__Measurement_of_Joint_Motion__A_Guide_to_Goniometry_3rd_Edition

CHAPTER 7 THE HAND 143 e>.'tended than when flexed. There was no effect on PIP FIGURE 7-7 \\X'riting usually requires finger-thumb prehension motion with changes in MCP joint position. in the form of a three-point pinch. Knutson and assoCi3tcs21 examined eight subjects to that require various types of finger-thumb prehension or study the effect of seven wrist positions on the totque full-hand prehension. Hume and coworkers· used an tequited to passively move the MCr joint of the index c1ccrrogoniomctcr and a universal goniometer to study \\\\'fjngeroThe findings indicated that in many wrist posi- ~::-':';[ions,- extrinsic tissues (those that cross more than one 35 right-handed men aged 26 to 28 years during performance of these 11 tasks. Of the tasks that were \"',,:::::?::ijoint» such as the extensor digitorum, extensor indicis, included, holding a soda can required the least amount of ·.::'f]cxor digitorum superficialis, and flexor digitorum :.cf(irpfundus muscles offered greater restraint to MCP flex- ,. ':·,'iorrand extension than intrinsic tissues (those that cross 'only' one joint). Intrinsic tissues offered greater resistance '[0 passive momenr ar the MCP joint when rhe wrisr was flexed or exrended enough to slacken the extrinsic tissues. F'unctional Range of Motion Joint motion. muscular strength and control, sensation, adequate finger lengrh, and sufficienr palm widrh and deprh are necessary for a hand that is capable of perform- ing functional, occupational, and recreational activities. Numerous classification systems and terms for describing functional hand patterns have been proposed.'·22-25 Some common patterns include (1) finger-thumb prehen- sionsuch as tip (Fig. 7-6), pulp, lateral, and three-point pinch (Fig. 7-7); (2) full-hand prehension, also called a power grip or cylindrical grip (Fig. 7-8); (3) nonprehen- sion, which requires parts of the hand to be used as an extension of the upper extremity; and (4) bilateral prehension, which requires use of the palmar surfaces of both hands.\" Texts by Stanley and Tribuzi,'· Hunter and coworkers,27 and the American Society of Hand Therapists28 have reviewed many functional patterns and lests for the hand. Table 7-4 summarizes the active ROM of the domi- nant fingers and thumb during 11 activities of daily living x- IP .1e as of nt of tis es ,e !s· li- FIGURE 7-6 Picking up a coin is an example of finger-thumb FIGURE· 7-8 Holding a cylinder such as a cup requires prehension that requires use of the tips or pulps of the digits. In full-hand prehension (power grip). The amount of metacar- >W this photograph the pulp of the thumb and the tip of the index pophalangeal and proximal interphalangeal flexion varies, as finger are being employed. dcpcnding on thc diamctcr of the cylinder. ....---,..--..---~--~-- _-~

144 PA RT II UPPER-EXTREMITY TESTING 'h finger and thumb motion, whereas holding a toothbrush subject who~(: tingers wert: hdd in a fixed position. The required the most motion. Joint ROM during other rasks, daily IOl';-1SUrCmcms wen: raken for 4 days wirh three \"1 such as holding a telephone, holding a fork, turning a types of gOlliolllcrcrs. These ;tuthors found imcnester key, and printing with a pen, were clustered around the reliability was lower than intratesH:r reliahility. No signif· 1, ft\"~j means lisred in Table 7-4. icant differences existed betwcen lllcasurcmcms taken ''ij~l; \\vith a dorsal (over-the-joint) finger goniometer, a univet· ~1 Lee and Rim29 examined the amount of motion sal goniomcter, or a pendulum goniomcter. required ar the joints of the fingers to grip five different- size cylinders. Data were collected from four subjects by Grorh and coworkers;·' had 39 therapists measure the means of markers and multi-camera photogrammetry. As cylinder diameter decreased, the amount of flexion of the PIP and DIP joims of the index and middlc fingers of one MCP and PIP joints increased. However, DIP joint flex- patienr, both dorsally and laterally, using either a six-inch ion remained consrant with all cylinder sizes. plastic universal goniometer or a DeVore mewl finger Sperling and Jacobson-SollermanJO used movie film in goniometer. No significanr difference in Illcasurcmcnrs their study of the grip pattern of 15 men and 15 women aged 19 to 56 years during serving, earing, and drinking was found bctween the tWO instrumcnrs. No differences activiries. The use of diffetenr digirs, rypes of grips, wt.:rc found betwcen the oors'l.l and lateral llH:aSllrCmcm contact surfaces of the hand, and relative position of the methods for seven of the cight joinr motions. \\vith mean digits was reported; however, ROM values were not differences ranging from 2 to 0 degrees. In a subsct of six included. therapists, inre-nester reliability was high for hoth mctn· Reliability and Validity ods, with ll\\tracbss correlation coefficients {ICes} rang- ing from 0.86 for brcr~ll methods to 0.99 for dorsal Several studies have been conducted to assess the relia- 1l1c::dwds. 111 terms of concurrent validity, therc were biliry and validiry of goniometric measurements in the signifit:(\\nr diffcrcrlCt::s in measurcmenrs ohraincd from hand. Most studies found that ROM measurements of radiographs. versus those frofll gonioUltrCtS excepting the fingers and thumb that were taken with universal goniometers and finger goniometers were highly reliable. LHerally mcasurtd index PIP extcnsion and flexion. Measurements taken over the dorsal surface of the digits appear to be similar to those taken laterally. Consistent Diffcrcllccs bctwcl'n radiogr<lphic alld goniolllctri<.: JIlC.1Sv with other regions of the body, measurements of finger urefllcnrs ranged frolll 1 ro 10 dq~rees, but these differ· and thumb ROM taken by one examiner are more reli- l'nces fllay have been dut ro variations in prc'Kl·durcs and able than measurements taken by several examiners. Research studies support the opinions of Bear-Lehman POSltlUlllng. and Abreu31 and Adams, Greene, and Topoozian,J2 that \\X/eiss and associates,15 cornparcd mcasurCIlH:IHS of the margin of error is generally accepred to be 5 degrees for goniometric measurement of joints in the hand, index finger Mep, PIP, and DIP joilH positions taken by provided thar measurements are taken by the same exam- a dorsal metal fingcr goniometer with those t:lkcn by the iner and that standardized techniques are employed. Exos l-Iandm;lsttT, a H<.lll-cffect instrumented exoskele~ Hamilton and Lachenbruch33 had seven testers take roll. Twelve subjects Wt:n: measured with each dcvice measurements of MCP, PIP, and DIP flexion in one during onc session hy one examiner, ;lIld again within 2 weeks of rhl' initial session. Tcst-retest reliability \\'.1;15 high IP :::: Interphalangeal; MCP ::: metacarpophalangeal; PIP = proximal interphalangeal; (SO) ::: standard deviation. for both Jcvices, with ICes ranging from O.9S to 0.99. Jvlean diffcn:m:cs bctween sessions for each instrument The 11 functional activities include: holding a telephone, can, fork, scissors, toothbrush, and hammer; using a zipper and comb; turn- wt:re statistically significanr bur less than I degree. ing a key; printing with a pen; and unscrewing a jar. fvleasurernenrs raken by the finger goniomctcr ':Hld those taken by the Exos Hanumastn were significandy,diHer- em (mtan diffcrl'nce = 7 degrees) hur highly correlated (r = 0.~9 to 0.94). Ellis, Bruton, and Goddard Jb placed one: subject in tWO splims while a {(>tal of 40 therapists measured rhe i\\l1.CP, PIP, and DIP joints of the middle finger by me:lOS of a dorsal finger goniomcter and a wire tracing. Each rherapist measured each joint three times with each device. The goniometer I.:onsistenrly produccd smaller r;mgcs and smaller s£<1ndard deviations rhan the wire tracing, indicating bener reliability for the goniometer. ,{ The 95 pacem confidl'ncc limit for the difference between measurements ranged from 3.8 ro 9.9 degrees for the goniometer and 8.9 to \"13.2 degrees for the wire tracing. Both methods had 1110re variability when distal joinrs wcre measured, possibly because of the shorrer kvers used to ,llign the goniometer or wire. Intratcster reliability was ahvays higher than ilHcrresrer reliability.

CHAPTER 7 THE HAND 145 10 Brown and colleagues37 evaluared rhe ROM of the measured by an upper extremity disability score (DASH). ee MCP, PIP, and DIP joints of two fingers in 30 patients to active MCP, PIP, and DIP flexion was measured in 50 er :falculate total active motion (TAM) by means of the patients by one examiner who used a dorsally placed if- \"dorsal finger goniometer and the computetized Dexter electrogoniometer NK Hand Assessment System. A rulet en Hand Evaluation and Treatment System. Three therapists was used to measure pulp-ta-palm distance in the same :r- \"~easured each finger three times with each device during patients. The correlation between pulp-to-palm distance one session. lntratester and intertester reliability was high and total active flexion was -0.46 to -0.51, indicating he fo'r both methods, with ICCs 'ranging from 0.97 to 0.99. that the measures were not interchangeable. The rela- ,jhe mean difference between methods ranged from 0.1 tionship between DASH scores and total active flexion was stronger (r = 0.45) than the relationship between \"'degrees to 2.4 degrees. ;i,The distance between the fingertip pulp and distal DASH scores and pulp-to-palm distances (r = 0.21 to :\"p~lmar Ctease has been suggested as a simple and quick 0.30). The authors suggested that total active motion is a Ylllethod of estimating total finget flexion ROM at the more functional measure than pulp-to-palm distance, MCP, PIP, and DIP joints.32• 38 MacDermid and cowork- and that pulp-to-palm distance \"should only be used to i,~J9 studied the validity of using rhe pulp-to-palm monitor individual patient progress and not to compare '4istance versus total finger flexion to predict disability as outcomes between patients or groups of patients. n \\~ange of Motion Testing Procedures: Fingers riICluded in this section arc the common clinical tech- either measure the MCP and IP joints from the lateral -~ques for measuring motions of the fingers and thumb. aspect or create alternative evaluation techniques. !eThese techniques arc appropriare for evaluaring these Photocopies, photographs, and tracings of the hand at the beginning and end of the ROM may be helpful. 'wotions in the majority of people. However, swelling and Dony deformities sometimes require that the examiner wire lerce; 'cnce., ~rees . wire lista!' orter :este~: ity. i

146 PA RT II UPPER-EXTREMITY TESTING Testing Motion .' . Flex the MCP joint by pushing on the dorsal surface of the proximal phalanx, moving the finger toward the Motion occurs in the saginal plane around a medial- palm (Fig. 7-11). Maintain the MCP joint in a neurral lateral axis. Mean finger flexion ROM values are 90 position relative to abduction and adduction. The end of degrees according to the AAOS? and the AMA,' and 100 flexion ROM occurs when resistance to further motion is degrees according to Hume and coworkers. 9 MCP flex- ion appears to increase slightly in an ulnar direction from felt and arremprs to overcome the resistance cause the the index finger to the little finger. See Tables 7-1 and 7-2 for additional information. wrist to flex. Testing Position Normal End-feel Place the subject sitting, with the fotearm and hand rest- The end-feci may be hard because of contact between the ing on a supporting surface. Place the forearm midway palmar aspect of the proximal phalanx and the between pronation and supination, the wrist in 0 degrees metacarpal, or it may be firm because of tension in the of flexion, extension, and radial and ulnar deviation; and dorsal joint capsule and the collateral ligaments. the MCP joint in a neutral position relative to abduction and adduction. Avoid extreme flexion of rhe PIP and DIP Goniometer Alignment joints of rhe finger being examined. See Figutes 7-12 and 7-13. Stabilization 1. Center the fulcrum of the goniometer over the Stabilize the metacarpal to prevent wrist motion. Do not dorsal aspect of rhe MCP join!. hold the MCP joints of the other fingers in extension because tension in the transverse metacarpal ligament 2. Align the proximal arm over the dorsal midline of will restrict the motion. the metacarpal. 3. Align the distal arm ovet the dorsal midline of the ptoximal phalanx. r FIGURE 7-11 During flexion of the metacarpophahmgcal joint, the examiner uses one hand [0 stabilize the subject'S metacarpal and to maintain the wrist in a neutral position. The index finger and the thumb of the examiner's other hand grasp the subject'S proximal phalanx to move it inco flexion.

CHAPTER 7 THE HAND 147 FIGURE 7-12 The alignment of the goniometer at the beginning of metacarpophalangeal flexion range of motion (ROM). In this photograph, the examiner is using a 6-inch plastic goniometer in which the arms have been trimmed to approximately 2 inches to make it easier to align over the small joints of the hand. Most examiners use goniometers with arms that arc 6 inches or shoreer when measuring ROM in the hand. FIGURE 7-13 At the end of metacarpophalangeal (Mep) flexion range of motion, the examiner uses one hand to hold the proximal goniometer arm in alignment and to stabilize the subject's metacarpal. The examiner's other hand maintains the proximal phalanx in Mep flexion and aligns the distal goniometer arm. Note that the goniometer arms make direct contact with the dorsal surfaces of the metacarpal and proximal phalanx, causing the fulcrum of the goniometer to lie somewhat distal and dorsal to the Mep joint.

148 PA R T 11 UPPER-EXTREMITY TESTING Motion occurs in the sagittal plane around a medial- Testing Motion .'!\" lateral axis. Mean MCP finger extension ROM is 20 Extend rlH.' \\lCP joilH hy pushing tlll thl' p~tllllar surlacc ';b degrees according to the AMA8 and 45 degrees according of the proximal phalanx. lllovil1~ £Ill..: fingt'r aW,ly from to the AAOS. 7 Passive MCP extension ROM is grearer dle palm (Fig. 7-14j. \\lainrain thl' .\\lCP joillt in a Y- than active extension. Mallon, Brown, and NunlcylO ll('lUr;t! position relatin' w ahducrion and ;1 dd lIl..:t ion. report rhat extension ROM at the MCP joints is similar The end of flexion RO.\\,1 occurs Whl'Jl f('sisr:lIIce ro across all fingers, whereas Skvarilova and Plevkova 11 furrher motion is felt :lnd ;l{tcmpts [() overcome reSiSt· note that the little finger has the greatest amount of MCP ;lIlC(' cause the wrist to extcnd. extension. Sec Tables 7-1 and 7-2 for additional infor- mation. Normal End-feel Testing Position The l'nd-fcl'l is firm because 01 tension in rhl' p;llrnar joint capsult' and in rill: palmar p!Jtc. Position rhe subject sitting, with the forearm and hand resting on a supporting surface. Place the forearm Goniometer Alignment midway between pronation and supination; the wrist in 0 degrees of flexion, extension, and radial and ulnar devia- S('(' Figures 7-15 and 7-16 for alignmcnt of the.1:l tion; and the Mep joint in a neutral position relative to goniomcter o\\\"(.'r rill' dors.1i aspen of the fill!!.l'rs. abduction and adduction. Avoid extension or extreme flexion of the PIP and DIP joints of the finger being I. CL'lHCr till' fulcrulll of the l;0niOl1lctl'r tJ\\'ef the tested. (If the PIP and DIP joints arc positioned in exten- sion, tension in the flexor digirorum superficialis and dorsal aspen 01 thc \\ICP joint. \", profundus muscles may restrict the motion. If the PIP and DIP joints are positioned in full flexion, tension in the ) :\\Ii~n the proximal arm over thc dorsal midlillt' of \"\" lumbricalis and interossei muscles will restrict the motion.) rhe ml'r~lclfpal. 1 Stabilization 3. :\\Iign rhe dist:ll arm over rhl' dors,lI midline of the Stabilize the metacarpal to prevent wrist motion. Do not rroxim;l! rhal<lIlx. hold the MCr joints of the other fingers in full flexion ~ because tension in the transverse metacarpal ligament Alternative Goniometer Alignment will restrict the motion. S('L' Figure 7-17 for alignment of the gOlliC.llll(;tcr O\\'('r the p;11nur JSpeli of rhe finger. This <11ignmclH should not used if swclling or hypcrtrophy is prcsem in the palm rhe hand. I. Ce::mer the:: fulcrulll of tht' goniomCter o\\'er rhe{ p;llllur ~lspe~r of the .\\ICP join£. .<r 2. Align tht.' proximal arm on:r rhe palmar midline oL'r the mCt;h.:arpal. \"Z; 3. Align rhl.' dism! <1f1ll o\\'Cr the palmar midlinc of rhe- proximal phalanx. ·ft FIGURE 7-14 During meracarpophalangeal exrension, t'll<.' ('xarnintr US,l..'S her index finger and thumb [(I :i grasp the subject's proximal phalanx and to move the phalanx dorsally, The examiner's other hand main- rains the subject's wrist in the neutral position, stabilizing (he metacarpal. I

CHAPTER 7 THE HAND 149 FIGURE 7-15 A full~circle, 6~inch plastic goniometer is being used to measure the beginning range of motion for metacarpophalangeal extension. The proximal arm of the goniometer is slightly longer than necessary for optimal alignment. If a goniometer of the right size is not available, the examiner can cut the arms of a plastic model to a suitable length. FIGURE 7-16 The alignment of the goniometer at the end of metacarpophalangeal (Mep) extension. The body of the goniometer is aligned over the dorsal aspect of the Mep joint, whereas the goniometer arms arc aligned over the dorsal aspect of the metacarpal and proximal phalanx. FIGURE 7-17 An alternative alignment of a finger goniometer over the palmar aspect of the proximal phalanx, the metacarpophalangeal joint, and the metacarpal. The shorter goniometer arm must be used over the palmar aspect of the proximal phalanx so that the proximal interphalangeal and distal interpha- langeal joints are allowed to relax in flexion.

.. ; joint in a neutral position relative to flexion and exten_ 'J 150 PA RT II UPPER· EXTREMITY TESTING sion. The end of flexion ROM occurs when resistance to . . . •, further motion is felt and attempts ro overcome the resis. tance cause the wrist to move into radial or ulnar devia- Motion occurs in the frontal plane around an anterior· tion. posterior axis. No sources were found for MCP abduc- tion ROM values. Normal End-feel Testing Position The end-feel is firm because of tension in the collateral Position the subject sitting, with the forearm and hand ligaments of the MCP joints, the fascia of the web space resting on a supporting surface. Place the wrist in between the fingers, and the palmar interossei muscles. odegrees of flexion, extension, and radial and ulnar devi- Goniometer Alignment ation; the forearm fully pronated so that the palm Sec Figures 7-19 and 7-20. of the hand faces the ground; and the MCP joint in 1. Center the fulcrum of the goniometer over Ihei~ o degrees of flexion and extension. dorsal aspecr of the MCP joint. Stabilization 2. Align the proximal arm over the dorsal midline of .... Stabilize the metacarpal to prevent wrist motions. the metacarpaL O. 3. Align rhe distal arm over the dorsal midline of the proximal phalanx. Testing Motion Abducr the MCP joint by pushing on the medial surface of the proximal phalanx, moving the finger away from the midline of the hand (Fig. 7-18). Maintain the MCP i FIGURE 7-18 During metacarpophalangeal (Mep) abduction, the examiner uses the index finger of one hand to press against the subject's metacarpal and prevem radial deviation at the wrist. \\Vith thc othcr '! ... index finger and thumb holding the distal end of the proximal phalanx, the examiner moves the subject's second Mep joint into abduction. ./:

CHAPTER 7 THE HAND 151 FIGURE 7-19 The alignment of the goniometer at the beginning of mcmcarpophalangcal abduction range of motion. FIGURE 7-20 At the cnd of metacarpophalangeal abduction, the examiner aligns the arms of the goniometer with the dorsal midline of the metacarpal and proximal phalanx rather than with the contour of rhe hand and finger.

~I ','; \"j; \"\"i :' §~ -1-S-2--P-A-R-T-I-I--U-P-P-E-R-.-E-X-T-R-E-M-'T-Y-T-E-S-T-I-N-G- ~- 'I~, tii ., ·· · Stabilization ,~ ,', \\~' ~ Motion occurs in the frontal plane around an anrerior- Srabilize the proximal phalanx to prevent motion of the wrist and the MCP joint. :' I :J posterior axis. Mep adduction is nor usually measured Testing Motion \"I,~ 'ttL1(' and recorded because it is the return from full abduction Flex the PIP joint by pushing on the dorsal sllrface of the ' / 8 ,i to the 0 starrlllg position, There IS very little adduction middle phalanx, moving the finger toward the palm (Fig. 7-21), The end of flexion ROM occurs when resistance lW\\ ';;i::,;, ROM ?eyond the 0 starring position. No sources were to further motion is felt and attempts to overcome rhe rcsisrance cause the MCr joint to flex. 0;~ found tor MCP adduction ROM values. i: Zi L ~~l·f :-:. ~-Ci: ,.. • ••• I • Motion occurs in [he sagittal plane around a medial- Normal End-feel j';.;;\",-;':g\" lateral aXIS, Mean PIP fmger flexion ROM values are 100 the AAOS7 and the AMA\" Usually, the end-feci is hard because of comact hen\\-'ccn );\"';;;:;;;~1-;;I degrees accord109 ro Hume and coworkers' and and 105 the palmar aspect of the middle phalanx and the proxi· degrees according ro Mallon, mal phalanx. In some individuals, the end·feel may he :l.I..lF(> Brown, I~nd Nunley. 10 PIP flexion is similar between the soft because of compression of soft tissue between rhe palmar aspect of the middle <lnd proximal phalanges. In If' '~;;l' ~:~:i:9 P::i:::les 7-1 and 7-2 for additional informa- other individuals~ the cnd~fecl may be firm hecause of I, 0::,: Place the subject sitting, with the forearm and hand rest- rcosion in the dorsal joint capsule and the colbrcra! liga- f iog on ~l supporting surface. Position the forearm in 0 ments. i'. ~ degrees of supination and pronation; the wrist in 0 Goniometer Alignment l ] '·'1~ degrees of flexion, extension, and radial and ulnar deviaw 1~- .~ tion; and the NICP joint in 0 degrees of flexion, extcn- See Figures 7-22 and 7-23. I : !Jlfl) _./ sion, ahduction, and adduction, (If the wrist and MCP 1. Center the fulcrum of the goniomcn.:r over rhe Joints arc positioned in full flexion, tension in the cxten- dorsal aspect of the PIP joint. i J.' :':: / -. sor digltorum communis, extensor indicts, or extensor 2. Align the proximal arm over the dorsal midline of I 1j digiti minimi muscles will restrict [he motion, If the MCP the proximal phalanx. II I calis and interossei muscles will reStrict the motion.) I.J 1 joint IS positioned In full extension, tenSIOn 10 the lumbri- 3, Align the distal arm over the dorsal midline of the middle phalanx. t,·;·1~~g, r\"'- ----~ hi 1'1 ,,'; t~;~'1 t, i 1,1 'il i:,:\";,~,> a j1'1 11, I: it'iJI FIGURE 7-21 During proximal interphalangeal (PIP) flexion, the examiner stabilizes the suhject's prox- '1 (:, II imal phalanx with her thumb and index finger. The ex;\\miner uses her other thumb and index finger to l;' ·1:'1- >*~'-'\"~ move the subject's PlP joint into full flexion. if ------ '11

CHAPTER 7 THE HAND 153 FIGURE 7-22 The alignment of the goniometer at the beginning of proximal interphalangeal flexion range of motion. FIGURE 7-23 At the end of proximal interphalangeal (PIP) flexion, the examiner continues to stabilize and align the proximal goniometer arm over the dorsal midline of the proximal phalange with one hand. The examiner's other hand maintains the PIP joim in flexion and aligns the distal goniometer arm with the dotsal middlinc of the middle phalanx.

154 PA RT II UP PER - EXT RE MIT Y T EST I N G PROXIMAL INTERPHALANGEAL Stabilization EXTENSION Srabilize the ptOximal phalanx to prevent motion of Motion Occurs in the sagittal plane around a medial- wrisr and the MCP joint. latetal axis. Mean PIP finger extension ROM values are Testing Motion o degrees accotding to the AAOS7 and the AMA.\" Data Extend the PIP joint by pushing on the palmar surface ftOm Mallon, BtOwn, and Nunley!O indicate a mean of 7 the middle phalanx, moving the finger away ftOm degtees of active PIP extension and 16 degrees of passive palm. The end of extension ROM occurs when PIP extension. PIP extension is generally equal for all to further motion is felt and attempts to overcome fingers.!O See Tables 7-1 and 7-2 for additional informa- resistance cause the MCP joint to extend. tion. Normal End-feel Testing Position The end-feel is firm because of tension in the palmar Place the subject sitting, wirh the forearm and hand rest- capsule and palmar plate (palmar ligament). ing on a supporting surface. Position the forearm in 0 degrees of supination and ptOnation, the wrist in 0 Goniometer Alignment (0''iljt1 degrees of flexion, extension, and radial and ulnar devia- 1. Center the fulcrum of rhe goniometer dorsal aspecr of the PIP joint. tion, and the MCP joint in 0 degrees of flexion, exten- 2. Align the ptOximal arm over the dorsal midline l ' sion, abduction, and adduction. (If the MCP joint and rhe proximal phalanx. t'~~~1 wrist arc extended, tension in the flexor digitorum super- ficialis and ptofundus muscles will restrict rhe motion.) 3. Align rhe distal arm over rhe dorsal midline of middle phalanx.

CHAPTER 7 THE HAND 155 of the DISTAL INTERPHALANGEAL FLEXION approximately 70 ro 90 degrees of flexion. (If the wrist aCe of and the MCP and PIP joints are fully flexed, tension in m the Motion occurs in the saginal plane around a medial- the extensor digitorum communis, extensor indicis, or lateral axis. DIP finger flexion ROM values are 90 extensor digiti minimi muscles may restrict DIP flexion. er degrees according to rhe AAOS7 and 70 degrees accord- If the PIP joint is extended, tension in the oblique reri- line ing ro the AMA.8 Hume and coworkers9 and Skvarilova nacular ligament may restrict DIP flexion.) and Plevkova II report a mean of 85 degrees of active DIP flexion. DIP flexion is generally equal for all fingers.'o Stabilization See Tables 7-1 and 7-2 for additional information. Stabilize the middle and proximal phalanx to prevent Testing Position further flexion of the wrist, MCP joints, and PIP joints. Position the subject sitting, with the forearm and hand Testing Motion resting on a supporting surface. Place the forearm in 0 degrees of supination and pronation; the wrist in 0 Flex the DIP joint by pushing on the dorsal surface of the degrees of flexion, extension, and radial and ulnar devi- distal phalanx, moving the finger toward the palm (Fig. ation; and the MCP joint in 0 degrees of flexion, exten- 7-24). The end of flexion ROM occurs when resistance sion, abduction, and adduction; Place the PIP joint in ro further motion is felt and anempts ro overcome the resistance cause the PIP joint to flex. FIGURE 7-24 During distal interphalangeal (DIP) flexion, the examiner uses one hand to stabilize the middle phalanx and keep the proximal interphalangeal joint in 70 to 90 degrees of flexion. The exarn~ ioer's other hand pushes on the distal phalanx to flex the DIP joint.

156 PART II UPPER-EXTREMITY TESTING 1. Center rhe fulcrum of rhe goniometer over the dorsal aspect of the DIP joint. Normal End-feel The end-feel is firm because of tension in rhe dorsal joint 2. Align the proximal arm over the dorsal midline of '1; capsule, collateral ligaments, and oblique rerinacular the middle phalanx. ligament. 3. Align the distal arm over the dorsal midline of the Goniometer Alignment distal phalanx. See Figures 7-25 to 7-27. FIGURE7-25 Measurement of the beginning of disral interphalangeal (DIP) flexion range of motion is being conducted by means of a half-circle plastic goniometer with 6·inch arms that have been trimmed to accommodate the small size of,t~e DIP joint. --.-----_.-.~---~---~-'

CHAPTER 7 THE HAND 157 FIGURE 7-26 The alignment of the goniometer at the end of distal interphalangeal flexion range of motion. Note that the fulcrum of the goniometer lies distal and dorsal to the proximal interphalangeal joim axis so that the arms of the goniometer stay in direct contact with the dorsal surfaces of the middle and distal phalanges. FIGURE 7-27 Distal interphalangeal nexion range of morion also can he measured hy using a finger goniometer that is placed on the dorsal surface of the middle and distal phalanges. This type of goniome· tec is appropriate for measuring the small joinrs of the fingers, thumb, and toes.

158 PART II UPPER-EXTREMITY TESTING DISTAL INTERPHALANGEAL EXTENSION Stabilization Motion OCCUtS in the sagittal plane atound a medial- Stabilize rhe middle and proximal phalanx to prevent latetal axis. Most references, such as the AAOS7 and the extension of the wrist, Mep joints, and PIP joints. AMA,' reporr DIP finger extension ROM values to be 0 degrees. However, Mallon, Brown, and NunleylO reporr Testing Motion a mean of 8 degrees of active DIP extension and 20 degrees of passive DIP extension. DIP extension is gener- Extend the DIP joint by pushing on the palmar surface of ally equal for all fingers. 1O See Tables 7-1 and 7-2 for the distal phalanx, moving the finger away from the additional information. palm. The end of extension ROM occurs when resistance to further motion is felt and attempts to overcome the Testing Position . resistance cause the PIP joint to extend. Position the subjecr sitting, with the forearm and ha~d Normal End-feel resting on a supporting surface. Place the forearm in 0 degrees of supination and pronation; the wrist in 0 The end-feel is firm because of tension in rhe palmar degrees of flexion, extension, and radial and ulnar devi- joint capsule and the palmar plate (palmar ligament). ation; and the MCP joint in 0 degrees of flexion, exten- sion, abduction, and adducrion. Position the PIP joint in Goniometer Alignment approximately 70 to 90 degrees of flexion. (If the PIP joint, MCP joint, and wrist are fully extended, tension in 1. Center the fulcrum of the goniometer over the the flexor digitorum profundus muscle may restrict DIP dorsal aspect of the DIP joint. extension.) 2. Align the proximal arm over the dorsal midline of the middle phalanx. 3. Align the disral arm over rhe dorsal midline of the distal phalanx.

CHAPTER 7 THE HAND 159 Range Of Motion Testing Procedures: Thumb \\

160 PAR T I J UPPER-EXTREMITY TESTING Range of Motion Testing .\\,tailHaill tht: C~tC ioiut ill 0 degn.:es of ahdlh.:tion. The Procedures: Thumb end of flexion ROI\\l o((urs when r(:~israll(t: to further CARPOMETACARPAL FLEXION !l1orion is ft:lt and am::mpts ro o\\,cn,:olll(\" rhl' rt::slstance l.:,ltI~t: rllt.o wriST TO deviate uln;Hly. Motion occurs in the plane of the hand. When the Normal End-feel subject is in the anatomical position, the motion occurs Thl' clId-feel m,ly he soh hecHlsl.' of (OlJ(,H.:r betwcen in the frontal plane around an anterior-posterior axis, Jl)usc!t: hulk ot rhe r1l1..:llar l'!l1illL'IlCC and rhe p;tlm of rhe Mean CMC thumb flexion ROM is 15 degrees, accord- hane!' or it may hL' firm because of tension ill the dorsal ing to the AAOS.' joinr c\\psule and the l.'xtt:nsor pollicis hrevis alld ;lhduc- Testing Position tor pollicis hrevis nltl\"di.:s. Position the subject sitting, with the forearm and hand Goniometer Alignment resting on a supporting surface. Place the foreatm in full SL't Figun.:s 7-33 and 7-34. supination; the wrist in 0 degrees of flexion, extension, I. CC1HCf the fulcrum of the goniollleta o\\\"(:r [he and radial and ulnar deviation; and the CMC joint of the palmar aspL'U of tht.' first CMC joilH. thumb in 0 degrees of abduction. The MCP and IP joints 2, :\\Ii~ll thl.' pro:\\imal arlTl with the venrral midline of of the thumb are relaxed in a position of slight flexion. the LldillS llsing tht:: vl.'ntral surLlCt' of rhe radial (If the MCP and IP joints of the thumb are positioned in hC<ld ,mel radial styloid proCt.:ss for rdL'fL'nCl.'. full flexion, tension in the extensor pollicis longus and 3. Align the dist;ll arm with the \\'cnrralmidline of the ;._:~- brevis muscles may restrict the motion,) firST metacarpal. Stabilization In the beginning positions for t1exioll ;\\111.1 e:\\rclIs;on, rht:.' goniometer rn;\\~' indicate approximately 30 to 50 Stabilize the carpals) radius, and ulna to prevent wrist motions. dtgrt::cs rathcr than 0 dq;rccs, depending on th(;' shape of Testing Motion thl.: hand and wrist position. ·fhe clld·posirion degrees should he suhtracted from the hl'ginnirq;-position Flex the CMC joint of the thumb by pushing on the (!t:grecs. A IllC,lsurCl1le[l[ that begins ,H ].) dt,:grces and dorsal surface of the metacarpal, moving the thumb ends at 10 degrccs should be recorded as 0 [() 25 degrees. toward the ulnar aspect of the hand (Fig. 7-32). FIGURE 7-32 During carpometacarpal (CMC) flexion. rhe l'x;lIuin(\"r uses rhe:: index finger and rhumb of one hand to srabilize the carpals, radius, and ulna to prc.:V('ll( ulnar deviation of rhe wrisL The cx:unllta's the other index finger and thumb flex the CMC joinr by moving the first me::ral.:arpal medially.

CHAPTER 7 THE HAND 161 FIGURE 7-33 The alignment of the goniometer at the beginning of carpometacarpal flexion range of motion of the thumb. Note that the goniometer does not read 0 degrees.

.162 PA RT II UPPER·EXTREMITY TESTING (U\\\\-;ud rhe fadlal ;l~pccr of rhl.: hand (Fig. 7-35), .' \\binr:,ill rhl' CVIC iOIIH in 0 dcgn.:t.:s of :thdu(rioll. The ..,. • end 01 l'X(t.'II:-.ioll RO.\\l Ol.:<.:urs whl:11 ft'sisr:UKt.· {() funher mution i:-. felt and ,l{tt:lllprs to OVt: 1'1,':0 1lH,: [he rl'~isrance Morion occurs in rhe plane of rhe hand. When rhe subiecr calise the wrist 1'0 dt:\\'iatt: radially. is in the ana comical position, the motion occurs in the fromal plane around an anterior~posterioraxis. Reported Normal End·feel values for CMC rhumb exrension ROM are 50 degrees, according ro rhe AMA: and vary from 20 degrees7 ro The.: cnd·fed is firm hCGllIst: of rellsion in tht' :lIHcrior 80 degrees,J· according ro rhe AAOS. However, rhe joint l'<lpsulc ;lIH.I tht flexor pollicis brc.:vis, adductor; measuremenr merhods used by rhe AAOS and rhe AMA pollicis, opponens pollicis, and first dorsal inrtrossei appear to differ from the method suggested hete. This mllsc!t.:s. m\"'ion is also called radial abducrion. Testing Position Goniometer Alignment Position the subjecr sitring, with the fotearm and hand St:c Fi~lIfeS 7-36 and 7-37. ,',', resting on a supporting surface. Place the forearm in full supination; the wrist in 0 degrees of flexion, extension, I. Ct.:nrcr thl' fulcrum of I'he goniOlllttcr o\\'tr the<~' and radial and ulnar deviation; and the CMC joinr of the thumb in 0 degtees of abduction. The MCP and II' joinrs p:11lllar aspect of the first C.\\'lC joint. of the thumb are relaxed in a posirion of slight flexion. (If the MCr and Ir joints of rhe thumb arc positioned in full 2. Align rhL' proximal arlll wirh rhL' \\'L'll[f~ll midline of extension, tension in the flexor pollicis longus muscle may restrict the 1110tion.) rhl.· radius, using the \\'('lHr:11 sllrt:H.:e of rht: r.1dial. hl.'ad ;tnd £Ill.' r;tdia! s(~'loid process tor reference. 3. r\\lign [h(: disul arm with rhe vtntralmidline of rhei' first met:h..:aqul. Stabilization [n the bq:inning position::. tor f!L'xioll .1llJ t'xtctlsion, the gOlliol1ll.·rcr lIIay imlicHt: ;lpproxim:Hdy 30 (Q 50 Stabilize the carpals, radius, and ulna to prevent \\vrisr dtgrct's r:lthef than 0 i.kgrel.'s. tkpclIding Oil the shape of:,: 1110tiol1s. rhe hand and wrist position. 'rhe l'lld-position degrees); should be st!hrracrl.~d from rhe beginning-position Testing Motion c!cgrcl's . .-\\ IllC<1sureml.'!H rhat begins at 35 degrees and Extend the CMC joinr of the thumb by pushing on the t.:n~ls at 55 dtgrt.:es shoulJ ht.: rt.:..:o;dt.:J as 0 ro 20 degrees.., palmar surface of the metacatpal, moving the thumb ,~ FIGURE 7-35 During carpometacarpal extension ot thl: thumb, rht' ('xamin\"r uscs olle h;,llld to stabilize thc carpals, radius, and ulnar thereby prevcnting r:H.kl! dcvi:Hio!1 of rhe subii.:cr\\ wrist; thi..' eXclmilll'f'S ocher hand is lIsed to pull rhe firse mcracarp<lliarcrally into l:X{CIiSioll.

CHAPTER 7 THE HAND 163 35), The ,her iOCe nOr ctor lssei the Ie of ,dial :e. f the ;lon, ) 50 le of FIGURE 7-36 The goniometer alignment for measuring the beginning of carpometacarpal (C!viC) exten- ;rees sion range of motion is the same as for measuring the beginning of CMe flexion. rees. FIGURE 7-37 The alignment of the goniometer at the end of carpometacarpal (CMe) extension range of motion of the thumb. The examiner must be careful to move only the CMe joint into extension and not to change the position of the wrist during the measurement.

164 PA R T II UPPER-EXTREMITY TESTING CARPOMETACARPAL ABDUCTION tion ROM occurs when resistance to further motion is ':' felt and attempts to overcome the resistance cause the Motion occurs at a right angle to the palm of rhe hand. When the subject is in the anatomical position, the wrist to flex. motion OCCUtS in the sagittal plane around a medial- lateral axis_ Abduction ROM is 70 degrees, according to Normal End-feel the AAOS; 10 however, the measurement method appears to differ from the method suggested here. This motion is The end-feel is firm because of tension in the fascia and also called palmar abduction. the skin of the web space between the thumb and the index finger. Tension in the adduc[Qr pollicis and first Testing Position dorsal interossei muscles also contributes to the firm end· Position the subject sitting, with the forearm and hand feel. resting on a supporting surface. Place the forearm midway between supination and pronation; the wrist in 0 Goniometer Alignment degrees of flexion, extension, and radial and ulnar devia- See Figures 7-39 and 7-40. tion; and the CMC, MCP, and IP joints of the thumb in 1. Center the fulcrum of the goniometer over the odegrees of flexion and extension. lateral aspect of the radial styloid process. Stabilization 2. Align the proximal arm with the lateral midline of Stabilize the carpals and the second metacarpal to the second metacarpal, using the center of prevent wrist motions. second MCP joint for reference. Testing Motion 3. Align the distal arm with the lateral midline of the first metacarpal, using the centet of the first Mep Abduct the CMC joint by moving the metacarpal away joint for reference. from the palm of the hand (Fig. 7-38). The end of abduc- FIGURE 7-38 During carpometacarpal abduction. the examiner uses onc hand to stabilize the subject's second metacarpal. Her other hand grasps the subject's first metacarpal just proximal [Q the metacar- pophalangeal joint to move it away from the palm and into abduction. -- -----_ ...

CHAPTER 7 THE HAND 165 FIGURE 7-39 At the beginning of carpometacarpal abduction range of motion, the subject's first and second metacarpals are in firm contact with each other. However, when the arms of the goniometer arc aligned with the first and second metacarpals, the goniometer will not be at 0 degrees. FIGURE 7-40 The alignment of the goniometer at the end of carpometacarpal abduction range of motion.

. .PA RT II UPPER-EXTREMITY TESTING Testing Position ' .. • •• • Position the subject sitting with the forearm and hand testing on a supporting surface. Place the forearm in full Motion oCCUtS at a tight angle to the palm of the hand. supination; the wrist in 0 degrees of flexion, extension) :, When the subject is in the anatomical position, the and radial and ulnar deviarion; and the IP joints of the motion occurs in the sagittal plane around a medial- thumb and lirtle finget in 0 degrees of flexion and exten_ latetal axis. Adduction of the CMC joint of the thumb is sian. not usually measured and recotded because it is the rerum to rhe 0 srarring posirion from full abduction. Stabilization . . . . . • • •' , Stabilize the fifth metacarpal to prevent wrist motions. Motion is a combination o(abduction, flexion, medial Testing Motion axial rotation (pronation), and adduction at the.CMC joints of the thumb. Contact between the tip of rhe Move the first metacarpal away from rhe palm of thumb and the tip of the little finger is usually possIble, hand and then in an ulnar direction roward the lirtle ptoviding that opposition at the CMC joint of the little finger, allowing the first metacarpal to rotate (Figs. finger and slight flexion at the MCP joints are allowed. and 7-42). Move rhe fifth metacarpal in a palmar and Alternately, COntact between the tip of the thumb and the radial direction toward the thumb. The end of OPPOSItion; base of the little finger is usually possible, providing that ROM occurs when resisrance to further motion is slight flexion of the MCP and IP joints of the thumb is and attempts to overcome the resistance cause the allowed. to deviate or the forearm to pronate.

CHAPTER 7 THE HAND 167 '~.\"''_i ::\"-\"'._\" .::\"\"\"-\"\"\"\"-'\" ~ FIGURE 7-41 At the beginning of the range of motion in opposition, the examiner grasps the first and fifth metacarpals, The subject's hand is supported by the table, FIGURE 7-42 During opposition] the first and fifth metacarpals arc moved toward each ocher by plac- ing pressure on their dorsal surfaces. This subject's hand docs not have full range of morion.

168 PA RT II UPPER-EXTREMITY TESTING Normal End-feel measure the distance between the tip of the thumb and the tip of the little finger (Fig. 7-43). Alternatively, a The end-feel may be soft because of contact between the muscle bulk of the thenar eminence and the palm; or it ruler may be used to measure the distance between the may be firm because of tension in the CMC joint tip of the thumb and the base of the little finger at rhe capsule, fascia, and skin of the web space between the palmar digital crease or the distal palmar crease.40 thumb and the index finger; and in the adductor pollicis, first dorsal interossei, extensor pollicis brevis, and exten- The AMA Guides to the Evaluation of Permanent sor pollicis longus muscles; and in the transverse ImtJairment8 recommends measuring the longest metacarpal ligament (which affects the little finger)_ distance from the flexion crease of the thumb IP joint to the distal palmar crease directly over the third MCP joint Goniometer Alignment (Fig. 7-44). However, this measurement method seems more consistent with the measurement of CMC abduc- The goniometer is not commonly used to measure the tion. range of opposition. Instead, a ruler is often used to FIGURE 7-43 The range of motion (ROM) in opposition is determined by measuring the distance beeween the lateral tips of the subject's thumb and the little finger. The examiner is using the arm of the goniometer to measure. bur any ruler would suffice. The photograph does not show the complete ROM of opposition because its purpose is co demonstrate how the ROM is measured. When full ROM in oppo- sition is reached, the tips of the little finger and the thumb are touching. I I I I

CHAPTER 7 THE HAND 169 FIGURE 7-44 In an alternative method of measuring thumb opposition, the examiner uses a ruler to find the longest possible distance between the distal palmar crease directly over the mecacarpophalangeal joinr of the middle finger and the nexioo crease of the thumb interphalangeal joim. (From Stanley, BG, and Tribuzi, SM: Concepts in Hand Rehabilitation. FA Davis, Philadelphia, 1992, p 546, with permission.)

''w\"\" 170 PA RT II UPPER-EXTREMITY TESTING \\) uZ:: METACARPOPHALANGEAL FLEXION Testing Motion • Vi Flex the MCP joint by pushing on the dorsal aspect of the \",i!. ~t, Motion occurs in the frontal plane around an anrerior- Sl::'iim posterior axis when the subject is in the anatomical posi- proximal phalanx, moving the [humb toward the ulnar':!~*$\"f,'{; tion. Mean flexion ROM values arc 50 degrees according aspcc[ of the hand (Fig. 7-45). The end of flexion ROM;:>\"::i ~F to the AAOS,' 60 degrees according to the AM A,8 and oCCurs when resistance to further motion is felt and::/;( if attempts to overcome the resistance cause the CMC joint:;~,: '\" 55 degrees according to DeSmet and colleagues.'\" See j~. : C1.~ Table 7-3 for more information. to flex. '/M' f Testing Position Normal End-feel Position the subject sitting, with the forearm and hand The end-feel may be hard because of contact between the.iff : resting on a supporting surface. Place the forearm in full supination; the wrist in 0 degrees of fIe-xion, extension, palmar aspect of the proximal phalanx and the first'''-' and radial and ulnar deviation; the CMC joint of the metacarpal, or it may be firm because of tension in the~ >- thumb in 0 degrees of flexion, extension, abduction, dorsal joint capsule, the collateral ligaments, and the'~':S;' ,'-o,;C-;,' adduction, and opposition; and the IP joint of the thumb is in 0 degrees of flexion and extension. (If the wrist and extensor pollicis brevis muscle. <r;\",,\" IP joint of [he thumb' are positioned in full flexion, tension in the extensor pollicis longus muscle will restrict 1. the motion.) Goniometer Alignment See Figures 7-46 and 7-47. 1. Center [he fulcrum of the goniometer over dorsal aspect of the MCP joint. ~_ 2. Align the proximal arm over [he dorsal midline of\" ~. Stabilization the metacarpal. 5mbilizc the first metacarpal to prevent wrist motion and 3. Align [he distal arm with [he dorsal midline of the flexion of [he CMC joint of the [humb. proximal phalanx. FIGURE 7-45 During meracarpophalangeal flexion of rhe rhumb, the examiner uses rhe index finger and [humb of one hand to stabilize the subject's first metacarpal and maintain the wrist in a neutral posirion. The examiner's other index finger and rhumb grasp the subject's proximal phalanx [0 move ir into flex- IOn.

C!iAPTER 7 THE HAND 171 he .ar Iv! nd 1m the irSt rhe rhe FIGURE 7-46 The alignment of the goniometer on the dorsal surfaces of the first metacarpal and prox- imal phalanx at the beginning of metacarpophalangeal flexion range of motion of the thumb. If a bony deformity or swelling is prescnt, the goniometer may be llligned with the lateral surface of these bones. FIGURE 7-47 At the cnd of metacarpophalangeal flexion, the examiner uses one hand to stabilize the subject's first metacarpal and align the proximal arm of the goniometer. The examiner uses her other hand to maintain the proximal phalanx in nexioo and align the distal arm of the goniometer.

172 PA R T II UP PER - EXT REM I T Y T EST I N G Testing Motion .., Extend the MCP joint by pushing on the palmar surfac€ of the proximal phalanx, moving the thumb toward tli~ Motion occurs in the frontal plane around an anterior- radial aspect of the hand. The end of extension R01It postetior axis when the subject is in the anatomical posi- occurs when resistance to further motion is felt and tion. Mean extension ROM values are 0 degrees attempts to overcome the resistance cause the CMC joint according to the AAOS,' and 14 degrees (actively) and 23 to extend. degrees (passively) accotding to Skvarilova and Plevkova.' , Normal End-feel Testing Position The end-feel is firm because of tension in the palmar joint capsule, palmar plate (palmar ligament), inrer- Position the subject sitting, with the forearm and hand sesamoid (cruciate) ligaments, and flexor pollicis brevis. resting on a supporting surface. Place the forearm in full muscle. supination; the wrist in 0 degrees of flexion) extension, and radial and ulnar deviation; the CMC joint of the Goniometer Alignment thumb in 0 degrees of flexion, exrension, abduction, and opposition; and the IP joint of the thumb in 0 degrees of 1. Center the fulcrum of the goniometer flexion and extension. (If the wrisr and the IP joint of the dorsal aspect of the MCP joint. thumb are positioned in full extension, tension in the flexor pollicis longus muscle may restrict the motion.) 2. Align the proximal arm over the dorsal midline of\" the metacarpal. Stabilization 3. Align the distal arm with the dorsal midline of Stabilize the first metacarpal to prevent motion at the proximal phalanx. wrist and at the CMC joint of the thumb.

CHAPTER 7 THE HAND 173 INTERPHALANGEAL FLEXION Testing Motion ;'Motion occurs in the frontal plane around an anterior- Flex the IP joint by pushing on the distal phalanx, >-:'sterior axis when the subject is in the anatomical posi- moving the tip of the thumb toward the ulnar aspect of _ 'on. Mean IP flexion ROM of the thumh is 67 degrees, the hand (Fig. 7-48). The end of flexion ROM occurs ;;\"cording to Jenkins and associates,13 and 80 degrees, when resistance ro further motion is felt and attempts to '\"according to DeSmet and colleagues,14 and Skvarilova overcome the resistance cause the MCP joint to flex. Jand Plevkova.\" See Table 7-3 for more information. Normal End-feel \"Trsting Position Usually, the end-feel is firm because of tension in the '?osition the subject sitting, with the forearm and hand collateral ligaments and the dorsal joint capsule. In some ,1!esting on a supporting surface. Place the forearm in full individuals, the end-feel may be hard because of contact ~;;:supination; the wrist in 0 degrees of flexion, extension, between the palmar aspect of the distal phalanx, the \";nd radial and ulnar deviation; the CMC joint in 0 palmar plate, and the proximal phalanx. -;'.pegrees of flexion, extension, abduction, and opposition; ;:~?d the MCP joint of the thumb in 0 degrees of flexion Goniometer Alignment 'a?d extension. (If the wrist and MCP joint of the thumb :are flexed, tension in the extensor pollicis longus muscle See Figures 7-49 and 7-50. !liay restrict the motion. If the MCP joint of the thumb is 1. Center the fulcrum of the goniometer over the fully extended, tension in the abductor pollicis brevis and dorsal surface of the IP joint. ',the oblique fibers of the adductor pollicis may restrict the ;-inotion through their insertion into the extensor mecha- 2. Align the proximal arm with the dorsal midline of nism.) the proximal phalanx. Stabilization 3. Align the distal arm with the dorsal midline of the distal phalanx. Stabilize the proximal phalanx to prevent flexion or extension of the MCP joint. FIGURE 7-48 During interphalangeal flexion of the thumb, the examiner uses one hand [Q stabilize the proximal phalanx and keep the metacarpophalangeal joint in 0 degrees of flexion and the carpometacarpal joint in 0 degrees of flexion, abduction, and opposition. The examiner uses her other index finger and thumb to flex the distal phalanx. ! ---_._-_.~._-,--,----_._---------~

PART II UPPER-EXTREMITY TESTING i~ (a FIGURE 749 The alignment of the gon-iometer at the beginning of inrerphalangeal flexion range of S~ morion. The arms of the goniometer arc placed on the dorsal surfaces of the proximal and distal phalanges. However, the arms of the goniometer could instead be placed on tbe lateral surfaces of the Ti proximrd and distal phalanges if tbe nail protruded or if there was a bony prominence or swelling. p( 'i; r~: ar ex of tic 0, jo: pc 51 St: fie FIGURE 7-50 The alignment of tbe gon-iometcr at the end of interphalangeal flexion range of morion. The examiner holds the arms of the goniometer so that they maintain close contact with the dorsal surfaces of the proximal and distal phalanges.

CHAPTER 7 THE HAND 175 INTERPHALANGEAL EXTENSION Testing Motion ~[~f;::¥otiOn occurs in the frontal plane around an anterior- Extend the IP joint by pushing on the palmar surface of the distal phalanx, moving the thumb toward the radial ;f~:;::0,ll,'posterior axis when the subject is in the anatomical posi- aspect of the hand. The end of extension ROM occurs Y:t;:rttion. Mean extension ROM at the IP joint of the thumb when resistance to further motion is felt and attempts to ?/t\"i~ 20 degrees, according to the AAOS7, and 23 degrees overcome the resistance cause the MCP joint to extend. ,ii-(actively) and 35 degrees (passively) according to Normal End-feel Skvarilova and Plevkova.', The end-feel is firm because of tension in the palmar joint 'i Testing Position capsule and the palmar plate (palmar ligament). Position the subject sitting, with rhe forearm and hand Goniometer Alignment reSting on a supporring surface forearm. Place the fore- 'i,;arm in full supination; the wrist in 0 degrees of flexion 1. Center the fulcrum of the goniometer over the \",\"{extension, and radial and ulnar deviation; the CMC join; dorsal surface of the IP joint. :,,:.:of the thumb in 0 degrees of flexion, extension, abduc- '(:,(,tion, and opposition; and the MCP joint of the thumb in 2. Align the proximal arm with the dorsal midline of \"';;:: 0 degrees of flexion and extension. (If the wrist and MCP the proximal phalanx. '/' joint of the thumb are extended, tension in the flexor pollicis longus muscle may restrict the motion.) 3. Align the distal arm with the dorsal midline of the distal phalanx. Stabilization Stabilize the proximal phalanx to prevent extension or flexion of the MCP joint. _ _~ ._. T~_

176 PA RT II UPPER· EXTREMITY TESTING Muscle length Testing Procedures: soc digirorunl profundus of the S~Hnc: finger (Fig. Fingers The second and third p'llmar ilHL'ro:.sci !llusclt.:s originate LUMBRICALS, PALMAR AND DORSAL INTEROSSEI proximallr from the ulnar sides of rhe mct:lcarpal of the The lumbrical, palmar, and dorsal interossei muscles ring and linle fingers, rcspccrivcly, and inscn distal1>' into- cross the Mep, PIP, and DIP joints. The first and second the ulnar side of tht.: proximal phalanx ano rhe lumbricals originate proximally from the radial sides of the tendons of the flexor digitorum profundus of the mechanism of the extensor digirorlll1l profundus of index and middle fingers, respectively (Fig. 7-51). The same fingers. third lumbrical originates on the ulnar side of the tendon of the flexor digitorum profundus of the middle finger The four dorsal intcrossci art· hipt.:nniform and the radial side of the tendon of the ring finger. The that originate proximally from two \"djaccnr me[;,,:a,,)al, fourth lumbrical originates on the ulnar side of the (Fig. 7-53): the first dorsal intcrossci from tendon of the flexor digitorum profundus of the ting rnct3C<lrp,1Is of rhe rhumb nnd index finger, rhe secon,je-ii finger, and the radial side of the tendon of the little finger. Each lumbrical passes to the radial side of the correspon- from the metacarpals of the index and middle fingers, ding finger and inserts distally into the extensor mecha- nism of the extensor digitorum profundus. third from rhe l1ler;l(~lrr:rlls of tht: middle :.1Ild ring and the:: fOllrth from rhe metacarpals of rhe ring and The first palmar interossei muscle originates proxi- fingers. The dorsal inrcrossci inst.:rt distally inw rhe mally from the ulnar side of the metacarpal of rhe index of the proximal phalangt.:s and lhe t.:xrcnsor finger and inserts distally into the ulnar side of the prox- of rhe extensor digirorulll profundus of rhe same imal phalanx, and the extensor mechanism of the exten- When rhese muscles contract, du.'>, flex rhe :v1CP and extend rhe PIP alld DlP joinrs. Tht.:sc\" Illuscles passively lengthened hy placing thl' MCP joinrs in sian and the PIP and DIP joilHs in full flexion. If 3rd lumbrical _ _-!-'-I.I. ,_ ~b-4o/,r-LL'umlbsr'ical 2nd Palmar 4th Lumbrical interossei 2nd Lumbrical 3rd Palmar interossei 'liJi1f---hf-- Flexor digitorum profundus FIGURE 7-51 An anterior (palmar) view of the hand showing FIGURE 7-52 An anterior (p;llm:H) vit'\\V of rhe hand sho,w<n,g the proximal attachments of the lumbricals. The lumbricals the proxima! and distal artachrnt:nrs of tht: palmar ;ntt:rOSsCl.;; insert dismlly into [he extensor digirorurn on the posterior surface of the hand. The palmar interossei also anadl dist:llly to the extensor rorum on rhe posterior surface of rlh: hand.

CHAPTER 7 THE HAND 177 4th Dorsal lumbricals and rhe palmar and dorsal inrerossei are short, interossei rhey will limit MCP exrension when rhe PIP and DIP joints are positioned in full flexion. 3rd Dorsal interossei If MCP flexion is limited regardless of the position of the PIP and DIP joinrs, the limitation is due to abnor- Abductor malities of the joinr surfaces of the MCP joinr or short- digili ening of rhe palmar joinr capsule and the palmar plate. minimi Starting Position ....~\\\\]it~IfLlt~t Extensor digili Position the subject sitting, with rhe forearm and hand ~) minimi resting on a supporting surface. Place the forearm II midway between ptonation and supination; and the wrist in 0 degrees of flexion, extension, and radial and ulnar deviation. Flex the MCP, PIP, and DIP joinrs (Fig. 7-54). The MCP joinrs should be in a neutral posirion relarive to abduction and adduction. lsI Dorsal interossei Extensor digilorum ?JJ'IGUR,E 7-53 A posterior view of the hand showing the prox- \"attachmcnrs of the dorsal interossei on the metacarpals, arid the distal attachments into the extensor mechanism of the .J_, ,.. eiiensor digitorum. extensor indicis. and extensor digiti minimi t?:;\\/;nusclcs. :>; t·- . ~ assei .howing FIGURE 7-54 The starring posicion for testing the length of the lumbricals and the palmar and dorsal H:rossel. interossei. The examiner U$CS one hand to stabilize the subject's wrist, and the other hand to position the ;or digi· subject's metacarpophalangeal, proximal interphalangeal, and distal interphahlOgeal joints in full flexion.

PA RT II UPPER-EXTREMITY TESTING Stabilization Normal End-feel Stabilize the metacarpals and the carpal bones to prevent The end-feel is firm because of tension in the lumbrical wrist motion. palmar and dorsal interossei muscles. I Testing Motion Goniometer Alignment Hold the I'll' and DIP joints in full flexion while extend- ing the MCr joint (Figs. 7-55 and 7-56). All of the See Figure 7-57. fingers may be screened together, but if abnormalities are found, testing should be conducted on individual fingers. 1. Center the fulcrum of the goniometer over the The end of flexion ROM occurs when resistance to dorsal aspect of the MCr joint. further motion is felt and attempts to overcome the resis- tance cause the PIP, DIP, or wrist joints to extend. 2. Align the proximal arm over the dorsal midline of the metaeatpal. 3. Align the distal atm ovet the dorsal midline of the proximal phalanx. t FIGURE 7-55 The end of the motion for testing the length of the lumbricals and the palmar and dorsal ! interossei. The examiner holds the subject's proximal interphalangeal and distal interphalangeal joints in $, full flexion while moving the metacarpophalangeal joint into extension. t ,~ ~ i @ ,,1 ~ ~ H I l.,~ l l I,,~ I1 f,, ~ \\j ,; M ~ri

CHAPTER 7 THE HAND 179 Extensor digilorum 1st Dorsal interossei FIGURE 7-56 A lateral view of the hand showing the first lumbrical <lod the first dorsal inrerossci muscles being stretched over the metacarpophalangeal, proximal interphalangeal, and distal interpha- langeal joints. FIGURE 7-57 The alignment of the goniometer at the end of testing the length of the lumbricals and the palmar and dorsal interossei muscles. The arms of the goniometer arc placed on the dorsal midline of the metacarpal and proximal phalanx of the finger being tested.

180 PA R T II UPPER·EXTREMITY TESTING REFERENCES 22. ( __I..:Hli.·...l. I\"', ;md (,film-ft. IH(: ,\\dllh prl'i't'Il.,JUll: i'.IIi:\"'OIS and I. Levangie, PL. and Norkin, CC: Joint Structure an? Function: A :lCHlJl·nd.uUfe :-(,r pw..·. hn. I 11.1/l.i I her !:l ~ I. \\ ')S'), Comprehcnsive Aml)'sis, cd 3. FA D:l.vis, Philaddplu:l, ,200.1. 23 . .\\I..!vm, J: Rill'urn.!ll.... !),.,Cl'l·: ()\"''''lll',l1lon -Ihn.lpy 1. Tubiana. It: Architecrure and functions of the hand. In rUbl:lOa, R, Rdl.lbdn;\\(ioll. t:d 2.. 1-:\\ 11.\\\\',.. , l'jU!.hielplll.l. IIJ:-;L Thominc:, JM, and :Vb.ckin, E (cds): Examination of the H:lIld and 14. \\\\'.\",I~l.,on :\\H: [\\,LiU.llillll .. r dh.Jbdltll·\" .lIlt! Tn ..:-,l Upper Limb. \\VB S:lUndcrs, Phibdc1phi~. 1984: . \\'\\\"H1'>OIl: :\\11,: r1l·x:bh..' Imp!.lm Ih: ..t:~:l(,rl :\\f:hfoJll\",,:~ 3. Krishnan, J, and Chipc.:hasc, L: Passive aXIal rOraOon of the .:I1l! l_xtrl'n:H1l'''' (:\\' :\"l,,,iw. \\1 I.(,tll\". \\,,-;. mct:lcarpoph:lbngc;ll join!. J Hand Surg 22B:270, 2000. . 25. :-\":,III;(.'r, .IR: l'rdl\"!I\"lk 1:1I~\\Clli\"lIl\" 1,1 th,· illllll.l!I h,wl!, J Anat, 4. C)\"riax. JI-I. and Cyriax. PJ; llIustr:ltcd ;Vianllal of Orthop41cdlC X9:\\,,·;.I'15_'. 16. ·li.,w.:n, 1'.-\\ ..Hl,II·lllll1· \\\\·.l~:ll'·r. \\: hlll.. I:11I!.d \"\\',llll,ltltlil of iht: hand. Medicine. nuncrwonhs. London, 1983. 5. Kahenborn, FM: M:lnu:l.1 Mobilization of the Joines: The III \\t.\\ll1n·, I',C, .wd \"l\"n1>l1/l, \\.\\\\ \\l\"ll-.J: (\"llll·pt' III Hand~ Rdl.lhllit;I'iion. F:\\ 1>,ll';\", I'hd.\"klpll1,l. I'J';.!.. _ Extremities, cd 5. Obf Norlis Bokhandcl, Oslo, I orway, 1999.. 27. Ilulli,'r, .1,\\-1. ,·t .d: RL\"il.lhdllafll,1l of till' 11.1Il.t: \\\\lr~: ..'ry .md Therapy~_ 6. Ranney, 0: The h:md :15 a concept: Digital differences and their n:! \" CV .\\-!o.. h,·, ....! I (,tH',. l<i'm. importance. Clin :\\nat 8:281,1995. .' 2H\" -\\mrn~-;lll ~u(;ei\\- \"f I Lilli! Th,'r,lpl\":': (llIlll.d 7. Ametican Academ\" of Orthopaedic Surgeons: JOint Motlon: Rn'I'llmll\"l1d;}(J\\'II~,nl ~ . .-\\ .. 1IT. <':lm.lj.:.t', I 'J')!' 29. Ln'. 1\\\\1, Jnd RUlI, k: :..h·.l\"llh·llll·lll III l::l~:l'r lum! .1I1~1r, .md m;:I:l<i~_ Methods of Mcasur'ing Jud Recording. AAOS, Chicago, 1965. lIHl!I; llll~'·: 101(..... illrltl~ ..:ylLlllln grq\" '-Cdl\\·ll~·. .I 1'.lHllled Eng 8. American Medical Association: Guides lO the EV;lluarion of Perm:lnelll Impairment, ed 3. AMA. Chic;lgo, 1990. .. 1.1: 152. 19<;1. 9. Hume, M, er :'II: Functional range of morion of (he JOlOtS of rhe 30. :-'l\"l'r1il1~. I.. ;lll,i J.1..·.. h..OII ....\"li,·fl\"fl.lll. t ': TI1\\' ~np 1'·Ii;l·nl of Ihe hand. J Hand 5urg (Am) 15:240, 1990. . 1ll':111:1V h.lnd ,!uflm.:. ,·,IIIll!.!. ~...·,ll1d J Rl·h.l!lll .\\It'd 'J: 11). 1977, 31. Ik.lr-(L\"hm;lIl, J. .I!lJ ;\\brl'~l, IH.: h'.ll\\l.)lm~ tb ..· h,md: 1-.\"11(;'0\"; ill reli; 10. Mallo:l, WJ, Brown, HR, and NunlC)', JA: Digital ranges of morton: Normal values in young adults. J Hand Sur£, (Am) 16:882, 1991. .1bdH\\- :lll,! \\·ahdH\\·. Pin\" '1 iI..·r 6\": I 02 \\, I 'JS'/. II. Sharilova, n, and Plcvkova, A: Ranges of joint motion oi the Jduh 32. :\\d,lll·b. L~, (;rn·;ll\". L\\'c' .md ·IOpllClJ:.ll1, L R.lll].:.\" (,f fll(,rion. I hand. Acta Chir Plasr 38:67,1996. 12. Kisner, C, and Colby, LA: Therapeutic Exercise: Foundations :lnd :\\men\":;!!1 Sn...-i(·t\\, or ll.lnd Th~·r,lpl.,h: <. ltl1l,.11 ;\\\"s<.'ssmen Techniques, cd 4. FA Davis, Philadelphia, 2002. inRl'd'l1Hllt'n\"Lttl\"II~, ni 2.. ;\\ ...1IT, <..i\\l~'.I].:.('. II)\")! . 13. Jenkins, M, ct al: Thumb joint motion: What is normal? J H3nd .D. I Lllll1l1011. (;r. ;l1ld Lh..-ht:llhl'l~..:h. )1:\\: RrlJ.lhdHY ,.f ~:onlorn{:tl'r~ Sur£, (Brl 23:796, 1998. '.' ,h';l\"~';IlU: linger iuin: ,ln~:k. I'll:'\" Tlwr .;9:.16.\\,1')(,'). 14, DeSmet, L, et al: Metacarpophalangeal and tntc.rph3Ian~eal fleXIon 3·L Cr(l(h. (,. ~'t ;\\i: Ct,nioltwtn' 01 tho i,n'\\1111,1! .lnd dhUI interphi1~, of the thumb: Influence of sex and age, rd:mon w hg:lmemOlls L\\l\\\\-:e,iI 1Ull1[-,. 1',1'1 II: l'l:h','II\\l'T\\! prdl'rL·ll~I..'\" iiiIL'['utl\"l' reliability, ;\\!\\l'i ~'UJkU:'l','l1r ,>;\\lidltl'. I H;III.! Th~'r 1·1:2:; ..!(lOI. injury. Acta Ortho!, Belg 59:357, 1993. \". 35. \\X'l-i ..... 1'l, n .11: t:\"111~ '!il,' E:\\I.l.. l'bT1d!l1~lqn to tncl .. un: digital :';mC:l' ot T1\\(ltlllll: Reii.'li'lIl:v .md \\':tli,li!\\', .'Ini J-:n~: J'h\\'\\ 16:323, 15. Beighron, P, Solomon, L, and Soskolne, CL: Articular moblllt)· In:ln Afric:'lO population. Ann Rheum Dis 32:413, 1973. , I'I<)·-\\' 16. Albndcr, E, et al: Norm::d rnngc of joint movements III shoulder, 36. LUi .. , H. Brt:lPtl, :\\, ;111\\,1 Cudd:lI\"d, JI{: .l(,inl ;111~k hip, wrist and thumb with special reference to side: A comparison bet\\vccn twO populations. 1m J Epidcmiol 3:253, 1974. (Ompal'J11\\'l' \\tu,i\\ ('~. !Ill' ['di;lbilitY Ili ~()lli(\\llll'tr~' . T{lr rIll' lund. Uil1 Rdl~lhi! 11:)!·I. 1\")1)\"\", t 7. Joseph, J: Further studies of the metac:lrpophabngcal and Inter· 3i, Ihowl:. :\\. l\"l ;11: Vali,lll\\' .1Il;.! rdi,lbdig' (.I tI1\\,' [)oter Han phabngcal joints of the thumb. J Anat 85:221, 1951. JF\\'.lhLlt!illl ;lIHI Th\\'f;lP~' ~y.. tl'lli :ll h,llld\";l\\IUru! p.lill·IH\\. Han IS. Shaw. SJ. and Morris, MA: The range of motion of the met:lC:lr· r!wr 13:_~7. 2000. poph:llange:ll'joim of the thumb and its relationship to injury. J 38. ern·lll'. WI), and j-ln:klll.llI . .If) (l·d.. j: Till' Cl:IH.....11 \\khllrrlllcllt Hand Surg (Br) 17:164, 1992. .. .. l(IllH ,\\h.,ion. :\\ll1l'n,',Hl ;\\.:.llklll~· til OrchOp.l..dl...· ~urgcon_ 19. Fairb:lnk, JCf, P)'nsen, PB, :lnd PhIllips, H: QU3ntl[:lnV~ measure· ·I{O\\l·tlltlJli. HI.. 1994. ments of joint mobility in adolescents. Ann Rheum DIS 43:288, 39. \\i.klkrmiJ. JC, l'r .11: \\'.Il!dlt~· ('1 I'UII\"lcl'l'.dlll ,h..f.ln\":l' 1984. un' t-,f :ill~l'f tln:IOIl. I H.m.! ~llr~ 26H:4.~!. 2001. 20. Nicholson, B: Clinical evaluation. In Stanley, BG, and Tribu'l.i, SM: 40. C.lInbrid~~·. CA: I{.ll~t:.\\'·ol·n:oll..n lI1,·.I~url·m,·llb \"i Ihe h3lld. I, Concepts in Hand Rehabilitation. FA Davis, Philadelphia, 1992. h-1. \\'\\HUlltl'r, ,Ii \\l·d:l: Rdl.lbl1tt.uillll (It rhl.' Il.lltd: )llrgcry an 21. Knutson, JS, ct al: Intrinsic and extrinsic cOll.tr~bU[ions .to rhe Tha,lpy: ed _i. CV \\Ios-h~·. Sr l.(!lli), I<)~j). passive moment at the mct:lcarpophabngeal JOint. J B,omecn 33,1675.2000.

\",':,:: \"':r,' -'.' ,.:,

The Hip .: Structure and Function head of the femur. The joint is enclosed by <l strong, thick capsule, which is reinforced anteriorly by rhe iliofemoral Iiofemlor;al Joint and pubofemoral ligaments (Fig. 8-2) and posteriorly by hip joint, or coxa, links the lower extremity with the the ischiofcmoralligament (Fig. 8-3). The proximal joint surface is the acetabulum, is formed superiorly by the ilium, posteroinferiorly Osteokinematics the ischium, and anteroinferiorly by the pubis (Fig. The hip is a synovial ball-and-socket joint with 3 degrees The concave acerabulum faces laterally, inferiorly, of freedom. Motions permitted at the joint are flexion- extension in the sagittal plane around a medial-lateral anteriorly and is deepened by a fibrocartilaginous axis, abduction~adductionin the frontal plane around an ~.c('talbullar labrum. The distal joint surface is the convex anterior-posterior axis, and medial and lateral rotation in the transverse plane around a vertical or longitudinal ilium Iliofemoral ligament Ischium Pubofemoral ligament FIGURE 8-1 An anterior view of the hip joint. FIGURE 8-2 An anterior view of the hip joint showing the iliofemoral and pubofemoralligamenrs. 183

184 PART 111 LOWER·EXTREMITY TESTING rotation, the fl'moral head slides postL'riorly on the : :llL'rahullilH. During I,u(:ral rotation, tht: ft.:I1Hlral head Ischiofemoral slides antcriorly. III abduction, thl' femoral head slides. ligament infc:riorlr. In addlH.:rion. rhe femoral head ~Iid('s superi_ orly. Capsular Pattern The capsular pattern is lh;lracrerized by <l marked rion of medial rotation accompanied by limitations flexion and ahduction. i\\ slight limitation Illay he in extension, bur no limir:Hion is present ill ('jrher lateral rotation or adduc[ion ..~ FIGURE 8-3 A posterior view of the hip joint showing the ~ Research Findings ischiofemoral ligament. Effects of Age, Gender, and Other Factors axis.' The axis of motion goes through the center of the femoral head. Tahk 8-1 shows hip rangt: of motion (RO\\-l) v;1lucs from variolls SOUfces. The age:. gender, meaSlIr(.'ml'rl[ insrru- Arthrokinematics mcnr lISl,J. and number of SlIOjcds mcaslIrl·d ro obrain rhe A.-\\OS3 and Ar-./I:\\·\\ \\'allics were nor reponed. Boone In an open kinematic (non-weight-bearing) chain, the and f~z('n,5 Svennillgsc::n and associates.;' ;111<1 Roach and convex femoral head slides on the concave acetabulum in ~vlile~/ used ;1 universal goniometer. Svel\\ningscl1 and a direction opposite to the movement of the shaft of the bone. In flexion, the femoral head slides posteriorly and associates\" measured r~lssivc RO;\\'1 in hoch males and inferiorly on the acetabulum, whereas in extension, the females. whereas RO;lCh and ;\\liles:' measured active femoral head slides anteriorly and superiorly. In medial ROi'v1. Boone and Azefl''i '1lso measured active RO\\;1 but only in males. Age Rcscarchl'fs tcnd to agr('(' that :tge affects hip and that rhe effeers .1ft motion speciiic and gender ,pecific. Tablc 8-2 ,hows passive ROM valllcs neonates as reported in five s!L1dies. s- l .! All values prl'senrl'd in Table 8-2 were obtained by means of a universal goniomerer. A comparison ot rhe nconare's passive RONt \\'alues shown in Table 8-2 wirh the values _'_~A of older children and adulrs shown in Table 8-1 reveals ;:f{~ 'iIi: TABLE B-1 Hip Motion: Values in Degrees . ' \"~'\" \". 122.3 (6.1) 32.0 (B.O) 9.8 (6.8) 32.0 (9.0) 45.9 (9.3) 26.9(4.1) 47.3 (6.0) 47.2 (6.3) (SD) = Standard deviation. • Measurements taken with subjects in the supine position.

CHAPTER 8 THE HIP 185 TA8LE 8-2 Effects of Age on Hip Motion in Neonates 6 Hours to 4 Weeks of Age: Mean Values in Degrees :,~,(SDY =' Standard deviation. ;>.,:; .. All values in this row represent the magnitude of the extension limitation. . .. t rested with subjects in the supine position. *Tested with subjects in the side-lying position. that the neonates studied have latget passive ROM in the neuttal position (returning to 0 degrees from the end most hip motions except fot extension, which is limited. of the flexion ROM). \"-15 Waugh and associates\" found : The neonate's ROM in hip lateral and medial rotation that all 40 infants tested lacked complete hip extension, arid abduction is much latget than the ROM values of with limitations ranging from 21.7 degrees to 68.3 adults and oldet childten fat the same motions. Also, the degrees. Schwarze and Denton' found mean limitations relationship between hip lateral rotation and medial of 19 degrees fat boys and 21 degrees for girls, and totation appears to differ from that found in a majority Broughton, Wright, and Menelaus lO found a mean hip of older children and adults. Hip lateral rotation values extension limitation of 34.1 degrees in 57 boys and girls. for the neonates are considerably greater than the values Forero, Okamura, and Latson 15 found that all 60 for medial rotation, whereas in children and adults the healthy full-term neonates studied had hip extension lateral rotation values are either about the same or less than the values for medial rotation. '5 Kozic and limitations. colleagues,17 in a study of passive medial and lateral Limirations in hip extension found in the vety young rotation in 1140 children aged 8 to 9 years, found that 90 percent of the children had less than 10 degrees differ- are considered to be normal and to decrease with age as ence between lateral and medial rotation. Ellison and seen in Table 8-3. The rerm \"physiological limitation of coworkers,18 in a study of 100 healthy adults and 50 motion\" has been used by Waugh and associatesS and patients with back problems found that only 27 petcent Walker lJ to describe the normal extension limitation of of healthy subjects compared with 48 percent of patients motion in infants. According to Walker,13 movement had greater lateral rotation than medial rotation. The large number of patients who had greatet lateral than into extension evolves without the need for intervention medial rotation suggests a rotational imbalance that may and should not be consideted pathological in newborns be telated to back problems. and infants. Usually, a teturn from flexion to the neutral position is anained in childten by 2 yeats of age. However, as seen in Table 8-2 the most dramatic Extension ROM beginning at the neutral position effect of age is on hip extension ROM. Newborns and usually approaches adult values by early adolescence. infants are unable to extend the hip from full flexion to Btoughton, Wtight, and Meneiaus lO found that by 6 months of age, mean hip extension limitations in infants had decteased to 7.5 degtees, and 27 of 57 subjects had TABLE 8-3 Hip Extension Limitations in Infants and Young Children 4 Weeks to 5 Years of Age: Mean Values in Degrees

186 PA R Till LOWER-EXTREMITY TESTING F1~tg~ .~ 122.6 (5.2) 33.0 (7) 31.0 (8) ~,j 11.6 (5.0) 34.0 (8) 32.0 (8) (EXt~nston 46.8 (6.0) 11 B.O (13}jJl 26.3 (2.9) 17.0 (8h~ ~~Hijon 47.1 (5.2) 39.0 (12)lj .Mifuaion,)f' 47.4 (5.2) :Medtaf;{ot~ti>0\"~'i~<;;§J:rA;::'9 30,0 (,;]~ Latera,'I,-i?Y~ti?n;,:·::';\\:;:',:';'/:,}{:1:~)DX 29.0 (9) (SD) \"\" Standard deviation. no limitation.9 Phelps, Smith, and Hallum H found that ::-tr:H<.:d :1 redlll.:n.l :lhility III ;Huin ;1 1ll:11iral ~{arrillg posi~ 100 percent of the 9- and 12-momh-old infants tested (n = 50) had some degree of hip ex«nsion limitation. At 18 !lon for hip flL':..:ion, The rnC:lll SLlrling po.,irlo!1 for both ~~roup~ for 11ll.,:;l:-,url'fJlCI1tS of flc:\\lon RO.\\\\ was 11 months of age, 89 percent of infants had limitations, and dcgrces instcad of 0 dvgrecs. The Illc:lll RO.\\[ v<lluts at 14 months, 72 percent still had limitations. ohuillcd for both ;1gc groups for hip filI.ltioll, :lhdudion, The values in Table 8--4 supplied by Svenningsen and ;l1!d :H.ldu.... rio!1 W{:rt.: !·I [0 25 dcgrcc5 k:-. ... tll,111 rilL' ~\\\\'<:r· associarcs6 were obcaincd by means of a universal ,I!!-l' V;J!lll'S puhli::-Ih:d by !Ill\" A,\\OS, ~ Thi\" finding goniometer from measurements of passive ROM, pnn\"idc'> s(rollg :-'1l~lP0!'i for dll' liS(' ot\" ,lgc-;lppropriatc whereas the values supplied by the other authofs 7,20 were obtained by means of a universal goniometer from norm:'., measurements of active ROM. Very little difference is evident between the ROM values for hip flexion and hip j:11111..':> JII,! Parkcc~'l IJlC;J:-,urL'll :l\\..:ri\\'1..' ;llld passive abduction across the life span of 4 [Q 74 years in contrast RO.\\1 :1[ the hip. kIlCC, .Ind ankle in SO hL'~ddl~· llIL'1l and womell r~ll1ging frwil -0 YC:1r:-. to 92 ~'l-;Ir~ of age, to hip medial and lateral rotation, which have the great- est d~crease in ROM. Roach and Miles7 have suggested \\1easun..'llll'llt\\ 01 hip ahdw..:rioll RO!\\1 Wl~rl..' takcn with J. that differences in active ROM representing less than 10 percent of the arc of motion are of little clinical signifi- lllli\\'cr:>:d gOJliOIlH:rl'f. :\\11 miler 1lll',lS11rl'lllenrs were UkC'1l with ;1 l.l'ighroll fk:\\ol1letcr, Systcllwric de~reascs cance, and that any substantial loss of mobility in indi- if! hoth :Idi\\'c :Illd pas~i\\'l' RO,\\,1 were found in subjects viduals between 25 and 74 years of age should be viewed hl'(WCl'I1 70 alld 92 ~·c:lrs or agc. Hip ahdm:rion as abnormal and not attributable to aging_ In the data lkcl\"c:I:-;('d rhl' 111(I\"r wirh Jge ;l11d was 33A fK'rCL'nr kss in from Roach and Miles7 hip extension was the only the oldl..'sr group of ml'H ,Ifld womerl (thosc ,Ignl ~5 TO 92 motion in which the difference berween the youngesr and yc:,rs) (t)lllp;\\rl.:d with Ihc youngest group \\rh(J~e agl..'d 70 the oldest groups constituted a decrease of more than 20 w 74 j'l'~lI\"s), :\\/h:lkl! :llld LUlTal rot:ltiOll aiso ckcr(,;lsed percenr of the available arc of morion, (ollsider;lbly, hill the d(,~I\"l'~ISl' was nor ;\\s gre:H ~IS dur Orher authors who have investigated age or gender seen ill abdudion. In <..:onrr;lst. hip f1c,i<..l1l \"virh {he- knee effecrs on the hip include Allandet and colleagues;21 L'ithcr L':\\IClldl'llor fkxrd W;h iL'J::-r :lffl'l..'!Cll hy ;l~l', with ~i signit'icliH !\"n!lH..'cioli (HXllrrillg. only ill (ho:'>1.: o!da rhan Walker and colleagucs;22 Boone, \\'(Talkcr, and Perry/3 85 j'C;lrs of ;lgl', I\\lssi\\'c RO;vl Wi1:\\ greater [h;1I1 active James and Parkcr;24 Mallinger and Stcffan;25 and Svcnningscn and associatcs.6 Allander and collcagues21 IZ()M for;lll ioinr 1ll0l'ions lcs[cd, wirh (he !argesl differ- measured the ROM of different joints (i_e_, shoulder, hip, ence (7 degrc('~) occurring III hip flc:\\lon with the knee wrist, and thumb metacarpophalangeal joints) in a popu- flexed, lation of 517 females and 203 males between 33 and 70 :\\lrhnugh SW'JlllingsL'1I ;lIlt! ;\\sso..:iarL's\" s(IIdi!.:,,1 hip years of age. These allthors found that older groups had RO;\\{ ill fairly young subjects ,761 males and females significantly less hip rotation ROM than younger agl'd.:l to 28 y...Jrs), rhest' allthor~ found rhar t:vt:n ill this groups. Walker and colleagues22 measured 28 active limired age spall, rhe RO:\\l for most\" hip ll1miolls showcd motions (including all hip motions) in 30 women and 30 ;\\ deCl'l:;lSC with incrcJsing age, Huwcver, the reductions men ranging from 60 to 84 years of age. Although Walker and colleagues22 found no differences in hip ill RO.VI varied according ro rhe morion, Dc-.:rl';lscs in f1('xion, ilbducrion, lllL'di~1 rmiHio!l, ,lOti {{Hal roration ROM between rhe group aged 60 to 69 yeats and the wac gre;lter rhan decreases in ,:xtension, adduction, and group aged 75 to 84 years, both age groups demon- brcral rotation. NOl\\;\\ka :H1d associates,l(, ill :I study of 77 tll:alrh}' mall' volunteers '.Igcd 15 to 73 yL';U'S, (oulld (h:1(' passive

CHAPTER 8 THE HIP 187 hip !tOM decreased progressively with increasing age, an approximate 25 percent decrease in ROM, whereas bur no change was observed in knee ROM in the same women had a decrease of only about 11 percent. population. Body-Mass Index Gender Keftunen and colleagues'7 found that former elite athletes with a high body-mass index (BMI) had lower Theeffects of gender on ROM are usually age specific toral amoum of hip passive ROM compared with former 'and motion specific and account for only a relarively elite athletes with a low BMI. Subjects in the study _small-amount of roral variance in measurement. Boone included 117 former e1ire athletes between the ages of 45 and'coworkcrs23 found significant differences for most and 68 years. Measurements were taken by means of a Myrin goniometer, with the subjects in the prone posi- h.ip :.rnorions when gender comparisons were made for tion. Escalame and coworkers\" determined that there was a loss of at least one degree of passive range of ehree age groupings of males and females. Female chil- motion in hip flexion for each unit increase in B1vlI in a dren (1 to 9 years of age), young adult females (21 to 29 group of 687 community-dwelling elders (those who years of age) and older adult females (61 to 69 years of were 65 years of age to 78 years of age). Severely obese age) had significantly more hip flexion than rheir male subjects had an average of 18 degrees less hip flexion counterparts. However, female children and young adult than non obese subjects as measured in the supine posi- females had less hip adduction and lateral rotation than tion with an inclinometer. BMI explained a higher males in comparison groups. Both young adult females proportion of the variance in hip flexion ROM than any and older adult females had less hip extension ROM than males. Allander and colleagues\" found that in five of other variable examined by the authors. Lichtenstein and eight age groups rested, females had a greater amOunt of hip rotation than males, Walker and eolleagues22 found associares29 studied interrelationships among the vari- that 30 females aged 60 to 84 years had 14 degrees more ables in the srudy by Escalante and coworkers'8 and ROM in hip medial rotation than their male counter- concluded that BMI could be considered a primary direct parts. Simoneau and coworkers26 found that females determinant of hip flexion passive ROM, (with a mean age of 21.8 years) had higher mean values in both medial and lateral rotation than age-matched On the other hand, Bennell and associates '9 found no male subjects. The authors used a universal meral effecr of BMI on active ROM in hip rotation in a srudy goniometer to measure active ROM of hip rotation in 39 comparing 77 novice bailer dancers and 49 age-marched females and 21 males, In Contrast to Walker and controls between the ages of 8 and 11 years. The control colleagues22 and Simoneau and coworkers,26 Phelps, subjects, who had a higher BMI than the dancers, also Smith, and Hallum ,., found no gender differences in hip had a significantly greater range of lareral and medial hip rotation in 86 infants and young children (aged 9 to 24 rotation . .months). :':.i~;-Svenningsen and associates6 measured the passive Testing Position ROM of 1552 hips in 761 healthy males and females between 4 years of age and 28 years of age. Females of all Simoneau and coworkers26 found that measurement age- groups in this study had gre;ucr passive ROM than posirion (sitting versus prone) had lirtle effect on active males for total passive RON1, total rotation, medial rom- hip medial rotation in 60 healthy male and female college tion, and abduction. Female children in the 1I-year-old studems (aged 18 to 21 years), but that position had a age group and the I5-year-old age group and female significant effect on lateral rotation ROM. Lateral rota- adults had greater passive ROM in hip flexion and tion measured with a universal goniometer on subjects in adduction than males in the same age groups, Males had the sitting position was statistically less (mean, 36 greater passive ROM in hip lateral rotation than females degrees) than it was when measured on subjects in the in the 4-year-old group and the 6-year-old group and prone position (mean, 45 degrees). Bierma-Zeinstra and in adults. This finding is in agreement with that of associaresJO found that both lateral and medial rotarion ,Boone. 20 ROMs were significantly less when measured in subjects , James and Parker24 found that women were signifi- in the sitting and supine positions compared with those in cantly more mobile than men in 7 of the 10 motions the prone position. However, Schwarze and Dcnton9 tested at rhe hip, knee, and ankle. Ar the hip, women had found no difference in hip medial and lateral rotation ,grearer mobility than men in all hip motions except .bduction. This finding is in agreement with that of passive ROM measurements taken in subjects in the :Boone but opposite to the findings of Svenningsen and associarcs.6 Men and women had similar mean values in prone position than in measurements taken in 1000 hip flexion ROM, both with the knee flexed and with the neonates in the supine position. :knee extended in the group aged 70 to 74 years, but in Van Dillen and coworkersJl compared rhe effects of the group between 70 and 85-plus years of age, me\" had knee and hip position on passive hip extension ROM in 10 patients (mean age, 33 years) with low back pain and .I! 35 healthy subjects (mean age, 31 years). Both groups had less hip extension when the hip was in neutral abdu.c-

188 PA RTill LOWER-EXTREMITY TESTING -~ TABLE B-S Effects of Position on Hip ROM: Mean Values jn Degrees\" (SO) = Standard deviation. 33.1 * Active ROM measured with a universal goniometer. 36.0 t Passive ROM measured with a universal goniometer. 34.2 39.9 tion than when the hip was fully abducted. Both gtOUpS also displayed less hip extension ROM when the knee sllbjl.,.'crs. Non-hip brer;ll roration as :l pcn\":l'nragc of was flexed to 80 degrees than when the knee was fully :lCriv(' hip R01\\l l was 40 pt:n,:cIH in dancers <.:omparcd extended (Table 8-5). This finding lends support for with 20 percell[ in control suhjects. l'he ill(rcased Kendall, McCreary, and Provance,J2 who maintain that rorsiollal forces on rhe rnedi;d aspCd of rhe knee. anklc, changing the knee joint angle during the Thomas test for and foor ill rilL' young J~I1(('rs putS this g.roup ~r high risk hip flexor length can affect the passive ROM in hip of injury'. Similar ro tht: findings of (;ilbtr!. Gross, and extension (see Muscle Length Testing Procedures Section Klug,;' the authors tnund no r<.:lationship hetween later in this chapter for information on the Thomas test). llumhl.:r of yt;1f~ ot training. and btL'ral ror~Hion ROM, Arts and Sports which :lgain suggests a gl.'ll(;[ic comporu.:nt of RO:Y1. The A sampling of articles related to the effects of ballet, ice authors Jid !lor offer In c:'\\pbn<lrion for the f;l(t that the hockey, and running on ROM are presented in the control suhjt:'crs h~ld a grL'arcr 1\\0\\1 in lateral motion . following paragraphs. As expected, the effects of the dun rhe daTH':<.:r~; instead. ;:hey h~'porh('sizcd that a short- activity on ROM vary with the activity and involve ening of the hip extensors (r('sulring. from constant usc) motions rhar ·are specific (0 the particular activity. Gilbert, Gross, and Klug33 conducted a study of 20 :lIld rhe: d,\\nccrs' avoidance of full hip medial rotation female ballet dancers (aged II to 14 years) to determine mighr aCl'ounr for rhe tao rhat the dalh.:crs had less hip the relationship between the dancer's ROM in hip lateral rotation and the turnout angle. An ideal turnout angle is medial rotation th:lll rhe colltrol subiL'cts. a position in which the longitudinal axes of the feet are 'rylcr ;lfld colleagucs\"'1 found rh~H a group of 25 profes- rotated 180 degrees from each other. The authors found that turnout angles were significantly greater (between 13 si()[l;\\l male icc IHKkc'y pbyers had about 10 (legrces less and 17 degrees) than measurements of hip lateral rota- hip l'xt('llsion RO~\\'I rhan a group of 25 marched control tion ROM. This finding indicates that the dancers were using excessive movements at the knee and ankle subjects. The authors postubted thar rht' loss of hip to attain an acceptable degree of turnout. According c:'\\tcnsioll in the hockey pbyers was prob;lbly due ro tight to the authors, the use of compensarory motions at the anterior hip cap~lIle structures and tight iliopsoas knee and ankle predisposes the dancers to injuty. The dancers had had 3 years of classical ballet training and muscles. The flexed hip and knee posture.\"assullled br [he still had not been able to arrain the degree of hip lateral rotation that would give a 180-degree turnout angle. pbYl'rs during skating probably contributed to the Consequently, the authors suggest that hip ROM may be muscle shortness and loss of hip extension H.O~L Van genetically determined. .\\lcclH:lcn and (:ollcaguesJ,S used gonion\\ctry CO measure hip RO!v1 in J6 lllale runners who had sllsraincd funning Bennell and associates19 derermined that age-matched conttOl subjects had significantly greater active ROM in injuril'S during. rhe year bur who wcrc fir at rhe rime of hip lateral and medial tOtation than a group of 77 ballet the srudy. No righr·lef[ differences in hip RO!\\.-'I were dancers (aged 8 to 11 years), alrhough there was no found e:irher in rhe previously injure.:d g.roup or in a significant difference in rhe degree of turnout between the two groups. The amounr of non-hip lateral rotation IVas control group of rUllIH.:rs who had not sustained an significantly greater in the dancers than in the control injury. I-Io\\\\'l'ver. hip RO~,t in the iniurcd group was on average 59.4 degrees or about 10 degrees less than thl' :\\vcrage 1\\0.\\11 of 68.1 degrees in runners withour IIlJUrtes. Disability Srculrjcns and associates,;6 lIsed a universal gOlliomcrer to mcasure bil::Heral ;1Crivt' assistivc RO~t .H the hip and knee in 198 patients with osreoarthritis (OA) of the hip or knee, These authors fOllnd rhat gellerally a decrease in

CHAPTER 8 THE HIP 189 hip ROM was associated with an inctease in disability, but that association was motion specific. Flexion contrac- tures of either hip or knee or both were found in 72.5 percent of the patients. Hip flexion contracrures were present in 15 percent of the patients, whereas contrac- tures ar the knee were found in 31.5 percent of the patients. Hip extension and lateral rotation showed significant relationships with disability in patients with knee OA, whereas knee flexion ROM was associated jvith disability in hip OA patients. Twenty-five petcent of thevatiation in disability levels was accounted for by differences in ROM. Mollinger and Steffan,25 in a study of 111 nursing home residents, found a mean hip exrension of only 4 degtees (measuted with the residents in the supine posi- tion with the leg off the side of the table and the cqntralareral knee flexed). Beissner, Collins, and f:{olmes37 found that lower-extremity passive ROM and upper-extremity muscle force are important predictors of flInction for elderly individuals living in assisted living residences or skilled nursing facilities. Conversely, upper extremity ROM and age ate the strongest predictors of function in elderly individuals residing in independent living situations. Functional Range of Motion FIGURE 8-4 Ascending stairs requires between 47 and 66 degrees of hip flexion depending on stair dimensions:1O Table 8-6 shows the hip flexion ROM necessary for selected functional activities as reported in several measured hip and knee active ROM with an electrogo- sources. An adequate ROM at the hip is important for niometer during gait in 240 healthy male and female indi- meeting mobility demands such as walking, stairclimbing viduals aged 10 to 79 years of age. Age-related changes (Fig. 8-4), and performing many activities of daily living were slightly more pronounced at slow gait speeds than that require sitting and bending. According to Magee,38 at fast speeds, but the rate of changes was less than 1 ideal functional ranges are 120 degrees of flexion, 0 degree per decade, and no distinct pattern was evident, degrees of abduction, and 20 degrees of lareral rotation. However, as can be seen in Table 8-6, considetably less ROM is necessary for gait on level surfaces.39 Livingston, Stevenson, and Olney40 studied ascent and descent on stairs of different dimensions, using 15 female subjects between 19 years of age and 26 years of age. McFayden and Winter41 also studied stairclimbing; however, these authors used eight repeared trials of one subject. In a study to determine the effects of age-related ROM on functional activity, Oberg, Krazinia, and Oberg42 TA8LE 8-6 Hip Flexion Range of Motion Required for Functional Activities: Values in Degrees from Selected Sources ..

190 PA RT III LOWER-EXTREMITY TESTING except that hip flexion-extension appeared to be affected I less than other motions. I Other functional and self-care activities require a 1 larger ROM at the hip. For example, sitting requires at least 90 to 112 degrees of hip flexion with the knee flexed (Fig. 8-5). Additional flexion ROM (120 degtees) is necessaty fot putting on socks (Fig. 8-6), squatting (115 degrees), and stooping (125 degrees).'\" Reliability and Validity Studies of the reliability of hip measurements have included both active and passive motion and diffetent types of measuring instruments. Therefore, comparisons arnong studies arc difficult. Boone and associates43 and Clapper and \\'(Iolf'-' investigated the reliabiliry of meas- urements of active ROM. Ekstrand and associates,45 Pandya and colleagucs,46 Ellison and coworkers,I8 Van Mechelen and colleagues,\" Van Dillen and coworkers,\" Croft and associates,4? Cibulka and colleagues,4S and Cadenhead and cowotkers'9 studied passive motion. Bierma·Zcinstra and assoclatcsJO studied the reliability fFIGURE S-6 Purring Oil :,>ocb. rnplirl':- 12tl dq~rl'l':- (If fkxion, or20 dq.:rlT.\" ot Jhdll ..·li(lll .In...l :~u d..·,l'.rt·c... Lltl'l\".d ro!.\\(ioll ..iS FIGURE 8-5 Sitting in a chair with of hoth ;h,'rlve :l1HI I';\\s~i\\'c RO:v1. Tahk' K-7 provides a . I requires 112 degrees of hip flexion. J8 s:llnpling lit inrr:Hl'\",rcr :lIId jll{l'rre~(a rcklhiliry Sfudies. I BO(lll(' :llId :lss(Jci:llCs\":; conducfnl ;1 study in which I fpur physi...:ll rhcr:ll'i\",rs used ;1 univcr\":ll goniolllcter ro~'~, j lllt.-:l$lIft.' ,Kri\\'c ItO\"t of three uppa-l.·\\:Hl·l1liry !1lotions <tlld three lo\\\\'cr-L'xrrcll1iry 111orioilS in 12 malt: \\'Olll1ltc:crs~' I :I!!.cd 1(; [0 54 \\'t.':ll\"\", One of lilt' 1Il0tiOllS h:stcd was hip\"\" i Jilduulnll. Th~n.' Illl';lS11n:l1h.:IHS were ukcl\\ hv each I lest';;f ;H c,l(h of (our scssions si.:ht.'dllkd (111 ~l 'weekly; \" basis for 4 \\\\'t.'tks, Inrr;ut.'sclT 1\"t.'li:lhiliry {or hip :Ihdllcrion::, was r = 0,75, with a (ot;11 sLlIl\"'!anl de\\'iarioll bcrween' IllCaSllrCl\\lCnrs of 4 dL'gn:es rakcll Iw rhe S:lIl1C resters, Inref(i,.'srcr reliahility f(';r hip abducrion \\\\-';\\$ r = 0.55; wirh ~1 rocal srandard (!t-\"iarioll of 5.2 (kgn..'t.'s bt:f\\\\'cen measurcmcnt's rakl'l1 by difftTL'!H IL'~[l\"l\"S. Clapper and \\'\\'01(1-1 compared rht.· rdi:lbilit\\, of thev; Orrhoranger (Orrhorronit:s, Davrona BC:lch. i:l:t')l an, electronic (Olliputl'd pendulum goniOllltlt.:r, widl dl<1r of;,::; the universal goniollh.:ter in a study oj adi\\\"(, hip l11orion'~'

TA8LE 8-7 Intratester Reliability ' . CHAPTER 8 THE HIP 191 . involving 10 males and 10 females between the ages of 23 series. Standardization of ptocedutes imptoved reliability and 40 yeats. The authots found that the univetsal considerably. The intcrcesrcr coefficicm of variation was goniometer showed significantly less variation within significantly lowet in the second seties than in the first when the procedutes wete not standatdized. sessions than the Orrhoranger, except for measurements :;~f hip adduction and latetal rotation. The authors In a study by Pandya and colleagues,46 five physical , concluded that the universal goniometer was a morc reli- therapists using universal goniometers measured passive '~ble instrument than the Orrhotanget. The poat cotrela- joint motions including hip extension in the upper and :tion between the Otthotanget and the universal lower exttemities of 105 children and adolescents, aged 1 . ··;goniometer fat measurement of hip adduction and to 20 years, who had Duchenne muscular dystrophy. :; abduction ROM values demonstrated that the twO Inttarestet reliability was high fat all measutements; the instruments could not be used inrerchangeably. intraelass correlation coefficient (ICC) ranged from 0.81 . Ekstrand and associates\" measured the passive ROM to 0.94. The intratester reliability for measurements of of hip flexion, extension, and abduction in 22 healthy hip extension was good (ICC = 0.85). The ovetall ICC men aged 20 to 30 yeats. They used a specially for interrestet reliabiliry fat all measurements tanged constructed goniometer to measure hip abduction and a from 0.25 to 0.91. Intettestet reliability for measure- ments of hip extension was fair (ICC = 0.74). The results flexometcr to measure hip flexion and extension in twO indicated the need for the same examiner to take meas- urements for long-term follow-up and to assess the testing series. In the first series, the testing procedures results of therapeutic intervention. lVere not controlled. In the second series, procedures •,. wete standatdized and anatomical landmatks wete indi- Ellison and cowotkets 18 compared passive ROM .,...\":·cated. The intratestet coefficient of variation was lower measurements of hip rotation taken with an inc,linomctcr .. jehan the interrestet coefficient of variation for both TABLE B-8 Intertester Reliability

192 P t-\\ R T i l l l.OWER·EXTREMITY TESTING and a llHivas:t1 gOlliof11{'[(:r and found uo sjgnifi~alH :-.rudy ot p:l~:-.i\\'e RO:\\'1 in Iw.:dial :lnd I:Hcral hip rOtation diffcrL'Tl~(:s ht:[wceJl rhe lllt.:ans. Both IJl:-.trtllllciH:\" were in 100 p;uicnrs with lo\\v back pain, t!t:llTlIlincd rhat fOr found to bt: f<:liahlc, hm the authors prdcrn.:d tht: inch- this group of p:Hienrs, rne:lsurcnlellrS of rot:HiOll taken in IH.1I1H:tt:r bCGwse it was casic::r [() usc. Croft and asso~ih atl.:s·1? llst:d ;\\ fluid·filkd indinOIllL\"H:r cllll.'d it Plurimcrcr 1111.: prolle..' position Wtrt: l1lore reliable rh:lll those taken in tht: sirring position. Bicrf1l:1-Zt.'illstra and associatcs30 (() t!cH:rmine rhl' intcncsrtr rdi;dliliry of pa:-.:-.iVl..· hip flex- t.:ol1lpared [he.:: reliability of hip ROM IlH:asuremcnts ion ~ll1d rotation RO,~\"I ll'lCaSUfl.:lJH:!lt:, [;Ikcn hy six (lin i- t:lkcn hy rnt.':lllS of an ek({ronic inclinometer with those cians. T'he clinicians rook RO\\'I mtasun:llIcms of hoth hips ill six p;1rlclHs with ()~r<:o:Hrhriris involving ollly ollL' taken by IllC;lllS of ;:1 univcrsal goniollleter. 'fhc two hip joinL F1exioll was Il1c:lsun.:d with rhe p,tricl1t in ell<..' insrrullle..'lHs showtd equal iIHr:HtSrcr reliahiliry for bOth :Il.'rivc aud passive hip RC):\\t ill gcncral; howc\\'er, the supine position l,jdll'r to maxil11ulTl flexion or [(l rilL' irHrarcstt:r rcliahiliry of thL' inclinomerer W:IS higher rhan point whcll furrhcr lllOrion \\\\':lS rcsrriucd hy pain. Thl: rhat of the goniolllCtL'f for passivL' hip rorarion, '{'ftC incli- nOlllctn also llild higher ilHt:rtesfl'r rl'liahiliry (or active n..:sulrs showed no diffcrl.'IK'(' hctwccn rhe nH:aSUr(:l11cnn. rakell by onc c:\"\\,unillcr and rhost: rakl.'11 hy orhu l.':\"\\~un· medial rotation than dk' goniolllerer, and rhe authors iners, bur rhe dcgrcc.: of ;lgrCl:Illl.'!lt \\\\,:IS grc:Hcsr for 1ll<:,lS' c:llIriollt'd [har rhe ill~tfllll\\L'l1tS should nor be used imer- ur('lllellts of hip fksioll, Cihulk:l Jnd collcagues,'IS in a L:hallf:?,cably, Range of Motion Testing Procedures: Hip FfCUR.E S·7 A lateral view of rht hip showing surface anatomy bndmarks for aligning the goniorncrt:!' for measuring hip f1exioJl and extension, Greater trochanter femu; Lateral epicondyle femur FICURI'. ~.~ A lateral view of the hip showing hony anaromicallandmatks ior aligning the goni\"m\"er.

CHAPTER 8 THE HIP 193