1. Lab 3 Upper Extremity
Part 2. Range of Motion

2. Case Study
A 55 year old man who works in a ware house as a clerical worker has complained of pain and discomfort above his elbow on the lateral side. He has discomfort in the area plus in the posterior compartment of his arm and wrist plus loss of strength at the end of his working day and at home. He performs filing, mousing and computer keyboarding and general clerical duties plus he is required to lift merchandise up to 5 kgs in and out of bins at waist height and above 20 – 30 times per day. He is also required to drive a truck and do deliveries from time to time.
He has been diagnosed with an over use injury and has been resting and taking anti-inflammatory drugs for two weeks and is now ready to get back to work. He has to be tested and prepared for work by a Kinesiologist.

3. Scan
Start with a general posture scan with patient standing in functional position.
Patient has a
poked head
Kyphosis
Increased Cervicle Lordosis
Check for discolouration of limbs, lesions, bruises, capillary refill

4. Functional Ability Tests
1. Lifting boxes to waist height increasing weight and noting any weakness or pain.
2. Flexion/Extension at wrist and fingers to test for weaknesses or pain in problem area which is the posterior aspect of forearm. Begin without resistance and then slowly increase resistance.

5. Muscles Muscles for Supination of Forearm Supinator
Muscles for Forearm Pronation
-Pronator Teres
-Pronator Quadratus

6. Muscles Involved in Movement
Extensors of Wrist & Fingers:
Extensor Carpi Radialis, Brevis, and Longus
Extensor Carpi Ulnaris
Extensor Digitorum Communis
Extensor Digiti Minimi
Lumbricals

7. Muscles Involved In Movement
Flexors of the wrist and fingers:
Flexor Carpi Radialis
Palmaris Longus
Flexor carpi ulnaris
Flexor digitorum superficialis
Flexor digitorum profundus
Lumbericales
Flexor digiti minimi

8. Muscles for Movement Radial Deviation Ulnar Deviation
Flexor Carpi Radialis
Ulnar Deviation
Flexor Carpi Ulnaris
Extensor Carpi Radialis Longus/Brevis
Extensor Carpi Ulnaris

9. Joint Limitations - Supination
Joint is Humeroradial, superior radioulnar, and inferior radioulnar
LIMIT:
Tension in pronator muscles, quadrate ligament, palmar radioulnar ligament, oblique cord, and interosseous membrane

10. Joint Limitations - Pronation
Contact of Radius on the Ulna
Tension in quadrate ligament, dorsal radioulnar ligament of inferior radioulnar joint, interosseous membrane, supinator, and biceps brachii

11. Joint Limitations – Flexion of the Wrist
Midcarpal and Radiocarpal Joints
Tension in the Posterior radiocarpul ligament and posterior joint capsule

12. Joint Limitations – Extension of Wrist
Occurs at Midcarpal and Radiocarpal Joints
Limitations: tension in the anterior radiocarpal ligament & anterior joint capsule, contact between radius & the carpal bones

13. Joint Limitations – Radial & Ulnar Deviation
Radial Deviation:
Occurs at Midcarpal and Radiocarpal joints
Limitations: Tension in Ulnar collateral ligament, ulnocarpal ligament & Ulnar portion of joint capsule, contact between radial styloid process & the scaphoid bone
Ulnar Deviation:
Occurs at Radiocarpal (Predominantly) & Midcarpal joints
Limitations: Tension in the radial collateral ligament & radial position of joint capsule

14. Joint Limitations - Finger
Flexion
Joints involved: metacarpophalangeal, proximal interphalangeal, distal interphalangeal
MCP: Tension in posterior joint capsule, collateral ligaments; contact between the proximal phalanx and metacarpals
PIP: Contact between the middle and proximal phalanx; soft tissue opposition of the middle and proximal phalanges; tension in the posterior joint capsule and collateral ligament
DIP: Tension in the posterior joint capsule, collateral ligaments, and oblique retinacular ligament

15. Joint Limitations - Finger
Extension
MCP, PIP, DIP
MCP: tension in the anterior joint capsule, palmar fibrocartilagenous( palmar ligament)
PIP: tension in the anterior joint capsule, palmar ligament
DIP: tension in anterior joint capsule, palmar ligament

16. Range of Motion Two types we deal with: PROM  Passive Range of Motion
The range of motion that is achieved when an outside force causes movement around a joint
AROM  Active Range of Motion
- The range of motion that can be achieved through the action of the agonist muscles for a specific joint movement
“Home on the Range: Range of Motion, Know Your Limits” www. everybodyfitness.com”

17. Active Range of Motion Supination/Pronation of Elbow
Substitution/Trick Movement – Supination – Adduction and external rotation of the shoulder, and ipsilateral trunk side flexion.
Pronation – Abduction and internal rotation of the shoulder, and contralateral trunk side flexion

18. Passive Range of Motion
Supination/pronation of Elbow
Start: Patient Sitting
Arm at side
Elbow flexed at 90 degrees
Forearm in mid position

19. Goniometer – Pronation/Supination
Start: The arm is at the side, and the elbow is flexed to 90 degrees with the forearm in midposition. The wrist is neutral, and the fingers are extended
Therapist: The patient stabilizes the humerus using the nontest hand
Goniometer Axis: The axis is placed at the tip of the middle digit
Stationary Arm: Perpendicular to the Floor
Movable Arm: Parallel to the tips of the four extended fingers

20. Passive Range of Motion
Therapist:
Stabilizes the humerus with one hand
Grasps distal radius and ulna with other hand
END FEELS
-Forearm is rotated externally for supination
-End Feel Firm
Forearm is rotated internally for pronation
End Feel hard/firm

21. Active Range of Motion Assesment- Wrist Flexion/Extension
Substitution/Trick Movement
Wrist ulnar or radial deviation

22. Passive Range of Motion Assessment
WRIST
Start: Patient sitting, forearm is resting on the table in pronation, wrist in neutral position, fingers relaxed

23. Stabilize the Forearm
Grasp metacarpals, thumb placed horizontally in palm of hand
Apply slight traction to and move hand anteriorly to assess wrist flexion; apply slight traction & move hand posteriorly to assess wrist extension

24. End Feel Wrist Flexion – Firm Wrist Extension – Firm on Hand
Average 120 m Flexion 0-80 degrees
Extension 0 – 70 degrees

25. Goniometer axis – level of ulnar styloid process
Stationary Arm – Parallel to longitudinal axis of ulna
Movable Arm – Parallel to longitudinal axis of 5th metacarpal
Stablize 4th and 5th metacarpal to keep from any deviation

26. Active Range of Motion – Ulnar and Radial Deviation
Substitution/Trick Movement
Ulnar or Radial deviation of the fingers, wrist flexion, and wrist extension

27. Passive Wrist Ulnar and Radial Deviation
Start – Sitting
Forearm resting on table in pronation
Neutral Wrist
Hand Hangs over end of table
Therapist
-Metacarpals from radial aspect (Ulnar deviation)
-Grasp metacarpals from ulnar aspect to assess radial deviation
End Feel – Ulnar Deviation  Firm
-Radial Deviation  Firm/Hard

28. Goniometer Stabilize forearm
Axis--dorsal aspect of wrist over capitate
Stationary arm-> midline of forearm
Moveable armparallel to longitudinal axis of third metacarpal

29. Average Range Of Motion
Ulnar deviation Thirty degrees
Radial deviation Twenty degrees

30. Metacarpophalangeal Flexion/Extension
Start--> Patient sitting
Forearm resting on table
Wrist in neutral position
Fingers relaxed

31. Therapist Stabilize proximal phalaynx for assessment of PIP and DIP
Grasp middle phalaynx to assess PIP or distal phalaynx to assess DIP joint
END FEELS
PIP flexion-hard/soft/firm
DIP flexion- firm
PIP extension- firm
DIP extension- firm

32. Goniometer Axis for dorsal surface of PIP or DIP (flexion)
Extension palmar surface of PIP or DIP
Stationary arm
PIP parallel to longitudinal axis of proximal phalanx
DIP parallel to longitudinal axis of middle phalanx
Movable Arm
PIP  Parallel to longitudinal axis of middle phalanx