3. Non-Capsular Patterns

Resisted Movements: Clinical Pearl - Remember, completing resisted movements at mid-range puts less stress on __________ tissue!

- Inert

Resisted Movements: Advantages for Resisted Testing at Mid-Range (3)

- Inert tissue is not stressed - More comfortable for the patient - If positive for pain at mid-range then very likely a contractile problem and more damage present

What is instability generally associated with?

- Instability is associated with disruption of normal anatomical features (e.g. fractures/ruptures)

Pathomechanical: Characteristics & Normal Example

- Jammed (abrupt hard end-feel) - Never normal (note: would feel like bony block where it shouldn't)

(AROM) Non-Capsular Patterns: Extra-Articular Limitations Definition

- Joint is "normal" but overall ROM is limited (e.g. fibrotic shortening of a muscle(s) or edema around the involved joint)

What does non-arthritic conditions include?

- Ligament/partial capsule injury - Non-arthritic "internal derangement": an internal disturbance that results in a change in the normal resting position of a joint that causes pain and ROM loss - Extra-articular limitations

(AROM) Non-Capsular Patterns: Extra-Articular Limitation What is the clinical presentation?

- Limitation of movement in one direction, with full painless ROM in all other directions

STTT- AROM, PROM, and Resisted Ligament/Partial Capsule Tear: Depending on the tissue and the degree of injury, some movements will be...(3)

- Limited and painful - Full ROM and painful - Full ROM and pain-free

Empty: Characteristics & Normal Example

- Limited by sever pain, no resistance felt - Never normal

Resisted Movements: Clinical Question - If a muscle exhibits weakness, what are some reasons for the changes in strength? (5)

- Local contractile lesion - Neurological deficit - Pain/reflex inhibition - Disuse - Psychological (hysteria, anxiety, other)

Grade I Strain

- Mild - Muscle is tender and painful but has normal strength

Grade I Sprain

- Mild tear - Pain, hypermobility and normal capsular end-feel

Grade II Strain

- Moderate - Increased pain, mild swelling (bruising), and noticeable loss of strength

What is hypermobility generally associated with? (2)

- Motor control deficits - Increased soft tissue extensibility

(AROM) Non-Capsular Patterns: Internal Derangement What is the clinical presentation? (3)

- Movements that 'engage' the fragment are limited and painful - Movements that don't 'engage' the fragments are full and pain-free - Patients may also mention having popping, clicking, catching or sticking at the involved joint

Pain with Resistance: Acuteness & Possible Pathology

- Sub-acute (chemo-mechanical) - Sub-acute traumatic arthritis; fibrosis of tissue occurring

Clinical Points to Remember

- 1st resistance you feel with PROM is the muscle not the joint - If there is a "BIG" ROM loss it may not take as much "force" to get to end-of-range (grade your forces appropriately) - ALWAYS perform PROM so you can assess the end-feel even if the patient is in "PAIN" otherwise you get no relevant information from the examination! - Not only are we evaluating the "restrictor of movement" we can also get an assessment of the condition (SINSS) - "End-feel" assessment is a hallmark component of the ART iN PT

Bony: Characteristics & Normal Example

- Abrupt and doesn't move - Elbow extension in pronation

Pain Felt Before Resistance: Acuteness & Possible Pathology

- Acute (mainly inflammation) - Typically after injury, acute traumatic arthritis

Resisted Movements: Clinical Question - If all contractions are painful, what should we be thinking?

- Acute or large inflammatory response in the joint - Bursitis - Fracture - Patient has low pain threshold - Secondary gain

Resisted Movements: Disadvantages for Resisted Test at EOR

- Any inflammation of the joint or joint capsule will be painful with strength testing at EOR (increased tension through active and inert tissue)

Review: What are capsular patterns generally associated with?

- Arthritis

Summary of STTT in an Examination: Preliminary Examination

- Begin with "scanning" examination consisting of active movements to establish which joint is at fault - Then proceed to examination in detail of the incriminated joint or tissue by use of passive and resisted movements

(AROM) Non-Capsular Patterns: Extra-Articular Limitations Application Question - If you had fibrotic shortening of the pectoralis major muscle following a mastectomy procedure, what may the patient present with clinically?

- Changing the kinematics of the muscle tissue and its ability to produce force - Pain with actions of the pectoralis major muscle (i.e. shoulder flexion, horizontal adduction...)

Pain Felt After Resistance: Acuteness & Possible Pathology

- Chronic or non-acute (mechano-chemical) - Usually a mechanical dysfunction; due to tissue stretch/stress

Grade III Sprain

- Complete tear - No pain (sense no fiber attachment), hypermobility and a very "soft" capsular 'end-feel'

STTT - AROM, PROM, and Resisted Movements: "End-Feel" Clinical Question - How might our qualitative assessment vary between AROM and PROM?

- During AROM assessment we will be able to appreciate patient tolerance, strength, quality of movement (without assistance), as well as active demonstration of functional resistance - During PROM we can better assess end-feel and appreciate the "feel" of the pathology associated with movement at the effected joint

STTT - AROM, PROM, and Resisted Movements: "End-Feel" Definition

- During PROM, the sensation the examiner feels at the end of the "available" range of motion is called the "end-feel"

Resisted Movements: Advantages for Resisted Test at EOR (3)

- EOR requires less force to provoke pain due to muscle in lengthened position - More efficient due to already being at EOR from PROM and OP - Stronger positive if there is a contractile injury

Pain & No Resistance: Acuteness & Possible Pathology

- Empty end-feel - Usually serious pathology

Capsular: Characteristics & Normal Example

- Firm with a slight give to stretch - Wrist flexion (soft), wrist extension (medium), knee extension (hard)

Sprains and Strains: Clinical Note - With any kind of sprain or strain the patient will demonstrate...(2)

- Guarding - Altered propioception

Constant Pain (Regardless of Resistance): Acuteness & Possible Pathology

- Hyper-acute problem - Very acute arthritis, systemic arthritis flare up, fracture, cancer, visceral problems

Resisted Movements - Painful with Repetition: How do we interpret this info?

- Muscle is strong and painless, patient reports pain after number of repetitions - Possible intermittent claudication is probable; increased irritation to tendon (e.g. impingement; tendonosis etc) - Possible local ischemia occurring due to myofascial dysfunction (e.g. myofascial pain syndrome; mild lesion; DOMs etc.)

Soft Tissue Approximation: Characteristics & Normal Example

- No resistance but limits movement - Knee flexion

STT T -AROM, PROM, and Resisted Movements Clinical Question: Would you always assess muscle strength of a muscle in a resting position?

- No, you would also want to assess at the end of available range (EOR) with the effected muscle on stretch - This will increase stress on tissue without increasing the force needed to provoke pain

What are non-capsular patterns caused by?

- Non-arthritic conditions

(PROM) End-Feels for Capsular Patterns: What is normal capsular movement?

- Normal presentation of a joint's ROM (no restrictions) - Clinical Note: We would not say 'normal capsular patterns' to describe unrestricted movement; a normal capsular pattern infers dysfunctional movement

Resisted Movements: Disadvantages for Resisted Testing at Mid-Range

- Not efficient in the examination (i.e. will have to test all movements [AROM/PROM/resisted test]) - No functional assessment

Clinical Interpretation: Would expect _________ motion to be limited with this non-capsular patterns.

- Only one

STT T -AROM, PROM, and Resisted Movements Material Review: Maximal isometric testing of contractile tissues as ___________ and _________. test; generally completed at __________.

- Pain provocation, strength, mid-range (resting joint position

Grade II Sprain

- Partial tear - Pain with moderately excessive movements and a "soft" capsular end-feel

Resisted Movements - Strong and Painful: How do we interpret this info?

- Possible minor lesion to contractile tissue (1st degree strain) - Contraction hurts, but damage is probably minimal - Now weakness is apparent, at this point...

Resisted Movements - Weak and Painful: How do we interpret this info?

- Probable more serious lesion to contractile tissue (2nd degree) - Serious trouble is present (e.g. fracture; excessive effusion)

Resisted Movements - Weak and Painless: How do we interpret this info?

- Probable more serious lesion to contractile tissue (3rd degree) - Possible neurological involvement (e.g. UMN; LMN involvement) - Assess for fatigable weakness (e.g. Myasthenia Gravis)

When we discuss capsular pattern and non-capsular pattern, what characteristic of ROM are we assessing?

- Quality of ROM

STTT- AROM, PROM, and Resisted Ligament/Partial Capsule Tear: Clinical Application - What would we use STTT to assess?

- Quality of joint ROM (passive or active) - This includes joints that present with both capsular and non-capsular patterns

Spasm: Characteristics & Normal Example

- Reactive response (sudden arrest of movement) with no recoil - Never normal

Springy/Elastic: Characteristics & Normal Example

- Rubbery block, tone recoil - Ankle DF with knee extended (stretch)

Ligamentous Injuries: Strain or Sprain?

- SPRAIN!

Muscle Injuries: Strain or Sprain?

- STRAIN!

Boggy: Characteristics & Normal Example

- Squishy - Never normal

Resisted Movements: When completing MMT, keep to these steps (at mid-range or EOR):

- Stable position of the joint involved - Isolate one muscle or group only (as best you can) - Maximum resistance without secondary joint movement (build your force from minimal to maximal force) - Note whether strong vs weak; painless vs. painful

Resistance without Pain: Acuteness & Possible Pathology

- Stiff (mechanical) - Not usually as main complaint; something fibrotic

Resisted Movements: With MMT, what else is assessed?

- Strength

STTT - AROM, PROM, and Resisted Movements: "End-Feel" Clinical Interpretation: It gives the examiner info about...

- The "restrictor" of the movement (e.g. muscle vs fear avoidance; bone vs inflammation) - In other words, it's the way to assess if a joint is moving "normally" or "dysfunctionally" (restricted) by the way it "feels" - You will use the "end-feel" category to document your associated observation that match the listed characteristics

(AROM) Non-Capsular Patterns: Extra-Articular Limitations Clinical Question - What are the differences and similarities between extra-articular and internal derangement?

- The difference is that extra-articular limitations occur outside the joint while internal derangement happens within the joint - In both cases, the patient can report having mono-planar restrictions and pain with AROM/PROM

(AROM) Non-Capsular Patterns: Internal Derangement What may be happening to the joint with a subjective report like this?

- The fragment may be preventing normal ROM by preventing normal arthrokinematics - This may cause subjective reports of clicking and catching while also irritating surrounding nociceptive structures (resulting in pain)

Grade III Strain

- There is no going back... - Complete tear (e.g. muscle rips into two; shear away from its tendon) - Complete loss of muscle function - Acute high pain level with significant swelling and discoloration with an obvious deformation of tissue - Sub-acute and chronic patient will have significantly reduced or no pain with muscle contraction

Resisted Movements - Strong and Painless: How do we interpret this info?

- This finding would indicate normal contractile tissue; so, nothing is wrong...

STTT- AROM, PROM, and Resisted Ligament/Partial Capsule Tear: What is the clinical presentation?

- Usually localized pain occurring with movements that stretch the ligament or portion of the capsule

(PROM) End-Feels for Capsular Patterns: A few causes and intervention... Boney, Boggy, & Empty

Boney: - Osteophyte blocking motion, subluxation of bone and/or fracture fragment blocking motion Boggy: - Hemarthrosis and/or significant edema formation - Requires aspiration or soft tissue mobilization to move fluid from the area Clinical Treatment: - Grade I-II mobilizations to reduce pain and restore ROM; soft tissue mobilization to move fluid; general exercises to increase tolerance to ADLs/iADLs Empty: - Acute subacromial bursitis, guarding, tumors, excessive effusion - Clinical Note: Generally speaking, no muscle spasms will be involved

(PROM) End-Feels: Even more causes and intervention... Early & Late Spasm

Early Spasm: Reactive muscle spasm "early" in ROM caused by: - Arthritis, grade 2 muscle/ligament tears, fractures near a muscle insertion or dural compression - Always associated with inflammation Late Spasm: Reactive at end of available range caused by: - Irritable hypermobility or instability (e.g. chronic ligamentous tear) Clinical Treatment: - For both, remove stresses to the region with orthotic or stabilization exercises Clinical Pearl: - "Hypermobility is reversible - instability is forever."

(PROM) End-Feels: ...and more possible causes and intervention Elastic & Springy

Elastic (Muscle Recoil): - Muscle tone may be normal in some regions, like the knee to protect the capsule; if felt elsewhere then suspect hypertonicity (i.e. clonus) Springy (Non-Muscular Rebound): - This is not normal and mostly felt with internal derangement (think about closing a door on a rubber eraser) Clinical Treatment: - Manipulation, non-rhythmic mobilization; if this doesn't resolve the loose body may need to be removed/repaired surgically

(PROM) End-Feels for Capsular Patterns: A few causes and intervention... Hard & Soft Capsular Patterns

Hard Capsular Pattern (i.e. stiff): - Pericapsular tissue hypomobility - Arthrosis, adhesions, or scarring (usually chronic condition) Soft Capsular Pattern (i.e. 'pillow-ey): - Has soft (boggy) end-feel with a restricted ROM - Synovitis; soft tissue edema Clinical Treatment: - Both will require some type of stretching or joint mobilization, but WHAT TYPE is important - Prolonged stretching (into the plastic range) with OP and grade III-IV mobilizations for hard capsular end-feels (significant scarring) - Gentle prolonged with grade I-II mobilizations for soft capsular patterns (inflammatory presentation

Summary of STTT in an Examination: Passive Movements

Inert structures: - Joint capsule, ligaments, bursae, fascia, displacements, dura mater, nerve roots Examine for: - Pain - Limitation - End-feel Principle findings: - Capsular pattern: pain and limitation in fixed proportion - Non-capsular pattern: ligamentous sprain, internal derangement - Extra-articular limitation: muscle

What is the source of symptoms for non-capsular patterns?

Joints that lie under the symptomatic area - Shoulder example: AC, SC, G-H Soft tissues that lie under the symptomatic area - Shoulder example: deltoid, pectorals, biceps, G-H ligament, capsule, nerves Tissue that refer to the symptomatic area - Shoulder example: facet joints, muscles, nerves (root or branch)

(AROM) Non-Capsular Patterns: Internal Derangement Types of Internal Derangement

Loose (body) fragments that occupies part of the joint space (e.g. fragment of cartilage, bone, meniscus, labrum) Intra-articular structures: - Mensicus - IV disc - Hyaline cartilage - Labrum

(PROM) End-Feels: Possible causes and intervention! - Pathomechanical & Empty

Pathomechanical (Jammed): - It can be very hard like bone on bone, or more 'springy' like internal derangement - Clinical Treatment: Indicates a biomechanical dysfunction requiring manipulation or non-rhythmic mobilization. Similar to 'springy', may require additional treatment if the loose body or injury doesn't resolve on its own Empty: - Clinical Note: No end-feel is ever reached! The test is stopped due to extreme pain; this is always caused by a a serious pathology (or psychological condition)

Summary of STTT in an Examination: Resisted Movements

Resisted movements: - Contractile structure; muscles, tendons, and attachment to bone Examine for: - Pain - Weakness Principle findings: - Pain: lesion of appropriate contractile structure - Painless weakness: interference with conduction of nerve - Strong and painless: normal