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© 1996 The Journal of Bone and Joint Surgery, Inc. Normal Range of Motion of the Joints of the Upper Extremity in Male Subjects, with Special Reference to Side*   , ESKISEHIR, TURKEYInvestigation performed at the Department of Orthopaedics, University Hospital, Osmangazi University, Eskisehir
We measured, with a universal full-circle manual goniometer, the active and passive arcs of motion of the shoulder, elbow, forearm, and wrist in 1000 healthy male subjects who were right-hand dominant and who ranged in age from eighteen to twenty-two years. The ranges of motion on the right side were significantly smaller than those on the left. We concluded that the contralateral, normal side may not always be a reliable control in the evaluation of restriction of motion of a joint.
Measurements of the range of motion of joints commonly are recorded in a patient's medical record, as they are considered to be acceptable clinical data for the evaluation of impairment14. Operative intervention frequently is necessary for the treatment of an infection, fracture, dislocation, traumatic injury, or other impairment of or about a joint, and the functional outcome of the treated extremity must be evaluated critically. A number of reports have provided estimates of the normal ranges of motion of joints of the upper extremity1,3,5,6,12,13,15,16. Some of these reports did not describe the population that was surveyed or specify the method of measurement that was used. As it often has been assumed that there is no important difference between the ranges of motion on the right and left sides, the uninvolved limb has been used routinely for comparison with the affected limb in the presence of disease or other lesions7,16. Much of the available data regarding side-related changes in the range of motion have been derived from studies in which the size of the sample was too small to demonstrate a difference between the sides5,12. The purpose of the present study was to determine the active and passive ranges of motion of joints of the upper extremity in male subjects, with special reference to the side (dominance) of the extremity.
One thousand healthy male volunteers, who were eighteen to twenty-two years old, had a physical examination before entry into military service. All were functionally right-handed and therefore were considered to be right-hand dominant. Any individual who had a history of illness or injury involving any joint of either upper extremity was excluded from the study.
Two examiners ( Active and passive ranges of motion were measured with a full-circle manual goniometer made of flexible clear plastic with arms that were thirty centimeters long; this device fulfilled the requirements of a universal goniometer as described by Moore. The protractor portion was divided into 1-degree increments. A small scale on one of the arms made it possible to obtain measurements to the nearest degree. The joints chosen for study were the shoulder, elbow, forearm, and wrist of both upper extremities. The examiners followed specific written directions that defined the position of the extremity and the alignment of the goniometer for measurement of each range of motion; the terminology used in the directions was that established by The American Academy of Orthopaedic Surgeons. The subjects were in the supine position for all measurements except that of extension of the shoulder, for which they were in the prone position. The study was performed in two stages. A pilot study was carried out initially to test the goniometer and to ascertain if the measurements were associated with acceptably low intra-examiner and inter-examiner errors. Before the measurements were made, the goniometer was determined to be accurate to within 1 degree by the measurement of known angles. Twenty subjects, who were not included with the 1000 volunteers, were evaluated independently by the two examiners. The first examiner made sequential measurements of the active and passive ranges of motion. The measurements were recorded, and the goniometer was reset to 0 degrees. The second examiner then measured the active and passive ranges of motion of the same subject, in the same sequence. To reduce the effects of muscle fatigue, the subject was allowed to rest for two minutes between the measurements of passive motion by the first examiner and the measurements of active motion by the second examiner. The sequence was repeated so that the ranges of motion of each subject were measured twice by each examiner. Intra-examiner reliability was determined by a comparison of the first and second measurements of each motion by each examiner. Inter-examiner reliability was determined by a comparison of the first measurements by the first examiner with the first measurements by the second examiner for each subject. After all of the data had been collected for each subject, the examiners were asked to note factors that might have affected the reliability of the measurements. The second portion of the study involved measurement of the active and passive ranges of motion of the shoulder, elbow, forearm, and wrist of both extremities in 1000 male subjects with use of the same protocol as in the pilot study. Measurements were performed first on the left extremity and then on the right. The statistical analyses in the second portion of the study consisted of the calculation of means, standard deviations, t scores, and p values. The Student t test was used to compare the motions on the right side with those on the left. Ninety-five per cent confidence intervals also were calculated for both the general population of the study and the individuals.
The pilot study demonstrated that the mean intra-examiner reliability was within 1.2 degrees for each measurement and that the mean inter-examiner reliability was within 1.6 degrees. The second portion of the study demonstrated significant differences between the right and left shoulders with regard to passive neutral abduction (p < 0.01), active and passive neutral adduction (p < 0.001 for both), active and passive inward rotation (p < 0.001 and p < 0.01, respectively), active and passive outward rotation (p < 0.001 for both), active glenohumeral abduction (p < 0.001), active and passive horizontal flexion (p < 0.001 for both), active and passive horizontal inward rotation (p < 0.001 for both), and active horizontal extension (p < 0.01). Significant differences between the right and left extremities also were noted with regard to active and passive flexion as well as active and passive extension of the elbow (p < 0.001 for all), active and passive supination of the forearm (p < 0.05 and p < 0.001, respectively), and active and passive extension as well as active and passive radial deviation of the wrist (p < 0.001 for all). In all instances, the motion was significantly greater on the non-dominant (left) side (Table I).
Active neutral abduction, passive glenohumeral abduction, passive horizontal extension, and active and passive horizontal outward rotation of the shoulder; active and passive pronation of the forearm; and active and passive flexion and ulnar deviation of the wrist were not significantly different between the two sides and were excluded from the analysis. The 95 per cent confidence intervals that were calculated for the general population for the difference between the right and left extremities with regard to motion of the shoulder were 1.2 to 3.7 for passive neutral abduction, 3.1 to 4.0 for active neutral adduction, 3.5 to 4.6 for passive neutral adduction, 1.8 to 3.7 for active inward rotation, 7.6 to 8.7 for passive inward rotation, 3.0 to 4.4 for active outward rotation, 2.8 to 4.5 for passive outward rotation, 8.6 to 10.3 for active glenohumeral abduction, 5.5 to 6.8 for active horizontal flexion, 3.2 to 4.3 for passive horizontal flexion, 1.7 to 3.6 for active horizontal inward rotation, 3.4 to 4.8 for passive horizontal inward rotation, and 2.1 to 3.9 for active horizontal extension. The 95 per cent confidence intervals for the elbow were 1.7 to 3.0 for active flexion, 2.2 to 3.3 for passive flexion, 1.0 to 2.3 for active extension, and 1.8 to 3.7 for passive extension. For the forearm, the 95 per cent confidence intervals were 0.7 to 2.6 for active supination and 1.7 to 3.4 for passive supination. The 95 per cent confidence intervals for the wrist were 9.1 to 10.1 for active extension, 8.9 to 10.8 for passive extension, 3.2 to 4.1 for active radial deviation, and 5.2 to 6.1 for passive radial deviation (Table I). The 95 per cent confidence intervals that were calculated for individuals for the difference between the right and left extremities with regard to motion of the shoulder were 1.0 to 4.5 for passive neutral abduction, 0.2 to 6.5 for active neutral adduction, 0.4 to 7.9 for passive neutral adduction, 0.7 to 5.4 for active inward rotation, 3.2 to 13.2 for passive inward rotation, 0.2 to 8.0 for active outward rotation, 1.4 to 6.5 for passive outward rotation, 0.7 to 18.0 for active glenohumeral abduction, 2.3 to 10.3 for active horizontal flexion, 1.8 to 5.7 for passive horizontal flexion, 1.7 to 4.0 for active horizontal inward rotation, 3.0 to 5.7 for passive horizontal inward rotation, and 1.2 to 5.4 for active horizontal extension. For the elbow, the 95 per cent confidence intervals were 1.0 to 4.1 for active flexion, 0.7 to 9.0 for passive flexion, 0.1 to 4.0 for active extension, and 0.4 to 3.9 for passive extension. The 95 per cent confidence intervals for the forearm were 0.6 to 2.9 for active supination and 1.5 to 4.2 for passive supination. For the wrist, the 95 per cent confidence intervals were 7.2 to 11.5 for active extension, 5.3 to 14.7 for passive extension, 2.5 to 5.2 for active radial deviation, and 3.2 to 8.3 for passive radial deviation (Table I). Additional comparisons revealed that the passive ranges of motion were greater than the active ranges for all of the joints. This was especially true for neutral adduction, inward and outward rotation, horizontal flexion, and horizontal inward rotation of the shoulder; flexion and extension of the elbow; supination of the forearm; and extension and radial deviation of the wrist.
Objective measurements of joint function are being required with increasing frequency as indices of improvement following a certain course of treatment. In addition, they are often an essential component of an impairment rating. In the current study, side-specific measurements of certain types of joint motion were obtained with use of a universal goniometer. Goniometry is the method most widely used to measure range of motion, and its reliability is affected by many factors4,7,9,15. A review of the literature revealed that many of the reported studies of the motion of the joints of the upper extremity in normal men were based on small numbers of subjects3,5,6,12,13,15,16. Some of these reports did not indicate whether the values represented the active or the passive range of motion or whether the values that were given for the normal range of motion were appropriate for all age-groups. These previous reports also did not specify the gender, occupation, cultural and social status, dominant hand, or social background of the subjects; the position of the subjects during measurement; or the number of subjects who were evaluated to estimate the normal range of motion. This makes comparison of the results difficult or impossible. There has been no unanimity among previous authors with regard to the normal range of motion of the joints of the upper extremity, and differences were found between the results obtained in the present study and those reported previously2,3,5,16. We noted significant differences between the right and left sides with regard to several different ranges of joint motion. This is in contrast with some previous reports in which inconsistent differences between the right and left sides were attributed to chance, leading to the recommendation that the contralateral, normal extremity can be used to determine the normal range of motion in an individual who has restricted motion of a joint7,14,16. As Hurt stated, "The most reliable indication of the normal for any patient is the measurement of motion in the unaffected joint on the opposite side." This conclusion has been based on studies involving small numbers of patients5,12. Our observation that the ranges of motion on the left side were larger than those on the right side was consistent with the findings reported by Allander et al. and by Nemethi. The reduced mobility on the right side compared with that on the left might have been the result of slight degenerative changes in the joint as well as damage to the ligaments of the right upper extremity in a right-handed population. A difference of 5 to 10 degrees of motion often may be important in the evaluation of a patient, and it must be remembered that when the total range of motion of a joint (for example, the arc of flexion and extension of the wrist) is calculated the importance becomes more prominent. Because of the variability in motion according to gender, race, and age, national estimates of joint mobility should be determined and should include the side of the dominant limb, the gender and race of the subjects, and the method used to measure the motion of the joint.
NOTE: The authors thank Mr. K. Özdamar, Professor of Statistics, for his help.
*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.
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Abstract
Introduction
. G. and N. K.) evaluated each of the subjects independently. The examiners were orthopaedic surgeons with ten and four years of specialty practice and were employed at the orthopaedic clinic of University Hospital, Osmangazi University, Eskisehir, Turkey. 
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