Passive Joint Movement Part 1:
by Timothy O. Fearon
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It would be better to have all readers of this article in a clinical setting. It is there the seemingly simple concept of palpation genuinely comes to life. It is utterly impossible to master through reading so you must bring your intellectually honest alter ego into the room with you every time that you see a patient for this development to occur. Having been schooled at the feet of clinical masters this is my take on the underappreciated value of passive motion assessment.
Our primary goal is to determine what can be done to improve the current presentation of our patient problem at its’ present stage. This should dwarf the unnecessary compulsion to name it. This compulsion no doubt carries over from the disease model of medicine where knowing what the disease is becomes significant to directing the course of treatment. In difference the naming of the problem contributes very little to solving typical musculoskeletal dysfunction.
Our first line of investigation is obviously information from the patient. Then we have the visual clues of observation of the resting status and active function. This array of information should arm us with a hypothesis that consolidates and focuses the remainder of our exam.
The third tier of our exam is what truly distinguishes us from the rest of the medical community. Our passive movement exam goes well beyond testing to determine anatomical integrity. The first touch reveals information that we compare to normative data that we have accumulated in our tactile vocabulary through the many patient encounters in our past.
The warmth of an acutely sprained ankle is an immediate indication of vascular changes in acute injury. The tight inter-articular edema of an acute sprain contrasts with the boggy feel of pitting edema in a sub-acute ankle left in the dependent position too long. Similarly the tense feeling of muscle guarding feels entirely different than the relaxed feel of a patient releasing the limb to our control during examination. Each of these contributes to our sense of patient status, potential treatments and prognostication.
When we engage in passive motion assessment there is a changing status that is imparted to our hands throughout the movement. A resistance free travel through the full excursion of passive range is characteristic of the healthy joint. We have an entirely different sense of caution when we feel resistance half way through a normal motion excursion. This painless abnormality in function cautions us to be more meticulous in our assessment than we would be with the sense of movement tolerance that the healthy joint imparts. This sense of feel is most evident and most informative at the end of the possible range and delivers the critical information of how a joint feels mechanically when it has arrived at the end of it’s possible range.
I feel a sense of obligation to hinge the entire depiction of end feel around the stratification that James Cyriax originated in the mid 20thcentury. While the following may not be verbatim, it is surely paraphrasing his work. In the effort to communicate more precisely with words the conversation that was going on between his hands and his patients’ joints he published the following 6 stratifications of types of end feel:
1. Bone-to-bone: An abrupt halt to movement created by two hard surfaces coming in contact with each other. Attempting further excursion is vain and potentially damaging. The classic normal example here is the end range of elbow extension. The pathological examples would include anatomical boney anomalies and pathological healing secondary to trauma. The examiner must be aware of this distinct end feel prior to any consideration of treatment via passive motion.
2. Spasm: Muscle spasm occurring prior to actually reaching the anatomical end of range. If the presentation is such that one can safely travel beyond the abating spasm the end feel as the boney partners reach congruency is characteristically “hard”. This is a contraindication to manipulation and the joint should be treated with caution when using passive movements. The intent of passive movement for treatment here would be to treat the pain and attempt to move the onset of spasm further back in the range.
3. Capsular-Feel: A hard arresting of motion with some give at the extreme, commonly likened to the sense of resistance when attempting to stretch leather. The normal example here would be the sense of resistance when arriving at the end of range of hip or shoulder rotation in the non pathological. When this arrives prematurely in the range, which is to say before the anticipated anatomical limit, there is an indication of capsular limitation to range. The implications for treatment depend on the relationship between the onset of pain and resistance relative to the available range.
4. Springy Block: An intra-articular block precludes full range creating a spring like block such as one may feel if they attempt to close the overloaded trunk of a car. This indicates an internal derangement in the joint. The classic example is the bucket handle tear of the medial meniscus. This is never a normal occurrence. Treatment implications are to avoid further attempts at physiologic motion as it will be in in vain and possibly deleterious. Accessory motion of the joint perhaps coupled with physiologic and accessory combinations attempting to eliminate the block through restoring anatomic relationships hold potential in treatment.
5. Tissue Approximation: The normal abutment of soft tissue masses coming in contact with each other as a joint moves toward its end range of movement. The joint itself could continue into a further excursion if there were less soft tissue mass. The classic example would the biceps limiting further excursion of elbow flexion.
6. Empty Feel: Pain stops the passive motion before the examiner discerns any articular resistance. The patient cannot tolerate further range and hence the search for the end feel comes up empty. Classic examples would include the severe exacerbation of a rheumatologic joint, the painful nature of the immediately post dislocated glenohumeral joint, or the presence of significant disease.
These are the primary categories of end feel. As the examiner increases the quantity of patient experiences she will begin to recognize variations of these end feels, in much the same way as we recognize variations in other palpation oriented experiences. Handshakes vary greatly and impart an almost immediate sense of how we should grip the arriving hand yet they each remain a hand shake. As our “palpatory vocabulary” increases we instinctively learn how to appropriately treat the present hand involved in our conventional greeting of each other. This simple concept should be readily understood because we do it so often. Because we do this so often we rarely discuss it but everyone has a sense of an appropriate response to a hand that is greeting your own based solely on feel. Consider the difference between a hug for your grandmother and that for your brother whom you have not seen in a year, if there were a need to describe this difference in experience you could, but only completely to someone who has experienced a hug. This same experience should be that which we develop expertise at handling an ever increasing variety of joints in various presentations. Of utmost importance is how we allow that joint to guide our handling of it as we try to improve its’ functional status.
Part 2 : The Relationship between Pain and Resistance and its influence on Technique
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