2 Orthopaedic Medicine - management principles Phrase coined by James Cyriax (1929)Diagnosis and treatment of soft tissue lesionsThe diagnostic approach-A healthy structure will function painlessly, a faulty structure will not each structure from which pain could arise is tested in turnthe structure that cannot operate without bringing on the pain is the culpritGY/2007
3 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?
4 Contractile TissueStructures that have the capacity to contract & relaxMuscle, musculo-tendinous junction, body of tendon, teno-osseus junction, bone at insertion of tendonTest by resisted movements ie. isometric contraction (or by passive stretching)
5 Resisted movementsIf a resisted movement proves painful it is likely that structure is the source of painThe passive movements should be full and painless (unless you are putting the contractile structure at fault on stretch NB. Applied anatomy!)
6 When applying a resisted movement Joint should be held in mid-range so no inert structures are stretchedNo movement should take place at the jointMuscles other than those being tested must not be includedThe patient should produce a maximal contractionCare re: your standing position - need to be able to detect pain +/- weakness
7 Findings Strong & painless – NAD Strong & painful – minor lesion in muscles or tendonWeak & painless – complete rupture or nerve lesionWeak & painful – significant lesion in muscle/tendon, possible fracture
8 Inert Tissue Structures that lack the capacity to contract & relax capsule, cartilage, ligament, bursa, fascia, neural tissueTest by passive stretching or by squeezing
9 Passive movementsIf there is a limitation of movement an inert structure is likely to be at faultNeed to establish if the limitation of movement is in a capsular or non-capsular pattern
10 Capsular PatternWhen 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.
11 End feelThe 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 normalDifferent types of end-feel imply different disorders
12 End feel Normal Hard – bone, ligament eg. Elbow ext Soft – tissue approximation eg. Elbow flexElastic – capsularPathologicalSpringy – intra-articular block eg. Loose bodySpasm – hard twang eg. Arthritis, fractureEmpty – pain limits movement eg. Acute bursitis, neoplasm
13 Pain behaviour of different tissues Bone – minimum reference with local area of tendernessCapsules, ligaments, bursa – can refer stronglyMuscles, tendons – minimal reference
14 From this distinction, tension can be applied manually by the examiner to assess the contractile and inert structures separatelyTherefore, any suspected structure can be assessed by subjecting the tissues about it to a routine of passive & resisted movementsIn 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
16 Examination Condition at rest Active movements Passive movements Test for inert and contractile tissueCheck for: pain, power, range, painful arc, willingnessPassive movementsTest inert tissueCheck for: pain, range, end feel, crepitus, capsular pattern
17 Examination Resisted Movements Neurological tests Palpation Test contractile tissueCheck for: pain and powerNeurological testsPalpationTo localise exact site of lesionObjective testsBlood, X-ray, EMG, scan
18 Treatment Mobilisations Grade A – passive movements within painfree rangeGrade B - passive movements to end of joint rangeGrade C - passive movements to end of joint range & overpressure of minimal amplitude
19 Treatment Massage Acute – gentle massage up to 10mins Chronic – DTF to numbness + 10minsDTF-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
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