Orthopaedic Medicine

1. Orthopaedic Medicine Mazyad Alotaibi

2. 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

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 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)

5. 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!)

6. 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

7. 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

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

9. 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

10. 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.

11. 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

12. 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

13. Pain behaviour of different tissues • Bone – minimum reference with local area of tenderness • Capsules, ligaments, bursa – can refer strongly • Muscles, tendons – minimal reference

14. 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

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

16. 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

17. 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

18. 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

19. 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