__Measurement_of_Joint_Motion__A_Guide_to_Goniometry_3rd_Edition

PART IV TESTING Of THE SPINE AND TEMPOROMANDIBULAR JOINT Alternative Mea5urement Method for Thoracic and process of the seventh cervical vertebra, and zero Lumbar Flexion: Double Inclinometer both instruments prior to beginning the mOtion (Fig. 12-11). 1. Use a skin-marking pencil to mark the midline of 3. At the end of the motion, rcad and notc the infor- the midsacrum and the spinolls process of the mation on both inclinometers (Fig. 12-12). The seventh cervical vertebra with the subject in the difference between the two inclinometers indicates upright 0 starting position. the amount of thoracic and lumbat flexion ROM. 2. Posirion one inclinometer over the midsacrum. Position rhe other inclinometer over the spinous FIGURE 12-11 The starting position for measuring thoracic and lumbar flexion with both inclinometers \"'1 ;Jligncd and zeroed. 'j , 1,-.•,. 'j i;:iV,o\\t //'ii!i,:::'i.:'(,(..',:':j };thl 3~._

CHAPTER 12 THE THORACIC AND LUMBAR SPINE 347 FIGURE 12-12 Inclinometer alignment at the end of thoracic and lumbar flexion range of motion.

348 PART IV TESTING Of THE SPINE AND TEMPOROMANDIBULAR IOINT LUMBAR FLEXION suggests that they lll:l~' limit fkxioll. hm the: ac..:rual actiolls of thl\" inh:r~pillall\"s and r1w intl\"rtransvcrsarii Testing Position Illi.:diall\"s and lataall,:s art.: ulIknown,1 Place the subject standing, with the cervical, thoracic, and lumbar spine in 0 degrees of lateral flexion and rota- Measurement Method for Lumbar Flexion: tion. Modified-Modified Schober Tesfs.38 or Simplified Stabilization Skin Distraction Method39 Stabilize the pelvis [Q prevent anterior tilting In the original Schoher 1111.:£l1Od, tht examiner madl\" onlv tW{) marks on the suhject's hack. The first mark wa's Testing Motion m'H.h.:;l( the.: lumhos;ll.:Tal junction and the second 10 em Ask the subject to bend forward as far as possible while ;lhove the: first mark on the spine. :vtaCf<lC ;1IHI \\X/right7 keeping the knees straight. decided W Illodif>' the Schober I1h.:dlOd bt'(~lUSC they hclicvL'd skin 1Il0VL\"IllCIlt was a problem ill thl\" original Normal End-feel method and dl:lt the skin was more firmly atuchl\"d in the The end feci is firm owing to stretching of the ligamen- tum flavum, posterior fibers of the annulus fibrosus and zygapophyseal joint capsules, thoracolumbar fascia, iliolumbar ligaments and the multifidus, quadratus lumborum, iliocostalis lumborurn, and longissimus thoracis muscles. The location of the following muscles 11-.,--,.~~J-...~/---i 15cm FIGURE12-13 A line is drnwn berween the two posterior FIGURE 12-14 Thl..· t;lpl\" IllI..':lSllrt\" is aligllt\"J hl..'[wt\"l·n [ht:' upper superior iliac spines and the point dt which the lower end of rhe tnpt: measure should be positioned. The location of the 154 cI11 <llld thL' !owt:1\" bndm:Hk:-: :H the beginning of lumbar flt:xion mark shows that all five of the lumbar vcnchrac in this subject r:ln~c oj motion. P:lpt:r rape \\V.IS pbl..'cd O\\'e,:r tht' skin lllarking arc included. p(·llI.:il dms w impro\\T visibility oi landlll:lrks for rhe phow- graph.

CHAPTER 12 THE THORACIC AND LUMBAR SPINE 349 below the lumbosacral junction. However, bcginw berween 15 and 18 years of age and a mean of 5.8 em rhe measurement 5 cm below rhe lumbosacral junc- (SD = 0.9 cm) in female subjecrs in rhe same age group. places the most superior mark at L2 or L3; therefore, measurement in Macrae and Wright's7 modified Tape measure alignment: MMST merhcld does nor include rhe entire lumbar spine. Furrhenno're, examiners experienced difficulties in accu- 1. Use a skin-marking pencil ro mark rhe subjecr's rwo posterior superior iliac spines. Use a ruler to locate locaring rhe lumbosacral juncrion. Macrae and and mark a midline point on the sacrum that is on W!.'n''''o method is presented in this text as an alternative a level wirh rhe iliac spines. Make a mark on rhe me,asu.rernellr merhod following rhe Modified-Modified lumbar spine rhar is 15 em above rhe midline sacral Sctlober Tesr (MMST).18 or rhe simplified skin disrracrion mark (Fig. 12-13). me,rh,)d,39 which is presented in rhe nexr paragraph. 2. Align rhe rape measure between rhe superior and The MMST uses rwo marks, one over rhe spine on a rhe inferior marks. (Fig. 12-14) Ask rhe subjecr [0 connecting the two posterior-superior iliac spines bend forward as far as possible while keeping rhe and rhe orher over rhe spine 15 cm superior [0 rhe knees straight. mark. This rechnique was proposed by van 3. Mainrain rhe rape measure againsr rhe subjecr's Adriche,n and van dec Korsr38 to eliminate errors in iden- back during rhe movement bur rhe allow rhe rape rifi,carion of rhe lumbosacral juncrion and [0 make sure measure to unwind to accomodate the motion. At rhe end of rhe flexion ROM, nore rhe disrance rhe enrire lumbar spine was included. berween rhe two marks (Fig. 12-15). The ROM is Van Adrichem and van der Korsr,.18 using rhe MMST, rhe difference berween 15 cm and rhe lengrh meas- ured ar rhe end of rhe morion. a mean of 6.7 cm (SD = 1.0 em) in male subjecrs FIGURE 12-15 The rape measure is stretched between the upper and the lower landmarks at the end of lumbar flexion range of motion.

I I Z 1-3-S-0--P-A-R-T-I-V--T-E-S-T-I-N-C--O-f-T-H-E-S-P-I-N-E-A-N-D-T-E-M-P-O-R-O-M-A-N-D-I-B-',-'L-A-R-JO-I-N-T is: !! II) I~ Alternative Measurement Method for Lumbar I~ Flexion: Modified Schober Technique? 2. Align the tape measure between the most superior I::> Macrae and Wright found an average of 6.3 cn/ of flex- and the most inferior marks. Ask rhe subject to bend forward as far as possible while keeping the c: . ion in healthy adults, and Battie and coworkers53 found knees straight. Z an average of 6.9 cm in a similar group of subjects. 3. Maintain the rape measure against the subject's back during the movement and notc the distance ~ 1. Use a skin-marking pencil to place a mark at the between the most superior and the most inferior U lumbosacral junction. Place a second mark 10 marks at the end of the ROM. The ROM is the I< centimeters above the first (measure to the nearest difference between 15 em and the length measured ~ millimeter). Place a third mark 5 centimeters below at the end of the motion. ~ the first (lumbosacral junction). ! :I: ~. : ; ; I\" :o:> I e:J ~I -.z~Il ~I \\\\ ~ :m I \\~0' ~I I I FIGURE 12-16 The starring position for measurement of lumbar flexion range of motion, with incli- nometers aligned and zeroed.

CHAPTER 12 THE THORACIC AND LUMBAR SPINE 351 temative Measurement Method for Lumbar 3. Zero borh inclinomerers, and ask rhe subjecr to exion: Double Inclinometer bend forward as far as possible while keeping rhe knees srraighr. be ROM in flexion is 60 degrees according to the 4. Note the information on the inclinometers at the AMA4 and 0 to 66 degrees (for males 15 to 30 years of end of rhe flexion ROM (Fig. 12-17). Calculare lumbar flexion ROM by subrracting the degrees gel according to Loeb!.s from rhe dial of rhe sacral inclinomerer from rhose on rhe dial on.the TI2 inclinomerer. The degrees on 1. Use a skin-marking pencil to place a mark in rhe the sacral inclinometer are supposed to represent midline of rhe midsacrum and a second mark over hip flexion ROM.\" rhe spinous process of TIl. Place one inclinometer over the spinous process of Tl2 and rhe other over rhe midsacrum. (Fig. 12-16). FIGURE 12-17 The end of lumbar flexion range of motion, with inclinometers aligned over the s'pinous processes of T12 and 51.

352 PART IV TESTING Of THE SPINE AND TEMPOROMANDIBULAR JOINT •• • • .. • Testing Motion Motion occurs 111 the sagittal plane around a medial- Ask the subject to extend rhe spine as far as possible (hg. lateral axis. J2-18). The end of the extension ROM occurs when the pelvis begins to tilt posteriorly. Testing Position Normal End-feel Place the subject standing, with the cervical, thoracic, and lumbar spine in 0 degrees of lateral flexion and rota- The end feel is firm owing to stretching of the zygapophy- tion. seal joint capsules, anterior fibers of the annulus fibroslls, anterior longitudinal ligament, reccus abdominis, and Stabilization external and internal oblique abdominals. The end-feel Stabilize the pelvis to prevent posterior tilting. also may be hard owing to contact by the spinous processes and the zygapophyseal facets. FIGURE 12-18 At the end of thoracic and lumbar extension range of motion, the examiner uses one hand on the subject's anterior pelvis and hcr other hand on the posterior pelvis to prevent posterior pelvic tilting. If the subject has balance problems or muscle weakness in the lower extremities, the mcasurement can be taken in eithcr thc prone or sidc~lying position.

CHAPTER 12 THE THORACIC AND LUMBAR SPINE 353 Measurement Method for Thoracic and Lumbar 3. Keep the tape measure aligned during the motion E~tension: Tape Measure and record the measurement at the cnd of the ROM (Fig. 12-20). The difference between the Usc a skin-marking pencil to mark the spmolls measurement taken at the beginning of rhe morion processes of C7 and SI. and that taken at the end indicates the amount of Align the rape measure between rhe twO marks and thoracic and lumbar extension that is present. record rhe measurement (Fig. 12-19). FIGURE 12-19 T~lPC measure alignment in the starting posi~ FIGURE 12-20 At the end of thoracic and lumbar extension tion for measurement of thoracic and lumbar extension range range of motion, the distance between the tWO landmarks is less of motion. \\'\\Ihcn the subject moves inro extension, the tapc slides into the tape measure case in the examiner's hand. rh:m it was in the starting position.

•, !q Z ; ::3-=S-:4--P-A-R-T--rV--T-E-S-T-rN-C-O-F-T-H-E-S-p-r-N-E-A-N-O-T-E-M-P\"'O-R-O=-M-A-N-O-r-g\"'U-L-A-R-J\"'O-r-N-T O::l Normal End-feel \"'I<eoo::UI, LUMBAR EXTENSION - The cnd feci is firm owing to stretching of rhe anterior longitudinal ligament, anterior fibers of rhe annulus I~ Testing Position fibrosus, zygapophyscal joint capsules, rectus abdominis I.....I Place the sUbi.cct .standing, with rhe cervi~al, thoracic, and external and internal oblique muscles. The end-feel i~ and lumbar spme 10 0 degrees of lareral flexIOn and rota- may also be hard owing to contact between the spinous < ~ tIOO. processes. oUWI Stabilization Measurement Method for Lumbar Extension: Modified Modified-Schober or Simplified Skin i~. Stabilize the pelvis to prevent posterior tilting. Distraction 0; 1. Use a skin-marking pencil to place marks on the i:= i Testing Motion right and left posterior superior iliac spines. Use a IIV~i Ask the subject to extend the spine as far as possible. The end of the exrension ROM occurs when rhe pelvis begins is i to tilt posteriorly. U .w MI· 0g:1i ~~II 1W-1}l s~Pl ~i 0wi1 '~-I'i c.::\"! I l ,r~y I I ! § g il i l%i I I ~ IP I, i m ~ i'\" i'~' FIGURE 12-21 Tape measure alignment in the starting position for measurement of lumbar extension ~ range of motion with usc of the simplified skin distraction method (modified-modified Schober method). m ,N I ,@ ~ il

\\. CHAPTER 12 THE THORACIC AND LUMBAR SPINE 355 ruler to locate and mark a midline point on the 1. Use a skin-marking pencil to place a mark ar the sacrum that is on a level with the posterior superior lumbosacral juncrion. Place a second mark 10 cm iliac spines. Make a mark on rhe lumbar spine thar above the first mark (measure to the nearest is 15 em above the mark on (he sacrum. millimerer). Place a third mark 5 cm below the first 2. Align the rape measure between the superior and mark (lumbosacral juncrion). the inferior marks on rhe spine, (Fig. 12-21), and ask rhe subject to bend backward as far as possible. 2. Align rhe rape measure between rhe most superior 3. At the end of the ROM, note the distance between and rhe most inferior marks. Ask the subject to pur the superior and the inferior marks (Fig. 12-22). the hands on rhe buttocks and to bend backward as The ROM is the difference between 15 cm and the far as possible. length measured at the end of the motion. 3. Note the distance between the most superior and \"Alternative Measurement Method for Lumbar the mosr inferior marks ar rhe end of the ROM and Extension: Modified Schober Technique subtract the final measurement from the initial\"!5 cm. The ROM is the difference berween 15 cm and ..·\",Battie and coworkers\" found a mean of 1.6 cm in 100 rhe lengrh measured at rhe end of the morion .;tN: healrhy adulrs. . /:'1.;':' FIGURE .12-22 Tape measure alignment at the end of lumbar extension range of motion, with use of the simplified skin distraction method.

356 PART IV TESTING Of THE SPINE AND TEMPOROMANDIBULAR JOINT THORACIC AND LUMBAR LATERAL Stabilization FLEXION Stabilize the pelvis to prevent lateral tilting. ROM ranges from 18 to 38 degrees with usc of a goniomctcr l2 and from 5 [0 7 em with usc of a tape mCilS~ Testing Motion urc. 54 Ask the subject to bend the trunk to one side while keep- ing the arms in a relaxed position at the sides of the hodv. Testing Position Keep both feet flat on the floor with the knees extend;d (Fig. 12-23). The end of the motion occurs when the heel Place the subject standing, with the cervical, thoracic, begins to rise on the foot opposite to the side of rhe and lumbar spine in 0 degrees of flexion, extension, i.lnd motion and the pelvis begins to tilt laterally. rotation. \" .. I FIGURE 12-23 The end of thoracic and lumbar lateral flexion range of motion. The examiner places both hands on the subjccc's pelvis to prevent lateral pelvic tilting.

CHAPTER 12 THE THORACIC AND LUMBAR SPINE 357 '!~(0~ormal End-feel degrces (in a group 20 to 29 years old) to 18.0 degrees (in a group 70 ro 79 years old). Sec Table 12-2 for addi- \"ji/The end-feel is firm owing ro rhe stretching of the 'j;J'{\"conrralateral fibers of the annulus fibrosus, zygapophy- tional information. 12 According to Sahrmann;'5 more ';';~~Wseal joint capsules, imenransvcrse ligaments, thora- :?Jiigcolumbar fascia, and the following muscles: exrernal and than rhree-quaners of thoracic and lumbar lareral flexion \"\"'->-~--oblique abdomina Is, longissimus rhoracis, iliocostalis ROM rakes place in rhe thoracic spine. lumborum and rhoracis lumborum, quadratus lumbo- 1. Usc a skin-marking pencil to mark the spinous processes of C7 and Sl. 'W,--YWium, multifidus, spinalis choracis, and serratus posterior 2. Cenrer the fulcrum of the goniometer over the Y/:jnferior. The end-feel may also be hard owing to impacr posterior aspect of the spinous process of 51. if'~;of the ipsilareral zygapophyseal facers (right facets when \")@';bending to the right) and the restrictions imposed by the 3. Align the proximal arm so that it is perpendicular \":!I,'ribs and cosral joints in rhe upper thoracic spine. ro rhe ground. 0\". 'fJMeasurement Method for Thoracic and Lumbar ,cr/Loteral Flexion: Universal Goniometer 4. Align the distal arm with the posrerior aspeer of the spinous process of C7 (Figs. 12-24 and 12-25). 'Fitzgerald and associates 12 found rhat lateral flexion measured with a goniometer ranged from a mean of 37.6 FIGURE 12-24 The subject is shown with rhe goniometer FIGURE '12-25 At the end of thoracic and lumbar lateral flex- aligned in the starring position for measurement of thoracic and ion, the cxnmincr keeps the distal goniometer arm aligned with lumbar lateral flexion. the subjccc's scvcnrh cervic.tl vertebra. The cxalilincr makes no attempt ro align rhe distnl nrm with the subject's vertebral column. As can be seen in the photograph. the lower thoracic and upper lumbar spine become convex CO the Idt during right latcral flexion.

358 PAR T I V T EST I N G 0 F THE S PIN E AND T [ ~'l r 0 R 0 \\:1 A N 0 I f) l) t /\\ R l 0 I N r Alternative Measurement of Thoracic and Lumbar .... lI~~l· ... h th;H .1 11l.lr~ ..... hould hl' Ilude fin rht,· Ihig.h, where Lateral Flexion: Fingertip-to-Floor Method the IIp of lht,· thIrd fInger re~l\"\" III thl: \"t;1rtillg position. A~:~'­ 1. Place the subject in the erect standing position, with the arms hanging freely at the sides of the .. l·'.:Olld nurk .. llll\\lld hI: I1l;Hk oil t!li: leg ar rhe point-'-<: body. Ask the subject to bend ro the side as far as possible while keeping both feet flat on the ground \\\\\"hl'n: the lip ot rhe rlllrd Illl).!\",:r f\"c\"-l\" ,l( thl.' {;nd o f ttwh~'';, and the knees extended. LHn;ll flexion !{U.\\1. The t1iSI:lnCe hctw(;t:11 the !~l.;lrk~ i\", tht,· r1~()r;ll.'(llulJll.);l~ ll~().\\ 1. In ;1 ~tud)' involvini::;;- 2. Ar the end of the ROM, make a mark on the leg )~} ht,';llthy sllhln:{~, \\'klhn . totlild dlal [11(,' 11I(,'<1n ROM~~ level with the tip of the middle iinger. Usc a rape measure to measure the distance between the mark ill I:Hcr:d f1cxion t ..... ing dli~ ll.'..:hniqul' \\\\';lS 22 <:1Tl (SD ==~; on the leg and rhat on the floor (Fig. 12-26). One problem with this merhod is that it may be affected )\".4 l,,:Ill). by the subject's body proportions. Therefore, it should be used only to compare repeated measure- ments for a single subject and not for comparing one subject with :morher subject. In a variation of the fingertip-to-floor method, designed to account for differences in body size, MellinS-! ozw <c<::- FlCURE t:!-:!6 At rhl' cnd ot thor:h.:i( ;llh.l lumb,lr !;l!l'r;11 flex- inll r:lllge of l11olion, rill' t'~:lll1int,'f\" is using :1 ['!J'l' 1I1C.lsurt to dL'rt,>rmirll' [he diq;lIKl' from dlt' tip ot' the sllhkl:r's rhil'd finger ((J the door. !.;l!c[';iI ptlvic rilrl1lg )!loldd he ,l\\\"oilbl.

CHAPTER 12 THE THO RA C I CAN D L U MBA R S PIN E 359 Alternative Measurement Method for Thoracic and 3. Ask the subject ro bend ro the side as far as possi- ..~ Lumbar Lateral flexion: Double Inclinometer ble while keeping both knees straight and both feet firmly on the ground (Fig. 12-28). '.: According ro the AMA, the ROM is 25 degrees ro each side of the body.4 4. At the end of the ROM, norc the information on the dials of both inclinometers. Calculate lateral 1. Use a skin-marking pencil ro identify locations on flexion ROM by subtracting the reading on the the spinous processes of S1 and T1. sacral inclinometer from that on the dial of the thoracic inclinometer. Repeat the entire measure- 2. Place onc inclinometer ovec the S1 spinous process ment process to measure lateral flexion on the and the other over that of T1 and then zero both other side. inclinometers (Fig. 12-27). FIGURE 12-28 Inclinometer alignment at [he end of thoracic -~ and lumbar lateral flexion range of motion. ~i FIGURE 12-27 The subject is in the scarting position for meas- urement of thoracic and lumbar lateral flexion \\'1!irh both incli- ,1\"1 nometers aligned 3nd zeroed. ~r i! ij ;1 }\\ :\\ H it ,: J~ If: .

360 PART IV TESTING OF THE SPINE AND T[J'vlPQROMANOIBUlAR jOINf ••• • •: I ••• L·~lPSLJh.'s; supr;\\SpillOUS, irH~,[\"\"PII'lOUS, ~lJld iliolumhar liga~ mel\\{ .. ;llld rhe !ollowillg 1ll11:-'c1c:-.: n:..:tll~ ;\\bdolllinis, Motion occurs in the transverse plane around a vertical l:xtcfIl;l! .lfId illlC:r1Ial ohliqucs ;llId 1l111ItilidliS. ,lIld ~C:lni­ .. pill:lli~ dlOf.h.:i\", ilnd rnLlIlIfl..: .... TIll.: L\"lld-fl'i.:l lIlay ;llso be aXIs. lurd owing 10 (ollt;h.:1 hCIWLTll til<.: zyg.lpophy':>cal facets. Testing Position Measurement Method for Thoracic and Lumbar Rotation: Universal Goniometer Place the subject sitting, with the feet on the floor to help stabilize the pelvis. A seat without a back support is Sc~ hgHn.·~ 12-30 ami 12-:ll. preferted so that rotation of the spine can occur freely. The cervical, thotacic, and lumbar spine are in 0 degrees I. Cl'mer (hl' fulnulll of the gOllIOllll'((T ova the of flexion, extension, and lateral flexion. (,,:l,.:llfcr of tilt.: Cf.wi.d .hpCl,.'1 of the ... uhicct·~ ht·ad. Stabilization 1 Align lht., proxillul :Hlll paLd1c1 [0 ;\\ll 1I1l:1gll1ary Stabilize the pelvis to prevent rmation. Avoid flexion, lifll' hCt'Wl:l:1l the [\\\\'o prnlllilll'lll tuhercles on the extension, and lateral flexion of the spine. ili:lC (ri..':',t~. 3. Align dh.: distal :lfl1l with all imaginary line Testing Motion hl'tWt'l'1l rhe two ;ll..TOllli'll prlll:{:s~L·S. Ask rhe subject to turn his body to one side as far as possible keeping his trunk erect and feet flat on the floor (Fig. 12-29). The end of the motion occurs when the examine.r feels the pelvis start to rotatc. Normal End-feel The end-feel is firm owing to stretching of rhe fibers of the contralateral annulus fibrosus and zygapophyseal joint capsules; cos[Qtransvcrse and costovertebral joint FIGURE 12-29 The ...t1hjl\"..:1 i.. shown;1I lill' to-lIll 01 rhl\" dlOr:1Cic :\\I\\d lumbar rnurioll r.lllgl' uf 1110tlOli. The sUhlt\"CI i~ sl,:ltt:d on ;1 low siool without a hack fI.::-l ~o (h.lI Splll,lI 1Il0\\TlIU:II( (:;111 OL(,:UI' without iIHcrlL'rCIl<..\"l,'. TIll' l'\\,lIIlJlIlT PI):'lll\\,lllS hr.'!' h:1I1ds llll tlll' su!,jcct'<; ili;\\I.': __Tests 1(1 pn'ven! pch'ic [\"o!'llioll.

CHAPTER 12 THE THORACIC AND LUMBAR SPINE 361 FIGURE 12-30 In the starting position for measurement of rotation range of motion, the examiner stands behind the seated 5ubjecr. The examiner positions the fulcrum of the goniometer on the superior as peer of the subject's head. One of the examiner's hands is holding both arms of the goniomcrcr nligncd with the subject's acromion processes. The subject should be positioned so that the acromion processes arc aligned directly over the iliac tubercles. FIGURE 12-31 At the end of rotation, one of the examiner's hands keeps the proximal goniometer arm I aligned with the subject's iliac ruberclcs while keeping the distal goniometer arm aligned with the subject's right acromion process. j .~ i ,

362 PART IV TESTING OF THE SPINE AND TEMPOROMANDIBULAR JOINT Alternative Measurement Method for Thoracic and 3. Place one inclinometer at S1 and the other Over the Lumbar Rotation: Double Inclinometer spinous process of the seventh cervical vertebra and zero both inclinometers (Fig. 12-32). According ro the AMA; rotation ROM measured with use of inclinometers is 30 degrees to each side. 4. Ask the subject to rotate the ttunk as far as possi- ble without moving into extension. (Fig. 12-331. 1. Use a skin-matking pencil to place a mark over the spinous processes of 51 and the seventh cervical Note the degrees shown on the inclinometers at the vertebra. end of the morion. The difference between the incli- nomerer readings is the rotation ROM. 2. Place the subject in a forward-flexed standing posi- tion so that the subject's back is parallel to the ground. I FIGURE 12-32 The subject is in the smrting position for mtasurcmcnr of thoracic and lumb<lr roration. with inclinometers aligned and zeroed.

CHAPTER 12 THE THORACIC AND LUMBAR SPINE 363 .~ -~ , .~ I FIGURE 12-33 The subject is shown with the inclinomcrcrs aligned at the end of thoracic and lumbar rotation range of motion.

364 PART IV TESTING OF THE SPINE AND TEMPOROMANDlflUI AR IOINf REFERENCES 19. Cbl'll. ~r·. \\'1 :11: fh'li.dlllin' H! !Ill' lumh,lr \"\"t~:lll,li nm!lon ftll':I,urC' J ()..ItIClll IIIl·lIl1,d,; <\"urr.1.:..: \"Indln\"llIl',n\", I. Uogduk, N: Clinical Anatomy of the Lumh.:l( Spine and Sacrum, ltljl \\',IWII<JII .\\lcd cd 3. Churchill Livingstone, New York, t 997. W:217.I')'J7. 2. Cyriax, JH, ;'Ind Cyriax, P: Illustrated Manu:ll of Orthopaedic Mcdicint'. Buth:rwonhs. London, 1983. 3D, \\1:t:'t:l'. '1'(;, l.'1 :d: Sl'ill:d r~1l1f~t: (JI mUIIUll. :\\\",\"ur~I~'Y :Illd <'Oun;cs J. American Academy of Orthopaedic Surgeons: Joint Motion: oi I:rn'f with IIldillOrtll:tri... 1ll~',hlHCllH;lIt, \"'pllll' 2.2: I ')76. 1l.)1J7, Method of MC;lsuring :lnd Recording. 1\\1\\05, Chic:tgo. 1965. 31. ;-\":il:o.:hkJl·. JF....'I .11: Rdl.lhllilY III Ih ..' :\\lIll\"rU':;11l ~l ....dical 4. Amcricnn Medical Association: Guides to the Evaluation of :\\'~ClL'l:ill('ll (>lllllt:~' '\\\\od\\·1 fur .\\h..,I:--lIrlllg \"iplll,d l{aJlj;l: of Permanent Impairmcllf, cd 3. AMA, Chicago, 1988. ,\\lo(il'Il, II' illlpliLlti'\"1 for wlH>k',pl·r:-.t1l1 lI11p:lIrlllt:f1I r:ltings. 5. Loebl, WY: Measurement of spinal posture and range of spinal movement. Ann Phys Mcd 9:103.1967. ~pirl\"\" 2,1:2t~2, 1\\j99, 6. Sullivan, MS. Dickinson, CE, and Troup, JOG: The influence of 32. lln:um, j, \\'t;.'lhl:rg, .1. :l1ld BIJlfOn, .IF,: Rdi:lhility alld \":()I\\I.:urrCnt .:lgc and gender on lumbru spine range of motion. A study of 1126 ..,;tliduv 'Ill lhe Hi{()M II for llle,l:'llrill}: lumbar lHohilin', J healthy suhiccrs. Spine 19:682, 1994. \\bnlp'ul:lIivl: I'hyslol T1lt\"r 11\\:497, pJ'}), . 7, Mncr:lc, IF, and Wright, V: Measurement of back movemenl, Ann 33, ,\\1:ld\"(lf1. \"1'1. )'ntlda:--. JW. :ll1d ~1l11l;H1, \\'J: Rl:prlldu\":lbilit}' of Rheum Dis 28:584, '1969. 8. Moll, ]MH, ;Uld Wright, V: Norm:ll r,:mgc of spin:.! mobility: An IlIlIlh;H ,pin..· r:Hl!~C of 111<,11111\\ lUe;l,utl'llll'lll'> lhlllg lilt\" h:l..:k r:logc objecti\\'e dinical srudy. Ann Rheum Dis 30:381,1971. id t!Hltill1l devi\":l·,.l ()rrhop ~plJr1~ l'hy~ -l'her 21J:·1:'\"(). 1999, 9. Anderson, JAD, :lnd Swecrman, B1: 1\\ combined flcxi-rulc hydro- 34. Revllold\". I'\\'l(j: \\1t::I~urcrnl'lH lit 'opiml IlH'bdll:': \" ~'olJ\\rarison goniomerer for measurement of lumbar spine :lnd irs s;lgirr31 (If ~hr\"T lllt'lh\"d:., RIl..'U1llal\"l i{(.·h:lhil I,t: I so. 1'-)75, movelllelH. Rhcumatol RchnbiI14:173, 1975. 10. Gr;lI:oYetsky, S. et 011: A database for estim;Hing normal spinnl 35. .\\lilkr. .\\11-1. lot .11: .\\h-.hllrl'lIll'nl 01 ,plllallllohili,y Il1lhe :.agillal motion derived from non·inv;;'Isive measurements. Spint' 20: 1036, 1995, pbllt': f'(.'w ~kll1 dl'lr,I\"'1l011 ll'dmiqlll' ':lJIllp,I(1.'l1 \\\\\"lIh ......t,lblished II. ~1cGrl'gor, \"H, McC:lrthy, 0 and Hughes SP: Motion char::H.:tcr· isrics of rhe lumbar spine in the normal popubtion. Spine JIIIl'lll('11:.. Rh..,tlm,11111 II :,1. 1'}S·I, 20:2421,199S. 12. Fitzgerald, GK, ct 31: Objective assessment with establishment of 36, !'Ilrlek. J, 0.'1 al: (:IJrrt:bli~'ll h'lwl'l'l1 r:ldlt)gr~lphl( .Ind dillical normal vnlut's for lumbar spine r::lnge of motion, Phys Ther 63,1776,l9a3. 1ll(.\\lSllrl'll\\l'rH ot lumh;\\r spilll' 1l1lWl'll1l'Il[, Br I Rht:lllluwI22:197, 13. E~oobtein, NA. ct ;;'II: Lumbar cxtension range of Illotion in elementary school children. Absrr Phys Ther 72:535, 1992. I '-)S ). 14. SlIghara, M, er al: Epidemiologic;ll stlldy on the change of mobil- ity of Ihe thoraco·lumbar spine and body height wirh age as 37. (,III. K. l\"1 ;11; Rqw,ll;lblllly \"i rour dillk:11 'lIl'lhfld~ lllr ,1\\\\1,:,'''lllcnr indices for scnility. J Hum Ergol (Tokyo) 10:49, 1981. ui lum\"ar ,'plllalll1tl(J('11. Spillt' 1>:'0. I'IXS, 15. Freidrich, M, cc 31: Spin;].l posture during stooped w:llking under 38. V;H1 :\\dridlt\"llI. J:\\;\\1. _lIld \\'.lll .I..-r '-'\"r'-1 . .IK: :\\'~l'''tll'''lH (,i the vcnical sp:lce constraints. Spine 25:1118, 2000. fkxlhilily of till' 11l1ll!J:lr 'pllll-, :\\ pdt,! '1Ih.J~' ill ~'hildrl'll and 16. Sjolic. AN: Access to pedescri:ln roads, daily 3crivities and physi- :ldoks~'Clll\";, SCllld I Rh~'llrn:lf()1 2:Si. I'F,', cal performance of adolescelHs, Spine 25:1965, 2000. 39_ (;reenl·. \\VL\\..Jlld Jin:klll;lll. II> (.....1<1: 'I'll.... Chui~-.tl .\\kasuh:lllent 17_ Ensink, FB, Ct al: l.umbar range of morion. Influence of time of day 3nd individuals factors on measurements. Spine 21:1339, (If JOlllf .\\1('llon, :\\nll'ni,:;lll ;\\ ....ldl\"TIl~, ;.r (lnlll,p,lnll~' Surgcons. 1996. RO:'l't!lCIllt.l1L IY9·1, 18. Sullivan, MS, Sho3f, l.D, and Riddle, Ol.: The rekltionship of lumbar flexion to disability in patients wirh low back pain. Phys olD, LUhbhl. 0: Dl'll-rullll,1I1011 01 rhl\" ...lp!l.d tllobdily til fhl\" lumbar Ther 80:240, 2000. 'pim', :\\~.t:l (lrlhop ~'H::llldF:2-11. I 'J(,(\" 19. l.undberg, G, and Gerdlc, B: Correlations between joint and spin:ll mobiliry. spinal sagiu:!l configuration, segmental mobility, 41, YOlld,I'.I\\V, SUlllan, VI :llld (;;Hrt'll, TI{: !{~'li,lbilllY e,i nw;lSurc- segmcnt31 pain symptoms and disabilities in female homecarc lll(.·lIb o( Il1mh,lr Spilll\" ~.I~i'f.llll\\ohilily \"bl.ltllt'tl \\\\ nh Ihe Ikxible personncl. Scnnd J Rehab Mcd 32: 124, 2000. ,:urn', .I Urthop 'i~,rh Phy:-- TIll'r 11: I >. 1')95, 20. Kujab UM, Cf al: l.umbar mobility and low back pain during 42. KatJ.II\\;lll. \\'fH. CUlIl'r, 1':\\..1Il~1 :\\...h. IL\\: I>l/tt'rt'll~'~\" Hl rdi.lhility adolescence. A longitudin:\\1 three-year follow'lIp study in athletcs \"f 1111.' ikxihk rult'r ftlr till\" ..'xp~'rit'll ...nl.llld t1ovi,,\"l\" It'~lt'r, :\\hsiraci and controls. Am J Sports Med 25:363, 1997. h:b. 2t)(lO, ,I Orthop Spo!'lS Phys Th..'r)()::\\'I. 20(10, 21. Nanrass, Cl., et al: Lumbar spine range of motion .1S n measure 43. Bn':lll, 1.\\1. ~'l ,l!: 11l\\'\\'SIIC.:Hioli ot tllt' tk\"ibl t' rull'r:1\\ a llOlllllV,l- of ph)'sical and functional impairment: An invesrigation of valid- :Ol\\.'l· lIlt:_lsurl' of IlImh.lr illrdo'l'> ill hl.l(k .111,1 \\\\'hll~' ,Idull ft-lIul ... ity (;lbstract). Clin Rehabil 13:211, 1999. :--,Hllple popul.lliom, .I Orthop \\porh I'h:.. ~ Thn II; '. I<JN9, 22, Shirl~')\" FR, Ct al: Comp;lrison of lumbar r:lnge of motion using 44, 1.0\\'1.'11. nXo·. Rurhstl·in. J.\\1. :Illd I'er,ollllh. \\\\1,1: Rell.lhllilY o( din- rhree measurcmelH devices in patienrs with chronic low back p:lin. Spine 19:779, 1994. 1,,';11 11l('.lSttrl'lIWlll\" oi IlImh,lf I..rdn,j, f.lkt·ll wilh ,I ilt-xihk rule, 23. Hsich, CY, :lnd Pringle. RK: R:lnge of morion of the lumbar spine I'hvs Thl'r 69: tJ(J. l'lS'J, 45. Sd~(\"flklll~lll. .\\1. 0.'[ ,11: ;\\ (hilled 101.1 tor llll'~l\"'llrlll~~ ([llk'iional requin:d for four activilies of daily living. J Manipulative Ph)'siol ;lxial rOI;I!lotl, I'hyj. Th.. r -5: 151. !')<J5, Ther 17:353. 1994. 24. Patd, RS: IlItr.Hesrer .1l1d interresrcr rcli3bility of the inclinomcter 46. St:h ..'nkl1l;lll,.\\1. l'l .1!; Spin:d rllO\\\"t:lJll'fll ,llId rrrtortll:l1Kt' of ;1 in measuring lumbar flexion, Phys Ther 72:544, 1992. :.t~\\II<lili~ r...lI.:h ta\"k ill p:lrlil.'il'aill\" \\\\'nll ,Ill.! widHllt1 1'.Hkinson 25. Williams, R. CI al: Rcliabilit), of the modified-modified Schober di\"l\".IH'. Phy:. -'h'r :.; I: 1-100, .!\\J{) I, and double \"indinnllletcr methods for measuring lumbnr flexion 47. Pl\"tl\"rSt~ll. (~1. l't ,11: Illlr:lOhstrn:r ;llld illll'rnb,~'r\\'('f n:!iahiliry of and eXlension. Phys Ther 73:26, 1993. .1\"Yl1ll'{<Il11alll' :.ubje..'t':- IhOf;\\t:olumh,'r 1:1111:\\' (II lllotilll1 ll~illg the 26. Maycr, RS, er al: V:lriance in thc mC;.lSUrClllenr of sagirmlillmhar OS I (;:\\-(,(100 ~pill~' .\\lotlon :\\n:llyto.,r. J Otlhtlp \\I'\"rl' I'h~':, Ther rang~' of 1lI00ion nlnong examiners, subjects, and instruments, Spine 20:1489,1995. !.!{l;lO-.I'J<}i, , 27. Saur, PMM, er al: l.umbar range of motion: Rcliability and V:llid- 48. j{ohin~oll. \\\\1:. l\"1 .i1: 11lIr.hubwo.\"l n'l.;lhtlHy 1'1 ,pm:t1 r.lIl~e (It ity of the inclinn!neter tl\"Chniquc ill the clinical Il1c;\\suremcnr of trunk f1exibiliry. Spine 21: I332, 1996. l1lotion :\\Ild Vt'I(J... it~, tklt'rlllltll,d hy vid\\'ll lHolioll .llJaly:'ls. I'hys 28. Sam(l, DC, er ;11: Validity of thrt'c lumb:H sagittal morion meas· Till'r ;.1:626. I '}91. urement merhods: Surface inclinomcters comp:lred with radi- ographs.1 Occup Environ l\\.lcd 39:209, 1997. 49. SIL\"lf.lll. T. t'( .11: ;\\ Ill'\\\\' ll'dlltlqm' I(lr Illl.'.I'Ufillr, luml';lr ~q!l1l('n­ 1.11 lIlotlon 1lI \\'j\\'o: lI1l'thod. ,K..'ura.:y .1Ild prclillllll.Hr rc!>uhs. Spllll' 22: l:it,. 1<}'J-, 50, Kr.lI ..... II. :lll.! Ilir\"dlland. RI': .\\-11l1111111111 lllU:.,,'uJ.lr iillll''':' I......rs jn ~dH)(l! ... hildrcl1, Res Q FXl'r..' ~pon 15:1 7 l\\, I\"S·1. 51. NidHl!aS . .1:\\: Ri .. k 1;\\\\.·lor...... port .. 111l'l.1 il'l Ill' :lIld fill.' onl1.'lpedic syslt'm: :\\ll O\\'l·f\\'il'w,.J Spl'Tt:. .\\'kd '>:2.·U. 1975, 52. Hrodic. D:\\. I\\ird. 11:\\. ,lilt! \\Vrigill. V: .Ioim 1.1'l;;I~' in :.dl.'cled .llhlcli..: pOPlll.lllOliS. .\\ hod S~'i Spl,n:-- F.X\\'(l' 1·1: I 'JO. 1'1:\\2. 5.1. Ibfti~'. \\IC, t·t ;11: Thl· rok IIi :.pill.11 Ilt','I;lhilily til Iud: pain CClillpl.1illh illilldustry,:\\ pr\\J~pl'o.'lIVl' sludy, Spilll' 15:76:\\. [<}<)O. 54, .\\kllin. (;1': :\\\":Cllr~l\\'y of 1l11':Jsllrill!~ btn,l) fln:illll uj the splfle willl.1 1.ll't·. Chn Hil)llll·~'h I:SS. I')S(, 55. S;lhrm.11J1l. S:\\: DI,'~Il,,~i:-- ;IIHI Tn',llllll'lll ot \\!ov.. 11lC ll t Illlp.lirtlll.\"llI Syn.!nulll·\" .\\llIshy. \"'1 l.olli\". 2f)(11.

, • Structure and Function Zygomatic arch Temporomandibular Joint Maxilla --lm~~~ Articular eminence of Anatomy ~ temporal bone Mandibular The temporomandibulat JOint (TMJ) is the articula- fossa tion between the mandible, the articulat disc, and the tempotal bone of the skull (Fig. 13-1A). The disc divides Mastoid the joint inm twO distinct pans, which arc referred to process as the uppet and lower joints. The larger upper joint consists of the convex articular eminence and concave Mandibular condyloid mandibular fossa of the temporal bone and the superior process surface of the disc. The lower joint consists of the convex surface of the mandibular condvle and the concave infe- Styloid process rior surface of the disc. 1-3 Th~ articular disc helps the , convex mandible conform [0 the convex articular surface Mandibular of rhe temporal bone (Fig. 13-18).2 A The TMJ capsule is described as being thin and loose above the disc but taut below the disc in the lower joint. Articular disc Short capsular fibers surround the joint and extend berween the mandibular condyle and the articular ;:\".- disc and between the disc and the temporal eminence.3 Longer capsular fibers extend from the temporal bone to Joinl capule the mandible. B The primary ligaments associated wirh the TMJ are the temporomandibular, the srylomandibular and rhe FIGURE 13-1 (A) Lateral view of ,he skull showing the sphenomandibular ligaments (Fig. 13-2). The muscles associated with the TMJ are the medial and lateral ptery- temporomandibular joint (TMJ) and surrounding srructur~.s. ; goids, temporalis, masseter, digastric, srylohyoid, mylo- (B) A lateral view of the TMj showing the articular\"ci,is(aI1~a hyoid and geniohyoid. portion of the joint capsule. ' Osteokinematics The upper joint is an amphiarthrodial gliding joint. The lower joint is a hinge joint. The TMJ as a whole allows 365

366 PART IV TESTING OF THE SPINE AND TEMPOHOlvlANDIBULAR JOINT e\\:ccs'->I\\'e prOlrUSIO!l, hut their C\\::lC[ function has not heen verified. 'The diag,htTic and Lneral prerygoid muscles produce Ill,llldihubr depressioll.I,;~The mylohyoid and geniohy- Fibrous oid Tlluscles ;lssist ill the motiun, especially against resis- capsule Ll!lCl'. ,,\\ \\landibubr ckvarioll is produced by the teJll~l()r;llis, 11l:lSSeter, :lflll IlH.'dial pterygoid l1ltlscles,I,,)'-5 Spheno- which are responsible for llLlim:lining the fn:.'l'way space. mandibular -~\\:::::::::::::::('-lil~ ¥l-....,,\"'-- Tempormandibular \\landihubr protrusion is ;1 result of hilatLT:l1 action of the Ilwsseter, 1,\\ l1ledi,l!, I, ;,'l alld Lner,l! )..\" ptcrygoid ligament ligament Stylomandibular lHusCleS. 'fhe Illylollyoid, sl':'lohyoid, ;llld digastric ligament TllllScles Illay :lssisr.' Retrusion is hrought ahout hI' bilat- eral action of the posterior fibLTS of the temporalis A Mandibular angle llluscles 1 by the diagasrric,I.;\"-~ middle, and deep fibers of the IllJsseter I,,,; and hy the \"rylohyoid , m;.'lohy- oid,I,\\ ,lnd geniohyoid I. \\.\\ llluSCle\". \\landibuLlr devia- ~f@~®:::::::?j~-::-=:--- Joint capsule tio!l is produced hy :l ulliLHn:l! COlHr;lCtioll of the medial __\\~F=~~~:::~- Sphenomandibular JIltJ bteral pterrgoid muscles. I\" r\\ llllil:lttTJI contraction of rhe rcmp(lr~l!is muscle C~lllSCS dn'iation to the same side. _---'l\\1\\ ligament CerviC:ll spine nHlst..·!<.·S may he :lCtiv,Hcd in conjunc- rion with Ti\\1.J IllUSCIeS beC:l11Sl' a t..,losc functional rela- tionship exists berwccn rhl..' hcad ,md rhe ncck. I ,4-'J B Coordinal'ed and parallel I11m'('lllCllts ,It thc Ti\\lJ and FIGURE 13-2A (A) A lateral view of the temporomandibular ,:en'ieJl spine joilHs luve heen ohserved in somc studies, joint showing the oblique fibers of the temporomandibular liga- ment and the stylomandibular and sphenomandibular liga~ Jnd resc:lrchcrs sLlgge\"r rh:lr prepnlgr:llllllled neural mcnts. (B) A medial view of the temporomandibular joint showing the medial portion of the joint capsule and the stylo- commands rna:' simulrancotlsly aeti\\\"ltc both jaw and mandibular and sphenomandibular ligaments. ncck muscles. -(j motions in three planes around three axes. All of the Arthrokinematics motions except mouth closing begin from the resting position of the joint in which the teeth are slighrly sepa- i\\L1ndibul:u depression (Illourh opening) occurs in rhe rated (freeway space).3.4 The amount of freeway space, s~lgi([;ll pbne and is ,1ccomplishcd hy rorarion and sliding which usually varies from 2 mm to 4 mm, allows free of the m;llldihubr condvles. C:olldylar rotation is anterior, posterior, and lateral movement of the comhined \\vith :uHnior and inferior sliding of the mandible. The functional motions permitted are t..-ondyles on the inferior surfac(' of rhe discs, which also mandibular elevation (mouth closing) and depression slidc anteriorly {tr;msLlteJ ,dong [he tClllpor<l1 articular (mouth opening), protrusion (anterior translation) and eminenccs. i\\bndihuhr eln\"Jtioll (!Houth closing) is retrusion (posterior translation), and right and left lateral ;li..:colllplished hy roration of the lll,mdihubr condyles on deviation (excursion). Maximal contact of the teeth in the discs Jild sliding of the dis,:s with the condyles poste- mouth closing is called centric occlusion. riorly and superiorly Oil the tempo!\"Jl :Hticular Cmlnl'llCes. The oblique portion of the temporomandibular liga- ment limits mandibular depression, retrusion, and rota- In protrusion, thc bilat't,.'ral condyles and disl·s translate tion of the condyle during mouth opening. The rogl'ther JIHeriorly :llld inferiorly ;llong thl~ t(,lllporal horizontal porrion of the temporomandibular ligament arricubr eminences. 'rhl' lllovement takes pbce ;It the limits posterior translation of the mandibular condyle in upper loint, and no rot,ltion occurs during this motion. In retrusion and lateral deviation of the mandible. The func- latcr'll deviation, O!lC llundibular condyle :lnd disc slide tions of the stylomandibular and sphenomandibular liga- inferiorly, anteriorly, ;md medially along the articular ments are controversial. According to Magee,5 the eminence. 'rhe other mandibLllJr condyle rotates about a ligaments keep the condyle, disc, and temporal bone in verrical a\\:is and slides Illediallv within rhe nundibular close approximation. These ligaments also may prevent fossa. For cx;u11ple, in left la'tcral deviation, the left condyle spins ;lml the right slides ;llHeriorly. Capsular Pattern In the clpsulJr p,l[[er!l, mandihular depression is limited to 1 (11l\\ \\virh deviarioll roward the n:srri(ted sidc. 5 Protrusion is limited and ;lCcompanil'd by deviation

CHAPTER 13 THE TEMPOROMANDIBULAR JOINT 367 TABLE 13-1 Mouth Opening Range of Motion in Subjects 18 to 61 Years of Age: Mean Linear Distance in Millimeters 46~O~:Jj/j~i1z*'5~·1~ Dijkstra and coworkers 17 investigated the relationship .... between vertical and horizontal mandibular ROM in 91 F = Females; M = males; (5D) = standard deviation. healthy subjects (59 women and 32 men) with a mean ·1 \" -.Measurements were obtained with an Optotrak jaw-tracking system. age of 27.2 years. A mean ratio was found rangi~g from : t Measurements were obtained with a millimeter ruler. 6.0:1 to 6.6:1 berwecn vertical and horizontal ROM. ,::.:·1,i Individual ratios ranged from 3.6 to 15.5, and correia- ~The instrument that was used was not reported, tions between the vertical and rhe horizontal ROM \"~ measurements were weak. Therefore, based on the results ,!! :ii':>/':': of this study, the authors concluded that the 4:1 ratio between vertical and horizontal ROM that has been used .: ''i~ /;~ward the restricted side:' Lateral deviation is limited on in the past\" should be replaced by the approximately 6:1 ; ratio found in this study. However, the authors found O';the side opposite the restriction.4 that the ratio has poor predictive value. A review of ,.j values in Tables 13-1 and 13-2 indicates that the ratio ~ Research Findings between mandibular depression (vertical ROM) and \"i lateral deviation (horizontal ROM) is bctween 4:1 and The normal range of motion (ROM) for mouth opening 5:1. Dijkstra and coworkers· 17 measurements of incisal 1-1 is considered to be a distance sufficient for the subject to linear distance during mouth opening included the over- place two or three flexed proximal interphalangeal joints bite measurement, and this addition may account for '~ within the opening. Thar distance may range from 35 some of the differences between these authors' ratios and mm to 50 mm and is considered to be a meaSute of func- the ratios shown in the tables. tional opening, although an opening of only 25 mm to 35 mm is needed for normal activities. 5 A definition of normal range of mouth opening as 40 mm to 50 mm was arrived at by consensus judgements made at a 1995 Permanent Impairment Conference by representatives of all major societies and academies whose members treat TMJ disorders. 1O Similar mean ROMs for mouth open- ing, from a low of 43.5 mm to a high of 52.1 mm, are presented in Table 13-1. The linear distances for protru- sion and lateral deviation are presented from three sources in Table 13-2. TABLE 13-2 Protrusion and Lateral Deviation Effects of Age, Gender, and Other Factors (Deviation) Range of Motion: Mean Linear Distance in Millimeters Age ,:,~,-,;. ,1'(;., Thurnwald 19 found that the ROM in all active TMJ motions except retrusion decreased with increasing age. 8::~;:~l:\" Mouth opening decreascd from a mean of 59.4 mm in the younger group to 54.3 mm in the older group. The study ·&f;~ifi9;tJ2.~ ~ involved 50 males and 50 females ranging from 17 to 65 years of age. The author also found a decrease in the (SD) = Standard deviation; F = female; M = male quality of six passive nccessory movements with increas- • Measurements were obtained with an Optotrak jaw tracking ing age. Resistance to passive accessory movement and crepitus increased in the older group. A number of other system. studies have investigated populations of children, adoles- t Measurements were obtained with a millimeter ruler. cents, and elderly individuals to determine the prevalence '* The instrument that was used to obtain measurements is unknown. of TMJ disorders in these age groupS.2o-24 § Normal values may vary depending upon the degree of overbite Gender (greater movement) and underbite (lesser movement). Studies investigating the effects of gender on tenqpI)[CI- mandibular function in a healthy DODUla['Lon

368 PART IV TESTING Of THE SPINE AND TEMPOROMANDIBULAR IOINT Thurnwald 19 determined that the subject's gender signif- conrrol group. The :ltlrhOTS suggested that the TOI might t icantly affected mouth opening and lateral deviation. he a berra measure than simple lincaT distance measures The 50 males in the study had a greater mean range of for mouth opening. In ~I subscqllcnr study, Nlillcr and f mouth opening (59.4 mm) than the 50 females (54.0 associates;o compared the TOJ in I) patients with a 1 mm). The males also had a greater mean ROM in right disorder with rhe Tal in a control group of II individu- I lateral deviation, but the difference berween genders in ills without Tivtj disorders. B:lscd on rhe results of the this instance was small. No effect of gender was appar- study, rhe :lllthors concluded [h,lt rhe TOI appears ro be \"I· ent on passive accessory motions. Lewis, Buschang, and indcpcndcnt of age, gender, and rnandibubr length. Throck-morton14 found that males had significantly 11 greater mouth opening ROM (mean = 52.1 mm) than Head and Neck Positions females (mean = 46.0 mm) in the study (see Table 13-1). h\" Higbie and associates I 'i investig;ned the dfcets of head \" In contrast CO the findings of Lewis, Buschangl and POSI{lOIl (forward~ neutral. and rt:triH:red) on mouth Throckmorton,I-I Westling and Helkimo25 found rhat opt.:ning in 20 healrhy males and 20 hc.:;llrhy females the angular displacement of the mandible in relation to herwcen IS and 54 years 01 i1gl..·. i\\louth opening ROlvl the cranium (angle of mouth opening) in maximal jaw lIll:i1SUf'cd with a millimcrcr rukr was significanrly differ- opening in adolescents was slightly larger in females than l'J1( 31ll0ng thc rhrec posirions. rvlourh op('ning was grem- in males. This finding might have been influenced by the fact that females generally reach adult ROM value' by est in th(' forw:lrd head posirion (mean = 44.5, SO = 10 years of age, whereas males do not reach an adult 5.3), kss in the ncurral hC:ld posirion (mc:ln = 41.5, SO ROM values until 15 years of age.26 :. 4.8), and Ic:asr in rhe rt'tractcd hC~ld positioll (mean = Mandibular Length 36.2, SD :::: 4.5). Day-to-dJ}' reliability W:15 fOllnd to vary from 0.90 to 0.97, depending 011 head position, <lnd the Dijksrra and collcagues,27 in a study of mouth opening sWl1cbrd error of I1H:asun.:mcnr (SEM) nll1gcd from 0.77 to 1.(~9 mm, also depending 011 head position. :\\s a result in 13 females and 15 males, found that the linear of the findings, the Juthors concluded rhar rhe head posi- fion should be controlled when mouth opening flleasure- distance between the upper and the lower incisors during m(:nrs <.lre takcn. Howcver, the authors found that an mandibular depression was significantly influenced by error of I nlln to 2 I1H11 occurred rl:gardkss of the posi- mandibular lengrh. In a more recent study, Dijkstra and tion in which the head was placed . associarcs28 investigated the relationship between incisor .distances, mandibular length, and angle of mouth open- Temporomandibular Disorders ing in 91 health'y subjects (59 women and 32 men) rang- The srrlH.:rUfe of the T:vl.fs and the fa<.'( rhat these joints ing from 13 to 56 years of age (mean 27.2 yearsl. Mouth opening was influenced by barh mandibular length and get so l11uch use predisposes rhe joinrs, associatcd liga- angle of mouth opening. Therefore, it is possible that l11ents. and musculature ro injury, mechanical problems, subjects with the same mouth opening dismncc may and (h:generative changes. For example. the: articular disc differ from each other in regard to TMj mobility. Lewis, m.1Y becol11e cntfapped, defofmed. Of tofn; the capsule Buschang, and Throckmorton I-t found that mandibular m:1Y hel\"OI1lC rhickened; rhe lig;lI11cnrs may become short- length accounted for some of the gender differences in ened or kngrhencd; and the muscles l1l;lY become mouth opening and for most of the gender differences in infbl11cd, contracted, and hypcrtrt)phied. These prohlems condylar translation in mouth opening. Westling and may givl.' riSt' to ,,1 variety of sympWI1lS and signs thar arc Helkim025 found that passive ROM as measured by included in the temporomandibular disorder {TiVIDj clas- mouth opening was strongly correlated to mandibular sific1tiol1. Restricted mouth opening ROivl is considered length. to be one of the imporranr signs of T(-';{D.:?'J Popping or clicking noises (or hoth) in the joint during mouth open- To adjust for mandibular lengrh, Miller and cowork- ing and/or closing and deviation of the mandible during ers29 conducted a study to determine whether a \"mouth momh opening and closing 111:1>' be present. lft...!:?: ...!4.]1 opening index\" developed by the authors might be able Other signs and symprol11s includc facial pain. muscular to differentiate between TM] disorders of arthrogenous pain;; I and tenderness in rhe region of rhe TwlJ, either origin and those of myogenous origin. Forty-seven unilarerally or hilaterally. hC<1dachcs, and stiffness of rhe patients and 27 healthy control subjects were included in ncd\". TwlDs appear to be morc pn:vJlcnr in felllJlcs of all the srudy. The temporomandibular opening index (TOI) agl..'s after puberty, <.llrhough the ;KtlIal percentages of was determined by employing the following formula: women affected varies Jillong inv(·srig;lrors ..!·U.l..>I-H The n,:ason for this gender prefl'f(:.'!l(e h:1s bt'(.'ll Jttributcd a TOI = (PO - MYOI PO + MYO) x 100. \"PO\" in the Ilumber of facrors including, among others, greater stress levels in women;''> hormonal influenccs;\\.! ,11ld habits of formula refers to passive opening and \"lvlVQ\" refers to \"do!esccllt girls that arc c'trclllely harmful to the maximal voluntary opening. A significant difference was tcmporomandibular joinrs (('.g., intensive gum chewing, found berween the mean TOI between the two groups of patients and between the myogenous and the control groups but not between the arthrogenous group and the

CHAPTER 13 THE TEMPOROMANDIBULAR JOINT 369 1 coO£inuous arm leaning, icc crushing, nail biting, biting TMJs. lmrarcsrcr. inrcnestcr. and tcst-retest rcliabiliry II foreign objects, jaw play, clenching, and bruxism).'6,!! varied between 0.90 and 0.96. However, in contrast to the findings of Walker, Bohannon, and Cameron 11 and ......;.,,,!,''' Reliability and Validity thosc of Higbie and associates,15 the authors found that rhe smallest detectable difference of maximal mourh I Most of the following srudies agree that TM] ROM opening in this group of subjects varied from 9 mm to 6 measurements of the distance between rhe upper and the mm. Based on these results, a clinician would have to lower incisors are reliable. The validity of these ROM measure at least 9 mm of improvement in maximal measurements is more controversial. Walker, Bohannon, mouth opening in this group of patients to say that and Cameron II found that measurements of incisor improvement had occurred. distances for mouth opening had construct validity. However, some authors question how differences in the The following studies investigated incisor distances as length and size of the mandible affect linear distance a measure of mandibular condylar movements. Buschang measurements. and associares, \" in a sample of 27 healthy females 23 to 25 yeats of age, found that measurements of incisor Walker, Bohannon, and Cameron \" detetmined that morion during protrusion and lareral deviation provided six TMJ motions measured with a millimeter ruler were moderately reliable measures of condylar translarion. The linear distances that the incisors moved during 'reliable. Measurements were taken by twO resters at three lateral deviation provided the best measure of contralat- sessions, each of which wete sepatated by a week. The 30 eral condylar translation. Travers and coworkers,13 in a srudy involving 27 females, determined thar the incisor subjects who were measured included 15 patients with a linear distance in maximal mouth opening does not TM] disorder (13 females and 2 males with a mean age provide reliable informacion about condylar translation, of 35.2 years) and 15 subjects without a TM] disorder because normal individuals perform mouth opening with (12 females and 3 males with a mean age of 42.9 years). highly variable amounts of condylar translation. Dijkstra The intratester reliability intraclass correlation coeffi· and colleagues,!? in a study of 28 healthy volunteers (13 cients (ICCs) for tester one ranged from 0.82 to 0.99, and females and 15 males) between 21 and 41 years of age, the intratester teliability for tester two tanged from 0.70 found that linear distance between the central incisors in to 0.90. Intettester reliability ranged from good to excel· maximal mouth opening was only weakly related to condylar movement. Lewis, Buschang, and Throck- lent (ICC = 0.90 to 1.0). However, only mouth opening morton,14 who studied incisor movements in mouth measurements had construct validity and were useful for opening in 29 men and 27 women, concluded that inci- discriminating between subjects with and without TMJ sor movements should not be used as an indicator of disordets. The technical error of measurement (difference condylar translation. between measurements that would have to be exceeded if the measurements were to be truly different) was 2.5 mm The influence of mandibular length on incisor distance for mouth opening measurement in subjects without a measurements in mouth opening has been well docu- TM] disorder. Higbie and associates lS also found that mented. 14,25,!7,!8 The TOI mouth opening index was ROM measurements of mouth opening were highly teli· able with usc of a millimetet ruler. Twenty males and 20 developed by Miller and coworkers!' and Miller and females with a mean age of 32.9 years were measured by associates. 30 According to these authors, the index is two examiners. Intrarcsrer, imertcsrcr, and rcst-retest reli- independent of mandibular length as well as gender and ability ICCs ranged from 0.90 to 0.97, depending on age. If additional research suppottS the authors' claims, head position. SEM values indicated that an error of 1 use of the TOI would increase the validity of incisor mm to 2 mm existed for the measurement technique used measurements of mouth opening. Additional information in the study. Kropmans and colieagues3S found similar about the TOI is presented in the section on mandibular high reliability in a srudy of mourh opening involving 5 length. male and 20 female patients with painfully restricted

I; .\"'l. ! ... 1==-----------------------------zi 370 -en,~ PART IV TESTINC OF THE SPINE AND TEMPOROMANDIBULAR JOINT 0::& Range of Motion Testing Procedures: Temporomandibular Joint ~I ~i~ ~0I\" :;:1 OB o0:: j11 : dQ.. }1 !I (I t:: \\!!1 V;~ c~.:,[1 :O:>i,l'~ U.~L.L.I'l< 00:::;11 ~i...., 1 ~i -\"\",J~~~~~~I~~:-0rtiZ-f=~3~~1'd Maxilla ---¥'IiIiI'.,- Lateral incisor Central incisors Canines ~i Mandible u..~1 FIGURE 13-3 The adult has between 28 and 32 permanent teeth including 8 incisors, 4 canines, 8 premolars, and 8 to 12 molars. The central and lateral incisors and canines serve as landmarks for ruler I0\" L.L.I <m~j placement. 0::8H .~ •.~ •• • • 13-4). The subject may assist \\vith the motion by open- ing the mouth as far as possible. The end of the motion r! OCCllrs when resistance is felt and attempts to produce ?i additional motion cause the head to nod forward (cervi- ivlorion occurs 111 the sagittal plane around a I11cdial- cal flexion). (j Normal End-feel J lateral axis. Functionally, the mandible is able to depress The end-feel is firm owing to stretching· of the joint :1 approximately 35 mm to 50 mm so that the subject's capsule, retrodiscal tissue, and the temporomandibular ligament, as well as the masseter, temporalis, and medial itj three fingers or two knuckles can be placed between the pterygoid muscles:I.\" upper and the lower central incisor teeth.5 According to '1 the consensus judgements of the Permanent Impairment Conference, the normal ROiv1 for mourh opening ranges 11 between 40 mm and 50 mm. 10 The mean ROlv'l in Table 3 13-1 shows ranges from 43.5 mm to 52.1 mm. I Testing Position Measurement Method ;j Place the subject sitting, with the cervical spine in 0 lvleasure the dist'ance between the upper and the lower U degrees of flexion, extension, tunal flexion, and rotation. central incisor teeth \\vith a ruler (Fig. 1.3-5). In normal active movement, no Lueral deviation OCCllrs during !i1 depression. (f lateral deviation docs occur, it may take the Stabilization form of either a C-shapcd or an S-shaped curve. \\Xlith a C-shaped curve, the deviation is to one side and should ~J Stabilize the posterior aspecr of the subject's head and be noted 011 the recording form. \\'(/ith an S~shaped curve, ~ neck to prevent flexion, extension, lateral flexion, and the deviation occurs first to one side and then to the opposite side.\" A description of the deviations should be ,,~i rorarion of rhe cervical spine. included on the recording form (Fig. 13-6). q Testing Motion i! Grasp the mandible so that it' fits between the thumb and i the index finger and pull the mandihle inferiorly (Fig.

CHAPTER 13 THE TEMPOROlvlANDIBULAR JOINT 371 , ,. FIGURE 13-4 At the end of mandibular depression, one of the FIGURE 13-5 At the end of mandibular depression range of examiner's hands maintains the end of the range of motion by morion, the examiner uses the arm of a plastic goniometer to pulling the jaw inferiorly. The examiner's other hand holds the measure the distance between the subject's upper and lower central incisors. back of the subject's head to prevent cervical motion. 0 0 0 L R R R ,,,,,,,, L L 4cm A Bc FIGURE 13-6 Examples of recording deviations in temporomandibular motions. (A) Deviation Rand L on opening; maximum opening, 4 ern; lateral deviation equal (1 em each direction); protrusion on func~ tional opening (dashed lines). (B) Capsule-ligamentous pattern: opening limited to 1 ern; lateral deviation greater to R than to L; deviation to L on opening. (e) Protrusion is I em; lateral deviation to R on protru- sion (indicates weak lateral pterygoid on opposite side). (Magee, D]: Orthopedic Physical Assessment, ed 3. \\VB Saunders, Philadelphia, 1997, p. 165, with permission).

CHAPTER 13 THE TEMPOROMANDIBULAR JOINT 371 ,S \"\"OJ 11>\" 13-4 At the end of mandibular depression, onc of the FIGURE 13-5 At the end of mandibular depression range of motion, the examiner uses the arm of a plastic goniometer ro e}(aminer's hands maintains the end of the range of motion by measure the distance between the subject's upper and lower central incisors. pulling the jaw inferiorly. The examiner's other hand holds the back of the subject's head to prevent cervical motion. 0 0 0 L R R R ,,,,,,,, L .r~ 4cm A Bc FIGURE 13-6 Examples of recording deviations in temporomandibular motions. (A) Deviation Rand L on opening; maximum opening, 4 em; lateral deviation eq\\lal (1 em each direction); protrusion on fUBc- tional opening (dashed Jines). (B) Capsule-ligamentous pattern: opening limited to :1 em; lateral deviation greater to R than to L; deviation to L on opening. (e) Protrusion is 1 em; lateral deviation to R on protru- sion (indicates weak lateral pterygoid on opposite side). (Magee, DJ: Orthopedic Physical Assessment, ed 3. WB Saunders, Philadelphia, 1997, p. 165, with permission).

i;,,] 'il-3-7-2--P-A-R-T-'-V--T-l-S-T-'-N-G--O-F-T-H-E-S-P-1-N-E-A-N-O-T-E-M-P-O-R-O-M-A-N-O-'-:-B-'-!-L-A-R-J-O-'-N--::T 0:: •• • the movement by pushing the chin i.lrHcrior!y as far as possible. The end of the motion occurs wht:n resistance is •< • -' felt and attempts at additional motion CllISt: anterior :::l Illorion of the head (fig, J 3-7), This translatory motion occurs in the transverse plane. <Xl Normal End-feel o Normally, the lower central incisor teeth arc able to Z prorcude 6 mm ro 9 mm beyond rhe uppcr cemral incisor The end-feel is firm owing to stretching of the Joint < reerh, However rhc disrance may range from 3 mms 10 10 capsule, rcmporoJll:lndihular, styl(Hll~lIldiblilar~1I1d sphe- ::E mm 4 Sce Table 13-2 for addirional information, nOJ11,-1!1dibular ligaments, as well as the rcmporalis, 0' masseter, digastric, stylohyoid, mylohyoid and geniohy- 0::' oid nlusclcs.,l,.5 ' 0c..:,. ' Testing Position Measurement Method I tvlei.\\surc rhe disrancc bt:twecn rhe lower central incisor ::E, Place the subject Slftlng, with the cervical spine In 0 and the upper central incisor tecth with a rape measure or ruler (Fig, 13-8). Alternarively, rwo \\\"(>rtical lines drawn u.I, 011 rhe upper and lower canines or lateral incisors may be ~. degrees of flexion, extension, lateral flexion, and rota- llsed as the landmarks for measurelllcllt. 11 Vi' rion, The TMJ is opened slighrly. u.I. \"0::' :o::l Stabilization ou.I Stabilize the posrerior aspecr of the head and neck ro U prevcm flexion, extension, lateral flexion, and rotation of 0:: the cervical spine. Q. \"'Z Testing Motion t= Grasp rhe mandiblc berwecn rhe rhumb and the fingers <II _.u.I from undernearh the chin. The subjecr may assisr with I- 0Z , S ::E U.; 0, U: Z < 0:: .~..- FIGURE 13-7 At rhe cnd of mandibular protrusion range of FIGURE 13-8 At the end of protrusion range of motion. the morion, the examiner uses one hand to swbiJizc the posterior aspect of the subject'S head while her other hand moves the examiner uses the end of il plastic goniometer w measure the mandible into protrusion. distance ber\\veen the subject's upper and ]0\\\\1(.'[ cenrral incisors. The subject maimains the position.

CHAPTER 13 THE TEMPOROMANDIBULAR JOINT 373 I •• I: Testing Motion This translatory motion occurs in the transverse plane. Grasp the mandible between the fingers and the thumb and move it to the side. The end of the motion occurs The amount of lateral movement to the right and Idr when resistance is felt and arrcmprs to produce additional sides should be similar, between 10 mm and 12 mm2 but motion cause lateral cervical flexion (be careful co avoid may range from 6 mm to 15 mm.s According to the depression, elevation, and protrusion and retrusion during the movement) (Fig. 13-9). consensus judgement of the Permanent Impairment Normal End-feel Conference, the normal ROM is between 8 mm and 12 mm. lO See Table 13-2 for additional information. The normal end-feel is firm owing to stretching of the joint capsule and temporomandibular ligaments, as well Testing Position as the temporalis, medial, and lateral pterygoid muscles. Place the subject SittIng, with the cervical spine in 0 Measurement Method degrees of flexion, extension, lateral flexion, and rota- tion. The TMJ is opened slightly so that the subject's Measure the distance between the most lateral points of upper and lower teeth are not touching prior to the start the lower and the upper cuspid or the first bicuspid teeth of the motion. with a tape measure or ruler (Fig. 13-10). Alternatively, two vertical lines drawn on the upper and lower central Stabilization incisors may be used as landmarks for measurement. Stabilize the posterior aspect of the head and neck to prevent flexion, extension, lateral flexion, and rotation of the cervical spine. FIGURE 13-9 At the end of mandibular lateral deviation range FIGURE 13-10 The examiner uses the end of a plastic of motion, the examiner uses one hand to prevent cervical goniometer to measure the distance between the upper and the motion and 'the other hand to maintain a lateral pull on the lower canines. mandible.

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Arch Or:ll Bioi 45:6~5, 2000,. , ;\\ ~-lllllp;ln,\"n \"\"I\\~TCn iOllr 1Ill'rhmk .I Or.1I Rdl.lhll 22.:439, S_ Z;lfar. H: Imegr:lle<! j:'lw :lnd neck fLlnction III man. Studies of I 'J~l'\\. mandibular and head-neck movement.s during jaw opening·c1os- lS. 1)llk~rr;l, Pl', t·/ ,Ii: '1lf111l·II.·~· 01 rn.lndlhlll.LI' fl'llglh 01\\ mouth l,p~·a!l;g. .J (11'.11 lh·h.lill! 2t>: 11-, l';N'I. ing rasks. Swcd Oem J 143($uppl): I, 2000. 29. \\lIlln. \\'1. ~.: .11: .\\ mOll!!. j'r~'lllll;\": mJex {l.r p:lti~·lIt.. with 9. Eriksson, )·0, el :'II: Cu-ordinatl:d mandibubr and head-m:ck Il·mp..rlllll.m.llhuI.H dl..(>r~il·r .. \" J {)r,ll Rdl;lhd !.{,: '~·I, 1999. 1l100'crtlcnts during rhythmic jaw :'Ic{ivities in man. J Dem Res 30. .\\h\\ier. VJ. t'f .11: Th~· !t·rnpofOrll,llldihui.lr Opl'II11l;: llldn: \\TOlj ill p.i1a·nh with dll'~'d li,.:k ;It\\d ,I ~'OIHrlJl grollp wtfh n\" !l'mporo- 79,1378. lOOO. l11;llldihllbr dl';'(IHkr\", (T\\H)j: .111 illlli;d \",wdy, .J Or.1i Rehabil to. Phillips, OJ. et :\\1: Guide 10 eV3111:)(ioo of pcrm;wenr imp:\\irmenr 27:.'\\ I;;. 200(l. .• ~ (Ii the (empormn:llldibular joint. J Cr:wiomandibubr Prac( 31. hpu.;,iw. C.I. P:lI11Il:l:I, 1'.1. :Inu f:;HIlUt1 ...\\(;: ;\\s~ol'i:HiIiIlS in 425 P:\\liClHS h:l':ing Il'lllporo[1\\:ll1uihubr disordns. J KL·!lttl(:ky \".Ied 15:170,1997. \"\\:-'0(\" 9S:1.I.\\, 2(}0 I. II. \\X':llker. N, Hoh:lIl1lon, RW, :Hld ClIlleton, 0: Oiscrimin:'lm valid- 32. Lt· Rl·S,:h~·. I.: Fpidt'lIliu\\ugy (.f {l'llIpUnlln;llIdihubr disurders: ity of relllpor()lll~l:ldibllbr joim rangl' oi mOTion measurcments impliGuions i(lr till' ill\\·nlig.lliun of l'El0Ifl~i(\" f:l\\:wrs. Cril Rev obmined with a ruler. J Orthop SPOrtS Phys Ther 30:484, 2000, Or,t1 Bii,I.\\·kd S: 1.91. 1997. I 12. Buschang. 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i'?, JNormative Range of JTMotion Values TABLE A-l Shoulder, Elbow, Forearm, and Wrist Motion: Mean Values in Degrees Mas = American Association of Orthopaedic Surgeons; AMA = American Medical Association; M ::: males; F = females. I Values obtained with a universal goniometer. n • Minus sign indicates flexed position. II ;! ,';I 'i \" 'I'! 1 375

376 APPENDIX A TABLE A-2 Glenohumeral Motion: Mean Values in Degrees GLENOHUMERAL 51 56 106 Flexion 103 105 20 Extension Abduction 129 63 49 Medial rotation 108 94 lateral rotation M - males; F = females. Values obtained with i'I universal goniometer. TABLE A-3 Finger Motions: Mean Values in Degrees FINGER MCP 91 100 95 90 0 Flexion 26 20 45 0 Extension 108 105 105 100 FINGER PIP 85 0 70 Flexion Extension 85 68 90 0 80 FINGER DIP Flexion Extension DIP:.: Distal interphalangeal; Mep \"\" melacarpophalilngeal; PIP = proximal interphalangeal. MOS \"'\" American Association of Orthopaedic Surgeons; AMA == American Medical Association; M ~ Males; F = females. • Values obtained with a metallic slide goniometer on dorsal asped. I Values obtained with a universal goniometer on lateral aspect. t Values obtained with a digital goniometer on dorsal aspect.

APPENDIX A NORMATIVE RANGE Of MOTION VALUES 377 TABLE A-4 Thumb Motions: Mean Values in Degrees (Me = carpometacarpal; F = females; IP = interphalangeal; M = males; MCP = metacarpophalangeal. .. Values obtained with a metall1c slide goniometer on dorsal aspect. t Values obtained with a computerized Greenleaf goniometer. *Values obtained with a gonimeter applied to the dorsal aspect. -'..;; 15.0 132 IS' K~EE ;-Fiexio'n Extension ~ M = males; F = females. • Values refer to extension limitations. t A 1994 MOS value.

378 APPENDIX A . TABLE A-6 Ankle and Foot Motions: Mean Values in D e g r e e s · ANKLE 59 51 13 16 11 20 Dorsiflexion 26 60 56 19 (Subla'a,) 64 50 Plantar flexion 37 12 (Subtala,) 26 35 21 17 15 Inversion 86 Eversion 45 70 FIRST MTP Flexion Extension F \"\" females; M ~\" males. All range of motion values in the table obtained with a universal goniometer. TABLE A-7 Cervical Spine Moti.ons: Mean Values in Centimeters and Degrees CERVICAL SPINE 64 47 39 60 74 01 em 0.4 em 32 45 j Flexion 68 78 54 55 56 53 45 Extension 86 84 43 47 26 28 43 48 22 em 19 em 64 45 .;~ 4S 49 61 72 50 S3 72 79 11 em 60 Right lateral flexion- 74 75 13 em 41 12 em 11 em Right rotation 64 MOS =:: American Association of Orthopaedic Surgeons; AMA = American Medical Association; F = female; M = male . • Values in degrees were obtained for active range of motion using the cervical range of motion (CROM) instrument, 1 Values in degrees were obtained for active (Act) and passive (Pass) range of motion with use of the OS] CA-6000 Spinal Motion Analyzer. t Values in centimeters were obtained with a tape measure. § Values in centimeters obtained with a tape measure appear in the first column, whereas values in degrees obtained with a Myrin gravity- referenced goniometer appear in the second column. NB: AMA values in degrees were obtained with use of a universal goniometer and MOS values in degrees were obtained with use of an incli- nometer.

APPENDIX A NORMATIVE RANGE OF MOTION VALUES 379 TABLE A-8 Thoracic and Lumbar Spine Motions: Mean Values in Centimeters and Degrees lR';\"\" .:' ,_~on. Exten~ion \" '-:\" -Righ!,~te~ n' ilf9?~i~llo,~::!ii1:lJ7j,~ AAOS = American Association of Orthopaedic Surgeons; AMA = American Medical Association; F = female; M = male • lumbar values obtained with use of the modified Schober method. f lumbar values obtained using the modified-modifi~Schober (simplified skin distraction) method $ lumbar values in the first column were obtained with the BROM II. lumbar values in the second column were obtained with double inclinometers. § lumbar values obtained with the OSI CA·6000. , lumbar values for thoracolumbar extension and lateral flexion were obtained with a universal goniometer. lower values afe for ages 70-79 years and higher values are for ages 20-29 years. NB; MaS values for thoracolumbar motions were obtained with a universal goniometer. AMA values were obtained with use of the two- inclinometer method for lumbar motions of flexion, extension, and lateral flexion. The value for rotation is for the thoracolumbar spine. TABLE A-9 Temporomandibular Motions: Mean Values in Millimeters = =Fwd Forward; Neut = neutral; Retract retracted . • Values were obtained for active range of motion (ROM) with an \"-cm plastic ruier marked in millimeters. t Values represent consensus judgments of nonnal ROM made at the Permanent Impairment Conference. *Values were obtained for active ROM with a rufer. § Values were obtained for active ROM with Vernier calipers as the measuring instrument.

380 APPENDIX A REFERENCES 20. Roach. KE, ;lIld .\\-tile:.. Tl'; N(lrlll;l! hip :lIal knee activc range of \"Ii mOl ion: Thc rd;lli()il~hipof :l~t:. Ph yo; Tlwr 71: 656, 1991. 1. Wanat:tbc, H, C( :II: The range of joint motion of the cxucmiric.\"S in hcahhy Japanese people: lbc differences according to age. (Cited 21. CrcclIl·. WB. :1Il<! Iln:klll:lil. JD kd:o.): Tlw C1illic:d :VlcaslIrcmcnr in W:llkc:r,JM: Musculoskdcml developmenr::\\ review. Phys Ther of Joint :vtutiUll...\\meriC:!1! A(,\":ldCIlIY III ()nIH>p:lcclk Surgeons, 71,87H, 1991.) Ro:.emlllil. Ill. 1994. 2. noone, DC, ::Ind then, Sf': Normal range of motion of joints in 22. ;'I.-lc\"::lgni, C, et al: Iblancc and ankle rall~e of IIIUlioll in COInmu- !lity dwelling W(Hnl·1l a~nl 6·~87 Y(,·;lfS: :\\ ....orrc1:uioil:l1 stud)'. male subj<:crs. J none Joint Surg 6-1: 756, ·1979. Phvs Ther ~O; 10lH, 100(1. 3. Greene, Bl, and Wolf, 51.: Upper extremiry joint movcrncr.t: 23. to.\"l~P(lil, TG, ,mJ (:001\\\\':111. ~IW: Thl.\" rebliollship betweell static Comp:uison of n..-o mC:lSUrcOlcnt devices. Arch Phys Mcd Renahil Inwer l'xtrcllllrr tlle:ISlHClllCfltS :mJ n::lr!uot motion during walk- 70,288, 1989. in~. Phy,> Tht·f 24:JO~, 19%. 4. W.alkcr, ]M, Cl 31: Active mobiliry of the extremities in older 24. YouJas, J. ct al: Nurmal r:lllgc (If motion of tht' cervical spine: An subjects. Ph)'s Ther 4:919,1984. inirial goniornctric swd)'. Phys Ther 72:770,1991. 5. Downey, PA, Fiebert, I, and Stackpole-Brown, JB: Shoulder range of motion in perSons aged sixty and older. (abstract). Ph)'s Ther 25. L:mtz, C\\, Chell, J. and UlIf.:h. IJ: Clinic:d v:t1idi[y :lrld s[:lbilir)' of 71,575,1991. ;luivc and passive cl:fvical ranl;t: of lIUl[iOIl with rcg;ud rtJ [otal 6. Amerie;!.n AC:ldcmy of Orthopaedic Surgeons: Joint Motion: Method of measuring and recording. American r\\cadcmy of ;lIId unipbn;lr mOlion. Spine l·I:)(lSl, 1999\" Onhop:lcdic Surgeons, Chic:lgo, 1965. 26. Hsich, C· Y and Ycung, 1\\\\'(/: :\\ctive fwck mociOll measurements 7. Americ:ln Medic:l1 Association: Guides ro the Evaluation of Permancnr Imp:tirmeor, cd 3. AM\", Chicago 1988. with;l l:lpC nW;IMHc. .J Orthop SPOflS Ilhys Ther S:S8, 1986. 8. Ellenbecker. TS, cr al: Glenohumeral joint inu;mal and external 27. Iblugun • .1;\\. CI :11: Imcr·and imr:llt:stcr rcliahility n( fll(:asuring rotation r\"mgt of motion in e1itc junior tcnni!' pl:lycrs. J Onhop neck mutions with rap'· JIIt'aSUfl· and Myrin Gr:wiry·Rcierencc Spons Ph)·s Ther 24:336, 1996. GlIllionWIl\"f. J Orth!>p Spnrrs I'h)':. Ther 9:24S. 19M9. 9. Boon, Aj, and Smith, J: Manual scapubr stabilization: Irs t:ffccr on 28. .-\\runican ~ll·dic;\\1 :\\s~()(:ialioll: Guidt:s wille EV;I!u;ltion of shoulder for:nion:\\1 r;lnge of morion. Arch Ithys Med Rchabil 81,978. 2000. PCCll1:1l1CllI hnpairnwm. l:d 4. :\\:'-.'1:\\, Chicago, 1993. 10. L.1nnan, 0, Lehman, T, and Toland, M; Esrablishm,·Jlt of norrn:\\- rive data for the range of motion of the glenohumeral joint. M:lstcr 29. flab', S,\\I, TaJ:I, \\'({t.. C:mnil.:lud, E:'-.I: $pinalillohility in yhllng of Science thesis, University of Mass.1chusens, Lowell, 1996. child~ell\" Ph\\\"s \"'\"her (,(,: 1(,II? 19}:6\" I I. Sknrilov:l, B, .1nd Plevkova, A: Ranges of joint marion of rhe :ldulr hand. Acta Chir Plast 38:67, 1996. 30. ~;loll. JMI-l:;lIHJ \\·';:ri~.\\l. V: Norm:,1 r:lllgC of spinallllohiliry: An 12. Humc, M, C[ :'\\1: Functional range of motion of the joims of the objective dillicd study. Ann Rhl.:\\llll Dis :~O:3SI, 1971. hand. J Hand Surg 15A:240, 1990. 31. van Adricht'tll, JAM, ;llld V:Hl dn Knrio!. JK: AsscssmCl\\[ of fit-xi· hilir\\\" of the Itu\"nh;lr ~pil\\e. r\\ pilot sllldy in children ;lnd adolcs· 13. M:\\llon, \\'OJ, Brown, HR, and Nunley J1\\: Digiral ranges of motion: Normal values in young adults. J '-land Surg 16r\\:882, ccnt~. Scmd J RheumalOl 2:Si. 1973, 1991. 32. Brcull1, .I, \\'(Iihcrg. J. ;lnd Boltoll . .IE: Rl'Iiability ;Hld COlKtlrrCnt 14. Jenkins, M, et al: Thumb joint motion: What is normal? J f·bnd validity 01 the BRO\\'l II for lllt·asurilll; lumbar mobility. J Surg 2.18,796,1998. \\bnip·lll:nivc Physiol Tht·r 1H:4 1J7. 1995. .J.J. \\.kgrtgor, AH. ,\\'h.:C,rrhv. 1D. ;,nd H\\J~hcs. SP: \\!otiOll l;h;lrac~ IS. DcSmett. L, ct :'II: l\\-tct:'lcarpophalangc:l1 and inrcrphabnge:'ll nex- ion of (he thumb: Innuencc of scx :'Ind .1I;C. rebrian to lig:lnlcncous rcri~ril:s of dw lumb:\\( Sf)inc in rhe Ilorm;ll POpIlLHion. Spine injury. Act;l Orhtop Belg 59:37,1993. 20:2421, 1995. 16. Waugh, KG, cr :'II: Measuremenr of selected hip, km:e :\\nd ankle 34. Fitzgerald. CK. t'r :d: ObjL'(rin· ;lSM:SSrn('rlt with csrabli\"shmenr of joint motions in newborns. Phys Ther 63:1616,1983. norm;ll V:l!IH:S f,lr lumbar spint\" f:lll~c (If lllotion. Phys Ther ()3: 1776, 19S3. 17. Drews, JE, Vraciu, JK, :lnd Pellino. G: R.1nge of moti?n of the lower cxtrcmities of newborns_ Ph)·s Occup Ther Pedlatr 4:49, 35. Walhr, N. Boh;1I11l0l1. RW. Camefon. D: V;)lidir~· of tcmporo· 1884. mandihubr jllinl r;lng(,· (.1 IIUlliufl llIe:lsur(,\"Il\\Cllts (lhf:lim·d with a 18. Schw:lcze, OJ. and Demon, JR: normal values of neanntallimbs: nill·r. J (}nhop Spons Phys Ther .10:484. :WOO. An evaluation of 1000 neonates. J Pediatr Onhop 13:758, 1993. 36. flhillips. DJ. et al: Guidc [() l·\\':llll:Hion of pl·rtil:UlClU impairment 19. Phelps, E, Smith, LJ, and I·hllum, A: Normal ranges of hip motion of infants between 9 and 24 months of age. Dev Med Child oi thl· tl'lllporolTlandibubr joint. J Craniolll:lndibu!:lr Pfa.;t Neural 27:785, 1985. 15:170.1997. 37. Iligbie. EJ. (,·1 al: Efin·l (If IH:ad POSilioll nil Vl\"niCll mandibular upt-'Iling. J Orthup Spuns. Phys Th...r 29: 127. 1999. 38. ThIlfIlW;lld. 1':\\: The din·r (Ii :l~'\" ;md ~(,·Illkr (Ill normal tc:mporo- m,lIldihubr juint mu\\'t:mclU. l'hysi(lfht:r Thl\"ory Pr;tI.:( 7;20.9, 1991.

Joint Measurements I by Body Position I EXtension' Flexion Pronation Abduction SlJpiriation SubtilJar inversion Medial rotation Flexion Subtatar. evel1ion EXtension latercario'tat!on Radial deviation Toes Ulnar deviation Cervlca spine Flexion AII,motions Medial rotation Thoracic, and 'lumbar spine eXlon lateral rotation Temporomandibular joint Abduction Adduction Do'Fsiflexion Plantar flexion Flexion Inversion D,orsiflexion Eversion Plantar flexion Midta'rsal inversio\"n Inversion Midtarsal. eversion Eversion All motions MIdtarsal inversion Flexion MidtarSal 'eversion Extension All motions lateral flexion Rotation Rotation Flexion' EXtension Depression Litteral flexion Anterior protrusion Lateral deviation 381

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TABLE C-3 Inclinometers APPENDIX C GONIOMETER PRICE LiST 385 . r :'~~if:ii~;$ed-~~rt~J~~!~Rf;:,~~~:i~~i~I~I~~:~M:~~if~1~~;~~:i~~~~a-~~i~~~~~i~e~n3~~~t~f~1i1~;~;'!\" i~~~~~t{~]r~Jtr::~~~~~fij'; 1:.;.- \\/~rDuait·sea.le_-'nclrj{om'eiet;Jr, '., 379.95tt ;~;~;;.~;,.,; 349.99'''' i~~~~iM (Iumba(range:of.motion iqslfUfnent) Measures;!umbar rangeo(motion .';.\"i'{; ').',.'i0.'/,,- <::i ...i-\";.$';?l_}.\\~>/i:~, ...,-:..;,,~!;~/;<,,:,::c-~. '-c\"--:,,~;':' •.i';:. --_.....~:;:. §g~_..d~ \"\"\" ...-;'~':c<'cjf'_\"-\"-' • • _ ..::.:L«;,-;.,,;::::o,\",,;;,,_;_~~£:.., '.r. Best Priced Products 1--800-824-2939 The Saunders Group 1-800-966-3138 American 38 Scientific 1-888-326-6335 ProMed products 1-800-542-9297 'North Coast Medicall-80Q-821-9319 ... flag House 1-800-793-7900 tt Sammons Preston 1--800-323-5547

Range of Motion-TM] and Spine Right \\ Patient's Name _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Date of Birth .1 Left 1 Date Temporomandi Depression Anterior Protrusion Lateral Deviation-Right Lateral Deviation-Left Comments: Cervical Spine Flexion Extension Lateral Flexion-Right Lateral Flexion-Left Rotation-Right Rotation-Left Commems: Thoracolumbar Spine F exion Extension Lateral Flexion-Right Lateral Flexion-Left Rotation-Right Rotation-Left Comments: Lumbar Spine Flexion Extension Comments:

388 APPENDIX D Range of MOlion-Upper Extremity Date of Birth Right Paricm's Name Date Left Examiner's Initials Shoulder Complex Flexion Extension Abduction Medial ROlation Lateral Rotarion Comments: Glenohumeral Flexion Exrc:l1sion Abduction i\\ledial Rotation Lltcral Rotation Comments: Elbow and Forearm Flexion Supination Pronation Comments: Wrist flexion Extension Ulnar Deviation R~1Clial Deviation Comments:

APPENDIX D NUMERICAL RECORDING FORMS 389 ~ Range of Morion-Hand ; Paricnfs Name Dare Dare of Birrh Left Examiner's Initials Righr Thumb CMC Flexion CMC Exrension CMC Abducrion CMC Opposition MCP Flexion IP Flexion IP Exrension Index Finger MCP Flexion MCP Extension MCP Abducrion PIP Flexion DIP Flexion Middle Finger MCP Flexion MCP Extension MCP Radial Abduction MCP Ulnar Abduction PIP Flexion DIP Flexion Ring Finger MCP Flexion MCP Extension MCP Abduction PIP Flexion DIP Flexion Lirtle Finger MCP Flexion MCP Extension MCP Abduction PIP Flexion DIP Flexion Comments: d

390 A P PEN D I X D Range of Motion-Lower Extremity Patient's Name Dare of Birrh Left Right Date Examiner's Initials Hip Flexion Extension Abducrion Adduction Medial Rotarion Luera I Rotation Knee Flexion Ankle Dorsitlexion Plantarflexion Inversion-Tarsal Eversion-Tarsal lnversion-Subralar Evcrsion-Subtalar Inversion-Midtarsal Eversion-wI idrarsal Great Toe MTP Flexion MTP Exrension MTP Abducrion lP Flexion Toe - - MTP Flexion MTP Extension MTP Abduction PIP Flexion DIP Flexion DIP Extension Comments:

APPENDIX D NUMERICAL RECORDING fORMS 391 ; Muscle Length Date of Birth Right Paticnfs Name Date Left Examiner's Initials Upper Extremity , Biceps Brachii Triceps Brachii ~~: Flexor Digitorum Profundus & Superficialis Extensor Digirorum , Lumbricals Comments: :\"- Lower Exrremity i Hip Flexors-Thomas Tesr Rectus Femoris-Ely Tesr ,., Hamstrings-SLR Hamstrings-Distal Hamstring Length Test i Tensor Fascia Lata-Ober Test Gastrocnemius /'; Comments: I' l~W. ?c< 't? ~. t Fe L

A \"b\" following a pagc number indic:lIcs a box; an \"f\" indic3(es 3 figure, and a \"[\" indicates a (able. A cervical spine, 298t-299t, 298-299 for extension, 102 Abduction. Sec specific joints elbow, 94-95, 9St for flexion, 100, 101£ Achilles tendon hand, 142 of muscle length, 107, 107f, 109, l09f hip, 184t, 184-187, 186t for pronation, 103, 103f anatomy ot 288, 288f knee, 223t-224t, 224-225 for supination, 105, 10Sf shoulder, 61t, 61-62 general proceduTCS for, 27f-29f, 27-30 Acromioclavicular joint temporomandibular joint, 367, 367t exercise for, 30 anatomy of, 59, 59f thoracic and lumbar spine, 334, in hand testing: arthrokinematics of, 60 for abduction, 150, 151f, 164, 165f osteokinematics of, 59-60 335t-336' for adduction, 152, 153f wrist, 113t, 113-114 anatomical landmarks for, 145f ActiVl.' range of motion. Scc also Range of Age {or extension, 148. 149f, 154, 158, 162, motion range of motion and, 11-12 defined,6-7 ankle and foot, 247, 247t-2491 163f, 172, 175 testing of, 7 cervical spine. 297-299, 2981-299t for flexion, 146, 147f, 156, 156f-157f, elbow, 94t-95t, 94-95 Activities of daily living hand, 141 160, 161f, 170, 171f, 173, 174£ functional range of motion in hip, 184-187, 185'-1861 for muscle length, 178, 179f ankle and foot, 250-252, 251 f-252f, 251 t knee, 223t-224t, 223-225 for opposition, 168, 168f-169f cervical spine, 302f-303f, 302-303 shoulder, 611, 61-62 in hip testing elbow, 961. 96-97, 971-981 temporomandibular joint, 367, 3671 for abduction, 198, 199f hand, 1431, 143-144, 144' thoracic and lumbar spine, 333-334, for adduction, 201, 20H hip, 1891-1901, 189t, 189-192 anatomical landmarks for, 192£-193f knee, 225, 2261-2271, 226' 335'-336t for extension, 196, 197f shoulder, 63, 64f--65E. 64t wrist, 112f, 112-113 for flexion, 194, 195£ thoracic/lumbar spine, 337f-338f, Alignment for lateral rotation, 205, 20Sf 337-338 in ankle and foot testing for medial rotation, 203, 203f wrist, 115t-116t, 115-117, 116f-1l7f for loe abduction. 285, 285f for muscle length, 210, 211f, 214, 215(, anatomical landmarks for, 255f, 263f, Adduction. Sec spe<:ific joints 218,219£ Adductor longus and brevis muscles 269£. 2791 in knee testing for dorsiflexion, 257f-259f, 257-258 an<ltomy of, 207 for eversion, 267, 267f-268f, 273, 273[, anatomical landmarks for, 229f in Thomas test. 206f-211f, 20~211 for extension, 232 Adolescents 277f-278£. 277-278 for flexion, 230, 231 f low·back pain in, 337 for toe extension, 282, 283f for muscle length. 232, 235. 235f, 239, range of motion in for toe flexion, 280, 281 f, 28~287 for inversion, 265, 265f, 271, 271f, 274, 239f ankle and foot, 247t in shoulder testing, 68, 68f-69f cervical spine, 298t-299t 275f elbow, 94, 94t for muscle length, 290, 200f for abduction, 80, 8Of-81f for plantarflexion, 261, 262f anatomical landmarks for, 68f--69f hip, 184', 186t in cervical spine testing for extension, 76, 76f-nf knee, 224, 224' anatonticallandmarks for, 307f-309f for flexion, 72, 72f-73f shoulder, 61, 6H for extension, 314f-317f, 315-317 for lateral rotation, 88, 88£-89£ thoracic and lumbar spine, 334, for flexion. 310f-313£, 311-313, for medial rotation, 84,84.f-85f for lateral flexion, 318, 319f-323f, in temporomandibular joint testing 335t-336', 336 anatomical landmarks for. 370£ wrist, 113t, 113-114 321-323 for depression, 370, 37If temporomandibular joint disorders in, for rotation, 324, 325f-328f, 326, 328 for lateral deviation, 373, 373f 368-369 in elbow testing for protrusion, 372, 372f anatomical landmarks for, 99, 99f in thoracic and lumbar spine testing urban versus rurJ,1, 336 393 Adults range of motion in, 11 ankle and foot, 247,-248t, 247-248 , j

394 IN 0 EX Alignment (Continued) c<1psular pattern in, 241 of inlerphilkmgeal joints .\" , anatomical landmarks for, 343f dorsiflexion of toes, 246 for extension, 357£-359£. 357-359 fingers, 138 } (or nexioo, 3-16, 346£-347£, 350f-351f. end-fl.'Cl determin<1tions and, 20 thumb,140 ; 350-351 functional range of motion in. 250-252, for rotation, 360, 361f-363t 362 of intervertebral and zygapophyscal '1,i 251f-252f, 25lt joints, 297 in wrist tf..'Sting reliability of testing of, 253, 253t 1 .matomicallandmarks for, 119f rcsearch findings in, 248t-249t, 248-249 of lumbar spine, 333 for extension, 122, 123f tillocrural testing of, 256f-259f, 256-259 of melncarpophalangeal joints, 138-139 t for flexion, 120, 12lf eversion of of metntnrsophalangeal joints, 245 of muscle length, 131, 13lf. 135, reliilbility of testing of, 253. 254t of midt<1Tsal joint, 245 ---l. 135f subtalar testing ot 272f-273£, 272-273 of radioulnar joints, 93 for radial deviation, 124, 125f tarsal testing ot 266f-268f, 266-268 of scapulothoracic joint, 60 for ulnar deviation, 126, 127f inversion of of stemoclaviculilr joint, 59 rctiilbitity of testing of, 253, 25·H of subtillnr joint, 243-244 American Academy of Orthopnedic subtalar testing o£, 270f-271 f, 270-271 of t\"locnlral joint, 241 Surgeons tars.,1 testing of, 264f-265f, 264-265 of t..lrsomdatars<11 joints. 245 range of motion findings of osleokinematics of, 241, 243-24-1 of temporomandibular joint, 366 ankle, 246, 246t, 37St plantarflexion of of thoracic spine, 332 elbow, 94, 9·H, 3751 functional range of molion in. 250-252, of tibiofemoral and patellofcmoml joints, foot, 246, 246t, 3781 hand, 14m, 140-1-11, 3761-3771 25lf,25H 222 h;p, IlH, IlHI, 3771 relinbility of testing of. 253, 253t of tibiofibulilr joints, 241 knee, 224, 377t tnlocmral testing of. 26Of-262f. 260-262 of wrist. 1I2 shoulder, 60. 601, 375t range of motion of Ascending st'lirs spine, 333. 3341, 3781-3791 ngc ilnd, 247, 247f r\"lOge of motion neccss<1ry for disease and. 250 wrist, 112t, 112-113, 375t functional, 2.50-252, 25lf-252f, 25lt ankle and foot, 251, 251 (, 251t Amcriciln Medical Associiltion gender and, 248t, 24&-249 h;p, 189, 1891, 1891 injury and, 250 knl..\"'C, 225, 226f, 226t r.,nge of motion findings of normntive values for, 378t Athlett>s ankle, 246, 2461, 378t numericill recording form for, 390f ankle sprains in, 250 c1bmv, 94, 941, 375t reliilbility and validity in testing of. low-back pain in, 337 foot. 246, 2461, 378t Atlantoaxiill joint. Sct' also Cervical spine hand, 140t, 1-10-141,3761-3771 252-254, 253t-254t anatomy of, 295, 295f h;p, IlH, IlHt, 3771 research findings in. 246t-248t, 246-247 nrthrokinemiltics of, 296 knee, 223t, 223-224. 377t subtalar eversion of oSh.'Okinematics of, 295-296 shoulder, 60, 6Ot, 375t testing of. 272f-273f. 272-273 Atlanto-occipit<11 joint Scc also Cer\\\"ic~1 spine, 298t, 333, 334t, 37St-3i9t subtillilT inversion of spine weist. 112t, 112-113, 375t testing of, 270f-271f, 270-271 aniltomy of, 295, 295f t.,locrural dorsiflexion of arthrokinematics of, 296 n_'Cording guide of, 34 testing of, 256f-259f, 25fr259 capsular pilttem in, 296 Anatomical landmarks talocrural plantarflexion of ostl'Okinemiltics of, 295-296 tC'Sting of, 260f-262f, 260-262 Axes goniometer alignment using, 27, 27f tilrsal eversion of in ostl'Okinematics, -I, 5f ankle, 2551, 2631, 269f leshng 01, 2661-2681, 266-268 cervical spine. 307f-309f tar::;al inversion of B elbow. 99, 99f tl'Sting of, 264£-265f, 264-265 Bnck Range of Motion Device fOOl, 2551, 2631, 2691, 2791 Ankylosis hand, 145f, 159f sagillal-frontal-transverse-rotation price of, 385t h;p, 1921-193f method of recording, 34 retinbility of, 339t, 340 knee,229f Anterior-posterior axis Ballet shoulder, 68f-69f defined, 4, 5£ r.lnge of motion of hip and, 18S temporomandibular joint. 370f Arm. St'C also specific joints; Upper- Baseball players thoracic and lumbar spine, 343f extremity testing shoulder rotiltion in, 62-63 wrist. 119f muscle length testing in, 106f-l09L Basic concepts, 3-14 106-107 Beighton hypermobility score. 10, lit Anntomy rilnge of motion of, 99f-105, 99-105 Benign joint h)'permobility syndrome nnkle nnd foot, 241, 242f-246f, 243-245 stnlCture and function of, 9lf-93f, 91-93, defined. 10 cervical spine, 295f-297f, 295-296 1061, 108f Biceps brachii muscle elbow, 91f-93f, 91-93 ArthrokinemJtics muscle length testing of, 106£-107(, hand, 137f-1391, 137-139 of acromioclavicular joint, 60 h;p, 183f-184f, 183--llH of atlanto-occipital and atlJntoaxial joints. 106-107 knee, 221f-222f, 221-222 296 Biceps femoris muscle shoulder, 57--60, 58f-59f of carpometacarpal joint, 138-139 temporomandibular joint. 365, 365f-366f defined, 4 anatomy of, 212, 212t 236, 23M thoracic and lumbar spine, 331-333, of glenohumerill joint, 57-58 in dist.ll hamstring length test, 236f-239f. 3321-3331 of humeroulnar and humeroradiill joints, wrist, 111£-112f, 111-112 92 2.16-239 of iliofemoral joint, 184 in straight leg test, 212f-215f, 212-215 Ankle. St:c also Foot Biologic;)l variation anatomical landmarks of, 255f, 263f, 269f standard deviation indicating, 44, 44t analomy of, 241-244, 2421-244f Body position arthrokinematics of, 241, 243-245

joint measurements and, 38lt in cervical spine testing IN 0 EX 395 Body size of extension, 316-317, 317f of flexion, 312-313, 313f of extremity joint studies, 40 range of motion and of lateral flexion, 322-323, 323f of spinal studies, 40 ankle and foot, 250 reliability of, 304t, 304-306 Cup holding cervical spine, 302 research findings in, 298, 299t r<\\nge of motion necessary for of rotation, 328, 328f Body~mass index hand, 143, 143f range of motion and price of, 385t Cybex inclinometer elbow, 95 Cervical spine, 295-328 hip, 187 in thoracic and lumbar spine (('Sting, knee, 225 anatomicall~ndmarksof, 307f-309f 340 shoulder, 62 anatomy of, 295f-297f, 295-297 arthrokinematics of, 296-297 D Bubble goniometers, 24-25, 25f capsular pattern in, 296-297 Degrees of freedom of motion extension of C defined,6 age and, 299-301, 300t-JOlt Depression CA-6000 Spine Motion Analyzer 'esting of, 314f-317f, 314-317 in cervical spine testing flexion of testing of mandibular, 370, 37]f reliability of, 305 age and, 299t-.301t, 299-300 Descending stairs testing position and, 301-302 testing of, 3IOf-313f, 310-313 in thoracic and lumbar spine testing lateral flexion of r<lnge of motion ncCl'Ssary for of functional i'lctivities, 337 .esting of, 318f-323f, 318-323 ankle and foot, 251, 251f, 251t reliilbility of, 339t, 341-342 osteokinematics of, 295-297 hip, 189, 189f, 189. range of motion of knee, 225, 226f, 2261 Calcaneus age and, 297-299, 299t-301t anatomy of, 288, 288f body size and, 302 Deviation. See specific joints functional, 302f-303f, 302-303 Devore goniometer Capsular fibrosis gender and, 299'-301 t, 299-301 capsular pattern in, 10 normative values for, 378t price of, 383t numerical recording form for, 387f reli<lbiHty of, 144 Capsular pattern of rcstricted motion reliability and validity of testing ot Dexter Hilnd Evaluation and Treatment of atlanta-occipital and atlantoaxial joints, System 296 303-306,304' reliability of, 145 of carpometacarpal joint, 139 research findings in, 297, 298t Diabetes mellitus defined,9 testing position and, 301-302, 38lt ankle and foot range of motion in, 250 example of, 9b rotation of Disability of glenohumeral joint, 58 age and, 300, 3OOt-3Olt range of motion and of humeroulnar and humeroradial joints, testing of, 324(-328f, 324-328 92 Children hip, 188-189 of iliofemoral joint, 184 range of motion in, 11 thoracic and lumbar spine. 337 of interpha:langeal joints ankle and foot, 247t, 247-248 Disorders. Set: also specific conditions fingers, 138 cervical spine, 299t ankle and foot, 250 thumb,140 elbow, 94, 94t temporomandibular joint, 368-369 of intervertebral LInd zygapophyseal !Up, 184'-186t, 184-186 Distal goniometer arm joints, 297 knee, 223t-224t, 223-224 dcfined,28-29,29f of lumbar spine, 333 shoulder, 61, 6lt Distal hamstring length test, 236f-239f, of metacarpophalangeal joints, 138-139 wrist, 113, 113t 236-239 of metatarsophalangeal joints, 245-246 Clavicle Distal interphalangeal joints. Sec of midtarsal joint, 245 as shoulder anatomical landmark, 68f Interphalangeal joints of radioulnar joints, 93 Coefficients in range of motion testing, 9t, 9-10 correlation, 45-47, 46t Distal tibiofibular joint. St'e Tibiofibular of subtalar joint, 244 intradass, 46-47 of talocrnral joint, 241 of variation joints of temporom<mdibular joint, 366-367 in reliability evaluation. 45 Doorknob turning of thoracic spine, 332 of replication, 45 of tibiofemoml and patellofemoral joints, Collateral ligaments range of motion necessary for 222 elbow, 91, 92f wrist, 115, 115t, 116f of tibiofibular joints, 2-1] Concurrent validity of wrist, 112 criterion-related validity and, 39 Dorsal interossei muscles Construct validity muscle length testing in. ]76f-179f, Carpal tunnel syndrome applications of, 4Q-41 176-179 wrist position and, 117 defined, 40 Content validity Dorsiflexion. See Ankle; Foot Carpometacarpal joints. Sec also Hand defined,39 Double inclinometers anatomy of, 137f, 138 Correlation coefficients arthrokinematics of, 138-139 intraclass, 46-47 in cervical spine testing capsular pattern of, ]39 Pearson product moment, 46, 46t of extension, 316, 316£ ostcokinematics at ]38 in reliability evaluation, 45-47, 46t of flexion, 312, 312f range of motion of, 14D-141, 14lt Criterion-related validity, 39-40 of lateral flexion, 322, 322f normative values for, 377t of rotation, 326, 327f Carrying angle in thoracic and lumbar spine testing elbow, 91-92 age and, 334 disability and, 334 Cervical Range of Motion Device of flexion, 346, 346f-347f, 35], 351f of lateral flexion, 359, 359f reliability of, 339t, 339-340 of rotation, 362, 362f-363f Down syndrome hypennobility in, 10 Drinking

396 IN DE X range of molion in, 11 156,160,162,164,168,170,172-173 ,;nkle and foot, 247t-2481, 247-248 in hip testing, 194, 196,198,201,203, range of motion necessary for cervical spine, 289-299, 299t ccrvi<:<11 spine, 302 c1b(l\\\\f, 95, 95t 205,210,213,218 elbow, 96t, 96-97, 97£ hip, IMt, 1861, 186-187 in knt'C tt.-sting, 2.:.10, 232, 238 hand, 144 knl\"C, llit-224t, 224-225 in shoulder testing, 72, 76, SO, 84, 8S shoulder, 63, 64t, 65f shoulder, 61 in temporomandibular joint testing, wrist. 115t, 116-117 thoracic and lumbar spine, 334, 370,371-373 Driving 335'-336' in thoracic and lumbar spine testing, r.loge of motion necessary for wrist. 113 ccrvic..\\l spine. 303. 303f Electrogoniometers 344,348,352,3~1,357,360 in elbow testing.. 98 Duchenne's muscular dystrophy overview of, 25-26 in wrist testing, 120, 122, 126 tC'Sting reliability in, 65 in range of motion testing. 8, 8t Ely 10\" Dynamometers of rectus femoris muscle length, 232-235, general proccdurt'S for, 20-21 potentiometers nnd, 25 2331-2351 in shoulder E End·fccls abduction nf. 80 Eating abnmmal, St in ankle and foot extension of, 76 runge of motion nCCes.<;ilry for abduction of, 284 flexion of. 72 cervical spine, 302 dorsiflexion of, 20, 257 lateral rotation of, 88 elbm\\', 96l, 96-97 eversion of, 267, 273, 277 medial rotntion of, 84 hand. 144 in temporom:mdibular joint shoulder. 63, 64t, 65f extension of. 282 dl\"prt'SSion of, 370 wrist, 11St, 116--117 flexion of, 280, 286-287 lateral deviation of. 373 Elbow. See a/so specific joints inversion of. 265, 271. 274 anatomical landmarks of, 99. 99£ muscle length testing in, 289 protrusion of, 372 anatomy of, 91 £-93£,91-93 plantarflexion of, 261 in thoracic and lumbar spine arthrokinematics of, 92-93 in cervical spine cnpsular pattern in, 92-93 extension of, 352, 354 c.\"trying angle of, 91-92 extension of. 314-315 flexion of, 344 extension of latcral flexion of, 3-18, 357 end-feci determinations and, 21 flexion of. 310 rotation of, 360 recording of, 31-32. 32f lateral flexion of, 318 in wrist testing of. 102 rotation of. 324 extension of. 122 flexion of defined,8 flexion of. 120 end-fl..-el determinations and, 20 in elbow muscle length testing in, 130, 133 exercise for, 30 extension of, 21. 102 radiol deviation C'f, 12-1 goniometer alignment for, 27f-28f, flexion of, 20, 100 ulnar deviation of, 126 30 muscle length testing in, 107, 109 Errors recording of,3l, 31£, 34b pronation of, 102 measurement, 29, 41. 43 reliability studies of, 41 supination of, 105 Eversion. Set' Ankle; Foot testing of, 36, 100, 100£ in hand Exos Handmastcr hyperextension of abduction of, 150, 164 rcli.,bility of, 144 recording of. 31-32, 32f ildduction of, 152 Explanntion procedure~, 34-35 ligaments of, 91, 92f extension of. 148. 154, ISS, 162,172,175 muscle length testing in, 106£-109£, flexion of, 146, 156, 160, 170, 173 example of. 34-35 106-109 muscle length tcsting in, 176, 178 ostrokinematics of, 92-93 opposition of. 168 exercise for, 36 pronation of in hip Extension. S.'e specific joints testing of, 102£-103(, 102-103 abduction of, 198 Extensor digiti minimi musch.- range of motion \"ddudion of, 201 testing position and, 381 t extension of, 196 muscle length testing of. 132f-135, range of motion of, 99f-l05f, 99-105 flexion of, 194 132-135 <1ge and, 94t-951, 94-95 muscle length testing in, 210, 213-214. body.mass index and, 95 Extensor digitorum muscle example of, 12b, 13£, 14b, 14£ 218 functional, 961, 96-97, 97£-98£ rotation of. 203, 205 muscle length testing of. 132f-I35, gender .lod, 95 in knee normative values for, 37St extension of. 232 132-135 numerical recording form fo., 388£ flexion of, 230 Extensor indicis muscle rcli\"bility and validity in testing of, muscle length testing in, 238 97-98 muscle length testing of, 132f-135, research findings in. 941-95t, 94-96 normal. St 132-135 right l_'t'rS/lS left side and, 95 in ankle and foot testing, 257, 261, sports nnd, 95-96 265,267,271,273-274,277,280,282, Extremity joint studies supination of 2S4 criterion-related. vntidity of, 40 testing of, 104£-105£, 104-105 in cervical spine testing, 310-311, 314-315,318,324 F Elderly adults in elbow testing, 100, 102, 105, 107, Face validity 109 in hand testing. 146, 148, 150, 152,154, typos of, 39 FASTRAK system in thoracic and lumb.u spine testing, 341-342 Finger. See 111~() Hand an\"tomyof, J37f-139f. 137-139 arthrokincmatics of, 138 capsular pallcm in, 138 osteokinematics of. 137-138 range of motion of, 140, 140t-141t

functional. 143-144, 144t gender and, 248t, 248-249 IN D EX 397 normative values for, 376t injury and, 250 numerical recording form for, 389f normative values for, 378t anatomy of, 57, 57f-58f Fingertip-to-floor method numerical recording form for, 390f arthrokinematics of, 57~58 in thoracic and lumbar spine testing reliability and validity in tt.>sting oE, capsular pattern of, 58 of flexion, 345 osteokinematics of, 57 of lateral flexion, 358, 358f 252-254, 253'-254t range of motion of reliability at 340--341 research findings in, 246t, 246-247 Fishermen testing position and, 249t, 249-250, abduction in, 78, 79f, 80 lumbar and thoracic spine testing in, exten.<;ion in, 74, 75f, 76 335-336 38lt flexion in, 70, 71f, 72 Flexible rulers transverse tarsal eversion of lateral rotation in, 86, 87f, 88 in cervical spine h..>sting medial rotation in, 82, 83f, 84 reliability ot 306 testing nf, 276f-278f, 276-278 normative values for, 376t in thoracic and lumbar spine testing transverse tarsal inversion of numerical recording form for, 388f age and, 334 research findings in, 60t, 6CJ.-61 reliability ot 341 testing of, 274f-275f, 274-275 Flexion. See specific joints Forearm, 91-109. See also Elbow Goniometers, 21-27, 22£-25£. See also Flexor digitorum muscles muscle length testing in, 128f-13l£, anatomical landmarks of, 99, 99f specific typt-'S of instruments 128-131 range of motion alignment of, 27f-29f, 27-29. See tllso Flexor muscles of hip anatomy of, 206£, 206-207 testing position and, 38lt Alignment muscle length testing in, 206f-211f, range of motion of, 99f-lOSE, 99-105 e1ectrogoniometers as, 25-26 206-211 fluid (bubble), 24-25, 25f Fluid goniometers, 24-25, 25f normative values for, 375t gravity-ciepcndent, 24-25, 25f reliability of numerical recording form for, 388f measurement errors with, 29 in elbow testing, 98 structure and function of, 91£-93f, 91-92 metal,22 in knt..'e testing, 228 Forefoot. See also Foot pendulum, 24, 25f Foot. See also Ankle in transverse tarsal eversion testing, plastic,22 anatomical landmarks of, 255f, 263t 269t 276f-278f,276-278 price lists for, 383t-385t 279f in transverse tarsal inversion testing, proximal and distal arms of, 28-29, 29f anatomy of, 241-245, 242f-245f 274f-275f,274-275 recording of measurements with, 29-34, arthrokinematics of, 245 Frt'Cdom of motion dcgret-'S dorsiflexion of defined,6 31f-33f functional range of motion in, 250-252, Frontal plane reliability of, 41-43, 43t defined, 4, 5f 251f Fulcrum in ankle and foot testing, 252-254, reliability of testing of, 253, 253t in goniometer alignment, 29 253'-254t eversion of Functional axial rotation device reliability of testing of, 253, 254t in thoracic and lumbar spine testing, in cervical spine testing, 303-306, 304t transverse tarsa.! tt.>sting of, 276f-278f, 341 in elbow testing, 98 Functional range of motion in hand testing.. 144-145 276-278 ankle and foot, 250-252, 251f-252f, 251t in hip tl.'Sting.. 190-192, 19lt interphalangeal extension of cervical spine, 302f-303f, 302-303 in knee testing, 227t, 227-228 elbow, 96t, 96-97, 97f-98f in shoulder testing, 66-67 testing of, 287 hand, 143f, 143--144, 144' in temporomandibular joint testing, interphalangeal flexion of hip, 189f-1901. 189t, 189-192 knl..\"C, 225, 226f-227f, 226t 369 tt.>sting of, 287 shoulder, 63, 64f-65f,64t in thoracic and lumbar spine testing, inversion of thoracic and lumbar spine, 337f-338f, 337-338 338-342,339t reliability of testing of, 253, 254t wrist, 115t-116t, 115-117, 116f-117f in wrist testing, 117-119 transverse tarS-II tt.>sting of, 274f-275f, universal, 21-24, 22f-24f. See also G Universal goniometer 274-275 Gastrocnemius muscle visual t.>stimation verSlIS, 26-27 metatarsophalangeal abduction of Gonjometry anatomy of, 288, 288f basic concepts in, 3f, 3-14, 5f-7£, 8t-9t, testing of, 284f-285£, 284-285 muscle length testing in, 288f-291£, lIt,I3H4f metatarsophalangeal adduction of basic objcctivt.'S in, 1 288-291 defined, 3 testing of, 286 Gender example of, 3b, 3f metatarsophalangeal extension of explanation procedure for, 34-36 range of motion and, 12 indications for, 4 testing of, 282£-283f, 282-283 ankle and foot, 248t, 248:-249 tt.'Sting procedurt.>s in, 35-36 metatarsophalangeal flexion of cervical spine, 299t-300t, 299-301 Gravity-dependent goniometers elbow, 95 overview of, 24-25, 25f testing of, 28Of-281£, 280--281 hand, 141, 14lt reliability of osteokincmatics of, 245-246 hip, 186t, 187 in cervical spine testing, 303, 306 plantarflexion of knl.'e,225 in thoracic and lumbar spine testing, shoulder, 6Ot, 61--62 functional range of motion in, 250, temporomandibular joint, 367-368 340--341 251f thoracic and lumbar spine, 334-335, Gripping 335t-336' reliability of testing of, 253, 253t wrist, 114 range of motion nt.'Cessary for range of motion of hand, 143f, 143--144 Glenohumeral joint age and, 247, 247f Grooming. See Personal care activitk.'S disease and, 250 Guides to the Evaluation of Permanent functional, 250-252, 251£ Impairmerd, 34