Capsular and Noncapsular Patterns
Original Editor - Gayatri Jadav Upadhyay
It was James Cyriax who along with other authors developed the idea of the scanning examination. That was the origin of the concepts of “contractile” and “inert” tissue, “end feel,” and “capsular patterns” and this contributed greatly to the development of a comprehensive and systematic physical examination of the moving parts of the body.
Broadly speaking, there are two patterns of range of motion used in the interpretation of joint motion:
- A capsular pattern of restriction is a limitation of pain and movement in a joint specific ratio, which is usually present with arthritis, or following prolonged immobilization.
- A noncapsular pattern of restriction is a limitation in a joint in any pattern other than a capsular one, and may indicate the presence of either a derangement, a restriction of one part of the joint capsule, or an extra-articular lesion, that obstructs joint motion.
How to examine Capsular Pattern? With passive movement, a full ROM must be carried out in all possible directions. A mid-range movement will not elicit potential findings. While evaluating the end feel, the examiner must look at the pattern of limitation or restriction.
According to Dutton, capsular patterns are based on clinical findings rather than research; perhaps that's why the capsular patterns may be different or inconsistent.
There will be a presence of a typical pattern in the joint, if the capsule of the joint is affected. This pattern could be a resultant of joint reaction with muscle spasm that leads to capsular constriction. There could be osteophyte formation too as a possible factor for restriction. Each joint has a characteristic pattern of limitation. Capsular pattern cannot judge the endfeel. Only the joints controlled by muscles exhibit capsular pattern. E.g. The distal tibiofibular joint and the sacroiliac joint does not have any capsular pattern. A study done by Hayes et al explained the usefulness of pattern of limitation, but they also pointed that the proportion of limitation should not be used.
A clinician should be aware about the joint limitation that exists but isn't capsular in nature. For example in the shoulder joint in case of subacromial bursitis, abduction may be restricted but with minimal restriction in rotation component of joint. In such cases the capsular reaction may not be exhibited but other tissues such as ligaments could get adhered. There could be restriction in just one movement or direction with pain where other directions or movements remain pain free with full range of motion. Other possibilities for joint restriction in one or more direction can be because of loose bodies and/or extra articular adhesions which does not affect the capsule. Hence Noncapsular pattern.
- Cyriax J: Textbook of orthopaedic medicine, vol. 1: diagnosis of soft tissue lesions, ed 8, London, 1982,Balliere Tindall.
- Dutton M: Orthopedic examination, evaluation and intervention, New York, 2004, McGraw-Hill.
- Hayes KW, Petersen C, Falconer J: An examination of Cyriax’s passive motion tests with patients having osteoarthritis of the knee. Phys Ther 74:697–708,1994.