ACTIVE RANGE OF MOTION BOX: 11.2 CAPSULAR PATTERNS FOR DISTAL UPPER EXTREMITY

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1 4 Orthopedic Assessment in Massage Therapy A B C D Figure 11.7: Finger MCP flexion (A), PIP flexion (B), DIP flexion (C), and MCP, PIP, and DIP extension (D). BOX: 11.2 CAPSULAR PATTERNS FOR DISTAL UPPER EXTREMITY Elbow Flexion more limited than extension Forearm Radioulnar joints Pronation and supination usually equally limited A B Wrist Flexion and extension equally limited. Possible slight limitation in radial and ulnar deviation Figure 11.8: Finger MCP abduction (A) and adduction (B). Fingers In the metacarpophalangeal (MCP), proximal interphalangeal (PIP), and distal interphalangeal (DIP) joints, flexion and extension occur in the sagittal plane (Figure 11.7). Movement at the MCP joint occurs as the finger is brought toward the anterior surface of the palm from anatomical position. Returning the finger to anatomical position is extension in the MCP; hyperextension is movement past full extension. Average range of motion for MCP flexion is 90 0 ; hyperextension is approximately 30 0 with more passive motion possible than active. Movement at the PIP and DIP joints occurs as the tip of the finger is brought toward the anterior surface of the palm in flexion. The finger is in full extension in anatomical position and ordinarily there is no additional range of extension available. Average range of motion for finger flexion at the PIP joint is ; average range of motion at the DIP joint is Abduction and adduction at the MCP joint occurs in the frontal plane (Figure 11.8). Abduction is different for the four fingers because finger abduction is movement away from the midline of the hand versus the midline of the body. 4 Adduction is the return to anatomical position. No range of motion values for adduction or abduction are usually calculated at the MCP joint. Capsular patterns Range of motion testing in the elbow, forearm, wrist, and hand requires evaluation at several articulations. It is important to consider the role of the joint capsule Thumb CMC joint Abduction most limited Extension limited after abduction Thumb MCP & IP joints Flexion more limited than extension Fingers MCP, PIP, & DIP joints Flexion limited most, followed by extension when assessing joint function. Pathological problems in the capsule, such as fibrosis, may be visible with the joint s capsular pattern. The capsular pattern is a pattern of movement restriction that is characteristic to each individual joint. It is present in both active and passive motion. Capular patterns are represented by a sequential listing of the movements from most likely to least likely limited. See the description of capsular patterns for this region in Box ACTIVE RANGE OF MOTION In the history, the practitioner identifies movements or positions that cause pain or discomfort. This information is used to guide more detailed evaluation of active movements using the single-plane motions described above. Active movements employ contractile tissues, while also moving inert tissues in the process. Pain during active movement indicates problems in either the contractile or inert tissues associated with that movement. Further testing with passive motion and manual resistance helps clarify the tissues at fault. When performing active range-of-motion (AROM)

2 Chapter 11 Elbow, Forearm, Wrist, & Hand 5 BOX 11.3: MUSCLE ACTIONS OF THE ELBOW, FOREARM, & WRIST Elbow Flexion Extension brachialis Triceps brachii biceps brachii Anconeus brachioradialis pronator teres extensor carpi radialis longus flexor carpi radialis flexor carpi ulnaris Forearm Pronation Supination pronator teres biceps brachii pronator quadratus supinator Wrist Flexion Extension flexor carpi radialis extensor carpi radialis longus flexor carpi ulnaris extensor carpi radialis brevis palmaris longus extensor carpi ulnaris flexor digitorum superficialis extensor digitorum flexor digitorum profundus Wrist Radial Deviation Ulnar Deviation extensor carpi radialis longus extensor carpi ulnaris extensor carpi radialis brevis flexor carpi ulnaris extensor pollicis longus extensor pollicis brevis flexor carpi radialis abductor pollicis longus evaluations, consider the position of the limb to ensure that the target tissues are engaged. For example, active elbow flexion and extension are usually evaluated with the client in a vertical (either seated or standing) position. When the client actively flexes the elbow (by lifting the forearm toward the upper arm), the elbow flexors are engaged concentrically. When the elbow returns to anatomical position it is not the elbow extensors that are responsible for the action, but the elbow flexors as they employ an eccentric contraction. Engaging the elbow extensors requires a change in body position or in the way resistance to the movement is offered. Active movement is commonly stopped near the end range of motion by stretching antagonistic muscles. Other factors that could prematurely limit active movement in this region include ligamentous or capsular damage, muscle contractures, pain from nerve compression or tension, tendinosis, tenosynovitis, fibrous cysts, or joint disorders such as arthritis. Identifying structures involved in active movement and comparing those with results from passive movement and manual resistive tests helps identify the cause of movement restriction. To perform AROM evaluations, refer to the step-by- step instructions in Chapter 3. Also review the guidelines of how to interpret the results from these tests in the same section. The muscles engaged to perform actions of the elbow, forearm, wrist, and hand are listed in Boxes Other muscles may also contribute to the motion and subsequent dysfunction. When performing the tests, motions the practitioner suspects may be painful should be reserved for the end of the evaluation process. PASSIVE RANGE OF MOTION During passive range-of-motion (PROM) evaluations inert tissues are moved, but the contractile tissues are not engaged. Pain during passive movement predominantly implicates inert tissues as the cause. Pain from contractile tissues could occur at the end range of passive movement as the antagonistic muscles are stretched, although it would be those tissues that concentrically contract in the opposite direction of the movement. Passive motion is performed after active for several reasons. When active movement is performed first, movement restrictions due to pain are established without causing additional discomfort. The client will not move

3 Chapter 11 Elbow, Forearm, Wrist, & Hand 19 Figure 11.26: The elbow flexion test. flexion of the thumb, because these are primary motions of the adductor pollicis muscle. Weakness of this muscle is more specifically tested with the Froment s sign discussed in the section on Guyon s canal syndrome. Special Tests Elbow Flexion Test The client is standing or seated and brings both elbows into full flexion with the forearms supinated and the wrists hyperextended (Figure 11.26). The client should adopt the position on both sides at the same time so a comparison with the unaffected side can be made. If symptoms are reproduced within about 60 seconds, compression of the 66, 67 ulnar nerve in the cubital tunnel is likely. Explanation: The position puts tensile stress on the ulnar nerve while decreasing space within the cubital tunnel. If the condition is present, these actions aggravate the client s symptoms. Note the similarity of this test position to the upper limb tension test #4. The variation of adding shoulder abduction makes this test more sensitive. Froment s sign See Guyon s Tunnel Syndrome. Upper limb tension test #4 See Nerve Compression and Tension Pathologies near end of chapter. Differential Evaluation Guyon s tunnel syndrome, thoracic outlet syndrome, carpal tunnel syndrome, other regions of ulnar nerve compression or tension, systemic disease, space-occupying lesions in the elbow, ligament damage in the elbow, cervical radiculopathy, myofascial trigger point referral, diabetic neuropathy, osteophytes in the elbow region. Suggestions for Treatment Relieving compression on the affected nerve is the primary goal of treatment. Encourage the client to eliminate activities that keep the elbow flexed for long periods or apply pressure to the cubital tunnel (leaning on the elbows, for example). Splints that keep the elbows in extension are helpful for people who sleep with the elbows in flexion. Even low levels of compression, if left on the nerve for long periods, can require a lengthy period of rehabilitation to restore normal function. If conservative measures are not successful, surgery is sometimes performed. A common surgical procedure involves moving the ulnar nerve to a different location so it is not compressed within the tunnel. Massage is helpful for cubital tunnel syndrome because a primary cause is muscular hypertonicity in the flexor carpi ulnaris (FCU). Techniques such as deep stripping or massage with active engagement help reduce overall tension in the muscles and decrease compression on the ulnar nerve. Particular caution should be observed in applying pressure to the flexor carpi ulnaris near the region of ulnar nerve entrapment so as not to aggravate the pathology. PRONATOR TERES SYNDROME The symptoms of pronator teres syndrome (PTS) can be identical to those of carpal tunnel syndrome because they are both peripheral median nerve compression syndromes. Some suggest that PTS is under-diagnosed because carpal tunnel syndrome has received more attention. 43 Characteristics PTS develops from compression of the median nerve by the pronator teres muscle. It is sometimes referred to as pronator syndrome. According to Wertsch, 68 the term pronator syndrome also includes median nerve compression by other structures in the elbow such as the ligament of Struthers or the bicipital aponeurosis (lacertus fibrosus). As the median nerve passes the elbow it runs between the two heads of the pronator teres muscle, where the nerve may be compressed (Figure 11.27). Compression can be due to muscle hypertonicity or fibrous bands within the muscle pressing on the nerve. 69, 70 In some cases pressure is placed on the nerve by anatomical anomalies, such as the nerve traveling deep to both heads of the pronator teres. 71 In this situation, the nerve may be compressed against the ulna by the pronator teres muscle itself. PTS results from repetitive motions that cause hypertonicity in the pronator teres. Occupational activities such as hammering, cleaning fish, or performing any activity that requires continual manipulation of tools can cause overuse of the pronator teres. 72 The hypertonicity then causes nerve compression and the symptoms are felt in the median nerve distribution in the anterior forearm and hand (Figures 11.45). Women are affected more than men, but the reason why is not clear.

4 20 Orthopedic Assessment in Massage Therapy lacertus fibrosus superficial head median nerve deep head Figure 11.27: Anterior view of the left elbow showing the two heads of the pronator teres muscle. The median nerve runs between the two heads and is compressed in this region in pronator teres syndrome. (3-D anatomy image courtesy of Primal Pictures Ltd. Most symptoms of nerve compression radiate distal to the site of compression. Aching forearm pain and paresthesia along with pain in the median nerve distribution in the hand is likely to be PTS and should not be assumed to indicate carpal tunnel syndrome. 73 In some cases, nerve compression pain can radiate proximal to the site of compression. All potential sites of compression should be considered in the differential evaluation process. 74 While PTS and carpal tunnel syndrome both affect the median nerve and have similar symptoms, there are distinct differences. PTS pain is exacerbated by repetitive elbow flexion and symptoms occur in the forearm as well as the hand. Carpal tunnel syndrome is aggravated by wrist movements and pain is not experienced as much in the forearm. In both cases, atrophy is possible in the thenar muscles of the hand, which are innervated by branches from the median nerve. The median nerve can be compressed in more than one location. There could be carpal tunnel compression and pronator teres compression simultaneously (see the double or multiple crush phenomenon described in Chapter 2). Another cause of median nerve compression near the pronator teres involves a fibrous band from the biceps brachii muscle. This band connects the distal portion of the biceps brachii to the ulna on the forearm and is called the lacertus fibrosus or bicipital aponeurosis. The median nerve runs under the lacertus fibrosus and may be compressed by it, particularly during strong repetitive contractions of the biceps brachii. 43 In some cases, pronator teres compression pathologies affect the anterior interosseous nerve (AIN) and not the median nerve. The AIN branches off the median nerve as it passes between the two heads of the pronator teres. Some authors consider AIN compression part of pronator teres syndrome, but AIN involvement is also called anterior interosseous nerve syndrome. 75 AIN syndrome rarely produces sensory symptoms because the nerve is almost exclusively composed of motor fibers. 43 If the AIN is compressed it shows up clinically as motor weakness in the index finger and thumb, making it difficult to form a pinch grip with those two digits (see description of the pinch grip test below). 76 History The client reports aching, shooting, or sharp, electricaltype pain, as well as paresthesia in the median nerve distribution of the hand. These symptoms might be felt in the anterior forearm as well. Pain is aggravated when performing activities that use the pronator teres muscle against resistance, such as using a screwdriver or hand-held power tool. 72, 77 Ask about repetitive elbow movements that aggravate symptoms. Clients with carpal tunnel syndrome often report night pain; those with PTS generally do not. 43 Prolonged wrist flexion during sleep aggravates carpal tunnel syndrome because it decreases the space in the carpal tunnel and presses on the median nerve. Because wrist flexion does not affect the pronator teres muscle, this wrist position does not increase nerve compression symptoms in PTS. Observation There are no prominent visual indicators of pronator teres syndrome. Nerve compression may cause atrophy of the forearm and hand muscles supplied by the median nerve (see Nerve Compression and Tension Pathologies at the end of the chapter for muscles supplied by the median nerve). If only one hand is symptomatic, it should be compared with the opposite side to determine differences in muscle size. The muscles of the thenar eminence (fleshy bundle of muscles on the thumb side of the hand) are likely to show signs of atrophy when compared to the unaffected side. Palpation Tenderness and hypertonicity are common in the forearm flexor muscles and the pronator teres muscle. Symptoms are aggravated when palpating the pronator teres, as pressure is increased in the region of nerve compression. Range-of-Motion and Resistance Testing AROM: Active motion without resistance rarely causes discomfort in any direction unless the condition is advanced. There may be slight discomfort at the end of active supination if the wrist is hyperextended and the supination is performed with the elbow extended. Pain or discomfort with this maneuver is due to simultaneous stretching of the pronator teres and the median nerve, which pulls the nerve taut against the dense muscular fibers. Symptoms present if active motions are performed against resistance (holding a heavy implement in the hand during motion, for example).

5 Chapter 11 Elbow, Forearm, Wrist, & Hand 21 Figure 11.28: The pronator teres test. Figure 11.29: The pinch grip test. Image shows inability to prevent the index finger DIP joint from extending during pinch grip. PROM: Passive supination can produce pain if the wrist is hyperextended and the elbow is extended, due to simultaneous stretching of the pronator teres and the median nerve. MRT: Pain might be felt during resisted pronation of the forearm and possibly during resisted elbow flexion. Weakness may be evident in the flexors of the hand or fingers, due to impairment of motor signals from the median nerve. Special Tests Pronator Teres Test The client is standing with the elbow in 90 0 of flexion. The practitioner places one hand on the client s elbow for stabilization and the other hand grasps the client s hand in a handshake position. The client holds this position as the practitioner attempts to supinate the client s forearm (forcing the client to contract the pronator muscles). While holding the resistance against pronation, the practitioner extends the client s elbow (Figure 11.28). If this motion reproduces the client s pain or discomfort there is a good chance of median nerve compression by the pronator teres. The client should keep the elbow relaxed during the test, because holding the elbow firmly in flexion will not allow elbow extension. Explanation: The pronator teres is engaged in an isometric contraction, which increases compression of the median nerve. Once the pronator teres is contracted and the elbow is extended, the contracted muscle is forcefully lengthened, producing greater potential nerve compression. Pinch Grip Test This test is specific to anterior interosseous nerve syndrome. The client firmly pinches the tips of the thumb and index finger together (Figure 11.29). If the client is unable to do this without hyperextending the DIP joint of the index finger, anterior interosseous nerve motor signals could be impaired due to proximal compression of the nerve near the elbow. This test is similar to Froment s sign, although motor signals in different nerves are tested. Explanation: The anterior interosseous nerve innervates the flexor digitorum profundus muscle that flexes the DIP joint of the index finger. This muscle is also necessary to hold the finger in a normal pinch grip without hyperextending the DIP joint. If the nerve is compressed, impaired motor signals causes muscle weakness. Differential Evaluation Carpal tunnel syndrome, other median nerve entrapment sites, cervical radiculopathy, thoracic outlet syndrome, tumors or space-occupying lesions of the anterior elbow, medial epicondylitis, medial apophysitis (little league elbow), myofascial trigger point referrals, diabetic neuropathy. Suggestions for Treatment The primary focus of treatment is reducing compression on the median nerve. If the primary pathology is hypertonicity of the pronator teres, the condition is easier to address than if there are other anatomical considerations. Massage is helpful, as it can be directly applied to the pronator teres muscle. Static compression methods are used to treat myofascial trigger point activity aggravating the surrounding muscles. Deep stripping or pin-and-stretch methods are also helpful. Traditional treatment includes splints or braces that are used to change elbow biomechanics and reduce compression on the affected nerve. Stretching methods are valuable to decrease nerve compression by improving flexibility in the pronator teres. BOX 11.9: CLINICAL NOTES Pronator teres dysfunction: The pronator teres can be a common cause of median nerve entrapment. Due to its function it may also be involved in medial epicondylitis.

6 32 Orthopedic Assessment in Massage Therapy C6 C6 medial brachial cutaneous nerve T1 radial nerve C7 C8 C5 medial antebrachial cutaneous nerve Figure 11.44: Dermatomes of the upper extremity (Mediclip image copyright, 1998 Williams & Wilkins. All Rights Reserved). lateral antebrachial cutaneous nerve General Neuromuscular Disorders A median nerve B In many cases, soft-tissue dysfunctions occur that are not given a specific name. Adequate assessment determines the most likely tissues involved and takes into account pathologies that may or may not have specific titles. The following three sections provide an overview of general soft-tissue disorders when they occur in the elbow, forearm, wrist, and hand. Chapter 4 provides a thorough discussion of the pathological process of nerve compression and tension, hypertonicity, myofascial trigger points, and muscle strains in any region of the body. Chapter 4 also includes the history, observation, palpation, and relevant tests sections of assessment for these conditions. Unique assessment procedures and/or specialized information on these conditions as they occur in the elbow, forearm, wrist, and hand are provided below. NERVE COMPRESSION & TENSION PATHOLOGIES Nerve compression or tension pathologies produce symptoms in the elbow, forearm, wrist, or hand from either a cervical radiculopathy (spinal nerve root compression) or a peripheral neuropathy (peripheral upper extremity nerve injury). There are numerous locations in the distal upper extremity where peripheral neuropathies could occur; many are discussed as discrete conditions earlier in the chapter. Other common regions where nerve compression might occur in the elbow, forearm, wrist, and hand are listed in Box Sensory symptoms from a radiculopathy may also be felt in the distal upper extremity and are experienced within the dermatome associated with that nerve root (Figure 11.44). Sensory symptoms of peripheral neuropathy are felt in the region of cutaneous innervation for the nerve affected (Figure 11.45). Peripheral neuropathies cause motor dysfunction and produce weakness in the muscles innervated by the affected nerve (Box 11.12). radial nerve C ulnar nerve Figure 11.45: Cutaneous innervation of the upper extremity in the anterior arm (A) posterior arm (B) dorsal hand (C) and palmar hand (D). BOX: REGIONS OF POSSIBLE NERVE ENTRAPMENT D radial nerve Consult Chapter 4 for a thorough discussion of what to look for in the history, observation, and palpation sections when evaluating nerve compression and tension pathologies. Radial and Posterior Interosseous Nerves The spiral groove on the posterior aspect of the humerus Under the supinator muscle in the radial tunnel Median and Anterior Interosseous Nerves Under the bicipital aponeurosis (lacertus fibrosus) Beneath the Ligament of Struthers The carpal tunnel Ulnar Nerve In the cubital tunnel In Guyon s tunnel

7 Chapter 11 Elbow, Forearm, Wrist, & Hand 33 BOX: MUSCLES INNERVATED BY THE RADIAL, MEDIAN, & ULNAR NERVES Radial Nerve Main Trunk Brachialis Triceps brachii Anconeus Brachioradialis Extensor carpi radialis longus Posterior Interosseous Branch Supinator Extensor carpi radialis brevis Extensor digiti minimi Extensor carpi ulnaris Extensor digitorum Extensor indicis Abductor pollicis longus Extensor pollicis brevis Extensor pollicis longus Median Nerve Main Trunk Flexor carpi radialis Pronator teres Palmaris longus Flexor digitorum superficialis Abductor pollicis brevis Opponens pollicis Flexor pollicis brevis (superficial head) Lumbricales (1st & 2nd) Anterior Interosseous Branch Flexor pollicis longus Flexor digitorum profundus (lateral part) Pronator quadratus Ulnar Nerve Ulnar nerve Adductor pollicis Abductor digiti minimi Opponens digiti minimi Flexor digiti minimi brevis Flexor digitorum profundus (medial part) Flexor carpi ulnaris Lumbricales (3rd & 4th) Palmaris brevis Palmar interossei Dorsal interossei Flexor pollicis brevis (deep head) Range-of-Motion and Resistance Testing AROM: Active movement may produce pain if the affected nerve is stretched. In some cases movements may also compress the nerve causing exacerbation of symptoms. Consider the biomechanics of each motion and how it affects the nerve being evaluated. PROM: The same principles apply as for active motion. MRT: In nerve compression or tension pathologies, the affected nerve causes weakness in the muscles it innervates. Manual resistive tests evaluate muscle strength and are important for determining weakness levels in nerve pathologies. Depending on the location of the compression pathology, weakness may be apparent in some or all of the muscles innervated by the affected nerve. The more proximal the compression site, the greater the number of muscles affected (Figure 11.46). A list of primary upper extremity motor nerves and the muscles they innervate is provided in Box Table 1 at the end of the chapter provides a chart of muscles, their resisted actions, and potentially affected nerves or nerve roots. Distal end of nerve Muscle 2 Muscle 3 Muscle 1 Compression Site B Proximal end of nerve Compression Site A Figure 11.46: Muscles affected by different regions of nerve compression. If compression occurs at Site A, muscles 1, 2, & 3 are affected. If it occurs at Site B, only muscles 2 and 3 are affected. Special Tests Upper limb tension tests (ULTTs) evaluate symptoms in neural tension or compression pathologies. There are four common ULTTs; the first two test the median nerve, the radial is tested by the third, and the fourth tests the ulnar. The numbering of these tests is not consistent in medical texts; in this text they are numbered ULTT 1 4. To avoid confusion in treatment notes, identify the ULTT used by the nerve being stressed during the test. For example, treatment notes might state, ULTT #2 with median nerve bias. General instructions: The practitioner performs a series of movements that gradually increase tension on the nerve. Symptoms, if present, will increase as movements are added. Movements are performed in the order listed with each test. During testing, ask the client about changes in symptoms after each movement. Once the client experiences symptoms, it is not necessary to complete the remainder of the movements, especially if the symptoms are strong. Upper Limb Tension Test #1 (Median nerve bias) The client is in a supine position. The practitioner stands facing the client s head on the testing side. The client s elbow is flexed at the beginning of the test. The final position of the shoulder in ULTT #1 is contraindicated if shoulder instability is present (Figure 11.47) Test Movements 1. Shoulder is brought into depression. 2. Arm is abducted to about Forearm is supinated. 4. Wrist and fingers are hyperextended. 5. Shoulder is laterally rotated. 6. Elbow is extended. 7. Neck is contralaterally flexed.

8 36 Orthopedic Assessment in Massage Therapy A B C D E F G H I J K L M N Figure Myofascial trigger point referral patterns: Biceps brachii (A), Brachialis (B), Brachioradialis (C), Extensor carpi radialis brevis (D), Extensor carpi radialis longus (E), Extensor carpi ulnaris (F), Extensor digitorum (G), Supinator (H), Flexor carpi radialis (I), Flexor carpi ulnaris (J), Flexor digitorum profundus & superficialis (K), Flexor pollicis longus (L), Palmaris longus (M), Pronator teres (N). (Images courtesy of Mediclip, copyright 1998 Williams & Wilkins. All rights reserved)..

9 Chapter 11 Elbow, Forearm, Wrist, & Hand 37 A B C Figure Myofascial trigger point referral patterns: Triceps brachii (A, B), Adductor pollicis (C). (Images courtesy of Mediclip, copyright 1998 Williams & Wilkins. All rights reserved).. TABLE 1: WEAKNESS WITH MANUAL RESISTIVE TEST POSSIBLE NERVE INVOLVEMENT MUSCLE RESISTED ACTION POSSIBLE NERVE INVOLVEMENT IF ACTION WEAK Abductor pollicis brevis thumb abduction median (C7-C8) Abductor pollicis longus thumb abduction radial (C7-C8) Adductor pollicis thumb adduction ulnar (C8-T1) Anconeus elbow extension radial (C6-C8) Biceps brachii elbow flexion musculocutaneous (C5-C6) Brachialis elbow flexion musculocutaneous (C5-C6) Brachioradialis elbow flexion radial (C5-C6) Extensor carpi radialis brevis wrist extension radial (C7-C8) Extensor carpi radialis longus wrist extension radial (C6-C7) Extensor carpi ulnaris wrist extension radial (C7-C8) Extensor digitorum finger extension (MCP joint) radial (C7-C8) Extensor pollicis brevis thumb extension radial (C7-C8) Extensor pollicis longus thumb extension radial (C7-C8) Flexor carpi radialis wrist flexion median (C6-C7) Flexor carpi ulnaris wrist flexion ulnar (C7-T1) Flexor digitorum profundus finger flexion (DIP joint) median (C8-T1) Flexor digitorum superficialis finger flexion (PIP joint) median (C8-T1) Flexor pollicis longus thumb flexion median (C7-C8) Palmaris longus wrist flexion median (C7-C8) Pronator quadratus forearm pronation median (C7-C8) Pronator teres forearm pronation median (C7-C8) Supinator forearm supination radial (C6-C7) Triceps brachii elbow extension radial (C6-C8)

10 38 Orthopedic Assessment in Massage Therapy TABLE 2: JOINTS, ASSOCIATED MOTIONS, PLANES OF MOTION IN ANATOMICAL POSITION, AXIS OF ROTATION, AND AVERAGE RANGE OF MOTION Joint Motion Plane of Motion Axis of Rotation Avg. ROM (degrees) Elbow Flexion Sagittal Medial-lateral 150 Extension Sagittal Medial-lateral * Forearm Pronation Transverse Vertical 80 Supination Transverse Vertical 80 Wrist Flexion Sagittal Medial-lateral 80 Extension Sagittal Medial-lateral 70 Radial Deviation Frontal Anterior-posterior 20 Ulnar Deviation Frontal Anterior-posterior 30 Thumb (CMC) Flexion Frontal Anterior-posterior 15 (CMC & MCP) Extension Frontal Anterior-posterior 20 (CMC & MCP) Abduction Sagittal Medial-lateral 70 (CMC & MCP) Adduction Sagittal Medial-lateral * Thumb (MCP) Flexion Frontal Anterior-posterior 15 (CMC & MCP) Extension Frontal Anterior-posterior 20 (CMC & MCP) Abduction Sagittal Medial-lateral 70 (CMC & MCP) Adduction Sagittal Medial-lateral * Thumb (IP) Flexion Frontal Anterior-posterior 80 Extension Frontal Anterior-posterior * Finger (MCP) Flexion Sagittal Medial-lateral 90 Extension Sagittal Medial-lateral 30 Abduction Frontal Anterior-posterior * Adduction Frontal Anterior-posterior * Finger (PIP) Flexion Sagittal Medial-lateral 100 Extension Sagittal Medial-lateral * Finger (DIP) Flexion Frontal Anterior-posterior Extension Frontal Anterior-posterior * *Average range-of-motion values are either 0 or not usually calculated

11 Chapter 11 Elbow, Forearm, Wrist, & Hand 39 TABLE 3: QUICK REFERENCE TABLE FOR CONDITION ASSESSMENT AROM PROM MRT Elbow flexion test Finklestein test Froment s sign Golfer s elbow test Phalen s test Tennis elbow test Tethered median nerve stress test Tinel s sign ULTT #1 ULTT #2 ULTT #3 ULTT #4 Pinch grip test Pronator teres test Carpal Tunnel Syndrome Cubital Tunnel Syndrome De Quervain s Tenosynovitis Ganglion Cyst Guyon s Canal Syndrome Lateral Epicondylitis Medial Epicondylitis Muscle Strains Muscular Hypertonicity Nerve Compression & Tension Olecranon Bursitis Pronator Teres Syndrome Radial Tunnel Syndrome Trigger Finger Notes 1. Cyriax J. Textbook of Orthopaedic Medicine Volume One: Diagnosis of Soft Tissue Lesions. Vol 1. 8th ed. London: Bailliere Tindall; Hislop H, Montgomery J. Daniels and Worthingham s Muscle Testing. Philadelphia: W.B. Saunders; Berryman Reese N, Bandy WD. Joint Range of Motion and Muscle Length Testing. Philadelphia: W.B. Saunders Co.; Neumann DA. Kinesiology of the Musculoskeletal System. St. Louis: Mosby; Kendall F, Kendall-McCreary E, Geise-Provance P. Muscles: Testing and Function. 4th ed. Baltimore: Williams & Wilkins; Shaffer K, Shaffer J. Dupuytren Contracture. emedicine [web page] Available at: Accessed February 7, Ravid M, Dinai Y, Sohar E. Dupuytren s disease in diabetes mellitus. Acta Diabetol Lat. May-Aug 1977;14(3-4): Attali P, Ink O, Pelletier G, et al. Dupuytren s contracture, alcohol consumption, and chronic liver disease. Arch Intern Med. Jun 1987;147(6): Burge P, Hoy G, Regan P, Milne R. Smoking, alcohol and the risk of Dupuytren s contracture. J Bone Joint Surg Br. Mar 1997;79(2): Benson LS, Williams CS, Kahle M. Dupuytren s contracture. J Am Acad Orthop Surg. Jan-Feb 1998;6(1): McFarlane RM. On the origin and spread of Dupuytren s disease. J Hand Surg [Am]. 2002;27(3): Zerajic D, Finsen V. Dupuytren s disease in Bosnia and Herzegovina. An epidemiological study. BMC Musculoskelet Disord. Mar ;5(1): Silman AJ, Pearson JE. Epidemiology and genetics of rheumatoid arthritis. Arthritis Res. 2002;4 Suppl 3:S Gabriel SE, Crowson CS, O Fallon WM. The epidemiology of rheumatoid arthritis in Rochester, Minnesota, Arthritis Rheum. Mar 1999;42(3): Lee DM, Weinblatt ME. Rheumatoid arthritis. Lancet. Sep ;358(9285): Rattray F, Ludwig L. Clinical Massage Therapy: Understanding, Assessing and Treating over 70 Conditions. Toronto: Talus Incorporated; Neumeister M, Nguyen M. Rheumatoid Hand. emedicine [web page] Available at: