- Email: [email protected]
Influence of elbow flexion angle on mobilization of the proximal radio-ulnar joint: A motion analysis using cadaver specimens
Available online at www.sciencedirect.com
Manual Therapy 14 (2009) 278e282 www.elsevier.com/math
Original Article
Influence of elbow flexion angle on mobilization of the proximal radio-ulnar joint: A motion analysis using cadaver specimens Sadanori Ohshiro a, Egi Hidaka a, Shigenori Miyamoto b, Mitsuhiro Aoki b,*, Toshihiko Yamashita c, Haruyuki Tatsumi d a
Graduate School of Health Sciences, Sapporo Medical University, School of Health Sciences, South-3, West-17, Chuo-ku, Sapporo 060-8556, Japan Department of Physical Therapy, Sapporo Medical University, School of Health Sciences, South-3, West-17, Chuo-ku, Sapporo 060-8556, Japan c Department of Orthopaedic Surgery, Sapporo Medical University, School of Medicine, South-3, West-17, Chuo-ku, Sapporo 060-8556, Japan d First Department of Anatomy, Sapporo Medical University, School of Medicine, South-3, West-17, Chuo-ku, Sapporo 060-8556, Japan
b
Received 30 May 2007; received in revised form 20 February 2008; accepted 28 February 2008
Abstract The purpose of this study was to determine the most effective elbow joint flexion angle for mobilization of the proximal radioulnar joint. Five fresh-frozen cadaveric elbows were used to measure displacement of the radial head in the antero-medial and postero-lateral directions by traction force of 2 kgf and 4 kgf, respectively. Simulation of the gliding of the proximal radio-ulnar joint was performed at four elbow flexion angles (0 , 30 , 60 , 90 ). Data obtained from those flexion angles were compared using one-way repeated measures analysis of variance. Radial head displacement at 60 and 90 during antero-medial gliding were significantly greater than those at 0 and 30 ( p < 0.05) There were no significant differences in radial head displacement among four elbow flexion angles during postero-lateral gliding at 2 kgf and 4 kgf. Our findings suggest that proximal radio-ulnar joint mobilization in the antero-medial direction can be performed effectively at 60 and 90 elbow flexion. Ó 2008 Elsevier Ltd. All rights reserved. Keywords: Proximal radio-ulnar joint; Joint mobilization; Motion analysis; Cadaveric study
1. Introduction Anatomically, the elbow is a uni-axial hinge joint formed of two articulations, i.e., the humero-ulnar and humero-radial joints that allow for movement of flexion and extension, and is referred to as the cubital articulation. The cubital articulation and proximal radio-ulnar joint are collectively termed ‘the joint complex’. Pronation and supination are motions of the proximal radio-ulnar joint that play an important role on * Corresponding author. Tel.: þ81 11 611 2111x2874; fax: þ81 11 611 2150. E-mail address: [email protected] (M. Aoki). 1356-689X/$ - see front matter Ó 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2008.02.012
the motion of the wrist and fingers (Kapandji, 1982). Once this motion sequence of the upper extremity is disrupted, activities of daily living, such as having meals and perineal care, are severely restricted. One of the major causes of limitation in forearm rotation is post-traumatic contracture after fracture or fracture dislocation of the elbow. Even after appropriate treatment of these injuries by experienced orthopaedic surgeons, contracture of the elbow is occasionally observed. In such cases, physiotherapy for the elbow becomes extremely important. Restricted motion of the proximal radio-ulnar joint is considered to be caused by a thickening of the capsule and a reduction in the flexibility of the collateral ligaments (Morrey and An, 1985; Herting and Kessler, 1996).
S. Ohshiro et al. / Manual Therapy 14 (2009) 278e282
279
To solve this problem, joint mobilization of the proximal radio-ulnar joint has been used as an effective manual procedure (Miyamoto, 1985; Butler, 1994; Kisner and Colby, 2002). This procedure consists of gliding the radial head in an antero-medial direction for pronation contracture of the forearm, and in a postero-lateral direction for supination contracture (Maitland, 1991; Herting and Kessler, 1996; Edmond, 2006). However, there has been no report concerning the evidence of the effective elbow flexion angle for proximal radio-ulnar joint mobilization. In this experiment, fresh-frozen cadaveric elbows were used to measure the displacement of the radial head during antero-medial and postero-lateral gliding at four elbow flexion angles (0 , 30 , 60 , 90 ). The purpose of this study was to determine the most effective elbow joint flexion angle for mobilization of the proximal radio-ulnar joint.
2. Materials and methods 2.1. Preparation of the specimens On February 27, 2006, the Ethical Committee of our university approved all types of surgical training, and biomechanical studies using frozen-thawed cadavers donated to the Department of Anatomy. This experiment used five frozen-thawed upper extremities that were obtained from five fresh cadavers aged 60e87 years at death (average, 78.2 years) after the acquisition of informed consent prior to death. Two right elbows and three left elbows were taken from two male and three female specimens. The elbows were kept in a freezer at e20 C after disarticulation at the glenohumeral joint. Specimens with a limited range of elbow and forearm motion were excluded from this study. Thawing of the specimens at room temperature began 12 h prior to the experiment. All soft tissue was removed from the elbow and forearm, sparing the joint capsule, ligaments, and interosseous membrane. Thawing was confirmed through preconditioned movement of the glenohumeral and elbow joint in all directions. 2.2. Set-up of specimens for mechanical analysis In this experiment, a wooden jig, consisting of a table and a square column, was used. The humerus was fixed to the wooden jig so that the long axis of the humerus was perpendicular to the ground. The elbow and forearm were allowed to move freely (Fig. 1). The flexion angle of the elbow was set manually at 0 , 30 , 60 , and 90 with neutral forearm rotation and neutral wrist flexion. These angles were set using goniometric measurement by an examiner. To simulate
Fig. 1. Set-up for the mechanical analysis of the radial head mobilization. The 3Space Magnetic Track system recorded radial head displacement to an accuracy of 0.2 mm RMS.
mobilization of the proximal radio-ulnar joint, a traction force of 2 kgf and 4 kgf was applied to the radial head perpendicular to the long axis of the radius shaft through tapes around the radial neck. Prior to this experiment, thumb pressure simulating the clinical performance of proximal radio-ulnar joint mobilization was measured by physical therapists using a JAMA pinch gauge (Hydraulic Pinch Gauge, JAMAR, Mississauga, Canada). Since the majority of pressure values were between 2 kgf and 4 kgf, traction forces of 2 kgf and 4 kgf were adopted in this biomechanical study. The traction was set in the antero-medial and posterolateral directions as adopted by gliding techniques in joint mobilization manuals (Maitland, 1991; Herting and Kessler, 1996; Edmond, 2006). A six-degree-of-freedom electromagnetic tracking device (3SPACE FASTRAK; Polhemus, Colchester, Vermont) was used for the precise measurement and monitoring of radial head movement. This device enabled the measurement of the three-dimensional position and orientation of the receivers relative to the absolute coordinates generated by the magnetic transmitter. Within a 250-mm range from the magnetic source, the root mean square (RMS) error in positional accuracy was 0.2 mm (Kitaoka et al., 1997). To determine the center of the capitulum of the humerus, a hole of 5 mm in diameter was created from the anterior aspect of the capitulum. To determine the center of the radial head, a hole of 5 mm in diameter was created from the anterior neck of the radius. Thus, the amount of radial head displacement against the capitulum humeri
S. Ohshiro et al. / Manual Therapy 14 (2009) 278e282
during radial head gliding was measured twice in each direction at 0 , 30 , 60 and 90 of elbow flexion (Fig. 2). Throughout the experiment, which was performed at room temperature (22 C), the specimens were kept moist by spraying with saline solution every 5e10 min. 2.3. Statistical analysis One-way repeated measures analysis of variance (ANOVA) was used to determine difference in the radial head movement among the four sets of conditions; i.e., 0 , 30 , 60 and 90 of elbow flexion. Bonferroni’s multiple comparisons test was used as a post hoc test. Statistical significance was set at a ¼ 0.05.
Radial head displacement (mm)
280
Antero-medial traction of the radial head (2 kgf) 5
*
*
4
*
*
3 2 1 0
0°
30°
60°
90°
Elbow joint flexion angle Fig. 3. Displacement of the radial head during traction in an anteromedial direction by 2 kgf of traction force. *p < 0.05.
4. Discussion 3. Results 3.1. Antero-medial gliding During the application of both 2 kgf and 4 kgf of traction force, radial head displacement at 60 (2.1 0.7 mm and 3.2 1.1 mm) and 90 (2.0 0.3 mm and 3.0 1.0 mm) of elbow flexion were significantly ( p < 0.05) greater than those at 0 (0.7 0.2 mm and 1.1 0.3 mm) and 30 (1.2 0.2 mm and 1.5 0.2 mm), (Fig. 3 and Fig. 4, respectively). 3.2. Postero-lateral gliding No significant differences in radial head displacement between the four flexion angles were observed during the application of traction force at either 2 kgf (1.2 0.7 mm for 0 , 1.3 0.4 mm for 30 , 1.9 0.5 mm for 60 , and 1.5 0.8 mm for 90 of elbow flexion) or 4 kgf (1.5 0.9 mm for 0 , 2.0 0.7 mm for 30 , 2.0 0.4 mm for 60 , and 1.5 0.6 mm for 90 of elbow flexion) (Fig. 5 and Fig. 6, respectively).
Joint mobilization consists of low velocity reciprocating passive motion to produce intra-capsular joint movement with varying amplitudes, and is indicated for use with joints in either a loose-packed or resting position (Kaltenborn, 1993; Neuman, 2002; Takei, 2005). Favorable results have been reported for joint mobilization as a treatment for impaired joint function in the extremities and spine (Miyamoto, 1985; Fabio, 1992). In the field of physical therapy, therapists have used manual procedures for the treatment of rotational contracture of the forearm. These procedures consist of gliding the radial head in an antero-medial direction for pronation contracture of the forearm, and in a postero-lateral direction for supination contracture (Maitland, 1991; Herting and Kessler, 1996; Edmond, 2006). However, there have been no reports concerning the effective elbow flexion angle for proximal radioulnar joint mobilization. In the present study, we determined the most effective elbow flexion angle for mobilization of the proximal radio-ulnar joint by direct measurement in cadaver models. During gliding of the radial head in an antero-medial direction to simulate joint mobilization for pronation contracture of the forearm, displacement of the radial
Radial head displacement
Antero-medial traction of the radial head (4 kgf)
Fig. 2. Measurement of the radial head displacement by 3Space Traction in the antero-medial (a) and postero-lateral (b) directions is shown. Radial head displacement was measured with an electromagnetic tracking device.
5
* *
*
4
* 3 2 1 0
0°
30°
60°
90°
Elbow joint flexion angle Fig. 4. Displacement of the radial head during traction in an anteromedial direction by 4 kgf of traction force. *p < 0.05.
281
Postero-lateral traction of the radial head (2 kgf) 5 4 3 2 1 0
0°
30°
60°
90°
Radial head displacement (mm)
Radial head displacement (mm)
S. Ohshiro et al. / Manual Therapy 14 (2009) 278e282
Postero-lateral traction of the radial head (4 kgf) 5 4 3 2 1 0
0°
Elbow joint flexion angle Fig. 5. Displacement of the radial head during traction in a posterolateral direction by 2 kgf of traction force.
head significantly increased at 60 and 90 of elbow flexion. The reason for this result is considered to be due to the direction of the fibers comprising the lateral collateral ligament of the elbow. The lateral collateral ligament is composed of the radial collateral ligament and the annular ligament, each of which has its own biomechanical properties. The radial collateral ligament blends with the annular ligament of the proximal radio-ulnar joint and the outlying band of the annular ligament blends with the supinator crest of the ulna. The posterior fibers of the radial collateral ligament are tight during elbow flexion, and the anterior fibers of the ligament are tight during elbow extension which simultaneously effects the tension of the annular ligament (Morrey and An, 1985; Olsen et al., 1998; Oatis, 2004). Sixty and 90 degrees of elbow flexion, at which the amount of antero-medial displacement of the radial head was the largest in our study, are intermediate positions of the elbow in which the anterior and posterior fibers of the radial collateral ligament are loose. Reduced tension in both sets of fibers of the ligament may also relax the annular ligament. On the other hand, during gliding of the radial head in a postero-lateral direction to simulate joint mobilization for supination contracture of the forearm, there were no significant differences in radial head displacement among four elbow flexion angles. The reason for this result is considered to be the tension produced by the middle fibers of the radial collateral ligament, as these fibers are thick and remain tight across the total range of the elbow flexion (Olsen et al., 1996, 1998; Lockard, 2006). Increased off-setting of the joint facet on the ulna during postero-lateral gliding of the radial head may contribute to this tightness. There are limitations in this study. First, since the elbow specimens were harvested from aged cadavers, the mechanical properties of the ligaments might be different from those of specimens from younger people in whom elbow contracture tends to occur. Although specimens with a limited range of elbow and forearm motion were excluded from this study, the elbows of
30°
60°
90°
Elbow joint flexion angle Fig. 6. Displacement of the radial head during traction in a posterolateral direction by 4 kgf of traction force.
aged specimens have varying degrees of osteo-arthritic changes. This pathology may affect the displacement of the radial head. Since the anatomical structure of the collateral ligaments and the direction of their fibers are similar between the younger and the aged specimens, the results of this study are considered to be applicable to younger patients (Muraki et al., 2007). Second, in the present study, we measured the displacement of the radial head during the mobilization procedure, but did not measure the strain on the collateral ligaments. To analyze the behavior of the lateral collateral ligaments in the elbow during joint mobilization in greater detail, the strain on each collateral ligament should be measured in future studies. 5. Conclusions Five fresh-frozen cadaveric elbows were used to measure the displacement of the radial head during antero-medial and postero-lateral gliding at four elbow flexion angles. Our findings suggested that proximal radio-ulnar joint mobilization can be effectively performed by gliding in the antero-medial direction at 60 and at 90 of elbow flexion. Elbow flexion angle had no effect on the postero-lateral mobilization of the radial head. Acknowledgment The authors would like to thank Gen Murakami, MD, PhD for providing us the fresh-frozen cadaver specimens. The authors also thank Eiichi Uchiyama, MD, PhD; Daisuke Suzuki, PhD; Takayuki Muraki, PhD; Hiroshi Takasaki, RPT; Hitoshi Miyamoto, RPT, and Misaki Fujii, RPT for their technical assistance. References Butler DS. Physical therapy of the cervical and thoracic spine. 2nd ed. New York: Churchill Livingstone; 1994. pp. 217e244.
282
S. Ohshiro et al. / Manual Therapy 14 (2009) 278e282
Edmond SL. Joint mobilization/manipulation. 2nd ed. London: Mosby Elsevier; 2006. pp. 86e87. Fabio RP. Efficacy of manual therapy. Physical Therapy 1992; 72(12):853e63. Herting D, Kessler RM. Management of common musculo-skeletal disorders. 3rd ed. Philadelphia: JB Lippincott; 1996. pp. 238e239. Kaltenborn FM. The spine. 2nd ed. Minneapolis: Olaf Norlis Bokhandel; 1993. pp. 1e87. Kapandji IA. The physiology of the joints: annotated diagrams of the mechanics of the human joints. 5th ed. New York: Churchill Livingstone; 1982. Kisner C, Colby LA. Therapeutic exercise, foundations and techniques. 4th ed. Philadelphia: FA Davis; 2002. pp. 216e256. Kitaoka H, Luo ZP, An KN. Analysis of longitudinal arch supports in stabilizing the arch of the foot. Clinical Orthopaedics and Related Research 1997;341:250e6. Lockard M. Clinical biomechanics of the elbow. Journal of Hand Therapy 2006;19(2):72e80. Maitland GD. Peripheral manipulation. 3rd ed. Oxford: ButterworthHeinemann; 1991. pp. 183e189.
Miyamoto S. Joint mobilization of a shoulder joint. Journal of Physical Therapy 1985;13(2):187e90 (in Japanese). Morrey BF, An KN. Functional anatomy of the ligaments of the elbow. Clinical Orthopaedics and Related Research 1985;201:84e90. Muraki T, Aoki M, Uchiyama E, et al. Strain on the repaired supraspinatus tendon during manual traction and translation glide mobilization on the glenohumeral joint. Manual Therapy 2007; 12(2):231e9. Neuman DA. Kinesiology of the muscloskeletal system, Missouri: Mosby; 2002. pp. 3e24. Oatis CA. Kinesiology, the mechanics and pathomechanics of human movement. Philadelphia: JB Lippincott; 2004. pp. 186e229. Olsen BS, Nielsen KK, Vaesel MT. Posterolateral elbow joint instability. The basic kinematics. Journal of Shoulder Elbow Surgery 1998;7(2):19e29. Olsen BS, Vaesel MT, Jens O. Lateral collateral ligament of the elbow joint, anatomy and kinematics. Journal of Shoulder Elbow Surgery 1996;5(1):103e12. Takei H. Joint mobilization for bone and joint disease. Physical Therapy Science 2005;20(3):219e25 (in Japanese).
Manual Therapy 14 (2009) 278e282 www.elsevier.com/math
Original Article
Influence of elbow flexion angle on mobilization of the proximal radio-ulnar joint: A motion analysis using cadaver specimens Sadanori Ohshiro a, Egi Hidaka a, Shigenori Miyamoto b, Mitsuhiro Aoki b,*, Toshihiko Yamashita c, Haruyuki Tatsumi d a
Graduate School of Health Sciences, Sapporo Medical University, School of Health Sciences, South-3, West-17, Chuo-ku, Sapporo 060-8556, Japan Department of Physical Therapy, Sapporo Medical University, School of Health Sciences, South-3, West-17, Chuo-ku, Sapporo 060-8556, Japan c Department of Orthopaedic Surgery, Sapporo Medical University, School of Medicine, South-3, West-17, Chuo-ku, Sapporo 060-8556, Japan d First Department of Anatomy, Sapporo Medical University, School of Medicine, South-3, West-17, Chuo-ku, Sapporo 060-8556, Japan
b
Received 30 May 2007; received in revised form 20 February 2008; accepted 28 February 2008
Abstract The purpose of this study was to determine the most effective elbow joint flexion angle for mobilization of the proximal radioulnar joint. Five fresh-frozen cadaveric elbows were used to measure displacement of the radial head in the antero-medial and postero-lateral directions by traction force of 2 kgf and 4 kgf, respectively. Simulation of the gliding of the proximal radio-ulnar joint was performed at four elbow flexion angles (0 , 30 , 60 , 90 ). Data obtained from those flexion angles were compared using one-way repeated measures analysis of variance. Radial head displacement at 60 and 90 during antero-medial gliding were significantly greater than those at 0 and 30 ( p < 0.05) There were no significant differences in radial head displacement among four elbow flexion angles during postero-lateral gliding at 2 kgf and 4 kgf. Our findings suggest that proximal radio-ulnar joint mobilization in the antero-medial direction can be performed effectively at 60 and 90 elbow flexion. Ó 2008 Elsevier Ltd. All rights reserved. Keywords: Proximal radio-ulnar joint; Joint mobilization; Motion analysis; Cadaveric study
1. Introduction Anatomically, the elbow is a uni-axial hinge joint formed of two articulations, i.e., the humero-ulnar and humero-radial joints that allow for movement of flexion and extension, and is referred to as the cubital articulation. The cubital articulation and proximal radio-ulnar joint are collectively termed ‘the joint complex’. Pronation and supination are motions of the proximal radio-ulnar joint that play an important role on * Corresponding author. Tel.: þ81 11 611 2111x2874; fax: þ81 11 611 2150. E-mail address: [email protected] (M. Aoki). 1356-689X/$ - see front matter Ó 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2008.02.012
the motion of the wrist and fingers (Kapandji, 1982). Once this motion sequence of the upper extremity is disrupted, activities of daily living, such as having meals and perineal care, are severely restricted. One of the major causes of limitation in forearm rotation is post-traumatic contracture after fracture or fracture dislocation of the elbow. Even after appropriate treatment of these injuries by experienced orthopaedic surgeons, contracture of the elbow is occasionally observed. In such cases, physiotherapy for the elbow becomes extremely important. Restricted motion of the proximal radio-ulnar joint is considered to be caused by a thickening of the capsule and a reduction in the flexibility of the collateral ligaments (Morrey and An, 1985; Herting and Kessler, 1996).
S. Ohshiro et al. / Manual Therapy 14 (2009) 278e282
279
To solve this problem, joint mobilization of the proximal radio-ulnar joint has been used as an effective manual procedure (Miyamoto, 1985; Butler, 1994; Kisner and Colby, 2002). This procedure consists of gliding the radial head in an antero-medial direction for pronation contracture of the forearm, and in a postero-lateral direction for supination contracture (Maitland, 1991; Herting and Kessler, 1996; Edmond, 2006). However, there has been no report concerning the evidence of the effective elbow flexion angle for proximal radio-ulnar joint mobilization. In this experiment, fresh-frozen cadaveric elbows were used to measure the displacement of the radial head during antero-medial and postero-lateral gliding at four elbow flexion angles (0 , 30 , 60 , 90 ). The purpose of this study was to determine the most effective elbow joint flexion angle for mobilization of the proximal radio-ulnar joint.
2. Materials and methods 2.1. Preparation of the specimens On February 27, 2006, the Ethical Committee of our university approved all types of surgical training, and biomechanical studies using frozen-thawed cadavers donated to the Department of Anatomy. This experiment used five frozen-thawed upper extremities that were obtained from five fresh cadavers aged 60e87 years at death (average, 78.2 years) after the acquisition of informed consent prior to death. Two right elbows and three left elbows were taken from two male and three female specimens. The elbows were kept in a freezer at e20 C after disarticulation at the glenohumeral joint. Specimens with a limited range of elbow and forearm motion were excluded from this study. Thawing of the specimens at room temperature began 12 h prior to the experiment. All soft tissue was removed from the elbow and forearm, sparing the joint capsule, ligaments, and interosseous membrane. Thawing was confirmed through preconditioned movement of the glenohumeral and elbow joint in all directions. 2.2. Set-up of specimens for mechanical analysis In this experiment, a wooden jig, consisting of a table and a square column, was used. The humerus was fixed to the wooden jig so that the long axis of the humerus was perpendicular to the ground. The elbow and forearm were allowed to move freely (Fig. 1). The flexion angle of the elbow was set manually at 0 , 30 , 60 , and 90 with neutral forearm rotation and neutral wrist flexion. These angles were set using goniometric measurement by an examiner. To simulate
Fig. 1. Set-up for the mechanical analysis of the radial head mobilization. The 3Space Magnetic Track system recorded radial head displacement to an accuracy of 0.2 mm RMS.
mobilization of the proximal radio-ulnar joint, a traction force of 2 kgf and 4 kgf was applied to the radial head perpendicular to the long axis of the radius shaft through tapes around the radial neck. Prior to this experiment, thumb pressure simulating the clinical performance of proximal radio-ulnar joint mobilization was measured by physical therapists using a JAMA pinch gauge (Hydraulic Pinch Gauge, JAMAR, Mississauga, Canada). Since the majority of pressure values were between 2 kgf and 4 kgf, traction forces of 2 kgf and 4 kgf were adopted in this biomechanical study. The traction was set in the antero-medial and posterolateral directions as adopted by gliding techniques in joint mobilization manuals (Maitland, 1991; Herting and Kessler, 1996; Edmond, 2006). A six-degree-of-freedom electromagnetic tracking device (3SPACE FASTRAK; Polhemus, Colchester, Vermont) was used for the precise measurement and monitoring of radial head movement. This device enabled the measurement of the three-dimensional position and orientation of the receivers relative to the absolute coordinates generated by the magnetic transmitter. Within a 250-mm range from the magnetic source, the root mean square (RMS) error in positional accuracy was 0.2 mm (Kitaoka et al., 1997). To determine the center of the capitulum of the humerus, a hole of 5 mm in diameter was created from the anterior aspect of the capitulum. To determine the center of the radial head, a hole of 5 mm in diameter was created from the anterior neck of the radius. Thus, the amount of radial head displacement against the capitulum humeri
S. Ohshiro et al. / Manual Therapy 14 (2009) 278e282
during radial head gliding was measured twice in each direction at 0 , 30 , 60 and 90 of elbow flexion (Fig. 2). Throughout the experiment, which was performed at room temperature (22 C), the specimens were kept moist by spraying with saline solution every 5e10 min. 2.3. Statistical analysis One-way repeated measures analysis of variance (ANOVA) was used to determine difference in the radial head movement among the four sets of conditions; i.e., 0 , 30 , 60 and 90 of elbow flexion. Bonferroni’s multiple comparisons test was used as a post hoc test. Statistical significance was set at a ¼ 0.05.
Radial head displacement (mm)
280
Antero-medial traction of the radial head (2 kgf) 5
*
*
4
*
*
3 2 1 0
0°
30°
60°
90°
Elbow joint flexion angle Fig. 3. Displacement of the radial head during traction in an anteromedial direction by 2 kgf of traction force. *p < 0.05.
4. Discussion 3. Results 3.1. Antero-medial gliding During the application of both 2 kgf and 4 kgf of traction force, radial head displacement at 60 (2.1 0.7 mm and 3.2 1.1 mm) and 90 (2.0 0.3 mm and 3.0 1.0 mm) of elbow flexion were significantly ( p < 0.05) greater than those at 0 (0.7 0.2 mm and 1.1 0.3 mm) and 30 (1.2 0.2 mm and 1.5 0.2 mm), (Fig. 3 and Fig. 4, respectively). 3.2. Postero-lateral gliding No significant differences in radial head displacement between the four flexion angles were observed during the application of traction force at either 2 kgf (1.2 0.7 mm for 0 , 1.3 0.4 mm for 30 , 1.9 0.5 mm for 60 , and 1.5 0.8 mm for 90 of elbow flexion) or 4 kgf (1.5 0.9 mm for 0 , 2.0 0.7 mm for 30 , 2.0 0.4 mm for 60 , and 1.5 0.6 mm for 90 of elbow flexion) (Fig. 5 and Fig. 6, respectively).
Joint mobilization consists of low velocity reciprocating passive motion to produce intra-capsular joint movement with varying amplitudes, and is indicated for use with joints in either a loose-packed or resting position (Kaltenborn, 1993; Neuman, 2002; Takei, 2005). Favorable results have been reported for joint mobilization as a treatment for impaired joint function in the extremities and spine (Miyamoto, 1985; Fabio, 1992). In the field of physical therapy, therapists have used manual procedures for the treatment of rotational contracture of the forearm. These procedures consist of gliding the radial head in an antero-medial direction for pronation contracture of the forearm, and in a postero-lateral direction for supination contracture (Maitland, 1991; Herting and Kessler, 1996; Edmond, 2006). However, there have been no reports concerning the effective elbow flexion angle for proximal radioulnar joint mobilization. In the present study, we determined the most effective elbow flexion angle for mobilization of the proximal radio-ulnar joint by direct measurement in cadaver models. During gliding of the radial head in an antero-medial direction to simulate joint mobilization for pronation contracture of the forearm, displacement of the radial
Radial head displacement
Antero-medial traction of the radial head (4 kgf)
Fig. 2. Measurement of the radial head displacement by 3Space Traction in the antero-medial (a) and postero-lateral (b) directions is shown. Radial head displacement was measured with an electromagnetic tracking device.
5
* *
*
4
* 3 2 1 0
0°
30°
60°
90°
Elbow joint flexion angle Fig. 4. Displacement of the radial head during traction in an anteromedial direction by 4 kgf of traction force. *p < 0.05.
281
Postero-lateral traction of the radial head (2 kgf) 5 4 3 2 1 0
0°
30°
60°
90°
Radial head displacement (mm)
Radial head displacement (mm)
S. Ohshiro et al. / Manual Therapy 14 (2009) 278e282
Postero-lateral traction of the radial head (4 kgf) 5 4 3 2 1 0
0°
Elbow joint flexion angle Fig. 5. Displacement of the radial head during traction in a posterolateral direction by 2 kgf of traction force.
head significantly increased at 60 and 90 of elbow flexion. The reason for this result is considered to be due to the direction of the fibers comprising the lateral collateral ligament of the elbow. The lateral collateral ligament is composed of the radial collateral ligament and the annular ligament, each of which has its own biomechanical properties. The radial collateral ligament blends with the annular ligament of the proximal radio-ulnar joint and the outlying band of the annular ligament blends with the supinator crest of the ulna. The posterior fibers of the radial collateral ligament are tight during elbow flexion, and the anterior fibers of the ligament are tight during elbow extension which simultaneously effects the tension of the annular ligament (Morrey and An, 1985; Olsen et al., 1998; Oatis, 2004). Sixty and 90 degrees of elbow flexion, at which the amount of antero-medial displacement of the radial head was the largest in our study, are intermediate positions of the elbow in which the anterior and posterior fibers of the radial collateral ligament are loose. Reduced tension in both sets of fibers of the ligament may also relax the annular ligament. On the other hand, during gliding of the radial head in a postero-lateral direction to simulate joint mobilization for supination contracture of the forearm, there were no significant differences in radial head displacement among four elbow flexion angles. The reason for this result is considered to be the tension produced by the middle fibers of the radial collateral ligament, as these fibers are thick and remain tight across the total range of the elbow flexion (Olsen et al., 1996, 1998; Lockard, 2006). Increased off-setting of the joint facet on the ulna during postero-lateral gliding of the radial head may contribute to this tightness. There are limitations in this study. First, since the elbow specimens were harvested from aged cadavers, the mechanical properties of the ligaments might be different from those of specimens from younger people in whom elbow contracture tends to occur. Although specimens with a limited range of elbow and forearm motion were excluded from this study, the elbows of
30°
60°
90°
Elbow joint flexion angle Fig. 6. Displacement of the radial head during traction in a posterolateral direction by 4 kgf of traction force.
aged specimens have varying degrees of osteo-arthritic changes. This pathology may affect the displacement of the radial head. Since the anatomical structure of the collateral ligaments and the direction of their fibers are similar between the younger and the aged specimens, the results of this study are considered to be applicable to younger patients (Muraki et al., 2007). Second, in the present study, we measured the displacement of the radial head during the mobilization procedure, but did not measure the strain on the collateral ligaments. To analyze the behavior of the lateral collateral ligaments in the elbow during joint mobilization in greater detail, the strain on each collateral ligament should be measured in future studies. 5. Conclusions Five fresh-frozen cadaveric elbows were used to measure the displacement of the radial head during antero-medial and postero-lateral gliding at four elbow flexion angles. Our findings suggested that proximal radio-ulnar joint mobilization can be effectively performed by gliding in the antero-medial direction at 60 and at 90 of elbow flexion. Elbow flexion angle had no effect on the postero-lateral mobilization of the radial head. Acknowledgment The authors would like to thank Gen Murakami, MD, PhD for providing us the fresh-frozen cadaver specimens. The authors also thank Eiichi Uchiyama, MD, PhD; Daisuke Suzuki, PhD; Takayuki Muraki, PhD; Hiroshi Takasaki, RPT; Hitoshi Miyamoto, RPT, and Misaki Fujii, RPT for their technical assistance. References Butler DS. Physical therapy of the cervical and thoracic spine. 2nd ed. New York: Churchill Livingstone; 1994. pp. 217e244.
282
S. Ohshiro et al. / Manual Therapy 14 (2009) 278e282
Edmond SL. Joint mobilization/manipulation. 2nd ed. London: Mosby Elsevier; 2006. pp. 86e87. Fabio RP. Efficacy of manual therapy. Physical Therapy 1992; 72(12):853e63. Herting D, Kessler RM. Management of common musculo-skeletal disorders. 3rd ed. Philadelphia: JB Lippincott; 1996. pp. 238e239. Kaltenborn FM. The spine. 2nd ed. Minneapolis: Olaf Norlis Bokhandel; 1993. pp. 1e87. Kapandji IA. The physiology of the joints: annotated diagrams of the mechanics of the human joints. 5th ed. New York: Churchill Livingstone; 1982. Kisner C, Colby LA. Therapeutic exercise, foundations and techniques. 4th ed. Philadelphia: FA Davis; 2002. pp. 216e256. Kitaoka H, Luo ZP, An KN. Analysis of longitudinal arch supports in stabilizing the arch of the foot. Clinical Orthopaedics and Related Research 1997;341:250e6. Lockard M. Clinical biomechanics of the elbow. Journal of Hand Therapy 2006;19(2):72e80. Maitland GD. Peripheral manipulation. 3rd ed. Oxford: ButterworthHeinemann; 1991. pp. 183e189.
Miyamoto S. Joint mobilization of a shoulder joint. Journal of Physical Therapy 1985;13(2):187e90 (in Japanese). Morrey BF, An KN. Functional anatomy of the ligaments of the elbow. Clinical Orthopaedics and Related Research 1985;201:84e90. Muraki T, Aoki M, Uchiyama E, et al. Strain on the repaired supraspinatus tendon during manual traction and translation glide mobilization on the glenohumeral joint. Manual Therapy 2007; 12(2):231e9. Neuman DA. Kinesiology of the muscloskeletal system, Missouri: Mosby; 2002. pp. 3e24. Oatis CA. Kinesiology, the mechanics and pathomechanics of human movement. Philadelphia: JB Lippincott; 2004. pp. 186e229. Olsen BS, Nielsen KK, Vaesel MT. Posterolateral elbow joint instability. The basic kinematics. Journal of Shoulder Elbow Surgery 1998;7(2):19e29. Olsen BS, Vaesel MT, Jens O. Lateral collateral ligament of the elbow joint, anatomy and kinematics. Journal of Shoulder Elbow Surgery 1996;5(1):103e12. Takei H. Joint mobilization for bone and joint disease. Physical Therapy Science 2005;20(3):219e25 (in Japanese).