GROSS EXAMINATION

GONIOMETRY:
Measurement of Joint Motion
Hampton University
Department of Physical Therapy
PHT 604 Tests and Measurements
Fall 2011
Dr. Y. Rainey, PT, MS, DPT, CEEAA

Objectives
The student will be able to:
Define and distinguish between the components of a
screening vs. examination
Apply the principles of goniometry and muscle length
testing as part of tests and measurement procedures
Compare/contrast normal and abnormal end-feel
classifications
Accurately measure and record results of UE and LE
joint goniometric measurements

Objectives

Accurately measure and record results of one and two-
joint muscle length tests
Internalize the significance of evidence-based practice
as it relates to performing tests and measures
during a patient examination

Screening vs. Examination

Screening
Determining the need for further examination or
consultation by a physical therapist or for referral to
another health professional. Cognitive screening: Brief
assessment of the patients/clients thinking process
(e.g., ability to process commands).
APTA Guide to Physical Therapist Practice, pg. 682
Screening vs. Examination
Examination
A comprehensive screening and specific testing process
leading to diagnostic classification or, as appropriate, to
a referral to another practitioner. The examination has
three components: the patient/client history, the
systems review, and tests and measures.
APTA Guide to Physical Therapist Practice, pg. 679
SCREENING vs. Examination
Examples of patient/client screening methods
Observation
Other healthcare
personnel or family
Medical record
Screening vs. EXAMINATION
Examination
A comprehensive screening and specific testing process
leading to diagnostic classification or, as appropriate, to
a referral to another practitioner.
APTA Guide to Physical Therapist Practice, pg. 679
Goniometry
Muscle Length
MMT
GONIOMETRY

Measurement of Joint Range of Motion
Assessment of the musculoskeletal system
Angles created at the joints 2
0
movement of the
bony skeleton by the muscles

Measurement tool: Goniometer

Goniometry

One part of a comprehensive joint evaluation
The amount (range) of motion that is available at a
specific joint (ROM)
Joint motions are described as they occur in the cardinal
planes of motion.
From the anatomical position, what motions occur in:
Frontal plane?
Sagittal plane?
Transverse plane?

Goniometry

Preferred sequence for measuring joint ROM:
AROM: active range of motion
Unassisted, voluntary movement of a joint
Performed by the patient/client without
examiner assistance
Screen for amount, quality, pattern of motion;
occurrence of pain and crepitus; subjects
willingness to move

Goniometry

Sequence (cont.)
PROM: passive range of motion
Movement performed by therapist
Patient does not assist
Used if abnormal AROM is observed
Enables examiner to assess the joint for reasons or
causes of abnormal movement
Goniometry
Applications
Determine presence or
absence of impairment
Establish a diagnosis
Develop prognosis,
treatment goals, and
POC
Evaluating progress or
lack of progress toward
treatment goals
Applications
Modifying treatment
Motivating the
patient/client
Researching
effectiveness of
therapeutic techniques
or regimens
Fabricating orthoses,
prosthetics, and other
adaptive equipment
Documentation
0-180 degree notation system (aka, neutral zero
method)
UE/LE and spinal joints begin at 0 degrees moves
toward 180 degrees
Anatomical zero = 0 degree point for the testing
position (some exceptions)
Most commonly used by physical therapists


End-Feel
END-FEEL is a resistance to further motion at the end of
PROM
Detected by the examiner during PROM
Influenced by
joint structure
contact of joint surfaces
passive muscle tension (normal tone or 2
0
soft
tissue shortening)
reflexive muscle tension (spasticity)
soft tissue approximation

End-Feel Classifications
NORMAL (physiologic) end-feels
Soft
Firm
Hard
ABNORMAL (pathologic) end-feels
Soft
Firm
Hard
Empty
Normal End-Feel Classifications
Soft Soft tissue approximation
Contact between soft tissue of muscle tissue such
as in knee flexion
Firm Muscular, Capsular, or Ligamentous stretch
Passive elastic tension of hamstring muscles,
anterior joint capsules, or selected ligaments
Hard Bone contacting bone
Olecranon process (ulna) and the olecranon fossa
(humerus)
Abnormal End-Feel Classifications
Soft Occurs sooner
or later than usual in
the ROM; occurs in a
joint that normally
has firm or hard end-
feel; Feels boggy
Soft tissue edema
Synovitis


Firm Occurs sooner
or later than usual in
the ROM; occurs in a
joint that normally has
a soft or hard end-feel
Increased muscle
tone
Capsular, muscular,
ligamentous and
fascial shortening

End-Feel Classifications
Hard Occurs sooner
or later than usual in
the ROM; occurs in a
joint that normally has a
soft or firm end-feel; a
bony grating or bony
Chondromalacia
Osteoarthritis
Loose bodies in joint
Myositis ossificans
Fracture

Empty No real end-feel
because pain prevents
reaching end of ROM; no
end-feel felt 2
0
patients
protective muscle
splinting or muscle spasm
Acute joint
inflammation
Bursitis
Abscess
Fracture
Psychogenic disorder

Factors affecting ROM
Age-related changes in adults may include joint
specific or motion specific declines.
Evidence includes research on extremities and the
spine
Gender differences appear to trend toward adult
females having slightly greater ROM than males
Evidence supports these findings in numerous
joints and trunk movements
Muscle Length Testing
Defined as maximal distance between the
proximal (origin) and distal (insertion) attachments
of a muscle to bone.
Measured indirectly by determining the maximal
PROM of the joint(s) crossed by the muscle
Purpose: determine if joint hyper- or
hypomobility is caused by the length of the
inactive antagonist muscle or other structures
Muscle Length Testing
One-joint muscles
One-joint muscles cross
and influence motion of a
single joint
Muscle length test of one-
joint muscle is the same as
measurement of PROM in
the opposite direction of
that muscles active
(agonist) motion

If the one-joint muscle is
shorter than normal,
PROM in the opposite
direction will be decreased
and the end-feel will be
firm (muscular stretch)
Example: Shortened hip
adductors (add. Longus,
brevis, magnus) would
limit hip ABduction

Muscle Length Testing
Two-joint muscles
Two-joint muscles cross and influence the motion of
two joints
Length of two-joint muscle is usually not sufficient to
allow full PROM to occur simultaneously at all joints
crossed by these muscles = Passive insufficiency
Example: Triceps is passively insufficient during full
shoulder flexion and full elbow flexion

Muscle Length Testing
Two-joint muscles
To allow full ROM and ensure sufficient muscle length
at one joint , the muscle must be put on slack at all
other joints
Assessing length of two-joint muscle
Muscle is maximally lengthened over proximal joint and
held in position
Attempt is made to maximally lengthen the muscle over
the distal joint until firm end feel is felt
Muscle length is indirectly determined by measuring
PROM at the distal joint

Reliability and Validity
RELIABILITY:
Agreement between successive measures of the same
joint
Intratester and Intertester Reliability: High
+ 5 degrees is generally accepted in clinical practice;
research evidence supports that figure for
intratester reliability, slightly higher for intertester
reliability



Recommendations for Improving Reliability of
Goniometric Measurements (1)
Use consistent, well-defined positions
Use consistent, well-defined, and carefully palpated
anatomical landmarks to align the goniometer
Use the same amount of manual force to move
subjects body part during successive measurements of
PROM
Urge subject to exert the same effort to move the body
part during successive measurements of AROM
Recommendations for Improving Reliability of
Goniometric Measurements (2)
Use the same device to take successive measurements
Use a goniometer that is suitable in size to the joint
being measured.
If examiner is less experienced, record the mean of
several measurements rather than a single
measurement
Have the same examiner, rather than different
examiner, take successive measurements
Reliability and Validity
VALIDITY: True representation of the actual joint
angle or joint ROM
Important that the therapist is familiar with the
scale of the specific tool used
Evidence re: Goniometry
Face Validity:
Portney and Watkins (2000) report that face validity for
the goniometer is high because the measurement is
based on direct observation
Content Validity:
Gajdosik and Bohannon (1987) established content
validity based on the PTs knowledge of anatomy
combined with skills associated with taking the
measurements
Evidence re: Goniometry
Reliability: Many studies show that reliability
Was higher when successive measurements were taken
by the same examiner Intratester reliability higher
than Intertester reliability
Intertester reliability improved when all examiners
used consistent, well-defined testing positions and
measurement methods
Mean standard deviation of measurements taken by
one examiner is 5 degrees (1 sd)