Joint Capsular Patterns: Complete Cyriax Reference Table

What Is a Capsular Pattern?

A capsular pattern is a predictable, proportional limitation of passive range of motion that occurs when the joint capsule is the primary source of pathology.

James Cyriax first described this concept in his Textbook of Orthopaedic Medicine (1954). His observation was straightforward: when a joint capsule becomes inflamed or fibrosed, it does not restrict movement equally in all directions. Instead, each joint produces a distinctive, recognizable pattern of restriction reflecting the anatomy of its capsule.

Formal definition: “The reproducible limitation of joint movements when the joint capsule is the limiting structure.” (Magee, 2014)

Understanding capsular patterns is foundational to orthopedic physical therapy assessment. It helps you determine whether a restriction is likely intraarticular, whether the capsule is the limiting structure, and what pathologies to consider.

---

How Capsular Patterns Develop

The mechanism follows a consistent sequence:

1. Intraarticular pathology triggers synovitis or capsulitis
2. Passive stretching of the inflamed capsule produces pain
3. Over time, capsular fibrosis creates proportional ROM restriction
4. The restriction pattern reflects the relative surface area of the capsule around the joint

For example, the glenohumeral joint has a large inferior capsule. Conditions like adhesive capsulitis (frozen shoulder) restrict lateral rotation most, followed by abduction, then medial rotation. This is consistent with which portions of the capsule are under greatest stretch in each direction.

Common causes of a true capsular pattern include:

• Osteoarthritis
• Rheumatoid arthritis
• Capsulitis / adhesive capsulitis
• Post-immobilization stiffness
• Septic arthritis

Capsular vs. Non-Capsular Patterns

Not all joint restriction is capsular. Distinguishing the two is clinically important.

Capsular pattern: proportional restriction consistent with the expected joint pattern, usually accompanied by end-feel that is firm or hard, with or without pain throughout range.
Non-capsular pattern: restriction that does not match the expected capsular distribution. This suggests the capsule is not the primary structure involved.

Causes of non-capsular restriction include:

• Ligament adhesion or sprain
• Internal derangement (meniscal tear, loose body, osteochondral lesion)
• Extraarticular pathology (muscle contracture, bursitis, neoplasm)
• Fracture

Finding a non-capsular pattern should shift your differential toward these structures.

---

Cyriax Capsular Pattern Reference Table

Magee, DJ: Orthopedic Physical Assessment, 6th ed., 2014

Joint	Capsular Pattern (greatest restriction listed first)
Temporomandibular	Limitation of mouth opening
Occipitoatlantal	Extension and side flexion equally limited
Cervical Spine	Side flexion and rotations equally limited; extension
Glenohumeral	Lateral rotation > abduction > medial rotation
Sternoclavicular	Pain at extreme range of movement
Acromioclavicular	Pain at extreme range of movement
Humeroulnar	Flexion > extension
Radiohumeral	Flexion, extension, supination, pronation
Proximal Radioulnar	Supination > pronation
Distal Radioulnar	Pain at extremes of rotation
Wrist	Flexion and extension equally limited
Trapeziometacarpal	Abduction > extension
MCP and IP Joints	Flexion > extension
Thoracic Spine	Side flexion and rotation equally limited; extension
Lumbar Spine	Side flexion and rotation equally limited; extension
SI, Symphysis Pubis, Sacrococcygeal	Pain when joints are stressed
Hip	Flexion, abduction, medial rotation (order varies by stage)
Knee	Flexion > extension
Tibiofibular	Pain when joint is stressed
Talocrural (Ankle)	Plantar flexion > dorsiflexion
Subtalar (Talocalcaneal)	Limitation of varus range
Midtarsal	Dorsiflexion, plantar flexion, adduction, medial rotation
First MTP	Extension > flexion
Second to Fifth MTP	Variable
IP Joints (foot)	Flexion > extension

How to Apply Capsular Patterns Clinically

Capsular patterns are most useful when integrated with the rest of your assessment. Here is how to apply them:

Step 1: Assess passive ROM. Note which movements are restricted and by how much. Test at end range and assess end-feel.

Step 2: Compare to the expected pattern. Does the restriction match the capsular pattern for that joint? Is the proportional order consistent?

Step 3: Interpret the finding. A positive capsular pattern suggests intraarticular pathology with capsular involvement. Consider your differential: OA, inflammatory arthritis, capsulitis, post-immobilization.

Step 4: Look for non-capsular signs. If the pattern does not match, look for ligamentous, meniscal, or extraarticular causes. A sudden elastic end-feel with flexion restriction at the knee, for example, points toward internal derangement rather than capsular involvement.

Step 5: Correlate with other findings. Capsular pattern alone does not confirm a diagnosis. Use it alongside active ROM, resisted testing, special tests, palpation, and history.

---

Evidence and Limitations

Cyriax’s capsular patterns remain widely taught and clinically useful, but the evidence on their diagnostic accuracy is mixed and worth knowing.

Studies validating the concept have found the glenohumeral pattern in adhesive capsulitis to be relatively consistent: lateral rotation is reliably the most restricted movement. For the hip, research supports the pattern in osteoarthritis, though the order of restriction (flexion, IR, abduction) can vary depending on disease stage.

Studies questioning the concept have found less consistency at the knee, where the expected flexion-dominant restriction does not always hold. Critics also note that “proportional” restriction is difficult to operationalize reliably across examiners.

The practical takeaway: capsular patterns are a useful framework for clinical reasoning, not a standalone diagnostic tool. They increase your pre-test probability for certain pathologies and help guide your differential. They should not be used in isolation.

---

References

Rundquist PJ, Anderson DD, Guanche CA, Ludewig PM. Shoulder kinematics in subjects with frozen shoulder. Arch Phys Med Rehabil. 2003;84(10):1473-1479.
Cyriax J. Textbook of Orthopaedic Medicine, Vol. 1: Diagnosis of Soft Tissue Lesions. 8th ed. London: Bailliere Tindall; 1982.
Magee DJ. Orthopedic Physical Assessment. 6th ed. St. Louis: Saunders/Elsevier; 2014.
Bijl D, Dekker J, van Baar ME, et al. Validity of Cyriax’s concept capsular pattern for the diagnosis of osteoarthritis of hip and/or knee. Scand J Rheumatol. 1998;27(5):347-351.

You may also be interested in:

• The Joint Capsule
• Tissue Healing Times/Phases