Transcript File

Orthopaedic Medicine
Mazyad Alotaibi
Orthopaedic Medicine
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Phrase coined by James Cyriax (1929)
Diagnosis and treatment of soft tissue lesions
The diagnostic approach
-A healthy structure will function painlessly, a
faulty structure will not
each structure
from which pain could arise is tested in turn
the structure that cannot operate without
bringing on the pain is the culprit
Primary decisions
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About which joint does the lesion lie?
Does the lesion lie in inert or contractile
tissue?
Is there a loss of range in the Capsular
Pattern?
Contractile Tissue
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Structures that have the capacity to contract
& relax
Muscle, musculo-tendinous junction, body of
tendon, teno-osseus junction, bone at
insertion of tendon
Test by resisted movements ie. isometric
contraction (or by passive stretching)
Resisted movements
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If a resisted movement proves painful it
is likely that structure is the source of
pain
The passive movements should be full
and painless (unless you are putting the
contractile structure at fault on stretch
NB. Applied anatomy!)
When applying a resisted
movement
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Joint should be held in mid-range so no inert
structures are stretched
No movement should take place at the joint
Muscles other than those being tested must
not be included
The patient should produce a maximal
contraction
Care re: your standing position - need to be
able to detect pain +/- weakness
Findings
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Strong & painless – NAD
Strong & painful – minor lesion in
muscles or tendon
Weak & painless – complete rupture or
nerve lesion
Weak & painful – significant lesion in
muscle/tendon, possible fracture
Inert Tissue
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Structures that lack the capacity to
contract & relax
capsule, cartilage, ligament, bursa,
fascia, neural tissue
Test by passive stretching or by
squeezing
Passive movements
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If there is a limitation of movement an
inert structure is likely to be at fault
Need to establish if the limitation of
movement is in a capsular or noncapsular pattern
Capsular Pattern
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When a joint is irritated by trauma,
disease or degeneration, the inflamed
capsule contracts, producing a loss of
range in a set proportion.
This is known as a capsular pattern.
Each joint has its own capsular pattern.
End feel
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The significance of the end feel is the
degree to which it corresponds or
differs from what the end feel would be
if the joint were normal
Different types of end-feel imply
different disorders
End feel
Normal
 Hard – bone, ligament eg. Elbow ext
 Soft – tissue approximation eg. Elbow flex
 Elastic – capsular
Pathological
 Springy – intra-articular block eg. Loose body
 Spasm – hard twang eg. Arthritis, fracture
 Empty – pain limits movement eg. Acute bursitis,
neoplasm
Pain behaviour of different tissues
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Bone – minimum reference with local
area of tenderness
Capsules, ligaments, bursa – can refer
strongly
Muscles, tendons – minimal reference
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From this distinction, tension can be applied
manually by the examiner to assess the
contractile and inert structures separately
Therefore, any suspected structure can be
assessed by subjecting the tissues about it to
a routine of passive & resisted movements
In addition, each lesion has a distinctive
history, and the taking of a thorough
subjective assessment with the objective will
seldom fail to identify the condition
Assessment
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Subjective
Objective
Inspection: deformity, colour, wasting,
swelling
Palpation: heat, swelling, synovial thickening
– not tenderness
Examination
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Condition at rest
Active movements
Test for inert and contractile tissue
Check for: pain, power, range, painful arc,
willingness
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Passive movements
Test inert tissue
Check for: pain, range, end feel, crepitus, capsular
pattern
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Examination
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Resisted Movements
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Neurological tests
Palpation
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Test contractile tissue
Check for: pain and power
To localise exact site of lesion
Objective tests
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Blood, X-ray, EMG, scan
Treatment
Mobilisations
 Grade A – passive movements within
painfree range
 Grade B - passive movements to end of
joint range
 Grade C - passive movements to end of
joint range & overpressure of minimal
amplitude
Treatment
Massage
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Acute – gentle massage up to 10mins
Chronic – DTF to numbness + 10mins
DTF
-muscle belly – always in shortest range
-musculo-tendinous junction – relaxed or on stretch
-tendons – with sheath – on stretch
- without sheath – taut or relaxed
-ligaments – prior to Grade C manipulation