Why End-Feel Matters in PROM Interpretation
Passive range of motion (PROM) end-feel is the quality of resistance perceived at the end of available motion when the examiner moves the joint and the patient remains relaxed. End-feel interpretation helps you estimate what is most likely limiting motion (capsule, muscle, swelling, bone, or protective guarding) and whether the limitation pattern fits a typical capsular restriction or a more focal/non-capsular problem.
End-feel is not a single “moment.” It is interpreted by combining: (1) the resistance quality at end range, (2) the timing relationship between pain and resistance, and (3) the pattern of restrictions across motions.
How to Elicit End-Feel Reliably (Step-by-Step)
- Position for relaxation: Support the limb so the patient does not need to hold it up. Use bolsters/towels to reduce guarding.
- Move slowly into end range: Use a smooth, controlled speed. Rapid movement can trigger stretch reflex and create a false “spasm” end-feel.
- Use graded overpressure: Apply gentle overpressure only at the end of available PROM, increasing gradually until you feel a clear end point or the patient’s symptoms limit further pressure.
- Monitor the pain–resistance sequence: Note whether pain occurs before resistance, at the same time, or after resistance.
- Compare sides and motions: Compare to the contralateral side when appropriate and compare multiple motions within the same joint to identify patterns.
- Re-check if unsure: If the end-feel seems inconsistent, reposition, slow down, and repeat. Inconsistent end-feel often indicates guarding, poor stabilization, or variable patient relaxation.
Normal End-Feels: Definitions, Meaning, and Examples
Firm End-Feel
Definition: A distinct, resilient “leathery” resistance at end range.
Typical limiter: Capsule, ligament, or muscle-tendon unit at normal tension.
Clinical meaning: Often normal, but if it occurs early (reduced ROM) it suggests capsular tightness, ligamentous limitation, or shortened muscle depending on the motion and joint.
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- Shoulder: Firm limitation in external rotation (ER) with reduced ROM may suggest capsular restriction (e.g., adhesive capsulitis pattern) if other motions match.
- Hip: Firm limitation in internal rotation (IR) may indicate capsular tightness or early osteoarthritic change when paired with other capsular-pattern losses.
- Ankle (talocrural): Firm limitation in dorsiflexion (DF) often indicates posterior talar glide restriction/capsular tightness, especially if plantarflexion is relatively less limited.
Soft End-Feel
Definition: A yielding, “spongy” resistance, like tissue approximation.
Typical limiter: Soft tissue approximation (muscle bulk) or swelling/effusion if unusually boggy.
Clinical meaning: Normal in some motions due to tissue approximation; abnormal if it feels boggy and occurs earlier than expected.
- Knee: Normal soft end-feel in flexion due to calf–thigh approximation; if flexion is limited with a boggy feel and discomfort, consider effusion.
- Hip: Soft end-feel in flexion can be normal due to abdominal/thigh approximation; if early and uncomfortable, consider anterior soft tissue tightness or swelling.
Hard End-Feel
Definition: An abrupt, unyielding stop.
Typical limiter: Bone-to-bone contact or a “bony block.”
Clinical meaning: Can be normal at end range in some joints/motions; abnormal if it occurs prematurely or is painful.
- Elbow is classic (not the focus here), but in lower limb: a hard stop in ankle DF that occurs early and is painful may suggest anterior impingement/osteophytes rather than simple capsular tightness.
- Hip: A hard, early stop in hip IR with groin pain may suggest bony morphology/impingement rather than pure capsular limitation.
Abnormal End-Feels: Definitions, Meaning, and Examples
Empty End-Feel
Definition: The examiner cannot reach a mechanical end point because pain stops the movement first.
Typical limiter: Pain-dominant condition (acute inflammation, fracture, severe tendinopathy, highly irritable joint).
Clinical meaning: Suggests irritability is the primary limiter; mechanical conclusions about capsule vs muscle are less reliable until symptoms settle.
- Shoulder: PROM abduction limited by sharp pain before resistance after acute injury may present as empty end-feel.
- Ankle: After acute sprain, DF may be limited by pain before resistance (empty), especially if swelling is significant.
Spasm End-Feel
Definition: A sudden, involuntary muscle contraction that stops motion.
Typical limiter: Protective guarding due to pain, instability, or perceived threat.
Clinical meaning: Often indicates acute injury, high irritability, or patient apprehension. It can mimic a firm end-feel but is typically more abrupt and variable.
- Hip: Spasm during hip extension PROM may occur with acute anterior hip pain or lumbar referral, limiting interpretability.
- Shoulder: Spasm/guarding during ER in apprehensive patients can resemble capsular tightness but changes with reassurance and slower handling.
Springy Block (Rebound) End-Feel
Definition: A “bouncy” resistance with a rebound sensation, as if something is in the way and the joint springs back.
Typical limiter: Intra-articular derangement or mechanical obstruction (commonly meniscal pathology at the knee), loose body, or unstable fragment.
Clinical meaning: Suggests a mechanical block rather than generalized stiffness; often non-capsular and motion-specific.
- Knee: Springy block during extension PROM can indicate a meniscal tear or loose body, especially if extension is disproportionately limited.
- Ankle: A springy block is less classic but may occur with loose bodies/impingement; interpret alongside history and symptom behavior.
Pain–Resistance Relationship: A Fast Clinical Filter
Use the sequence of pain and resistance to infer whether the primary limiter is irritability (pain) or stiffness (mechanical restriction).
| Finding during PROM | Interpretation | Likely primary limiter | Examples |
|---|---|---|---|
| Pain before resistance | Symptoms limit motion before a mechanical barrier is reached | Inflammation/irritability, acute tissue injury, high sensitivity | Acute shoulder bursitis-like presentation; acute ankle sprain with swelling |
| Pain and resistance together | Mechanical restriction and symptoms rise together | Stiffness with concurrent irritability | Early adhesive capsulitis; hip OA flare with capsular tightness |
| Resistance before pain | Mechanical barrier reached with minimal symptoms until end range | Stiffness-dominant limitation (capsule/muscle) | Chronic ankle DF restriction; chronic shoulder capsular tightness |
| No pain, early hard stop | Non-yielding block without symptom provocation | Bony block/structural limitation | Hip bony morphology limiting IR; ankle anterior impingement with minimal pain |
Capsular vs Non-Capsular Restriction: Pattern Recognition
A capsular pattern is a predictable proportional limitation of motions typical of capsular involvement. A non-capsular pattern is any other pattern: disproportionate loss of one motion, pain in one direction only, or a block that does not match capsular expectations.
Decision Table: Linking Patterns to Probable Impairments
| Pattern observed | End-feel tendency | Probable impairment | What to check next (within assessment) |
|---|---|---|---|
| Capsular pattern across multiple motions | Often firm, consistent | Capsular restriction (e.g., synovitis, adhesive capsulitis, OA-related capsular tightness) | Compare proportional losses across key motions; assess symptom irritability via pain–resistance sequence |
| One motion disproportionately limited | May be hard, springy, or firm | Non-capsular: focal joint restriction, impingement, muscle length limitation, or intra-articular block | Identify whether limitation is joint-specific (glide-related) vs muscle-related (changes with position) |
| Empty end-feel in multiple directions | Empty | High irritability/inflammation; mechanical inference unreliable | Reassess with symptom modulation; consider swelling/acute injury signs |
| Spasm/guarding varies between trials | Spasm | Protective guarding, apprehension, instability perception | Slow down, improve support, use reassurance; see if end-feel becomes consistent |
| Springy block in a specific direction | Springy block | Mechanical obstruction (e.g., meniscus/loose body) | Look for locking/catching history; compare extension vs flexion limitation |
| Boggy/soft limitation with swelling signs | Soft/boggy | Effusion/edema limiting motion | Observe for swelling; check whether limitation increases with sustained pressure |
| Hard stop early, not modifiable | Hard | Bony block/osteophyte/structural constraint | Determine if pain is present; check if limitation is consistent and direction-specific |
Guided Comparisons Across Shoulder, Hip, Knee, and Ankle
Shoulder: Capsular Limitation vs Guarding vs Bony Block
Common capsular-style presentation: ER is typically most limited, followed by abduction, then IR (often described clinically as ER > ABD > IR limitation). End-feel is usually firm, and resistance often appears before pain in stiffness-dominant stages, or together in more irritable stages.
Non-capsular clues: A single painful arc or a direction-specific block that does not match the proportional pattern suggests non-capsular issues (e.g., focal pain limitation, guarding, or structural block). Spasm that changes with reassurance and support suggests protective guarding rather than true capsular stiffness.
Hip: Capsular Pattern vs Muscle Length vs Bony Morphology
Common capsular-style presentation: IR and flexion are often notably limited, with abduction also limited; end-feel tends to be firm. If resistance appears early with minimal pain, think stiffness-dominant capsular restriction; if pain rises early, think irritability overlay.
Non-capsular clues: A hard, early stop in IR (especially if paired with groin pain and a very direction-specific limitation) can suggest bony morphology/impingement rather than generalized capsular tightness. If limitation changes substantially with knee position or pelvic stabilization, consider muscle length or control contributions rather than joint capsule alone.
Knee: Effusion and Mechanical Blocks vs General Stiffness
Effusion-limited motion: Knee flexion may feel unusually soft/boggy and limited earlier than expected. Pain may occur before resistance if the joint is irritable.
Mechanical block: A springy block, especially in extension, suggests internal derangement or loose body. This is typically non-capsular and direction-specific (extension limited more than flexion).
Stiffness-dominant limitation: A firm end-feel with resistance before pain in multiple directions suggests capsular/soft tissue stiffness rather than an acute mechanical block.
Ankle (Talocrural): Dorsiflexion Restriction vs Impingement vs Swelling
Capsular/joint restriction: Limited DF with a firm end-feel is common and often reflects talocrural capsular tightness or posterior glide restriction. Resistance typically appears before pain in chronic stiffness.
Anterior impingement/bony block: A hard or abrupt stop in DF, especially if very direction-specific and reproducible, suggests anterior impingement/osteophytes rather than pure capsular tightness.
Swelling-dominant limitation: After sprain, DF may be limited with an empty end-feel (pain-limited) or a boggy/soft limitation if effusion is prominent.
Mini-Algorithm: Identify the Most Likely Limiter
1) Is there a clear mechanical end point? If no → Empty end-feel → pain/irritability dominates. 2) If yes, what is the quality? - Firm → capsule/ligament/muscle (use pattern + position changes) - Soft/boggy → approximation or swelling/effusion - Hard → bony block/impingement - Springy block → intra-articular obstruction - Spasm → guarding (re-test with relaxation/support) 3) Check pain–resistance sequence: - Pain before resistance → irritability - Resistance before pain → stiffness 4) Check pattern across motions: - Proportional multi-direction loss → capsular pattern likely - One-direction loss/disproportionate → non-capsular likelyShort Case Vignettes (Identify the Likely Limiter)
Case 1: Shoulder PROM with Firm End-Feel and Patterned Loss
Findings: PROM ER is markedly limited with a firm end-feel; abduction also limited with firm end-feel; IR limited but less so. Resistance appears before pain; pain is mild at end range.
Most likely limiter: Capsule (stiffness-dominant capsular restriction consistent with a capsular pattern).
Case 2: Shoulder PROM Stopped by Pain Without a Clear End Point
Findings: PROM abduction stops early due to sharp pain; examiner cannot reach a firm barrier; repeated attempts produce similar pain-limited stopping; end-feel described as empty.
Most likely limiter: Pain/irritability (empty end-feel; mechanical inference about capsule vs muscle is not primary).
Case 3: Hip PROM with Hard, Early Stop in Internal Rotation
Findings: Hip IR PROM is very limited with an abrupt hard stop; other motions are relatively less limited; pain is provoked in the groin near end range.
Most likely limiter: Bony block/impingement-type structural limitation (non-capsular, direction-specific hard stop).
Case 4: Knee PROM Extension with Springy Block
Findings: Knee extension PROM lacks the last 10–15 degrees; examiner feels a springy rebound; flexion is less restricted; patient reports intermittent catching.
Most likely limiter: Mechanical obstruction (springy block consistent with intra-articular derangement/loose body/meniscal involvement).
Case 5: Knee PROM Flexion Limited with Boggy Soft End-Feel
Findings: Knee flexion PROM is limited earlier than expected; end-feel is soft and boggy; discomfort increases with sustained pressure; visible swelling present.
Most likely limiter: Swelling/effusion (soft/boggy limitation rather than firm capsular stiffness).
Case 6: Ankle Dorsiflexion PROM with Firm End-Feel and Minimal Pain
Findings: Talocrural DF PROM is reduced compared to the other side; end-feel is firm; resistance appears before pain; plantarflexion is relatively preserved.
Most likely limiter: Capsule/joint restriction (stiffness-dominant DF limitation consistent with talocrural restriction).
Case 7: Ankle Dorsiflexion PROM with Abrupt Hard Stop
Findings: DF PROM stops abruptly with a hard end-feel; the stop is highly reproducible; pain is mild or absent; limitation is direction-specific.
Most likely limiter: Bony block/anterior impingement (hard end-feel, non-capsular pattern).
Case 8: Hip PROM with Spasm That Changes with Handling
Findings: During hip flexion PROM, the limb suddenly “catches” with muscle tightening; on a second attempt with slower movement and better support, ROM improves and the end-feel becomes more firm than abrupt.
Most likely limiter: Guarding/spasm (variable end-feel suggests protective response rather than fixed mechanical block).
Practice Drill: Rapid End-Feel Sorting
For each joint, choose one restricted motion and perform three slow PROM trials with identical stabilization. After each trial, record: (1) end-feel label, (2) pain–resistance sequence, (3) whether the end-feel is consistent across trials. Then decide the likely limiter using the mini-algorithm.
- Shoulder: ER at 0–45° abduction (note firm vs spasm vs empty).
- Hip: IR in a stable pelvis position (note firm vs hard stop).
- Knee: Extension end range (note springy block vs firm vs empty).
- Ankle: Talocrural DF (note firm capsular vs hard impingement vs empty post-sprain).
