Introduction to Palpation

I. Introduction
a. Professional touch, examination by touch
b. Used to identify anatomical structures
c. Clinical: to identify find tissue changes (texture, tension, swelling), pain
i. Body Landmarks
1. Harder tissue
ii. Muscle
1. Softer & pliable
2. Ask patient to contract when palpating
iii. Tendon
1. Muscle to bone
2. Firm, round and moveable structure
3. Deeper than muscles
4. Ask the patient to contract the muscle or move the structure
iv. Ligament
1. Bone to bone
2. Flat or round, depends on the ligament
1. MCL flat structure of the knee
2. LCL round structure of the knee
ii. Nerves
a. Some can be palpated (ulnar nerve)
b. Feels similar to tendon but can give a tingling/numbing sensation distal
to patient
iii. Arteries
a. Soft and pliable, can feel it pulsating
II. Clinical Pearls
a. Patient Position
i. Comfortable
b. Flat fingers; one finger to isolate the structure for exam
i. Gently but with enough pressure to feel structure underneath
b. Depth of the structure
c. Isolate the structure
II. Palpation
a. By continuous practice and thinking hard through the fingers,
i. In other words, concentrating upon the sensations of tissue tension observed from
the fingers
b. It is possible to acquire an understanding and working knowledge of the elusive quality
of the manipulative skill, tissue tension sense
i. Stoddard, 1959. Manual of Osteopathic Technique
II. Palpation Continued
a. Palpation is an art
i. Feeling subtle changes in tension
ii. Response of tissues to your testing and treatment
iii. Recognizing what is tender before patient reports it as such
b. Most PT have the ability to feel normal from abnormal
c. Practice practice, practice
i. Practice with lateral border of middle finger, the MCP from side to side
b. Practice Palpating
i. Quarter, nose of George Washington
ii. Radial pulse, vary pressures to determine most ideal
 iii. Needle under several pages of newspaper
iv. Hair between book pages feel outline and position
II. Palpation Scientific Difficulties
a. Subjective
i. Entirely private, presents difficulty with presentation
ii. Cannot be performed by two people at same spot at same time
iii. Accuracy to locate exact location and tenderness in soft tissue and body
landmarks varies from poor to excellent (refer to future power point on
measurement validity and reliability)

Cervical Spine
I. Lecture 1 Content Objectives
a. Name the main bones and muscles of the skull and cervical spine
b. Describe the bones of the cervical spine with its main bone landmarks
c. Describe the main muscles of the cervical spine
d. Describe the main ligaments of the cervical spine
e. Describe the main nerve roots of the cervical spine with its dermatomes and myotomes
f. Describe the sensory innervation of the head and neck
g. Describe the main blood vessels of the neck
II. Bones of the Skull (neurocranium)
a. The skull has 8 Bones
i. Ethmoid (1)
ii. Frontal (1)
iii. Occipital (1)
iv. Parietal (2)
v. Sphenoid (1)
vi. Temporal (2)
b. The skull protects the brain and the organs of vision, taste, hearing, equilibrium, and
smell. The skull provides attachments for muscles that move the head/neck and control
facial expressions and chewing
c. Cranial bones are commonly palpated after trauma for signs of fracture (deformities and
edema)
d. For surface anatomy, the relevant bones to be aware and palpate are the:
i. Frontal
ii. Occipital
iii. Temporal
iv. Sphenoid
v. Parietal
b. Acute and recent deformities may indicate a fracture. Severe tenderness and swelling
may also indicate a fracture
c. The skull has several joints called sutures. Sutures have little, if any, movement in
neonates and small children. In adults, they fuse and no longer move. Gaping of the
sutures in small children may indicate pathology like hydrocephaly.
d. Fontanels
i. Spaces between cranial bones filled with membranes, it provides pliability for the
skull in childbirth. Bone growth eventually fills the spaces by age two.
II. The Spine: Cervical
a. The spine has 33 vertebrae, the vertebrae from the mechanical framework of the spine.
i. 7 Cervical
ii. 12 Thoracic
iii. 5 Lumbar
 iv. 5 Sacral
v. 3 5 Coccygeal
b. The vertebrae protect the spinal cord and nerve roots, provide stability for body weight
and flexibility for movements of the spine and extremities.
c. In embryonic life, the spine only has one curvature, a convexity posteriorly and concavity
anteriorly.
d. When a child, it develops four distinct curvatures:
i. Cervical lordosis
ii. Thoracic kyphosis
iii. Lumbar lordosis
iv. Sacral kyphosis
b. The bones of the spine change shape and help mold these curvatures. The curvatures
help the spine absorb load (as a shock dampener, when loaded) partially because of their
curvatures.
II. The Cervical Spine
a. We refer to the cervical vertebra by numbers (C1 to C7). They are numbered from
cranial to caudal direction.
b. The typical cervical spine segment (C2-3, C3-4, C4-5, C5-6, C6-7) consist of:
i. 2 vertebrae
ii. 1 disc
iii. 4 facets (joint surfaces)
b. A typical cervical vertebra consists of:
i. 1 spinous process
ii. 1 vertebral body
iii. 2 transverse processes
iv. 2 pedicles
v. 4 facts (2 superior and 2 inferior)
b. The cervical spine has two atypical vertebrae:
i. Atlas (C1)
ii. Axis (C2)
b. The atlanto-occipital and atlanto-axial joints do not have a disc.
c. Atlas (C1) does not have a spinous process (SP). Axis (C2) has an odontoid process
(dens) that serves as the pivot point for 50% of the rotation of the cervical spine.
d. From C2 to C7, the spinous processes are bifid, short and stout
e. Unlike the vertebra in other parts of the spine, the transverse processes (TP) of the
cervical spine has 2 foramina for the vertebral artery, these protect the blood supply of the
brain. The TP also serve as location for muscle attachment.
II. Cervical Segment
a. Typical
i. Pedicles
1. Unite the vertebral body with the articulating surfaces.
ii. Lamina
1. Unite the articulating surfaces with the spinous process
1. Articulating surfaces belong to the facet joints or zygapophyseal
joints
b. Atypical
i. Atlas and Axis bone anatomy
ii. Upper cervical spine joints, anterior cut with anterior arch of atlas and anterior
part of occiput removed
II. Typical Thoracic Vertebra
 a. The thoracic spine also has atypical vertebrae with several articulating surfaces for the
ribs.
i. Distinguished by the presence of facets on the sides of the bodies for articulation
with the heads of the ribs, and facets on the transverse processes
II. Ligaments of The Spine
a. The function of the ligaments is to restrict mobility and provide stability.
i. They may modify and guide intervertebral movements
b. With the exception of the ligament flavum (or flava for plural) with about 70% elastic
fibers, the ligaments are mostly composed of collagen Type I fiber with design for
stiffness rather than flexibility.
c. Several spine ligaments run from the cervical to the lumbar spine:
i. Anterior longitudinal
ii. Posterior longitudinal
iii. Ligament Flava
iv. Interspinous ligaments
v. Supraspinous ligaments (replaced by the ligament nuchae in the cervical spine)
II. Ligaments Unique to Cervical Spine
a. The cruciform (apical and transvers bundles) and the alar ligament together with the
tectorial membrane are the main responsible to maintain the stability of the upper cervical
spine (occiput-atlas-axis).
b. The transverse portion of the cruciform ligament is perhaps the most important ligament
to maintain the odontoid process (Dens) in check during movements of flexion and
extension of the neck
II. Muscle of The Cervical Spine
a. Muscles are not often thought of as primary source of back and neck pain; however, they
often contribute to spine pain when dysfunctional
i. Good strength may prevent spine pain
b. Spine muscles may be grossly divided into:
i. Global (Superficial or extrinsic)
a. Tend to be large and balkier
b. Mainly responsible for movement
ii. Local (Deep or intrinsic)
a. Small or thin
b. Participate in the feedforward muscle activity to stabilize the spine prior
to limb movement and to protect spinal structures
b. Platysma
i. More a facial expression muscle than a stabilizer or mover
b. In physical therapy, soft tissue mobilization is often used to reduce muscle tenderness and
tension. In addition, exercises are often used to address weakness and improve spine
stability
II. Global (Superficial) Muscles of the Neck
a. Trapezius
b. Sternocleidomastoid
c. Platysma
II. Local (Deep) Muscles of the Neck
a. Anterior
i. Longus Capitis
ii. Longus Colli
iii. Scalenes
a. Anterior Scalene
b. Middle Scalene
 c. Posterior Scalene
iv. Rectus Capitis Anterior
v. Rectus Capitis Lateralis
b. Posterior
i. Rectus Capitis Posterior Minor
ii. Rectus Capitis Posterior Major (Suboccipital Triangle)
iii. Obliquus Capitis Superior (Suboccipital Triangle)
iv. Obliquus Capitis Inferior (Suboccipital Triangle)
v. Multifidus
b. The vertebral artery, suboccitial nerve, and the suboccipital venous plexus pass through
the suboccipital triangle
II. Key Points to Remember
a. The cervical spine has 7 segments with 7 vertebrae (2 atypical and 5 typical)
b. The vertebrae have a body, a spinous process, a transverse process, 2 laminae, and 2
pedicles
c. The spine has ligaments that run from the cervical spine to the sacrum and ligaments
located only in the cervical spine
d. The main function of the ligaments is to stabilize the spine
e. The cervical spine has muscles divided into superficial and deep.
i. Superficial (Global) muscles main job is to move the joints
ii. Deep (Local) muscles is to stabilize the spine

The Innervation of The Cervical Spine

I. In addition to the seven cervical vertebrae, the cervical anatomy features eight cervical nerve
roots (C1-C8) that branch from the spinal cord and control motor and sensory abilities for
different parts of the upper body.
II. The Nerve Supply of The Cervical Spine and Head
a. The nerve roots (spinal nerves) originate from several levels of the spinal cord and branch
out into nerve plexuses and then into peripheral nerves
b. When nerves are injured, sensory and motor disturbance will depend on the location of
the injury in the body (root, plexus, or peripheral nerve)
c. Nerve injury may cause sensory disturbance (anesthesia, paresthesia) and/or motor
disruption (paresis, paralysis)
d. In addition, when nerves are inflamed, because of mechanical friction or medical disease
(diabetic neuropathy), patients may perceive pain in the skin area supplied by the sensory
nerve root, the sensory nerve plexus, or the sensory peripheral nerve
e. Chronic nerve inflammation may lead to hypersensitivity and allodynia (pain with touch)
in the skin area supplied by the affected sensory nerve
f. Dermatome
i. A skin area innervated by the sensory fibers of a single nerve root

g. Myotome
 1.A group of muscles primarily innervated by the motor fibers of a single nerve
root
Myotomes Movement Muscles
C1-2 Neck flexion Anterior superficial/deep neck muscles
C3 Neck side flexion Longus capitis and cervicis, trapezius (upper fibers),
scalenus medius
C4 Shoulder elevation or scapular Trapezius (upper fibers) or lavator scapulae
elevation
C5 Shoulder abduction or external Deltoid, supraspinatus, infraspinatus
rotation
C6 Elbow flexion or wrist Biceps/brachialis, wrist extensors
extension
C7 Elbow extension or wrist Triceps, wrist flexors
flexion
C8 Thumb extension or ulnar Extensor pollicis longus, extensor pollicis brevis, ulnar
deviation deviators
T1 Hand intrinsics Adductors and abductors of the digits
III. The Blood Supply of The Cervical Spine and Head
1. Arch of the aorta has 3 branches:
1. Brachiocephalic artery
1. Divides into the right common carotid artery and the right subclavian
artery
2. Left common carotid artery
3. Left subclavian artery
ii. These arteries provide blood to both arms, the cervical spine, and the head
iii. Vertebral Arteries
1. Right and left arise from the subclavian artery
2. Run upward almost vertically inside the foramina of the transverse processes of
C6 to C2.
3. After reaching the foramen of the C2, they curve backward behind the superior
articular process of the atlas uniting to form the basilar artery
ii. Lesion to any of the above arteries or their branches may lead to stroke and spinal cord
lesion
iii. In physical therapy
1. Palpation of the carotid artery is often performed to access heart rate and blood
supply to the brain
2. Temporal artery (branch or external carotid) may be palpated to access heart rate
in infants or in differential diagnosis of headache to rule out arteries
3. Vertebral artery injury or occlusion may occur during spine manipulation,
cervical traction, and exercises
III. Key Points to Remember
a. The cervical spine has 8 nerve roots
b. Each nerve root has a sensory and a motor component
c. The nerves of the cervical spine supply the sensation and motor function of the muscle of
the upper extremities
d. A skin area innervated by the sensory fibers of a single nerve root is known as a
dermatome
e. A group of muscles primarily innervated by the motor fibers of a single nerve root is
known as a myotome
Clinimetrics of Tests & Measures in Physical Therapy Practice
I. Objectives
a. Define & Describe Clinimetrics
b. Discuss why clinimetrics is important in clinical practice
c. Discuss what makes a good test/measure
d. Discuss the basic constructs of reliability and validity
e. Compare the tenets of diagnostic validity:
i. Sensitivity
ii. Specificity
b. Discuss the meaning of Minimum Detectable Change (MDC)
II. Clinimetrics
a. The science of clinical measurements
i. It uses indexes (MDC) and scales to describe or measure symptoms, physical
signs and other clinical phenomena (Gait, Disability)
ii. It has a set of rules that help clinicians choose tests and measures to make clinical
decisions
b. Am I getting the results I should during my examination?
i. Accurate (no measurement error)
ii. Reliable (reproducible)
iii. Valid (measure what it is supposed to)
II. Reliability (Good Decision is Based on Good Measures!)
a. Reliability
i. Consistency of measurements
b. A reliable test will produce similar results across various conditions including different
testers and different environments
i. Intra-rater reliability
1. Examiner is able to reproduce his/her results overtime (hours, days)
ii. Inter-rater reliability
1. Two or more examiners are able to reproduce their results overtime
(hours, days)
II. Valid = True (Good Decision is Based on Good Measures!)
a. Validity
i. Each time a test/measure is performed we must understand how the results of the
test compare with the truth.
ii. An instrument is valid if it measures what it is supposed to measure
b. For concurrent validity, the method is often compared to a gold standard instrument
i. Manual radial pulse assessment is compared to EKG heart monitor
ii. Manual Muscle Test is compared to Muscle Test with Isokinetic Dynamometry
b. For diagnostic validity, the test is performed in subjects with and without confirmed
diagnoses and the truth verified
c. A valid instrument is always reliable (accuracy requires consistency), but a reliable
instrument may not be valid.
d. Quantitatively, we can use numbers to say if a test has good or bad reliability and validity
0.10 0.25 0.50 0.75 0.90
Very Poor Poor Acceptable Good Excellent
V. Palpation Reliability & Validation Studies
1. Inter-rater reliability Palpation of PSIS on iliac crest
1. 0.27 (poor). Cooperstein et al, 2016
ii. Inter-rater reliability Muscle Trigger points (symptomatic & asymptomatic tenderness)
1. Location of tenderness 0.18 to 0.60 (poor to moderate) depending on muscle (6
different muscles in total). Bron et al 2007.
 ii. Validity of Palpation Trans Process (C1)
1. Validation done with imaging test as gold standard.
2. 0.57 to 0.90 (acceptable to excellent). Copperstein et al, 2015.
V. Diagnostic Validity
a. Sensitivity (SnNout)
i. Ability of the test to identify correctly affected individuals
ii. Proportion of persons testing positive among affected individuals
1. True Positive Rate: A / A + C
b. Specificity (SpPin)
i. Ability of the test to identify correctly non-affected individuals
ii. Proportion of person testing negative among non-affected individuals
1. True Negative Rate: D / D + B
Disease or Injury Present Absent
Positive Test A B
Negative Test C D
c. Sensitivity Calculation
1. Ex: Sensitivity of sharp-dull test to detect sensory loss
2. Population 200 pts with diabetes, 100 pts have sensory loss and 100 do not
1. 31 pts test positive from 100 patients with sensory loss.
2. Sensitivity: 31 / 31 + 69 = 0.31 (Sensitivity is poor < 0.50)
3. Conclusion: Sharp-dull test only confirms the presence of sensory loss
in 31% of patients, it fails in 69% of all cases
iii. Specificity Calculation
1. Ex continued: Sharp-dull for sensor loss
2. Population 100 patients with diabetes and normal sensation
1. 16 positive tests out of 100 pts normal sensation
2. Specificity: 84 / 84 + 16 = 0.84 (good specificity > 0.84)
3. Sharp-dull test confirms the absence of sensory loss in 84% of all cases
and only identifies sensory loss incorrectly in 16% of all cases.
4. Conclusion: The test is useful when positive, not when it is negative.
Diabetes 100 Patients (pts) with Sensory 100 Patients (pts) with Normal
Loss Sensation
Positive Sharp-dull 31 patients 16 patients
test
Negative Sharp-dull 69 patients 84 patients
test
The Test must be Positive for sensitivity Negative for specificity
Use in the clinic Rule out Rule in
Calculation Sensitivity = 31/100 or 0.31 Specificity = 84/100 or 0.84
VII. Measurement Error & Minimum Detectable Change (MDC)
1. Standard error of measurement (SEM): amount of error one consider measurement error
1.SEM = Standard Deviation x (1-reliability [ICC])
ii. Minimum Detectable Change: the minimum amount of change that is not considered
measurement error.
1. MDC90 = Z-score (1.65, 90% CI) x SEM x 2
2. MDC95 = Z-score (1.96, 95% CI) x SEM x 2
ii. Example 2: Patient with Knee OA
1. Mr. JH, 55 y/o male
2. Evaluation day
1. R Knee flexion 90 & Extension -10 (PROM)
 3. Two weeks after intervention
1. R Knee flexion 100 & Extension -5
4. Patient Progress
1. Is the 10 gain considered real improvement for flexion and -5 real
gain for knee extension?
ii. Example 2: Continued, Stratford et al, Physiotherapy Canada, 2010
1. Intra-rater reliability for Knee ROM
1. 74 pts with knee OA
2. Flexion Test-Retest reliability 0.84 (ICC)
3. Extension Test-Retest reliability 0.60 (ICC)
2. Standard Error (SEM)
1. Knee flexion 4.1
2. Knee extension 2.7
3. MDC90
1. Knee flexion: 9.6
2. Extension: 6.3
ii. Example 2: Discussion
1. Flexion went from 90 to 100 = 10
1. The 10 knee flexion (>9.6) was real improvement
2. Extension went from -10 to -5
1. The -5 knee extension was measurement error (<6.3)
VII. Key Summary Points
a. Clinimetrics provides a frame for clinical decision making & judgment
b. Good clinical-decision making is based on accurate, reliable, and valid measures
c. A diagnostic test or measurement have little or no meaning without validity
d. Meaningful test scores should exceed the MDC90 of the tool or instrument utilized

Deep Tendon Reflex & Sensory Testing

I. Discuss sensory testing and Deep tendon Reflex Testing in PT Practice
a. Techniques
b. Indications
c. Validity (sensitivity & specificity)
d. Interpretation and documentation
II. Sensory Testing
a. Motor learning and movement performance are intrinsically related to sensation
b. The body used sensory input to guide out actions (motion, feelings, danger/safety).
c. Sensory input comes mainly from neuroreceptors: mechanical (pressure, speed,
vibration), temperature, and chemical.
d. Today, we will be dealing mostly with examination of mechanical receptors located
mainly on the skin.
e. We will discuss light touch, dull-sharp, and vibration examination
II. Indications for Sensory Exam
a. When to perform sensory Tests?
i. Light touch and vibration may be used to rule in or rule out sensory loss:
1. Patients with spinal disorders or spinal pain (observe dermatomes as
indicated).
2. Patients with suspected nerve lesions
3. Suspicion of or diagnosis/symptoms of CVA (cerebrovascular accident,
stroke) and SCI (spinal cord injury)
4. Patients at risk for pressure sores
ii. Sharp & Dull
 1. Rule in or confirm risk for pressure sores and burn (e.g.; neurological
lesions or diabetic patients)
II. Light Touch Testing
a. Screen skin with piece of cotton, tissue, or paper
b. Patient should have eyes closed during test
c. Touch is very light
d. Cover dermatomes and peripheral nerve areas as appropriate
e. Move from distal to proximal and compare bilaterally
f. Mix stimuli for patients (touch and no-touch)
g. Light touch with monofilaments (fishing line for example)
i. Monofilaments are the gold standard for light touch assessment
ii. Start with lightest filament and press lightly until filament bends
iii. If patient does not recognize touch, use next thicker filament on scale
iv. Score filament number or color when recognized. (repeat 3 times and use average
score)
II. Vibration with Tuning Fork
a. 128 Hz is said to be the best frequency (256 Hz is acceptable)
b. Have the patient close the ears to prevent auditory clues
c. Hold the stem of the tuning fork
d. Hit the prongs of the fork on your thigh, hip, opposite hand, or a hard surface
e. Touch the non-vibrating tip of the fork on a bony landmark of the extremity to be tested
f. Time how long it takes for person to stop feeling the vibration
g. Compare to opposite side (perform bilaterally)
II. Sharp/Dull
a. Use appropriate tool (example: paper clip for sharp, and rubber end of pencil for dull)
b. After demonstrating to patient, ask patient to keep eyes closed during test
c. Touch is very light
d. Test along dermatomes and peripheral nerve areas as appropriate
e. Ask patient to indicate sharp or dull to determine response
f. Move from distal to proximal
g. Compare to opposite side (perform bilaterally)
II. Deep Tendon Reflex Testing
a. Reflex Integrity
i. A deep tendon reflex (DTR) is a involuntary, predictable, and specific response to
a stimulus dependent on a reflex arc (sensory receptor, afferent neurons, efferent
neurons, and muscle)
b. Indications (screen motor/sensory integrity)
i. Every spine patient
ii. Insidious symptoms of unknown etiology
iii. Chronic condition not making progress
iv. Symptoms of muscle fatigue/weakness
v. Suspicion of central nervous system (CNS) or peripheral nervous system (PNS)
compromise
b. DTRs Technique
i. Use the same force for every hit. Flick the wrist.
ii. Avoid hitting the tendon more than three times
iii. Palpate & place tension on tendon before hitting it
iv. When having difficulty to elicit a reflex, have the patient look away, tighten
muscles away from tendon being tested, and/or test patient in supine (better
relaxation)
b. DTRs Interpretation
 i. Compare bilaterally
ii. When interpretation of response is questionable, compare upper extremity (UE)
with lower extremity (LE)
b. Documentation & Scoring
i. Absent or +1 may indicate nerve PNS lesion (nerve) or recent CNS lesion
(stroke, spinal cord)
ii. 2+ is normal
iii. 3+ maybe be normal or indicate CNS dysfunction
iv. 4+ and bizarre response = CNS culprit
b. Upper Extremity
i. Deltoid (C5)
ii. Biceps & Brachio-radialis (C6)
iii. Triceps (C7)
II. Key Points to Remember
a. Weak DTR may indicate PNS injury (or recent CNS lesion < 8 12 weeks)
b. Hyper DTR may indicate CNS lesion
c. DTRs Testing is useful to assist in diagnosis
d. The sensory exam described here is done to make a diagnosis and assess risk for injury
e. Light touch testing with monofilament is the best method for testing and documenting
sensory loss (compared to tuning fork and sharp vs. dull).

Muscle Length And Endfeel Assessment

I. Objectives
a. Define Terminology Associated with Muscle Length and Mobility
b. Compare one-joint muscle length assessment versus two-joint
c. Discuss endfeel assessment in clinical practice
d. Compare normal endfeel with abnormal endfeel
e. Compare active versus passive insufficiency
II. Terms Associated with Mobility
a. Contracture is a significant shortening of the muscle or periarticular tissues surrounding a
joint
b. Types of Contractures:
i. Myostatic
1. Reduction in sarcomeres in series
ii. Pseudomyostatic
1. Neurological (spasticity or hypertonicity) rather than muscular
iii. Arthrogenic or Peri-articular
1. Caused by the muscle/capsule/ligament & intra-articular adhesions
iv. Fibrotic
1. Severe tissue rigidity associated with fibrosis (permanent alteration of
connective tissue, increased crosslinks plus stronger chemical bounds
between collagen fibers)
b. Hypermobility
i. Range of motion above the expected normal for the joint
ii. Capsule and periarticular ligaments are often intact and the muscles often can
dynamically control the excessive motion
iii. Symptoms may or may not be present
b. Instability
i. Similar to hypermobility; however, the capsule and periarticular tissues are
damaged and the muscles often are not able to control the excessive motion
ii. Cartilage degeneration is likely to occur over time
 iii. Softer endfeel where firmer endfeel is expected
iv. Symptoms are common
b. Muscle Length
i. Maximal distance between proximal and distal attachment of a muscle
ii. Measured by determining the PROM motion of the joint(s) crossed by the muscle
1. Goniometer
2. Functional test (often with a tape measure)
b. Muscles may be:
i. Mono-articular
1. Cross one joint
ii. Bi-articular
1. Cross two joints
iii. Multi-articular
1. Cross several joints
b. Functional Muscle Length Test
i. Apley scratch test
1. Patient attempts to touch the opposite scapula to test range of motion of
the shoulder.
2. Testing abduction and external rotation
3. Testing adduction and internal rotation
b. Mono-articular Muscle Length Lateral Head of Triceps Brachial
i. True mono-articular muscle length is more challenging to measure than bi-
articular because of the role that other connective tissue play to limit ROM:
1. Lateral and medial head of triceps with long head shorted at the shoulder
2. Soft tissue approximation or bone to bone contact may prevent muscle
length measurement in normal subjects
II. Endfeel Assessment
a. End-feel analysis tells the therapist the structure stopping/blocking the movement
b. Normal end-feel and examples
i. Bone to bone (sudden stop, no resistance build up)
1. Elbow extension
ii. Soft tissue approximation (compression of a foam)
1. Elbow flexion
iii. Soft tissue stretch
1. Peri-articular (muscle, capsule, ligament): abrupt stop, sensation of
stretching a leather jacket, patient reports discomfort in immediate
proximity of joint
2. Muscle: movement stops more slowly than ligament/capsule, rubber
band stretch sensation, patient reports discomfort over muscle belly
being stretched
b. Abnormal End-feel & Examples
i. Bone to bone where another end-feel should be noted
ii. Peri-articular / Capsular perceived before the expected normal end-range (Knee
OA)
iii. Muscle stretch perceived before the expected normal the end-range
iv. Spring block
1. Loose body, cartilage, meniscus tear
2. It is similar to the sensation perceived during neck compression
v. Empty
1. Pain perceived before any structure is felt
vi. Muscle Spasm
 1. Fracture, infection, severe inflammation: e.g.; arthritis
2. Involuntary muscle contraction (twinge) before normal end-feel is felt or
after normal range is reached (hyper-mobility, instability
vii. Soft tissue stretch when firm tissue stretch is expected
1. Joint hypermobility or instability, excessive capsular laxity
II. Endfeel Reliability-Validity
a. Mulligan, IJSPT, 2015
i. Lachman test (anterior translation of the tibia on the femur to differentiate soft
capsular versus firm capsular) is a reliable and accurate reflection of the status of
the ACL (Specificity 100%, Sensitivity 81%).
b. Hamphreys et al (BMC Musculoskeletal Disorder, 2004)
c. Validity cervical fusion manual assessment, ability to detect bony block/severe
hypomobility. (Specificity 98%, Sensitivity 74%)
d. Patla, JMMT, 1993
i. Endfeel of the elbow: 80% agreement for passive flexion and 79% for passive
extension.
II. Passive Insufficiency Lack of Muscle Length
a. Passive insufficiency of a muscle is indicated whenever a full range of motion of any
joint or joint that the muscle crosses is limited by that mms length, rather than by the
arrangement of ligaments or structures of the joint itself (OConnel and Gardner)
b. Shortness of a bi-articular or multi-articular muscle; the length of the muscle is not
sufficient to permit normal elongation over both joints simultaneously (Kendall)
c. Occurs when an inactive, potentially antagonistic muscle is of insufficient length to
permit full ROM at the joints crossed by the passive muscle (Norkin, FA Davis, 2009)
II. Active Insufficiency Lack of Muscle Strength
a. A decrease in torque when the full ROM is attempted simultaneously at all joints crossed
by a multi-joint mm. (Norkin)
i. Length changes in mm, change in MA, passive restraint of lengthened
antagonists
ii. Sarcomere length appears to stay close to optimal length
1. MA & passive restraint may be more important
II. Key Points to Remember
a. Contractures may be caused by muscles or peri-articular structures
b. Muscle length measurement may be performed with goniometers or tape measures
c. It is challenging to measure mono-articular muscle length
d. Passive insufficiency is caused by tightness across bi-articular or multi-articular muscles
e. Active insufficiency is caused by weakness of bi/multi-articular muscles in shortened
position

Range of Motion Examination

I. Objectives
a. Define and discuss range of motion (ROM) and Associated Terminology
b. Discuss and compare passive range of motion (PROM) and active range of motion
(AROM)
c. Compare tools utilized to measure ROM
d. Compare different ways to document ROM
e. Discuss factors affecting ROM
f. Describe and discuss ROM technique procedures
II. ROM Definitions
a. ROM
i. Used to describe the amount of movement you have at each joint
 1. AROM is performed by patient alone
2. PROM is performed by therapist without any patient help
b. Endfeel
i. The resistance to movement that the therapist perceives at end-rage motion when
testing PROM
b. Goniometer
i. An instrument that measures angles
ii. In physical therapy, it is the most common instrument utilized to measure ROM
b. Hypomobility
i. Significant decrease from the normal expected ROM for subject age and gender
b. Joint ROM vs. Muscle Length Measurements
i. Joint ROM tests
1. Motion is measured with bi-articular muscles shortened
ii. Muscle Length tests
1. Bi-articular muscles are lengthened to assess muscle tightness
b. Axis of motion
i. Imaginary point where the joints pivot to form the angles that are recorded with
goniometers
b. Physiological or osteokinematic motion
i. Refer to gross movements of the shafts of bones rather than joint surfaces
b. Accessory or arthrokinematic motion
i. Refer to the small movements that occur involuntarily between joint surfaces
during physiological motions
ii. May also be used therapeutically in manual therapy techniques
1. Ex: approximation, separation, slide, glide, spin
II. Physiological Motions

Rotation Transverse Plane Abduction/Adduction Frontal Plane

Flexion/Extension Sagittal Plane
IV. Accessory Movements or Arthrokinematic
 V. Instruments to Measure ROM
1. Electrogoniometer
1. Computer assisted ROM assessment
2. Often used in research and seldom in the clinic
ii. Tape Measure
iii. Eye Balling
1. Visual estimation of ROM measurement can be used to get an overall overview
of the ROM in a quick screen of ROM
2. For documentation of patient progress, it is not acceptable
ii. Metal Universal Goniometer Versatile
1. Smaller used for the hand
ii. Plastic Full Circle Transparent Universal Goniometers
1. Most popular goniometer
V. Universal Transparent Goniometer
a. Stationary Arm
i. Placed parallel with the longitudinal axis of the fixed part
b. Movable Arm
i. Along the longitudinal axis of the movable segment
b. Axis of Rotation (Pin)
i. At the intersection of the stationary & movable arms

VII. Fluid & Gravity Goniometer

VIII. Factors Affecting Range of Motion

1. Gender
 1. Adult females > adult males
ii. Age
1. Children > adults > elderly
ii. Muscle Bulk
iii. Ligaments and joint capsule laxity
iv. Extensibility of the skin and subcutaneous tissue
VIII. The ROM Exam
a. Eyeballing performed before goniometry with AROM followed by PROM
b. During the AROM exam:
i. Note the ability and motivation to move without hesitance
1. Hesitance may indicate an active inflammation
ii. Note if the patient has full range against gravity
iii. If the patient has a symptom during motion, take note of the range, position, and
direction of movement
iv. Ask the patient to grade the pain during motion vs. resting
1. A small movement causing intense pain may imply a serious (fracture) or
reactive (inflamed) condition
b. The Normal AROM
i. Coordinated movement, no extraneous body compensation
ii. No facial expression of pain or discomfort
iii. Antagonists are relaxed and do not impair movement
iv. No hesitance to move joint
v. Normal range and without pain even at end-range
vi. Able to move against gravity without any difficultly
b. The Abnormal AROM
i. Facial expression of pain or discomfort during motion
ii. Painful arc or pain at end-range
1. Pain noted during partial range of the available motion
iii. Uncoordinated movement or compensatory movement
1. Associated joints are activated in order to perform movement
iv. Abnormal sounds during motion
1. Crepitus and others
v. Restricted range
vi. Excessive range
vii. AROM always slightly less than PROM
1. When AROM is much worse than PROM, suspect muscle tear or
neurological compromise
b. The PROM Test
i. During the AROM testing, before or at the end-range, the therapist checks PROM
with overpressure carefully
ii. When checking PROM, the therapist:
1. Feels for joint sounds with hands
2. Feels for excess or limitation of motion
3. Observes end-feel and compares with opposite side
iii. The therapist examines all primary AROM and PROM on the joint with
symptoms as well as primary AROM/PROM of the joint above and below
bilaterally
VIII. Goniometer Positioning and Stabilization
a. Positioning
i. Start with zero position
1. This is the reference point for the measurement
 2. If zero position cannot be achieved this much be documented
ii. Permit complete range of motion
1. If you are assessing joint ROM, be sure that some other structure (e.g.; a
tight muscle) does not interfere
2. If you are assessing some other structure (e.g.; a tight muscle, pain
limiting the motion) document exactly what is limiting the range of
motion (e.g.; hamstring tightness at 65 of hip flexion)
b. Stabilization
i. Poor stabilization is the most frequent cause of invalid measurements
1. Observe a normal ROM of elbow extension when movement of should
and arm masks a limitation actually measuring should and arm
movement
VIII. Goniometry Procedure
a. Position join in zero position and stabilize proximal joint component
b. Move joint to end of range of motion
i. To assess quality of movement
b. Determine end-feel at point where measurement will be taken
i. At the end of available ROM
b. Identify and palpate bony landmarks
c. Align goniometer with bony landmarks while holding joint at end of range
d. Read the goniometer
e. Record measurement
VIII. Goniometry Validity & Reliability
a. Validity
i. Goniometric measurements can be invalid; usually because of
1. Poor stabilization
2. Joint axis always moves during measurement with universal goniometer
b. Reliability
i. Upper extremity measurements are more reliable than lower extremity
measurements
ii. To maximize reliability always use the same:
1. Instrument
2. Positioning
3. Procedure
4. Examiner
VIII. Goniometric ROM Recordings
a. For most recordings, the measurement starts at 0
i. Elbow Flexion
1. Starts at full elbow extension or 0
ii. Neck Flexion
1. Starts at neutral position or 0
1. Midrange between flexion and extension
b. Some recordings the goniometer starts in an angle different from 0
i. In hip abduction and adduction, the goniometer readings start at 90
ii. In these cases, the reading at the beginning is taken as 0 and the reading at the
end of motion is added or subtracted from the 90
a. Final reading at end of hip abduction is 120 minus 90 = 30
b. Hence the score for hip abduction is 30
VIII. Recording ROM Measurements
a. Two main two methods
i. A single motion recorded at a time
 a. Elbow flexion 150 and extension 0 (normal)
b. Elbow flexion 130 and extension -5 (flexion missing 20 and extension
missing 5)
c. Elbow flexion 150 and Extension +5 (flexion normal and extension
with 5 hypermobility)
d. Shoulder external rotation 90 and internal 70 (normal)
e. Shoulder external rotation 45 and internal 60 (external missing 45 and
internal missing 10)
ii. Two movements recorded together with a 0 between motions to denote neutral
position when applicable
a. 90-0-70 Shoulder external and internal rotation (normal)
b. 45-0-60 Shoulder external and internal rotation (external missing 45
and internal missing 10)
c. 0-150 Elbow extension and flexion (normal)
1. No 0 needed to denote neutral position
b. 5-130 Elbow extension and flexion (Extension missing 5 and flexion
20)
VIII. Key Points to Remember
a. There are different tools to measure ROM. We will use mostly a goniometer
b. ROM readings may indicate normal, reduced, or increased motion
c. There are two methods to record ROM, we will use the single joint method
d. Standardized procedures to take ROM are important for good measurement validity and
reliability
e. Even when the patient has ROM within the normal expected values; pain, movement
compensation, or crepitus may indicate abnormality

ROM Measurement of The Cervial Spine

I. Cervical ROM Procedure with Tape Measure
a. Surface anatomy landmarks used to measure cervical motion with a tape measure:
i. Tip of the chin
ii. Sternal notch
iii. Acromion Process
iv. Mastoid Process
b. Cervical Flexion
i. The examiner uses a tape measure by determining the distance from the tip of the
chin to the sternal notch
b. Cervical Extension
i. One end of the tape measure is placed on the subjects chin and the other is
placed at the sternal notch
b. Cervical Lateral Flexion
i. One end of the tape measure is placed on the mastoid process and the other is
placed at the acromion process
b. Cervical Rotation
i. The examiner uses the tape measure to determine the distance between the tip of
the chin and the acromial process
II. Goniometer
1. Cervical Spine Flexion
1. Goniometer Alignment
1. Axis
1. External auditory meatus
2. Stationary arm
1. Vertical
2. Moving arm
1. Aligned with nostrils
b. Test Position
1. Subject sitting with lumbar and thoracic spines supported
2. Stabilize lumbar and thoracic spines
3. Flex cervical spine
ii. Cervical Spine Extension
a. Goniometer Alignment
1. Axis
1. External auditory meatus
2. Stationary arm
1. Vertical
2. Moving arm
1. Aligned with nostrils
b. Test Position
1. Subject sitting with lumbar and thoracic spines supported
2. Stabilize lumbar and thoracic spines
3. Mouth relaxed and slightly open
4. Extend cervical spine
ii. Cervical Spine Side Flexion
a. Goniometer Alignment
1. Axis
1. Spinous Process of C7
2. Stationary arm
1. Spinous process of thoracic spine
2. Moving arm
1. Posterior midline of head at occipital protuberance
b. Test Position
1. Subject sitting with lumbar and thoracic spines supported
 2. Stabilize lumbar and thoracic spines
3. Sidebend cervical spine
ii. Cervical Spine Rotation
a. Goniometer Alignment
1. Axis
1. Center of superior aspect of head
2. Stationary arm
1. Aligned with acromion processes
2. Moving arm
1. Aligned with tip of nose
b. Test Position
1. Subject sitting with lumbar and thoracic spines supported
2. Stabilize lumbar and thoracic spines
3. Rotate cervical spine
ii. Normative Values ROM in Degrees

III. Functional Cervical ROM

1. Sports Activities
1. Full ROM required in most sports
1. Swimming, tennis, soccer, etc.
ii. Activities of Daily Living (ADLs)
1. Minimum ROM required for most activities
2. 70 of rotation for back up a car and crossing a street
3. 45 to look up to the ceiling
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