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Range of Motion Restrictions
242 Plays14 days ago
Join Miranda Materi and Josh, both Certified Hand Therapists with over 10 years of experience teaching hand therapy education and more than 50 years of combined clinical expertise. In this session, they explore the key question every therapist faces: what’s really limiting motion?
Is the restriction capsular, musculotendinous, neural, or kinesiophobic in nature? Miranda and Josh break down how to differentiate these causes through clinical reasoning, assessment strategies, and treatment planning—helping therapists identify the true limiter and choose the most effective interventions for restoring motion and function.
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Transcript
Introduction and Causes of Joint Tightness
00:00:05
josh MacDonald
Hi, I'm Josh McDonald.
00:00:06
Miranda Materi
And I'm Miranda Materi, and we are Hand Therapy Academy.
00:00:10
josh MacDonald
Let's talk about tightness, tightness in joints and some of the different things that can cause it and how we're going kind of tease out which is which.
00:00:18
Miranda Materi
Yeah, so there can be a lot of different reasons for ah person to experience um lack of range motion or tightness in a joint. And there's a few I think of off the top of my head. One is capsular. I think that's usually the most obvious.
00:00:30
Miranda Materi
Another one is a peripheral nerve issue causing the loss of motion. um The third one I can think of as musculotendinous tightness. One could be skin, right? a big a thick scar can limit the range of motion. And then the last one could be...
00:00:47
Miranda Materi
um something more psychosomatic. So those were like a kinesiophobia or something like that. So those are the, what did I say? Five? Those are, I think the top five that I think up. There might be another one, but that's what I have off the top of my head.
Identifying and Treating Capsular Tightness
00:01:01
josh MacDonald
Okay. All right. So let's go through capsular first. How do you know when something is a capsular tightness?
00:01:07
Miranda Materi
Yeah, so for this one, I think um basically are how is there how are they actively moving and how are they passively moving? And if those are equal, then I'm thinking that's, or close, you know, sometimes you can get it a little bit more, but if those are pretty equal, you're thinking that's probably more of a capsular adhesion and a problem within the joint.
00:01:26
josh MacDonald
Yeah.
00:01:27
Miranda Materi
And the same for like a bony block that's still within the joint capsule.
00:01:32
josh MacDonald
Yeah. So a bony block is going to be a hard end feel. Like when you try to extend your elbow and it only goes so far and it kind of goes thud at the end, that's a hard end feel. But what we'll we talk about as a capsular end feel is when you get to the end and it's, it's not a hard dead stop, but it is a really like dense end point to it.
00:01:51
josh MacDonald
And that's what a capsular end feel is.
00:01:54
Miranda Materi
Yeah, and I think it's important to differentiate those, right? Because with the capsular tightness, you can make gains by doing, you know, total end range stretching and low load prolonged stretching versus um someone that has a bony infill. You're not going to be making gains in those.
00:02:08
josh MacDonald
Yeah, yeah. That could be heterotropic ossification. It could be bone spurs, could be hardware or loose bodies in the joint, all kinds of things.
00:02:15
Miranda Materi
It could be the sesamoid in the bone, right? I've never seen that in my life, but we had a patient that had that. So you know you never know if you are feeling that they need to go back and get x-rays and see the doctor.
00:02:24
josh MacDonald
Yeah,
Differentiating Musculotendinous and Scar Adhesion
00:02:25
josh MacDonald
definitely. um And then if we have a musculotendinous tightness, that's going to be where we have that Active range of motion is not, ah well, I guess in either case, you're going to have that tension along the whole muscle line and you're going to be to identify ah very soft end field. Soft is where like when I'm reaching down to touch my toes and I feel that tension in my hamstrings, I could keep going. It's just more uncomfortable as I go, but there's There's resistance, but there's no hard point where I feel like, no, that's all I've got other than discomfort.
00:02:56
josh MacDonald
And you feel that along that, the patient will feel that along that whole tendon line most often. So if it's a extensor tendon tightness on the dorsum of the hand, then as you do a fist, they may not feel it, but you include that other joint of the wrist that the muscle tendon crosses.
00:03:11
josh MacDonald
And they'll really feel that tension along the pathway of that musculotendinous unit.
00:03:16
Miranda Materi
Yeah, that's a great description. I think also noting a difference between active and passive range of motion will tell you too. So if if they have limited active but full passive, you know, say for like a flexor tendon, then you're thinking it's a musculotendinous problem.
00:03:31
josh MacDonald
Yeah. Yeah. Or another option for that same equation is it could be a scar adhesion. And so if I can get that patient in a full passive flexion with a flexor tendon injury, so I know their joints are all intact and their muscle tendon units are intact because I get them full down, but they can't get that range.
00:03:37
Miranda Materi
Yep.
00:03:48
josh MacDonald
It might be that tendon stuck in scar and that's what's keeping them from coming down further. And so then you work on a scar tissue issue.
00:03:56
Miranda Materi
Right. And scar was our next topic. So scar or skin tightness that you can usually visually see, or like Josh said, you can also palpate it, um or you can do it with your clinical clinical exam with the active versus passive range of motion.
00:03:58
josh MacDonald
Yeah.
00:04:08
josh MacDonald
Yeah. Yeah. And sometimes you can watch that skin pull or drag or pucker or behave differently at that point of adhesion. And so if you'd like watch along that muscle tendon line that's supposed to be pulling and look for any abnormalities and how that's working, even compare side to side, you can watch that skin or scar line behave differently.
00:04:29
Miranda Materi
Yeah, definitely.
Exploring Psychosomatic Tightness
00:04:30
josh MacDonald
yeah And then a psychosomatic issue where the patient has maybe a fear of movement or they've got maybe a writer's cramp or some of those things. um That's one where you're going to see that active range of motion is better than tolerated passive range of motion.
00:04:45
josh MacDonald
It may be a pain response that they're like um apprehensive about you doing stretching. It may be that they aren't um like they're blocking and guarding against the movement. But that's one of the indicators, not the only one where it's like, hey, they can move better when they're walking in the front door than when we sit down and start to move with them.
00:05:04
Miranda Materi
Right. If they're distracted or something doing better. And sometimes it really is. I mean, I know that sometimes you're like, it's okay, just move in. But sometimes I think their body is really good at protecting them, right? So even though they may be telling their hand to move, their brain is saying, no, I'm hurt, don't move.
00:05:13
josh MacDonald
Yeah.
00:05:19
Miranda Materi
So that would be an example of, you know, something psychosomatic, which we still know, we don't say that problem's not real.
00:05:22
josh MacDonald
Yeah.
00:05:24
Miranda Materi
It is very real, right? So We're not dismissing them or treating them differently. We're just trying to identify the cause because our treatment varies for all these, right? What you do for capsular tightness is totally different than what you're going to do um for a musculotendinous tightness issue.
00:05:38
josh MacDonald
yes Yeah. Yeah. And when we say psychosomatic, that can be a term that carries some baggage with it. And we're talking about just the very basic, that person's body does not have a structural integrity issue in the limited part.
00:05:51
josh MacDonald
There's other things going on. and Those are very valid things, but we would treat those differently than I would.
Treatment Methods and Patient Progress
00:05:56
josh MacDonald
Let's say I'm going to use the modified weeks scale to come up with a dynamic or static progressive or serial progressive split for that patient with a capsular and feelers.
00:06:06
josh MacDonald
I'm not going to use one of those for a patient who has guarding or kinophobia or those kinds of things because that's just going to force it and make the whole perception worse.
00:06:15
Miranda Materi
Right. Or even for like, same, you're not going to use a splint static progressive for a nerve tightness issue or for a shortened peripheral nerve.
00:06:22
josh MacDonald
Yeah.
00:06:23
Miranda Materi
You're not going to do that. Your treatment definitely varies.
00:06:26
josh MacDonald
Yeah. Yeah. And so it's important to be comfortable with identifying both based off of observation and physical feel how much or why that person's not moving.
00:06:37
josh MacDonald
So you can pick the right intervention as a result.
00:06:39
Miranda Materi
Right. Work smarter, not harder.
00:06:42
josh MacDonald
Right.
00:06:42
Miranda Materi
So if your're if your patient is not progressing within the next you know, two to three weeks, it might be that you haven't correctly identified the right problem, especially if their career if they're doing their home exercise program, they're doing everything you said, and they're not making those gains.
00:06:50
josh MacDonald
Yeah.
00:06:56
Miranda Materi
um and It could be that they have a different issue or they have multiple issues.
00:07:00
josh MacDonald
Yeah. And I think that's something that that two week mark is something I try to keep in mind and is a great like clinical um clinical pearl to keep in mind is that whether it's wound care or treatment progression or whatever, if you're doing something consistently and the patient is effective with their home program for two weeks and things aren't changing.
00:07:20
josh MacDonald
You need to find something different to try. Again, whether it's wound or whatever, we should be able to make changes to some degree, maybe not fix the problem within a two week span that we can say my pain is getting better or my motion is improving or my wound is closing with two weeks of intervention.
00:07:34
josh MacDonald
If it's going to take more than that, then we've got to kind of second guess what our our choices for treatment plan are.
00:07:38
Miranda Materi
Right. And it's not to say we expect them to get and better in two weeks. We just expect them to see them progressing along the continuum. And then make sure you're taking into account some of those other variables like their past medical history, are they diabetic, those things, because, you know that can extend it out.
00:07:52
Miranda Materi
So maybe it's two weeks for the healthy individual. Maybe it's two and a half, three weeks for, you know, somebody that has those quote comorbidities as well. But Josh is right. You should definitely see and maybe even some with those medically complex patients, you probably should still see some progress at two weeks.
00:08:05
Miranda Materi
It just might be slower.
00:08:05
josh MacDonald
Yeah. Yeah. And maybe it's using therapeutic use of self. Maybe it's using um breathing techniques and saying like, you know i need to go out from a completely non biomechanical model, but we should be able to see changes um in whatever we're working on with a patient. We should see some progress within that frame of time.
00:08:23
Miranda Materi
Yeah, definitely.
00:08:23
josh MacDonald
Yeah. Yeah.
00:08:24
Miranda Materi
Or it might be time to refer out to, right? We don't want to be afraid of using our partners and our teammates.
00:08:32
josh MacDonald
Yeah. Yeah, definitely. All right. Well, if you have any questions on any of that, or if you're unsure about maybe what the modified week scale is, we have that information on our Hand Therapy Academy platforms. You can reach us on email at info at handtherapyacademy.com, or you can find us on all of our social media platforms at Hand Therapy Academy.