1. Orthopaedic Medicine
Mazyad Alotaibi

2. Orthopaedic Medicine - management principles
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
GY/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 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 Passive 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 Neurological tests Palpation
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