Elbow and Wrist

Assessment in Physiotherapy
Physiotherapy Dept. University of Sharjah
 ROM
F o r muscles that pass over one joint only, the range of
motion and range of muscle length will measure the
same. . . .
, if the goal is to measure joint range of motion of a
joint in which a two-joint muscle is involved, the
second joint should be placed in a shortened position.
If the goal is to measure muscle length, the muscle
should be placed in an elongated position across all
joints affected, and a measurement should be taken
• The 4 steps for measuring ROM
 Step 1
• Accurate measurement of joint range of
motion and muscle length requires
stabilization of the proximal bony segment of
the joint being measured . Failure to provide
adequate stabilization will prevent isolation of
the intended motion and may allow the
patient to substitute motion at another joint
for the motion requested.
 Step 2
• Once the patient is positioned and the
proximal joint segment is stabilized,
the examiner should move the joint passively
through the available range of motion.
• This maneuver accomplishes a variety of objectives.
• First, by moving the patient through the range of motion to be measured , the
patient is mad e aware of the exact movement to be performed and can cooperate
more fully and accurately with the procedure.

• Second , a rough estimation of the patient's available range of motion can be m a

d e by the examiner. Estimating the patient's range of motion provides the
examiner with a self-check against gross errors in reading the goniometer.
• . Finally, moving g the patient passively through the range of motion allows the
examiner to note any limitations to full range of motion, such as those caused by
pain, muscle tightness, or other reasons.
• Clues to the cause of range of motion limitations may be obtained by examining
the quality of the resistance at the end of range of motion.
Each joint has a characteristic feel to the resistance encountered at the end of
normal range of motion.
 Step 3
• Aligning and realigning of the Goniometer

Three landmarks, as a minimum , are used to

align the goniometer at two postion
1. at the starting position .
2. the goniometer alignment must be
rechecked at the end to avoid tracking error .
 step 4
Determining and Recording the Range of
Motion with the Goniometer

• Determination of the patient 's range of

motion is accomplished by comparing the
reading taken from the goniometer with the
patient in the
starting position with a second reading that is
taken once the patient has completed the
movment
Range of motion
The range of motion of elbow flexion is
of 0° to 145° - 160°
 ELBOW FLEXION
•Biceps
•Brachialis
•brachioradialis
• Accessory Muscles:
Flexor muscles of the wrist and fingers (arising from media epicondyle of humerus).
BICEPS BRACHII
• Origin of Short Head: Apex of the coracoid process of the
scapula.
• Origin of Long Head: Supraglenoid tubercle of the scapula.
• Insertion: Tuberosity of the radius
• Action: Flexes the shoulder joint. The short head assists
with shoulder adduction. The long head may assist with
abduction if the humerus is laterally rotated.
– With the origin fixed, flexes the elbow joint, moving the forearm toward
the humerus and supinates the forearm.
– With the insertion fixed, flexes the elbow joint, moving humerus toward
the forearm, as in pull-up or chinning
exercises.
• Nerve: Musculocutaneous C5, 6
BRACHIALIS
• O: Humerus (shaft anterior, distal 1/2),
Intermuscular septa (medial)
• I: Ulna (tuberosity and coronoid process)
• A: elbow flexion primarily in pronated
forearm
• Nerve: Musculocutaneous, small branch
from radial,
C5, 6.
Brachioradialis
1) Origin: Proximal 2/3 of lateral supracondylar
ridge of humerus.
2) Insertion: Lateral, side of base of styloid process
of radius.
3) Nerve supply: Radial nerve C5 C6.
4) Action: Flexes the elbow joint; assists in
pronating the forearm to mid position and
assists in supinating the forearm to mid-position
 Group muscle test

Plus "Hold" at the end of the range when testing for "Grade 5".
Individual muscle test

What is the position for biceps individual test?

 ELBOW EXTENSION

• Triceps Brachii
• Anconeus
• Accessory Muscles
• Extensor muscles of the wrist and fingers
arising from lateral condyle of humerus.
 The range of motion of elbow
extension is from 0° to 145° 160°
 TRICEPS BRACHII
• Origin
– Long Head: Infraglenoid tubercle of the
scapula.
– Lateral Head: Lateral and posterior surfaces
of the proximal 1/2 of the body of the humerus (above radial
groove).
– Medial Head: Distal 2/3 of the medial and
posterior surfaces of the humerus (below the radial groove) and
from the medial intermuscular septum.
• Insertion: Posterior surface of the olecranon process of
the ulna and antebrachial fascia.
• Action: Extends the elbow joint. The long head also assists
in adduction and extension of the shoulder joint.
• Nerve: Radial, C6, 7, 8, Tl.
 Anconeus

• O: lateral epicondyle
• I: lateral side of olecranon process
• A: assist elbow extension, forearm
supination
• Nerve: Radial N (C7, C8, T1)
Group muscle test
 Alternate position
• Patient: Supine or short sitting

The examiner stands behind

the patient, supporting in
90° of abduction
Alternate position
• Which is better and why?
• When the shoulder is horizontally abducted, the long head of
the triceps is shortened over both the shoulder and elbow
joints. When the shoulder is flexed (horizontally adducted),
the long head of the triceps is shortened over the elbow joint
but elongated over the shoulder joint. Because of this two-
joint action, the long head is made less effective in the prone
position by being shortened over both joints, with the result
that the triceps withstands less pressure when
tested in the prone position than when tested in the
supine position.
While elbow extension is tested in the prone position, there must be awareness
that with the shoulder horizontally abducted the two-joint muscle is less
effective, and the test grade may be lower than it should be.
 FOREARM SUPINATION

• Biceps Brachii
• Supinator
 This movement occurs at radio-ulnar
joint
The radius and ulna articulate by
Synovial
• 1. Superior radioulnar joint
• 2. Inferior radioulnar joint
This range of motion of supination from the mid
position is approximately 0° to 90°.
 Supinator

• O:
– lateral epicondyle of humerus
– Annular lig. Of superior radio-
ulnar jt
– Supinator fossa and crest of
the ulna
• I: upper 1/3 of lateral surface
of radius
• Action: Supinates the
forearm.
• Nerve: Radial, C5, 6, (7).
Group muscle test
 FOREARM PRONATION

• Pronator teres
– O: medial epicondyle of humerus; coranoidprocess
of ulnar
– I: lateral aspect of radius in mid shaft
– A: forearm pronation; assist elbow flexion

• Pronator quadratus
– O: lower ¼ of anterior ulna
– I: lower ¼ of anterior radius
– A: pronation
The range of motion of forearm pronation from the mid
position is of 0° to 90°.
ROM
The range of motion of the wrist flexion is
approximately of 0° to 80°-90°.
 WRIST FLEXION
• Flexor Carpi Radialis
– O: medial epicondyle
– I: base of 2,3rd metacarpals
– Action: Flexes and abducts the wrist,
and may assist in
pronation of the forearm and in flexion
of the elbow.
– Nerve: Median, C6, 7, 8.

• Flexor Carpi Ulnaris

– O: medial epicondyle
– I: pisiform, hamate, base of 5th
metacarpal
– Action: Flexes and adducts the wrist,
and may assist in flexion of the elbow.
– Nerve: Ulnar, C7, 8, Tl.

• Accessory Muscle Palmaris Longus

 Flexor Carpi Radialis
• Bend your wrist toward
your thumb --- Relax.
• resistance. against the
thenar eminence for
testing flexor carpi
radialis
 FLEXOR CARPI ULNARIS
• Patient: Sitting or supine.
Fixation: The forearm is in full supination and either
rests on the table for support or is supported by the
examiner.
command: Bend your wrist toward your little finger --- Relax.
Pressure: Against the hypothenar eminence, in the direction of
extension toward the radial side.
The range of motion of wrist extension
is approximately of 0° to 70°.
 WRIST EXTENSION
• Extensor Carpi Radialis
Longus and Brevis
• Extensor Carpi Ulnaris

• O: lateral epicondyle
• I: dorsal aspect
– ECRL:
2ndmetacarpal base
– ECRB:
3rdmetacarpal base
– ECU: 5thmetacarpal
base
Group muscle test
Clinical tips
• tightness of the brachialis
can be distinguished from
tightness of the biceps
brachii
• IDENTIFYING TIGHTNESS OF THE BRACHIALIS MUSCLE: As a
one-joint muscle, tightness of the brachialis produces a flexion
contracture similar to the effects of capsular tightness at the
elbow, that is, unchanged by shoulder or forearm position (.
Therefore, tightness of the brachialis can be distinguished from
tightness of the biceps brachii by examining the effects of
shoulder position on elbow extension ROM.
Which one is more difficult?