End-Feel

Original Editor - Anas Mohamed Top Contributors - Anas Mohamed, Naomi O'Reilly, Lucinda hampton, Kim Jackson, Ahmed M Diab and Shaimaa Eldib

Introduction

The "End Feel" is a type of sensation or feeling which the examiner experienced when the joint is at the end of its available passive range of motion. There are multiple types of joint end-feels all of which are different for each individual.

• The end of each motion at each joint is limited from further movement by particular anatomical structures.
• The type of structure that limits a joint has a characteristic feel, which may be detected by the therapist performing the passive ROM.
• This feeling, which is experienced by the therapist, as resistance or a barrier to further motion, is called the end-feel

Normal End Feel

Normal end feel is when the joint has full ROM and the range is stopped by the anatomy of the joint.

3 Classic normal End Feels

1. Bony End Feel (bone to bone): this is a hard, unyielding, abrupt sensation that is painless. eg elbow extension.
2. Soft Tissue Approximation: full range of motion is restricted by the normal muscular bulk, feeling of soft compression, and is painless. Tissue meets tissue. eg flexion of the elbow, by biceps.
3. Tissue Stretch: there is a firm, springy type of movement with a slight give towards the end of the range of motion, normal elastic resistance that is felt when stretching soft tissue. eg lateral flexion of the cervical spine

Abnormal End Feel

Abnormal End Feel is when the range of the joint is less or greater than normal and is painful, or when a structure other than the normal anatomy of the joint stops the motion

6 Classic Abnormal End Feels

1. Bone to Bone (Bony) End Feel: occurs when one would not expect to find a bone to bone end feel, hard, unyielding end feel. Restriction occurs before the normal end of range movement caused by osteophytes, degenerative joint disease, mal-union of joint following a fracture etc.
2. Muscle Spasm End Feel: sudden and hard dramatic arrest of movement accompanied by pain which is invoked by the movement. Springy, rebound end feel. Reflexive (protective) muscle guarding designed to prevent further injury.
3. Empty End Feel: No physical restriction to the movement but with considerable pain. Maybe full range of motion but with pain. Example: acute bursitis, joint inflammation
4. Springy Block End Feel (Internal Derangement): springy or rebound sensation in a non-capsular pattern. Usually occurs before the end of the normal ROM. eg: loose cartilage, meniscal tissue within joints (eg. torn meniscus won’t be able to extend knee fully)
5. Leathery End Feel (Capsular Stretch End Feel): similar to tissue stretch but occurs when the ROM is reduced. Hard Capsular – thick quality and the limitation comes on abruptly. Soft Capsular- more often seen with acute conditions, stiffness occurs early in the range, increasing until the end of the range is reached.
6. Boggy or Soft End Feel: occurs if you have a joint effusion or edema, mushy with soft quality to it -may indicate acute inflammation. eg acute moderate to severe sprain, ligamentous injury

Significance

An appropriate assessment of end feel can support the examiner

• To assess the type of pathology present
• To identify the limiting structures and choose a focused and effective treatment
• Determine a prognosis for the condition
• And learn the severity or stage of the problem
• By determining if the pain or restriction is the main problem, the examiner can determine if a more gentle treatment should be given (pain predominating) or a more vigorous treatment (restriction predominantly).

Classification

The most widely recognized classification developed by Cyriax, Kaltenborn, and Paris have described a variety of normal (physiological) and the abnormal (pathological) end feels.

Normal end feels (physiological)

The normal end feels are generally described as

• Hard: Type of "Bone-to-Bone" stiff sensation that is painless. An example elbow extension

• Soft: There is a yielding compression (mushy feel) that stops further movement or gradual increase in resistance as muscle, skin and subcutaneous tissues are compressed between the body parts. Examples are elbow and knee flexion, which movement stopped by compression of the soft tissues, primarily the muscles

• Firm: There is a hard or firm (springy) type of movement with a slight give.Toward the end of ROM,there is a feeling of springy or elastic resistance. Tissue stretch is the most common type of normal end feel; it is found when the capsule and ligaments are the primary restraints to movement. Examples are lateral rotation of the shoulder,and knee and metacarpophalangeal joint extension.

Normal end feel

End-Feel	Structure	Examples
Soft	Soft tissue approximation	Knee flexion (contact between soft tissue of posterior leg and posterior thigh)
Firm	Muscular stretch	Hip flexion with the knee straight (passive elastic tension of hamstring muscles
	Capsular stretch	Extension of metacarpophalangeal joints of fingers (tension in the anterior capsule)
	Ligamentous stretch	Forearm supination (tension in the palmar radioulnar ligament of the inferior radioulnar joint, interosseous membrane, oblique cord)
Hard	Bone contacting bone	Elbow extension (contact between the olecranon process of the ulna and the olecranon fossa of the humerus

Normal soft end-feel

Normal hard end-feel

Normal firm end -feel

Abnormal end feels (pathological)

The Abnormal end feels are generally described as

• Soft: Occurs sooner or later in the ROM than is usual or in a joint that Soft tissue edema normally has a firm or hard end. Feels boggy, with a fluid shift.
• Firm: Occurs sooner or later in the ROM than is usual, or in a joint that normally has a soft or hard end.
• Hard: Occurs sooner or later in the ROM than is usual, or in a joint that normally has a soft or firm end. A grating or bony block is felt.
• Empty: No real end because pain prevents reaching the end of ROM.No resistance is felt except for the patient’s protective muscle splinting or muscle spasm.

Examples

End feel	Examples
Soft	Soft tissue edema Synovitis
Firm	Increased muscular tonus Capsular, muscular, ligamentous shortening
Hard	Chondromalacia Osteoarthritis Myositis ossificans Fracture Loose bodies in joint
Empty	Acute joint inflammation Bursitis Abscess Fracture Psychogenic disorder

Examination

Building up the capacity to decide the kind  of end feel takes practice and sensitivity.

• When assessing passive movement, the examiner should apply overpressure at the end of the ROM to determine the quality of end feel ( the sensation the examiner "feels" in the joint as it reaches the end of the ROM ) of each passive movement.

• Passive ROM, particularly towards the end of the motion, must be performed slowly and carefully when testing end feel.
• Secure stabilization of the bone proximal to the joint being tested is critical in preventing multiple joints and structure from moving and interfering with the determination of the end feel

• To be sure that severe symptoms are not provoked. If the patient is able to hold a position at the end of the physiological ROM (end range of active movement) without provoking symptoms or if the symptoms ease quickly after returning to the resting position, then the end feel can be tested. Pain with pathological end feel is common ( if the patient has severe pain at the end range, end feel should only be tested with extreme care).

References

1. Susan B.O'Sullivan, Thomas J. Schmitz, George D. Fulk. Physical Rehabilitation. 6th edition. F. A. Davis Company. 2014.
2. David J. Magee. Orthopedic Physical Assessment. 6th edition. Elsevier. 2014.