Forearm rotation is the result of movement that occurs between the elbow, forearm and wrist. Injuries to any of these can cause stiffness, pain or instability in supination or pronation. “Normal” range is 84˚ supination and 71˚ pronation, but the best “normal” for your patient would be the measurement of an uninjured side. This is because many people have more and expect to regain more range of motion that this.
Is “functional” rotation really functional?
“Functional” or “acceptable” rotation is widely considered to be 50˚ of supination and 50˚ of pronation. Rather, it was in 1981. But we know that the use of toilet paper (the ability to reach the sacrum) requires 45˚ to 65˚. Other functional tasks also require more than 50˚. Further adding complication is that demands have changed since then 1981 too. They would have tested a very different type of telephone back then!
Many of our patients want more than “functional” range. They want their forearm to move easily and comfortably, and they want to be able to use their injured hands rather than having to swap hands for some tasks. Sometimes it’s simple things like washing their face, shaving or choosing which hand they wipe with. Other times it’s using daily essential technology like phones or computers. It may be return to sport, playing a musical instrument, or cooking with ease. For some, they need to be able to lift and carry items for their trade, which is impossible without good supination. For others tied to a desk, it may be to type comfortably, which requires good pronation.
Function has changed a lot over the past decades. I have spent a sad number of hours today typing (in ≈70˚ pronation), and using my mobile/cellular phone (holding ≈80˚ supination, scrolling ≈70˚ pronation). I remember when patients used to complain about not being able to take coins in change as they couldn’t get their palm up to flat – I don’t hear that as much these days as a problem in this credit-card-swiping world. We, as clinicians, need to make sure we are constantly evaluating what a patient needs or wants to achieve to meet the demands of their life.
Stiffness or pain at terminal range of motion (ROM), or even anywhere past 50˚ supination or 50˚ pronation has long been considered a problem which isn’t “dysfunctional”. It makes it easier to discharge a patient from care when we are struggling to achieve full ROM easily or spontaneously. We may use those numbers to suggest a patient be happy with their “functional” ROM. We could further justify the chronicity, malunion, severity of the injury, hard-end feel for therapy plateauing.
We would be wise to ask what they can’t do or have difficulty doing, as well as ask them to complete some patient rated outcomes such as the Patient Rated Wrist Hand Evaluation (PRWHE) for clues to any dysfunction or dissatisfaction. From this questionnaire, for example, a patient having difficulty with turning a doorknob, or using “bathroom tissue”, may indicate rotation limitations. While less specific difficulties such as pain, carrying a 4kg object, work or recreation prompt the clinician to question whether rotation or other dysfunction are limiting that person.
Aim for more than 50˚ – 50˚
If you can achieve more than 50˚ in supination and/or pronation with some stretching and exercises, you should do so. If that doesn’t work and you have a therapy plateau, but remember that research proves that orthoses improve rotation despite:
– hard end-feel
– therapy plateau
Successful stretching orthoses will gain 40˚ to 50˚ on average in the stiffest of wrists and elbows. Always evaluate the following to ensure your orthosis will be a successful one:
– Does it firmly hold at end-of-range (always check that it does)?
– Can it be worn for hours daily?
– Can it be fabricated & fitted effectively?
– Can it be applied by the patient effectively?
If you are unable to fabricate a Colello, Shah or Lee custom thermoplastic orthosis, then a JAS SPS splint or a Dynasplint or One-80˚ Pronosupinator# are the best options. Other orthoses, such as neoprene TAP splints, will not pass the test in our experience.
Regaining normal rotation
So the goal is to exceed what was once considered to be “functional” range. It is realistic enough to achieve more than this range in the stiffest of wrists. Traditional stretching and exercises work for many patients, but when therapy plateaues, an orthosis is the proven next step that should gain 40˚ to 50˚, and supple, free movement. Wouldn’t your patient be delighted with that?
Conflict of interest
#Conflict of interest: UL Co are the inventors of the multi-award winning One-80˚ Pronosupinator. We have no financial interest in JAS or Dynasplint, but they are great orthoses which we would not hesitate to recommend to our patients. We are proud to claim that the One-80˚ Pronosupinator is one of the efficacious few orthoses available for forearm rotation.