Musculoskeletal assisment

CHAPTER 9 Head, Neck, and Trunk 489 prime movers when one rises from the supine position to from the weight being transmitted through the arms to get out of bed (see Fig. 9-177). In the supine position, the the thorax and abdomen and then to the pelvis, taking rectus abdominis is the most active abdominal muscle some of the load off the spine.80 This also results in addi- when the head is raised,72 contracting to stabilize the tional trunk stabilization and an extensor moment is thorax. The abdominal muscles contract isometrically applied to the lumbar spine79 through activation of the and function to stabilize the thorax and pelvis when per- transversus abdominus and subsequent increased tension forming pushing, pulling, or lifting activities.59 in the thoracolumbar fascia. Flexion of the trunk in standing position occurs as one Trunk Lateral Flexion. The erector spinae, intertransversa- picks up an object from the floor or ties a shoelace. Trunk rii, and posterolateral fibers of the external abdominal flexion is initiated by contraction of the abdominals and oblique, quadratus lumborum, and iliopsoas muscles the vertebral portion of the psoas major muscle.56 Once contribute to lateral flexion of the trunk. Lateral flexion the trunk is inclined forward gravity takes over to flex the is not used often in activities unless to pick an object up trunk. Flexion of the trunk is then controlled through from a low table at one’s side or when moving from a contraction of the erector spinae muscle until a “critical side-lying position to sitting on the edge of a bed or sit- position” is reached when the erector spinae muscle ting to a side-lying position. The lateral flexors contract relaxes and further flexion occurs through hip flexion.73 on the ipsilateral side to initiate movement and contract The posterior layer of the thoracolumbar fascia,74 elastic on the contralateral side to modify the movement in the forces generated in the extensor musculature as a result of upright position.56 the passive stretch on the muscles,75 and the posterior intervertebral ligaments support the trunk in the fully Trunk Rotation. The trunk rotator muscles include the flexed position when the erector spinae is relaxed. Wolf erector spinae, multifidus, rotatores, and internal and and coworkers76 identify the critical position to be at external abdominal oblique muscles. The internal and greater than 70° of trunk flexion, most often between 80° external abdominal obliques are the prime rotators of the and 90°. If further trunk flexion is required at the end of trunk.81 The extensor muscles function to counteract the the movement, the abdominal muscles must contract to flexion torque created by the oblique abdominal muscles force the movement.77 during trunk rotation.81 The muscles contract to rotate the trunk to change position while recumbent and when Trunk Extension. The erector spinae muscle contracts to one turns to look in a posterior direction, or reaches with initiate trunk extension in the standing position and the hand(s) in directions lateral or posterior to the trunk. once started, gravity pulls the trunk into further exten- sion and the movement is controlled by the contraction Posture. Electromyographic studies report slight activity of the abdominal muscles.56 The erector spinae contracts in the erector spinae muscle73 and slight contraction in again, if required, to force extension at the end of the the internal abdominal oblique muscle72 in standing. The ROM.56 When trunk extension is performed against resis- erector spinae contracts during unsupported upright sit- tance, the erector spinae muscle contracts to perform the ting but is relaxed when sitting in the “slumped” position entire movement. This occurs when the trunk is extended with the spine in full flexion.73 from a forward lean position in sitting, and in the prone position when the trunk is extended to reach for a light Breathing. The erector spinae is active during inspiration switch located at the head of the bed. when ventilatory demand is increased.82 With an increased inspiratory effort, forces are transmitted to the When lifting objects off the floor from a forward spine through the costovertebral and costotransverse flexed position, the pattern of muscle activity is the articulations encouraging flexion of the spine. Spinal reverse of that required to flex forward in standing. There flexion will cause a deflationary effect on the rib cage. is no contraction of the erector spinae muscles at the This deflationary effect is counteracted by the erector beginning of the lift, the thoracolumbar fascia, elastic spinae contracting to stiffen and extend the vertebral forces generated in the extensor musculature, and the column. posterior intervertebral ligaments take the load and the movement to extend occurs initially at the hip joints, as The abdominal muscles are inactive during expiration the pelvis rotates posteriorly. As the movement continues at rest. When ventilatory demands increase, the abdomi- the erector spinae muscle contracts close to the critical nal muscles (rectus abdominus, external abdominal position and the contraction continues until the erect oblique, internal abdominal oblique, and transversus position is reached.73 Great forces are placed on the trunk abdominus) contract to pull the rib cage down and when lifting in the forward flexed position; therefore, increase the intra-abdominal pressure, thus pushing the this position should be discouraged and the lift performed abdominal contents and diaphragm upward into the tho- with the back straight and the knees flexed78 with the racic cavity, decreasing the lung volume to expel air.83 object being lifted positioned as close to the body as pos- sible. When heavy weights are lifted and large forces are Gait.7 As the pelvis rotates forward on the side of the placed on the spine, the abdominal (primarily the trans- advancing leg, the trunk rotates forward on the opposite versus abdominus79), diaphragm, and intercostal muscles side to keep the body facing forward during the gait contract to increase the intra-abdominal and intratho- cycle. The erector spinae muscles contract on the contra- racic pressures so that the thorax and abdomen become lateral side to the supporting leg to prevent the trunk semirigid cylinders.80 This results in some of the force

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SECTION III Appendices Appendix A: Sample Numerical Recording Form: Range of Motion Assessment and Measurement Appendix B: Sample Recording Form: Manual Muscle Strength Assessment Appendix C: Summary of Patient Positioning for the Assessment and Measurement of Joint Motion, Muscle Length, and Muscle Strength Appendix D: Gait

Appendix A Sample Numerical Recording Form: Range of Motion Assessment and Measurement 494

APPENDIX A: Sample Numerical Recording Form 495 Range of Motion Assessment and Measurement Patient’s Name _____________________________________ Date of Birth/Age ____________________________________ Diagnosis __________________________________________ Date of Onset _______________________________________ Therapist Name ____________________________________ AROM ❒ PROM ❒ Signature ____________________________________ 3. The columns designated with asterisks (*) are used for indicating limitation of range of motion and referenc- Recording: ing for summarization. 1. The Neutral Zero Method defined by the American 4. Space is left at the end of each section to record hyper- Academy of Orthopaedic Surgeons1 is used for mea- mobile ranges and comments regarding positioning of surement and recording. the patient or body part, measuring instrument, 2. Average ranges defined by the American Academy of edema, pain, and/or end feel. Orthopaedic Surgeons,1 are provided in parentheses. Left Side Therapist Initials Right Side ** ** Date of Measurement Head, Neck, and Trunk Mandible: Depression Protrusion Lateral deviation Neck: Flexion (0–45°) Extension (0–45°) Lateral flexion (0–45°) Rotation (0–60°) Trunk: Flexion (0–80°, 10 cm) Extension (0–20–30°) Lateral flexion (0–35°) Rotation (0–45°) Hypermobility: Comments:

496 SECTION III Appendices Patient’s Name ________________________________________ Left Side Right Side ** ** Therapist Initials Date of Measurement Scapula Elevation Depression Abduction Adduction Shoulder Complex Elevation through Flexion (0–180°) Elevation through Abduction (0–180°) Shoulder (Glenohumeral) Joint Flexion (0–120°)2 Abduction (0–90° to 120°)2 Extension (0–60°) Horizontal abduction (0–45°) Horizontal adduction (0–135°) Internal rotation (0–70°) External rotation (0–90°) Hypermobility: Comments: Elbow and Forearm Flexion (0–150°) Supination (0–80°) Pronation (0–80°) Hypermobility: Comments:

APPENDIX A: Sample Numerical Recording Form 497 Patient’s Name ________________________________________ Left Side Right Side ** ** Therapist Initials Date of Measurement Wrist Flexion (0–80°) Extension (0–70°) Ulnar deviation (0–30°) Radial deviation (0–20°) Hypermobility: Comments: Thumb CM flexion (0–15°) CM extension (0–20°) Abduction (0–70°) MCP flexion (0–50°) IP flexion (0–80°) Opposition Hypermobility: Comments: Fingers MCP digit 2 flexion (0–90°) extension (0–45°) abduction adduction MCP digit 3 flexion (0–90°) extension (0–45°) abduction (radial) adduction (ulnar) MCP digit 4 flexion (0–90°) extension (0–45°) abduction adduction

498 SECTION III Appendices Patient’s Name ________________________________________ Left Side Right Side ** ** Therapist Initials Date of Measurement MCP digit 5 flexion (0–90°) extension (0–45°) abduction adduction PIP digit 2 flexion (0–100°) 3 flexion (0–100°) 4 flexion (0–100°) 5 flexion (0–100°) DIP digit 2 flexion (0–90°) 3 flexion (0–90°) 4 flexion (0–90°) 5 flexion (0–90°) Composite finger abduction/thumb extension— Distance between: Thumb–digit 2 Digit 2–digit 3 Digit 3–digit 4 Digit 4–digit 5 Composite flexion—Distance between: Finger pulp-distal palmar crease Finger pulp-proximal palmar crease Hypermobility: Comments:

APPENDIX A: Sample Numerical Recording Form 499 Patient’s Name ________________________________________ Left Side Right Side ** ** Therapist Initials Date of Measurement Hip Flexion (0–120°) Extension (0–30°) Abduction (0–45°) Adduction (0–30°) Internal rotation (0–45°) External rotation (0–45°) Hypermobility: Comments: Knee Flexion (0–135°) Tibial rotation Patellar mobility—Distal glide Patellar mobility—Medial-lateral glide Hypermobility: Comments: Ankle Dorsiflexion (0–20°) Plantarflexion (0–50°) Inversion (0–35°) Eversion (0–15°) Hypermobility: Comments:

500 SECTION III Appendices Patient’s Name ________________________________________ Left Side Right Side ** ** Therapist Initials Date of Measurement Toes MTP great toe flexion (0–45°) extension (0–70°) abduction MTP digit 2 flexion (0–40°) extension (0–40°) MTP digit 3 flexion (0–40°) extension (0–40°) MTP digit 4 flexion (0–40°) extension (0–40°) MTP digit 5 flexion (0–40°) extension (0–40°) IP great toe flexion (0–90°) PIP digit 2 flexion (0–35°) PIP digit 3 flexion (0–35°) PIP digit 4 flexion (0–35°) PIP digit 5 flexion (0–35°) Hypermobility: Comments: Summary of Limitation: Additional Comments: 1American Academy of Orthopaedic Surgeons: Joint Motion: Method of Measuring and Recording. Chicago: AAOS; 1965. 2Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis. 3rd ed. Philadelphia: FA Davis; 2001.

Appendix B Sample Recording Form: Manual Muscle Strength Assessment 501

502 SECTION III Appendices Manual Muscle Strength Assessment Patient’s Name ______________________________________ Date of Birth/Age ______________ ID __________________ Diagnosis ___________________________________________ Date of Onset _______________________________________ Therapist Name _____________________________________ Signature _____________________________________ Manual Muscle Testing (MMT) Method Used Date of Assessment: _____________ MMT method used: _____________ Date of Assessment: _____________ MMT method used: _____________ Date of Assessment: _____________ MMT method used: _____________ Date ot Assessment: _____________ MMT method used: _____________ Key: MMT Method Used. C Conventional “through range” grading I “Isometric” grading: b break test or m make test (eg: lb indicates “Isometric” break test) Left Side Right Side Motion Therapist Initials Nerve supply Date of Assessment Eyelid elevation Muscle CN III Eyelid closure CN VII Eyeball elevation Eye CN III Levator palpebrae superioris CN III Eyeball depression Obicularis oculi CN III Rectus superior CN IV Eyeball abduction Obliquus inferior CN VI Eyeball adduction Rectus inferior CN III Obliquus superior Elevation Rectus lateralis CN VII Adduction Rectus medialis CN VII Depression CN VII Eyebrows Elevation Epicranius CN V Corrugator supercilli Depression Procerus CN V Protrusion CN V Mandible Temporalis/masseter/medial pterygoid Lateral pterygoid/suprahyoid Pterygoids Remarks:

APPENDIX B: Sample Recording Form: Manual Muscle Strength Assessment 503 Patient’s Name/ID ________________________________________ Left Side Right Side Remarks: Motion Therapist Initials Nerve supply Date of Assessment Dilation Muscle CN VII Constriction CN VII Nasal Aperture Lip closure Nasalis/depressor septi CN VII Cheek compression Nasalis CN VII Elevation of angle CN VII Retraction of angle Lips/Mouth CN VII Depression of angle Obicularis oris CN VII Buccinator Upper lip elevation Levator anguli oris CN VII Zygomaticus major/risorius Lower lip elevation Platysma/depressor anguli oris/ CN VII Protrusion depressor labii inferioris CN XII Levator labii superioris/zygomaticus Hyoid bone depression Cervical Flexion minor Cervical Mentalis Cervical Extension Cervical Tongue Abduction Genioglossus Long Lateral rotation Thoracic Elevation Neck Accessory, CN XI Infrahyoid group Dorsal Adduction Flexor group Scapular Adduction Sternomastoid Accessory, CN XI Medial rotation Extensor group Dorsal Depression Scapular Scapula Accessory, CN XI Serratus anterior Upper trapezius Levator scapulae Middle trapezius Rhomboids Lower trapezius

504 SECTION III Appendices Patient’s Name/ID ________________________________________ Left Side Therapist Initials Right Side Date of Assessment Motion Muscle Nerve supply Flexion Flexion–Adduction Shoulder Axillary Extension Anterior deltoid Musculocutaneous Abduction Coracobrachialis Thoracodorsal Adduction Latissimus dorsi Subscapular Teres major Axillary Horizontal adduction Middle deltoid Suprascapular Horizontal abduction Supraspinatus Pectoral Internal rotation Pectoralis major Subscapular External rotation Teres major Thoracodorsal Latissimus dorsi Pectoral Flexion Pectoralis major Axillary Posterior deltoid Subscapular Extension Subscapularis Suprascapular Supination Infraspinatus Axillary Pronation Teres minor Musculocutaneous Flexion Elbow/Forearm Radial Extension Biceps Musculocutaneous/radial Brachioradialis Radial Remarks: Brachialis Radial Triceps Median Supinator Pronator teres Median Pronator quadratus Ulnar Radial Wrist Radial Flexor carpi radialis Radial Flexor carpi ulnaris Extensor carpi radialis longus Extensor carpi radialis brevis Extensor carpi ulnaris

APPENDIX B: Sample Recording Form: Manual Muscle Strength Assessment 505 Patient’s Name/ID ________________________________________ Left Side Right Side Motion Therapist Initials Nerve supply MCP extension Date of Assessment Muscle Radial MCP abduction Radial MCP adduction Fingers Radial MCP flexion-IP extension Extensor digitorum Ulnar Extensor indicis proprius Ulnar Extensor digiti minimi Ulnar Median Dorsal interossei Ulnar Abductor digiti minimi Ulnar Median Palmar interossei Median Lumbricales 1 and 2 Median Lumbricales 3 and 4 Ulnar Ulnar 5th MCP flexion Flexor digiti minimi PIP flexion digit 2 Flexor digitorum superficialis Median Ulnar digit 3 Flexor digitorum profundus Radial digit 4 Radial DIP flexion digit 2 Thumb Radial digit 3 Flexor pollicis longus Median digit 4 Flexor pollicis brevis Ulnar digit 5 Extensor pollicis longus Median Extensor pollicis brevis Ulnar IP flexion Abductor pollicis longus MCP flexion Abductor pollicis brevis Thoracic IP extension Adductor pollicis Thoracic MCP extension Opponens pollicis Thoracic Radial abduction Opponens digiti minimi Thoracic Palmar abduction Lumbar Adduction Trunk Opposition Rectus abdominis External oblique Flexion Internal oblique Rotation Extensor group Quadratus lumborum Extension Pelvic elevation Remarks:

506 SECTION III Appendices Patient’s Name/ID ________________________________________ Left Side Right Side Motion Therapist Initials Nerve supply Flexion Date of Assessment Muscle Lumbar Extension Femoral Hip Femoral Abduction Psoas major Gluteal Iliacus Sciatic Adduction Sartorius Sciatic Internal rotation Gluteus maximus Sciatic External rotation Biceps femoris Gluteal Flexion Semitendinosus Gluteal Semimembranosus Gluteal Extension Obturator Dorsiflexion Gluteus medius Gluteal Plantarflexion Gluteus minimus Gluteal Inversion Tensor fascia latae Gluteal Eversion Adductor group Sacral/lumbar Gluteus medius MTP flexion Gluteus minimus Sciatic IP flexion Tensor fascia latae Sciatic Sciatic MTP abduction External rotator group Femoral Knee Extension Peroneal Biceps femoris Tibial Remarks: Semitendinosus Tibial Semimembranosus Tibial Quadriceps Peroneal Peroneal Ankle Tibialis anterior Tibial Gastrocnemius Tibial Soleus Tibial Tibialis posterior Tibial Peroneus longus Peroneus brevis Tibial Tibial Toes Tibial Flexor hallucis brevis Peroneal Lumbricales Flexor hallucis longus Flexor digitorum longus Flexor digitorum brevis Abductor hallucis Abductor digiti minimi Dorsal interossei Extensor hallucis longus Extensor digitorum brevis Extensor digitorum longus

Appendix C Summary of Patient Positioning for the Assessment and Measurement of Joint Motion, Muscle Length, and Muscle Strength This summary chart is a resource the therapist may use to stabilization. In some instances, alternate start positions facilitate an organized and efficient assessment of joint are documented if commonly used in clinical practice. range of motion (ROM), muscle length, and muscle The following chart summarizes the preferred (P) and strength to avoid unnecessary patient position changes alternate (A) start positions used by the therapist when and fatigue. assessing and measuring joint motion and manually testing muscle strength. For assessment of muscle The assessment and measurement of joint motion, strength greater than grade 2, the patient is positioned that is, joint ROM and muscle length, and the manual against gravity (AG) for the test motion, and for strength assessment of muscle strength presented in this book, less than or equal to grade 2, the patient is in a gravity first shows the preferred start position for these assessment eliminated (GE) position, unless stated otherwise. techniques based on the position that offers the best 507

Joint Motion Sitting Supine Prone Sidely Standing Muscle Strength Sitting Supine Prone Sidely Standing 508 SECTION III Appendices Shoulder Complex P(GE)/A(AG) Scapular movements Shoulder Complex P(AG) P(GE) Elevation through flexion P(GE) P(GE) P P Serratus anterior P(GE) P(AG) P(GE) Glenohumeral joint flexion Extension AP Upper trapezius, P(AG) P(GE) A(GE) Elevation through levator scapulae P(AG) P(GE) abduction P Middle trapezius P(GE) P(AG) Glenohumeral joint P(GE) P/A(AG) AP Rhomboids P(GE)/A(GE) P(GE)/P(AG) abduction P(GE) Adduction AP Lower trapezius P(GE) Horizontal adduction/ P(GE) P Anterior deltoid P(GE) abduction P(AG) Internal rotation AP Coracobrachialis P(AG) P(AG) P Latissimus dorsi, External rotation AP P P(AG) Pectoralis major length AP teres major Pectoralis minor length Middle deltoid, P(AG) P(GE) P Elbow and Forearm P supraspinatus P(AG) Flexion/extension Pectoralis major Supination/pronation AP Posterior deltoid P(AG) Biceps brachii length P Subscapularis P(AG) Triceps length Infraspinatus, teres minor P(AG) P Elbow and Forearm Wrist and Hand PA Biceps P(AG) A(AG) All wrist movements Brachioradialis/brachialis P(AG) All finger and thumb P Triceps P(AG) P Supinator P(GE) movements Pronator teres, pronator P(GE) Long finger flexors length Long finger extensors quadratus Wrist and Hand length All muscles Lumbricales length Hip AP Flexion P P Hip A(AG) P Iliopsoas

Joint Motion Sitting Supine Prone Sidely Standing Muscle Strength Sitting Supine Prone Sidely Standing Extension P Sartorius A(AG) A(AG) P/A(AG) P(GE) P(AG) P(AssistedAG)* P(AG) P(AG) Abduction/adduction P Gluteus maximus, P(AG) hamstrings Internal/external rotation P A A P(GE) P(GE) Gluteus medius, gluteus P(GE) Hip flexors length P minimus P(GE) P(GE) Hamstrings length (SLR) P Tensor fascia latae P(GE) Adductors P(GE) Tensor fascia latae length AP Internal rotators P(AG) External rotators P(AG) Adductors length P Knee Hamstrings Knee Quadriceps Flexion/extension P P(AG) Patellar glides P P(AG) APPENDIX C: Summary of Patient Positioning for the Assessment and Measurement 509 Tibial rotation P Rectus femoris length AP Hamstrings length AP Ankle and Foot Ankle and Foot A Tibialis anterior Dorsiflexion AP P(AG) P(GE) Gastrocnemius P(GE) Plantarflexion AP Soleus P(AG) NWB P(GE) P(AG)WB P(AG) NWB P(AG)WB Supination/pronation: P Inversion/eversion P(GE) P(GE) components P Subtalar joint inversion/ PA Tibialis posterior P P(AG) eversion P(AG) P(AG) Peroneus longus, peroneus All toes movements P brevis P Gastrocnemius length A P All foot muscles Soleus length P P Spine Flexion Trunk Extension P Rectus abdominis A External oblique, internal P(GE) Rotation P oblique Extensor muscle group

Joint Motion Sitting Supine Prone Sidely Standing Muscle Strength Sitting Supine Prone Sidely Standing 510 SECTION III Appendices Lateral flexion P Quadratus lumborum P P(ResistedGE)† Trunk extensors, P P(GE) hamstrings (toe-touch test) Neck P Infrahyoid muscle group Neck All neck movements Flexor group Sternomastoid Extensor group P P P TMJ P Mandible and Face All TMJ movements All muscles of mandible and P face *P(GE) is equivalent to P(AssistedAG): when the patient is positioned AG to test strength less than or equal to grade 2, the therapist offers assistance equal to the weight of the limb to resemble the gravity eliminated situation. †P(AG) is equivalent to P(ResistedGE): when the patient is positioned GE to test strength greater than grade 2, the therapist offers resistance equal to the weight of the limb to resem- ble the against gravity situation.

Appendix D Gait The gait cycle consists of a series of motions that occur description of the normal gait pattern is provided so that between consecutive initial contacts of one leg.1 The gait the implications of the findings on assessment of joint cycle is divided into two phases: the stance phase, when range of motion and manual muscle strength can be the foot is in contact with the ground and the body understood in relation to gait. The average positions and advances over the weight-bearing limb, and the swing the motions of the joints during the gait cycle that are phase, when the limb is unweighted and advanced for- reported in this appendix were adapted from the Rancho ward in preparation for the next stance phase. Each phase Los Amigos gait analysis forms as cited in Levangie and is further subdivided into a total of eight instants1 or Norkin.2 The right leg is used to illustrate the joint freeze frames. Five instants occur in the stance phase and positions and motions of the lower limb throughout the three occur in the swing phase of the gait cycle. The gait cycle. 511

512 SECTION III Appendices Stance Phase Motion from A to B (Figs. D-1 and D-2): hip: extension (from 30 to 25° flexion); knee: flexion (from 0 to 15° flex- The lower limb is advanced in front of the body during ion); ankle: plantarflexion (from 0 to 15° plantarflexion); the swing phase and the stance phase begins at initial MTP joints of toes: 0°. contact (Fig. D-1) when the heel makes the first con- tact between the foot and the ground. At initial con- Motion from B to C (Figs. D-2 and D-3): hip: extension tact the pelvis is rotated forward and the trunk is (from 25 to 0° flexion); knee: extension (from 15 to 5° rotated backward on the stance side. The rotation of flexion); ankle: dorsiflexion (from 15° plantarflexion to the pelvis counteracts the trunk rotation to prevent 5 to 10° dorsiflexion); MTP joints of toes: remain at 0°. excessive trunk motion. On the opposite side the upper extremity is flexed at the shoulder. As the body Motion from C to D (Figs. D-3 and D-4): hip: extension advances over the supporting limb through the stance (from 0° flexion to 10 to 20° extension); knee: extension phase, the pelvis rotates backward and the trunk (from 5° flexion to 0°); ankle: dorsiflexion (from 5 to 10° rotates forward on the swing side. As the weight-bear- dorsiflexion to 0° dorsiflexion); MTP joints of toes: exten- ing leg extends at the hip, the upper limb on the oppo- sion (from 0 to 20° extension). site side extends. The average joint positions and the motions of the right lower limb in the sagittal plane Motion from D to E (Figs. D-4 and D-5): hip: flexion are described and illustrated. (from 10 to 20° extension to 0°); knee: flexion (from 0 to 30° flexion); ankle: plantarflexion (from 0 to 20° plan- tarflexion); MTP joints of toes: extension (from 30° exten- sion to 50 to 60° extension). Figure D-1 Initial contact (A). Figure D-2 Loading Figure D-3 Midstance (C). Figure D-4 Terminal stance (D). response (B).

APPENDIX D: Gait 513 Swing Phase Motion from G to H (Figs. D-7 and D-8): hip: remains flexed at 30°; knee: extension (from 30° flexion to 0°); The swing phase begins after preswing when the foot ankle: remains at 0°. leaves the ground and is advanced forward in the line of progression in preparation for initial contact. The posi- Motion from H to A (Figs. D-8 and D-1): hip: remains tions and motions of the right lower limb are described flexed at 30°; knee: remains extended at 0°; ankle: remains and illustrated. at 0°. Motion from E to F (Figs. D-5 and D-6): hip: flexion References (from 0 to 20° flexion); knee: flexion (from 30° flexion to 60° flexion); ankle: dorsiflexion (from 20° plantarflexion 1. Koerner I. Observation of Human Gait. Edmonton, Alberta: to 10° plantarflexion). Health Sciences Media Services and Development, University of Alberta; 1986. Motion from F to G (Figs. D-6 and D-7): hip: flexion (from 20° flexion to 30° flexion); knee: extension (from 2. Levangie PK, Norkin CC. Joint Structure & Function: A 60° flexion to 30° flexion); ankle: dorsiflexion (from 10° Comprehensive Analysis. 3rd ed. Philadelphia: FA Davis; 2001. plantarflexion to 0°). Figure D-5 Preswing (E). Figure D-6 Initial Swing (F). Figure D-7 Midswing (G). Figure D-8 Terminal swing (H).



Index Note: Page numbers followed by “f” denote figures; those followed by “t” denote tables. A MTP and IP joints of the toes, 339 Cervical spine, 392 normally limiting motion at the ankle movements, 394t Abducens nerves, 420 reliability, 414 Abduction and subtalar joints, 339f tape measure/ruler/calipers, 398, 399f primary movements at the ankle, validity, 414 horizontal, 9 of scapula, 7 dorsiflexion, and plantarflexion, Cheeks of wrist, 8 337 compression, 429, 429f Abductor digiti minimi, 215t, 225–226, 366t subtalar joint, 337 Abductor hallucis muscle, 366t in non–weight-bearing (NWB) Chest expansion, 458 Abductor pollicis brevis, 216t, 238, 238f conditions, 338 Circumduction, 9 Abductor pollicis longus, 216t, 237, 237f surface anatomy, 341–341f Clavicular head, 125 Accessory muscles, 324 toe movements, 340t Communication, 2 Acromioclavicular joint, 64 at the transverse tarsal, intertarsal, Concave–convex rule, 10, 11f Active range of motion (AROM), 4, 12 tarsometatarsal, and intermetatarsal Concave tibial condyles, 314 ankle and foot supination, eversion joints, 337f, 338 Concentric contraction, 32 motion assessment and measurement, Condylar joints, 391 component, 353 range of Convex femoral condyles, 314 ankle and foot supination, inversion ankle dorsiflexion and plantarflexion, Coracobrachialis, 116–117, 116f, 117f 342–347 Corrugator supercilii, 418t, 426 component, 351–352 MTP and IP joint flexion/extension of Criterion-related validity, 18 ankle dorsiflexion and plantarflexion, 342 lesser four toes, 360 assessment, 12–14 MTP joint flexion and adduction of the CROM. See Cervical range-of-motion (CROM) great toe, 357–360 using active exercise, 59t MTP joint flexion and extension of lesser Cross-legged sitting and knee flexion, elbow flexion–extension/ toes, 356 331, 334t MTP joint flexion and extension of the hyperextension, 145 great toe, 355 D glenohumeral joint abduction, 87 subtalar inversion and eversion, glenohumeral joint flexion, 81 348–350 Depressor anguli oris, 419t, 431 using relaxed passive movement, 60t supination/pronation inversion and Depressor labii inferioris, 419t, 431 scapular movements, 75–76 eversion components, 351–353 Depressor septi, 418t shoulder elevation through abduction, muscle actions, attachments, and nerve Digastric, 417t, 424 supply, 365t–367t Dorsal, 214t 85 Ankle dorsiflexion/ plantarflexion, 317, 388 Dorsal Interossei, 225–226, 366t shoulder elevation through flexion, 79 motion assessment and measurement, Dorsiflexion, 6 shoulder extension, 83 342–347 Double inclinometry, 401, 401f shoulder external rotation, 92 AROM assessment, 342 shoulder horizontal abduction and Ankle extension, 7 E Ankle flexion, 6 adduction, 88 Anterior fibers deltoid, 61t Eccentric contraction, 32 shoulder internal rotation, 90, 90f Anterior pelvic tilt, 9 Elbow and forearm, 141 supination, 147 Anterior superior iliac spine (ASIS), 323 of knee flexion-extension Anterior tilt, of scapula, 9 biceps brachii, 153, 153f PROM measurement, 314 Anterolateral neck flexor, 439 extension, 145–146, 145f, 146f universal goniometer, 315 Arches, 389 measurement, 14, 23 triceps, 161–162, 161f, 162f, 163f subtalar inversion and eversion, 348 AROM. See Active range of motion (AROM) flexion, 145–146, 145f, 146f of tibial rotation, 317 treatment Arthrokinematics, 10, 11f biceps brachii, 157–158, 157f, 158f using active exercise, 59t Atella, 313 brachialis, 159–160, 159f, 160f using relaxed passive movement, 60t brachioradialis, 159–160, 159f, 160f Activities of daily living (ADL), 66, 67, 302 B hyperextension, 145–146, 145f, 146f and knee flexion ROM, 331 movements, 142t in Asian and Eastern cultures, 331, 334t Back Range-of-Motion Instrument (BROMII), pronation, 147–148, 147f Adduction 402, 402f measuring, 148–152, 149f, 150f horizontal, 9 pronator quadratus, 166–167, 166f, 167f of scapula, 8 Ball-and-socket articulation, 5f pronator teres, 166–167, 166f, 167f Adductor brevis, 274, 280t Biceps brachii, 153, 153f, 155t, 157–158, 157f, supination, 147–148, 147f Adductor hallucis muscle, 366t biceps brachii, 164–165, 164f, 165f Adductor longus, 274, 279t 158f, 164–165, 164f, 165f, 173, 173f, measuring, 148–152, 149f, 150f Adductor magnus, 274, 280t 174–175, 174f supinator, 164–165, 164f, 165f Adductor pollicis, 216t, 239, 239f Biceps femoris, 270, 319, 324f, 325t, 326f, 334 surface anatomy, 144f Adhesions, 16–17 Bicondylar articulation, 5f, 391 triceps, 154 Brachialis, 155t, 159–160, 159f, 160f, 173, 173f Elbow extension, 145–146, 145f, 146f ADL. See Activities of daily living (ADL) Brachioradialis, 155t, 159–160, 159f, 160f, 173f, Elbow flexion, 145–146, 145f, 146f, 173 AMA. See American Medical Association (AMA) 174, 174f biceps brachii, 157–158, 157f, 158f Break test, 47 brachialis, 159–160, 159f, 160f American Medical Association (AMA), 400 brachioradialis, 159–160, 159f, 160f Amigos gait analysis, 333 BROMII. See Back Range-of-Motion Instrument Elbow hyperextension, 145–146, 145f, 146f Anatomical articulations, 4 Ellipsoidal articulation, 5f (BROMII) Ely’s test, 322 classification, 5t Buccinator, 418t, 429 End feel, 15 Anatomical joint, 4 abnormal (pathological), 15t Anatomical position, 4, 6f C normal (physiological), 15t Epicranius occipitofrontalis, 417t lateral view, 7f Carpometacarpal (CM) joints, 178, 180 Erector spinae, 462t posterior view, 7f Cervical range-of-motion (CROM), 17, 18f, 402 Ankle and foot articulations and movements of, 337–341 ankle joint, 337 515

516 Index Eversion, 388–389 abduction I Extensor carpi radialis brevis, 213t AROM assessment, 87 Extensor carpi radialis longus, 213t PROM assessment, 87, 87f Iliacus, 272, 279t, 304 Extensor carpi ulnaris, 213t universal goniometer, 87 Iliocostalis cervicis, 463t Extensor digiti minimi, 209, 214t Iliocostalis lumborum, 463t Extensor digitorum brevis muscle, 367t Glide, 10 Iliocostalis thoracis, 463t Extensor digitorum communis, 209, 209f, 214t Gluteus maximus, 280t, 307 Iliopsoas, 281f, 282, 282f, 304, 305 Extensor digitorum longus muscle, 367t Gluteus medius, 280t, 290, 290f, 291f, 292, 292f Extensor hallucis longus muscle, 367t Gluteus minimus, 280t, 290, 290f, 291f, 292, Individual versus group muscle test, 41–44, 42f Extensor indicis proprius, 209 Extensor indicisproprius, 214t 292f Inferior radioulnar joint, 142 Extensor pollicis brevis, 216t, 236, 236f Infrahyoid muscles, 436t, 434 Extensor pollicis longus, 216t, 235, 235f Goniometer, 16, 315. See also Universal Intermetacarpal distance (IMD) method, 205 External abdominal oblique, 462t Internal abdominal oblique, 462t Eyes goniometer measurements Interphalangeal (IP) joints, 182, 337, 339 Gracilis, 274, 280t Interspinales, 464t closure of eyelids, 427, 427f Gracilis flexes, 304 elevation of, 421, 421f Grading muscle strength, 324, 334 Intertarsal joints. See Plane articulation eyeball movements, 422 eyebrows, 426 against gravity, 44–47 Intertransversarii, 464t alternate methods, 49–51 Intrinsic muscles of the foot, 389 adduction of, 426 gravity eliminated, 47–49 Inversion, 388–389 medial angle depression, 427, 427f isometric muscle testing, 49 Isokinetic contraction, 32 Greater trochanter, 313 Isometric (static) contraction, 32 F Grip, 243 Isometric/palpation grading, 96, 96t–98t Isotonic contraction, 32 Face, muscles, 415, 416t–420t Group versus individual muscle test, 41–44, 42f Facial nerve, 426 J H Femorotibial joint. See Bicondylar articulations JAMAR hand grip dynamometer, 38f Hamstrings, assessment and measurement, Jaw movements, 392t Fifth finger metacarpophalangeal flexion, 229 319–320, 324 Joint articulations, of knee, 310f Finger Joint function, 386 alternate position—passive straight leg raise IP flexion–extension, 197–198 (PSLR), 320 of elbow and forearm MCP abduction–adduction, 195–196 functional range of motion, 168–171, 169t, MCP flexion–extension, 192–194 alternate position—sitting, 320 metacarpophalangeal extension, 224 biceps femoris, 319 170f, 170t, 171f, 172f metacarpophalangeal flexion, 228 full stretch, 320–320f of hand movements, 180t goniometer measurement, 320f muscles, 223 length, 319f arches of, 243, 245t Finger distal interphalangeal flexion, 232 passive knee extension (PKE) supine, 319 functional range of motion, 243 Finger proximal interphalangeal flexion, 230–231 semimembranosus, 319 of neck and trunk, 473 semitendinosus, 319 cervical spine, 473–474 First carpometacarpal joint. See Saddle articulation on slack, 320 thoracic and lumbar spines, 474–476 on stretch—firm, 320 of shoulder complex Flexion in upright sitting position, 320 elevation from 170Њ to 180Њ, 133 of Knee, 6 Hand functional range of motion, 133 of thumb, 6 AROM, 186, 186f horizontal adduction and abduction, of toe, 6 functional range of motion, 243 grasping function of, 243, 245–246 133t, 135, 136f Flexor carpi ulnaris, 213t, 217–218, 217f joint function, 243 internal and external rotation, 136–137, Flexor carpiradialis, 213t lateral view of, 184f Flexor digiti minimi, 207, 215t, 229, 229f surface anatomy, 185f 136f, 137f Flexor digiti minimi brevis muscle, 366t Hand-held dynamometer (HHD), 38 scapulohumeral rhythm, 133–134, 134f Flexor digitorum brevis muscle, 366t Head shoulder extension, 135, 135f Flexor digitorum longus muscle, 365t of the fibula, 313 of wrist Flexor digitorum profundus, 207, 213t, 232, muscles, 435–438 coupled wrist motion, 243 temporomandibular joint (TMJ) movements, finger position, 243 232f, 246 functional range of motion, 241–243, Flexor digitorum superficialis, 207, 208f, 213f, 403–405 Hinge articulation, 5f 241f, 242f 230–231, 231f Hip, 253 Joint positions Flexor hallucis brevis muscle, 365t Flexor hallucis longus muscle, 365t abduction, 263, 264f, 290, 293–294 close-packed position, 36, 37t Flexor pollicis brevis, 216t, 234, 234f measure of, 30 loose-packed position, 36, 37t Flexor pollicis longus, 216t, 233, 233f Joint ROM Foot functions, 386 adduction, 265–269, 265f, 296–297 assessment and measurement, 19–22, 19f, Forefoot abduction, 317 adductors, 274–275 Forearm articulations, 141 clinical test, 295 20f, 21f, 22f Full knee flexion, 311 extension, 262, 262f, 285–286 OB “Myrin” goniometer, 23–29 Functional joint, 4, 6f external rotation, 300–301 universal goniometer, 22–23 Funtional range of motion, 331 flexion, 60t, 260–262, 261f, 278, 281, K ankle dorsiflexion and plantarflexion, 293–294 386–388 flexors, 272–273, 273f Kinematics, 4 functional range of motion, 302–304 Knee foot movements, 387–388 hamstrings, 270, 270f, 271f gait, 333–334, 388 internal rotation, 298–299 extension, external rotation at the end of, joint function, 302 310 G lower extremity AROM flexion, 310 Gait, muscle function of, 333–335, 388–389 non-weight-bearing, 258–259, 258f gliding of the patella on the femur Gait cycle weight-bearing, 259, 259f during, 311 movements, 254t stance phase, 501, 502, 502f muscle function, 304–307 fully extended position of, 331 swing phase, 501, 503, 503f supine hip extensor test, 288, 288f, 289f joint axes, 311f Gastrocnemius knee flexion torque, 334 surface anatomy, 256f–257f motion assessment and measurement, range Gastrocnemius muscle, 318, 324, 334, 365t Hip external rotation, 317 Gemellus inferior, 279t of, 314–318 Gemellus superior, 279t Hip joint. See Ball-and-socket articulation movements, 312t Genioglossus, 420t Geniohyoid, 417t, 424 Hook grasp, 247 muscle length assessment and Glenohumeral joint, 65, 65f measurement, 319–330 abduction, 87, 87f Humeroulnar joint. See Hinge articulation flexion, 81–82, 81f, 82f normal limiting factors (NLF) of joint movements, 69t Hyperextension, 7 motion, 312f of knee, 315 patella during, 311 Hypermobility, 9 muscle actions, attachments, and nerve Hypoglossal nerve, 433 Hypomobility, 9 supply biceps femoris, 325t rectus femoris, 325t semimembranosus, 325t

Index 517 semitendinosus, 325t Longus colli, 436t flexion, 304–305 vastus intermedius, 325t Lumbar-pelvic rhythm, 476 internal rotation, 306–307 vastus lateralis, 325t Lumbricales, 211, 214t, 228, 228f, 366t of knee extensors, 335 vastus medialis, 325t of knee flexors, 334 patellofemoral articulations, 310f M of shoulder complex screw home mechanism, 310 external rotation, 139 surface anatomy, 313 Magnetic yoke, 413 flexion and adduction, 139 tibiofemoral articulation, 310f Make test, 47 internal rotation, 139 Knee extension, AROM measurement Mandible shoulder adduction and extension, 138 PROM measurement, 314 shoulder elevation, 138 universal goniometer, 315, 322–323 depression of, 424, 424f standing posture, 335 Knee extension, muscle strength assessment, elevation of424, 424f of trunk, 478–480 lateral deviation of, 425 Muscle length against gravity protrusion of, 425, 425f assessment and measurement, 319–330, movement, 328 Manual muscle strength assessment, 50f, palpation, 329 497–500 resistance direction, 329 492–496 ankle dorsiflexion and foot inversion, resistance location, 329 Manual muscle testing (MMT), 32, 38, 39, 45f, stabilization, 328 364–368 start position, 328 48f, 51 ankle plantarflexion, 368–373 substitute movement, 329 elbow extensors, 46f foot eversion, 375–377 Knee extension, 59t Manual resistance, 45–46, 46f foot inversion, 374 muscle strength assessment, gravity Masseter, 416t, 424 gastrocnemius muscle, 361–363, 361f Medial pterygoid, 417t, 424, 425 hamstrings, 319–320 eliminated Menisci, 310 interphalangeal flexion, 380–381 end position, 330–330f Mentalis, 420t knee flexion, 324–327 stabilization, 330 Metacarpophalangeal metatarsophalangeal abduction start position, 330–330f abduction, 225–226 substitute movement, 330 adduction, 227 (abductor digiti minimi and dorsal Knee extensors, muscle function of, 335 Metacarpophalangeal (MCP) joints, 182 interossei), 383 Knee flexion, AROM measurement Metatarsophalangeal (MTP) joint, 337, 339 metatarsophalangeal abduction of the PROM measurement, 314 Midcarpal joint, 177 great toe (abductor hallucis), 382 universal goniometer, 315, 322–323 metatarsophalangeal and interphalangeal Knee flexion, muscle strength assessment, MMT. See Manual muscle testing (MMT) extension, 383–385 metatarsophalangeal flexion, 378–379 against gravity Modified Ober’s Test, 276, 277 multi-joint muscle, 31, 31f bicep femoris, 326f Motion assessment and measurement, range of one-joint muscle, 29–30, 30f in isolated lateral hamstrings, 326 pectoralis major, 94, 94f in isolated medial hamstrings, 326 ankle and foot, 342–360 pectoralis minor, 95, 95f movement, 324 ankle dorsiflexion and plantarflexion, rectus femoris, 321–323 palpation, 324 342–347 toe movements, 378 resistance direction, 326–326f MTP and IP joint flexion/extension of two-joint muscle, 30–31, 30f resistance location, 324 lesser four toes, 360 using prolonged passive stretch, 61t stabilization, 324 MTP joint flexion and adduction of the treatment start position, 324 great toe, 357–360 using prolonged passive stretch, 61t substitute movement, 324 MTP joint flexion and extension of lesser Muscle strength, 32 Knee flexion, muscle strength assessment, toes, 356 assessment, 497–500 MTP joint flexion and extension of the isometric/palpation grading, 96, 96t–98t gravity eliminated great toe, 354–355 using resisted exercise, 62t end position, 327 subtalar inversion and eversion, 348–350 contraindications and precautions, 36, 38 stabilization, 327 supination/pronation inversion and dynamic tests, 47 start position, 327 eversion components, 351–353 instrument to assess, 38–39 substitute movement, 327 isometric testing, 47 Knee flexion ROM, 331 knee, 314–318 manual assessment of, 41–44, 42f for fast-paced running, 334 Mouth manual grading of for slow-paced running, 334 evidence of contraction, 39 while climbing stairs, 333f depression of angle, 431, 431f gravity as resistance, 39 while going down stairs requires, 332f elevation of angle of , 430, 430f manual resistance, amount of, 39 while lifting an object off the floor, 332f retraction of angle of, 430, 430f, 431, MMT methods, 39 while putting on a pair of trousers, 332f conventional method, 39 Knee flexors, muscle function of, 334 431f reliability, 39–41 Knee joint functions, 331 Movable arm, of goniometer, 22 validity, 39 rotational mobility of, 331 Multifidus, 464t recording, 49–51, 50f in walking, 331 Multi-joint muscle, 31, 31f treatment Kneeling and knee flexion, 331, 334t Muscle using resisted exercise, 62t Muscle testing terminology L contraction types, 32–33, 32f active insufficiency, 33–34 endurance, 33 muscle contraction, 32–33, 32f Lateral epicondyle of femur, 313 fatigue, 33 muscle endurance, 33 Lateral malleolus, 313 functional classification of muscle fatigue, 33 Lateral pelvic tilt, 9 muscle strength, 32 Lateral pterygoid, 417t, 424, 425 antagonist, 34 muscle works, 33, 33f Levator anguli oris, 419t conjoint synergists, 34 overwork, 33 Levator labii superioris, 419t counteracting synergists, 34 torque, 32, 32f Levator labii superioris alaequenasi, 419t fixating synergists, 34 Muscle work, ranges of Levator palpebrae superioris, 416t, 421 neutralizing synergists, 34 full range, 33 Ligamentous sprains, 16 prime mover or agonist, 34 inner range, 33 Ligamentum patellae tendon, 313 stabilizing synergists, 34 middle range, 33 Lips synergist, 34 outer range, 33 Muscle function Mylohyoid, 417t, 424 closure and protrusion, 429, 429f of elbow and forearm depression of angle, 431, 431f biceps brachii, 173, 173f, 174–175, 174f N elevation of, 432, 432f brachialis, 173, 173f brachioradialis, 173f, 174, 174f Nasal aperture and protrusion, 432, 432f elbow flexion, 173 constriction of, 428f Long finger extensors, 61t pronator quadratus, 175, 175f dilation of, 428, 428f Longissimus capitis, 463t pronator teres, 175, 175f Longissimus cervicis, 463t supinator, 174–175, 174f Nasalis, 418t Longissimus thoracis, 463t of gait, 335, 388–389 Longus capitis, 437t of head and neck, 476–478 of hip abduction, 306 adduction, 306 extension, 305–306 external rotation, 307

518 Index Neck stabilization, 314 Pronator quadratus, 156t, 166–167, 166f, 167f, cervical spine, 392 start position, 314–314f 175, 175f movements, 394t therapist’s distal hand placement, 314 flexion–extension, 407–409 measurement, 22f, 23 Pronator teres, 156t, 166–167, 166f, 167f, 175, lateral flexion, 410–411 MTP joint flexion and adduction of the great 175f movements, 406 muscles, 435–438 toe Protraction, 7 rotation, 412–413, 413f joint glide, 357 standard inclinometer, 400–401 stabilization, 357 PSLR. See Passive Straight Leg Raise (PSLR) surface anatomy, 396f, 397f start position, 357 tape measure/ruler/calipers, 398, 399f therapist distal hand placement, 357 Psoas major, 272, 279t, 304 temporomandibular joint (TMJ) movements, MTP joint flexion and extension of the great 403–405 Q toe, 355 Negative Trendelenburg sign, 295, 295f of patellar mobility—distal glide Quadratus femoris, 279t Neutral zero methods, 20, 22 Quadratus lumborum, 462t end feel, 316 NLF. See Normal limiting factors (NLF) procedure, 316 R stabilization, 316 Radiocarpal joint, 177. See also Ellipsoidal Normal limiting factors (NLF), 143f start position, 316 of patellar mobility—medial-lateral glide articulation O end feel, 316 Radioulnar syndesmosis, 6f procedure, 316 Range of motion (ROM), 310, 316, 324 OB “Myrin” goniometer, 13, 14, 17, 17f, 18, stabilization, 316 148, 468 start position, 316 AROM assessment, 12–14 subtalar inversion and eversion, 349 measurement, 14 ankle dorsiflexion and plantarflexion, 347 of tibial rotation, 317 goniometer placement, 347 Passive Straight Leg Raise (PSLR), 270 arthrokinematics, 10, 11f Patellar articular surface, 311 assessment and measurement, 485–490 gastrocnemius muscle, 363–363f Patellar mobility—distal glide, PROM contraindications and precautions, 12 joint ROM, 23–29 joint articulations and classification, 4, 5t tibial rotation measurement of, 316f measurement end feel, 316 end position, 318–318f procedure, 316 instrumentation, 16–17 goniometer placement, 318 stabilization, 316 reliability, 18 stabilization, 318 start position, 316 universal goniometer, 18–19 start position, 317 Patellar mobility—medial-lateral glide, PROM validity, 17–18 Ober’s Test, 276–277, 276f movement terminology Obliquus capitis inferior, 438t measurement of, 316f angular movements, 6–8, 8f Obliquus capitis superior, 438t end feel, 316 rotation movements, 8–9 Obliquus inferior, 416t, 422 procedure, 316 osteokinematics, 4 Obliquus superior, 416t, 422 procedure, 316 planes and axes, 4 Obturator externus, 279t start position, 316 PROM assessment, 14 Obturator internus, 279t Patellar tracking, 311 capsular pattern, 16 Oculomotor, 420 Patellofemoral articulation, 310f end feels, 15–16, 15t, 16t Omohyoid, 436t, 434 Pectineus, 274, 279t noncapsular pattern, 16 One-joint muscle, 29–30, 30f Pectoralis major, 94, 94f, 123, 123f normal limiting factors (NLF), 15 Opponens digiti minimi, 215t Pectoralis minor, 95, 95f recording, 27f Opponens pollicis, 216t, 240, 240f Pelvic elevation, 471–472 wrist and hand, 186, 186f Orbicularis oculi, 418t Peroneus brevis muscle, 365t Rectus abdominis, 462t, 460–462 Orbicularis oris, 418t, 429 Peroneus longus muscle, 365t Rectus capitis anterior, 437t Osteokinematics, 4 Physiological joint, 4, 6f Rectus capitis lateralis, 437t Piriformis, 280t Rectus capitis posterior major, 437t P Pivot articulation, 5f Rectus capitis posterior minor, 438t Rectus femoris muscle, 272, 276, 329f Palmar, 214t PKE. See Passive Knee Extension (PKE) assessment and measurement Palmar Interossei, 227 degree of muscle shortening, 323 Palmaris longus, 207, 213t Plane articulation, 5f Ely’s test, 322 Palpation, 2–3 Plantarflexion, 7 end position, 321–323, 323f Passive insufficiency, of muscle, 9, 10f, 29f Plantar interossei muscle, 366t goniometer measurement, 321–323, 323f Passive Knee Extension (PKE), 270 Platysma, 419t, 431 on slack, 322 Passive range of motion (PROM), 4, 12 Popliteus muscle, 324, 334 stabilization, 321–323 Positive Trendelenburg sign, 295, 295f start position, 321–323, 323f ankle and foot supination, eversion Posterior pelvic tilt, 9 on stretch—firm, 321– 323 component, 353 Posterior tilt, of scapula, 9 Thomas test position, 323 Power grips, 245, 245f muscle actions, attachments, and nerve ankle and foot supination, inversion component, 351–352 approach phase, 246, 246f supply, 325t finger and thumb positioning phase, 246 Rectus inferior, 416t, 422 ankle dorsiflexion and plantarflexion, 342–343 opening phase, 246, 246f Rectus lateralis, 416t, 422 assessment, 14, 21f static grip phase, 246–247, 247f Rectus medialis, 416t, 422 Precision grip, 245, 245f, 248–249, 249f Rectus superior, 416t, 422 capsular pattern, 16 approach phase, 248, 248f Resistance direction elbow flexion–extension/ hyperextension, finger and thumb positioning phase, 248, gravity eliminated 145–146, 145f, 146f 248f middle fibers of trapezius, 108, 108f end feels, 15–16, 15t, 16t lateral pinch, 249–250, 250f glenohumeral joint abduction, 87, 87f opening phase, 248, 248f Retraction, 8 glenohumeral joint flexion, 81, 81f pulp pinch, 249, 249f, 250f Rhomboid major, 109–111, 109f, 110f, 111f noncapsular pattern, 16 Precision handling, 245, 250–251, 250f Rhomboid minor, 109–111, 109f, 110f, 111f normal limiting factors (NLF), 15 approach phase, 248, 248f Risorius, 419t, 431 scapular movements, 77–78 finger and thumb positioning phase, 248, 248f Roll, 10 shoulder elevation through abduction, lateral pinch, 249–250, 250f Rotatores, 464t opening phase, 248, 248f 85, 85f pulp pinch, 249, 249f, 250f S shoulder elevation through flexion, 79, 79f Prehension, 243 shoulder extension, 83, 83f Procerus, 418t Saddle articulation, 5f shoulder external rotation, 92, 92f Sartorius, 272, 279t, 283, 283f, 324, 333 shoulder horizontal abduction and PROM. See Passive range of motion (PROM) Scalenus anterior, 437t Scalenus medius, 437t adduction, 88, 88f Pronation, 8, 147–152, 147f, 149f, 150f, 151f, Scalenus posterior, 437t shoulder internal rotation, 90 152f Scaption, 8, 66 supination, 147–148, 147f Scapular abduction and lateral rotation of knee flexion-extension measuring, 148–152, 149f, 150f end feels, 314 pronator quadratus, 166–167, 166f, 167f against gravity end positions, 314–314f pronator teres, 166–167, 166f, 167f joint glides, 314

Index 519 serratus anterior, 99, 99f, 100f posterior aspect of, 71f Shoulder joint, 65 gravity eliminated bony anatomy, 71f Single inclinometry, 400, 400f Soleus muscle, 365t serratus anterior, 101, 101f resistance direction, 108, 108f Spin, 10, 11f Scapular adduction scapular Spinalis capitis, 464t Spinalis cervicis, 464t against gravity abduction and lateral rotation, 99–101, Spinalis thoracis, 463t middle fibers of trapezius, 106–107, 106f, 99f, 100f, 101f Splenius capitis, 437t 107f Splenius cervicis, 437t adduction, 106–107, 106f, 107f Squatting and knee flexion, 331, 334t and medial rotation adduction and medial rotation, 109–111 Standard inclinometer, 17, 18f rhomboid major and rhomboid minor, depression and adduction, 112–113, Standing posture, muscle function of, 335, 389 109–111, 109f, 110f, 111f Static grip phase, 246, 247 112f, 113f Stationary arm, of goniometer, 22 scapular movements, 76, 76f, 78, 78f elevation, 104–105 Sternal head, 125 Scapular depression and adduction movements, 75–78 Sternoclavicular joint, 64 shoulder abduction to 90Њ, 120–122, 120f, Sternoclavicular joints against gravity lower fibers of trapezius, 112, 112f 121f, 122f anterior view of, 70f shoulder elevation, 66 Sternocleidomastoids, 477 gravity eliminated Sternohyoid, 436t, 434 lower fibers of trapezius, 113, 113f through abduction, 85–86, 85f, 86f Sternomastoid, 436t, 439, 439f through flexion, 79–80, 80f Sternothyroid, 436t scapular movements, 75, 75f shoulder extension, 83–84 Strength, factors affecting Scapular elevation shoulder flexion to 90Њ, 114–115 shoulder girdle, 64, 65f age, 34 against gravity sternal head, 125 angle of muscle pull, 34, 35–36 upper fibers of trapezius and levator surface anatomy, 71f–72f diurnal variation, 36 scapulae, 104, 104f upper extremity AROM, 73, 74f fatigue, 36 Shoulder elevation, 66 gender, 34 gravity eliminated through abduction length–tension relations, 34–36 upper fibers of trapezius and levator AROM assessment, 85 muscle contraction, type of, 34 scapulae, 105, 105f PROM assessment, 85, 85f muscle size, 34 universal goniometer, 86, 86f speed of muscle contraction, 34 Scapular movements, 68t through flexion temperature, 36 AROM assessment, 75, 75f AROM assessment, 79 training effect, previous, 36 abduction, 76, 76f PROM assessment, 79, 79f Stylohyoid, 417t, 424 adduction, 76, 76f universal goniometer, 80, 80f Subdeltoid joint, 6f depression, 75, 75f muscle function, 138 Subscapularis, 127–129, 127f, 128f, 129f, 139 elevation, 75, 75f Shoulder extension Substitute movements, 19–20 lateral (upward) rotation, 76, 76f against gravity Substitute movements, 42–44 medial (downward) rotation, 76, 76f latissimus dorsi and teres major, 118, 118f Subtalar joint, 317, 337 PROM assessment AROM assessment, 83 abduction, 78, 78f gravity eliminated Superior radioulnar joint, 141–142. See also adduction, 78, 78f latissimus dorsi and teres major, 119, 119f depression, 77, 77f joint function, 135, 135f Pivot articulation elevation, 77, 77f PROM assessment, 83, 83f Supination, 8, 147–152, 147f, 149f, 150f, 151f, prone, 84f Scapular rotation, 9 sitting, 84f 152f Scapulohumeral rhythm, 133–134, 134f universal goniometer, 84, 84f biceps brachii, 164–165, 164f, 165f Screw home mechanism, 310 Shoulder external rotation measuring, 148–152, 149f, 150f Semimembranosus, 270, 319, 324f, 325t, 326f, against gravity supinator, 164–165, 164f, 165f infraspinatus and teres minor, 130–131, Supinator, 156t, 164–165, 164f, 165f, 174–175, 334 Semitendinosus muscle, 319, 324f, 325t, 326f, 334 130f, 131f 174f Semispinalis capitis, 464t alternate assessment and measurement, 93, 93f Supine hip extensor test, 288, 288f, 289f Semispinalis cervicis, 464t AROM assessment, 92 Suprahyoid, 417t, 424 Semispinalis thoracis, 464t gravity eliminated Syndesmosis, 4 Semitendinosus, 270 Serratus anterior, 99–101, 99f, 100f, 101f infraspinatus and teres minor, 132, 132f T Serratus anterior muscle activity, 102 PROM assessment, 92, 92f SFTR Methods, 28 universal goniometer, 92, 92f Talocrural (ankle) joint, 337 Shock absorber, knee joint as, 331 Shoulder flexion, 8 Tape measure, 17, 17f Shoulder abduction, 8 and adduction Tarsal canal, 337 Shoulder abduction to 90Њ Temporalis, 416t, 424 coracobrachialis, 116–117, 116f, 117f Temporomandibular joint (TMJ), 391–392 against gravity Shoulder flexion to 90Њ middle fibers of deltoid and movements, 403–405 supraspinatus, 120, 120f, 121f against gravity reliability, 414 anterior fibers of deltoid, 114, 114f validity, 414 gravity eliminated Tensor fascia latae, 272, 273, 276, 280t, 294, middle fibers of deltoid and gravity eliminated supraspinatus, 122, 122f anterior fibers of deltoid, 115, 115f 294f, 329 Therapist posture, 3–4, 3f Shoulder complex, 64, 66–67, 68t, 69t Shoulder girdle, 64, 65f, 96t–98t Thomas test position, 323 alternate test, 102–103, 102f, 103f Shoulder girdle depression, 9 Thumb anterior aspect of, 72f Shoulder girdle elevation, 9 bony anatomy, 72f Shoulder horizontal adduction adduction, 239 clavicular head, 125 CM abduction, 204 extension, 118–119, 118f, 119f and abduction external rotation, 92–93, 92f, 93f, 130–132, AROM assessment, 88 caliper measurement, 205, 205f 130f, 131f, 132f posterior fibers of deltoid, 125–126, ruler measurement, 205, 205f flexion and adduction, 116–117, 116f, 117f 125f, 126f universal goniometer, 204–205 glenohumeral joint, 65, 65f PROM assessment, 88, 88f CM flexion–extension, 200–201, 202–203 abduction, 87, 87f universal goniometer, 89, 89f IP flexion–extension, 202–203 flexion, 81–82, 81f, 82f interphalangeal extension, 235 movements, 69t against gravity interphalangeal flexion, 233 horizontal abduction, 125–126 pectoralis major, 123, 123f metacarpophalangeal extension, 236 horizontal adduction, 88–89, 88f, 89f, metacarpophalangeal flexion, 234 123–124, 123f, 124f gravity eliminated movements, 181t internal rotation, 90–91, 90f, 91f, 127–129, pectoralis major, 124, 124f muscles, 223 127f, 128f, 129f opposition, 206, 206f isometric/palpation grading, 96 Shoulder internal rotation palmar abduction, 238 joints and movements, 68t–69t against gravity radial abduction, 237 lateral aspect of, 72f subscapularis, 127, 127f bony anatomy, 72f AROM assessment, 90 movements, 69t, 78 gravity eliminated pectoralis major, 9494f subscapularis, 128–129, 128f, 129f pectoralis minor, 95, 95f PROM assessment, 90, 90f universal goniometer, 91, 91f

520 Index Thyrohyoid, 436t, 434 flexion, 446–448, 449, 450–452, 466–467 shoulder elevation Tibialis anterior, muscle assessment lateral flexion, 453–455 through abduction, 86, 86f movements, 442t through flexion, 80, 80f against gravity muscles, 460–461, 462t–464t movement, 364 rotation, 456–457, 466–467 shoulder extension, 84, 84f stabilization, 364 surface anatomy, 444f, 445f shoulder external rotation, 92, 92f start position, 364 thoracic and lumbar spines, 441, 443 shoulder horizontal abduction and Two-joint muscle, 30–31, 30f gravity eliminated, 368 adduction, 89, 89f Tibialis anterior muscle, 365t U shoulder internal rotation, 91, 91f Tibialis posterior muscle, 365t subtalar inversion and eversion, 348, 350 Tibial plateaus, 313 Universal goniometer, 13, 14, 17, 17f, 18 Upper fibers of trapezius, 437t Tibial rotation, 310, 317f, 324, 333 ankle and foot supination, eversion component, 353–354 V AROM measurement, 317 ankle and foot supination, eversion external, 317 component, 353–354 Vastus intermedius, 325t, 329f greatest range of, 317 alternate measurements, 346 Vastus lateralis, 325t, 329f in men, 317 end positions, 345 Vastus medialis, 325t, 329f PROM measurement, 317 goniometer axis, 345 Valsalva maneuver, 12, 38 movable arm, 345 Visual observation, 2 end feels, 317 stabilization, 344 joint spin, 317 start position, 344 W procedure, 317 stationary arm, 345 stabilization, 317 gastrocnemius muscle, 362–362f “Winging” of scapula, 102, 103 start position, 317 glenohumeral joint abduction, 87 Wrist, 177 of total rotation ROM, 317 glenohumeral joint flexion, 82, 82f using OB goniometer joint ROM, 22–23 AROM, 186, 186f end position, 318–318f of knee flexion-extension extension, 187–189, 187f, 188f, 189f goniometer placement, 318 end position, 315–315f stabilization, 318 goniometer axis, 315–315f and radial deviation, 220–221 start position, 317 hyperextension, 315–315f and ulnar deviation, 221–222 in women, 317 movable arm position, 315 extension (not shown), 223 Tibial tuberosity, 313 stabilization, 315 flexion, 187–189, 187f, 188f, 189f Tibiofemoral joint, 310 start position, 315–315f and radial deviation, 212, 215 stationary arm position, 315 and ulnar deviation, 217 TMJ. See Temporomandibular joint (TMJ) MTP joint flexion and adduction of the great flexion (not shown), 219 toe, 358 functional range of motion, 241–243 Toe, grading of, 378t end position, 358 grasping function of, 243, 245–246 Toe flexors, 389 goniometer axis, 358 joint function, 241 Toe movements, 340t movable arm, 358 lateral view of, 184f Tongue, protrusion of, 433, 433f stabilization, 358 movements, 179t Torque, 32, 32f stabilization, 358 radial deviation, 8, 190–191 Transversus abdominus, 462t stationary arm, 358 surface anatomy, 185f Trendelenburg test, 295 MTP joint flexion and extension of the great ulnar deviation, 8, 190–191 Triceps, 154, 155t, 161–162, 161f, 162f, 163f toe, 356 Trigeminal nerve, 423 Z Tripod pinch, 249f Trochlear, 420 Zygomaticus major, 419t Trunk Zygomaticus minor, 419t extension, 446–448, 449, 450–452, 469–470 extensors and hamstrings, 459