Name:
NPTE - High Yield Review – Joint Restriction Patterns
Description:
NPTE - High Yield Review – Joint Restriction Patterns
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T00H10M02S
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Upload Date:
2023-04-01T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
[Dr. Dutton] This is the first in a number of high-yield presentations that we have put together to help you study for the NPTE examination. Certain elements need to be memorized for the NPTE and include the topic of joint restrictions and patterns, why? Well, because these restrictions and patterns can help with the formation of diagnostic hypotheses. That said, these restrictions and patterns are generalizations and should be viewed as such.
As this is an overview, I will only hit the major areas and not every joint, so as I go through this review, if some things don't sound familiar, spend some extra time reviewing those areas. Okay, let's get started. A close packed position is the joint position in which articulating bones have their maximum area of contact with each other.
It is in this position, the joint stability is greatest and is therefore the position where joint injuries tend to occur. Open packed positions are where the joint position is where the articulating bones have their minimum area of contact with each other. It is in this position that joint stability is the least and is therefore the position we use for joint mobilizations.
A capsular pattern of restriction is a limitation of pain and movement in a joint-specific ratio, usually present with arthritis or following prolonged immobilization. A non-capsular pattern of restriction is a limitation in the joint at any pattern other than a capsular one and may indicate the presence of either a joint derangement, a restriction of one part of the joint capsule, or an extra-articular lesion that obstructs joint motion.
While complicated in other aspects, the close packed positions of the zygapophyseal joints are the same in all areas of the cervical, thoracic, and lumbar spines, and that is full extension. The close packed position of the glenohumeral joint is abduction and external rotation. Although less important, it's worth giving a quick review of the other shoulder joints such as the acromial and sternoclavicular joints.
The close packed position of the ulnohumeral joint is extension. Like the shoulder, it's worth a quick review of the other elbow joint, the radiohumeral joint. The proximal and distal radioulnar joints have the same close packed position and that is 5 degrees of supination. At the wrist and hand, the wrist, or the radiocarpal joint, and the interphalangeal joints have the same close packed positions, which is full extension.
The metacarpophalangeal joints are at full flexion and the carpometacarpals are at full opposition for their close packed positions. At the hip, the close packed position is full extension, internal rotation and abduction. At the knee, the close packed position is full extension and external rotation of the tibia, and at the ankle and foot, the talocrural joint's close packed position is full dorsiflexion.
The subtalar, midtarsal, and tarsometatarsal joints have the close packed position of supination and the metatarsophalangeal and interphalangeal joints have the close packed position of full extension. The open packed position of the axial skeletal joints are as with the close packed positions, and that is the zygapophyseal joints are all the same in each area of the cervical, thoracic, and lumbar spines, but in this case, instead of full extension, the position is midway between flexion and extension.
The open packed positions of the appendicular skeleton joints are as follows. At the shoulder, the glenohumeral joint, it is 55 degrees of abduction, 30 degrees of horizontal adduction. This is not as easy as some of the other positions, so it will require memorization. The other shoulder joints, the acromial and sternoclavicular joints are easier and that is the arm resting by the side.
At the elbow, the ulnohumeral joint, the open packed position is 70 degrees of flexion and 10 degrees of supination, another one that's going to require memorization. However, the other elbow joint, the radiohumeral is more straightforward and that is full extension and full supination. The proximal and distal radioulnar joints have different open packed positions that will need memorization.
At the wrist and hand, the radiocarpal joint's open packed position is neutral with slight ulnar deviation. The other joints in this area will likely need more focus as they are quite variable. At the hip, the open packed position is between 10 to 30 degrees of flexion, between 10 to 30 degrees of abduction, and between 0 to 5 degrees of external rotation.
At the knee, the open packed position is 25 degrees of flexion, and at the ankle and foot, the talocrural joint's open packed position is 10 degrees of plantar flexion, midway between maximum inversion and eversion, while the subtalar, midtarsal, and tarsometatarsal joints while the subtalar, midtarsal, and tarsometatarsal joints have the open packed position of midway between the extremes of range of movement.
Devised by Cyriax, the capsular patterns are widely referred to and used in clinical practice, but there does not appear to be any scientific evidence to support the concept. However, it is still referenced in the NPTE. The capsular pattern of the spine is considered the same throughout the spine and that is side bending and rotation are equally limited and then extension is more limited than flexion.
The capsular patterns of the joints of the appendicular skeleton are quite varied and most will require some degree of focus and memorization. At the shoulder, the glenohumeral joint, there is some disagreement as to the capsular pattern, but the most commonly cited one is external rotation, more limited than abduction, which is more limited than internal rotation in a ratio of 321.
The other shoulder joints, the acromial and sternoclavicular joints do not appear to have a capsular pattern. At the elbow, the ulnohumeral joint, there is a greater limitation of flexion than extension at a ratio of approximately 41. However, the other elbow joint, the radiohumeral, does not appear to have a true capsular pattern and the same is true for the proximal and distal radioulnar joints.
At the wrist and hand, the capsular pattern for the wrist is invariably an equal limitation of flexion and extension throughout, but there are exceptions, particularly in the smaller joints of the hand. At the hip, as at the shoulder, the capsular pattern can vary depending on the source, but the most common description is a greater limitation of internal rotation than flexion and an equal limitation of abduction and extension compared to the other motions.
At the knee, the capsular pattern of the tibiofemoral joint is a greater loss of flexion and extension at a ratio of approximately 51. And finally, at the ankle and foot, the talocrural joint's capsular pattern is a greater loss of plantar flexion than dorsiflexion, while the other joints have quite a bit of variability. For example, at the subtalar joint, the capsular pattern is one of a greater loss of varus than valgus.
As described earlier, and as its name suggests, a non-capsular loss of joint motion differs from the capsular pattern and diagnostically, can indicate a number of non-capsular causes including an internal joint derangement such as a meniscal tear and extra-articular lesion or a lesion to only a small portion of the capsule. Whereas the capsular pattern typically impacts more than one plane of movement in joints like the shoulder and hip, non-capsular patterns typically produce a loss of motion in one plane only.
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