Orthopaedic Medicine

Orthopaedic Medicine Mazyad Alotaibi

Orthopaedic Medicine • 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 • 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 • 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 • 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 • 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 • 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 • Structures that lack the capacity to contract & relax • capsule, cartilage, ligament, bursa, fascia, neural tissue • Test by passive stretching or by squeezing

Passive movements • 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 non-capsular pattern

Capsular Pattern • 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 • 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 • Bone – minimum reference with local area of tenderness • Capsules, ligaments, bursa – can refer strongly • Muscles, tendons – minimal reference

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 • Subjective • Objective Inspection: deformity, colour, wasting, swelling Palpation: heat, swelling, synovial thickening – not tenderness

Examination • Condition at rest • Active movements • Test for inert and contractile tissue • Check for: pain, power, range, painful arc, willingness • Passive movements • Test inert tissue • Check for: pain, range, end feel, crepitus, capsular pattern

Examination • Resisted Movements • Test contractile tissue • Check for: pain and power • Neurological tests • Palpation • To localise exact site of lesion • Objective tests • 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 • 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

Orthopaedic Medicine