SHOULDER JOINT

The starting position is the position of the arm hanging freely along the body. Possible movements: abduction, forward flexion, backward extension, outward and inward rotation.

Abduction in the shoulder joint is partially carried out together with the scapula. In a healthy shoulder joint, abduction is possible up to 90° (without the participation of the scapula - Chaklin), and up to an angle of 180° - with the scapula. The protractor is attached to the joint from behind in the frontal plane, the hinge should coincide with the head of the humerus, one of the branches is installed along the body parallel to the spinal column, the other along the axis of the shoulder. To avoid deviation of the torso in the opposite direction, it is recommended to move the healthy arm at the same time as the patient.

Flexion (raising the arm forward) in the shoulder joint occurs in the sagittal plane, in the same plane a protractor is installed on the outer surface of the shoulder, one branch runs vertically, parallel to the body, so that the patient does not throw the body back. Flexion in the unchanged joint is possible by 20-30° (Gerasimova, Guseva) and with the participation of the scapula by 180°. Chaklin points out that 90° flexion is possible. According to Marx – 70°.

Extension also occurs in the sagittal plane. The protractor screw is installed in the middle of the head of the humerus. Extension is possible up to an angle of 45° (according to Marx 37°), it depends on the elasticity and fitness of the ligamentous apparatus of the joint and muscles. Therefore, it is necessary to measure extension in diseased and healthy joints.

Shoulder rotation is measured with the patient in a supine position. The arm is bent at the elbow joint at a right angle. The protractor is applied to the forearm so that its screw is at the level of the olecranon, the branches of the protractor go in the middle of the forearm, which is in an average physiological position (the average between supination and pronation). When rotating the shoulder inward or outward, one branch of the protractor follows the movement of the forearm, the second remains in the sagittal plane. In a healthy shoulder joint, outward rotation is possible by 80°, inwardly by about 90° (compare with the rotation of the other shoulder). According to Marx, internal rotation is 60°, external rotation is 36°.

ELBOW JOINT

Possible: supination, pronation, flexion and extension.

When measuring flexion and extension At the elbow joint, the forearm is in a mid-position between supination and pronation. The protractor is applied to the outer surface of the arm, the screw is at the level of the outer condyle of the shoulder. One branch goes along the middle of the shoulder, the other to the third finger of the hand. In a healthy elbow joint, flexion is possible up to an angle of about 40°, extension up to 180° (according to Marx, extension/flexion 10°/0°/150°). For comparison, the range of motion in another joint is measured. If, for example, flexion in the right elbow joint is limited to 90°, and extension to 160°, note: flexion contracture of the right elbow joint, range of motion 160-90°.

Supination and pronation occurs due to rotation of the head of the radius around the longitudinal axis of the bone and movement of the lower end of the beam around the lower end of the ulna. The hand is connected to the lower end of the beam, the latter also changes its position (supination - hand with palm up, pronation - palm down). Starting position: shoulder lowered, elbow at a right angle and pressed to the body. The forearm is in a horizontal plane, the forearm and hand are in a position midway between supination and pronation. Protractor in the frontal plane in front of the hand. The protractor screw is at the level of the extended third finger. Both branches are shifted and are in a vertical position. One branch remains in its original position, the other follows the brush. In a healthy elbow joint, supination is possible up to 90° (according to Marx in the radioulnar joint, pronation/supination is 80°-90°/0°/80°-90°).

RADIAL JOINT

Possible: flexion, extension, abduction and adduction. Starting position – the hand is turned downwards and has one axis with the forearm. The goniometer is located on the side. On the side of the fifth finger, the screw is at the level of the joint space of the wrist joint. One branch runs along the ulnar side of the forearm, the second along the fifth metacarpal bone.

The extension angle varies individually and is equal to 110°.

Flexion in a healthy wrist joint is possible up to 130° (according to Marx, from the zero position flexion/extension is 80°/0°/70°).

When determining abduction and adduction in the wrist joint, the starting position is: forearm and hand along the same axis in a supinated position. The protractor is applied to the palmar surface of the hand, the screw is on the line of the wrist joint. One branch runs along the forearm, the other along the third metacarpal bone. Protractor arrow 180°.

Abduction (movement towards the thumb) in a healthy joint is possible up to 160°, adduction (movement towards the little finger) is possible up to an angle of 135° (according to Marx, according to the neutral position - radial/ulnar abduction 20°/0°/30°).

Metacarpophalangeal and interphalangeal joints

Maybe: flexion and extension.

Starting position: the metacarpal bone and the main phalanx of the finger are located along the same axis. The goniometer is attached to the outer (movement in the 5th and 4th fingers) or inner (movement of the 1st, 2nd, 3rd fingers) side of the hand. Flexion in the metacarpophalangeal joint of the II, III, IV, V finger is possible up to 80°, extension up to 0°.

Metacarpophalangeal joint of the thumb has a different range of motion: flexion up to 45°, extension up to 15°.

IN interphalangeal joints Flexion and extension possible. The protractor is placed on the side of the finger, the branches run along the phalanges of the fingers. Flexion is possible up to 90°, extension up to 0°.

When flexion is limited, when the ends of the fingers do not reach the palm, the distance (in cm) to the end of the fingers or nail phalanx from the middle of the palm should be measured at the maximum possible flexion.

Lower limb

HIP JOINT

The starting positions can be: lying on your back, or on your side with your legs extended.

Possible: lead, adduction, flexion, extension, internal and external rotation.

When measuring abduction and adduction, the starting position is on the back, the protractor screw is at the level of the middle of the inguinal fold, one branch runs along the middle of the thigh, the other along the front surface of the body parallel to the midline.

The angle formed between the thigh during abduction and the length of the body is noted. In a healthy joint this angle is 130°. Adduction is possible up to an angle of 160-150°. If movement is severely limited, the assistant must fix the patient's pelvis. According to the neutral (0) position (according to Marx), abduction/adduction 50°/0°/40°.

Hip flexion can be measured in the supine position or on the unaffected side. The protractor is attached to the outer surface of the joint, the screw is at the level of the greater trochanter. One branch goes on the outer surface of the thigh, the other on the lateral surface of the body. The angle of flexion in healthy people is different (muscle, subcutaneous fat), therefore, for comparison, the angle of flexion is measured in the other leg. Flexibility up to 60° is possible. If the patient can straighten the leg up to 160°, we mark: flexion contracture of the hip 160°, and if flexion is possible up to 120°, note: flexion contracture of the hip 120°, range of motion from 120° to 160°.

Extension in the hip joint is determined with the patient positioned on the stomach or healthy side. Protractor for the outer surface of the thigh and torso. Extension varies from person to person and depends on the elasticity of the joint ligaments. The angle between the thigh and the torso can be 165°; in order for the measurement to be correct, one must ensure that the pelvis does not tilt forward or backward, for which the healthy leg must be straight or an assistant fixes the pelvis. According to Marx, extension/flexion is 10°/0°/130°.

Rotation is determined with the patient lying on his back, with his legs extended. The patellas are facing upward. The soles of the feet are at a 90° angle to the shin. The protractor is placed in the middle of the foot, the jaws are closed, they go to the second toe, the protractor screw is in the middle of the heel. (It is possible to determine rotational movements when the limb is bent in the hip and knee joints at an angle of 90°, the branches of the protractor are located along the axis of the lower leg.) When rotating inward or outward, the entire leg turns inward or outward, while one branch follows the movement of the foot, the other remains on place. Rotation outward by 60°, inward by 45° (depending on the elasticity and fitness of the ligamentous apparatus). According to Marx, rotation is external/internal 50°/0°/50°.

KNEE-JOINT

Possible: flexion and extension.

When measuring flexion, the patient can lie on his back, on his side or on his stomach, depending on the performance of which muscle groups we are testing. The protractor is applied to the outer surface of the leg, the screw at the level of the joint space of the knee joint. Flexion in a healthy knee joint is possible up to 45°, extension up to 180° (depending on the development of the muscles and subcutaneous fat layer). According to Marx, extension/flexion is 5°/0°/140°. If flexion is possible up to 60°, and extension up to 155°, then it should be noted: flexion contracture of the knee joint is 155°, the range of its movements is from 155° to 60°, in a healthy knee joint the range of movements is from 180° to 45°.

Abduction and adduction in the knee joint becomes possible with certain diseases or after injury as a result of damage to the ligamentous apparatus.

ANKLE JOINT

Possible: flexion, extension, supination and pronation.

Flexion and extension produced in the supratalar joint. The protractor is attached to the inner side of the ankle joint, the screw is at the level of the inner ankle, one branch goes along the middle of the shin, the other to the metatarsophalangeal joint of the big toe. In the middle position between flexion and extension (a person stands, leaning on the entire sole), the plane of the sole is at 90° with respect to the lower leg. In this position, an obtuse angle is formed between the first metatarsal bone and the tibia. We measure this angle and note that the average position between flexion and extension, for example 115°.

When bending (moving towards the sole), this angle increases and can reach 170°.

During extension (movement to the rear), the angle decreases and can be up to 70°.

According to Marx, dorsiflexion/plantar flexion is 20°-30°/0°/40°-50°.

Example. The foot is at an angle of 140°, extension is possible up to 125°. We note: flexion contracture of the ankle joint, range of motion from 140 to 125°. To find out how limited movements are in a diseased joint, it is necessary to measure them in a healthy one.

Supination and pronation occur at the subtalar joint of the foot.

When the foot is supinated, the heel bone and the entire sole become inclined to the plane of support. The inner edge of the foot rises and only the outer edge is stepped on. To measure supination, the subject stands on the edge of a table or chair. If the patient cannot stand, then when the patient is lying down, a board is placed under the sole in a position perpendicular to the length of the lower leg. The protractor is located in the frontal plane in front of the foot, the protractor screw is at the level of the first finger, both branches run parallel to the plane of support. The protractor arrow is at 0. When measuring supination, one branch of the protractor remains in its original position, the second is projected onto the plane of the sole. A healthy person can supinate the sole at an angle of about 50°.

Pronation is the raising of the outer edge of the foot. The patient steps only on the inner edge of the foot. The protractor is installed in the frontal plane, the protractor screw is at the level of the first finger. When measuring, one branch remains in its original position, the second is projected onto the plane of the sole, which is in an inclined position. In healthy people, pronation in the ankle joint is possible at an angle of about 25°.

The issue of age-related changes in the amplitudes of movements in large and small joints of the lower and upper extremities has not been sufficiently developed in the literature. One can only point out a number of works concerning age-related changes in large joints of the limbs (Saario Zanri, 1961).

We carried out goniometric studies of the amplitudes of movement in large and small joints of the limbs in the population of Astrakhan (2800 people) aged from 1 year to 84 years - 27 different amplitudes of movement in each age and sex group. In children under 6 years of age, the amplitudes of passive movements in the joints were measured; starting from 7 years of age, the maximum amplitudes of active movements were measured.

The results of variation-statistical analysis of the amplitudes of movement of the right joints of the limbs are presented in tables 25-26. As in the analysis of data on the mobility of all parts of the spine, here we can distinguish the three above-mentioned phases of age-related changes in the amplitudes of movements in the joints: 1) an increase phase, 2) a relative stabilization phase, and 3) a decrease phase. Heterochrony and varying intensity of their changes are also noted. In some amplitudes of movements, the phase of increase is short and lasts only until 2-3 years of age, in others it is significant (up to 17-19 years). The relatively stable phase can last until the age of 30-59 years. In old age and old age, there is already a significant decrease in mobility in the joints. Some ranges of movement have a large intensity of change, while others change relatively little. For example, the amplitude of extension in the wrist joint during an individual’s life in males and females changes by 40.8°, and the amplitude of flexion in this joint in men - by 23.3°, in women - by 26.7° . The amplitude of extension in the metacarpophalangeal joints changes in males by 46.5°, in females - by 43.6°, and the amplitude of flexion in these joints - by only 7.6 and 9.4°, respectively. Pronation and supination in the radioulnar joint (42-47°) have a high intensity of change. Sex differences are relatively small.

Table 25. Range of motion in the elbow and shoulder joints

Table 26. Range of motion in the hip joints

Let us give a brief analysis of age-related changes in individual joints.

1. The amplitude of flexion of the shoulder joint increases in boys up to 4 years old, in girls - up to 6 years old. The period of relative stabilization lasts until 20-29 years. After 40 years of age, an increasing decrease in the amplitude of flexion is observed.

2. The amplitude of extension in the shoulder joint increases in both sexes up to 3-6 years, then decreases slightly. A significant decrease in this amplitude begins from the age of 40-59 years.

3. The amplitude of abduction in the shoulder joint increases in both sexes up to 7 years. A period of relative stabilization continues until the age of 30-39, and then an ever-increasing decrease in this amplitude begins.

4. The amplitude of external rotation of the shoulder increases in boys and girls under 3 years of age. A relatively stable period lasts until 30-49 years, and then mobility progressively decreases.

5. The amplitude of shoulder internal rotation increases in both sexes up to 2-3 years. A relatively stable period with a slight decrease in this amplitude continues until 30-39 years, and then a more significant decrease occurs, especially in old age.

6. The amplitude of flexion in the elbow joint increases in individuals of both sexes up to 4 years. The reduction phase begins at 40-49 years of age.

7-8. The amplitudes of pronation and supination in the radial-ulnar joint increase in boys and girls up to 2-3 years of age. Moreover, at 1-2 years of age, the amplitude of pronation is greater than the amplitude of supination. In subsequent years, the amplitude of supination decreases to a lesser extent than the amplitude of pronation, as a result of which it significantly exceeds the latter. After 50 years, this difference in both sexes decreases significantly and in old age the amplitude of pronation again exceeds the amplitude of supination (Fig. 37).

Rice. 37. Age-related changes in the amplitudes of pronation and supination in the radial-ulnar joint in males.

1 - supination; 2 - pronation.

9-10. The amplitudes of flexion and extension in the wrist joint increase in both sexes up to 2-3 years. In subsequent years, the extension amplitude decreases to a much greater extent than the flexion amplitude.

11. The amplitude of abduction in the wrist joint increases up to 4 years. The relatively stable phase lasts until 50-59 years of age; in old and senile age this amplitude decreases significantly.

12. The amplitude of adduction in the wrist joint is less than the amplitude of abduction. This amplitude increases in both sexes up to 14-16 years. The phase of decrease in this amplitude begins only in old age (after 60 years).

13-14. The amplitudes of flexion and extension in the third metacarpophalangeal joint increase up to 3 years. At this age, the amplitude of extension exceeds the amplitude of flexion. In subsequent years, the extension amplitude decreases to a much greater extent than the flexion amplitude, especially starting from 17-19 years. A significant decrease in the amplitude of flexion occurs only after 60 years (Fig. 38).

Rice. 38. Age-related changes in the amplitudes of flexion and extension in the third metacarpophalangeal joint in males.

1 - flexion amplitude; 2 - extension amplitude.

15. The amplitude of flexion in the hip joint with the leg bent at the knee joint increases in boys up to 8-9 years, in girls - up to 5 years. The relatively stable phase continues in both sexes until 40-49 years of age. A significant decrease in this amplitude begins after 70 years.

16. The amplitude of flexion in the hip joint with the leg straightened at the knee joint (in a supine position) begins to decrease after a year; its significant decrease occurs after 60 years.

17. The amplitude of extension in the hip joint increases until 17-19 years of age, and begins to decrease after 40 years of age.

18-19. The amplitudes of outward and inward rotation of the femur increase sharply in both sexes up to 3 years of age. The amplitude of hip rotation outward is greater than inward. The relatively stable phase lasts until 40-49 years of age. In old and senile age, a significant decrease in these amplitudes is observed (Fig. 39).

Rice. 39. Age-related changes in rotation amplitudes in the hip joint in males.

1 - outward rotation; 2 - inward rotation.

20. The amplitude of hip abduction increases up to 5 years. In subsequent years (especially after 40-49 years) this amplitude decreases significantly.

21. The amplitude of hip adduction increases in individuals of both sexes up to 14-19 years of age. The phase of its decrease begins from 50-59 years old *.

22. The amplitude of flexion in the knee joint increases in both sexes up to 8-9 years. In subsequent years, there is first a slight, and then, starting from 50-59 years, an increasingly significant decrease.

23-24. The amplitudes of flexion and extension at the ankle joint increase up to 3 years. A relatively stable period with a slight decrease in this amplitude continues until 30-49 years. Over the age of 70 years, there is a significant decrease in this amplitude.

25-26. The amplitude of adduction at the ankle joint is less than the amplitude of abduction. The increase in the amplitude of adduction continues up to 2-3 years, the amplitude of abduction - up to 6 years. A significant decrease in these amplitudes begins from the age of 50.

27. The amplitude of pronation-supination mobility in the ankle joint increases up to 3 years. The amplitude of supination is much greater than the amplitude of pronation. With age, there is a significant decrease in these amplitudes, especially after 40-49 years.

Based on variation-statistical analysis of the presented material, we have developed norms for amplitudes of movement in the joints of the limbs for various age and gender groups.

It is important to use the goniometric technique for studying changes in the amplitudes of movements in the joints of the limbs as a result of balneotherapy and functional treatment (physical therapy) in people with diseases and injuries of the movement organs. Studies can be carried out both before and after individual procedures, and systematically throughout the entire course of treatment (for example, every 5 procedures).

Measuring joint ranges of motion immediately before and after various procedures is important for comparative analysis of the effectiveness of restoring mobility as a result of these procedures. Research shows that immediately after taking this procedure, there is an increase in the range of motion in the joints (relative to the range of movement before taking this procedure). Moreover, at the beginning of the course of treatment this increase is greater than at the end of the course.

Goniometric studies of the amplitudes of movement in the joints of the limbs, before and after taking sulfur baths and mud applications without and in combination with therapeutic exercises (Pyatigorsk) showed that the restoration of amplitudes of movements with the complex use of balneoprocedures and physical therapy occurs to a greater extent than with the use of balneoprocedures alone . For example, as a result of the use of sulfur baths alone without physical therapy, large values ​​of the dynamics of amplitudes of motion in the knee joint (more than 8°) occurred in 5.7% of cases, and in combination with physical therapy - in 33.4% of cases.

We conducted studies of changes in amplitudes of movement in the joints of the limbs under the influence of functional treatment (physical therapy) in evacuation hospitals of the Sverdlovsk region during the Great Patriotic War (V. A. Gamburtsev, 1952). Processing of the material from these studies (more than 1000 cases) showed that the restoration of mobility as a result of treatment in its simplest form occurred according to a 2nd order parabola equation. For each type of lesion, it was possible to establish typical average data for the restoration of joint movements. This made it possible to more deeply analyze the dynamics of movement recovery over a given period of time (Fig. 40).

Rice. 40. Dynamics of amplitudes of movement in the ankle joint under the influence of functional treatment in the hospital.

Based on the intensity and timing of restoration of mobility in the joints, three types of dynamics of increasing amplitudes can be distinguished: with high, medium and low rates of functional restoration.

If the rate of movement recovery according to goniometric studies is low, then it is necessary to change the treatment method. One of the doctor’s tasks is to identify and eliminate factors that inhibit the restoration of movements.

Analysis of goniometric indicators of restoration of movements in the knee joint for hip fractures as a result of complex treatment shows that the rate of improvement in motor function depends on the location and nature of the injury and treatment method. In fractures of the middle third of the femur, in a relatively large percentage of cases, types of curves with both high and low rates of recovery were encountered. For fractures of the lower third of the femur, types of curves with medium and low recovery rates were observed. The variability of results in cases of damage to the femoral diaphysis can be explained by the presence, on the one hand, of cases with significant bone destruction over a large area, which required long-term immobilization, and on the other hand, the presence of milder injuries.

Here are some examples.

1. Patient A-ov. Diagnosis: large-comminuted fracture of the upper thigh of the left femur. He was admitted to the evacuation hospital 2 months after the injury. There was a complete lack of mobility in the left knee joint. After 30 days of using therapeutic exercises, the range of motion in the knee joint reached 45°. Subsequently, due to complications with osteomyelitis and two sequestrotomies, there was a temporary decrease in mobility. After intensive functional treatment, after 3 months of treatment in the hospital, mobility in the knee joint increased to 70°, after 4 months - to 90° (the patient began to walk on crutches, stepping on his leg), after 6 months - to 100° (walked with a stick ), after 6 months - up to 116°. After 220 days, the patient was discharged to the unit with normal range of motion in the knee joint (140°). Restoration of movements proceeded with average intensity (type 2).

2. Sick Gr-ov. Gunshot fracture of the middle third of the right femur. As a result of active functional treatment, the range of movements increased after 25 days from 20 to 140°. Restoration of movements proceeded with high intensity (type 1).

3. Patient F-ov. Fracture of the upper third of the left femur. As a result of insufficient functional treatment, after 100 days of treatment in the hospital, the range of motion in the knee joint increased from 0 to 40° [low intensity of motion recovery (type 3)]. After applying more intensive functional treatment, mobility increased after 45 days to 108°.

In case of damage to peripheral nerves, a feature of the method for measuring the amplitudes of active movements is the need to take into account the most insignificant shifts in the restoration of mobility, since they characterize the beginning of nerve regeneration. In addition to measuring the amplitudes of active movements, here, to take into account neurogenic contractures, it is necessary to measure the amplitudes of passive movements.

In practice, there have been cases where, as a result of insufficient dosage and incorrect selection of treatment agents, the increase in mobility in the joints was insignificant, but as soon as the treatment method was changed, its effectiveness increased significantly.

* The amplitudes of movements in the hip joint in children aged 1 to 3 years were studied by R. I. Asfanbiarov (1960).

Movement in the joints is the main functional indicator of the activity of the organs of support and movement.

To study the function of the affected limb, a step-by-step study is carried out:

Mobility in joints;

The presence or absence of deficiencies in the installation of the limb;

Muscle strength;

Function of the joint and limb as a whole.

Always check the range of active movements in the joints, and when their restrictions - and passive. The range of movements is determined using a goniometer, the axis of which is set in accordance with the axis of the joint, and the branches of the goniometer are set along the axis of the segments forming the joint. Measuring movements in the joints of the limbs and spine is carried out according to the international method SFTR(neutral - 0 °, S - movements in the sagittal plane, F- in the front, T- movements in the transversal plane, R- rotation movements).

These measurements are recorded in degrees, for example the normal range of motion for the ankle joint is S: 25° -0° -45°. The count is made from the initial position of the limb. It is different for different segments of the limbs: for the shoulder joint the starting position is when the arm hangs freely along the body; for the elbow, wrist, hip, knee joints and fingers, the initial extension position is 180 °. For the ankle joint, the starting position is when the foot is at an angle of 90° relative to the lower leg.

To determine the functional state of the musculoskeletal system in the joints, the range of movements is measured: active (movements in the joint are performed by the patient himself) and passive (movements in the patient’s joint are performed by the researcher). The limit of possible passive movement is the pain experienced by the patient. Active movements sometimes largely depend on the condition of the tendon-muscular system, and not only

Rice. 1.5. Determination of range of motion in the shoulder joint: A- flexion and extension; B - retraction and adduction; B - external and internal rotation

from changes in the joint. In these cases, there is a significant difference between the range of active and passive movements. For example, with a rupture of the triceps brachii tendon, active extension of the forearm is sharply limited, while passive movements are possible within normal limits.

Physiological movements in joints

When studying range of motion, it is necessary to know the limits of physiological movements in the joints.

IN shoulder joint physiological movements - flexion up to 90 °, extension - up to 45 °, abduction - up to 90 °, further abduction occurs with the participation of the scapula and possibly up to 180 °. Rotation movements are possible in the shoulder joint (Fig. 15). When maintaining them in full, the subject can freely place his palm on the back of his head and lower it down between the shoulder blades (outward rotation) or touch the lumbar spine with the back of the hand and move the hand up to the shoulder blades (inward rotation).

Movements in elbow joint possible within the following limits: flexion - up to 150 °, extension - up to 0 °. Pronation-supination movements of the forearm in the elbow joint are determined in the position as shown in Fig. 1.6, and are possible within 180 °.

To determine the volume of rotational movements of the limbs, rotatometers are used (Fig. 1.7).

IN wrist joint movement carried out within 60-90° til

Rice. 1.6. Determination of range of motion in the elbow joint: A - - pronation and supination

Rice. Determination of range of motion in the elbow joint: A - flexion, extension and hyperextension; B - pronation and supination

leg retraction and 60-80° palmar flexion. Lateral movements of the hand are also determined - radial abduction within 25-30° and ulnar abduction within 30-40° (Fig. 1.8).

Rice. 1.8. Determination of range of motion in the wrist joint: A - dorsal and palmar flexion B - radial and ulnar deviation

Rice. 1.9. Internationally recognized designations of the joints of the II-V fingers: DIP - distal interphalangeal joint RIR - proximal interphalangeal joint MCP - metacarpophalangeal joint

Rice. 1.10. Internationally recognized designations of the joints of the first finger of the hand: IP - interphalangeal joint of the thumb MCP - metacarpophalangeal joint of the thumb CMC - carpometacarp joint of the thumb

Rice. 1.11. Abduction and adduction of the first finger in the plane of the palm

Rice. 1.12. Abduction and adduction of the first finger perpendicular to the plane of the palm

Rice. 1.13. Rotation of the first finger

Rice. 1.14. Flexion and extension of the first finger in the metacarpophalangeal and interphalangeal joints

IN fingers extension is possible within 180 °, flexion in the pyastkovo-phalangeal joints is possible up to an angle of 90 °, in the interphalangeal joints - up to 80-90 °. Lateral movements are also possible in the fingers. It is especially important to determine the abduction of the first finger and the possibility of opposition between the first and fifth fingers (Fig. 1.9-1.16).

Rice. 1. 15. Flexion and extension of the II-V fingers in the interphalangeal joints and metacarpophalangeal joint

Rice. 1.16. Opposition (opposition) and finger: A - starting position; B - start of movement; IN - position of opposition

Figure 1.17. Determination of the range of motion in the hip joint: flexion and extension in the supine position

Rice. 1.18. Determination of the range of motion in the hip joint: hyperextension in the supine position

Rice. 1.19. Determination of the range of motion in the hip joint: abduction and adduction in the supine position

Rice. 1.20. Determination of the volume of rotational movements in the hip joint: external and internal rotation in the supine position

IN hip joint normal range of motion: flexion - 140°, extension 0°, hyperextension - 10°, abduction 30-45°, adduction 20-30° (Fig. 1.17-1.20).

When examined in the position of hip flexion up to 90°, the volume of rotational movements increases

Rice. 1.21. Determination of the range of motion in the knee joint: flexion, extension and hyperextension

up to 90° (Fig. 1.20). The indicated figures are determined for a person who is in a supine position. The range of motion in a standing position decreases. The range of motion in the hip joint is greater with a flexed than with an extended knee joint.

IN knee joint movements are possible within the following range: extension 0°, flexion 120-150°. There is slight hyperextension - up to 10°. With the knee extended, lateral and rotational movements of the leg are impossible. When the knee is bent at an angle of forty-five, rotation of the tibia is possible within 40 °; when the knee is bent to 75 °, the volume of rotation of the tibia reaches 60 ° and minor lateral movements become possible (Fig. 1.21-1.23).

Range of motion in ankle joint lies within 20-30° of dorsiflexion (extension of the foot) and 30-50° of plantar flexion (Fig. 1.24). Adduction of the foot, as a rule, is combined with supination (rotation of the foot inward), abduction is accompanied by pronation (rotation of the foot outward) (Fig. 1.25).

During examination feet it is necessary to evaluate the shape, range of motion and condition of the arch. Typical conditions encountered in clinical practice are shown in Fig. 1.26.

When assessing foot movements, in addition to measuring the range of motion in the toes, it is necessary to evaluate the axis of the heel bone and the shape of the toes.

Impaired movement in the joint

When mobility in a joint is impaired, depending on the degree of restriction and the nature of the changes that disrupt normal joint mobility, the following conditions are distinguished:

1) ankylosis or complete immobility in the affected joint

2) rigidity - maintaining movements in the joint no more than 5 °;

Rice. 1.22. Clinical example of determining the range of motion in the right knee joint using an inclinometer: A - flexion; B - extension. There is limited flexion in the right knee joint

Rice. 1.23. Clinical example of determining the range of motion in the left knee joint: A - flexion; B - extension. There is a full range of motion in the left knee joint

Rice. 1.24. Determination of range of motion in the ankle joint: A - pronation; B - supination: B - dorsiflexion and plantarflexion

Rice. 1.25. Determination of range of motion in the joints of the toes: a) assessment of mobility in the toes; b) flexion measurements; c) extension measurements

Rice. 1.26. Foot examination. Often the variants of the structure of the forefoot are: a) Greek, b) square, c) Egyptian. Assessment of the medial longitudinal arch of the foot: d) normal; e) absence of an arch, but flat feet; f) abnormally high arch, or hollow foot. Assessment of the position of the hindfoot: g) normal position with valgus deviation of the calcaneus from 0 to 6 °; j) if the angle of valgus deviation exceeds 6 °, it is a valgus foot (in case of any varus deviation of the calcaneus, a varus foot is stated). The most important deformities of the fingers: l) HAMMER finger in the proximal interphalangeal joint m) HAMMER finger in the distal interphalangeal joint n) nail finger (according to JD Lelievre)

3) contracture - restriction of mobility in a joint, turns out to be the usual research methods;

4) excessive mobility, that is, expanding the boundaries of physiologically possible movements;

5) pathological mobility - mobility in atypical planes that do not suit the shape of the articular surfaces of this joint.

After determining the degree of impaired mobility in the joint, it is necessary to find out the nature of the pathological changes that caused the impaired movement, and the functional suitability of the affected limb with this change in movement in the joint.

Ankyloses are distinguished: a) bone, in which the property in the joint is caused by bony fusion of the articular ends of the articulating (Fig. 1.27) b) fibrous - arise as a result of fibrous, cicatricial adhesions between the articular surfaces (Fig. 1.28); c) extra-articular, when the cause of real estate in the joint is the extra-articular formation of bone fusion between articulating bones or ossification

Rice. 1.27. Bone ankylosis of the supracalcaneal-ankle joint: there is bony fusion between the supraccaneal and tibia bones

Rice. 1.28. Fibrous ankylosis of the supra-ankle joint: attention should be paid to the presence of a joint space

soft tissues surrounding the joint, with preserved joint space.

The decisive role in determining the nature of ankylosis belongs to radiography. With bone ankylosis, there is no joint space (Fig. 1.27), bone beams pass through the area of ​​​​the former articular space, connecting the articular ends of the bones into one whole. With fibrous ankylosis, the joint space is visible (Fig. 1.28). There are functionally advantageous and functionally disadvantageous ankylosis.

Positions in the joint are advantageous when, due to the mobility of adjacent joints, maximum functional fitness of the limb is achieved.

The functionally advantageous provisions are as follows:

For the shoulder joint: shoulder abduction to an angle of 60-70°, flexion to an angle of 30° and external rotation of 45°

For the elbow joint: flexion at an angle of 75-80 °, forearm in supinated position;

For the wrist joint: the hand is placed in dorsiflexion (extension) at an angle of 25° with ulnar abduction of 10-15°;

For the joints of the II-V fingers: in the metacarpophalangeal joints, flexion to an angle of 45 °, in the interphalangeal joints - flexion to 60 °; And the finger is placed in the position of opposition (opposition) with slight flexion of the terminal phalanx;

For the hip joint: hip flexion to an angle of 45° in a sitting profession and to an angle of 35° in a standing profession, abduction by 10°;

For the knee joint: flexion at an angle of 5-10 °;

For the ankle joint: plantar flexion of the foot to an angle of 5°.

Rigidity is caused by the development of large scar tissue against the background of altered articular surfaces. It differs from fibrous ankylosis in that very slight rocking movements are retained in the joint - up to 5°.

It is important to determine the causes of contractures that occur in the joints. According to the nature of structural changes in tissues, the following contractures are distinguished: arthrogenic (scar changes in the capsule and intra-articular ligamentous apparatus), myogenic (degeneration of muscle tissue), desmogenic (wrinkling of fascia and ligaments), dermatogenic (scar changes in the skin), psychogenic (hysterical), neurogenic (cerebral , spinal, reflex, etc.). Most often, contractures are mixed, since contracture, which initially arose as a result of changes in one tissue (myogenic, neurogenic), subsequently leads to secondary changes in the tissues of the joint (ligaments, joint capsule, etc.).

Isolated contractures (with one etiological factor) occur only in the early stages of development. According to the nature of the limitation of mobility in the joints, they are distinguished: bending, extension, drive, abduction and combined contractures.

For a better understanding of these concepts, we provide examples of the possible development of contractures in the hip joint:

Flexion contracture is characterized by the fact that the leg is in a flexion position at a certain angle and the patient cannot fully straighten the leg;

Extensor contracture is characterized by the fact that extension in the joint is possible to normal, while flexion is limited;

Adductor contracture is characterized by the fact that the leg is adducted, but it is impossible to move it to normal limits;

Abduction contracture - when the leg is abducted and adduction is impossible;

Combined contracture, for example, flexural-drive (in this case, extension and abduction of the leg to normal is impossible).

In contrast to the changes in the joints listed above, which are manifested by limitation or absence of movements in them, in some cases excessive and pathological mobility is observed. The study of lateral mobility in single-plane joints (elbow, knee, ankle and interphalangeal joints) must be performed with the joint fully extended.

Additional mobility can be caused by both changes in the soft tissues of the joint (ligament ruptures, changes in connection with flaccid paralysis) and destruction of the articular surfaces of the articulating bones (fracture of the articular surfaces, destruction after epiphyseal osteomyelitis, etc.).

Joints in which pathological movements reach a significant volume are called joints.

Rice. 1.29. Study of lateral mobility in the knee joint

dangling or loose. The study of excessive mobility in the joints is performed as follows. The researcher fixes the proximal segment of the limb with one hand, and with the other, grasping the distal segment, in a position of full extension in the joint, determines movements that are not characteristic of the joint (Fig. 1.29).

In some joints, pathological mobility is determined by special techniques. For example, when the crossed ligaments of the knee joint are damaged, the so-called “box” symptom occurs, which consists of anteroposterior displacement of the tibia. To determine this symptom, the patient lies on his back, bending the sore leg at the knee joint at an acute angle and resting his foot on the couch; the muscles should be completely relaxed. The doctor grabs the shin with both hands directly under the knee joint and tries to move it alternately anteriorly and posteriorly. When the crossed ligament is broken, anterior-posterior displacement of the tibia relative to the thigh becomes possible.

This information is intended for healthcare and pharmaceutical professionals. Patients should not use this information as medical advice or recommendations.

Assessment of the range of motion in the joints of the limbs

Doctor of physical therapy and sports medicine V. Ryvkin

Summarizing the experience of the physical therapy department in restoring the functions of the joints of the extremities, we offer our vision of the table for assessing the range of motion in the joints.

We have taken descriptive and dynamic human anatomy as the basis for measuring the range of motion in joints. Used uniform principle of angle measurement: "measured the angle between the distal (movable) part of the limb and the proximal (fixed) part of it».

Joint	Movement	Norm	Movement limitation, °
			minor	moderate	significant
Shoulder with shoulder girdle	Flexion		179-135	134-100	<100
	Lead		179-135	134-100	<100
Shoulder (simple)	Extension		59-40	39-15
	Rotation internal		89-45	44-20
	External rotation		89-45	44-20
Elbow (complex)	Flexion		31-70	71-90
	Extension		179-150	149-120	<120
Combined elbow-brachial	Pronation of the hand		89-45	44-20
	Supination of the hand		69-30	30-15
Carpal (combined)	Flexion		106-145	146-160	>160
	Extension		116-150	149-165	>165
	Abduction radial		161-175	176-185	>185
	Abduction ulnar		141-155	154-180	>180
Hip (simple)	Flexion with extension at the knee joint		91-120	121-150	>150
	Flexion with knee flexion		61-90	91-150	>150
	Extension		141-160	161-170	>170
	Lead		49-30	29-15
	Rotation internal		34-25	24-15
	External rotation		44-25	24-15
Knee (complicated)	Flexion		134-90	89-60
	Extension		179-170	169-160	<160
Ankle (complex)	bending		129-120	119-100	<100
	Extension		71-80	79-90

In the table we offer, we have changed incorrect settings tables for assessing joint movements Regulations on military medical examination(approved by Decree of the Government of the Russian Federation No. 123 of February 25, 2003), in which:

Rotation in the shoulder joint (internal and external) is not indicated.

Pronation and supination in the elbow joint impossible. The elbow joint is complex, consists of three joints (humeroulnar, humeroradial, radioulnar), and is trochlear in shape. Movements in the elbow joint are normally possible only around one transverse (frontal) axis: flexion-extension. Pronation and supination of the hand are ensured by three joints: the distal cylindrical radioulnar, the proximal cylindrical radioulnar and the humeroradial spherical. This is a combined joint. The range of motion is measured from the starting position “neutral” with elbow flexion (90°). Pronation is normally at least 90 degrees. Supination – at least 70 degrees.

and flexion at the elbow joint (90th position ": distal cylindrical radioulnar, proximal cylindrical radioulnar

Flexion at the hip joint depends on the condition of the knee joint. When the limb is bent at the knee joint, flexion at the hip joint up to 30 degrees differs from that if the knee joint is extended.

Extension in the hip joint is performed around the transverse axis and does not exceed 140° between the thigh and torso (but not 180°, as indicated in the Regulations...). Extension at the hip joint ensures correct gait and running.

Not marked rotation at the hip joint(internal and external).

Replace:

• the term "plantar flexion" to "flexion";
• the term "dorsiflexion" to "extension".

Not secured a unified approach to measuring range of motion in joints- movement of the moving part of the limb (distal) in relation to the fixed part (proximal).

Conclusions:

1. The proposed approach to measuring the range of movements in the joints of the limbs allows us to streamline the goniometry scheme.

2. The proposed version of the table for assessing range of motion in joints is more acceptable for practical work and for expert assessment of the degree of impairment of range of motion in joints of the limbs.

Depending on whether the patient himself makes movements in the joint or whether they are performed by the examiner without the patient’s effort, the movements are accordingly divided into active and passive.

joint, degrees, movements, volume, performed, hyperextension, knee, mobility, mobility, dorsal, normal, due

Depending on whether the patient himself makes movements in the joint or whether they are performed by the examiner without the patient’s effort, the movements are accordingly divided into active and passive.

There are also normal movements performed in the volume characteristic of a given joint in physiologically possible directions, and pathological movements in the joint. The latter include movements performed in unusual planes or limits for a given joint.

Movements in the joints can occur in the frontal and sagittal planes. In the frontal plane, they produce abduction (abductio) and adduction (adduclio), in the sagittal plane - flexion (flexio) and (extensio). In relation to the ankle and wrist joints, it is customary to add plantar, dorsal and palmar flexion (plantar flexion, dorsal extension of the foot, palmar flexion or dorsal extension of the hand, etc.). If the hand is abducted or adducted at the wrist joint, we speak of ulnar or radial deviation of the hand.

(rotatio) - external and internal - occurs around the longitudinal axis of the limb or its individual segments. For example, if you press your arm bent at the elbow joint at a right angle to your body and rotate your forearm outward as much as possible so that your palm faces upward, you speak of supination of the forearm. If the forearm is internally rotated and the palm is facing the floor, they speak of pronation of the forearm. The rotation of the forearms can also be determined by rotating the vertically raised forearms and hands with the elbow joints of the bent arms of the patient sitting at the table symmetrically installed.

The foot may also be rotated around its longitudinal axis (rotation of the foot inward - pronation, outward - supination). Rotational movements can also be performed by the body around its longitudinal axis.

Normally, movements in the shoulder joint are performed in the frontal plane - abduction up to 90 degrees and around the long axis of the shoulder - rotation inward and outward within 20-35 degrees. In the sagittal plane - flexion up to 130-135, extension up to 35-45 degrees. The arm extended forward to a horizontal position can be retracted back to an angle of 120 degrees and brought towards the opposite arm (towards the midline of the body) to an angle of 30 degrees. Further movements are possible, but they are performed by the entire shoulder girdle with the scapula and collarbone, especially when flexing and abducting the shoulder.

At the elbow joint, the forearm is flexed to an angle of 140-150 degrees, hyperextension in it is possible up to 3-5 degrees, especially in women.

In the wrist joint, movements are made towards the palmar surface - palmar flexion of the hand up to 45-75 degrees, towards the rear - dorsiflexion (or dorsal extension) up to 45-60 degrees, deviation of the hand to the radial side (abduction) - 15-20 degrees and ulnar (adduction) - 35-40 degrees. Prosupination movements of the hand (turning inward and outward) together with the forearm are performed within 80 degrees in either direction.

The following range of motion is typical for the joints of the lower limb. In the hip joint, flexion-extension movements are performed from the sagittal plane: flexion up to 120-140 degrees, extension, or hyperextension, up to 10-15 degrees. In the frontal plane, abduction up to 30-50 degrees and adduction up to 30-40 degrees are performed. Rotational movements are determined in the position of full extension of the hip or when it is flexed at the hip joint at an angle of 90 degrees.

The range of these movements occurs within 45 degrees in one direction (internal rotation) and the other (external rotation). Further movements in the hip joint are possible, but they are performed with the pelvis.

In the knee joint, movements are carried out in the sagittal plane: flexion up to 140-155 degrees, hyperextension in the knee joint is possible within 5-10 degrees.

In the ankle joint: plantar flexion up to 45-65 degrees, dorsiflexion (extension) up to 25-35 degrees. A small range of pronation and supination of the foot, accomplished in the ankle and talocalcaneal-navicular joints, is possible, as well as adduction and abduction of the forefoot within 30 degrees, accomplished through movement in small joints.

The range of movements in the spinal column is carried out by bending and turning the head and torso. With normal mobility in the cervical spine, the tilt of the head forward is 70-80 degrees, backward - 50. The rotation of the head to the right and left is 80 degrees. Normally, with straightened legs, the tilt of the body forward is 75-90 degrees, backward - 50-60, and the tilt of the body to the right or left is within 35-40 degrees. The range of rotational movements in the thoracic and lumbar spine is moderate (within 20-30 degrees).

The mentioned range of motion for each joint separately can vary upward or downward. The range of motion in a particular joint should always be determined in comparison with a healthy joint.

As a result of an inflammatory disease, injury, congenital deformity or systemic disease of the movement apparatus and support in the joint, changes may occur that lead to a limitation in the range of motion (incorrectly healed intra-articular or ordinary fracture, congenital stiffness or contracture of the joint, etc.), their increase or appearance pathological mobility in the joint.

In accordance with the degree of limitation of the range of motion in the joint caused by some pathological condition or its consequence, they are distinguished: contracture - the range of motion is preserved, but limited, rigidity - the range of motion is sharply limited, subtle, rocking movements are determined, no more than 3 -5°, and ankylosis - complete immobility in the joint, the articular surfaces are fused. When determining the degree of immobility, it is important to find out the nature of the pathological changes that led to limitation of joint function. The position of the limb in which it is located due to limited mobility in the joint or joints is noted (flexion position in the knee joint at an angle of 30 degrees, etc.).

Normally, there is sometimes slight excess movement in some joints. For example, in the hip, knee and elbow joints (especially in women), excessive hyperextension is normally observed. In men, especially in those with highly developed muscles, this is less pronounced. To determine hyperextension in the joint, hold the proximal segment with one hand, and with the other, hyperextend the distal segment of the limb and note its degree. If there is no hyperextension, and the movement is accompanied by a painful sensation, this indicates an early symptom of developing contracture, which is a consequence of the onset of a pathological process in the joint (for example, the absence of hyperextension in the joint is an early sign of tuberculosis). Along with limited mobility in the joint, excessive mobility in the joint can be a pathognomonic symptom in a number of diseases and injuries of the joints.

An increase in the range of motion in the plane characteristic of normal movement in the joint can be observed, for example, with the consequences of poliomyelitis (excessive hyperextension in the hip or knee joint, excessive hip abduction, etc.).

Pathological mobility can be a consequence of injury and various diseases (lateral mobility in the knee joint with the leg straightened after damage to the fibular or tibial collateral (side) ligaments; looseness in the ankle joint due to polio, etc.).

When determining excessive movement or pathological mobility, as well as when identifying contractures, the proximally located segment is fixed with one hand, and the degree of increase in the range of movements is determined with the other. Excessive mobility includes not only hyperextension in the joint, but also the usually absent lateral mobility in joints in which movements are normally performed in the same plane. These joints include the elbow, knee, interphalangeal joints of the toes and hands, and partially the ankle joint. Lateral mobility in the mentioned joints is determined with their full extension only if the lateral ligaments and articular surfaces are damaged (intra-articular fractures), the tone of the muscular-ligamentous apparatus decreases due to diseases such as progressive muscular dystrophy, the consequences of cerebral palsy, etc. Of all the listed joints, lateral mobility due to weakness of the musculo-ligamentous system most impairs the function of the knee joint. In this case, the supporting function of the lower limb is impaired, the patient complains of instability of the leg, its weakness, and uncertainty when walking.

When identifying the range of motion in a joint, first determine the comparative volume of active movements, then examine the range of passive movements and identify pathological mobility in the joint. The amplitude of movement is measured from the initial position occupied by the joint with a free vertical position of the torso and limbs. Movements in the joints of the spinal column (flexion, extension, abduction and adduction, bending to the right, left, rotational movements) should be performed smoothly, without jerking or violence. The range of motion is measured using a protractor.

The simplest protractor consists of a protractor with divisions from 0 to 180 degrees and two jaws. A graduated scale is attached to one of them, and the other has a pointed end. The branches are connected by a hinge. When measuring, the jaws of the goniometer are placed along the axis of the corresponding segments so that the ball of the jaws coincides with the axis of rotation of the joint. The pointed end of one of the jaws indicates the angle in degrees on the graduated scale of the protractor. In recent years, a protractor with a weighted end of a freely rotating arrow has become widespread. Thanks to this device (one end of the arrow with a load), the latter always occupies a strictly vertical position. By rotating the goniometer in a vertical plane and aligning one of its two mutually perpendicular lines with the axis of the bent segment, the desired angle of flexion of the limb in the joint is obtained. With this measurement method, the axis of rotation of the joint must coincide with the axis of rotation of the protractor needle. The range of rotational movements is measured with a rotameter. The degree of limitation of the normal range of motion in a joint can vary - from barely noticeable limitation to complete immobility in the joint.

When determining the range of movements in a joint, it is important to know the force with which they are performed. Sometimes, as a result of an illness or injury, the strength of a muscle or muscle group is preserved so much that it can provide the required amount of movement in the joint, but the strength of movement in the joint is so small that it does not satisfy the functional demands under normal normal load. An example is a decrease in strength or complete loss of function of the quadriceps femoris muscle when it is isolated due to cerebral palsy (poliomyelitis). A patient with this pathology cannot walk or put weight on a leg slightly bent at the knee joint when standing on one leg. To lean on it while walking or standing, the patient resorts to additional efforts, i.e. presses at the moment of support on the front surface of the thigh. With this action, he “locks” the knee joint, i.e. puts it in a position of full extension at the moment of loading the limb and holds it with the hand in such a position that makes the lower limb supportable. If such a knee joint is not “closed” under load, the leg will immediately give way at the moment of support and the patient will fall. That is why, in order to develop a treatment plan, it is extremely important to know the strength of both individual muscles and their groups, as well as the strength of antagonist muscles.