Upper Extremity Range of Motion: Case Study and Assessment

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 Forearm Pronation -Pronator Teres -Pronator Quadratus • Muscles for Supination of Forearm • Supinator

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 • 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 MotionSupination/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