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The range of motion (ROM) assessment is a fundamental part of the upper extremity evaluation. It provides important quantitative data that guides clinical reasoning and treatment planning. Limitations in shoulder, elbow, wrist, or hand mobility can significantly impact functional independence, affecting basic activities of daily living, such as dressing, feeding, and personal hygiene, as well as work or leisure activities. Assessing ROM enables clinicians to identify specific joint restrictions, distinguish between active and passive motion deficits, differentiate capsular from non-capsular patterns of restriction, and monitor progress throughout the rehabilitation process. Developing proficiency in the ROM assessment is essential when working with people with upper limb conditions.
Shoulder (Glenohumeral Joint)
Capsular pattern of the shoulder: external rotation (ER, also known as lateral rotation) is most limited, followed by abduction, and finally internal rotation (IR, also known as medial rotation). This can be simplified as: ER > ABD > IR.[1]
Shoulder movements
There are currently no published studies of normative ROM values in samples representative of the general population, but generally accepted active ROM values for the shoulder are as follows:[2][3]
150-180° of flexion
45-60° of extension
150-180° of ABDuction
30° of ADDuction
130° of horizontal ABDuction (also known as horizontal extension)
40-50° of horizontal ADDuction (also known as horizontal flexion or cross-body adduction)
When assessing shoulder range of motion, clinicians should exercise caution in several contexts. Acute fractures of the proximal humerus, scapula, or glenoid, as well as recent shoulder dislocations (particularly anterior instability), require careful consideration. In these cases, it may be necessary to delay passive range of motion testing until initial healing has occurred.
Patients who have had surgery, especially those who have had rotator cuff repairs, capsular shift procedures, or superior labral repairs, must adhere to surgeon-specified protocols on timing and planes of movement, as premature testing may compromise tissue healing.[1]
Patients with flaccidity or hypotonicity from neurological conditions, like stroke,[4]brachial plexus injury, or peripheral nerve lesions, are at particular risk during ROM testing. The loss of muscular support makes the glenohumeral joint vulnerable to capsular overstretching, subluxation, traction injuries to neurovascular structures, and hemiplegic shoulder pain. Clinicians should perform passive movements with careful humeral head stabilisation and avoid provocative end-range positions.
A modified assessment approach is necessary for people with active infection, severe osteoporosis, or suspected neoplastic involvement to prevent pathological fracture or further tissue damage.
Clinicians should be alert to signs of complex regional pain syndrome, where excessive movement may exacerbate symptoms. They should also monitor for altered movement patterns or excessive scapular compensation that may indicate rotator cuff pathology or neuromuscular dysfunction requiring alternative assessment strategies.[5]
Table 1. Goniometric Measurement of Shoulder ROM[6]
Goniometer Landmarks
Flexion
The patient is in supine:
Fulcrum: greater tubercle of the humerus
Proximal/stationary arm: aligned with the midline of the thoracic cavity (bifurcating the trunk)
Distal/moving arm: aligned with the lateral epicondyle of the humerus
Extension
The patient is in prone (or seated if the patient cannot tolerate prone):
Fulcrum: greater tubercle of the humerus
Proximal/stationary arm: mid-axillary line of the thorax
Distal/moving arm: lateral epicondyle of the humerus
ABDuction
The patient is in supine:
Fulcrum: anterior axis of the acromion process
Proximal/stationary arm: parallel to the midline of the sternum
Distal/moving arm: aligned with the humerus (between the medial and lateral epicondyles)
Internal Rotation
The patient is in supine with the shoulder abducted to 90° and the elbow flexed to 90°. A towel roll should be placed under the humerus to maintain the humerus in line with the glenoid:
Fulcrum: olecranon process
Proximal/stationary arm: perpendicular to the ceiling (or floor)
Distal/moving arm: aligned along the olecranon process and ulnar styloid process (following the ulna)
External Rotation
The patient is in supine with the shoulder abducted to 90° and the elbow flexed to 90°. A towel roll should be placed under the humerus to maintain the humerus in line with the glenoid:
Fulcrum: olecranon process
Proximal/stationary arm: perpendicular to the ceiling (or floor)
Distal/moving arm: aligned along the olecranon process and ulnar styloid process (following the ulna)
Elbow
Capsular patterns of the elbow: equal limitations in flexion, extension, pronation and supination.[1]
The generally accepted active ROM values for the elbow are as follows:[7]
When assessing elbow ROM, clinicians must exercise caution in several contexts. Acute fractures of the distal humerus, radial head, olecranon, or bones of the forearm require careful consideration. Passive ROM is typically contraindicated until the initial fracture has stablised and healing has occurred.
Patients who have had surgery, particularly after total elbow arthroplasty, must adhere to surgeon-specified protocols that consider triceps integrity and wound healing status. For these patients, premature or excessive ROM testing may compromise surgical repairs.
Joint stability and ligamentous integrity must be assessed before evaluating ROM in people with recent elbow dislocations.
The ROM assessment should be delayed in people with active infection, suspected malignancy, or acute inflammatory conditions, such as septic arthritis or acute olecranon bursitis, until appropriate medical management is initiated.[8]
The patient is in supine, with a towel roll placed underneath the humerus. The elbow (olecranon) should be free of the towel roll to allow for elbow hyperextension if it exists:
Fulcrum: lateral epicondyle of the humerus
Proximal/stationary arm: aligned with the midline of the humerus, using the acromion process as a reference
Distal/moving arm: aligned with the radius using the radial styloid process as a reference
Extension
The patient is in supine, with a towel roll placed underneath the humerus. The elbow (olecranon) should be free of the towel roll to allow for elbow hyperextension if it exists:
Fulcrum: lateral epicondyle of the humerus
Proximal/stationary arm: aligned with the midline of the humerus, using the acromion process as a reference
Distal/moving arm: aligned with the radius using the radial styloid process as a reference
Supination
The patient is sitting with the elbow flexed to 90°:
Fulcrum: just off to the side of the ulnar styloid process
Proximal/stationary arm: parallel to the midline of the humerus (bifurcating the humerus)
Distal/moving arm: laid across the palmar surface of the wrist across the radius
Alternative method: for patients with adequate grip strength, the patient can hold a pen or pencil; the fulcrum is aligned at the second metacarpophalangeal (MCP) joint, the moving arm is parallel to the pen/pencil, and the stable arm bifurcates the humerus
Pronation
The patient is sitting with the elbow flexed to 90°:
Fulcrum: aligned with the ulnar styloid process
Proximal/stationary arm: parallel to the midline of the humerus (bifurcating the humerus)
Distal/moving arm: laid across the dorsal surface of the wrist across the radius
Alternative method: for patients with adequate grip strength, the patient can hold a pen or pencil; the fulcrum is aligned at the second metacarpophalangeal (MCP) joint, the moving arm is parallel to the pen/pencil, and the stable arm bifurcates the humerus
Wrist
Capsular patterns of the wrist: equal limitation of both flexion and extension.[9]
The generally accepted active ROM values for the wrist are as follows:[10]
When assessing wrist range of motion, clinicians must exercise caution in several contexts. Acute fractures, particularly of the scaphoid bone, distal radius, or other carpal bones, require careful consideration, as delayed diagnosis or inadequate treatment can lead to non-union, avascular necrosis, and subsequent degenerative wrist arthritis.
Triangular fibrocartilage complex (TFCC) injuries require modified assessment approaches, as activities reproducing the mechanism of injury and pain should be avoided. Rehabilitation programmes for these injuries typically include immobilisation for 3 to 6 weeks before initiating range of motion exercises.
Patients who are post-surgery, including those who have had carpal tunnel release, TFCC repair, or scaphoid fixation, must adhere to surgeon-specified protocols to optimise wound healing and tissue repair.
Suspected carpal instability patterns (such as scapholunate dissociation) warrant careful assessment, as aggressive range of motion testing may exacerbate ligamentous injuries. ROM testing is contraindicated in people with active infection, including septic arthritis or tenosynovitis, until appropriate antimicrobial therapy is initiated.[8]
The patient is supine or seated at a table. Their forearm should be flush against the table, but their wrist should be free to move. This eliminates the need to stabilise proximal joints. Only the distal arm of the goniometer should move, as the proximal arm remains stable against the table with the forearm.
Fulcrum: over the triquetrum (located just dorsal to the pisiform on the ulnar side of the wrist). Clinical note: for ease in the clinical setting, position the fulcrum on the lateral aspect of the wrist, aligned with the triquetrum and in line with the longitudinal axis of the forearm.
Proximal/stationary arm: along the lateral midline of the ulna, using the ulnar styloid process and olecranon as references
Distal/moving arm: along the fifth metacarpal
Extension
The patient is supine or seated at a table. Their forearm should be flush against the table, but their wrist should be free to move. Passive range of motion or overpressure can be applied if active range of motion appears limited.
Fulcrum: over the triquetrum (located just dorsal to the pisiform on the ulnar side of the wrist)
Proximal/stationary arm: along the lateral midline of the ulna, using the ulnar styloid process and olecranon as references
Distal/moving arm: along the fifth metacarpal
Radial Deviation
The patient is supine or seated at a table. Their entire forearm and hand should rest flat on the table to prevent wrist flexion and extension, ensuring a single plane of motion. In neutral alignment, the third metacarpal aligns with the capitate, lunate, and radius—forming the stable middle pillar. Therefore, the goniometer arms should be in a straight line at the start position. Only the distal arm should move during measurement, while the proximal arm remains stationary, aligned with the forearm.
Fulcrum: over the capitate
Proximal/stationary arm: along the midline of the forearm
Distal/moving arm: along the third metacarpal
Ulnar Deviation
The patient is supine or seated at a table. Their entire forearm and hand should rest flat on the table to prevent wrist flexion and extension. Passive range of motion can be performed in this position while keeping the forearm and hand flush against the table.
Fulcrum: over the capitate
Proximal/stationary arm: along the midline of the forearm
Distal/moving arm: along the third metacarpal
Hand
Capsular patterns of the hand: Flexion and extension are equally limited at the radiocarpal and midcarpal joints. The metacarpophalangeal (MCP) and interphalangeal joints show equal limitation of flexion and extension. Abduction and extension are equally limited at the thumb carpometacarpal (CMC) joint, while flexion is relatively preserved.[9]
The generally accepted active ROM values for the hand and fingers are as follows.[11][12][13]Metacarpophalangeal (MCP) joints:
Joints of the hand and fingers
Thumb
50° of flexion
0° of extension
45-70 of ABduction
5-20 of ADduction
Digits II-V
80° of flexion
o° of extension
Interphalangeal joint of the thumb:
80° of flexion
0° of extension
Proximal Interphalangeal (PIP) joints:
up to 135° of flexion, varying by finger
0-20° of extension
Distal Interphalangeal (DIP) joints:
up to 90° of flexion, varying by finger
0-30° of extension
The following optional video explains the various movements of the thumb:
When performing hand ROM testing, several key precautions should be taken to ensure patient safety and accurate measurement.
Avoid forcing movement beyond the patient's tolerance, as this may exacerbate inflammation, damage healing tissues, or cause protective muscle guarding that invalidates results. Appropriately stabilise proximal joints to isolate the intended movement and prevent compensatory patterns that can lead to false readings or joint stress.
Exercise particular caution with acute injuries, post-surgical cases, and inflammatory conditions, such as rheumatoid arthritis, where gentle handling and modified testing techniques may be warranted. While some discomfort during end-range testing is expected, stop testing if the person experiences sharp or increasing pain. Be aware of contraindications to ROM testing, including unstable fractures, severe inflammation, or joint dislocation. Delay ROM for people who have had surgery until medical clearance is obtained.[9]
↑ 6.06.16.26.3Cunningham , S. Introduction to Musculoskeletal Concepts in Rehabilitation. Cervical Spine and Upper Limb Range of Motion Testing. Physioplus. 2025.
↑Quintero-Diaz KJ, Mendez-Antolinez LN, Pabon-Rozo CE, Mateus-Arias OE, Martínez-Torres J. Reliability of manual goniometry vs. photogrammetry for elbow and wrist range of motion. Physical Therapy Reviews. 2025 May 4;30(3):245-51.
↑ 8.08.1Magee, D. J. (2021). Orthopedic physical assessment (7th ed.). Elsevier.
↑ 9.09.19.2Rybski MF. The Wrist. InKinesiology for Occupational Therapy 2024 Jun 1 (pp. 199-222). Routledge.
↑Kaufman-Cohen Y et al. Wrist Plane of Motion and Range During Daily Activities. The American Journal of Occupational Therapy, 2018, Vol. 72(6).
↑Bland MD, Beebe JA, Hardwick DD, Lang CE. Restricted active range of motion at the elbow, forearm, wrist, or fingers decreases hand function. Journal of Hand Therapy. 2008 Jul 1;21(3):268-75.
↑YouTube. Abduction vs. Adduction, Flexion vs. Extension and Opposition of the Thumb | JJ Medicine. Available from: https://www.youtube.com/watch?v=P4WPk5mUr8I [last accessed 17/October/2025]
