__Measurement_of_Joint_Motion__A_Guide_to_Goniometry_3rd_Edition

CHAPTER 3 VALIDITY AND RELIABILITY 41 ~ill-ement tools to identify functional limitations and has poor reliability is not dependable and should not be used in the clinical decision-making process. ict disability.2I Joint ROM may be one such mea- Summary of Goniometric Reliability Studies ment tool. In Chaptets 4 through 13 on meaSUte- ~t ptocedures, we have included the tesults of research The reliability of goniometric measurement has been the focus of many research studies. Given the variety of St!Idies that report joint ROM observed during func- study designs and measurement techniques, it is difficult 'ti~nal tasks. These findings begin to quantify the joint to compare the results of many of these studies. However, some findings noted in several studies can be .\": iiiOtion needed to avoid' functional limitations. Sevetal summarized. An overview of such findings is presented here. More information on reliability studies that pertain :;;:reieatchets have artificially restricted joint motion with to the featured joint is reviewed in Chapters 4 through 13. Readers may also wish to refer to several reviewarti- ',j\"splintS or braces and examined the effect on func- cles and book chapters on this topic. 6.Z8-3. ~. oon.22- 24 It appears that many functional tasks can be ·~'2cornpleted with severely restricted elbow or wrist ROM, The measurement of joint position and ROM of the extremities with a universal goniometer has gener- ·q!providing other adjacent joints are able to compensate. A ally been found to have good-to-excellent reliability. '. recent srudy by Hermann and Reese25 examined the rela- Numerous reliability srudies have been conducted on .'\" ~tionship between impairments, functional limitations, joints of the upper and lower extremities. Some studies have examined the reliability of measuring joints held in .. add disability in 80 patients with cervical spine disorders. a fixed position, whereas others have examined the reli- ability of measuring passive or active ROM. Studies that ,odified:· ~,'The highest correlation (r = 0.82) occurred between measured a fixed joint position usually have reported higher reliability values than studies that measured rd crro~~ :_:_ i~pairment measures and functional limitation mea~ ROM.s,l2.3l.32 This finding is expected because more Iy of U( 'f sur~, with ROM contributing more to the relationship sources of variation and error are present in measuring p'lumba\",'\" th~n the other two impairment measures of cervical ROM than in measuring a fixed joint position. Additional sources of error in measuring ROM include with a.\\~ JJ,:m'uscle force and pain. Triffirr\"6 found significant corre- movement of the joint axis, variations in manual force applied by the examiner during passive ROM, and vari- ,omete2\" .0'-'Iadons between the amount of shoulder ROM and the ations in a subject's effort during active ROM. rclariorij: ,?,ability to perform nine functional activities in 125 The reliability of goniometric ROM measurements ,ns ma~; \"\"B~tients with shoulder symptoms. Wagner and varies somewhat depending on the joint and motion. ts were\"; '~0lleagues27 measured passive ROM of wrist flexion, ROM measurements of upper-extremity joints have been found by several researchers to be more reliable than subjects'.j , '''><tension, radial and ulnar deviation, and the strength of ROM measurements of lower-extremity joints,33,34 although opposing results have likewise been reported.\" Id skifli; ,the wrist extensor and flexor muscles in 18 boys with Even within the upper or lower extr~mities there are differences in reliability between joints and motions. For tanding@, puchenne muscular dystrophy. A highly significant nega- example, HeUebrandt, Duvall, and Moore,36 in a study of upper-extremity joints, noted that measurements of s were;. ,tive correlation was found between difficulty performing wrist flexion, medial rotation of the shoulder, and abduc- tion of the shoulder were less reliable than measurements one forf functional hand tasks and radial deviation ROM (r = of other motions of the upper extremity. Low37 found ROM measurements of wrist exrension to be less reliable 27·W·.y of ~.76 to -0.86) and between difficulty performing func- than measurements of elbow flexion. Greene and WolflS reported ROM measutements of shoulder rotation and [ements. tionaI hand tasks and wrist extensor strength (r = -0.61 wrist motions to be morc variable than elbow motion and other shoulder motions. Reliability studies on ROM phs for,' to -0.83). measurement of the cervical and thoracic spine in which a universal goniometer was used have generally reported relation -, lower reliability values than studies of the extremity joints.17•39....2 Many devices and techniques have been >rkers IS ,.' • Reliability developed to try to improve the reliability of measuring J3rienrs .'0 ;d radi.! The reliability of a measurement refers to the amount of Jctwecn consistency between successive measurements of the same variable on the same subject under the same condi- y of 54 tions. A goniometric measurement is highly reliable if It taken successive measurements of a joint angle. or ROM, on the h radi- same subject and under the same conditions yield the [ corre- same results. A highly reliable measurement contains I. Sarno little measurement error. Assuming that a measurement is d radi- valid and highly reliable, an examiner can confidently use of flex· t values its results to determine a true absence, presence, or ld with change in dysfunction. For example, a highly reliable 4 to 5 goniometric measurement could be used to determine the presence of joint ROM limitation, to evaluate patient progress toward rehabilitative goals, and to assess the effectiveness of therapeuric interventions. A measurement with poor reliability contains a large ) meas- amount of measurement error. An unreliable measure- Iscd to ment is inconsistent and does not produce the same vcment results when the same variable is measured on the same 'alidate subject under the same conditions. A measurement that

42 PART I INTRODUCTION TO GONIOMETRY spinal motions. Gajdosik and Bohannon6 suggested that thing :1 11l;ldlt'lll~Hi(;I1 model. dl'!lTlllillcd rh;u g(Hliomd; the reliability of measuring cenain joints and motions .1l~~h: ~~H)rtntel' ... with l(lIl~t'r .Hllh :lrc lllort' :lL·..:IILllc 1f1 II1c:l~uringa\"0' might be advetsely affected b)' the complexit)' of the ill;111 gPl!iOll1l·tt·\"'\" \\\\'lIh ;lffll .... joinr. Nleasurcmem of motions that arc influenced by (;tllli(>IlH:re~ movement of adjaccm joints or rnultijoim muscles may \\\\'Hh longer .Irtn... rl·dtll't· rhe dh.·d ... ot l'l\"ror~ III rill.: place, be less reliable than measurement of motions of simple hinge joints. Difficulr)' palpating bony landmarks and mCI.1t of till' g~/,~li~)llll\"rl\"r .lxi~.. ~ IO\\\\Tvl'r, RCJ.dl'>~t:ill. Mille.~ passivcl)' moving heavy bod)' pans rna)' also playa role in reducing the reliability of measuring ROM of the ;llltl I{(lcngcr found 1I0 dlttCI\\:Il(l' III fcll:lhdlt)' amon' lower extremity and spine.6•33 hrgc pLl\"til'. Lngc l11l'raL :lIhl sll1,IlI pLlstic universa Many smdies of joint mcaswcmenr methods have ~olli()llh.:tcr~ u...nl 10 Illt',lSllI\\' klll:e ,1lId dhow ROMi found intratester reliability to be higher than intertesrer reliability.17,31-J7.J9,4o..n-62 Reliability was higher when I{iddk·. Rorh:-(cill. :lIld L1Illh';' ,JiSIl rt\"fwrtnl IlO diffefl successive measurements were taken by the same exam· cncc III l'l'!i,lhilily hl'l\\\\'lTll Iargl.: .Jlld ... Ill.dl pb~tiL' llnive~~ iner than when successive measurements were taken by ... :11 ,;:,olliolllt'll'r:- lIscd W 1lll\";hHrt· ~llOulder RO.\\-!. \\~ :-\\tlllll'rous :..rudil·~ h:1Vl' COlllp:lrl·d tilt' mt'.lsuremerit~ different examiners. This is true for studies thar mea- sured joint position and ROM of the extremities and \\';l!1Il''' ;JIll! rt'li,lhi!ity ot' diffl'n:1H typt·s (d' dC\\'iccs llscdftf spine with universal goniomcrcrs and Other devices such as joint-specific goniometcrs;' pendulum goniometers, lIlL\";l.... llrt: ioint. '.{O.\\·t. ~~.l\\i\\·L\"'>11. pcndululll. and tlUi~ tape measures, and flexible rulers. Only a few studies found intertester reliabiliry to be higher than intratester ';:'1 HlHJllll'll'r:-, !ClIIlI-:,Pl'L:ltlL' lk\\·h':L\":>. {,I 1'1.' lllca:-urcs, and! reliability.63-66 In most of these studies, the time interval between repemed measurements by the same examiner wire traL'illg :\\IT S(lllll' elf rhl' dl'VILTS tll,H h;l\\'(: be'\" ~ was considerably greater than the time interval between measurements by different examiners. ,,-olllparni. ~tlldi;,::> (ol1lp;lflng ,.:Iillie,:al 11ll\":1SUrcment' dn·i .......·;o, h;1\\'t· hecl1 L:Ollllu([(·d Oil rhe sholJld('rJ6~i: The reliability of goniometric measurements is affected by rhe measurement procedure. Several studies cl how, \\i. ,r\" ;~, -;\" .. ;....; W risl. ; t.;\" 11<1 Ill!. L:, ~ \".\"~. \"'\" Il ip>i:,?I1' found that inrenester reliabiliry improved when all the examiners used consistent, well-defined testing positions knce'; -'°' ..'11 :Ulkk, -\" ..' I LLT\\'il\"d -\"I'I Ill', ;\",·;'.l\".·I,S! an't and measurement methods.44,-16.47.67 Intcrtestcr reliabil- ha.\\t(_hOr.l\\:olulHh:H Sr'llll', It',':lJ.-: I.\".: .... ; \"i! .\\ l;Hl~' ... rlldie:s ity was lower if examiners used a variety of positions and mea.. ·tOlllhl dittnl'lln· 10 '·allll.·\" .111\\.1 r\\·li:lhiJity hl·!Wl'l.'ll measurement methods. ... lIrt·llll·m dL\"vin' \\\\·hLTl·,lS SOlllC :-tudil·... h,l\\'c ft'purred n~ . Sta' Several investigators have examined the reliability of dit't'.,:n.·lIct\"s. .~~ using the mean (average) of several goniometric meas- M~ urements compared with lIsing one measurement. Low37 III (Olh,:11l:-ic.1I1, OJl rill.: h,lsis of l'l'li;Jhilin' sludics ari~ recommends lIsing the mean of several measurements ',~}M made with the goniometer to increase reliability over one nul' dillictl \\'.'\\['l.'ril.'llCl', wc rl'l.:Cllllilll·J1d ;lJl' followigi measurement. Early studies by Cobe6 ' and HewittG9 also Cli~ used the mean of several measurements. However, Boone procedures to imrro\\'l' rhl' rl'!iahilit\\, of ~()fliomcrrn and associates33 found no significant difference benveen vad repeated measurements made by the same examiner Illl'JSllrl'IlH:llh (Llhlc 3-1 L E\\;,lllliTlcr~ ~h(JlI!llllSl' (ons~~ during one session and suggested that one measurement ';)\\\\(ari taken by an examiner is as reliable as the mean fCIIl. wdl-der·illl..\"d rl':,.ring PO:-iljolb and :ll1aromicllla of repeated measurements. Rothstein, Miller, and van Roettger;' in a study on knee and elbow ROM, found IJJ;lfk~ ro ;lligll rhe :lrlllS of rill\" gOlliollll'kr. Dud ';':one: that intertester reliability determined from the means of rwo measurements improved only slightly from the Sllccl'ssin.: 1ll(':lSurCllll\"IHS ot' p;bsi\\'c 1\\0\\1. l'xamin t~~a~l intertester reliability determined from single measure- .. hould .. lri\\,l' 10 ;lppl~' ihe ,<lillt\" ;lIllOLlIl! ot' manual fo mid ments. In llltl\\·c the ... uhjccr\\ b(ld~·. I)urillg Sllc~(:ssi\\'l' IllC<lSU lllelH\"; (It ;lLri\"l.· RO.\\1. rill' \"uhil'L'i ... llOUld hL' urged, ~ha'l The aurhors of some texts on goniometric methods eXer[ thl.' ~;1I1l1.' l:tfor{ (u perforlll a Illution. To red suggest the use of universal goniomctcrs with longer 1lH.:;ISlm.\"l1ll·l1( \\,;Iri;lhilit~·, i( is pnllklH to rakt· repeat co~n: arms to measure joints with large body segments such as Illc:bllrelllCIHS 011 <l suhjn:t with the sainI.' 1~'Pl\" of m' the hip and shoulder.!\",o.7l Goniometers with shorter .• rhy! Sllrt::llll'nr dt:\\'ici.'. For n::llllpk, all l'.'\\;uniner should ra, arms are recommended to measure joints with small all repe;l[ed 1Il1.':1~lIrl.'lllL\"iHS of an RO.\\I wjrh ;J unive\" ».:urer body segments such as the wrist and fingers. Robson,\" ~<~>'~r <,S99:l ;:.:.pthreO')i ~()lli(lllll'f(:r, rarha t!l;lll f:lkilH.:. rhe ,'irq llll':lsurcmen ;.~\"expl ~~'ith ;1 lllli\\'l'rs:d ~Olli(lI1H.\"rt'r ~lIh.i the ..;c.,:olld lllL\"asllrcmi~t <'::'ure-t: wirh :1ll in(.:linolllcrer. \\'(it' belien' lllosr cxalllilh.,'rS lin<61\" ';, ,,~ \"!~$ clSin ;llld lllore ;lL'(llr:lll' t'() usc <l brgc LJllivci~1 ,me'retO6 .;:.oniollll'tl'r wh('n llleasuring ioinrs with LHgC bo,.; sq!.IlH:nts. ;llHI a slllall g(HliclIlll'rn when mcasuring jOlg~ ~;~(a{jb~l~J~ with sm:lll hod~' :-cgllll·llrs. Illl'XpcriclIL'l'd eX:llllincrs m~at wish w rake Sl'\\Tral llll':lsurCllll'IHS alld n..·l·ord the m - >c. data (;H't:r:lgl\"l 01 (hose 1l1l':tsur('lllCIHS to illlpro\\'...· rdi:lbiH :~ii;gig1~ cod hut Olle Illl';JSllrclllcl1t is lIsu:tlly sut't'iciellt for Illore eX riclli..:cd CX:1I11illcrs using good It..'chniquc. hn:llly, i u~ili illIP()!\"f:lllr to l\\'lllclllhcr thar SllC.·l'L\"ssi\\'{\" Illl'aSUrClllcnrs ~ ·/,s:,\".~!~,',f~'Vi~ more n.\"li:lhh· if r,lkcll h~' rhe :':illll\" l'x;lInillCf r:lthcr rh:. 4t~Y:~ In' dillLTc!H eX:lI11ill(\"r~. Tilt\" lllt';1I1 st:mdard dC\\'i:Hion~, '{~g~ r~'pt.';lfl\"(.1 RO.\\-I 1lll\":lStlrt:llll'llI (If l'xrrc-mitr joint:' rakcn .~~ : erro OIll' l'x~ll1liJ1LT t1Sill!!,,. a ulliversal .gOl'lio'lllcrcr has b~1~ ;\".,!:\",.\"

CHAPTE R 3 VAll D ITY AN D REL lAB 11ITY 43 Home- TABLE 3-1 Recommendations for Improving the Reliability of Goniometric Measurements ing an .~~ . l1Ctcrs ':;\" place-;- \"liller,\" ;5 lmong.\", . ivcrsal ROM._, differ--. Inlvcr- ementi: found to range from 4 to 5 degrees. 33•35 Therefore, ro show the calcularion of these statisrical tests are sed to show improvement or worsening of a joint motion meas- 'ured by the same examiner, a difference of about 5 presented. For additional information, including the fluid!, , degrees (1 standard deviation) to 10 degrees (2 standard assumptions underlying the use of these statistical tests, ;, and :/ . deviations) is necessary. The mean standard deviation the reader is referred ro the cited references. , been, increased to 5 ro 6 degrees for repeated measurements raken by different examiners.33•35 These values serve as a At the end of rhis chapter, two exercises are included emcm:;~ general guideline only, and will vary depending on the for examiners to assess theif reliability in obtaining joint and motion being tested, the examiners and proce- goniomctric measurements, Many authors recommend :r,36,3S dures used, and the individual being tested. that clinicians conduct their own studies to determine reliability among their sraff and patient population. p,77,78 Statistical Methods of Evaluating Miller29 has presented a step-by-step procedure for Measurement Reliability conducting such studies. 2 and ; havc Standard Deviation I mca- ted no In the medical literature, rhe Statistic mosr frequently used to indicate variation is the standard deviation.91 ,92 :S and Clinical measurements are prone to three main sources of The standard deviation is the square root of the mean of variation: (1) true biological variation, (2) temporal the squares of the deviations from the data mean. The oWing variation, and (3) measurement error!' True biological variation refers to variation in measurements from standard deviation is symbolized as SD, s, or sd. If we metric one individual ro another, caused by facrors such as age, denote each dara observation as x and the number of sex, race, genetics, medical history, and condition. observations as tl, and the summation notation I is used, :onSlS- Temporal variation refers to variation in measurements rhen the mean that is denoted by X, is: made on the same individual ar different rimes, caused by I Iand- changes in factors such as a subjecr's medical (physical) Ix )uring condition, activity level, emotional state, and circadian l1lners rhythms. Measurement error refers to variation in meas- mean = x = I force urements made··on the same individual under the same 11 'asurc- conditions at different times, caused by faerors such as ~ed co the examiners (testers), measuring instruments, and Two formulas for the standard deviation are given reduce procedural methods. For example, rhe skill level and below. The first is the definitional formula; the second is pea ted experience of the examiners, the accuracy of the meas- the computational formula. Borh formulas give rhe same f mea- urement instruments, and the standardization of the result. The definitional formula is easier to understand, d take measurement methods affect the amount of measurement but the computational formula is easier ro calculate. iversal error. Reliability reflects the degree to which a measure- 'cmcnt ment is free of measuremenr error; therefore, highly reli- Standard deviation = so= > (x-x)' 'emem find it able measurements have little measurement error. ,,-1 iversal Statistics can be used to assess variation in numerical SD = body data and hence to assess measurement reliability.91.92 A The standard deviation has the same units as the orig- .JOlntS digression into statistical merhods of testing and express- inal data observations. If the data observations have a ing reliability is included ro assist the examiner in normal (bell-shaped) frequency distribution, 1 standard .\"S may correctly interpreting goniometric measurements and in deviation above and below the mean includes about 68 understanding the literature on joint measurement. percent of all the observations, and 2 standard deviations mean Several statistics-the standard deviation, coefficient of above and below the mean include about 95 percent of lbiliry, variation, Pearson product moment correlation coeffi- the observations. : expc- cient, intraclass correlation coefficient, and standard ., it is error of measurement-are discussed. Examples that nrs arc ~ than jon of fen by I been

44 PART I INTRODUCTION TO GDNIOMETRY Grand mean (X) = (59+67 + 70+ 39+45) = 56 degrees. 5 It is important to notc that several standard deviations <1rioll indicating hiological vari;'Hioll is found in may be determined from a single srudy and tepresent 3-3. different sources of variation!' Two of these standard deviations are discussed here. One standard deviation The standard dc..:vimioll indicating hiological varia rio that can be determined represents mainly irztersubjecr variation around the mean of measurements taken of a equals 13.6 dcg,n:es. This standard deviation denotes group of subjects, indicating biological variation. This standard deviation may be of interest in deciding whether primarily inrcrsllbjl:<':c variation. Knowledge of intcrsUbf a subject has an abnormal ROM in comparison with other people of the same age and gender. Another stan- jeer variation may be hdrful in uc..:ciding \\vhcrher ( dard deviation that can be determined rcpresems intra- stlbjccr Ius an ahnnrl1l~tl RO!\\·t in comparison with othe~ subject variation around the mean of rncasurcmenrs pcople of the same agl.' and gender. Ii a normal dis[ribu;~ taken of an individual, indicating measurement error. This is the standard deviation of interest ro indicate {ion of rill' IllC;'Isurenll'nrs is ;lSSllml'(l, one wav of inter:' measurement reliabiliry. pn.:ting this stand,lrd deviation is to predier tha~ ahour 68~ An example of how to determine these twO srandard deviations is provided. Table 3-2 presents ROM meas- percell[ of all the subjccrs' meall 1(0'\\'1 IllC;lsurcmcn~\" urements taken on five subjects. Three repeated meas- would fall herween 41.4 dc:grccs and 69.6 Jt'grccs (pl~ urements (observations) were taken on each subject by the same examiner. or minus I S(;Hldard dt'vi,uioll around rhe ,:,r;llld mean ob' '\"/'&:; The standard deviation indicating biological variation 56 degrt·~·s). \\'(/<; would expeer (h;H ahow' 95 percent .0'1 :>j (intersubject variation) is determined by first calculating all the subjects' mean RO.\\l mcasuremenrs would fall the mean ROM measurement for each subject. The mean between 28.S degrees and 8.1.2 degrccs (plus or lllinusJ;~ '1 ROM measurement for each of the five subjects is found in the last column of Table 3-2. The grand mean of the standard deviations ;lround rhe grand llleiln of 56 i.Xl mean ROM measurement for each of the five subje£!.s ch:·grc(·s). tlDr: equals 56 degrees. The grand mean is symbolized by X. The standard dcviiltion indicating measurement e \"'.<j The standard deviation is determined by finding the (ill,rraslIhjcc[ v:lriation) 31so IS d('[(:rrnilled by first cal~ differences between each of rhe five subjects' means and app the grand mean. The differences are squared and added laCing the mean ROM measurcment for e<lch subjeC:ff together. The sum is used in the definitional formula for if t1 the standard deviation. Calculation of the standard devi- However, this standard deviation is dctermined bv fin'ik ing the difftrCllccs bcrwn'n cach of (he rhrcc rc'peat~ witl I1H:aSUreI1lCfl(S taken on a subjecr and the nh:;ln of [~ thg de~ a-: _subj('cr's 1l1l,:aSllremcnts. Thl..· dilfcn:ncc$ ;Ire squarcd indl added together. The sum is used in rhe ddinitio@ formula for the standard d('\\'iarion. Cdcularion of ~ oftn standard dcviarion indic<.Hing Illl.'astlrC!llellt error {Of ert'Ca:''c me~ (Iil rep~ me\", subjcC,t I ,is fOlJJ,l~1 in ·~lhlt.' 3-4. -~ Rdcrnng ro fable -,-2 and using rhe S:lIllL' proced~ as shown in Tablt: 3-4 for (.\"1I.:h slIhitcr, rhe smodafd' deviation for suhjed I :::: 5.3 (!t:grccs, the standard d~ 56 56 56 56 J' r;;-;:Irx-x)' = 9+121+196+289+121 = 736 degrees; SD= 56 (X- X)' -(,,-1) = V(5~i = 13.6 degrees.

C HAPTE R 3 VA LI 0 I TV AN 0 REllA Bill TV 45 =. . .~clbject 2 2.6 degrees, the standard deviarion a percentage and is not expressed in the units of the orig- inal observation. The coefficient of variation is symbol- anol~cI;-\"Ca3 = 4.0 degrees, the standard devIation for ized by CV and the formula is: . for-;.~\"'~i= 3.6 degrees, and rhe standard deviation for coefficient of variation = CV = S!? (100)% ,su~J~}.~-3.0 degtees. The mean standard deviarion for x ,, s~utIo'kJ·'e~fct\\'t~i-l£.i\"1'ec;.J's•juebcjtese'rsstacnomdabrd'meddev'IiSardioentesrmanm.deddividyibnsugmbym'mthge For the example presented in Table 3-2, the coefficient ugl. ·,· ,·\".,';: '/;er.9f.snbJe,cts; which IS 5: of variation indicating biological variation uses the stan- ·1Si:'•.'.;.:•..(.: ,: .,:\", dard deviation for biological variation (standard devia- tion = 13.6 degrees). \"5.3 + 2:6+4.0 + 3.6 + 3.0 = -18-.5 =3.7degrees SD= . '.' 5 5 \"\"'/.:'.y': j in TABLE 3-4 Calculation of the Standard 6CV = S~ (100)% = 1: 6 (100)% = 24.3% Deviotion Indi(a~in9 Measurement Error in DegreeS for SubJect 1 .._ The coefficient of variation indicating measurement error uses the standard deviation for measurement error (standard deviation = 3.7 degrees) L(x-iJ'p:~+16+ 36 = 56 degrees. CV =S!? (100)% = 3.7 (100)% =6.6% x 56 (Ji.SDe ,'(%':.%)' ,=, ~2 = 5.3 degrees In this example the coefficient of variation for mea- Surement error (6.6 percent) is less than the coefficient of T(n-1) variation for biological variation (24.3 percent). rhe standard deviation indicating intrasubject varia- Anorher name for the coefficient of variation indicat- ing measurement error is the coefficient of variation of tion'equals 3.7 degrees. This standard deviation is replication!' The lower the coefficient of variation of appropriate for indicating measurement error, especially replication, the lower the measurement error and the if the re\"eated measurements on each subject were taken better the reliabiliry. This statistic is especially useful in within a shorr period of time. Note that in this example comparing the reliability of two or more variables that the standard deviation indicating measurement error (3.7 have different units of measurement; for example, degrees) is much smaller than the standard deviation comparing ROM measurement methods recorded in indicating biological variation (13.6 degrees). One way inches versus degrees. of interpreting the standard deviation for measurement error is to predict that abour 68 percent of the repeated Correlation Coefficients measurements on a subject would fall within 3.7 degrees (\\ standard deviation) above and below the mean of the Correlation coefficients are traditionally used to measure repeated measurements of a subject because of measure- the relationship between two variables. They result in a ment error. We would expect that about 95 percent of the number from -1 to +1, which indicates how well an repeated measurements on a subject would fall within equation can predict one variable from another vari- 7.4 degrees (2 standard deviations) above and below the able. 2-4.91 A +1 describes a perfect positive linear mean of the repeated measurements of a subject, again (straight-line) relationship, whereas a -1 describes a because of measurement error. The smaller the standard perfect negative linear relationship. A correlation coeffi- deviation, the less the measurement error and the bettcr cient of 0 indicates that there is no linear relationship lhe reliability. between the two variables. Correlation coefficients are used to indicate measurement reliability because it is Coefficient of Variation assumed that two repeated measurements should be highly correlated and approach a + 1. One interpretation Sometimes it is helpful to consider the percentage of vari- of correlarion coefficients used ro indicate reliabiliry is attOn rather than the standard deviation, which is that 0.90 to 0.99 equals high reliability, 0.80 to 0.89 expressed in the units of the data observation (measure- equals good reliability, 0.70 to 0.79 equals fair reliabiliry, lUent). The coefficient of variation is a measure of varia- and 0.69 and below equals poor reliability!· Another tion that is relative to the mean and standardized so that interpretation offered by Portney and Watkins' states the variations of different variables can be compared. that correlation coefficients above 0.75 indicate good The coefficient of variation is the standard deviation reliability, whereas those below 0.75 indicate poor ro divided by the mean and multiplied by 100 percent. It is moderate reliability.

r 46 PART I INTRODUCTION TO GONIOMETRY Because goniomctfIC measurementS produce ratio sun:llltlH. II rht· iIHen:q1£, and b (hI.' slopt. The I.:qu;:nion asSO' level dara, the Pearson product moment correlation coef- varia ficient has been the cotcelation coefficient usually calcu- for a slope is: ance. lated to indicate the teliability of pairs of goniometric and:',; measurements. The Pearson product moment correlation slope = /; :: ~~(:y::,)L~:Yi coefficient is symbolized by r, and its formula is a nee: presented following this paragraph. If this statistic is used ~.(x-).:)·~ error [Q indicate reliability, x symbolizes the first measurement and y symbolizes the second measurement. '1'111.' equarioll tor ~1Il illtt'fcqH is: inn:rcqH ~ TI valu{ a j: -c;;; b:\\: the '; modi hH Ollr cX<llllpk, tht slope and inrcn.:cpt Jrt· cllcn-; form !att:d as follows: of te, a Jar) Refetcing to the example in Table 3-2, the Pearson gene) correlation coefficient can be used to determine the rela- Y-II .:0:0 /Ix = 55.6 - O.SS(5.LS) ,,\"'~ 8.26 teste· tionship between the first and the second ROM meas- cons: urements on the five subjects. Calculation of the Pearson The eql\\~\\[i()11 {If rhl' srraight li/lt: hc~r repr~senrillg the testCt produer moment correlation coefficient for this example re!.uionship hel\\\\'C'en rhe:: fir~;r ;lIld rhe st:coIl(! !llcasure· of te, is found in Table 3-5. The resulting value of r = 0.98 IllCnts ill rhc l'X:llllpk is y c=.' N.26 \"I, O.XBx, Although rhe~; the t indicates a highly positive linear relationship between the r valuL: illdic;H't'S high ..:orrcLHion, the t\\\\'o tlll:;lSUrl:melHs> testeJ singl, first and the second measurements. In other words, the :U(' not idenrical gin.·1l lhe linear eLjll;lrioll. two measurements arc highly correlated. One (\"(1/lCt'r!l ill iJHl'rprL'rin~ correbtioll (odfit:'il'nrs is seeOI {h~l[ the \\';llue of rht· l·orn·!ariol1 :l.. odficit'nr is markedly,: surer the I (x-x)(y-y) influcIll:ed hy the range of thl' ml·~\\SllrL'I1lL·nts, \\.\"~.\"~ The} parel r = -yrl.=-=;(x~-=x=f':-y\"';=L:~(y=_=y=)2 gn.:arer the hiologic11 vari,nioll bCtWctll individuals for; the Sl rht: IllC;lSUreIllCIH, the more extn... lllt· the r LtluC, so rh,H r' Sian, 650.6 _ _650_.6 _ =0.98 is clOSt'( to -lor -+ 1. Anmhcr limir:Hion is the f:lt:'r that to th (27.2) (24.4) the PC;lrson producr IllOnleIH correlation (ocfficicnt can In (:\\,;lILl~H(, the relationship berween only tWO variables or.. ance The Pearson product moment correlation coefficient mC;lSllr('I1lC!1ts at \" nme. 0.94. indicates association between the pairs of measurements rather than agreement. Therefore, to decide whether the 10 anlid rhe llecd for (;lkubting and interpreting\" men! Intcr both thl' corrdation coefficient :l11d a lillL':U equation, somt.· inq:srig;ltors uSt rhl' in(racl:tss corrchuion coeffi- twO measurements are identical, the equation of the cient {lCC) to evaluare rcli;\\bility. The inrraclass \\.:orrcla-;, mca~ sevc[ ~; straight line best representing the relationship should be ric)!) codficiellt is symholi ...cd as ICC. The ICC also':; relial determined. If the equation of the straight line represent- ;\\lIo\\\\'s rhe comparisoll of twO or more 1llC'<\\surcmcnrs at' How ing the relationship includes a slope b equal to 1, and an ;\\ timl'; OIlC call think of ir as all ;\\Vcr~lg(' (orrt!:1tion prod ;\\InOll~ all possible p:tirs of IllcaslirclllcfHs.')' This stiltis- the \\ intercept a equal [Q 0, [hen an r value that approaches sllbj( +1 also indicates that the two measurements arc identi- ric is determined from an analysis of v;Hiallce modell• whi..:h comp:Jrcs dit\"flTenr sources of \\'~Hiation. The ICe; Li cal. The equation of a straight line is y = a +bx, with x clem is COl1cl'prually expressed as the rario of rhe \\'ariance' symbolizing the first measurement, y the second mea- Surer TABLE 3-5 Calculation of the Pearson Product Moment -Co11r:r:e/,latJi£oi;,n Coefficient for the first (x) and beco Second Cv) ROM Measurements in Degrees - _~ ~. dete, -~; -:\" , indic Clent -1.92 0.36 do n 114.6B 20878.3366'§~ mc:a~ 175.68 243.36 ,'jt devi:: sran, r 293.28 57.761 mcOl 68.88 I ':: = 650.60 Star I = 738.80 The t 57 + 66 + 66 + 35 + 45 55 + 65 ;- 70 ;- 40 \" 48 that. X= 5 = 53.8 degrees; Y - -.---- -..- - -..------- ~ 55.6 degrees. 5

C HAP TE R 3 V A LID I T Y AND REllA B III T Y 47 sociated with the subjects, divided by the sum of the support because of irs practical interpretation in estima(~ as riance associated with the subjects plus error vari- avnace.96 The theoretical limits of the ICC are between 0 ing measurement error in the same units as the measure- and +1; +1 indicates perfect agreement (no error vari- ance), whereas 0 indicates no agreement (large amount of ment. According [Q DuBois, 101 \"the standard error of measurement is the likely standard deviation of the error made in predicting true scores when we have knowledge error variance). only of the obtained scores.\" The true scores (measure- There are six different formulas for determining ICC ments) are forever unknown, but several formulas have values based on the design of the srudy, the purpose of been developed to estimate this statistic. The standard Ihe study, and the type of measurement3 •96,97 Three rc ca!cu} error of measurement is symb olized as SEM, SEm .. avs~roir­ models have been described, each with twO different If the standard dcviarion ,~., forms. In Modell, each subject is tested by a different set Smcas. indicating biological Hing Ill( ation is denotcd SDx, a correlation coefficicnt such as the Illcasure- of testers, and the testers are considered representative of intraclass correlation coefficient is denoted ICC, and the oughtilf a larger population of testers-to allow the results to be llJ\"cmeri.'f£ Pearson product moment correlation coefficient is (?J generalized to other testers. In Model 2, each subject is denoted r, the formulas for the SEM are: ficiel1ts,~, rested bv the same set of testers, and again the testcrs are markedl)' SEM ~ SD.. V I-ICC conside;ed representative of a larger population of ,'I.!,9S T~~ lesters. In Model 3, each subject is tested by the same set or duals fcit of testers, b~t the testers are the only testers of intcrest- SEM~SDx ~ , so thaff. the results arc not intended to be generalized to other fact t~i testers. The first form of all three models is used when :cicnt c# single meas~tem~ms (1) are compared, whereas the The SEM can also be determined from a repeated riablesdi measures analysis of variance model. The SEM is equiv- ;::£..- second fornlisiused when the means of multiple mea- alent to the square root of the mean square of the ;~ error. 10-'. 103 Because the SEM'IS a speCl.aI case 0 f thc rcrprcu~g surements (k) are compared. The differem formulas for standard deviation, 1 standard error of measurement above and below the observed measurement includes the cqlla[io~ the ICCiar~ identified by two numbers enclosed by true measurement 68 percent of the time. Two standard parenth~~es,The first number indicates the model and errors of measurement above and below the observed ~n coeffE measurement include the true measurement 95 percent of ;s correl~ the secpnqn)!~b~r indicates the form. For further discus- the time. ICC alsiJ sion, example~; and formulas, the reader is urged to refer to the foll01\"'iJlg,rexts3 and articles.96-98 It is important to note that another statistic, the stan- 'exaniple,In OUf dard error of the mean, is often confused with the stan- a repeated measures analysis of vari- dard error of measurement. The standard crror of the mean is symbolized as SEM, SE\"t> SEi, or Si.',4,9,,92 The ance was conducted and the ICC (3,1) was calculated as usc of the same or similar symbols to represent different 0.94. Tilis ICC model was used because each measure- statistics has added much confusion to the reliability menc ~~as takcn by the same tester, there was only an literature. These two statistics are not equivalent, nor do they have the same interpretation. The srandard error of interest in applying the results to this tester, and single the mean is the standard deviation of a distribution of means taken from samples of a population. I ,2,n It measurements \",Jere compared rather than the means of describes how much variation can be expected in the several measur~mems. This ICC value indica res a high means from future samples of the same size. Because we reliability ben,,;';;n rhe three repeated measuremems. are interested in the variation of individual measure- ments when evaluaring reliability rather than the varia- However, this value is slightly lower than the Pearson tion of means, the standard deviation of the repeated measurements or the standard error of measurement is product momem correlation coefficiem, perhaps due to the appropriate statistical tests to use. 104 the variability added by the third measuremenr on each subject. Let us return to the example and calculate the stan- dard error of the measurement, The value for the intra- Like the Pearson product moment correlation coeffi- class correlation coefficient (ICC) is 0.94. The value for cient, the ICC is also influenced by the range of mea- SDx , the standard deviation indicating biological varia- surements between the subjects. As the group of subjects tion among the 5 subjects, is 13,6. becomes mare homogeneous, the ability of the ICC to SEM ~ SOx VI-ICC delecragreemenr is reduced and the ICC can erroneously md,cate poor reliability.J·96,99 Because correlation coeffi- cients are sensitive to'the range of the measurements and do not p,rovide an index of reliability in the units of the VD.06V13.6 1- 0.94 = 13.6 = 3.3 degrees ;~,~~u~~.~e,n~,_:some,expertsprefer the use of the standard ~~.la~~9,11.,: o~~,t.he··· repeated measurements (intrasubjecr stan\"d, ~F,;',d:...'d,:,~'Y.N'~t}qn) or the standard error of measure- menttoassessffeliability 4,99,100 S':' .i,)/;':>'::' <:')i:',:,:',':\\'//-::,:','}:',5i',.; • tCln9.Cl.tCi:!~nor of Measurement Tthh~'a.t~i,·~·\"~'/~\"~i/.'f,'~/,!/~!r.!~!'or of measurement is the final statistic 1\"'~I~y,~)'\"hereto evaluate reliability. It has received '::::,;':::\\:';\":/:::,:i< i;f~~~l~;,

48 PART I INTRODUCTION TO GONIOMETRY Likewise, if we use the results of the repeated meas- ·included in the belief that understanding is reinforced by ures analysis of variance to calculate the SEM, the SEM practical application. Exercise 6 examines intraresrer reli- ability. Intratester reliability refers to the amount of equals the square root of the mean square of the error = agreement between repeated measurements of the same joint position or ROM by the same examiner (tesrer). An vlO:9 = 3.3 degrees. intratesrer reliabiliry study answers the question: How accurately can an examiner reproduce his or her Own In rhis example, abour rwo thirds of the time the true measurements? Exercise 7 examines intcrtester reliabil- measurement would be within 3.3 degrees of the ity. Interrester reliability refers to the amount of agree- observed measuremem. ment between repeated measurements of the same joint position or ROM by different examiners (testers). An Exercises to Evaluate Reliability intertester reliability study answers the question: How accurately can one examiner reproduce measurements The two exercises that follow (Exercises 6 and 7) have taken by other examiners? been included to help examiners assess rheir reliabiliry in obtaining goniometric measurements. Calculations of the standard deviation and coefficient of variation arc 1. Select a subject and a universal goniometer. 2. Measure elbow flexion ROM on your subject three times, following the steps outlined in Chapter 2, Exercise 5. 3. Record each measurement on the recording form (see opposite page) in the column labeled x. A measurement is denoted by x. 4. Compare the measurements. If a disctepancy of mOte than 5 degrees exists between meas- urements, recheck each step in the procedure to make sure that you are performing the steps correcrly, and then repeat this exercise. 5. Continue practicing until you have obtained three successive measurements that are within 5 degtees of each other. 6. To gain an understanding of several of the statistics used to evaluate reliability, calculate the standard deviarion and coefficient of variation by completing the following steps. a. Add the three measurements togethet to determine the sum of the measutements. L is the symbol fot summation. Record the sum at the bottom of the column labeled x. b. To determine the mean, divide this sum by 3, which is rhe number of measurements. The number of measurements is denoted by n. The mean is denoted by x. Space to calculate the mean is provided on the recording form. c. Subtract the mean from each of the three measurements and record the results in the column labeled x-x. d. Square each of the numbers in the column labeled x-x, and record the results in the , column labeled (x-x)'. Add the three numbers in column (x-x)' to detetmine the sum of the squates. Record the . at the bottom of the column labeled (x-x)'. Jo the standard deviation, divide this sum by 2, which is the number of meas- ,-. (~{G!P~~tS minus 1 (n-1). Then find the square root of this number. Space to calculate the ,ta'}dar~ deviation is provided on the recording form. ;roc(jet.e,IIDu,e the coefficient of variation, divide the standard deviation by the mean. ,·.. !t!BPlj(t?is.number by 100 percent. Space to calculate the coefficient of variation is 'p\"loyided0tl 'the recording form. J}e,jJ\"e,~f.this pr?cedure with other joints and motions after you have learned the testing §pr(;i2eilufeS. ..... -''<'i' f/i;I:.~<:.-:-,

CHAPTER 3 VALIDITY AND RELIABILITY 49 forced bf RECORDING FORM FOR EXERCISE 6. INTRATESTER RELIABILITY ester re~? Follow the steps outlined in Exercise 6. Usc this form to record your measurements and the result of your calculations. naUnt _Of Subject's Name - - - - - - - - - - - - - - - Date _ the sa~ oster). ~ Examiner's Name - - - - - - - - - - - - - - - - - - - - _ _ on: HO$ . Jointand Motion _ Right or Left Side her o~if Passive or Active Motion _ Type of Goniometer _ r rcliabi¥ of agr~ I. Mea~urement X x--x (X_X)2 , arne iohn , x- ;rers). Ai 1 LX2 = ion: H~~ I' , suremenu' 12 ';;~ ~~ ;f\"\" ';P;; C',I \" Ix= I(X-X)2 = I> =-_ Yx ,,=3 Mean of the three measurements = x = = L .. J \"S[andard d .. = )~ (X-X)2 eVlatlOn \" or use SO = 2 y 2 _(Ix_) _x - tl n-l =Coefficient of variation = S~ (100)% x ,- e ; i- s g

50 PART I INTRODUCTION TO GONIOMETRY 1. Select a subject and a univetsal goniometer. ,, 2. Measure elbow flexion ROM on your subjecr once, following rhe steps outlined in Chaprer REFEREI 2, Exercise 5. 3. Ask twO orher examiners to measure the same elbow flexion ROM on YOilr subject, using your goniometer and following the steps outlined in Chapter 2, Exercise 5. 4. Record each measurement on the recording form (see opposite page) in the column labeled x. A measurement is denoted by x. 5. Compare the measurements. If a discrepancy of more than 5 degrees exists between meas- urements, repeat this exercise. The examiners should observe one another's measurements to discover differences in technique that might account for variability, such as faulty align- ment, lack of smbilizarion, O( reading the wrong scale. 6. To gain an understanding of several of the statistics used to evaluate reliability, calculate the mean deviation, standard deviation, and coefficient of variation by completing the follow- ing steps. a. Add the three measurements together to determine the sum of [he measurements. I is the symbol for summation. Record the sum at the botrom of the column labeled x. b. To determine the mean, divide this sum by 3, which is the number of measurements. The number of measurements is denoted by 11. The mean is denoted by x. Space to calculate the mean is provided on the recording form. c. Subtract the mean from each of the three measurements, and record the results in the column labeled x-x. d. Square each of the numbers in the column labeled x-x and record the results in the column labeled (x_x)1. e. Add the three numbers in column (x_x)1 to determine the sum of the squares. Record the results at the bottom of column (X-x)I f. To determine the standard deviation, divide this sum by 2, which is the number of mea- surements minus 1 (11 - 1). Then find the square root of this number. Space to calculate the standard deviation is provided on the recording form. g. To determine the coefficient of variation, divide the standard deviation by the mean. Multiply this number by 100 percent. Space to calculate the coefficient of variation is provided on the recording form. 7. Repeat this exercise with other joints and motions after you have learned the testing proce- dures. RECORDING FORM FOR EXERCISE 7. INTRATESTER RELIABILITY 1. 0 W Follow the steps outlined in Exercise 7. Usc this form to record your measurements and the results of your calculations. 2. K, Subject's Name _ Date _ Ri 3. p, Examiner 1. Name _ R, Examiner 2. Name _ Joint and Motion _ S, 4. R, Examincr 3. Namc _ Right or Left Side _ al I Passive or Activc Morion _ Type of Goniometer _ 11 5. Si rc 6. G a\", 7. A m r 8. G IT 9. E S,

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Il' \\trl'II\\~lh, l'~1 2, \\\\'itJi.lIll~ & Wi I\\;dl illlUl'l· •.~()()(l, 47. Rothstein, 1M, Miller, Pl, <llld Roettger, RF: Goniomctric relia· ';,,'w.: 72. Rill'sl'II, 1': A Itll'llll,d III I'Cdll~'l' Ill,' v,ll'I,lbk IIW;I,Ufl'IIICIll. '-\\111I 1'!Jvs ~k\" S:2.(,.~. 19(,(,. 73. (;tlod,nn. 1_ ~'l .11: (,hl;'~'.ll Illl'lill,d, 1,1 g..llll'llw.ry: :\\ .:o::r!.,-., 11\\·l' qll~k [\"IS.II-II R..,h.lhl1 1·1:10. I')').!. jJ- 74. l'l·lh~·rid~,.\\1. ,'f .11: t'olli,,·~lrrl·llI \".didH\\ .Ill.l111ll·rll'..f,;r rd~~ 01 Ill,i\\l·h.11 .III.! illlld-l>.lSl·.l g,\\\"lil>lIl{·I~·r, ltJr .I~'!ln· c1ho~\" \" \\,t mUllE,n, I'h~'\" I h~'1' hS:'/M;, I'ISS, ' 75. !\\f(>WIl, :\\. l't ;11: V;lIiditv .llll! r~'li;lhili(y tli' !Ill·

CHAPTER 3 VALIDITY AND RELIABILITY 53 '11;\"'. and therapy system in hand-injured parients. J Hand Ther uremcm merhods: Surface inclinometers. J Occup Environ Med i,\"!lt'i Or:;? diss,·;37.2000. 031: USI.~g t.h,e . Ha,I1~l1lastc-r (0 measure .. 39,217,1997. .1.1:342'0: Exos digital PL, ct 90. Brcum, J, \\Xrilbcrg, J, and Bolton, JE: Reliahility and concurrent rVlll,:nt:,<' r \"gel,of motion: Rel13blllry and valldlry. Med Eng I'hys 16:323, validity of the BROM II for me:asuring 11IIub:ar mobility. j ltl wire\", l:~r; MP, :lOd Wolf, SL: Compariso~ of the rcliabiliry. of Manipulative I'h)'siol Ther 18:497, 1995. Ill-\\iO!l':: the Orthocanger .:ln~ the smndard &?OIometer for assesslf'g 91. Cohon, T: Stalislics in Medicine. Little, Brown, Boston, 1974. oddied::: .; 2~~a~ive .. lower extremity range of mO(lon. Php Ther 68:214, 92. Dawsol1~Saundcrs. B, and Trapp, RG: 83Sic and Clinical luLlli\\\"ej;: Biostatistics. Appleton & L.'wse, Norwnlk, cr, 1990. G. 78.\"\",,I1f9IJ.i8;s8o.n. JB. d Sahrman, ~r\\: Pratterns·~ hlP r~tatl.on: 93. Francis, K: Computer communication: Reliability. Phrs Ther an Rose, SJ, 66,1140, 1986. ':;rA comparison bcrwcen healthy subJecrs and paIlents wnh low 94. Blesh, TE: Measuremenr in Ph)'sical Education, cd 2. Ronald . back pain. Ph)'s Ther 70:537, 1990. Press, New York, 1974. Cired by Currier, DP: Elements of Research in Phpical Therapy, ed 3. Williams & Wilkins, -9 Rheault. \\VI. ct al: Intcrrcster reliability and concurrent validity of ~~ 'c fluid-bascd and universal goniometers for active knee flexion. Balrimore, 1990. Rr:physTliee68,1676,1988. 95. Bland, jM, ::md Airman, DG: Measurement error and correbtion 80~'Ba\"rtho(omy,JK, Ch:lOdlcr, and Kaplan, SE: V~lidifY analysis coefficienrs. (stntistics no[cs], n:\"'1j 31.1:41,1996. i~i .~ of fluid goniometer measurements of knee flcxlon (abstract). 96. Lahey, l'vIA, Downey, RG, and 5aal, FE: IntracIass correbrions: :. '. Phys Ther 80,546, 2000. . .. . There's more there than nleelS the eye. Psychol Bull 93:586, '81. ,Rome. K) and CowlI~son, F: r\\ rehablhty stud)' of the uOIversal 1983. goniomcter, fluid goniomcter, and e1cctrogoniometer for the 97. Shout, PE, and Fleiss. JL; Imrac1ass correbtions: Uses in assess· ~.•~ 'measurement of anklc dorsiflexion. Foot Ankle Int 17:28, 1996. ing r.:lter rcliabilit),. Psychol 8u1l86:420, 1979. 82. Whitc, OJ. et al: Rcli:lbility of three methods of mc:\\suring cervi- 98. Krebs. DE: Compueer communic.:ltion: Imraclass correlation ., cal motion (abstract I. Phys Ther 66:771, 1986_ v cocffjciems. Phys Ther 64: 1581, 1984. 83:' Reynolds, PMC: Measurement of spinal mobility: r\\ comparison 99. Stratford, P: Rcliabiliry: Consistency or differentiating among subjects? {lerters to the editorl. Ph~'s Ther 69:299, 1989. 'ofthree.mcthods. Rheumawlo Rehabil 14:180, 1975. 84.;;i,1iiller: MH, ct :\\1: Mcasurement of spinal mobilir)' in the s:lgirt:ll 100. Bland, jM, and Altman, DC: .\"h'asurcmcm error. (statistics J; 5'pla.n,e: New skin distraction techniquc compared wirh t:st:tblished notesJ. BM] 312:1654,1996, \" \",;; ,/'m'cthods. ] Rhcumarol 11:4, 1984. 101. DuBois, PH: An Introduction to PsydlOlogical Statistics. Harper of';, 85~,;i:',9.i.U,'K, ct 0.1: Repeatability of four clinical methods for assess- & Row, New York, 1965, p 401. . I '.'<-:,,:,::/: 1t1Cllf lumbar spinal motion. Spine 13:50, 1988. 102. Stratford, P: Usc of [he st:lI1d:trd error 3S a n:li,lbilitv index of '86'~: qn,~Ol\"hl., 0: Determin:nion of the sagittal mobility of rhe lumbar interest: An applied example using elbow flexor stre~gth data . , spin~. ,Acta Orrhop Scand 37:241,1966. Phys Ther 77:745,1997. 103, Eliasziw, M, et al: Statistic:11 methodology for the concurrent 87~(;' 'W~ite; OJ, et al: Reliability of three clinical methods of mcnSl\\r- ,''\"':,'/..ing: ,Iaternl fle,xion in the thoracolumbar pine (abstractj. Phys assessmenr of inrerrater and imr:H3-tcr reliability: Using '),Thee 67,759, 1987. goniomctric measurement as nn example. Phys Ther 74:777, 8~; ~[ay'er, RS, et al: Variance in the measurement of sagirral lumbar 1994. ,.' range of motion among examiners, subjects, and instruments. 104. Bartko, jJ: Rationale for reporting standard deviations rather .Spine20,1489, 1995. [han standard errors of [he I1lC:IO. Am J Psychiatry 142: 1060, 89. '; Chcl,l, SP, et al: Reliability of the lumbar sagittal motion mens- 1985. \"'/Illix:r:-} ',: ilnion; .... ,·xPl:ri.f '-I:·16J,·~~ ,. h\\lnng t'rl'Il((: \"ilil~' 00 .:!;.US,,:,: ,! tk~­ d'lll<:C 1')'17. WiHll' Ollil\"lI. ~ ~:l' of lkills. I'.tf.l- hilil}\"

-, ,_.' <J)per~Extremity ;~i~ting . j~c:tives -- , ,\",,,~.' ~-\"-.- ~-, Of',1PLETION OF PART II THE READER WILL BE ABLE TO: hd~ntify: Correct derermination of the end of the .t)\\.ppropriare planes and axes for cash range of motion Correcr identificarion of the end-feel '~- __ l}pper~_extrf:mity joint motion _ ?ttp,crurenhat limit the. end of the range of Palpation ofthe appropriate bony land- ;lpotion . . marks ; ···f.,,<pected normal end,feels Accurate alignment of the goniometerand \",'Describe: - .. correct reading and recording testin~posirions use.d f~r each upper-. 5. Plan goniomerricmeasuremems of the «elltremity jointrnotioll·a!)d.rnusc!e Icllgth shoulder, elba)\\', ,vrist, and hand lha.t arc' , organized by body positi()n .• ._ <\"itiest/.i .•·.·> i.·' '.' .•.. 6_ Assess intratesrer and inlencsrer reliability -~$onionlet~~ alignme~-~' \"Capsular pattern of restricted motion of goniometric measurements of Ihe upper- _~ang\"\"f morion necessary for selected exrremityjoints using methods described in '<i(unctiQIl\".l,activitiese . ·•..·••·• . . ' ••..•• •Chapter 3. explain:, <, 7. Perform tesls ofmusde length at the. shaul.. 'fIoW age, gender, and' other facrorscan der, elbow, wrist, a~d hand indudi\"g: !§taffectthe range of motion A dear explanation of the tesring proce- -~tl9\\v~~91Jr~e~_,,()terroi_:,ln m~a~l;Ir~ment can dure' ai:<,l~'Her,ff(flefcIlt1 re~ling results ~e..a• '.s• u/remie'n\"t of i Proper 110sitiot)ingo{rhe subjeerin the gpniometric any ',starting p'osirion\" , 'upper-extreinity' joint induding: .: 'Adeqmlteslabilization .dear explanation of the \",sting proce- Use of appropriate resting motion '[1\"''d1~ugreeiP9~i~iQ;ingofthesubjest Correcr idemification of rhe end-feel !\\.deqllate stabilization of the ptoximal Accume aligOllle~tofthegolliometer and ~~i-i5~-~ joil~_t comp()nenr' cor~C:ctreadipgand:.recording: '---c-\";'. .. ;_-:, ..-: ,, ~/f~sting position~, stabilization techniques, e[\\d-fecl~;and goniometer alignment for the p~r#i~~lTIitiesare pr~sentedinChapters:l thro~gh 7. The goniomerric evaluarion i...nEx, .et.c.,i~e, inChapt~~2. 5',Step'sequence .\", ~.. , ,.: :' . \" .. ' . presented , \" \" , ' .. . .. . ' j, \" L

The Shoulder / ::',( , f?1 !!I ;;:,\"1 1'-;': • Structure and Function Glenoid fossa Coracoid process ';bi~nohumeral Joint Acromion process Anatomy Head of The glenohumeral IOlOt is a synovial ball-and-socket joint. The ball is rhe convex head of the humerus, which , humerus faces mediall)', superiorly, and posteriorly with respect to . the shaft of the humerus (Fig. 4-1). The socker is formed Greater ',: b)' the concave glenoid fossa of the scapula. The socket is tubercle jh~lIow and smaller than the humeral head bur is deep- ~ned and. enlarged by the fibrocartilaginous glenoid Lesser labtum. The joint capsule is thin and lax, blends with the tubercle glenoid labrum, and is reinforced by tlie tendons of the rotator cuff muscles and by the glenohumeral (superior, Scapula - ' \\ - - middle, inferior) and coracohumeral' ligaments (Fig. 4-2). Glenohumeral Humerus O~teokinematics joint ;<)l)(?glenohumeral joint has 3 degrees of freedom. The <,:'>:,,:~?tions permitted at the joint are flexion-extension, ,\"! aqduction-adduction, and medial-lateral rotation. In addition, horizontal abduction and horizontal adduction are functional motions performed at the level of the shoulder and are created by combining abduction and /\",efijlon, and adduction and flexion, respectively. Full :\\Wl'~:~p~gmeer.aolf, motion: (ROM) of the shoulder requires scapular, and clavicular motion at the gleno- ~':::<\"l ~,~eral~ s~e~noclavicular, acromioclavicular, and scapu- '!/: ,Ot o~aclc JOints. Arthrokinematics FIGURE 4-1 An amerior view or the glenohumeral joint. ~~~ion at the glenohumeral joint occurs as a rolling and s I mgof the head of the humerus on the glenoid fossa. 57 I I1 •.

58 PART\" UPPER-EXTREMITY TESTING Coracoid process curib!!-c of the fir,.,( rih (hg. 4-3/\\1. The jOIlH ... urfacl,.·... ;1r(.\" saddlc-shaptd. Thl..' cl;l\\\";udar joint ,>ur(;H:l\" is l\"OIlV<:X Art Coracohumeral c(:phaltJ:.:alllbll~· :lnd f.,:OllC;t\\'f: ;IfHt:rop(l... rtTjod~·. The '; '\" Du' ligament ()pposil1~ JOint surface, loc,lt(·d ;1l rluo' llOh,:h formed hy . rhe l1lanuhriulll oJ rhe ~rernlllll :llld dll' fir .. r L'oq:ll I..·arri~ sur: Greater tubercle Iagl'. il, L\"lH1C;1Vl' Cl'ph;l!OCllIlhlly and COflV,,:X :lIl[CfOpoS' in t of t lesser h.:riorh-. :\\11 'lrril.,:llbr di'l.c divide.. ill<: joinr ililO [Wo, POt tubercle Sc,:p:lr;!'h: comp:lrllllclll.... :{ con Glenohumeral ·fh.. as.. cJ(.:iau:d i(lim Glp.... td .. is ~[roll~ :\\lld feillt(lfCl:d as t ligament by ,lnrnior ;lm!!)(),ruiof ~c lig;\\llH:!lh {Fig. 4-.\\H I. Th(:se:7 lat sun 1i!!.:lllH..·Jlb !il1ljr :IIHeriur-po<.,[niol' 1ll0\\'L\"llll,:nt 0/' rhe dOl rlledialelld 01 lill..' r1avick, Tilt' (o... rocLwicubr li,~alll(,ll[, > (IQI \",hidl L'xtt:·lld... Inllll rhl' iute'rior ...lIrLII..\"(· of rhl\" rnnliall'nd ACI of rhe 1..\"!:l\\·jl..\"le ro [hc: first rih, limirs cl:n\"indar t.:1c\\\":nion Am and pro!r'Kriotl. Th(· in!L'rda\\\"icular ligall1i.:nr 1..':'; [tnd:; Thi mg frolll on.... ('I:l\\·idl' W ;\\I\\(lrhcr and Illllirs C\\I..\"c;,;si\\'c in!t.:rior 1ll0\\TI1lCfl[ ot rhe i.:Ia\\'i(Ic.~ surl Osteokinematics seal con The SC joit\\{ h:b 3 dcgrL\"L\"~ 01 frl'l'I..Iolll, ;ll1d motion,1; '\" Th< l:on,isrs of 1ll0\\'cilll.: 11 [ of (hI.' ,.:l.ll'i .,:k Oil lillo,' 'tl'rfllim. surl Th,,·...(' llIocion<., :He dv<.,crihcd hy rh ..· 1110\\'cJn(\"IH dr rhe\" infe Th< 1:1l1..·1':1I i.'nd of lht: cLl\\\"il..'lt:. Clavicular mo(ino, ilh.:lude ... jn' ,ll in ll-dL'j) rL.'\" ... in 11, prot ra u iOll- l\"U LI L' [i Oil, ~11l,J :II\\(C:< flOI'-PO\"ll:rtO!\" l'OLltlOIl.~· ~ Stcrnoci'l\\'lCl.i!ar iOU'1t FIGURE 4-2 An anterior view of [he glenohumeral joint show- ACfr ing the coracohumeral and glenohumeralligamenrs. The direction of the sliding is opposite to the movement M,,!Il11brlurn - - - - T - \" .., ACfe of the shaft of the humerus. The humeral head slides posteriorly and inferiorly in flexion, anteriorly and supe- 01 Pfoe riorly in extension, inferiorly in abduction, and superi- sternum orly in adducrion. In lateral rotation, the humeral head l$! costal carlilage slides antetiorly on the glenoid fossa. In medial rotation, ;1 the humeral head slides posteriorly. The sliding motions help to maintain contacr between rhe head of the seal humerus and the glenoid fossa of rhe scapular during the rolling motions. ;.' Capsular Pattern An:Cllor sternocl'Wlculaf FIGl ligament lar j, The greatest restriction of passive motion is in lateral rotarion, followed by some restriction in abduction and FIGURE 4-3 fA) :\\1I ;l1lltTipf \"it\\\\\" cd rhi..' SICl\"lwd:l\\·j,.:ul.lf (SO Jess restriction in medial rotation. 1 j()inl SIH)\\\\,illg rlll' hone srfUClIln:<; ;lllll ;lni..:ub .. di,(. (H) .~ ;lnr(:fior \\·i ..·\\\\, ot rh,,' SC joint $howillg. Ih,,· iIl[Cfd:l\\,i....lIl:1r, S~ Sternoclavicular Joint and ,:osrol.\"!:\\\\\"i,,·ul.lf li~;lnH'Il(~. Anatomy The sternoclavicular (SC) joint is a synovial joint linking the medial end of the clavicle with the sternum and the

<:). CHAPTER 4 THE SHOULDER 59 'laces are !:j;f:fi~f1:t\" . Coracoclavicular ligament ; convex ~'ArthrokinematlCs Acromioclavicular ligament dy. The . rJlled hv ' /': Duiiti'iLclavicular elevarion and depression, the convex Clavide r~ll I.:arri'- sUrface. of the clavicle slides on the concave manubrium i'~,a direction opposite the movement of the lateral end FIGURE 4-5 An anterior view of the acromioclavicular (AC) IrC\"ropOS- _.;\" of the clavicle. In protraction and retraction, the concave joint showing the coracoclavicular, acromioclavicular, and cora· nro two' portion of the clavicular joint surface slides on the coacromial ligaments, convex surface of the manubrium in the same direction 'infon.:ed . as the lateral end of the clavicle. In rotation, rhe clavicu- n. These lar joint surface spins on the opposing joint surface. In summary, the clavicle slides inferiorly in elevation, supe- of the .rio.rly in depression, anteriorly in protraction, and poste- 19amenr, riorly in retraction. :di,,! end Acromioclavicular Joint <:h.'\\'arion Anatomy t'xrcnds -r,.: The acromioclavicular (AC) joint is a synovial joint link- . inferior i! ing the scapula and rhe clavicle. The scapular joint surface is a concave facet located on the acromion of the Ill(ltion ;capula, (Fig. 4-4). The clavicular joint surface is a ;!i.-'l'Iltllll. COflvex' facet located on the lateral end of the clavicle. rh~..joint contains a fibrocartilaginous disc and is r ~lt rhe su~rounded by a weak joint capsule. The superior and include if\\feri()rAC ligaments reinforce the capsule (Fig. 4-5). d alltc~ Th~,s()~acoclavicular ligament, which extends between Acromioclavicular joint Clavicle the clavicle and the scapular coracoid process, provides additional stability. \\--- -=-..\" ~; Osteokinematics Acromion lsI Arb process The AC joint has 3 degrees of freedom and permits movement of the scapula on the clavicle in three planes.J arldagc Scapula - ----:l~~-_ Numerous terms have been used fO describe these motions. Tilting (tipping) is movement of rhe scapula in ( FIGURE 4-4 A posterior-superior view of the acromioclavicu- the sagittal plane around a coronal axis. During anterior lar joint. tilting the superior border of the scapula and glenoid )c1avlcutar fossa moves anteriorly, whereas the inferior angle moves posteriorly. During posterior tilting (ripping) the superior cnl border of the scapula and glenoid fossa moves posteri- orly, whereas rhe inferior angle moves anteriorly. lar (SCI !H) :\\n Upward and downward rotations of the scapula occur Jar, SC, in the frontal plane around an anterior-posterior axis, During upward rotation the glenoid fossa moves cranially, whereas during downward rotation the glenoid fossa moves caudally. Prorraction and retraction of the scapula occur in the transverse plane around a vertical axis, During protrac- tion (also termed medial rotation, or winging) the glenoid fossa moves medially and anteriorly, whereas the vertebral border of the scapula moves away from the spine. During retraction (also termed lateral rotation) the glenoid fossa moves laterally and posteriorly, whereas the vertebral border of the scapula moves toward the spine. The terms abduction-adduction have been used by various authors to indicate the motions of upward

60 PA RT II UPPER·EXTREMITY TESTING 166.7 (4.7) 167.6 48.7 62,3 (9,5) 83.6 184.0 (7.0) 68,8 (4,6) 103.7 (8,S) • Values are for male SUbjects 18 months to 54 yeilrs of age. 1 Values are for male and female subjects 18 to 55 years of age. rotation-downward roration as well as protracrion- Arthrokinematic5 rcrcacrion. 1 ,4 ~ Research Findings Arthrokinematics Effect5 of Age, Gender, and Other Factors Motion of rhe joint surfaces consists of a sliding of the concave acromial facet on the convex clavicular facet. rlbk -i-I \"hows tht' flll';lll value;., of :-houldef (O~<i!' Acromial sliding on the clavicle occurs in the same dirt~C­ rion as movement of the scapula. 1\\0.\\,1 llle:lsurelllclHS OhCliil(,:d fnJln v;lrinus sources.j d;\\tJ 011 ~lg('. ~l:Jldl'r, and rl11111hn (}f ..;ubj('us rhat-~ Scapulothoracic Joint 1lll';lSllfed to ohr;lill the V:dllt'S rqwned tor rhe .'\\me>:~­ Anatomy Academy of Orrhop;lnli( Sllrl;eolls \\r\\AOSj\" in 1~, ~llld (or rhe All)el'ic~lll \\ll'di.cJI A.. ~(lL·i,Hi()l1 (A\\'tA)6;)r The scapulothoracic joint is considered to be a functional rather than an anatomical joint. The joint surfaces are nor l1oted, Boone ;llld AZell . Ilh:~l~UrL'd :h.:ri\\'l:: ROM';:'>; the anterior surface of the scapula and the posterior ;1 1I1l iV('l\":-.a I !.!.Ol1iOlllt'tn in lUlJ m~lks ht'I\\\\'('('11 IS rri~ suriace of the thorax. ~lIld :)-i ~\",:;l;S of Jgl.:, Greene :lml \\'(ifJlf~ Ille;lsun:d l~'\" Osteokinematics Rl).\\\\ with :\\ uni\\'l'rs~ll gOlliol1H:tcr in 10 males::' The motions that occur at the scapulothocacic joinr atc I() fCIll;lk:<. ~lgnl I X to 55 ~'l':lrS, LJIlIc.;;..; mh<:fwisc n.,. caused by the independent or combined motions of the sternoclavicular and acromioclavicular joints. These rhe rt',llkr ~holiid aSSlllllt' rh:n shoulda RO!\\'( refe- motions include scapular elevation-depression, upward- downward rotation, anterior-posterior tilting, and shoulder I,:ulllpkx R O : \\ 1 . ? ' & < prorraction-rerraction (also called medial-lateral rota· h:w stll<.Iic:. 1t,1\\'\\: spe~ifil'ally 1l1C:lslIrcd gl<:nohu.~': lion). 1\\0.\\ \\ using (linie\\1 roob SUL\"il as a lllli\\TfS:ll gonio.ill' The glcllOhulIll'l\"J! jOint i... geneLdly \\.:onsider~; ..'OIHrihlllc Jbnllt 120 dcg,rcl':- of fkxioll ;111(\\ bcrwe~~ .:111(\\ 120 degrees of ~\\bdllUioll to shoulder CO'.~:\"\"\" ,III ~t'ncr:ll, till' O\\'\\,:r;lll r;Hlo ot gknohume.: Illorions, ' 'iQ(i;2$i(16..2)\" 'ik '~~~.~~f;~~J;i;<,c:·(i·'., \" :49..2: .. (9,0)',:'.• ,..,••• , •; \"6.2.8 (12.7) 50,9 (12,6) 56.3 102,8 (10.9) 104.6 9\"\"..4 : 2<\"H. I 2 :- . 2 )\"/i ;ii''': 108,1 (14,1) .>~.. \" , .. Values are for male and female subjects 21 to 40 years of age, t Values are for male and female subjects 12 to 18 years of age, l: Values are for subjects who were elite tennis players 11 to 17 years of <lge.

CHAPTER 4 THE SHOULDER 61 were s2apgJl§tl~o,:ac,c motion during flexion and abduction is goniometet on Caucasian males. Although the values :f1can 3,9-JI Therefore, about two-thirds of shoul- obtained from Wanatabe and coworkers15 for infants arc 1965, greater than those obtained from Boone'6 for children were if(J]lJ\"lplex motion is attributed to the glenohumeral between the ages of 1 and 19 years, it is difficult to shows the mean values of glenohumeral compare values across studies. Within one study, Boone l6 USing from three sources. Lannan) Lehman, and Boone and Azen7 found that shoulder ROM varied little in boys between 1 and 19 years of age. onrhs TAlon,i '\" measured passive ROM using a universal H.:rive goy,i\"rneter in 20 males and 40 females aged 21 to 40 There is some indication that children have greater an and Smith J3 examined 50 high school values than adults for certain shoulder complex motions. ored) am.le\":> (32 females and 18 males) for passive medial Wanatabe and coworkers '5 found that the ROM in 'fS to glenohumeral rotation. Ellenbecker and shoulder extension and lateral rotation was greater in cpll~i115U[:S'\"measuted active rotation in 113 male and 90 Japanese infants than the average values typically Hcral reported for adults. Boone and Azen7 found significantly lcrcr, tennis players between the ages of 11 and 17 greater active ROM in shoulder flexion, extension, d to three studies used manual stabilization of lateral rotation) and medial rotation in male children ~capulla and universal goniometers to obtain gleno- h~;hl~:~ measurements. More studies arc needed to between 1 and 19 years of age compared with findings in el normative values for glenohumeral ROM, espe- male adults between 20 and 54 years of age. However, cially.in older adults. they found no significant differences in shoulder abduc- Age tion owing to age, Table 4-4 summarizes the effects of age on shoulder A review of shoulder complex ROM values presented in Table 4-3 shows very slight differences among children complex ROM in adults. There appears to be a trend for ftom bitth through adolescence. Values from the study by older adults (between 60 and 93 years of age) to have Wanatabe and coworkers IS were derived from measure- lower mean values than younger adults (between 20 and ments of passive ROM of Japanese males and females. 39 years of age) for the motions of extension, lateral rota- The mean values listed from Boone'6 were detived from tion, and abduction. Values cited from Boone l6 were measurements of active ROM taken with a universal obtained from measurements made with a universal TABLE 4-4 Effects of Age on Shoulder Complex Motion in Adults 20 to 93 Years of Age: Mean Values In Degrees

62 PA RT II UPPER-EXTREMITY TESTING goniometer of active ROM in male subjects. The values had greater glt:llohufTlcral RO:\\t tor shoulder abduction til from Walker and associates!7 were obtained from meas- as well as lateral and rota I rotation. Six age groups with urements of active ROM in 30 male subjects using a subjects bc['w('cll 20 and 40 years of Jgc wen.: included in sh universal goniometer. The values from Downey, Fiebert, the stLIdy'. These gender differences were prestnr in all <lgc w: and Stackpole-Brown!\" were obtained from measure- groups. rVblts had. on average, 92 percent of the ROM be ments of active ROM made with a universal goniometer of their fernalt counterparrs, rhe difference being most Bi. in 140 female and 60 male shoulders. It is interesting to marked in abduction. Lannan, Lehman, and 'folJnd, 11 in ba note that the standard deviations for the older groups are a study of 40 women and 20 men aged 21 to 40 years, hi1 much larger than the values reported for the younger found d1<lt womell had statistically significant greater groups. The larger standard deviations appear to indicate allloullts of glenohumeral flexioll, cxtension, abduction, R( that ROM is more variable in the older groups than in medi<ll and Lueral roration than men. The mean differ· ('£lees typicllly varied betwcen 3 and 8 degrees. goon and ab the younger groups. However, the fact that the measure- Smith, I, in ,1 srudy of 32 temalt's and 18 maks ,1gtd 12 99 ments of the two oldest groups were obtained by differ- to 18 ytars, reported that femaks had significlmly more tio ent investigators should be considered when drawing lateral and tot,ll rotation than null'S. T'he Illean differ· conclusions from this information. cnce in Lueral and total rotation was 4.5 and 9.1 degrees, rC<J rcspectively. Ellenbecker and colleagues I·! swdied 113 val In addition to the evidence for age-related changes Illak and 90 femall' elitt tennis players aged 11 to 17 we presented in Tables 4-3 and 4-4, West,'9 Clarke and years (sec 'Etble 4-2). Their data secm to indicuc d1<lt the the coworkers,20 and AlIander and associares21 have also females had greater R01\\,1 than males for glenohuIlleral late identified age-related trends. West l9 found that older medial and lateral roration, although no statistical tests subjects had between 15 and 20 degrees less shoulder focllsed on the dfcct of gender on RO;'v1. bo' complex flexion ROM and 10 degrees less extension col ROM than younger subjects. Subjects ranged in age from Testing Position the first decade to the eighth decade. Clarke and cowork- fin' ers20 found significant decreases with age in passive A subject's posture and testing position h<1ve becn shown lat( glenohumeral lateral rotation, total rotation, and abduc- to affcct certain shoulder complex mmions. Kebaerse, the tion in a study that included 60 normal males and \\'1cClure, and Pratt,\":,; in a study of 34 healthy adults, pia: females ranging in age from 21 to 80 years. Mean reduc- measured active shoulder abduction i.mel scapula ROM and tion in these three glenohumeral ROMs in those aged 71 \\vhile subjects \\vere sitting in both ereer and slouched sho to 80 years compared with those aged 21 to 30 years, trunk postures. There W,15 significantly less active shoul- the ranged from 7 to 29 degrees. Allander and associates,2! der abduction RO\\l in the slouched than in the erect in a srudy of 517 females and 203 males aged 33 to 70 postures (mean difference :;,-: 23.6 degrees). 'fhe slouched I years, also found that passive shoulder complex rotation posture also resulted in more scapula elevation during 0 ROM significantly decreased with increasing age. to 90 degrees of abduction and less scapula posterior tiit- bee' ing in the interval between 90~degree and l1l<1ximal non Gender abduction. Prie tion Several studies have noted that females have greater Sabari and associatcs\":'! studied 30 adult subjects and~ shoulder complex ROM than males. Walker and nored greatcr arnOUfl(S of active and passive shoulder year coworkers,17 in a study of 30 men and 30 women <1bduction measured in the supine than in the sitting posi- between 60 and 84 years of age, found that women had tion. The mean differences in abduction ranged frol11 3.0 tian statistically significant greater ROM than their male to 7.1 degrees. On visui.lI inspection of the data there the counterparts in all shoulder motions srudied except for were also greater amounts of shoulder flexion in the mal( medial rotation. The mean differences for women were supine vcrsus the sitting position; llO\\VeVCr, these differ· 20 degrees greater than those of males for shoulder ences did not attain significance. cant abduction, 11 degrees greater for shoulder extension, and com 9 degrees greater for shoulder flexion and lateral rota- Body-Mass Index and tion. Allander and associares,2! in a study of passive Assc shoulder rotation in 208 Swedish women and 203 men Escalante, Lichenstein, and Hazuda 12 studied shoulder sian, aged 45 to 70 years, likewise found that women had a complex flexion ROM in 695 community-dwelling medi greater ROM in total shoulder rotation than men. subjects, aged 65 to 74 years, who participated in the San later, Escalante, Lichenstein, and Hazuda22 studied shoulder Antonio l.ongitudinal Study of Aging. Thcy found no ROll flexion in 687 community-dwelling adults aged 65 to 74 relationship between shoulder flexion and body-masS diffel years and found that women had 3 degrees more flexion index. and than men. and ~ Sports Gender differences have also been noted in gleno- to r humeral ROM, Clarke and associates,20 in a study that Several studies of professional and collegiate basell,au included 60 males and 60 females, found that females players have found a significant increase in lateral medi, gleno arm. were femal hume nonpl Po' shaul, latera

CHAPTER 4 THE SHOULDER 63 ;lbdllcrion t'o~on.RJdOerMcoamndplaexdeicnretahsee in medial rotation ROM of the Chang, Buschbacker, and Edlich.'\" Ten male power lifters oups with dominant shoulder compared and 10 aged-matched male nonlifters were included in the study. The authors suggest that athletic training lCluded ill :,ith'the nondominant shoulder. These differences have programs that emphasize muscle strengthening exercise without stretching exercise may cause progressive loss of tin ollag, been found in position players as well as in pitchers. ROM. the ROM Bigliani and coworkers\" studied 148 professional base- Functional Range of Motion cing mo~ ball playets (72 pitchers and 76 position players) with no Numerous activities of daily living (ADL) require )bnd, 12 i~' history of shoulder problems. Mean lateral rotation adequate shouldet ROM. Tiffin,'o in a study of 25 patients, found a significant correlation between the 40 yeaI~i ROM measured with the shoulder in 90 degrees of amount of specific shoulder complex motions and the ability to perform activities such as combing the hair, nr greater 'abduction was 113.5 degrees in the dominant arm and purring on a coat, washing the back, washing the contralateral axilla, using the toilet, reaching a high shelf, Ibduelio& 99.9 degrees in the nondominant arm. Mean medial rota- lifting above the shoulder level, pulling, and sleeping on the affected side. Flexion and adduction ROM correlated :on diffe'\" tion ROM, recorded as the highest vertebral level best with the ability to comb the hair, whereas medial and lateral rotation ROM correlated best with the ability to [10011 and reached behind the back and converted to a numerical wash the back. :s \"ged 12 ,iue,'was significantly less in the dominant arm. There Several srudies\"·32 have examined the ROM that occurs during certain functional tasks (Table 4-5). A Illdy mort were no signific3pt diffcrences between the dominant and large amollnt of abduction (112 degrees) and lateral rota- tion is required to reach behind the head for activities ;on diff\". the nondominant arms in shoulder nexion and shoulder such as grooming the hair (Fig 4-6), positioning a neck- tie, and fastening a dress zipper. Maximal flexion (148 . I degrees, lareral rotation measured with the arm at the side of the degrees) is needed to reach a high shelf (Fig. 4-7), whereas less nexion (36 to 52 degrees) is needed for self- ,died III body. A srudy by Baltaci, Johnson, and Kohl'6 of 15 feeding tasks (Fig 4-8). Thiery-eight to 56 degrees of extension and considerable medial rotation and horizon- Ilro17 collegiate pitchers and 23 position players had similar tal abduction are necessaty for reaching behind the back for tasks such as fastening a bra (Fig 4-9), tucking in a .Ie [hot In,· findings. Pitchers had an average of 14 degrees more shirt, and reaching the perineum to perform hygiene activities. Horizontal adduction is needed for activities lohumcral Iareral rotation, and 11 degrees less medial rotation in performed in front of the body such as washing the contralateral axilla (104 degrees) and eating (87 degrees). sriccll tcs~ the dominant versus nondominanr shoulders. Position If patients have difficulty performing certain functional players had an average of 8 degrees more lateral rotation activities, evaluation and treatment procedures need to 'lOd 10 degrees less medial rotation in the dominant focus on the shoulder motions necessary for the activity. Likewise, if patients have known limitations in shoulder shouldet. All measutements of rotation were taken with ROM, therapists and physicians should anticipate patient difficulty in performing these tasks, and adaptations cell showN the shoulder in 90 degtees of abduction. should be suggested. Kcbacrsel Decreases in shoulder medial rotarian ROM have also R,eliability and Validity hy \"dulr~ been noted in the dominant (playing) compared with th~ Hda ROM The intratester and intertester reliability of measurements nondominant (nonplaying) arms of tennis players. Chinn, of shoulder motions with a universal goniometer have j slouched Priest~ and Kent,!' in a study of 83 narional and inrerna- been studied by many researchers. Most of these studies have presented evidence that intratester reliability is rive shoul· Iional men and women tennis players aged 14 10 50 berrer than interrester reliability. Reliability varied according to the morion being measuted. In othet words, 1 rhe erea }'ears, found a significant decrease in active mcdial rota- the reliability of measuring certain shoulder motions was better than the reliability of measuring other motions. c slouched rion ROM of the shoulder complex in the playing versus Hellebrandt, Duvall, and Moore,33 in a srudy of 77 Il during 0 the nonplaying arm (mean difference = 6.8 degrees in sterior tilt· males, 11.9 degrees in females). Men also had a signifi- I maximai cant increase in lateral rotation ROM in the playing compared with the nonplaying arm. A study by Kibler ,bjects and and~coUeagues2. of 39 members of the U. S. Tennis e shouldi' Association National Tennis Team and touring profes- ining posj~ i sional progtam found a decrease in passive glenohumeral d from lQ mediarrotation ROM, an increase in glenohumeral dala Iherl Iate,al rotation ROM, and a decrease in total cotation ion in thf ROM in the playing versus the nonplaying arm. The :lese JiffeB differences in medial rotation ROM increased with age and'-years of tournament play. A srudy by Ellenbecket and associates 14 of 203 junior elite tennis players aged 11 to 17 years reported a significant decrease in aaive d shouldci medial rotation RoM and total rotation ROM of the :y-dwcUing glenohumeral joint in the playing versus the non playing I in the Sal! aIm. The average differences in medial rotation ROM found no wete 11 degrees in the 113 males and 8 degrees in the 90 body-m3.SS females. There were no significant differences in gleno- humerallateral totation ROM between playing and nonplaying arms. Power lifters were found to have dec teased ROM in Ie bascbaU,.· shoulder complex nexion, extension, and medial and Heral rora,:;, lateral rotation compared with nonlifters in a srudy by

64 PA RT II UPPER· EXTREMITY TESTING TABLE 4-5 Maximal Shoulder Complex Motion Necessary'for F,undioriill ~a1Vities:-Meari Vlll,ues -- \" -- In Degrees __ ' ' . _ -_ . 52 (8) M.llsen ..)1 /r 36 (14) Silft1ee-Rad ct al n .? 22 (7) Saf<1ee·Rad et ill 18 (10) Safilce-Rad et al 87 (29) Matsen ~ri~~~t_~ wit~,~i~Up --'~;,t, 1&l~~~; '~'~~~on ~;i~f ll:i~ 43 (16) Safaec-Rad et al ;~iA~/;;';':{- - ,.1.i<~0 -;li/Y \". ;t%ft~ \"':'!;f,jA tH{{~Lrvfedial,rotati~frt,,*£ ./!~~tMf! 31 (9) Safaee-Rad et al 23 (12) Safaee-Rad et al ',Washin'g'iax,Hla' ,.;::-:~~>, '\"\" ;':\\(,/,~~,;.'(;,:; <'f':)<0>flexionY~;0/~:/\"' ';';I.\\:0X1i>';:\"':' 52 (14) Matsen ~o:~,~,~~g:L''i,!:,,:':'i' 104 (12) Matsen !;.y.;: '<;'~';;:<i;; ;':>;'i.~: «,,:ii\",\"::'(;',},:Hol\"iZ(}r,~'i;'~(fdlJdld'n>;',i: 112 (10) Matsen Matsen hair-l,!: '<:< /': ,'-\"\" :,!-/;:(%~!?tlU'F'~i~~~~':~Wt1~~)f~,1t' 54 (27) ~\"~{2S~' eleV~~i;\"~;\" Y?>';;:~:_,:, ~\":;~Df~: \"~~~~o~~~~~~:on j~'; 148 (11 ) Matsen 'Maximal reaching up back7 !/~~~ --', ;:5Ex~~nsion5~!;,:,,~;{~~>!/p:,q}/i, 55 (1 7) Matsen Horizontal\" ;'i:,:/i'i;:','L':?~;H:::--:V;?'i'<{?:::<:~~»\"i\"':~':'i;';' ;:,>;;:~ 'J///:;\";\"\"; 56 (13) Matsen abdu'cti~~ ~;-\": .6. 9 (1 1) Matsen 38 (10) Re:(~:~i_ci;h-;i:;,#,j;;g\":-'\"/~'/p,\\e::i::i;n{-eum\"'I;,i:/;:\";;:'J :,/~;+:'/. ),,;>:!,_i;>:,\";_'>;:;'ji'\\:~:Y-'HExo~JelilzslOon'rt(a/\\(iai~'lJ•\"~,<'tY.i~::oi:~::',::i>:;::':,;~~; 86 (13) Matsen '). MalSen ~ Eight normal subjects were assessed with electromagnetic sensors on the humerus. t Ten normal male subjects were assessed with a three·dimensional video recording ~Y'i({'m. J The 0 degree starting position for measuring horizontal adduction and horizontal doclucllon was in 90 degrees of ....bdllction. FIGI der I FIGURE 4-6 Reaching behind rhe head requires a large pati. amount of abduction (112 degrccs}31 and lateral rotarion of rhe of ~ shoulder. med FlCURE 4-7 I{~~;h:hil\\g nhji.'i.:rs Oil :1 high slll'lf rcquin.:s degrn's of sllOuhkr flexioll.,ll ShOl meal rang lake, by t mea~ gonil devie B, meas der c rion, Inver gonic male, rotati able mori( tester reliab

CHAPTER 4 THE SHOULDER 65 FIGURE 4-8 Feeding tasks tequite 36 to 52 degtees of shoul- der flexion.31,32 patients, found the intratester reliability of measurements FIGURE 4-9 Reaching behind the back ro fasten a bra or of active ROM of shoulder complex abducrion and bathing suit requires 56 degrees of extension, 69 degrees of medial rotation ro be less than the intratester reliability of shouldet flexion, extension, and lateral totation. The horizontal abduction,31 and a large amount of medial rotation mean difference between the repeated measurements tanged ftom 0.2 to 1.5 degrees. Measurements wete of the shoulder. taken with a universal goniometer and devices designed hy the U.S. Army for specific joints. For most ROM lar (r = 0.96 and 0.97, respectively) for lateral rotation measutements taken throughout the body, the univetsal ROM. goniometet was a more dependable tool than the special devices. Pandya and associates,35 in a study in which five testers measured the range of shoulder complex abduc- Boone and coworkets34 examined the reliability of tion of 150 children and young adults with Duchenne measuring passive ROM for lateral rotation of the shoul- muscular dystrophy, found that the intratester intraclass correlation coefficient (ICC) for measurements of shoul- ~er complex, elbow extension-flexion, wrist ulnar devia- der abduction was 0.84. The intertester reliability for measuring shoulder abduction was lower (lCC=0.67). In ~lonl hip abduction, knee extension-flexion, and foot comparison with measurements of elbow and wrist Invetsion. Fout physical therapists used universal extension, the measurement of shoulder abduction was less reliable. gOOiOmeters to measure these motions in 12 normal males once a week for 4 weeks. Measurement of lateral Riddle, Rothstein, and Lamb36 conducted a study ro tOtation ROM of the shoulder was found to be more teli- determine intratester and intertcstcr reliability for passive able than that of the other motions tested. For all ROM measurements of the shoulder complex. Sixteen motions except lateral rotation of the shoulder, intra- tester reliability was noted to be greater than intertester tebability. Intratester and intereester reliability was simi-

66 PART II UPPER-EXTREMITY TESTING physical therapists, assessing in pairs, used two different latcral rOLHioll RO\\! of the ~houldt:r W;lS Illore rc:liabl e ? sized universal goniometers (large and small) for rheir chall R(J:\\t IHC:<\\Sllrellh.'I\"HS of tht: fOfl..'arlll <1l1d wrisr. measurements on 50 patients. Patient position and ~\\-killl ~t,lfJdard de\\'i,HlllllS hc(wl'L'n rc:pe;Hl-J 11)t:;bllrc- goniometer placement during measurements were not flH.:lH of shoulda brt:r:d roratio!l RO.\\! \\\\'cre 'iilllibr to controlled. ICC values for intrarester reliability for all rho~e of [hl- f(lrC:~1r1ll and largl-r than rho::.\\.: 01 [hl' wrist. motions ranged from 0.87 to 0.99. ICC values for intertester reliability for flexion, abduction, and lateral Sahari and IlssOl:i;Ht.'S,,~·l cX:llllinc:d inrr;Ir:1tlT rl'liability ~\\ rotation ranged from 0.84 to 0.90. Intertester reliability in thl' rneasurCIlll'fl[ of activ(.- ~Hld p:lssi\\'t.' slH>1I1dc'c )': l\"ornplc:x flt'xioll and ahduc[ion ROtvt when 30 adults ,:\" was considerably lower for measurements 'of horizontal wt:rt: posirionl'd in supine: ;lIld sirrillg posirions. Thl' ICes r. abduction, horizontal adduction, extension, and medial bc:twt:l·n rwO trials hy the S;Hlll' tL'\"::.tl:r for t:at.:h pro('t:durc I rotation, with ICC values ranging from 0.26 to 0.55. ranged in v:llul.' from 0.9-1 ro 0.':J9. indic.:aring high inrra~:~ The authors concluded that passive ROM measurements rester rl'li:lbilirv, rcgardk:ss of whtthcr rh(: mcasurtrllenrs \":';,, for all shoulder motions can be reliable when taken by were :ll..'tivt: or 'p~lS~ive, or whcthcr ther were taken with ::;1;' the same physical therapist, regardless of whether large dlt: subjl'cr in tht supine Of rhl' sirring posi[ioll. Ices) or small goniometers are used. Measurements of flexion, bt:fwn'll l1le:lsurt:l1lcnrs r,1ken ill supine comp<Ued wirh abduction, and lateral rotation can be reliable when t;lkcn in sirring positions r;\\ngc:d (rom 0_64 ro O_S I. There assessed by different therapists. However, because \\\\·(Te no significanr JiHLTt,:nccs berween l'olllp;tr;lhk· flcx-, repeated measurements of horizontal abduction, hori- ion IllCaSurCfll('IHS t;lkl'll ill supine ;lod sining posirions_ zontal adduction, extension, and medial rotation were HO\\\\,C\\,(T, significllHly grearer ahdw...:tiull RO~'l unreliahle when taken by more than one tester, these found in the supine dUll ill the sining pusioon. measurements should be taken by the same therapist. in;1 srudy by \\lacDcrmid '1IH.I C()IIt.';l~lles. IS cwo expc- Greene and Wolf\" compared the. reliability of the ricncl·d phy~ic:ll rher;lpisrs lIlC.'asurcd p;lSsin: ~hollider Ortho Ranger, an electronic pendulum goniometer, with CC.Hllpk·x rorarioll RO\\( in 34 p;uienrs wirh ;\\ variery of that of a standard universal goniometer for active upper shoukkr p'Hhologies. r\\ unin:rsal goniollH:rcr W;\\::. llSl-d toi extremity motions in 20 healthy adults. Shouldet lllcaSllr(' Lw::r;ll rotation with th(· shoukkr in 20 to 30:£ complex motions were measuted three times with each degrees of ;lbJucrion. ImrartsrL'!'\" ICC:s (().s~ alld 0.93):~ instrument during three sessions that occurred over a ;lIld imerresre:r ICCs (0.S5 ;ll1d O.~O) wac high, 2-week period. Both instruments demonstrated high Inrratestc:r standard errors of Il1c::1SlIrell1ellt (5E.\\ 15' (4.9 intra-session correlations (ICCs ranged from 0.98 to ;lnd 7.0 degrn:s) and inrerresrc.:r SE.\\(s (7.5 and 8.0·' 0.87), but correlations were higher and 95 percent confi- degrees) also indicared good rc.:li;1bility. The SE:Vts indi·,~. dence levels were much lower for the universal goniome- cttc:: thm diHercl1cc::~ of 5 to 7 dcgrt:t:s could be ~HtTihllted>; ter. Measurements of medial rotation and lateral rotation to 1l1l:;lsurt:Il1C:1H error when rhe same tl'stcr repears a~:M were less reliable than measuremems of flexion, exten- lIl(\"~lsurCflltnr. and aboul S degrl'l's could lw arrrihurcd [0' sion, abduction, and adduction. There were significant' Illl-.tlSurc::rnenr error whl-n diffc'\"fl'!H resters take a Illcas-- differences between measurements taken with the Ortho lIrtml'll(. Smith I ~ _;;~ Ranger and the universal goniometer. Interestingly, there were significant differences -in measurements between Boon and studied 50 hi.d. l s\\.:hool arhletes (0': ~ dererrnine the rc:liabiliry of mcasuring passive shol1lde(~ sessions for both instruments. The authors noted that the rotatiol1 1\\0:'\\/1 \\.... irh and withollt lllallual subilizarion of}': daily variations that were found might have been caused [he scapub. Four expcricll<.:ed phrsical tht:rapislS work54 by normal fluctuation in ROM as suggested by Boone ing in pairs wok goniolllcrric n;(,~lSllr('lllenrs with rhe: and colleagues,H or by daily differences in subjects' shoulder in 90 dcgrt:cs of abdunion ,lilt! n:pc;ut:d rhose efforts while perfotming active ROM. measurCments 5 d:1YS larer. S...·;lpular sr;lhiliz;lrion. which,: Bovens and associates,37 in a study of the variability rt:sldtct! in more isolared gknohll[ller:lll1lorioll, pl'oducedJ and reliability of nine joint motions throughout the significantly smaller RO\\;I values dUll whcn rhe s('apula'~; body, used a universal goniometer to examine active \\\\·as nor stahilized. According ro rhe :lurhors. illtr~HCsrer' lateral rotation ROM of the shoulder complex with the rt:liJbility for Illedial rmarion was poor for nonsrahilized arm at the side. Three physician testers and eight healthy subjects participated in the srudy. Intratester reliability l11otion (ICC = 0.23. SENt = 20.2 degrees). and good fot stabilized 1110tion (ICC = 0.60. SUvi = S.O). The ;luthot; . coefficients for lateral rotation of the shoulder ranged scare rh,n inrr,HL'ster [(·Iiability for l;Hera] rotarion wa('i from 0.76 to 0.83, whereas the intertester reliability good for both nonstabilized (ICC \" 0.79, SENt = 5.6)?' 9.1):1coefficient was 0.63. Mean intratester standard devia- I: tions for the measutements taken on each subject ranged and stabilized motio!l (ICC = 0.53. SEM = IIHcrrl'sr(\"r reliability lor meJial rOration improved (ront I from 5.0 to 6.6 degrees, whereas the mean intertester !lollStabilized morion (ICC = 0.13, SLyi = 21.5) '0: I standard deviation was 7.4 degrees. The measurement of Slahilized motion (ICC = O.3N. SENt = 10.0). and wa;: \"t -:i' ,::\" .'

CHAPTER 4 THE SHOULDER 67 able' comparable for both nonstabilized and stabilized lateral rer in six patients with shoulder pain and stiffness. ·rist.} Tiffin, Wildin, and Hajioff4o studied the reliability of rotation (ICC = 0.84, SEM = 4.9 and ICC = 0.78, SEM using an inclinometer to measure active shoulder urc~',f~ complex motions in 36 patients with shoulder disorders. ~ 6.6), respectively. Bower41 and Clarke and coworkcrs20 examined the reli- r to,:,5:;r;; The reliability of measurement devices other than a ability of measuring passive glenohumeral motions with a hydrogoniometer. Croft and colleagues\" investigated universal goniometer for assessing shoulder ROM has the reliability of observing shoulder complex flexion and also' been studied and is briefly mentioned here. lateral rotation, and sketching the ROMs OntO diagrams that were then measured with a protractor. Jl,tratester and intertester reliability for the different motions and methods varied widely. Green and associ- ates\" investigated the reliability of measuring active shoulder complex ROM with a plurimeter-V inclinome- '/. . . was ·xpe· llder ' ty of £: ed to,~' o 30')7; ),ig93nr>:: (4.9\" 8,0.- indi.£: nlred ,~:t~ cs t9M uldet;' on of \\·ork.:: \"','/ ~ 1 the \" i\" rhose, / ,. chien , \" i:~ Juced .. ; apula .. :!i tcste(\"i,' .~: ilizeq,,:t ,e! fo'~~ .thow' I was 5,6}\" 9.1).' from 51 to I waSt., ;:t;

r 68 PA R T II UPPER-EXTREMITY TESTING Range of Motion Testing Procedures: The Shoulder full ROM of the shoulder requires movement at the throughoul rill\" ~h(lllldL'r complex. l1J:lkillg isoLuion of glenohumeral, SC, AC, and seapulothotacic joints. To g.!Cllohllll11.:ral I11<I(iOI1 diffi,,:uh. (.cfwill \"'[lldil'~ have make measurements more informarive, we suggest hegun l'~r;1hlishillg :-.Olll(,: 1I0rnl<.Hi\\T \\'altlL'~ CClhk 4-2) < using two methods of measuting the ROM of the shoul- alld 'b~L·ssillg rhe: rl.'liahili[v of thi~ 1ll1.:,lSUfCllll.'!lt 1l\\(.:th()d.1~ der. One method measures passive motion primarily at '1'111.: sb.:ond lllt:rhod !1k·;·\\Sures. full motion of tht shoul- ':',;: the glenohumeral joint. The other method measures rtilT cOlllplt:X and is ll~l,:t'lll ill l.:\\';dllarill~ rhe fUIH:rional passive ROM at all the joints included in the shoulder RO\\t oi rhl' shoulder. This mort\" [ri:ldiriollal Illt,:r!lod of complex. asst:ssing. shoukkr Illotion incorpor:l[cs thl' subilii'.;1tion i We have found the method that measures primarily of till.: r1wr:1L\"i .., spine :Ind rih (:age. Ti...·all· re~i$(anCi': to:,1 i.: gienohumwli motion is helpful in identifying gleno- further motioll is typicdly due to rhe strt:tch ot srrUlrurcS,.!f; humeral joint problems within the shoulder complex. I,.'onllt:c('ing rill..' cla\\\"icll..' ell [hl..' St(:fllllll1. and ('he sClpllla to')':': The ability to differentiate and quantify ROM at the tht rihs ;l'nd spinl.:. RO.\\I valu..,s for shoulder (()nlplc,,'F glenohumeral joint from other joints in the shoulder lIlmiOIl ;If<: pr('~cnrc::d ill TJhks 4-1. 4-3, :lIld 4--1. Both':. complex is important in diagnosing and trearing many Illl\"thod~ 01 !1H::lsurint: the 1<0\\1 of thl' shouldl..'r are ~ shoulder conditions. This method of measuring gleno- prcsl:lHtd in rht: tollowill~ dis(us~i(lils (If stahiliz,Hion,:> humeral motion requires the usc of passive motion and [('chlll(lutS ilnd (:nd-fn·ls. HowL'v\"'r, rhl..' :di!!,IlIHl..'1H of the::'\" careful stabilization of the scapula. Active motion is gk~rH•lhullH.:ral ::0\"\" gonioIlH.:tlT is [h(' S,lnlC tor mcasuring and,{: avoided because it results in synchronous motion s.houlder COlllpkx IllOri(H1S, Scapula + Sternum _-\\- ,.j If) \\ FIGURE -l--11 An amerior 'View of (he humerus, david srernum, ;:md scapula showing bOll)' anatomical landmark': for aligning: rhe goniometer. :;' -.

CHAPTER 4 THE SHOULDER 69

70 PA RT II UPPER·EXTREMITY TESTING FLEXION Shoulder Complex Flexion Motion occurs in the sagittal plane around a medial· Stabilize the thorax to prevcnc extension of the spine an lateral axis. Mean shoulder complex flexion ROM is 180 degrees according to the AAOS,' 167 degrees according movement of the ribs. The weight of the trunk may assi to Boone and Azen,> and 150 degrees according to the stabilization. AMA 6 Mean glenohumeral flexion ROM is 106 degrees according to Lannan, Lehman, and Toland l ! and 120 Testing M o t i o n t degrees according to Levangie and Norkin. 3 Sec Tables 4-1 to 4-4 for additional information. Flex the shoulder by lifting the humerus off the exarnin~ Testing Position ing table; bringing the hand up over the subject's head!: Place the subject supine, with the l>nees flexed to flatten Maintain the extremiry in neutral abduction and adduc\" the lumbar spine. Position the shoulder in 0 degrees of abduction, adduction, and rotation. Place the elbow in tion during the motion. -$;:: extension so that tension in the long head of the triceps muscle does not limit the motion. Position the forearm in Glenohumeral Flexion ,. 'ff- odegrees of supination and ptonation so that the palm of The end of glenohumeral flexion ROM occurs when. the hand faces the body. resistance to further morion is felt and attempts to ove~~ Stabilization come the resiscance cause upward rotation, posterior Glenohumeral Flexion ing, or elevation of the scapula (Fig. 4-14). Stabilize the scapula to prevent posterior tilting, upward Shoulder Complex Flexion rotation, and elevation of the scapula. The end of shoulder complex flexion ROM occurs resistance to further motion is felt and attempts to come the resistance cause extension of the spine motion of the ribs (Fig. 4-15).

CHAPTER 4 THE SHOULDER 71 FIGURE 4-14 The end of the ROM of glenohumeral flexion. The examiner stabilizes the lateral border of the scapula with her hand. The examiner is able [0 determine that the end of the ROM has been reached because any attempt to move the extremity into additional flexion causes the lateral border of the scapula (Q move anteriorly and laterally. ';i ~,- FIGURE 4-15 The end of the ROM of shoulder complex flexion. The examiner stabilizes the subject's trunk and ribs with her hand. The examiner is able [0 determine that the cnd of the ROM has been reached because any attempt to move the extremiry into additional flexion causes extension of the spine and movement of the ribs.

, ;,')' PART II UPPER-EXTREMITY TESTING Normal End-feel Goniometer Alignment :., Glenohumeral Flexion This goniometer alignment is used for measuring humeral and shoulder complex flexion (Figs. The end-feci is firm because of rension in rhe posrerior rhrough 4-18)_ band of rhe coracohumeralligamenr and in the posterior joint capsule, and the and in the posterior deltoid, tetes 1. Center the fulcrum of the goniometer minor, teres major, and infraspinatus muscles. lateral aspect of the greater tubercle. Shouldec Complex Flexion 2. Align the proximal arm parallel to the mJ.daxilla'l line of the thorax. The end-feci is fitm because of rension in rhe cosrocla- vicular ligament and SC capsule and ligaments, and rhe 3. Align the disral arm with the lateral midline of latissimus dorsi, sternocostal fibers of the pectoralis humerus. Depending on how much flexion major and pectoralis minor, and rhomboid major and medial rotation occur, the lareral epicondyle of minor muscles. humerus or the olecranon process of the ulnar be helpful references. -:> i i• J, .' :i· FIGURE 4-16 The alignment of the goniometer ~lt the beginning of the ROM of glenohumeral and shoul- der complex nexion.

CHAPTER 4 THE SHOULDER 73 FIGURE 4-17 The alignmcm of the goniometer at the end of the ROM of glcnohumcfJ.1 flexion. The examiner's hand supports the subject's extremity and maintains the goniometer's distal arm in correct alignment over the larernl epicondyle. The examiner's other hand releases its stabilization and aligns the goniometer's proximal arm with the btcral midline of the thorax. FIGURE 4-18 Thc ..'.llignmcnr of the goniometer at the end of the ROM of shoulder complex flexion. More ROM is noted during shoulder complex flexion th:ll1 in glenohumeral flexion.

74 PA RT II UPPER-EXTREMITY TESTING EXTENSION and anterior tilting (inferior angle moves posteriorly) of the scapula. Motion occurs in the sagittal plane around a medial- latcral axis. Mean shoulder complex extension ROM is Shoulder Complex Extension 62 degrees according to Boone and Azen/ 60 degrees according to the AAOS,s and 50 degrees according to the The examining table and the weight of the trunk srabi- AMA.6 Mean glenohumeral extension ROM is 20 lize the thorax to prevent forward flexion of the spinc. degrees as cited by Lannan, Lchman, and Toland. 12 Scc The examiner can also stabilize the trunk to preVi.'llt Tables 4-1 ro 4-4 for additional information. rotation of the spine. Testing Position Testing Motion Position the subject prone, with the face rurned away Extend the shoulder by lifting the humerus off the exam- from the shoulder being tested. A pillow is not used ining table. Maintain the exrremiry in neutral abduction under the head. Place the shoulder in 0 degrees of abduc- and adduction during the motion. tion, adduction, and rotation. Position the elbow in slight flexion so that tension in the long head of the biceps Glenohumeral Extension brachii muscle will not restrict the motion. Place the forearm in 0 degrees of supination and pronation so that The end of ROM occurs when resistance to further the palm of the hand faces the body. motion is felt and attempts to overcome the resistance cause anterior tilring or elevation of rhe scapula (Fig. Stabilization· 4-19). Glenohumeral Extension Shoulder Complex Extension Stabilize the scapula ar the inferior angle or at the The end of ROM occurs when resistance to further acromion and coracoid processes to prevent elevation motion is felt and attempts to overcome the resistance cause forward flexion or rotation of the spinc (Fig. 4-20).

CHAPTER 4 THE SHOULDER 75 FIGURE 4-19 The end of the ROM of glenohumeral extension. The examiner is stabilizing the inferior angle of the scapula with her hand. The examiner is able to determine that the end of the ROM in exten- sion has been reached because any attempt to move the humerus into additional extension causes scapula to tilt anteriorly and [0 elevate, causing the inferior angle of the scapula to move posteriorly. Alternatively, the examiner may stabilize the acromion and coracoid processes of the scapula. FIGURE 4-20 The end of the ROM of shoulder complex extension. The examiner stabilizes the subject's trunk and ribs with her hand. The examiner is able to determine that the end of the ROM has been reached because any attempt to move the extremity into additional extension causes flexion and rotation of the spine.

76 PA RT II UPPER-EXTREMITY TESTING Normal End-feel Goniometer Alignment Glenohumeral Extension This goniometer alignment is used for measuring glen The end-feel is firm because of tension in the anterior humeral aod shoulder complex extension (Fig;. 4-21 t band of the coracohumeral ligament, anterior joint 4-23). capsule, and clavicular fibers of the pectoralis major, coracobrachialis, and anterior deltoid muscles. 1. Center the fulcrum of the goniometer Over lareral aspect of the greater tt.bercle. Shoulder Complex Extension 2. Align the proximal arm parallel to the midaxill The end-feci is firm because of tension in the SC capsule line of the rhorax. and ligaments, and in the serratus anterior muscle. 3. Align the distal arm with the lateral midline of t humerus, using the lateral epicondyle of humerus for reference. FIGURE 4-21 The alignment of the goniometer at the beginning of the ROM of glenohumeral and shoul~ der complex extension.

CHAPTER 4 THE SHOULDER 77 : glcno. 1-21 to VCr the axillary, c of the of the FIGURE 4-22 The alignment of the goniometer at the end of the ROM in glenohumeral extension. The examiner's left hand supports the subject's extremity and holds the distal arm of the goniometer in correct alignment over the lateral epicondyle of the humerus. FIGURE 4-23 The alignment of the goniometer at the end of the ROM in shoulder complex extension. The examiner's hand that formerly stabilized the subject's trunk now positions the goniometer

78 PART II UPPER· EXTREMITY TESTING ABDUCTION Shoulder Complex Abduction Motion occurs in the frontal plane around an anterior- Stabilize the thorax to ptevent !ateral flexion of the spine. ~ posterior axis. Mean shoulder complex abduction ROM is 180 degrees according to the AAOSs and AMA: and The weight of the trunk may assist stabilization. 184 degrees according to Boone and Azen. 7 Glenohumeral abduction ROM is 129 degrees as noted Testing M o t i o n \" by Lannan, Lehman, and Toland,12 ·and 90 or 120 degrees according to Levangie and Norkin. 3 See Tables Abduct the shoulder by moving the humerus laterallyf,' 4-1 to 4-4 for additional informarion. away from the subject's trunk. Maintain the upped extremity in lateral toration and neutral flexion and:01 Testing Position extension during the motion. Position the subject supine, with the shoulder in lateral Glenohumeral Abduction rotation and 0 degrees of flexion and extension so that the palm of the hand faces anteriorly. If the humerus is The end of ROM occurs when resistance to furrher-'\" nOt laterally rotated, contact between the greater tubercle of the humerus and the uppet portion of the glenoid fossa motion is felt and attempts to overcome the resistance;~ or the acromion process will restrict the motion. The elbow should be extended so that tension in the long cause upwatd rotation or elevation of the scapula (Fig.t head of the triceps does not restrict the motion. 4-24). ~ Stabilization Shoulder Complex Abduction ;2 Glenohumeral Abduction • Stabilize the scapula to prevent upward rotation and elevation of the scapula. The end of ROM occurs when resistance to furthert: motion is felt and attempts to overcome the resistance cause latetal flexion of the spine (Fig. 4-25).

CHAPT~R 4 THE SHOULDER 79 FIGURE 4-24 The end of the ROM of glenohumeral abduction. The examiner stabilizes the latent! border of the scapula with her hand to detect upward rotarion of the scapula. fu Alternatively, the examiner may stabilize the acromion and coracoid ·processes of the scapula to detect cleva· tion of the scapula. FIGURE 4-25 The end of rhe ROM of shoulder complex abduction. The examiner stabilizes the subject's trunk and ribs with her hand to detect lateral flexion of the spine and move- ment of the ribs.

80 PA RT II UPPER-EXTREMITY TESTING Normal End-feel Goniometer Alignment Glenohumeral Abduction This goniometer alignnll.:m is USt,d for measuring humeral and shoulder (ollll'k·x :lhdlletiol1 (Figs. 4--.: The end-feel is usually firm because of rension in rhe 4-28)_ middle and inferior bands of rhe glcnohumeral ligament, inferior joint capsule, and the teres major, and clavicular 1. Center the fulcrul1l of the goniolll<:rer c1ose't fibers of the pecroralis major muscles. 3nrcrior aspect of rhe Jt.:rollliJI proc('ss. Shoulder Complex Abducrion 2. Align the proximal ;1r11l so dl:ll it' is parallef midline of the ;l1Hl'l\"ior a\",I'(,'([ of thl.,.' sternum. The end-feel is firm because of rension in rhe costoclavic- ular ligamenr, sternoclavicular capsule and ligaments, 3. Align the distal arm with rhe ;IIHnior midli and latissimus dorsi, sternocostal fibers of the pectoralis the humerus. Dcpl.'nding Oil rhe :lIlHHIIl[ of a major, and major and minor rhomboid muscles. rion and bccral roI:Hioll dur h:1S occurred' medial epicondyle may hL· ;1 helpful refcrenc)'\" FIGURE -1-26 Thl' alignmc Ihl' goniOllll'tl'r ;H lhe bcginni\" the RO.\\-l in gknohurl1crar ~houidl'r ..:ompkx ;Ihduuion.

CHAPTER 4 THE SHOULDER 81 :s~. FIGURE 4-27 The alignment of the goniometer at the end of the ROM in glenohumeral abduction. The examining table or the examiner's hand can supporr the subject's extrcmity and align the goniometer's distal arm with the anrcrior midline of the humerus. The examiner's other hand has released its stabiliza- tion of the scapula and is hold~ ing the proximal arm of the goniometer par:lllci to the ster- num. FIGURE 4-28 The alignment of the goniomcter at the end of the ROM in shouldcr complex abduction. Note that the humerus is latcrally rotated and the medial epicondyle is a help- ful anatomical landmark for aligning the distal arm of the goniometer.

82 PA R T II UPPER· EXTREMITY TESTING ADDUCTION . Stabilization Ivlorion occurs in the frontal plane around an antero- CICl1ohulllcr,ll Medi'1l Rot:ltion posterior axis. Adduction is not usually measured and recorded because it is rhe return (Q rhe zero starting posi- 111 rill\" hq.~innillg 01 rhl.: 1\\0\\1, ~t;lhiliza(i(lll i~ often tion from full abduction. llccded at rht: disr:d ('IH.I oi £Ill: humerus to kt'I.:p rht' sh()ul~ (!t-r ill 90 dq!.fl'l:'o of ahdtluiol1. 'r{-l\\\\'~lrd rill: tilL! of (he MEDIAL (INTERNAL) ROTATION . RO~vt. lht: chn'ick ;Hld ,.:oroc(lid alld 'H.:roillioll processes \\X1hcn the subject is in anatomical position, the motion of rhl: sc,lpub arc SLlhilized to prC\\'ClH :ll)t~:ri()r tilting occurs in the transverse plane around a vertical axis. When the subject is in the testing position, the motion ;111<.1 protrac['ion ot tilt:: scapula. occurs in rhe sagittal plane around a coronal axis. Mean shouldet complex medial rotation is 69 degrees according Shoulder Compl<:x i\\1cdial Rotation to Iloone and Azen.' 70 degrees according to the AAOS,s and 90 degrees according to the AMA:' Mean gleno· Sl'~lhiliz,lt'ioll is otrtfl llL'c(kd ilt rht: di:-t;\\l elld of the humeral medial roration is 49 degrees according to hUllh:rus to k('('p r/H: shouldl'f in YO dcgrl'L's ot :lbdunioll. Lannan) Lehman, and Toland,11 54 degrees according to Tht' thorax Illay be stahilized hy rhe wcight of the Ellenbecker, \\., and 63 degrees according to Boon and slIhjl.'(.:I\\ (fllnk or with tht: l:X;llnillcr\"s h:lnd [() prt.'\\TIlt SmithU See Tables 4-1 to 4-4 for additional informa· flexion or roUtiOll of thl' spillt'. cion. Testing Motion Testing Position .\\ h:di:llly rO{;Ht' rht: :-.houldLT hy l1lo\\'ing rht: fOft,::UIll .1 me· Position the subject supine, with the arm being tested in rindy, hringing rhL: palm of rhL: hand toward rill' Iloor, 90 degrees of shoulder abduction. Place the fotearm .\\bim:,ill rhe shCluld(.T in 90 lkgr(TS of ahduuloll and {he perpendicular to the supporting surface and in 0 degrees elhow in 90 dcgn:c~ of lIL:XiOfl during rhL: Illotioll. of supination and pronation so that the palm of the hand GknohurlH.:ral J\\tedi~,l ROtation faces the feet. Rest the full length of the humerus on the examining table. The elbow is not supported by the The end of RO\\! O';l.:llrs when rcsisr:llK't' {() examining table. Place a pad under the humerus so that motion is ft:lr and at{cmpts co O\\\"crCOll1t' lhe rhe humerus is level with rhe acromion process. (HUSC an anrcrior tilt or protracrioll of the scapula (Fig, 4-291. Shoulder Complex J\\I\\cdial R()(;.lrion TIlt.: (.ond of ROyl occurs when resistance to motion is fdt and a({('llIpts W on:n.:ol1l(' the rc\"istal1l:e: calise flcxHHl or rOLltion of the spint' (Fig. 4-30\").

CHAPTER 4 THE SHOULDER 83 Hl IS often p rhe shoul. end of rh In prO(;C crior rilti flOIl. FIGURE 4-29 The end of the ROM of glenohumeral medial {internal} rotation. The examiner stabilizes the acromion and coracoid pro-cesses of the scapula. The examiner is able to determine that the end of ro the ROM has been reached because any attempt to move the extremity into additional medial rotmion causes the scapula to tilt anteriorly or protract. The examiner should also maintain the shoulder in 90 ,«; degrees of abduction and the elbow in 90 degrees of nexion during the motion. :,; I;· ro further (' rCSIstanct 30). FIGURE 4-30 The end of the ROM of medial (internal) rotation of the shoulder complex. The examiner Ii' stabilizes the distal end of the humerus to maintain the shoulder in 90 degrees of abduction and the elbow in 90 degrees of flexion during the motion. Resistance is noted at the end of medial rotation of the shoul- der complex because attempts to move the extremity into further motion cause the spine to flex or rotate. The clavicle and scapu!.) are allowed to move as they participate in shoulder complex motions.

84 PA RT II UPPER· EXTREMITY TESTING Normal End-Feel Goniometer Alignment Glenohumeral Medial Rotation This goniometer alignment is used for measuring The end-fee! is firm because of tension in the posterior humeral and shoulder complex medial rotation joint capsule and the infraspinatus and teres minor 4-31 to 4-33). muscles. 1. Center the fulcrum of the goniometer Shoulder Complex Medial Rotation olecranon process. The end-feel is firm because of tension in the sternoclav- 2. Align the proximal arm so that it is either icular capsule and ligaments, the costoclavicular liga- dicular to or parallel with the floor. ment, and the major and minor rhomboid and trapezius muscles. 3. Align the distal afm with the ulna, using the non process and ulnar styloid for reference. FIGURE 4-31 The alignment of the goniometer at the beginning of medial rotation ROM of the gleno~ humeral joint and shoulder complex.

CHAPTER 4 THE SHOULDER 85 alil;nrnelltof the goniomerer at the end of medial rorarion ROM of the glenohumeral T:eh~,:~\"~t\"£'-l\"~i\";e;~x;a:m~ ointheer rusheasnodnheohldasndthteo support the subject's forearm and the distal arm of the goniometer. body and the proximal arm of the goniometer. ;10- rotation ROM of the shoulder

86 PA RT 11 UPPER· EXTREMITY TESTING LATERAL EXTERNAL) ROTATION cler in 90 degrees of abduction. Toward rh<: end of the ROM, the spine of the scapula is stabilized to prevent \\X1hcn the subject is in anatomical position, the motion posterior tilting and retraction. occurs in the transverse plane around a vertical axis. When the subject is in the testing position, the motion Shoulder Complex Lateral Rotation occurs in the sagittal plane around a coronal axis. Mean shoulder complex lateral rotation is 90 degrees according Stabilization is often needed at the distal end of the to the AAOS5 and AMA6 and 104 degrees according to humerus to keep the shoulder in 90 degrees of ahduc~ Boone and Azen.7 Mean glenohumeral medial rotation is tion. To prevent extension or rotation of the spine, the 94 degrees according to Lannan, Lehman, and Toland,12 thorax may be stabilized by the weight of the subject's 104 degrees according to Ellenbecker,14 and 108 degrees trunk or by the examiner's hand. according to Boon and Smith. 13 See Tables 4-1 to 4-4 for additional information. Testing Motion Testing Position Rotate the shoulder laterally by moving the fore<lfm posteriorly, bringing the dorsal surface of the pillrn of the Position the subject supine, with the arm being tested in hand toward the floor. Ivlaintain the shoulder in 90 90 degrees of shoulder abduction. Place the forearm degrees of abduction and the elbow in 90 degrees of flex· perpendicular to the supporting surface and in 0 degrees ion during the motion. of supination and pronation so that the palm of the hand faces the feet. Rest the full length of the humerus on the Glenohumeral Lateral Rotation examining rable. The elbow is not supported by the examining table. Place a pad under the humerus so that The end of ROl'v1 occurs when resistance to further the humerus is level with the acromion process. motion is felt and attempts to overcome the resistance cause a posterior tilt or retraction of the scapula (Fig. Stabilization 4-34). Glenohumeral Lateral Rotation Shoulder Complex Lateral Rotation At the beginning of the ROM, stabilization is often The end of R01'vl occurs when resistance to further needed at the distal end of the humerus to keep the shoul- motion is felt and attempts to overcome the cause extension or rotation of the spine (Fig. 4-35).

CHAPTER 4 THE SHOULDER 87 )f the FIGURE 4-34 The end of lateral rotation ROM of the glenohumeral joint. The examiner's hand stabi- 'event lizes the spine of the scapula. The end of the ROM in latera! rotation is reached when additional morion causes the scapula to posteriorly tilt or retract and push against the examiner's hand. )f the lbduc· Ie, [he bjeet'S >rcarOl of the in 90 ,f flex- further isr<1ncc I\" (Fig. further ~istance .5). FIGURE 4-35 The end of lateral rotation ROM of the shoulder complex. The examiner stabilizes the distal humerus to prCVCIH shoulder abduction beyond 90 degrees. The elbow is maintained in 90 degrees of flexion during the motion.

88 PART II UPPER· EXTREMITY TESTING Normal End-feel Goniometer Alignment Glenohumeral Lateral Rotation This goniometer alignment is used for measuring gleno- humeral and shoulder complex larcral roration (Figs. The end-feci is firm because of tension in the anrerior 4-36 to 4-38). joint capsule, the three bands of rhe glenohumeral liga. mcor, and the coracohumeral lig<lmcnt, as well as in the 1. Cemer rhe fulcrum of rhe goniomerer over the subscapularis, the teres major, and the clavicular fibers of the pectoralis major muscles. olecranon process. Shoulder Complex Lateral Rotation 2. Align the proximal arm so rhar it is eirher parallel to Or perpendicular to rhe floor. The end-feci is firm because of tension in the SC capsule and ligaments and in the latissimus dorsi,. sternocostal 3. Align the distal arm with rhe ulna, using the fibers of the pectoralis major; pectoralis minor, and serra- olecranon process and ulnar styloid for reference. tuS anterior muscles. FIGURE 4-36 The alignment of the goniometer at the beginning of lateral (marion ROM of the gleno- humeral joint ;:md shoulder complex.

CHAPTER 4 THE SHOULDER 89 ICter over FIGURE 4-37 The alignment of the goniometer at the end of lateral rotation ROM of the glenohumeral joint. The examiner's hand supports the subject's forearm and the distal arm of the goniometcr. The examiner's orhcr hand holds the body and proximal arm of the goniometer. The placemenr of the examiner's hands would be reversed if thc subject's right shoulder were being tested. , FIGURE 4-38 The alignment of the goniometer at the end of lateral rotation ROM of the shoulder complex.

90 PA R T il UPPER·EXTREMiTY TESTING REFERENCES 22. 1',\\\\':~ILiI1:,', ;\\. J,lchl'll\\ll'HI. \\1). ;lild ILl/.\\ld~l, III': (klcl'lllllLlllh (Jf L Cyriax, JB, and Cyriax, Pl: Illustrated Manual of Orthopaedic \\houl,kr ;lllclclh,,\\\\' ikxio!l I';l!l.l'l': Rl'\\ldh trolll :)1,' 'UI1 ,-\\nlOllio Medicine. Buncrworrhs, London, 1983. l\"llgillldin;d ~lu,l)- ()j ,lgill)~, :\\nhriti\\ CHl' !{l'\\ 12:277. 1')')'1, 2. Culham, E, and Peat, M: Functional anatomy of the shoulder 23. f(l'h,ll'!\\l', \\1, \\lc:Clurc, P, ,lIld l'r.nt, \",-\\: Th(Jr;hX pO\\I,I(O[I df<:ct (1I1 \\huulder f.lngc ui !l\\lJtiot1, \\lr\"ll)~dl. ;lild IhH'l'dllm'fhi()ll~ll complex. J Onhop Sports Phys Ther 18:342, 1993. \\clj1uhr killl'f1Llli~'\\. ,-\\rch I'h:'\\ .\\hod Rt,luhiIS():'H). 1')'1'), 3. Levangie, P, and Norkin, C: Joim Structure and Function: A 24. S;lh;ni. IS. n ~d: COlliorlJl:[ric ~1\\~C\\\\IlI\\.'flt ot \\h()1I1dn [;lllg,' of Comprehensive Analysis, cd 3. FA Davis, Philadelphia, 200 I. Tll(J!i()Jl: C:()I11I'~lri\\ul\\ of !C\\UIl~~ in \\lIpinc and \\ining pu\"iti()lls. 4. Kalrenborn, FM: Manual Mobilization of the Extremity Joints, ,'\\r(h I'll\\'\\ \\kd Rduhil ?\\J:fl4, I '/(JS, cd 5. Olaf Norlis Bokhandel, 0510,1999. 25. Bit~bni. LU, C't ;d: 'ihoulder !ll()tiUIl :l1ld !:lxity inlhe Pf()k~\\i(jll~ll 5. American Academy of Orthopaedic Surgeons: Joint Motion: Method of Measuring and Recording. AAOS, Chicago, 1965. h;;whall pLiycl', ,'\\m J Spun\\ .\\led 2):(,09, 1997, 6. American Medical Association: Guides to the Evaluation of 26. lI.du,:i. C. !ohn\\oll. R, ;llld Kohl II: Shoulder r;lIlge ot Illoriull Permanent Impairment, cd 3. AMA, Chicago, 1988. <..'h;lf~lcteri\\(il'\\ ill collcgi~llc h~l\\ch~dl pLJYCf\\, I 'iP(JI'(\\ ,\\led Phys J'I!IlC~~ -II :2;6, 20(j 1, 7. Boone, DC, and A1.cn, SP: Normal range of motion in mnle subjects. J Bone Joint Surg Am 61:756,1979. 27. Chinll, C.l, l'ril'~t, .II), ~111,1 f(CJll. 1',;\\; U[ll1C! t'xtH'lIll(Y Llllgc of IIIOtiUll, gnp ~trcngth ,tlld glrdl III Ilighly .. kdlt:d t('lInl~ pL1YcrS. 8. Greene, BL, and Wolf, S1.: Upper extremity joint movement: Compnrison of two mensuremem devices. Arch Phys Med Phys TI1t'r)·H 74, 197·l. Rehabil 70:288,1989. 28. r.:il\\I,·r, \\\\'1\\, L't ;d: Should\"r r;III~~l' or' motio!l in eli!e t,'IHlh play- 9. Soderberg, G1.: Kinesiology: Application to Pathological lVlotion. Williams & Wilkins, Baltimore, 1986. ns: FHt:d oi ;IW' :llld ~'l';tr\\ oi !lJllriLlfllt:ll[ I'Ll:', ;\\m.l S[)u!'ts .\\led 2·1:27<), 19%, 10. Doody, SG, Freedman, L, and Waterland, JC: Shoulder move· ments during abduction in the scapular plane. Arch Phys !\\.'led 29. Ch'lm~. DL BU\\<.:hhad,cr. LT, ,llld Fdlich. RF: Lllllitn! loint Rehabil51:595, 1970. f1tohd'ilY III j10Wl'!' Iiftl'l'\\ , o'\\111.l Sports .\\kd 1();2S(J, 19Kk, 11, Poppen, NK, and Walker, PS: Forces at the glenohumeral joim in 30. {,dllt:, 1'1); Thl' fl'I~Hi(ln\\hip hl'IWl'l'Il mU!IO!l ut the \\lwul,lt:r ;111(.1 abduction. Clin Onhop 135:165, 1978. tlw \\LHnl :thility (0 j1l'r!(I('!ll ;lcti\\,itit~\\ of d:uly living, ,I !',Olll' .Joint 12. Lannan, D, Lehman, ·r~ and Toland, M: Establishment of norma- tive data for the range of motion of the glenohumeral joint. Sllr~ NIH], ] (l'iS, tvbster of Science Thesis, University of Massachusetts Lowell, 31. \\Ll'hl'll, I-'A, l'I ai: l't':ldi<..-.li F\\:Ii\\LlliiHl .tnd .\\Llll.l;~l'III\\'nt \\It' [he 1996. \"lHJlllder'. \\VP, \"'lunder.;, I'hi!,lddphi;l, I 'J'J.l, 13. Boon, AJ, :llld Smith, 1: Manual scapular stabilization: Its dfect 32. 'i,lf.ll'l'-Ibd, I,. ct :d: >';()rrn.ll fUIl<..,tion:d Llllgl' oj 1I\\,,[i\"ll (lj upper on shoulder rotational range of motion. Arch Phl's l\\.'1ed Rehabil 11mb l(lilltS dllriflg pnhH'm'llkl' ()j thrn' feedi!!;: ,k11\\llll'\\, :\\rch SI,978, 2000. l'l1\\'~ .\\In! ]{,'h,lhil -I ::;()5. 1')(1('1, 14. Ellenbecker, 1'5, et al: Glenohumeral joinr internal and external rotation range of motion in elite junior tennis players. J Orthop 33. I kikhr.lndt. 1-'.'\\, ()U\\-:l!1, F><,Ill<i .\\lollf'e. .\\11: Ill<' lilLhU!'l'illt·1lt Sports Phys Ther 24:336, 1996. of IUI!ll l11otiun, I':1rt 111: Rl'li:d,tlily uj ;':O!llulll,'lr\\\" l'hy~ '1')1\\:1' Rev 15. \\,(Ianatabe, H, et al: The range of joint motions of the extremities 2'1:\\(12, ]').\\9, in healthy Japanese people: The difference according to age. Nippon Seikeigeka Gakkai Zasshi 53:275, t 979. Cired by 34. B()I'!ll', DC. <'t ,Ii: Rl,ILlhllit'., ur ;:()ni(Htl\"tri~' 111l';1~t:r,'rt1l'IH\\, [lhrs W3lker, JM: MllSCllloskcJet31 development: A review. Phys Ther 71,878, 1991. rhl'r)S:I.l)~, !'rs, 16. Boone, DC: Techniques of measurement of joint motion. (Unpublished supplement to Boone, DC, and Azen, SP: Normal 35. 1';I[1d\\',l, S. '.'t ,11: R\"ILlhillly (lj ;':(lni()!l1l'tric lllt',I~\\lr-,'rncllt~ in range of motion in male subjects. J Bone Joint Surg Am 61:756, P~l[iC;ll~ with Ilu<..']Wllfll' rIH1\\~'uhr ..h'\\troph\\, Ph~s T!ln (,); 1),;9, 1979.) 17. Walker, pv1, et al: Active mobility of the extremities in older 1'JS:;, subjects. Phys Ther 64:919,1984. 36. Riddle, [H\" !{()[hSrnll, .1,\\1, ,ltHI Llmh, 1\\1: (,OJ\\lllfit,,:rk fl,ji:lbil· 18. DO\\vney, PA, Fieben, I, and Stackpole-Brown, JB: Shoulder range il~ III ,I -:lillk-~d \\l,ttillg: Shollldn ll\\l',l~\\lr,'lll,'l\\h, I'lly\" Ther h \"7:1,6S, I 'JS7 of motion in persons aged sixty and older [abstractJ. Phys Ther 71,S75, 1991. 37. !lu'.-ells, :\\.\\!I', l't ~II: V~HLlhility ~\\lld rt'li~lhl!ity of l(lillt Illl'.l\"ure- 19. West, CC: Measurement of joinr motion. Arch Phys Med Rehabil lllelHS, ,\\ml ~pons \\led IS:SS. 1'!9(), 26:414,1945. 38. \\L!<..IlL'fmid, Je:. VI ;d: (l1(r;lll'Slt'r ;lI1d illll'rlt'\\tcr r\"li;lhliir~' of 20. Clarke, GR, et al: Preliminary studies in measuring range of gllni(Hlll'fric rJll'JSlIf'Vllll'!H ot p.hsiv,· b[Cr.11 \\!t('lIld,'f nll;llioll, motion in normal and painful stiff shoulders. Rheumatol Rchabil 14:39, 1975. IILllld TIlt'1' 12:!S-:', 19')(1. 21. Allandcr, E, t't al: Normal range of joint movement in shoulder, hip, wrist and thumb with special reference to side: A compari- 39, (;I't'l'n. A, l'1 ,II: :\\ S,Jlllbrdiln! pro[()co! tor nlt',]\\urnfl,'ll[ of son between two populations. Inr J Epidemiol 3:253, 1974. r;lllgl' of ll)()\\'l'!lll'nl of the sh(ltllde~ using til,' I'I1ifilllt'(l'f'V indi- lHlll1l\"tl'r ~ll1d ~ISSl'SSIJlt'll[ of its inrr;tf;lll'l' ~ll1d illll'rLl1er fl'iLlhiJity. :\\nbrins C,m' Ih·s 1 1;·1), [lj,!S. c:.40. Tiffill. I'D, \\Vildill. ;llld fLlIiotf, (): The I'cpro,lll<..'ihility of !l\\CISUf,'ml'IH of \\houldn !llO\\'l'111C1l1. :\\<..'[;l OnIHIj' \"'-~llld \"7():,)2l, 1')99, 41. lI(l\\\\'l'r. 1-\\:1): l'fw h~'drllf~(JlIj()[Il<'t,'r ;llld ;t ..sc~~n\\l'llt (ll f~lrno­ hUllll'Ld juill[ monon, J:\\\\l~( l'hy\\iolhn 2S:12, I(lS2, 42. Crllt!, 1', ('[ ;11: Ob\\,'r\\n \\;m:l!,ill(1 III 11l,\\\\Stmllf: ek'\\':ltiO!l ,\\lid extt:rILd rUla(iull 01 tilt' .. h(lttldl'~. I\"r .J RhclIlll,\\l(d 33:')42, 1'J'J.!.

lII:lllh of ~ , $1 \\ :\\ntonio 1')'19. The Elbow and Forearm I (Ill dfL\"Ct ~ Structure and Function The proximal joint surface of the humeroradial joint is the convex capitulum located on the anterior lateral 1\":lblt1nal Humeroulnar and Humeroradial Joints surface of the distal humerus. The concave radial head on the proximal end of the radius is the opposing joint J9~. Anatomy surface. r:lIlge of The humeroulnar and humeroradial joints between the The joints are enclosed in a large, loose, weak joint upper arm and the forearm are considered to be a hinged capsule that also encloses the superior radioulnar joint. '1)~j!i(Jns, compound synovial joint (Figs. 5-1 and 5-2). The proxi- Medial and lateral collateral ligaments reinforce the sides mal joint surface of the humeroulnar joint consists of the of the capsule and help to provide medial-lateral stability fe~~ioflal convex trochlea located on the anterior medial surface of (Figs. 5-3 and 5-4 ).' the distal humerus. The distal joint surface is the concave f Il!otlon trochlear notch on the proximal ulna. When the arm is in the anatomical position, the long kd Phys axes of the humerus and the forearm form an acute angle r,IlI~L\" of ~; players, p 'J nl~ play- I n . . .\\ k d t\"d juint s, lld~'r and JIlL' Joint 'H oi tht: j,f upper ~\", Arch .llr~·lllellt ),/ rilL'( /{e\\' J 'n ... r'hy) IlL'lIb on :.5:IH9, rdi.lhil- ,y, Thl'r 11~·;1.\"lIrl'- h,li,y of r(f{:lrillll. Coronoid fossa o f'1lI~'1H ...,./-- Humerus ----1\\-'1Humerus ~ '. \\' lIh::Ii- , !:, 1,1 :!r:lbilily, J: \\ Olecranon fossa \" bilil~' of 'Lateral epicondyle Olecranon Capilulum process :-n:.;n. Humeroradial ,. ~ll'110' joinl ----~~~ :IL·\\\".lfl{'1l Radial head ~_ _ Lateral epicondyle Humeroradlal ,)3:'),12. .~--- Radial head Trochlea Medial -----l'. Coronoid process epicondyle Humeroulnar joiot - - - - +Radius +-_:...- Ulna +--- Radius FIGURE 5-1 An anterior view of the elbow showing the FIGURE 5-2 A posterior view of the elbow showing [he humeroulnar and humeroradial joints. humcroulnar and humeroradial joints. 91 ·1 .._-------~'.=.,,--'...--'

92 PA R T II UPPER-EXTREMITY TESTING - - +Humerus Medial epicondyle coronoid fossa of the humerus or until soft tissue in the anterior aspect of rhe elbow blocks further flexion. Annular ligament Joint capsule Ar the humeroradial joint, the concave radial head Radius slides posteriorly on the convex surface of rhe capitulum ? during extension. In flexion, the radial head slides anteri- orly until the rim of rhe radial head enters rhe radial fossa '0 of rhe humerus. Medial Copsular Pottern ;,: collateral The capsular pattern is variable, but usually the range of 00<: ligament morion (ROMI in flexion is more limired than in exten- sion. For example, 30 degrees of limitation in flexion 0\" /------=~ would correspond to 10 degrees of limitation in exten~ }- Ulna sion.4 FIGURE 5-3 A medial view of the elbow showing the medial (ulnar) collateral iigamenc, annular ligamcm, and joint capsule. at the elbow. The angle is called the \"carrying angle.\" Superior and Inferior Radioulnar Joints This angle is about 5 degrees in men and approximately 10 to 15 degrees in women.2 An angle that is gteater Anatomy (more acute) than average is called \"cubitus valgus.\" An angle that is less than average is called ·'cubitus varus.\" The ulnar porrion of the superior radioulnar joint includes both the radial notch located on the lateral Osteokinematics aspecr of rhe proximal ulna and the annular ligament (Fig. 5-5). The radial notch and the annular ligament The humeroulnar and humeroradial joints have 1 degree of freedom; flexion-extension occurs in the saginal plane Superior radioulnar joint around a medial-lateral (coronal) axis. In elbow flexion and extension, the axis of rotation lies approximately Radial head through the center of the trochlea. J l:::::j~'!41-- Radial nolch Arthrokinematics At the humeroulnar joint, posterior sliding of the concave trochlear notch of the ulna on the convex trochlea of the humerus continues during extension until the ulnar olecranon process enters the humeral olecranon fossa. In flexion, the ulna slides anteriorly along the humerus until the coronoid process of the ulna reaches the floor of the Humerus Radius ---'\"' Ulna Annular ligament Ir m lateral --++- Radius FI< epicondyle Ulnar notch Ulnar head rao m, Joint caputa Ulnar styloid process na _)>f&~ Radial styloid process - - - t 1 ' Lateral collateralllgament Ulna Inferior radioulnar joint FIGURE 5-4 A lateral view of the elbow showing the latetal FIGURE 5-5 Anterior view of the superior and inferior radioulnar joints. (radial) collateralligamem, annular ligament, and joint capsule.