A patient who has limited movements throughout the arc of forearm supination and pronation due to moderate to severe pain. Which of the following manual therapy techniques to the proximal radioulnar joint is MOST appropriate to perform initially?

• A. 5° supination with 90° elbow flexion, small-amplitude mobilizations at the beginning of ROM
• B. 10° supination with 70° elbow flexion, large-amplitude mobilizations at the end of ROM
• C. 35° supination with 70° elbow flexion, large-amplitude mobilizations in the middle of ROM
• D. Full supination with full elbow extension, small-amplitude mobilizations at the end of ROM

Answer: (C)

When a joint has limited rotation across the entire arc and pain is a limiting factor, the best first move is to use a mobilization that targets the middle of the ROM with a larger, safe amplitude. For the proximal radioulnar joint, that means positioning the elbow around 70 degrees of flexion and the forearm in mid-range (about 35 degrees of supination) so the radial head can glide smoothly within the annular ligament without being pushed into end-range pain.

Applying large-amplitude movements in that mid-range helps improve joint play and ROM while keeping the end ranges (where pain tends to be worse) out of the initial treatment. This approach desensitizes the tissue and lays the groundwork for gradual progression toward full ROM as pain decreases.

The other options either start too close to the painful end ranges or use small amplitudes at the start or end of ROM, which is less effective for gaining ROM when pain limits motion across the arc.