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Assessing lower extremity range of motion (ROM) is a fundamental clinical skill. Measuring how far a joint can move provides important information that guides nearly every aspect of patient care. When ROM is limited, patients may struggle with basic activities, such as walking, climbing stairs, or getting dressed. Conversely, excessive motion can indicate joint instability or ligamentous injury. By systematically measuring ROM early in the assessment process, clinicians can identify which joints are problematic, understand whether limitations follow predictable patterns (such as capsular restrictions), and establish a baseline against which to measure progress. Importantly, ROM deficits rarely exist in isolation: restriction at one joint often forces neighbouring joints to compensate, potentially creating a cascade of secondary problems. Mastering accurate, reliable ROM measurement represents not just a technical skill, but a gateway to understanding how joint mechanics influence the broader rehabilitation process.
Hip
Capsular pattern of the hip: the most limited movements are internal rotation (IR or medial rotation), ABduction (abd), and flexion (flex); with extension the least limited. This can also be expressed as IR > Flex > Abd > Ext.[1]
According to the American Academy of Orthopaedic Surgeons and the American Medical Association, the generally accepted range of active hip ROM values are:[2][3]
When assessing hip ROM, clinicians need to be aware of several precautions to ensure patient safety and accurate measurement. Contraindications to ROM testing include acute hip fractures, recent hip arthroplasty (particularly when there are specific precautions based on surgical approach), severe osteoporosis, acute inflammatory conditions, and suspected deep vein thrombosis.[1][3] Following total hip arthroplasty, movement restrictions typically depend on the surgical approach. Posterior approaches traditionally require patients to avoid hip flexion beyond 90°, adduction past the midline, and internal rotation. Conversely, anterior approaches may restrict extension and external rotation, though modern evidence suggests earlier mobilisation protocols may be appropriate for selected patients.[4][5] Clinicians should also screen for hip pathologies, such as femoroacetabular impingement, labral tears, or avascular necrosis, which may cause pain during specific movements, particularly combined flexion, adduction, and internal rotation.[6]
The patient is supine, with their back flat against the table. The trunk is stabilised against the table; the proximal arm of the goniometer should not move if the patient maintains this position.
Fulcrum: greater trochanter of the femur
Proximal arm: along the lateral midline of the pelvis (parallel to the trunk)
Distal arm: along the femur, using the lateral epicondyle as a reference
Extension
The patient is prone, flat against the table. The patient must remain flat, avoiding lumbar hyperextension or pelvic lift.
Fulcrum: greater trochanter of the femur
Proximal arm: along the lateral midline of the pelvis (parallel to the trunk)
Distal arm: along the femur, using the lateral epicondyle as a reference
ABduction and ADduction
The patient is supine, flat on the table with their legs sliding outward. Keep the patient flat to avoid hip flexion or extension substitution movements.
Fulcrum: anterior superior iliac spine (ASIS) of the same lower extremity
Proximal arm: straight across from the ASIS to the opposite ASIS (bridging between the two)
Distal arm: along the midline of femur, using the patella as a reference (or the tibial tubercle if the patella is subluxed/dislocated)
Note: for adduction, abduct the opposite leg to allow the tested leg to cross the midline
Internal and External Rotation
Option one: seated, legs hanging off the table. The patient must not shift their weight off the side being tested.
Fulcrum: patella
Proximal Arm: perpendicular to the floor
Distal Arm: along the lower leg, using the midpoint between the medial and lateral malleoli as a reference
Option two: prone, knee bent to 90°, legs hanging off the end of the table
Fulcrum: patella (knee hanging off the table edge)
Proximal Arm: perpendicular to the ceiling (or floor)
Distal Arm: along the midline of the lower leg
Prerequisites: requires normal rectus femoris muscle length and the patient must tolerate the position
Knee
Capsular pattern of the knee: flexion (most limited), extension (slightly limited), or flexion > extension.[2]
While the capsular pattern indicates flexion is more limited than extension, extension is typically the most difficult motion to regain after injury or surgery. This is commonly referred to as an "extension lag."[7]
According to the American Academy of Orthopaedic Surgeons and the American Medical Association, the generally accepted range of active knee ROM values are:[2][3]
130-150° of knee flexion
0° of extension; with up to 10-15° hyperextension considered normal, particularly in females
Clinicians must be aware of contraindications to ROM testing, including acute knee fractures,recent knee arthroplasty or ligament reconstruction, acute haemarthrosis, suspected deep vein thrombosis, acute inflammatory conditions (septic arthritis), and acute patellar dislocation.[3] Following total knee arthroplasty, early mobilisation is generally encouraged, though clinicians should be aware of surgeon-specific protocols and healing timeframes. Aggressive stretching in the immediate post-operative period should be avoided, particularly in the first 6-8 weeks.[8] Care must be taken with patients with ligamentous instability to avoid excessive stress on healing or compromised structures, with particular attention to rotational forces and valgus/varus stresses.[1] Clinicians should screen for meniscal pathology, as certain movements (particularly combined flexion and rotation) may provoke pain or mechanical symptoms such as locking or catching.[9]Patellar tracking should be observed during knee flexion and extension, as patellofemoral dysfunction may limit ROM or produce pain, particularly in terminal extension or deep flexion.[10] When assessing hyperextension, ensure the measurement is genuine joint motion rather than posterior capsular laxity or genu recurvatum, and be vigilant for signs of ligamentous hypermobility syndromes.[11]
Proximal arm: along the femur, using the greater trochanter as a reference
Distal arm: along the fibula, using the lateral malleolus as a reference
Note: the proximal arm will move during this measurement, as the motion is performed in supine to avoid muscle tautness
Extension
The patient is supine, with a towel roll under the heel to allow hyperextension
Fulcrum: lateral epicondyle of the femur
Proximal arm: along the femur, using the greater trochanter as a reference
Distal arm: along the fibula, using the lateral malleolus as a reference
Ankle
Capsular pattern of the talocrural joint: plantarflexion (most limited) > dorsiflexion.[2]
Capsular pattern of the subtalar joint: varus/inversion (most limited) > valgus/eversion.[2]
According to the American Academy of Orthopaedic Surgeons and the American Medical Association, the generally accepted range of active ankle ROM values are as follows.[2][3]
Clinicians must be aware of contraindications to ROM testing, including acute ankle fractures, recent ankle or hindfoot arthroplasty or arthrodesis, acute ligamentous ruptures (particularly grades II-III sprains in the acute phase), severe osteoporosis, acute inflammatory conditions (e.g. septic arthritis, gout), suspected deep vein thrombosis, and acute Achilles tendon rupture.[3] Patients with chronic ankle instability or previous lateral ligament injuries require careful assessment to identify residual laxity, proprioceptive deficits, or mechanical instability that may affect ROM testing and functional outcomes.[12] Clinicians should screen for syndesmotic injuries (high ankle sprains), as these require modified ROM testing to avoid excessive external rotation and dorsiflexion forces that stress the healing syndesmosis.[13]
The patient is supine or prone with their knee bent to avoid gastrocnemius stretch.
Fulcrum: lateral aspect of the lateral malleolus
Proximal arm: along the fibula, using the head of the fibula as a reference
Distal arm:Parallel to the 5th metatarsal (maintaining equal distance—not directly aligned)
Documentation: the 90° starting position is transposed to 0°; dorsiflexion is measured above this, and plantarflexion below
Weight-bearing dorsiflexion can be measured with a goniometer or an inclinometer aligned on the tibia. Assessing dorsiflexion in weight-bearing is functionally important and should be included when appropriate. However, it requires adequate balance, strength, and lower extremity control; the modified lunge test or wall test can quantify functional dorsiflexion range.[14]
Inversion and Eversion
The patient is supine, with their legs off the edge of the table in a neutral foot position. The patient will naturally attempt plantarflexion with inversion and dorsiflexion with eversion. Therefore, it's important to maintain a neutral position as much as possible.
Fulcrum: midway between the malleoli
Proximal arm: along the anterior tibia, using the tibial tuberosity as a reference
Distal arm: along the 2nd metatarsal
Goniometer type: small, flexible goniometer along the anterior surface of the leg
Foot
Capsular pattern of the metatarsophalangeal (MTP) joints: extension/dorsiflexion (most limited) > flexion/plantarflexion
First MTP joint dorsiflexion is crucial for normal gait mechanics during the terminal stance and pre-swing phases. Loss of this motion significantly impacts push-off and can lead to compensatory movement patterns.[7]
Capsular pattern of the interphalangeal (IP) joints: flexion (most limited) > extension.
Capsular pattern of the midtarsal (transverse tarsal) joint: dorsiflexion, plantarflexion, adduction, and medial rotation (variable limitations).
Capsular pattern of the tarsometatarsal joints: limited mobility in all directions (particularly plantarflexion and supination).[2]
According to the American Academy of Orthopaedic Surgeons and the American Medical Association, the generally accepted range of active ROM values at the foot are as follows.[2][3]
First MTP joint (great toe):
70-90° of dorsiflexion (extension)
30-45° of plantarflexion (flexion)
Lesser MTP joints (toes 2-5):
40-50° of dorsiflexion (extension)
35-40° of plantarflexion (flexion)
IP joints (all toes):
35-60° of proximal IP (PIP) flexion
50-60° of distal IP (DIP) flexion
0° (neutral) of IP extension
Midfoot complex (combined motion):
20-30° of forefoot supination (combined inversion and adduction)
10-20° of forefoot pronation (combined eversion and abduction)
Clinicians must be aware of contraindications to ROM testing, including acute foot fractures (metatarsal, phalangeal, or tarsal bones), recent forefoot or midfoot surgery (bunionectomy, hammertoe correction, metatarsal osteotomy, arthrodesis procedures), acute Lisfranc injuries or post-operative Lisfranc repair, severe osteoporosis with risk of stress fracture, acute inflammatory conditions (e.g. gout, septic arthritis, acute rheumatoid arthritis flare), and suspected or confirmed osteomyelitis.[3] Following forefoot surgery, particularly first MTP joint procedures for hallux valgus or hallux rigidus, clinicians must adhere to surgeon-specific protocols regarding ROM progression and weight-bearing status. Patients will typically need to avoid aggressive passive stretching for 6-12 weeks post-operatively to protect healing soft tissue and bony corrections.[15]
When assessing MTP joint motion, be vigilant for hallux rigidus (degenerative arthritis limiting great toe dorsiflexion), hallux valgus deformity, sesamoiditis, turf toe injuries (first MTP sprain), or Morton's neuroma, all of which may significantly limit ROM and produce pain with movement.[15] Lesser toe deformities, including hammertoes, claw toes, and mallet toes, alter normal arthrokinematics and may present as fixed versus flexible deformities that respond differently to ROM testing.[16]
MTP Dorsiflexion (Extension) and Plantarflexion (Flexion)
The patient is supine. Position the goniometer slightly to the side of the toe rather than directly on top. Ensure the fulcrum remains aligned across from the joint line, and align the proximal and distal arms with their respective bones (metatarsal and phalanx).
Fulcrum: dorsal aspect of the MTP joint itself
Proximal arm: along the midline of the metatarsal
Distal arm: along the phalanx
Lesser Metatarsophalangeal and Interphalangeal Joints
The patient is supine, with the goniometer positioned slightly laterally due to the small joint size and toe contours.
Fulcrum: positioned at the joint line (dorsal aspect)
Proximal arm: aligned with the proximal bone segment
Distal arm: aligned with the distal bone segment
Resources
The following videos highlight the importance of assessing active hip, knee, and ankle ROM.
↑ 2.02.12.22.32.42.52.62.7American Academy of Orthopaedic Surgeons. Joint Motion: Method of Measuring and Recording. Edinburgh: Churchill Livingstone; 1988.
↑ 3.03.13.23.33.43.53.63.7Norkin CC, White DJ. Measurement of joint motion: a guide to goniometry. FA Davis; 2016 Nov 18.
↑ 7.07.17.27.37.47.5Cunningham , S. Introduction to Musculoskeletal Concepts in Rehabilitation. Trunk and Lower Limb Range of Motion Testing. Physioplus. 2025.
↑Nunes GS, Stapait EL, Kirsten MH, de Noronha M, Santos GM. Clinical test for diagnosis of patellofemoral pain syndrome: Systematic review with meta-analysis. Physical Therapy in Sport. 2013 Feb 1;14(1):54-9.
↑Remvig L, Jensen DV, Ward RC. Epidemiology of general joint hypermobility and basis for the proposed criteria for benign joint hypermobility syndrome: review of the literature. Journal of Rheumatology. 2007;34(4):804-809.
↑Fu K, Jia S, Lin S, Xu C, Fang Z. Risk factors for chronic syndesmotic instability after the first episode of acute ankle sprain: a cross-sectional study of 356 cases. Foot & Ankle International. 2025 Jan;46(1):92-101.
