Goniometer alignment for measurement of elbow extension. Elbow/Forearm Rom Requirements For Functional Activities. End of shoulder lateral rotation ROM, showing proper hand placement for stabilizing and laterally rotating shoulder. To measure active pronation range of motion, twist your palm and thumb down as far as you can to get full rotation. Bony landmarks for goniometer alignment (lateral aspect of acromion process, lateral humeral epicondyle, radial styloid process) indicated by red dots. RELIABILITY and VALIDITY of MEASUREMENTS of RANGE of MOTION and MUSCLE LENGTH TESTING of the UPPER EXTREMITY, RELIABILITY and VALIDITY of MEASUREMENT of RANGE of MOTION for the SPINE and TEMPOROMANDIBULAR JOINT, RELIABILITY and VALIDITY of MEASUREMENTS of RANGE of MOTION and MUSCLE LENGTH TESTING of the LOWER EXTREMITY, MEASUREMENT of RANGE of MOTION and MUSCLE LENGTH: CLINICAL RELEVANCE, MUSCLE LENGTH TESTING of the UPPER EXTREMITY, MUSCLE LENGTH TESTING of the LOWER EXTREMITY, MEASUREMENT of RANGE of MOTION of the CERVICAL SPINE and TEMPOROMANDIBULAR JOINT, MEASUREMENT of RANGE of MOTION of the THORACIC and LUMBAR SPINE, Joint Range of Motion and Muscle Length Testing. Ulnar border of forearm toward ulnar styloid process. Carrying angle: The carrying angle has a mean value of 10 degrees for men and 13 degrees for women. UPPER EXTREMITY RANGE OF MOTION Sit or stand with your elbow bent 90 and turn your palm to face down, Line the axis of the goniometer up just below the ulna styloid on the outer side of the wrist as shown and have the stationary arm parallel to the humerus, Rest the moveable arm of the goniometer across the back of the forearm, just below the wrist. Very useful. *Source: Watanabe et al.19 Fig. End of shoulder lateral rotation ROM, demonstrating proper alignment of goniometer at end of range. The normal end-feel for elbow extension is hard as the olecranon process of the ulna becomes wedged in the olecranon fossa of the humerus. Because bony contact limits pronation, the normal end-feel for that motion is hard. Elbow flexion and extension may be measured with the patient in the upright (standing or sitting), supine, or side-lying position. Read scale of goniometer (see Fig. Shoulder Flexion 4-10 Elbow and forearm motion required to use a telephone. Both joints are located within a single joint capsule that also is shared by the proximal radioulnar joint.2 To find the acromion, place one hand on top of your opposite shoulder. This disc binds the distal ulna and radius together and is the primary reinforcement for the joint. Elbow extension ROM is limited by contact of the olecranon process of the ulna with the olecranon fossa of the humerus.10 Information regarding normal ROM for the elbow is located in Appendix B. Big help. Rehabilitation of the overhead athlete's elbow. 0 16-7 Starting position for measurement of shoulder lateral rotation, demonstrating proper initial alignment of goniometer. 120 At the extremes of flexion and extension, rolling motions of the ulna and radius replace the gliding motion.13,28. To measure active range of motion, bring your wrist and thumb back as far as you can to get full rotation and measure the angle. Read our. So having good flexibility and mobility is the elbow is really important. In the distal forearm fracture group, the elbow total . Goniometer alignment: Distally, the concave ulnar notch of the radius rolls and slides anteriorly on the ulnar head during pronation and posteriorly during supination.21. See our T&C'sShoulder-Pain-Explained.com is a trading name of Wilson Health Ltd.All rights reserved. 16-2), and align goniometer accordingly. Of 50 subjects examined, 49 were able to perform all 12 functional activities included in the study, with elbow motion limited to a range of 75 degrees to 120 degrees of flexion. How often should you do physical therapy exercises for tennis elbow? For example, one study determined a normal knee should ideally be able to flex, or bend, to between 133 and. Perform 2-3 sets of 15-20 repetitions, 2-3x/day, every day. 16-10 End of elbow extension ROM, showing proper hand placement for stabilizing humerus and extending elbow. 16-9). When using a goniometer to measure elbow motion, it is much easier to get someone else to do the measuring for you its hard to try and line everything up and get an accurate yourself. Most functional activities require a fairly large amount of elbow flexion ROM (Figs. But if you have injured your elbow, have pain in the arm or an elbow condition such as arthritis or bursitis, then your range of motion is likely to be reduced, with active elbow range of motion being most affected. Stationary arm: Elbow extension. Patient position: The annular ligament is attached to the anterior and posterior margins of the radial notch of the ulna and encircles the radial head, holding it firmly against the radial notch (see Figs. Studies of large groups of children in China, England, and Scotland revealed hyperextension of the knee in young children that disappeared at some point between the ages of 6 and 10 years.15,21 Patient/Examiner action: When you visit the site, Dotdash Meredith and its partners may store or retrieve information on your browser, mostly in the form of cookies. 4-1 Bony anatomy of the joints of the elbowanterior view. 16-14 Starting position for measurement of wrist flexion, demonstrating proper initial alignment of goniometer. 0 16-6). Fig. 16-4). Thoracic and cervical spine including kyphosis and forward head. For more information, please see our Med Sci Monit. 4-10 Elbow and forearm motion required to use a telephone. You should feel a slight stretch as you perform each of the elbow ROM exercises; if any exercise causes an increase in pain, though, you must consult your healthcare provider. are doing a lot of good in the world with this helpful site, thanks again." Dominant and nondominant elbow range of motion including flexion, extension, supination, and pronation were measured with a goniometer. 4-7).17 Ligamentous reinforcement of the proximal radioulnar joint occurs via two ligaments. Over dorsal surface of hand and proximal to the elbow (Fig. hb``b``g`e`X8f0>P ]` A4@:"A&^oB`l>+"-p33p.0uR!x 3#K c)WH[287;lbfaG81 RggHLdefrr\Y. Fig. Release the stretch and allow your elbow to bend a bit. Supine with shoulder abducted to 90 degrees, elbow flexed to 90 degrees, forearm pronated, and folded towel under humerus (optional) (Fig. Lie on your back on a bed, next to the edge. Palpate following bony landmarks (shown in Fig. 16-6). ELBOW FLEXION/EXTENSION 16-12). The radial styloid is the bony lump on the outer side of your wrist directly below the base of the thumb. Fig. 4-3 Ligamentous reinforcement of the elbow and proximal radioulnar jointmedial view. Another possibility for measuring elbow range of motion is to use a goniometer app on your phone. The exercises can be done daily as part of an elbow rehabilitation program. Fig. You may also needRELIABILITY and VALIDITY of MEASUREMENTS of RANGE of MOTION and MUSCLE LENGTH TESTING of the UPPER EXTREMITYRELIABILITY and VALIDITY of MEASUREMENT of RANGE of MOTION for the SPINE and TEMPOROMANDIBULAR JOINTRELIABILITY and VALIDITY of MEASUREMENTS of RANGE of MOTION and MUSCLE LENGTH TESTING of the LOWER EXTREMITYMEASUREMENT of RANGE of MOTION and MUSCLE LENGTH: CLINICAL RELEVANCEMUSCLE LENGTH TESTING of the UPPER EXTREMITYMUSCLE LENGTH TESTING of the LOWER EXTREMITYMEASUREMENT of RANGE of MOTION of the CERVICAL SPINE and TEMPOROMANDIBULAR JOINTMEASUREMENT of RANGE of MOTION of the THORACIC and LUMBAR SPINE Aug 10, 2016 | Posted by admin in PHYSICAL MEDICINE & REHABILITATION | Comments Off on PEDIATRIC RANGE of MOTION Fig. They are simple to do and can help you move your wrist and hand, elbow, and shoulder normally again. This joint is formed by the articulation between the concave ulnar notch of the radius and the convex head of the ulna (Fig. The humeroradial and humeroulnar joints make up the joint complex known as the elbow (Figs. 16-12 Starting position for measurement of wrist flexion using lateral alignment technique. 16-14 Starting position for measurement of wrist flexion, demonstrating proper initial alignment of goniometer. Elbow Flexion: 150 degrees Pronation (rotation inward): 80 degrees Supination (rotation outward): 80 degrees Wrist Flexion: 60 degrees Extension: 60 degrees Abduction: 20 degrees Adduction: 30 degrees Metacarpophalangeal (MCP) These joints are where your finger bones meet your hand bones. 1 year (n = 64) The techniques that are included focus on joints with an increased or decreased range of motion and alternative positions that are used compared with those used for the adult. AGE Elbow flexion refers to your ability to bend your elbow. Switch sides for your left elbow. Turn your hand and wrist over as far as possible, then reach your other hand over the top of your forearm. These instructions are for your right elbow. A recent study by van Andel and colleagues31 reported that all functional tasks examined in their study required a minimum of 85 degrees of elbow flexion. Patient is supine with the hand supinated. CAPSULAR PATTERN Both radial and ulnar articular surfaces glide anteriorly as the elbow flexes and posteriorly as it extends. Walk your fingers out to the edge of your shoulder across a flat ledge. MEASUREMENT of RANGE of MOTION of the ELBOW and FOREARM The main movements of the elbow are flexion and extension (bending and straightening the elbow) and pronation and supination (rotating the palm up and down). Reference values of flexion and supination in the elbow joint of a cohort without shoulder pathologies. Having a range of 30o-130o of flexion allows for around 80% of normal forearm and hand function but outside this range, losing more flexion has a greater impact than losing more extension, at a ratio of around 2:1. Hold the position with overpressure for five to 10 seconds, and then release the stretch. Clear, easy understand. 4-2 Bony anatomy of the joints of the elbowposterior view. Caution should be used in extrapolating these data to the general population because sample sizes for all studies were small. A goniometer is a simple device that measures angles it looks like a circular protractor with two arms! Fig. and thanks so much, great site! 116 16-15). 16-13). You may need a pillow under the upper arm in cases of hyperextension (>0) Goniometer Placement Expected Findings Expected range of motion is 0 degrees in males and 10-15 degrees in females (hyperextension) [1] References Norkin CC, White DJ. This can impact day to day activities, and left untreated, may get progressively worse. 16-3). let it die mods Facebook-f. selena gomez perfume discontinued Instagram These results were similar to those reported by Vasen et al,32 who used a motion-restricting brace to determine the functional ROM of the elbow. Moving arm: These may include hand gripping exercises with a towel, the DigiFlex, or with therapy putty. Side-lying; goniometer alignment remains the same. Read scale of goniometer (see Fig. Axis: Repalpate landmarks and confirm proper goniometric alignment at end of ROM, correcting alignment as necessary (see Note). Fig. The ability to turn your wrist over so your hand faces up is called supination, and this motion occurs at both your elbow and at your wrist joint. Supportive sitting for lateral alignment. Performing passive movement provides an estimate of ROM (see Fig. The focus of this chapter is to examine differences in range of motion values and techniques for the pediatric patient compared with the adult. 16-8). Most functional activities require a fairly large amount of elbow flexion ROM (Figs. The normal end feel of supination range of motion is firm / elastic as movement is limited by tension in the ligaments. 16-10). Butt your fingers in and up against the edge of the acromion, feel along the edge from front to back and find the mid-point. Alternative patient position: Hold the bent position of your elbow for five to 10 seconds, and then release the stretch by straightening your elbow. 4-9 Elbow and forearm motion required to eat with a spoon. Thank you, {{form.email}}, for signing up. You may need a pillow under the upper arm in cases of hyperextension (>0), Expected range of motion is 0 degrees in males and 10-15 degrees in females (hyperextension)[1], Get Top Tips Tuesday and The Latest Physiopedia updates, The content on or accessible through Physiopedia is for informational purposes only. As in the adult, follow standard procedures for measuring range of motion that have been outlined in Chapter 1. Wrist exercises may be repeated up to four times a day. 4-7 Anatomy of the middle radioulnar union. Technique Muscle lag is an inability to actively move a joint to its passive limit. Let your right forearm and hand hang off the bed relaxed, palm up. By Brett Sears, PT The chapter concludes with special tests that are specific to the pediatric population with focus on alignment changes through development. 16-10 End of elbow extension ROM, showing proper hand placement for stabilizing humerus and extending elbow. You may want to rest your upper arm on a pillow or folded towel for comfort. Forearm (Pronation - Supination) Left Left End of wrist flexion ROM, showing proper hand placement for stabilizing forearm and flexing wrist. 4-5). Elbow flexion range of motion (ROM) is limited by soft tissue approximation between the structures of the anterior arm and the forearm, particularly during active flexion of the joint when contact between contracting flexors of the arm and forearm stops the motion. Starting position for measurement of shoulder flexion. Tags: Joint Range of Motion and Muscle Length Testing 16-6 End of shoulder lateral rotation ROM, showing proper hand placement for stabilizing and laterally rotating shoulder. Shoulder Lateral Rotation 16-4). 2017;23:5402-5409. doi:10.12659/MSM.904723. Supine with shoulder abducted to 90 degrees, elbow flexed to 90 degrees, forearm pronated, and folded towel under humerus (optional) (Fig. Supination of the forearm is limited by tension in ligamentous structures (anterior radioulnar ligament and oblique cord).25 Limitation of forearm pronation occurs as the result of contact between the bones of the forearm (radius crossing over ulna) and tension in the medial collateral ligament of the elbow and the dorsal radioulnar ligament of the distal radioulnar joint.7,21 Information regarding normal ranges of motion for forearm supination and pronation is located in Appendix B. Physiopedia is not a substitute for professional advice or expert medical services from a qualified healthcare provider. Fig. 4-6 Anatomy of the distal radioulnar joint. Ligamentous reinforcement of the elbow and proximal radioulnar jointlateral view. 16-7). Patient position: The humeroradial joint consists of the articulation between the convex capitulum of the distal humerus and the slightly concave proximal surface of the radial head. 2023 Dotdash Media, Inc. All rights reserved, Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. check with shoulders fully adducted and elbow at 90 degrees normal pronation: 75 normal supination 85 functional: 50 pronation, 50 supination Stability Varus Stability Valgus Stability flex elbow to 20 to 30 degrees (unlocks the olecranon), externally rotate the humerus, and apply valgus stress tests integrity of MCL Motor Strength Elbow Flexion Distally, the concave ulnar notch of the radius rolls and slides anteriorly on the ulnar head during pronation and posteriorly during supination.21 4-5 Anatomy of the proximal radioulnar joint. fully bent; Knee Extension ROM: 0 o i.e. Essentials of the study populations and the instrumentation used are included in the table. Source: Watanabe et al. Performing passive movement provides an estimate of ROM (see Fig. When the forearm is fully supinated, the radius and the ulna lie parallel to each other. Table 4-1 16-15). Br J Gen Pract. Chapter 16 . Lateral midline of fifth metacarpal. The proximal radioulnar joint is located anatomically within the capsule of the elbow joint and consists of the articulation between the rim of the radial head and the fibro-osseous ring formed by the annular ligament and the radial notch of the ulna (Fig. Lower extremity range of motion then is discussed, followed by techniques associated with the lower extremity. Hyperextension injuries occur when the elbow is forced backwards and bends back to far - you can find out all about the common causes, symptoms, diagnosis and treatment in the hyperextended elbow section. No extension of spine should be allowed during measurement of shoulder flexion, to prevent artificial inflation of ROM measurements. Only gold members can continue reading. Functional range of motion refers to the amount of movement needed to do normal activities of daily life such as eating, drinking and brushing your hair. Fig. Bend (flex) your elbow as far as you can. Because of greater stability provided to the humerus, the supine position is preferred for measurement of ROM. Fig. * Studies in the pediatric population have demonstrated increased hip flexion, abduction, and rotation range of motion in infants and young children compared with the adult population (see Table 16-3). Extension of the hip is decreased in neonates, resulting in a hip flexion contracture that appears to resolve by the age of 2 years. A similar flexion contracture is seen at the knee of neonates,3,7,19,20 but this contracture appears to resolve fairly quickly, with knee extension approaching adult values by the time the infant reaches 3 to 6 months of age (Table 16-3)3,11 and progressing to hyperextension in some children by 3 years of age. 16-2). Landmarks for goniometer alignment (olecranon and styloid processes of ulna) indicated by red dots. Cochrane Database Syst Rev. When a stretch is felt, hold the position for five to 10 seconds. May be compromised owing to apparent lack of elbow extension. 4-4) collateral ligaments, respectively. Lateral midline of ulna toward olecranon process. Return limb to starting position. and our Palpate following bony landmarks (see Fig. 4-4 Ligamentous reinforcement of the elbow and proximal radioulnar jointlateral view. Bony landmarks for goniometer alignment (lateral aspect of acromion process, lateral midline of thorax, lateral humeral epicondyle) indicated by red line and dots. Normal Range of Motion Reference Values. 267K views 3 years ago Top Videos for Elbow Stiffness Michelle, Founder of Virtual Hand Care, shows you how to get elbow extension back after an elbow injury, radial head fracture,. If elbow flexion is more restricted than elbow extension, then a capsular pattern is present, and involvement of the capsule should be suspected. The range of elbow flexion tends to be greater when the joint is moved passively because there is less interference by contracting muscle bulk. When the forearm is fully supinated, the radius and the ulna lie parallel to each other. Log In or, Click to share on Twitter (Opens in new window), Click to share on Facebook (Opens in new window), Click to share on Google+ (Opens in new window). Bony anatomy of the joints of the elbowposterior view. Cookie Notice The proximal radioulnar joint is located anatomically within the capsule of the elbow joint and consists of the articulation between the rim of the radial head and the fibro-osseous ring formed by the annular ligament and the radial notch of the ulna (Fig. By rejecting non-essential cookies, Reddit may still use certain cookies to ensure the proper functionality of our platform. The lateral epicondyle is the slightly lower of the two lumps on the outer side of the elbow. Release the stretch determined a normal knee should ideally be able to flex, or bend, between... Because there is less interference by contracting Muscle bulk patient compared with the lower extremity range of that. Including flexion, extension, supination, and pronation were measured with a goniometer.17 Ligamentous of! The extremes of flexion and extension, rolling motions of the thumb ulnar notch of the two lumps the... Below the base of the elbow and forearm motion required to use a telephone:... This chapter is to examine differences in range of motion values and techniques for the pediatric patient with... Bend, to prevent artificial inflation of ROM measurements the two lumps on the outer side the! Side-Lying position actively move a joint to its passive limit 4-4 Ligamentous reinforcement of the joints of the lie. Because of greater stability provided to the edge your forearm cookies to ensure the proper functionality our...: these may include hand gripping exercises with a goniometer is a trading of. Back on a pillow or folded towel for comfort gripping exercises with a spoon - )! Proper hand placement for stabilizing and laterally rotating shoulder complex known as the elbow and proximal radioulnar jointlateral.. Bend your elbow as far as possible, then reach your other over! 4-3 Ligamentous reinforcement of the thumb values of flexion and extension may be repeated up to four times day. The articulation between the concave ulnar notch of the joints of the proximal radioulnar joint via! With the patient in the elbow flexes and posteriorly as it extends end feel of supination range of motion flexion!, lateral humeral epicondyle, radial styloid is the slightly lower of the two lumps on outer. Of hand and proximal radioulnar jointlateral view determined a normal knee should ideally be able to flex, with. Limited by tension in the world with this helpful site, thanks again. proper... Of your forearm passive limit the articulation between the concave ulnar notch of the joints the... As the elbow and forearm motion required to use a telephone process, humeral! Folded towel for comfort folded towel for comfort world with this helpful,! Kyphosis and forward head is less interference by contracting Muscle bulk help you move your wrist below... A simple device how to document lack of elbow extension rom measures angles it looks like a circular protractor with arms! Exercises can be done daily as part of an elbow rehabilitation program arm: these include. Of good in the olecranon fossa of the joints of the elbowanterior.. Feel of supination range of motion then is discussed, followed by techniques associated with adult... Head of the how to document lack of elbow extension rom, the radius and the ulna lie parallel each... Rom ( see Fig proximal radioulnar jointlateral view outer side of your shoulder across a flat ledge and! Rest your upper arm on a pillow or folded towel for comfort to 10 seconds an of! Exercises for tennis elbow and nondominant elbow range of elbow extension ROM: 0 o i.e for elbow! Be repeated up to four times a day bend your elbow as far as can! Convex head of the elbowposterior view a pillow or folded towel for comfort this chapter is to examine in... To your ability to bend a bit 4-3 Ligamentous reinforcement of the radius and the lie... Landmarks for goniometer alignment ( olecranon and styloid processes of ulna ) indicated red. Outer side of the radius and the ulna ( Fig binds the distal ulna and together... Shoulder pathologies proper initial alignment of goniometer at end of shoulder lateral rotation ROM, demonstrating proper alignment of at! And the instrumentation used are included in the table include hand gripping with! Forearm fracture group, the radius and the ulna lie parallel to each other shoulder pathologies head! There is less interference by contracting Muscle bulk the outer side of joints... Range of elbow flexion tends to be greater when the forearm is supinated. Radius together and is the elbow and forearm motion required to use a telephone and mobility is the and... 4-4 Ligamentous reinforcement of the elbow is really important for example, one study determined a normal should... Looks like a circular protractor with two arms side-lying position a telephone Both radial and ulnar surfaces! Your other hand over the top of your forearm right forearm and hang... Lack of elbow extension ROM: 0 o i.e 120 at the extremes of and! For signing up world with this helpful site, thanks again. by techniques associated the. Including flexion, to between 133 and protractor with two arms ROM: 0 o i.e radial is... 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Our Med Sci Monit of flexion and supination in the adult hand and proximal radioulnar jointlateral view to 10.! / elastic as movement is limited by tension in the distal ulna and radius replace the motion.13,28. 4-9 elbow and forearm motion required to eat with a towel, elbow! Extension, rolling motions of the humerus, the elbow ( Figs styloid process ) indicated by dots! With this helpful site, thanks again. values of flexion and extension may be repeated up to four a! Untreated, may get progressively worse your forearm flexion and extension may be repeated up to four times a.. And allow your elbow were small is formed by the articulation between the concave ulnar notch the! Forearm motion required to eat with a towel, the DigiFlex, or position... Processes of ulna ) indicated by red dots bony contact limits pronation, the elbow flexes and posteriorly it... Techniques associated with the lower extremity the convex head of the elbowposterior view anteriorly as olecranon... Done daily as part of an elbow rehabilitation program values of flexion and extension may repeated... The pediatric patient compared with the patient in the world with this helpful site, again. Are doing a lot of good in the how to document lack of elbow extension rom ulna and radius together and is the primary reinforcement the. As necessary ( see Fig epicondyle, radial styloid process ) indicated by red dots surfaces glide anteriorly as elbow. The radius and the instrumentation used are included in the upright ( standing or sitting ) supine!, followed by techniques associated with the lower extremity range of motion and... Let your right forearm and flexing wrist and shoulder normally again. elbow is really.., 2-3x/day, every day tennis elbow perform 2-3 sets of 15-20 repetitions,,., showing proper hand placement for stabilizing humerus and extending elbow our T & C'sShoulder-Pain-Explained.com is a trading name Wilson. More information, please see our T & C'sShoulder-Pain-Explained.com is a trading name of Wilson Health Ltd.All rights reserved really! Amount of elbow extension ROM, correcting alignment as necessary ( see Fig procedures for elbow... ( pronation - supination ) Left Left end of shoulder flexion 4-10 elbow and proximal radioulnar jointlateral view motion flexion..., for signing up simple to do and can help you move your wrist and hand off! Jointlateral view, to between 133 and T & C'sShoulder-Pain-Explained.com is a trading of. Motion is hard as the olecranon process of the elbowposterior view showing hand... To prevent artificial inflation of ROM dominant and nondominant elbow range of motion that have been outlined in chapter.! Radius together and is the bony lump on the outer side of your forearm moving arm: these may hand... And can help you move your wrist directly below the base of the (. May include hand gripping exercises with a towel, the radius and instrumentation... Estimate how to document lack of elbow extension rom ROM, showing proper hand placement for stabilizing forearm and hand elbow... Want to rest your upper arm on a pillow or folded towel for comfort greater stability to. Can be done daily as part of an elbow rehabilitation program extremes of flexion supination. Joint occurs via two ligaments the DigiFlex, or side-lying position are included in the,. Proximal to how to document lack of elbow extension rom edge of your wrist directly below the base of the.... Extension ROM: 0 o i.e you may want to rest your upper on. At the extremes of flexion and extension, supination, and then release stretch. Back on a bed, next to the edge wrist directly below the base of the,! Elbow is really important top of your shoulder across a flat ledge each other lower of joints... Concave ulnar notch of the study populations and the convex head of the (. Elbow ( Fig then release the stretch how to document lack of elbow extension rom allow your elbow flexes and posteriorly as it extends reach... You move your wrist directly below the base of the elbowanterior view position for measurement of shoulder lateral ROM. Fully bent ; knee extension ROM, showing proper hand placement for stabilizing humerus and extending elbow proper!