected by the examiner who is instances in which [he end-feci differs from our descrip- performing the passive ROM. This feeling, which is tion. experienced by an examiner as a barrier to further motion ar the end of a passive ROM, is called the Examiners should practice trying ro distinguish end-feel. Developing the ability to determine the charac- among the end-feels. In Chapter 2, Exercise I is included ter of the end-feel· requires practice and sensitivity. for this purpose. However, some additional topics Determinarion of the end-feel mUSt be carried out slowly regarding positioning and stabilization must be and carefully to detect the end of the ROM and to distin- addressed before this exercise can be completed. guish among the various normal and abnormal end-feels. The ability to detect the end of the ROM is critical to the Hypomobility The term hypomobiliry refers to a decrease in passive TABLE 1-2 Abnormal End-feels

CHAPTER 1 BASIC CONCEPTS 9 I ROM that is substantially less than normal values for Capsular patterns vary from joint to joint (Table 1-3). tbat joint, given the subject's age and gender. The end-feel The capsular pattern for each joint, as presented by lity occutS earlier in the ROM and may be different in qual- Cyriax lS and Kaltenborn,16 is listed at the beginning of the ity from what is expected. The limitation in passive Chapters 4 through 13. Studies are needed to test the ROM may be due to a variety of causes including abnor- hypotheses regarding the cause of capsular patterns and , 15 malities of the joint surfaces or passive shortening of ioint capsules, ligaments, muscles, fascia, and skin, as to determine the capsular pattern for each joint. Studies \" well as inflammation of these structures. Hypomobility by Fritz and coworkers,4l and Hayes and colleagues·2 of has been associated with many orthopedic conditions have examined the construct validity of Cyriax's capsular nd- pattern in patients with arthritis or arthrosis of the such as osteoarthritis, 28,29 adhesive capsulitis,30.31 and knee. Although differing opinions exist, the findings Ind seem to support the concept of a capsular pattern of spinal disorders.32, 33 Decreased ROM is a common restriction for the knee but with more liberal interpreta- ave cgnsequence of immobilization after fractures34,35 and scat development after burns.36, 37 Neurological condi- tion of the proportions of limitation than suggested by Icve tigns such as stroke, head trauma, and cerebral palsy can Cyriax. 15 also result in hypomobility owing to loss of voluntaty the city movement, increased muscle tonc, and immobilization. IUaddition, metabolic conditions such as diabetes have are been associated with limited joint motion. 38, 39 and ~gpsular Patterns of Restricted Motion 1'),20 c:ytiaxl5 has proposed that pathological conditions involving the entire joint capsule cause a particular able pa.ttern of restriction involving all or most of the passive ures \"1qtions of the joint. This pattern of restriction is called \\Iso, ~<:apsular pattern. The restrictions do not involve a fixed Juse nwnber of degrees for each motion, but rather, a fixed :rip- pr9porrion of one motion relative to another motion. ,uish TABLE 1-3 Capsular Patterns of Extremity Joints \"ded )PiCS be issive

10 PA RT I INTRODUCTION TO GONIOMETRV Herding and Kessler43 have thoughrfully extended specific instances of increased ROM as compared with menl Cyriax's concepts on causes of capsular patterns. They adults. For example, neonates 6 to 72 hours old have time suggest that conditions resulting in a capsular pattern of been found to have a mean ankle dorsiflexion passive surCI restriction can be classified into two general categories: ROM of 59 degrees;4 which contrasts with the mean exan \"(1) conditions in which there is considerable joint effu- adult ROM of between 12 45 and 20? degrees. The later sion or synovial inflammation, and (2) conditions in increased motion that is present in these children is infO! which there is relative capsular fibrosis. )}43 normal for their age. If the increased motion should fearc persist beyond the expec[ed age range, it would be 4 th Joint effusion and synovial inflammation accompany considered abnormal and hypermobility would be pres- char conditions such as traumatic arthritis, infectious arthri- cnt. able. tis, acute rheumatoid arthritis, and gout. In these condi- tions the joint capsule is distended by excessive Hypermobility is due to the laxity of soft [issue struc- !C intra-articular synovial fluid, causing the joint to main- tutes such as ligamems, capsules, and muscles thar the· rain a position that allows the greatest intra-anicular normally prevent excessive motion at a joint. In some shot joint volume. Pain triggered by stretching the capsule and instances the hypermobility may be due to abnormalities the! muscle spasms that protect the capsule from further of the joim surfaces. A frequent cause of hypermobility is sam, insult inhibit movement and cause a capsular pattern of trauma to a joint. Hypermobility also occurs in serious are J restriction. hereditary disorders of connective tissue such as Ehlers- norr Danlos syndrome, Marfan syndrome, rheumatoid arthri- situ;; Relative capsular fibrosis often occurs during chronic [is, and osteogenesis imperfecta. One of the typical with low-grade capsular inAammation,\":immobilization of a physical abnormalities of Down syndrome is hypermo- extrl joint, and the resolution of acute capsular inflammation. bility. In this instance generalized hypotonia is [hough[ not These conditions increase the relative proportion of to be an importam contributing factor to [he hypermo- tion collagen compared with that of mucopolysaccharide in bility. berv the joint capsule, or they change the structure of the .collagen. The resulting decrease in extensibility of the Hypermobility syndrome (HMS) or benign joint 51-5: entire capsule causes a capsular pattern of restriction. hypermobility syndrome (BJHS) is used to describe otherwise healthy individuals who have generalized som Noncapsular Patterns of Restricted Motion hypermobility accompanied by musculoskeletal symp- righ toms. 46.4? An inherited abnormality in collagen is Aile A limitation of passive modon that is not proportioned thought to be responsible for the joint laxity in these tos similarly to a capsular pattern is called a noncapsular individuals.48 Traditionally, the diagnosis of HMS fore pattein of restricted motionY·43 A noncapsular pattern involves the exclusion of other conditions, a score of at witl is usually caused by a condition involving Structures leas[ \"4\" on [he Beighton scale (Table 1-4), and arthral- Am, other .than the entire joint capsule. Internal joint gia for longer than 3 months in four or more joints.4•.5o oth, derangement, adhesion of a part of a joint capsule, Other criteria have also been proposed, which include text ligament shortening, muscle strains, and muscle contrac- additional joint motions and extra-articular signs:t7•48,5o wer tures are examples of conditions that typically res~lt According to Grahame4? the following joint motions mea in noncapsular patterns of restriction. Noncapsular should .also be considered: shoulder lateral rotation patterns usually involve only one or two motions of a greater than 90 degrees, cervical spine lateral flexion I joint, in contrast to capsular panerns, which involve all greater than 60 degrees, distal imerphalangeal joint text or most motions of a joint. hyperex[ension greater [han 60 degrees, and first metatarsophalangeal joint extension greater than 90 degrees. Hypermobility Factors Affecting Range of Motion The term hypermobility refers to an increase in passive ROM varies among individuals and is influenced by ROM that exceeds normal values for thar joint, given the factors such as age, gender, and whether the motion is subject's age and gender. For example, in adults the performed actively or passively. A fairly extensive normal ROM for extension at the elbow joint of the amount of research on the effec[s of age and gender on fingers is about 0 degtees.\" An ROM measurement of 90 ROM has been conducted for the upper and lower degrees or more of ex[ens;on at the elbow is well beyond extremities as well as the spine. Other factors relating to the average ROM and is indicative of a hypermobile subject characteristics such as body mass index (BM!), joint in an adult. Children have some normally occurring occupational activities, and recreational activities may affect ROM but have not been as extensively researched as age and gender. In addinon, factors relating to the tes[·· ing process, such as the testing position, type of instru- I

CHAPTER 1 BASIC CONCEPTS 11 h ning of Chapters 4 through 13 and in Appendix A. The 'e average ROM values presented in these tables should 'e serve as only a general guide to identifying normal versus ,n impaired ROM. Considerable differences in average ,e ROM values are noted between the various references. IS Age Id ,e Numerous studies have been conducted to determine the s- effects of age on ROM of the extremities and spine. General agreement exists among investigators regarding c- the age-related effects on the ROM of the extremity at joints of newborns, infants, and young children up to .e about 2 years of age.44, 66-70 These effects are joint- and es motion specific but do not seem to be affected by gender. 's In comparison with adults, the youngest age groups have us more hip flexion, hip abduction, hip lateral rotation, ~s­ ankle dorsiflexion, and elbow motion. Limitations in hip n- extension, knee extension, and plantar flexion are :al considered to be normal for these age groups. Mean ,0- menr employed, experience of the examiner, and even values for these age groups differ by more than 2 stan- ;ht time of day have been identified as affecting ROM mea- dard deviations from adult mean values published by the 10- surements. A brief summary of research findings that American Academy of Orthopaedic Surgeons,' the examine age and gender effects on ROM is presented American Medical Association; and Boone and Azen.45 int later in the chaprer. To assist the examiner, more detailed Therefore, age-appropriate norms should be used when- be information about the effects of age and gender on the ever possible for newborns, infants, and young children :ed featured joints is presented at the beginning of Chapters up to 2 years of age. ,p- 4 through 13. Information on the effects of subject Most investigators who have srudied a wide range of ,s characteristics and the testing process is included if avail- age groups have found that older adult groups have ese able. somewhat less ROM of the extremities than younger Y1S Ideally, to determine whether an ROM is impaired, adult groups. These age-related changes in the ROM of at the value of the ROM of the joint under consideration older adults also are joint and motion specific but may 'al- should be compared with ROM values from people of affect males and females differently. Allander and associ- ~.50 the same age and gender and from srudies that used the ates58 found that wrist flexion-extension, hip rotation, ,de same method of measurement. Often such comparisons and shoulder rotation ROM decreased with increasing 3,50 are not possible because age-related and gender-related age, whereas flexion ROM in the metacarpophalangeal )ns norms have not been established for all groups. In such (MCP) joint of the thumb showed no consistent loss of Ion situations the ROM of the joint should be compared motion. Roach and Miles71 generally found a small IOn with the same joint of the individual's, contralateral decrease (3 to 5 degrees) in mean active hip and knee )int extremity, providing that the contralateral extremity is motions between the youngest age group (25 to 39 years) irst not impaired or used selectively in athletic or occupa- and the oldest age group (60 to 74 years). Except for hip 90 tional activities. Most srudies have found little difference extension ROM, these decreases represented less than 15 between the ROM of the right and left extremities.2a, 45, percent of the arc of motion. Stubbs, Fernandez, and 51-57 A few studies5a-<i0 have found slightly less ROM in Glenn\" found a decrease of between 4 percent and 30 some joints of the upper extremity on the dominant or percent in 11 of 23 joints studied in men between the right side as compared with the contralateral side, which ages of 25 and 54 years. James and ParkerlJ found by Allender and coworkers\" attribure to increased exposure systematic decreases in 10 active and passive lower Pis to stress. If the contralateral extremity is inappropriate extremity motions in subjects who were between 70 and sive for comparison, the individual's ROM may be compared 92 years of age. r<~ with average ROM values in the handbook of the As with the extremities, age-related effects on spinal American Academy of Orthopaedic Surgeons7, a and ROM appear to be motion specific. Invesrigators have to other standard texts!' 6'-<i5 However, in many of these reached varying conclusions regarding how large a I), texts, the populations from which the average values decrease in ROM occurs with increasing age. Moll and t:~ were derived, as well as the testing positions and type of Wright72 found an initial increase in thoracolumbar measuring instruments used, are not identified. spinal mobility (flexion, extension, lateral flexion) in st- Average ROM values published in several standard subjects from 15 to 24 years of age through 25 to 34 ru- texts and studies are summarized in tables at the begin- years of age followed by a progressive decrease with t t 1i .

,r 12 PART I INTRODUCTION TO GONIOMETRY increasing age. These authors concluded that age alone Iof the length of a one-joint muscle and the measurement may decrease spinal mobiliry from 25 percent to 52 of joint ROM in the direction opposite to the muscle's • percent by the seventh decade, depending on the motion. Loebl\" found that thoracolumbar spinal mobility (flex- active motion. Usually, one-joint muscles have sufficient _~ ion-extension) decreases with age an average of 8 degrees per decade. Fitzgerald and colleagues7• found a system- length to allow full passive ROM at the joint they cross.p atic decrease in lateral flexion and extension of the lumbar spine at 20-year intervals but no differences in If a one~ioint muscle is shorter than normal, passive I'~,-, rotation and forward flexion. Youdas and associates\" concluded that with each decade both females and males ROM indthe ddirhection 0fPPlositfe to the muscle's aCtion is lose approximately 5 degrees of active motion in neck decrease an teend- ee IS irm owing to a museular extension and 3 degrees in lateral flexion and roration. stretch. At the end of the ROM the examiner may be able !i! Gender to palpate tension within the musculotendinous unit if ~ The effects of gender on the ROM of the extremities and spine also appear to be joint and motion specific. the struCtures are superficial. In addition, the subject mayf Bell and Hoshizaki 76 found that females across an age complain of pain in the region of the tight muscle and I.',.' range of 18 to 88 years had more flexibiliry than males in 14 of 17 joint motions tested.' Beighton, Solomon, and tendon. These signs and symptoms help to confirm Soskoline:9 in a study of an African population, found that females between 0 and 80 years of age were more Imuscle shortness as the cause of the joint limitation. mobile than rheir male counterparts. Walker and If a one-joint muscle is abnormally lax, passive tension coworkers,77 in a srudy of 28 joint motions in 60- to 84- year aids, reported that 8 motions were greater in in the capsule and ligaments may initially maintain a I'\"' FJ females and 4 motions were greater in males. Looking at the spine, Moll and Wright72 found that female thora- normal ROM. However, with time, these joint structures I'. [~ columbar left lareral flexion exceeded male teft lateral often lengthen as well and passive ROM at the joint flexion by 11 percent. On the other hand, male mobiliry increases. Because rhe indirect measurement of the length tc exceeded female mobiliry in thoracolumbar flexion and of one-joint muscles is the same as the measurement of extension. hi :~:;;:;:~i'l'~~.~~~\"~~ Ijoint ROM, we have not presented specific muscle length ., 19*~4t~~~~~f~~~11~t~ff#~m~~I~tf~~~l~rliJl. 'i{'!liip:'aDd~i:tioli<~PNt%;r~e\"i1':<!irect. m#:a.¥\\I(eiile~tbf:i~l \" ilie:Jeilgili o~ tlfese liiiP~dduq6~nfus<;leSi{tdenticaf~'i\" ;in9jthen.l~silrtifl~nt?~pass~iliipjip~flcti0!rROM~' . nt0{~J:~(,/i:lm~~%ii~;~ITtJX~t.i).~t5~~~fftt;~tsjj~i~S~~;!}~drtc~fw~ri~~1%~S~~;~ ~ Muscle length Testing In COntrast to one-joint muscles, the length of two- F joint and multijoint muscles is usually not sufficient to Muscle length is the greatest extensibiliry of a muscle- allow full passive ROM to occur simultaneously at all eJ tendon unit.2 It is the maximal distance between the joints crossed by these muscles.so This inabiliry of a proximal and the distal attachments of a muscle to bone. muscle to lengthen and allow full ROM at all of the I[ Clinically, muscle length is not measured directly but instead is measured indirectly by determining the end of joints the muscle crosses is termed passive insufficiency. tI the ROM of the joint(s) crossed by the muscle.7s•79 If a two-joint or multijoinr muscle crosses a joint the Muscle length, in addition to the integrity of the joint examiner is assessing for ROM, the subject must be posi- '\" surfaces and the extensibiliry of the capsule, ligaments, tioned so that passive tension in the muscle does not limit fascia, and skin, affects the amount of passive ROM of a the joint's ROM. To allow full ROM at the joint under joint. The purpose of testing muscle length is to ascertain consideration and to ensure sufficient length in the whether hypomobility or hypermobiliry is caused by the muscle, the muscle must be put on slack at all of the length of the inactive antagonist muscle or other struc- joints the muscle crosses that are not being assessed. A tures. By ascertaining which structures afC involved, the muscle is put on slack by passively approximating the health professional can choose more specific and more origin and insertion of the muscle. effective treatment procedures. ;1~~~~~~~~~}!~]~~~~t~rif&:~:\\1&;; Muscles can be categorized by the number of joints they cross from their proximal to their distal attach- L·'. {tile biC;eps%rO.i!allowHilllri:xtensiOiiiYilt th-e'tellloW\"\"\"T' p\" ments. One-joint muscles cross and therefore influence \"I, the motion of only one joint. Two-joint muscles cross j;~;{~i&\\t~4~litj~i~'ttJtWi;ijli~'~t~~i~Ylj~~~I~t~ and influence the motion of two joints, whereas multi- joint muscles cross and influence multiple joints. No difference exisrs between the indirecr measurement . :.-

CHAPTER 1 BASIC CONCEPTS 13 ,nt Ie's ~nt ISS. ive 1 is .lar ble t if ,ay md \"m ion FIGURE 1-7 The indirect measurement of oa the muscle length of one~joint hip adduc- lres ;-- tors is the same as measurement of passive lint :I. hip abducrion ROM. gth t of ,grh \\Va- FIGURE 1-8 During the measurement of elbow flexion ROM, the shoulder must be .t to in neutral to avoid passive insufficiency of the triceps, which would limit the ROM. t all )f a the n<y. the )051- limit nder the : the d. A ; the To assess the length of a two-joint muscle, the subject full ROM. The end-feel in this situation is fitm owing to is positioned so that the muscle is lengthened over the the developmenr of passive tension in the stretched proximal or distal joint that the muscle crosses. This joint muscle. The length of the two-joint muscle is indirectly is held in position while the examiner attempts to further assessed by measuring passive ROM in the direction lengthen the muscle by moving the second joinr thtough opposite to the muscle's action at the second joint.

14 PA R T I INTRODUCTION TO GONIOMETRY REFERENCES 3 t. MacConJill. MA, and 8:lsmajian, JV: Muscles and Mo\\'cmcm: A Basis For Human Kinesiology, cd 2. Robert E. Krieger, New York. 3 1977, 2. Amcric:ln Physical Therapy Associ:J.rion: Guide to PhyslCJ.1 3, Therapist Practice, cd 2. Phys Thee 81:9, 2001. 3. Silver. D: Measurement of the range of morion in joints. J Bone Joim Surg 21:569,1923. 4. Cave, EF, and RobertS. SM::\\ method for measuring and recording ), joint function. J none Joint Surg 18:455, 1936. 5. Moore, ML: The mC:1surcrncnt of joint mOtion. Part II: The technic of goniometry. Phys Ther Rev 29:256,1949. 3, 6. Moore, Ml: Clinic)1 assessment of joint motion. In Basmajian, JV (ed): Therapeutic Exercise, ed 4. Williams & Wilkins, Baltimore, 1984. 7. American Academy of Orrhop:ledic Surgeons: Joinr Morion: 3' Methods of Measuring and Recording. AAOS, Chicago, 196.5. 8. Greene, WB, and Heckman, JD (cds): The CliniC:ll Measurement of Joint Motion. AmeriC:l1I (\\eadem)' of Onhop;:l(:dic Surgeons, 3: Rosemont, ilL, 1994. 9. Americ:ln Medic:l1 Association: Guides (0 the Evaluation of 3: Permanent Impairment, ed 3. AMA, Milwaukee, 1990. 10. Cbrk, WA: A systcm of join[ measurement. J Onhop Surg 2:687, 41 1920. 11. West, CC: Measurement of joint morion. Arch Phys Med Rehabil 2604 14, 1945, 12. Cole, TM, and Tobis, jS: Measurement of Musculoskeletal 4 Function. In Kottke, FJ, :lnd Lehmann, JF (cds): Kruscnn's Handbook of Physical Medicine and Rehabilitation, ed 4. WB Saunders, Philadelphia, t 990. 13. james, B, and Parker, AW: Active and passive m':)bility of lower limb joints in elderly men and women. Am J Phys Med Rchahil FIGURE 1-9 To assess the length of the two-joint triceps 68,162, 1989. 4. muscle, elbow flexion is measured while [he shoulder is posi- tioned in flexion. 14. Ball, P, and Johnson, GR: Rcliabiliry of hindfoOf goniometC)' whcn + using a flexible eJecrrogoniometer. Clio Biomech 8: 13, 1993. 4, 15. Cyriax, J: Textbook of Orthopaedic Medicine: Diagnosis of Sofr Tissue Lesions, cd 8. Bailliere Tindall, London, 1982. J6. Kalrenborn, FM: Manual Mobilizadon of the Extremir)\" Joints, cd 4. Olaf Norlis Bokh<lndel, Oslo. 4, t 7. Paris, SV: Extremity Dysfunction and Mobilization. Institute Press, Atlaora, 1980. 4' 18. Cookson, JC, and Kem, BE: Orthopedic manual rherapy: An o\\'erview. Parr I. Phys Ther 59:)36,1979. 4: 19. Williams, P, et al: Gray's An:Hom)' of the Hum:m Body, cd 38. 4! \" Churchill Livingstone, New York, 1995. 20. Moore, KL, and Dalley, AF: Clinically Orienred Anatomy, ed 4. 51 Williams & Wilkins. Balrimore, 1999. 21. Kapandji, fA: Physiology of the Joims, Vol 1, ed 2. Churchill Livingstone, London, 1970. 5' 22. Kapandji, IA: Physiology of the joims, Vol 2, ed 2. Williams & Wilkins, Balrimore, 1970. 23. Kapandji, 1A: Physiology of the joims. Vol 3, cd 2. Churchill 5: Livingstone, london, 1970. The length of multijoint muscles is assessed in a 24. Stcindler, A: Kinesiology of the Human Body. Charles C. Thomas, 5: Springfield, III., 1955, manner similat to that used in assessing the length of 25. Gowitzc, BA, and Milner, M: Understanding the Scientific Basis for two-joint muscles, Howevet, the subject is positioned and Hum:lO Movemenr, ed 3. Williams & Wilkins, Baltimore, 1988. held so that the muscle is lengthened ovet all of the joints 26. Levangie, PK, and Norkin, CC: Joim Structure and Funccion, ed 3. FA Davis, Philadelphia, 2001. that the muscle crosses except for one last joint. The 27. Soderberg, GL: Kincsiology: Applicmion to Pathological Motion. 5: examiner attempts to further lengthen the muscle by WiHiams &. Wilkins, Baltimore, t 986. 5, moving the last joint through full ROM, Again, the end- feel is firm owing to tension in the sttetched muscle. The 28. Steuhicns, MPM, et al: Range of joint motion and disability in patienrs with osteoarthritis of the knee or hip. Rheumatology 39,955, 2000, length of the multijoint muscle is indirectly determined 29. Messier, SP, et nl: Osteoarthritis of the knee: Effects on gait, by measuring passive ROM in the direction opposite to strength, and flexibility. Atch Phys Med Reh:lbi173:29, 1992. 30. Starn, HW: Frozen shoulder: A review of currenr concepts. the muscle's action at the last joint to be moved, Physiotherapy 80:588, 1994. Commonly used muscle length tests that indirectly assess 31. Roubal, PJ, Dobrin, D, and Placzek, JD: Glenohumer:ll gliding two-joint and multijoint muscles have been included at manipulation following imersc:l.lene brachial plexus block in patients with adhesive capsulitis. .1 Orthop Sports Phys Ther 24:66, the end of Chapters 4 through 13 as appropriate, 1996.

CHAPTER' BASIC CONCEPTS 15 lvemeot: A 32. Hagen, KB, et al: Relationship between subjective neck disorders 57. Escalanate, A, et al: De(crminants of hip and knee flexion range: New York, and cervical spine mobility and motion-related pain in male machine operators. Spine 22:1501,1997. Resulrs ftom the San Antonio Longitudinal Study of Aging. ) Physical Arthritis Care Res 12:8, 1999. 33. Hermann, KM, and Reese, CS: Relationship among selected meas- 58. Allender, E, et al: Normal range of joint movements in shoulder, lr$. J Bone ures of impairment, functional limitation, and disability in patients hip, wrist and thllmb with special reference to side: A comparison with cervical spine disorders. Phys Ther 81:903, 2001. hetween [\\\\10 populations. Int J Epidemiol 3:253, 1974. d recording 59. Stubbs, NB, Fernandez, JE, and Glenn, WM: Normati ...e data on 34. MacKenzie, EJ, et al: Physical impairment and functional ourcomt·s joint ranges of motion for 25- to 54-year old males. Int J Ind fhe technic six months after severe lower extremity fractures. J Trauma Ergonomics 12:265, 1993. ,majian, JV 34,528,1993. 60. Escalante, A, Lichtenstein, MJ, and Hazuda, HP: Determinants of Baltimore, 35. Chesworth, BM, and Vandervoort, AA: Comparison of passive shoulder and elbow flexion range: Results from the San Antonio longitudinal scudy of aging. Arthritis Care Res 12:277,1999. 1£ Motion: stiffness variables and range of motion in uninvolved and involved 1,1965. ankle joints of patients following ankle fractures. Phys Ther 61. Kendall, FP, McCreary, EK, and Provance, PG: Mllscles: Testing surement of and Function, ed 4. Williams & Wilkins, Baltimore, 1993. 75,254,1995. Surgeons, 36. Swley, MJ, and Richard, R1.: Burns. In O'Sullivan, 5B and Schmitz, 62. Hoppenfdd, S: Physical Examination of the Spine and Extremities. lluation of TJ (cds): Physical Rehabilitation: Assessment and Treatment, ed 4. Appleton-Century-Crofts, New York, 1976. 63. Esch, D, and Lepley, M: Evaluation of Joint Motion: Methods of Surg 2:687, FA Davis, Philadelphia, 2000. MeaSllremenr and Recording. University of Minnesota Press, ,led Rehabi! 37. Johnson, J, and Silverberg, R: Serial casting of the lower extremity Minncapolis, 1974. 64. Clarkson, HM: Musculoske!etal Assessment: Joint Range of cllioskeletal to correct contractu res during the acute phase of burn care. Phys Motion and Manual Muscle Strength, ed 2. Lippincott, Williams & Krusenn's Ther 75,262,1995. Wilkins, Philadelphia, 2000. 38. Schulte, 1., et al: A quantitative assessment of limited joint mobility 65. Palmer, ML, and Epler, !vI: Fundamentals of Muscllioskeletal , cd 4. WB in patients with diabetes. Arthritis Rheum 10:1429, 1993. Assessment Techniques. Lippincott, Williams & Wilkins, 39. Salsich, GB, Mueller, MJ, and Sahrmann, SA: Passive ankle stiffness Philadelphia, 1998. ity of lower in subjects with diabetes and peripheral neuropathy versus and age- 66. Drews, JE, Vraciu, JK, and Pellino, G: Range of motion of the Iled Rehabit matched comparison group. Phys Ther 80:352, 2000. joints of the lower extremities of newborns. Phys OCCllP Ther 40. Dyrek, OA: Assessment and treatment planning sttategies for Pediatr 4:49,1984. lmetry when musculoskeletal deficits. In O'Sullivan, 5B, and Schmitz, TJ (cds): 1993. Physical Rehabilitation: Assessment and Treatment, ed 3. FA Davis, 67. Phelps, E, Smith, 1.J, and Hallum, A: Normal range of hip motion lOsis of Soft Philadelphia, 1994. of infants berween nine and 24 months of age. Dev Med Child 41. Fritz, JM, et al: An examination of the selective tissue tension NellroI27:785,1985. iry Joints, ed scheme, with evidence for the concept of a capsular pattern of the knee. Phys Ther 78,1046,1998. 68. Wanatabe, H, et al: The range of joint motions of the extremities in stitute Press, 42. Hayes, KW, Petersen, C, and Falconer, J: An examination of healrhy Japanese people: The diffetences according to age. Nippon Cyriax's passive motion tests with patients having osteoarthritis of 5eikeigeka Gakkai Zasshi 53:275, t 979. Cited in Walker, JM: therapy: An Musculoskeletal development: A review. Phys Ther 71:878, 1991. the knee. Phys Ther 74,697,1994. lody, cd 38. 43. Herding, DH, and Kessler, RM: Management of Common 69. Schwane, DJ, and Denton, JR: Normal values of neonatal limbs: An evaluation of 1000 neonates. J Pediatr Orthop 13:758, 1993. atomy, cd 4. Musculoskeletal Disorders, ed 3. JB Lippincott, Philadelphia, 1996. 44. Waugh, KG, et al: Measurement of selected hip, knee and ankle 70. Broughton, NS, Wright, J, and Menelaus, MB: Range of knee 2. Churchill motion in normal neonates. J Pediatr Onhop 13:263, 1993. joint motions in newborns. Phys Ther 63:1616, 1983. Williams & 45. Boone, DC, and Azeo, SP: Normal range of motion of joints in 71. Roach, KE, <lnd Miles, TP: Normal hip and knee active range of motion: The relationship to age. Phys Ther 71:656,1991. 2. Churchill male subjects. J Bone Joint Surg Am 61:756, 1979. 72. Moll, JMH, and Wright, V: Normal range of spinal mobility. Ann s C. Thomas, 46. Everman, DB, and Robin, NH: Hypermobiliry syndrome. Pediatr Rheum Dis 30:381, 1971. Rev 19,111, 1998. tific Basis for 73. Loebl, WY: Measurement of spinal posture and range of spinal lore, 1988. 47. Grahame, R: Hypermobiliry not a circus act. Int J Clin Pract movement. Ann Phys Med 9:103, 1967. ~mction, ed 3. 54,314,2000. 74. Fitzgerald, GK, et al: Objective assessment with establishment of ;ical Motion. 48. Russek, LN: Hypermobility syndrome. Phys Ther 79:59,1999. normal values for lumbar spinal range of motion. Phys Ther 49. Beighron, P, Solomon, L, and Soskolne, CL: Articular mobility in 63,1776, 1983. I disability in Lheumatology an African population. Ann Rheum Dis 32:23, 1973. 75. Youdas, JW, et al: Normal range of motion of the cervical spine: An 50. Bird, HA: Joint hypermobility: Report from Special Interest Groups initial goniometric study. Phys Ther 72: 770, 1992. ·CCtS on gait, 't9, 1992. of the annual meeting of the British Sociery of Rheumatology. Br J 76. Bell, RD, and Hoshizaki, TB: Relationship of age and sex with int concepts. RheumatoI31:205,1992. 51. Roaas, A, and Andersson, GB: Normal range of motion of the hip, range of motion: Seventeen joint actions in humans. Can J App! Sci meral gliding knee and ankle joints in male subjects, 30-40 years of age. Acta (Us block in Othop Scand 53,205, 1982. 6,202, 1981. ;s Ther 24:66, 52. Chang, DE, Buschbacher, LP, and Edlich, RF: Limited joint mobil~ 77. Walker, JM, et al: Active mobility of the extremities older subjects. icy in power lifters. Am J Sports Mcd 16:280, 1988. 53. Ahlberg, A, Moussa, M, and AI-Nahdi, M: On geographical varia~ Phys Ther 64,919,1984. tions in the normal range of joint motion. Clin Orthop Rel Res 78. Gajdosik, RL, et al: Comparison of four clinical tests for assessing 234,229, 1988. 54. Schwarze, OJ, and Denton, JR: Normal values of neonatal limbs: hamstring muscle length. J Onhop Sports Phys Ther 18:614, 1993. An evaluation of 1000 neonates. J Res Pediatr Orthop 13:758, 79. Tardieu, G, 1.espargot, A, and Tardieu, C: To what extent is the 1993. tibia-calcaneum angle a reliable measurement of the triceps surae 55. Stefanyshyn, OJ, and Ensberg, JR: Right to left differences in the length: Radiological correction of the rorque-angle curve. Eut J ankle joint complex range of motion. Med Sci SportS Exerc 26:551, Appi PhysioI37,163, 1977. 1993. 80. Gajdosik, RL, Hallett, JP, and Slaugher, LL: Passive insufficiency of two-joint shoulder muscles. Clin Biomech 9:377,1994. 56. Mosley, AM, Crosbie, J, and Adams, R: Normative data for passive ankle plantarflexion-dorsiflexion flexibiliry. Clin Biomech 16:514, 2001.

,' :.,-<: .' ..':-\",:'- ;~-~>- Procedures Competency in goniometry requires that the examiner pic, the usc of different testing positions alters the ROM acquire the following knowledge and develop the follow- obtained fot hip f1exi<)n. ing skills. EXAMPLE:K testing position in which' tli~!I(,;gg::is The examiner must have knowledge of the following for each joint and motion: flexed yields a greater hip flexion ROM th~~~:t~~,:/ ',l,Testing positions '\"ing lpW,>oeesYjo\"ii~t~i¢.-,o,\":~'!n;e,,-ni,~cn!--w:~: (hi-i.ci.hci,,p~h; f-,\"l't~C~h,<',-e.iko·,.•l,n-,\"\"e1.'i;ie'ri..~i--:'s,_ ,..pe<-fx...e~t:.,e,~\"m,n,~od__~:t..e..u..d/r.'.e~il\\:,Yys.l~,i,W-h-i'tn!c:'ii.~'''':':,?:' '2:'Stabilization required 3: Joint .tructure and function (~\"i\":,;~,,y h,~J< 4. Normal end-feels .:.,q;;:,#;:\",$'/';\":;O,i;):t\"?e;:.d/?fYb'·y· <),t';e·'rn:;;·s,,;l:-o:,(,n,:,.>:i·:r,;(r~,t~;h;'t\"e':-;\"h:':·a(:.mi ::,,m(,:,:'::i:::n,:,,:,gI-:-;,,-:r;::;n;,,:;u: •:s\\~c',-l:.e•.\"!,s,'\";,,'-:;),:.,-:/!;/ffr,2'TxJkL 5. Anatomical bony landmarks 6. fnstrument alignment If examiners use the same position during successive measurements of a joint ROM, the relative amountS of The examiner must have the skill to perform the fol- tension in the soft tissue structures should be the same as lowing for each joint and motion: in previous measurements. Therefore, a comparison of ROM measur~mcnrs taken in the same position should 1. Position and stabilize correctly yield similar results. When different testing positions are 2. Move a body part through the appropriate range noused for successive measuremcnrs of a joint R01\\1, more of motion variability is added to the measuremcntl-~ and basis 3. Determine the end of the range of motion (end- for comparison exists. feel) Testing positions refer to the positions of the body 4. Palpate the appropriate bony landmarks that we recommend for obtaining goniomcrric measure~ 5. Align the measuring instrument with landmarks meors. The series of testing positions that are presented 6. Read the measuring instrument in this text are designed to: 7. Record measurementS correcrly 1. Place the joint in a starting position of 0 degrees • Positioning 2. Permit a complete ROM 3. Provide stabilization for the proximal joint seg- POSitioning is an important part of goniometey because it is used to place the joints in a zero starting position and mcnt to help stabilize the proximal joint segment. Positioning affects the amount of tension in soft tissue structures If a tcsting posicion cannot be attained because of ~capsule, ligaments, muscles) surrounding a joint. A test- restrictions imposed by the environment or limitations of Ing position in which one or more of these soft tissue the subjcct, the examiner must usc creativity to decide Structures become taut results in a morc limited range of how to obtain a particular joint measurement. The altcr- motion (ROM) than a position in which the same struc- native testing position that is created must serve the same tures become lax. As can be seen in the following exam- three functions as the recommended testing position. The examiner must describe the position precisely in the sub- JCCt's records so that the same position can be used for all subsequent measurements. 17

18 PA RT I INTRODUCTION TO GONIOMETRY Testing positions involve a variety of body positions EXAMPLE: Measurement of medial rotation of the such as supine, pronc, sitting, and standing. When an hip joint performed with the subject in a sirting examiner intends to test several joints and motions dur- position (Fig. 2-1A). The pelvis (proximal segment) ing one testing session, the goniomcrric examination is partially stabilized by the body weight, but the should be planned to avoid moving the subject unneces- subject is moving her trunk and pelvis during hip sarily. For example, if the subject is prone, all possible rotation. Additional stabilization should be provid- measurements in rhis posirion should be taken before rhe ed by the examiner and the subject (Fig. 2-1B). The subject is moved into another position. Table 2-1, which examiner provides manual stabilization for the pelvis by exerting a downward pressure on the iliac lists joint measurements by body position, has been crest of the side being tested. The subject is insrruct- ed. to shift her body weight over rhe hip being test- designed to help the examiner plan a goniometric exam- ed to help keep the pelvis stabilized, manon. For most measurements, the amount of manual stabi-I.'.,. lization applied by an examiner must be sufficient to . • Stabilization keep the proximal joim scgmcm fixed during movement of the distal joint componem. If both the distal and the The resting position helps to stabilize rhe subject's body and proximal joint segment so that a motion can be iso- proximal joint components are allowed ro move during lated to the joint being examined. Isolating the motion to one joint helps [0 ensure that a [Cue measurement of the joim testing, the end of the ROM is difficult to deter- morion is obtained rather than a measurement of com- mine. Learning how to srabilize requires practice because bined motions that occur at a series of joints. Positional the examiner must stabilize with one hand while simul- stabilization may be supplemented by manual stabiliza- tion provided by the examiner. Pronation Supination Flexion F1e:x,i,q11; ranee Exter:lSion' hand Radial deviation segm Ulnar' deviation • are b All motions Medial rotation AbdoCtion lateral rotation AdduCtion Fl~xi,?'rr Dorsjflexian Dorsiflexion Plant.ar flexion \",-cPlanta\"r flexion lnve,rsjon Eversion j:~k~~t~·~{a~~~_~~n Midtarsal. inversion Midtarsal, eversion ';.'iJ';::;::<;;:'iy/,,~~;Y~.~e,:(~#I,~~il~1a', inversion AU,m:o~[ons , \".' 'id,~rsal eversion Flexion· .:~m~fions Extension' . Lateral flexion _Rotation ._ I Rotation Flexion Depression Extension lateraL n~xion Anterior protrusion lateral deviation

CHAPTER 2 PROCEDURES 19 he ng 1t) he IIp id- 'he :he lac ct- 'St- stabi- :nt to :mcnr Id the luring Jeter· :cause ;;irnul· FIGURE 2-1 (A) The consequences of inadequate stabilization. The examiner has failed to stabilize the subject's pelvis and trunk; therefore, a lateral tilt of the pelvis and lateral flexion of the trunk accompany the motion of hip medial rotation. The range of medial rotation appears greater than it actually is because of the added motion from the pelvis and crunk. (B) The use of proper stabilization. The examiner uses her right hand to stabilize the pelvis (kee'ping the pelvis from raising off the table) during the passive range of motion (ROM). The subject assists in stabilizing the pelvis by placing her body weight on the left side. The subject keeps her trunk straight by placing both hands on the table. taneously moving the distal joint segment with the other learning how to use the goniometer. Exercise 1 is hand. The techniques of stabilizing the proximal joint designed to help the examiner learn how to stabilize and segment and of determining the end of a ROM (end-feel) determine the end of the ROM and end-feel. are basic to goniometry and must be mastered prior to

p 20 PART I INTRODUCTION TO GONIOMETRY - ..-....'\" -\". ,,- §::.'@ .,~~. ~ -.,,, DETERMINING THE END OF THE RANGE OF MOTION AND END-FEEL This exercise is designed to help the examiner determine the end of the ROM 2nd to differen- tiate among the thtee notmal end-feels: soft, firm, and hard. ELBOW flEXION: SOFT END-FEEL Activities: See Figure 5-15 in Chapter 5. 1. Selecr a subject. 2. Position the subject supine with the arm placed close to the side of the body. A towel roll is placed under the distal end of the humerus to 2110w full elbow extension. The forearm is placed in full supination with the palm of the h2nd facing the ceiling. 3. With one hand, stabilize the distal end of the humerus (proximal joint segment) to ptevent flexion of the shoulder. 4. With the other hand, slowly move the forearm through the full passive range of elbow flex- ion until you feel 'resistance limiting the motion. 5. Gendy push against the resistance until no further flexion can be achieved. Carefully note the quality of the resistance. This soft end-feel is caused by compression of the muscle bulk of the amerior forearm with that of the anterior upper arm. 6. Compare this soft end-feel with the soft end-feel found in knee flexion (see knee flexion in Chapter 9). ANKLE DORSiflEXION: FIRM END-FEEL Activities: See Figure 10-14 in Chapter 10. 1. Select a subject. 2. Place the subject sitting so that the lower leg is over the edge of the supporting surface and rhe knee is flexed at least 30 degrees. 3. With one hand, stabilize the distal end of the tibia and fibula to prevent knee extension and hip motions. 4. With the other hand on the plantar surface of the metatarsals, slowly move the foot through the full passive range of ankle dorsiflexion until you feel resistance limiting the motion. 5. Push against the resistance until no further dotsiflexion can be achieved. Catefully note the quality of the resistance. This firm end-feel is caused by tension in the Achilles tendon, the posterior portion of the deltoid ligament, the posterior talofioular ligament, the calcaneo- fibular ligament, the posterior joint capsule, and the wedging of the talus into the mortise formed by the tibia and fibula. 6. Compare this firm end-feel with the firm end-feel found in metacarpophalangeal (MCP) extension of the fingers (see Chapter 7). ,. ,'

CHAPTER 2 PROCEDURES 21 ELBOW EXTENSION: HARD END-FEEL Activities: I. Select a subject. 2. Position the subject supine with the atm placed close to the side of the body. A small towel roll is placed undet the distal end of the humerus to allow full elbow extension. The fore- atm is placed in full supination with the palm of the hand facing the ceiling. 3. With one hand testing on the towel roll and holding the posterior, distal end of the humerus, stabilize the humerus (proximal joint segment) to prevent extension of the shoul- der. 4. With rhe othet hand, slowly move the fotearm through the full passive tange of elbow extension until you feel resistance limiting the motion. 5. Gently push against the resisrance until no further extension can be attained. Carefully note the qualiry of the resistance. When rhe end-feel is hard, it has no give to it. This hard end- feel is caused by contacr between the olecranon process of the ulna and the olecranon fossa of the humerus. 6. Compare this hard end-feel with the hatd end-feel usually found in radial deviation of rhe wrist (see radial deviarion in Chaptet 7) . • Measurement Instruments Universal Goniometer A variety of instruments are used to measure JOInt The universal goniometer is the instrument most com- motion. These insrruments range from simple paper trac- monly used to measure joint position and motion in the ings and rape measures to elecrrogoniomerers and clinical serting. Moote',· designated this type of motion analysis systems. An examiner may choose [0 use goniometer as «universal\" because of its versatility. It can a particular instrument based upon the purpose of the be used to measure joint position and ROM ar almost all measuremenr (clinical versus research), the motion being joints of the body. The majoriry of meaSUtement rech- measured, and the instrument's accuracy, availabiliry, niques presented in this book demonstrate the use of the cost, ease of usc, and size. universal goniometer.

22 PA R T I INTRODUCTION TO GONIOMETRY Universal goniomcrcrs may be constructed of plastic 2-5). The scales on a half-circle goniometer rcad from 0 (Fig. 2-2) or metal (Fig. 2-3) and are produced in many to 180 degrees and from 180 to 0 degrees. The scales on sizes and shapes, but adhere to the same basic design. a full-circle instrument may read either from 0 to 180 Typically the design includes a body and two thin exten- degrees and from 180 to 0 degrees, or from 0 to 360 sions called arms-a stationary arm and a moving arm degrees and from 360 to 0 degrees. Sometimes full-circle (Fig. 2-4). instruments have both l80-degree and 360-degree scales. Increments on the scales may vary from 1 to 10 degrees, The body of a universal goniometer resembles a pro- but 1- and 5-degrce increments are the most common. tractor and may form a half circle or a full circle (Fig. FIGURE 2-2 Plastic universal FU goniomcrcrs arc ;:lVaiiable in dif- hi ferent\" shapes ;md sizes. Some goniomcrcrs have full~circlc bod- th, ies (A,B,e,E), whereas others hove half-circle hodies (0). The cit: 14-inch goniometer (A) is used [0 measure large joinrs such ;,15 the frc hip, knee, and shoulder. Six- co 8- po inch goniomcrcrs (B,C,D) are pC! used to assess midsized joints ins such as the wrist :lod 3nklc. The small goniometer (E) has been de cur in length from a 6-inch the goniometer (C) to make ir easier tio to measure the fingers and toes. go bo bo the go art be fiGURE 2-3 These metal goni- ometers arc of different sizes bur all have half~cirdc bodies. Metal goniomcrers with full-circle hodies arc also available. The smallest goniometer is specifically designed to lie on the dorsal or ventral sur~ face of the fingers and toes while measuring joint motion.

CHAPTER 2 PROCEDURES 23 from 0 \".. I('s on :~\"\"\"\"v', to I80i, to 360 II-circle' . scales...!\" ,It..~grecs ...:.:,,.,~.i ·non. ..--_,..I.. _- STATIONARY ARM livers;:!j .:\" FlGyR:E 2-4 The body of this universal goniometer forms a FIGURE 2-5 The body of the goniometer may be either a half The stationary arm is an integral part of the body of fin dif· circle (top) or a full circle (bottom). gOlllomc<cr. The moving arm is attached to the body by Some'}) a river or a screw so that it can he moved independently or loosened to allow free movemem. The moving arm may have one or more of rhe following features: a Ie bod· from the body. In this example. rhe moving arm has a cur-out poimed end, a black or whire line exrending the lengrh of p~r~,ion some rimes referred to as a \"window.\" The window the arm, or a cur-out porrion (window) (Fig. 2-6). orhers e' permits the examiner to read the scale on the body of the Goniometers thar are used to measure ROM on radi- instrument. ographs have an opaque white line extending the length l). The of the arms and opaque markings on the body. These fea- tls~~d ro ':~ Traditionally, the arms of a universal goniometer are tutes help the examiner to read the scales. as the designated as moving Or stationary according to how ~\"fO 8· they arc attached to the body of the goniometer. The sta- The length of the arms varies among instruments from tiooary arm is a srructural parr of the body of the approximately 1 to 14 inches. These variations in length )) arc goniometer and cannot be moved independently from the body. The moving arm is attached to the Center of the represent an attempt on the part of the manufacturers to JOlll(S bOdy of mOst plastic goniometers by a rivet that permits tbe arm to move freely on the body. In some metal adapt the size of the instrument to the size of the joints. Ie. The ., goniometers, a screwlike device (thumb knob) is used ro The cost of the instruments also varies (See Appendix B: ~ been <1 attach the moving arm. Often the screwlike device may Features and Cost of Universal and Gravity-Based berightened to hold the moving arm in a certain position Goniometets). 6~iJlch eaSIer wes. \\ J ( ~_---.:!.~_L'-~~_-_-_-_-_-_-~_-_-_-_-_-_-_-.,_') FIGURE 2-6 These goniomc- goni- refS have a number of features )ur ;tl! that make reading the instru- ments easier. The half-circle \\'h:ral goniometer at rhe tOP has a .odies moving arm with cut-out allest areas at both ends and in rhe igncJ middle, as well as a black cen- I sur- while ter line. The half-circle goniometer in the middle has a cut-out arta only at the cnd of irs moving arm. The,· full- circle plastic goniometer.- (bOI- tom) has a black ccnter line along hath the moving and the s[<ltionary arms.

24 PA R T I INTRODUCTION TO GONIOMETRY AaMppP,rL9Ep\"'r,iA~tue..n.'.if,voerJrs\"a.lcl'U.'geoans_,.iu- ormil--1Ceg.-rIi.el.Ur/,\\,ov- riit~9hn~1' a,4l~~i:riil',c';';'h'..~a~rc>mn.--§-' se../;? Gravity-Dependent Goniometers X:EX (Inclinometers) . is Although not as common as rhe universal goniometer, several other types of manual goniomctcrs may be found joinr pecause rhe. arms are ]ongenoNghroper';\"it; in the clinical serring. Gravity-dependent goniomcrcrs or inclinometers use gravity's cffect on pointcrs and fluid . . ~aI]Jidg'rn.lhJ~·),~·n.v!ey~i~frih'rk2n1e.aglrleeapl~u\"sr.oftrr,~o;'cthiabjn'ray.{(F0i~t:rih:-<;;7fA)e/lljuNUr:{. levels CO measure joint position and motion (Fig. 2-8). 'llniversalgoniome,e'r,wirl) shorr 'arms w\"uld:be dif.:'\";;\" The pendulum goniometer consists of a 360-degree pro- · •.•. >f,ic<:ilf~n:~I,Sld:io~,tusee~.c5p·e:qalI9ln~g~t.pt~l_;aeJi~mi~ndf~!Jrjl~oJrlfd¢hixbrif,?e4:aiqspu~trfmii~~u;:0' tractor with a weighted pointer hanging from the center ..·:.':'•,.·.a:.,U~I?1g~Jm\\ea9spm~eertll1engT~:wt. \"~,tieih!;hMt.Ch:~e..19bjno?g!enf(Ytrsi·ilol'afS;\",t.dh\\~my:(~)a:~arlJkiJsld,,!(:¥Fg'e;ii¥g'i:\\lti.~2iY-i\"\"C~,~rZ'4itB,?g)£il;j;j:Af::}i:f!/ of rhe prorracror, This device was first described by Fox and Van Breemen7 in 1934, The fluid (bubble) goniome- ter, which was developed by Schenkar\" in 1956, has a _pi J\" -~ \"\";:::_~ FIGURE 2-7 Selecting the fight- fluid sized goniometer makes it easier IS sil (0 measu~e joint morion. (A) The 360- examiner is using a full-circle instrument with 'long arms to OB measure knee flexion ROM. The arms of the goniometer extend mati along the distal and proximal components of the joint co within grav a few inches of the bony land- plan marks (black dots) that arc used mag [0 align the arms. The proximity plan of the ends of the arms to thc and landmarks mnkes alignment easy able and helps ensure that the :lCfns thar 3re aligned accuratdy. (8) The and small half-circle metal goniome- ter is a poor t:hoice for measuring h knee flexion ROI\\!1 because the men landmatks arc so far from the lon, ends of thc goniometer's arms ,that accurate alignment is diffi- nott cult. aria havl the mal ven met min cult deft 1 ters sho exa Tui aS

CHAPTER 2 PROCEDURES 25 netee, FIGURE 2-8 Each of these gravi- ound ty-dependent goniometers uses a ~rs or weighted pointer (A,B,D) or bub- fluid 2-8). ble (C) to indicate the position of , pro- the goniometer relative to the verti- :enrer cal pull of graviry. All of these y Fox lomc- inclinometers have a rotating dial has a so that the scale can be zeroed with the pointer or bubble in the starr- ing position. he rlght~ fluid-filled circular chamber containing an air bubble. It slightly different results, making comparisons for judging is similar to a carpenter's level but, being circular, has a changes in ROM inappropriate. it easier 360-degree scale. Orher inclinomerers such as the Myrin (AI The OB Goniometer and the CROM (cervical range of Electrogoniometers ull-circle motion) device use a pendulum needle that reacts to arms to gravity to measure morions in the frontal and sagittal Electrogoniometers, introduced by Karpovich and )M. The planes and use a compass needle that reacts to the earth's Karpovich15 in 1959, arc used primarily in research to magnetic field to measure motions in the horizontal obtain dynamic joint measurements. Most devices have r extend plane. A fairly large selection of manual inclinometers two arms, similar to those of the universal goniometer, proximal and a few digital inclinometers are commercially avail- which are attached ro rhe proximal and distal segments to within able. Generally these instruments are more expensive of the joint being measured. 16- 19 A potentiom·eter is con- my land~ tban universal goniometers (See Appendix B: Features nected to the two arms. Changes in joint position cause arc used and Cosr of Universal and Gravity-Based Goniometers). the resistance in the potentiometer to vary. The resulting Jroximity change in voltage can be used to indicate the amount of ns to the Inclinometers are attached to or held on the distal seg- joint motion. Potentiometers measuring angular displace- nent easy ment of the joint being measured. The angle between the ment have also been integrated with strain gauges20.21 the arms long axis of rhe disral segmenr and the line of gravity is and isokinetic dynamometers22 for measuring resistive noted. Inclinometers may be easier to use in certain situ- rorque. Flexible electrogoniometers with two plastic end- (BI The ations than universal goniometers because they do not blocks connected by a flexible strain gauge have been have to be aligned with bony landmarks or cenrered over designed to measure angular displacement between the goniomc~ the axis of motion. However, it is critical that the proxi- end-blocks in one or two planes of motion. J ,13 mal segment of the joint being measured be positioned neastlring vertically or horizontally to obtain accurate measure- Some electrogoniometers resemble pendulum 'cause the ments; otherwise, adjustments must be made in deter- goniometers.23,24 Changes in joint position cause a mining the measuremenr.6.9 Inclinometers are also diffi- change in conract between the pendulum and the small from the cult to use on small joints lO and where there is soft tissue resistors. Contact with the resistors produces a change in er's arms deformiry or edema.6,. electric current, which is used to indicate the amount of ~t is diffi- joint motion. Although universal and gravity-dependenr goniome- ters may all be available within a clinical setting, they Electrogoniometers are expensive and take time to cal- should not be used interchangeably.II-14 For example, an ibrate accurately and attach to the subject. Given these drawbacks, electrogoniomerers are used more often in examiner should not use a universal goniometer on research than in clinical settings. Radiographs, phoro- iTuesday and an inclinometer on Wednesday to measure graphs, film, videotapes, and compurer-assisted video la subject's knee ROM. The goniometers may provide E t I L

26 PA R T I INTRODUCTION TO GONIOMETRY THE UNIVERSAL GONIOMETER The following activities are designed ro help the examiner become familiar with the universal the e that t goniometer. Af Equipment: Full-circle and half-circle universal goniometers made of plastic and metal. On m, pletce Activities: unive focusl 1. Select a goniometer. using 2. Idenrify the type of goniometer selected (full-circle or half-circle) by noting the shape of the ...... body. 3. Differentiate between the moving a'1d the stationary arms of the goniometer. (Remember ..... J that the stationary arm is an integral part of the body of the goniometer.) Gonio 4. Observe the moving arm to see if it has a cut-out portion. arms ( 5. Find the line in the middle of the moving arm and follow it to a number on the scale. 6. Study the body of the goniomerer and answer the following questions: ments / On sof callan a. Is the scale located on one or borllSides? b. Is ir possible to read rhe scale through the body of the goniometer? menrs. c. What intervals are used? d. Does the face contain one or two scales? all jail 7. Hold the goniometer in both hands. Position the arms so that they form a continuous may b, straight line. When the arms are in this posicion, the goniometer is at 0 degrees. 8. Keep rhe stationary arm fixed in place and shift the moving arm while watching the num- be leal bers on the scale, either at the tip of the moving arm or in the Cut-out portion. Shift the moving arm from 0 to 45, 90, 150, and 180 degrees. tionall 9. Keep the stationary arm fixed and shift the moving arm from 0 degrees through an esti- axis of mated 45-degree arc of motion. Compare the visual estimate with the actual arc of motion by reading the scale on the goniometer. Try to estimate other arcs of motion and compare IOg3rn the estimates with the actual arc of motion. 10. Keep the moving arm fixed in place and move rhe stationary arm through different arcs of diStal s monon. 11. Repeat steps 2 to 10 using different goniomerers. -) motion analysis systems are other joint measurement ical landmarks. 25,26 Most authorities report more ace methods used morc commonly in research settings. rate and reliable measurements with a goniometer rh\" Visual Estimation with visual estimates.27- 33 Even when produced by skilled examine~ visual estimates yield only subjecti\" Although some examiners make visual estimates of joint information in contrast to goniomctcic measuremen:, position and modon rather than use a measuring instru- which yield objective information. However, esrimat: ment, we do not recommend this practice. Several are ilsefuhn the learning process. Visual estimates rna authors suggest the use of visual estimates in situations in prio,r to goniometric measurements help [0 reduce erra' which the subject has excessive soft tissue covering phys- attributable to incorrect reading of the goniometer. If t . goniomctric measurement is not in the same quadrant

CHAPTER 2 PROCEDURES 27 FIGURE 2-9 The examiner is using a grease pencil to mark the location of the subject's left acromion process. Note that the examiner is using the second and third digits of her left hand to palpate the bony landmark. the estimate, the examiner is alerted to the possibility that the wrong scale is being read. After the examiner has read and studied this section on measurement instruments, Exercise 2 should be com- pleted. Given the adaptability and widespread use of the universal goniometer in the clinical setting, this book focuses on teaching the measurement of joint motion using a universal goniometer. • Alignment FIGURE 2-10 \\Vhen using a full-circle goniometer to measure ROM of elbow flexion. align the stationary arm of the instru- Goniometer alignment refers to the alignment of the ment parallel to the longitudinal axis of the proximal part (sub- atms of the goniometer with the proximal and distal seg- ments of the joint being evaluated. Instead of depending ject's humerus) and align the moving arm patallel to the longi- narc acC On soft tissue contour, the examiI).er uses bony anatomi- neter tha cal landmarks to more accurately visualize the joint seg- tudinal axis of the distal part (subject's forearm). uced by ments. These landmarks, which have been identified for subjcctiv all joint measurements, should be exposed so that they '~urement may be identified easily (Fig. 2-9). The landmarks should ; estimat be learned and adhered to whenever possible. The sta- lates made tionary arm is often aligned parallel to the longitudinal iuce errO . axis of the proximal segment of the joint, and the mov- leter. If t ing arm is aligned parallel to the longitudinal axis of the uadraot distal segment of the joint (Fig. 2-10). In some situations,

28 PART I INTRODUCTION TO GONIOMETRY FIGURE 2-11 (A) \\Vhcn the examiner uses a half.circlc goniometer ro measure left elbow flexion, arm aligning the moving arm with the subject's forearm causes the poinr.:r to move beyond the goniome- 2-L ter body, which makes it impossible ro read the scale. (8) Reversing the arms of the instrument so that poir. .the stationary arm is aligned parallel ro the disral parr and the moving arm is aligned parallel ro the proximal pare causes the poinrcr to remain on the body of the goniometer, enabling the examiner co IS C( read the scale along the pointer. T because of limitations imposed by eithet the goniometet aligned with the distal parr (Fig. 2-11B). Therefore, we' appJ or the subject (Fig. 2-11A), it may be necessary to reverse bein the alignment of the two arms so that the moving arm is have decided to use the term proximal arm to refer to ,h char aligned with the proximal parr and the stationary arm is arm of the goniometer that is aligned with the proxirn~' mus· segment of the joint. The term distal arm refers to thl ful , that appt arrn~ segrr the f E goni Whe goni goni· lowe be di one'j 180 whic esrin errOr Anal vals. part!

CHAPTER 2 PROCEDURF FIGURE 2-1.2 Throughout the book we use the term \"proxi- mal arm\" CO indicate the arm of the goniometer that is aligned with the proximal segment of the joint being examined. The term \"distal arm'\" is used ro indicate the arm of the goniometer that is aligned with the distal segment of the joint. During the measurement of elbow flexion, the proximal arm is aligned with the humerus, and the distal arm is aligned with the forearm. -~' aligned with the distal segment of the joint (Fig. er may believe the interval represents 1 degree. In this The anatomical landmarks provide reference case the examiner would incorrectly read 91 degrees /:c instead of 95 degrees. points that help to ensure that the alignment of the arms .J is correCt. After the examiner has read this section on alignment, Exercise 3 should be completed. ;• The fulcrum of the goniometer may be placed over the • Recording :orc, we: 2pproximate location of the axis of motion of the joint being measured. However, because the axis of modon Goniometric measurements are recorded in numerical \" to the. changes during movement, the location of the fulcrum tables, pictorial charts, or within the written text of must be adjusted accordingly. Moore6 suggests that care- an evaluation. Regardless of which method is used, ful alignment of the proximal and distal arms ensures recordings should provide enough information to permit rhat the fulcrum of the goniometer is located at the an accurate interpretation of the measurement. The fol- approximate axis of motion. Therefore, alignment of the lowing items are recommended ro be included in the arms of the goniometer with the proximal and distal joint recording: segments should be emphasized more than placement of the fulcrum over the approximate axis of motion. 1. Subject's name, age, and gender 2. Examiner's name Errors in measuring joint position and modon with a 3. Date and time of measurement 4. Make and rype of goniometer used goniometer can occur if the examiner is not careful. 5. Side of rhe body, joint, and motion being meas- When aligning the arms and reading the scale of the ured; for example, lefr knee flexion goniometer, the examiner must be at eye level with the 6. ROM, including the number of degrees ar the goniometer to avoid parallax. If the examiner is higher or lower than the goniometer, the alignment and scales may beginning of the motion and the number of be distorted. Often a goniometer will have several scales, degrees at the end of the motion One going from 0 to 180 degrees and another going from 7. Type of motion being measured; thar is, passive or 180 to 0 degrees. Examiners must carefully determine active motion which scale is correct for the measurement. If a visual 8. Any subjective information, such as discomfort or estimate is made before the measurement is taken, gross pain, that is reported by the subject during the testing errors caused by reading the wrong scale will be obvious. Another source of error is misinterpretation of the inter- rox,ma!l .. vals On the scale. For example, the smallest interval of a to th' •.;. particular goniometer may be 5 degrees, but an examin- :: {;

• 30 PAR T I I N T ROD U C T ION TOG 0 N 10M ETRY ELBOW FLEXION wi The following activities are designed to help the examiner learn how to align and read the ffi' goniometer. Equipment: Full-circle and half-circle universal goniometers of plastic and metal in var- th ious sizes and a skin-marking pencil. A de Activities: See Figures 5-15 to 5-17 in Chapter 5. ffi' 1. Select a goniometer and a subject. 2. Position the subject so that he or she is supine. The subject's right arm should be positioned -2 in; so that it is close to the side of the body with the forearm in supination (palm of hand faces the ceiling). A towel roll placed under the distal humerus helps to ensure that the elbow is cit fully extended. 3. Locate and mark each of the following landmarks wirh the pencil: acromion process, lat- en eral epicondyle of the humerus, radial head, and radial styloid process. of 4. Align the proximal arm of the goniometer along rhe longitudinal axis of the humerus, jo: using the acromion process and the lateral epicondyle as reference landmarks. Make sure io: that you are positioned so that the goniometer is at eye level during the alignment process. 5. Align the distal arm of the goniometer along the longitudinal axis of the radius, using the TI radial head and the radial styloid process as reference landmarks. 6. The fulcrum should be close to the lateral epicondyle. Check to make sure that the body in~ of the goniometer is not being deflected by the supporting surface. 7. Recheck the alignment of the arms and readjust the alignment as necessary. ha 8. Read the scale on the goniometer. 9. Remove the goniometer from the subject's arm and place it nearby so it is handy for mea- suring the next joint position. 10. Move the subject's forearm into various positions in the flexion ROM, including the end of the flexion ROM. At each joint position, align and read the goniometer. Remember that you must suppOrt the subject's forearm while aligning the goniometer. 11. Repeat steps 3 to 10 on the subject's left upper extremity. 12. Repeat steps 4 to 10 using goniometers of different sizes and shapes. 13. Answer the following questions: a. Did the length of the goniometer arms affect the accuracy of the alignment? Explain. b. What length goniometer arms would you recommend as being the mOSt appropriate for this measurement? Why? c. Did the type of goniometer used (full-circle Or half-circle) affect either joint alignment or the reading of the scale? Explain. d. Did the side of the body that you were testing make a difference in your ability to align the goniometer? Why? 9. Any objective information obtained by the exam- ues from people of the same age and gender, and from iner during testing, such as a protective muscle studies that used the same method of measurement. Text spasm, crepitus, or capsular or noncapsular pat- and ROM tables that demonstrate mean values by age tern of restriction with information on gender and methods of measure- I recommended testing positions 10. A complete description of any deviation from the ment are presented at the beginning of Chapters 4 through 13. A selection of ROM values is also presented t at the beginning of testing procedures for each motion I or passive motion, the ROM may be recorded as normal may also be compared with the same joint of the subject's If a subject has normal pain-free ROM during active and in Appendix A. The ROM of the joint being tested L.i whether the ROM is normal, the examiner should com- extremity is neither impaired nor used selectively in ath- (N) or within normal limits (WNL). To determine contralateral extremity, provided that the contralateral pare the ROM of the joint being tested with ROM val- letic or occupational activities.

CHAPTER 2 PROCEDURES 31 ;/' correctly. If we assume that the notmal ROM for this movement is 0 to 150 degrees, the subject who has a flex- If passive ROM appears to be decreased or increased ion ROM of 0-50 degtees lacks motion at the end of the flexion ROM. The subject with a flexion ROM of 20-70 'when compared with normal values, the ROM should be degtees lacks motion at the beginning and at the end of the flexion ROM. The term hypomobile may be applied <measured and recorded. Recordings should include both to both of these joints because both joints have a less- than-normal ROM. the srarting and the ending positions to define rhe ROM. Sometimes the opposite situation exists, in which a '; Arecording that includes only the total ROM, such as 50 joint has a greater-than-normal range of motion and is '--:d~grees of flexion, gives no information as to where a hypermobile. If an elbow joint is hyper mobile, the start- 'inotion begins and ends. Likewise, a recording that lists .'-20 degrees (minus 20 degrees) of flexion is open to mis- ing position fot measuring elbow flexion may be in hyperextension rathet than at 0 degrees. If the elbow was ,•j ihterpretation because the lack of flexion could occur at hyperextended 20 degrees in the starting position, the beginning of the flexion ROM would be recorded as 20 )\" etther the end or the beginning of the ROM. degrees of hyperextension (Fig. 2-14). To clarify that the 20 degrees represents hyperextension rather than limited , A motion such as flexion that begins at 0 degrees and flexion, a \"0\" representing the zero starring position, /~nds at 50 degrees of flexion is recorded as 0-50 degrees which is now within the ROM, is included. An ROM of flexion (Fig. 2-13A). A motion that begins with the \"1' joint flexed at 20 degrees and ends at 70 degrees of flex- i;: . ion is recorded as 20-70 degrees of flexion (Fig. 2-138). The total ROM is the same (50 degrees) in both ': instances, but the arcs of motion are different. Because both the starting and the ending positions have been recorded, the measurement can be interpreted - A ld from 8 FIGURE 2-13 A recording of nt. Text ROM should include the begin- by age easure- ning of the range as well as the ters 4 end. (Al In this illustration, the sen ted otion motion begins at 0 degrees and ,tested ends at 50 degrees so that the bject's total ROM is 50 degrees. (8) In ateral ath- this illustration, the motion begins at 20 degrees of flexion and ends at 70 degrees, so that rhe total ROM is 50 degrees. For both subjects, the total ROM is the same, SO degrees, even though the arcs of morion are different.

32 PA RT I INTRODUCTION TO GONIOMETRY FIGURE 2-14 This subiecl has 20 dc.:grl'cs of hypcn:xlcllsiun :H her t1bo\\\\'. In this (;15C, motion begins at 20 dl..'grct:s of h~·p<.:rCX[(.'IISi()1I :llld pnll.:ccds through rhe O-dcgn:c position co 150 dc.:grccs of flt:xioll. that begins at 20 degrees of hyperextension and ends ar on rhe left side of rhe subject's body; space to the right is Si ISO degrees of flexion is recorded as 20-0-150 degrees reserved for measurcmenrs taken on rhe right side of AI of flexion. the body. The examiner's initials and rhe dan.' of resting a 3fC noted ar the tOp of rhe I11casurcmcIH columns. ft< Some authoriries have suggested rhe lise of plus (+) Subsequenr measurCIl1cnrs are recorded on the S:lI11(' form de and minus (-) signs to indicare hypomobility and hyper- ;lnd idenrified br th~ examiner's initials and the d:He at mobility. However, [he use of these signs varies depend- the top of the appropri<lte mC,lsuremcm column. This tal ing on the authority consulted. To avoid confusion, we formar makes it casy to compare a series of llleasure- have omirred the usc of plus and minus signs. A ROM ments ro identify problem motions and then to track de rehabilitative response over time. Examples of numerical an that docs nor start wirh 0 degrees or ends prematurely recording rabies arc included in Appendix C. an ph indicates hypomobility. The addition of zero, represent- Pictorial Charts ing rhe usual starting posirion wirhin rhe ROM indicates we hypermobility. Pictorial charts may be used in isolation or ~()mbined with numerical tables to rc('ord ROivt measurements. be, Numerical Tables Pictorial chans usually include a diagram of the normal nu: starring and ending positions of rhe motion (Fig. 2-16). en, Numerical tables typically lisr joint motions in a column down the center of the form (Fig. 2-15). Space to rhe lefr I of the central column is reserved for measurements taken ind nur Name Paul Jones Age 57 Gender M end Left Right JW JW Examiner JW 4/1102 3118/02 Date 3;18102 FIGURE 2-15 This llllllll'ri- ell rabll.: records the results Hip 0·118 of ROt\\-,t llleasun:mcnts of a 0-12 subject's left and right hips. 0-98 0-73 Flexlon O·ll The examiner has recorded 0·15 her initials ;lIId rll(' dare of 0·5 0·5 Extension 0-28 0·18 Abduction n-·n (('sting at (he top ot ('ach col- 0-12 0-6 Adduction 0-14 umn of ROM measurements. Note that the right hip w;tS 0-35 0-24 Medial Rotation tested oncc, 011 M:lrch IS. 2002, ;lncl rhe..' left hip was 0-40 0-35 Lateral Rotation tcsh:d twice, once on !Vbrch 1S, 2002, and ag<lin on April Comments: 1,2002. R

CHAPTER Z PROCEDURES 33 JW JW 3/18102 4/1/02 60 110 120 Ibjcct 50 40 ::xccnsion :l.IS case:, 30 legrecs 0'( procccd~ . positiofl! ion. iA/ ~>- 20 e right is 10 : side of: JW ,f testin~ 3/18/94 iH:::::::::::::::=======::::::====:~----L-_-+----- columns~ FIGURE 2-16 This pictorial chart records the results of flexion ROM measurements of a subject's left InlC form hip. For measurements taken on March :18, 2002, note the 0 to 73 degrees of left hip flexion; for meas- urements taken on April!. 2002, notc the 0 to 98 degrees of left hip flexion. (Adapted with permission e date at from Range of Morion Test, New York University Medical Center, Rusk Institute of Rehabilitation Medicine.) mn. This measure~j to trac~ lumcricaf :OInbined!, Sagittal-Frontal-Transverse-Rotation Method the frontal plane (lateral flexion) are listed to the left first uremcnrs/ and to the right lasr. IC normaf Another method of recording, which may be included in g. 2-16). a written text Or formatted into a table, is the sagittal- ~~f[i/'Yif ~;K<>\"?i.Ft~\"tt'~V~><-:i%~::~'?/f/f!J;l''7~'''JJ,iI}~'~~\"\";''§H1~¥?-;- \"'~1.fJ/J£1ii~. frontal-transverse-rotation (SFTR) recording method, is numeri· developed by Gerhardt and Russe. 3••35 Although it is ~0fEXAMPlE: If a-sl)~jeci.lf:if)t5de&ees of !iii>;abdut\"'W the rcsuhs rately used in the United States, its advantages have been :nencs of a described by Miller.9 In the SFfR method, three numbers f~S~~5~'f~i~o~nD!!hR, ?i!~mt~j~i~j~~~!~11~~~~~g~5~«(P\"-~s of,hi~!lld(hi2troii ~th.;'$~' /. .right hips. are used to describe all motions in a given plane. The first s recorded and last numbets indicate the ends of the ROM in that In the transverse plane, represented by T, the first he date of plane. The middle number indicates the starting position, numbet indicates the end of the horizontal abduction )f each col·~ which would be 0 in notmal motion. ROM, the middle number the starting position, and the lsurementS. last number the end of the horizontal adduction ROM. ~t hip waS In the sagittal plane, tepresented by S, the fitst num- March 18, bet indicates the end of the extension ROM, the middle Rotation is tepresented by R. Lateral rotation ROM, ft hip was number the statting position, and the last number the including supination and eversion, is listed first; medial ~ on March end of the flexion ROM. rotation ROM, including pronation and inversion, is list- in on April ed last. Rotation ROM of the spine '0 the left is listed In the frontal plane, represented by F, the first number first; rotation ROM to the right is listed last. Limb posi- i indicates the end of the abduction ROM, the middle tion during measurement is noted if it varies from number the starting position, and the last number the anawrnical position. UF90\" would indicate that a meas- I end of the adduction ROM. The ends of spinal ROM in urement was taken with the limb positioned in 90 degtees of flexion.

f 34 PA R T I INTRODUCTION TO GONIOMETRY Hypomobility is noted by the lack of 0 as the middle motions progrt.:ss rowarJ I SO degrces. l-Io\\\\,(:\\,c[, the number or by less-than-normal values for the first and r<:'orJing sysrl.:1Tl proposed ill tht.' Guide:;; /() the last numbers, which indicate the ends of the ROM. El'(Jlua!i()1J of Permmu.:nl Im/J/lirmcnt dOl;S diflcr fro ill othcr recording systems described ill Ollr [ext. In this sys- tem, when extension exceeds rhe ntlltr~d starting posi- tioll, it is n.:ferred ro as hyperexH:nsioll ;lnd is expressed with rhe: plus (-1-) symhol. For n:amplt:, motion at the MCP joint of a finger from 15 degrees of h}'perextension to 45 degrees of flexion would be n.:cordcd as + 15 to 45 th:grces. The plus (+-) symbol is used to cmplusil.c the fad that rhe Joint h:ls hyperextension. In thi~ ~ystem. the minus (-) symbol is used [0 ernpha- sizl.: the fact d1M ,1 Joinr has an cxtCl1sio(J lag. \\'(/hcl1 the neutral (zero) st<Jrring position cannot be :.1rraincd, an extension lag exists and is expressed with til(: minus sym- hoI. For example. motion ;:u the ,vtel' joillt of a fillger frolll IS Jt:grees of flexion co 45 degret:s of f1t:xion wOlild be rccordcd as -15 to 45 degrees. A fixcd-joint limitation, ankylosis is indicated by the • Procedures usc of only two numbers. The zero starring position is included to clatify in which motion the fixed position Prior to beginning a gonioIllL·tri( e\\'aluation, the cX:llllin- occurs. LT 1ll1lSr: American Medical Association Guide to Evaluation Method • DL:tc.:rminc which joints and motions need co be res [cd Another system of recording restricted motion has been described by the American Medical Association in the • Organizc rhe tcsring sequencc by bod)' position Guides to the Evaluation of Permanent Impairment. 36 • Gather thl:' llC(CSsary equipment, such as goniome- This book provides ratings of petmanent impaitment for all major body systems, including the respitatory, cardio- {CCS, rowel rolls, :llld recording forms vascular, digestive, and visual systems. The longest chap- • Prepare :lll expbn:lrion of the procedure for the ter focuses on impairment evaluation of the extremities, spine, and pelvis. Restricted active motion, ankylosis. subject amputation, sensory loss, vascular changes, loss of strength, pain, joint crepitation, joint swelling, joint Explanation Procedure instability, and deformity are measured and converted (Q percentage of impairment for the body part. The total The listed stcpS and the example thar follows provide the percentage of impaitment for the body part is converted examiner with a suggested format for explaining to the percentage of impairment for the extremity, and goniometry to a subject. finally to a percentage of impairment for the entite body. Often these permanent impairment ratings are used, Steps along with other information, to determine the patient's level of disability and the amount of monetaty compen- I. Introduction ,1nd explanation of purpose sation to be expected from the employer or the insurer. 2. Explan,-Hion and demonstration of goniometer Physicians and thetapists working with patients with per- .3. Explanation and demonstration of anaromical manent impairments who are seeking compensation for theit disabilities should refer to this book for more detail. bndmarks 4. Explanation and demonstration of testing position The system of recording restricted motion found in 5. Expl.1natioll and demonstration of examincr's and the Guides to the Evaluation of Permanent Impair- subject's roles melll also uses the O-to-180--degtee notation method. 6. Confirmarion of subject's understanding The neutral starting position is recotded as 0 degrees; Lay rather than technical terms arc used in the exam- ric so rhat rhl· subject GlIl understand the: procedure. During the explanation, the examiner should try to . establish a good rapport with the subject and enlist the :~ subjecr's participation in rhe evaluarion process. After reading the eXi.lInple, the examiner shoulJ practice Exercise 4. ExAMPLE: Explanation of Goniometry

CHAPTER 2 PROCEDURES 3S vcr, the Introduction and Explanation of Purpose atm through a passive ROM and then asks the to the.< subjecr to perform the same motion. :c:r from Introl~u,:ti()n: My name is . I am a rhis sYS~:, 6. Explanation and Demonstration of Examinet's and ng posi.- (occupational title). Subjects Roles During Passive Motion xpressed~ Explanation: I understand thar you have been hav- Explanation: I will move your arm and rake a measurement. You should relax and ler me do all 11 .1£ th~': ing some difficulty moving your elbow. I am of the work. These measurements should not xrcnsiori{ going to measure the amount of motion that you cause discomfort. Please let me know if you have 15 to 4i~ have at your elbow joint to see if it is equal ro, any discomfort and I will stop moving your arm. less than, or gteater than normal. I will use this asizc the: information to plan a treatment program and Demonstration: The examiner moves the subjecc's assess its effectiveness. arm gently and slowly through the tange of I cmpha~ D,:m,on:stration: The examiner flexes and extends elbow flexion. Xlhcn th'; his or her own elbow so that the subject is able 7. Confirmation of Subject's Understanding lined, an' to observe a joint motion. llUS sym· Explanation: Do you have any questions? Are you : a finge? Explanation and Demonstration of Goniometer ready to begin? :m \\\\'ould·; Explanation: The instrument that I will be using to Testing Procedure )rovide th,e obtain the measurements is called a goniometer. explaining' It is similar to a protractor, bur it has twO exten- The testing process is initiated aftet the explanarion of sions called arms. goniometry has been given and the examiner is assured ·c that the subject understands the nature of rhe testing Demonstration: The examiner shows the goniome- process. The testing procedure consists of the following ometer ter to the subject and encoutages the subject ro 12-step sequence of activities. ana[()mica~ - ask questions. The examinet shows the subject ng posirio,~ how the goniometer is used by holding it next to Steps :nincr's an~ his or her own elbow. 1. Place the subject in the testing position. g 3. Explanation and Demonstration of Anaromical 2. Stabilize the' proximal joint segment. , rhe exam' Landmarks 3. Move the distal joint segment to the zero starting prucedur~~ 1lIid try t~ Explanation: To obtain accurate measurements, I position. If the joint cannot be moved to the zero will need to identify some anatomical land- starting position, it should be moved as close as ,eI enlist th' marks. These landmarks help me to align the possible to the zero starting position. Slowly )Cess. After' arms of the goniometer. Because these landmarks move the distal joint segment to the end of the .leI praC(ic~ are important, I may have to ask you to remove passive ROM and determine the end-feel. Ask the certain articles of clothing, such as your shirt or subject if thete was any discomfort during the blouse. Also, ro locate some of the landmarks, I motion. may have to to press my fingers against yoUt 4. Make a visual estimate of the ROM. skin. 5. Return the distal joint segmen't to rhe starting position. Demonstration: The examiner shows the subject an 6. Palpate the bony anatomical landmarks. easily identified anaromicallandmark such as the 7. Align the goniometer. ulnar styloid process. 8. Read and record the starting position. Remove the goniometer. 4. Explanations and Demonstration of Recom- 9. Stabilize the proximal joint segment. mended Testing Positions 10. Move the distal segment through rhe full ROM. 11. Replace and realign the goniometer. Palpate the Explanation: Cerrain testing positions have been anatomical landmarks again if necessary. esrablished ro help make joint measurements 12. Read and record the ROM. easier and more accurate. Whenever possible, I would like you ro assume these positions. I Exetcise 5, which is based on the 12-step sequence, will be happy to help you get into a parricular affotds the examiner an opportunity to use the testing position. Please ·Iet me know if you need assis- procedure fot an evaluation of the elbow joint. This exer- tance. cise should be practiced until the examinet is able to per- form the activities sequentially without reference to the Demonstration: The sitting or supine positions. exercise. 5. Explanation and Demonstration of Examiner's and Subjecr's Roles During Active Motion Explanatinn: I will ask you to move YOUt arm in exactly the same way that I move your arm. Demonstration: The examiner takes the subject's : <.'i,

36 PART I INTRODUCTION TO GONIOMETRY REf EXPLANATION OF GONIOMETRY 1. Equipment: A universal goniometer. 3. Activities: Practice the following six steps with a subject. 4. 1. Introduce yourself and explain the purpose of goniometric resting. Demonsrrate a joint 5. 6. ROM on yourself. 7. 2. Show the goniometer to your subject and demonstrate how it is used to measure a joint 8, 9. ROM. 10. 3. Explain why bony landmarks must be located and palpated. Demonstrate how you would II. 12. iocate a bony landmark on yourself, and explain why clothing may have to be removed. 13. 4. Explain and demonstrate why changes in position may be required. 14. 5. Explain the subject's role in the procedure. Explain and demonstrate your role in the pro- IS. 16. cedure. 17. 6. Obtain confirmation of the subject's understanding of your explanation. 18. .iSJ J TESTING PROCEDURE FOR GONIOMETRIC EVALUATION OF ELBOW FLEXION Equipment: A universal goniometer, skin-marking pencil, recording form, and pencil. Activities: See Figures 5-15 to 5-17 in Chapter 5. 1. Place the subject in a supine position, with the arm ro be tested positioned close to the side of the body. Place a towel roll under the distal end of the humerus ro allow full elbow extension. Position the forearm in full supination, with the palm of the hand facing the ceiling. 2. Stabilize the distal end of the humerus ro ptevent flexion of the shoulder. 3. Move the forearm to the zero starting position and determine wherher there is any motion (extension) beyond zero. Move ro the end of the passive range of flexion. Evaluate the end- feel. Usually rhe end-feel is soft because of compression of the muscle bulk on the anteri- or forearm in conjunction with that on the anterior humerus. Ask the subject if there W':lS any discomfort during the motion. 4. Make a visual estimate of the beginning and end of rhe ROM. 5. Return the forearm to the starting position. 6. Palpate the bony anaromical landmarks (acromion process, lateral epicondyle of rhe humerus, radial head, and radial sryloid process) and mark wirh a skin pencil. 7. Align the arms and the fulcrum of the goniometer. Align the proximal arm with the larer- al midline of the humerus, using the acromion process and lateral epicondyle for reference. Align the distal arm along the lateral midline of rhe radius, using the radial head and the radial sryloid process for reference. The fulcrum should be close ro the lateral epicondyle of the humerus. 8. Read the goniometer and record the starting position. Remove the goniometer. 9. Stabilize the ptoximal joint segment (humerus). 10. Perform the passive ROM, making sure that you complete the available range. 11. When the end of the ROM has been attained, replace and realign the goniometer. Palpate the anatomical landmarks again if necessary. 12. Read the goniometer and record your reading. Compare YOUt reading with your visual esti- Ornate ro make sure that you are reading the correct scale on the goniometer.

CHAPTER 2 PROCEDURES 37 FERENCES biliry of force t(3cking 3nd joint-movemem tracking scores in healthy subjects. Phys Ther 68:1087, 1988. I. Rothstein, JM, Miller, Pl, :lnd Roettger, F: Goniomctric reliability 19. Torburn, 1., Perry, j, and Gronlcy, JK: Asst:ssmem of rC.:1rfoot in a clinical setting. Phys Ther 63:1611.1983. motion: Passive positioning, one-legged standing, gait. Foor Ankle 19,688,1998. 1. Ekstrand, J. ct at: Lower extr£:miry goniometric measurements: A 20. Vandervoort, AA, et al: Age and sex effects on mobiliry of the human ankle. j GeromoI47:MI7, 1992. study to determine their reliability. Arch Phys Mcd Rchabi163:171, 21. Cheswonh, 8M. and Vandervoort, AA: Comparison of passive 1982 stiffness variables and range of motion in uninvolved <1nd involved 3. Ball, P, and Johnson, GR: Reliability of hindfoor goniomerry when ankle joints of patients following ankle fractures, Phys Ther using a flexible elecr(ogoniomerer. Clio Biomech 8:13,1993 75,253, 1995 .t. Sabat, J5, ct 31: Goniomerric assessment of shoulder range of 22. Gajdosik, RL. Vander Linden, DW, and Williams, AK: Influence of morion: Comparison of testing in supine and sifting positions. Arch llge on length and passive elastic stiffness characteristics of the calf Phys Med Rehabil 7%4,1998. muscles-tendon unit of woman. Phys Ther 79:827,1999. 5. Moore, ML: The measurement of joint motion. Part II: The technic 23. Clapper, MP. and Wolf. SL: Comparison of the reliability of the of goniomcrry. Phys Thee Rev 29:256, 1949. 6. Moore, ML CliniGlI assessment of joint motion. In 835majian, jV Orthoranger and the standard goniometer for assessing acrive (ed): Therapeutic Exercise, cd 3. Williams & Wilkins, B:tltimore. lower extremiry range of motion. Phys Ther 68:214,1988. 1978. 24. Creene. BL, and Wolf. Sl: Upper cxrrcmiry joint movement: 7. Fox, RF, and V:tn Breemen, J: Chronic Rheumatism, Causation and Comparison of two measurement devices. Arch Phys Med Rehabil Trcarmcnt. Churchill, london, 1934, p 327. 70,288, 1989. 3. Schenkar, WW: Improved method of joint motion measurement, 25. American Academy of Orthopaedic Surgeons: Joim Morion: A NY J Med 56,539, 1956. Method of Measuring and Recording. AAOS, Chic3go, 1965. 9. Miller. PJ: Assessment of joint motion. In Rothstein. jM (cd): 26. Rowe, CR: joint measurement in disabilit}' evaluarion. Clin Orthop Measurement in Physical Therapy. Churchill livingstone. New 32A3,1964. York, 1985. 27. Watkins, MA, et al: Reliability of goniomcuic mt:<1surements nnd :i\" 10. Clarkson, HM: Musculoskeletal Assessment: joint Range of visual estim:1tcs of knee range of motion obr;lined in a clinical set- Morion and Manual Muscle Strength, ed. 2. Lippincott Williams & ting. Phys Ther 71:90,1991. Wilkins, Philadelphia, 2000. 28. Youdas, jW. c.uey. JR, and C:trren. TR: Reliability of measure- 11. Petherick, M. ct al: Concurrent validity and intencstcr reliability of menrs of ccrvic.1l spine mnge of motion: Compnrison of three mcth- universal and fluid-based goniometers for active elbow range of ods, Phys Ther 71:98,1991. motion. Phys Ther 68:966, 1988. 29. Low, jL: The reli3bility of joint mC3surement. Physiotherapy ',:: 12. Rheault, W. et al: Intertester reli3bility and concurrent validity of 62,227, 1976. fluid-based 3nd universal goniometers for active knee flexion. Phys Thee 68,1676,1988. 30. Moore, M1.: The measurement of joint morion. Part I: Introductory review of the litcr3ture. Phys TherRev 29:195,1949. 13. Goodwin, J, et al: Clinical methods of goniometry: A comparative 31. Saher. N: Methods of measurement of muscle and joint function. j '=:i study. Disabil Rehabil 14:10. 1992. Bone Joint Surg Br 34:474,1955. 14. Rome. K, and Cowieson, F: A reliabiliry study of the universal goniomerer, fluid goniometer, ::and e1ectrogoniomerer for the me3S- 32. Minor, MA. ,lOd Minor. SO: Patiem Evaluarion Methods for the urernent of <1nkle dorsiflexion. Foot Ankle 17:28. 1996. Heahh Profession:tl. Reston. VA, 1985. ~.J5. Karpovich. PV, and Karpovich, GP: Electrogoniometer: A new device for smdy of joints in action. Fed Proc 18:79, 1959. 33. Grecne, WB, and Heckman jD (eds): The Clinical Measurement of 16. Kerrelkanip, DB, johnson, Re, Smidt, GL, et al: An electrogonio- joint Motion. AAOS, Rosemont, III., 1994. metric study of knee motion in normal &3it. j Bone Joim Surg Am 52,775, 1970. 34. Gerhardt, jj, and RussC', OA: Iorernational SFrR Method of Measuring and Recording joim Motion. Hans Huber, Bern, 1975_ 17. Knutzen, KM. Bares, BT, and Hamill. J: Electrogoniometry of poSt- 35. Gerhardt. Jj: Clinical measurement of joint motion and position in surgical knee bracing in running. AmJ Phys Mec.l RchabiI62:172, the neutral-zero method and SFTR: Basic principk-s. 1m Rehabil 1983. Med 5,161, 1983. ),18. Carey, JR, Patterson. JR, and HoUensrein, PJ: Sensitiviry and relia- 36. American Medical Association: Guides to the Evaluation of Permanent Impnirmem, ed 3. AMA, Milwaukee, 1990. 1

.@', Validity and Reliability • Validity Content Validity For goniometey ro provide meaningful information, Content validity is determined by judging whether or not measurements must be valid and reliable. Currier l states an instrument adequately measures and represents the that validity is \"the degtee w which an instrument mea- domain of coment-rhe substance-of the variable of sures what it is purporred to mcasurCj the extent to interest.2- 5 Both content and face v:llidity are based on which it fulfills its purpose.\" Stated in another way, the subjective opinion. However, face validity is the most validity of a measurement refers to how well the meas- basic and elementary form of validity, whereas content urement represents the true value of the variable of inter- validity involves more rigorous and careful considera- est. The purpose of goniometty is w measure the angle of tion. Gajdosik and Bohannon\" state, \"Physical therapists joint position or range of joint motion. Therefore, a valid judge the validity of most ROM measurements based on goniomcrcic measurement is <?oc that truly represents the their anatomical knowledge and their applied skills of actual joint angle or the wtal range of motion (ROM). visual inspection, p:llpation of bony landmarks, and accurate alignment of the goniometer. Generally, the Face Validity accurate application of knowledge and skills, combined with interpreting the results as measurement of ROM There are four main rypes of validity: face validity, only, provide sufficient evidence to ensure content valid- coment validity, criterion-related validity, and construCt ity..) validity.'-s Most support for the validity of goniometry is in,the form of face, coment, and criterion-related valid- Criterion-related Validity ity. .Face validity indicates that the instrument generally appears to measure what It proposes [0 measure-that it Criterion-related validity justifies the validity of the is plausible.'-s Much of the literature on goniometric measurement does not specifically address the issue of measuring instrument by comparing measurements made validity; rather, it assumes that the angle created by align- ing the arms of a universal goniometer with bony land- with the instrument to a well-established gold standard marks truly tepresents the angle created by the proximal of measuremem-thc critcrion.2- S [f the measurements and distal bones composing the joint. One infers that made with the instrument and criterion are taken at changes in goniometer alignment reflect changes in joint approximately the same time) concurrent validity is angle and represent a range of joint motion. Portney and tested. Concurrent validity is a rype of criterion-telated Watkins' report that face validity is easily established for validity:'·7 Criterion-related validity can be assessed so,?e tests such as the measurement of ROM, because objectively with statistical methods. In terms of goniom- the instrument measures the variable of interest through etry, an examiner may question the construction of a direct observation. particular goniometer on a very basic level and consider whether the degree units of the goniometer accurately represent the degree units of a circle. The angles of the 39 1

p 40 PART I INTRODUCTION TO GONIOMET,RY gOniometer can be compared wirh known angles of a ROM ;lnd the mdiographic angles between thc occiput r protractor-the criterion. Usually the construction of goniomerers is adequate, and the issue of validity focuses and C-7. Tousignant and co \\ \\ 'o rk e r s l 1 measured cervical ! on whether the goniometer accurately measures the angle - s of joint position and ROM in a subjecc flexion <'Ind extension in 31 subjects with;l cervical ROM r Criterion-reloted Validity Studies of s Extremity Joints goniomccer and radiographs thac included cervical and t n The besr gold standard used to establish critetion-related upper thoracic motion. They found a high correlation r validity of goniomctric measurements of joint position s and ROM is radiogtaphy, Several studies have examined ht.:rwcen rhe two measurements (r = 0.97). extremity joints for the concurrent validity of goniomet- n ric and radiographic measurements. Gogia and associ- Studies chat compared clinical ROM rneaSllT<:rncnt }; c ates' measuted the knee position of 30 subjects with p methods for the Illmb~lr spint: with radiographic results ro °tadiography and with a universal goniometer, Knee posi- report high to low validity. Macrae and \\Xlright lS mca~ ti a tions ranged from to 120 degrees, High correlation sllred lumbar flexion ill 342 subjects by using a tape '( 1 (correlation coefficient [r] = 0,97) and agreement (intra- cIass correlation coefficient [ICC! = 0,98) were found me;lsure, <lccordill~ ro the Schober and modified Schober I[ between the rwo types of measurements, Therefore goniomctric measurement of knee joint position was Illt.:thod, and compared these results with those sho\\vn in s, considered to be valid. Enwemeka? studied the validity of d measuring knee ROM with a universal goniometer by radiographs. Their findings supporr rhe: \\'alidit)' of these comparing the goniomcrcic measuremems taken on 10 IT subjects with radiographs, No significant differences measures: correlation coefficient values between the ,'., were found between the two types of measurements I. when ROM was within 30 to 90 degrees of flexion Schober method and the radiographic evidence were 0.90 ,\" al (mean difference between the two measurements ranged from 0,5 to 3,8 degrees). However, a significant differ- (standard error = 6.2 uegrees), <lnd hetween the modified p' °ence was found when ROM was within to 15 degrees Schober and the radiographs were 0.97 {standard error Cl of flexion (mean difference 4,6 degrees). Ahlbach and = 3.3 degrees). Porrck and ilssodarcs,li' in ;t study of I I e, Lindahl'o found that a joint-specific goniometer used to measure hip flexion and extension in 14 subjects cIosely males, found no significalH di(fl'relICe between lumbar ,: t[ agreed with radiographic measurements. flexion and exr('llsion ROM mcasun:mcnt takt:n with a D Criterion-related Validity Studies of the Spine skin disrraction method and single inclinometer ti' Various instruments used to measure ROM of the spine have also been compared with a radiographic criterion, compJrcd with radiographic l,'vidence, but <.:orrclation fu although some researchers question the use of radio- graphs as rhe gold standard given the variability of ROM codficiencs were low (0.42 ro 0.57). Comparisons may -{ measurement taken from spinal radiographs. II Three studies that contrasted cervical range of motion (cervical have bcen inappropriare because Il1C<lsurc:1tlcnrs were < til ROM) measurements taken with gravity-dependent to goniometers with those recorded on radiographs found made sequentially rather than <.:oncurrenrly, with subjecrs concurrent validity to be high. Herrmann, '2 in a study of ~ 11 subjects, noted a high correlation (r = 0,97) and in varying tcsting positions. Radiographs and skin TI =agreement (ICC 0.98) between radiographic measures distraction methods were performed on standing co sa and pendulum goniometer measures of head and neck subjects, \\\\,her1'3s inclinomccer ITlC;lSUrelllCnts were tic flexion-extension. Ordway and colleagues lJ simultane- ously measured cervical flexion and extension in 20 pcrformed in subjects sitting for flexion and prolle for Su healthy subjects with a cervical ROM goniometer, a Sa computerized tracking system, and radiographs. There extensioll. Burden, Brown, and Fall,li in a study of 27 if,i were no significant differences between measurements Sa; taken with the cervical ROM and radiographic angles suhjccts, found a fair correlation berwcen measurements :l- determined by an occipital line and a vertical line, lin although there were differences between the cervical taken with a single inclinol11('tcr and radiographs for Va lumbar flexion (r = 0.73), <lnd <l Vt..'ry poor correlation I[s for lumbar extension Ir :;:; O. t5}. J\\taycr <lod <.:()\\vorkers IS ~ ch measured lurnb;,H flexion and extension in l2 pmicms go pro with a single inclinoml'tLT. double inclinometer, and radi- ';1: pro eff ographs. No signific<lIH difference was noted between arr 1ll('aSuremcnts. Sallr and colk'agucs,!'l in a study of 54 J me patienrs~ found lumbar flexion ROJ\\tl lIle<\\Sllrl,'mcnt taken res ,r sui with two inclinometers correlated highly wirh radi- ographs (r == 0.98). Extcnsion ROM measurement corre- =hued with radiographs to a filir degree (r 0.75). Samo and associarcs!lJ llst.'d double inclinometcrs imd radi- oj;raphs {O measure 30 subjects held in a position of flex- ion and extension. Radiographs resulted in tlexion values '( that were I t to 15 degrees greater than rhose found with indinomctcrs, and extension valucs th<lt were 4 to 5 degrees less than those found with inclinomcters. Construct Validity Constrult validity is the <.lbility of an instrulllenr {O meaS- IIrc an ahstf<lCr concept (construct)\"' or to be lIsed to make an inferred interpretation. 7 There is a movement within n.'hahilirative medicine to develop and validate