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Liberty You will find in this section hot NEW articles which we feel are of national importance to all folks.  These in-depth scientific forensic works are brought to you as a free service from AAJTS.  If you wish to become a member of the Academy and receive weekly Articles, join now!


     In Part one, you were familiarized with all of the types of medical conditions, which can simulate an injured joint in need of rehabilitation.  Situations where there are co-conditions, which make you responsible for both medicine, and the applications of manual medicine, an aspect of the total health care would be application for an acute trauma absent any connection with the underlying condition or contraindicated.    

    As you will see on the Auto Part 7 Human biomechanics, it has been firmly established that the spinal column offers an intricate lever system associated with prime movers, muscles, as well as the primary and the secondary stabilizers the ligaments, tendons and other bones.  This biomechanics system allows the biped to move about efficiently under the forces of gravity especially while carrying external loads.  Oftentimes if the body is unable to balance the centers of load with the forces experienced especially performing repetitive activities, postural stresses, or strains with associated reflex tensions may occur.  There may be combinations of incidents where joints are overworked, jammed or stretched, strained, and/or sprained and possibly deformed.  This “jamming” (joint compression), overexertion (injury to the joint beginning during or within their physiological range of motion), or extension (injury to the joints beyond their physiological range of normal motion including axial traction) and again combinations produce insidious complaints of human suffering. 

     Upon biomechanical examination discovery may include joint restrictions and excessive joint motion not limited to joint instability.  When we record the range of motion findings noting any limitations with pain responses and to what degree, or absence of pain response, the examiner is assessing osteokinematic motion which is the movement that occurs between bones.  Yet a sound biomechanical examination assess the arthrokinematic movements that occur between joint surfaces.  Accessory movements are those arthrokinematic movements that must occur in order for normal osteokinematic movement.  While assessing arthrokinematic movements the examiner notes joint play motions.  Joint play movements are those accessory movements that can be produced passively at a joint but cannot be produced actively.  Note those restrictions to your applied motion indicating the joint is in a close packed position also known as maximal congruence.  When a joint is restricted in a closed packed position and a subsequent trauma occurs to the joint, conditions such a fractures, dislocations, capsular tears and so forth can occur.1 

     Conversely a joint is in a loose-packed position, which is less stable and has more joint play; trauma could induce strains and sprains to at the associated tissues about the joint.  Thus, your forensic biomechanical examination would include whether the joint in question is closed packed or in maximal congruence, restricted, unstable or normal.  With this knowledge, one can than prognosticate joint status.  Whether manipulation could prevent a future serious injury, is a medically necessary procedure, or rule out manipulable lesion.2 It is amazing what person’s who allege knowledge in presentation of manual medicine will indicate about the “human status of a joint under scrutiny”!    A forensic biomechanical understanding of the human body is a priori to the study of manual medicine. 

     We have now established the fact that specificity in our knowledge; examination and comprehension of human motion and response to life are a priori.  Gross range of motion established over estimated normal with the degree of pain noted at that degree of motion yields a good understanding of the Osteokinematic status of our patients.  However, too often moderate to severe sprain injury patients remains chronic. 

     We now understand the fact that assessing the Arthrokinematic movements during a biomechanical examination greatly assist the examiner with further necessary specificity in understanding our patients’ Biomechanical status.  Remember arthrokinematic movements occur between joint surfaces where osteokinematic movements only assess movement between bones.  For normal osteokinematic movement to occur, accessory movements must be normal.  Again accessory movements were those arthrokinematic movements which must occur in order for normal osteokinematic movement.  Noting arthrokinematic accessory movement such as joint play motion and end feel are the harbingers of joint status. 

     Thus prior to presenting Medical Narrative Report Writing or Examination, a more comprehensive discussion of joint passive movements will be presented.  Arthrokinematic End Feel is the perception the biomechanical examiner “feels” in the articulations as they reach the end of “normal” range of motion.  Gross obvious aberrant motions need not be discussed.  However a “proper evaluation of end feel can help the examiner to assesses the type of pathology present to determine a prognosis for the condition and learn the severity or stage of the problem”.  End feels motions have been broken down into three classic normal patterns and five classic abnormal patterns.  The three classic normal end feel patters are “Bone to Bone, Soft-Tissue Approximation and Tissue Stretch”.  

Bone to Bone is a painless hard and unyielding compression” that stops further movement.  This end feel is likened to elbow and knee flexion where the muscles stop movement.  It has been reported that in ectomorphic individuals with little muscle bulk, the end feel of the elbow flexion might most often be bone-to-bone.   

Tissue Stretch is the most common type of normal end feel.  This end feel can be described as “spring” or at the end of the range of motion there is a feeling of elastic resistance.  It has been described as feeling “rising tension”.  Various tissue thicknesses are consistent with degree of elasticity.  For example the Achilles tendon stretch may be vary elastic as compared to the slightly elastic wrist flexion.  Major injury to ligaments often causes a softer end feel until the tension is taken up by other tendons, ligaments, bones, connective tissue and other structures.  Examples of Tissue Stretch are lateral rotation of the shoulder and metacarpophalangeal joint extension.  The five classic abnormal end feels are “Muscle Spasm”, Capsular, Bone to Bone, Empty and Spring Block”.   

Muscle Spasm is the most studied pattern.  Cyriax MD, the father of the classification of joint end feels called Muscle Spasm effects the “vibrant twang”.  It was a sudden dramatic arrest of movement often accompanied by pain with the end feel being sudden and hard.  Muscle Spasm has been divided into early due to inflammation and late due to instability and the resulting irritability caused by movement.   

Capsular is very similar to tissue stretch save it also has been divided into hard capsular when end feel has a "Thick" quality to it and soft capsular when it is similar to normal but has restricted range of motion.  The hard capsular is seen in more chronic conditions and the soft capsular is more often seen in acute conditions.  The end feel is likened to soft and boggy as the result of synovitis or soft tissue edema.  Then Bone to Bone becomes similar to normal bone-to-bone end feel except it occurs prior to normal end motion.   

Empty end feel is detected when movement produces considerable pain.  Examples could be acute subacromial bursitis or a neoplasm

Springy Block end feel is similar to tissue stretch where there is a rebound effects which usually indicates an internal derangement within the joint.  Examples are torn meniscus of the knee when it is locked or unable to go into full extension. 


1.      Warwick and Williams, Gray’s Anatomy, 35th British Edition, W.B. Saunders Company, pp. 400-4007

2.      Kessler R.M., Hertling D., Management of Common Musculoskeletal Disorders.  Harper & Row p. 86-90, 1983.

3.      Magee, Orthopedic Physical Assessment, 2nd Edition, W.B. Saunders Company, pp. 12-13

4.      Harrison’s Principles of Internal Medicine Ninth Edition

“The Health of the people is really the foundation upon which all their happiness and all their powers as a State depend.”  Benjamin Disraeli


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