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