CEBU DOCTORS’ UNIVERSITY ➔ Researching the effectiveness of

COLLEGE OF REHABILITATIVE SCIENCES therapeutic techniques or regimens (for

DEPARTMENT OF PHYSICAL THERAPY example, measuring outcomes following
exercises, medications, and surgical
PT 201: Principles of PT Evaluation procedures)
“INTRO TO ROM, MMT & ST” ➔ Fabricating orthoses and adaptive
Prepared by: Jose Francisco S. Lunday, PT INTERN 2023
Supervised by: Albert Niño F. Kotico, PTRP
equipment

RANGE OF MOTION KINEMATICS

GONIOMETRY ➔ is the study of motion without regard for
➔ “Gonia” + “metron” the forces that are creating the motion.
◆ is derived from two Greek words: ➔ describes the motion of bony segments
gonia, meaning “angle,” and metron, including the type, direction, and
meaning “measure.” magnitude of motion; location of the bony
➔ refers to the measurement of angles, in segment in space; and the rate of change
particular the measurement of angles or velocity of the segment.
created at human joints by the bones of ➔ Three types of motion:
the body. 1. Translatory (linear displacement)
➔ Measuring instrument used: Goniometer ➢ all points on a segment move in
➔ Determine both a particular joint position the same direction at the same
and the total amount of motion available time.
at a joint 2. Rotary (angular displacement)
➔ Part of a comprehensive examination of ➢ the bone spins around a fixed
joints and surrounding soft tissue point.
3. Combination of translatory and rotary
➔ Performance of active joint motions
motion
(AROM) = subject willingness to move
➔ Performance of passive joint motions
Arthrokinematics
(PROM) = examiner assess
➔ Motion at a joint occurs as the result of
movement of one joint surface in
Why is there a need for an ROM
relation to another joint surface
assessment?
➔ term used to refer to the movement of
➔ Determining the presence or absence of
joint surfaces.
impairment
➔ Establishing a diagnosis
➔ Developing a prognosis, treatment goals,
and plan of care
➔ Evaluating progress or lack of progress
toward rehabilitative goals
➔ Modifying treatment
➔ Motivating the subject
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 Joint Motion: Arthrokinematics OSTEOKINEMATICS
➔ refers to the gross movement of the
shafts of bony segments rather than the
movement of joint surfaces.

PLANES & AXES

1. SLIDE
● A slide (glide), which is a translatory
motion, is the sliding of one joint surface
over another, as when a braked wheel
skids.

➔ Three cardinal planes of the body:

PLANE AXIS

Sagittal plane Medial–Lateral Axis

● proceeds from ● envisioned as a
the anterior to the line that is
posterior aspect perpendicular to
of the body. the sagittal plane
2. SPIN and proceeds
● The median
● A spin is a rotary motion, similar to the from one side of
sagittal plane the body to the
spinning of a toy top. All points on the divides the body other.
moving joint surface rotate around a into right and left
fixed axis of motion halves
● Motion: Flexion &
Extension

Frontal plane Anterior–Posterior

● proceeds from axis.
one side of the ● lies at right angles
body to the other to the frontal plane
and divides the and proceeds
3. ROLL body into front from the anterior
● A spin is a rotary motion, similar to the and back halves. to the posterior
spinning of a toy top. All points on the ● Motion: aspect of the
abduction and body.
moving joint surface rotate around a
adduction
fixed axis of motion
Transverse Plane Vertical axis
● is horizontal and ● lies at right angles
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 examiner. or may be provided by an
divides the body to the transverse
into upper and plane and unimpaired region of the individual’s
lower portions proceeds in a body, or by a mechanical device.
cranial to caudal
direction. PASSIVE RANGE OF MOTION
➔ is the arc of motion produced by the
RANGE OF MOTION application of an external force by the
➔ is the arc of motion in degrees between examiner.
the beginning and the end of a motion in ➔ The individual remains relaxed and
a specific plane. plays no active role in producing the
➔ may occur either at a single joint or at a motion.
series of joints. ➔ Motion attained by therapist without
➔ Starting position: Anatomical position or assistance from the subject
neutral position. ➔ Integrity of the joint surfaces
➔ Three notation systems: ➔ Done before MMT
1. 0 to 180 degree system ➔ (+) pain= stretch on contractile and
● hyperextension is used to noncontractile tissue
describe a greater than normal
extension ROM. Note: Test AROM > PROM.
2. 180 to 0 degree system
3. 360 degree system END FEEL
➔ may be detected by the examiner who is
ACTIVE RANGE OF MOTION performing the passive ROM when
➔ arc of motion produced by the slight overpressure is applied at the end
individual’s voluntary unassisted muscle of the motion.
contraction. ➔ must be carried out slowly and carefully
➔ Subject unassisted during motion to detect the end of the ROM and to
➔ Subject’s willingness to move, distinguish among the various normal
coordination, muscle strength, and joint and abnormal end-feels.
ROM. ➔ NORMAL END FEEL:
➔ Pain- stretch of ligaments, joint End-Feel Description Example
capsules, bursa, fascia, skin
SOFT Soft tissue Knee flexion (contact
➔ If limited, physical exam should include approximation between soft tissue of
additional testing to clarify the problem posterior leg and
posterior thigh)

ACTIVE ASSISTED RANGE OF MOTION FIRM Muscular stretch Hip flexion with the knee
straight (passive tension
➔ is the arc of motion produced by the of hamstring muscles)
individual’s muscle contraction assisted Capsular stretch Extension of
by an external force. metacarpophalangeal
joints of fingers (tension
➔ During the examination process the in the anterior capsule)
external force is provided by the
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 Ligamentous Forearm supination
stretch (tension in the palmar Joint Restricted Motions
radioulnar ligament of
the inferior radioulnar Glenohumeral Greatest loss of lateral rotation,
joint, interosseous joint moderate loss of abduction, minimal
membrane, oblique cord) loss of medial rotation

HARD Bone contacting Elbow extension (contact Elbow complex Loss of flexion greater than loss of
bone between the olecranon (humeroulnar, extension; rotations full and painless
process of the ulna and humeroradial, except in advanced cases
the olecranon fossa of proximal
the humerus) radioulnar joints)

Forearm Equal loss of supination and pronation,

➔ ABNORMAL END FEEL: (proximal and only occurring if elbow has marked
distal radioulnar restrictions of flexion and extension
End-Feel Description Example joints)

Soft Occurs sooner Soft tissue edema Wrist Equal loss of flexion and extension,
or later in the Synovitis (radiocarpal and slight loss of ulnar and radial deviation
ROM than is midcarpal joints) (Cyriax) Equal loss of all motions
usual or in a (Kaltenborn)
joint that
normally has a Hand Loss of abduction (Cyriax); loss of
firm or hard Carpometacarpal abduction greater than extension
end-feel. Feels joint—digit 1 (Kaltenborn)
boggy
Carpometacarpal Equal loss of all motions
Firm Occurs sooner Increased muscular joint—digits 2–5 Equal loss of flexion and extension
or later in the tonus Capsular, (Cyriax)
ROM than is muscular, ligamentous, Metacarpophalan
usual or in a and fascial shortening geal and Restricted in all motions, but loss of
joint that interphalangeal flexion greater than loss of other
normally has a joints motions (Kaltenborn)
soft or hard
end-feel. Hip Greatest loss of medial rotation and
flexion, some loss of abduction, slight
Hard Occurs sooner Chondromalacia loss of extension; little or no loss of
or later in the Osteoarthritis Loose adduction and lateral rotation (Cyriax)
ROM than is bone fragments in joint Greatest loss of medial rotation,
usual or in a Myositis ossificans followed by less restriction of extension,
joint that Fracture abduction, flexion, and lateral rotation
normally has a (Kaltenborn)
soft or firm end-
feel. A bony Knee Loss of flexion greater than extension
grating or bony (tibiofemoral
block is felt. joint)
Empty No real end-feel Acute joint inflammation Ankle (talocrural Loss of plantarflexion greater than
because pain Bursitis Abscess joint) dorsiflexion
prevents Fracture Psychogenic
reaching end of disorder Subtalar joint Loss of inversion (varus)
ROM. No
resistance is felt
Midtarsal joint Loss of inversion (adduction and medial
except for
rotation); other motions full
individual’s
protective
Foot Loss of extension greater than flexion
muscle splinting
Metatarsophalan
or muscle
geal joint—digit 1 Loss of flexion greater than extension
spasm.
Loss of extension greater than flexion
Metatarsophalan
CAPSULAR PATTERNS OF THE JOINT geal joint—digits

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 2–5

Interphalangeal
joints

HYPOMOBILITY
➔ Refers to a decrease in ROM that is
substantially less than normal values for
that joint, given the individual’s age and
gender.
➔ Decrease in passive ROM that is
substantially less than normal values for
that joint, give the subject’s age and
gender
➔ Fx, stroke, head trauma, cerebral palsy,
and complex regional pain syndrome MUSCLE LENGTH TESTING
➔ is the greatest extensibility of a muscle-
HYPERMOBILITY tendon unit.
➔ Refers to the ability of one or more joints ➔ It is the maximal distance between the
to actively or passively move beyond proximal and the distal attachments of a
normal limits given the individual’s age muscle to bone.
and gender
➔ Clinically, muscle length is not
➔ Increase in passive ROM that exceeds measured directly; instead, it is
normal values for that joint, given the measured indirectly by determining the
subject’ age and gender maximal passive ROM of the joint(s)
➔ Increased ROM beyond expected age crossed by the muscle.
➔ Laxity of soft tissue, trauma, genetics ➔ TYPES:
➔ Hypermobility syndrome (HMS) or 1. One joint muscles
benign joint hypermobility syndrome ● cross and therefore
➔ Can be assessed through: Benington influence the motion of
Hypermobility Score only one joint.
2. Two-joint muscles
● cross and influence the
motion of two joints
3. multi-joint muscles
● cross and influence
multiple joints.
➔ Passive insufficiency is the inability of a
muscle to lengthen and allow full ROM
at all of the joints the muscle crosses.

POSITIONING
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 ➔ Refers to the positions of the body Temporo All
recommended for obtaining both mandibul motions
ar
goniometric and muscle length
measurements.
➔ Vital because it is used to place the
STABILIZATION
joints in a zero starting position when
➔ Helps to stabilize the individual’s body
measuring range of motion.
and proximal joint segment so that a
➔ POSITIONING:
motion can be isolated to the joint being
Joint/ Position
Body
examined.
Region ➔ Positional stabilization may be
Prone Supine Sitting Standing supplemented by manual stabilization
provided by the examiner
Shoulder Ext Flexion
Abd ➔ keep the proximal joint segment fixed
IR during movement of the distal joint
ER
segment
Elbow Flex

Forearm Pronation UNIVERSAL GONIOMETER

Supinatio
n

Wrist All
motions

Hand All
motions

Hip Ext Flex IR

ER Abd ER
IR Add

Knee Flexion

Ankle & Subtalar DF DF

Foot Inv & Ev PF PF
INV
EV
INV
EV
➔ is the instrument most commonly used
Midtarsal Midtarsal to measure ROM in the clinical setting.
INV INV
Midtarsal Midtarsal ➔ Goniometer Construction
EV EV ◆ Universal goniometers (UGs)
Toes All All may be constructed of plastic or
motions motions metal and are produced in many
Cervical Rotation Flex sizes and shapes but adhere to
Spine Ext the same basic design.
Lat Flex
Rotation ◆ Composed of:
1. Body
Thoracolu Rotation Flex
mbar Ext
Spine Lat Flex
Rotation

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 ★ Resembles a protractor Gravity-dependent Goniometers
and may form a half (Inclinometers)
circle or a full circle.
★ The scales on a half-
circle goniometer read
from 0 to 180 degrees
and from 180 to 0
degrees
★ The scales on a full-
circle instrument may
read either from 0 to
180 degrees and from
180 to 0 degrees, or ➔ Gravity-dependent goniometers or
from 0 to 360 degrees inclinometers use gravity’s effect on
and from 360 to 0 pointers and fluid levels to measure joint
degrees. position and motion
★ Sometimes full-circle ➔ Pendulum goniometer consists of a 360-
instruments have both degree protractor with weighted pointer
180-degree and 360- hanging from the center of the
degree scales. protractor.
2. Arms ➔ Fluid (bubble) goniometer has a fluid-
★ are designated as filled circular chamber containing an air
moving or stationary bubble.
according to how they ➔ Flexible electrogoniometers with two
are attached to the body plastic end blocks connected by a
of the goniometer. flexible strain gauge have been
★ The stationary arm is a designed to measure angular
structural part of the displacement between the end blocks in
body of the goniometer one or two planes of motion.
and cannot be moved
independently from the ALIGNMENT
body. ➔ Refers to the alignment of the arms of
★ The moving arm is the goniometer with the proximal and
attached to the center of distal segments of the individual’s joints.
the body of most plastic ➔ Use: the bony anatomical landmarks.
goniometers by a rivet
that permits the arm to
move freely on the
body.

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 ◆ Type of motion being measured
(passive or active)
◆ Any subjective information, such
as discomfort or pain, that is
reported by the individual during
the testing
◆ Any objective information
obtained by the examiner during
testing, such as a protective
muscle spasm, crepitus, or
➔ Proximal arm to refer to the arm of the capsular or non capsular patterns
goniometer that is aligned with the of restriction
proximal segment of the joint ◆ A complete description of any
deviation from the recommended
➔ Distal arm to refer to the arm aligned
testing positions
with the distal segment.
➔ Fulcrum of the goniometer may be
A. Numerical Tables
placed over the approximate location of
the axis of motion of the joint being
measured.

RECORDING
➔ are recorded in:
A. numerical tables
B. pictorial charts,
C. within the written text of an
evaluation ● typically list joint motions in a
➔ Must include the following: column down the center of the
◆ Individual’s name, age, and form
gender
◆ Examiner’s name or initials B. Pictorial Charts
◆ Date and time of measurement
◆ Type of goniometer/inclinometer
used
◆ Side of the body, joint, and
motion being measured (for
example, left knee flexion)
◆ For ROM, include the number of
degrees at the beginning and end
of the motion. For muscle length, ● May be used in isolation or
include only the degrees at the combined with numerical tables
end of the motion. to record ROM measurements.
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 Pictorial charts usually include a 1. Introduce self & explain purpose.
diagram of the normal starting 2. Explain & demonstrate goniometer.
and ending positions of the 3. Explain & demonstrate anatomical
motion landmarks.
4. Explain & demonstrate testing position.
C. Sagittal–Frontal–Transverse– Rotation 5. Explain & demonstrate examiner &
(SFTR) subject’s role.
6. Confirm subject’s understanding.

Testing Procedure:
7. Place the subject in the testing position.
8. Stabilize the proximal joint segment.
9. Move the distal joint segment to the
zero starting position. If the joint cannot
be moved to the zero starting position,it
should be moved as close as possible to
the zero starting position. Slowly move
the distal joint segment to the end of the
passive ROM and determine the end-
feel. Ask the subject if there was any
discomfort during the motion.
10. Make a visual estimate of the ROM.
11. Return the distal joint segment to the
starting position.
12. Palpate the bony anatomical landmarks.
13. Align the goniometer.
14. Read and record the starting position.
● In the SFTR method, three Remove the Goniometer.
numbers are used to describe all 15. Stabilize the proximal joint segment.
motions in a given plane. 16. Move the distal segment through the full
● The first and last numbers ROM.
indicate the ends of the ROM in 17. Replace and realign the goniometer.
that plane. Palpate the anatomical landmarks again
● The middle number indicates the if necessary.
starting position, which would be 18. Read and record the ROM.
0 in normal motion.
● The SFTR may be included in a MANUAL MUSCLE TESTING
written text or formatted into a ➔ Break Test
table ◆ Manual resistance is applied to a
limb or other body part after it has
PROCEDURE completed its range of movement
Introduction & Explanation:
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 or after it has been placed at end ● Sensitivity to differences in contour and
range by the examiner. bulk of the muscles being tested in
◆ At the end of the available range, contrast to the contralateral side
or at a point in the range where ● Awareness of any deviation from
the muscle is most challenged, normal values for range of motion and
the patient is asked to hold the the presence of any joint laxity or
part at that point and not allow deformity
the examiner to "break" the hold ● Understanding that the muscle belly
with manual resistance. must not be grasped at any time during
➔ Active Resistance Test a manual muscle test.
◆ application of manual resistance
against an actively contracting CRITERIA FOR ASSIGNING A MUSCLE
mus cle or muscle group (i.e., TEST GRADE
against the direction of the
movement as if to prevent that
movement)
◆ “Active resistance test”
◆ During the motion, the examiner
gradually increases the amount
of manual resistance until it
reaches the maximal level the
subject can tolerate and motion GRADE 5 ● ability to complete a full
ceases (NORMAL) range of motion or
MUSCLE maintain end-point range
Examiner and the value of the Muscle test against maximal
● Knowledge of the location and resistance.
anatomical features of the muscles in a GRADE 4 ● muscle group that is able
test. (GOOD) to complete a full range
● Knowledge of the direction of muscle MUSCLE of motion against gravity
fibers and their "line of pull" in each and can tolerate strong
muscle. resistance without
● Knowledge of the function of the breaking the test position
● "gives " or "yields" to
participating muscles
some extent at the end
● Consistent use of a standardized of its range with maximal
method for each different test resistance
● Consistent use of proper positioning and
stabilization techniques for each test GRADE 3 ● The muscle or muscle
(FAIR) group can complete a full
procedure.
MUSCLE range of motion against
● Ability to identify patterns of substitution. only the resistance of
● Ability to detect contractile activity gravity
during both contraction and relaxation. ● Tested muscle moves
full range against gravity
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 but additional resistance, MUSCLE plane, the gravity-minimized
however mild, causes position
the motion to break
● The examiner must be
sure that muscles given Sample Documentation for Manual Muscle
a grade of 3 are not in Testing
the joint "locked" position
during the test

GRADE 2 ● can complete the full

(POOR) range of motion in a
MUSCLE position that minimizes
the force of gravity.
● This position often is
described as the
horizontal plane of
motion

GRADE 1 ● the examiner can detect

(TRACE) visually or by palpation OVERVIEW OF TEST PROCEDURES
MUSCLE some contractile activity
in one or more of the ➔ The Break Test
muscles that participate ◆ Manual resistance is applied to a
in the movement being limb or other body part after it has
tested (provided that the completed its range of movement
muscle is superficial or after it has been placed at end
enough to be palpated) range by the examiner.
GRADE 0 ● completely quiescent on ◆ The term "resistance" is always
(ZERO) palpation or visual used to denote a force that acts
MUSCLE inspection in opposition to a contracting
muscle.
PLUS (+) AND MINUS (-) GRADES ➔ Active Resistance Test
◆ An alternative to the break test is
GRADE 3+ complete a full range of
(FAIR+) motion against gravity, and the application of manual
MUSCLE the patient can hold the end resistance against an actively
position against mild contracting muscle or muscle
resistance. group (i.e., against the direction
of themovement as if to prevent
GRADE 2+ The 2+ Grade is clearly
that movement).
(POOR+) distinguished from Grade 2,
MUSCLE which indicates that full ➔ Application of Resistance
range is completed with no ◆ In manual muscle testing, the
resistance. application of external force
(resistance) at the end of the
GRADE 2- complete partial range of
(POOR-) motion in the horizontal range in one-joint muscles allows
consistency of procedure rather
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 than an attempt to select the ◆make a differential diagnosis
estimated midrange position. ◆
differentiate between structure
◆ In two-joint muscles (e.g., ◆
understand unusual signs
the medial or lateral ◆
unravel difficult signs and
hamstring muscles), the symptoms
point of maximum ➔ always perform special tests with
resistance is generally at or CAUTION!
near midrange. ➔ Contraindications:
➔ The point on an extremity or part ◆ severe pain is present
where the examiner should apply ◆ acute/irritable jt conditions
resistance is near the distal end of the ◆ instability d. Osteoporosis
segment to which the muscle attaches. ◆ pathologic bone disease
◆ There are two common ◆ active disease process
exceptions to this rule: the ◆ unusual signs and symptoms
hip abductors and the ◆ major neurologic signs
scapular muscles. ◆ pt. Apprehension

SPECIAL TEST
➔ a.k.a clinical accessory test, provocative
test, motion test, palpation test,
structural tests.
➔ to determine whether a type of dse,
injury or condition is present if test is (+),
it is strongly suggestive if test is (-), it
DOES NOT RULE OUT THE
CONDITION.
➔ best to know the:
◆ sensitivity of the test: ability of the
test to identify the person who
has a particular condition,
dysfunction, or disease when
they do (true positive)
◆ specificity of the test: to
determine which people do not
have a particular condition,
dysfunction, or disease (true
negative)
➔ more accurate: right after injury with
anesthesia chronic conditions
➔ uses :
◆ confirm a tentative diagnosis

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