Selective Tissue Tensioning

• Selective Tissue Tensioning helps to identify pain generating tissue using findings from AROM, PROM, MMT, end-feel, and palpation.
• Selective tissue tensioning assesses findings from ROM, MMT, and palpation and is used for identifying/isolating musculoskeletal lesions/pain.
• Active ROM tests a patient's willingness to move a limb, the amount of motion they can generate, and requires muscle force.
• Passive ROM focuses more on the inert structures that limit movement and does not require muscle force.
• MMT focuses on the quality of force generation of the muscle and tests the contractile structures.

Contractile vs Non-Contractile

• Initial goal is to determine if the tissue at fault is contractile or non-contractile.
• Contractile tissues include the muscle-tendon unit and are force generating.
• Contractile tissues are likely to have pain or weakness during Active ROM.
• With contractile tissues, pain or weakness may be found with MMT.
• With contractile tissues, pain may be elicited by stretching or passive lengthening.
• Non-contractile tissues include ligaments, capsules, bones, dura, nerve roots, etc.
• Non-contractile tissues are symptomatic during passive movement, especially at end-range.
• Non-contractile tissues may demonstrate a capsular pattern of loss or abnormal end-feel.

PROM Findings

• Abnormal PROM findings include hypo- or hypermobility.
• Excessive PROM may be with or without pain.
• Limited PROM may be with or without pain.
• Impaired PROM with normal MMT may indicate capsule, ligament, dura, nerve root, or boney origin involvement.
• Hypermobility: patient demonstrates excessive ROM in one or more motions at a joint, that may or may not be painful, but they do not demonstrate a capsular pattern.
• Causes ofypermobility: ligamentous laxity, chronic ligament sprain/rupture, or hypermobility syndromes exist.
• Hypomobility: patient demonstrates limited PROM in one or more motions at a joint, that may or may not be painful.
• Ligament tightness or sprain, decreased muscle length/contracture, internal joint derangement, or articular lesion can be possible causes of hypomobility.
• Capsular fibrosis, inflammatory condition, arthritis, and prolonged immobilization can also cause the capsular pattern.

End-Feel

• End-feel is the barrier to further motion at the end of PROM.
• Normal end-feels are soft (soft tissue compression), firm (capsule, muscle, or ligamentous stretch), and hard (boney lock).
• Abnormal end-feel occurs earlier or later than expected for that joint, or is different than the expected end-feel.
• Empty end-feel means there is no restriction by tissue, the patient is limited by pain.
• Springy end-feel indicates a loose body may be limiting ROM and will feel bouncy.
• Soft end-feel occurs when normal is firm or hard, and feels boggy.
• Firm end-feel occurs when normal is soft or hard.
• Hard end-feel occurs when normal is soft or firm.

MMT Resistance Testing

• Abnormal MMT findings include pain and weakness.
• There may be pain and NO weakness, weakness and NO pain, or pain AND weakness.
• If MMT is symptomatic and PROM is normal a contractile lesion has occurred.

Contractile Pain and Weakness Combinations

• Contractile: Pain and No Weakness
  • Assuming normal PROM exists, the patient will demonstrate normal AROM, but may be painful.
  • The patient can take applied isometric resistance, but it increases pain.
  • Low grade muscle strain, tendinitis, or hematoma in the muscle are possible causes.
• Contractile: Weakness and No Pain
  • Assuming normal PROM exists, the patient is not likely to demonstrate normal or close to normal AROM due to strength loss.
  • The patient demonstrates weakness on isometric testing.
  • Nerve involvement, complete tendon rupture, or chronic partial tendon rupture are possible causes.
  • With complete rupture, no movement is likely to occur, but contraction of the muscle belly should still be palpable.
• Contractile: Weakness and Pain
  • Assuming normal PROM exists, the patient is not likely to demonstrate normal or close to normal AROM, and may also be painful.
  • The patient demonstrates pain and weakness w/isometric testing.
  • Higher grade muscle strain, tendinopathy, acute partial tendon rupture, or fracture are possible causes.

PROM and MMT

• Decreased PROM and pain/weakness with MMT will point to tissue involvement.
• Start with the most painful or most impaired tissue.
• Additional tests and measures are likely needed to localize lesion.
• Consider some type of systemic problem.

Selective Tissue Tension Limitations

• Selective tissue tension does not work well for complex conditions or combined diagnoses.
• SLAP tears are also a limitation to selective tissue tension.
• It is not specific enough in isolation to make a diagnosis, is applied only at the tissue-level and has been historically implemented for large joints.
• Variable reliability, based on practitioner experience and body region.
• Results from tissue tensioning tests need to be combined with subjective reports of impairment and confirmed with additional testing.