Measurement of Joint Motion: A Guide to Goniometry

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Library of Congress Cataloging-in-Publication Data

Names: Norkin, Cynthia C., author. | White, D. Joyce, author.

Title: Measurement of joint motion : a guide to goniometry / Cynthia C.
Norkin, D. Joyce White; photographs by Jason Torres, Jocelyn Greene
Molleur, and Lucia Grochowska Littlefield; technical advisor, George
Kalem, III ; illustrations by Timothy Wayne Malone.
Description: Fifth edition. | Philadelphia : F.A. Davis Company, [2016] |
Includes bibliographical references and index.
Identifiers: LCCN 2016026126 | ISBN 9780803645660 | ISBN 080364566X
Subjects: | MESH: Arthrometry, Articular—methods | Joints—physiology |
Joint Diseases—diagnosis
Classification: LCC RD734 | NLM WE 300 | DDC 612.7/5—dc23 LC record available at
https://lccn.loc.gov/2016026126

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 Preface
The measurement of joint motion is an important compo- provided and updated with each edition. Current evidence of
nent of a thorough physical examination of the extremities the effects on range of motion of an individual’s characteris-
and spine, one which helps health professionals determine tics such as age, gender, body mass, and recreational/occupa-
function, identify impairments, and assess rehabilitative sta- tional activities, as well as the effects of the testing process
tus. The need for a comprehensive text with sufficient writ- such as testing position and type of measuring instrument
ten detail and photographs to allow for the standardization of have been consistently included in each edition. In this man-
goniometric measurement methods—both for the purposes of ner, clinicians have been supported in their efforts to integrate
teaching and clinical practice—led to the development of the evidence-based practice as they determine an individual’s
first edition of the Measurement of Joint Motion: A Guide to impairments and set rehabilitative goals.
Goniometry in 1985. Our approach included a discussion and We have made some changes in the fifth edition as part
photographs of testing position, stabilization, end-feel, and of our ongoing search for ways to present current informa-
goniometer alignment for each measurable joint in the body. tion in an easily accessible format. New tables and text have
The resulting text was extremely well received by a variety of been added that summarize up-to-date research findings on
health professional educational programs and was used as a the reliability of the assessment of joint motion with universal
reference in many clinical settings and research studies. goniometers and, where appropriate, inclinometers and smart
Subsequent editions were expanded to include muscle phone applications. For the first time, these tables include
length testing at joints where muscle length is often a fac- absolute measures of reliability such as standard error of
tor affecting range of motion. This addition integrated the measurement (SEM) and minimal detectable change (MDC)
measurement procedures used in this book with the Ameri- that allow clinicians to estimate their measurement error to
can Physical Therapy Association’s Guide to Physical Ther- decide whether changes in range of motion values reflect real
apy Practice. Illustrations and anatomical descriptions were changes in their patients. Two exercises have been added to
added so that the reader had a visual reminder of the joint Chapter 3 that will help the reader understand and apply these
structures and muscles involved in range of motion. Informa- statistical tests. Extensive new tables have been included that
tion on osteokinematics, arthrokinematics, and capsular and make it easy to find current research results on joint motions
noncapsular patterns of limitation was included. Illustrations needed to perform a wide variety of functional tasks. Sum-
of bony anatomical landmarks and photographs of surface mary Guides for each joint that include essential information
anatomy were added to help the reader align the goniometer about testing positions, stabilization, and goniometer and/
accurately. Inclinometer techniques for measuring range of or inclinometer placement can be quickly located in a new
motion of the spine and some alternative positions and align- Appendix B. In addition, readers will benefit from the more
ments for goniometric measurement of the range of motion of than 80 new photographs and illustrations that are included to
certain extremity joints were presented to coincide with cur- better explain concepts and enhance learning.
rent practice in some clinical settings. In spite of the many changes over the years, this book
In the years following initial publication, a consider- continues to present goniometry logically and clearly. Chap-
able amount of research on the measurement of joint motion ter 1 discusses basic concepts regarding the use of goniom-
appeared in the literature. Consequently, later editions have etry to assess range of motion and muscle length in patient
included a chapter on the reliability and validity of joint mea- evaluation. Arthrokinematic and osteokinematic movements,
surement, as well as joint-specific research sections in each elements of active and passive range of motion, hypomo-
chapter that focus on measurement procedures. Research bility, hypermobility, and factors affecting joint motion are
findings to establish normative range-of-motion values and included. The inclusion of end-feels and capsular and noncap-
the motion needed for a variety of functional tasks have been sular patterns of joint limitation introduces readers to current
iii

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 iv Preface

concepts in orthopedic manual therapy and encourages them position, stabilization, testing motion, normal end-feel, and
to consider joint structure and muscle length while measuring goniometer alignment for each joint and motion follows in
joint motion. a format that reinforces a consistent approach to evaluation.
Chapter 2 takes the reader through a step-by-step process The extensive use of photographs, illustrations, and captions
to master the techniques of goniometric evaluation including eliminates the need for repeated demonstrations by an instruc-
positioning, stabilization, instruments used for measurement, tor and provides the reader with a permanent reference for
goniometer alignment, and the recording of results. Exercises visualizing the procedures. At the end of each chapter there
that help develop necessary psychomotor skills and demon- is a review of current literature regarding normal range of
strate direct application of theoretical concepts facilitate motion values; the effects of age, gender, and other factors
learning. on range of motion; functional range of motion; and the reli-
Chapter 3 discusses the validity and reliability of mea- ability and validity of measurement procedures. This structure
surement. The results of the most contemporary validity and makes it easy for readers who are focused on learning mea-
reliability studies on the measurement of joint motion are surement techniques, as well as readers who are focused on
summarized to help the reader focus on ways of improving reviewing the research literature for evidence-based practice,
and interpreting goniometric measurements. Mathematical to find what they are seeking.
methods of evaluating reliability are shown along with exam- We believe that the fifth edition provides a comprehen-
ples and exercises so that the reader can assess their reliability sive coverage of the clinical measurement of joint motion and
in taking measurements. muscle length that supports evidence-based practice. We hope
Chapters 4 through 13 present detailed information on that this book will make the teaching and learning of goni-
goniometric testing procedures for the upper and lower extrem- ometry easier and improve the standardization and thus the
ities, spine, and temporomandibular joint. When appropriate, reliability and validity of this examination tool. Readers are
muscle length testing procedures are also included. In each encouraged to provide us with feedback on our current efforts
chapter, a logical sequence progresses from an overview of to bring you a high-quality, user-friendly text.
joint structures, osteokinematic and arthrokinematic motions,
and capsular patterns of limitation to specific measurement CCN
procedures. Information on anatomical landmarks, testing DJW

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 Contributing Authors

Erin Hartigan, PT, DPT, PhD, OCS, ATC David A. Scalzitti, PT, PhD
Associate Professor Assistant Professor
Physical Therapy Department Program in Physical Therapy
University of New England George Washington University
Portland, Maine Washington, DC

Reviewers

Becca D. Jordre, PT, DPT, GCS Mary T. Marchetti, PT, PhD, GCS
Associate Professor Assistant Professor
Physical Therapy Department Physical Therapy Department
The University of South Dakota Duquesne University
Vermillion, South Dakota Pittsburgh, Pennsylvania

Heather MacKrell, PT, PhD Rebecca A Reisch, PT, PhD, DPT, OCS
Physical Therapist Assistant Program Director Associate Professor
Health Sciences Department Physical Therapy Department
Calhoun Community College Pacific University
Tanner, Alabama Hillsboro, Oregon

Jill Manners, MS, MPT, LAT, ATC, PT Kimberly Varnado, PT, DPT, OCS, FAAOMPT
Program Director and Professor Assistant Professor
Athletic Training Education Program Physical Therapy Department
Western Carolina University Midwestern University
Cullowhee, North Carolina Glendale, Arizona

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 Acknowledgments
We are very grateful for the contributions of the many people the photographs or provided painstaking research support for
who were involved in the development and production of Mea- the fifth edition.
surement of Joint Motion. We wish to thank David Scalzitti We wish to express our appreciation to these dedicated
and Erin Hartigan who added their considerable expertise as professionals at F. A. Davis: Margaret Biblis, Editor in Chief,
researchers and educators to update Chapter 3: Validity and Melissa Duffield, Senior Acquisitions Editor, and Laura
Reliability of Goniometric Measurement, and Chapter 8: Horowitz, Developmental Editor, for their encouragement
The Hip, respectively. Photographer Jason Torres of J. Tor- and commitment to excellence. Our thanks are also extended
res Photography in New York used his skills and experience to George Lang, Director of Content Development; Jennifer
to produce the new high-quality photographs that appear in Pine, Manager of Developmental Editing; Cindy Breuninger,
this fifth edition. We are appreciative of the access provided Managing Editor; Sharon Lee, Production Manager; Caro-
by the University of Massachusetts Lowell to take these pho- lyn O’Brien, Manager of Art and Design; Daniel Domzalski,
tographs in the teaching laboratories of the Department of Illustration Coordinator; Elizabeth Stepchin, Project Editor;
Physical Therapy. The late Jocelyn Molleur, who assiduously Nichole Liccio, Administrative Assistant; and Marsha Hall,
took the photographs for the third and fourth editions, and Project Manager, Progressive Publishing Services. We are
Lucia Grochowska Littlefield, who produced the photographs very grateful to the numerous, faculty, students, and clini-
for the first and second editions, are also responsible for this cians who over the years have used the book or formally
important feature of the book. Timothy Malone, an artist from reviewed portions of the manuscript and offered insight-
Ohio, used his talents and knowledge of anatomy to create ful comments and helpful suggestions that have improved
the excellent illustrations that appear in this as well as past this text.
editions. We also offer our thanks to colleagues Erika Lewis Finally, we wish to thank our families: Cynthia’s daugh-
and Kyle Coffey, as well as Jessica LeBlanc, Conor Norden- ter, Alexandra, and her daughters, Taylor and Kimberly; and
gren, Samantha Rollings, Rachel Blakeslee, Chris Fournier, Joyce’s husband, Jonathan, and sons, Alexander and Ethan,
Colleen DeCotret, Rebecca D’Amour, Alexander White, and for their continuing encouragement and support. We will
Claudia Van Bibber, who graciously agreed to participate in always be appreciative.

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4566_Norkin_FM.indd viii 14/10/16 9:46
 About the Authors
Dr. Cynthia C. Norkin is Dr. D. Joyce White is
Associate Professor Emerita, Associate Professor, Depart-
School of Physical Therapy, ment of Physical Therapy,
Ohio University. She holds University of Massachusetts
a Doctorate of Education Lowell. She holds a Doctor-
degree and an Advanced ate of Science degree in Epi-
Master of Science in Phys- demiology and an Advanced
ical Therapy degree from Master of Science degree in
Boston University, a Bach- Physical Therapy from Bos-
elor of Science degree from ton University, and a Bach-
Tufts University, and Cer- elor of Science degree in
tificate in Physical Ther- Physical Therapy from the
apy from the Bouvé-Boston University of Connecticut.
School. She founded the School of Physical Therapy at Ohio Dr. White’s research, teaching, and clinical experience have
University and served as Director for 11 years. Previously, predominantly focused on the assessment, treatment, and con-
she spent 10 years at Boston University as an Assistant Pro- tributing causes of musculoskeletal conditions of the upper
fessor of Physical Therapy, Sargent College, where she and and lower extremities. She has authored research articles and
Dr. White initially wrote Measurement of Joint Motion: A book chapters, and presented numerous conference papers in
Guide to Goniometry. Dr. Norkin is the co-editor and contrib- these areas. The American Physical Therapy Association has
uting author of the book Joint Structure and Function: A Com- presented her with the Dorothy Briggs Memorial Scientific
prehensive Analysis, currently in its fifth edition. Inquiry Award. Dr. White is a recipient of the University of
Massachusetts Lowell Award for Teaching Excellence where
she has taught for over 25 years. She has also held academic
appointments at Boston University, Sargent College.

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4566_Norkin_FM.indd x 14/10/16 9:46
 Brief Contents

PART I INTRODUCTION TO PART IV TESTING OF THE SPINE

GONIOMETRY AND MUSCLE LENGTH AND TEMPOROMANDIBULAR
TESTING, 1 JOINT, 409
Chapter 1 Basic Concepts, 3 Chapter 11 The Cervical Spine, 411
Chapter 2 Procedures, 19 Chapter 12 The Thoracic and Lumbar
Spine, 469
Chapter 3 Validity and Reliability of
Goniometric Measurement, 43 Chapter 13 The Temporomandibular
Joint, 519
PART II UPPER-EXTREMITY
TESTING, 65 APPENDIXES
Chapter 4 The Shoulder, 66 A: Normative Range of Motion Values, 537
Chapter 5 The Elbow and Forearm, 115 B: Summary Guides for Measuring Range
of Motion, 543
Chapter 6 The Wrist, 149
C: Joint Measurements by Body Position, 553
Chapter 7 The Hand, 187
D: Numerical Recording Forms, 555
PART III LOWER-EXTREMITY
TESTING, 253
Index, 561
Chapter 8 The Hip, 255
Chapter 9 The Knee, 315
Chapter 10 The Ankle and Foot, 345

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 Contents

PART I INTRODUCTION TO Gravity-Dependent Goniometers

GONIOMETRY AND MUSCLE LENGTH (Inclinometers), 31
TESTING, 1 EXERCISE 4: Inclinometers, 33
EXERCISE 5: Inclinometer Alignment for
Chapter 1 Basic Concepts, 3 Cervical Rotation, 33
D. Joyce White, PT, DSc; Cynthia C. Norkin, PT, EdD Electrogoniometers, 34
Goniometry, 3 Radiography, 34
Kinematics, 4 Photography, 34
Arthrokinematics, 4 Smartphones, 34
Osteokinematics, 5 Visual Estimation, 34
Planes and Axes, 6 Recording, 35
Range of Motion, 7 Numerical Tables, 36
Active Range of Motion, 8 Pictorial Charts, 37
Passive Range of Motion, 8 Sagittal–Frontal–Transverse–Rotation (SFTR)
Hypomobility, 10 Method of Recording, 37
Hypermobility, 12 American Medical Association Guides to
Factors Affecting Range of Motion, 13 Evaluation of Permanent Impairment
Muscle Length Testing, 14 Method, 38
Procedures, 38
Chapter 2 Procedures, 19 Precautions to Range of Motion and Muscle
Cynthia C. Norkin, PT, EdD; D. Joyce White, PT, DSc Length, 38
Positioning, 19 Preparation for Testing, 38
Stabilization, 22 Explanation of Procedure, 39
EXERCISE 1: Determining the End of the Testing Procedure, 39
Range of Motion and End-Feel, 23 EXERCISE 6: Explanation of Goniometric
Measurement Instruments, 24 Testing Procedure, 40
Universal Goniometer, 24 EXERCISE 7: Testing Procedure for
EXERCISE 2: The Universal Goniometer, 30 Goniometric Measurement of Elbow
EXERCISE 3: Goniometer Alignment for Flexion ROM, 40
Elbow Flexion, 30

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Chapter 3 Validity and Reliability of Research Findings, 92

Goniometric Measurement, 43 Effects of Age, Gender, and Other
David A. Scalzitti, PT, PhD; D. Joyce White, PT, DSc
Factors, 92
Validity, 43 Functional Range of Motion, 97
Face Validity, 43 Reliability and Validity, 100
Content Validity, 43
Chapter 5 The Elbow and Forearm, 115
Criterion-Related Validity, 43
D. Joyce White, PT, DSc; Cynthia C. Norkin, PT, EdD
Construct Validity, 45
Structure and Function, 115
Reliability, 45
Humeroulnar and Humeroradial Joints, 115
Summary of Goniometric Reliability Studies, 45
Superior and Inferior Radioulnar Joints, 116
Statistical Methods of Evaluating
Range of Motion Testing Procedures, 118
Measurement Reliability, 47
Landmarks for Testing Procedures, 118
Exercises to Evaluate Reliability, 54
Elbow Flexion, 120
EXERCISE 8: Intratester Reliability, 54
Elbow Extension, 122
EXERCISE 9: Intertester Reliability, 56
Forearm Pronation, 122
EXERCISE 10: Calculation of the Standard
Forearm Supination, 124
Error of Measurement and Minimal
Muscle Length Testing Procedures, 126
Detectable Change, 58
Landmarks for Testing Procedures, 126
EXERCISE 11: Calculation of the Pearson
Elbow Flexors, 126
Product-Moment Correlation Coefficient,
Biceps Brachii Muscle Length Test, 127
Standard Error of Measurement, and
Elbow Extensors, 128
Minimal Detectable Change, 60
Long Head of the Triceps Brachii Muscle
Length Test, 128
PART II UPPER-EXTREMITY Research Findings, 130
TESTING, 65 Effects of Age, Gender, and Other
Factors, 130
Chapter 4 The Shoulder, 66 Functional Range of Motion, 133
D. Joyce White, PT, DSc Reliability and Validity, 137
Structure and Function, 66
Shoulder Complex, 66 Chapter 6 The Wrist, 149
Glenohumeral Joint, 66 D. Joyce White, PT, DSc
Sternoclavicular Joint, 67 Structure and Function, 149
Acromioclavicular Joint, 68 Radiocarpal and Midcarpal Joints, 149
Scapulothoracic Joint, 69 Range of Motion Testing Procedures, 151
Range of Motion Testing Procedures, 70 Landmarks for Testing Procedures, 151
Landmarks for Testing Procedure, 70 Wrist Flexion, 153
Flexion, 72 Wrist Extension, 156
Extension, 76 Wrist Radial Deviation, 159
Abduction, 80 Wrist Ulnar Deviation, 161
Adduction, 84 Muscle Length Testing Procedures, 163
Medial (Internal) Rotation, 84 Landmarks for Testing Procedures, 163
Lateral (External) Rotation, 88 Wrist Flexors, 163

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 Contents xv

The Flexor Digitorum Profundus and Flexor Thumb: Metacarpophalangeal Flexion, 222
Digitorum Superficialis Muscle Thumb: Metacarpophalangeal Extension, 224
Length Test, 164 Thumb: Interphalangeal Flexion, 225
Wrist Extensors, 167 Thumb: Interphalangeal Extension, 227
The Extensor Digitorum, Extensor Indicis, Muscle Length Testing Procedures:
and Extensor Digiti Minimi Muscle Length Fingers, 228
Test, 168 Landmarks for Testing Procedures, 228
Research Findings, 170 Metacarpophalangeal Flexors, 228
Effects of Age, Gender, and Other Factors, 170 Lumbricals, Palmar Interossei, and Dorsal
Functional Range of Motion, 173 Interossei Muscle Length Test, 230
Reliability and Validity, 178 Research Findings, 233
Effects of Age, Gender, and Other
Chapter 7 The Hand, 187 Factors, 233
D. Joyce White, PT, DSc
Functional Range of Motion, 236
Structure and Function, 187 Reliability and Validity, 239
Fingers: Metacarpophalangeal Joints, 187
Fingers: Proximal Interphalangeal and Distal
PART III LOWER-EXTREMITY
Interphalangeal Joints, 188
TESTING, 253
Thumb: Carpometacarpal Joint, 188
Thumb: Metacarpophalangeal Joint, 189 Chapter 8 The Hip, 255
Thumb: Interphalangeal Joint, 190 Erin Hartigan, PT, DPT, PhD, OCS, ATC; D. Joyce White, PT, DSc
Range of Motion Testing Procedures: Structure and Function, 255
Fingers, 191 Iliofemoral Joint, 255
Landmarks for Testing Procedures, 191 Range of Motion Testing Procedures, 256
Fingers: Metacarpophalangeal (MCP) Landmarks for Testing Procedures, 256
Flexion, 192 Hip Flexion, 258
Fingers: Metacarpophalangeal Extension, 194 Hip Extension, 260
Fingers: Metacarpophalangeal Abduction, 197 Hip Abduction, 262
Fingers: Metacarpophalangeal Adduction, 199 Hip Adduction, 264
Fingers: Proximal Interphalangeal Flexion, 199 Hip Medial (Internal) Rotation, 266
Fingers: Proximal Interphalangeal Extension, 201 Hip Lateral (External) Rotation, 268
Fingers: Distal Interphalangeal Flexion, 202 Muscle Length Testing Procedures, 270
Fingers: Distal Interphalangeal Extension, 204 Landmarks for Testing Procedures, 270
Fingers: Composite Flexion of the MCP, PIP, Hip Flexors, 270
and DIP Joints, 205 Thomas Test, 272
Range of Motion Testing Procedures: Hip Extensors, 278
Thumb, 206 Straight Leg Raising (SLR) Test, 279
Landmarks for Testing Procedures, 206 Hip Abductors, 283
Thumb: Carpometacarpal Flexion, 208 Ober Test, 283
Thumb: Carpometacarpal Extension, 211 Modified Ober Test, 287
Thumb: Carpometacarpal Abduction, 214 Research Findings, 288
Thumb: Carpometacarpal Adduction, 216 Effects of Age, Gender, and Other Factors, 288
Thumb: Carpometacarpal Opposition, 216 Functional Range of Motion, 294

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Reliability and Validity of Hip Range of Talocrural Joint: Dorsiflexion, 352

Motion Measurements, 296 Talocrural Joint: Plantarflexion, 355
Reliability and Validity of Muscle Length Landmarks for Testing Procedures: Tarsal
Testing, 303 Joints, 357
Tarsal Joints: Inversion, 358
Chapter 9 The Knee, 315 Tarsal Joints: Eversion, 360
Cynthia C. Norkin, PT, EdD Landmarks for Testing Procedures: Subtalar
Structure and Function, 315 Joint (Rearfoot), 363
Tibiofemoral and Patellofemoral Joints, 315 Subtalar Joint (Rearfoot): Inversion, 364
Range of Motion Testing Procedures, 317 Subtalar Joint (Rearfoot): Eversion, 366
Landmarks for Testing Procedures, 317 Transverse Tarsal (Midtarsal) Joint: Inversion, 368
Knee Flexion, 318 Transverse Tarsal (Midtarsal) Joint: Eversion, 370
Knee Extension, 320 Landmarks for Testing Procedures:
Knee Rotation, 320 Metatarsophalangeal and Interphalangeal
Muscle Length Testing Procedures, 321 Joints, 372
Landmarks for Testing Procedures, 321 Metatarsophalangeal Joint: Flexion, 374
Knee Extensors, 321 Metatarsophalangeal Joint: Extension, 376
Ely Test, 322 Metatarsophalangeal Joint: Abduction, 378
Knee Flexors, 325 Metatarsophalangeal Joint: Adduction, 379
Distal Hamstring Length Test, 326 Interphalangeal Joint of the First Toe and
Research Findings, 329 Proximal Interphalangeal Joints of the
Effects of Age, Gender, and Other Factors, 329 Four Lesser Toes: Flexion, 380
Functional Range of Motion, 332 Interphalangeal Joint of the First Toe and
Reliability and Validity of Range of Motion Proximal Interphalangeal Joints of the
Measurement, 335 Four Lesser Toes: Extension, 380
Reliability and Validity of Muscle Length Distal Interphalangeal Joints of the Four
Testing, 341 Lesser Toes: Flexion, 381
Distal Interphalangeal Joints of the Four
Chapter 10 The Ankle and Foot, 345
Lesser Toes: Extension, 381
D. Joyce White, PT, DSc
Muscle Length Testing Procedures, 382
Structure and Function, 345
Landmarks for Testing Procedures, 382
Proximal and Distal Tibiofibular Joints, 345
Ankle Plantarflexors, 382
Talocrural Joint, 345
Gastrocnemius Muscle Length Test: Supine
Subtalar Joint, 347
Non-Weight-Bearing, 382
Transverse Tarsal (Midtarsal) Joint, 348
Gastrocnemius Muscle Length Test: Standing
Tarsometatarsal Joints, 349
Weight-Bearing, 385
Metatarsophalangeal Joints, 349
Research Findings, 387
Interphalangeal Joints, 350
Effects of Age, Gender, and Other Factors, 387
Range of Motion Testing Procedures, 351
Functional Range of Motion, 393
Landmarks for Testing Procedures: Talocrural
Reliability and Validity, 396
Joint, 351

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 Contents xvii

PART IV TESTING OF THE SPINE Chapter 12 The Thoracic and Lumbar

AND TEMPOROMANDIBULAR Spine, 469
JOINT, 409 Cynthia C. Norkin, PT, EdD
Structure and Function, 469
Chapter 11 The Cervical Spine, 411 Thoracic Spine, 469
Cynthia C. Norkin, PT, EdD Lumbar Spine, 470
Structure and Function, 411 Range of Motion Testing Procedures, 472
Atlanto-Occipital and Atlantoaxial Landmarks for Testing Procedures, 472
Joints, 411 Thoracolumbar Flexion, 473
Intervertebral and Zygapophyseal (Facet) Thoracolumbar Flexion: Tape Measure, 474
Joints, 413 Thoracolumbar Flexion: Fingertip-to-Floor, 475
Range of Motion Testing Procedures, 415 Thoracolumbar Flexion: Double
Landmarks for Testing Procedures, 415 Inclinometers, 476
Cervical Flexion: Universal Goniometer, 418 Thoracolumbar Extension, 477
Cervical Flexion: Tape Measure, 420 Thoracolumbar Extension: Tape Measure, 478
Cervical Flexion: Double Inclinometers, 422 Thoracolumbar Extension: Prone Push-Up, 479
Cervical Flexion: Single Inclinometer, 423 Thoracolumbar Extension: Double
Cervical Flexion: Cervical Range of Motion Inclinometers, 480
Device, 424 Thoracolumbar Lateral Flexion, 481
Cervical Extension: Universal Goniometer, 426 Thoracolumbar Lateral Flexion: Universal
Cervical Extension: Tape Measure, 428 Goniometer, 482
Cervical Extension: Double Inclinometers, 429 Thoracolumbar Lateral Flexion:
Cervical Extension: Single Inclinometer, 430 Fingertip-to-Floor, 483
Cervical Extension: CROM Device, 432 Thoracolumbar Lateral Flexion:
Cervical Lateral Flexion: Universal Fingertip-to-Thigh, 484
Goniometer, 434 Thoracolumbar Lateral Flexion: Double
Cervical Lateral Flexion: Tape Measure, 436 Inclinometers, 486
Cervical Lateral Flexion: Double Thoracolumbar Rotation, 487
Inclinometers, 437 Thoracolumbar Rotation: Universal
Cervical Lateral Flexion: Single Goniometer, 487
Inclinometer, 438 Thoracolumbar Rotation: Double
Cervical Lateral Flexion: CROM Device, 439 Inclinometers, 489
Cervical Rotation: Universal Goniometer, 440 Lumbar Flexion, 490
Cervical Rotation: Tape Measure, 442 Lumbar Flexion: Modified-Modified
Cervical Rotation: Single Inclinometer, 442 Schober Test (MMST) or Simplified Skin
Cervical Rotation: CROM Device, 444 Distraction Test, 490
Research Findings, 445 Lumbar Flexion: Double Inclinometers, 492
Effects of Age, Gender, and Other Lumbar Flexion: Single Inclinometer, 493
Factors, 445 Lumbar Extension, 495
Functional Range of Motion, 452 Lumbar Extension: Modified-Modified
Reliability and Validity, 454 Schober Test or Simplified Skin Attraction
Test, 495

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Lumbar Extension: Double Inclinometers, 496 Overbite, 526

Lumbar Extension: Single Inclinometer, 497 Protrusion of the Mandible, 527
Lumbar Lateral Flexion, 499 Lateral Excursion of the Mandible, 528
Lumbar Lateral Flexion: Double Research Findings, 530
Inclinometers, 500 Effects of Age, Gender, and Other
Lumbar Lateral Flexion: Single Factors, 530
Inclinometer, 501 Reliability and Validity, 533
Research Findings, 503
Effects of Age, Gender, and Other Factors, 503 APPENDIXES
Functional Range of Motion, 507
Reliability and Validity, 509 A: Normative Range of Motion Values, 537

Chapter 13 The Temporomandibular B: Summary Guides for Measuring Range

Joint, 519 of Motion, 543
Cynthia C. Norkin, PT, EdD C: Joint Measurements by Body Position, 553
Structure and Function, 519
Temporomandibular Joint, 519 D: Numerical Recording Forms, 555
Range of Motion Testing Procedures, 522
Landmarks for Testing Procedures, 522
Depression of the Mandible (Mouth Index, 561
Opening), 522

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 I
PA R T

INTRODUCTION TO
GONIOMETRY AND MUSCLE
LENGTH TESTING
This book is designed to serve as a guide for learning how to instruments such as goniometers and inclinometers are intro-
assess range of motion and muscle length. Part I presents the duced so that examiners become competent in their use. The
background information on the principles and procedures nec- validity and reliability of goniometric measurements are
essary for understanding goniometry. Practice exercises are explored to encourage thoughtful and appropriate use of these
included at appropriate intervals to help the examiner apply techniques in clinical practice. Parts II through IV present the
this information and develop the psychomotor skills neces- procedures for the examination of joint range of motion and
sary for competency in measuring joint motion and muscle muscle length testing of the upper and lower extremities, the
length. Different types of joint range-of-motion measuring spine, and temporomandibular joints.

OBJECTIVES
After completion of Part I, which includes chapters soft, firm, and hard end-feels
on Basic Concepts, Procedures, and Validity and hypomobility and hypermobility
Reliability, you will be able to: capsular and noncapsular patterns of restricted
motion
1. Define: goniometer and inclinometer
goniometry reliability and validity
kinematics intratester and intertester reliability
arthrokinematics face, content, criterion-related, and construct
osteokinematics validity
range of motion
end-feel 4. Explain the importance of:
muscle length testing testing positions
reliability stabilization
validity clinical estimates of range of motion
palpation of bony landmarks
2. Identify the appropriate planes and axes for each recording starting and ending positions
of the following motions:
flexion–extension, abduction–adduction, and 5. Perform an evaluation of elbow joint motion,
rotation including:
a clear explanation of the procedure
3. Compare: proper placement of the individual in the
active, active assistive, and passive ranges of recommended testing position
motion adequate stabilization of the proximal joint
arthrokinematic and osteokinematic motions component

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 correct determination of the end of the range of 6. Give an example of a muscle length test.
motion
correct identification of the end-feel 7. Perform and interpret intratester and intertester
palpation of the appropriate bony landmarks reliability tests, including standard deviation,
accurate alignment of the goniometer coefficient of variation, correlation coefficients,
correct reading of both the goniometer and the standard error of measurement, and minimal
inclinometer, and recording of the measurements detectable change.

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 1
CHAPTER

Basic Concepts
D. Joyce White, PT, DSc
Cynthia C. Norkin, PT, EdD

Goniometry Goniometry is an important part of a comprehensive

examination of joints and surrounding soft tissue. A compre-
hensive examination typically begins by interviewing the indi-
The term goniometry is derived from two Greek words: vidual and reviewing records to obtain an accurate description
gonia, meaning “angle,” and metron, meaning “measure.” of current symptoms; functional abilities and activities of daily
Therefore, goniometry refers to the measurement of angles, in living; occupational, social, and recreational activities; and
particular the measurement of angles created at human joints medical history. Observation of the individual’s body to assess
by the bones of the body. The examiner obtains these mea- bone and soft tissue contour, as well as skin and nail condi-
surements by placing the parts of the measuring instrument, tion, usually follows the interview. Gentle palpation is used to
called a goniometer, along the bones immediately proximal determine skin temperature and the quality of soft tissue defor-
and distal to the joint being evaluated. Goniometry may be mities and to locate pain symptoms in relation to anatomical
used to determine both a particular joint position and the total structures. Anthropometric measurements such as leg length,
amount of motion available at a joint. leg circumference, and body volume may be indicated.
The performance of active joint motions by the individ-
Example: The elbow joint is evaluated by placing the
ual during the examination allows the examiner to screen for
parts of the measuring instrument on the humerus
abnormal movements and gain information about the indi-
(proximal segment) and the forearm (distal segment)
vidual’s willingness to move. If abnormal active motions
and measuring either a specific joint position or the
are found, the examiner performs passive joint motions in an
total arc of motion (Fig. 1.1).
attempt to determine reasons for joint limitation. Performing

t
FIGURE 1.1 The left upper en
gm
extremity of an individual in 145˚ ls
e
sta
the supine position is shown. Di
The parts of the measuring
instrument have been placed
along the proximal (humerus)
and distal (radius) body segments
and centered over the axis of
the elbow joint. When the distal Proximal segment
segment has been moved toward
the proximal segment (elbow
flexion), a measurement of the
arc of motion can be obtained.

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 4 PART I Introduction to Goniometry and Muscle Length Testing

passive joint motions enables the examiner to assess the tissue a translatory motion, is the sliding of one joint surface over
that is limiting the motion, detect pain, and make an estimate another, as when a braked wheel skids (Fig. 1.2). A spin
of the amount of motion. Goniometry is used to measure and is a rotary motion, similar to the spinning of a toy top. All
document the amount of active and passive joint motion as points on the moving joint surface rotate around a fixed axis
well as abnormal fixed joint positions. of motion (Fig. 1.3). A roll is also a rotary motion, similar to
Following the examination of active and passive range of the rolling of the bottom of a rocking chair on the floor or the
motion, resisted isometric muscle contractions, joint integrity rolling of a tire on the road (Fig. 1.4).
and mobility tests, and special tests for specific body regions In the human body, slides, spins, and rolls usually occur
are used in conjunction with goniometry to help identify the in combination with one another and result in angular move-
injured anatomical structures. Tests to assess muscle perfor- ment of the shafts of the bones. The combination of the sliding
mance and neurological function are often included. Diagnos- and rolling is referred to as roll-gliding or roll-sliding4 and
tic imaging procedures and laboratory tests may be needed. allows for increased motion at a joint by postponing the joint
Functional outcome measures are often required for Medi-
care, Medicaid, and health insurance documentation.
Goniometric data used in conjunction with other informa-
tion can provide a basis for the following:
• Determining the presence, absence, or change in
impairment1
• Establishing a diagnosis
• Developing a prognosis, treatment goals, and plan of care
• Evaluating progress or lack of progress toward rehabilita-
tive goals
• Modifying treatment
• Motivating the individual
• Researching the effectiveness of therapeutic techniques
or regimens (for example, measuring outcomes following
exercises, medications, and surgical procedures)
• Fabricating orthotics and adaptive equipment
FIGURE 1.2 A slide (glide) is a translatory motion in which
the same point on the moving joint surface comes in
Kinematics contact with new points on the opposing surface, and all
the points on the moving surface travel the same amount of
distance.
Kinematics is the study of motion without regard for the forces
that are creating the motion. When referring to the human
body, kinematics describes the motion of bony segments
including the type, direction, and magnitude of motion; loca-
tion of the bony segment in space; and the rate of change or
velocity of the segment. The three types of motion that a bony
segment can undergo are translatory (linear displacement),
Axis

rotary (angular displacement), or more often a combination

of translatory and rotary motion.2 In translatory motion, all
points on a segment move in the same direction at the same
time. In rotary motion, the bone spins around a fixed point.
These three types of motion will be explained in more detail
in the following subdivisions of kinematics: arthrokinematics
and osteokinematics. In arthrokinematics, the focus is on how
joint surfaces move and interact, whereas in osteokinematics,
the focus is on movements of the shafts of bones.

Arthrokinematics
Motion at a joint occurs as the result of movement of one
joint surface in relation to another joint surface. Arthroki- FIGURE 1.3 A spin is a rotary motion in which all the points
on the moving surface rotate around a fixed central axis.
nematics is the term used to refer to the movement of joint The points on the moving joint surface that are closer to the
surfaces.3,4 The movements of joint surfaces are described as axis of motion will travel a smaller distance than the points
slides (or glides), spins, and rolls. A slide (glide), which is farther from the axis.

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 CHAPTER 1 Basic Concepts 5

TABLE 1.1 Arthrokinematic (Accessory/Joint

Play) Joint Motion Grades
Grade Joint Status
0 Ankylosed
Axis Axis
1 Considerable hypomobility
2 Slight hypomobility
3 Normal
4 Slight hypermobility
5 Considerable hypermobility
6 Unstable

FIGURE 1.4 A roll is a rotary motion in which new points on

the moving joint surface come in contact with new points on
the opposing surface. The axis of rotation has also moved,
in this case to the right. subjectively compared with the same motion on the contra-
lateral side of the body or with an examiner’s past experience
testing people of similar age and gender as the individual.
compression and separation that would occur at either side of An ordinal grading scale of 0 to 6 is often used to describe
the joint during a pure roll. The direction of the rolling and the amount of arthrokinematic motions6 (Table 1.1). These
sliding components of a roll-slide will vary depending on the motions are also called accessory or joint play motions.
shape of the moving joint surface. If a convex joint surface
is moving, the convex surface will roll in the same direction
as the angular motion of the shaft of the bone but will slide
Osteokinematics
in the opposite direction (Fig. 1.5A). If a concave joint sur- Osteokinematics refers to the gross movement of the shafts
face is moving, the concave surface will roll and slide in the of bony segments rather than the movement of joint surfaces.
same direction as the angular motion of the shaft of the bone The movements of the shafts of bones are usually described
(Fig. 1.5B). in terms of the rotary or angular motion produced, as if the
Arthrokinematic motions are examined for amount of movement occurs around a fixed axis of motion. Goniometry
motion, tissue resistance at the end of the motion, and effect measures the angles created by the rotary motion of the shafts
on the individual’s symptoms.5 The ranges of arthrokinematic of the bones. Some translatory shifting of the axis of motion
motions are very small and cannot be measured with a goni- usually occurs during movement; however, most clinicians
ometer or standard ruler. Instead, arthrokinematic motions are find the description of osteokinematic movement in terms of

A B
Angular
motion

Angular
motion

Roll
Roll

Slide
Slide

FIGURE 1.5 (A) If the joint surface of the

moving bone is convex, sliding is in the
opposite direction to the rolling and
angular movement of the bone. (B) If
the joint surface of the moving bone is
concave, sliding is in the same direction as
the rolling and angular movement of the
bone.

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