Hand Surgery Source

Total Active ROM

Test, Exam and Signs

Historical Overview

  • Range of motion (ROM) is an essential component of hand function evaluation and one of the most commonly measured variables by hand surgeons.1,2
  • Historically, physicians used a metric ruler or goniometer to measure active ROM.3 Manual goniometers can measure joints efficiently, but their use may result in up to 10° of inaccuracy.4 By 2006, a new goniometer was developed, particularly for the measurement of small joints.5

Description

  • Total active ROM, or total active motion (TAM), is the sum of the active metacarpophalangeal (MP), proximal interphalangeal (PIP), and distal interphalangeal (DIP) arc of motion in degrees of an individual digit. This value can then be compared with that of the contralateral hand or a normative value to provide a more accurate assessment of each digit’s active ROM.6,7

Pathophysiology

  • There are a number of conditions that may contribute to loss of TAM, including rheumatoid arthritis (RA), osteoarthritis (OA), Dupuytren’s disease, trigger finger, trigger thumb, and neurological injuries.6,8
  • TAM can also be restricted by pain, fracture, or tenosynovitis, and in patients recovering from hand surgery such as a flexor tendon repair. In inflammatory tenosynovitis, there will be a decrease of active flexion.7,9

Instructions

  1. Obtain an accurate and complete patient history, including any sports-related injuries. Ask the patient to rate the amount of pain s/he normally experiences in their fingers on a scale from 1-10.
  2. Evaluate the patient’s ability to flex and extend the MP, PIP, and DIP joints of each finger, and measure values for each joint separately with a goniometer.3
  3. Calculate the TAM by subtracting the total active flexion of the MP, PIP, and DIP joints from the total extension deficit of the same joints.7
  4. Repeat the same steps on the corresponding joints of the contralateral hand.
  5. Calculate TAM% by dividing the TAM of the injured finger by the TAM of the contralateral finger.7

Variations

  • Active ROM also evaluates flexion and extension, as well as pronation, supination, abduction, adduction, and rotation of affected joints in the hand, wrist, and/or elbow, and it does not summate the values for finger flexion and extension.

Related Signs and Tests

  • Dorsal-volar technique for wrist ROM4
  • Pulp-to-palm, active
  • Range of motion: Active
  • Range of motion: Passive
  • Total passive ROM
  • Jebsen hand function test10
  • Grip strength
  • Nerve conduction studies
  • Radiographs
  • Magnetic resonance imaging (MRI)

Diagnostic Performance Characteristics

Approximate Typical Active ROM Values9,10

Joint

Motion

Degrees (°)

MP

Extension

0

Flexion

90

PIP

Extension

0

Flexion

120

DIP

Extension

0

Flexion

40-50

 

TAM Evaluation System of the American Society for Surgery of the Hand7

Score

TAM%

Excellent

Normal

Good

<75

Fair

50-75

Poor

<50

 

Diagnoses

  • RA
  • OA
  • Trigger finger
  • Trigger thumb
  • Dupuytren’s disease
  • Tenosynovitis
  • Metacarpal fracture
  • Phalanx fracture
  • Extensor tendon laceration
Presentation Photos and Related Diagrams
Measuring Range of Motion with Digital Goniometer
  • Digital Goniometer
    Digital Goniometer
  • Measuring MP joint range of motion with the digital goniometer
    Measuring MP joint range of motion with the digital goniometer
  • Measuring PIP joint range of motion with the digital goniometer
    Measuring PIP joint range of motion with the digital goniometer
Definition of Positive Result
  • A positive result occurs when the patient displays a TAM% that is fair or poor in at least one of the digits evaluated.
Definition of Negative Result
  • A negative result occurs when the patient displays a TAM% that is good or excellent in every digit evaluated i.e. the patient has a normal range od motion in all joints.
Comments and Pearls
  • For patients with RA, therapy gloves may improve active ROM.11
  • In order to assess finger ROM thoroughly, the wrist must be in neutral position to allow tendon excursion of the fingers’ long flexors and extensors. Flexion of one finger is measured by maximally flexing the other three fingers, and extension of one finger is measured by maximally extending the other three fingers actively.1
  • If there is a difference between joint active and passive ROM, this is called active-passive mismatch, which may be caused by a tendon adhesion.3
Diagnoses Associated with Tests, Exams and Signs
References
  1. Culp R, Jacoby S. Musculoskeletal Examination of the Elbow, Wrist and Hand: Making the Complex Simple. New Jersey: SLACK Incorporated, 2012.
  2. Carter TI, Pansy B, Wolff AL, et al. Accuracy and reliability of three different techniques for manual goniometry for wrist motion: a cadaveric study. J Hand Surg Am 2009;34:1422-28. PMID: 19703734
  3. Stam HJ, Ardon MS, den Ouden AC, et al. The compangle: a new goniometer for joint angle measurements of the hand. A technical note. Eura Medicophys 2006;42(1):37-40. PMID: 16565684
  4. Gates DH, Walters LS, Cowley J, et al. Range of motion requirements for upper-limb activities of daily living. Am J Occup Ther 2016;70(1) Epub ahead of print. PMID: 26709433
  5. Adams BD, Grosland NM, Murphy DM, McCullough M. Impact of impaired wrist motion on hand and upper-extremity performance(1). J Hand Surg Am 2003;28(6):898-903. PMID: 14642503
  6. Hume MC, Gellman H, McKellop H, Brumfield RH Jr. Functional range of motion of the joints of the hand. J Hand Surg Am 1990;15(2):240-3. PMID: 2324451
  7. Rayan G, Akelman E. The Hand: Anatomy, Examination, and Diagnosis. Philadelphia: Lippincott Williams & Wilkins, 2012.
  8. Kenney RJ, Hammert WC. Physical examination of the hand. J Hand Surg Am 2014;39(11):2324-34. PMID: 25442747
  9. Nasir SH, Troynikov O, Massy-Westropp N. Therapy gloves for patients with rheumatoid arthritis: a review. Ther Adv Muskuloskelet Dis 2014;6(6):226-37. PMID: 25435925