Orthopedic Screening (ROM & ROM with Overpressure)

Rapid triage of musculoskeletal pain using a three-step sequence: Active ROM → Passive ROM with Overpressure → Resisted Isometrics.

Goal: Differentiate contractile (muscle–tendon) from inert (capsule, ligament, cartilage, bursa) sources and spot capsular patterns.

Bedside Algorithm

  1. Active ROM (AROM): Patient moves through full planes. Note range, pain arc, and quality.
  2. Passive ROM + Overpressure (PROM+OP): Clinician moves the limb to end-range; apply gentle, sustained OP to stress inert tissues.
  3. Resisted Isometrics: Test mid-range with no joint motion to stress contractile tissue without capsular stretch.

Interpretation Guide

  • Pain with AROM only (PROM+OP painless; iso painless) → motor control/load intolerance.
  • Pain with PROM+OP (capsular end-feel; AROM limited similarly) → inert structure (capsule/ligament/cartilage/bursa).
  • Pain/weakness with isometrics (PROM+OP painless) → contractile lesion (muscle–tendon).
  • Pain in all three (esp. at end-range) → severe/irritable; consider joint/bursal inflammation or serious pathology.

Overpressure: firm, controlled end-range load; stop if sharp/replicated red-flag pain.

Region Presets (What to Test)

Shoulder

  • AROM: Flex, Abd, ER (at side), IR (hand behind back). Note painful arc (60–120° Abd).
  • PROM+OP: Same planes; end-feel/capsular stretch. Capsular pattern: ER > Abd > IR limitation.
  • Isometrics: Flex, Abd, ER, IR, elbow flex/ext (rule-out referred biceps/triceps).

Contractile pain ↑ with resisted ER/Abd → rotator cuff; PROM+OP pain end-range → capsulitis/bursal irritation.

Elbow

  • AROM: Flex/Ext; Pronation/Supination.
  • PROM+OP: End-range flex/ext; OP pron/sup with elbow at 90°.
  • Isometrics: Wrist ext (lateral tendon), wrist flex (medial tendon), pron/sup.

Pain with resisted wrist ext > PROM → lateral tendon lesion; end-range ext PROM+OP pain → capsule/impingement.

Wrist/Hand

  • AROM: Flex/Ext; Rad/Uln dev; thumb motions.
  • PROM+OP: End-range all planes; assess capsular end-feel.
  • Isometrics: Wrist flex/ext, RD/UD; thumb abd/opp.

PROM+OP pain with firm end-feel → capsular; focal pain with resisted thumb abd → 1st dorsal compartment tendon.

Hip

  • AROM: Flex, Ext, Abd/Add, ER/IR (90° flex).
  • PROM+OP: End-range in each plane; Capsular pattern: IR > Flex > Abd (often).
  • Isometrics: Flex, Ext, Abd/Add, ER/IR.

Pain with OP IR/Flex suggests intra-articular; isolated pain with resisted Abd → gluteal tendon.

Knee

  • AROM: Flex/Ext; note locking/catching.
  • PROM+OP: End-range flex/ext; tibial IR/ER in 90° flex for joint line pain.
  • Isometrics: Quad set, hamstring, ankle PF/DF (regional screening).

PROM+OP joint-line pain with rotation → meniscus; resisted quad pain > PROM → patellar/quad tendon.

Ankle/Foot

  • AROM: DF/PF; Inv/Ev; great toe ext.
  • PROM+OP: End-range DF/PF; talocrural and subtalar stress.
  • Isometrics: DF, PF, Inv, Ev; great toe ext.

Pain with resisted PF (mid-range) → Achilles tendon; PROM+OP Inv/Ev pain → ligament/capsule.

Cervical Spine

  • AROM: Flex/Ext; Rot; SB. Note symptom peripheralization.
  • PROM+OP: Overpressure in sitting; assess end-feel and symptom response.
  • Isometrics: Flex/Ext/Rot/SB at neutral (break tests gentle).

PROM+OP pain/stiffness across multiple planes → capsular; focal pain with resisted rot → muscular.

Lumbar Spine

  • AROM: Flex/Ext; SB; Rot; repeated movements for directional preference.
  • PROM+OP: OP via overpressure or passive segmental PA’s.
  • Isometrics: Trunk flex/ext (submax), hip isometrics for referral screening.

Centralization with repeated ext → discogenic; PROM+OP pain with firm end-feel → facet/capsular.

Documentation Snapshot

Region Plane AROM PROM + OP Isometric Interpretation
Shoulder Abduction Painful arc 60–120° End-range pain (capsular/bursal) Resisted Abd painful/weak Contractile if iso > PROM; inert if PROM+OP end-range > iso
Knee Flexion + Tibial Rot Catching/locking Joint-line pain with OP + rot Isos painless Suggests meniscal; add special tests as needed
Ankle Plantarflexion WNL or painful end-range PROM Inv/Ev painless Resisted PF painful/weak Suggests Achilles tendon involvement

Add capsular pattern notes where applicable; escalate to diagnostic testing if inert pathology suspected or red flags present.

Stop / Refer Immediately if:

  • Severe/unremitting night pain, fever, unexplained weight loss.
  • Progressive neuro deficit, cauda equina signs, multi-directional trauma pain.
  • Fracture suspicion, infection signs, vascular compromise.