1. Structural vs Functional Approach in Musculoskeletal Pathologies Structural vs Functional Approach in Musculoskeletal Pathologies June 1 st, 2013 9:15-10:30 AM Dr. Alban Merepeza BA. D.C. www.porthopehealthcentre.com Port Hope Ontario.

2. What is the difference between structural and functional pathologies? How do you diagnose and treat them? Why is it important that we (and you) understand both? Finally we will cover some specific cases of these two kinds of pathologies.

3. Dr. Vladimir Janda MD (1923-2002) Czech neurologist Observed two schools of thought in musculoskeletal medicine: Observed two schools of thought in musculoskeletal medicine: Traditional structural approach based on anatomy and biomechanics.. Traditional structural approach based on anatomy and biomechanics.. and and Functional approach is based on understanding of the function of structures and how they relate to each other in a system. Functional approach is based on understanding of the function of structures and how they relate to each other in a system.

4. Structural pathologies are damages to any anatomical structure. Ex. A muscle tear on the bicep muscle during a bicep curl, a tear on the hamstring muscles during sprinting, a fracture of the femur during a collision in a football game, a sprain of the ligaments on a ankle roll over ect. Ex. A muscle tear on the bicep muscle during a bicep curl, a tear on the hamstring muscles during sprinting, a fracture of the femur during a collision in a football game, a sprain of the ligaments on a ankle roll over ect.

5. Orthopaedic medicine is influenced and guided by a structural approach to pathologies. Orthopaedic medicine is influenced and guided by a structural approach to pathologies. It relies heavily on visualization of the structures through imagery such as x- rays, diagnostic ultrasound, MRI and CT Scans. It relies heavily on visualization of the structures through imagery such as x- rays, diagnostic ultrasound, MRI and CT Scans. Clinicians then focus their treatment on repairing these damaged structures. Clinicians then focus their treatment on repairing these damaged structures. This is done through immobilization (to allow healing), surgery and rehabilitation (exercises). This is done through immobilization (to allow healing), surgery and rehabilitation (exercises).

6. The structural approach is the foundation of medical education and practice. In some cases however many of the diagnostic tests are inconclusive or negative for structural lesions (damage). The clinicians in these cases have difficulties on coming up a diagnosis. More likely the cause of lesions then is functional.

7. Dr. Janda defined functional pathologies as impairment in the ability of a structure or physiological to perform its function. These type of pathologies are more difficult to detect and diagnose. These type of pathologies are more difficult to detect and diagnose. This is not visualised through diagnostic imaging. MRI, x-rays US do not show structural damage. This is not visualised through diagnostic imaging. MRI, x-rays US do not show structural damage.

8. Clinicians must visualise and understand the dysfunction by analyzing the complex interaction of the structures and systems. Structural or Functional? Structural or Functional? Chronic shoulder pain due to subacromial impingement is a common complaint. This pathology can be structural (primary) or functional (secondary)..

10. Structurally this can be caused by bony structures such as subacromial spurs (bony projections from the acromion), osteoarthritis spurs on the acromioclavicular joint, and variations in the shape of the acromion. Structurally this can be caused by bony structures such as subacromial spurs (bony projections from the acromion), osteoarthritis spurs on the acromioclavicular joint, and variations in the shape of the acromion. These structural abnormalities reduce the space under the acromion and cause an impingement of the rotator cuff soft tissues causing pain. These structural abnormalities reduce the space under the acromion and cause an impingement of the rotator cuff soft tissues causing pain.

11. Structural approach to treatment in this case is to repair the damaged structure through surgery. Ex. -Remove the hooked acromion or remove the subacromion spurs. Ex. -Remove the hooked acromion or remove the subacromion spurs. -Repair a torn rotator cuff. -Repair a torn rotator cuff. What if patients has subacromial impingement but x-rays, MRI, US are all negative? What if patients has subacromial impingement but x-rays, MRI, US are all negative?

12. In this case it is a Functional subacromial impingement. There is typically weakness on the scapular muscle stabilizers and/or muscle imbalance which causes aberrant movement and impingement as a result. There is typically weakness on the scapular muscle stabilizers and/or muscle imbalance which causes aberrant movement and impingement as a result. This requires a good understanding of the function and biomechanics of the shoulder and the approach to treatment is significantly different from the structural approach.

13. As you can see this structural and functional pathology of the shoulder presents differently and should be treated differently. As you can see this structural and functional pathology of the shoulder presents differently and should be treated differently. This understanding of the difference between the two is essential for clinicians’ success. The clinicians who fail to employ both approaches to their practice are doomed to fail. This understanding of the difference between the two is essential for clinicians’ success. The clinicians who fail to employ both approaches to their practice are doomed to fail.

14. Other functional pathologies explained. Other functional pathologies explained. Jumper’s knee

15. Osgood-Schlatter Disease

16. Plantar Fasciitis

17. Lower-Cross Syndrome

18. Upper-Crossed Syndrome

19. Iliotibial Band Syndrome

20. Why do you need to know ? Because you are at the front line. Because you are at the front line. Often the first professionals to notice pathologies. Therefore refer to the right professionals for care. Often the first professionals to notice pathologies. Therefore refer to the right professionals for care. There is a time for “no pain no gain” and there is a time that you might need to modify your exercise, change intensity, duration and maybe try different kind of exercise. There is a time for “no pain no gain” and there is a time that you might need to modify your exercise, change intensity, duration and maybe try different kind of exercise.

21. Thank you !