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1 Principles of orthopaedic medicine
1 Clinical reasoning in orthopaedic
3 Connective t,issue inflammation, repair and
remodelling
medicine 3
41
4 Orthopaedic medicine treatment
2 Soft tissues of the musculoskeletal
system 25
techniques
51
Chartered Society of Physiotherapy (CSP) endorsed a
Introduction to Section 1
Clinical Guideline for the Use of Injection Therapy by Physiotherapists that
was originally prepared
by the
The, im of this book is to provide principles of diagnosis
Association of Chartered Physiotherapists in Orthopaedic
and treatment that can be applied to any of the soli tissue
Medicine (ACPOM), a clinical interest group of the CSP
lesions encountered in clinical practice.
(1999). Since then, physiotherapists working as rheuma
This first section presents the theory behind the princi
tology or ortJlopaedic practitioners, as seniors in hospital
ples imd practice of urthopaedic medicine, beginning with
clinics or in private practice have risen to the challenge,
the theory underpinning the assessment procedure towards
taking care to comply with stringcnt protocols and direc
clinical diagnosis. Clinical diagnosis involves the develop
tions
ment of
a
hypothesis through the consideration of both
subjective
(CSP 2008).
Courses in onhopaedic medicine (see Appendix
1)
provide an excellent grounding in the theolY and practice of injections, particularly since the modules are attended
low, with a review of the healing process, aiming towards
by both doctors and physiotherapists in an atmosphere
an understanding of the effects of injury on the soft tis
of shared experience. Separate courses in injection ther
SUE's. This should enable the application of approprizlte
apy have now been developed that include supelvised
treatment to the different phases of healing to achieve the
practice in the clinical setting to allow the demonstration
restoration uf full, painless function.
of competence. More relevant, however, is the devel
Building on the theory of the first chapters, the first
opment of confidence in performing the techniques,
section ends with a presentation of the principles of treat
facilitated by co n tin u e d application and evaluation of
ment as applied in orthopaedic medicine and discusses
practice.
the techniques of mobilization and injection, aims and Clinical tips are provided throughout Section 1 to emphasize clinical application and indications for use. In December within the
1995 injections were declared to be
scope
of physiotherapy
At the time of writing, physiotherapists Illay attend pre scribing courses but limited prescribing rights, including
application and indications for use.
practice and the
those applicable for musculoskeletal injections, are still under discussion. Clearly a close relationship must be maintained with the medical profession, but physiotherilpy autonomy should also be supported.
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Within this text, injections must therefore be consid
of the scant pharmacology taught at undergraduate level,
ered to be as pertinent to the physiotherapist reader as to
the physiotherapist may find it beneficial to explo re some
the doctor.
A
bri ef presentation of relevant pharmacology
additional reading in this area.
and general considerations is presented. However, in view
REFERENCES Chartered Society of Physiotherapy, 1999. Clinical guideline for the use of injection therapy by physiotherapists. Chartered Society of Physiotherapy, London. Chartered Society of Physiotherapy, 2008. Chartered Society of Physiotherapy (CSP) position paper on the mixing of medicines in physiotherapy practice. CSP, London.
2
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1 Clinical reasoning in orthopaedic medicine
SUMMARY
CHAPTER CONTENTS Summary Referred symptoms Discussion of the poss ible mechanisms
3 3 4
and patterns of referred pain
Segmental reference
5
Clinical examination
14
Observation
14
History
15
Age, occupation, sports, hobbies and
15
l ifestyle Site and spread
15
Onset and d u ration
16
Symptoms and behaviour
16
Past medica l history
16
Other loint involvement
16
M edicat ions
Inspection
17
Colour changes
17
Muscle wasting
17
Swelling
17 17
Heat
17
Swelling
18
SynOVial thickening
the inert structures and resisted movements to test the contractile structures. This chapter is divided into two parts, The first discusses 'referred symptoms' and includes patterns and 'rules' of referral of pain and other symptoms from different structures. The second, 'clinical examination', describes the theory behind Cyriax's logical method of subjective and objective examination, which, by reasoned elimination, leads to the incrimination of the tissue in which the lesion lies.
17 17
Bony deformity
Palpation
Orthopaedic medicine is based on the life's work of the late Dr James Cyriax (1904-1985). He developed a method of assessing the soft tissues of the musculoskeletal system, employing a process of diagnosis by selective tension, which uses passive movements to test
18
REFERRED SYMPTOMS Patients usually complain of pain but there may be other symptoms that cause them to seek advice, such as stiff ness, weakness, numbness and pins and needles. Since pain is the most usual complaint, it will form the basis of this discussion. Whether right or wrong in their assessment, patients usually localize their pain as coming from a certain point and can describe the area of its spread, although some
State at rest
18
Examination by selective tension
18
referred and explored the pattern of referred pain to try
Active movements
18
to establish some rules that would help in its interpreta
Passive movements
18
Resisted tests
Palpation
© 201 0 Elsevier Ltd
22 22
times only vaguely. Cyriax considered that all pain is
tion towards establishing its true source (Cyriax
&
Cyriax
1993). The study of pain itself is a vast topic, most of which is outside the scope of this book, and the reader is
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referred for a detailed accou nt to the many other sources that confine themselves to the in-depth study of this field. Nevertheless, pain a nd its behaviour are relevant to orthopaedic medicine, particularly i n the assessment procedures, both towards the achieveme nt of an accurate clinical diagnosis and as a guide to the effectiveness of the treatment techniques applied. To be able to identify the source of ule pain, a thorough knowledge of applied and functio nal anatomy is essen tial, coupled with an understa nding of the behaviour of pain, particularly in relation to its ability to be referred to areas other than the causative site. It is ac knowledged that other influences ca n affect the perception of pain a nd within this chapter referred pilin will be discussed, with a brief consideration of psychosocial factors.
Discussion of the possible mechanisms and patterns of referred pain It is commonly found i n clinical practice that pain of visceral origin can mimic that of somatic origin ('pain arisi ng from noxious stimulation of one of the muscu loskeletal components of the body', Bogduk 2005) and vice versa. Pain arising from pathology in the hean, for example, may produce a spread of pain into the arm, imi tati ng the pain of nerve root sleeve compression from a cervical lesion. Similarly, mid-thoracic back pain may arise from a stomach lesion. Visceral pain tends to be inflammatory in origi n, since the v iscera are relatively insensitive to mechanical pressure, whereas somatic pain can arise from either or both causes ( Lundeburg & Ekholm 2002 ). There have been several suggestions put forwiHd for the mechanism o f refer red pai n a nd the more signifi cant ones are discussed here. McMahon ct al ( 1995) cite Sinclair who suggested that primary sensory neurons have bifur cati ng axons which i nnervate both somatic and vis ceral structures. Some evidence was found for this theory, but some of the fi ndings were chal le nged, panicularly as such axons had failed to be demonstrated in appreciab le numbers. While unable to find neurons with visceral and somatic fields, McMahon et al mention that Mense and colleagues did find a few single sensory neurons with receptive fields in two tissues, in both skin and muscle in the tail of a cal, but overall there was scant support for Sinclair's suggestion. M ore recently, Sameda et al (2003) have demonstrated peripheral axons dichotomizing (branchi ng into two) into both the L5, L6 disc and groin skin in rats. This could provide a possible explanation for pain referred to the groin area from damage to the L5 and S 1 nerve roots from L4-L5 and L5-S 1 disc herniation in humans, in spite of the nerve supply of the g roin area arising from the higher lumbar spinal nerves.
Evidence has been provided for the mechanism that visceral and somatic p rimary sensory neu rons converge onto common spinal neurons, causi ng co nfusion i n the ascending spinal pathways and leading 10 misinterpreta tion of the origi n of the pain. The mess age from the pri mary lesion could be w rongly interpreted as coming from the area of pain referral (Vecchiet & Gia mberardino 1997, Robinson 2003). This has been dubbed the convergence p rojection theory. 1\ side-t rack from the 'converge nce-projection theory' is the 'convergence-facilitation theory', attributed to McKenzie (cited in McMahon et al 1995), which claimed that the viscera a re insensitive Jnd that visceral afferent activity does not directly give rise to pain. It was suggested that an irritable focus was produced within the spinal cord, where somatic inputs would take over to produce abnormal referred pain in the appropriate segmemal dis t ribution. Th is theory was not generaJiy accepled, how ever, since it denied that true visceral pai n could exist. However, it did p rovide an explanation for heightened referred sensations, including that of secondary hyperal gesia (Vecchiet & Giamberardi no 1997). Its basic concepts have been developed u nder the descriptor of 'central sen sitization' that explains hyperalgesia and the prolongation of chronic pain as arising from the augmented response of signalling neurons in the central nervous system as a result of inflammation or compression of nerve structures (Niere 1991, Butler 1995, Mendelson 1995, Campbell & Meyer 2006). As men tioned above, there are no separate ascending spinal pathways for the transmission of visceral pain, and sensations from the viscera are represented within the somatosensory pathways, that also lI'ans fer sensations from somatic structures (Galea 2002). This can lead to confusion in differential diagnosis between pain arising from visceral lesions and that arisi ng from musculos kel etal lesions. Galea describes how the level o f the spinal cord to which visceral afferent fibres project depends on their embryonic i n nervation and notes that many viscera migrate well away from their embryoniC derivation dur ing development, such that visceral referred pain may be perceived at remote sites. Referred pain does not only present itself for misinter pretation between visceral and somatic structures but is also a phenomenon which may prevent accurate l ocaliza tion among the musculoskeletal tissues. Gyriax & Cyriax (1993) suggested that the misinterpretation of pai n occurs at cortical level where stimuli arriving at certain corti cal cells from ule skin can be localized accurately to that area. When stimuli from other deeper tissues of the same segmental derivation reach those same cells, the sensory cortex ma kes assumptions on the basis of past e.xperience and attributes the source of the pai n to that same area or skin. This acc ounts for the dermatomal reference of pain but the theory can be extended to include the referral of other symptoms from structures within the same segment.
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SEGMENTAL REFER ENCE Knowledge of the nerve supply of soft t issue structures, coupled w i th fac tors affect i ng segmental reference and the general r u l es o f referred pain, is a useful aid to d i agnos is. I t w i l l hel p t o d i rec t the c l i n ician to the t rue source of the patient's pain and so fac i l itate the a p p l ication of ef fect ive treatment. Several workers have tried to es tablish patterns of referred pain by exa m i n i ng the dermatomes. However, the dermatomes a p pear to vary accord i ng to the different meth ods for defi n i ng them. These m a i n l y derive fro m embry onic development, observation of herpetic eruptions, areas of Vasodi latation res u l t ing from nerve root s tj m u l ation and the areas of tactile sensation rem a i n i ng after rh izotomy (surgical severance) of spinal nerve roots, as described below. These derma tomes are referred to as embryonic, herpetic, vasod i latation and tac t i l e, respectively Sir Henry H ead (1900) laid the foundat ions for the mapping of derma tomes by analysing herpetic eru p t ions. Herpes zoster is an i nnam matory les i o n of the s p i n a l gan g l ia wh ich p roduces an eruption on the skin i n the cor responding segmental cuta neous area. By d efi n i ng the derma tomes i n this way, little overla p was found and there was only slight variation between subjects stud ied. Stricker & Bayl iss, as descr i bed by Foerster (1933), used fa radic s t i m u lation of the distal part of a d ivided pos terior root to produce vasod ilatation. Th is produced a clearly defi ned area s i m i lar to the dermatomes defi ned i n the isolation method, but s l ig h tly smaller i n size. The s k i n is suppl ied by both ven tr a l and dorsal nerve roots. Foerster (1933) exa m i ned the areas of sl
experi ments conducted over the past century (Fig. 1.1) They pro posed tbat the overlapping of dermatomes and their variab i l i ty d eserved more emphasis and that to rep resent dermatomes as autononlOUS zones of cutaneous sensolY i n nervation is u n re l iable. However, des p i te the experi mental fi n d i ngs, the exten t of i nd ivid ual dermatomes, espec i a l l y i n t h e l im bs, is l a rgely based on clinical evidence and Stand ring (2009) ac know l edged that t h is l eads to a wide vari a t ion between the opin ions of d ifferent d isc i p l i nes. The d er m a tomes g iven in this book a re drawn m a i n l y f ro m the c l i n ical ex perience of Cyr i ax and are d ifferent from those g i ven in Gray's Anaromy (Stand ri ng 2009), for exa m ple. In the authors' experience, they provide a basic g u ide for c l i n ical practice and are p resented as s hown i n Fig ure 1.2.
Nerve root dermatomes I n general the muscle groups l i e under the dermatome which shares tbe same nerve s u p ply. H owever, the d e r matome and myotome may not overl ie each other a n d there are s o m e apparent exceptions to t h is r u l e. Th is can c ause confusion in the consideration of referred pain, i ll that a l esion i n the relevant m uscle m ay a ppear to refer pain to an u n re l a ted site and vice versa. As mentioned above, the viscera may a lso refer pain to appare n t l y u nrel ated s ites and t h is shou l d a lso be con s i dered w i t h i n d ifferentia l d i agnosis. Pap pano & Bass (2006) p resent a case study desc r i b i ng referred shoulder pain preced i ng abdo m i nal pai n in a teenage g i rl with gastric perfora t i o n . The paper also highlights other con d i tions as referring to the shoulder i nc lud i ng peritonitis, cholecystitis and subdiap h rag matic endometriosis. Post l a p a roscopy shoulder pa i n is noted, w h e re carbon cl iox i de used for i nflation a p p l ies stretch to the d i a p h rag m. Sloan (2008) p rovides further deta i l l isting righ t-sided periscap u l a r pain in gal l b ladder d isease and i n tersca pu l a r pain in ao rtic d issection. The m ost com m o n l y encou ntered d isc repancies are as fo l l ows: •
•
•
•
•
•
•
Scapular m uscles a re supplied by C4-C7, but underlie thoracic derma tomes Latiss i m us dorsi is s u p p l ied by C6-C8, bu t u nderlies thoracic and l u m bar dermatomes Pectora l is major is s u p p l ied by C5-Tl but u nderl ies th oracic dermatomes The heart, a th oracic structu re, is suppl ied by C8-T4 and may refer pain i nto the arm, ax i l l a and chest The d ia p h ragm is s u p p l ied by C3-C5 and diaphragmatic i rritation m ay lead to p a i n being felt in the epaulette region of the shoulder The gluteal m uscles are s u p p l ied by L5, SI-S2 b u t underlie L l-L3 d e r m a tomes The testicle is suppl ied by Tll-TI2, but underlies the S4 dermatome where pain may be fe l t l ocall y o r can be referred to the lower t horacic or u pper l u m bar regions.
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C2 C3 C4 C5
C4 T2
T3
T2
T3 15 17 T9
T10
T11 L1
Figure 1.1 T h e evidence-based dermatome map representing t h e most consistent tactile dermatomal areas for each s pi nal dorsal ne rve root found in most individ uals. based on t h e best available evidence. The dermatomal areas shown are NOT autonomous zones of cutaneous sensory innervation since, except in t h e m idline where overlap is m inimal, adjacent dermatomes overlap to a large and variable extent. Blank regions i n dicate areas of major variability and overlap. S3, S4 and S5 supply the per i n e u m but are not shown for reasons of clarity From Lee M W L. McPhee R W, Stringer M D 2008 An eVidence-based approach to h uman dermatomes. Clin ical Anatomy 21363-373. Reprinted with permission of John Wiley & Sons, Inc.
Cyriax (1982) and Cyriax & Cyriax (1993) identified sev
dermatome, and a lumbar lesion involving compression
eral factors that influence the referral of pain:
and inflammation of the L4 nerve root may refer pain
• •
and associated symptoms to the big toe, at the distal end
Strength of the stimulus
of the L4 dermatome.
Position of Lhe structure in the dermatome
•
Depth of the structure
•
Type or nature of the structure.
Position in the dermatome Pain and tenderness tend to refer distally Therefore
a
structure placed more proximall y in t.he
Strength of the stimulus
capable of referring its symptoms over a greater distance
The more acutely inflamed or irritable the l esion (i.e. the
to the end of the dermatome.
greater the stimulus), the further into the dermatome
The length or distance of dermatomal referral is partic
w i l l the symptoms be referred (Inman & Saunders 1944).
ularly obvious in the limbs, where the dermatomes tend
For example, an acutely inflamed subacro mial bursitis
to be long. However, if the dermatome is short, even with
may refer its pain to the wrist, the distal extent of the CS
an acutely inflamed or irritable lesion, the reference will
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Clinical reasoning in orthopaedic med icine
C1
C2
(�)
C3
(bj
C5
�� �H�
T3
T2
(
T4 T5 T6 T7 T8 T9 T10
Figure 1.2 Dermatomes. (Conesa & Argote 1976, Cyriax 1982, Cyriax & Cyriax 1993.)
C 1: top of head (Fig. 12a) C2: side and back of the head, upper half of the ear, cheek and upper lip, nape of t h e neck (Fig. 12b) C3: entire neck, lower man d i ble, c h i n, lower half of the ear (Fig. 12c) C4 epaulette area of the s houlder (Fig. 12d) C5: ante rolateral aspect of the arm and forearm as far as the base of the thumb (Fig. 1.2e) C6: ante rolateral aspect of the a r m and forearm, thenar e m i n e nce, t h u m b and index fi nger (Fig. 1.20
0: posterior aspect of the arm and forearm, index, middle and ring f i ngers (Fig. 1.2g) C8: medial aspect of the forearm, medial half of the hand, middle, ring and little fingers (Fig. 12h)
Tl: medial aspect of the forearm, upper bou ndary u ncerta i n (Fig. 1.2 i) T2 Y-shaped dermatome, medial condyle of h u m erus to axilla, branch to ste r n u m and branch to scapula (Fig. 1.2j)
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L1
L2
+ L3
L4
'j
i
L5
®
81
82
83
Figure 1.2 (Contin ued) B: area at front of ch est, patch in axilla (Fig. 1.2 k) T4, 5, 6: circli ng trunk above, at and below the nipple area (Fig. 121)
n,8 c i rcl ing t ru n k at lower costal margin (Fig. 121) T 9, 10, 1 1: circling the trunk, reac h i n g the level of the u m b i licus (Fig. 121) T12 margins u ncertain, extends i n to groin, covers greater trochanter and t h e iliac c rest (Fig. 1.2/) L 1: lower abdomen and g roin, lumbar region between levels L2 and L4, upper, outer aspect of the buttock (Fig. 12m) L2: two separate areas lower lumbar region and upper b u t tock, wh ole o f the front of t h e t h igh (Fig 12n) L 3: two separate areas: upper buttock, medial aspect and front of the th igh and leg as far as the medial malleolus (Fig. 120) L4 lateral aspect of the thigh, front of the leg crossi ng to the medial aspect of the foot, big toe only (Fig. 1.2p) L5: lateral aspect of t h e leg, dorsum of the whole foot, fi rst, second and third toes, inner half of the sole of the foot (Fig. 1. 2q) 5 1: sole of t h e foot, lateral two toes, lower half of t h e posterior aspect of the leg (Fig. 12r) 52 poster ior aspect of the wh ole t h i g h and leg, plantar aspect of the heel (Fig. 12s) 5 3: circular area around the anus, medial aspect of the thi g h (Fig. 12t) 54: saddle area: anus, perineum, genitals, medial upper thigh (Fig. 12t) 55 coccygeal area (Fig. 12t)
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halt at the end of its dermatome, or the most distal der matome in the event of more than one nerve supply. Structures within the hand and forefoot are already at the distal end of their relevant dermatome. Referral of symptoms is therefore less and such lesions are easier to localize (Inman & Saunders 1944).
Depth of the structure Skin is the only organ that provides precise localization of pain and is of course the most superficial structure (Cnatz 1991). Cyriax (1982) proposed that lesions in the more deeply placed structures tend to give greater reference of pain, which was also the finding of Kellgren (1939) and Inman & Saunders (1944). The deeper structures there fore give rise to greater misunderstanding in terms of clin ical diagnosis. Joint, ligament (e.g. medial collateral and anterior cru ciate ligaments) and bursa lesions tend to conform to this assumption but a notable exception is provided by lesions within bone. Pain and tenderness arising from fractures or involvement of the cortical bone tend to be welliocaliz.ed, even though bone itself is the most deeply placed tissue in musculoskeletal terms. Lesions involving the cancellous part of bone may give the more typical pat tern of referred pain. Segmental pain arising from lesions in the deeply sited viscera can also be misleading.
Nature of the tissue The factor of depth of the structure should perhaps be considered alongside that of the nature of the tissue, since studies to observe the effect of lesions in tissues of differ ent nature and site on patterns of referred pain are hard to dissociate. Kellgren (1938, 1939) observed patterns of referred pain induced by the injection of 6% hypertonic saline into deeply placed structures including muscle, tendon sheaths, fascia, periosteum and interspinous ligaments. On injection of muscle, diffuse referred pain was pro duced which appeared to follow a segmental pattern and was associated with deep tenderness rather than hyper aesthetic skin. Willing et al (2000) compared local and referred pain following intramuscular capsaicin injection into the brachioradialis muscle and intradermal injection in the skin above the muscle. Intradermal injection pro duced more intense but localized pain whereas referred pain was more marked after the intramuscular injection and was deeply located as well as referring to skin. Kellgren also observed that pain arising from the limb muscles tended to refer to the region of the joints moved by these muscles, where it could easily be confused as arising frol11 the joint itself. Farasyn (2007) adds suppon to the observation that muscles refer pain, describing that a local muscle lesion can give rise to a wider area of pain, separate from the tender local injury and often described as 'burning'.
medicine
Tendon sheath and fascia gave sharply localized pain. Stimuli did not produce pain from anicular cartilage or compact bone but when applied to cancellous bone a deep diffuse pain was produced. Stimulation of the inter spinous ligaments gave rise to segmentally referred pain which, as in muscle, was associated with tenderness in the deeply placed structures. Inman & Saunders (1944) noted a variability of sensi tivity of the different structures beneath the skin, creatir.g a 'league table' of those tissues with the highest sensitiv ity to those with the least, as follows: bone, ligaments, fibrous capsules of joints, tendons, fascia and muscle. These findings were supported in pan by Kuslich et al (1991), who investigated tissues in the lumbar spine as potential sources of low back pain using progressive local anaesthetic during exploratory operation of the spine. Their emphasis too was that muscles, fascia and the peri osteum and compact layer of bone (they did not test cancellous bone) were relatively insensitive. In contrast, in the work of Travell & Simons (1996) trigger points in muscle have been identified as a focus of hyperirritability which gives rise to local tenderness and referred pain. It had been particularly noted by Inman & Saunders (1944) that capsules and ligaments were most sensitive close to their bony attachments, and therefore most likely to be pain-producing following trauma to these com monly injured sites. Controversy has existed for many years as to whether the disc or the zygapophyseal joint is the primary source of back pain, especially when associated with pain in the limb. Aprill et al (1989) studied the reference of pain from the cervical zygapophyseal joints to establish whether each joint had a specific area of reference of pain in a segmental distribution. They found reasonably dis tinct and consistent segmental patterns of pain referral associated with joints between each of the levels of C2C7 , but there was no referral of pain into the arm from any of the tested levels. The paper acknowledged that the study had not set out to distinguish the pain arising from zygapophyseal joints from other potential sources. In support of this pattern of referraL Cooper et al (2007) set out to determine the patterns of referred pain arising from celvical zygapophyseal joints by using diagnostic blocl<s to establish pain referral patterns in symptomatic subjects. There was considerable overlap of referral areas and patients described the symptoms in lines, spots or patches that were mostly confined to the neck and shoul der region. They reponed some variation from the results of their previous studies conducted on non-symptomatic subjects and suggested that the outcome might be due to the length of time that patients had been experiencing symptoms. Maintaining the emphasis on the nature of the tissue, two pain syndromes of somatic and radicular origin have been described associated with the spinal joints (Bogdul< 2005). In somatic pairl syndromes it is proposed that the source of the pain could be in any structure in the spine
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Radicular pain occurs as the result of compression of dorsal root ganglia when activity occurs not only in nociceptive a.,xons but also in A-beta fibres (Niere 1991, Bogduk 2005). Disc herniation is the most common cause of radicular pain. However, as well as compression of the dorsal root ganglion, from anatomical abnormali ties, leakage of inflammatory mediators from the nucleus pulposus into the epidural space has also been proposed as a cause of radicular pain (Peng et ill 2007). Both mech anisms may result in an inflammatory reaction causing hyperexcitability and spontaneous ectopic activity in the dorsal root ganglion, which is interpreted as pain. This can also add to central sensitization at the dorsal horn synapses (N iere 1991). As discussed above, experimental compression of dor sal root ganglia or previously damaged nerve root has been shown to cause radicular pain. The clinical experi ments of Smyth & Wright show this pain to be produced in a particular form, namely lancinating and shooting in quality, and referred in relatively narrow bands (Smyth & Wright 1959, Bogduk 2005). Taking into account the overlapping nature of somatic and radicular pain refer ral patterns, Robinson (2003) suggests that the patient's description of the pain itself may be more reliable than the location. Table 1.1 attempts to draw out the key dif ferences between somatic and radicular pain, based on subjective Jnd objective descriptors, to aid clinical reason ing and diagnosis. Bogduk (1994) proposed that somatic and radicu lar pain syndromes can coexist. For example, the annu lus fibrosus of the disc may be a source of somatic low
that receives a nerve supply, i.e. muscles, ligaments, zygapo physeal joints, intervertebral discs, dura mater and dural nerve root sleeve. Somatic pain is not associated with neu rological abnormalities and does not involve nerve root compression. The quality of somatic pain is described as dull, diffuse and difficult to localize. For clarity, 'somatic pain' is distinct from 'visceral pain' where the nox.ious stimulation occurs within an organ. It is also distinct from 'neurogenic pain' where the nocicep tive information arises as a result of irritation or damage to the axons or cell bodies of a peripheral nerve, not to the nerve endings (Bogduk 2005). A further distinction should be made between 'radicu lopaLlIY' and 'radicular pain'. RadiCIIlopathy is a neurological condition where con duction is blocked in the axons of a spinal nerve or its roots. Conduction block in sensory a.,'(ons results in numbness, and conduction block in motor axons results in weakness. Radiculopathy is a state of neurological loss and it does not result in pain, either in the back or limbs. However it may, or may not, be associated with radicular pain. The aetiology (cause) of both can be the same but the mechanisms are different. I.n radicular pain syndromes, the radicular (root) pain arises as a result of irritation of a spinal nerve or its roots. Contrary to the traditional belief, it is not caused by com pression or traction of nerve roots, unless the nerve root has become sensitized by previous damage (I<uslich et al 1991). Robinson (2003) confirmed this by stating that an inflammatory component or already damaged nerve root is necessaty before a nerve root will produce pain.
Table 1.1 Key differences between spinal somatic and radicular pain
RADICULAR PAIN
SOMATIC PAIN
Source of pain;
A deep
musculoskeletal structure,
e.g. dural
Pain deriVing from damage or i rritation
of the
n erve root sleeve, muscle, zygapophyseal joint,
spinal nerve t i ssue, pa rticular ly the dorsal root
with a nerve supply from a spec ific segment.
g anglio n .
-
Pain is referred where;
Segmentally referred dermatomal according to the nerve supply
Pain is described as;
of
pain
the structure.
Deep ache, vague, poorly localized.
Segmental ref rence, more
commonly to distal
end of dermatome i n l i mb (l ittle back pain). Lanci nat i n g, bur n i ng, severe, rad i at i ng , deep, strap-like, narrow, well
localized,
may be latent
I n nature. Is there any neurology;
None associated. Nociceptive stimulation
Yes. Usual ly associated with radlculopa thy
of somatic structures will not ne u rological s i gn s .
weakness and reduced reflexes In the
produce any
-
giving paraesthesia, n umbness, muscle appropriate segment.
-
Cli nical tips
Somatic pain can precede, and often be
Once c h ronic, radicular pain becomes more
associated With, radicular p,lIn since the dural
difficult to di ff er ent iat e from somatic pain due to c ent ra l senSitization, i.e. increased exc i billty of pain-related central nervous system neurons and the widening out of th e pain field.
nerve sleeve is a somatic structure surrounding the spinal nerve roo t .
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back pain but may a lso cause secondalY com pression by a postero latera l displacement causing compression of the nerve root leading to rad ic u l a r pai n . H owever, a lesion cannot select ively compress nociceptive axons; therefore, for compression to be the source of rad icular pain, other neurological abnormal i ties associated with radiculopathy should be present, e.g. paraesthes ia, nu m bness, musc l e weakness and l oss of reflexes ( l3ogdu k 2005 ) . l
description 'pain rad i a t i ng below t h e knee' as represent ing rad icu l a r pain rather tha n refe rred soma t ic p a i n is u nreliable. As ment ioned above Bogd u k (2005) cla i ms that for referred leg pain to be radicular in origin, arising from compression of a nerve root, i t m ust be acco m pa n ied by other signs of com pression - paraesthesia and m uscle weakness. If these a re absent, pain referred to t.he l i m b m u s t be somatic i n origi n . Schafer et a l ( 2 009) have a t te mpted to c l assi fy tJle c ausal mech a n isms of l eg pain i n to fou r groups that may h e l p to guide t reatment a p proaches, a l though they acknowledge that there is l i kely be some overl a p . As wel l as rad icular pain w i t h motor l oss and musculoskeletal (somatic ) causes, they propose that leg pain can a lso arise from cen t ral and peripheral nerve sensitizatio n . W i th i n this text, specific consideration of visceral referred pain is provided w i th i n the app ropriate c hapters as pan of d i fferen ti a l d i agnosis. H owever, j ust as we have attemp ted to sepa rate out the characteristics of somatic and rad icular pain, Vecch iet & C i amberard i no ( 1997) have desc ri bed general aspects of visceral pain tha t can be borne in m i nd, particularly for those cond itions req u i r i ng more u rgen t referral, for exa m p l e myocardial i n fa rct ion, pancrea t i tis, e tc . I n i t i a l ly, the p a i n is usually fel t i n the s a m e s i te along t h e m id l i ne o f the chest or abdomen, m a i n l y in the lower sternal a rea and the epigastric region, rega rdless of the viscera a ffected. It is generally perceived as a deep, d u l l , vague sen sation t h a t is poorly defi ned and m ay n o t b e able t o be desc ri bed . J t can vary from a sense o f d iscom fon to one of oppression or heavi ness and may be asso cia ted w i th autonomic s igns such as p a l l o r, sweating, nausea, vo m i t i ng a nd changes in heart rate, b lood p res sure a nd temperature. Strong e motional reactions are a lso often p resent and i nc l ud e a nxiety, anguish and someti mes even feeli ngs of i mpending death . Com mon features o f segmental l y referred pain were identified by Cyriax as 'rules' of referred pain ( Cyriax 1982, Cyriax & Cyri a,,( 1 993) . As w i th a l l p ronounced 'ru les', exceptions may be noted, but nonetheless they act as a general gu ideli ne in assessing p a i n behaviour a n d locating t h e causative l esion. H e developed rules for refer ral of pain fro m u n i la teral structures as represen ted i ll tJle Box below.
Rules of referred pain from unilateral structures •
It
•
It refers distal ly.
does
not cross the
•
It refers seg m ental ly.
•
It
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occupies
part
m id l i n e .
or all of
its dermatome.
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A notab le exception to the rules of referred pain is provided by the dura maier w hich, as a centrally placed structure, p roduces so called 'multisegmental reference' on compressio n or irritation.
M ultisegmental reference of pain
T h roughout his writing Cyriax referred to the phenom enon of 'extrasegme ntal' reference of pain (Cyriax 1982, Cyriax & Cyriax 1993 ) . He used the term to explain the observation that sy mptoms arising from the dura ma ter do not obey the rules of referred pain, in terms of refer ring segmentally, but rather th:1I a pattern of reference is p roduced whic h is 'outside' or 'extra' to that of the seg ment. With another inte rpretation, the terminology falls sho rt of being ideal si nce it implies that the pain is not experienced within the segment in which the causative lesion is housed. This is not so a nd 'multisegmental' would perhaps be a more correct term. The ventral aspect of the dura mater, the a n nulus fibro sus a nd ot her cen tral spi n a l structures are i nnervated by the sinuvertebral nerve which sends branches to segments above a nd below its level of origin ( Bogduk 2005 ) . This could accoun t for t he multiseg mental reference of pain arisi ng from compressio n of central structures. Mu ltisegmentally referred pai n is felt diffusely across several segments, usually as a dul l backg round ache, and is often associated with tender ness or trigger spots ( Fig. 1 .3). I t may vary and other unilate ral symptoms mig ht be superimposed upon it, as in lesions i nvolving p ressure on both the dura a nd the dural nerve root sleeve. Mention of the effect of compression of the dura mater leads to the general observation that lesions associated with compression of neural tissue p roduce varying patterns and nature of symptoms, according to the tissue involved. These wjll be listed as described in the Box facing. begin ning with the dura mater i tself.
Psychosocial factors
Whenever pain itself is the central focus for i nforma tion towards clinical diag nosis, consideration needs to be given to both its sensory and affective aspects. Thus discLlssion within t his section on the characteristics of referred pain has been based on the sensory compo nent of pain, addressi ng the mec ha nism and factors of referred pain, particularly relating to its dermatomal distribut ion. The concept of 'central pain' has been discussed, arising from changes within the central nervous system ( Butler 1995, Mendelson 1995). However, notwithstanding the contribution of centra l pai n to the chronic state, atten tion needs to be given to the affective aspects of pai n as an emotional experience rather than as a pure sensation ( Butler 1995 ). The so-called psychosocial factors (involv i ng aspects of both social a nd psychological behaviour)
Figure 1 .3 TSP =
rviultisegmental pain. CSP = cervical spine pain; thoracic spine pain; LSP = lum bar spine pain.
can have valying effects o n the patient's perception of pain as well as distorting the account given to the clinician. In addressing this issue in o rt hopaedic medicine, the term 'psychogenic pain' has traditio nally been used. The term has survived the controversy on whether or not it exists and, according to the litecature review of Mendelson ( 1 995), the work of Engel. Walters and Merskey has led to a general accepta nce that pain can be amplified or evoked by psychological factors. However. the term 'psychoso cial' is currently more commonly used and several studies provide evidence that certain persona lity traits and expe riences of individuals have p redisposed them to the per· sisting cycle of c h ro n ic pain (Waddell 1998). An initial organic basis should not be ig nored how ever. Shaw et al (2007) looked at shared and independ ent associati o ns of psychological factors among men with low back pain and suggested that early intervention will do much to avoid chronicity with its attendant psychoso cial factors and persistent work disability.
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D u ra mater •
Mu ltisegmental reference of pain and tenderness (Fig. 1 3).
S p i n a l cord •
No p a i n ,
m u l tiseg m en ta l reference o f paraesthesia, I e .
i n both feet, or a l l extremities i f associated w i t h cervical lesions. •
May produce upper motor neuron l es i o n with spastic muscle weakness.
•
May p roduce a spastic gait.
•
May produce an extensor
plantar response.
Dural nerve root sleeve •
Pa i n produced on
compr ess i
on of
t he tissue, i.e. t h e
pressure or 'compression ph e nom e no n ' (Cyriax 1982). •
Segmental reference
o f pa i n
in all
•
Difficu l t to ascribe an aspect to the pain, e . g . anterior •
or lateral . •
Difficu l t t o define a n edge t o the p a i n .
Nerve root •
•
N e u rolog i cal signs and symptoms a r e produced on co m pressi o n through the dural sleeve: -
seg m e n ta l reference
of
paraesthesia felt at t he di s ta l
end of the dermatome -
lower motor neuron lesion with flaccid m uscle wea kness
-
absent or red u ced refl exes
-
may become p ai n -sensitive.
Nerve trunk •
Symptoms produced on release of pressure, i . e . t h e ' release phenomenon' (Cyriax 1982), e . g . after sitting on a hard gate with pressure p l aced on the sciatic n erve trunk
•
•
or p a r t o f the
dermatome. •
lde n t i fication of a sign i fica nt psychological i n fl uence w i l l a ll ow for modification in the treatment a p p roach adopted a n d certai n l y may provide a con traind ication fo r some of the tech niques used i n orthopaed ic med i cine, most nota b ly the m a n i p u l ative t reatmen ts used for s p i n a l pai n . Cyriax ( 1982) p resented characterist ics w h ich, i f recog n ized in patients, give an i nd ication that a ffective i n flu ences are a p red o m i n a n t feature of the co m p l a i nt and should be taken i nto account i n a rriving a t a d iagnosis, as wel l as in subsequent treatment selection or appropriate referral . H e suggested that a ny o r a l l o f the follow i ng featu res m ight be present:
for a period of time, a shower of 'painful pins a nd needles ' will be experienced in the leg until the nerve recovers. Sensation of deep pain f u l paraesthesia in the c u ta n eous distribution of t he ne rve t r u n k .
•
Some aspect; no edge to t h e symptoms.
•
The lo nge r the compression, the greater the length of time before the onset o f pins and needles, e . g . the thoraCIC outlet syndrome produces d i ffuse pins a n d needles I n a l l five d i g i t s of o n e o r both h a n d s after g oi n g to bed at n ig ht, several hours after the com p res sio n has been released from the brachial plexus.
Peripheral nerve •
Compression
•
Clear edge a n d aspect to the symptoms, e.g. carpal
produces paraesthesia a n d n u mbness.
tu nnel syn d rome producing pa raesthesia and/or c u tan eo us distribution of t he lateral t h ree and a half digits on t h e palmar aspect of the hand, or me ral g ia paraesthetica involving co m p ressio n of the n umbness in the
lateral cutaneous nerve of the t h i g h , which is associated with a clearly demarcated area of
paraesth es i a a n d/or
n u m bn ess in the a n terolateral aspect of the t h i g h .
•
N o recogn iza b l e pattern of sym ptoms or signs in the subjective or objective exa m i nation Poor cooperation i n both sections o f the exa m i nation Overenthusiastic assista nce from the patient, often accom p a nied by an element of 'tri u m p h' if the c l inica l d iagnosis remains obscure Patients may seek the a nswer expected of them Mutual ly contradictory signs through an inco m p l ete knowledge of the cond ition.
Juddering is a response occasional ly noted on r
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Several effective approaches have been devised i n the treatment 0(" chronic p a i n (Chartered Society of Physiot herapy 2006a, 2006b) . These are often based on the concept of increasi ng activity a nd fi tness levels a n d p romoting t h e max i m that ' h u r t d o e s not equ ate t o harm'. S k i l l ed counse l l i ng m ay also be req u i red. This text has set o u t to acknowledge the possible infl uence of psychosocial factors but does not i ntend to expand further on its man ageme nt. The i n terested reader is referred to appropriate texts relating to t h is work.
and milgnetic resonance i maging ( M R I ) scans can be employed as necessalY but do not form part of the basic exam i nation proced ure. The orthopaed i c med i c i ne assessment procedure fol lows a set model for t h e col lection of cl i nical data. I t con tains the fol lowi ng elements: •
Observation, noting face, ga it a nd posture A detai led history I nspection for bony d eformi ty, co lour changes, m uscle wasting and swe l l i n g Pa lpation for heat, swell i ng a n d synovial thi c ke n i ng State at rest Exami nation by select ive tension, assessing active, passive and resisted movements Pa l pation for the s ite of the lesion, once the causative structure has been identi fied.
• •
• • •
CLI N I CAL EXAMI NATION
•
Cyriax's start i ng point i n the development of orthopae dic med icine was the pre m ise that a l l p a i n has a source. It was a s i rrJple extension of that logic t hat, to be effec tive, a l l treatment must reach the source and a l l treatment m ust bene fi t the l esion. Cyriax was i ntrigued by the n u m ber of patients passi ng t h rough orthopaed ic clinics who presented with normal X-ray fi nd i ngs, and acknowledged the soft t issues as the source of the com p lil i n ts. H e devised a mechanism of c l i n ical exa mi n a t i o n to establ ish the source of the pilin which was logical and method ical, and was d e l iberately pared to the m i n i m u m procedure in order to d iscover in which tissue the lesion l ay. H is sty l e of assessment con formed to the claim of Sir .Robert H utch i nson in 1 897, that 'evelY good method of case taki ng should be both com p rehensive and concise' ( H u n ter & Bom ford 1 9 63). A n i m portant emphilsis of Cyriax's exa m i nation proce d u re is Ulat negat ive fi n d ings are as significan t as the posi tive, e l i m i na t i ng from t h e enquilY t hose structures w h i c h a r e no! a t fau l t . The syste maUc approach h e devised pro duces i\ set of fi n d i ngs that can be i n terpreted through logical reaso n ing, i n tegra t i ng the assessment w i th existing k nowledge towards eventual c l i n ical d iagnosis. The term 'd iagnosis' at t h is stage i m p l ies the hypothesis aga i nst which we all work, which becomes proven or disproven in l ight of the patient's subsequent response. In rece n t years, much work has been devoted to devel oping areas o f spec i a l ist assessment. H owever, t he ort ho paedic med ici n e examination procedure gives c l i n icians a soun d fra mework from w h ich to start and any specia l exa m i nation tech n i q ues c a n b e superimposed u p o n i t . For exa m p l e, once a basic spi nal assessment h a s been carried out, extra neura l tissue sensitizing tests can be i nc l uded to search for aspects o f neural tension, repeated or co mbi ned movements can be i ncl uded, or loca lized j o i n t pal pation a nd mob i l i ty tests can be a p p l ied. A further aim of the exa m ination i s to establ ish whethn or not the lesion is suitable for the treatments offered in o rthopaedic medicine or other a l l ied treatment modal ities, or whether the patient would more suitably be referred o n for a p propriate specia l ist opinion. More detai l ed tests such as b l ood tests, X-rays, com puted tomography (Cr)
OBSE RVATION
l· •
Face Posture
•
Gait
Note the patient's face, posture and gail. A general observation is made as the patient is met, or even before the meeting without the patient's knowledge, for exa m p l e w hen t he patient is wa l king across the car park or approach i ng reception. Observe the patient's face for a ny signs of sleeplessness and pai n . Serious d isease acco m pan ied by u n relenting pa i n is usua l l y i nd icated i n the patie nt's overa l l demeanour. I t c a n b e useful t o note whether the patient's appearance matches the h istory as i m porta n t clues can be provided, particularly relating to t.he psychosocial component of the condition. Cert a i n postures ind icate specific cond itions. An a n talgic posture (one assumed by the patient to avoid p a i n) is often adopted in neck p a i n as a WIY neck, or as a l atera l s h i ft when associated w i t h a l um bar lesion . I n the u p per l imb, note a ny apparent guardi ng, per haps with an a l tered arm swing associated with a p a i n fu l shoulder, el bow o r even wrist. The patien t's gait pattern may be altered, with a l i m p indica t i n g p a i n or a l eg l engt h discrepancy. A n al tered s tride may be due to l i m i tation of m ovement at a joi nt, or protection from weight-beari ng. The lise of an aid such as a stick or crutches p rovides an obvious clue to the need for extra support to avoid or to assist with weight bearing. As part of the overa l l observa t ion, a check m ay a l so be made o n w hether such aids are being used correctly.
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beg i n t h e p a t i e n t i nterview wi t h an open question sLi c h as
HI STORY
'What can I do for you ? ' or 'W hat bri ngs you to mel' and ulen to a l low the h istory to be expressed i n the p a t i ent's own words. Anyth i n g not m e n t ioned can be searched fo r
History or su bjective examination •
after the p a t i e n t has fi n i s h ed speaking. Of course, not all patie nts w i l l o b l igingly revea l t h e i r
Age, occupation, sports, hobbies and lifestyle
history a n d some gu idance w i l l be req u i red t o I<eep to t h e
•
Site and spread
•
Onset and d u rati on
bet\veen a l l owing the patient time to speal< a nd co ntro l l i ng
•
Symptoms and behaviour
the i n terview to prevent i rrelevant devia tion ( 13 l a u
•
Past medical h i story
•
Other jOin t i n volvement
•
Medications
releva n t . Nonetheless, a bal ance s h o u l d s t i l l be sought
1989).
The model fo r h istory-t a k i n g i n orthopaedic m e d i c i n e w i l l n o w be d escribed. T h e cl i n ic i a n s h o u l d n o t e the rel eva n t deta i l s fro m t h e h istory o n t h e p a t i e n t's record card for s u b se q u e n t i n terpretation w h i l e accepting t h a t t h e process of c l i n i c a l reaso n i n g conti nues t h ro u g h o u t t h e i n te rv i ew a nd t h a t the 'rambling thoughts of a c l i n ic i a n '
A co m p l ete history is take n frolll th e patient to ascertain
c a n n o t - and s h o u l d n o t - be i m peded .
as mLich i n formation as possi b l e a b o u t the co n d i t i o n . At some j o i n ts the h i story is m o re relevant t h a n at o t h e rs with respect to d i agnosis. The h istOlY of t h e s p i n a l joints
Ag e. occupation. sports. hobbies
a n d knee j o i n t, for i ns t a n ce, may give many c l ues to d iag
and lifesty le
nosis w h ereas w i t h m a n y of the c o m m o n l y e n c o u n t ered co nd i t i ons of t he shou l d e r or h i p, such as caps u l i tis, the h istory gi ves a l m os t no c l u es at a l l . The term ' h istoIY' i m p l ies a chro n o l ogical acco u n t of h ow the co n d i t ion has progressed but this fo rms p a rt of a broader compass that i ncludes other aspects, such as aggrava t i ng and al leviat i ng facto rs or past med i c a l history. The h i story-taking i s rea l l y the subjective part of the exa m i n ation procedure and it is trad i t i o n a l i n medical and physiotherapy practice to use a model fo r the co l l ec t i o n of cl i n i cal d a ta fro m the patient ( Beck m a n & Frankel
1984 ) .
Most m o d e l s, i nc l u d i n g the model used i n o rthopaed ic med ici ne, i nvolve the catego r i z i ng o f the subjective exa m i nation u ncleI' d i ffe rent head i ngs t o ensure that a l l i n forma tion is col lected. However, i f th i s pattern is adhered to too rigidly it can be restri ct i n g fo r t h e p a t i e n t . The use of closed questions to steer patients' responses resu l ts in i nterviews bei ng physician-jphysiotherapist-Ied and co nsta nt i n ter ru ptions may restrict the fl uency o f pat i e n ts' accounts sud1 that they are prevented fro m presenting the true n a t u re of the prob l e m ( Beckman & Fra n ke l
1984,
Siau
1989).
Studies on the p rocess of h istory-ta k i ng revea led that physicians i nterrupted and took contTol of the i n terview on average 1 8 s into the co nsultation, and t h a t by ask ing specific closed questions they h a l ted the spo n taneous �ow of i n formation ( Beckman & Frankel
1984)
H owever,
T h e a g e of the patient m a y be relevant a s cena i n cond i t i o ns predo m i nanUy affect certai n age groups. For example, ch i l dren m a y suffer fro m PerU1es' d isease or s l i pped e p i physis i n the hi p, p u l led el bow, or loose bod i es associated with osteocho n d ri t i s dissecans i n the knee. Ad olescents may suf fe r from Osgood-Sch l a tter's d isease or m a l Lrad<.i ng prob lems i n the knee. Mechanical l u m b a r lesio ns, l iga ment or tendon injuries are common in the m i d d l e-aged and dege n erative osteoanhrosis is usu a l l y su ffe red by u1e elderly. Occu pation mily be rel eva n t in terms of the postures adopted w h i l e at work a nd t h e acti v i t i es involved i n Lhe patient'S job. I n Lh i s respect, it is i m porta nt to explore t h e j ob's req u i re m e n ts ra t h e r than merely to n o t e t h e j o b t it l e. An overview of th e p a t i e n t's ge n er a l l i festy le may give d u es to the cause of the prob l e m and, r e l a t i n g t o treat ment, ca n provide an i n d i ca t i o n of the requ i re me n ts fo r rehab i l i t a t i o n back to fu l l activi ty. For exa m p l e, tendon or mu scle b e l l y l es i o n s fre q u e n u y occur i n spo rts req u i ri n g explosive activi ry, a s i n ten n is and squash, a n d t h e s pe c i fic req u i re m ents of the sport w i l l need to be considered to b e a b l e to grade the reha b i l i tation progra m m e il p p ro priately. Those engaged i n a m o re sedentary occu p a t i o n o r l i festy l e m i g h t be p ro n e to b a c k p a i n and w i l l n e e d to be encouraged to i ncrease t h e i r general act ivi ty as p a rt o f m anagement and to prevent recurrence.
if a l l owed to co n t i n u e u n i n terrupted a nd w i Lh no specific guidance, patients tal ked on average fo r less than
2 m i n,
during which time most of the i n formation req u i red by the phys i c i a n
1989). This study was ( 1989) who found the t i me taken to w i t h 89 of the 1 00 patients surveyed speak I 'll min and 41 of those fo r less than 30 s.
WilS
disclosed ( S l a u
Site and spread As referred to at the beg i n n i n g of t h is c h a p ter, patients usu
repeated by W i l k i nson
ally co m p l ain o f p a i n but t h e re may be other sym p t o ms
be even sho neI',
that cause u1em to seek advi ce, such as stiffness, wea k ness,
i ng for less than
n u m b ness a nd p i n s an d need les, for exam p l e. Whatever
Bearing t he previous poi nts in m i nd, w h i l e consid
th e sym ptoms, m u ch i n fo r m a t i o n can be gai ned towards
eration o f the va rious catego ries adopted in orthop aed i c
d i agnosiS by estab l is h i n g where the symptoms are a nd
med i c i n e is necessary, i n cl i n ical practice i t is better to
th e i r overa l l spread. For insta nce, it is i m port a n t to know
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not just where the symptoms are now but where they have
period of resting. What is the dai l y pattern of the symp
been. A low back pain often travels into the leg but usually
toms? Joint stiffness more marked in the morning indi
becomes less apparent in the back as it does so, a typical
cates the presence of i n flammation, and questions on
presentation of nerve root irritation of mechanical origin.
how long it takes to ease will provide an indication o f
A low back pain moving into the leg without rem ission in
irritability or severity. I f the l esion was associated with
the bacl< implies a spreading l esion and requires a differ
sudden trauma,
ent interpretation.
activity to provide information on the severity of the
Several factors can influence t h e site and spread o f sym ptoms a n d these were described in the fi r s t p a n of
could the patient continue with the
l esion and/or instability? Serious pathology may present with unrelenting pain;
this chapter. The site and spread of the symptoms can
nig h t pain is likely to be
be an indication of t h e overall irritability of the lesion as
benign musculoskeletal lesions do not present with con
well as prov iding a clue to the structure at fault by con
stant, unremitting pain and there is u sual l y some position
sidering the 'rules' (mentioned earlier) for the referral
of rest wbich eases pain, or some periods when the pain
of symptoms that can arise from different somatic and
is easier or even absent. In distinguishing between serious
neurological structures.
pathology and an irritable musculoskeletal lesion it can be
Onset and duration
disturbs sleep, with more serious path ology possibly being
i\
featu re. Cenerall y speaking,
helpful to distinguish whether the pain prevents sleep or impl icated in the former. With musculoskeletal lesions,
The mode of onset of the lesion can provide indicators
however, i t may be the case that specifi c postures, SUcil as
which lead to a clinical diagnosis and can also contrib
sitting up for neck pain, have to be adopted to allow sleep.
ute t o the treatment selection a n d overall prognosis of
There will be special questions at each joint which are
the condition. Was t h e onset sudden or gradual? Meniscal
rel evant to t h e patient's symptoms. For example, how do
tears and acute muscle belly lesions come on suddenly
stairs affect knee pain? How does a cough or sneeze affed
wh ereas overuse ten don and bursa problems and nuclear
back pain? Does the patient with neck pain experience
disc lesions have a gradual onset. Fradures usually have a
any dizziness? Peninent questions asked at each joint
sudden onset associated with trauma but systemic condi
region will aid diagnosis and, imponantly, wilJ also rule
tions or serious pathology such as tumours have an insid
out any contraindications to treatment.
ious onset. None of these l atter conditions is suitable for treatment within the specialism of orthopaedic medicine. In the lumbar spine the mode of onset leads towards a
The clin ician will also wish to investigate if there have been any previous episodes of similar complaints. Spinal pain may be a progression of the same condition and
particular hypothesis with regard to pathology, which then
a lumbar disc l esion may characteristically present as
provides a guideline for treatment selection. For example,
increasing episodes of worsening pain.
a gradual onset may respond more effectively to treatment with u-actj on, while, in the absence of any contraindications, a sudden onset may require manipulative treat ment. The duration of the symptoms is important as an
Past medical history Asking about the past and present existence of serious
indicator of the acute or chronic stage in healing which
illness,
in itself gives guidance for the treatment approach to be
dents gives insight into the patient's medical h istory.
unexplained weight
loss,
operations or acci
adopted, as wel l as indicating the l i kely effectiveness and
Past trauma or serious illness may be relevant to current
progress of treatment applied. For example, the acutely
diagnosis, e.g. old fracture of the tibia leading to degen
sprained liga ment will require a gentle approach to treat
erati ve changes in the ankl e joint, Or mastectomy for car
ment aiming to reduce swelling to promote h ealing and
cino ma followed by the formation of bony secon daries in
to prevent adverse scar tissue formation. In contrast, the
the spine. As well as past medical history, establish gen
chronic ligamentous lesion will require a more aggres
eral h ealth and any ongoing conditions and treatment.
sive approach to treatment aiming to r estore function
Explore other previous or current musculos keletal prob
by breaking down any adverse adhesion formation with
lems with previous episodes of the current com plaint, any
stretching and manipulative techniques as appropriate. A
treat ment given and the outcome of treatment.
lumbar lesion of gradual onset is less l i kel y to respond to treiltment if it has been present for 3 months than if it has been present for I month.
Other joint involvement This particularly gives clues to the patient's pain being associated with syste m i c joint disease. It will alert the
Symptoms and behaviour
examiner to the presence of inflam matOlY arthritis, such
The way the pain behaves will assist diagnosis. Mechanical
as rheumatoid a rt h ritis and ankylosing spondylitis, and
joint lesions are usualJy better for rest and worse on activ
also to degenerative osteoarthrosis, a l l of which have a dis
ity. Also, changing posture can al ter the pain. L.igamen tous
tinctive pattern of onset and joints affected. Inflammatory
lesions like movement and are usually worse after a
joint disease, most notably rheumatoid arthritis, provides
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a contra i n dication t o m a n i pula t i ve t reatment, especially
heat, swel l i ng and p a i n
in t he cervical spi ne.
There may be signs of bruising following trauma, that
It may be i n dica t ive of infect io n .
may be distal to t he site of the le.sion, or pallor, mottl ing or reddening associ atecl w i th c i rcula t O lY or sympathetic
Medications These g i v e
il
invo lvement. The p resence of scars and rashes may a l so
clue t o past or underlying disease, e . g . the use
be indicative of relevant patho logy.
of tamox i fen indic
pathology
which necessitates their prescri ption.
Antidep ressants can give an indication of the emotio n a l
Muscle wast i ng A ny obvious musc le wast i n g is noted. This may have its orig i n in a n eurological cond i t ion, usually from nerve root compression at the releva n t sp i n a l level, as a resul t of reflex muscle i n hibition associated w i th j o i n l e ffusion (de Andrade et al 1 9 6 5 ) , or as a consequence of disuse. The cause of the wasting will usually become apparent as the examination p roceeds.
state o f patients which may provide a cont ra i n d i cation to some treatments. However, it shoul d a l so be noted thJt low-dose antidepressa nts may be used as an adjunct to ;malgesics in the management of chro n i c pa in.
Swe l l i ng Swelling i s indicative of the presence o f inflammation
The qua n t i ty and regularity of the close o f analgesic and
resulting from trauma or overuse, as in tenosynovitis and
non-steroidal anti- i n flammatory drugs provide an i n dica
bursitis or arthritis. S we l l i n g which presents immedi
t ion of the level of p a i n being experienced by t he patient
ately indicates bleedi ng i n the area. Other swe l l i ngs may
and can be used as a n objective marker to monitor the
i nclude haematomas, gang l i a , l i pomas and soft t i ssue
p rogress of treatment i n te rms of noti n g whether higher
nodules.
or lower cl oses are needed to cont rol the pa i n .
PALPATION I NSPECTION Hav ing completed the hi stolY, the patient i s i nspected, suitably undressed and in a good l ight, paying p a rt icular attention to a ny bony dejorl1 li ty, colour cha l1ges, muscle wast ing or swelling.
l·
Heat Swe l l i n g Synovial thickening
Inspection •
Pal pate a peripheral joint
At this stage of the objective examination, peripheral jo ints are p
Bony deformity Colour changes
the fo rm of heat, swell i n g a n d synovial lhicke n i ng. The
•
Muscle wasting
•
Swelli n g
t h e end o f the examin a lion when the structure at fault has
--------�
been identified t hrough the rest of the examination p ro cedure. It may also be necessary to palpate for peri pheral pulses at this stage if c i rculatory d i sturbance i s suspected.
Bony deform ity This may i n clude spi n a l asymmetry, leg length discrepancy, excessive val.gus or varus deformity at joints, bony lumps
Heat
or exostoses. Obvious distortion of bony or joint contours
The j o i n t is palpated [or heat using the back of t he hand
fol lowing trauma could indicate fracture or dislocation .
a nd comparing the same aspect o n each side. The same ha nd is used throughout since the domi n a n t ha nd may be a few degrees warmer than the non-dom i n ant. Any
Colour changes
bandagi n g or support that the patient has been wearing
Redness may i n dicate the presence o f acute i n tJ amma t i o n
which co u l d have wa rmed the area should be taken into
as one of the fou r card i n a l signs o f i n flamma t i on: redness,
account.
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Pri n c i p l es of ortho paed ic med i c i n e
Swe l l i ng
Active movements give a n idea of the
Swelling is often apparent on inspection alone but may
and the
be p a l p ated for, p a r t i cu l a rly to detect m i n or swe l l ing, i n t h e knee, fo r exa m p l e.
available i n the joint, the
power
pain
rallge
of move m e n t
experienced b y t h e p a t i e n t
i n t h e Ill u scle groups. They a r e not carried
out ro u t i ne ly a t a l l j o i nts, s i nce t h ey Me n o n -selective and em p l oy both i n ert a n d c o n t ract i l e tissues. H owever, t h ey are useful in esta blishing the
Synov i a l th icken i n g
of t h e patient to perform t h e move m e n ts as
Synovia l thicke n i ng h a s a 'boggy' fee l t o it and indiciltes the presence and level of inflammation in a joint. It is particul,ul y evident i n rheumatoid arthritis at the wrist, a n kle and Imee.
willingness
all
i n d i cator
of the level of pain b e i n g experienced w i t h i n each range. In t h is role t h ey can act as
iI
gu ide to the range of move
ment ava i l a ble before appl ying pilssive s t resses to the j o i nt and can be used
il t
any j o i n t to ga i n that i n forma
t i o n i f necessa ry. Active m o vem ents c a n also be used to eliminate neigh
STATE AT REST
bouring joints as a potentia l source of p a i n . For exa m p l e,
The state at rest must be established before any exa m i nation requiring joint movement or muscle activi ty takes place, i n order t o provide a basel i ne against w h i c h t o note the effect of a ny such movements. There may or may not be any symp toms at rest. Comparison can then be made with subseq u e n t movements wh ich m a y m a ke t h e symptoms better or worse. An open q uest i on such as ' H ow do you feel as you are s t a n d i n g/ s i t t i n g t here7' u s u a l l y el icits the status q uo and avoids the leading use of the word ' p ai n '. Based on
the
observa t i o n
that
normal
tissue fu nc
t i o ns p a i n lessly whereas a b nomlal tissue does not, Cyri a.x devised a method of app lying appropriate stress to the structures surrounding eadl joint in order to test their function. Passive movements were e m ployed to test the so called inert structures s u ch as j o i n t caps u l es and l iga m en ts, whereas resisted tests were used to test t h e contract i l e
SliLIC
t u res i n corporating muscle, tendon a n d attach ments to b o n e. This then was the method of applying selective ten s i o n to t issues (Cyriax 1 9 82, Cyriax & Cyriax 1 9 9 3 ) and the movements he propou nded wi l l now be described.
as p a n of tile s h o u l d e r exa m i n a t i o n , s i x act i ve nec k move m e n t s a re pe r fo rmed . If the pil t i en t's p a i n i s not e l icited then t h e cervical s p i n e is e l i m i n a t ed from t h e en q u i ry a t th a t i n i t i a l st"ge. They are a lso most i m porta n t in i l l ustra ting how wi l l i ng t h e p a t i e n t is to move, with respect to psyc hosocial factors "nd p articu la rly n o t i n g any u n usual or b i zarTe responses. The appropr i a teness of the p a t i e n t's response can be s i gn i f icant i n the s u bseq u e n t selection o f trea tment tech n iq u es . Th is is h e l p fu l when assess i n g the so-ca l l ed 'e m o t i o n a l ' j o i n ts, i .e. the j o i n ts w h i c h are prone to an exagge ration of symptoms and whic h include all spinal areas, the shoul ders and, to
iI
lesser extent, t h e h i ps.
A p a rt i c u l a r s i gn k n own as t h e
pairrful arc
is d e m o n
strated b y
a
u sefu l fi nd i n g
towards d i agnosis. For ex a m p le, a p a in fu l a rc may be found o n active abduct i on at t h e s h o u l d e r if a l e s i o n l ies in the s u b a cro m i a l b u rsa, or the su pra s p i n a tus, i n frasp i na tus or subsca p u l a ris teno-osseous a ttach m e n ts, where i t may be p i n c h ed as it passes u n d e r t he coracoacro m i a l
EXA M I NATION BY SELECTIVE
arch before pass i ng beyo n d and beneath i t , o u t o f harm's
TE N S I ON
way. The p a inful arc is not u s u il i l y fo u n d in i s o l a t i o n a n d positive fi n d i ngs on o t h e r tests w i l l fu rther i n cri m i na te
Throu ghout this discussion of exa m in a t i on by s e l ec t i ve
t h e causative structure.
tension and withi n t h e objective exa m i n a t i o n i n the fo l l owing regional cha p t ers, c o m p a rison should a l ways be m a de w i t h the o t h e r s i de, w h e re a p p ro p ri a te.
Active movements Active movements •
Range
•
Pain
Passive movements Passive movements •
Pain
•
Ra n g e
•
End-feel
•
Power
•
Passive movements test the i ll ert
W i l l i n gness
t h e j o i n t caps u l e, j o i n t m e n isci, l igamen ts, fascia, b u rsae,
•
Pain f u l arc
d u ra mater a n d t h e d u r a l nerve root s leeve. RelaXed m us
structures
wh ich i n clude
c l e and t e n d o n can act as i n ert s t r u c t u res when t h ey a re
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stretched by their oppos ite passive movem ent. Passive movements principa l l y give i n formation o n pain, range and elld-feel. The observation of pain and range o f movement w i l l be fa m i l iar to a l l cl i n i cians working with soft tissue lesions. However, the notion of end-feel may be a new concept which is part icularly valuable in the assessment of the so ft tissues and is in herent in the o rthopaed ic med icine approach. End-fCcl is the speci fi c sensation i m pa rted through the exami ner's ha nds at the extreme of passive movement (Cyriax 1 982, Cyriax & Cyriax 1 99 3 ) .
Normal end-feel Normal end-feel •
Hard
•
Soft
•
Elastic
Normal end-feel is divided in to t h ree categories: h a rd, soft and elast ic. Normal bone-to-bone approx i m at i on, as in extension o r t he el bow, gives a characteristic hard elld-feel to passive movement. A 50ft end-feel i s characteristic of a stop to the movement brough t about by approxi mation of t issue, as in passive knee or e l bow flexion. An elastic end-feel is fel t when the tissues are p laced on a passive st rE'tch and is the e l astic resistance produced in the i n ert tissues at the end of range in normal joi nts. Exa mples a re provided in stretch i ng the end of range o f l ateral rotation a t the shoulder o r h ip . There may b e a range of end-feels w i t h i n the 'el astic' group, but a l l are ind ica t i ve of normal t i ssue tension, such as the 'leathery' end -feel o f passive p ronation and supi na t ion o f the fo rearm, or the even t ighter 'rubbery' end-feel o f ankle plantarflexion and wrist flexion where the resist ance to the movement is in pan provided by the tendons spa n n i ng the j o i n t . I'ain i s al so a component at t h e extreme end o f range o f normal movements, acting as a protection in prevent ing co nti nuation o f movement to the po i nt o f producing t issue damage.
Abnormal end-feel Abnormal end-feel •
'Hard'
•
Springy
•
E m pty
The sensation i m p a rted in the abno rrnal end-feel fa l l s i n to th ree categories: 'hard', spri ngy, and em ply. The cause of the abnormal 'hard' end-feel is d i ffer ent fro rn that o f the n o r m a l hard bo ne-to-bone end-feel and i l is a panicular fea t u re of the movements l i m i ted in arthrit is. I n early a r t h r i t is, j o i n t movement is i n i t i a l l y l i m i ted by pai n, and i nvol u ntary muscle spasm h a l ts the movement (Cyriax 1 9 8 2 ) . Th i s i nvo l u ntary muscle spasm provides a brake to the movement a nd feels 'hard' to the exa m i ner. Certai n l y the end-feel fee l s harder than expected, but in the early stages somt: el ast icity is preserved . Early arthritis of the hip, for exa mple, may produce a 'hard' end-feel on eit her passive flexion or medial rotation but i t should be emphasized t h a t t h i s is not caused by bony degenerative cha nge bl ocking the j o i n t movement. This d i fference i s i mportant a s i t a i ds t h e cl i nician i n the selection o f treat men t tech n i q ues. In more advanced a rt h ri t is, the 'hard' end-feel is also d ue to capsul a r cont racture (Cyriax 1 98 2 ) . The capsular resistance together w i t h the i n vo l u n tary muscle spasm may st i l l a l l ow some 'give' a t the end of ra nge, but i t w i l l n o t feel a s elastic a s the earlier stage. In late arthritis, bony changes may occur, lead i ng to a gen u i n e h a rd end feel and the crepitus associated with advanced a rthrit is, as we l l as that arisi ng fro m i nvo l u n ta ry m uscle spasm a n d capsular contractu re. An abnormal springy elld-feel is associated with mt:cha n ical j o i nt d isplacement, usu a l l y a loose body. The sensa tion i m parted to the exa m i ner is one of not quite get t i ng to the end of range, w i t h the j o i nt spr i nging or bouncing back. It is sim ilar to the sensation of trying to close a door with a small piece o f rubber or grit caught in t h e hinge wh ich causes the door to s p r i ng back. The abnormal end-feel associated with i n vo l u ntalY muscle spasrn is d i ffe rent frorn that produced by vo l u n tary muscle spasm. Vo lun tary muscl e spasm comes in abruptly to halt the movement and i ndicates acute pa i n o r serious pathology. If t h e pa i n is very severe i t may also be associated w i th an e mpty end-feel . An empty end-feel occurs where the exa m i ner does not have the opport u n i ty to app reciate the true end-feel because the patient c a l l s a h a l t to the movement prerna l U rely and u rgently because o f pain, o ften ra ising a h a nd to prevent further movement. The sensation i m parted to the exam i ner is em pty, as described, in that the com p l a i n t of serious pain comes o n before any spasm o r tis sue resista nce. The e mpty end-feel is associated w i t h serious path o l ogy such as fracture, neo plasm o r sept i c a rt h ri t is. A fu r ther cause may be a highly i rritable l esion such as acute subacro m i a l bursitis where the e m p ty end-feel is i nstantly apparent 0 11 passive abduction of the shoul der. The assessment of end-feel together with the restriction o f movement a t each j o i n t produces a panicu l a r pattern which is eit her 'capsular' or 'non-capsu la r'.
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Cyriax evaluation scheme was h ighly rel iable in assess ing patients wit h shoulder pain. Fritz et al ( 1998 ) found ev i dence to support the concept of t he capsular pattern in the innamed or osteoart hritic knee whereas, although they established some support for the capsular pattern i n the knee, Gijl et al ( 1 998) were unable to recommend it as a valid test. No support fo r the capsular pa ttern at the h ip was provided by the studies of Bijl et al ( 1 998) and K lassbo et al (2003) a n d it was quest ioned by Sims ( 1 999).
The capsular pattern
Capsular pattern •
I n dic a te s arthritis
•
Va ries from
•
15 l i m i tation of move m e n t In a fixed
joint to joint proportion
The capsular pattern is a limitation of movement in a de fined pattern w h ic h is specific to each joint and indi cates the presence of an arthritis. The pattern varies from joint to joint and i� cha racterized by l im itation of move ment in a fixed pro port ion. I t is the same whatever the cause of the arthritis (Cyriax 1982, CyriiLx & Cyriax 1993 ) and the h istory w ill suggest the form of arthritis, be it d egenerat ive, innammatory or traumatic. Table 1.2 pro v ides a list of the capsular patterns for all t he j oints and spinal regions. Characteristically, the movements restricted in the cap sular pattern take on the ' h a rd' end-feel of arthritis, differ ent from the expected normal elastic capsular resistance. The reason fo r the development of the capsular patte rn could be the presence of joint effusion, causing the joint to assume the posi tion of ease and/or protective mus cle spasm ( Eyring & Murray 1 96 4 ) . An effusion is often p resent in an arthritis and the acuteness of the condi tion determines the quan tity of the ef fusion. Joints with symptomatic effusions are held in the position of ease mentioned above and movements out of thi s position produce pain. Eyring & Murray ( 1 964) noted a possible relationsh ip between i ntra-articular pressure and pain. Experiments were conducted to determine the position of minimulll pressure in various joints and i t was observed that symp tomatic joints w ith effusion spontaneously assume a position of min imum pressure, which coincides with that of minimum pain. The involuntary muscle spasm, in protecting the pain fu L in na med jo int, prevents the use o f the painful range of movemen t and if the range of movement is underused it w i l l become limited. In arthritis, the individual joints resent some movements more than others, hence tbe cap sule contracts disproportionately, making some move ments more limited than others and giving rise to the characteristic pattern of limitation. For examp le, in the study conducted by Eyring & Murray the position of m in imum pressure for the elbow "'ias found to be between 30° and 70 ° of nexion. The pressure was not influenced by either pronation or sup inat ion. The capsular pattern of the elbow joint is proportionally more l imitation of flex ion than extension but without i nvolvement of pronation or sup inatio n . The capsular patterns described in "Table 1 . 2 prov ide a usefu l guide to diagnosis of arth ritis but research sup port is mixed. Pellecchia et al ( 1 996) established that the
Non-capsular pattern
Non-capsular pattern •
I ntra-articu l a r d is plac ement
•
Ligamentous lesion
•
Extra-articular lesion
The non-wpsular pattern of a joint is, quite simply, any t hing other than the capsular pattern. That is, it is a limi tation of movement that does not conform to the capsular pattern and occurs as a result of a component or part of the joint being affected rather t h a n the whole joint A mechanical lesion such as a n intra-articular d isplace ment produces the non-capsular pattern which may be evi dent at the spinal joints and i n a loose body at the elbow joint or a meniscal tear at the knee. A mechanical lesion in a dege nerative joint may produce a non-capsular pat tern superimposed on the capsular pattern. A ligamentous lesion will give pain and possible limi tatio n of the movement which stretches the structure. However, sprains of l igaments w h ic h form an integ ral part of the capsule itself, such as the anterior talofibu lar l igament of the ankle a nd the medial co llateral l iga ment of the knee, cause a secondary capsu l itis and hence a non-capsular pattern is super im posed on the capsular pattern. S i nce a contractile unit can be stretched by pass ive movement, the u n it may respond as an inert structure when rel axed, producing pain when i t is stretched by the passive mov ement in o ppos ition to its functional move ment. For example, the subscapularis muscle a n d ten don which produce medial rotation at the shoulder w i ll be stretched by passive lateral rotation. This is also par ticularly ev ident in acute tenosynovitis when the i nvolved tendon is pulled t hrough its innamed synovial sheath. In acute tenosynovitis at the wrist, for example, pain will be produce d on the appropriate resisted test and the oppo site passive movement, e.g. de Quervain's tenosynov itis. A n eXira-articular lesion such as a bursitis p roduces a non-capsular pattern and c o m ill only presents as a 'lllud dIe' or mixture of sig ns involving passive and resisted tests, w hen any movement wh icll squeezes or stretches the innamed b u rsa will produce positive signs.
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Table 1 .2 Capsular patterns JOINT
CAPSULAR PATTERN
S h o u lder joint
Most limitation of lateral rotation Less l i mitation of abduction Least limitation of medial rotation
E l bow joint
More l imitation of flexion than extension
Radioulnar jo i nts
Pain at end of range of both rotations
Wrist joint
Equal l i mitation of flexion a n d extension Eventual fixation i n the m i d-position
Trapezio-first metacarpal j o i n t Metacarpophalan geal joi nts
Most limitation of extension L i m i tation of radial deviation and extension Joints fix i n flexion and d r i ft into u l n a r deviation
Interphalangeal joints
S l i ghtly more l i mitation of flexion than extension
Cervical spine
Demonstrated by the cervical spine as a whole:
Equal l i mitation of side flexions Equal l i mitation of rotations Some lim itation of extension Usually full flexion
Demonstrated by the thoracic spine as a whole:
Thoracic s p i ne
E q u a l l i m itation of rotations E q u a l l i m itat ion of side flexions Some l i m itat ion of extension Usually f u l l flexion Hip joint
M o s t l i m itation of m e d i a l rotation Less l i mitation of flexion and abd uction Least l i m itat ion of extension
Knee joint
More l i mitation of flexion t h a n extension
A n k le joint
More l i mitation of pla ntarflexion than dorsiflexion
Subtalar j o i n t
I ncreasing l i m itat ion o f s up i nation
-
Eventual fixation i n pronation Mid-tarsal joint
Lim itation of adduct i o n a n d supi nation Fo refoot fixes i n abduction and pronation
First metatarsophalangeal jOint
Some l i m i tation of flexion Other metatarsophalangeal joints
-
-
-
-
Marked l i m i tation of extension --
May vary: Tend to fix in extension
I nterphal a n gea l joi nts
Fix in flexion
Lumbar spine
Demonstrated by
-
the lumbar spine as a whole:
L i m i tation of extension Equal l i mitation of side flexions Usually f u l l flexion '1
he
movements which
become limited in th e capsular pattern take on a
c h a r a cteri st ica ll y 'hard' end-fee l .
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Resisted tests
Resi sted t e sts may produce any o f several fi n d in gs , e a c h o f
w h i c h has a different impl ica t i o n . The test m a y be:
Resisted tests Pain Power
- n orma l
•
S t ro ng and parnless
•
St ro ng and p a i n f u l - contractile lesion
•
Weak and pain less
-
neur ol ogi c al wea k ness; comp lete
rupture •
Weak a n d p a i n ful - pa rti a l rupture o r s eri ou s p a th o l ogy s u c h as fracture or bone tumour
•
Resisted i s o m e t r i c m uscle tests assess t h e coT/ tTl/ctile
•
t i o n , t e n d o n and the t e n o -osseoLis a t tach m e n t to bone -
All resisted tests about t h e joint painful or j u ddering - serious pathology, or marked psychosocial component.
fo r paill a n d power. The t e n d o n is not strictly a c o n t rac t i le s t ruct u re b u t
P a i n f ul on repetition - claudication o r p rovocation of overuse injury or less irritable lesi o n
UT/it - c o m p r isi ng t h e m uscle, m u sc u l o te n d i nous j u nc
i s tested as pa rt of t h e fu n c t i o n a l contract i l e
u n i t . W h e n assess i ng the resisted tests i t i s i m po rta n t to
1 001< fo r reprod u c t i o n of t h e p a t i e n t's prese n t i n g pa i n a n d
rO ll t i ne exa m i n a t i o n for a s p i n a l j o i n t, test i n g fo r root
th ere a re spec i fi c p o i n t s to b e a r i n m i n d which ensure
si gns. (See Chs. 8, 9, 13 and J 4 )
t h a t, as fa r as poss i b l e, o n l y the con t rilctiJe u n i t i s bei n g
H av i n g co m p l eted t he subjective and objective exa m i
tested ra t h e r t h a n t h e i n e rt structu res. I t is ilcce pted th a t,
na t i o n sequence t h e ca us a t i ve s t ru c t u re, i f n o t i ts p a t h o l
a l t h ough j o i n t movement m ay not be seen to occur, iso
ogy, w i l L i n a l most a l l cases, hilve bee n i d e n t i fied ( C y r i a.x
metric m uscle co n t raction w i l l cause co m p ression a n d
1 982,
j o i n t shea r i n g a nd, i n t h e s p i n a l j o i n ts, a rise i n i n tr a d is
Cy ri a x &
C y riax 1 9 9 3 ) .
cal pressure ( La m b 1 9 9 4 ) . The j o i n t shou l d be p l aced i n t h e m i d-pos i t ion w i t h t h e
PALPATION
i n ert structures relaxed s o t h a t n o s t ress fa l l s u p o n t he m . The m uscle gro u p is tested isometrical ly, a s s t rongly as poss i b l e, so e n c o u ragin g m axi m a l vol u n t a ry c o n t ract i o n
At t h is stage pa l pa t i o n of the structure determi ned to b e
but w i t h o u t al lowi ng move m e n t to occu r a t t h e j o i n t. Th is
a t fau l t m ay be made to i d e n t i fY the s i te o f t h e l es i o n to
also e n s u res t h a t m i n o r lesions w i l l be detected. Pa tie n t
w h i ch ap propriate trea t m e n t can be appl ied .
a n d exa m i ner's body pos i t i o n i n g should be such t h a t a l l
I f the d iagnosis i s st i l l u nclear fu rther tests may b e added
m uscles n o t b e i n g tested are e l i m i n ated fro m t h e test i n g
e ither mecha n i ca lly, for exa m p l e us ing techniques of neural
procedure.
tension tests, comb i n ed, repeated or acces�ory move m e n ts, or w i t h t h e use of b l ood tests, X- rays, electrom yography
I n a d d i t i o n to the act ive, pass i ve and resisted tests, a
brief n e u ro l ogical exa m i n a t i o n is i n c l ud ed as part of t h e
( EMG)
o r sca n n i n g tec h n i q ues, as ment ioned above.
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Ba i ll i e re Ti ndal1,
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C l i n ical reaso n i ng in orthopaedic med icine
Cooper, C , Ba i l ey, B., Bogd u k,
N.,
ea l
t
n e u rons w i t h d i choto m i s i n g a ffere n t
joint
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fi b res t o b o t h the l u m bar d isc a n d
p a i n m a ps. A m . Acad . Pa i n Med. 8,
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zygapop hys
I ., 1 9 8 2 . Tex tbook of
Orth o paed ic Med i c i ne, 8th e d n . B a i l l iere Ti n d a l L Lon d o n . Cyriax, I . , Cyriax, P., 1 9 9 3 . Cyriax's I l l ust ra ted M a n u a l of O r th opaed i c Med i ci ne. B u tterwo rt h
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t\ ., I., 1 96 5 . l o i n t distension and
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I. Bone l o i ll l S u rg. 4 7 A, 3 1 3 -3 2 2 . Eyri ng, te. l , M u rray, W R , 1 % 4 . The effect of j o i n t pos i t io n on the pressure o f i n t ra a n icu l a r effus i o n . J . i3one J o i n t Su rg. 4 6A, 1 2 3 5 - 1 2 4 1 . Farasyn, A , 2007. Referred muscle p a i n is p ri ma ri l y pe r i r h eral i n o r i g i n th e barrier-d a m t heory. l'vl cd . Hypodl .
6 8, 1 4 4 - 1 5 0 . Foerster, 0., 1 93 3 . The derm atornes i n m a n . Brai n 56, 1 -3 9 . F ri tz, I . M . , De l i t to, A.,
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V, 1 9 5 9 . Sci a t i ca
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s h o u l d e r p a i n p reced i n g abdominal
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Revo l u ti o n . C h u rch i l l Li v i ngsto ne,
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23
Copyrighted Material
2 Soft tissues of the musculoskeletal system
CHAPTER CONTENTS
CONNECTIVE TISSUE 25
Summary
25
The connective ti ssues form a large class of tissues respon·
Connective tissue cel l s
25
sible for p roviding tensi l e strength, substa nce, el asticity
Extracellular matrix
27
Connective tissue
and density to the body, as wel l as facilitating nourish· ment and defence. Connective tissue has a major role in
Irregular connective tissue
29
repair fol lowing trauma a n d a mech a n ica l role in pro·
Regu l ar connective tissue
30
viding connection and leverage for movement, as wel l as
31
Tendons Ligaments and joint capsules
33
Cartilage
34
preventing friction, pressure and shock between mobile structures. Connective t issue is t h e m ain focus of treat· ment p rocedures in orthop aedic medicine. Connective tissue consists p ri m a ri l y of cells embedded
Muscle
35
in an extracell u l a r ma t rix which is composed of fibres
Nervous tissue
36
and an interfib ri l l a r compon e n t - the a m orp hous ground
36
maintenance of the m atrix depends on t h e cells within i t
substance
Behaviour of connective tissues to mechanical stress
(Fig.
2.1).
The
synthesis,
degra dation
and
(September e t al 2007 ). Not all types of connective t i ssue cell are found i n each tissue, and the cell content can a l ter, with some cells being resident in the tissue and others b rought to specific areas at times of need. Genera l l y, the cells make up a p p roxi· mately 20% of the tissue vo lume a n d main l y consist of fibroblasts, macrophages and mast cells.
Connective tissue cells
SUMMARY Orthopaedic medicine is concerned with the examination, diagnosis and treatment of
Fibroblasts Fibro b lasts, usually the most abundant of the con nective
soft tissue lesions. In order to understand
the relevant mechanisms of inj ury and repair
and the rationale for treatment of soft tissue lesions, the soft tissues themselves need to be defined and examined. The principal soft tissues of orthopaedic medicine encompass the connective tissues, muscle tissue and nervous tissue. Within this chapter, basic histology and biomechanics of the soft tissues relevant to
tissue cells, are responsible for producing the contents of the extrace l l u lar matrLx, n amely fi bres a n d amorphous grou nd substance. They are found lying c l ose to the b u n d l es of fibres they produce and are closely rel a ted to chondrob l asts a n d osteobl asts, the cells responsible for produci ng cartilage and bone matrix. The less active mature fibrobl asts are known as fibrocytes. Si nce fibroblasts produce t h e contents of the extra·
orthopaedic medicine will be studied to provide
cell u lar matrix, they play a key ro l e in the repair proc·
background knowledge for clinical practice.
ess after inj ury. Stearns (1940b) observed t h a t once fibre
©
2010 ElseVier LId
25
Copyrighted Material
I
1
I
Principles of orthopaedic medicine
Macrophage
Collagen fibres
FibroblasI
EIaslic fibre
Masl cell
Fal cell
Figure 2.1 I rregul ar connective tissue, cellular a n d fibre content. Adapted from C orm ac k 0 'Ham's Histolog y ' © liPPincott Wi ll i am & Wilkins (1987) with permission.
formation was initiated the fibroblast was able to produce an extensive network of fibrils in a remarkably short time. Myofibroblasts are specialized cells which contain con tractile filaments producing similar properties to smooth muscle cells. They assist wound closure after injUiy. Macrophages (histiocytes or mononuclear cells)
Macrophages may be resident in the connective tissues or circulating as monocytes which migrate to an area of injury and modulate into tissue macrophages (ICowler 1989). They are large cells that have two important roles. The first is phagocytosis and the second is to act as direc tor cells, in which role they have a considerable influence on scar formation (Hardy 1989). As a phagocyte, the macrophage acts as a housekeeper to the wound, ingesting cellular debris and subjecting it to lysosomal hydrolysis, thus debriding the wound in preparation for the fibroblasts to begin the repair process. Matter such as bacteria and cellular debris is engulfed by the phagocyte on contact. As a director cell, the macroprlage chemically activates the number of fibroblasts required for the repair proc ess. They also play an important role in muscle regenera tion leading to increased satellite cell differentiation and muscle fibre proliferation (Grefte et al 2007). A reduced number of macrophages i n muscle tissue has been shown to lead to reduced muscle regeneration (Shen et al 2008). Corticosteroids can inhibi t the function of the macrophage
in the early inflammalOlY stage, r esul ti n g in a delay in fibre production (Dingman 1973, Leibovich & Ross 1974, Fowler J 989 ). This should be taken illlo consideration when exploring treatment opt ions in the early stage.
Clinical tip Treatment te ch niques that agitate tissue fluid i n crease the c ha nc e contact of the ma cropha g with debris and ca n be applied dur i n g the early stage of inf l a m m a ti on to promote phagocytosis (Evans 1980), e.g. gentle transverse frictions and grade A mobilization (see Ch. 4) as well as heat,
ice, ultrasound, pulsed electromagnetic energy, etc.
Mast cells
Mast cells are laJge, round cells containing secretory gran ules that manufacture a number of active ingredients including heparin, histamine and possibly serotonirl . HIe contents of the mast cell granules are released in response to mechanical or chemical trauma and they therefore play it role in the early stages of inflammation. Heparin tem porari ly prevents coagulation of the excess tissue Ouid and blood components in the injured area while histamine causes a brief vasodilatation in the neighbouring non injured area (Wilkerson 1985, Hardy 1989). Serotonins are internal nociceptive substances released during plate let aggregation in response to tissue damage. They cause contraction of blood vessels and activate pain signals (I
26
Copyrighted Material
Chapter
I
I
2
Soft tissues of the musculoskeletal system
Extracellular matrix
Tropocollagen unit
The extracellular matrix accounts for about 80% of the total tissue volume, with approximately 30% of its sub stance being solids and the remaining 70% being water. It consists of fibres Jnd the interfibrillar amorphous ground substance, the substances responsible for supporting and
Collagen fibril --�_rl'!I
nourishing the cells. The amorphous ground substance also
determines
the
connective
tissue's
compliance,
Collagen fibres---M
mobility and integrity. The fibrous portion of connective tissue is responsible for determining the tissue's biomechanical
properties.
Primitive collagen -----tee;;.
'rwo major gTOUpS of fibres exist: collagen fibres and elas
fibre
lic fibres.
Collagen fibres Collagen is a protein in the form of fibre and is the body's 'glue'. It possesses two major properties, great ten sile strength and relative inexlensibility, and forms the major fibrous component of connective tissue structures, i.e. tendons, ligaments, fascia, sheaths, bursae, bone and cartilage.
',--
--�----'_-_-.l(/�j.I ,"--
Individual collagen fibres are normally mobile within the amorphous ground substance,
producing discrete
shear and gliding movement as well as dealing with compression and tension. Collagen is also the main constituent of scar tissue, in which it demonstrates its
Figure 2.2 Collagen agg reg ati on. Reprinted from H ard y M The Biology of SCilr Formation. Phys i ca l T he ra py (1989) 69 (12) 1014-1024, with perm issi on.
great versatility by attempting to mimic the structure it replaces. Collagen fibres are large in diameter and appear to be white in colour. They are arranged in bundles and do
loads and resisting pull. Crimp patterns may also vary between different ligaments and different tendons.
not branch or anastomose. They are flexible but inelastic individually The arrangement and weave of individual collagen fibres and coJiagen fibre bundles give the con nective tissue structure elastic qualities; for example, an
Production and structure of collagen fibres and collagen cross-linking
individual piece of nylon thread is inelastic, but when
Procollagen, the first step in collagen fibre formation,
woven to produce tights, the weave gives the material
is
elasticity (Peacock 1966). Collagen fibre bundles elon
acids are assembled to form polypeptide chains, which
gate under tension to their physiological length and recoil
are attracted and held together by weak intramolecular
produced
intracellularly
by
the
fibroblast.
Amino
hydrogen bonds known as cross-links (Fig. 2.2). Three
when tension is released. The bundles of fibres are laid down parallel to the lines
polypeptide chains bond to form a procollagen molecule
of the main mechanical stress, often in a wavy, sinusoidal
in the form of a triple helix which is exocytosed by the
or undulating configuration. This gives the tissue an ele
fibroblast into the extracellular space.
ment of crimp when not under tension. Crimp provides a
Once outside the cell the chains are known as tropo
buffer so that longitudinal elongation can occur without
collagen molecules and several tropocollagen molecules
damage, as well as acting as a shock absorber along the
become bonded by intermolecular cross-links to form a
length of the tissue, to control tension (Amiel et al 1990).
filament or microfibril (Fig.
2.3).
With the maturation
Collagen fibres are strong under tensile loading but weak
into tropocollagen, the cross-links are stronger covalent
under compressive forces, when they have a tendency to
bonds and occur at specific nodal intercept points, mak
buckle. The orientation of the collagen fibres determines
ing the structure more stable (Nimni 1980, Donatelli &
the properties that a structure will have. Crimp patterns are
Owens-Burkhart
dependent upon function and therefore differ in different
at every level of organization of collagen acting to weld
1981,
Hardy
1989). Cross-links exist
tissues, i.e. the arrangement of collagen fibres perpendicu
the units together inlo a rope-like structure (Fig. 2.4).
lar to the surface in articular cartilage provides a cushion
Intermolecular cross-linking in particular gives collagen
ing force for weight-bearing, while the parallel arrangement
its great tensile strength as it matures. The greater the
in tendons provides great tensile strength for transmitting
intermolecular cross-linking, the stronger the collagen
Copyrighted Material
27
I 1 I
Principles of orthopaedic medicine
Cross-link
Amino acid chains
COllagen{ a� filamenl
:2
u _� �__ ___ __\
Figure 2.3 Intramole cular cross-links. Reprinted from Hardy M The Biology of Scar Formation. Phys ical Therapy ( 1 989) 69 (1 2): 1 0 1 4-1024, wit h permission
Collagen I filament L Collagen I L
filament
Figure 2.4 tnter mole c ula r cross-links. Reprinted from Hardy M The Biology of Scar Formation. Physical Therapy ( 1 989) 69 (12) 1 014- 1 0 24, with permission.
continue to aggregate together into larger and larger bundles and the production, aggregation and orientation of collagen are strongly influenced by mechanical tension and stress. Bundles of collagen are arranged in a specific pattern to accommodate to the function of each individ ual connective tissue structure (Chamberlain 1982). I t has been shown that when fibroblasts grown in tis sue culture are subjected to regional tension, the cells exposed to the tensile forces multiply more rapidly and orient themselves in parallel Jines in the direcrion of ule tension (Le Gros Clark 1965). Stearns (1940a, 1940b) identified that internal and external mechanical factors influence fibre orientation. Cell movement and occasional cytoplasmic retraction produced early local orientation of fibres, while a period of secondary orientation of fibres into heavy parallel layers was probably the result of external mechanical factors. This secondary orientation of fibres appeared to take place during the remodelling phJse of wound healing and is the way ill w h i ch soft tissue structures develop in response to intermittent stress and mechanical tension.
Clinical tip structure, with bone being considered to be the most highly cross-linked tissue (Hardy 1989). Collagen turnover, the dynamic state of the tissue, may be related to the number of cross-links with fibres being continuously and simultaneously produced and broken down. When collagen production exceeds breakdown, more cross-links develop and the structure resists stretching. If collagen breakdown exceeds production there is a reduc tion in the number of Goss-links and the structure stretches more easily (Alter 2000). Immature collagen tissue pos sesses reducible cross-links and as collagen matures these reducible links stabilize to form stronger non-reducible cross-links. Excessive cross-link fonnation can be prevented in immature scar tissue by the application of transverse frictions and graded mobilization techniques. Established cross-links in adhesive scar tissue are mobilized by trans verse frictions before the longitudinal orientation of the fibres can be encouraged through the appl.ication of graded stress. I n some instances manipulative rupture of adhesive scar tissue is indicated (see Ch. 3).
Clinical tip Transverse frictions and mobilization techniques used in or tho paed ic medicine aim to mobilize the reducible and mature scar tissue cross-links.
Many microfibrils make up a collagen fibril and many coJiagen fibrils make up a collagen fibre. Collagen fibres
The influence of mec hanical stress and tension on collagen alignment can be used
to advantage in
orth opaed ic
medicine during the repair process, when collagen fibres are init ially laid down in the early repair phase and in the later remodelling phase of hea l ing . 111 order to promote tissue gliding and to regain tissue length , the graded mobilization techn iqu e s is advocated.
-1I
use
of
Immobilization produces rapid changes of collagen tissue as it adapts to its new resting leng1h. Collagen which develops in the absence of mechanical stress (i.e. in the absence of movement) has a random orientation, a change in the numbers and thickness of the fibres and loss of ground substance. This reduction in the lubricating inter6bular gel allows greater adherence at the fibre-fibre interface (Hardy & Woodall 1998). Collagen takes on many forms and functions: In ten dons it is tough and inelastic, in cartilage it is resilient. while in bone It is hard. This difference in srructure is related to the diameter, orientation and concentration of the fibres. Col.lagen fibres have been classified into groups (Nimni 1980). The most common form is type 1 collagen consisting of large-diameter fibres, found abundantly in structures subjected to tensile forces. Type II collagen consists of a mixture of large- and narrow· diameter fibres and is abundant in structures subjected to pressure or compressive forces. Reticulin is considered to be a delicate supporting network of fragile type II I colla gen fibres; it may be present in the earliest stages of soft tissue repair.
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Elastic fibres
Elasti c fibres, consisting of the protein elastin, are yellow in colom and much thinner and less wavy than colla gen fibres. Elastic fibres run singly, never in bundles, and freely branch and anastomose. Elastic fibres provide the tissue with extensibility so that it can be extended in all directions but if tension is constantly exerted in one d irection the elastic fibres may be laid down in sheets known as lamellae, e.g. I igamen tum f1avum (the 'yellow ligament'). Elastic fibres make up some of the connective tissue fibres of l igaments, joint capsules, fascia and connective tissue sheaths.
Amorphous ground substance
The connective tissue extracellular matrix comprises the interfibrillar amorphous ground substance, with its fibrous content. As well as maintaining the mobility and integrity of the tissue structure at a macrostructural level, the amor phous ground substance is responsible for nourishing the living cells by facilitating the diffusion of gases, nutrients and waste products between the cells and capillaries. It contains carbohydrate bound to protein (Standling 2009). The carbohydrate is in the form of polysaccharides, hexuronic acid and amino sugars, alternately linked to form long-chain molecules called glycosaminoglycans (GAGs). The main GAGs in connective tissue matrix are hyaluronic acid, chondroitin-4-sulphilte, chondroitin-6-sulphate and dermatan sulphate (Donatelli & Owens-Burkhart 1981). When GAGs are covalently bonded to proteins, Ule mol ecules are called proteoglycans (Cormack 1987). These proteoglycan molecules have the property of attracting and retaining water (Bogduk 2005). This hydration of struc tures depends on the proportion of proteoglycans and the flow of water into the extracellular mau-L'(. Increased hydra tion creates rigidity in the extracellular matrix, allowing it to exist as a semisolid substance or gel, which improves the tissue's ability to resist compressive forces. Therefore tis sues which are subjected to high compressive forces, such as bone and articular cartilage, have a h i gh proteoglycan content. The proteoglycans also form a supporting sub stance for the fibre and cellular components. Decreased hydration allows it to exist as a viscous semisolut ion or sol, which improves the tissue's ability to resist tensile forces. Therefore tissues which are subjected to high tensile forces, such as tendons and ligaments, have a low proteoglycan concentration (Levangie & Norkin 2001) ·rhe concentration of GAGs present in tissues is related to their function and gives connective tissue structures viscous properties. More water is associated with a higher GAG concentration and rabbit Iigamentous tissue has a significantly greater water content than that in rab bit tendinous tissue (Amiel et al 1982). This increase in CAG and water content alters the viscoelastic properties and may provide the ligament with an additional shock absorbing feature that is unnecessary in most tendons. .
The amorphous ground substance forms a lubricant, filler and spacing buffer system between collagen fibres, fibrils, microfibrils and the intercellular spaces (f\keson et al 1980). It reduces friction and maintains distance between fibres as well as facilitating the discrete shear and gliding movement of individual collagen fibres and fibrils. It is the lubrication and spacing at the fibre-fibre interface that are crucial to the gliding function at nodal intercept points where the fibres cross in the tissue matrices (Amiel et al 1982). If the tissues are allowed to adopt a stationaty attitude (i.e. becoming immobile), anomalous cross-li nks form at the nodal i ntercept points. A balance between the cross-linl< formation relative to the tissue's tensile strength and mobility is important to normal connective ti ssue function. Excessive cross-li nking and loss of GAGs and water volume result in loss of the critical distance between the fibres. The fibres come into contact with eadl other and stick together leading to altered tissue function and pain resulting from loss of extensibility and increased stiffness. The elasticity of connective tissue fibres together with the viscosity of the amorphous ground substance gives connective tissue structures viscoelastic properties which ensure that normal connective tissues are mobile. The biomechanical properties of connective tissue depend on the number and orientation of collagen fibres and the proportion of amorphous ground substance present Each connective tissue structure is specifically designed for function but the tissues can be grouped sim ply into irregular and regular connective tissue.
Clinical tip The aim in or thopaedi c medicine is to maintain normal connective tissue mobility through the phases of acute infl a m mation, repair and re m odelling and to regain mobility in the chroniC inflammatory situation. This m obilit y is essential to function and the bias ot orthopaedic medicine treatment techniques is towards pr eserv ing the mobility of connec tive tissue structures. ,
IRREGULAR CONNECTIVE TISSUE Irregular connective tissue consists of a mixture of collagen and elastic fibres interwoven to form a loose meshwor.i< that can withstand stress in any direction (Fig. 2.5). Its main function is to support and protect regular connective tissue structures. The following examples of irregular connective tissue are commonly encountered in orthopaedic medicine. The dura mater is the outermost of three irregular con nective tissue sleeves which enclose the brain and the spi nal cord. It is extended to form the dural nerve root sleeve
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Figure 2.5 Ir regu lar con n ective tissue. (Paratenon; elastic V a n Gieso n stain.) Provided by Dr. T Brenn. -
that invests the nerve roots within the intervertebral foramen. At or just beyond the intervertebral foramen the dural nerve wot sleeve fuses with the epineurium of the nerve root. The dura mater and dural nerve root sleeve extensions are formed of sheets of collagen and elastic fibres providing a tough but loose fibrous tube. The dura mater is separated from the bony margins of the vertebral canal by the epidural space that contains fat, loose con nective tissue and a venous plexus. Th ese structures are mobile in a non-pathological state and can accommodate normal movement (Netter 1987, Palastanga et al 2006, Standring 2009). Adhesions may develop in the dura mater and dural nerve root sleeve, compromising this mobility and giving rise to clinical symptoms. An apolleurosis is a sheet of fibrous tissue that increases the tendinous attachment to bone. It distributes the ten don forces, increasing the tendon's mechanical advantage, and needs to retain mobility in its attachment to perform its function. The epilllysium is a layer of irregular connective tissue surrounding the whole muscle; the peri",ysium surrounds the fascicles within the muscle; and the elldolnysium sur rounds each individual muscle fibre. In a similar arrangement, a fibrous sheath, the epiTleu ";UIII, surrounds each nerve; the pe";TleuriulII surrounds each fascicle; and each individual Herve fibre is invested in a delicate sheath of vascular loose connective tissue, the endoneurium. Since connective tissue mobility is impor tant to the function of muscle, its arrangement in nerve structure implies that it is also important to the function of nervous tissue. The paraumon is an irregular connective tissue fibroelas tic sheath, adherent to the outer surface of all tendons. It is composed of relatively large amounts of proteoglycans to provide a gliding surface around the tendon, allowing it to move freely among other tissues with a minimum
of drag (Menilees & Flint 1980). True tendon synovial sheaths are found most commonly in the hand and foot where they act to reduce friction between the tendon and surrounding tissues. The synovial sheath consists of two layers, an outer fibrotic sheath and an inner synovial sheath which has parietal and visceral layers. Between these two layers is an enclosed space containing a thin film of synovial fluid. The synovial sheath may also assist in tendon nutrition (J6zsa & [(annus 1997). Like the synovial tendon sheaths, bursae, fiat syno vial sacs, also prevent friction and pressure and facilitate movement between adjacent connective tissue structures. Bursae can be subcutaneous (e.g. the olecranon bursa), subtendinous (e.g. psoas bursa), sub- or intermuscu lar (e.g. gluteal bursa), or adventitious - developing in response to trauma or pressure (e.g. subcutaneous Achilles bursa). Fascia lies in sheets to facilitate movement between the various tissue planes. Deep fascia has a more regular formation as it forms a tigh t sleeve to retain structures, adds to the contours of the limbs and is extended to form the intermuscular septa. It provides a compressive force which facilitates venous return and may act as a mechani cal barrier preventing the spread of infection. Fascia may develop retirlaw/a which hold tendons in place, preventing a bowstring effect on movement, e.g. the retinacula at the ankle. It may produce thickenings, forming protective layers such as the palmar and pla/lI.ar apOTleuroses, or it may form envelopes to enclose and pro tect major neurovascular bundles, e.g. the femoral sheath in the femoral triangle.
Clinical tip Tissue injury i nvolves th e surroundi ng and supporti ng i rreg ular connective tissue as well as the regular co n n ective tissue structure itself. It is therefore important to recog n ize the ex tensi ve nature of i rre g ular connective tissue and its close relationship with the regular co nnective ti ssue structures encountered in orthopaedic med i cine .
REGULAR CONNECTIVE TISSUE In contrast to irregular connective tissue, this group of tissues has a highly organized structure with fibres run ning in the same linear direction in a precise arrangement that is related to function (Fig. 2.6) The main collagen fibre bundles will be aligned parallel to the line of major mechanical stress, which functionally suits such structures as tendons and ligaments that are mainly subjected to unidirectional stress (Donatelli & Owens-Burkhart 1981).
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Figure 2.7 Structure
Figure 2.6 Regular connective t issue .
Gleson stain)
(Tendon; elastic-Van
Provided by Dr. T Brenn.
The following examples of regular connective tissue are commonly encountered in orthopaedic medicine.
Tendons Muscles and tendons are distinct tissues, although they functionAlly act as one structure, the contractile unit. The tendon cells are derived from the embryonic mesen chyme, the tissue occupying the Meas between the embry onic layers, classifying tendon as a connective tissue (Standring 2009). Muscle cells are derived from meso derm, the intermediate embryonic layer, such that muscle itself belongs to a separate tissue group. The tendon is an inert structure which does not contract, but as part of the contractile unit it is directly involved in muscle action. Therefore the tendon is assessed by resisted testing via the muscle belly. Active movement does not produce transverse movement within the tendon but its fibrous structure may be moved passively by transverse frictions, to prevent or to mobilize adhesions. A tendon provides tensile force transmission and storage and release of elastic energy during locomotion - which is particularly important for many spons and activities (Witvrouw et al 2007).
Functions of tendons • •
To att ach a muscle to bone. To transmit the force of muscle contraction to the bone to produce functional movement.
•
•
To set the muscle belly in the optimal position for functional movement and to affect the direction of muscle pull. To be a ble to glide with i n the s urrounding tissues, a cceptin g stress and tensile forces with minimal drag.
of a tendon.
Tendons are exposed to strong, unidirectional forces and to Function they require great tensile strength iwd inelastic properties. They are able to withstand much greater tensile forces than ligaments and are composed of closely packed parallel bundles of collagen micro fibrils, fibrils and fibres, bound together by irregular connective tissue sheaths into larger bundles (Fig. 2.7). Most fibres are oriented in one direction, parallel to the long axis, which is the direction of normal physiological stress (Alter 2000). Tendons do not usually contain any elastic fibres since their muscle belly acts as an energy damper such that elastic fibres are not required (Akeson 1990). They do have the ability to store and release elastic energy, however, and rehabilitation programmes should aim to increase tendon elasticity. Tendon elasticity has been shown to increase significantly with ballistic stretch· ing (Witvrouw et al 2007). The fibres are large-diameter type .I collagen, well suited to accept tensile forces. The proteoglycans are packed in between the fibres and, because the tendon is so compact, there is little room for the tendon cells or an adequate blood supply. The tendon's blood vessels lie in the epitenon (adherent to the surface of the tendon) and the endotenon (a division between collagen fibre bundles) (Gelberman et al 1983). The vascularization of tendons is relatively sparse compared witll that of muscles (Alfredson et al 2002). Calcification may occur within the tendon structure that is generated by extracellular organelles known as matrix vesicles. Proteoglycans in the tendon usually suppress the mineralization but ageing and diabetes may alter proteoglycan levels, thus allowing calcification of the normally unmineralized extracellular matrix (Gohr et al 2007). As mentioned above, tendons are surrounded by it fibroelastic paratenon functioning as an elastic sleeve to facilitate their gliding properties and permitting free movement in the surrounding tissues. Under the para tenon, the entire tendon is surrounded by the thin con nective tissue sheath of the epitenon; the two together are sometimes referred to as the peritendon. On its inner surface the epitenon is continuous with the endotenon, which invests each tendon fibre (J6zsa & Kannus 1997). The musculotendillous jUllctioll is the area where tension generated in the muscle fibres is transmitted from intra cellular contraaile proteins to extracellul.ar connective tissue
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proteins. It is a relatively weak area making it susceptible to injury (I6zsa & Kannus 1997). The teno-osseous junction is the point of insertion of the tendon into the bone where the viscoelastic tendon transmits force to the rigid bone. At this point the ten don goes though a transition from tendon to fibrocar tilage, mineralized fibrocartilage and finally bone. The mechanism of overuse injuries involving the teno-osseous junction, or enthesis, is not well understood. Benjamin et al (2006) note that bony spurs are well documented at numerous en theses and tend to occur with high levels of physical activity. They are more frequently found in males and occur more commonly with increasing age. They can be compared to osteophytes forming around the articu lar surfaces in anhritic synovial joints. Some individu als appear LO have a greater tendency to form bone than others, both at joint margins and at entheses. Where bony spurs are well documented, e.g. at the attachment of the plantar fascia and the Achilles tendon, osteoarthritis-like degenerative changes have been noted in the enthesis fibrocartilage of the fascia or tendon. The term tendinopathy is a generic descriptor to indicate clinical conditions affecting tendons. The inflammatory model of tendon pain has been challenged (Khan & Cook 2000, Cook et al 2000) and 'tendinopathy' is a more appropriate term since it does not commit to pathology. The terms 'tendinosis', 'paratendinitis' and 'tendinitis' are rese..,ed as histopathological labels. Tendinopathy wiJl be used throughout this text to indicate painful overuse ten don lesions and a discussion on the aetiology and patho logical processes associated with tendinopathy is included in Ch. 3. Tenosynovitis occurs in ensheathed tendons and involves the synovium rather than the tendon itself. Inflammation of the synovium can produce adhesions between the two layers of the sheath which may produce a palpable crepi tus (Cyriax 1982). Adhesion formation interferes with the normal function of the tendon sheath, which is to allow controlled movement of the sheath around the tendon and to facilitate nutrition by forcing synovial fluid into the tendon ( Barlow & Willoughby J 992).
Clinical tip ----
In order
to maintain or restore the gliding
properties
of
the tendon within its synovial sheath, transverse frictions
I
are applied with the tendon on the stretch. This position allows the therapist to roll the sh eath over a firm tendon
ba s e , imitating the function of the tendon _
sheath.
-----1
Tenova ginitis is a term used to describe thickening of the synovial sheath (Cyriax 1982) and is associated with chronic tenosynovitis, e.g. de Quervain's stenosing teno synovitis of the sheath containing the abductor pollicis longus and extensor pollicis brevis tendons.
As with all other connective tissue structures, tendons remodel in response to mechanical demand and they are sensitive and responsive to changes in physical load, a property which may be demonstrated by a difference in structure within one tendon unit. Eccentric exercise pro grammes affect type I collagen production and tend to increase tendon volume over the long term, an impor tant consideration in the rehabilitation of tendinopathies (Alfredson & Cook 2007). Merrilees & Flint (1980) looked at the macrostructural features of different regions of the flexor digitorum pro fundus tendon in the rat. This tendon, in common with most tendons, is subjected to longitudinal stress through out its length, but it also possesses a sesamoid-like area as it passes under the calcaneus and talus. In this area the Lendon is subjected to compressive forces, as well as to the normal longitudinal stress. In the zone subjected to tension, the collagen fibres were arranged in longitudinal bundles, but in the zone subjected to pressure, the sesamoid-like area took on a form similar to that of fibrocartilage, i.e. a loose weave of collagen fibres and chondroc}rte-like cells arranged in col umns perpendicular to the main fibre axis. This illustrates the ability of connective tissue structures to adapt to different functions and to changes in physical loads in a normal situation. In abnormal situations, such as a period of immobility when physical demand is reduced, adaptations in collagen turnover occur. When physical demand is increased, collagen produdioll increases. The turnover (synLhesis and lysis) of collagen is a continuing process allowing the remodelling and adaptation of Struc tures to suit demand. Several factors affect the mechanical forces that act on tendons and influence Lheir adaptation in response The different types of activity and the location of the tendon in the body induce different levels of force on tendons, since different tendons are subject to different levels of mechanical loading. The relative size between the muscle and the tendon and the level of muscle con traction also affects the stress applied to the tendon, as does the position and movement in the adjacent joints and the activity witbin the antagonist muscles (Wang et al 2006). With regard to viscoelasticity, Eliasson et al· (2007) set out to obse..,e the effect of disuse on the mechanical properties (primarily creep and hysteresis) in the Achilles tendon. Achilles tendon was ha..,ested at 1 and 6 weeks from 78 rats divided into three experimental groups. Two of tl1e groups were immobilized and the other served to provide loaded controls. The result showed that the tendons lost viscoelasticity (i.e. as shown by the effects on creep and hysteresis) which was possibly more influenced by glycosaminoglycan chains than collagen. The most marked biochemical change in tendon ageing is decreased tensile suength. Collagen cross-linking increases and alters the mechanical propelties of the tendon; the abil ity to witJlstand load, the modulus of elasticity and tensile
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s gen f i b r e ol l a c � � : : : � i ;;;=l Elastic fibres �1iillll Crimp pattern in a relaxed ligament Flmovement exibili ty, retquIo occur ring elatastia 1c0propert i e s, t o al l o w normal ResiunYileieldnce,ing rtoequiexcessi l ing vtensie movement lelnstt rengthat, taoJObeinttough and
strength all decrease and there is an increase in mechanical stillness ( l(annus et al 2005 ) .
Ligam ents and joint caps u l es
Properties of liga ments and joint capsules
le e
The joint capsule and its supporting ligaments a re similar in function, both allowing and restraining movement at the join ts. Ligaments can be considered to be a rei n force ment of the joint capsule in an area of special stress. As inert tissue structures they are assessed by passive move ments, which should be applied at the extremes of range to The ligaments, together with the fibrous capsule, guide a nd stabilize the a rticular surfaces. When excessive stresses are applied to a joint, proprioceptive impulses recruit a muscle response so that the passive stabilizing effect of the ligament is reinforced by dynamic muscle stabiliza tion (Akeson et al 1 98 7 ) . To meet its functional requirements o f resisting shear as well as tensile and compressive forces, the structure of a is different from that of a tendon. The main ligamentous fi b res are 70-80% collagen laid down in bundles, which assume a wavy configuration providing an element of elongation and recoil to facilitate movement ( Fig. 2 . 8 ) . I nterwoven with these main fibre bundles are 3-5% elastic fibres, to enhance extensibility and elasticity (Al<eson et al 1 98 7 ) . When ligaments are put under lon gitudinal tensile stress, the parallel wavy bundles of col lagen straighten oul to prevent excessive movement and to provide tensi Ie strength. Although the joint capsule is similar in function to liga ments, its structure is slightly different. The capsule con sists of sheets o f collagen fibres which form a fibrous cuff joining opposing bony surfaces. The fibrous strudure is predominantly collagen but, rather than a a rray of fibres, its pattern is more a criss-cross weave, with the fibres becoming more parallel as the capsule is loaded ( Fig. 2 . 9 ) (Amiet et al 1 9 90, Woo et al 1 9 90). The ability of the fibres to change and straighten depends on them being mobile and able to slide independently of one Capsular contractures in the form of disorgan ized collagen will prevent independent fibre gliding at the nodal intercept points, considerably reducing function and causing pain. The joint capsule has two layers: an outer fibrous cap sule and a n internal synovial membrane. The outer
test fu ncti o n.
Elastic fibres
Crimp straightened under tension Structure of a l igament.
Figure 2,8
'-<5--==---
l igament
paral l e l
another.
Criss-crofoss weave collagen fibres majAlstriegossnment r linesinofto
Figure 2.9
Structure of the joint capsule.
fibrous capsule is strong and flexible but relatively inelas tic. It is supported fun ctionally by its ligaments which may be intrinsic, forming an integral part of the joint capsule (e.g. corona ry and medial collateral ligaments of the knee), or accessory, being either intracapsular (e.g. the cruciate ligaments) or extracapsular (e.g. lateral collateral ligaments of the knee). The fibrous capsule is perforated by vessels and nerves and contains afferent sensory nerve endings, mechanoreceptors and nociceptors.
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Princip les of orulopaedic med i c i n e
The sy novial m e m b ra n e is m a i n l y a loose co n n ective tissue mem brane w i t h a degree of elast icity to prevent its fo lds and v i l l i beco m i ng n i pped d u r i n g move m e n t . I t covers a l l surfaces w i t h i n t h e j o i n t except the a rt i c u l a r surfaces themselves and m e n isci. Adi pose fa t pads may exist in the j o i nt, a c t i n g as shock absorbers, a n d d is t i nct fri nges of sy noviuill m a y b e present, e.g. t h e p l icae o f the knee j o i n t . These fo lds, Cri nges and v i l l i al low the j o i n ts to acco m modate to move m e n t . T h e synovi u m is a hi gh ly ce l J u l a r m e m brane co n t a i n i n g synovi ocytes, i . e. t h e synovi u m - p roducing ce l l s, a n d col lagen fi b res. I t has a r i c h ne rve, b l ood a n d l y m p h a t i c s u p p l y. A ca p i l l a ry network i s s i t u a ted o n the i n n e r sur fa ce of the synovi u m to produce synov i a l f l u i d . Synov i a l
Hyaluronic acid
"�
backbone
�
) c," 0•• '0
� -
Glycosamlnoglycan chain
fl u id is p a l e ye l l ow a n d viscous. I t lu bricates the l i ga men tous structures o f the j o i n t a n d no uri shes cart i l age and men isci t h rough a mechanism of trans sy novial flow aided by movem ent (Akeson e t al 1 9 8 7 ) . I n a n a r t h r i t i s o f a joi nt, the i n fl a m m a t i o n causes p a i n a n d i n vo l u n talY m uscle spasm w h i c h prevents fu l l range of move m e n t . The relat ive i m m o b i l i ty causes changes to occur i n the con nective t i ssue whic h lead to capsular contractu re, further l oss of fu nction and pa i n . Th i s wi l l be seen c l i n i cally as the cap s u l a r pattern (see Ch.
1).
Figure 2. 1 0 Pr ote ogl ycan complex of hyaline cartila ge. Adapted from Gray's Anatomy 40th edn by S. S tandring. (2009) By p e rm i ssi on o f E I evier Ltd.
S t a n d r ing 200 9 ) . The a n n u l us fibrosus i n the l u mbar
Clinical tip
s p i n e has a un ique geomet rical pattern of col l agen fibres.
Trauma can cause a haemarthrosis a n d the di fference between this and a trauma-induced synovial effusion is i n d i ca ted c l i nica l l y by the imm ediate onset of sw el l i n g as a result of b le ed i n g into the j oint , as opposed to the more slowly developing synovial effusion, s om et i mes over several hours.
Hyaline car t i l a ge is articular cartilage. Its rel a t i vely s o l i d ge l-like m a t r i x provides
it
weight-beari ng su rface w h i c h
is e l a s t i c and resista n t t o co m p ress i o n . I t m o u l ds t o the s h a p e of the bones, prese n t i n g a sm ooth a11 ic u l a r su rface for move m e n t . H ya l i n e a rt i c u l a r cartil age i s
co m posed
of sca n t i l y
deposi ted c h o n d roblasts a n d chond rocytes wh ich pro d uce the gel extrace l l u l a r matri x consisting of type "
Cartilage
co l l agen fibres a n d am orphous gro u n d substa nce. The
Cartil age is a weight-bea ring con nective t i ssue d i spJaying
m o l ec u l a r proteoglycan aggregates which rese m b le bottle
extrace l l u l a r
m a t rix
con ta i ns
d i s t i n ct i ve
l a rge
super
a com b i n a t i o n of rigi d i ty, w h ich is resista n t to compres
brushes ( Fig. 2 . 1 0 ) . These prov i d e a network for tra p p i ng
s i o n , resil ience and some ela s t i ci ty. It i s rel a t ively avascu
and reta i n i ng water wh ich sign i fi c a n t l y contribu tes to
lar a nd re l i es on t i ssue flu i d fo r n o u r i s h m e n t . There are
the res i l i e n ce of cart i l age (Cormack 1 9 8 7 ) . The col lagen
t h ree m a i n types:
fi b res the m s e l ves are re l a t i vely weak u n der co m p ression:
1.
therefore the water-e n h a n ced m a t ri x compensates fo r this
E l a stic c a r t i lage
2.
F i b rocart i l age
3.
Hya l i ne cart i l age.
by provid i ng a resi l ie n t weight-bearing su rface. Three separate structural zones exist in hya l i n e articu lar carlilage whidl contribute to its biom echanical funCl.ions
Elastic c a r t i l age consists of a m a t rix of yel l ow elastic
( N o rd i n & Frankel 2001 ) . A superficial zOlle helps to prevent
fibres a n d i s very res i J i e n t . I t is fo u nd in t h e external ear,
friction between the joint surfaces a n d to distribute the com
t h e e p i g l o t t i s a n d t h e l a rynx.
pressive forces. It consists o f fi ne, tangential, densely packed
Fibrocartilage has a l a rge proport i o n of type r co l l agen
fibres l y i n g in a plan e para l l e l to the a rticular su rface (Fig.
fibres i n i ts m a trix, providing it w i t h great tens i l e strength.
2 . 11 ) . In lhe midd le, vertical zone the cel ls are arranged i n
Exa m p l es a re the a n n u l u s fi b rosus o f the i ntervertebral
vertical co l u m ns, perpendicular t o the surface, wilh scattered
d i scs, the men isci of the knee j o i nt, the acetab u l a r and gle
col lagen fibres. The middle layer a l l ows deformation of the
noid l a b ra, the a rti cular d i sc of the acro m i oclavi cu l a r and
coll agen fi b res absorb i n g some o f the co mpressive fo rces.
wrist j o i n ts, the l i n i ng of the grooves that house tendons,
The deep zone forms a t ra n s i t io n between the articular car
a n d as a t ransi tional cart i l age at the teno-osseous j u nction
tilage a nd the underlying calci fied carti lage layer; the fi b res
of the tendons (Cormack 1 9 87, Palastanga et al 2006,
are arranged i n rad i a l b u n d l es. H ya l i ne a rticular cartil age
34
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Ch apter
I 2 I
S o ft tissues of the m uscu l oskeletal system
Perimysium -��;;;;;;�;::: Zone superforicilaalyer zone 1
ae
Zone 2: intermediate zone or l y r
Fasciculus
ordeeplayerzone
--I'-f----
Zone 3
Tidemark carCaltciliafieged
Muscle fibre Blood capil ary Axon neurBloodoofnvesselmotor ,.. Perimysium Blood vessels Endomysium l muscle.
my e
Figure 2.12 C o n nect ive tissue component of skeletal F ro m A na t o and H u m a n Movement by P a a stanga N , Field D a n d Soames R, R p r i n t e d by perm ission of ElseVier Ltd.
Cortex
il
Trabeculae
Figure 2.1 1 Zonal arra n g e m e n t of a r t i c u l a r ca rt a ge . From Orth o pa e d i c and S po rts Physical Therapy by Gould J A
cartil age w i t h o u t a l l owing new fl u i d to be taken up, lead i ng to degenerati o n .
Reprinted b y permission o f Elsevier Ltd.
has no blood vessels and depends o n fl uid flow through compressive forces for nutrition. Th is fl uid flow depends on the magnitude and duration o f the compressive force and a balance of weight·bearing and non-weight-bearing is i mponant to i ts hea l th ( Levangie & Norki n 2001 ) . The zo nal arrangement of cart i l age provides a 'we l l sprung mattress' arrangement to c o p e w i t h co mpress ion fo rces. The variation i n col lagen fi b re o rientation i n each zone enables the articular carti l age to vary its material property with d i rection of the load .
Clin ical tip
l
A r t i c u l a r ca rti a g e req u i res movement for n ut r i t i o n a n d to
i s ial
m a i n ta i n f l u i d levels W i t h i n its matrix in order
co m p ress iv e forc es .
to withstand
P ro l o n ged l o a d i n g reduces f l u i d
levels i n the m a t r i x th ro u g h t h e
action of
e ss e n t therefore, to m a i n t a i rl mobilization of i nf l a me d or deg e n e ra te joints
M uscle tissue is a separate tissue gro up responsible for conlJacti o n a nd fu nct i o n a l movement. I t co nsists of cel l s known as muscle fibres due t o t h e i r lo ng, narrow shape, M uscle has a l a rge con nective tissue component which supplies i ts nutrients for its metabol ism and fac i l i tates con traction by prov i d i ng a co ntinu o ll s connective tissue h arness. Th is continuous h a rness con s is ts of the e p i my s i u m, peri mysium and endomys i u m ( Fig, 2, 1 2 ) , Each end o f the harness is co nti nuous with strong connective tissue structures wh ich ancilor it to its a tta chment s .
Clinical tip
normal i mi r muscle i r s
------
is
Connective tissue mobility is
important to
muscle function, Although skeletal muscles have some
tissue creep,
which m a y lead t o degenerative changes. It
MUSCLE
,
The fluid content of articular cart i l age is resp o ns i bl e for i ts nutri tion as wel l 3S its mecha n ical properties, a l l ow i ng diffusion of nutrients a nd products between the cells and the synovial fl u i d . When ca rti l age is l oaded, the flu i d in the 'spo nge' moves, w h ich is i m po rtant for the m ech a n i c a l properties o f t h e cart i l age as w e l l as for j o i nt l ub rica tion. I ntermi ttent loading creates a pumping effect b u t prolo nged loading w i l l eventua l l y press fluid out o f t h e
regenerating properties, hea l n g of large muscle belly lesions largely through the fo r a t o n of s ca tissue. Disorganized scar tissue alters function and acts as a phySi ca l barrier to re ge n era t i ng fb e .
Skeletal m uscle is of obvious concern in orthopaedic med icine and fol l ow i ng tra u m a it is capable o f some regenerating properties, During the heal i ng of i n j u red muscle tissue, satellite cel l s, located next to the muscle fi bres, are capabl e of for m i ng completely new muscle fibres or restoring damaged m uscle fibres ( G refte e t a l 2007 ) . At the p ro l i fera t i o n stage t h e sate l l ite cells beco m e 35
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I 1 I
P r i n c i ples of orthopaedi c m ed ici ne
myoblasts that may either fuse to each other to create new myofibres or may fuse to existing damaged myofibres for repair. Macroph�ges are i mponant in muscle regener�tion since their infiltration leads to increased satellite cell pro liferation and d i fferenti ation. Most muscle injuries heal without dysfunctional scar tissue but large muscle belly lesions resulting from major trauma will be filled with a mixture of disorganized scar tissue and new muscle fibres, which can inhibit regeneration and lead to incomplete functional recove ry.
NERVOUS TISSUE Nervous tissue is designed for the conduction of nerve i mpulses and initiation of function. The central nervous system is largely devoid of connedive tissue, being made up of specialized tissue held together by neuroglia. Three cOllnective tissue meninges (pia mater, arachnoid nlater and dura mater) and the cerebrospinal fluid protect the system inside its bony framework.
Clinical tip Conn ective tissue
mob i lity is essential to the normal
function of the cen tra l and pe r i p her al nervous systems. C ompression of any part of the system or reduction in connective tissue
mobility will compromise function.
The peripheral nervous system is not so delicate, with connective tissue constitut ing part of the nerves, providing strength and resilience, The epineurium is an outer con nective tissue sheath enclosing large nerves. The perineu rium surrounds each fascicle or bundle of nerve fibres and the endoneurium invests each individual nelve fibre.
BEHAVIOUR OF CONNECTIVE TISS UES TO MECHANICAL STRESS Excessive mechanical stress is responsible for connective tissue injllly and manual techniques utilize mechani cal stresses to mobilize, permanently e longate or rupture scar tissue, where the adhesions formed are preventing full painless function, Understanding the mechanical response of connective tissue structures to stress is helpful in interpreting mechanisms of injury and rationalizing treatment progra mmes. However, it should be appreci ated that most experimental evidence has been derived from ani ma l and cadaveric specimens in the laboratory setti ng, and the phys ical principles have been adapted in order to explain the mechanical properties demonstrated. Connective tissue can change its structure and Function in response to applied forces by altering the composition
of the extracellular matrix, demonstrating its dynamic nature and the relationship between form and function ( Levangie & Norkin 2001). The stress, or load, is the mechanical force applied to the tissue. The strain is the resultant deformation pro duced by the applied stress. The stress-strain curve is a way of illustrating the reac tion of connective tissue structures to loading (Fig. 2, [ 3 ) . Experi mentally, a tensile stress i s applied to collagen until it ruptures. The applied stress or elongating force is plot ted on the y axis and the strain, the e.xtent to which col lagen elongates, measured as a percentage of its original length, is plotted along the x axis. Collagen at rest is crimped; �s stress is applied, the fibres straighten initially, responding with an elastic type of elon gation and the crimp pattern is lost (Akesoll et al 1 987, Hardy & Woodall 1 998, Bogduk 2005,). The straighten ing out of the fibres is represented by the first part of the curve, known as the we region. Crimp straightens easily and there is little or no resistance to the applied stress At the end of the toe region some of the elongation may be due to sliding of the collagen fibres in the interfibrillar gel (Nordin & Frankel 2001). The capacity of the tissues to lengthen is initiall y deter mined by their structural weave; the more regularly oriented the collagen fibres, the shorter the toe region, for example a I igament displays a shorter toe region than the more loosely woven joint capsule but a longer toe region than the more regularly arranged ten don (Threlkel d 1992, H ardy & Woodall 1 998).
I
Toe region
Li_ r_ g_ io_ a_ __ _ _ re... n__ ne _ Yield point Complete rupture
, , , , , Elastic limit -,'- - , , , , , , , , , , , , , ,
;:0 ru D il 3 ru ()
a � E ro
Strain!
"
...' ::..:---::---::----7---!=---!=---::,..----:!� % elongationi Elastic range
deformation Plastic range
Figure 2. 1 3 Stress-strain curve. Adapted from Bogd uk 2005, Nordin & F r an ke l 200 1 , Kei r 1 99 1 , Kis ne r & C olby 1 990 in Sports Injuries by C Norris. Reprinted by permission of Elsevier Ltd.
36
Copyrighted Material
Chapter
I 2 I
Soft tissues of the musculoskeletal system
The second pan of the curve is known as the linear The straightened fibres real ign in the l i near d i rec tion of t.he appl ied st ress and the structure becomes longer and t h i n n er. I n the first hal f of the l i near region water and proteogly cans are d isplaced and the chem ical cross-links between fibres and fibrils are stra i n ed , producing a resistance or stiffness in the tissue, so thilt a p rogressively greater stress is req u i red to produce equiva lent amounts of elongation. The steeper the stress-stra i n cu rve, tJle stiffer the tissue. If the deform i ng stress is removed at th is poi nt, the elastic p rop ert i es of the collagen tissue a l l ow the structure to return to its origi nal resti ng lengt h . [n tJle early part of the l i near region a poi nt is reached at which s lack is taken up i n con nective tissue and this represents the end of passive range. reg iol/.
Clinical tip Passive movements ap pli ed during clinical examination represen t the stress applied to take up the slack. The strain is represented by the range of movement observed
and the end-feel of the movement.
[ n the second h a l f of the l i near region, stress causes some of the stra i ned cross-l i n ks to break and microfailllre begins to occur in a few overstretched fi b res. Microfa i l u re is said to occur somewhere a fter 4% of el ongation has been achieved ( Bogd u k 2005 ) , at wh ich point the col la gen is said to have reached its elastic lilllit. A traumatic stress appl ied a t this stage produces m i nor p a i n and swel l i ng but no cl i nical l axity (equiva l e n t to a Grade [ i n j u ry - see Ch. I I for defi n i tions of the grades of i n j u ry as appl ied to the med i a l col l atera l l igament of the knee ) . O nce t h e elastic l i m i t of col l agen h a s been exceeded, col l agen exh i b i ts plastic properties, the p roperty of the tissue to deform permanently when l oaded beyond i ts elastic l i m i t, a nd progressive m icrofa i l u re prod uces per manent e l o ngation once the deforming stress is removed . A traumatic stress appl ied within the p l astic range pro duces more p a i n and swel l i ng, together w i th some c l i n i ca l laxity (equiva lent t o a G rade I I i n j u ry - see C h . 1 1 for defin itions of the grades of i n j u ry as appl ied to the med i a l colJateral l igament of tbe knee) . A further i n crease i n stress causes major coll agen fibre fai l u re a n d t h e yield poill! is reached, represented by the peak of the stress-strai n curve, where a large nu mber of cross- l i n ks are i rreversibly b roken . The stress-st rai n curve d rops rap i d l y, i n dicating macrofailllre or comp lete rup ture, where the structure is u n able to sustain further stress even though it may rem a i n physical l y in tact. Threl keld ( 1 99 2 ) , reponing Noyes et a l , s tated t h a t the estimated m acrofa i l ure of connective tissue occ u rs at a p prox i mately 8% of elo ngation. \"'a ng et a l ( 2006) propose that this is a conservative figure and state 1 2% as the percentage va lue fo r complete rupture. They suggest that even this value could be a n underesti mation and that it m ight be as
m uch as 14% o f elongation. A trau m a t ic stress that pro d uces complete rupture causes severe pain i n i t i a l l y which is fol l owed by less pai n a nd gross c l i n ical l ax i ty (equ iva l e n t to a Grade 1 1 1 i n j u ry - see Ch. 11 for defin i t ions of the grades of i n j ury as a p p l i ed to the med i a l col l ateral l igament of the knee) . The st ress a p p l ied t o t issues c a n be d ivided i nto several categories (Norris 2004, Bogdu l< 2005 ) : •
•
•
•
a p u l l i n g or e longating force a p p l ied I.ongi lud i n a l l y para l l el to the long axis of the structure Compressive stress a pushing or squash i ng force appli ed perpendicular to the l ong axis of the structure Shear s t ress a s l id i ng fo rce a p p l ied across the long axis of the structure Tors iollal stress - a twisti ng force or torque appl ied i n opposite d i rect ions about a n axis of rotation. Tellsile s tl-ess
-
-
-
Col lilgen, however, does not have p u re elastic proper ties and the presence of the a morphous ground substance provides a viscous fl u i d factor. Therefore the viscoelastic p ropert ies of co l l agen m ay be affected by the type of stress appl ied and the speed of a p p l ication, infl uencing the out co me of the d i fferent mob i lization tech niq ues used in orthopaed ic med ici ne, as d iscussed in Ch. 4. The SL'iffness of a structure is its resistance to deforma tion u nder the appl ied stress. A stiff structure d isplays reduced e l astic properties a nd a shorter toe phase. Scar tissue, which fonns "'� lh i n a connective tissue structure, is not as elastic as the su rrou n d i ng normal tissue (Fig 2 . 1 3 ) . Therefore, slack will be ta ken u p sooner i n the adherent scar tissue and mobilization techn iques can be applied to produce elongation or rupture. Tou gh scar tissue req u i res considera b l e force or stress to defonn i t, and it does not eas ily resu me its origi nal shape. Once the fai l u re point of scar tissue is reached it ruptures relatively q uickly (Norris 2004 ) . The viscoelllS!ic properties o f connective t issue struc tures cause them to behave d i fferently u nder d i fferent loading rates. If the structure is loaded q uickly it behaves more stimy than the same t issue loaded at a s l ower rate (Th re l keld 1 99 2 ) . Tendons, for exa mp le, are more eas i l y deformed at low stra i n rates where they absorb more energy but are less effective at transmi tting loads. At h igh stra i n rates, they become stiffer and are less easi ly deformed but are more effective a t moving l a rge loads (Wang et al 2006 ) . H igher force, short d uration stretch i ng at normal or lower temperatures favours recoverab le elastic tissue deformation whereas low force, long d uration stretching at h igher temperatures favours permanent p lastic deforma tion (Warren et al 1 9 7 1 , Leban, cited in AJ ter 2000 ) . Warren et a l ( 1 9 7 1 ) considered the effect of tem pera ture and load on elongation of the col lagen fi b re structure of rat ta i l tendon. A range of l oads was appl ied at selected temperatures of 39, 4 1 , 4 3 and 4 5 ° C. The greatest elon gation with l east m icrodamage was achieved w i th l ower loads at the h igher therapeutic temperatures. Tbe m echa nism of a combi ned appl ication of temperature and load affected the viscous flow propert ies of col l agen . 37
Copyrighted Material
I 1 I
Princ iples of orthopaedic medicine
loading a n d u n l oad i n g st ress-s t ra i n cu rves are not identi
Clinical tip
cal as wo u l d be demonstrated i n a purely e l astic structu re.
The a i m of mobilization is to maintain or regain the gliding f u n cti on and length of the tissues, allowing or restoring full pain less function.
The original l englh may not be ach i eved and the d i ffe rence between the two lengths is known as
set.
Repeated or cyc l i c a l l o a d i ng mily ach i eve an i nc rement of e l o ngat i o n with each loa d i ng cycle. Th is may lead to eve n t u a l fa i l u re o f t h e structure t h rough accu m u l ated
Th is behav i o u r o f t h e t issue i s u t i l ized in t issue mobi
fa tigue. A l a rger load re q u ires fewer re petitions to produce
l i z a t i o n tech n iques. Adhesions may be r u p t u red by a
fa i l u re, but a certa i n m i n i mu m load ( t h e e n d u rance l i m i t )
q u i c k l y a p p l i ed s h e a r s t ress, o r s t retched by a s l ow sus
m ust be a p p l ied to ach i eve t h i s effect ( Norris
2004).
I ncreilsi ng t h e temperature of a
The aim o f mo b i l ization is to m a i n t a i n or regai n t h e
structure a l l ows lower sustai ned l o ads to achieve greater
gl iding fu nction a n d length of t h e t issues, al l ow i n g o r
tai ned
tens i l e stress.
elon gation (Warren et a l 1 9 7 1 , lI suba et al
Cl-eep
2007).
restoring fu l l pa i n l ess fu n c t i o n . Mo b i l ization t o m a i n ta i n
is a property of viscous structures w h i ch occurs
t i ssue fu nction is conducted w i th i n th e elas t i c ra nge, w h i l e
when a prolo nged s t ress is a p p l ied i n the linear phase.
m o b i l iza t i o n a i med ilt e l o ngat i ng or rupturing establ ished
Creep, or elonga t i o n of the tissue, is i n versel y proportional
scar t i ssue ad hes i o ns occurs by applying ap p ropriat e s t ress
to the velocity of the stress and t h e s l ower the appl ied
at t h e end of t h e l i neilr region a n d with i n t h e plastic range
lengthening ( H ard y & Wood a l l
of the tiss ue. Ti m i n g of appl ication of the mobi l iza t i o n
occurs through a gradual reanange
stresses i s im port a n t a n d is deter m i ned by t h e grade o f the
ment of the co l l agen fibres, proteoglycan gel and water
i nj u ry and resu l tant i rrita b i l i ty o f tbe t issues. Young SC
stress,
the greater the
1 998)_
D efo rma t i o n
and/or t h rough stra i n ing and perhaps brea king some of
t issue is 'ripe' fo r m o b i l ization and ca n be a l tered by st ress
the co l lagen fi b re cross- l i nks ( Bogd u k
When the
parameters that do n o t a ffect ol der scar tissue. The ten
s t ress i s released, res u m p t i o n of the original l e ngth of the
s i l e strengt h l i m i ta t ions of the h ea l ing tiSSUES should be
2005).
structure occurs at a s l ower rate t h a n its deformation and
respected, and u llcon t ro l l ed or overaggressive m o b i l ization
this mech a n ica l behaviour is known as hysteresis - i.e. t he
avo ided ( 1\;ladden c i t ed in H a rdy & Woodall ( 9 9 8 ) .
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p a i n come fro m ? Spo rts Med. Arthroscopic Review 8, 1 7 - 3 1 .
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C o h r, C , Fah ey, M . , Rose n t h a l . A , 2007. Ca l c i fi c tend o n i t is: a mode l . Con nect. Tissue Res. 48, 2 8 6 - 2 9 1 . C o u l d , l A , 1 9 9 0 . Onhopaed ic a n d Sports Phys i c a l Thera py, 2 n d ed n . Mosby, S t . L o u i s .
F A Davis, P h i l a d e l p h i a . Merri l ees, M .I . , r\ i n e M . H . , 1 98 0 . U l trastructural stud), o f t e n s i o n
Ed i n b u rgh. Stearns, M L , 1 9 4 0 a S t u d ies o n t h e deve l o p m e n t o f co n n ect i ve t i ssue i n t ra ns p a re n t ch a m bers i n the r a b b i t's e a r, I . A m . I. A n a t . GG, 1 3 3 - 1 7 6.
Stea rns, M . L. , 1 9 4 0b. S t u d i e s o n t h e devel o p m e n t o f co n n ective tissue i n transpare n t c h a m b e rs i n the
a n d pressure zones i n a rab b i t
rab b i t's e a r, I I . Am.
flexor t e n d o n . A m . I . All a t . 1 5 7,
55-97.
87- t06.
N e tter, r H . , 1 9 8 7 . M uscu loskeletal system, p a n I . C i b a Co l l ect i o n of Medical I l l ustrati o n s . Ciba-Geigy, S u m m i t, New l e rsey. N i m n i , 1v1 . E. , 1 9 8 0 . The m olecu l a r
J.
{\ na t . G 7 ,
Th reJl<eld, A I , 1 9 9 2 . The e ffects o f m a n u a l therapy on connect i ve t i ssue. Phys. Ther. 72, 8 9 3 - 9 0 2 . LIsuba, M , Ai
correct ion w i t h low torque - long
o rga n is a t i o n o f co l l agen a n d i ts
d u ra t i o n repeated stretch i ng. C l i n .
'Iorensllla, R., Von d e n H o ffe, J . w.,
ro l e in determ i n i ng t h e b i ophysica l
O rl ho p . Re l a t . Res. 4 5 G, 7 0 - 7 8 .
et aI., 2007. Skeletal muscle
properties of the co n n ective t i ssues.
development and regen era ti on . Stem
B i o rheol ogy 1 7, 5 1 - 8 2 .
C refte, S., Ku i j pers-I agt m a n , A . M . ,
Ce l l s Dev. I G, 8 5 7 - 8 G 8 .
Nord i n, M . , Fran l<el , V. H . , 2 0 0 1 B a s i c
I l a rdy, M A , 1 9 8 9 . T h e b i o l ogy o f scar
B i o mechan ics of t h e M uscu l os keletal
fo r m a t i o n . Phys. Ther G9, 1 0 1 4 -
S ystem, 3 rd ed n . Lippincott, Wi l l ia m s
1023 .
Ha rdy, lvi, Wooda l l, W., 1 9 9 8 .
& W i l k i ns, P h i l a d e l p h i a . N o rris, e . M , 2004 . Sports I nj u ries:
Therapeutic effects o f h e a t , c o l d a n d
D i agnosis a nd Ivl a nage m e n t
stretch o n connective t i ssue. I . H a ncl
to r Phys i o t h e ra p ists, 3 rd ed n .
Ther I I ( 2 ) , 1 4 8- 1 5 2 .
Bu tterwort h - H e i n e m a n n, Oxford .
16zsa, L., Kan n us, P , 1 9 9 7 . I l u ma n
Pa l a s t a nga, N . , Field, D., Soames, R . ,
W a n g, I., Los i fi d us, M . , F u , F , 200 6 . B iomech a n i c a l b a s i s fo r
t e nd i n o pa t hy. C l i n . O n h o p . Re l a t . Res. 4 4 3 , 3 2 0 - 3 3 2 . Warren, e. C . , Le h m a n n , I I '. , Kob l a n s k i ,
I . N . , 1 9 71 . E l o n g a t i o n o f t h e ra t t a i l tendon: e ffect o f l oad a n cl tem peratu re. Phys. M e d . Reh a b i l . 5 2 , 4 65 - 4 7 4 .
W i l kerson, G . B , 1 9 8 5 . I n fla m m a t i o n i n co n nect i ve t issue: eti o l ogy a n d
Ten d o n s : A n a to m y, Phys i o l ogy
2 0 0 6 . A n a tomy a nd H u m a n
m a n age m e n t . Alh l . Tra i n . W i n t e r,
a n d Pa t h o l o gy. I [ u m a n K i net ics,
Movement, 5 t h ecl n . Ilutterwort h ·
2 9 8 -301 .
Ch a m pa i gn, I l l i n ois. J
tendons. I n : M a ffu l l i, N . , Renstrom,
p , Leadhetter, W. B. ( Eds) Ten d o n I nj u ries: B a s i c Scie nce a n d C l i nica l
H e i n e m a n n, Ed i n b u rgh. Peacock, E.E" 1 9 G G . S o m e b i o c h e m i c a l a n d b i o physical aspects o f j o i n t stiffness. A n n . S u rg. I G 4 , 1 - 1 2 . September, AV, Schwe l l n u s, M . P , Co l l i ns, lvI, 2007. Tendon a n d
WitvTouw, E" M a h i eu, N . , Roosen, P., et a i , 2007. The role of s t re tc h i n g i n t e n d o n i n j u ries. lk I . Spons M e d . 4 1 (4), 224-226.
Woo, S . L-V, \'lia ng, e.W , Newton, P O., e t a I ., J 990. Th e response o f
Medici n e. S p ri nger-Ve rlag, London,
l i ga m e n t i n j u ries: the genet i c
pp. 2 5 -3 1 .
c o m p o n e n t I review l . Sr. I Spo rts
stress e n h a nceme n t . I n: D a n i e l , D . ,
M ed . 4 1 ( 4 ) , 24 1 - 2 4 6 .
Akeson, W. H ., O'Co n no r, 1 . 1 . ( Ed s )
Kapit, W , M acey, R . , Meisa m i , C , 1 9 8 7 . The Physiol ogy Coloring Book . I l arperCo l l i ns, N e w Yo rk. Khan, K . M . , Cook. 1 . 1 . . , 2000. Overuse tendon i n j u ries: where does t he
Shen, W., Li, V , Zhu, I , e t a i , 2 0 0 8 . I n teract i o n between macroph ages.
TC F- B L a n d the COX-2 p a t h wa y d u ri n g the i n fl a m m a tory p h ase o f
Copyrighted Material
l ig a m e n ts to s t ress d e p ri v a t i o n a n d
K n e e Ligaments: S t ruc t u re, F u n c t i o n , I n j u ry a n d Repair. Li ppincott, W i l l i a ms & W i l k i ns, P h i l ad e l ph ia, pp . 3 3 7 - 3 4 9 .
39
3 Connective tissue inflammation, repair and remodelling The degree of inflammation in response to injury
CHAPTER CONTENTS
depends on the degree of trauma. A minor injUlY causes
41
Summary
a minimal response whereas a major injUlY wi l l pro duce a significant infiammatolY response which will pass
Inflammatory phase
42
Repair phase
45
Remodelling phase
45
acute and chronic muscle belly lesions, ligamentous
47
lesions, overuse tendinopathy,
47
bursitis and med1anical joint displacements.
Adhesion formation and contracture
Factors which may affect wound healing
through acute, subacute and chronic phases. Lesions encountered in orthopaedic medicine include
Acute
inflammation
is
tenosynovitis,
significant
and
can usually recall the precise time and
a11hritis,
the
m o de
patient
of onset.
Following injury the inflammatory response is rapid with
SUMMARY An injury causes disruption of connective tissue unity. The body's response to this is generally thought to be one of inflammation,
Bleeding
repair and remodelling, ultimately to restore anatomical structure and normal function to
Inflammation
the damaged tissue. However, recent studies have questioned the presence of inflammatory changes in chronic overuse tendon lesions and the inflammatory model has been challenged. This chapter examines the different phases of healing and explores the process of scar tissue formation and its implication in restoring or preventing pain-free function. General principles of treatment are applied to each phase, aiming to facilitate healing, and the factors which promote or impede healing are considered.
Proliferation
The different phases of connective tissue healing are not separate and each is overlapped by the other, with one response signalling another until the wound is bridged by scar tissue (�ig. 3.1). After an initial, relatively shon bleeding phase, the infiammatolY phase prepares the area for healing. the repair phase rebuilds the structure and
Hours
Days
Weeks
Months
Figure 3.1 Tissue repair phases and timescale. (Online.
the remodelling phase provides the final form of the tis
Available: httpJ/www.electrotherapy.org. Reprinted by
sue (Hardy 1989, B rought o n et al 2006, Watson 2009).
permission of Professor Tim Watson)
© 2010 Elsevier Ltd
41
Copyrighted Material
I
1
Principles of orthopaedic medicine
I
noticeable pain and swelling, which can .last for hours or
focal degeneration (i.e. tendinosis) can .lead to panial and
days. With chronic inflammation, the patient cannot usu
complete tears (J6zsa & Kannus
ally recollect the onset and the reaction is low-grade with
as vascular supply, age and genetics can playa part in the
1997).
Other factors such
less noticeable pai n and swelling. Ch ronic in fla m mation
pathogenesis of tendinopathy (Wang et al
may occur as a progression from acute inflammation or
research is needed to understand the mechanisms of
2006).
More
as a result of overuse, and can last for weeks, months or
tendinopathy at the tissue, cellular and molecular levels
even years.
to be able to develop more effective evidence-based treat
As mentioned in Chapter
2,
the inflilmmatory model
in chronic tendon lesions has been challenged and the pathological process may involve degenerative rather than inflammatory changes (Cook et al
2000).
2000,
Khan & Cook
A short discussion on the aetiology and pathol
ment protocols for tendinopathy. Where the pain comes from in tendon lesions is also still unclear and r�ees et al
(2006)
put forward mechani
cal, vascular and neural theories, suggesting that the pain arises from
a
combination of factors. AI fredson et ill
ogy associated with chronic tendon lesions follows here
(2002)
before the phases of healing are described.
might be involved.
had suggested previously that neovascularization
The degenerative changes in chronic tendon lesions
Structural damage noted in tendinopathy may include
include collagen fibre breakdown, increased ground sub
panial tearing of the collagen fibres, and an elemell! of
stance, neovascularization, increased number of nerve
rest. especially from the aggr;lvating activity, is appropri
filaments and increased immunoreactivity of substance r
ate to allow time for healing. The low metabolic activity
ilnd calcitonin; there are no signs of chemical inflamma
in tendon causes an extended healing period, (Wang et 31
tion in chronically painful tendons (I
2000,
Alfredson et al
Wang et al
(2002)
2000,
2006).
A controlled, graded programme of strengthen
ing. stretching and eccentric exercises can be introduced
2006).
concur thaI pathology is linked
guided by pain and function (Brukner & I
2007);
bal
to degradation of collagen and hypercellularity_ Tendons
listic stretching also has an important role in rehabilita
experiencing tendinosis contain no inflammatory cells
tion (Witvrouw et al
2007).
but exhibit changes in the collagen fibre ultrastructure (Alfredson et al
2005)
2002,
Tasto et al
2003,
Richards et al
with irregular fibre arrangement and a high con
centration of glycosaminoglycans (Alfredson et al
2002).
INFLAMMATORY PHASE
Local hypoxia, repetitive microtrauma or impaired wound healing may also contribute to tendinopathy (Richards
2005). Timdinopathy
The initial inflammatory reaction involves vascular Jnd cellular changes. InjUly is rapidly followed by transient
et al
has been adopted as a more appropriate
term since it does not commit to pathology. The terms
vasoconstriction, lasting for
5-10 min,
and is succeeded
by vasodilatation which may result in haemorrhage. If the
'tendinosis', 'paratendinitis' and 'tendinitis' are reserved
lesion is still bleeding at the time of treatment this will
as histopathological labels that need to be confirmed by
necessitate careful management Figure
histopathological studies.
Tenosynovitis
is distinct from tendinopathy; it occurs
3.2
illustrates the components of the acute and
chronic inflammatory responses, which will be referred to
in ensheathed tendons and involves the synovium rather
below. As described in Chapter
lhan the tendon itself. Inflammation of the synovium can
prises cells embedded in an extracellular matrix of fibres,
2,
connective tissue com
produce adhesions between the two layers of the sheath
with an interfibrillar amorphous ground substance that is
which may produce a palpable crepitus (Cyriax
assumed within the background spaces in the diagram.
1982).
Characteristics of tendinopathy include a combination
In the early stage of inflammation the blood vessel Willis become more permeable and plasma and leukocytes leak
of pain, swelling and impaired performance_ The aetiology of tendinopathy appears to be multifac
into the surrounding tissues as inflammatolY exudate or
torial and the pathogenesis is unclear. It has increased in
oedema. Swelling may take a few hours to develop and
the general population and is found in both those who
the amount of swelling is determined by the type of tissue
participate in recreational sport and those with a more
involved in the injury. For example, Illuscle bellies Illay
sedentary lifestyle, as well as in more elite athletes. Other
produce considerable swelling and bleeding but the struc
contributing factors will be discussed for specific tendon
ture of tendons prevents the collection of fluid and they
lesions, as well as their management. in the relevant chap
do not easily swell. Similarly, ligaments themselves do not
ters that follow.
usually show dramatic swelling but capsular ligaments
Repetitive strain can reduce the ability of the tendon to endure further tension,
disrupting its microscopic
and macroscopic structure, but Rees et al
(2006)
pro
pose that underuse could also be a factor. Inflammation
(e.g. the medial collateral ligament of the knee) may pro voke a traumatic arthritis of the joint causing considerable pain and swelling. Swelling may also be restricted physi calJy by fascial bands and intermuscular septa.
(i.e. tendinitis or peritendinitis) may be the initial find
The vascular response is directly due to damage of
ing in tendon overuse and if this progresses the ensuing
blood vessel walls and indirectly due to the influence of
42
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Chapter
Connective tissue inflammation, repair and remodelling
I 3 I
Mast cell
Fibroblast
CONNECTIVE TISSUE CELLS
Smooth
-....�-� .. ---+-"'"---.---.:-
muscle
VESSELS
Eosinophil
Endothelium ___.L-----=----'-Basement membrane
'f '}s,/
� .o<>OooooooO"
CONNECTIVE MATRIX
\...,�
�
TISSUE Elastic fibers
-./
)\
...\',) ----' ) ----/'
Proteoglycans
Collagen fibers
Figure 3.2 The components of acute and chronic inflammatory process, circulating cells and proteins, cells of blood vessels, and cells and protei n s of the extracellular matrix. From Patho logic Basis of Disease 7th edn by V Kumar, N Fau st o
chemical mediators. These che . mical
pressure on surrounding tissues. Chemical pain arises
heparin and histamine, released by the mast cells (Fig.
through chemosensitive nerve receptors which are sen
3.2), bradykinin originating from plasma and plasma
sitive to histamine, serotonin, bradykinins and prostag
proteins, serotonin from platelets and prostaglandins,
landins which are released into the tissues durin g this
which are hormone-like compounds, produced by all
inflammatolY phase. However, most nociceptors ( pai n
cells in the body.
receptors) are sensitive to more than one type of stimu
Heparin
temporarily
prevents
the
lus. The inflammatory substances may cause extreme
excess tissue fluid and blood in the area. Bradykinins
stimulation of nerve fibres without necessarily causing
have multiple effects. They are potent mediators of the
them damage.
coagulation
of
inflammatory response, can directly cause pain and
The nociceptors become progressively more sensitive the
vasodilatation, can activate the production of substance P
longerthe pain stimulus is maintained and pro-inflammatory
Substance P
prostaglandins are believed to sensitize nociceptors lead
promotes vasodilatation, increases vascular permeabil
ing to a state of hyperalgesia, an increased response to a
and can enhance prostaglandin release.
ity and stimulates phagocytosis and mast cell degranu lation, with the subsequent release of histamine and
painful stimulus ( Wil kerson 1985, I
If the tissue is still haemorrhaging, attempts must be
serotonin. Prostaglandins may provoke or inhibit the
made to stop this as blood is
inflammatory response. Histamine and serotonin pro
cause chemical and mechanical pain, as well as pro l ong
duce a short-lived vascular effect whereas both brady
i n g the inflammatory process (Dingman
kinins and prostaglandins promote more
1980). This is particularly true of a haemarthrosis where
long-term
vasodilatation (Broughton et al 2006). The overall vas cular activity is responsible for the gross signs of inflam mation: heat
(calor),
pain and tenderness
UlillCt/O laesa)
redness
(dolor)
(rubor),
swelling
(tumor),
and disturbed function
(Peery & Miller (971).
strong irritant and will 1973,
Evans
aspiration should be considered. In the first few hours of the early inflammatory phase fibronectin, a st ructura l glycoprotein which acts as a tis sue 'glue', appears in the wound, deposited along strands of fibrin in the clot
Inflammation causes pain and tenderness. Mechanical
a
( Broughton
et al 2006, Standring
2009). This fibrin-fibronectin meshwork is associated
pain is due to mechanical stress, tissue damage, mus
with immature fibroblasts, which are thought to deposit
cle spasm and the accumulated oedema causing excess
type III collagen fibres to provide a scaffold for platelet
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43
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1
I
Principles of orthopaedic medicine
adhesion and anchorage for further invading fibroblasts
The new vessels supply oxygen and nourishment to the
(Nimni 1980, Lehto et al 1985).
injured tissues, but are delicate and easily disrupted.
In minor injury, the inflammatory process is short and
Relative immobilization is necessary at this stage and heat
the scar tissue produced is minimal. The red blood cells
is contraindicated as it will cause increased bleeding from
break down into cellular debris and haemoglobin pig
the fragile vessels (Hardy 1989).
ment, and the platelets (Fig. 3.2) release thrombin, an
Inflammation is a normal response to either trauma or
enzyme which changes fibrinogen into fibrin. The fibrin
infection and to have no inflammatory response would
forms a meshwork of fibres which trap the blood clot and
mean that healing would not occur. T'oo little inflamma
an early scar is formed.
tion will delay healing and too much inflammation will
If the injury is significant, the next stage of the inflam
lead to excessive scarring. The so-called PRICr. plinci
matory phase is phagocytic. Circulating monocytes mod
pie of employing protection, relative rest, ice, compres
ulate into macrophages (Fowler 1989) (Fig. 3.2) and
sion and elevation in the early stages can help to control
join the resident macrophage population to clear the
heat, swelling and pain and to reduce, but not abolish,
debris from the site of injury through phagocytic action
inflammation.
(Leibovich &
1974). The macrophages increase
The control of swelling is ilnponant towards regain
in great numbers during the first 3 or 4 days (Dingman
Ross
ing function since the greater the amount of inflamma
1973). They engulf any matter with which they come
tory exudate, the more fibl1n will be found in the area
into contact, clearing the wound environment and pre
which becomes organized into scar tissue (Evans 1980).
paring it for subsequent repair. As well as performing a
Although
phagocytic role, the macrophage acts as a director cell,
mobilization should be encouraged as early as possi
pain
inhibits
normal
movement,
graded
directing the repair process by chemically influencing an
ble to promote healing and to avert adverse scar tissue
appropriate number of fibroblast cells activated in the
formation.
area.
Pain itself can be reduced further by analgesic drugs.
l'vlacrophages also have a role in muscle regeneration,
Non-steroidal anti-inflammatory drugs (NSAIDs) modify
stimulating the production of satellite cells that align
the inflammatolY response, reduce chemical pain and
themselves to muscle fibres where they are capable of
reduce temperature by inhibiting the production of pros
forming completely new muscle fibres or restoring dam
taglandins. There are exponents of the so-called 'NICE'
aged muscle fibres (Grefte et al 2007). Further support for
principle, adding in the prescription of non-steroidal
their importance is provided by Shen et al (2008) who
drugs to the usual first-line after-care of injury. However,
observed that a reduced number of macrophages in mus
a counter view is that these should not be prescribed for
cle tissue is associated with reduced muscle regeneration.
the first 2 or 3 days after injury since they will tend to
Fisher & Rathgaber (2006) observed muscle regeneration
delay healing (Boruta et ill 1990, Watson 2009). It may
after acute blunt trauma to the gastrocnemius muscle in
be more appropriate to allow the body's natural inflam
rats and noted an initial degenerative process with early
matory response
peal
cetamol and/or physical measures such as mobilizJtioll,
days, following which numbers of macrophages declined
massage and electrotherapy as appropriate meLhods of
and satellite cells were noted beneath the basal lamina of
pain control.
muscle fibres. A regenerative process then began and after
G days numerous irregularly arranged sarcomeres were
10
Corticosteroids
proceed with analgesics such JS para
are
contraindicated
in
the
acute
inflammatory phase as they inhibit macrophage activit)'
observed, composed of thicl< and thin microfilaments and
which delays debridement of the wound and scar tissue
Z bands.
production by delaying the onset and proliferation of the fibroblasts (Leibovich & Ross 1974, Hardy 1989). Each stage of the inflammatory phase is essential
10
the repair
process and suppression in the early stages will delay
Clinical tip
healing.
-----
The principles of p rotection, rest, ice, compression
Gentle transverse frictions and controlled mobilization
and elevation (PRICE) are applied in acute injuries, the
can be initiated early to allow healing in the presence
irritability of the tissues, usually indicated by the level
of movement, as guided by the irritability of the tissues.
of pain on movement, providing a guide for when
Mobilization is initiated very gently, to start moving the
mobilization techniques are appropriate.
injured connective tissue towards regaining painless func tion, but without unduly stressing the healing breach. OVerstressing the healing tissue would disrupt the early fragile scar and set up a secondary inflammatory response,
A stage of neovascularization is also reached, with
leading to excess scar tissue formation. Mobilization also
capillaries starting to develop after about 12h and con
has an effect
tinuing to develop for a further 2 or 3 days (Daly 1990).
to reduce pain.
44
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011
the mechanoreceptors which is thought
Chapter
I 3 I
onnective tissue inflammation, repai r and remodelling
edges remain in apposition. Consider a clean, stitched
Clinical tip
skin wound, when the stitches are usually safely removed
Gentle frictions together with gentle mobilization will agitate tissue fluid and increase the chance co nt act of the macrophage with cellular debris, so promoting healing
after 7 days and the wound has sufficient tensile strength to withstand movement. Large, unapproximated wounds are deep as well as wide and healing initially requires the formation of granulation
(Evans 1980)
tissue. It may be several days after injury before the fibrob lasts initiate fibre formation and several weeks before there is sufficient collagen to provide enough tensile strength for the wound to withstand normal movement.
REPAIR PHASE
Therefore all timings mentioned above are approximate and the clinician will conduct a thorough assessment. The
The repair phase is simultaneous with the inflammatory
level of irritability of the tissues is a guide to the time for
phase and overlaps the remodelling phase.
application of the appropriate graded mobilization.
Some tissues, e.g. the synovial lining of the joints, bone and skeletal muscle, are capable of direct regeneration. All other connective tissues are incapable of regeneration, and repair of these structures involves a reconstruction process of the damaged tissue by collagen fibre or scar tis sue formation. Scar tissue does not have exactly the same
Clinical tip The level of irritability is a guide to the application of the appropriate graded mobilization.
properties or tensile strength as the tissue it is rebuilding, but its structure comes to resemble that tissue closely to ensure that normal function is regained (Douglas et al 1969, Hardy 1989, Watson 2009).
During the early part of the repair process, a stage of wound contraction occurs assisted by the contractile
Once the wound has been prepared by phagocytosis,
action of myofibroblasts
(Gabbiani et al 1971,
Daly
the macrophage becomes the directof of repair and signals
1990). Linear wounds contract rapidly while circular or
an appropriate number of fibroblasts to the area. As the
rectangular wounds contract relatively slowly (Grillo et al
inflammatory phase subsides the fibroblast becomes the
1958, Fowler 1989, Hardy 1989, Daly 1990, Standring
dominant cell in the repair phase and synthesizes the con
2009). Wound contracture, as distinct from contraction,
nective tissue matrix, comprising the amorphous ground
results from fibrosis or adhesion formation and this will
substance and collagen (Fig. 3.2). Fibroblasts may appear in
be discussed later in this chapter.
the wound during the first 24 h after injury, but maximum
Initial collagen fibre formation is random. The number
numbers are not achieved until day 5-10 ( Bryant 1977,
of collagen fibres and the tensile strength of the wound
Chamberlain 1982, Fowler 1989). They do not decrease in
increase substantially
number until 3 weeks after the injury (Chamberlain 1982).
injury to become approximately 15-20% of the normal
Fibroblasts secrete the amorphous ground substance
strength of the tissue (Hardy 1989, Daly 1990, Hardy &
during the
first
3
weeks
after
which provides the cross-linking mechanism for the colla
Woodall 1998). However, the tensile strength does not
gen fibres it also synthesizes. This arrangement 'glues' the
depend entirely on the number of fibres, since after this
wound together, with cross-links forming at appropriate
time the number of collagen fibres stabilizes but the ten
nodal intersect points (see Ch. 2). Once the fibroblasts
sile strength of the wound continues to increase. Tensile
are stimulated to produce collagen there is rapid closure
strength is related to a balance between the synthesis and
of the healing breach. Collagen fibres proper are laid
lysis of collagen (the production and breakdown of colla
down approximately 5-10 days after injury and the repair
gen, a continuous, dynamic process), the development of
process continues as they arrange themselves into larger
collagen cross-links and the orientation of collagen fibres
units or bundles (Stearns 1940b, Chamberlain 1982).
into the existing weave. This process of maturation is
Macrophages continue to stimulate the production of satellite cells, important for the regeneration and repair of
known as the remodelling phase (van der Meulen 1982 , Standring 2009).
muscle tissue. At the proliferation stage the satellite cells become myoblasts that may either fuse to each other to create new myofibres or may (use to existing damaged myofibres for repair (Grefte et al 2007).
REMODELLING PHASE
The rate of repair is directly related to the size of the wound (Stearns 1940a, 1940b). A small wound with
The remodelling phase sees the new collagen or scar tis
approximated edges will heal quickly with a minimal
sue attempt to take on the physical characteristics of the
inflammatory response and collagen fibres will be laid
tissue it is replacing. It begins in earnest approximately
down early to bind the edges together, provided that the
21 days after injUly and continues for 6 months or more,
45 Copyrighted Material
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1
I
Principles of orthopaedic medicine
possibly even for years. Broughton et al (2006) suggest
Cross-linking is responsible for the tensile strength of
that the process can actually begin much earlier than the
new, desirable scar tissue, but if the cross-linking becomes
peak of 21 days, from approximately 8 days, and provide
excessive it will be responsible for the toughness and lack
support for the remodelling stage continuing for I year.
of resilience of unwanted fibrous adhesions (Kloth &
Remodelling is responsible for the final structural orienta
Miller 1990). Immobilization causes loss of the ground
tion and arrangement of the fibres as well as the tensile
substance, which reduces the interfibrillar distance and causes friction between the collagen subunits, facilitating
strength. Initial. immature scar tissue is weak and the fibres are oriented in all directions through several planes.
the formation of excessive cross-links (Al<eson el al \967, Akeson 1990).
Remodelling allows these randomly arranged fibres to
Collagen fibre formation and orientation conform to
become rearranged in both a linear and a lateral orien
lines of stress within connective tissue, and are similar in
tation in a 'well-mannered network' (B roughton et al
this respect lO osseous alignment (Le eros Clark 1965,
2006). The orientation of collagen fibres occurs in two
Price 1990, Standring 2009). Ligaments require strong scar tissue fibres within their
ways: through induction and through tension. Normal tissue adjacent to tJle wound induces structure
parallel wavy weave to be capable of resisting excessive
in the replacement scar tissue. Thus dense tissue induces
joint stresses as well as being able to relax ilnd fold when
dense, highly cross-linked scar tissue while pliable tissue
t.he tension is removed. The scar tissue formed between
induces loose, less cross-linked scar tissue (Hardy 1989).
the ligament and bone must mimic t.
The final physical weave of the collagen so formed is
allow normal movement of the joint (Hardy \989). Scar
responsible for the functional behaviour of the wound
tissue formed within a muscle belly needs to be flexible to allow the muscle fibres to broaden as the muscle contracts
within the connective tissue it is replacing.
and extensible enough to allow the muscle to lengthen when stretcl1ed. Scar tissue within tendons must be ori ented in a parallel weave along the lines of mechanical stress to ensure mJximum tensile strength of the tendon
The application of appropriate stress by graded mobilization ensures that collagen fibre orientation occurs
while also maintaining its gliding properties.
throughout the tissue and matches its function.
Clinical tip Internal and external stresses
apply
tension to the
wound during the remodelling phase, e.g. muscle tension, joint movement, passive gliding of fascial planes, connec tive tissue loading and unloading, temperature changes and mobilization (Hardy 1989).
It is recognized that
both mobilization and immobilization can strongly influ ence the structural orientation of collagen fibres (Stearns 1940a, 1940b, Akeson et aI1987). During the maturation phase of scar formation, imma
To avoid adverse scar tissue formation, gentle t ransver se fridions and a progress i ve ly increasing range ot rnobilization should be continued range
of
u ntil
a full pain-free
movement is restored. This aims to prevent
excessive cross-links occurring between individual fibres and encourages fibre alignment. ApplYing app ro priat e
stress to restore l en g t h should avoid the necessity to stretch.
ture scar tissue is converted to mature scar tissue and the cross-linking system changes from weak hydrogen bond ing to strong covalent bonding (Price 1990). While the
Collagen synthesis and remodelling continue in the 6
scar tissue is relatively immature the weak electrostatic
months following injury with the tissue returning to ils
bonding forms reducible cross-links which allow scar tis
normal state of activity 6-12 months after inju·ry under
sue to be mobilized with a gentle, steady stress. During
normal conditions (Daly 1990). I'lowever, the increase in
this stage transverse frictions and mobilization within the
lensile strength in fascia and other dense connective tis
limits of pain are appropriate to maintain the mobility of
sues is thought lO take much longer (Dingman 1973)
immature scar tissue with graded mobilization promoting
Fully
the alignment of fibres.
approximately 70% of their original strength (Douglas
Remodelling involves the reorganization of scar while
repaired
skin
wounds
eventually
achieve
only
et al 1969, Blyant 1977, Daly 1990).
it matures with fibres bei ng absorbed, replaced and re
As the scar matures, it becomes dense, tough and less
oriented. When stresses arising from mobilization are
resilient than immature scar tissue. The developing stable
applied to collagen
fibres, the resultant piezo-electric
cross-links become more prolific and the stronger cova
(generation of small voltages called streaming
lent bonds ,,"hich form do not yield as readily to ilpplied
effect
potentials) is beli. eved
stresses (Price 1990).
tion, maintenance, alignment and absorption of collagen fibrils (Price 1990, Standring 2009).
An
increasing
depth
of
transverse
frictions
pro
vides pressure and lateral stretch to the mature scar.
46 Copyrighted Material
Chapter
I 3 I
Connective tissue inflammation, repair and remodelling
Deeper transverse frictions and a greater range of mobi
decreased collagen synthesis and increased collagenase
lization are required to mobilize mature scar tissue com
actjvity (Carrico et al 1984). This effect may be transferred to the use of intralesional steroid for chronic innamma
pared with immature scar tissue.
tion in chronic connective tissue lesions such as tendin opathy, bursitis and some chronic ligament strains.
Adhesion formation and contracture Synthesis and lysis, together with orientation of the colla gen fibres (i.e. remodelling), ensure the final form of scar tissue. A balance is needed between collagen synthesis
FACTORS WHICH MAY AFFECT WOUND HEALING
and lysis for an appropriate turnover of collagen and suf ficient stresses should be applied to the tissue to stimu late fibre orientation but without disrupting the healing breach. This has implications for the grade of mobiliza tion applied and is discllssed in Chapter 4. Increasing the size of the healing breach would set up secondary innammatory changes, leading to excessive scar tissue formation and eventual contracture, adhesions and fibrosis. Excessive scar tissue, adhesions or contracture within any soft tissue structure will impede function and cause pain. Pain itself, as a characteristic of innammation, acts as an inhibitor to normal function and, if a state of
Clinical tip In considering various factors which can promote, delay or lead to poor repair, assessment of connective tissue lesions should take Into account the following factors:
· I
•
Time of onset and the time lapse since injury.
•
Inappropriate or overaggressive mobilization relating
•
•
•
An abnormal excessive production of scar tissue may •
1990). Hypertrophic scars develop when excessive col
•
keloid scarring involves excessive collagen deposits in
Anatomical structures involved directly and indirectly in Medical conditions which may affect wound healing, e.g. circulatory disorders, clotting disorders, diabetes.
result in hypertrophic or keloid scars (Daly 1990, Price lagen is deposited within the original wound site while
Stage reached in the inflammation, repair, remodelling
the lesion.
innammation presents an ongoing chronic functional problem which may be difficult to treat.
to irritability of the lesion. phases.
chronic innammation is maintained, the function of the tissue will continue to deteriorate. This self-perpetuating
Extent of the lesion.
Age. Medications which might affect management and healing, e.g. anticoagulants, analgesics, anti inflammatory drugs.
the tissues surrounding the scar. In the connective tissue structures important to orthopaedic medicine, this exces sive production of scar tissue may be seen as adhesion formation and contracture either within the healing struc ture or within the surrounding tissues.
Chronic uaurna can cause excessive movement or ten sion on devitalized tissues, promoting unwanted scarring
In the treatment of hypertrophic scarring, prolonged pressure has been used to restore the balance between col
This may be the mechanism of chronic overuse syn dromes in which repetitive trauma disrupts tissue unity.
lagen synthesis and lysis (Hardy 1989). In a chronically
Haematoma formation retards the healing process by
innamed wound where excessive scar tissue has been pro
acting as an irritant, producing a mechanical bloc kage
duced, the technique of deep transverse frictions applies
which separates the torn edges and provides
pressure to the area of scar tissue as well as providing a
for infection (Dingman 1973).
lateral stress to mobilize adhesions.
Infection of the injured tissue presents
a
a
medium
serious com
plication which delays the healing proces s. Age, according to Mulder (1990), can delay cell migra tion and proliferation, wound contracture and collage n
Clinical tip
remodelling, and decrease the tensile strength of th e
In chronic lesions, deep transverse frictions and graded
wound, so increasing the chance or wound dehiscence
mobilization techniques are applied to mobilize the
or splitting. Experimental wounds in young rats showed
existing scar tissue. Alternatively, an intralesional injection
better mechanical properties in terms of greater strength,
of corticosteroid may be given.
elastic stiffness and energy absorption than those in older rats. The fibre organization was more complex and better organized in the young rats and healing was observed to be faster (Holm-Pedersen & Viidik 1971).
The use of intralesional corticosteroid is said to pro duce
keloid
regression
through
its
multiple
Changes in the gel-fibre ratio OCCUlTing with age are con
steroid
sistent with the changes occurring with immobilization.
effects, which include inhibition of fibroblast migration,
Contractures tend to occur more frequently, after less trauma
47 Copyrighted Material
I
1
I
Principles of orthopaed i c med icine
and after s h o rter periods of time in the relatively i mm o b i l e
after the macrophage i nvasion, i . e. a fte r 3 days, t h e i r effect
joi nts of t h e elderly. C h e m i c a l changes i n t h e ge l - fibre ra tio
o n wo u n d hea l i n g i s much less severe ( Fowler 1 9 8 9 ) .
have been noted i n such t issues as the skin and the n ucleus
An t i coagu l a n ts,
e.g.
heparin
and
warfarin,
prolong
b leed i ng a n d d e l ay wou n d he a l i ng.
p u l posus o f o l der i n d i v i d u a ls (Akeson et al 1 9 G 8 ) . Th e fol l ow i n g med i ca t i ons, t h era p i es and cond i t i o n s m a y also a ffeCt w o u n d hea l i n g.
The e ffect of c h e m o t h e ra py depends on t h e d rugs used an d th e i r dosage,
W h i l e a n t i - i nfla m m a t ory med ication may n o t be t h e m os t a p p ro p r i a te tre a t m e n t for a c u te i n fl a m m at i o n , i t s
but
fi bro b l ast
pro l i feration
may be
affected and s u b seq u e n t l y co l l agen sy n t h esis i s d e layed ( Carrico et al 1 9 8 4 ) .
use i n c h ro n ic l es i o n s i s most appropriate for s u p pressing
Rad i o t h era py ra d i a t i o n can d a mage fi b roblas ts, cause
i n fla m m a t i o n a nd rel ievi n g p a i n . NSAI Ds, e it he r t a ken
vascu l a r d a m age a n d decrease col lagen prod u c t i on, b u t i t
o ra l l y o r topic a l l y a p p l i ed , may be used i n co n j u n c t i o n
depends o n the dose, freque ncy a n d location o f t he irra
w i t h phys i c a l measures ( P RI CE)
d i a ted area i n re l a t i o n t o the i n j u ry s i te ( M u lder 1 9 9 0 ) .
.
NSAIDs do n o t cause
a s i g n i fi ca n t c h ange in c o l l agen syn th e s i s; they i n h i b i t
Acq u i red i m m u n e d e fi c i e ncy syndrome ( A I DS) p a t i e n ts
prod uCt ion o f h i s t a m i ne, sero to n i n a n d prostagl a nd i n s
are in a state of i m m u nosu ppression a n d t h i s w i l l delay
( W i l kerson
t h e hea l i ng process.
1 9 8 5 ) . H owever, aspi r i n ,
in add i t i o n to its
a n t i - i n fl a m m atory funct i o n, i n h i b i ts p la t e l e t aggrega t i o n a n d m ay pro l o n g bleed i ng ( Ra ng et al
2003 ) .
D i abetes appears to a ffect the i n fl a m m a t o ry stage ra t h e r t h a n coll agen syn t h esis, i m p l ying t h a t i n su l i n i s i m por
The oral i ntake of conicosteroids i n h i b i ts c o l l agen syn
t a n t i n t h e early phase of hea l i ng ( Carrico et al 1 9 i1 4 ) .
thesis, reduces t e n s i le strength a n d d e l ays wou n d heal
Other factors which cou l d a ffec t heal i n g i n c l ude vita
ing ( D i ngm a n 1 9 73, Ahonen et al 1 9 8 0 , M u l der 1 9 9 0 ) .
m i n A and C deficie ncy, prote i n d e privat i o n , l o w tem
2009 ) ,
Corticosteroids a d m i nistered i n t h e acute i n flam matory
perature (Watson
phase i nte rfere with macrophage m i gration but i f del ivered
systemic c o n n e c t i ve tissue disorders.
Ahonen, J., / i born, It., Zederfe l d t, B., 1 9 80. H o rmone i n A uence on wound h ea l i n g. In: H u n t, T K . ( Ed . ) Wo u n d H e a l i n g a n d Wo u n d I n fect ion: Theory and S u rgical Practice. Appleton Century Croft, New York pp. 9 5 - 1 0 5 . Akeson, W . , 1 9 9 0 . The response o f l igaments t o stress modulation a n d ovelview of t h e l i ga m e n t heal i ng response. I n : D i1 n i e l , D . , Akeson, W H . , O'Connor, J . J . (Ed) I(nee Ligaments: S t ructure, Function, I n j U ly a nd Repa i r. Lipp i n cott, W i l l i ams & W i l k i ns, Ph i l a d e l p h i a, p p . 31 5 - 3 2 7 . Akeson, W., A m i d D . , La Violette, 0 , 1 9 6 7 . Th e connective t i ss u e response to i m m ob i li ty : a study of chondro i t i n-4 a n d G-su l fate and dermi1tan s u l fate changes i n perii1rt i c u l a r connect ive t i ssue of control and i m mob i l ised knees of dogs. Clin. Ol1hop. 5 1 , 1 8 3- 1 9 7 . Akeson, W , A m i e l , D . , LaViol ette, D . , et a l . , 1 9 G8. T h e co n nective tissue response to i m mobil ity: an accelerated ageing response? Elq) Cero n to l . 3, 2 8 9 - 3 0 1 . Akeson, w., Am iel, D., Abel, M . F. , e t �L 1 9 8 7 . Effects o f i m mobi [ isation on
j o i nts C l i n . Orthop. Rel a ! . Res. 2 1 9 ,
tend i n opathy. Phys. Sports Med. 2 8 ( G ) , 3 1 -4 1 .
28-3 7 . Al fredson, H . , B j u r, D . , Thorsen, 1( , et
sys t e m i c vascu l a r d isorders and
a I . , 2 0 0 2 . H igh intrate n d i n ous
lactate l evels in pa i n ful c h ro n i c Ach i l les ten d i nosis. A n i nvestiga t i o n u s i n g m i crodia lysis tech n ique.
J. Orthop. Res. 20 (5 ), 9 3 4 - 9 3 8 . Boruti1, P.M , B i s h op, J . O . , Braly, W. C . , e t i1 1 . , [ 9 9 0 . Acute lateral ankle
Cyriax, J , 1 9 8 2 . Tl'xtbook of Onhop at�dic Medici ne. 8 t h ed n. Ba i l l i ere Tindall, London. vol I . Da ly, T.J , 1 9 90. The repair phi1se of wound h ea l i n g - re-epithel i i1 l ization and con t ract i o n . In: Kloth, L.C., McCu l lock, 1 M .. Feedar, J A ( Ed ) Wound H e a l i n g: Ai terni1tives
l ig�ment i n j uries: l i terature review.
in Ma nagement. 1° A Davis,
Foot A n k l e 1 1 , 107 - 1 1 3 .
P h i l ad e l p h ia, pp. 1 4 - 2 9 .
Broughton, C , J a n is, J., Atti nger, C, 2006. The basic scie nce of wound heal ing. Plas!. Reconstr. Surg. 1 1 7 ( 7 S ) , 1 2S -3 4 S . Brukner, P., K h a n , K . , 2007 . C l i n i c a l S p o n s M e d i ci ne, 3 rd ed n. McC raw H i l l, Sydney. Brya n t, W, 1 9 7 7 . Wo und h e a l i ng. C l i n . Sym p. 2 9 , 2 - 2 8 Carrico, T. ) . , M e h r hof, A . I . , Cohen, I . K., 1 9 8 4 . Biol ogy o f wound h ea l i ng. Surg. C l i n . N . A m . G 4 , 7 2 1 - 7 3 1 . Cham berl a i n , G . J . , 1 9 8 2 . Cyriax's friclion massage: i1 review. J . Orthop. Spons Pilys. Ther. 4 , 1 G - 2 2 . Cook, J . L.. K h a n , I<' M . , M a ffu l l i , N . , et a I . , 2 0 0 0 . Overuse t e n d i nosis, not tend i n o pa thy, pan 2 : applying the new approach to pate l l a r
48
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D i ngmiln, R.O., 1 9 7 3 . Fi1Clors o f cli nical Significance affec l i n g wound he�l i ng. Laryngoscope IB, 1 5 4 0- 1 ') 5 4 . Douglas, D . M ., f'orrester, J . e . , Ogilvie, R . R . . 1 9 G 9 . Physical chi1racteristics of c o l l agen i n the li1ter stages of wound h e a l i ng. Br. J S u rg. 5 G, 2 1 9 - 2 2 2 . Evans, P., 1 9 80. The h e a l i n g process i1t ce l l u l a r level a review r'hysiotherapy GG, 25G-259. Fis her, B. D., Rarhgaber, M . , 200G. An overview of m uscle regeneration fo l l owing acute i n j u ry. J Phys. Ther. Sc i . 1 8 ( 1 ) , 5 7 - G 6 . Fowler, J . D . , 1 9 8 9 . Wound hei1 l i ng: a n overvi ew. Sem i n . Vet. M ed . Surg. 4 . 25G-2G2. C a b b i a ni , C , Rya n, C ll., M a j no, C . . 1 9 7 1 . Presence of mod i fi ed
Chapter
I 3 I
Connective tissue i n fl ammation, repair and remodel l i ng
fi b roblasts in gran u l at i o n tissue and their possible role in wou n d contracti o n . Experientia 2 7 , 54 9 - 5 5 0 . G refte, S., [(u ijpers-Jag1man, A . M . , ' [ o rensma, R., e t a I . , 2007. Skeletal muscle development and regeneration. S tem Cells Dev. 1 6, 857-8G8. G ril lo, H . C., Watts, c .T., G ross, I ., [ 95 8 . Studies in wounel he,l l i ng: [ . con t raction and the wound contems. /\n n . Surg. [ 4 8, 1 45 - 1 5 2 . [ [ardy, M . A . , 1 9 8 9 . The biology of scar formation. Phys. Ther. 69, 1 0 1 4 - 1 0 2 3 . I l ardy, lvI . , Wooda l L W , 1 9 9 8 . Therareutic effects of heat. cold and s t retch on con nective t issue. J. H anel Ther. I [ ( 2 ) , 1 4 8- 1 5 2 . I 101m-Pedersen, P., V i i d i k, A . , 1 97 1 . Tensile properties and morphology of healing wou nds i n young and old rats Sca n d . J . Plast. Reconstr. Surg. 6, 24-35. J6zsa, L., [(a rmus, P , 1 99 7 . f l u m a n lendons: ;-\natomy, Physiology and Pathology H u man Ki netics, Cham paign, I l l i no is. I(han, I(IvL, Cook, L t.. , 2000. Overuse tendon i n j u ries: where does the p a i n come from ? Sports ivIed. Mth rosc. Rev. 8, 1 7-3 1 Kloth, L.C, M i l l er, 1(. 1 1 ., 1 ') 90. The i n n a m m atory response to wound ing. I n : Kloth, L.e., IvlcCu lloci<, [.J'vJ., reeda c J .A. ( Eel ) \;\found Heali ng: Altel'l1atives in Ivlanagement. F A Davis, P h i l adelphia, pp. 1 4 - 2 9 . [(umar, V., ,:austo, 1\) ., Abbas, A X , 200G. Pathologic Basis of Disease, 7th edn. Sau nders, P h i l adelphia. I .e Gros Cl ark, W E , 1 % 5 . The Tissues of the Body. 5 t h ed n. Oxford Un iversity Press, Oxford .
Lehto, M., Dua nce, v. e., Restall, D . , 1 9 8 5 . Col lagen and fibronect i n i n a heal ing skeletal muscle i n j ury. I . Bone J o i n t S u rg. 6711, 820-827. Leibovich, S J , Ross, R., 1 9 7 4 . The role o f the macrophage i n wound repai r. i\m . I Path o l . 78, 71 - 9 1 . M u l der, G D , 1 99 0 . Factors comp lica t i n g wou n d rep a i r. I n : 1(loth, L. c., McCu l ] oci<, jJvt. , Feedar, I ( Ed ) Wou n d Heali ng: A itel'l1atives in Management. F A Davis, Ph i ladelph ia, pp. 4 3 -5 1 . N i m n i, M E , 1 9 80. The molecular organ isation o f col l agen and i ts role i n determ i n i ng the b i o p hysical p roperties o f the connective tissues. l3iorheology 1 7, 51-82. PeelY, T. M . , M i l ler, E N . , 1 9 7 1 . Pathology: A Dyn a m ic I n t roduction to Med ic i ne and Su rgery, 2 n d eel n . Little, Brown, Boston . Price, I I ., 1 9 90. Connective t issue in wou nd hea l i ng. In Kloth, L.C., McCu l l ock, I . M . , reeelar, I . (Ed) Wound H ea l i ng: Al ternatives i n Ma nagement. F f\ Davis, P h i ladelph ia, pp. 3 1 -4 1 . Rang, H . P. , Dale, M . M . , Ritter, I . M., et al., 2003 . Pharmaco logy, 5th edn. C h u rch i l l Livi ngstone, Ed i n b u rgh . Rees, I., Wilson, A . , Wolman, R., 2 0 0 6 . Cu rrent concepts i n the ma nagement of tendon d isorders. Rheumatol ogy 4 5 , 508-5 2 1 . Richards, P., W i n , T, J o n es, P., 2005. The d istribution of m i crovascu l a r response i n Ach i l l es tendi nopathy assessed by colour a n d power Dopp ler Skeletal Rad i o l . 34 ( 6) , 3 3 6 -3 4 2 .
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Shen, IN , Li, y, Zhu, J. et a I ., 2008. I n teracti o n between macro p hages. TG r-ll ! , and the COX-2 pathway d u r i n g the i n fl a m matory p hase of skeletal muscle hea l i n g af1er i n j U iy. J . Cel l . Phys i o l . 2 1 4, 405-4 1 2 . Standri ng, S., 2009. C ray's Anatomy: The Ana tomica l B a s i s of C l i n ical Practice, 4 0 th edn. C h u rch i l l Livi ngstone, Ed i nburgh. Stearns, 1vI . L. , 1 940a. Studies on the deve l o p m e n t of connective tissue in transparent chambers i n the rabbi t's ear, I. A m . I . Anat. 66, 1 33 - 1 76 . Stearns, IvI . L. , 1 94 0b. Stud ies on t h e develo p m e n t of connective tissue i n transpare n t chambers i n the rab b i t's ear, I I . A m . J. Anat. G7, 5 5 - 9 7 . Tasto, J . P., C u m m i ngs, I , Medlock, V , et al., 2003. The tendon treatment center: new horizons in the t reatment of tend i nosis. Arth roscopy 1 9 ( S u p p l . 1 ), 2 1 3 -2 2 3 . van der Meulen, J . H . C., 1 9 8 2 . Present state of knowledge on processes of hea l i ng in col l agen structures. I n t. J. Sports Med. 3, 4 - 8 Wang. )., Losi fidus, 1vI . , F u , F , 200G. [liomechan ical basis for ten d i nopathy. C l i n . O[[hop. Rel a t . Res. 4 4 3 , 3 20-33 2 . Watson, T ( 2 0 0 9 ) . Tissue rep a i r p h ases and t i m escale. O n l i ne. Ava i l a b l e : h t t p llwwwelectrotherapy.org. W i l kerson, C.B., 1 9 8 5 . I nfla m m a t ion in con nective tissue: etiology a n d manageme n t . !\t h l . Tra i n . Win ter, 298-301 . Wi tvrouw, E., M a h ieu, N . , Roosen, 1'., et a l . , 2007. The rol e of stretch i ng i n tendon i n j u ries. Br. I . Sports Med. 4 1 ( 4 ) , 2 24 - 2 2 G .
49
4 Orthopaedic medicine treatment techniques
Local a n aesthetic
75 76
51
Contraindlcations to corticosteroid or local anaesthetic injection
52
'No-touch' technique
76
53
Needle size
76
Syringes
76
54
Non-steroidal anti-inflammatory drugs
77
Aims of transverse frictions
56
Epidural i njections
78
Principles of application of transverse frictions
59
Sclerosant therapy (prolotherapy)
78
Graded mobilization techniques
61
Peripheral graded mobilization techniques
61
CHAPTER CONTENTS Summary
Mobilization
General principles of orthopaedic medicine treatment tech niques Transverse frictions
Peripheral Grade A mobilization
61
Aims of peripheral Grade A mobil ization
61
Over the years. the emphasis of treatment
Peripheral Grade B mobilization
62
for musculoskeletal lesions has moved from
Aims of peripheral Grade
62
B
mobilization
Peripheral Grade C manipulation
64
Aims of peripheral Grade C manipulation
64 64
Spinal graded mobilization techniques
Spinal Grade A mobilization
64
Spinal Grade B mobilization
64
one of total immobilization to one of early mobilization. The benefits of early mobilization have become clear and. while a short period of immobilization may still be necessary. the overall aim of orthopaedic medicine treatment techniques is to restore full painless function to the connective tissues through appropriate mobilization.
Spinal Grade C manipu lation
64
The selection of techniques depends on several
Aims of spinal and sacroiliac joint manipulation
65
factors that include the stage the lesion has
Discussion o n the effects of spinal manipulation
65
reached in the healing cycle. with particular
69
Traction
attention to the overall irritability. An accurate assessment and clinical diagnosis allows the effective application of the selected treatment techniques and the development of a carefully
Indica ions for traction at peripheral joints
70
rationalized treatment programme.
Indications for spinal traction
70
The treatment techniques used in orthopaedic
Discussion on the evidence for the a ims and I'Hects of traction
70
Orthopaedic medicine inj ection techniques
73
medicine fall into two broad categories of mobilization and injection. and within this chapter the techniques will be considered in turn. on the basis of the theory presented in
Corticosteroid injections
73
the preceding chapters. with notes on their
Tria mcinolone acetonide
74
application.
© 20 1 0 Elsevier L d
Copyrighted Material
51
I
1
I
Principles of orthopaedic medicine
Treatment techniques used in orthopaedic medicine may be categorized as follows:
INJECTION
MOBILIZATION • Tr a n s ver se fr icti on s • Grade A mobilization • Grade B mobilization
• Grade C manipulation • Tract i on
•
Corticosteroid
•
Local anaesthetic
•
Sc lerosant therapy
1
A
A
B B
MOBILIZATION Connedive tissue structures are more responsive
to a
decrease in mechanical demand !.han they are to progres sive increases (Tipton et al
1986).
Therefore, depriving
the healing soft tissues of motion and stress can lead to a number of structural cha n ges within the ar ticular and peri artiClilar connective tissues !.hat may be difficult to reverse. These changes may include all or some of the following: •
Disorganized fibre orientation
•
Adhesion formation at the fibre-fibre interface
•
Adhesion formation between ligaments, tendons and
( Fig .
4 . 1)
Schematic diagram of the weave pattern of coll agen fibres. A a n d B represent IIldlvldual collagen fibres with cross-linkage in place to stabilize th e structure. In nor m al tissue, re pr e se nte d by the left-hand diagram�, some separation IS allowed between the fibres and the fi bre s can move apart. A d h esi on formation al nodal intercept POints at the fibre-fibre in te rfa ce is represented in the fight-hand diagrams at c and d; this a d h esion formation will Interfere With the free gliding of fibres an d inhibit normal tissue fun ction. From Woo S L, Mathews J V. Akeson WHet al 1975 Con n ec tive tissue re s pon s e to ImlTlobility. ArthrillS and Rheumatism 18: 257-264. Reprinted w i th perm ission of Wiley-Liss, Inc., a subsidiary of J ohn Wiley and Sons, Inc. dysfunction was not simply due to con n e ctive tissue �tro
their surrounding connective tissue •
I
Figure 4.1
Reduced tensil.e strength of ligaments, tendons and
phy, as there was no statistical difference in the quantity
muscles
of collagen fibres, but due to an increase in collagen turn
Loss of the gliding capacity of connective tissu e,
over and to other changes within the connective tissue
especially te ndons
matrlx (Amiel
•
Weakening of ligament and tendon insertion points
lar ch anges
•
Inhibition of muscle fibre regeneration by scar tissue
The changes noted were:
•
Proliferation of fibrofallY tissue i n to the joint space
•
•
and adherence to cartilage surfaces •
adhesion formation between synovial folds
Alteration of the dynamics of collagen turnover (syn th esis/lysis)
Cart i lage erosion and osteophyte formation
•
Development of ano malous cross-l i n ki n g of existing and new collagen fibres
Decrease in the vo lume of synovial fluid with
•
et a l 1982). Loitz et al (1988) not ic l�d simi within a 3-week period of immobilization.
•
Random deposition of new collagen fibres within the exist i ng co l lagen weave.
1960, En neki n g &. Horowitz 1972, Akeson et al 1973, 1980, 1986, Videman 1986, Hardy 1989, Jarvinen &. Lehto 1993).
in the quantity and quality of th e amorphous ground sub
It is nOLiceable that !.hese connective tissue changes, asso
stance, consistent in all connective tissue structures, which
(Burke-Evans et al
In explanation of the changes a difference
was
noted
ciated with immobilization, are sim il a r to the changes seen
amounted to
with the degenerative ageing process.
aminoglycans (GAGs). As a result, the critical distance
J
reduced con centr at i o n
of water and glycos
The le n gth of connective tissue structures tends to
and separating effects between adjacent collagen fibres
adapt to the shortest distance between or i gin and inser
were reduced an d the inter fibri l la r lubrication was lost.
tion, wh ich pro du c es the consequences
of immobiliza
Fri ction deve lo ped at the fibre-fibre in terface leading to
tion that can lead to pain and long-term loss of function
the development of anomalous cross-linl<s which altered
(Videman
1986).
the gliding function
Several authors have discussed the effects of stress and motion deprivation on healing connedive tissues in ani
1967, 1973, 1986, Woo &. Madden 1 976, Woo 1982,
mal experiments (Akeson et al et al
1975, 1990, Arem 1 990 ) . During a 9-week
Akeson
period of immobilization,
of the collagen fibres. This forma
tion of cross-links was observed to be time-dependent and occurred when fibres remained stationary for of time, i.e. assumed
J
it
period
stationary attitude.
The incorpo ra t i on of new, disorganized collagen fibres into
the
52
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ex ist i ng collagen
weave physically restrains
Chapter
I
4
I
Orthopaedic medicine treatment t echn iques
mobi l i ty. Overa l l this has an e ffect of a l te ring the e lastic ity, plastic ity and plia b i l ity of the connective tissue struc tures (Eliasson et al 2007). It is i mportant to note that adhesion formation is a normal part of the repair process and it cannot be prevented ent i rely. However, it lTtay be possible to prevent excessive or unwanted ad hesions, or to mob i lize them i f they develop u n w i t t i ngly. Treatmen t a i ms to mai ntain or rega in t h e anatomy and biomecha ni cal function of col lagen fibres, enab ling them to deal w i t h tension, compress ion, shear a n d glide. Col lagen turnover (synthesis/lysis) is a normal, dy namic process that is i n fluenced by stress and motion. When deprived of these physical forces t h rough immo bilization, the balance of col lagen turnover is lost and a greater rat io of immat u re col lagen fibres is present w i t h a pote ntia l for the fo rmation of increased anomalous, reducible cross-links. Pliable young scar t issue is ripe for early mobilizat ion techniques that wil l reduce th e forma tion of anomalous cross-l i n ks. Stress and motion deprivation are also responsible for the random, d isorganized deposition of new col lagen fibres w i t h i n the existing weave that resul ts in an overall reduction in tensi l e strength. Col lagen tissue has elastic properties, Illainly by virtue of the weave o f its col lagen subunits, and it w i l l become relative l y ine lastic if that weave is altered (Peacock 1966 ) . The carefuL cont rol led appl ication of normal stress and mot i o n w i l l sti m u late new col lagen to be laid down in para l l e l with the exist ing weave and the collagen tissue wil l mainta in i ts elas tic ity, plastic ity and tens i l e strengt h . Wolfrs law, relating to laying down of trabeculae in cance ll ous bone a long the l ines of stress, could be broadened to encompass the response of the Illuscul oskeletal system to stress as a whole (Akeson 1 9 90). Immobi lizat ion affects rhe g l i d i ng fu nction of tendons and l igaments by virtue of the restrict i ng adhesions fai l i ng to elongate to permit pain-free function (Weiner & Peacock 1971). [n orthopaedic medici n e the principles of mobi l ization, i ncl uding t.ransverse healing tendons in tendinopathy, and tenosynovitis. The appl ication of ma nipu lation to rupture adhesions to per m i t nomlal glid i ng function may be necessary in lesions o f tennis elbow a n d some chro n i c l igamentous strains. In muscle lesio ns, collagen or scar tissue formation pro vides a necessalY framework for muscle fibre regeneration. However, excessive scar t i ssue may form a physica l barrier and h inder the progress of the regenerating musc l. The connective t issue component of musc les is subject to the usual d e l eterious changes of immobilization, as described in Chap ter 3. An adequate period of relative rest, depending on the injury and i rritabil ity of the lesion, is required to al l ow t he musc le to regenerate sufficiently to combat the mechanical forces of m o b i l ization (Lehto et JI 1985, Jarvinen & Lehto 19 93). The be nefit of earl y mob i lization to the regeneration of muscle was explored by Faria el al (2008) who obselved musc l e fibre regenera t ion in the rat atl h and 3 days after i n jury, w i t h daily
swimmi ng for 15 min and 45 min d uration. They fo und that the ea'r1 i er mob ilizat ion for 45 min sh owed improved regenera tion . Th is wou l d appear to support early mobili zat ion for i n j u red musc l e t issu e and the suggestion that ear ly application of graded mobilization, includ ing trans verse frictions, wi l l main ta in muscle func tion and stimu late structura l or i e n tation wit. h out the excessive forma t i o n of scar t issue. Articular cbanges d uring periods of immob i l ization depend on t h e restriction of the movement, the length of the immobilization period and the amount of con tact, pressure and fri ction between the j o i n t surfaces. The amount of synovial fluid is red uced, which renders the articu lar cartilage more vulnerabl e to injury by fric t ion a n d pressure. I.,onger periods o f immobilization o f 45-60 days have shown cartilage e rosion, subchon d ra l cyst and osteophyte formation, consisten t with the cbanges observed c l i n i cally i n joi nts affected by osteo arthrosis and age-related changes. Studies i n volving the immob i l ization o f rat knee j oints showed that if immo bil ization d i d not exceed 30 days t h e changes due to immobil izat i o n were reversib le, b ut the longer t h e joints were immobi lized, the longer it took to remobilize them, irresped ive of the method used (Burke-Evans et a l 1 960). Degenerative changes o cc u rr ing d uring immobilization can be partly inh ibited by traction and continuous pas sive motion (V ideman 1 9 86). The beneficial effects of intermittent and continuous passive motion have been we l l documented (Loitz et al 1988, Takai e t aI 1991). The original concept of cont i n uous passive mot.ion the harmful effects of immobil ization (Salter 1989). Joints were moved contin uously through a predeterm ined range of movement Th is app l i cation of cycl ical tensile loading fac i l i tates the orientation of collagen fibres, providing ten sile strength and a stronger functional and structural repair of connective tissue, incl uding articula r cartilage.
General principles of orthopaedic medicine treatment techniques Sof t tissue inju ry involves a l l tissues in t h e i n j u re d area t o valying degrees a n d can b e c l assified into three degrees of severity (Chartered Society o f Physiotherapy 1 9 9 8 ) : •
•
•
Crade I or m i l d injUlY invo l ves overstretch ing o f the s t ructures with min imal swe l li ng and bruising, mild pai n, no joint instability, minimal musc l e spasm and m i nimal loss of function. Crade ff or moderate i n j u ry involves some tearing of fibres wi th moderate swelling and bru ising, moderate pain on movement, moderate muscle spasm, some l oss of function and possi b l e joint i nstability. Crade ffJ or severe injury involves a complete tear of the injured structure with Significant swe l ling and bru ising, severe pain at rest and severe disturbance of function. 53
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I
1
I
Pr i nc ipl es of orthopaedic medicine
Injuly also reduces the tissue's ability to accept tensile
delivered 2-3 times per week for 2-3 weeks. However,
stress, the extent of which is proportional to the degree
clinical experience shows such lesions to be generally
of tissue damage. Rather than consider an injury acute in
resistant to treatment and the following offers a plausible
terms of days since onset, it is wiser to consider acuteness
explanation. If the pathological process of such lesions
in terms of the irritability of the lesion. In approaching the
is degeneration rather than inflammation, this may alter
application of treatment in this way, the dinician makes a
the view on prognosis, with the patient being more likely
judgment on the amount of intervention and the appro
to take many months to recover fully. The application of
priate time to apply it. In 1998 the Chartered Society of
deep transverse frictions to chronic lesions clinically pro
Physiotherapy (CSP), the professional body of physiother
duces tenderness in the region, which takes time to settle.
apy in the UK, endorsed the Guidelines for the Management
The work of Gregory et al (2003), discussed below, sug
of SoJi. Tissue (MusClllosheletal) Injwy with Protection, Rest, Ice, Compression and Elevation (PRICE) During the First 72
gests that ultrastructural changes as a result of transverse
Hours that were prepared by the clinical interest gcoup,
slLldy mentioned is an animal model) and this may have
frictions may take up to G days to resolve (although the
the Association of Chartered Physiotherapists in Sports
implications for considering the application of the tech
Medicine (ACPSM) (CSP 1998). The principles of PRICE
nique on a weekly basis, for example.
are applicable to any acute injury.
In summary, the aim of mobilization treatment tech
Protection is applied according to the severity of the
niques applied in orthopaedic medicine, including trans
injury and pain. Based on animal studies, the ACPSM
verse frictions, is to prevent or to reverse the connective
Guidelines (C<:;P 1998) suggest that a moderate, second
tissue changes associated with a period of immobiliza
degree injury requires 3-5 days' protection, while a mild or
tion. It is important to recognize that stress deprivation
first degree injury requires a shorter period and a severe or
causes rapid structural changes and recovery is much
third degree injUly requires longer. Rest is required follow
slower, and this must be taken into account when prepar
ing acute injury to reduce metabolic demand and blood
ing treatment programmes.
flow. However, a balance must be achieved with sufficient
Careful consideration should be given to the applica
controlled movement of the injured and surrounding
tion of other treatment modalities, either simultaneollsly
structures while avoiding any undue stress of the healing
or consecutively with the application of appropriate mobi
breach. Once it has been judged, based on irritability, that
lization. Abusive use of movement can produce mechani
the newly formed fibrous tissue can withstand some con
cal forces sufficient to stretch or disrupt the healing breach,
trolled stress, increased movement is encouraged to stimu
producing
late the alignment of fibres. Healing within the presence
soft tissue lJauma leads to secondary inflammation and
excessive
scar
tissue
formation.
Additional
of movement ensures the development of a strong mobile
the vicious circle of chronic inflammation (Noyes 1977).
scar. Ice, wmpressioTl and elevation can be applied in con
The correct amount of movement applied at the appropri
junction with the suggested treatment regimes given below.
ate time is the key.
Until recently, it has generally been assumed that there
Mobilization should be used at optimum levels, with
is an inflammatory component involved in chronic over
appropriate grade,
use tendon lesions, hence the term 'tendinitis'. The worl<
duration
10
range,
force,
direction,
speed and
achieve the specific treatment aims (Arem &
of Khan & Cook (2000) and Cook et al (2000) chal
Madden 1976). Hunter (1994), however, correctly points
lenged this thinking based on the evidence of numerous
out that, although soft tissue mobilization techniques
studies which showed few or no inflammatory cells asso
are known to be clinically effective, no research has been
ciated with such lesions. Instead changes consistent with
conducted to establish the grade of mobilization required
the degenerative process (tendinosis) have been noted
for each stage of the healing process. Orthopaedic medi
together with a poor healing response. Hence the term
cine mobilization techniques
tendinopathy has been adopted to describe chronic over
the specific mobilization techniques, Grades A, B and C)
(transverse frictions and
use tendon lesions where the pathology has not been his
are graded on the basis of patient feedback and observa
tologically confirmed.
tion against the under-pinning knowledge of the different
This raises several issues, not least, how can corticos
phases of healing and the experience of the clinician. The
teroid injection, a known anti-inflammatoty treatment,
appropriate depth and grade of mobilization technique
resolve pain in tendinopathy if there is no inflammatory
is applied according to the severity of the lesion and this
component to the lesion? Khan & Cook (2000) highlight
is determined in pan by assessment of irritability, rather
clinical experience together with reference to a number
than in terms of length of time from the onset.
of studies which show corticosteroid injection to provide at least short-term pain relief. but the mechanism of that pain relief remains unknown. Another issue involves the patient's prognosis. Based on
TRANSVERSE FRICTIONS
an inflammatory model, it is commonly suggested that the tennis elbow patient or the Achilles tendon patient
Massage is the manipulation of the soft tissues of the
will recover with treatment such as those suggested below
body with the hands using varying degrees of force
54
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Chapter
I
4
I
Orthopaedic m edic in e
treatment techniques
(Carrecl< 1994) and a dominant theme in tlle literature
one exception, most studies use a small sample, making
shows massage to be a therapeutic art lacking scientific
it difficult to generalize results to a wider population, and
support. It involves the laying-on of hands and mimics
several involve animal models. No one treatment modal
natural gestures such as rubbing a painful area or sooth
ity has been show[l to be Significantly better than another,
ing a child's injury by kissing it better. As one of the
and some studies use subjective terms such as 'traditional'
oldest forms of analgesia, it conveys feelings of caring,
and 'standard physiotherapy' to indicate the use of com
touch and rela;l(ation which indicate that both physical
bined modalit.ies. There is no consensus on a standardized
and psychological factors are relevant (Huebscher 1998,
method of application, with techniques varying from three
Braverman & Schulman 1999). Hemmings et al (2000)
I-min applications to a IO-min continuous application in
demonstrated a high patient satisfaction rate associ
one session. J. Kerr (unpublished work 2006) conducted
ated with massage. Techniques include effleurage (glid
a survey in Scotland and analysed 86 questionnaires to
ing movements), petrissage (kneading) and tapotement
establish musculoskeletal physiotherapists' current prac
(striking), all of which are generally accepted to have their
tice in the use of frictions for treating soft tissue lesions.
effects in the superficial tissues such as the skin.
Frictions were used by 83.7% of those surveyed and treat
Mennell (cited in Chamberlain 1982) first introduced specific massage movements cal.led 'fridion' in the early
ment times ranged from 3 to 5 min for acute lesions and were consistent at just below 10 min for chronic lesions.
1900s. Cyriax further developed this technique, adding
Stratford et al ( 1989) evaluated the use of phonophore
movement for the treiltment of pain due to inflammation
sis (the delivery of drugs via the skin using ultrasound)
caused by trauma. He described 'deep' friction massage
and transverse frictions for tennis elbow but the lack of
which reaches deep structures of the body such as liga
statistical power was deemed to be due to the small silm
ments, muscles and tendons, to distinguish it from the
pie size. Vasseljen ( 1992) demonstrated that 'traditional
general massage described above (Cyriax 1984) . The tech
physiotherapy' methods of transverse frictions and ultra
nique of transverse frictions has been further refined in
sound performed better than laser in tennis elbow under
recent years to allow the grading of the technique accord
subjective, but not objective, testing. However, the subjec
ing to tbe irritability of the lesion and patient feedback.
tive interpretation in this study may have bee[l more reli
Transverse frictions, therefore, are a specific type of con nective tissue massage applied precisely to move the target
ably evaluated using qualitative research methods. Assessing the effect of the addition of transverse frictions
tissue - of tendons, muscles and ligaments - for a specific
to a 'standard' physiotherapy
purpose. They are applied prior to and in conjunction
et al ( 1992) showed no significant difference between
programme,
Schwellnus
with specific mobilization techniques to gain their effeds.
comparison groups in the treatment of iliotibial band fric
The term 'deep' transverse fridions has been deliber
tion syndrome. This study was identified for the Cochrane
ately avoided as the blanket term to prevent the abuse of
Library by Brosseau et al (2002) as the only randomized
this technique. Unfortunately, deep transverse friction has
controlled trial to meet investigation criteria. In providing
been taught to many therapists ilS just that, ilnd the tech
a rationale for their research, Schwellnus et al suggest that
nique has not been adapted or graded to suit the lesion
the effect of transverse frictions is to realign fibres without
to gain specific purpose. Consequently, it has developed a
detaching them from their origins. However, this is incon
reputation for being very painful for the patient and tiring
sistent with current physiological evidence which shows
for the therapist. often being abandoned for these reasons
fibre alig,nment to occur along the lines of the applied
(Ingham 1981, Woodman & Pare 1982, de Bruijn 1984,
stress. Therefore it is the applied mobilization technique
Cyriax & CYTiax 1993) . It is an underrated modality at our
following the application of transverse frictions which is
fingertips (pun intended) and, when applied correctly, it
important for realignment of fibres. Verhaar et al (19%) conducted the only study to inves
is an extremely useful technique. Transverse frictions can be graded in depth and dura
tigate the use of transverse frictions combined with mobi
tion of application for acute and chronic lesions. [f cor
lization, in this case a manipulation for tennis elbow. A
rectly applied, an analgesic effect is achieved and it does
prospective randomized controlled trial was conducted
[lot have to be a painful experience for the patient. in this
with 106 patients divided into two groups, one receiving
text. the terms gentle transverse frictiOIl5 (for acute irri
transverse frictions and Mill's manipulation (see Ch. 6)
table lesions) and deep transverse frictiolls (for chronic
and the other corticosteroid injection. Short-term follow-up
non-irritable lesions) will be used to give an indication
showed significant improvement in both groups, with the
of the grade requi red for specific treatments. However,
injection group faring better than the transverse frictions
no attempts have been made to quantify this grade and it
group, while long-term follow-up showed no statistical
should be developed in response to patient feedback and
difference between the two groups. An honest evalua
according to the experience of the therapist.
tion of the limits of this study is included by the authors,
The evidence base to support the use of transverse fric
citing reasons such as fail.ing
tions needs urgent development. but a number of stud
together with blinding and organizational difficulties.
ies exist which suggest plausible reasons for the effects of
They suggest that as the conclusion of the study identi
the technique, paving the way for future research. With
fied all methods of treatment as effective, then the least
55
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Principles of orthopaed ic medicine
invasive, least expensive and most time-efficient should
were potentially beneficial and would facilitate the heal
be used, in this case injection. However, injection is an
ing process, or would aggravate the injury if present.
invasive technique and the number of patients requiring
Kelly (1997) conducted a study specifically to test trans
surgely in the injection group in the long term was not
verse frictions as a single modality, although this involved
addressed in the study.
normal volunteers rather than symptomatic patients. The
Pellecchia et al (1994) demonstrate some support fOI 'combined
modalities'
including
transverse
gastrocnemius muscle in 46 subjects received 5 min deep
frictions
transverse frictions. An increase in the range of movement
when compared with iontophoresis (delivery of drugs via
(dorsiflexion) and force of isometric muscle contraction
the skin using electrical energy), but conclude that ionto
(plantarflexion) OCCUlTed, indicating that transverse fric
phoresis may be more effective and efficient. The study is
tions may promote improved muscle function. Credit in
limited by its small sample size of 26 subjects, scant dis
this study was also given to motivational and psychologi
cussion on how randomization and blinding occurred
cal factors arising from the hands-on treatment; this has
and a lack of analysis of the six subjects who dropped
further implications for external validity.
out. The authors discuss the limitations of their study,
lwatsuki et al (2001) appear to corroborate the work of
explaining that ethical considerations resulted in deci
Kelly in an investigation into the biting force of the masti
sions which favoured the interests of the patients over a
catory muscles in subjects diagnosed with cerebrovascular
stronger experimental design. This study clearly illustrates
accident before and after transverse frictions. improved
the difficulties experienced in developing good experi
function due to an increase in the biting force of these
mental evidence.
muscles was demonstrated
Drechsler et al (1997) provide a clear rationale for
an
experiment to compare two treatment regimes for ten
The reason for the result
was deemed to be due to relaxation of muscle spasm, although the sample size was small.
nis elbow, while also adding to the current debate on the
Fernandez-de-las-Peflas et al (2005) set out to prove
deficiencies of treatment regimes which address inflam
that trigger pointing (ischaemic pressure technique) was
matory rather than degenerative causes of tendinopathy.
beller than frictions for treating myofascial trigger points.
A 'standard' treatment group was exposed to several inter
However, in their pilot study (with a total of 40 subjects
ventions including transverse frictions while a neural
split into two groups), both techniques were equally effec
tension group was exposed to mobilization of the radial
tive in reducing tenderness. The frictions were applied for
nerve. Results showed no significant difference for any
less time than the 10 min currently advocated on the basis
variable tested; nevertheless, it is concluded that neural
of clinical experience but the study may have implications
and joint mobilizations together were superior to the
in widening out the range of situations where the applica
'standard' treatment techniques.
tion of frictions could be beneficial
In contrast to the above studies, Davidson et al (1997)
Despite the paucity of evidence, good clinical results
and Cehlsen et al (1998) used animal studies to pro
have been observed following transverse frictions and,
vide support for the application of augmented soft tis
until proven ineffective, its use is advocated according to
sue mobilizations, applied parallel to the fibre direction,
certain principles discussed below. The above studies sug
to promote the healing process in tendinopathy. These
gest that possible beneficial effects include improved mus
soft tissue pressures could be considered to be similar
cle function, stimulation of an inflammatory reaction and
to the pressures delivered by deep transverse frictions.
repair due to proliferation and activation of fibroblasts in
Controlled application of microtrauma through pressure
the absence of inflammation. if ultrastructural changes
in this way promoted fibroblastic proliferation and activa
occur local to the applied pressure and take time to sub
tion, dependent upon the depth of the pressure applied,
side, this has implications for ensuring that the technique
leading to repair in the absence of inflammation.
is delivered to the target tissue and for the timing of sub
Parallels could be drawn with a study conducted by Cregory et al (2003) who used an animal model to
sequent applications of the technique. A snapshot of current practice is provided in Table 4.1
in
that lists the 'top ten' lesions treated with frictions drawn
previously normal muscle tissue following 10 min deep
from a survey of 86 physiotherapists' practice in the mid
transverse frictions. Obvious reddening of the skin was
Lothian area of Scotland
demonstrate the
ultrastructural changes
occurring
(I.
Kerr, unpublished work 2006).
present immediately after deep transverse frictions, with in�ammation and changes in myofibre morphology still apparent 24 h later. However, the ultrastructural changes described after 6 days were not those routinely associated with regeneration of muscle tissue after injury, such as
Aims of transverse frictions To i nd u ce pain rel ief
haemorrhage, inflammation and macrophage activity, but
An in-depth discussion of the pain-relieving effects of
more consistent with the repair process. it was also clear
manual therapy techniques is outside the scope of this
that the ultrastructural changes occurred locally under the
book and the reader is referred to the work of Vicenzino &
area to which treatment had been directed. What the study
Wright (2002), who provide an account of the current evi
was unable to clarify was whether or not these changes
dence. Pain relief following the application of transverse
56
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Chapter
I 4 I
Orthopaedic medicine treatment techniques
Table 4.1 'Top 10' lesions treated with transverse frict ions
(86 respondents)
The traumatic hyperaemia induced by the application of deeper graded transverse frictions over a longer period of time in chronic lesions may produce analgesia through changes in the local microenvironment of the tissues via an
POSITION
LESION
1
Lateral collateral l ig amen t of the
increased blow flow. These changes may include removal of
a n kle
2 r-3
Rotator cuff tendons
4 lS
Medial col lateral lig ment of the knee
the chemical irritants that sensitize or excite local nocicep tors, a decrease in local oedema and pressure, the produc tion of local heat and facilitation of the repair process. Pain modulation may be induced through several com
Tennis elbow
plex phenomena, including spinal and central nervous sys tem med1anisms acting individually or in combination, to produce desired effects. The gate control theory proposed
Achilles tendlnopathy
by Melzack & Wall in 1965 is a theory of pain modulation
6
Muscle strain
level, especially nociceptive impulses. \"'ithin the spinal cord
7
Patella tendmopathy
8 I--9
that affects the passage of sensory information at spinal cord there are mechanisms which 'open the gate' to impulses pro voked by noxious stimuli, and mechanisms which 'close the
Tend i n o p a thy
gate', thus reducing the awareness of noxious stimuli.
Golf
the A-beta fibres, that reduce the excitability of the nocicep
Pressure
low-threshold
mechanoreceptors,
tor terminals by presynaptic inhibition, effectively 'closing
De Qu ervilln's tenosynovitis
10
stimulates
the gate' on the pain. The A-beta fibres are myelinated, fast conducting fibres which basically 'overtake' the slow con ducting fibres to reach the gating meci1anism, closing it to
frictions has been clinically observed and a number of working hypotheses are proposed to substantiate this. Farasyn (2007), for example, suggests that frictions applied to muscle releases stimulation of sensitized neurons and reduces referred pain.
incoming painful stimuli. The greater the mechanorecep tor stimulation, the gTeater the level of pain suppression (Bowsher 1994, Wel. ful spot reduces pain, enabling the transverse frictions to be graded in depth, specific to individual lesions, and thus to produce their beneficial effects. The reduction in pain achieved seems to be fairly long lasting, possibly longer than expected. Transverse fric tions, like rubbing or scratching the skin, are considered
Aims of transverse frictions
l.
to be
To Induce pain relief.
•
To produc
•
To produce
therapeutic
it
form of noxious counterirritation that leads to
a desired analgesic effect (de Bruijn 1984). Inhibition, mo vement
a traumatic h ype ra emia • To I m p rov e fun ct i on
which produces lasting pain relief. is believed to be In chroniC leSions
through the descending inhibitory control systems via the periaqueductal grey area - the key centre for endogenous opioid analgeSiC mechanisms
Endogenous opioids are
inhibitory neurotransmitters which diminish the intensity of the pain transmitted to higher centres (de Bruijn 1984,
The reduction in pain is experienced as a numbing or analgeSiC effect, i.e. a decrease in pain perceived by the patient who will often acknowledge this by saying you
Melzack & Wall 1988, Coats 1994). De Bruijn (1984) treated
13
patients with deep transverse
frictions to various soft tissue lesions. The time required to
have 'gone off the spot'. I-lowevec with faith in diagnosis
produce analgesia during the application of deep trans
and accurate knowledge of anatomy, this should be the
verse frictions was noted to be 0.4-5.1 min (mean 2.1 min)
Signal to grade the friction more deeply to apply benefi
while the post-massage analgesic effect lasted 0.3 min-48 h
cial treatment appropriate to the lesion.
(mean 2Gh).
Following treatment the comparable signs can be reas
Carreck (1994) evaluated the effect of a IS-min gen
sessed and a reduction in pain and increase in strength is
eral lower limb massage (effleurage and petrissage) on
usually noted. This induced analgesia is utilized to allow
pain perception threshold in 20 healthy volunteers and
the application of graded mobilization techniques in
showed that the massage significantly increased the pain
acute lesions. In chronic lesions, an initial analgesic effect
perception threshold for experimentally induced pain.
is required through the application of a gentler grade of
Conversely, Kelly (1997), using deep transverse frictions
transverse frictions; the technique is then applied with
on normal volunteers,
increasing depth to provide a traun1atic hyperaemia and
in the pain pressure threshold, although there was an
pain rei ief to allow graded mobilization to be applied.
improvement in function that will be discussed below.
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reported no significant change
51
I
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Pri nciples of orthopaedic medicine
Massage in i ts various forms is considered t o be a pla
When applied in the early inflam matory phase, gentle
cebo, having a therapeutic effect on the psychological
transverse frictions (approximately six sweeps) cause an
aspects of pain. There is no doubt that a professional alti
agitation of tissue fluid that may increase the rate of phago
tude, including a thorough patient assessment and diag
cytosi s by chance contact with the macrophages ( Evans
nosis, an explanation of the problem and the bene ficial
1980).
effects of the proposed treatment intelvention, together
matory stage following injuty, depending upon the irrita
with involve ment of patients in their own recovery, has
bility of the condition. it is applied in this 'gentle' manner
It is a useful treatment to apply in the acute inflam
great effect. Transverse frictions as a form of massage may
before scar tissue formation has truly begun, but should be
also have a placebo effect.
graded appropriately to avoid increased bleeding or disrup tion of the healing breach. I n an experiment to evaluate pain and range of move
To produce therapeutic m ovement
ment in acute lateral l igament sprai n of the ankle, the
Transverse friction aims t o achieve a transverse sweeping
effect of transverse frictions together with Crade A mobi
movement of the target tissues - muscles, tendons and
lization was compared to Grade A mob i l i zation alone
ligaments - to prevent or e l i m inate adhesions (Wieting & Cugalj
2 0 04 ) .
(Kesson & Rees, unpub l i shed work
2002 ) . The experimen
This transverse movement, together with
tal group received transverse frictions and Grade A mobi
graded mobilization, discourages the stationalY attitude
l i zation, while the comparison group received Grade A
of fibres that promotes anomalous cross-link formation.
mobilization alone. The sample size of 16 was too small
By combining transverse friction and mobilization i n this
to allow statistical significance or general ization but the
way, the technique attempts to reduce abnormal fibrous
experimental group showed a greater overa ll
adhesions and improve scar tissue mobility by encouraging
in range of movement and a greater overall decrease in
2002,
pain on single leg standing than the comparison group.
normal alignment of soft tissue fibres ( Brosseau et al Wieting & Cugalj
2004,
Lorenzo
2008 ) .
The therapeutic
movement may facil i tate the shear and g l iding properties
However,
illcrease
it was noted that twO sub jects experienced
a decreased range of movement and four experienced
of collagen, allowing subseq uent longitudinally applied
increased pain on s ingle leg standing in the experi men
stresses, through graded mobil i zation techniques, to stimu
tal group. The mean number of days post-i nj ury for the
late fibre orientation towa rds enhanced tensile strength. In
experimental group was
this way adhesion formation is prevented in acute situa
i n a larger trial it could have i mplications for assessing the
tions and mobilized in chronic situations.
4.4
and if this trend were upheld
appropr iate time to apply transverse frictions in terms of
Friction potential l y exists whenever two objects come
assessment of irritabil i ty. The suggestion is that the appro
into contact with each other, w h i ch is w h y it is i mpor
priate t i m e for applying transverse frictions and Crade A
tant that the depth of applicatioll of transverse frictions
mobil ization cannot be determ ined in terms of nu mber
should ensure that the therapist's finger makes contact
of days post- injury, but should be assessed in terms of the
w i t h the target tissue, albeit via the skin and superficial
injury sustained and the irr i tability of the lesion.
tissues. A shear force is one that attempts to move one
In the chronic infl amm atory phase, deep transverse
object over or against another and is applied parallel to
frictions produce t h erapeutic movement, increasing fric
the contacting surfaces i n the direction of t.he attempted
t i onal forces and generating heat to soften and mobil i ze
movement. The greater the contact force v i a the th erapist's
adhesive scar tissue. This prepares the structure for other
finger on the target tissue and/or the rougher the con
graded mobilizations that a i m to apply longitudinal
tacting surfaces, the greater the force of friction. i magine
su·ess.
rubbing your
hands together;
the
harder
you
press,
the greater the contact force and the greater the friction gene rated ( Levangie & Norkin
2001 ) .
Friction generates
heat and may therefore promote movement of the tissues
To produce a traumatic hyperaemia i n chronic lesions
by reducing pain and v i scosity
I n creasing the depth of transverse frictions, i.e. the con
A therapeutic to-and-fro
tact between the therapist's finger and the target tissue,
movement a i ms to m i mic
the function of the target tissue to prevent adhesive scar
together with an i ncrease in time of the appli cation of the
tissue formation in acute Jesi ons and to mobilize estab
technique to approx i mately
lished scarri ng in chronic lesions. For this reason, muscle
trau matic hyperaem i a and is lIsed exclusively for chron ic
bellies are placed into a shortened position to faci l itate
lesions. The hyperaemia is caused by the mechanical
broadening of the muscle fibres and liga ments are moved
action of the technique ( Brosseau et al
1 0 min
produces a control l ed
2002 ) .
across the underlying bone. in the case of tendons, trans
A superficial erythema (redness) develops i n the skin
verse frictions a i m to move the structures passive/y, either
through dilatation of the arteri oles and it i s assumed
within the su rrounding connective tissue or between a
that the same reaction is occurring in the deeper tissues
tendon and its sheath . Tendons in sheaths are therefore
w here the effect is required (Winter
put on the stretch to allow mobilization of the sheath
of redness that develops under the finger may also be
around the solid base of the underlying tendon.
slightly raised and warm (a wheal), indi cating increased
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19G8).
The area
Chapter
I 4 I
O rt hopaedic medicine treatment tech n i ques
permeab i l i ty of the ca p i l l a ry wa l l s that a l lows tissue fl u i d t o pass i n t o the surro u nd i n g area ( N orris 2004 ) . Massage, w h i c h i n creases b l ood
flow
i n t h i s way,
changes the
m i croenviro n m e n t of t h e t i ssues, prod u ci ng local heat and decreas i ng p a i n by faci l i t a t i n g the removal o f c h e m i cal i rritants which sensi tize or excite local nociceptors. Th is Illay al so produce a decrease i n p a i n by fa ci l i ta t i n g the transportation o f endo genous opiates. The work of G regory et al ( 2003), described ab ove, i n d i cated
t h at
tra nsverse
frictions
a p p l ied
fo r
10 m i n
produced ul trast ructural changes i n s keletal muscle i n i t i a l l y co nsistent with the i n fl a m m atory p rocess a n d u l ti mately w i t h t h e reparative process. T h e observation o f the redness a n d t h e w h e a l fo l l ow i n g t h e a p p l ication of 10 m i n transverse fri ctions may be sufficient to s t i m u l a t e a control led i n fi a m matory reac t i o n wh ich could be responsi b l e fo r boosting the rep a i r p rocess in chro n i c lesions. A p p l y i n g appropriate graded m o b i l izat i o ns after the friction tec h n i q u e a i ms to e n s u re hea l i n g w i t h i n the presence of move m e n t a n d the prod u c t i o n of a strong mob i l e scar. Although no c l i n ical evidence exists to support th e exact t i m i ng of 1 0 m i n a ft e r ach ievi n g an a n a l gesic effect, it is the a p p rox i mate t i m e taken to i n d uce a n d observe the s k i n cha nges described. However, tenderness in the target and overlying tissues may be a product of the i n d uced
To i m p rove f u n ct i o n T h e therapeutic
m o ve m e n t
a c h i eved
and
pain
rel ief
i n d uced by transverse fricti o n s produce a n i m med iate c l i n i c a l i m p rove m e n t i n fu nct i o n of t h e struct ure t reated. This can be dem o n s t rated by reassess m e n t of the compa ra b l e signs i mmed i a t e l y after trea t m e n t a n d p rovides an opti m u m s i t u a t i o n for t h e a p p l i ca t i o n of other graded m o b i l i z i n g techn iques. As d iscussed a b ove, Kel ly ( 1 9 9 7 ) and I watsuki e t al ( 2 0 0 1 ) cond ucted stud ies which d e m o nst rated i m p roved m uscle fu nct i o n in terms of strength of con traction, w i t h K e l l y a l s o d e m o n stra t i ng i n c reased range of movemen t .
Principles of applicat i on of transverse frictions Tra n sverse frictions s h o u l d be appl i ed to t h e exact s i te of t h e l es i o n . Th is re l i es o n c l i n ical d i agnosis a nd p a l p a t i o n of the l e s i o n, based on a n a to m i ca l k n o w ledge and the struct u ra l orga n ization of t h e tissue. Te n d e rness is n ot necessa ri l y an accurate l o ca l i zing s ign, t h e refore p a l pa t i o n must reproduce the patient's p a i n and be d i ffe rent i n co m parison w i th t h e other l i m b . Tra nsverse fi· ictions are a l ways appl ied transve rse ly across the longitud i n a l fibre orientation of the st ructure ( Fig. 4 . 2 ) .
i n fl a m matory respo nse; there fore at least 48 h ( pOSS i b l y
G
days, see t h e work b y G regory et a l described above ) i s
reco m me nded between t h e trea t m e n t sess ions i n ch ro n i c lesions, i n o r d e r fo r t h e tender ness to s u bs i d e. T h e work of Davidson et al ( 1 9 9 7 ) and Geh lsen et al ( 1 9 9 8 ) sug gests that in chronic tend i nopathy ( i .e. a degenerative process) rep a i r may occ u r i n t h e absence of i n fl a m m a t i o n b y i n creasing the n u m be r a n d activity of the fibro b lasts. Th eir work suggests that greater fi b ro b l astic p ro l i fe ra t i o n and activity occur w i th deeper pressures, i nd i c a ti ng the appropria teness of deeper graded transverse fric t i o n s i n chro n ic lesions. Al though t h e tra u m a t ic hypera e m i a may be d es i r a b l e i n chro n i c lesio ns, t h is is not Lhe case i n acute l es i o n s where the response is al ready excess ive. G e n t l e transverse fri cti ons app l i ed to acute lesions fo r ap prox imately six sweeps after ach ievi ng an a n a l gesic effect are pe rformed w i th reduced depth a n d t i me to avoid prod u c i n g t h i s tra u m a t i c hypera e m i a . S u c h patie n ts are treated ide a l l y on a d a i l y basis, or as often as poss i b l e, to ensure h ea l i ng w i t h i n the presence of move ment a n d to encourage t h e fo rmation of strong m o b i l e scar tissue.
Clinica l tip The exact grade of transverse frictions is determined by the i r r i tability of th e lesion and throu g h feedback from the patient, but, to be effective, they must be deep enough to reach the target tissue.
Figure 4.2 Transverse frictions of: (a) a tendon (supraspinatus); (b) a tendon in sheath (peronei); (c) a ligament (medial collateral) in flexion and extension; (d) muscle be lly (hamstring).
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1
I
Princip les of orthopaedic med i c i ne
This a i ms to prevent or mobilize ad hesion for mation between ind ividual fibres and between fibres and the sur round ing connective tissues. Application of the tech nique in this manner deters a stationary attitude of fibres and a i m s to preven t or mobiliz e anomalous cross-links. The longi tudinal st ress applied i n accompanying graded mobi l ization techniques sti mulates fi b re orientation w i t h i n the col lagen weilve and increilses tensile strength. Tra nsverse fri ctions are appl i ed with sufficient sweep to cover the full width of the s tructure, theoretically a i m i ng to move the con nective tissue fi b res transversely across the whole affected si te. The therilpist must be pos itioned to ensure t hat this sweep i s maintained th rough the app l i cation of body weight. With the transverse f ricti o n t ech niques de mo ns tra t ed in t he p hotographs within this book, the direction of friction usua lly follows the direction in which the fi nge rs or thumbs are poi nti n g . Arrows have been i ncluded where the d irection of movement d i ffers from that 'rule' or to emphasize the direction where it ma y not be cl ea r.
Ligaments are put under a sma l l degree of tension to tigh ten the overlying soft tissues, allowing the target tissue to be reached.
•
The therapist should adopt a position that u t i l izes body weight opti mally, ensuring sufficien t sweep and depth. Tra nsverse frictions can place considerable strain on the hands (Sevier & W i lson 1999 ) , Snodgrass et ill (2003) l ooked a t factors re lating to thumb pai n i n physiotherilpists and manual techn iques in general were hig h l ighted as the cause of pain fo r all symptomatic subjects stud ied . W h i lst not ideal, handheLd devices have been developed to help to preve nt occupational i njury but strain on the d igits can be red uced by using body weight to pelform the techn ique. Care should be taken to adopt a position that places the operator at a mechanical advan tage. Sitting is possi ble, but the most effecti ve position to a pply body weight is with the patient situated on a plane l ower than Ille therapist. Consideration should also be g iven to the vari ety of ways the hands can be used to avoid fatigue and ovemse ( �'ig. 4 .3),
� ,
Transverse fr ictions are a p plied with effective depth, aim ing to reach and benefit the target tissue. Knowledge o f a natomy is para mount. The depth is mai ntained by applying the technique slowly a nd deli berately, but it is the shear force between the superfic ial tissues and the underlying target t issue wh ich generates friction and pro duces heat, as mentioned above. While this latter effect is desirab le, care m ust be taken to nlaintain the depth of the tec h n ique, as i n c reas i ng speed tends to l ift the effect towards the more super ficial tissues. The g rading il nd d uration of application of transverse frict i ons is i n tended as a cli n ical g u ide, the depth of tech n i q ue being dependent upon the irrita b i l i ty of the lesion and feed back from the patient. The depth of the i ni t ial sweeps s h o u l d a l ways be gen tle to gain an ana lgesic effect before proceedi ng w i th the effective frictions. Application in this way will d ispel the myth that transverse frictions are a pai n ful t reat ment tec h n i q ue. The patient is positi oned ta k i ng into acco u n t the situ ation in which the structure is most accessible and the degree of stretch or relaxation app ropriate: •
•
•
•
Te ndons in a sheath are placed on the stretch to a l low the trilnsverse frictions to roll the sheat. h around the firm base of the tend o n, facil ita t i ng fu nctional movement between the tendon and i ts sheath. Tendons are placed into a position of accessibility, with the lesion com m only lying at the teno-osseous j u nct i o n . Consideration is g iven to anato my. M uscu lotendi nous j unctions usually respond wel l to transverse frictions a n d need to be placed in a position of access i b ility. Muscle bellies a re placed in a shortened, relaxed posi tion to faci l i ta te b roaden i ng of the muscle fibres, i m i ta ting fu nction.
,Y
I
(a)
\
, '.
..
..
, '
\,
.'
\\
(c )
® Figure 4,3 Hand positions for transve rse frictions, (a) Index finger reinforced by m iddle fin ger; (b) middle finger reinforced by index finger; (c) thumbs; (d) ring f in ger; (e) pinch grip; (f) hands; (g) h an d guiding the flat of the elbow.
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Chapter
I 4 I
O rthopaed ic medicine treatment techn iques
The therapist's finger and the patient's skin and superfi cial tissues should move simultaneously to avoid raising a bl ister and to ensure th�t the superficial tissues are moving over the underlying target lissue, generating a friction force between the m. The most efficient way of achieving this is to apply the tedl n ique i n both d i rections. Pressure is first di rected downwards onto or aga inst the structure and then mai ntained while the tra nsverse sweep is appl ied. A� a general gu ideli ne, transverse fTictions are appl ied for an appropriate time to achieve the desired effects. For chronic lesions, 10 min after the ana lgesic effect has been adlieved is suggested . However. due to the i nd uced traumatic hyperae mia or local inOammatory response, treatment is repeated at a suggested minimum interval of 48 h to allow the tender ness generated in the target and overlying tissues to subside. It is suggested that gentle transverse frictions are appl ied to acute lesions for approximately six effective sweeps o nce SOJlle a nalgesia is ach ieved and the target tissue reached. It may be necessary to wOril through soft t issue swel l i ng asso ciated with ule injury, to be able to reach the target site. Treatment can be on a daily basis, if practi cally possible, to promote pain rel ief and therapeutic movement. These gu idel i nes a re l a rgely based 0 1 1 expert c l i n i ca l o p i n io n and, a s discussed above, no clin ical evidence has been found to support them. From the practical aspect, the d u rat ioll of appl ication usually fits in with appoint ment t i mes and a l l ows for both reassessment and the appl ication of other modal ities of treat ment j u d ged to be appropriate. Th is was not borne out by a su rvey by J. Kerr ( u n p u b l ished work 2006) however, where respond en ts did not c l a i m app o i n tment tim es as a factor in the n umbe r of m i n u tes they selected for the application of Frictions. Absolute contraind i cations to transverse fr ictions are few (see Box below). The tech nique is never appl ied to active con d itions, e.g. areas of active infection such as a boil or p i m ple or acti ve in fla m m atory arthritis in which the con nective tissue structures are too i rritable. Care is req u i red if there is fragi le skin or t he patient is currently u ndergoing anticoagu lant th era py. Bursitis may be aggravated.
GRAD ED MOBILIZATION TECH NIQUES Grade A, B and C mobi l izations (Saunders 2000) are spe cific mobil ization tec h n iq ues a ppl ied to achieve a par ticular purpose. Each mob i l ization described below is a n i n d i vidual technique a i m i ng t o achieve specific effects and one is not i ntended t o be a progress ion of the other. The terms a re used in d i ffere nt ways when referring to peri ph eral and spin
PERI PHERAL GRAD ED MOBILIZATION TECH NI QUES Peripheral Grade A mobi l ization Periphera l Grade A mobil ization is a passive, active or act ive/assisted mobi l ization pe.formed w i t h i n the patient's pa in- free range of movement, a i m ing to provide or maintain mo b i l i ty. It is appl ied w i t h i n the elastic range. I n peripheral lesions it is us u a l ly a pp l ied to i rritab le, acutely i n flamed or p
Ai ms of peripheral Grade A mobi l ization To prom ote tissue f l u i d a g itat i o n
!n peripheral lesions, G rade A mobi l izat i on, e i t h e r act i ve or passive, prod uces a gentle soft tissue movement agitat ing t issue fluid i n the acute i n flam matory phase and facil itating the phagocyt i c act ion o f the macrophages ( Evans 1 980). The movements are of sma l l a m p l i tude, s low, pain-free, without force and repeated often. To prevent a stat i o n a ry attitude of f i b res
Contraindications to transverse frictions local • Infection •
Inflammatory arthritis
•
Cu ta neou s malignancy Active skin disease • Deep vein th rombosis •
Caution • Frag i l e s k i n •
Anticoag ulant the ra py
•
B u rsit is
and blood clot t i n g
disorders
Periphera l Grade A mobil ization w i l l promote movement w i t h i n con nective t issue structures to prevent a st
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Principles of orthopaedic med i c i ne
I 1 I
a l iga m e n t is promoted by perfo r m i n g active p a i n - free m ovement, mainta i n i n g the l i ga m e n t's a b i l ity to gl ide over t h e u n derlying bone. I n overuse lesions, e.g. t e n d i nopat hy,
the
patient
m a i n t a i ns
normal
fu nction
by
perfo r m i n g move m e n t w i t h i n the p a i n - free range a n d avoi d i n g the pai n fu l move ments.
Peri pheral G rade B mob i l i zation A peripheral G rade B m o b i l ization is a mob i l ization per formed at the end of avai l a b l e range i n to the plastic rallge. It is a spec i fi c susta i n ed stretc h i ng tech n i q u e t h a t a i ms to fac i l itate perm a n e n t e l o nga t i o n of con n ective tissue.
tissue struct u res
Aims of peri pheral Grade B mobi l ization
Periphera l G rade A mob i l ization a i m s to i mpart s u ffi
To stretch ca psular adhesions
To a p p l y a longitu d i n a l stress to co n nective
cient l o n gi t u d i n a l s t ress to promote orientation of co l l a g e n fibres w i t h i n t h e ex i s t i ng para l l e l co l l agen weave. As acute lesions su bside, a n d once i t is j u dged that there is s u ffici e n t tensi l e strength in the wo u n d , the patient may beg i n to ' n u dge' p a i n to prov ide l o n gi t u d i n a l stress but without d isru p t i ng the hea l i ng breach. G rade A mobil iza t i ons performed i n t h is way are o f short d u ration, a re not fo rce fu l a n d are repeated often. Th is fo rm of m o b i l i zation i s a p p ropri ate fo r t h e repa i r phase of connective tissue i n j u ries, and as progress is made an i n creas i n g range of movement is encouraged. I n U) is way t h e deve l o p i n g scar tissue is stressed, not stretched (to avoid over-stress i n g t h e hea l i n g t i ssues), a i mi n g t o restore fu l l fu n c t i o n a l range. Tissues w h ich heal w i t h i n the presence of movement i n t h i s way should n o t req u i re 'trad i ti o n a l ' stretch i n g i n t o the p a i n fu l range.
I n t h e early stages of art h rit is, pain causes t h e j o i n t to be held i n a pos i t i o n of ease, restrict i ng movement of some parts of the j o i n t ca psu l e. Th is promotes a d isordered d eposi tion of collagen fi b res a n d the normal Oex i b i l ity of t h e j o i n t cap s u l e is i m peded by a n o m a l o us cross - l i n k fo r mation. The cha nges in the ca psu le contribute to contrac t u re a n d the ca psul a r ad hesions severely restrict the range of movement, caus i ng pain
a nd a l tered fu nct i o n . The
a i m of trea t m e n t by Grade B mobil ization is to lengthen t h e capsu l a r contracture perm a n e n t l y, to restore normal move ment. Adhesions mat develop wiUl i n the capsule of a syno vial joint tend to be tough and u ny i e l d i ng. The shou lder and hip joi nts co m monly dem onstrate this gross loss of fu nction and respond well to Grade B mobil ization, pro vid i ng the joi nts are in a non-irritable state. However, the tech n ique could be applied to any non- irritable capsu l itis
To p romote normal f u n ction
i n which pain and loss of movement are cl i n ical features.
Peri phera l Grade A mobil ization i s a p p l ied e a r l y i n t h e
w i t h the restricted movements demonstrating a 'hard' end
i n fla m m at ory phase to ensure t h a t fu nct ion is ra p i d l y regai n e d . Hea l i n g w i t h i n t h e presence of move m ent pro motes a ret u rn to fu nction, i . e. form fo l l ows fu nct i o n . The range of move m e n t is gra d u a l l y i n creased, a p p ly i ng suffi cient stress to the wo u n d to promote orientation of fibres. Control l e d m o b i l izat ion of acute lesions sho u l d prevent the need fo r s t retc h i ng tissue. In chronic i n j u ri es, once the lesion is re ndered p a i n free b y transverse
frictions o r cort i costeroid i n ject i o n,
norm a l move ment w i l l promote remode l l i n g and a l i gn ment of fibres and restora t i o n of fu nct i o n . However, u n t i l s igns a n d symptoms subsi de, i t i s suggested t h a t over use activity sho u l d be avoided i n l esions aggrava ted by re petitive move me nts, and resisted exercise and stretch i ng postponed u n t i l t h e scar tissue is ful ly m o b il i zed a n d the sel ect ive t e n s i o n tests p a i n - free.
Characteristica l l y the joint is l i m ited in the caps u lar pattern, feel (see Ch.
1).
Peripheral Grade B mob i l ization i s ai med
at restoring the movements l i m i ted in me caps u l a r pattern. Pe r i p hera l Grade B mobil ization is a p p l i ed at the end of ava i l a b l e range, appreciating the end-feel a nd the patien t's pain response. To be successfuL the end -feel should sti l l have some e l astic q u a l i ty, but the sensa tion o f m uscle spasm may also be apparent as the tech n ique is appl ied wim in a painful range. The tech nique is a slow, susta i ned and repeated stretch, perfo rmed a t the end of avail able range fo r the d u ration of the patie nt's pain tolerance. As soon as me end range pos i t i o n is released, an i m med i ate rel i e f of pain should be fe l t . If p a i n l i ngers at t h i s stage, me j o i n t may be too i rritable and the technique i n appropriate. Successful treatment is dependent upon patient com p l ia nce as the manage ment of the co n d i t i o n is long-term. Theoretica l ly the tissue to be stretched needs to be taken i n to the p l astic range to achieve permanent lengtheni ng,
To reduce a loose body or bony subl uxation i n a periphe ral joint
w i t h sufficient force appl ied to stra i n and break some of the co l lagen cross- l i nks i n th e adhesive scar tissue, produc i ng m icrofa i l u re. However, as the capsu l a r t i ssue possesses
To reduce a peri pheral j o i n t loose body (e.g. i n the h i p,
viscoelastic properties, t h is can be u t i l ized to ga i n increased
knee o r e l bow ) or a bony s u b l uxation (e.g. carpal bone),
range of m ove m e n t . The fo l l owing factors re lating to the
a G rade A m o b i l iza t i o n is performed u nder strong trac
behaviour o f connect ive t issue un der mechanical stress
2)
t i o n , the p r i n c i p a l co mponent of t h is tech n i q ue, giving
(see Ch.
the fra gment space to move.
suggested for tough, u nyiel d i ng caps u l a r ad hesions.
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can be appl ied to t h i s mobil ization, which is
Chapter
I 4 I
Orthopaedic medicine treatment techniq ues
Prolo nged i m m o b i l ization produces j o i n t co n t ractu re,
w i t h m o re i nvol ve m en t of the j o i n t capsu le t h a n t h e soft t i ssues surrou n d i ng t h e j o i n t ( Usuba et al 2007 ) . A s t a t ic
stretch of s low, susta i n ed, low fo rce, appl ied towa rds the e n d o f t he e lastic l i m i t o f the scar t issue, u t i l izes t h e vis cous flow phenomenon w h i c h e n a b l es the co n t racted
SCiH
t issue to creep or l e ngt h e n gra d u a l ly (Am i s 1 9 85, H a rdy & Woo d a l l 1 9 98, lIsuba et al 2007 ) . Grade [)
mobil iza t i o n i s a static stretch a p p l i e d to
the patien t's pain thres hold poi n t . The i n c reased l ength ach ieved is apparently due to cross- l i n k disruption, fi b re s l i p page and eventual structural cha nges ( H ardy & Wood a l l 1 9 9 8 ) . Lengthen i ng, u nder these circumstances, is inversely proportional to t.he velocity of the app l ied stretch w i th a slowly appl ied force meet ing w i th less resistance or sti ffness ( i t is easier to move s l owly t h rough a viscous med i u m ) .
Hysteresis ( t he slower rate a t w h i c h t h e structure recovers fro m the el ongating fo rce) may also play a rol e a n d can be l i n ked to cycl ical loading where subseq uent appl ications of Grade [) m o b il iza t ion achieve a modest i ncrement o f
increased l e ngt h w i t h each mobi l i zil t io n a p p l ied .
The s t ructural cha nges occurring i n t h e m o b i l ized t i ssue may prod uce a low-grade i n fl a m m atory response and t h e
To reduce pain [ n a rt h ritis, the i n fl a m matory changes involve b o t h the syn
ovi a l l i n i ng of the j o i n t and the fibrous capsule. The capsu l e develops sma l l lesions t h a t u n dergo scar tissue fo rmation, producing adhesions or capsu l a r thickeni ngs. The adhesions are a ffected by j o i nt movement wh idl, through abnormal tension, sti m u l ates the free nerve endings lying i n the cap su le, produ c i ng mechan ical pai n . The nerve endings also respo n d to the che m ical products o f i n fl a m ma t i o n - hista m i ne, k i n i n s a n d prostagl a n d i ns. [ m p u l ses are LIanspo rted in the n o n-myel i n ated C fibres and a 'slow', a c h i n g, t h rob b i ng p a i n i s produced wh ich is poorly defi ned, i .e. chem ical pa in ( Norris 2004 ) . The pain and associated i nvol u ntary musc l e spasm reduce movement, a l lo
wi ng h ea l i ng to occur
in a shonened pos i t i o n a nd res u l t i ng in reduced funct io n . Sustai ned or re p e t i t ive passive j o i n t move m e n t m ay m o d i fy t h e fi r i n g responses i n l a rge-d i a m eter mech a n o re cepto r j o i n t a fferents, part icu l a r l y when the capsu l a r stretch is m a i nta i ned at or near ule end o f range. This presents an
exp l a n a t ion
that
acco u n ts
fo r
the
pai n - rel i ev i ng
effects o f e nd-range m o b i l izat i o n , i n c l u d i ng passive G rade B stretc h i n g tech n iques as well as m a n i p u l at i o n .
p a t i e n t shou l d be warned a b o u t post-trea t m e n t soreness. The i m portance of co n t i n ued move m e n t to m a i n t a i n t h e e lo ngat i o n achieved ca nnot be stressed enough, a n d t h e p a t i e n t m u s t be given an a p p ropriate exercise p rogra m m e t o m a i n t a i n the range ach i eved. The opt i m u m d u ra t i o n and
freq uency o f the static
stretch hilS yet to be dete rm i n ed, but the work of Brandy &
Cli nical tip Peripheral Grade B mo b i l i zat i o n produces some treatment soreness. This gives a guide to irritabil ity of the lesion an d
progression of t rea t m e nt.
Irion ( 1 9 9 4 ) and Brandy et al ( 1 9 9 7 ) suggests that i n order
______
----1
to ach ieve a n i ncrease in range of knee flexion, a static stretch o f 30 s a p p l i ed to the hamstring m uscles is suffi
The
perm a n e n t
l e ngt h e n i n g
ach ieved
by
Grade
B
cient. However, lheir studies fa l l shon of determ i n i ng how
m o b i l ization reduces the m echanical stress a n d there fore
long the i ncreased flexi b i l ity in t h e m uscles lasted.
inflammation, w h i c h in t u m rel i eves p a i n . N o r m a l move
The appl ica tio n of heat rel ieves pain and lowers the viscos
wing a greater elo ngation
ity of coJ i agen tissue, al l o
of col la
m e n t pattellls are restored. Th is provides a s t i m u l u s to fibre a l ignment and orientation w i t h i n the c o l l agen weave
gen tissues for less fo rce. Warren et al ( 1 9 7 1 ) considered lhe
effect of temperature and load on elongalion of the co l l agen fibre strllcture of rat t a i l lendon .
A
range of loads was appl ied
.
To i m prove fu nction
at selected temperatures and the greatest elongation with least
T h e i n crease i n j o i n t range a n d p a i n re l i e f a c h i eved b y
m icrodamage was achieved w i lh lower loads at the higher
p e r i pheral Grade B m ob i l i z a t i o n i m p roves overa l l fu nc
therapeutic tem peratures. The mechan ism of a combined
t i o n . However, the gradual onset o f loss o f move m e n t
appl icalion of temperature and load affected the viscous
t h rough capsu l a r c o n t ra c t i o n can co nsid erab l y a l ter move
flow properties of col lagen and increasing the tem perature of
ment patterns. Careful assessment o f t h e p a t i e n t i s neces
a st.ructure a l l owed lower sustained loads to achieve greate r
sary a n d a trea t m e n t progra m m e p l a n ned w h i ch consid ers
elo ngation (Warren et a l 1 9 7 1 , Usuba et aI 2007 ) .
il l l com ponents of t h e dysfu nc t i o n , i n d u d i ng al tered bio
Ra ising l oca l temperature t o between 4 0 a n d 4 5 ° C
mechanics, muscle i m balance a n d neural tensi o n .
( 4 0 ° C i s t h e temperature o f a very hot bat. h ) ach i eves this
Peri p h eral G rade B m o b i l i za t i o n i s not u s e d exclusively
useful therapeutic effect. U l traso u n d can be appl ied to
for capsu l a r c o n t ractu res. I n chron ic m u s c l e, tendon a n d
produce t h i s t h erm a l e ffect as it has a preference fo r heat
l i ga m e n t l e s i o ns, a d a p t i ve s h o rte n i n g may be p a n o f an
ing c o l l (lgen t iss ue ( Low & Reed 1 9 9 4 ) . lIsuba et al ( 2007 )
overa l l dysfunct i o n . The s h o rt e n ed tissues can be stretched
fo u n d from t h e i r previous stud i es t h a t h eat c o m b ined
by a p p lying the p r i n c i p l es o f G rade B m o b i l ization, both
with s t retc h i ng was m o re effective than s t retc h i ng a l o n e
by the t herapist and as a home trea t m e n t reg i m e . G rade B
a n d , to a c h i eve its best effects, h e a t shou l d be app l ied
mob i l iza t i o n is a p p l ied o nce the struct u re has been ren
concurre n t l y with the G rade B m o b i l iza t i o n . However, fo r
dered fu nctio n a l ly p a i n - free by deep tra nsverse fric t i o n s
practi ca l pu rposes it is usua l ly ap pl ied befo re h a n d .
a n d negative fi n d i ngs are estab l is h ed on exa m i na t i o n by
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P ri nciples of orthopaed ic medicine
sel ective tens i o n . Con t racted tissue has a n i n fl u ence o n
tendon as a treat m e n t fo r t e n n i s e l bow ( C h .
neural structu res; however, neural t en s i o n tech n iq u es fa l l
m a n i pu l a t i o n a i ms to r u p t u re ad hesions i n te rfering w i t h
outside the scope o f t h i s text.
t h e m o b i l ity o f t h e t e n d o n at i ts i nsert i o n and w i th i n t h e
G).
The
adjacent tissues. T h e tendon is fi rst prepared b y deep
Peri phera l Grade C manipu lation Per i p h eral C r a d e C m a n i p u la t i o n
i s a passive move
transverse frictions to ga i n some pain rel i e f. fo l l owed by the m a n i p u l at i o n . The e lo n ga t i o n ga i ned must be m a i n ta i ned t h rough exercise.
m e n t performed at the end of avai l a b l e range and is a
Further trials are needed to subst a n t iate the a p p l i ca
m i n i m a l a mp l i t u d e, h igh ve l oc i ty t h rust. For cl a r i ty, it i s
t i o n of fri c t i o n s in tendinopath ies a nd the effectiveness
not s u s t a i ned, and s h o u l d be a p p l ied w i t h a sma l l, q u i c k
o f a p p l y i n g the M i l l s' manipu l a t i o n fo r the co m m o n
overpressu re, o nce a l l the s l a c k has b e e n t a k e n u p .
extensor teno-osseous j u nction at the e l bow A s m e n
M a n i p u l ative rupture o f s h o rtened s c a r tissue may b e
tioned above, the M i l ls' m a n i p u l a t i o n h a s trad i t i o n a l l y
a ppropriate i n p e r i p h e ra l l es io n s. T h e a i m o f the tech
b e e n a 'spe c i a l ' m a n i p u l a t i o n a n d t h i s is the o n l y exam
n iq u e i s m a n i p u l a tively to ru pture u nwan ted ad hesio ns,
ple of a teno-osseous j u nc t i o n b e i ng m a n i p u l ated i n cur
prod u c i ng p e r m a n e n t e l o ngal.i o n a nd resto r i n g fu l l p a i n
ren t orthopaedic m e d i c i n e practice. Th i s is ch a l l e nged by
l ess fu n c t io n . Th re l ke l d ( 1 9 9 2 ) expands o n the v iscous
Stas i nopo u l os & J o hnson (2007 ) , h owever. and other si tes
properties o f c o n n ec t i ve tissue and describes how w h e n
s u i tab l e for m a n i p u l a t i o n may e m e rge t h rough c o n t i n u i ng
the tissue is l o a d e d m o re q u i c k l y i t behaves m o re s t i ffly
reflection on practice; possibly spu rred on by the e mer
t h a n t h e s a m e tiss u es l o a d ed m o re s l o w l y. Thus ad h es i o n s
gence of evidence to s upport the use of the techn ique.
may be rupt u red m o re read i ly by stress il p p l ied q u i c kly, as i n m a n i p u l a t i o n . The s h o rt toe-phas e o f tJle ad h es i o n s e n s u res th
SPI NAL GRADE D MOBILIZATION TECH N I QUES
adhesions w h i l e the normal t issue rem a i n s i n tact. I t i s i m po rt a n t t h a t the elonga t i o n ach ieved s h o u l d be m a i n t a i ned by the p a t i e n t . I n o rthopae d i c med i c i ne, m a n i p u l a t ive r u p t u re o f u nwanted adhesions is a p p l ied in two s i tu a t i o n s :
Spinal Grade A mobil ization At t.h e s p i n al j o i n ts, a n d spec i fi ca l ly a t t h e cervical s p i n e, the term ' G rade A', is used to i n d i cate that the m o b i l iza t i o n tech n i que i s a p p l ied to m i d - rilnge, i . e. the m idd l e of the range ava i l a b l e.
Aims of peri pheral G rade C man i pu l ation
As w h e n a p p l i ed to peripheral j o i n ts, it s h o u l d be a p a i n - free mob i l i z a t i on thilt is used to reduce t h e p a t i e n t's p a i n a n d to fac i l i t ate move m e n t . It is particularly i n d i
M a n i pulative r u pture of unwa nted a dhesions between a ligament and bone
cated in the treatment of an acu te, i rr i t a b l e s p i n a l lesi o n .
Pe r i p h e ra l G ra d e C m a n i p u l a ti o n is a p p l ied to a ch ro n ic
Spinal Grade B mob i l ization
l i ga mentous spra i n o f two l ig a m e n ts i n t h e lower l i m b, the med i a l co l l ateral l ig a m e n t at the k n ee and the l a teral co l l at.er a l l i ga m e n t a t the a n kJ e . U nwan ted ad hesions may have developed between the l iga m e n t and the u n d e r l y i n g b o n e t h a t d isrupt the n o rmal fu n c t i o n a l move m e n t o f the j o i n t and on exa m i n at i o n a non-capsular pattern o f pa i n a n d l im i ta t i o n w i l l b e fo u n d . The l iga m e n t i s prepared by deep t ra nsverse fric t i o ns to ach i eve an a n a lgesic e ffect and
the
m a n i pu l at i o n
fo l l ows
i m med iately.
Effective
m a n i p u l a t i o n s h o u l d achi eve i n stant res u l ts a n d vigoro u s exercise is req u i red to m a i n t a i n t h e len gthen i ng ach ieved . Re ha b i l i t a t i o n m ust a d d ress a l l comp o n e n ts c o n t ri b u t i ng to the dysfu nct i o n .
At the s p i n a l j o i n ts, the t e r m 'Grade B m o b i l izat i o n' i s used to ind icate that t h e m o b i l izat i o n tec h n i q u e is per fo rrned to the end of the avai l a b l e range. A s with peripheral j o i n ts, it a i ms to reduce pain and faci l i tate move m e n t . The i m pol1alll d i fference is that. whereas i n peripheral j o i nts the Grade B m o b i l ization is norm a l l y performed i n to a pa i n fu l range, with l i kely provocation of i nvo l u ntilty muscle spasm, the Grade B mob i l ization at the spinal j o i n ts should never be appl ied i n to pain or muscle spasm and the tech n ique should be stopped i m med i ately i f either is provoked.
Spinal G rade C manipulation
To ru pture ad herent scar tissue at the teno osseous j u nction of the common extensor tendon (te n n i s e l bow)
The d efi n it i o n of a G rade C m a n i p u l a t i o n is sh ared by
A speci a l m a n i p u l a t i o n ( M i l ls' m a n i p u l a t i o n ) i s a ppl i ed
I t i s wo rth repe a t i n g t h a t. as fo r p e r i p heral j o i nts, s p i n a l
at the teno-osseous j u n c t i o n o f the co m mo n exte nsor
G rade C m a n i p u l a t i o n is not sustai ned, a n d s h o u l d b e
botb peri pheral a nd s p i n a l j o i n ts : G rade C man i p u l a t i o n i s a passive move m e n t perfonned a t the e n d o f ava i l a b l e range a n d i s a m i n i m a l a m p l i t ude, h igh vel oc i ty t h rust.
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Chapter
I 4 I
O rt hopaed ic m e d i c i n e treat m e n t tech n i ques
appl ied with Cl s m a l l , q u ick overpressu re, o n l y when a l l t h e slack has been taken u p . W i t h i n the orthopaedic medicine approach, s p i n a l G rade C man i pu l a t i o n c a n b e appl ied to t h e sacroiliac j o i n t as wel l as to the cervical, thoracic and l u mbar s p i ne.
Aims of spinal and sacro i l iac joint ma nipulation To restore move ment In the spinal or sacro i l iac joi nts in wh ich a non-caps u lar pattern exists, ind icating i n ternal derangement l i m i li ng the range of Inovement in some, but not a l l d i rections, man ipu lation aims to 'unlock' the joint, possibly reducing the i nter nal derangement and rel ieving compression to restore full, pain less functio n . As suggested above, the effects of mobi l ization and m a n i pulation may not be that simple and are probably m u l t i factorial, i nvolving a l l adjacent tissues.
of the study and a l l were screened for contrai ndications, i n c l u d i ng vertebal artelY insuffiency, before being treated with manipulation. The si ngle session resulted in corti cal evoked responses for u p to 3 0 m i n post- manipulation before ret u r n i ng to basel i n e levels. These transient cortical c hanges may help to exp l a i n the mechanisms respon s i b l e for the p a i n rel ief and restoration of fu nction fol lowing m a n i pulation. I t must not be forgotten that s p i n a l m a n i p u l ation can a l so re l i eve pain tll rough the pl acebo effect of s k i l ful hand l ing and care. I ndeed, Ernst ( 20 0 0 ) offers the op in ion that 'the success of m a n i pulation is l a rgely due to a p lacebo effect'. Further d i scussion on t h is topic is outside the scope of this book except to acknowledge the ro l e of t h e p lacebo e ffect a s one of t h e myriad of factors that can affect trea t m e n t ou tcomes. It i s not possi b l e to q u a n t i fy t h i s effect, a l though m a ny t r i a l s try t o e l i m i nate i ts effect by esta b l is h i ng con trols. A d iscussion fo l l ows on man i p u l a t i o n, its proposed effects a nd how they m ight be ach ieved.
To rel i eve pain M a n i pu lation-induced hypoalgesia ( pa i n rel ief) is wel l docu men ted (vVrigh t 1 99 5 , Vernon 2 0 0 0 ) . Restoration of fu nctional m ovement may i n itself l ead to reduct i o n i n pai n, but rel ief of pai n m a y a l s o be req u i red fi rs t to achieve t h is. Pa i n re l ief may a lso occur through sti m u l a t i o n o f t h e mechanoreceptors effect i ng t h e pain-gate mechanism or t h rough s t i m u lation of the descend i ng i n h i b i tory controls. Mech a n o rcceptors w i t h i n the j o i n t ca psule and s p i n a l ligaments are s t i m u l ated b y the t e n s i o n created by spinal m a n i pulation. Th is i n h i b i ts the s m a l l-dia meter nocicep tor affere n t i n p u t to the ascend i ng pathways at spinal cord level via the gat i ng mecha n is m described above. The rel ief of pCl i n achieved reduces the reflex muscle spasm and an increase i n t h e range of movement occurs. The periaqueductal grey ( PAG) area of the b ra i n, as a control centre fo r endogenous ana lgesia, is considered to play an i m portant role in the control of pa i n . Two d i ffer ent forms of a nalgesia may be produced: an opioid form that seems to be associated with sym pa thetic i n h ib i t i o n and takes a period of t i m e t o develop, a n d a no n-opioid form t hat is associated with sympathetic excitation that has a more rapid onset. Spinal mani pulation has an i m med iate effect, producing pai n rel ief with i n seconds or min utes due to the n o n-opioid form, associated with sympathetic excitation that is related to m ec h a n i cal noci ception. Over a period of about 20-4 5 m i n the a n a lgesia changes to the opioid form associated with sym pathetic i n h i b i t ion. S p i n a l man ipulation provides an appropriate s t i m ulus to activate the descen d i ng p a i n i n h i b itory sys tems fro m the PAG to the s p i n a l cord (Wright 1 99 5 ) . Haavi k-Tayl or & M u rphy ( 2007) looked a t 1 2 subjects with a h istory of recurren t neck stiffness and neck pain, to establish the effect of m a n i p u lation on sensori motor i nte gration. The subjects had no acute sym ptoms at the t i me
D i scussion on the effects of spinal mani pulation By defi n i tion, t o manipulate is defined as ' t o work w i th one's h a n ds, to treat by m a n i pu l ation' (Chambers Dictionary 200 6 ) . H istorica l l y the term was a p p l ied to describe any tech n ique that was appl ied using t h e h a nds. The term manipulation has now come to m ean 'a m i ni m a l a m p l i tude, h igh-ve locity move m e n t performed at the end of range'. The essence o f this defi n i t i o n has been adopted by all practitioners of m a n ipulation, and may a lso com m o n l y be termed 'Grade C', 'high velocity th rust' or 'Grade V' tech niq ue, etc. Spinal m a n i pu l ation can produce an i m mediate red uct io n in p a i n and a d ra m atic restorat ion of range of movement, but the mec h a n i s m by which m a n i p u l a t i o n ach i eves this is not wel l u nderstood. C l i n icians m u s t work t o t h e curre n t b e s t models i n attem pting t o provide an explanation for their manual treatment i n terve n t i o ns to both profess ional co l l eagues and patients a l i ke. The benefit of m a n i p ulation may come from many i n ter related factors rather t h a n a s i ngle mec h a n i s m . A major factor towards successful m a n i pulation is i n the selection o f a ppropriate pat i e n ts with unco m p l icated back pa i n of recen t onset. A key poi n t o f an appl ied m a n i pulation is that i t is pas sive, i .e. out of the patien t's con tro!, and, as w i t h spinal Grade B mobil ization, it should never b e performed t h rough p a i n or spasm . It a i ms to move beyond the end of tJle passive range of the joint i nto the 'para p hysiologi cal space', described by Sandoz ( 1 9 7 6 ) as existing a fter the end o f the passive l i m i t but befo re the l im i t of a na tom ical integrity is reached where damage can occur. Th i s sect i o n w i l l bliefly d iscuss some theories that rel ate
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P r i n ciples of orthopaedic med i c i n e
to t h e proposed effects o f m a n i p u l at i o n . The evidence t o support t h e application of m a n i p ulation a s part o f the management o f back pain wi l l be d iscussed w i t h i n the relevant chapters covering the cervical, thoracic a n d l u m bar regions of the spine and the sacroi l iac joint. The effects o f m a nipu lation o n the soft tissues are s t i l l t o be ful l y establ ished b u t moves have been made towards developi ng a 'theol)' of m a n ip u l a t i o n' to expl a i n treat ment o utcomes. D rawn from the consensus of opi nion of many authors, the broad effects of m a n i p u l ation are the rel ief o f pain, re l ief of m uscle spasm and the res to ration of movement a nd fu nctio n . Twomey ( 1 99 2 ) drew together, t h e n generally d is m issed, the trad i t ional theories that m a n i p u l ation reduces subluxations, co rrects vertebral a l ignment, adjusts nuclear prolapse or tems joint adhesions. Shekelle ( I 99 4 ) modi fied these theories, however, suggesti ng that manipulation releases e ntrapped Si'l10via l folds or p l i cae, 'unbuckles' d ispl aced motion segments, relaxes hyperton ic m uscle by sudden stretch i ng, or d isrupts articular or periarticular ad hesions. With respect to the fi rst hypothesis l isted above, sy no vial fri nges are described w i t h i n the facet j o i n t ( Bogd u k 2005) but theories sugges t i ng t h a t t hey m ay present a s a p r i m a l)' o r secondary sou rce of p a i n through en trap ment a re u nsubstantiated. Twomey ( 1 99 2 ) has a l ready described the sy novia l fri nges as 's lippel)" structures that are u n l i kely to be trapped. Earlier, Taylor & Twomey ( 1 9 8 6 ) presented the hypoth es is that, rather than i m p l icating the synovi a l fringes, the 'acute locked back' arises from i mpaction of a tag of articu l a r cartilage within the apop hyseal space, rather as a torn men iscus i n the knee that, being con nected to a wel l i n nervated capsu le, ca n be a sudden cause o f pai n . 'Gappi ng' of the j o i n t surfaces c o u l d al low the tag to return to its normal position so rel ieving the load on the capsul e, allowing normal movement to return a nd a su bsequent red uction in p a i n . This model depends o n the demonstration that 'gapping' of t h e apophyseal j o i n t does i ndeed occur with m a n i p u l ation, which w i l l n o w be explored . The relat ive m ovements between the target and other vertebrae are d i fficult to demonsHate and several stud ies rely o n ly on mathematica l predictions based on the forces a p p l ied. Dolan & Adams (2001 ) support that moderately flexed postures tend to un load the apophy seal joints. 111 is is a lso supported by Punjabi et al c ited i n Lee & Evans ( 2001 ) , w h o note tha t flexion i ncreases t h e size of the intervertebral fora m i na. Gal et al ( 1 99 5 ) per formed a series of l ower t horacic m a n i p u l ative t h rusts o n two unenbalmed post-cigor mortis h u m a n cadavers and recorded s ign i ficant relative movements during t hrusts, that were p r i m a r i ly berween the targeted vertebra a n d i m mediately adjacen t vertebrae. Vertebral pairs rem a ined sl ightly hyperextended after the t h rusts, even when the postero a n te ri o r forces had retu rned to preload levels. The l i n k to the in vivo situation is probab ly u n rel iable but Gal
et al concluded that their fi n d i ngs m ight be a useful step towards u nderstan ding the deformation behaviour of the vertebral col u m n d u r i ng m a nipulation. Soli nger ( 1 99 6 ) set out to develop a n anali'lical theol)' to descri be the dynam ics of smal l movement impulses appl ied to vertebrae i n manipulation. He noted an i n i tial passive osc i l l a to ry response t o t h e thrust, governed by l igamentous and d iscoge n ic forces, and a subsequent less regu lar motion that he postulated was caused by muscu lar reflex contractio ns. He a lso measured relative separa t i o ns of t he L2, L3 vertebrae in vivo fol lowing h igh-speed m a n i p u l a t ive t hrusts and demonstrated that both force a n d speed or d u ration of the thrust are i m porta n t to opti m ize the efficacy of m a n i p u l a t i o n . Zusman ( 1 99 4 ) corroborates the suggestion that m a n i p u lation moves or frees the i m pedi ment, perm i t t i ng movement and h a l t i ng nocicept ive i n pu t and associ ated m uscle spas m . He also h ighlights the need for this to be demonstrated and suggests that magnet ic resonance i m aging ( M R I ) w i l l hold the key to demonstrating what is bappening at spinal level as m a ni pulation is appl ied. Cra m er et a l ( 2000) performed a small random ized u'ial on 1 6 hea l thy subjects comparing the effects of side posture with rotation positioning and side-posture with rotation adjust i ng ( m a n i pu l a t i o n ) on the l umbar zygapo p hysea l joi nts, as eval uated by before and after measure ments of M R I scans. Two other small grou ps in the study were measured in the neutral pos i t ion, both before and a fter m a n i p ulation. The side-posture with rotation posi t i o n i tself produced s o m e separation t h a t was apparently increased fo llowing m a n i p u l ation . Th is compara tive increase was less than 1 min. Both groups measured i n neutral remai ned unchanged. The authors o f t.he study acknowledge that a larger cl i n ical t ri a l is needed to define their res u l ts fu rther. The techn ology for produci ng moving M Rl i mages ( i n terventional MRI ) has now been developed and McGregor et al (200 1 ) used lhis method to observe the effects of Grade I and G rade I V posteroanterior mob i l i zation i n the cervical spine t o assess for a n y movement a t i n d ividual s p i n a l levels. The scans demonstrated clear deformation of the overlying soft tissues and some angu l at i o n of the spine as a whole but m i n i maL i f a ny, i n tervertebra l movement ( Fig. 4 . 4 ) . Twomey ( 1 99 2 ) noted t h e common belief a t t h e t i me t h a t the d isc was not the primal)' cause of back pa in and t h a t the zygapophyseal joint was more l i kely to be the sou rce of the problem. Adams & H u tton ( 1 981 ) and Adams et a l ( 2002) have exam i ned the biomechanical behaviour of the d isc u nder d i fferent stresses, support i ng the s h i ft of evidence tOwards i nternal derangements w i t h i n the outer a n n u l us o f the d isc as the primary cause of back p a i n . Bogd u k (2005) describes com m o n theories of d iscal patho logy that he terms ' in ternal d isc disruption' where the i n ternal arc h i tecture of the d isc is disrupted with degradation of the nucleus pu lposus and the presence
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1 99 2 )
recovery ( B us h e t a l
m ay provide a m o re p l au s i b l e
exp l a na t i o n fo r resol u t i o n o f d isc prola pse (see C h .
13).
Several e a r l i e r a n d m o re rece n t stu d i es have a i med to exa m i n e the e ffect o f forces o n the s p i n e to exp l a i n d i sc degenera t i o n ( Farfa n et al N oren et al
1 991 ,
1 9 70, Ad a m s &. H u tton 1 9 8 1 , 1 996, Adams et a l 2002)
Krismer et a l
t h at may prov i d e t h e gro u n d wo rk towards t h e deve l o p ment of a hypothesis for t h e mechanism o f treat m e n t effects,
particu l a rly
on
the
a p p l ica t i o n
m a n i pu l a t i o n tech n i q ues. Bogd u k
( 2005)
of
rota t i o n a l
describes tor
s i o n i n j u ries tha t can s t ra i n the col l agen fibres o f t h e a n n u l us fib rosus, co m pa ra b l e to a l i ga m e n t s p ra i n . H e warns t h a t t h e condi t i o n has y e t to be d e m o nstrated i n v i vo b u t offers a feas i b l e model ( discussed bel ow) fo r t h e p a t hol ogy acqui red on i n j u ry and fo r the e ffect o f m a n i p u l a t i o n i n re l i eving sy m p toms. The reflex response to m a n i p u l a t i o n has i nv i te d study towards c l a r i fica t i o n o f t h e t h era p e u t i c bene fits o f m a n ip ulation.
Herzog et al
( 1 99 9 )
d e m o nstrated consistent
EMG reflex res ponses fo l l o w i n g m a n i p u l a t i o n . C o l l oca &. Ke l l e r
( 2001 )
a nd Kel le r &. Col l oca
( 2000)
s t u d i ed t h e
EMG reflex responses to m a n i p u l a t i o n a nd fo u n d t h a t p a t i e nts w i t h fre q u e n t to consta n t l ow b a c k p a i n tended to have m o re m a rked responses t h a n p a t i e n ts w i th occa s i o n a l or i n term i t t e n t back p a i n . Eva ns
( 2002)
d i scusses
mech a n i s m s fo r t h e re laxa
tion of hypertonic m u scle, descri b i ng both red u c t i o n i n paras p i n a l sponta neous e lect ro myogra p h y act i vi ty a n d red uct i o n i n hyperalgesia o f p a raspi n a l myofascial t r ig ger p o i n ts. S i nce hyperto n i c m uscle, i .e. m uscle spasm, wou l d tend to be protecti ve, h e suggests tha t the e m p h asis
Figure 4.4 Sagittal i mages obtained d u ring (a) G rade 1 PA mobilization of 6th cervical vertebra; (b) G ra d e 4 PA mobilization of 6t h cervical vertebra. From M c G regor A,
s h o u l d be on the creation o f post- m a n i p u l a t ive hypo a l ge sia that may lead i n i tsel f to re l ax a t i o n o f hyperto n ic m us
Wra g g P. Ge droyc W M W (200 1 ) Can interventional M R I p rovi de an insi ght I nto t h e mechan ics o f a poste rior-a nterior mobilisatio n ) C l in ical Biomechan ics 1 6 926-929. Repri nted by permission of Elsevier Ltd.
cle, t h e mech a n i sms o f w h ich are s t i l l b e i ng i n vestigated. Leh m a n et a l
( 2001 )
a p p l ied a p a i n fu l mech a n i ca l s t i m
u l us above t h e s p i n ous process i n
17
subj ects w i t h c h ro n i c
l ow b a c k pa i n a n d fou n d t h a t m a n i p u l at i o n weakened t h e e n s u i n g electromyography response. A l th o ugh there was no stat isti ca l S ig n i ficance i n t h e res u l ts a n d the e ffects
o f rad ia l fissures in the l u m ba r s p i n e that may reach t h e
were short term, the possi b i l i ty of these responses ca u s i ng
o u te r t h i rd o f t h e a n n u l us. T h e o u t e r a n nu l us is known
some of t h e c l i n ica l ly observed benefic i a l effects, i nc l ud
to have a nerve s u p p ly a nd may therefore present as a
i ng red uction of pain a n d decrease i n hyperto n ic i ty of
p r i m a ry cause of back p a i n . [n i n t e rn a l d isc d i s ru p t i o n ,
m uscles, has been put fo rward .
t h e external su rface re m a i ns essen t i a l l y n o r m a l b u t t he nucleus may b u l ge, as
a
bu lge or protrusion, i n to t h e
outer layers o f t h e d i sc, where i t m a y a l s o produce pai n . M ixter &. B a r r
( 1934)
Wyke's work on t h e n e u rol ogy of j o i nts was p i votal in provi d i ng a m o d el t o ex p l a i n the reflex relaxa t i o n o f periarticu l a r m uscles fo l l ow i ng sudden s t retching o f t h e
were t h e fi rst to suggest that rup
t u re o f the i n terve rtebra l d isc could be a caus a l factor i n
capsu l e, periart i c u l a r l ig a m e n ts and t e n d o ns (Wyke
1 979, 1 980).
Wyke
( 1 9 79)
a n d Zusman
( 1 994)
1 967,
suggested
sciatica, d n d Cyriax was o n e o f the first c l i n ic i a n s t o pro
t h a t passive movements may act i vate the mechanorecep
pound that in nuclear p ro l a pse d iscal material r u p t u res
tors w i t h i n caps u l a r and other t issues.
t h rough the outer a n nu l us i n t o t h e vertebral canal, w h e re it can have a seco n d a ry effect on pa i n -sens i t i ve struc t u res. Cyriax
( 1 982),
Two m ey
( 1 99 2 )
a n d Zus m a n
( 1 99 4 )
In
addition,
J(a tavich
( 1 99 8 )
concludes
that
the
deform a t i o n o f j o i n t ca p s u l e c a n m od i fy reflex m o t o r
all
respo nses, lead i n g to c h a nges i n m uscle tone. T h e a u t h o r
suggest t h a t m a n i pu la t i o n i s u n l i ke l y t o cha nge or benefit
n o t e s t h e work o f Cla rke w h ere sustai ned o r repe t i t i ve pas
a nuclear d isc p ro l a pse a nd t h e re i s l i t t l e s u p port from the
sive j o i n t move m ent, o r i n d eed pressure over the j o i nt, h as
l i terature t h a t m a n i p u l a t i o n is - or is not - effective w i t h
been shown to m o d i fy fi r i n g responses in l a rge-d i a m eter
t h i s underlying pathology. T h e model o f s p o n ta n eous
mechanorece ptor j o i n t afferents, part i cu l a rl y when t h e
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capsul a r stretch is m a i ntained at or near the end o f range. This p resents an explanation that accou n ts for the p a i n re l ieving effects o f end-range mobil ization, i ncluding pas sive Grade B stretch i ng tech n i ques (see above) as wel l as manipulation. I f these observations are p u t together, mobil ization a n d manipulation m a y stimu late mechanoreceptors t o modi fy neural activity within the central nervous system, altering reAex pathways that affect the vol u n tary and involuntary activation of muscles and lead ing to relief of muscle spasm, increased movement and reduction in pain (Wright 1 99 5 ) . The general rule is that m a n i pulation should n o t be appl ied through spasm and that other tech niques or modali ties, such as graded mobilizations, heat or electro therapy, may need to be applied to achieve refle.:", relaxation of this protective mechanism. It was the opinion of Brodeur ( 1 99 5 ) , however, that the high velocity thrust of manipula tion had a spl i t second's chance to affect the capsule a nd the Golgi organs within the periarticu lar contractile structures before any reflex spasm could resist the movement. Cyriax, in 1 984, and for at l east 50 years before, d id not shirk from h is o p i n i o n that 'w hen m i nor ligamentous adhesions l i m i t m ovement and cause p a i n they should be m a n i p u l atively ruptured'. H is statement referred m a i n ly to perip heral j o i n ts, and i n s p i n a l lesions he tended to refer to the effects of m a nipulation on what he termed 'sm a l l ca rt ilaginous displacements'. H e put forward rJ1ese d isruptions of the a n n u l us fibrosus as a primary cause o f l ow back p a i n of s u d d e n o nset, a theory t hat is supported by Bogdu k ( 2005) (see below ) . Lamb ( 1 99 4 ) suggested that man ipulation 'releases m i nor adhesions' and Zusman ( 1 994) acknowledges the formation of fragile collagen fibrils in the early stages of repai r, suggesting that graduated or 'abrupt' alteriltion in the length or location of undesirable and restri ctive scar tissue is the most logical means by which ranges of movement m i ght be i m proved with manually del ivered passive move ments: the 'abrupt' presumably describing manipulation. Cramer et al ( 2000) presen t a theoretical model of m a n i pulation breaking adhesions w i t h i n the zygapophy seal j o i n ts and Bogd u k ( 2005 ) describes torsio n i n j u ries that ca n strain the co l l agen fibres o f the a n n ulus fibro sus, comparable to a l igament spra i n . If the fibres can be i n j u red by torsion, the i m p l icat i o n is that they can be affected by m a n i pu l a tive tec h n iques, particul a rly those appl ied with rotati o n . D o l a n & Adams (2001 ) com m ent o n the mathematical models that are o ften used to q u a n t i fy the overa l l forces and m o ments acti ng on the l u mbar s p ine, a nd ex:pla i n that i n o rder t o describe h o w s p i n a l t issues can be i n j u red, it is necessary to d istribute t hese forces between and w i t h i n d i fferent s p i n a l structures. They e mphasize that it is the co ncentration of the force w hich causes i n ju ry and el icits pai n . I t m ay be reasonable, there fore, to extra polate that o p i n i o n to propose that i t is a l so the concentration of fo rce o n the appl ication o f m a n ip u lation that can l ead to the rel ief of pain.
Scientific evidence is perhaps l acking in terms of know ing exactly what does happen to adverse adhesions, if t hey are i m p l icated in j o i n t hypomob i l ity, but biomechan ical models ilre usefu l towards the development of hypothesis. As referred to above, Threlkeld ( 1 99 2 ) describes the vis cous properties of con nective tissue and explains t hat when a tissue is loaded more quickly it behaves more stiffly than the same tissue loaded more slowly. Thus ad hesions may be ruptured more readily by stress appl ied q uiCkly, as in man ipulation. If the concentration of forces appl ied in manipu l ation tends to fa l l selectively on the resisting scar tissue within the annul us, before the normal tissue is affected (Threl keld 1 99 2 ) (see Ch. 2), t h is can provide a sound model for the achievement of i ncreased movement and pain rel ief with particu lar presentations of back pilin. Manipu lation is often associated w i t h an audible 'crack', said to be due to cavi tation of the joi nts; a small d i version onto the subject of cavitation is pertinent at this stage. The forces appl ied on manipu lation i ncrease t he joint vol u me, w i t h a corresponding decrease in A u i d par tial pressure, creating a gas bubble as the i n tra-articular gases are drawn out o f the sol ution. As t he flu i d rushes i n to the a rea o f l ow pressure vol u m e, the gas bubble col lapses, prod ucing the 'crack' ( Herzog et al 1 99 3 ) . Some practi ti o ners argue that the 'crack occurs' as the bubble forms b u t any signi ficance in the distinction is unclear. G ibbons & Tehan ( 2001 ) propose that it is the cavita tion that d isti nguishes m a n i pu lative techniq ues from orJ1er m a n u a l moda l it ies and many c l i n icians judge the success of a man ipulation by whether or not cavitation occurs (Conway et a l 1 99 3 ) . G ibbons & Tehan focus on appro priate pos i t i o n i ng to be able to localize forces to achieve cavitation, w i t h the i m p l ication that it is a neces sary component, a l though they do not speci fy why. Ross et al ( 2004) state that cav i tation is not an accu rate guide to being specific in m a n i p u l a t io n s i nce it can occur at m u lt i p l e j o i nts �nd is only accurate 50% o f the t i m e in m a n i pulation. I n general, the m a n i pu l at ive tech n i q ues used in the orthopaed ic medicine approach do not req u ire specificity, a l t hough some are appl ied 'at the pain fu l level', as will be seen i n the relevant spin;} 1 chapters. Brodeur ( 1 9 9 5 ) provided a com p rehensive review of the 'aud i b l e release' associated with joint m a n i pulation. H e c ited a n early study by Roston & H a i nes which dem onstrated with serial X-rays o f the t h i rd metacarpal joint that i f the distrilction fo rce was h igh enough i n the t h i rd metacarpophalangeal j o i n t to produce a crack there was a d ramatic increase in joint space of u p to 3 m m . Cavitation was not ach i eved i n lax o r overly tight articular capsules but an i ncrease in the j o i n t space was s t i l l apparent, albeit that i t was ach ieved more steadi Iy. Gi bbons & Col l i ns ( 2001 ) ai med to determ ine whether h igh velocity thrust manipu lation of the atlanto-axial joint i m p roved pre-existing atlanto-axial rotation asym meliy i n asymptomatic subjects, and then to compare this w i t h tbe effects of a sham thrust without cavitation. The results indi cated that while there was a trend towards improvement
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of the more restricted rotation in both the cavitation and non -cavitation groups, neither reached signi ficance and no evidence was provided that the noiseless man ipulation is or is not as effective as the manipu lation with cavitation. The p l acebo effect of the patient hearing or feel i ng a 'click' can be powerfu l ; it can be perceived that 'som e thing has been done' to remove the calIse of t h e i r p a i n . More nervous or suspicious patients m i g h t perceive that the fact that 'someth i ng has been done' cou ld have m ade them worse, however. Sweetman ( 2009) updated the review on 'dicks and clunks' and concluded that there was no correlation between cavitation and the typical electromyographic changes p ro duced at manipu lation, nor with therapeutic benefit. The orthopaedic medicine approach to manipu lation does not focus on the requirement to achieve cavitation. Evans ( 2002) provides an i nteresti ng d i scussion of the effects of m a n ipulation but a ppears to m isrepresent that Cyriax suggested that m a n i pu l a t ion coul d benefit n uclear hern iation. As d iscussed i n Chapter 1 3, Cyriax ( 1 982, 1 98 4 ) did attribute presen tations of low back p a i n to d is cal pathology but produ ced models of 'carti l aginous' a n d 'nuclear' d isplaceme n ts, devis i ng associated sets of s igns and sym ptoms to gu ide treatment choice. The cart i l agi nous presentation was l i n ked to d isruption of the a n nulus of the disc, often, perh aps erro neously, c a l led ' fragments' of carti l age, and was suggested as b e i ng suitable for manipulation where changes could be effected w i t h i n the col l agen structure o f t h e a n n u l us, with a co nsequent sudden reduction in p a i n . The 'nuclear' p resentation was designated by Cyriax as b e i ng more sui tably treated with traction, in line with the more progressive or p rolo nged positions more a p prop ri ate fo r inducing movement i n the viscoelastic nucleus, a s Evans suggests. Evans' t h eories relating to struct u res with i n ule zyga pophyseal jo int as a possible cause of the 'locked back', and as d iscussed above, are i ndeed feasible but t hey are no more proven than t heories rela t i ng to sym p toms asso ciated w i t h torn fibres w'i t h i n the co l lagen structure of the a n n u l us, as put fo rward by Bogd u k (2005) and l ess expl icitly by Cyriax h i mself. Thus, i n the meanti me, the model of d is ruption of fi b res w i t h i n t h e outer a n n u lar layers can provide a possible e ffect of m a n ipulation in break i ng down a d h esions in t h e outer a n n u l us. W h i l e the debate on t h e pathology of back p a i n and the effects of m a n i pulation w i l l no doubt co n t i nue, Ule reader of this text will be encouraged to devise treatment progra m m es based on models of p rese n tation and patient selection, w i t h careful consideration of patients' h is tory and prese n t i ng s igns a nd sym ptoms, a nd t horough scree n i ng for poss i b l e co ntraind ications to treatment. As a fi n a l consideration, Lee et al ( 1 99 6 ) d raw attention to the many variations in technique that may affect the movements a t the spi ne. They ca n be s u m m a rized as: the magnitude of the a p p l ied fo rce, the rate of i ncrease of the fo rce, the d u ration of load i ng and the accuracy and speci ficity of the a p p l ication of the force. These, along
with other variations i n the patient, the c l i n i cian and the treatment couch, all need to be considered w i t h i n the c l i n i ca l reaso n i ng process and can confo u nd efforts to develop a n u l ti ma te theory of spinal m a n i p u l a t io n .
Pri nciples o f a p p l i cation of s p i n a l a n d sacroil iac j o i n t m a n i p u lation Cert a i n p r i n c i pl es need to be considered i n order to apply the tec h n ique effect ively. A shon- or long-lever arm is used and a torque or twist i ng force is usually appl ied, taking up the slack i n the sur rou nd i ng con nective tissue to i nduce a passive movement at one or more spinal joints ( Hadler et al 1 987). The m i nimal ilm p l itude, h igh velocity thrust is of great i mportance si nce tissues loaded quickly behave more stiffly and have a h igher u l t i mate strength (see Ch. 2 ) . Thus, as the spinal man ipu la tive tech n ique is applied, the force needed to affect the target tissue does not cause damage to the sLilToun d i ng structures (Thre l keld 1 992), i.e. the weak I. i n k i n the chain effect. M a n i pulative reduction is more l i kely to succeed if the j o i n t space is increased. Therefo re a n e l e m e n t o f distrac tion is usua l l y i nc l uded. S p i n a l m a n i pu lation, in particu lar, requ i res s k i l fu l handl ing t h a t takes time and practice to acq u i re. The hands m ust be co n t i n uously sens i tive to the end-feel of the joi nts a n d a ny abnormal end-feel, e.g. bony resistance or m uscle spasm, should a lert the m a n i p u l ator to abandon the procedu re. Successful m a n i pulation req u i res accurate c l i n ical d iagnosis and t h e choice of the right pat ient with know ledge of the effects, contra i nd ications and l i m i ts of t he tech n ique. Thought, care a n d expert s k i l l are esse n tials, together with a n expl anation to the patient of the d iagno sis, trea t m e n t and poss i b l e co m p l ications, in order to ga i n i n formed conse n t . Safety is essential and the p recaut ions necessary w i ll be d iscussed i n the a p p ropriate chapters.
TRACTION The terms traction and distraction have the same meaning i n descri b i ng a force a p p lied to produce separation of joi n t surfaces a n d widening of the joint space. There is a conven tion that t raction is appl ied to spinal joi nts and distraction to peripheral j o i n ts, but this is not a hard and fast ru le. Th is section co nsiders the theolY u nderp i n n i n g the trac tion and distraction techn iques used in orthopaed ic med icine for both perip h e ral and s p inal joints. E m p h asis wi l l b e p l aced o n the use o f tract i o n a s a trea t m e n t for back and neck pai n . M a ny other treatment mod a l ities e m p l oy d is t raction i n the treatme n t of peripheral j o i n t l es i o ns and the a i ms and effects w i l l be described briefly h ere. The general indications for traction and distraction wil l be mentio ned, but mese, togeu1er with the con trai n dications for lreatment, wili be discussed i n greater detail in the fol lowing dlapters.
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The a i ms of t raction were origi na l ly devised fro m Cyriax's hypot heses o f the effects o n the s p i n a l j o i n ts. They have been developed subseque n t ly to encompass the peri phera l j o i n ts, w here appropriate, and may be stated as fol. lows:
To rel ieve p a i n Pai n rel ief t h rough !he use o f t ractio n is gained b y rel i ev ing pressure. Tracti o n red uces the compression force, m uscles relax a nd the pressure on the j o i n t and pai n sensi t i ve structures is reduced.
To create space The application o f d istraction/ traction creates a degree of space w i t h i n the j o i n t, a l lowing a d isplaced bu lge or frag ment, a loose body or a d isplaced carpal bone room to move.
To prod uce n egative pressu re wit h i n a joint Creating space wilh i n the j o i n t creates a suction effect that helps to move a displaced i n t ra-articu l a r fragment.
To tighten the l igaments a round a joint Tigh ten ing up of the l igaments around !he j o i n t produces a centripetal fo rce. A d isc d isplacement w i l l tend to be pushed towards the centre as t h e tract i o n is a p p l ied.
To red uce a loose body i n a peripheral j o i nt D istraction is the m a i n element of the m a noeuvre, with a G rade A m o b i l izat i o n appl ied d u r i ng t racti o n . The aim is to move the displaced fragment to a nother area of the j o i n t where i t does not block j o i n t movement.
Ind ications for traction at peri phera l joi nts S t i ff osteo a n h ri tic j o i nts respond wel l to distraction, as do joints demonstrating the caps u l a r pattern fo l l owing adaptive changes i n response to tra u m a t ic anhritis. The d istraction is appl ied to i ncrease mob i l i ty, using lon gitudinal or lateral d istraction tech n iques, which may produce separat ion of j o i n t su rfaces a nd assist mobi l ization by s t retc h i ng the j o i nt capsu l e and capsu lar l igaments. I t m ay be a p p l ied m a n u a l ly as a treatment i n i tsel f o r i n conjunction with mobil ization a n d m a n i pulation techniques. Where signs a n d symptoms i nd icate the presence of a l oose body i n a join t, or a carpal bone needs to be relo cated, d istraction before G rade A m o b i l ization is appl ied. The d istraction of joint surfaces a llows space for move ment of the fragment, assisted by the accompanying suction effect which d istraction tends to p roduce.
Ind ications for spinal traction Cyriax ( 1 9 8 2 ) identi fied factors fro m the patient's h is tolY, together w i t h certa i n sym ptoms and signs, which he bel ieved were characteristic of a n uclear disc p rotrusion . Treatment w i t h sustained traction was therefore ind icated to reduce the protrusion. H e stated that, with a nuclear protrusion, the pai n is usually of gradual onset, often with no recol lection of the mode or time of onset. There is usually l ittle central pain, but referred pain is usually present in the arm o r leg. The pattern of spinal m ovement is non-capsu lar and t he movements provoke the l i m b pain. Cyriax ascribed the pathology to posterolateral move ment of the protrusion, compressing the dural nerve root s leeve and prod ucing u n i lateral pain. Smyth & Wright ( 1 958) had a lso p roposed this mechan ism but when, in the l ight of i nvestigation, o p i n i o n moved away from the notion of a 'jel ly- l i ke' nucleus, thus refu t i ng the pos s i b i l i ty of a nuclear ooze, Cyriax's hypothesis was largely rejected . The empi rical findings nonetheless remai ned that tracti o n cou ld afford rel ief with that particu lar onset and pattern of p a i n . Mathev.'s & H ickling ( 1 9 7 5 ) suggested t h a t traction should be a p p l ied to a defined syn d rome rather than a spec i fi c condition. This would appear to be a more satis factory prem ise agai nst which c l i n icians from the myriad o f m uscu losl(eletal backgrounds ca n apply t he basic pri n ciples, w h i l e the debate o n pathology con t i n ues as fresh evidence emerges. Apart from the application of mecha n i cal traction, i n t h e cervical spine most of t h e mobil ization a n d manipu lation tec h n i q u es are performed u nder manual traction.
Clinical tip When applying the techniques of traction or distraction to t he
cervical spine or peripheral joi nts, the following
principles should be employed •
Body wei g h t should be used.
•
The a p p l ication of body weigh t should be achieved by
•
The d istraction/traction should be sustained
leanll l g out with straight arms. a moment or two to become esta blished
for before
proceed i n g with the ma noeuvre.
Di scuss ion on the evidence for the aims and effects of traction To provide some support for the ai ms, the fol l owing paragraphs set out to review the evidence for the effects and effectiveness of lraction, particu larly as a treatment for back and neck pain. S i nce the d iscussion covers a l l regions of the spine it is m ore appropriate to \(eep i t
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together with i n this section than to attempt to d ivide i t i n to t h e appropriate spinal chapters. Traction is genera l ly co nsidered to be an e m p irical treatmen t', stated Colach is & Stro h m ( 1 965), and, in spite o f several well organized t rials to demo nstrate the con trary, this statement u n fortunately con t in ues to be t rue. In these days of evidence-based practice, dema nds have been made for tract ion, as an expens ive, t i me-consu m i ng mod a l i ty, to be stopped as a t reatment u n t i l evidence for its effectiveness has been produced . Mat hews & H ickl i ng's presentation of their paper ( 1 9 7 5 ) was crit icized for not honestly stating that no evidence had been found and a n editorial i n t h e British Medical Journal (Trial b y tract i on', 8MI 1 9 76) urgently cal led for thorough research i nto trac tion to avoid fu rther waste of resou rces. Swezey ( 1 98 3 ) represented the views of the many who use t ract i o n when he acknowledged that 'there i s a co n sensus among thoughtful c l i n icians that traction is useful, and unti I fu rther study argues to the co ntrary, it deserves a place in our therapeutic armamentariu m'. Sharing t.hat view, Sau nders ( 1 9 9 8 ) set out to eval uate the reviews that were considered for the Clinical Gu idelines jor the Management of Low Back rain (Wadde l l et al 1 99 6 ) that concl uded that 'traction does not a p pear to be effect i ve for low back pain with rad icul opathy'. Saunders provides an i nteresting discussion which addresses the methodological weaknesses of the stud ies selected for the review, suggesting that the randomized controlled trial on this single moda l i ty, a i m i ng for statisti cal significance, is cl i n ically i nappropriate and that a multi modal approach to treatment, i ncl uding the use of spe cific and general exercise p rogram m es, is l i kely to be more real istic in the clinical setting. He compares the tri als in the reviews to a separate series o f articles which, while they may not have achieved statistical s ign i ficance, have suggested that traction may be effective for a specific population. Van der Heijden et al ( 1 9 9 5 a ), in one of the reviews co nsidered by Waddel l et al ( 1 9 9 6 ) , acknowledge that the stud ies they incl uded 'do not a l low clear conclusions due to method ological flaws in their design and conduct'. Van der H eijden et al ( 1 9 9 5 b ) also designed a p i lot study to compare the effect of h igh-dose con t i nuous l umbar trac tion a nd low-dose conti nuous l u mbar traction o n the magnitude and rate of recovery for pat ients with low back pai n . They tentat ively concl uded that tract ion seemed to be more effective than sham traction in the short term but acknowledged that the s m a l l n u m bers i nvolved prevented the ach ievement of statistical signi ficance. Fol l owing eval uation of the pi lot study, it was extended by Beurskens et al ( 1 9 9 7 ) to include a total o f 1 51 subjects. Beurskens et al were meticulous in their methodology, i ncluding patient selection, but nonetheless the study fai led to dem onstrate a significant d i fference between the two groups. A l iterature search conducted by van Tu lder & Koes ( 2002 ) for Clin ical Evidence Concise, the sel f-acclai med 'i nternational source of the best ava i lable evidence for
effective health care', concluded that randomized co ntrol led trials found conflict i ng evidence and no support fo r the e ffects of t ract ion for both acute and chro n i c low back pai n . The question of patient selection and the parameters of the stud ies reviewed are left u nstated, however, and Saunders ( 1 9 9 8 ) warns that we s hould avo id making j udg ments about t ract ion based on reports d rawn fro m reviews without cri t ically reviewing the articles ourselves. There was no mention in the same issue of Clinical Evidence Concise of the effects of traction on cervical pai n . A study h as emerged that supports t h e i n c l usion of tr�c tion in the treatment of confirmed sym ptomatic d isc her n i ation and therefore i mp l ies the i mporlance of patient selection in eval uating the technique. OZlUrk et al ( 2006) set out to assess the effect of continuous l u m bar tract ion on the size of hern iated d isc material i n l u m bar d isc her niation. The size of the herniation was m easured by com puted tomography. Folty-six pat ients with l u m bar d isc herniation were i ncluded in this randomized contro l led trial; 24 patients were assigned to the traction group and 22 patients to the control group. Both groups were given phys ical therapy modalities i nclud i ng hot pacl<s, ultrasound and d iadyna mic currents, and the experimental group was a lso given tract ion, conti nuously for 1 5 m i n . Al l patients were given 1 5 sessions of daily (weekdays) treatment by the same physical therapisl. The size of the herniated d isc material decreased significantly only in the traction group. Data collected for the c l i nical signs and symptoms also showed i ncreased i m provement in the traction group. Traction has been docu mented as a treat ment for back pain at least si nce the t i m e of H i ppocrates ( H u me Ken d a l l 1 95 5 ) . Cyriax h i mse l f developed his fi rst traction b e d i n 1 949 and col laborated w i t h his physiotherapists o n how i t could be used to rel ieve the symplOms produced by nuclear d isc p rotrusion. H is belief was that pa i n of gradual onset, usua l ly associated with leg pain, was due to nerve root co mpression from herniated nuclear material through a tea r i n the an nulus, i.e. a d isc protrusion (see Ch. 1 3 ) . Cyriax's hypot hesis was that effeoive traction co u l d produce a suction e ffect with i n t h e d isc to d raw the nuclear materia l cen t ra l l y a nd away fro m the nerve roOI. At the same time a mecha n i cal 'push' wo uld be given 1 0 the hern iated material by tighten ing the l iga ments span n i ng the b ulge - the posterior 10ngi lUdi nai l igament in particul ar. Andersson et al, c ited in Lee & Eva ns (200 1 ) , studied i ntrad iscal pressure and showed Cyria'\:'s hypoth esis of a sucti o n effect 1 0 be u n founded. However, Cyriax had clai med that i n order 10 ach ieve these effects tractio n woul d need 10 produce separation of the i ntervertebral and zygapophyseal joints between the vertebrae accom pan ied by tensio n i n g of the i ntelvertebral ligaments, and there is co nsiderable evidence that this separati o n occurs. To demonstrate the separation of the vertebrae, Cyriax ( 1 9 8 2 ) com pared two X-rays of the cervical spine taken before and after the appl i cation of ' fa irly' strong m a n u a l traction for several seconds. He measu red an i ncrease of 2 . 5 m m at each of the j o i nts between the fourth cervical
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a nd fi rst thoracic vertebrae. H is m ax i m u m m a n ua l trac tion had p reviously ( i n an experi m e n t i n 1 9 5 5 ) been esti mated to be 1 4 0 kg, but h i s use of the term 'fai rly' i mp l ies something less than that. S i m i l a rly, before and a fter X-rays of the l u mbar spine were superimposed upon each other after 50 kg o f t ract i o n h ad been appl ied for 10 min, and a wide n i ng of the d i sc space was observed. l ud ovitch ( 1 9 5 2 ) took a series of X-rays as p rogres sive poundages were appl ied to the cervical spine o f seven patients. H e observed that with 4 5 l b ( 20 . 5 k g ) o f static, vertical traction there was separation of the i n ter body joi n ts o f C2-C7 and a s m a l l widen i ng of the zyga pophyseal joi n ts . A s i m i l a r serial study was performed by Colachis & Strohm ( 1 966), but using 30 1 b ( 1 4 kg) of i nterm ittent cervical tract i o n at a 24 ° a ngle of p u l l . I n a l l 10 subjects the mean separation of t h e vertebrae increased p ropol1ional ly, both a nteriorly and posterioriy, to a maxi mum at 25 m i n . O n t h e assu m p t i o n that i ncreased d isc space w i t h trac t i o n would be m a n i fest i n an i ncrease in h e ight. Worden & H u m phrey ( 1 9 6 4 ) appl ied sustai ned traction of up to 1 3 2 1 b ( 6 0 kg) to normal fit m a l es. The tract i o n was d ivided between the head and thorax and pelvis and a n kles for 1 h o n each of seve ral consecut i ve days. They demonstrated an average i ncrease i n height of 8 mm. They continued to observe twO subjects and noted that t hey lost their i ncreased height at a rate of 4 mmjh . In the Colachis & Stro h m study m e n t i o ned above, no i ncrease in posterior separation rem a i n ed at 20 m i n after the ces satio n of traction but the residual a nterior separation was statistica l l y sign i ficant (Col achis & Stro hm 1 9 6 6 ) . Mathews ( 1 9 6 8 ) used epidu rography, i nvolving the i njection o f rad io-opaque contrast med i u m i nto the epi d u ra l space for subsequent rad i o l ogical i n vestigation, and a p p l ied 1 20 lb ( 5 5 kg) o f lumbar tract ion to th ree patients, two with suspected d isc p rotrusions and one contro l . I n o n e patient the bu lge of t h e protrusion began to decrease in depth from 4 min and was further decreased at 20 m i n , w i t h pan i a l recurrence o n release. Evidence was provided for Cyriax's proposed suct ion effect o n observi ng a second patient where not only was there a red uction i n the depth of the m u l t i p l e protru sio ns, but a lso co ntrast med ium appeared to have been d rawn i nto the d isc s paces, i m p lying the production of nega tive pressure with i n the d isc. The appa re n t suction e ffect may be a sequel to the redu ct i o n of l oad on the d isc when traction is appl ied. N achemson ( 1 9 8 0 ) , with the use o f a m i niatu re i ntra d iscal pressure transd ucer, measured the a pproximate l oad o n the L3 d isc in a 70 1
had d i sadvan tages i ll terms of expense, i f prol onged hospitalization was i nvol ved, as wel l as i ncapacitating the patient. Lum b a r traction, o n the other hand, wou l d a l l ow the p a t i e n t to continue with d a i ly activ i t i es and com m i t m e nts. Lee & Evans ( 2001 ) have exa m i n ed loads in the l u mbar spine during t raction therapy and p ropose that traction does not s i m ply produce axia l d istract i o n of the spine. They suggest that tract ion also produces a flexion moment leading to an i ncrease in the posterior height of the d iscs a nd a flattening of t h e l u mbar lordosis. Th is effect is e n hanced by the use of the Fowler's position ( h i ps and knees flexed to 90 ° ) and may have c l i n ical signi ficance in tighte n i ng the posterior a n n u l us and the overlyi ng posterio r longitudinal l iga ment. theoretica l l y s t i m u l a t i ng mechanoreceptors and red ucing a confi ned disc prolapse towards the rei ief o f p a i n . Lumbar flexion has been demonstrated t o i n crease t h e s ize o f the i ntetvenebral foram i n a ( Punjabi e t a l cited i n Lee & Evans 200 1 ) a n d t h i s wou ld tend t o support the use of tract i o n as a treatment tool to e n l a rge a pathologica l l y narrowed foramen, i . e. with symptoms of s p i n a l stenosis. S i nce the ambula n t position s ubjects the d isc to com pressi ve forces ( Nachemson 1 9 80), certa i n considerations need to be appl ied to prevent t h e l oss o f the benefits of t ract io n between treatments. Cyriax ( "1 9 8 2 ) claimed that tract ion needs to be: • •
• •
As strong as possible A p p l ied for as l o ng as is both practicable a nd to l erab le A p p l i ed dai ly, or at least five ti mes a weel< A p p l ied con t i n uously
When Cyriax proposed that the physiological and bio mechanical effects o f static traction were more effective at redUCing a nuclear protrusion, the debate of co ntinuous (static) versus i nterm ittent t raction had l i ttle evidence to su pport either side. Wyke, refe rred to i n Cyriax ( 1 9 8 2 ) , obselved t hat motor activity i n the sacrosp inal is muscles i ncreased a� the d is tract i ng force was i n creased, u n t i l the mechanoreceptors in the tendons were stimul ated, prod ucing an i n h i bi tory effect a fter which the stress was a l l owed t o fal l o n the s p i n a l j o in ts. Cyriax c l a imed t h a t elect romyographic ( EMC) s i l ence i n t he sacrospinalis was not achieved u n t i l 3 m i n i nto the a p p l ication o f tract i o n . For this reason h e proposed that i nterm i t tent traction would n o t be a s suit able to produce nuclear movement, s i nce repeated p u l l s of s horter d u ration wou l d con t i nually e l icit the stretch reflex, producing m uscu l a r contract ion and prevent i ng j o i n t distract ion. Cyriax's a rgument for wan t i ng to avoid muscular con traction is supported by the study of Coldie & Reich m a n n ( 1 977) to exa m i ne t h e i n fl uence o f traction 0 11 the cervi ca l spi ne. They observed that the force of muscle contrac t i o n in the cervical spine could overcome a traction force in excess of 30 kg ( G6 I b ) .
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However, Hood & Chrisman ( 1 9 6 8 ) used EMC record i ngs of l u m b J r sacrospi n a l is activity to co m pa re t h e e ffect of static and i nterm ittent traction and found no d i ffer ence. Moreover, Klaber Moffett e t al ( 1 990) i nvest igated the effects o f sust
In some cases a n i njection is more appropri ate ( e.g. bursi tis), a n d in others tra nsverse frictions may be more appro priate (e.g. m usculotendi nous lesions). I njections tend to be more cost-effective when compared to m a n ual therapy (e.g. caps u l i t is). The need for collaboration between the patient, physician and physiotherapist is emphasized to ascerta i n the best mode of treatment for the patient.
Corticosteroid i njections Corticosteroids have a pote n t a n t i - i n fl a m m a to ry e ffect, much m ore d ra matic tha n the a n t i - infl a m m atory e ffect o f no n-stero id a.! anti-i nfl a m m a to ry d rugs ( NSAI Ds), and a l-e therefore used therapeutica l ly to achieve t h is e ffect i n o rthopaedic medicine. They a re JPplied i n tra-art ic u l a rl y o r i n tra l esio na l ly fo r c h ronic infl a m m a tOlY lesions, i nclud i ng i n fl a m ma tory arthritis. The i ntense a n t i - i n fl a m m cttory e ffect is also beneficial in some acute lesions ( e.g. ctcute b u rsitis o r a n acute fl a re in chro n i c a rt h ri t is) but is unwanted i n other conditions (e.g. acute muscle belly lesion and acute l igamentous l esions) because of its det rimental effects o n col l agen prod ucti o n . Corticosteroids are a lso ind icated in many c h ro n i c con d i t i o ns, i nc l u d i ng tend i nopathy, where i n fl a m ma t i o n may not be a feature a n d their exact mode of action is not yet fu l l y u nderstood in this situation.
Uses in orthopaedic medicine
-------.--�
•
C h ronic te n d i nop a t h y a n d ten osy n ovi t is
•
Acute and
•
Infl a mmatory arthritis and acute episodes of
chronic
d eg e nerative
ORTHOPAEDIC MEDICINE I NJECTION TECHN IQUES This text will provide a n o u t l i n e o f the principles and a ppl ication of i nject ion therapy. The interested reader is referred to other texts that cover i njections i f further detail is requ i red . In orthopaedic med ici ne, i nject i o n tech n iques are often an a l ternative treatment to transverse frictions and mobil ization tech niques. Transverse frictions a nd mobi lization JPpear to be most efficacious when used together o r with other physiotherapy mod a l i t ies. Th i s a lso appl ies to the use of i njection techn iques that a lso benefi t from attention t o biomechilnical a n d causative factors to prevent recurrence. H owever, i njection tech n i q ues may i n i t i a l l y stand alone to a llow for a period o f relative rest a n d protect ion to ga i n maximum benefit from the i njec t i o n . The d rugs admi nistered o ften have effects for some time after the a pplication of treatment and they m ust be given t i me to ach ieve these beneficial effects. In many insta nces the orthopaedic medicine clinician has a choice o f treatments to apply: either i n j ection or transverse frictions and mobilization (e.g. tendinopathy).
•
b u rsitis
o steoat h ro s i s
Epidural, via sacral hiatus
•
Nerve entrapment syndromes
•
Some li gament sprains
As wel l as their a n t i - i n n a m m atory e ffect, corticosteroids have other potent effects, i nc l ud i ng i m m u nosu ppression and a d e l ay in the normal physiological process of heal i ng. These effects cannot be sepa rated fro m the beneficial effects o f corticostero ids. Much of the reported u nwan ted effects of cort icosteroids i nvolve systemic h igh-dose appl ications of the d rugs for long periods o f t i me. A loca l l y appl ied injection o f cort icosteroid in ortho paed i c medicine a i ms to ach ieve a rap id a n d i ntense local anti-inflam m a to lY effect. The l ocal e ffect wi l l depend on the dose applied, the rel a t i ve potency of t h e corticosteroid and its so l u b i l i ty, which detenni nes the len gt h o f time it stays i n the tissues. In orthopaedic medici ne the a i m is to give t he s m a llest dose t hat wil l achieve the d es i red effects, a l t hough there is i ncreas i ng evidence that la rger doses may give better resu.lts in some co nd itions, e.g. osteoarth ritis of t h e knee a n d hip and capsu litis a t the shoulder.
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Pri nciples of orthopaed ic medicine
I n t ra-articular injections a re most a p p ropriate if there is a n i n flammatory com ponent; lherefore they are i nd icated whenever a j o i n t capsule is i n flamed, e.g. in rheu matoid arthritis, traumatic arthritis and acute ep isodes of oste oa n h rosis. I mra lesional i n j ections a re appl ied to c h ro n i c tend i nopathy, tenosynovi tis, b u rs i t is and l igam ent.ous l esions, usual ly associated w i t h i nfla m m atory arth ritis. The use o f cort icosteroids would seem to affect a l l stages o f the i n flam matory p rocess, the i n i t i a l acute phase of heat, redness, swel l i ng and pain, as well as the p ro l i f erat ive phases of repa i r and remodell ing. Corticosteroids a lso produce a potent i m mu nosu ppres sive effect, which is why it is so i m porta n t to pay atten tion to aseptic tech n i q ue. In this text the corticosteroid referred to is triamci nolone acetonide. Two d i fferent concentrat ions of triam cinolone acetonide, Adcortyl ( 10 mg/ mL) a nd Kenalog (40 mg/ m L), p rovide versa t i l i ty for d i fferen t a p p l ications. In spite of the past trad i t ional use o f Adcortyl, as noted in older orthopaedic medicine texts, i<ena log is now in much wider use and recom mended dosages o f t ri a m ci nolone acetonide are usually obtai ned by d rawing up the appropriate vol u me of Kenalog. I n l ight o f t h is, Adcortyl w i l l not be referred to from h ere on.
Corticosteroid i njection tech n ique The appropriate dose ( corticosteroi d alo ne, or m ixed with local anaesthetic) w i l l be determ i ned by the size o f the j o i n t or lesion to be i njected and the previous response to i n j ection, if any. The size o f the patient is a nother bas i c factor to take i nto accou n t when decid i ng o n the dose. For m a ny of the i nject i o ns in t h is book a range is pro vided fo r the dose of corticosteroid and c l i n i cal j udgment will be needed to guide selection. With regard to m ixi ng the d rugs, at lhe t i me of writ i ng it is i l legal under the Med ici nes fo r H u man Use Regu lations ( 1 9 9 4 ) for physiotherapists to mix cortico steroid and local a naesthetic in the same syringe as part o f a patient group d i rection ( PC D ) , since that wou ld be considered to create a new p roduct which is not l i censed for use. The Chartered Society o f Physiotherapy presented a pos i t i o n paper in M a rch 2008 (CSP 2008) that was pre pared in co l laboration with the Medici nes a nd H ea l t h care products Regulatory Agency (MHRA ) and the Department o f Health a nd PCD Website Board m e mbers. I t was made clear t h a t to com ply with the l aw, when working under a peD, CS P mem bers would need to mod i fy their i njection practice which wou l d i nvolve choosing to use a pre- m ixed com merc i a l l y ava i lable preparation; giving two separate i njectio ns; not u s i ng loca l anaesthetic o r varying a d m i n istration tech n i ques so that p roducts do n o t m ix i n the syringe, e.g. using separate syringes for each d rug. A patient specific d i rection (PSD) is a written pre scription fro m a doctor, dentist or other i ndepend ent prescriber where the patient is identified by name. Physiotherapists can m ix the d rugs under a PSD, i n
accordance w i t h the doctor's d i rectio ns, and i n these situations the m ixing of d rugs is the doctor's di rect responsi b i l i ty. Phys iotherapists tra i ned in i nj ection ther apy a re advised to contact the CS P for i n formation a nd u pdat i ng.
Triamcino lone aceton ide •
i<enalog 40 mg/ m L, usually co ntai ned in ( Fig. 4 . 5 ) .
1
m L vials
Accu rate needl e placement i s esse n t i a l . Th is depends o n cl i n ical diagnosis. Knowledge of anatomy w i l l al low accu rate location of the lesion and avoid u n necessary com p l i cations. Points worth consideli ng are: • • • •
• •
The tissue in which the lesion l ies H ow deep the lesion l ies The extent of the lesion The posit ion of the patient to m a ke the site of the lesion accessible The d irection i n w h i ch the needle should be i nsened The length of needle a nd the size of syringe requ i red.
U nwanted side-effects of corticosteroid thera py Most of the u n p l easant side-effects of corticosteroid therapy re late lO large, long-term doses o f the d rugs taken system ica l ly. In lool
l ml
KENALO
_neAcelonid mg in I ml
INTRA·ARTICULAR TRA·MUSCULAR
.--
Figure 4 . 5 Contai ners of d r u gs in common use for m u scu loskeletal injections.
74 Copyrighted Material
Chapter
I 4 I
Ort hopaedic medicine t reatment tech n i ques
produce syste m ic s ide-effects fro m a s i ngle local cortico
because o f the
stero i d i n ject i o n , al t h ough it is acknow l edged that it can
Raynau l d e t al ( 2003 ) c o n d u cted a ra n d o m ized, d o u b l e
risk
of steroid
a rthropat hy.
H owever,
h a ppen w i t h l a rger doses.
b l i nd, p l acebo-co n t r o l l ed t r i a l to d e t e rm i ne t h e e fficacy o f
Post-injection flare is a sel f- l i m i t i ng i ncrease in p a i n
l o ng-term i n tra-art i c u l a r cort icosteroid i n j ec t i o n (40 mg
occurring 6- 1 2 h after i nj ec t i o n once t h e local a n aes t h e t i c
t ri a m c i n o l o n e aceto n i d e every 3 months) i n osteoa rt h r i
effed has subsided . S y m p to ms u su a l l y resolve w i t h i n 4 8 h ,
tis o f the k n ee. T h e 1 - a n d 2-year fol l ow- u p showed n o
b u t m a y m i m ic i n fect i o n , wh ich s h o u l d be suspected i f
d i ffe rence i n t h e l o s s o f j o i n t s pace over t i m e between the cort icosteroid i njection gro u p and t h e s a l i n e i n j ected
sym ptoms do not s e t t l e i n the expected t i m e .
Local soft tissue atrophy and pigment challges. These m a y
gro u p . There was a trend in the corticosteroid gro u p to
occur w i t h i n accurate need l e p l acement a nd/or lea kage o f
s h ow greater sym p t o m a t i c r e l i e f w i t h p a i n and s t i ffness
fl u id, particularly of l o ng-act i n g corticosteroids, i n to s u b
s i g n i fi ca n t l y i m p roved . The a u th o rs concl uded that t here
cutaneous t issue, a n d h ave been docu m e nted to promote
was n o s i g n i fi ca n t d e l eterious effec t o n the a n a t o m ical
fa t necrosis, dermal a t ro p hy, s e n i l e pu rpu ra, depigmenta
j o i n t stsuc t u re in e i ther group, i nd i ca t i n g that repeated
t i o n a n d subcutaneous atrophy ( ro n ec et al 1 9 7 7 , M a rks
i n tra-articu l a r i n ject i o ns a re safe.
et al 1 9 83, G r i l let & Dequeker 1 9 9 0 ) . These subcuta neous
Iatrogenic (clinician induced) septic arthritis is a rare b u t
cha nges may be revers i b le, a l t h ough t h e patient may be
avo i d a b l e s i de-effect. I t is d i fficu l t to esta b l ish t h e exact
l eft with l o ng- l as t i ng evid e n ce o f i nject i o n . The best way
i nc i d e n ce fo r s e p t i c a rth ritis and H ughes ( 1 9 9 6 ) suggests
to m i n i m i ze the risk o f this s i de-effect is accurate need l e
figu res t h a t range w i d e l y between 1 : 1 5 000- 5 0 000. ) . D .
p l ace m e n t and good need I e proprioce p t i o n . S o m e i n j ec
I(n o t t ( perso nal com m u n ication 2009 ) p u l l s t h e range i n
tors also advise using hydrocort isone for s u perficial i n j ec
c l oser t o between 1 : 2 0 000-30 000. Th e ' n o touch' tech
t ions as, being m o re s o l u b le, it is less l i ke l y to cause these
n ique described b e l ow is advised.
Systemic effects include: hyperglyca e m i a in a d iabetic
prob l e ms.
Connective tissue weafienillg is b e l i eved t o occur d u e to
patie nt; fac i a l fl ush i n g i n t h e first 2-3 days a nd lasti ng a
a loss i n ten s i l e s t rength of t h e co l l agen tissue, poss i b l y
d ay or two; menstrual d is t u rba nce, i n clud i ng p os t me no
lead i n g to tendon rupture i n p a rt i cu l a r. T h e b a l a n ce o f col
pausal b l ee d i ng.
lagen synthesis is al tered to prod uce degrad a t i o n of fi b res and new i m ma t u re scar t issue i s l a i d down. A p propriate mobi l iz a t i o n is req u i red at t h e right t i me to encou rage a l ig n m e n t of fi b res and i n c reased tens i l e s t rengt h . T h e corticosteroicl w i l l a ffect t h e n o r m a l tissue a s we l l as t h e d a m aged tissue. D u ring i t s t i m e o f act i o n , corticos tero i d p o te n t i a l l y causes a weake n i n g o f col lagen fi b res,
Loca l anaesthetic The earl iest local a n aesthet ic, coca i n e, fi rst u s e d i n 1 8 60, was e m p l oyed as a local a n aesthetic for su rge ry. A syn t h e t i c subs t i t ute, proca i n e, was deve l o ped in
1 905 a n d
m a n y o t h e r c o m p o u nds have s i nce b e e n p ro d u ced .
d a maged a n d normal, a n d t h i s s h o u l d be recognized as a pote n t i a l hazard . For t h is reason i t i s espec i a l l y i m por t a n t t h a t steroid is not i nj ected i n to the body o f a tendon, o n l y i n to i ts sheath o r at the teno-osseous j u n d i o n . I n a l l cases, t h e p a t i e n t i s i nstructed t o rest from aggrava t i n g
Uses of local anaesthetic in orthopaedic medicine •
Used together with corticosteroids for d iag nostic
a p proxi
•
To treat chronic b u rsitis.
mately a 2-week period, it wou l d see m a p p ro p r i a te to
•
As part of a n e p i d ural injection via the sacral h iatus.
activities w h i l e n o r m a l , p a i n -free fu n c t i o n is e n co u raged,
p u rposes and therapeutic p a i n relief for the pati e n t.
to provide mech a n ical st i m u l us fo r the new fi b res. S i nce tJi a m c i n o l o n e
aceto n i d e
is
absorbed
within
advise t h e p a t i e n t to rest for u p to 2 weeks i f p ract i ca l .
Steroid arthropathy, a Charcot-type arthropathy, has been reported in assoc i a t i o n with corticosteroid i n jections; h owever, reports have refuted th is ( G r i l l e t & Dequeker
Local an aest h e t i cs wo rk by p e netra t i n g t h e nerve s heath
1 9 90, Cameron 1 9 9 5 ) . I t has been considered that t he
and axon m e m b ra n e . They produce a revers i b l e b l ockade
deteriora t i o n in the ca rti lage and j o i n t m ay be m o re l i ke l y
to i m p u lse c o n d u c t i o n a n d d o this more read i l y i n s m aJ l
to be d u e to t h e u nderlying i n fla m ma tory or degenerative
d i a meter,
cond ition rather than the trea t m e n t w i t h corticosteroids.
Nocicept i ve
It is a p p ropriate to i nstruct the p a t i e n t to rest fo l lowi ng
b l ocked m o re read i l y ( Ra n g et a l 2003 ) .
m ye l i nated and
and
u n myel i n a ted
sym pa t h e t ic
i m p u l ses
nerve are
fi b res.
therefore
i n tra-a rt i c u l a r i n j ect i o n Ca mero n ( 1 9 9 5 ) reviewed the evi
Th is p a i n - re l ievi ng e ffect o f local a n aesth e t i c i s uti l i zed
d ence on steroid arthro pa t hy and fou nd t h a t the greatest
in orthopaed i c m ed ic i n e for i ts t h e ra pe u t i c and d i agnos
risk o f i ts d evelo p m e n t is from prolo nged, h igh-dose oral
tic effec ts. G iven toge.t her with corticosteroid, l ocal a naes
steroids i n t h e presence of associated u nderlyi ng d isease.
t h e t i c a l lows i m m e d i a t e reassess m e n t of the p a t i e n t to
There is a general consensus t h a t repeated cort i coster
confirm d i agnosis and to e ns u re th a t the l es i o n h as been
oid i n j ec t i o ns i n t o weight-bea r i n g j o i nts s h o u l d be l i m
co m p l et e l y i n fi l tsated.
ited t o a max i m u m o f two, or perhaps t h ree, p e r year
re i i e f a n d m ay reduce t h e effects o f pos t - i n j ec t i o n flare
Copyrighted Material
It gives the p a t i e n t i n i t i a l p a i n
75
I 1 I
Pri nciples of orth opaedic m edici n e
from corticostero i d i n jection. I t i s a l so usefu l t o d istribute
•
Fracture
the corticosteroid t h roughout the exte n t o f the lesion a n d
•
Psychosis
c a n provide a n e l e m e n t o f d i stensio n w h i ch may be use
•
Regu l a r doses of systemic steroids
fu l in j o i nts and b u rsae
•
I m m u nosu ppressed patient
in t h is text, l i docaine ( l ignoc a i n e ) hydroch l o ride w i l l
•
Tubercu l os is ( n on-active)
b e used. I t h a s a rapid rate o f onset Jnd moderate d u ra
•
Preg n a n cy
t i o n . It m a y be used as 0 . 5%, 1 % or 2 % s o l u t i o n and t h e maxi m u m d o s e i s 2 0 0 mg ( e q u a l to 20 m L of a 1 % s o l u t i o n , fo r exa m p l e ) . Th is dose is w i t h i n safe l i m its t o give by i n fi l t ra t i o n to a fit a d u l t of average we ight; it would be u n safe t o give t h i s dose i n t ravenously.
' No-touch' technique A 'no-touch' tec h n i q u e is esse n t i a l to m i n i m ize t h e risk of i n fect i o n . It is esse n t i a l to avoid i n j e c t i n g in the pres ence of i n fection because t h e corticosteroid a l s o has an
U n wa nted sid e-effects of l ocal a n aesthetic It is i m po r t a n t to recogn ize t h e m ax i m u m dose of local a n aes t h e t i c i n order to avoid t h e u nw a n ted s ide- effects ( Ra n g e t al 2 0 0 3 ) and patients s h o u l d always be ques tioned
abou t sensitiv ity to
p revious
i n jections.
i m m u n osuppressive e ffect. The fo l l ow i n g p roce d u re describes the fu l l i n jection proced ure and i n corporates t h e 'no-touch' tech n ique: •
pat i e n t and a fter scre e n i ng for COl1trailldiwtiom,
Steps
d iscuss Ole treatment optio ns, e n sure that the patient
s h o u l d a l ways be taken to e n s u re t h a t the needle does n o t
u n derstands the proposed trea t m e n t and guil1
l i e in a b l ood vesse l, by perfOim i ng a safety aspira t i o n before i nject i o n, t o avo id g i v i ng t h e dose i n t ravenously. Central
Ilervous
system
effects may i n i t i a l l y be d u e
t o s t i m u l a t i o n a n d may i nc l ud e fee l i ngs o f i nebriation and
l ight-headed n ess,
restlessness and
tremor,
c o n fu
il1/ormed comell/. •
Pos itiol1 the patiel1t Ill a k i n g sure that t h e lesion a n d
•
Assemble equ ipmellt - need l es, syri nges, a lcohol
i njection s i te are access ible. s"vabs, co tton wo ol, sh� rps b i n, p l aster; checl< and
sion progress i ng to extre m e agita t i o n . Further i ncrease in d rug l eve l s l eads to depress i o n of the c e n t ra l nervous system w h ich may prese n t as sed a t i o n , twitch i ng, con vu l s i o n
o r res p i ratoty depress i o n wh ich
is pote n t i al ly
I i fe- t hre a t e n i ng. Curdiovascular effects may present as a co m b i na t i o n
of myocard ial
depress ion
and
vasod i la t a t i o n
p roduc
ing sudden hypotens ion w h i c h may b e l ife-th rea t e n i ng. Myocard i a l d e p re ssion occurs as a res u l t of i n h i b i t i o n o f
record d rugs. •
Wash hands - soap a n d water/surgical scrub.
•
Draw up the corticosteroid and local a n a esthetic change l1eedle fo r d e l i very.
•
Marh shi,1.
•
Apply gloves or wash hands.
•
Clearl the sh irl - a l co h o l swabs, etc.
•
Deliver the il1jectioll
tech n i que (see below), w i t h d raw and dispose of
a rterioles a n d sympathetic i n h i b i t io n .
s h a rps; apply plaster/dressillg, ensuring there a re no
A llergic reactiol1s i nc l ude rashes a n d a n a p h ylaxis wh ich,
m u s t be t r a i n e d in h o w t o recogni ze a n d man age t h i s co m p l i c a t i o n .
w i thout touch ing the need l e
to i n fi l t ra t i o n , use appropriate peppe r i ng o r b o l us
t h e l ocal a n aesth e t i c e ffect on the s mo o t h muscle of the
req u i s i te that a ny pract i t i o n ers using l oc a l an aesthe t i c
-
or the i n j ec t i o n s i te. PerFo r m a safety a s p i rat i o n prior
sod i u m cu rrent in card i a c m u scle. Vaso d i l at a t i o n is d u e t o
a l t hough ra re, can b e l i fe t h reate n i ng. It is th erefore a pre
Having decided that i nject ion is a p propriate for your
a l lergies to these. •
Reassess after 5 m i n keep the p a t i e n t in the
d e p a rt ill e n t for 3 0 Ill i n to check that there is no react i o n . Advise re l a t ive rest fo r a p p roxilllately 2 weeks; reassess t h e outcome.
Contra indications to corticosteroid or local anaesthet ic injection
N eedle size ( F i g . 4.6) Syri nges ( F i g . 4.7)
Absolute •
Absence or w i t h d rawal of patient consent
•
A l l e rgy to corti costero i d or l oca l a n aesthetic
•
Sepsis
Two techn iques are genera l l y used to del iver t h e i n jec t i o n . A bolus technique is used fo r joint spaces and bur sae, where no resistance is fel t on pressing the p l u nger.
•
Syste m ic - sign i fica nt/febri l e (e.g. act ive TB)
•
Local
•
Suspected
t\ pepperil1g lech lliqlle is used fo r tendon i nsertions a n d l iga m e n ts w h e re a series of s m a l l d rop lets is d e l ivered throughoLit the substa nce of the s t ru c t u re to cover the extent a n d depth of t h e l e s i o n . Lack
Relative
o f response
to
corticosteroid
i n j ection
m ay
req u i re a review of t h e dia gnosis a n d t h e tech n i q u e. It i s
•
Poorly co n t ro l l ed d iabetes or hyperte nsion
fa i r l y cO lll m o n t o have a rel a pse or recurrence of symp
•
Ant icoagu l a n ts
to lllS in soft tissue lesio ns. Th is is particu l a r ly l i kely if
or
bl ood c l Olling d i sorders
76
Copyrighted Material
Chapter
I 4 I
Orange 25G
xi"
Orthopaedic medicine trea t m e n t tec h n iques
Blue 23G x 1 "
Green 21 G
x
1 -t'
Spinal
Sl
1 = � --
l --
Tuberculin 1 ml
2.5 ml
5 ml
Fi g u re 4.7 Syringes in common use for mus c u l oskeleta l
i nj ection s . Fig ure 4.6 Needles in common use for musculoskeletal
inject i ons
N SA I Ds p rod uce t h e fo llowi ng t h ree m a i n effects: Anti- inflammatory: t h ey mod i fy t h e i nfi a m malOry
•
rea c t i o n by red uci ng vasod i l a t a t i o n , o e d e m a a n d permea b i l i ty o f the postca p i l l a lY ven ules. t h e p a t i e n t ret u rns to t h e overuse a d i v i ty too soon or t h e
A n a lgesic: t h ey reduce p a i n by i n h i b i t i ng
•
prostag l a n d i n fo rmat i o n . They are t h e refore most
cause o f t h e prob l e m i s not p roperly i n vestigated and
e ffective in t re a t i ng the c h e m i ca l p a i n produced by
re med ied. No n·steroi d a l d rugs also aim
10
i n fl a m m a t i o n in w h i c h the prostag l a n d i ns sensit ize
reduce i n fl a m m a t i o n
the nocicep t o rs. They h ave l i t t l e e ffect in mech a n ical
a n d rel i eve p a i n associated w i t h muscu l oskeletal l esions
pain, w h i ch is w h y t h ey a re n o t p a rt ic u l a rl y e ffective
a n d a l t hough t h e i r m ec h a n i s m o f action is d i ffere n t, a
in t rea t i ng t h e acute p a i n associated w i t h rece n t d i sc
note of t h e i r e ffects m ig h t be useful at t h i s p o i nt .
p ro t ru s i o n . A ntipyretic: t h ey reduce a raised t e m perature, but have
•
Non-steroidal anti -inflam matory drugs (NSAI DS)
no effect o n t h e n o r m a l body t e mperature. NSAlDs
com mo n l y
p rescribed
indude
i b u p rofen,
naproxen, i n d o metacin, p i roxicam, d iclofenac and aspi r i n .
These are some of the most w id e ly lIsed d rugs for musculo·
I n a c u t e i nfla m m atory m uscu l o s k e l e t a l l e s i o n s (e.g.
skeletal lesions as wel l as the sym pt o m s o f h ea d a c h es, fl u ,
acute m uscle b e l l y l e s i o ns, acute l ig a m e n t spra i ns and
col ds and o t h e r m i no r aches a n d p a i ns. H owever, nearly
acute tenosynov i t i s ) i t is p ro b a b l y better to a l l ow the
3-5
a l l N SA I Ds have s i de-e ffects, t h e most notorious being
fi rst
gastro i n test i nal proble ms, w h ich c a u t i o n aga i nst t h e i r
u s i ng a n t i - i n fl a m m a to ry d rugs such as the corticosteroids
long-term use. They ca n a l so cause h a r m to t h e k i d neys
( Boruta et a l 1 9 90, Watson 2009 ) . If the c o n d i t i o n i s very
if t a ken
days o f the i n fl a m matolY p h ase to pass before
fo r prolo nged peri
pai n fu l , N S A l Ds may be a d m i n istered, or other a n a lge
ods in susce p t i b l e i nd i v i d u a l s; N SA I Ds seem to h ave th e i r
sics such as paracet a m o \ ' toge t h e r w i t h th e physical treat
action w i t h i n t h e i n j ured tissue itse l f
ments of contro l l ed a n d p recise m o b i l izat i o n cou p l ed
a n d t h e ca rd iovascu l a r system
Copyrighted Material
77
I 1 I
Princ i p l es of orthopaedic medicine
w i t h protect i o n , relat ive rest, ice, compression a n d e leva
using a
tion ( PRI C E ) . I n ch ro n ic i n fl a m m atory states, however,
sa l i ne is a n a l terna t i ve which is safe r a n d has t h e s a m e
the use of corticosteroid i nj ec ti o n is s t rongly i nd icated
e fficacy, b u t d o e s n o t g i v e t h e i n i t i a l short-term pai n rel ief
and most beneficial, but the p a t i e n t s h o u l d be i nstructed
w h ich may be helpfu l d iagnost i ca l ly.
to rest fo l l owi ng i nject i o n .
n o - touch
tech n i q u e.
M ixi ng t h e stero i d w i t h
Ivl ost s t u d i es of epid ural reveal a n overa l l efficacy rate ( remova l o f p a i n o r worthwh i l e reduct i o n ) o f a p p rox i m a t e l y 70%.
Epidura l i njections T h e u s e o f e p i d u ra l i n j ec t i o ns m a y be a p pro priate i n t h e m a n ag e m e n t o f low b a c k p a i n , particula rly if sciatica is a l s o present (see C h . 1 3 ) . The o r t h o paedic m e d i c i n e
Sclerosant therapy (prolotherapy) The a i m of sclerosa nt therapy is to i ncrease l iga ment
a p p roach is i n ject i o n v i a t h e ca u d a l rou t e w i t h t h e a i m of
or tendon mass a n d
bat h i ng t h e d u ra m a t e r and s e n s i tized nerve roots in an
strengt h . Exp e r i m e n ts have shown a sta tistically sign i fi
I iga m e n t-bone or tendon-bone
a n t i - i n fl a m m a t o ry solution w i t h o r without l oca l a naes
cant i n crease i n col lagen fi b r i l d i a meter ( Liu et a l 1 9 8 3 ) ,
the tic to rel i eve p a i n .
sugges t i n g t h a t scleros i ng s o l u t i o n has a n i n fl uence o n con nective tissue at the i nsert i o n si tes.
Uses o f epidural i njections in orthopaed ic
Uses of sclerosant therapy in orthopaedic
medicine •
Hyperacute p a i n .
•
Radicular p a i n .
•
medicine
C h ro n i c b a c k or leg p a i n , w i t h or without neurological deficit
•
Tri a l trea tment for p a i n rel i e f prior to consideration for s u rgery.
l
•
Recurrent or c h ro n i C episodes o f low back pain, With
o r Without leg p a i n •
Re cu r re n t sacro i liac j o i n t subl uxation.
•
Other con d itions associated with ligamentous l axity, e g su b luxi n g cap itate bone.
Sclerosa n t sol u t i o n s i n c l u d e hypel10 n i c d ex t rose and Bush & H i l l i er ( 1 9 9 1 ) d i scuss three poss i b l e mecha n isms o f pain r e l ief, ci t i ng B h a t i a & Pari k h a n d G u pta et al, who join Cyri�x ( 1 9 8 4 ) i n t h e suggestio n t h a t t h e i n t roduct i o n o f t h e fl u id l o c a l a naesthetic into t h e e p i
sodi u m m o rr h u ate and most prac t i t i o n e rs are now u s i ng hyperton i c dext rose The fo l l owi ng P2G m ix t u re has been c o m m o n l y used in the past
d u r a l space is eno ugh i n itse l f to i n flu ence t h e rel a t i o n
•
P h e n o l 2 % wlv
s h i p between t h e d isc a n d nerve roo t . B us h & H i l l ie r
•
Dextrose 2 5 % wlv
( 1 9 91 ) a l so c i l e Wa l l & M elzack i n descri b i n g how, i n
•
G l ycerol 30% w/v.
s p i t e o f its s h o rt act i o n , t h e l ocal a n aesth et i c may none t h e l ess b reak a pain cycl e . Cort i costero i d i s usua l l y added to the s o l u t i o n , h owever, with the logic o f red u c i n g both the swel l i n g and i n fl a m ma t i o n at the d isc-nerve root i nte rface as a n a d d i t i o n a l benefit of the l a rge-vo l u m e i nj ec t i o n ( B ush & H i l l i er 1. 9 9 1 ) . S t u d ies have shown t h a t a l though local a n aesthetic i n the e p i d ural m ix t u re gives s h o rt-term p a i n rel ief (a few h o u rs ) it m a kes no d i fference to the outcome in the med i u m to l o ng term. Accu racy o f need le p l ace m e n t is i mp roved considera b l y i f the i njec
The sclerosant causes an i n tense i n fl a m m atory reac t i o n at t h e site of i n ject i o n . The i n t e n t i o n i n prod ucing such a n i n tense i n A a m m atOlY react i o n is to sti m u late the fo r m a t i o n o f scar t issue. The i m m a t u re scar t issue laid d o wn is encouraged to co n t ract and s h O rllC1l by. avo i d i ng
movem e n t a n d s t ress d u r i ng t h e re pair and remod e l l i n g p h ases. T h e i n tense react ion causes considerable p a i n , b u t i t wou ld not be rat i o n a l to u s e a n t i - i n fl a m matory med ica t i o n fo l l o w i n g sclerosant th erapy.
t i o n is given w i th the aid of X-ray i m agi ng. It s h o u l d be st ressed t h a t, a l t h ough e p i d u ra l i n j ec t i o n via t h e caudal ro ute ca n be perfo r m ed as a n o u t p a t i e nt p rocedure, t h e i nj ect i o n s h o u l d o n l y be carried o u t by
U nwanted side-effects of sclerosant thera py
an experienced med ical pract i t i o n e r w h o has u n d e rgone
S t ro n g p h e n o l p e n e t rates the nerve e n d i ngs prod u c i ng a
a p p ro p r i a te t ra i n i ng.
local a naesthetic effect ( Good m a n & G i lman 1 9 70) w h i ch
The i n j ec t i o n typ i ca l l y i nvo l ves t h e i n t ro d u ct ion o f
is perm a n e n t . I t is not known whether the velY low c o n
80 m g t r i a m ci n o l o n e aceto n i d e i n 2 0 - 2 5 m L procai ne,
ce n t ra t i o n s u s e d i n scl erosa nt i nject i o ns have a ny e ffect
l i doca i n e or b u p ivaca i ne i n tro d u ced via t h e sacral h ia t us,
OU1er t h a n a n t iseptic.
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Ortho paed i c med icine trea t m e n t tec h n iques
Table 4.2 Summary of principles of orthopaedic medicine treatment applied to soft tissue lesions Acute m uscle belly lesions
PRIC E Gentle transverse frictions in a shortened pos i t i o n, six sweeps after a n a lgesic effect G rade A mo bil ization Progressing to a n i n creased depth of transverse frictions and Grade A + m o b i l ization until the f u l l range of movement is restored Ideally treat dai ly, o r as often as pos s i b l e, i n the early phase
t-C h ronic m uscle belly
Deep transverse frictions i n shortened position, 1 0 m i n after a n a lgesic effect
lesions
G rade A + mo bil ization No resisted exercise o r G rade B m o b i l i zation (i e stretching) until p a i n -free o n testing t h ro u g h the a p pl ication o f selective t e n s i o n ( w h e n stretc h i n g i s i n d i cated o nl y if t he structure is j u dged to be restricting range)
M usculotend i nous lesions
Deep transverse frictions i n access i b l e posi t i o n, 1 0 min after a na l geSIC effect
(us u a l l y chronic)
G rade A + mo bil ization C o rticosteroid injection is not cont ra i n d icated, b ut t h e ab ove reg i me n is g e n e r a l l y thought to be more effective PRI C E
Acute tenosynovitis
Gentle transverse frictions, s i x sweeps after a n a lgesic effect -
C h ron i c tenosynovitis
-
Grade A mo bil ization C orticosteroid injection, bolus tech n i q u e between tendon and sheath Rela tive rest (Grade A mo bil ization) OR Deep transverse frictions, tendon o n a stretch G rade A mo bil ization
C h ronic tendi nopathy, teno-osseous j u n ction
C orticosteroid i njection, peppering tec h n i q u e at t h e bone-tendon i nt erface Relative rest (Grade A m o b i l ization) OR Deep transverse frictions, 1 0 min after a n a lg esic effect G rade A m o b i l i zation M i l l s ' m a n i pu lation, special technique for tennis e l bow
Stage I caps u l l tis
C o rticosteroid injection, bo lus tech n iq u e Rela tive rest (Grade A mobil ization), progress i n g to i n creased mobilization once pain settles OR Grade B mo bil ization
Stage I I capsulitis
C orticosteroid i nject i o n , bolus tech n iq u e Relative rest ( G rade A mo bil ization), progressi n g t o increased m o b i l ization once pa i n settl es OR G rade A m o b i l ization, distraction tech ni q ues
Stage III caps u l iti s
G rade B m o b i l ization
Acute bursitis
C o rticosteroid injection, peppering o r b o l us tec h n i q u e Relative rest ( G r a d e A mo bil ization)
C h ronic bursitis
C o rticosteroid injection, l a rge vol u m e local anaesthetic, low dose, idea l l y b o l us tec h n i q u e Relative rest ( G rade A mobi l i zation)
(Continued)
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Pri ncip les of orthopaed ic med icine
Ta ble 4.2 Continued
Acute l igament lesion
PRICE Gentle tra nsverse frictions, six sweeps after analgesic effect Grade A mobilization Progressing to an increased depth of transverse frictions and Grade A+ mobilization until the full range of movement is restored Idea lly treat daily, or as often as possible, in the early phase
C h ronic ligament lesion
Deep transverse frictions, 1 0 min after analgesic effect Grade A+ mobilization Manipulation appl ied to chronic medial collateral liga ment sprain of the knee and lateral ligament sprain of the ankle following the application of sufficient deep transverse frictIOns to achieve analgesic effect OR Corticosteroid i njection Relative rest (Grade A mobilization)
Ligamentous laxity
Sclerosant therapy (prolotherapy) Relative rest
Loose body
Grade A mobilization appl ied under strong manual traction
Subluxed carpal/tarsal bone
Grade A mobilization appl ied under strong manual traction
Acute cervical lesion
'Bridging' mobilization techn ique G rade A mobilization
.-
-
Subacute/chronic cervical lesion
Mobilization under manual traction, progressing to manipulation if necessary (NB vertebrobasilar artery test should be conducted before manipulation)
Acute lumbar lesion
'Pretzel' mobilization technique Grade A mobilization Caudal epidural injection
Subacute/chronic lu mbar lesion
Mobil ization techniques Manipu lation Traction Ca udal epidural injection
Sacroiliac Joint lesion
Mobil ization techniques Manipulation Exercise
This table
is not intended as a
recipe, but acts as a guide to the i n tegration of the principles of orthopaedic
medicme
into cl inical practice.
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Zusman, M., 1 9 9 4 . W h a t does
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2 Practice of orthopaedic medicine
5. The shoulder 6. The elbow
125
7. The wrist and hand 8. The cervical spine
9.
10. The hip
87
The thoracic spine
11.
The knee
247 283
12. The ankle and foot
153
13.
181
The lumbar spine
14. The sacroiliac j oint
225
321 363 411
treatment techniques presented. [n the sections on treat
Introduction to Section 2
ment indications and application, the words 'may' and 'might' will often be encountered. They are not intended
Section 2 adopts a regional approach, encompassing the
to imply a wishy-washy attitude to practice, but rather to
shoulder, elbow, wrist and hand, cervical spine, thoracic
acknowledge the existence of options and to underline
spine, hip, knee, anlde and foot, lumbar spine and sacro
the fact that final decisions should rest with clinicians,
iliac joint. Anatomy, assessment, lesions and treatment
on the basis of judgment. The ability of clinicians to
techniques are discussed in turn for each region. Throughout this book, anatomy is presented
draw from available evidence, and lheir clinical experi a 'need
ence to apply clinical reasoning during assessment and
to know' basis, being confined to what is clinically relevant
the planning of treatment regimes, should always be the
in the context of orthopaedic medicine. It is not intended
priority.
011
that, through its presentation here, anatomy can be learned
It has been our experience in reaching orthopaedic
afresh, but rather that it should act as a reminder of the
medicine that students gain confidence and competence
subject taught so stringently at undergraduate level. It may
more rapidly if they can at first be guided step by step
also stimulate the reader to return to specialized anatomy
through the techniques with feedback on their perform
texts to explore eacll region in greater detail in the pur
ance. Though unable to provide feedback, this book
suit of increased accuracy, particularly in peripheral ioint
aims to enable students to check treatment techniques
lesions, and enhanced clinical effectiveness.
in the unsupervised clinical situation, and reflective self�
This book is not intended to be a cookbook whose recipes must be followed rigidly in the application of the
evaluation is encouraged to help to develop the skills from there.
Copyrighted Material
5 The shoulder
CHAPTER CONTENTS
119
Tendinopathy of the long head of biceps
121
87
Summary
88
Anatomy
Inert structures
Contractile Structures Guide to surface marking and palpation
88 92 93 93
Lateral aspect
94
Anterior aspect
94
Palpation of the insertions of the rotator cu f t ndons
95
Commentary on the examination
96
Observation
96
History (subjective examination) Inspection
96
State at rest
98
Examin tion by selective tension (objective
98
98
examination) Capsular lesions
'Frozen shouldf'( (adhesive capsulitis) Non-capsular lesions
105 105 110
Acute subacromial bursitis
110
Acromioclavicular joint
111
Subacromial impingement syndrome
Chronic subacromial bursitis Contractile lesions
113 114 114
Supraspinatus tendinopathy
115
Infraspinatus tendinopathy (±teres minor)
117
r
SUMMARY The shoulder can be a minefield of misdiagnosis
Posterior aspect
© 20 to Eisevi
Subscapularis tendinopathy
with lesions grouped under the broader, non specific headings of 'rotator cuff syndrome', 'impingement', 'instability' or 'frozen shoulder'. Diagnosis can be difficult if lesions coexist. It is not uncommon to find a tendinopathy or bursitis in conjunction with a secondary arthritis. Reference of pain from the cervical region may mimic that from the shoulder, requiring assessment of both joints to be sure of the origin of the symptoms. Shoulder pain may also be due to pathology in the chest and visceral structures, making thorough examination essential. Knowledge of anatomy and the use of selective tension aid the incrimination of the causative structure. Palpation then identifies the specific site of the lesion to which effective treatment can be applied. The orthopaedic medicine treatment techniques discussed below should be integrated into clinical practice alongside techniques drawn from other modalities; the importance of addressing the cause as well as the symptoms cannot be stressed enough. This chapter outlines the relevant anatomy of the shoulder region with guidelines for palpation. The assessment procedure follows, incorporating the pertinent elements of the
87
Ltd
Copyrighted Material
I 2 I
Practice of or th o p aedi c medicine
The lateral angle of the scapula is broadened to form
subjective and objective examination towards the identification of shoulder lesions. The lesions are discussed and treatments are suggested. based on the principles of theory
the pear-shaped glenoid fossa that articulates with the
and practice.
biceps and a roughened infraglenoid tubercle gives origin
head of the humerus at the glenohumeral joint A rough ened supraglenoid wbercle gives origin to the long head of to the long head of triceps. The spine of the scapula is subcutaneous and, hav ing arisen from the upper dorsal surface of the scapula,
ANATOMY
it widens laterally, projecting forwards to form the dis tinctive acromioll process. When the acromion is viewed laterally it may be obselved to be flat, sl ightly curved or
Inert structures
to have an anterior hook-like process. The last two may
I n the shoulder region, simultaneous coordinated move
predispose to rotator cuff pathology since they reduce the
ments occur at four articulations between the scapula,
vel1ical dimellsions of the subacromial space (Flatow et al
clavicle, humerus and sternum: the glenohumeral joint,
1 9 94, Pratt 1994, Hulstyn & Fadale 1995).
acromioclavicular
joint,
sternoclavicular
joint
and
The lower border of the crest of the spine of the scap
scapulothoracic joint. The glenohumeral joint (shoulder
ula is continuous with the lateral border of the acromion
joint) is the most mobile joint in the body and is the first
and forms a useful palpable bony landmark: the posterior
link in a mechanical chain of levers that allows the arm
angle of the acromiol!. The allteromedial border of the
to be positioned ill space. The joint is inherently unstable
acromion shows an oval facet for articulation with the
and it relies more on its surrounding muscles for stability
clavicle at the acromioclavicular joillt.
than on the shape of its joint surfaces and ligamentous
lust above the glenoid fossa, the prominent hook-like
constraints. Movement at the spinal joints increases the
coracoid process springs up and forwards to lie below the
range of movement available to the glenohumeral joillt
outer clavicle. With the arm in the anatomical position,
(Nordin & Frankel
the coracoid points directly forwards to form a prominent
The large, against
the
2001).
flat scapula is suspended by its muscles posterolateral
thoracic
wall and
overlies
palpable bony landmark. The clavicle
is subcutalleous,
running
horizontally
the second to seventh ribs in the neutral position. It is
between the acromion process of the scapula and the
attached to the strut-like clavicle by the acromioclavicu
manubrium sterni, with which it articulates. On its lat
lar joint and together they position, steady and brace the
eral aspect is a small oval facet that articulates with the
shoulder laterally, so that the arm can clear the trunk.
acromion at the acromioclavicular joint.
The clavicle transmits the weight of the upper limb to the
Inferiorly and laterally is a rounded conoid tubercle
axial skeleton via the coracoclavicular and costoclavicular
from which a roughened trapezoid line runs fOlvvards and
ligaments, and the glenohumeral joint provides the upper
laterally. Both give attachment to the separate parts of the
limb with its wide range of movement.
coracoclavicular ligament, which firmly fastens the clavi
The inferior junction of the medial and lateral borders
cle to the scapula via the coracoid process.
of the scapula forms the inferior angle, which lies over the
The upper part of the humerus expands to bear a head
seventh rib and is crossed by latissimus dorsi. The lateral
and the greater and lesser tuberosities. The head of the
border provides the origins of teres major below and teres
humerus is approximately hemispherical and provides an
minor above. The medial border is long, providing attach
articulating surface that is much greater than its scapular
ment for the levator scapulae and the rhomboid muscles;
counterpart, the glenoid fossa. SurroundiQg the head of
it joins the short superior border at the superior angle.
the humerus is a slight constriction that 'represents the
The suprascapular notch lies at the junction of the supe
anatomical neck and separates the head from the two
rior border with the coracoid process. This notch is COI1-
tuberosities. The head of the humerus joins the shaft at
verted by the superior transverse scapular ligament into a
the SlIrgical neck so called because it is the COLnmon site
foramen for the passage of the suprascapular nerve. The
of fracture of the humerus.
suprascapular vessels pass above it.
The greater tuberosity is large and quadrilateral and is
The dorsal surface of the scapula is divided by the spine
the most lateral palpable bony landmark at the shoulder.
of the scapula into fossae above and below. The smaller
Projecting laterally beyond the acromion, it is covered
upper supraspinous fossa gives origin to the suprasp
by the deltoid muscle and is continuous with the shaft of
inatus muscle and the lower, larger infraspinous fossa
the humerus below. Three articular facets sit on its superior
gives origin to infraspinatus. The two fossae communi
and posterior surface for the attachment of supraspinaw5,
cate laterally at the spinoglenoid notch through which
infraspinatus and teres minor. Supraspinatus inserts into
runs the suprascapular nerve. The costal surface shows a
the highest or superior facet, infraspinatus into the mid
slight hollowing for the origin of subscapularis and its
dle and teres minor into the lower or inferior facet. In
medial border is roughened for the insertion of serratus
reality these tendons are not separate, but together with
anterior.
subscapularis they interdigitate at their insertions to form
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a fibr ous thickening of the capsule, the r otat or cu ff The sharp medial edge of the g reate r tuber osity forms the lateral Iip of the bicipital groove (intertubercular sulcus) which receives the inserti on o fpect oralis ma j or. The lesser tuberosity is a b ony pr ojecti on that lies bel ow and lateral t o the c orac oid pr ocess. It receives the inser ti on of subscapularis on its medial aspect and its sharp lateral edge forms the medial lip o f the bicipital gr oove which receives the inserti on o fteres ma j or. The stemoc/ulJiCLIlar joint is a syn ovial j oint between the medial end ofthe clavicle and a notch on the super o lateral aspect of the manubrium sterni. A fi br ocartilagi n ous disc is p ositi oned between the j oint sur faces. It is an important j oint since it is the p oint of attachment of the upper limb t o the axial skelet on. The acromioclavicular joint is a syn ovial plane j oint with its articular surfaces covered wi th fibrocartilage. A wedge-shaped fibrocartilaginous disc dr ops d own into the j oint fr om the superi or aspect of the j oint caps ule , pr oducing a partial division o f the joint. The articular facet on the lateral aspect of the clavicle is directed in fer o laterally and the corresponding facet on the medial border of the acr omi on is directed superomedially, pr oduc ing a tendency for the clavicle t o override the acromion. The plane o f the j oint tends t o be varia ble, but may run sl ightly obliquely, sl oping medially fr om superior t o in ferior. The j oint is surr ounded by a fi br ous capsule that is thickened superiorly and in feri orly by the parallel fibres of the capsular ligaments running between the tw o b ones ( Fig . 5.1). The stability o f the acr omi oclavicular j oint is pr ovided by the str ong accessory c orac oclavicular ligament. The clavicle acts as a s tr ut or brace and all ows the scapula t o r otate and glide forwards and backwards. The m ovements at the acromioclavicular j oint are passive, in the same way as th ose of the sacroiliac j oint. The small
am oun ts o f m ovement available make it impossible t o determine a capsular pattern, although as a syn ovial j oint it can be affected b y arthritis. The coracoclavicular ligament is separate fr om the acromioclavicular j oint, but in str ongly binding the scap ula t o the clavicle via the coracoid process it provides a stabilizing c omp onent to the j oint. The ligament has tw o parts, the trapez oid and c on oid ligaments, which are sep arate anat omically and functionally. The m ore h oriz on tal trapez oid ligament acts as a hinge for scapular m otion, while the m ore vertical conoid ligament acts as a l ongi tudinal axis for scapular r otati on. Together, the ligaments prevent medial displacement o f the acromion under the clavicle. The glenohumeral joint is a syn ovial ball-and-socket j oint between t he head of the humerus and the glenoid fossa of the scapula, deepened by the fibrocartilaginous glen oid la brum (Fig. 5.2). The tw o articular surfaces are inc ong ruen t, with the relatively large head of the humerus pr oviding a surface area three t o four times tha t of the glen oid fossa (Hulstyn & Fadale 1995). The en orm ous range of movement is there fore at the expense o f j oint stability. With n o inherent bony stability availa ble, stabil ity is dependent primarily up on the static ef fects o f the capsuloligamentous structures and the dynamic effects o f the surrounding muscles. The li mited j oint v olume and a nega tive intra-articular pressure provide a form o f static stability. The action of muscle f orces, mainly the r otat or cuf f, pr oduces c ompressi on o f the head o f the humerus in t o the glen oid la brum, pr oviding imp ortant dynamic sta bility and steering the j oint sur faces during m ovement (Speer 1995). The joint capsule, lined with syn ovium, is thin and spa ci ous, with a large v olu me, n ormally o f between 15 and 30mL ( Ca i l lie t 1991, Halder & An 2000). It attaches t o the edge o f the glen oid medially and surrounds the
Joint capsule and superior acromioclavicular ligament
Clavicle
------�
Coracoclavicular
----::::---\-':'
ligament Acromion process Coracoid process
-----(--, Joint capsule and inferior acromioclavicular ligament
Figure 5.1 Acromioclavicular joint, showing intra-articular disc an d ligamen ts . From Anatomy and Human Movement by N, Fie ld D and Soames R 2006. Reprinted by permission of Elsevier Ltd.
Palastanga
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Joint capsule and superior --� acromioclavicular ligamenl
�---- Arlicular disc .;----- Acromioclavicular joint
Subdeltoid
.------ Joint capsule and inferior
bursa
�������������
/�
capsular --ligament
acromioclavicular ligament
��-- Supraspinatus muscle Glenohumeral j oi nt
Deltoid ---J-Th1-l
tJL:::;.:.-/---- -- Fibrous labrum
muscle
----
Articular cartilage Glenoid fossa of scapula
'----- Axillary recess
Figure 5.2 Cross-section of glenohumeral joint showing internal structure. From Anatomy and Human Movement by Palastanga N. Fi e ld D and Soames R 2006. Reprinted by permission of Elsevier Ltd.
F igure 5.3
External aspect of glenohumeral joint showing axillary pouch and capsular ligaments
anatomical neck of the humerus laterally, except f or its inferomedial pan that descends to attach to the shaft of the humerus. approximately 1 cm below the art.icular margin. The inferomedial portion forms a loose axil lary pouch or fold and consists of randomly organized collagen fi bres (Hulstyn & Fadale 1995). Although this arrangement facilitates movement, this part of the capsule is relatively weak, as it is not supported by muscles, and is often subject to strain. The capsular fi bres are mainly horizontal and are rein forced anteriorly by three capsular ligaments, the superior,
middle and inferior glenohumeral ligamL>tILs, which are evi dent only on the interior asped of the capsule (Fig. 5.3). The three bands together form a Z-shape reinforcement to the anterior c aps ule (Kapandji 1982). The inferior gleno humeral ligament complex plays a major sta bilizing role in supporting the humeral head in a hammod< or broad sling. particularly during a bduction (Hulstyn & Fadale 1995, Speer 1995). AJI three bands of the glenohumeral ligaments are taut in lateral rotation, and a bduction stresses the middle and inferior bands. This may be significant in the develop ment ofthe capsular pattern ofthe shoulder joint.
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The rotator cuff muscles (supraspinatus, infraspina tus, teres minor and su bscapularis) act as extensi ble liga ments to support the capsule, assisted by the long heads of triceps and biceps. Much of the capsule is less than 1 mm thick, but it is thickened to between 1 and 2 mm near its humeral attachment where it receives the rota tor cuff tendon fi bres (Hulstyn & Fadale 1995). The rota tor interoal is a fi brous gap between the supraspinatus and su bscapularis tendons and is therefore part of the rotator cufF. It is composed of fi bres from supraspinatus and su bscapularis together with the coracohumeral liga ment, the superior glenohumeral ligament and parts of the capsule. The key structure of the interval is the coracohumeral ligament, which attaches between the dorsolateral aspect of the base of the coracoid and the greater, and to some extent the lesser, tu berosities. It would seem to be impor tant for inferior sta bility of the glenohumeral joint and in limiting lateral rotation (jost et al. 2000), possi bly con tributing to the capsular pattern if the interval becomes reduced. The wide range of movement availa ble at the gleno humeral joint consists of flexion, extension, abduction, adduction, medial and lateral rotation that all combine to allow circumduction. The range of elevation may be up to 180° and may occur through flexion in the sagittal plane, or abduction through the coronal plane. The most functional movement is a bduction in the plane of the scapula, known as scaptioll. This is not a fixed plane but occurs 30-40° anterior to the coronal plane of the humerus (Frame 1991). It places deltoid and supraspinatus in an optimal position to elevate the arm ( Nordin & Frankel 200 1). Abduction is accompanied by lateral rotation in the coronal plane which allows the greater tu berosity to clear the acromion; scaption does not involve this element of concomitant lateral rotation (Frame 199 1). Active elevation consists of abduction from 0-60° occurring at the glenohumeral joint, 60- 120° occurring at the scapulothoracic joint and 120- 180° occurring at the glenohumeral and scapulothoracic joints together with side flexion of the trunk to the opposite side (Kapandji 1982). Approximately 90° of passive gleno humeral a bduction is achieved with the inferior angle of the scapula fixed. The range of lateral rotation is 80-90° and medial rotation 100- 1 10°, with full range achieved only by taking the arm behind the back. Rolling and translational (gliding) movements also occur and the glenohumeral joint surfaces can be sepa rated by distraction. Muscle forces acting on the joint sta bilize it and produce a combination of shearing and compression forces, maintaining the humeral head in the glenoid fossa. The nerve supply to the glenohumeral joint is mainly from the C5 segment. Cameron (1995) looked at the shoulder as a weight bearing joint. Although this joint is traditionally considered
to be non-weight- bearing in character, he applied simple physical principles showing this not to be the case. With the weight of the adult arm estimated to be approximately 5 k g, forces equivalent to three times body weight are transmitted throu gh the shoulder during simple daily activities. The comcoacromial ligame1lt is an accessory ligament of the shoulder joint, forming an osseoligamentous arch over the superior aspect of the shoulder joint and the subacromial bursa. It is triangular in shape and approxi mately I cm wide. Its apex attaches to the anterior aspect of the acromion and its base to the lateral aspect of the coracoid process. The coracoacromial arch is separated from the underlying tendons by the subacromial bursa. The coracoacromial ligament is unusual in that it attaches to two parts of the same bone, probably functioning as a buffer; it provides sta bility for the head of the humerus against upwards displacement and protects it from direct vertical trauma (Petersilge et al 1997). Numerous small bursae are associated with the shoul der joint. An anterior subscapular bursa lies between the tendon of subscapularis and the anterior capsule, consist ently communicating with the joint. The synovial lining of the joint extends to form a sheath around the long head of biceps in the bicipital groove. A bursa, which communicates with the joint, may be present between the tendon ofinfraspinatus and the posterior capsule. The subacromial bursa is independent of the shoul der joint and normally does not communicate with it. It was descri bed by Codman in 193 4 as the largest and most complicated bursa in the body forming a secondary scapulohumeral joint (Beals et al 1998). It therefore has a special role in the biomechanics of the shoulder joint and is frequently a cause of pain. It is a smooth synovial sac containing variable thin bands or plicae and is sur rounded by fatty areolar tissue ( Hulstyn & Fadale 1995). Beals et al ( 1998) identified by cadaver studies that only the anterior half of the under-surface of the acromion is contained within the su bacromial bursal cavity, which may have implications for injection of the subacromial bursa, particularly if a posterior approach is used. Its deep layer lies over the rotator cuff tendons and the head of the humerus (Cooper et al 1993). Medially it extends under the acromion to the acromioclavicular joint line and lat erally it caps the greater tuberosity, separating it from the overlying deltoid muscle. The subacromial space is sometimes considered to be a joint (Kapandji 1982, Pratt 1994). This is not a true articulation but it is critical to shoulder movement. As supraspinatus pulls the greater tuberosity superiorly and medially, the walls of the subacromial bursa glide over one another allowing the head of the humerus to slide (Netter 1987). The su bacromial space is approximately 7- 1 4 mm deep (Frame 199 1) and is occupied by the sub acromial bursa, the supraspinatus tendon, the superior part of the capsule of the shoulder joint and the tendon of the long head of biceps. The tightly packed structures move constantly in relation to one another and there is
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the pote n t i a l fo r fr i c t i o n and dege n e ra t i o n . Inflam m a t i o n ,
abduction with an early rise i n tension in supraspi natus
degenerat i o n , the shape o f the acro m i o n o r degen.e ra
fixi ng the h u m e ral head, and e n a b l i n g d e l t o i d to work a t a
t i o n of the acro m i oc l avicu l a r j o i n t can a l l c o n t r i b u t e to
better mechan ical advan tage ( Ca i l l i e t 1991, Frame 1 9 91).
a red u c t i o n o f the ve rtical proportions or stenosis of t h e
It may be that d e l t o i d and s u p rasp i n atus can i n iti ate and
subacro m i a l space. I m p i nge m e n t o f a pai nful structure
com plete a fu l l range of abduction i ndependently.
in the space may produce a p a i n fu l arc between 60 a n d 1200 of a b d u ct i o n .
Infraspinatus (suprascapular nerve C4-C6) is
a
th ick
tria ngu l a r muscle that takes origin fro m the m ed i al \Wo thirds of the i n fraspi nous fo ssa. I ts fibres converge to for m a broad, thick tendon, passing over the posterior
Contractile structures
j o i nt capsu le, w i th which it b l e nds, and i nserting i nto the
Four s h o rl muscles (supras p i n atus, i n fraspinatus, teres
m i dd l e o f the three facets on t he greater tuberosity o f the
m i n or and subscapu lilris) pass from the scapula to the
humerus, some of i ts fibres i n terdigitating w i t h the adja
head of the h u merus and these are known as t h e rota tor
cent s u p raspi natus. Together with teres m i n o r, with wh ich
cu ff. The rotator cu ff m uscles are particularly i m portant to
it is somet i m es fused, i n frasp i n a t us produces latera l rota
the fu nction of the s h o u lder, working together as extensi
t i o n of the g l e n o h u meral jo i n t d u r i n g elevation.
ble l iga ments to provide dyna mic stability, m a i n t a i n i ng
Teres minor (axi l l ary nerve C5-CG) takes origin from
and cen tralizing the head of the humerus in the glenoid
the u p pe r two- t h i rds of t h e lateral border of the scapula,
fossa.
above the origin of t eres major. It i nserts i nt o t h e lowest
Shoulder
movement,
part i c u l a rl y
e l evation,
is
governed by force coup l es that i nvolve t h e i n teract i o n of
of t h e t h ree facets on t h e posterior aspect of the greater
deltoid a n d t h e (otator c u ff m uscles (Nord i n &. Frankel
tuberosit y ble n d i n g with the posterior capsul e as it passes
2001 ). The rotator cuff m uscles m a i ntain the j o i n t's a p po
over i t . I t fu nct i o ns with i nfrasp i n a tus to produce latera l
sition, preven t i ng excessive superior tra nslatory movement
rotation of the g l en o h u m e ra l j o i n t .
that would l ead to i nstab i l i ty.
Subscapularis
(u pper a n d
l ower
subsca p u l a r
netve
As the rotator cuff tendons i nsert into t h e head of the
C5-CG) takes origin from the m e d i a l two-thi rds of the
h u mer us t h ey b l e n d with the caps u l e of the j o i n t form
subscapu lar fossa on the costal surface o f the sca p u l a, and
i n g a th ickened co m m o n tendinous cuff. Fibres fro m
i nserts by a broad, thin, me m b ranous tendon i n t o the
subsca p u laris a n d i n frasp i natus i n terd igit.ate w ith t h ose
l esser tuberosity of t h e hu merus. It re i n forces t h e anterior
of s u prasp i na t u s i n t h e i r deep layer, fac i l i ta t i n g the d is
caps u l e, fr om w h i ch i t is partially separated by a b u rsa
t r i b u t i o n of forces d i rectly or i n d i rectly over a wider area
w h i ch communicates with the j o i n t It fu nctions to pro
(Cla r k &. Harry m a n 19 9 2 ) . The tendon of t h e l o n g head
d uce med i a l rot a t i o n of t h e glenohumnal j o i n t . F i b res
of b i ceps exits the caps u l e t h rough a rei n forced fo ra men
fro m subsca p u l a ris a n d s u p rasp i n atus b le n d together to
at t h e j u n ction o f t h e insertions o f s u p ras p i natus a n d sub
contri bute to t h e rotator interval (see above).
scapularis onto t h e hu merus (Hu l s tyn &. Fad a l e 1995).
Trapezius (s p i n a l accessory nerve, XI a n d ventral ra m i
These tendons are freq uently a source of pain t h rough
o f C3-C4) i s a l a rge, flat tria ngular muscle fo r m i ng a tra pezium with i ts o p posite n u m ber. It has a l o ng l i n e of
degeneration and overuse. SupraspiTUltus (suprasca pu l a r nerve C4-CG) takes ori
attach m e n t fro m the su perior nuchill l i ne, external occ i p i
g i n fro m the medi a l two - t h i rds o f the suprasca p u l a r fossa.
t a l protrubera n ce, l i ga mentum nuchae il n d the spi nous
The fi b res, w h i c h are b i p e n n ate, converge to pass u n d e r
p rocesses a n d i n terve n i n g supras p i n ous l iga ment from
t h e acro m i o n , b l e n d i ng w i t h the ca psu le o f t h e s h o u l
C7 to T12. The upper fibres descend to the posterior bor
d e r j o i n t a n d a d j acent t e n d o n fi b res of subscap u l aris
d er o f the lateral t hi rd of the clavicle, the m id d l e fi b res
and i n fraspinatus, in ser t i n g mainly i n to t h e u p per o f the
pass ho rizontally to t h e m ed i a l border of the acro m i o n
th ree facets on t h e greater tuberosity. As t h e tendon
and t h e lower fibres pass upwards t o the crest of the
passes to it s i n sertion it appears to b e reinfo rced by the
s p i n e of the scap u l a . I n conjunction with other muscl es,
coraco h u m era l l iga m e n t that runs p a ra l l e l and is firmly
trapez i u s sta b i l i zes the scapula for fu nctional movement
ad here n t to it (Clark &. Harryman 1 9 9 2). Suprasp i n a t us
o f the arm a nd the i n d i v i d u a l port i o n s of the muscle
prod u ces a b d u c t i o n of U1e glen o h umera l j o i n t but i ts
assist other muscles in prod u c i n g pr i m a ry movement.
exact ro l e in the mech a n ism of shoulder moveme nt is
The u pper fibres or trapezius and levator scapu lae sus
cont roversi a l .
p e n d the sca p u l a against the thoracic cage and are con
S u praspinatus,
toge t h e r w i t h t h e o t h e r rotator c u ff
stantly active d u ri n g a m b u l ation (Paine &. Voight 1993).
muscles, stab i l izes the head of the h u merus, providing
Trapezi u s,
horizontal compress i o n and red u c i n g vert ical d i s p l ace
force cou p l e to rotate tbe scap u l a on the t h o racic wa l l
men t. It is considered to be respon s i b l e fo r i n i t i a t i n g
(Fra me 1 9 9 1).
abduction b y h o l d i ng t h e h ead o f t h e h u m erus down on the g l e n o i d , before delto id takes over at approximate l y 200,
together
Rllomboids,
w it h
serratus
a n terior,
fo rms
a
major a n d m i nor (rhomboid branch of
t.h e
to prov i d e t h e force for a b d u c t i o n (Pratt 1994, Pal astanga
ment fro m the l ower l i gamentum n uchae and the spines
et al 2006). However, both s u p ra s p i n a tu s and deltoid
o f C7 to T5 and pass to the medial border of the scapula,
have been shown to be active throughout the range of
to assist in its stab i l ization aga in st the t h o racic cage. The
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rhomboids are active in scapular retraction, which is essential for overhead throwing movements and swim ming strokes, e.g. crawl (Paine & Voight 1993). Levator scapulae (C3-CS) descends from the transverse
processes of the atlas and axis to the medial upper scapu lar border. Together with the rhomboids it controls and positions the scapula. Latissimus
dorsi
(thoracodorsal nerve
CG-C8) has
all extensive origin from the lumbar spine, thoraco
activities of reaching and pushing. Loss of its neIve supply leads to winging of the scapula. Movement of the scapula on the thoracic cage occurs
at the scapulothoracic joint between two fascial planes, the most superficial of which lies between subscapularis and serratus anterior (Kapandji 1982, Prall 1.994). The surrounding muscles stabilize this joint and dynamically position the glenoid fossa to facilitate efficient gleno humeral movement (Paine & Voight 1993).
lumbar fascia and thorax. The fibres converge towards the
Coracobrachialis (musculocutaneous nerve CS-C7) orig
humerus, allaching to the infnior angle of tJle scapula as
inates from the tip of the coracoid process, where it forms
they pass by. The tendinous fibres twist through an angle of 1800 before inserting into the Hoor of the bicipital groove. Ai the shoulder latissimus dorsi extends, adducts and medially rotates the humerus. Teres major (lower subscapular nerve, CG-C7) passes
rrom the lower dorsal aspect of the scapula near the
a conjoint tendon WiLh the short head of the biceps, and inseI1s into the medial aspect of the middle of the shaft of the humerus. It adducts the humerus, its position being analogous to the adductor group of muscles at the hip. Biceps brachii (musculocutaneous nerve CS-CG) has a short head arising from the ti p of the coracoid proc
inferior angle to insert into the medial lip of the bicipi
ess and a long head originating within the capsule or the
tal groove. It functions together with latissimus dorsi to
glenohumeral joint from Ule supraglenoid tubercle and
adduct and medially rotate the humerus and together they
adjacent glenoid labrum. The intracapsular part of the
fonn the posterior fold of the axilla. In conjuncLion with
tendon is surrounded by a double sheath, an extension of
pectoralis major, teres major stabilizes the shoulder joint. Deltoid (axillary nerve CS-CG) gives th . e
the synovial lining of the glenohumeral joint (Standring
rounded contour. The muscle has three sets of fibres whicll all converge to insert into the deltoid tubercle in th . e of the lateral aspect of the shaft of the upper humerus. The anterior fibres allach to the anterior border of the lateral
2009). The long head passes through the subacromial space and exits the joint behind the transverse humeral ligament, emerging between the insertions of supraspina tus and subscapularis. It continues on into the bicipital groove together with its synovial sheath. The two muscle
ulird of the clavicle and assist Hexion and medial rotation.
bellies fuse to insert into the tuberosity of the radius via
The middle fibres allach to ule acromion, assisLing abduc
the biceps tendon. Biceps has its main effect at thE' elbow where it is a powerful supinator and elbow flexor. The long head exens a stabil izing effect on the superior aspect of the shoulder joint, which may be important if the shoulder becomes less stable (Jtoi et al 1994). Jts passage laterally,
tion, ilnd me posterior fibres attach to the lower lip of the crest of the spine of the scapula assisting extension and lat eraJ rotation. The direction of the muscle fibres is almost vertical and the muscle's basic action is to elevate the head of the humerus up into the overhanging coracoacromial arch (Cailliet 1991). Overall, deltoid is a powerful abductor of the glenohumeral joint but its function is dependent on
then turning a 900 angle into the bicipital groove, assists forward flexion orthe shoulder (Cailliet 1991). Triceps (radial nerve CG-C8) originates by three heads.
vicular part CS-CG, sternocostal part C7-C8, TI) is a thick
The long head arises from the infraglenoid tubercle of the scapula and the glenoid labrum, where it exerts a stabi lizing effect on the shoulder joint. It also assists adduc
triangular muscle, originating as two separate parts from
tion and extension movements of the humerus from
supraspinatus and the other rotator cuff muscles. Pectoralis major (lateral and medial pectoral nerves, cla
the anterior chest wall to inseI1 into the lateral lip of the
the flexed position. The lateral head originates from the
bicipital groove. As the fibres cross to the arm they twist to
humerus above and lateral to the spiral groove, and the
form the anterior axillary fold. The two parts of the mus cle are both powerful adduClors and medial rotators of the
medial head from the posterior humerus below the spi ral groove. The three heads come together to insert into
humerus; the clavicular part produces flexion. Together
the olecranon process. The main action of the triceps is to
with latissimus dorsi, pectoralis major acts in climbing activities and is involved in pushing and mrowing.
extend the elbow.
Pectora/is minor (both pectoral nerves, CG-C8) passes
from the upper ribs to the coracoid process. In conjunc tion with other muscles that anchor the scapula, pectoralis minor protracts, depresses, rotates and tilts the scapula. Sen-aw.s anterior (long thoracic nerve CS-C7, descend
GUIDE TO SURFACE MARKING AND PALPATION
ing on its external surface) has an extensive origin from thE' side of the thorax, passing round the thoracic cage to insert into the medial border of the costal surface of the scapula. It is responsible for sta bil iz i ng the scapula during elevation and protraction of the scapula in the functional
Posterior aspect (Fig. 5.4) Palpate the inferior angle of the scapula which, in most people, can be grasped between a finger and thumb.
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Root of the spine of
Palpate the acromioclavicular joint line that lies between
the scapula level with
l-2cm, or approximately a finger's width, medial to the
T3 spinous process
lateral border of the acromion. The clavicular end of the
Acromion
joint may project a little higher than the acromion since
Teres minor
it overrides it slightly, and this may produce a slight step
Teres major
down between the clavicle and acromion. If this is not obvious, palpate laterally along the anterior surface of the clavicle until a small, V-shaped depression is found
Seventh rib '-"'-t-tf---I-- Inferior angle of the scaputa L...__ .. --++_---';-- Seventh thoracic
vertebra
that indicates the anterior joint line. It may also be found by palpating medially, approximately one finger's width inwards from the lateral border of the acromion. Once identified, the joint line should be palpable from above. Apply a downwards pressure on the lateral end of the
Figure 5.4 Pos t e r i or aspect of the shoulder.
clavicle and ask the model (or patient) to flex and extend the shoulder to feel movement at the joint. Palpate the
Abducting the arm may make the inferior angle easier to locate as it advances around the chest wall. Palpate along the medial and lateral borders of the scapula. The lower medial border is subcutaneous and more readily palpable, lying parallel to and approximately three fingers' width from the spinous processes. Visualize the position of latissimus dorsi as it crosses the inferior angle, and track the teres major and minor muscles that take origin from the lateral border of the scapula. Teres major originates below teres minor. The crest of the spine of the scapula may be visible and is readily palpable. Feel it sloping medially down to meet the medial border of the scapula at the level of the spinous process ofT3. Palpate the lateral end of the spine of the scapula and follow the lower border round until it joins the lateral border of the acromion. A sharp 90° angle is formed here, the posterior angle of the acromiol!, which is a useful bony landmark. Palpate the flat upper surface of the acromion which is
anterior edge of the acromion. Below the junction of the lateral third and the medial two-thirds of the clavicle, in the lateral infraclavicular fossa, feel the prominent coracoid process which forms an anterior projection when the arm is resting at the side.This is covered by the anterior deltoid and deep palpation which may be uncomfortable - is necessary. With a finger on the coracoid process, abduct the arm and the coracoid should move out from under your palpating finger. Moving slightly downwards and laterally from the cora coid process, palpate the lesser tuberosity of the humerus Immediately lateral to it is the bicipital groove and further laterally still the greateT tuberosity should be palpable. Place the arm in the anatomical position and feel the greater tuberosity lying laterally and the lesser tuberos ity lying anteriorly on either side of the bicipital groove. Relax the arm, allowing it to fall into the more functional position with some medial rotation, and feel the greater tuberosity lying more anteriorly and the lesser tuberosity medially
subcutaneous and forms the summit of the shoulder, lying just lateral to the acromioclavicular joint. Palpate the
Acromioclavicular
anterior edge of the acromion with an index finger and the
joint
posterior angle with a thumb, to appreciate its width.
Acromion process C oracoid-----___J,.-.
Lateral aspect
process
Palpate the lateral edge of the acromion. Note its depth and visualize the position of the subacromial bursa beneath it. Follow the anterior and posterior portions of the deltoid muscle down on to its insertion into the deltoid tubercle.
Greater----t-tu berosity Lesser tuberosity Bicipital groove
Anterior aspect (Fig. 5.5) Palpate the clavicle; it is usually visible and palpable throughout its length in most people. Start at the medial end and follow the anterior curve as it lies over the first
Subscapular
fossa " "
rib, then the reverse curve that produces a hollow at the lateral end of the clavicle. Below this hollow, between del toid and pectoralis major, lies the infraclavicular fossa.
Figure 5.5 Ante r i or aspect of the shoulder.
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The STeater tuberosity can b e easily locat ed as it lies in l in e w ith and abov e th e lat eral epicon dy le o fthe humer us. I t can be g rasp ed w ith th e thumb, ind ex an d mi d dl e fin g ers p lace d on its a nterior, super ior an d pos te rior sur fac es . No te i ts w id th. Th e gr ea ter tube ro si ty is sl ightly w ider fro m a n terior to post erior than th e acromion proc ess. T ry to v is ual iz e i ts thr ee fac ets for th e inser tions o f supra sp ina tus, in frasp inatus an d t er es m inor.
Pa lpation of the insertions of the rotator cuff tendons To palpa te slI praspinatus, the g rea te r tub erosity m ust b e brou gh t forwa rds fro m un de r th e acro mion to expose its s up erior fac et. Pos i tion th e pa tien t sit t ing up a t an angle o f abou t 4 5 0 agai ns t th e co uch . Medially rotat e and exten d th e ar m to pos ition it b eh in d th e back. Palpa te for th e a n ter io r edg e o f th e acro m ion a nd loca te th e gre ater t uberosi ty. Th e ten don o fsuprasp inatus is running d irec tly forwar ds be tween th e two bony points, ro ughly in lin e w ith th e posit ion o fa sho ul der s t rap (reme mber tha t y ou ha ve turn ed th e g rea ter tub erosity to l ie mor e an ter i orly ). T he ten don o f ins ert io n is app roxi ma tely one fin g er 's w id th (F ig . 5.6). To palpa te infraspinatus, th e gr ea ter tub eros ity m us t be br oug ht backwar ds fr om un der the acr o mi on t o expose i ts mi d dle face t. Positi on the patie nt in s i de -lying wi th the hea d ra ised on tw o p ill ows (o r o ne fol de d). Res t the pa t i ent 's han d on the cheek, o r on the p il l ow alongsid e th e fac e. The for ear m sho ul d be free to allow th e elbow to drop to p roduc e a d d uc tion an d la te ral ro ta t io n a t th e sho ul der ( Fig. 5 . 7 ) . Palpat e fo r th e post e r ior angle of the acro mi on an d loca te the greater t uber osi ty. Th e ten don o f in fraspinat us runs parall el to th e spin e of th e scap ula t o ins ert in to th e great er t ub erosity,
i m m e d iat ely b elow the post erior ang le o f th e ac romion. Th e tendon o f ins ert ion is app ro ximat ely two fing ers w ide. Tog eth er with th e ins ertio n o f teres minor th e ten don is three fingers wi de. To locate slIbscaplllaris, pos i tion th e ar m wit h th e hum er us in th e ana tom ical position. E i the r palpa te the coracoi d p roc ess an d mov e la terally an d slightly dow n war ds, or i den t i fy th e bicip i tal g roove an d m ove d irectly m edially t o fin d th e sha rp lat eral lip o fthe l esse r tuberos ity (Fig. 5 . 8 ) . Follow ro un d on to th e m edial asp ec t of the l ess er tuberosity to locat e th e ins er t ion o f s ubscap ularis. The ten do n i tsel f canno t be felt an d th e un derl ying bon e is t en der to palpa tion . Th e ten don is approxima tely three fing ers w ide.
Figure 5.6 Position o f arm for palpation o f the supraspinatus
tendon.
Figure 5.7 Position of arm for palpation of the infraspinatus tendon.
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Figure 5.8 Position o f
arm
for palpation o f t h e subscapularis tendon.
H i story (subjective examination)
COMMENTARY ON THE EXAMI NATION
The age, occupation, sports, hobbies alld li(estyle o f t h e p a t i e n t m a y give cl ues to d i agnosis. I nsta b i l ity is t h e m a i n
T h e h i story at t h e s h o u l d e r i s i m po l1ant, a l t hough i t prob· a b ly will not reveal a concl usive d i agnosis. Cyriax
( 1982 )
consid ered the s h o u l der to be an ' h o nest' j o i n t but most clues a re re l a ted to t h e a n a to my at t h e s h o u l d e r and are revealed in the objective exa m i na t i o n ra t h er than in the patien t's acco u n t . Les i o n s may be co m p l i cated and due to a con t r i b u t i o n of several factors. For i nstance, pain tends to cause i m m o b i l i ty a nd i t is not u n c o m m o n to fi n d a sec· o n d a ry capsu l i tis acco m panying b u rs i t i s or tend i nopalhy.
cause o f i m p i nge m e n t i n t h e younger p a t i e n t . The younger p a t i e n t engaged in physical work or active in sport may have a m i n o r i nsta b i l i ty problem or a I � bral tear related to overuse, producing second ary i m p i nge m e n t . The m id d l e aged
patient
may
present
with
overuse
rotator
cuff
l esio ns, i m p i n ge m e n t or chro n i c b u rs i t is. I n t h e o l d e r age group, d egenerat ive rotator cuff l e s ions or tears w i t h seco n d a lY o r i d i o p a t h i c caps u l i t i s m a y occur. Overuse i n j u ries are a c o m m o n cause of p a i n fel t a t the s h o u l d e r a n d the l i festyle o f t h e pati e n t can be d i rectly responsi b l e for the co n d i t i o n . Knowledge o f l i festy l e i s useful to
Observation
advise t h e pat i e n t on preve n t i ng recurrence.
A ge n e r a l observation of t h e p a t i e n t's face, posture and
S ho u l d e r i n j u ries a re c o m m o n in t h row i ng spons, swi m·
gaiL w i l l a l e rt the exa m i ne r to a b n o rm a l i t ies and serious
m i ng a n d all overhead activit ies. Ten n i s strokes i nvolve
i l l ness. Acute su bacro m i a l b u rs i t i s produ ces a co n s t a n t
rotation, abduction a n d e l eva t ion, l ead i ng to repe t i t ive
a c u t e p a i n that d istu rbs �Ieep a n d t h e p a t i e n t l oo ks t i red .
a n d st.ressfu l use of the arm in the overhead posi t i o n , pos
The acute s h o u l d e r is usua l l y h e l d in a pos i t i o n of
s i b l y ca usi ng insta b i l ity and i m pi ngemen t p a i n that may
co m fort, i .e. mediaJJy rotated with t h e e l bow flexed and
be associated w i t h a labra l lesion (McCa n n &. B igl i a n i
su pported . An a l te ra t i o n in t h e rhyt h m ical arm swing may
1994 ).
be obvious. The head of the h u m e rus i s so posi t i o ned in
W i t h the i ncreasi ng u s e o f s h o u l d e r arth roscopy, d i agnosis
t h e g l e n o i d that fu nct i o n a l move m e n ts tend to occur i n
o f gl e n o i d l a b ra l tears has become more co m m on, notably
I t is relevant to know w h i c h is the d o m i n a n t a r m .
d i ago n a l patterns a n d t h is s h o u l d be evi d e n t i n t h e a r m
types of SLAP (superior l a b r u m from a n terior to posterior)
swing d u r i n g ga i t activity.
l es i o n . The patient complai ns of a d u l l t h ro b b i n g ache i n
Due to t h e m a ny a n atom iCid c o m p o n e n ts that make
the j o i n t that can cause d i fficu l ty i n sleeping. There i s usu
up t h e s h o u l de r region and t h e interre l ations h i p between
a l ly pain and a catc h i n g fee l i ng as the arm is t h rown into
the fu nct i o n of each group, lesions can be subtly co m ·
tbe overhead posi t i o n a nd compression o f t he j o i n t may
p l i cated. M u l t i p l e lesions c a n exist a n d i nstab i l i ty can
also produce i mp i ngem e n t pai n.
p roduce seco n d a ry p ro b l e m s at the s h o u l d er. In focusing
La b ra l tears are d i fficu l t to d i agnose cl i n i c a l l y and to
o n t h e d i ffe re n t i a l d i agnosis of spec i fi c l e�ions, orth opae
d i s t i nguish [rom other causes o f i m p i ngem e n t . Several
d i c m e d i c i n e l o o ks a t co m m o n lesions a t t h e s h o u l d er.
tests have been devised but none of t h e m is 100% sensi
For m o re d e t a i l e d coverage of s h o u l d e r i ns t a b i l ity a nd i ts
tive o r spec i fic ( G uanche &. Jones 2003, Bru kner &. K han
re l a t i o n s h i p to s h o u l der lesions t.he reader is referred to
2007 ) . A system a t i c review conducted by M u nro &. H ealy
o t h e r texts t h a t cover t h is subject.
( 2009 ) , on t he va l i d i ty a n d accuracy o f c l i n ical tests to
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The shoul d er
detect l a b ril l pathology o f t he should er, fo u n d l i m ited
Acro m ioclavicular lesions m e usual l y associated with a
evidence fo r the biceps l o ad i ng tests, the i n te r n a l rota
trau m a t i c onset. Degenerati o n of the j o i n t in th e m i d d l e
tion resistance test, the Kim test a n d the Jerk tests as accu
aged to elderly may res u l t fro m repeated trau m a a n d pro
rate tests fo r d i fferentiating l abral pathol ogies in sel ected
vide a n a l ternat ive cause of pil i n .
populati ons. Other tests did not produce such accurate results. The reader is referred to the paper fo r a description of the tests themselves o r t h ey may be fo u n d in Hattam &
An acute su bacrom iill bursitis has a c h a racteristic sud den onset w i th no a p pa re n t Ciluse. The co m m o n
s h o u lder l esions o f overuse tend i n o
Smea t h a m ( 2 0 10 ) . Surgical repa ir is needed in most cases
pathy, b u rs i t i s o r capsu l itis present most ryp ica l ly w i t h a
and the associated i n sta b i l i ty s h o u l d be add ressed as part
gra d u a l o nset of p a i n d u e to overuse fa ctors. A caps u l i t is may be preci pitated by t ra u m a, b u t this is o ften m i nor
of re h a b i l it ation. Throwing has several d i ffe rent mechanisms, fo r exam
and the patient ca nnot reca ll t h e i nc i d e n t . S t i ffness and
ple the straight-arm t.h row o f the j avel in, the centrifugally
loss o f fu n c t i o n a l movement are usua iJy i n d i cative o f Cilp
i nduced velocity of hammer throw ing, the explosive push o f
s u l i t i s . Ten d i nopathy may be provoked by overs t retching
put t i n g the shot or the spi n n i ng pul l of t h e discus t h rower.
o r contra ct i o n aga i nst strong resistance.
A 'dead arm' syndrome may be produced du ring t h e accel eration phase of throwing, when the arm becomes useless a nd drops down by the s i d e. It may be associated w i th
The duration of the symptoms gives an i n d i cat i o n of the stage the lesion hilS reached in the i n fl a m matory cyc l e. N o n -specific shoulder p a i n
may be assoc i a ted with
p i ns and needles and takes several m i n utes to recover. It is
nelve e n t ra p m e n t. whic h wo u l d be confi rmed by signs of
considered to be due to momentary subluxation of the
object ive weakness but with no pa i n on s h o u l d e r move
glenohu meral j o i n t associated with com press ion o f the bra
ments ( B i u ndo & H a rris 1 99 3 , Schu lte & \Vam e r 1 9 9 5 ) .
chial plexus ( Copeland 1 993, Clamette & M i n i aci 1 9 9 8 ) .
The behaviour of t h e p a i n is releva n t t o d iagnosis with the
The s i te o f t h e p a i n does n o t rel iably ind icate t he site o f
common lesions prod ucing typical m uscu loskeletal pa i n
t h e l es i o n . The shoulder j o i nt a n d i t s surro u n d i n g caps u l e,
o n move m e nt w h i c h is eased by rest. The patient s h o u l d b e
l iga m ents a n d muscles are m a i n ly derived fro m the C5
asked i f t h e pain is constant or o n ly present on movement,
segment. Lesi o n s of any of these structures w i l l cause the
givi ng an i n d ication o f t h e i critabil i ry of the l es i o n . Chronic
pain to be referred i nto the C5 dermatome w h i ch extends
overuse ten d inopat.hy or bursitis often prod uces a d u l l ache
i nt o the a n terolateral aspect of the arm and forearm as
rather than a pain, al though twi nges of pai n may be expe
fa r as the base of the thumb. The most co m m o n poi nt of
rienced i f i mp i ngement occurs d u ri ng movement. An acute
referral fo r these st ructures is to t h e area over the i nsertion
subacro m i a l b u rs i t is p rod uces severe pa i n that is constant
o f deltoic! . Rotator cu ff pat hol ogy usua l l y produces a n tero
and often u n relenti ng, disturbing s l ee p .
lateral shoulder p a i n (Cl arnette & M i n iaci
( 9 9 8 ) . The
A caps u l i t i s sh ows a n i ncreasi ng worse n i n g p a i n , refer
more i rritable th e les i o n, the furthe r the referra l of pa i n
r i ng fu rther a n d fu rther i nto the CS dermatome. The
i n to t h e C5 dermatome, such that t h e spread o f pain wi l l
i n fl am matory nature of the p a i n Illay be obvious i n CO Ill
give
p l a i nts of pa i n and stiffness on waking. 'Ca tch i ng' pa i n
j o i n t lying prox i m a l ly i n its derm atome, t h e gleno h u m eral
Illay be described on activ ities such a s reac h i ng fo r a seat
joint h as the potential to refer p a i n over a considerable
belt or i nto t h e back of the car, or p l a c i n g an arm in a
d istan ce. The cervical s p i ne may produce pain i n the
coat sleeve, a n d may ind icate i m p i nge m e n t of structu res
shoulder area o r refer p a i n i n to the C5 dermatome; there
u nd e r the coracoacrolll i a l arch.
fo re it w i l l need to be excl uded as a s o u rce of sym ptoms. The acro m ioclavicu l a r j o i nt and surro u n d i ng l iga m e n ts
The behaviour c a n a l so help to assess the severiry a n d i r rit a b i l ity of t h e l es i o n as we l l a s d i s t i ng u i s h it fro m a
produce an accurate localization of p a i n over the j o i nt.
lesion tllat is referring pa i n i nto t h e s h o u l d e r area. I f the
This is because, i n contrast to the glenohu meral j o i nt, the
patient i s u n a b l e to l ie on that s i d e because the i ncrease
acro m ioclavicu l a r joint is a su perfic i a l j oint giving l i tt l e
in p a i n d isturbs sleep, the lesion is i rr i t a b l e. It may i n d i
reference.
cate a c h ro n i c sub acrom i a l b u rsitis, rotator cuff l es i o n or
The symplOms and behaviour need to be considered.
more commonly a n i rr i t a b l e ca psu l itis. Sleep i n g postures
The shou lder area i s a po i n t of refen·al of p a i n from
may cause stress i n structures, i n ducing m i c rot ra u ma or
other deep structures. The cervical s p i n e i n p a rt i c u l a r can
i m p i nge m e n t .
refer pai n to the area and visceral prob lems may m i m i c musculoskeletal les io ns. The d i a p h ragm i s a C 4 structure and w i l l produce p a i n fel t at the p o i n t of the shoulder if affected by adj acent cond i t i o ns such as pleu risy. The onset of the pa i n may be sudden or gra d u a l . If t h e onset w a s s u d d e n i t i s i m portant t o k n ow i f there w a s a n y
Three questions •
D oe s
the pain spread below the elbow) (site and
spread)
related tra u m a, with the poss i b i l i ry o f fracture. A fa l l on the outstretched hand may i n it i ate a tra u m a t i c shoulder
•
C a n you lie on that side at night? (symptoms)
j o i nt caps u l i t i s or, less co m m o n l y, chro n i c subacro m i a l
•
Is the pain constant? (behaviour)
bursitis, tendon stra i n o r acrom ioclavic u l a r j o i n t spra i n .
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A l oss of fu nctional activity such as b e i ng unable t o do up a bra or reach into th e back pocket w i l l i n dicate l i m itation of move m e n t . There may be evide nce of shoul der i nstabi l i ty or la bral tears i n patients co m p l a i n i n g of 'clicki ng', 'snapping' or feel i ng as if the shoulder is 'co m i n g out'. Crepitus o r gra t i n g s o u n d s m a y i n d icate dege nerative cha nges. To d isti ngu i s h t h e lesion from one of cervical or th or acic origin the patient s h o u l d be questioned about t h e presence o f paraesthesia, a n d w h e t h e r p a i n i s i ncreased o n a cough, s n eeze or deep breath . H e aviness, t i redn ess, puffin ess, swea t i ng or a l tered t e m p e ra t u re may ind icate associated or referred a u tonomic sy m ptoms. Assess m e n t of other joint involvement will i n d icate gen eral ized a rthritis, poss i b l y rheumat oid. It is also i n terest ing to note whether the patient has had previous s h o u l der prob l e m s s i n ce both ' frozen s h o u l d e r' ( a d h esive caps u l i tis) a n d acute su bacro m i a l bursitis often affect the other shoulder s o m e years a ft e r the fi rs t i n c i d e nce. In frozen s h o u l d e r the patient may co m p l a i n of cervical i nvolve ment and t h e re may be associ ated trigger points over the posterior aspect o f the shoulder ( C rubbs 1 9 9 3 ) . Th i s may be due to com pensatory overuse of other m uscles and holding the shoulder i n a pos i t i o n of ease, or may be i n d i ca t ive of abno r m a l n e u ral m o b i l i ty. The past medical Ilistory w i l l a l en t h e exa m i ner to seri ous i l l ness a n d opera t i o ns experienced by t h e patient. The patient s h o u l d be speci fi ca l ly asked about a h istory o f d iabetes s i n ce there i s an associa t i o n between d iabe tes m e l l itus a n d the deve l o p m e n t o f a frozen s h o u l d e r ( Owens- B u r k h a rt 1 9 9 1 , Clarnette & M i n iaci 1 9 9 8 ) . The exa m i n e r s h o u l d be o n the a l e rt fo r poss i b l e contra i n d i cat i o n s t o trea t me n t . A n i n d i c a t i o n of t h e patien t's cur re n t s t a t e of h ea l t h is necessary and the patient s h o u l d be asked a bout recent u nexp l a i ned weight loss. Tu m o u rs i nvol v i n g t h e s h o u l d e r area are rare but a h i story of pri m a ry tumour shou l d raise the suspicion of m e t astatic d is ease as a poss i b l e d i agnosis (Clarnette & M i ni aci 1 99 8 ) . As we l l a s past medical h i s tory, estab l is h any ongo i ng
Inspection The patient should
u n dress t o a l l ow
the area to be
i nspected i n a good l ight. A general i nspection will determ i n e any bony deform ity. Look at t h e pos i t i o n of the cervical spine and take
a n overall view of t h e s p i n a l c u rvatures in genera l . The general posture of the p a t i e n t can be i m porta n t a nd any obselva t i o ns of a symmetry are recorded i f they are rele va n t to the pres e n t i n g cond i t i o n . It has been postulated that abno rm al cervical and thoracic postu re, particularly a n i n creased thoracic kyphosis, alters the res ting position of t h e sca p u l a a n d may be related to shoulder pa i n caused by overuse ( Green fi e l d et al 1 9 95 ) . The attitude o f the shoulder should b e noted. I s one h i gher t h a n the other or excess ively med ia l l y rotated ? [ n a frozen should er, one shoulder may be held higher than the other d ue to pain, with the scapula el evated and retracted. The pos i t i on o f the scapu lae should be noted. Are they more or less sym metrical, lying approximately three fi ngers fro m the m i d l i ne, or are they excessively retracted or pro tracted? There may be evidence of winging of the scapul a b u t th is i s usually more obvious on movement. Lumps, scars, bony pro m i n e nces and bruising should be obse rved . A pro m i n e n t bump at the end of the clavicle may s i g n i fy an old fractu re or d is l oca tion of the acromio clavicul ar j o i n t . Colour changes a n d swelling a r e un usual fi n d i ngs a t
t h e s h o u l d e r u n l ess associated w i t h d i rect tra u m a . M uscle wasting is suspected if the s p i n e of the scapula is pro m i
ne nt, due t o neuritis or rotator cu ff rupture. I n chro n i c rota tor cuff tend i nopathy a nd/or degenera t i ve tears, wast ing o f s u p ra s p i natus a n d i n fras p i natus may be obvious. The 'pop-eye' deform ity of a ru p t u re of the l o ng head of t h e biceps is usual l y obvious, but the patient d oes not part i c u l arly co m p l a i n of pa i n . I n de ltoid atrop hy, squar i ng of the shoulder occurs as d e l t o i d is no lo nger rounded Ollt over the h u m eral head and may be i n d icative of an te rior d islocation ( C l a rnette & M i n iaci 1 9 9 8 ) .
con d i t ions and treat m e n t . Explore other previous or cur rent m u scu loskeletal pro b l e m s with previous episodes o f t h e current compl ai nt, any trea tment given and the o u t
Before any moveme nts are performed, the state at rest is
com e o f trea t m e n t . Medications curre n t l y bei ng t a k e n by t h e p a t i e n t are
determ i ned
State at rest establ ished to provide a basel i ne for subsequent comparison.
to e l i m i n ate possi b le co n tra i n d i cations to
t reat m e n t . The a m o u n t
of a n a l gesia
req u i red
by the
p a t i e n t gives a n i n d i ca t i o n of the severity o f the les i o n . From t h e h istory, the poss i b l e d i agnoses a re noted . I f
Examination by sel ective tension (objective examination)
t h e eve n t u a l d i agnosis is one o f caps u l i tis, t h ree special
The suggested sequence fo r an object ive exa m i nation of
q u estions rel ating to the spread of p a i n and p rovocation
the shoulder w i l l now be given, fo llowed by a commen
factors asked d u ri n g the h i s to ry (see Box page 9 7 ) will
tary i nc l ud i ng the reaso ning in perform i ng the movements
give a n i n d ica t i o n of t h e severity of the lesion and act as a
and the sign i fi ca nce of the possible fi n d i ngs. Comparison
gui d e to tre a t m e n t .
s h o u l d a l ways be made with the other side.
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The shou l der
Resisted tests
E l i m inate the cervical spine •
Active cervical extension ( F i g . 5 . 9a)
•
•
Active right cervical rotation (Fig. 5 9b)
•
•
Adiv left cervical rotation
•
•
Adlve right cervical side flexion (Fig. 5 . 9d) Act i ve left cervical side flexion (Fig. 5. ge) Active cervical flexion (Fig. 5.9f)
• •
(Fig.
5 .9c)
• • •
Active elevation through flexion ( Fig.
•
Passive elevation ( F i g .
•
Active el eva ti o n through
5 . 1 0)
•
5.1 1) abduction for a painful a rc
(Figs 5 . 1 2 and 5. 1 3)
l.
•
•
Passive shoulder flexion and adduction (scarf test) (Fig.
5.23)
Palpation •
Passive glenohumeral movements
5 . 1 7) 5 . 1 8) Resisted shou lder lateral rotation ( F i g . 5 . 1 9) Resisted shoulder medial rotation ( F i g . 5 20) Resisted elbow flexion ( F i g . 5.2 1 ) Resisted elbow extension (F i g . 5 22)
Accessory test for acromioclavicular j o i n t o r lower fibres o f su bscapu laris
Shoulder elevation tests •
Resisted shoulder abduction ( F i g .
Resisted shoulder adduction ( F i g .
Once a diag nosis has been made, the structure at fault is pa l pated for the exact site of the lesion
Passive lateral rota tion ( F i g .
5. 1 4) 5 . 1 5) rotation (Fig. 5 1 6)
Passive abduction (Fig. Passive medial
/- , o
Figure 5 . 9 Six active movements of the cervical spine (a) extension; (b, c) rotations; (d, e) side flexions; (f) flex i o n .
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Figure 5 . 1 3 Va rying a r m position to explore for a painful arc.
Figure 5.10 Active shoulder elevation.
Figure 5.1 1 Passive should er elevatio n .
Figure 5. 1 2 Active elevation t h rough abduction, looking for a painful arc.
Figure 5 . 1 4 Passive lateral rotatio n .
1 00
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I 5 I
The shoulder
Figure 5. 1 5 Passive abduct i o n .
Figure 5. 1 6 Passive medial rota tion.
Figure 5 . 1 7 Resisted abduction.
Figure S. 1 8 Resisted adducti o n .
101
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Pract i ce of orth opaedic med icine
Figure 5 . 1 9 Resisted lateral rotati o n . Figure 5 . 2 1 Resisted elbow flexion
Figure 5 . 2 0 Resisted m e d i a l rotation. Fi gu re 5 . 22 Resisted elbow exten s i o n .
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Chapter
I 5 I
The shou l d er
on active move m e n t as co n tract i o n of the Ill uscle groups tends to ra ise the h u m eral head and reduce the space; i t is ge nera l ly fo u n d between G O and 1 20 0 o f abduct i o n . B e prepared t o explore fo r a p a i n fu l arc, especi a l ly i n t h e l ight o f find i ngs l ater i n the exa m i na t i o n , rem e m bering that a d i agnosis i s not made u n t i l t h e ful l exa m i n a t i o n has been co m p l eted. The pos i t i o n may be m o d i fied to p l ace the rotator cuff tendons i n to a m o re vul nera b le posi t i o n fo r co m p ress i o n aga i nst t h e coracoacro m ia l arch. Elevat i o n of the h u merus m rough abduct i o n
i n the
coronal p l a n e favours co m p ression o f t h e d istal end o f me suprasp i natus tendo n . Abduction witl1 medial
rotation,
palm down, bri ngs i n fraspi natus fo rwards and i ncreases me poss i b i l ity o f its co m p ression, wh i l e abduct i o n with l a teral rotation, p a l m up, brings the upper part of subscapularis to face upwards to be co m p ressed against the arch ( Figs 5 . 1 2 and 5 . 1 3 ) . Forward elevati o n i n tlle sagittal p l a ne co m b i ne d witll latera l rotation, paJ m up, co m p resses m e t e n d o n of me l o ng head of me b i ceps ( Burns & W h i pp l e 1 9 9 3 ) . T h e passi ve g l e n o h u m era l move m e n ts a r e cond ucted l o o k i n g fo r p a i n, range o f move m e n t and e n d - fe e l . S i nce va r i a t i o n in move m e n t between i nd iv i d u a l s is probab l e, movements s h o u l d a lways be c o m p a red w i t h t h e o t h e r s i de.
However, va r i a t i o n between s i d es m a y exist, for
exa m p l e in ten n is p l ayers or fast bowlers, who may have a
Figure 5 . 2 3 The scarf test.
greater range of o n e ro t a t i o n , at t h e expense of t h e o t h e r, o n the d o m i na n t s i d e. Passive l ateral a n d m ed i a l rota t ions have a n o r m a l elastic end - fe e l ; passive abd uct i o n is
The exam i n ation o f the shoulder s h o u l d fi rst exclude
assessed fo r range o f movement o n ly, since i t i s n o t pos
poss i b l e cervical l e s i o ns; therefore s ix active cervical m ove
s i b l e to a p p reciate the e nd-feel . Assess m e n t o f t h e passive
ments are perfo rmed a n d if a pattern of signs e m erges
g l e n o h u mera l movements m ay c o n fi r m the presence o f
i m p l icat i ng tlle cervical s p i n e then a fu l l assess ment of t h is
t h e capsu l a r pattern, i n d i ca t i ng a rt h ri t i s .
region must be conducted. Three e l evat i o n
tests are co ndu cted
fo r the g l e n o
h u m eral j o i nt. S i nce t h e s h o u l d e r i s considered to b e a n
Capsular pattern at t h e glenohumeral joint
'emo t i o n a l ' a r e a , act i ve el eva t i o n i n d icates t h e p a t i e nt's
•
Most l i m i tation of lateral rotatio n .
w i l l i ngness to move the j o i n t . The range o f move m e n t
•
Less l i m itation o f a b d u c lio n .
and l e v e l o f pa i n s h o u l d then be consistent w i th o t h e r
•
Least l i m itation of medial rotat i o n.
fi n d i ngs as the o b j ective exa m i na t i o n proceeds. Passive eleva t i o n is added to assess p a i n ,
range of
movement and end-fe e l . The n o r m a l end-feel o f passive
As move m ents beco m e l i m i ted in the capsu l a r pattern
e l eva t i o n i s e l astic. Any l i m i t a t i o n o f passive e l eva t i o n
t h ey deve l o p a n a b n o r m a l ly ' h a rd' end-fe e l . The capsu l a r
suggests t h a t t h e capsu l a r pattern exists a t t h e g l e n o
pattern res u l ts i n overa l l l i m i t a t i o n o f passive e l eva t i o n .
h u m eral j o i n t and t h is w i l l be co n fi rmed when t h e pas
Li m i t a t i o n o r p a i n at t h e end o f range o f lateral ro t a t i o n
s i ve g l e n o h u m eral move m e nts are assessed i n dividual ly.
o n l y m a y be a sign o f e a r l y capsu l i t is.
Active e l evation t h rough abduct i o n is conducted i n
I t may not b e poss i ble fu l ly to assess t h e range o f m e d i a l
t h e coro n a l p l a n e t o assess fo r t h e presence o f a p a i n
ro t a t i o n i n severe capsu l it i s s i nce t h e acco mpanying l i m i
fu l arc. Th i s invo l ves abduction to 9 0 ° fo l l owed by l a t
tat i o n o f abduct ion prevents t h e a r m fro m b e i ng placed
e r a l ro tat i o n, to e n a b l e the grea ter tu berosity to clear
b e h i n d th e p a t i e n t's back. As a gu ide for subsequent co m
the coracoacro m i a l arch. The test perfo rmed in t h is way
parison, measure the range o f m o ve m e n t against cert a i n
i s usua l l y co ns istent w i th t h e p a t i ent's acco u n t of symp
l a n d m a r ks that c a n be reached by t h e h a n d , e.g. pocket,
toms. H owever, fu nct i o n a l ly, t h e arm i s more co m m o n ly
b u ttock waist, i n ferior angle o f sca p u l a . S u bacro m i a l b u rsitis provides a typ ical exa m p l e o f a
l i fted t h rough sca p t i o n (see p. 91 ) . A p a i n fu l arc i s a l oc a l i z i n g sign a n d i n d icates i m p i nge
n o n -capsu l a r pattern of move m e n t at t h e s h o u l der. W h i l e
m e n t o f a p a i n ful structure in the subacro m ial space -
m e acro m i oclavicu l a r j o i n t does n o t d e m o nstrate i t s own
which structure w i i. l be revea led o n l y by co m p l et i ng t h e
caps u l a r pat tern, i t produces a n o n-capsu l a r pattern o f
fu l l exa m i na t i o n procedure. A n a r c is m o re easi ly e l ici ted
move m e n t a t t h e g l e n o h u m e r a l j o i nt .
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Practice of orthopaedic med i c i n e
The res isted tests a re c o n d u c t e d l o o ki n g for p a i n a n d
reason the resisted tes t s may be accessory signs in sub
red uced power wh i c h w i l l i n d i c a t e a muscl e l e s i o n o r
acro m i a l b u r s i t is, or s h ow i n volve m e n t of t h e j o i n t . To
poss i b l e n e u ro l ogical i n vo lve m e n t . T h e resisted
tests
co n firm d i agnosis, t h e resisted tests may be repeated i n
p e r formed i n the u p right pos i t i o n a p p l y a d egree o f
l y i ng, w i t h some j o i n t d is t ract ion, where t h e e ffect o f
u pwards sheari ng a n d co m p ress i o n t o t h e gle n o h u meral
co m p ress i o n a n d shear o n t h e j o i n t i s reduced (Figs 5 . 24
j o i n t i n s t a b i l i z i n g the head o f t h e h u m e rus. Fo r t h i s
and 5 . 2 5 ) .
Figure 5.24 Resisted shoulder abduction with distraction.
Figure S.25 Resisted elbow extension with d i stra cti on
1 04 Copyrighted Material
Chapter
I 5 I
The shou lder
Resisted abduction tests m a i n ly supraspinatus; resisted adduction
tests l a t i ssimus d o rs i
and
pectora l is m a j o r;
The movem e n ts l i m i ted in t h e capsu l a r pattern have a c h aracteristic ' h a rd' e n d - fee l , a l t h o ugh this is less marked
resisted l a teral rota t i o n tests ma i n ly i n frasp i n atus a n d teres
i n the early stage, and a ny rest ri ct i o n of the glenohu meral
m i nor; resisted med i a l rotation tests m a i n ly subsca p u l a
range i s u s u a l l y consistent w i t h an overa l l l oss o f s h o u l
ris; resisted el bow flex i o n tests b i ceps; and resisted e l bow
der e l evatio n . The presence of the c a p s u l a r pattern at t he
extension tests triceps. The a na t o m i ca l i n terdigitation of
shou l d e r i n d i cates art h ri t is. Co m m o n ly t h is is i d i o p a t hic,
the tend i nous i nsertions of the rota tor cuff tendons means
p r i m a ry art h r i t i s o r tra u m a t i c (secondary) arthri tis. This
that the resisted tests described Illay not d e fi n i tively i m p l i
is syn o ny m o us w i th frozen sho u l d e r o r ad hes ive caps u l i
cate one tendon; subsequent palpation of the structures
t is, a s d iscussed below. Less c o m m o n ly, t h e s h o u l d e r c a n
i m p l icated w i l l identify t he site of t h e lesion.
b e a ffected b y degenerative osteoarthrosis, rheumatoid
Pai n ful wea kness o n resisted test i n g may i n d icate par
arthritis o r any of the spondyloart h ropath ies.
t i a l ru pture, b u t i t may be d i fficu l t to decide w h et h e r a test is prod u c i n g rea l o r a p p a r e n t wea k n ess si nce the pat i e n t is l i m i ted by p a i n from m a k i n g a m axi m a l effo rt ( Pellecchia et al 1 9 % ) . I n ath letes i t may be d i fficu l t t o produce posit ive fi nd i ngs, espec i a l l y o n resisted testi ng, as the symptoms m ay only be provoked d u r i ng the a t h l e t i c o r sport i ng act i v i ty itse l f I t may be necessaty for t h e pa t i e nt to provoke the pai n before t h e exa m i n a t i o n is carried ou t . An accessOlY test, the 'scarf test (as in pUlling a scarf over the o pposite shoul der), may be performed to local ize the les i o n . This compresses the acrom ioclavicu l a r j o i n t or i m p i nges the l ower fibres of t h e subscapu laris tendon against the coracoid process. I t may also be positive as part of the 'mudd l e' of signs of a chronic subacrom i a l b u rsitis. Pa l pat i on i s conducted for t he s i te of the lesion, but on l y a l ong the structure determi ned to be at fau l t s i nce the s h o u l d e r is notorious fo r tender trigger p o i n ts. Through this scheme, a work ing d iagnosiS i s estab l ished on w h i c h to base a treat m e n t programme, w i t h constant m o n i toring a n d reassessment. This a p p roach is just o n e poss i b l e way of assessi ng t h e s h o u l der. Pe l lecch ia et al ( 1 9 % ) l ooked at t h e i n t e neste r reliab i l i ty of the Cyriax eva l u a t i o n and showed it to be h igh l y rel i able in the assessment of patients w i t h shou l de r pain, fac i l i tat i n g the identi fication of d iagnostic categories fo r subjects with shoulder p a i n . However,
the
approach
does n o t i nvestigate
hyper
mobi l. i ty at t h e shoulder with consequent instab i l i ty, and the reader is recommended to e m p l oy provocative i nsta b i l i ty tests as appropriate. I n add ition, spec i fi c i m p i nge m e n t tests and tests for labral tea rs can be e m p loyed as necessaty (see H allam & Smeatham 2 0 1 0 ) . The exa m i na t i o n of neu ra l structures can a lso be i n corporated i nto the p rocedure.
'Frozen shoulder' (adhesive capsu l it i s) The term (rozen s h o u l d e r is c o m m o n l y used by t h e gen era l p u b l i c to describe a ny s t i ff o r p a i nful s h o u l der, b u t it is a n overused term, m u c h c r i t i cized, si nce i t ap pears to avoid a m o re s p e ci fi c d iagnosis. It is, however, a n easy term to use and d escribes the signs and sym p toms i n d i cat i n g i nvolvement of the caps u l e o f t he shoulder j o i n t, wh i c h is t h e key factor. The n at u r a l h istory of the c o n d i t i o n is t h a t i t fol l ows a pallern of i ncreas i n g signs a n d symptoms ( freez i ng), fo l l owed b y a p l a teau stage (frozen ) before a s l ow, s p o n ta neous recovery of part i a l o r co m p l ete function ( t hawing) . RecovelY tends to occur w i t h i n 1 -3 years (Wadsworth 1 9 8 6 ) . A short p a i n fu l period is associated w i t h a s h o rt recovery period a n d a l o nger p a i n fu l period w i t h a l onger period of recovety (OwenS - B u rkhart 1 9 9 1 ) . Several a u t h o rs have reviewed the h istory of t h e fro zen s h o u l d e r (Wadsworth 1 986, Owens- Burk hart 1 9 9 1 , Anton 1 99 3 ) . I t was fi rs t descr i b ed b y D u p lay i n 1 8 7 2 a n d Cod m a n was respo n si b l e fo r u s i n g the term 'frozen s h o u lder' in 1 9 34, but used it in asso c i a t i o n w i t h rota tor cuff te n d i n o pa t hy. N ev i aser i n troduced the concept o f ' ad hesive capsu l i t is' in 1 94 5 because o f the appearance o f the t h ickened, adherent capsu l e that cou l d be peeled from the bone l i ke sti cky p laster. The cause of t h e con d i t i o n is u n k nown. It i s probably m u l ti facto r i a l , i ncl ud i ng a period of i m m o b i l izat i o n d u e to pai n , a n d m a y i n cl u d e l ocal periart i c u l a r i n fl a m m a tory and dege ne ra ti ve c h a nges. Assoc i a t i o n w i t h other l e s i ons has been reported, i n c l u d i n g cervical s p ine d i sorders, dys fu nction of n e u ra l stru ctu res, t h o ra c i c s p i n e im m o b i l i ty, thoracic o r breast s u rgery, trau m a , neu ro l ogical d isease, reflex
CAPSULAR LESIONS
sym p a t h e t i c
dystrop hy,
cardiovasc u l a r
d isease,
stro ke, sys t e m i c disease, i n part i cu la r d iabetes mel l itus, a n d the presence of i m munological facto rs, e.g. h u m a n l e u kocyte a n t igen
( H LA)-B27
(Jeracitano e t al
1 992,
Anton 1 9 9 3 , G rubbs 1 9 93, S t a m 1 9 9 4 ) .
capsular pattern at the glenohumeral joint -
•
M ost l imitation of la teral rotation.
•
Less limitation of ab d uction.
•
Least lim itation of medial rotation.
Pathology of frozen s h o u lder I n a review of t h e l i teratu re, various authors observed a n d reported tJle fo l l owing cha nges seen at arthrograp hy,
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arthroscopy and surgery (Wadsworth 1 9 86, Owens-Bu rkhart 1 9 9 1 , Wi l ey 1 9 9 1 , ll ht hoff & Sarkar 1 99 2 , Anton 1 99 3 ,
•
Recurrence o F t he cond i t i o n i ll t h e other s h o u l d er within 2 - 5 years is com mo n ( Cyriax 1 9 8 2 ) .
Grubbs 1 9 9 3 , U i tvlugt et a l 1 9 93, Stam 1 9 9 4 , B u n ke r & Ant h o ny 1 9 9 5 , B u n ke r et al 2000, S m ith et al 2001 ) : •
•
•
•
Vo l u mes of less t h a n 10 m L, co m p a red w i t h t h e
Secondary frozen s h o u lder
n o r m a l i n t ra-articu l a r vo l u me, and a fa i l u re to fi l l t h e
Causes of secondary frozen shoulder may include trauma or
subsca p u l a ris b u rsa o r b iceps t e n d o n sheath
any con d i t i o n which causes i m mo b i lization of the shoul
I n fl a m m a tory cha nges, a d h e s i o n fo rmation,
der, e.g. neurol ogical con d i t i o ns, fracture and pain associ·
e rythematous fi b rinous p a n nus over t he synov i u m
ated with b u rsitis or tendinopathy, thyro id disease, cardiac
a n d loss of t h e red u nd a n t axi l l ary fo ld
d isease, thoracic surgery, p u l m o nary d isease, d i abetes mel
Fi brosis, n o t i n fla m m at i o n , w i t h changes s i m i la r to
l i tus, postmenopausal hormonal cha nges, or psycho l ogi
t h ose seen i n D u puytren's d isease of t h e h a n d
cal factors such as de press ion, apathy and emotional stress
Retract ion of the caps u l e away fro m t h e greater
(Owens-Bu rkhart 1 9 9 1 , Stam 1 994, Siegel et al ( 9 9 9 ) .
t u b e ros i ty, t h icke n i n g o f the coraco h u meral l iga m e n t
Th i s type o f art h r i t i s m o s t freque n t ly occurs seco nd
a n d subscapu l aris tendon, a n d a l oss of the n o rmal
a ry to trau m a . A p a i n fu l s h ou l d er may be kept r e l a t ive ly
i n terval between t h e glenoid and h u meral head.
i m m o b i l e by i nvolu n t a ry muscle spasm, co n t r i b u t i ng to
I nvolvement o f the j o i n t capsule seems to be a com m o n feature of a l l cases stud ied, b u t the above l ist shows that debate sti l l continues over the nature of that i nvolvement. Frozen shoulder consists o f a s p o n taneous o nset of gra d u a l l y i ncreasi ng s h o u lder p a i n , referring to t h e d e l t o i d r e g i o n and forearm i f severe, with a n i ncreasing l i m ita t i o n of m ove me n t . Lu n d berg ( 1 9 6 9 ) d ivided the syn d r o m e into p r i ma ry or seco n d a ry types: •
Pri m a ry frozen s h o u l der is i d i o p a t h i c
•
Secondary frozen s h ou lder occurs fo l l ow i n g a
pain and s t i ffness, b u t the cl ose prox i m ity of other ana tom ica l structures may also b e re l evant. The su bacro mial b u rsa, rotator cuff tendons and the long head of the b i ceps are a l l c l osely related to the capsu l e of the s h o u l d e r j o i n t a n d i t may b e poss i b l e fo r changes i n these struc tures to have a secondary effect on the capsule. If prec i p i tated by trau ma, the i ncident may be m i nor and the i n i tial pain usu a l ly settles. Therefore the patient may have d i fficu l ty
reca l l i n g a tra u matic i n cident o r
associating i t w i th the o n s e t o f the p a i n . A s a gu i d e l i ne,
prec i p i t a t i n g tra u ma or ca n a r ise from o t h e r causes. The 'stero id-se n s i t ive arth ritis' and 'tra u m a t i c a rt h r i t is', as described by Cyriax ( 1 9 8 2 ) , fi t i n to the p r i m a ry and seco n d a ry groups, respectively.
the con d i t i o n ca n b e classi fied i n t o t h ree stages, each o f w h i c h gives a n i n d i ca t io n o f t h e i rrita b i l ity o f the les i o n a nd a suggested progra m me of trea t me n t . T h e t h ree spe cial questi o n s ta ken fro m the h istOlY (see b e l ow) and the assessm e n t o f the degree o f caps u l a r pattern, together w i th the end-feel of the passive movemen ts, provide rel i a b l e d i agnostic criteria.
Pri m a ry frozen s h o u lder Cyriax
( 1 982)
cal led
this
co n d i t i o n
'steroid-sensitive
arth r i t is' o r ' m o n oarticu l a r r h eumatoid a rthrit is'. The con d i tio n seems part i cu l arly resista n t to physical trea t m e nt, but responds w e l l to cort icosteroid i nj ec t i o n . B u n ker & An t h o ny ( 1 9 9 5 ) described t h e p a t h o l ogy a s s i m i la r to D u puytren's d isease w i t h i ncreased col lagen, myo fi b robJ ast a nd fi b ro p l a s i a . Of the 50 pat i en ts wi t h p r i m a ry i d i o p a t h i c froze n s h o u lder s t u d i ed, 5 8 % a l so had D u p uytren's d isease elsewh ere. There was a lso an associa t i o n w i th d ia betes. AJthough the co n d i ti o n is said to be fi brosi n g ra ther th a n i n fla m matory, once deve l o ped, the i n fl a m m a tory d r ivers fo r D u puytren's d isease a n d frozen s h o u l d e r are s i m i l a r : TGF-� ( t ransfo r m i ng growth factor beta) and P D G F ( p latelet-derived growth factor) ( Fu n k 2008 ) . The p a t i e n t's co n d i t i o n fo l l ows a typical pattern:
Stage
7
After t h e p reCi p I ta t i ng i nc i d e n t, t h e i n i t i a l p a i n settles. Approxi m a t e l y 1 week l a ter, pai n develops and grad u a l l y i n creases. The p a i n is fe l t over t h e area o f d e l to i d , b u t a s i n fla m ma t i o n i n creases, the p a i n is referred fu rt her into the C5 dermato me. The extent of reference of p a i n i nd i cates t h e d egree o f severity of t h e c o n d i t i o n . Thi s stage develops over several weeks and p a i n is the key feature, not the l i m ited m ove m e n t . S i nce the s h o u lder j o i n t has a wide range o f movement, the early deve l o p i ng capsu l a r pattern may not affect func t i o n a n d t h e p a t ie nt may be o b l ivious to t h e l oss of move m e n t at t h i s stage. D iagnosis in t h i s early stage is not easy b u t it becomes co ncl usive once the capsu l a r pattern of l i m ited move m e n t occurs. I f treated early enough, it may be poss i b l e to abort t h e progressive cycle of the cond i
•
The pat i e n t is u s u a l ly between 40 a n d 70 years o l d
t i o n . U n fortu nately, as p a i n is the m a i n fea t u re of t h i s
•
Wo m e n are a ffected s l ig h t l y more freq u e n t ly t h a n
stage and n o t loss o f fu ncti o n , p a t i e nts may not s e e k h e l p
men
fo r t h e co n d i t i o n e a r l y e n o ugh .
•
There is no reason fo r t h e onset
•
The cond i t i o n progresses s l owly to sponta neous
a nd sym p t o m s t h a t class i fies the p a t ie nt as having stage 1
recovery over 2 - 3 years
capsu l i t is and i n d icates a possib l e l ine of trea tment.
The exa m i n a t i o n of t h e p a t ie nt provides a set of signs
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Chapter
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5 I
The shoulder
From t h e h istory the t h ree special q uestions reveal that: •
The p a i n is usua l l y above t h e e l bow
•
The pain is not u s u a l l y co nstant
•
The p a t i e n t can u s u a l l y sleep on t h a t s i d e a t n ig h t.
in
a l o ng-term fo l l ow-up (aver
operatively, s h owed 5 0 % of p a t i e n t s to h ave residual m i ld p a i n or s t i ffness of the shoul der, or bot h . L i m i t a t io n of la te ra l rota t i o n was present w h e n restriction o f moveme n t
A m i nor capsu l a r pa tte rn exi sts ( t h is may i n volve
was a fea t u re.
l atera l ro tation on ly) •
( 1 992),
age 7 years) of id iopa th ic frozen s h o u l d e r treated ljl o n
The o b j ective exa m i n a t i o n shows t h a t : •
move m e n t , espec i a l l y l a teral rotation a nd fu l l e l evati·o n . S h a ffer et al
Stage 3 s h ows s i m i l a r s igns a n d sym ptoms to stage 1
The end -feel of passive move m e n ts rem a i ns rel a t ively elast ic, but is h a rder than t h e normal end-fe e l .
and the same trea t m e n t m ay be a p p lied toge t h e r w i t h reha b i l i ta t i o n ,
T h e h istory and exa m i n a t i o n i n d icate a rel a t ive ly n o n
i n c l u d i n g strengt h e n i ng
and
stretch i n g
ex.ercises, towards fu l l fu ncti o n .
i rritable j o i n t caps u l e t h a t m a y respond to p e r i p heral Grade
B
mob i l i z at i o n
or corticosteroid
i n ject i o n .
Of
cou rse, any m o b i l i z i n g tech nique c a n be a p p l i ed to such a j o i n t and the trea t m e n t progra m me fo r each i n d i v i du al
Three questions •
patient is fo r m u l a ted b a s ed on t h e th erapist's experi
Does the pain spread below the elbow? (site and spread)
ence. Orthopaed i c medicine treatment tech n iq ues will be
•
described b e l ow.
Ca n you lie on that side a t night? (symptoms)
•
I s the pain constanP (behaviour)
Stage 2 Pain and loss of fu n c t i o n a re now the key features of t h e cond i t i o n . T h e caps u l a r pattern h as developed to a ffect abduction and t ive ly,
the
medial rot a t i o n adversely, and, s u bjec
l a t ter is
the
most
i nconve n i e n t fu nct i o n al
movement for t h e p a t i e n t to lose. As the pa i n gradu a l l y peaks and spreads, t h e p a t i e n t not ices a n i n a b i l i ty t o reach i n to a b a c k pocket, for exa m p l e, or to do u p a bra. The l i m i ta t i o n of l a teral ro tation is apparent i n that the patient is u n a b l e to comb the h air. hom t h e h istory t h e t h ree special questions reveal th at:
Treatment techniques for frozen shou lder There i s n o st a n d a rd agreed trea tm e n t fo r frozen s h o u l der. Va rious a p p roaches have b e e n advocated, i ncl ud i ng a n a l gesic d rugs, corticosteroid i n jections,
m o b i l iza t i o n
tech n iques and exercises o f various fo rms, m a n i p u l a t i o n under a naesthet ic, brisement ( forci b l e brea k i n g o f adhe sions) or d i stension arthrograp hy, a r t h roscopic d isten s i on and s u rgical release o f a d h es i o n s ( H su & Chan 1 9 91 ,
•
The pai n u s u a l l y spreads beyond t h e el bow
H u l s tyn & Weiss 1 9 9 3 , S h a r m a et al 1 9 93, Ogi lvie- H a rris
•
The pa i n is u s u a l l y co nstant
et ill 1 9 9 5 ) . M icro a d h e s i o l ys i s has been developed a s a
•
The pat i e n t usually c a n n o t s leep on t h a t s i d e at n igh t.
m i n i m a l l y i nvasive tec h n i q ue
for re l eas i ng adhesions
w i t h s ignifi c a n t subjective and objective i m prove m e n t s
The objective exa m i n a t i o n s h ows t h a t :
( M n et al 2 0 0 8 ) . S t u d i e s on no n-operat ive trea t m e nts
•
A fi.J i I capsu l a r pattern is p resent
•
Th e characteristic ' h a rd' e n d - feel of a rthri tis exists due to i nvo l u n tary m uscle spasm and capsular
fo r frozen s h o u l der have shown t h a t ph)ls i o therapy ( no t d e fi n e d ) i m p roves ra n ge o f move m e n t b u t n o t necessar ily p a i n r e l i e f. Corticosteroid i njections h ave a benefit fo r
co ntracture. The h istory and exa m i n a t i o n reveal a n i rritable j o i n t capsule. T h e presence o f the capsular pattern is marked . Adhesion forma t io n in the axi l lary fold, tigh t n ess in the anterior capsular ligamen ts, shortening of subsca p u laris and contracture of the rotator in te rval com b i ne to l i m i t lateral rotati o n rtnd abduction sign i ficantly, producing lhe caps ular pattern. At this stage corticostero id injection may be used to lreat the pa i n and/or relatively gentle p a i n - free mobil ization may be appl ied to restore accessory range. The orthopaedic medicine treatment tecJlIl iques w i l l be desa-ibed bel ow.
s h o rt-term pain relief o n l y b u t no l o ng-term p a i n r e l i e f ( H as l a n & Ce l i ke r 2 0 0 1 , Ryan 2005 ( c i ted i n Fu n k 2007 ) ) . The a i m o f treatm e n t i n each o f th e measures l isted above, as in t h e use o f orthopaed i c med i c i n e tech n i q ues, is to rel ieve pa i n and restore fu nct i o n . For primaty frozen shoulder, i .e. ste ro id-sensi t ive a rthritis, Cyriax ( 1 98 2 ) suggested a course of i n tra-articular i n j ections o f corticosteroids to treat the pa i n . These are given over increasing i n tervals and, with the rel i e f of pain, a gradual i n a-ease in movement occurs with recovery to full funcLion. For secondary frozen shoulder, i.e. t ra u m a t i c a rt h rit is, the c l i n ici a n has a ch oice of trea t m e n t depe n d e n t u p o n
Stage 3
t h e stage of i rr i ta b i l i ty a n d the techn iques ava i l a b l e. Those
If the pat ie n t progresses t h rough t h e co m p l ete cycl e of t h e
reco m m e n ded in o rt h opaedic m e d i cine w i l l be described,
cond i t ion, t h i s represents t h e st age o f recovety T h e p a i n
b u t the reader i� urged not to b e l i m i ted to t h is cho ice,
is set t l i n g a n d rece d i n g a n d fu l l fu n ct i o n a l move m e n t is
b u t to draw on ex perie nce of o t h e r m o b i l iza t i o n tec h
return i ng. H owever, t h e e n d res u l t o f t h e con d i t i o n may
n iques t h a t c a n be i ncorp ora t ed to provide a n i nd ivid u a l
leave t h e p a t i e n t with a degree o f pa i n and s o m e l i m i ted
trea t m e n t progra m m e for e a c h p a t i e n t .
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Practice of orthopaed i c medicine
Injection of the glenohumeral joint (Cyriax 1 984, Cyriax 8. Cyriax 1 993)
l
Suggested needle size: 2 1 G x 1 !2 i n (0.8 x 40 mm) or 2 in (0.8 x 50 mm) green needle D ose : 2 0 - 40 mg triamcinolone acetonide in a total volume of 3- 5 mL
Position the patient comfo rtably either in prone-lying or s i l l i ng in a chair (Fig. 5 . 2 6 ) . Place the a ffected arm to rest in medial rotati o n across the abdomen with the elbow flexed. Stand behind the patient and place your thumb o n t he posterior a ngle o f the acro m i o n and you r index o r m iddle fi nger on t he coraco id p rocess. I nsert the needle J cm below you r t h u m b placed o n the acromion and d i rect i t forvva rds towards the i ndex fi nger placed o n the coracoid process ( Fig. 5 . 2 7 ) . Once the needle rests agai nst
the articular surface, deliver the i n jection as a bolus, with· d rawi ng sl ightly if there is resistance. An exp l anation o f the cond ition and prognosis is i m portant. The principle is to give another injection if the pain begins lO peak, which usually occurs at increasing i ntervals. Genera l ly not more than three or fou r in jections are given in tota l . The patient is i nstruCled to apply relative rest for up to 2 weeks and then to begin pain-free mobili zatio n. I njections o f corticosteroid are efficacious i n treat ing frozen shoulder provid i ng the patients selected fu l fi l the d iagnostic criteria based o n Cyriax, described above i n stages 1 , 2 and 3 o f t h e cond ition (Ca meron J 995 ) . Jacobs e t al ( 1 991 ) lool<ed at t h e e ffect o f admin istrat ing i n t ra-arucular steroids with distension for the manage ment of the early frozen shoulder. Fifty patients with frozen shoulder were d ivided i nlO three treatment groups: a dis tension group on ly, a steroid group only and a steroid and distension group. A total o f three i njections were offered at 6-week in tervals using the posterior approach described above. All patients were provided with an i n formation sheet explaining capsul itis and a home exercise programme. All patients entered i nto the study showed improvement d u ri ng treatment. with a decreased need for analgesia and i mprovement i n pain symptoms. A sign ificantly increased rate of improvement in the range of passive abduction and forward flexio n occurred in the two groups treated with i n t ra-articular corticosteroid, indicating a positive role for the use of corticosteroids in the early frozen shoulder.
G rade B Mobilization (Saunders 2000)
Figure 5.26 I nje c t ion
of the glenohumeral J oi n t, sitting.
F i gure 5.27 Injection of the glenohumeral joint, showing di rection of approach and needle position.
Peripheral Grade B mobilization (see Ch. 4) is applied to the non-irritable j o i n t only. The a i m is to rel ieve pain and i ncrease the range of movement. H ea t may be used beforehand to assist the tech n i que si nce heating e n ha nces the viscoelast ic properties of the capsule. The condi tion, prognosis and treatment are explained carefu l ly to the patient s ince the recovery t i m e may be pro lo nged over m a ny months, or even years, and the patient must be encouraged to con ti n ue the stretch i ng techniques at home, eventually tal
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I 5 I
The shou lder
Figure 5.28 Grade B mobilization of the g len ohu me ra l joint
fig u re 5.29 Ret u rn i ng the a rm from the elevated position, with dist r a cti on for comfort
to the patient. An i ncrease in mob i l i ty is often reported
is deemed t o be n o n - i rritable a n d techn iques c a n b e pro
before the reduction of pa i n b u t both are i n d ications for
gressed, add i n g G[ade B m o b i l i za t i o n .
con t i n u ed t reatment.
Distraction techniq ues These are a fO lm of Grade A m o b i l izat i o n s i n ce they occ u r
Lateral distraction (Cyriax 1 984, Cyriax & Cyriax 1 993)
w i t h i n the pa i n -free range o f movement. T h e a i m is to restore t h e accessory range o f move m e n t to the j o i n t . The
Posi t i o n the patient comfortably in supine l y i ng close to
tech n iques can be appl ied toge t h e r w i t h Grade B m o b i l i
the edge o f t h e couch, w h ich is ra ised to ap proxi m a tely
za tion i n t h e n o n - i rritable j o i nt, t o settle t h e tissues after
hip he ight. Pl ace a p i ll ow u n der and aro u nd t h e arm to
tre a t ment, or alone i n the more i rritable j o i nt, particu
suppo rt i t in t h e loose packed pos i t i o n of add uction and
l a rl y if i n jection is not a n option. O n ce t h e end-feel of
some med i a l rotation. Place a h a nd i nto t h e axi l l a t o apply
the l i m ited move ments rega i ns some e l a s t i c i ty, th e j o i n t
the
l a teral
Copyrighted Material
d i s t ract i o n
while
s i m u l taneously a p p l y i ng
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Practice of orthopaedic medicine
therapy' fo r the descri p t i o n of its use. Other m o b i l i zing tech n iques can also be i n corporated into th is regi me.
NON-CAPSULAR LESIONS Acute subacromial bursitis The existence o f t h i s co n d i t i o n as described by CyriiL' ( 1 9 8 2 ) a n d Cyriax & Cyriax ( 1 9 9 3 ) is con troversial and i t may be t h e s a m e as, or s i m i l a r to, a cond i t i o n described by o t h e rs as acute ca l c i fic tendi nitis. The ca l c i fi c deposit in the rotator cuff, usu a l l y s u p rasp i n a tus, i ncreases i n size a nd ruptures i n t o t h e subacro m i a l b u rsa ( Berg 1 9 9 7 ) . figure 5.30
This p rovides a p l au s i b l e expl a n a t i o n fo r t h e acute o nset
Latera l distraction.
a nd i n te n s i ty of the p a i n in the relat ively s h o rt acute p h ase. M agnetic reso n a n ce i m a g i ng (M Rl) wou l d co n firm the presence o f c a l c ifi c deposits and/or i n fl a m m a t i o n in the subacro m i a l space o r overlying rotator cuff Acute sub acro m i a l b u rsitis is a completely separate e n t i ty fro m c h r o n ic subacro m i a l b u rs i t is, described b e. l ow It has a typical p resentation o f a rapid o nset of pain fo r n o appar e n t reaso n . The pa i n is fel t in the s h o u l der area; i t rapidly i n c reases i n seve rity a nd w i t h i n hours the pain is referred i nto t h e w h o l e C5 dermatome. The patient may look ti red and u nwe l l as the cond i t i o n is very p a i n ful and disturbs s l eep. S i nce the bursa is a n extra-articu l a r structu re, it is not protected by i nv o l u n ta ry muscle spas m . Vo l u n tary m uscle spasm is responsible fo r t.he patient h o l d i ng the arm in an a n talgic posi t i o n, and in the attempt to sleep the patient l oses the protective vo l u n tary muscle spasm, w a k i ng with severe p a i n . Severe twinges of p a i n are experie nced o n attempted active movement, espec i a l ly abduct io n, w h ich co m p resses the p a i n fu l bursa in the su bacro m i a l space. It is i m portant to co nsider serious pathology and onward refer ral s h o u l d be made if the severe p a i n does not settle w i t h i n
1 week. OLherwise, the cond i t i o n is sel f- l i m i t i ng a n d is usu a l ly very IllUdl better with i n 7 - 10 days, clearing completely w i th i n G weeks, but p ro n e to recurrence ( CyriiLx 1 9 8 2 ) . On exa m i na t io n, a non-capsu l a r pattern o f l i m i ted move m e n t is prese n t . Vo l u n t a ry muscle spasm is respon Figure 5.3 1 Caudal
s i b l e fo r p ro d u c i n g a n e m p ty end-feel
distraction.
co u nterpressure to the p a t i en t's e l bow,
011
exa m i n a t i o n ,
where t h e exa m i n er i s aware that m uc h m o re range i s res t i n g aga i nst
yo ur hip (Fig. 5 . 3 0 ) . Th e d istracti o n is h e l d fo r as l o ng as possi b l e and repeated o ft e n .
ava i l a b l e b u t the p a t i e n t w i l l not tol erate fu rther move ment. U s u a l ly full l ateral rota t i o n can be coaxed, espe· c i a l l y with a l it t l e d istrac t i o n a p p l i ed t o t h e j o i n t , but the range of abductio n is severely l i m i ted by p a i n, i nd i cating a n o n-capsu l a r pattern . Swel l i ng and tenderness may be p resent along the l a teral b o rder o f t h e acro m i o n .
Caudal distraction
Treat m e n t does n o t a l ter t h e course o f t h e con d i t i o n b u t s h o u l d t a k e t h e fo rm o f p a i n - re l i e v i n g m oda l i t ies and
Pos i t i o n the p a t i e n t as a b ove. Hook your fo rearm i n to the
a n exp l a n a t i o n to t h e patient. The a p p l icat i o n o f trans
crook o f the p a t i e n t's flexed e l bow (Fig. 5 . 31 ) . A p p l y sus·
cutaneous nerve s t i m u l a t i o n and oral ad m i n istra t i o n of
t a i n ed a n d repeated caud a l d istract i o ns.
a n a lgesics are a p p ro p riate. Advice should a l so be given
A 'seat b e l t' can b e used to aid the d istraction tech n iq u es, b u t the reader is referred to cou rses a n d texts o n 'seat bel t
on s l e e p i n g pos i t i o n , sugges t i ng that
the a rm s h o u l d
be w e l l s u p p o rted b y p i l lows, band aged to the side or
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Chapter
I 5 I
The shoulder
supported i nside a tight-fitting T-shirt to mai ntain com fort when the protective muscle spasm is lost. A collar and-cuff s l i ng provides less support but may be used if the patient is u nable to tolerate the compression of t h e previous suggestions. An injection of conicosteroid is usually help ful, although it may increase the pain initially as the bursa is already swol len and very painful. The technique is the same as for chronic subacromial bursitis, see page 114, but less volume is used. Treatment, ideally, consists of an i n jection of a sma l l volume of low-dose local anaestheti c together with a n appropriate amount of corti costeroid.
General advice
should be given on how to support the area w h i l st t h e symptoms settle and other pain-relieving modalities can be appl ied.
Figure 5. 32 Injection of the subacromial bursa.
Injection of acute subacromial bursitis Suggested needle siz e : 21 G x 1 X i n (0 8 x 40 m m) green needle
Dose 20 mg triamcinolone aceton ide in a total vo lume of 3 mL
Position the patient comfortably in sitting with the arm hanging by the side. Locate the midpoint of the lateral border of the acromion and insert t h e needle just below, at an oblique angle upwards with respect to the acromion (Figs 5 . 3 2 and 5 . 3 3 ) .
Figure 5.33 I njection of the subacromial bursa showing
Acromioclavicular joint
direction of a p p roach and needle position.
The pai n from the acromioclavi cu lar joint is character istically fel t in the epaulette region of the shoulder. The onset may be precipitated by trauma - either a fall on the outstretched hand or a direct blow such as a heavy fall agai nst the wall w h i l e playing squash, in a rugby tadde or
Allman classified injuries of the acromioclavicular joint into three categories (Ca illiet 1 9 91 , Ha rtley 1 9 9 5 ) : •
On examination,
a non-capsular pattern
of gleno
humeral movement is present with pain felt at extremes
tenderness and n o joint i nstability. •
coracoclavicular ligament remains i ntact, there is no
acromioclavicular joint itself does not display a capsular it S
such. The diag nosis is confirmed by a positive
scarf test reproducing the pain by compressing and shear ing the joint ( Hallam & Smeatham 2 0 1 0 ) . Degenerative osteoarthrosis affects t h e acromioclavicu lar joint, espec ially i n those who have beefl extremely active in sport ( Stenlund 1 9 9 3 ) . Overuse can p rovoke a
Type II injury i nvolves teari n g of capsuloliga mentous fibres and mi nor subluxation, but as the
of passive elevation, l ateral and medial rotation; the pattern
Type I injury is sprain or partial tearing of the capsuloligamentous fibres with local pa i n and
at touchdown.
i ns tability. •
Type 1 I l injury is d is location of the acromioclavicular joint with disruption of the capsule afld the coracoclavicular ligament. Treatment for type I I I i n jury is usually surgery. Orthopaed ic medicine treatment may be useful in type
traumatic arthritis of the degenerate joint. The degenera
and II lesions. I n Chronic lesions, corticosteroid injec
tive changes cause narrowing and osteophyte formation,
tion of the joint may be curative. If the superior aspect of
w h i ch can have a secondary effect on the structures i n the
the capsular ligament i s involved, i t may be treated with
subacromial space.
transverse fridions as appropriate.
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Pract i ce of orthopaedic med icine
the presence of the anicu lar d isc ma)' make emry d i fficu l t .
Injection of the acromioclavicular joint (Cyriax 1 984, Cyriax 8. Cyriax 1 993)
Insert the need l e i n to t h e j o i n t and del iver t h e injection as a bol us, or pepper the superior l igament if needle emry p roves to be d i fficu l t (Fig. 5.35). This would be more appro
Suggested needle size: 23G x 1 i n (0 6 x 25 mm) blue needle or 25G x 5/8 in (0.5 x 1 6 m m) oranqe need l e Dose: 1 0 - 2 0 mg triamci nolone a cetonide i n a total volume of 0.5 m L - 0 . 7 5 m l
priate fo r chronic lesions and, if acute, it is more appropri ate to al low t.he ligamentous lesion to seu le i f entry in to the j o i n t i s not poss i b l e, to avoid possible delay i n healing. The p a t ient is advised to maintain a period of relative rest for a p p roxi mately 2 weeks fol lowing i njection.
Pos i t i o n t h e pati e n t co m fortably i n sitt i ng or half-lying and palpate the superior aspect of the j o i n t l i n e ( F i g. 5 . 3 4). There is considerable variat ion i n the size, shape and d i rec tion of the joint surfaces and if the j o i n t is na rrowed by degenerative changes it may be d i fficu l t to en ter. The nee dle may have to be angled obliquely i n feromedi a l l y a nd
Transverse frictions to the superior acromioclavicular capsular ligament (Cyriax 1 984, Cyriax 8, Cyriax 1 993) Stand beh i n d the seated patient and palpate the joint l i ne. Using an i n d ex fi nger rei n forced by a m i d dle finger, t h u m b-down on the scapula for co u n terpressu re, d i rect the pressure down onto the tender I igament and i mparl the transverse frictions i n an anteroposterior d i rect i o n . The gra de of application w i l l depend on the irritab i l ity o f the lesion ( Fig. 5 . 36). Other m o b i l ization tec h n iques ca n be i ncorporated i nt o the trea t m ent regime for acrom ioclavicular stra i n a nd ma nage ment may i nc l ud e strapp i n g or t a p i ng th e joi nt, particul a r l y if the i n j u ry is type [ I .
Figure 5.34 Injection of the acromioclavicular j o int .
Figure 5.35 Injection of the acromioclavicular Joint showing d i rection of approach and needle pOSiti on .
Figure 5 . 3 6 Transverse frictions t o the acromioclavicular joint.
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Chapter
I 5 I
The shou lder
SUBACROMIAL IMPINGEMENT SYNDROME ' I m p i ngement syndrome' is a generic term for rotator cuff lesions encompassing a l l stages of tendon d isease. The subacromial bursa may also be involved and i m p i n ge ment may be due to subacromial space stenosis, i n flam mation and/or fibrosis of the contents o f t he space. Anatom ical anomal ies, part icularly type [ [ I hook-shaped acro mions or congen ital subacromial stenosis, may pre d i spose to i mpingement syndrome ( Fa rley et al 1 994, Frieman et al 1 994, Burkhart 1 99 5 ) . Shoulder i nstabi l i ty is also a possible mecha n ism, especi ally i n you nger athletes ( H anchard et al 2004, Brukner & Khan 2007 ) . Brukner & [(han ( 2007 ) emphasize t h a t ' i m p i ngement' is a c l i n ical sign, not a d i agnosis. I m p i ngement syn d rome accounts for 4 4 -66% of a l l complai nts of shoulder pa in (M ichener et a l 2004 ) . M icrotrauma o f the cuff tendons may i n terfere with their stabilizing fu nction, al lowing the h u m eral head to ride h igher in the glenoid and further reducing the sub acromial space. I mp i ngement may be associated with shoulder i nstabi l i ty, degenerative changes in the acro mio clavicular joint, osteophyte formation, degenerative spur formation under the acromion and th ickening of the coracoacro m i a l l iga ment. The rotator cu ff, especially su prasp inatus, maintains the subacromial space by depressi ng t.he h eild o f the hu merus to prevent superior translation during abduction and elevation movemen ts. Repetitive use, fatigue or overload results i n cu mulative microtrau ma, and the cuff muscles are unable to resist this superior translation, l eading to subtle instabi l i ty (Copeland 1 99 3 ) . Patients under 35 years, particula rly athletes using the arm in the overhead position (e.g. swi m m i ng, tenn is, squash, javelin, gol f), in which large ranges of movement, forces, acceleration and repetitive movements are i nvolved, may present with signs of impi ngement. Th is may be sec ondary to minor i nstab i l i ty, possibly i nvolving labral tears (Copeland 1 993, lobe & Pink 1 993, 1 99 4 ) . Subtl.e or sub clinical subluxation reduces the max i m u m congruency of the glenoid and it appears t hat the supraspinatus and i n fraspi natus tendons are pi nched i n the posterosuperior labrum. The combination of i nstabi l i ty, imp ingement and rotator cuff lesions should be co nsidered in the younger ath lete and the management d i rected at i mproving move men t patterns to correct the i nstabiJi ty ( I a n notti 1 99 4 ) . I n patients over 35 years, changes occur i n t h e subacromial space which are related to degeneration and the ageing proc ess. Fatigue and degeneration of fibres may produce muscle i mbalances which lead to altered neuromuscular control and abnormal movement patterns. The h umeral head is no longer effectively depressed and superior translation occurs, com promising the subacromial space (Copeland 1 993, Wilk & Arrigo 1993, Greenfield et al 1 995) .
Richards et al ( 2005) demo nstrated a correlation between narrowed coracoh u meral d istance a nd subscapu laris tears and D i Mario & Fraracci ( 2005) also l i n ked this fi n d i ng to subacro mial i m p i ngement. The i m p i n gement syndrome i nvolves i n flammation and oedema i n the subacromial b u rsa i n the fi rst i nsta nce, and secondary t h ickening and fibrosis is fol l owed by partial o r ful l tears o f the rotator cuff. The tears a r e usua l ly longitu dinal and on the u ndersulface of the tendons, which may be re lat ively avascular com pared with the b u rsal surface (Ca i l l iet 1 9 9 1 , Uhthoff & Sarkar 1 992, Copeland 1993, Fukuda et a l 1 9 94, McCa nn & B igl iani 1 9 9 4 ) . Early ten don l esions may i nvolve intrasubstance tears and calcific deposits can occur within the substance o f the ten don ( Meister & Andrews 1993 ) . Neer ( 1 9 8 3 ) was responsible for c lassifying t.he i m p i ngement syndrome i n to t h ree progressive stages and provided additional evidence that i m pi ngemen t occurs aga i nst the an terior edge and u ndersurface of the a n terior t h i rd of the acro m ion and t h e coracoacro m i a l ligament; sometimes t h e acro m ioclavicu lar j o i n t is i n vo lved b u t not tJle l ateral edge o f the acromion: •
•
•
Stage I i m pi ngement i nvolves oedema and haemorrhage, characteristica lly seen in younge r patients. Conservative treatment at t h i s stage usual ly has good results and can reverse the co n d i t i o n . Stage I I fo l l ows repeated ep isodes of mechan ical i n fl a m m a t i o n and the subacromial b u rsa may beco m e th ickened and fi b rotic. This stage occurs in older patien ts and the shoulder fu nctions wel l for l ight use but becomes sym ptomatic after overuse, particularly in the overhead positio n . Neer recommends co nservative management, w i t h su rgery considered on Iy i f the condi tion fai l s to respond to treatment after an 1 8-month period. Stage I I I i nvolves i ncom plete or com plete tears of the rotator cuff, b iceps lesions and bone a l teration of the a nterior acromion and greater tuberosity. These are found a l m ost excl usively i n the over-40 age group, with tears of supraspinatus OCCUlTing i n a ratio o f 7 : 1 over biceps. Stage 1 I ] l esions are referred fo r surgical o p i n i o n . Neer also states that, in his experience, 95% o f tears of the cuff a re i n itiated by i m p i ngement wear rather than circu latory i mpairment or trauma, a l though t rauma may enlarge a n existi ng tear.
Cl i nical testing is of use in early screening but a subacro mial anaestl1etic i njection is more rel iable i n giving a defini t ive diagnosiS (Alvarez-Nemegyei & Canoso 2003). Positive impi ngement signs include painful or weak resisted abduc tion, external rotation or i nternal rotation and a painful arc, and there may be a combination of several signs if the sub acromial bursa is involved. The pain is usua lly felt in the del toid region. Mohtadi et al (2004) add maximal tenderness over the supraspi natus tendon as a sign of i m pingement. The most sensit ive tests have been found to be the H awkins-Ke nnedy, Neer and horizontal adduction tests
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Pra c t ice of orthopaed ic medicine
and the tests with the h ighest specificity are the 'drop arm' Yergason and pai n ful arc tests (Cal is et al 2000 ) . Johansson & Ivarson (2009 ) co nfirm further that the Neer i m p i ngement sign, H awki ns-Kennedy i m p i ngement test, Patte manoeuvre and J obe's test a re h ighly reproduc ible and therefore reliable to use in cl i n ical practice. The reader is referred to H attam & Smeatham ( 2010) for a descriptio n of the tests themselves.
of resistance, on the release of resistance or may produce several positive signs, e.g. p a i n on resisted abduction, lat eral rotation and el bow extension. The resisted tests may nOt be consistent and o n reassessment o f the patient a comp letely d i fferent set of resisted tests may be present. Treatment, ideall y, consists of an i n j ection of a la rge vol u m e of l ow-dose local a naesthetic together with an appropriate amount o f corticosteroi d . Injection o f c h ronic subacromial bu rsitis
Chronic subacrom i a l bursitis The subacromial bursa may be involved i n impingement syndrome and chronic subacromial bursitis is a relatively com mo n cause o f pain at the shoulder. H owever, i t can present a chall enge to d iagnosis because of the mudd led picture presented on exam i nation. The bursa's inti mate rela tionship with the capsule, the rotator cuff tendons and the biceps tendon makes it difficult to diagnose definitively and treatment response can help to confirm or refute d iagnosis. Furthermore, lesions can coexist, and a primary lesion can i ndirecuy affect the structures dosely related to it. I n review ing the anatomy it wil l be seen that the i n ner synovial aspect of the bursa is also the outer aspect of the rotator cuff, the supraspinatus tendon in particular. Therefo re, uley cannot be separated and a lesion of one may affect the other. Prolonged i nfla m mation can cause adhesion formation between the layers o f the bursa and m ay p roduce a sec ondary frozen shoulder. I n an u nwell patient subacromial abscess o r i n fective bursitis may b e suspected (Ward & Eckardt 1 99 3 ) . Chron ic subacro m ial bursitis has a gradual onset o f pain due to ule m icrotrauma of overuse. Together with rotator cuff lesions, chronic bursitis is a co mmon cause o f pain i n athletes using the arm in the overhead position, e.g. racquet sports, th rowing activities o f all kinds, swim m i ng, etc. Occasional ly it can be d i rectly caused by a fa l l on the outstretched hand or may be due to the congenital shape o f the acro m i o n process reducing the venical height o f the subacromial space illld producing impingement. Altered joint mechanics, posture, i ncorrect or overtra i n i ng and muscle i mbalances wh ich affect ule steering mechanism of the rotator cuff tendons are a l l factors which may contrib ute to chronic burs itis at the shoulder. The patient com p l a i ns of a l ow-grade ache over the i nsertion o f deltoid and may not be able LO sleep o n that side at n ight. On exa mi nation t here is a non-capsular pat tern o f m ovement, o ften wi th pain fel t a t the end of range of passive elevation. A p a i n fu l arc may be present and var ious resisted tests may a l so p roduce the pain. The room in the subacromial space is m in i ma l and i m p i ngement under the coracoacromial arch may i n flame the bursa, produci ng a pai n ful a rc on movement. The appli cation o f resisted tests prod uces some com pression o f the glenohu meral j oint and subacro m i a l space. Th is produces a characteristic m u d d l e o f signs asso ciated with a bursitis. The pain may be on the appl ication
S u g g es ted need le size:
21G
x
1 )6
in
(0 8 x 40 mm)
g reen needle
Dose: 2 0-40 mg triamcinolone acetonide in a total volume of 7 mL
Posit i o n the patient com fortably in sitting with the arm hanging by the side. Locate the m i d po i nt o f the latera l border of the acro m ion and i nsert the need le j ust below, at an oblique angle upwards with respect to the acromion ( Fig. 5.32). I nsert the need le and del iver the i n j ection as a bolus, havi ng detected t he a rea, or areas, of less resistance ( Fig. 5 . 33 ) . The synovial fol ds a nd ad hesions with in the b u rsa may present a resistance to the i njection and i t may be necessary to deliver the i n j ection by a series o f hori zontal withdrawals and rei nsertions once the need le is in p lace. The patient is advised to maintain a period of rela tive rest for approxim ately 2 weeks fol lowing i n j ection. Accord i ng to Beals et al ( 1 998), the bursa l ies u nder t he anterior half o f the acromion, so accurat" needl e p lace ment is i m portant. Nonetheless, a posterior approach is selected i n preference by some c l i n icians, ilS there is more roo m LO gil i n access to the subacromial space. Any differ ence in ou tcomes by using the d i fferent approaches has still to b e tested. As mentioned above, it may be difficult to distinguish chronic subacro m ial bursitis from chronic rotator cuff tendi nopathy and injection i nLO the subacromial space may be an appropriate dloice of treatment when the dilemma occurs. Atten tion shoul.d be paid to the mechanism by which the bursa becomes i nvolved, as described above. An expla nation is given to the patient together with restoration o f balanced forces, a i m i ng t o ensure normal shoulcler move ment and to avoid excessive superior translation
CONTRACTILE LESIONS The more com mon contradile lesions at the shoulder i nvolve the rotator cuff tendons, particularly supraspinatus. Rotator cuff lesions can vary from simple tend i nopathy to degeneration a nd partial or complete thickness tears. The lesion may be secondary to subacromial i m pingement and may also i nvolve the subacromial bursa a nd tendon o f the
1 14
Copyrighted Material
Chapter
I 5 I
The shoulder
long head of the b iceps, which all l ie in very close proxi m
tears; funher complications may include involvement of
i t y TendinopatJ1Y may lead to secondary capsul i tjs through
the nearby subacromial bu rsa or bi ceps tendon, or involve
abnormal movement patterns due to pain.
subtle instability or lesions of the glenoid labrum.
Tend inopathy occurs from the cum ulative effects of
The aim of treatment for rotator cuff tendinopathy i s
mi crotrauma which has a gradual onset, usually due to
t o relieve pain and t o restore full functional movement
overuse. Single traumatic incidents may produce tendino
to the shoulder, the resisted tests often proving weal<
pathy but this i s unusual, and the effect of trauma in this
and painful. This weakness may be d ue to tears o r m us
case i s more li kely to cause tearing of an already degener
cle inhibit ion d ue to pain. The cause of the l esion should
ate tendon. Other causes can be abnormalities in the ten
be determ ined and factors such as instabi l i ty and m uscle
don i lself or fatigue failure of muscles that provide suppon
i m balance should be add ressed, with the rehab ili tation of
mechanisms for the hum eral head in the glenoid. T h is can
movement patterns to ensure restoration of the dyna m i c
follow
stabil izing function of the rotator cuff. Excessive superior
prolonged
repeti tive
over-the-shoulder physical
loads, poor posture and vi bration (Alvarez-Nemegyei &
and anterior translation should be prevented, to avoid
Canoso 2003). Septe mber et al ( 2 007) have also explored
the long-term complications of i m p ingement which may
a genetic com ponent, noting thal, relative to a control
eventually lead to su rgery.
group, siblings have more tJ1an twice the risk of develop ing rotator cuff tears and nearly five ti mes the risl< of expe riencing sy mptoms.
Supraspinatus tend inopathy
Pain is localized to the deltoid area and, although
M R I i s h i ghly accurate in detecting full th ickness tears of
t he patient may be aware of a vague ache, the pain i s
the rOlator cuff with a specificity as high as 95%. I t is less
increased considerably by use and movements s u c h as
accurate at detecting partial thickness tears although this
reaching, pushing and pulling, in particular those act i v i
i s i m proving w i th contin uing development in technology
ties associated w i t h using t h e hands above shoulder level.
(].
Sm ith, unpublished study 200 8 ) .
On exa m i nation, pain is reproduced on the approp ri
T h e role o f M R J in ident i fy i ng supraspinatus tend i
ate resisted test and there may be l ocalizing signs of a
nopathy i s uncertain. Sein e t a l ( 2007) set out to deter
painful arc and/or positive scarf test. Res isted abd uction
m i ne i n traobserver and
may
rotation
ident ify ing supraspinatus ten d i nosis on M R I . The result
may implicate infrasp inatus and teres m inor, and resisted
was that a well-trained si ngle observer could iden t i fy and
impli(;lte supraspinatus,
resisted
lateral
interobserver rel i a b i l i ty when
medial rotation may implicate subscapularis. However, as
grade supraspinatus tendi nosis w i t h l i ttle var iation b u t
d i scussed 3bove, the tendons interd igitate and insert to
interobserver reliability was only f a i r t o good. The l i n k t o
form a tendinous cuff; therefore it can be di fficult to dif
symptoms may not b e expl i c i t i n lhat s o m e stud ies have
ferentiate between the tendons and i t may not be possible
identified abnormal signal intensity of s u prasp inatus i n
to make a definitive diagnosis.
asy m ptomat i c ind i v i d uals (Lewis & Tennent 2007). This
Two or more resisted tests may be posi t i ve and sub
was not the case i n this study, however, where supra
sequent palpation w i l l determine the site of the lesion.
spinatus tend inosis identified by M R I correlated well
Passive movements should be of full range with a normal
with positive i m p i ngement S i gns. The M RJ i m ages are
end-feel, but occaSionally the opposite passive movement
therefore more relevant if they are supported by cl inical
or end - range passive elevation reproduces the pain by
findings.
stretching or compressing the lend inous insenion respec
Dalton ( 1 994) reported that an area o f hypovascular
tively. A funher compl ication may be a secondalY capsuli
ity in supraspi natus, 1 cm f ro m i ts insertion, has been
tis, in which case a capsular pattern will be superimposed
both proposed and d isputed. A critical zone of vascular ischaemia has been proposed, existing between the supra
on the non-capsular pattern described above. Early onset of tendinopathy may respond to conserva
spinatus tendon and the coracohumeral ligament, where
t ive treatment and corticosteroid injection into t h e adja
degenerat ion and tears usually occur (Cailliet 1 9 91 ). The
cent subacro m ial bursa, or t ransverse fricti ons may be
critical zone is said to vary from being ischae m i c when the
successful. Extracorpo real shock wave therapy l i thotripsy,
vascu lar anastomosis i s constricted, to hyperaemic when
previously used to shatter stones in the k i dney, bladder,
it i s allowed to flow freely. The vessels are elongated when
ureters and gall bladder, has emerged as an appropriate
the arm is hanging by the s i d e and com pressed when the
treatment for calc ific tendonitis and has also shown prom
rotator cuff tendons contract to produce movement, both
ise in the treatment of tendinopathies ( H su et al 2008) .
potentially causing relative ischae m ia . H yperae m i a is said
The mechanism of how l i thotripsy acts or is beneficial i s
to occur only when the amI is passively supported at res t .
not fully understood. I t has been shown t o enhance neo
C l a r k & H a r ryman ( 1 99 2 ) , however, studied cadaver
vascular ization at the tendon-bone junction w i th early
shoulders aged between 1 7 and 70 years and found no
release of growth and proliferating factors which lead to
avascular area in supraspinatus. The blood vessels in the
i m proved blood supply and t issue regenerat ion.
deeper tendon layers were found to be s m all compared changes
w i th those in the superficial layers. There was no associ
within the tendon lead ing to parti a l or full thic kness
ated evidence of degeneration and the authors concluded
Tend inopathy
involves
focal
degenerative
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I 2 I
Practice of ort hopaedic medici ne
that the blood supply was adequate fo r the metabol ic
Ekeberg et al
needs of the t issue.
sou nd-gu i d ed
i n ject ion
i n jecti o n and
fou nd no i mport a n t d i ffe rences i n the
A lesion i n s u pras p i natus produces pain on resisted
( 2009) who compared su bacro m i a l u l t ra with
syste m ic gluteal
steroid
abduction. Weakness may also be present and it i s d i ffi
s h o rt-term ou tcomes. There was modest i m provement i n
cult to be cena i n whether this is d u e to muscle i n h i b ition
both groups. Weaknesses o f t h e study were acknowledged
because of the pain, o r panial o r fu l l thick ness tears o f the
in that t h ere was no s h a m i n jection group to exa m i ne the
tendon . A pa i n fu l arc or pain at the end of range of passive
effect of p l acebo, t h e i n j ec t i n g physician was not b l i n ded
elevat ion local izes t h e lesion to t h e d istal end of the tendon,
and the dose used of
usually at the teno-osseous j u n ction. I f pa i n i s produ ced on
m ight have b e e n regarded a s a low dose fo r t he systemic
20 mg triamcinolone aceto n i d e
resisted abduction o n ly, without this loca l iz i ng sign, the
treat m e n t . I t coul d also be clai med that t h e dose was
lesion i s proba b l y a t the musculotend inous j u nction. Either
towards t h e low e n d for t h at reco mmended fo r t h e suba c ro m i al b u rs a i n j ection b u t t h e role o f the local anaesthetic
way, palpation w i l l co n fi rm the exact site of the lesion. Cu rrently t h e w h o l e q u estion o f t e n d i n opa thy is under debate w i t h i n fl a m m a t i o n d isputed as a component of
i n clud ed i n the i n j ection s h o u l d also be considered as a poss i b l e contrib utor to u1e modest i m prove m e n t noted .
t h e pro b l e m and degeneration o f t he t e n d o n proposed
As m e n t i o n ed above, i n j ection i n t o the teno-osseOlIS
as the cause. This l eads to q u es t i o ns being asked with
j u nctions of t h e i n d i vi d u a l tendons is co n t roversial and
regard to t h e prognosis for the patient. A n i n fl a m m a tory
a d i rect l i n l< w i t h tendon ru p t u re has been proposed but
problem is expected to resolve w i t h trea t m e n t in up to
not prove n . A consensus of o p i n i o n is h a rd t o pin down
appro x i mately
3 weeks; a degenerative p ro b l e m w i l l take m u c h lo nger (see d iscuss i o n in C h . 3 ) . Fu rthermore, if
and there appears to be a range of practice between t hose
the p a t h o l ogy of rotator cu ff tend i n o pa t hy is degenera
patients, where the good health of t h e tendon is assumed,
who co n t i n ue to i nj ect i n to t h e tendon itsel f in you nger
tive, more q u es t i o n s a re raised, such as why corticost e roid
and t h ose who wou ld a l ways use an i n jection into the
i n jection rel ieves pai n . K h a n & Cook
su bacrom ia l b u rsa to be able t o bathe t h e i n t i mately
( 2000) acknow
l edge t h a t c l i n ical experience and some s t u d ies show t h a t
related t i ssues, wh i ls t avo i d i n g d i rect i n fi l t ra t i o n of the
cort i costeroid i nj ec t i o n produces s h ort-term re l ie f of p a i n
tendon structure. An u l trasou n d scan o f the tendons
i n t h ese l es i o n s al though t h e mech a n isms for t h is p a i n
prior to i n j ection o f the teno-osseous j u n ction, to estab l i sh the state of dege neration of the tendo ns, is co m m o n
re l i e f a re curre n t l y not known . The fo l l owing t reatment tech n i ques of i nj ecti o n a n d
practice. To exercise ca u t i on, a ge neric i n j ection i n to the
t ra nsverse frictions m a y be successfu l , b u t t h ey do not
su bacro m i a l b u rsa may be m o re appropriate, particu
stand a l o n e a n d should be incorporated i n t o a h o l istic
l a rly i f i m p i n gem e n t o f the degenerate tend o ns prod uces
trea t m e n t progra m m e in wh ich all com po n e n ts of t h e
i n fl a m m a t i o n i n the subacro m ial space. I t may be wise to
p a t i e nt's prob l e m a r e a d d ressed, i nc l u d i n g e l i m i n a t i n g
exploit th e effective n ess of a s u bacro m i a l i n jecti o n before
t h e poss i b le c a u s e . Inject i o n of th e i nd i v i d u a l tendons
considering i nject i o n of i nd ividual tendon i nsertio ns.
may be a p p ropria te, as d i scussed b e low, but there is
Hancl1ard e t al
(2004) note the absence o f good q u a l i ty
growi ng controversy o n whether t h i s cou ld co n t ri b u te to
evidence to support the use of i n j ections in the treatment
degenerative change, lead i n g to tendon ruptu re, a l th ough
of subacro m i a l i m p i nge ment syndrome and, in l ight of the
t h e current evidence does n o t s u p p o rt this.
associated risks, take u1e view that conserva tive treatment
( 1 983) compared two methods of
should precede the use of injections u nless severe pain is
corticosteroid i n ject i o n w i t h l ocal anaesthetic to va rious
present. This sllppons me case for treating the rotator cuff
s h o u l d e r j o i n t o r tendon l es i o ns. O n e m e thod was i njec
tendons with frictions first, as part of a p rogra m m e of
tion accurately p l aced a n a t o m i c a l l y i n t o the lesion, based
physiotherapy management, and to l eave i n jection as the
on d iagnosis by selective tension, and the o t h e r i n vo lved
second option rather than the 'treatment of choice'.
H o l l i n gworth et al
i n jection i n to th e trigger p o i n t o r the p o i n t most tender to p a l p a t i o n . The a n atomica l i n j ection gro u p gave
60%
su ccess co m p a red w i t h the tender or t r igger poi n t group, wh ich gave
It is lip to suitably q u a l i fied c l i n i cians to exercise judg m e n t based on current best practice and als o having ascer t a i n ed the v i ews of t h e i r local orthopaedic consul tants.
20% su ccess.
Alva rez- Nemegyei & Canoso
(2003) reponed success ful
treatment o f rotator cuff tendi nopathy with co n i coster oid s ubacro m i a l i n jection when compared with placebo. Matthews & G l o u s m a n
(2004 ) clai med th at accurate ster
o i d placement demonstrated radi ogra phica l l y is associ
Injection of the teno-osseous junction of supraspinatus (Cyriax 1 984. Cyriax & Cyriax 1 993)
ated w i t h i m p roved cl i n ical benefit at a 2-week eva l ua t.ion and Chen et al
( 2006) also described i mproved abd uction
range if i n ject i o n i n to the su bacro m i a l b u rsa is carried out u n der u l trasou n d g u i d ance co m p a red to a b l i n d i njection. However, the need for specifici ty in subacro m i a l i njec tion fo r rotator cu ff d isease was d is p u te d by a study by
l
Suggested needle size: 25G x 5/8 in (0.5 x 1 6 mm) ora nge need le or 2 3 G x 1 in (0 . 6 x 25 m m) blue needle Dose: 1 0 m g triamCi nolone acetonide in a total vo lume of 1 mL
116
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I
5 I
The shoulder
Fig u re 5.37 Injection of the supraspinatus ten d o n .
Figure 5 . 3 9 Transverse frictions t o t h e s u praspinatus tendo n , teno-osseous site.
Figure 5.38 I n j ec t i on direction
of approach
of t h e supras pi na tu s tendon
s h owi n g
an d needle positio n .
Position t h e patient i n sitting at a n a ngle o f 45 0 , medially rotating the shoulder a n d placing the arm beh i nd the back to expose the tendon i nsertion (Fig. 5 . 3 7 ) . insert the need l e perpendicular to t he teno-osseous j u ndion and del iver the injection usi ng a peppering technique ( Fig. 5.38 ) . The patient is advised to m aintain a period of relative rest for approxi mately 2 weeks fol l ow i ng i n j ectio n .
Transverse frictions to supraspinatus (Cyriax 1 984, Cyriax & Cyriax 1 993)
Teno-osseous junction Position the patient as above. Stand at the side of the patient and identify the area o f tenderness. Pl ace an
index finger, rei n fo rced by the m i d d l e finger, o n to the tendon and d i rect the pressure down onto the i nsertion (Fig. 5.39 ) . Del iver the frictions transversely across the fibres, keeping the i ndex finger para l lel to the a nterior edge of the acro m i o n process. The supraspinatus tendon is approximately one fi nger's width (1 cm) . Maintain the tec h n i que fo r 10 m i n a fter the analgesic e ffect has been ach ieved. Relative rest is advised where functional move ments may co nti nue, but no overuse or stretchi n g u n t i l pa in-free o n resisted testing.
Musculotendinous junction Position the patient i n silting w i t h the pai nfu l shoul der abducted to 9 0 0 a n d supported co m fortably o n the couch. Stand o n t he opposite side o f the patient but facing fo rwards with you r a rm straight across and behind the patien t's shoulders. Locate the musculotend inous j u nction i n the 'V' created by the clavicle and the acromion process (Fig. 5 . 4 0 ) . Usi ng the m i d d l e finger reinforced by the i ndex finger, d i rect the pressure down onto the tendon and deliver the transverse frictions by rotati ng the forearm for 10 m i n after the analgesic e ffect has been achieved. Relative rest is advised where func tional movements may co ntinue, but no overuse o r stretch i ng u n til pai n-free on resisted testi ng.
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I 2 I
Practice of orthopaedic medicine
Figure 5.40 Transverse frictions to the supraspinatus tendon, musculotendinous j u ncti o n .
Figure 5.41 Injection of the in fraspinatus tendon.
Infraspinatus tendinopathy (± teres minor) A lesion in i nfrasp i n atus and teres m i n or produces pain on resisted lateral rotation. A pa i n ful arc and pain a t t h e e n d of range o f passive elevation i n d i cate t h at t h e l esion l i es at the d is t a l end of the te ndon, usually at the teno osseous j u nct ion. If no arc is present the lesion is often a l i ttle furt her prox i m a l l y in the body o f t h e tendo n . Pa lp ation w i l l co n fi rm the exact site of t h e lesion.
Injection of the teno-osseous junction of infraspinatus (Cyriax 1 984, Cyriax & Cyriax 1993) Suggested needle size: 23G x 1 in (0.6 X 25 mm) or 23G X 1 y,; in (0 . 6 X 30 mm) bl ue needle or 21 G 1 X in (0 8 X 40 mm) green needle Dose: 1 0 mg tr iam ci n olo n e acetonide i n a total volume of 1 mL
The pOSi t i o n shown fo r t h e i n j ect i o n ( Fig.
Figure 5.42 I nje cti on of the in raspi natus tendon showing direction of a p proach and needle position.
X
5 .41 )
may
be un c o m fortable fo r the patient to m a i ntain and the pos i tion described here is prefera b l e. The p r i n c i p l es o f i n ject i o n a r e the same. Position the patient i n s i de-ly i n g w i t h the head raised on two p i l l ows (or o n e fo l d ed), t h e h a n d rest ing on the c h e e k a n d the fo rearm free to al low the elbow to d rop down below the s h o u l d e r. This later a lly rotates and add ucts the a ffected arm to expose t he greater t uberosity (Fig.
5.43).
Locate the area of tender
ness over the greater tuberosi ty, which now l ies a p p roxi mately two fi ngers' wi dth below to the posterior angle of the acro m i o n . I nsert the need le and d e l iver the i n j ec tion by a peppe ring tech n ique to the whole eX1ent of the
Figure 5.43 Transverse frictions to the infraspinatus tendon (and p osit i on for i nj ec t ion) .
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The shoulder
lesi on, wh ich may be up to 2-3 cm wide ( Fig. 5 . 4 2 ) . The patient is advised to maintain a period of relative rest for approximately 2 weeks fol lowing injection.
Transverse frictions to infraspinatus (Cyriax 1 984, Cyriax & Cyriax 1 993) Position the patient as above (Fig. 5 .43), or the a l ternative position can be used i f it ca n be tolerated by the patien t ( Fig. 5 .4 4 ) . Locate the area of tenderness and place a thumb on the area paral lel to the d i rection of the tendon fibres; rei nforce this with the other thumb (Fig. 5 .4 4 ) . Standing back t o apply body weight, press down onto the tendon and deliver a transverse sweep across the fi bres, aiming to touch the posteIior angle of the acromion with each stroke. The infraspi natus is two fingers (2 cm) wide; i f teres minor is i nvolved, t h e sweep should cover a width o f three fi ngers (3 c m ) . Ten minutes' friction is delivered after achieving the analgesic effect. Relative rest is advised where functional movements may continue, but no overuse or stretching until pain-free on resisted testing. If the lesion l ies in the body of the tendon, the tech nique for transverse fi'ictions is the same, but appl ied a l ittJe more proximal ly at tJle s i te of the l esion, identified by palpation.
Subscapularis tendi nopathy A l esion i n subsca p u laris produces pain o n resisted medial rotation. A p a i n fu l arc i n d i cates a lesion i n the u pper fibres; a positive scarf test ind icates a lesion i n the lower fi b res. Pal pation w i l l con firm the exact s i t e o f the lesion, wh ich may cover a large area of tendon, i .e. approxi mately th ree fi ngers (3 ern) wide. I njection of subscapularis (Cyriax 1 984, Cyriax & Cyriax 1 993) Suggested needle size 23G x 1
o r 23G x 1 y,; i n
in (0.6 x 25 mm) (0.6 x 30 mm) blue needle
Dose: 10 mg triamcinolone acetonide
in a total
vol u m e of 1 m L
Position the patient i n sitting with the arm supported to allow the h umerus to rest in the anatomical position ( Fig. 5 .4 5 ) . Locate the lesser tuberosity and deliver the injec tion by peppeIing technique to the Fu l l widtJl of the l esion at the i nsertion onto the l esser tuberosity (Fig. 5 . 4 G ) . The patient is advised to maintain a period of relative rest for approxim ately 2 weeks following i njection.
Transverse frictions to subscapularis (Cyriax 1 984. Cyriax & Cyriax 1 993) Position the patient as above and locate the area of ten derness (upper fibres, lower fibres or both) on the medial aspect of the Jesser tuberosity (Fig. 5.47). Place the thumb perpendicular to the d i rection of the fibres, parallel to the shaft of the h u m erus and directed laterally; deliver the
Figure 5.44 Alternative position
for transverse friction
massage of the infraspinatus tendon.
Figure 5.45 I nj ect i o n
of the subscapularis tendon. 119
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Practice of orthopaedic med i c i ne
transverse frictions in a supero-inferior direction trans versely across the
fibres. The subscapularis tendon is
appr oxima t ely three fingers wide
(3 cm).
If the full width
of the tendon is affected it may be necessary to divide the area into two sites for treatment as it is di fficult to friction across the entire structure and a blister may be raised . Ten mi nutes' transverse frictions a re delivered a fter the anaJgesic effect is achieved. Relative rest is ad vised where functional
Figure 5.46 Inj ection of the subsca p u l aris tendon showing d i rection of a p p roach and needle position.
Figure 5.47 Transverse frictions to the subscapularis tendon .
Figure 5.48 Alternative positions for transverse frictions to the subsca pularis tendon.
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Ch apter
I 5 I
The shoulder
movements may co ntinue, but no overuse o r st re tch i n g until pain-free o n resisted testing The therapist's p o sitio n can be varied to give better access to the tendon ( Fig. 5 . 4 8 ) . .
Tendinopathy of the long head of biceps
( Fig. 5 . 4 9 ) . Locate the bici p i tal groove and sl ide the need l e in, paral lel to the groove ( Fig. 5.50). Del iver the i n j ec t i o n by a b o l us tech n i que al ongside t h e tendon. The patient is advised to maintain a period o f relative rest fo r approxi mately 2 weeks fo l l ow i n g i n jection
, -C;)J
�
Injection of the long head of the biceps in the
so
bicipital groove
�.Q
Suggested needle size: 23G x 1
in (0.6 x 25
or 2 3 G x
b l u e needle
Dose:
1 1,; i n (0 6
1 0 mg
X
30 mm)
£"0
mm)
z·o 1"0
triamCi nolone aceton ide i n a total
volume of 1 mL
In i ts pos i t i o n in the subacro m i a l space, the tendon of the head o f b iceps may be i nvolved i n a n i mp i ngement syndrome. i t wil l produce pai n fe l t at t h e shoulder o n ,esisted el bow fl exi o n With the fo nner lesion, a pai nful arc is usually preselll o n forward flexion o f the shou lder with a stra ight a rm and the palm u ppermost. Posit i o n the patient in s i t t i ng with the arm supported so that the hu merus rests in t h e anatom ical position l o ng
.
\
Figure 5 . 50
i nj ect i o n
of the l o ng head of biceps tendon
showing d i rection of approach and needle position.
Figure 5.49 Injedion o f t h e long head of biceps tendon.
Figure 5 . 5 1 Transverse frictions to the long head of biceps tendon.
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Transverse frictions to the long head of the biceps (Cyriax 1 984, Cyriax & Cyriax 1 993) Posi tio n
t h e p a tie n t as above a nd p l ace a thu m b p a r a ll e l
t o the t e n d o n i n the groove, fi n gers wrapped around the
arm for co u n terpressure ( Fig. 5. 5 1 ) . D el iver the tra n sverse fric t i o ns
by
a l t e rn a t e l y rotating the arm i n to medial a nd
lateral ro t a t i o n . A l t e r n a t i v el y, the therapist may hold t h e patien t's a rm s t a t i o n a ry a n d d e l iver t h e fri c t i o n by a bduct i n g a n d a d d u c t i ng the th u m b. Re l a tive rest i s advised w h e re fu n ct i o n a l movem e n t s m a y con ti n u e, b u t no over use or s t retching u n t i l p a i n- free on resisted test i ng.
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S m i th , S . P. , Devaraj, V.S , B u n ker, T.D ,
1 24 Copyrighted Material
J. Orthop. Spons
6 The elbow
SUMMARY
CHAPTER CONTENTS
Summary Anatomy
125 125
Inert structures
125
Contractile structures
126
Guide to surface marking and palpation
127
Lateral aspect
127
Medial aspect
128
Anterior aspect
128
Posterior aspect
128
Commentary on the examination
129
Observation
129
History (subjective examination)
129
Inspection
130
Palpation
130
State at rest
131
Examination by selective tension (objective examination)
131
Capsular lesions
135
Non-capsular lesions
135
Loose body
135
Olecranon bursitis
137
Pulled elbow
138
Contractile lesions
138
Tenn is elbow
138
Golfer's elbow
147
Biceps
149
Triceps
150
Tennis elbow is the most commonly encountered elbow problem in clinical practice and probably presents the greatest challenge. T his chapter suggests an approach to its management, as well as addressing other common and more unusual lesions. To aid diagnosis and accurate treatment, the chapter begins by outlining the relevant anatomy and provides guidelines for palpation. A commentary on the history and objective sequence follows, leading to discussion of the lesions that may be encountered, with suggestions for their effective treatment and management.
ANATOMY Inert structures Together with the shoulder, the elbow functions to posi tion the hand in space. Anatomically the elbow consists of two articulations, the elbow joint proper and the supe rior radio-ulnar joint, both contained within the same joint capsule. The elbow jOint proper is a synovial hinge joint between the distal end of the humerus, comprisi ng the capitu lum and trochlea, and the proximal ends of the radius and ulna. The articular capsule surrounds the articular margi ns, originating anteriorly around the coronoid and radial fossae of the humerus and inserting into the annu lar ligament and anterior border of the coronoid of the ulna. Posteriorly it attaches to the olecranon fossa of the humerus and the o.lecranon of the ulna.
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I n common with other synovial hinge joints, the rela tively weak anicular capsule is reinforced by strong col l atera l l igaments. The medial collateral ligament fans out from the medial epicondyle, where it is closely related to the common flexor tendon and primarily resists valgus stresses. The lateral collateral ligament is a strong triangu l ar band fanning out from the lateral epicondyle, where it underlies and shares a close a natomical relationship with the common extensor tendon. It runs on to blend with the annular ligament below. The radial collateral ligament stabilizes the radial head, preventing varus stresses, and the annular I igament stabilizes the superior radioulnar joint. The elbow joint has two axes of motion and thus a greater inherent stability than the shoulder (Miyasaka 1999). The capitulum is roughl y hemispherical in shape and aniculates with the radial head. The trochlea is pulley- or spool-shaped and extends from the anterior aspect of the distal end of the humerus to the olecranon fossa poste riorly. Its prominent medial ridge provides a valgus tilt which con tributes to the carrying angle of the elbow joint. It aniculates with the trochlear notch of the ulna. On the distal anterior surface of the humerus sit the radial and coronoid fossae, accommodating the rims of the radial head and coronoid process of ulna in ful l flex ion. The olecranon fossa of the humerus accepts the ole cranon process of the ulna in ful l extension. The proxima l end of the radius consists of a head, neck and tuberosity. The radial head is cup-shaped superiorly for aniculation with the capitulum. The periphery of the head is an anic ulating surface for the superior radioulnar joint, articulat ing with the inner surface of the annular l igament. The radial tuberosity gives insenion to the biceps tendon. At the proximal end of the ulna is the massive, hook shaped olecranon process. Anteriorly, the coronoid process arises with the radial notch on its medial side for artic ulation with the radius at the superior radioul nar joint. The elbow joint itself permits flexion and extension cou pled with a sma l l amount of adjunct rotation (Stand ring 2009). About 1600 of passive flexion exists as the bones become almost parallel and the radial and coronoid fos sae allow for extra functional movement by accommodat ing the flexor muscle bulk. The normal end-feel of elbow flexion is soft due to approximation of the flexor muscles. Passive extension is achieved by locking the olecranon into the olecranon fossa; it corresponds to a 1800 angle and has a hard end-feel due to bone contact. The elbow joint receives a nerve supply from the mus culocutaneous, median and radial nerves anteriorl y, and the ulnar and radial nerves posteriorly (C5-C8). The superior (proximal) radioulnar joint is a uniaxial pivot joint permitting the movements of pronation and supination. These movements occur between the circum ference of the radial head in the fibro-osseous ring created by the annular ligament and the radial notch of the ulna. The annular ligament is covered internally by a thin layer of articular cartilage.
Movement occurring at the superior and inferior radio ulnar joints is rotation of the radius around the ulna to produce pronation and supination. The range of passive pronation is approximately 85 and passive supination 90°, normal ly with an elastic end-feel. The carrying angle (cubitus valgus) is evident in the ana tomical position. The medial end of the distal humerus projects more distally and anteriorly than the latera l , pushing the ulna lateral l y to produce this valgus angle. It is approximately 1 0 15 ° in men and 20-25 in women (Palastanga et al 2006). Miyasaka (1999) cites several references suggesting that the carrying angle in women is 1 3-160 and noting that one large study demonstrated no difference in the canying angle between men and women. The cubital fossa is situated on the anterior aspect of the elbow. Its proximal border is an imaginary line drawn between the two epicondyles of the humerus; its lateral border is brachioradialis and its medial border is pro nator teres. On the floor of the fossa lies supinator and biceps and the roof is formed by the overlying skin and fascia. The contents of the cubital fossa, from lateral to medial, are the tendon of the biceps in the centre, the bra chial artery and the median nerve. °
-
°
Contractile structures Biceps brachii (musculocutaneous nerve C5-C6) has two heads of origin. The muscle ends in a stout tendon which attaches deeply to the posterior aspect of the radial tuber osity. As the tendon passes to its insertion it twists so that its anterior surface comes to rest laterally. The tendon is separated from the anterior aspect of the radial tuberosity by the subtendinous bicipital bursa. The bicipital apo neurosis arises anteromedially from the distal end of the tendon and sweeps medially to b lend with the antebra chial fascia. Biceps is a powerful elbow flexor. Its second ary action, due to its insenion on the med ial aspect of the radius, is to assist supinator in supination of the forearm, particularly with the elbow joint in 900 of flexion; it has no supinating action in the extended elbow. Brachialis ( musculocuta neous nerve C5-C6) takes ori gin from the anterior aspect of the lower half of the shaft of the humerus and insens into the coronoid process of the ulna. As it crosses the elbow joint some of its deep fibres insen into the capsule of the elbow joint. Its action is to flex the elbow in either pronation or supination. Brachioradialis (radial nerve C5-C7) passes from a long attachment on the upper two-thirds of the lateral supracondylar ridge of the humerus to the distal end of the radius just above the styloid. It flexes the elbow, being most effective in the mid-pronation-supination position. Triceps (radial nerve C6-C8) has three heads of ori gin above the elbow, with its tendon inserting into the olecranon process. It is the main elbow extensor and is involved in pushing and thrusting activities as well as raising body weight on semiflexed elbows, as in getting up from a chair.
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Pronator teres (median nerve C6-C7) has two heads of origin: a humeral head from just above the medial epi condyle, the coronoid process and from the common �exor tendon, and an ulnar head from the medial side of the coronoid process. It passes down and laterally to insert into a roughened area along the lateral aspect of the shaft of the radius. Its main action is to pronate the forearm, especially against resistance. Pronator quadratus (median nerve C8, TI) binds the lower parts of the radius and ulna and is the principal pronator of the forearm. Supinator (posterior interosseous nerve CS-C6) has its proximal attachment from the supinator crest of the ulna, lateral epiCondyle of the humerus and the radial collat eral and annular ligaments. It wraps round the elbow obliquely, laterally and distally, to insert into the proxi mal third of the radius, and supinates the forearm, bring ing the palm of the hand to face upwards, whatever the degree of flexion at the elbow. Extensor carpi radialis longus (radial nerve C6-C7) takes its main origin from the lower third of the lateral supracondylar ridge, in part deep to the origin of brachio radialis, and some origin from the common extensor ten don. It passes to the radial side of the base of the second metacarpal. Extensor carpi radialis brelJis (posterior interosseous nerve C7-C8) takes its main origin from the lateral epi condyle via the common extensor tendon, in part deep to extensor carpi radialis longus, and inserts into the radial side of the base of the third metacarpal. It is very com monly involved in tennis elbow. Extensor carpi radialis longus and brevis extend the wrist and produce radial deviation. They work synergisti cally with the finger flexor tendons by holding the wrist in extension, allo"ving the finger flexors to form an effective grip (Palastanga et al 2006). Other muscJes which share tl1e origin from the com mon extensor tendon with extensor carpi radialis brevis and are also responsible for wrist extension are exten sor digito[um, extensor digiti minimi and extensor carpi ulnaris (which also produces ulnar deviation). All of these muscles are supplied by the posterior interosseous nerve (C7-C8). Flexor carpi radialis (median nerve C6-C7) arises from the medial epicondyle via the common flexor tendon and becomes tendinous above the wrist, before passing through its own lateral compartment under the flexor retinaculum. It inserts into the bases of the second and third metacarpals. Palmaris longus (median nerve C7-C8), often absent, arises from the medIal epicondyle via the common flexor tendon and passes over, not under, the flexor retinaculum, attaching to the distal flexor retinaculum and the palmar aponeurosis. Flexor digitorum superjicialis (median nerve C7-C8, Tl) lies in a slightly deeper plane than the above flexor mus cles and has a humeral head from the medial epicondyle
via the common flexor tendon and a small radial head. It divides to pass under the flexor retinaculum before enter ing the fingers to attach to the middle phalanx of each. Flexor carpi ulnaris (ulnar nerve C7-C8) has two heads of origin: a small humeral head from the medial epi condyle via the common flexor origin and an ulnar head from the ulna. It passes over the retinaculum into pisiform.
GUIDE TO SURFA CE MARKING AND PALPATION Lateral aspect (F ig. 6.1) Palpate the lateral supracondylar ridge, which is a sub cutaneous sharp ridge, giving part origin to extensor carpi radialis longus and brachioradialis. The lateral supracondylar ridge terminates in the lateral epicondyle, a small bony projection which you wrll pal pate more easily if the elbow is �exed. Visualize the small facet on the anterolateral aspect of the lateral epicondyle which gives origin to the common extensor tendon of the superficial wrist extensor muscles. This facet is approximately the size of the patient's lit tle finger nail. This appears to impose a mechanical dis advantage, since large forces are transmitted through the colllmon extensor tendon to this small site, leading to pos sible strain. The area may also be vulnerable to shearing stresses during all movements of the forearm. Palpate the head of the radius on the lateral side of the extended forearm; it is located in a posterior depression just distal to the lateral epicondyle. Confirm the correct position by rotating the forearm to feel the radial head move under your finger. Move proximally a short distance to palpate the radio humeral joint line, just above the radial head. It can also
Supracon dylar ridge
Common extensor origin
Humerus
Radius Lateral--��'Q epicondyle
Olecranon
Radioulnar joint line Figure 6.1
Ulna
Lateral aspect of the elbow in mid-position 127
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•
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Humerus
Radial tuberosity Radius
Common Hexor origin
Figure 6.2 Medial aspect
_a-- +- Common flexor origin
Medial epicondyle
Ulna
of the elbow in exten sion .
Pronator teres ---�'-"
be pa lpated by dropping into the dimple on the postero lateral aspect of the olecranon. The gap betwee n the head of the radius and the capitulum of the humerus should be obvious; flex your elbow and feel the joi nt open, provid ing the most accessible poi nt for an intra-anicular injec tioll. Flexion past 450 tightens the joint capsule, ma king the joint line less obvious. Identify brachioradialis, the most superficial forearm muscle on the lateral side of the forearm, by flexing the elbow against resistance in the mid-pronati on -supi nation position.
Flexor carpi radialis
----f-c -r-7F--I
\--1--- Flexor carpi ulnar is Hit--- Flexor digilorum superficialis
Palmaris longus
---�-+";" -I';' I
Medial aspect (Fig. 6.2) Palpate the medial supracondylar ridge which ends in the rounded knob of the medial epicondyle. Identify the medial epicondyle, which is subcutaneous and most easily felt with the elbow in extension. Palpate the ante rior aspect of the medial epicondyle, which provides the attachment for the common flexor tendon of the superficial wrist flexor muscles. Visualize the position of the superficial wrist flexor muscles by placing the thenar eminence of one hand onto the opposite medial epicondyle, and spread the dig its down the foreann to represent the following tendons (Fig. 6.3) • • • •
•
Thumb: pronator teres I ndex: flexor carpi radialis Middle: palmaris longus Ring: flexor digitofUm superficial is (deeper than the others and not so obvious) Little: flexor carpi ulnaris.
Figure 6.3 The pos i ti on of the muscles ari ing from the common flexor origin.
the tendon down to its insertion onto the radial tuberosity. The tendon of the biceps will be easily palpable as it passes deep inLO the cubital fossa, but the tuberosity may not feel distinct to the palpating finger, although it is ten der to deep palpation. Place the arm in the anatomical position of elbow extension and supination and note the obvious valgus angle, known as the carrying angle. It should be symmet rical bilaterally.
Anterior aspect It is not possible to palpate the joint line of the elbow anteriorly because of the position of the flexor muscles, but it can be visuali zed approximately 1 em below the elbow flexor crease that connects the medial and lateral epicondyles (Miyasaka 1999, Palastanga et al 2006). Locate the tuberosity of the radius by nexing the elbow to make the tendon of the biceps more obvious. Follow
Posterior aspect Palpate the proximal surface of the olecranon process, the point of the elbow that is subcutaneous and most easily palpated when the elbow is flexed. The olecranon gives insertion to triceps and a subcutaneous bursa, the ole cranon bursa, lies under the loose skin at the back of the elbow.
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or a (e.g. supracondylar, distal radius or ulna) and/or disloca tion. Possible neurovascular complications, secondalY to trauma, should be kept in mind. A sudden onset of pain associated with Jocking of the elbow could indicate a loose body. The duration of the symptoms may be long-standing. The most common lesions at the elbow are due to chronic overuse and result in the enthesiopathies of tennis elbow (lateral epicondylar tendinopathy) and golfer's elbow (medial epicondylar tendinopathy) . The common ten dons of the forearm flexors and extensors are susceptible to excessive use because they function across two joints. The causative factors may be intrinsic overload, from the force of muscle contraction; extrinsic overload, through excessive joint torque forces stressing the connective tis sue, stretching and eventually disrupting it; or a combina tion of intrinsic and extrinsic forces (Safran 1995) . These overuse injuries are often associated with the middle aged racquet sports player or individuals participating in throwing activities. Throwing motions may produce a valgus stress on the medial elbow and compressive forces at the lateral elbow. Such repetitive actions may result in micro trauma to the joint or surrounding tissues (Nicola \992). Climber's elbow affects brachialis, as climbing involves the use of the semi-flexed pronated forearm (Safran 1995). Overuse may cause friction between the radial tuberosity and the biceps tendon, resulting in inflam mation of the biceps subtendinous bursa, or an overuse lesion in the tendon itself. The duration of symptoms indicates the stage of the lesion in the inflammatory process and will also give an indication for the likely length of treatment, with more chronic lesions usually taking longer to resolve. The common presentation of tennis or golfer's elbow is pain Hypere;'(tension injuries
COMMENTARY ON THE EXA MINATION
may cause a
capsulitis,
fal l on the out-stretched hand may cause fracture
Observation Before proceeding with the history, a general observation of the patient's face, posture and gait will alert the exam iner to abnormalities and serious illness. The acute elbow is usually held in a position of flexion and a degree of supination, with medial rotation at the shoulder and the patient nursing the arm in a position of comfort. Lesions commonly found at the elbow are due to overuse when abnormalit.ies of posture are not usually observed.
H i story (subjective examinatio n) The age, occupatiol1, SPOTtS, hobbies and lifestyle of tbe patient may give an indication of the nature of the onset and cause of the injury, and will alert the examiner to possible postural or overuse problems. It may also give an indication of whether the source of the problem is in the cervical spine. Age may be relevant, as certain conditions affect par ticular age groups, for example conditions such as 'pulled elbow' (a subluxation of the small radial head in the relatively immature annular ligament), which affects children in the 1-4 years age group. Degenerative osteo arthrosis generally affects the elderly, while rheumatoid arthritis may involve the elbow at any age. Loose bodies can occur in adolescents, associated with osteochondritis dissecans, or in tbe middle-aged/elderly group, associated with degenerative changes in the articular cartilage. The overuse lesions of tennis and golfer's elbow tend to be a problem of middle age as the ageing process causes the tendinous material to become less extensible and more prone. to injury. The elbow joint and surrounding structures are situ ated within the C5-C7 and Tl dermatomes. However, the site of pain is usually well localized, indicating a less severe, superficial lesion. A spread of pain wou.ld indicate a more irritable lesion and possibly referral of pain from a deeper, more proximal structure. The patient may report local tenderness with an ole cranon bursitis or, more commonly, with a tennis or golf er's elbow, which may produce a diffuse reference of pain into the forearm, as well as point tenderness over either the lateral or medial epicondyle, respectively. The onset of the symptoms may be sudden, due to trauma, or gradual, due to overuse or arthritis. If the onset is traumatic in nature the mechanism of injury should be deduced. Acute injuries include dislocations and fractures of the radial head, olecranon and distal humerus (Safran 1995).
of weel<s' or even months' duration, while the less com
mon loose body has recurrent episodes of twinging, often resolving spontaneously. Arthritis is characterized by recurrent episodes of exacerbation of symptoms and has usually been present for months or years. The symptoms and behaviour need to be considered. The behaviour of the pain indicates the nature. of the lesion: mechanical lesions are eased by rest and aggravated by repeated movements, particularly those involved in ule mechanism of the lesion. For example, tennis elbow gives an increase of pain on gripping activities - simple things such as lifting a cup or pulling up bedclothes. Patients often report that knocking the lateral aspect of the elbow can give excruCiating pain and it is very tender to toum. Other symptoms described by ule patient could include t\-vinges of pain with locking of the elbow, usually just short of full extension, whim would indicate a possible loose body. A t>vinge. of pain in the forearm on gripping is also associated with a tennis elbow, causing the patient to drop me object and giving an apparent feeling of muscle wealrness.
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Paraesthesia may be indicative of nerve involvement and the exact location of these symptoms should be ascertained. Paraesthesia may be referred distally from the cervical spine, but as the ulnar nerve lies in an exposed location behind the medial epicondyle, it is occasionally subject to direct trauma. Both the posterior interosseous nelve (passing between the two heads of supinator) and the median nerve (pass ing between the two heads of pronator teres) are suscep tible to muscular compression. This may complicate the clinical presentation of either tennis or golfer's elbow and may be a reaSOn for a poor response to treatment. An indication of past mediCllI history, other joint involve ment and lIIedications will establish whether contraindi cations to treatment exist, or that the lesion is part of an ongoing inflammatolY arthritis. As well as past medical histolY, establish any ongoing conditions and treatment. Explore other previous or cUlTent musculoskeletal prob lems with previous episodes of the current compl�int, any treatment given and the outcome of treatment.
Inspectio n An inspection is conducted in standing with Ule upper limb resting in the anatomical position, if this can be achieved. Assess the overall posture from above down, looking for any bony deformity, noting the position of the head, the lordosis in the cervical spine, the position of both shoulders and the scapulae. Assess the carrying angle in the anatomical position, comparing it with the other side for symmelly Inspect for colour changes, including contusions and abrasions which are associated with direct trauma. These may be located at the point of the elbow or over either epicondyle. Bruising over the biceps or triceps muscles can occur in contact sports where a direct blow is pos sible. Abrasions may be a site of entry for bacteria, with septic olecranon bursitis being a possible result of such infection. Muscle wasting may be evident in the forearm if a patient has a long or recurrent histolY of tennis elbow Other musde wasung would be unusual and would probably be a neurological sign associated with cervical pathology. Swelling is usually associated with trauma. Jt may be diffuse, engulfing the elbow area, in which case the elbow will be fixed in the position of ease, to accommodate the swelling with minimal pain. The dimples seen at the back of a flexed elbow are obliterated if swelling is present, as here the capsule is lax and usually accommodates excess fluid. Immediate swelling indicates bleeding and a possible haemarthrosis. Swelling developing 6-24 h after trauma indicates synovial irritation and capsular involvement. Local swellings are associated with direct trauma. A local ized soft, boggy, fluduating swelling may be seen over the point of the elbow and is indicative of an olecranon
Figure 6.4 Palpation
for heat
bursitis. Occasionally patients complain of swelling over the lateral epicondyle in tennis elbow, but this is not always evident clinically.
Palpatio n Since the elbow is a peripheral joint, the joint is palpated for signs of activity. Heat indicates an active inflamma tion (Fig. 6.4), as does synovial thickening which is most easily palpable over the radial head in the more chronic state (Fig. 6.5). Swelling is usually most apparent in. the dimples at the back of the elbow and may be palp�ted in that area. Other swellings such as that associated with ole cranon bursitis or nodules can also be palpated to assess whether they are hard or soft.
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Figure 6.6 Passive elbow flexion.
and ruled out as necessary. Consider too the widespread area of referra l associated with cardiac pathology. The elbow joint and the superior radioulnar joint are assessed by four passive movements looking for pain, range and end-feel. In the normal patient pass i ve flexion has a 'so ft' end-feel and passive extension has a 'hard' end feel. At the superio r radioulnar joint, passive pronation and supination have an 'elastic' end-feel. The si gns elicited will establish whether or not the capsular pattern exists.
r Figure 6.5 Palpation for synovial thickening.
State at rest
Elbow and superior radioulnar joints
Examination by selective tension (objective examination) The suggested sequence for the objective examination w i l l now be given, followed by a commenta ry incl uding the reason i ng in performing the movements and the signifi cance of the possible fi n d ings. Comparison should always be made with the other side. It is important to screen other joints that may refer symptoms to the region. The 5th, 6th and 7th der· matomes pass over the elbow joint region and symptoms of cervical and/or shoulder origin should be considered
I
•
Passive elbow flexion (Fig. 6.6)
•
Passive elbow extension (Fig. 6.7)
•
Passive pronation of the superior radioulnar joint (Fig. 6.8)
•
Before any movements are performed. the state at rest is established to provide a baseline for subsequent comparison.
�
Passive supination
of the
superior radioulnar joint
(Fig. 69) •
Resisted elbow flexion (Fig. 6.10)
•
Resisted elbow extension (Fig. 6.11)
•
Resisted pronation (Fig. 6.12 a-<:)
•
Resisted supination (Fig. 6.12 a--c)
Pain provocation tests for tennis and golfer's elbow •
Resisted wrist extension for tennis elbow (Fig. 6.13 and 6.15a)
•
Resisted wrist flexion for golfer's elbow (Fig. 6.14 and 6.15b)
Palpation •
Once a diagnosis has been made, the structure at fault is palpated
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Figure 6.7
Passive elbow extension.
Figure 6.9
Figure 6.8
Passive pronation.
Figure 6.10
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Resisted elbow flexion.
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Figure 6.11 Resisted elbow extension.
Figure 6.12 (a-c) Hand and body positioning for resisted pronation a n d s u p i nation. 133
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Figure 6.14
Resisted wrist extension.
Resi sted wrist flexion.
Figure 6.15 Examples of further provocative tests: (a) resisted wrist extension from the flexed position; (b) resisted wrist flex ion from the extended position.
A loose body in the elbow joint produces a non-capsular pattern of movement with either limitation of passive flexion. or extension, but not both. The limited move ment has an abnormal 'springy' end-feel . The resisted tests are conducted for the muscles around the elbow, looking for pain and power. Resisted elbow flexion tests biceps and resisted elbow extension tests triceps. Resisted pronation tests pronator quad ratus and pronator teres, but since pronator teres takes origin from the common flexor tendon, this may be an accessory sign in golfer's elbow. Resisted sup ination tests biceps, since it is assessed with the elbow flexed, and supinator.
Two provocative resisted tests are conducted at the wrist to assess the common extensor and common flexor tendons for tendi nopathy Resisted wrist extension and resisted wrist flexion are assessed with the elbow joint fully extended. Since they are not required to stabi· lize the elbow in this close packed or locked position, they contract strongly to resist the wrist movements and allow minor lesions to be detected . To p rovoke pai n , further provocative tests can be applied for ten nis elbOl-v, e.g. passive wrist flexion, resisted wrist exten sion from the flexed position, resisted rad ial deviation and resisted middle finger extension. For golfer's elbow,
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resisted wrist flexion can be assessed from t h e extended position.
CAP SULAR LESIONS
Capsular pattern of the elbow joint •
M ore l i mitation of flexion than extension.
capsular pattern of the superior radioulnar joint
l.
Pain at the end of range of both rota ti o ns . Figure 6. 1 6 Injection of the elbow joint
The caps u l a r pattern indicates the p resence of arthri t is in the joint which, at the e l b ow, is freque n tl y rheumatoid arth ri tis. Degenerative osteoarthrosis is of i tsel f sym p tom free, b u t t ra u m a t i c art h ritis may be secondary to overuse or tra u m a of a restricted joint. Treatment of choice is a corticosteroid i n j ection into the el bow joint.
Injection of the elbow joint Suggested needle size: orange needle
25G x 5/8 in
(0.5
x
1 6 mm)
Dose: 20-40 mg triamcinolone aceton ide i n a total volume of 3-4 mL Figure 6.17 Injection of the elbow joint, sh owing direction of approa c h and needle position. Sit the patient with the elbow flexed to approxim ately
450
and the forearm pronated (Fig.
6.16).
Locate the
radio hu meral joint line on the postero l a teral aspect of the elbow. I nsert the needl e between the head of the radius and the capitulum ( Fig.
6.17).
Once intra-aI1icu lar, deliver the
activities such as gymnastics, t h rowing a n d racquet spons.
injection as a bolus. The patient is advised to mai n ta i n a
Repeated com pressive forces cause microtrauma between
period of relative rest for approximately 2 weeks fol l owing
t h e rad i a l head and capit u l u m and focal degeneration
injedion.
resu l t s i n fragmentation and the formation o f loose bod
Trau m a t i c arthri t i s can be treated w i t h o t h er physio
ies ( Patten
1995). Surgical
removal is advisa b l e i n this age
gro u p . Joji et al (20 0 1 ) present a case report to demon
t h erapeutic modalit i es.
strate osteochondritis dissecans occurring i n the med i a l aspect o f t h e distal h u m ell.ls o f a 17-year-old base b a l l p i tcher, wh ich is deemed to be l ess c o m m on than osteo
NON- CAPSULAR LESIONS
chondri t i s w i th l oose body for m a t i on fo und in the latera l aspect. Loose bodies can a l so be encountered in the m iddle
Loose body
aged or elderly group and may be associated with degen and
erative changes. They may be a fragment or fragments of
can give rise to l oose body fo rmat ion, particularly with
cartilage or bone, o r both ( osteochondra l ) , and can be
Osteochondri t i s dissecans
occurs
in
ado lescents
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associated with degenerative osteoanhrosis in the older adult (Saotome et al 2006). They can be stable, fixed in a synovial recess or bursa, or attached to synovial membrane, where they tend not to be displaced. Unstable loose bod ies can move freely in the joint where they can become trapped at irregular intervals between the articular bone ends, causing intermittent symptoms and joint derange ment (Bianchi & Martinoli 1999). Characteristically, the patient complains of a history of twinging pain, with the elbow giving way under pressure or locking, usually just short of full elbow extension. The history alone may be the only diagnostic evidence avail able since the loose body may spontaneously reduce. Sometimes diagnostic imaging may be necessary to iden tify and localize loose bodies before arthroscopic removal (1-101995). On examination, a non-capsular pattern may exist with either a small degree of limitation of flexion or extension, but not both. The end-feel to the limited movement is abnormally splingy. The treatment of choice to reduce a loose body is strong traction together with Grade A mobilization, theoretically aiming to shift the loose body to another part of the joint and to restore full, pain-free movement. There are two possible manoeuvres, both working towards elbow extension. The choice of starting man oeUVTe is random and sometimes it may be necessary to try both and repeat the most successful, although some times one manoeuvre is sufficient. As with all mobilization techniques, the patient is reassessed after every man oeuvre and a decision made about the next, based on the outcome.
Figure 6_18 Hand position
for
mobilization
for loose body in
the elbow Joint, towards extension and supi nation .
Mobilization for loose body in the elbow joint (Saunders 2000) Towards extension and supination Position the patient against the raised head of the couch, with the arm resting against a pillow and the elbow in approximately 900 of flexion. Use a butterfly grip with the thumbs placed on the flexor surface of the forearm, over the radius (Fig. 6.18). Face the direction of the supination movement and lift the leg farthest from the patient off the ground, leaning out to establish traction with straight arms. Step forwards, taking the elbow joint towards exten sion (not full range), while simultaneously rotating the forearm with several flicking movements towards supina tion (Fig. 6.19). The manoeuvre is easier to perform if you begin the rotation from a position of some pronation.
Towards extension and pronation The patient's position is the same. Face the movement of pronation, placing the thumbs on the extensor surface of
Figure 6_19 Body in the elbow
position for mobilization
for loose
body
join t, towards extension and supination step
forwards.
the forearm, over the radius (Fig. 6.20). Establish the trac tion as above and step bachvards, simultaneollsly rotat ing the forearm with several flicking movements towards pronation (Fig. 6.21). The manoeuvre is easier to perform
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is usually successful. but there are no guarantees that the condition will not recur. Excessive recurrences of the con dition may need referral for surgely.
Figure 6.20 Hand position for mobilization for loose body i n the elbow JOint, towards extension a n d pronat ion.
Figure 6.22 Injection of olecranon bursitis.
O lecranon bursitis Swelling and inflammation of the olecranon bursa can repeated pressure and frictio n , or to direct trauma of the bursa. The bursa is the most vulnerable structure to trauma on the posterior surface of the elbow and septic bursitis is not uncommon (Nicola 1992, Hoppmann 1993). The patient may present with an obvious swelling over the olecranon which is bOlk"Y and fluctuating. Provided sepsis is not present, conservative management includes aspiration, ice and non-steroidal anti-inflammatory drugs (Nico la 1992). Any physi o therapeut ic modality Illay be applied and corticosteroid injection may be given in the absence of infection. Seat the patient with the elbow supported in a degree of flexion. Pal [late the obvious swollen bursa and marJ{ a convenient point for inserting the needle. Insert the nee dle into the bursa (Figs 6.22 and 6.23) . Aspirate first to check for the presence of infection and, if clear. the injec tion can be delivered as a bolus. The patient is advised to maintain a period of relative rest for approximately 2 weeks following injection. occur due to
Figure 6.21 Body position for mobilization for loose body in the elbow joint, towards extension and pronation: step backwards.
if you begin the rotation from a position of SOJlle supination. The patient may need to be reviewed to assess the suc cess of the treatment. Generally speaking, the manoeuvre
Injection of olecranon bursitis (Kesson et al 2003)
Suggested needle size: 21G x 1 X in (0.8 x 40 m m ) green needle Dose: 10 mg triamcinolone acetonide i n a total
volume of 2 mL
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CON TRAC TILE LESIONS Tennis elbow
Figure 6.23 Inj ecti o n of olecranon bursitis. show ing of approach and needle position.
direction
Pulled elbow This condition usually presents to the general practition er's surgelY or the casualty department. Typically the child is aged between 1 and 4 years old and has a sudden onset of pain in the arm, followed by a reluctance to use the arm. The ch ild is unhappy and holds the arm in elbow flexion and pronatio n. The arm is pai n-free provided it is not moved. There may be a histolY o f the child stumbli ng or faIl i ng or it may occur if the child grabs the cot rails or other stationalY object whi le fall ing. Frequently the child is accompanied by a guilty parent, if pulling a resistant tod dler or lift ing the child by the arms and swinging them in play was the cause. The mechanism is thought to be a distal subluxation of the radial head through the an nular ligament (Hardy 1 978, Kohlhaas & Roeder 1995); however. X-rays taken before and after reduction show no evidence of displace ment (Hardy 1978). An X-ray is therefore of little value unless the nature of the trauma is significant when a frac ture dislocation of the elbow must be ruled out (Brukner & Khan 2007). Reduction of a pulled elbow involves supporting the child's elbow with one hand, feeling the radial head and providing counterpressure to axial compression. Quickly pronate the forearm through a small range wh ile main tain i ng a..-xial compression until a click is felt. The reduc tion is confirmed by immediate use of the arm by the child, to the subsequent relief of the parent. Adeniran & Merriam ( 1 994 ) reported a case of 'pulled elbow' in a 21-year-old woman, as an exception to the
Tennis elbow is the term commonly applied to a stra in of the wrist extensor muscles at the site of their common ori gin from the anterolateral aspect at the lateral epico ndyle of the humerus. I n the past it has been commonly referred to as 'lateral epicondylitis', but the absence of infiammatolY cells at the site of the lesion has led to this terminology being dropped. It is commonly a chronic lesion of more than 3 months' duration. Tendillopathy is a more appropriate description un less excision biopsy has been performed and the speci fic histopath ological fea tures of the specimen can be described, to be able to dis tinguish between tendinopalhy and tendinosis (Khan & Cook 2000). I t most commonly involves the extensor carpi radialis brevis tendon and is by far the most com mon lesion treated at the elbow, being five to eight times more common than golfer's elbow (Coonrad & Hooper 1973, Gellman 1 992, Gabel 1 999) . The condition may be resistalll to treatment and is prone to recurrence. Tennis elbow was first described in 1898 by Runge as 'writer's cramp' (Gellman 1 992, Verhaar et al 1 993). Of all diagnosed cases, 35-64% are associated with work related activities, with tennis players representing 8% of the total diagnosed. Repetitive loading seems to be a factor, with low-load activities such as keyboarding pos sibly representing the majority of patients. Workplace stress contributes to psychosocial factors (Gabel 1999). Repetitive wrist movements and unaccustomed activities are often blamed. However. competitive tennis players are susceptible to tennis elbow, 50% of them experiencing at least one episode (Noteboom et al 1 994). Altered biome chani cs, particularly of the bad
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gripping action is often related to occupational or spon ing activities and rarely is tennis elbow related to direct t rauma or a traumatic incident. The possibility of acute onset has been reported, however, in which case inflam matory changes might be present (Nirschl and Maffuli et al cited in Greenfield & Webster 2002 ). Point tenderness is present over the lateral epicondyle and the patient will often experience excruciating pain when the elbow is knocked. An apparent muscle weak ness may be reported, as pain is often accompanied by a severe twinge which causes the patient to drop relatively light objects (e.g. coffee cup). Pienimaki et al (2002) demonstrated similar subjective pain repons in tennis and golfer's elbow, but a greater reduction in grip strength associated with tennis elbow. On examination there is usually a full range of pain free movement at the elbow joint with pain on resisted wrist extension. Most authors seem to be in agreement that pain on resisted extension of the wrist and tender ness to palpation over the lateral epicondyle at the inser tion of extensor carpi radialis brevis are pathognomic of the condition. Greenfield & Webster (2002) conducted a survey of outpatient physiotherapists, seeking their opinion on current practice of tennis elbow, and identified 15 diag nostic tests, with the above two tests being used most commonly. Passive wrist flexion stretches the common extensor tendon and other resisted tests which may be positive include resisted radial deviation and resisted extension of the middle digit, which preferential ly stresses extensor carpi radialis brevis as it contracts synergisti cally, anchoring the third metacarpal to allow the digit to extend (Brukner & Khan 2007). A clinical observation of the authors suggests that apparent weakness on resisted wrist extension may be due to pain inhibition and this sign is a useful reassessment tool. Smidt et al (2002a) rec ommend the use of pain-free grip strength using a hand held dynamometer as a relatively easy test of functional disability in tennis elbow, showing it to have excellent reliability. Mills' sign is sometimes used to confirm diagnosis. The forearm is fully pronated and the wrist joint flexed. While maintaining this position, passive elbow extension is per formed and a positive sign is elicited if pain is reproduced at the lateral side of the elbow (Noteboom et al 1994, Sblveborn et al 1 995) . Cervical spine examination and radial nerve tension testing were the most popular differential diagnostic tests in the study by Greenfield & Webster (2002 ). Since the above positioning for the Mills' test and the radial nerve tension test are similar, this may present a false positive result as symptoms would be provoked if neural tension and/or tendinopathy were present. Palpation determines the site of the lesion. Of the cases of tennis elbow encountered, 90% involve the teno osseous junction of the common extensor tendon (Cyriax 1982) . Stratford et al (1989) demonstrated only a 22.5%
(a ) Figure 6.24 Four possible sites of ten n i s elbow: (a) t e no osseous ju nction (enthesis); (b) supracondylar ridge; (c) body of the com mon extensor tendon; (d) the m uscle bell ies.
occulTence at this site, hypothesizing that patients with ten derness over the lateral epicondyle and recurrent cases have a poorer short-term prognosis. They suggest that Cyriax would have seen more resistant cases in consultant prac tice whereas their research was conducted in primalY care. If remaining with Cyriax's clinical estimate, however, the remaining 10% involve the body of the tendon, the exten sor carpi radialis longus attachment on the supracondylar ridge or the muscle bellies (Fig. 6.24) (Cyriax 1982).
Mechan ism of ten n i s elbow The normal ageing process causes degenerative changes in collagen fibres and ground substance similar to the changes seen when tissues are immobilized (Akeson et al 1968). Degeneration and relative avascularity of the tendon make it susceptible to microtrauma through overuse activity. The repeated gripping action may initially produce trac tion of the common extensor origin causing microtrauma and inflammation (Foley 1993) . tvticroscopic and macros copic tears occur at the common extensor origin, with the development of fibrous scar tissue and contracture. Eventually. degenerative foci and calcification can occur (Coonrad & Hooper 1 973, Ernst 1992, Gellman 1992, Noteboom et al 1994) . Theoretically, initial inflammatory changes may pro duce a characteristic tendinopathy in an early acute lesion, but this is rarely seen clinically. Histologically, as the chronic condition develops, the degenerative features of tendinosis are thought to become paramount. This degenerative condition of the tendon is considered to be similar to the ongoing degenerative tendinosis seen in the Achilles tendon and rotator cuff tendons (Bennett 1 994 ). With continued overuse, the degenerative changes lead to microscopic tearing and scar tissue development within the tendon. An area of vascular granulation tissue devel ops which contains many nociceptive nerve endings, pos sibly explaining why the lesion is so painful (Brukner & Khan 2007).
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Chard et al (1994) co nducted histological studies of normal and biopsy tendon specimens (rotator cuff tendi nopathy and tennis elbow) to deteonine the mechanisms involved i n tendon degeneration. The major mechanism of tennis elbow or rotator cuff was not inflammation, but a sequence of degenerative changes which increased with age, although chronic traction is believed to have an effect. The tendons studied were considered to have an area of relative avascularity which seemed to predispose them to degeneration. The sequence of degeneration i ncluded changes in the blood vessel walls and fibroblasts and alteration in the gel to fibre ratio, with glycosaminoglycans replacing collagen fibres. This led to lack of maintenance of collagen turnover, loss of the wavy configuration of collagen fibres and transformation of the fibroblasts into chondrocyte-rype cel ls, with subsequent cartilage formation, calcification and eventual bone formation. It would seem that as the degenerative process progresses the tendon fibroblasts undergo fibrocartilaginous change, ulti mately to con vert the tendon to bone. This theory is supported by Edelson et al (2001 ) who examined a large number of cadaver elbow specimens and found characteristic bone formation at the point of usual tenderness to pal pation in the area that corresponded to the origin of extensor carpi radialis brevis. A C-shaped crescent of bone was identified along the posterior margin of the epicondyle, although it was also noted that the anatomical relation ship of both the insertion of the tendon and the lateral collateral I igament complex at this point could not be dislinguished.
Treatment of tennis elbow Treatment of tennis elbow should al ways look to address the causative factors. A ful l explanation should be given so that the patient is responsible for modifying activities to give treatment, whatever the moice, the best possible opportuniry. Lifting should be performed with a supina tion action rather than pronation (Gellman 1992), and various counterforce elbow or forearm supports are avail able to alter the stress on the com mon extensor origi n o r to rest the wrist t o avoid strain. Patient and therapist can discuss the best choice for the individual patient. With current knowledge that tendinopathy is more likely to be due to degenerative change than to inflamma tion, educating the patient in terms of prognosis becomes im portant. Many treatment options are available for the more common tendinopathies and several seem to have good pain relief in the short term. The patient needs to understand that a minimum of 3 - 6 months m ay be required to resolve their problem and that they have an impo rtant role to play in terms of activity modification ( Gabel 1999). Greenfield & Webster (2002) identified 24 different treatment moda lities, demonstrating that physiothera pists use j udgment largel y based on past experience when
choosing treatment for tennis elbow. Progressive stretch and strengthening were identified as popular treatments, with 67.5% of respondents using deep transverse fric tions and 64.4% using Mills' manipulation (see below). Although not specified in the study, it is assumed that the regime of deep transverse frictions to prepare the ten don, followed by Mills' mani pulation was used, as this is taught in the orthopaedic medicine approach . Many studies have set out to confirm the most effec tive way of treating tennis elbow but definitive evidence remains elusive. Summaries of key studies follow to pro vide a chronological overview of the principal research conducted. Stratford et al ( 1 989) failed to demonstrate statisti cal power in a study comparing deep transverse frictions with phonophoresis, and Vasseljen ( 1 992) demonstrated that 'traditional physiotherapy' consisting of transverse frictions and ultrasound performed better under subjec tive, but not objective, testing when compared with laser treatment. Solveborn et a l ( 1 995) conducted a study of 109 cases of tennis elbow treated with a single corticosteroid injec tion (10 mg triamcinolone) together with local anaes thetic. Bupivacaine (a long-acting local anaesthetic) was compared with lidocaine (lignocaine) (a short-acting l ocal anaesthetic) . An impressive improvement was reported 2 weeks after the i n jection, with the patients treated with bupivacai ne showing a significantly better outcome. However, at 3 mo nths the results in both groups showed deterioration and relapse, with patients seeking ot her treatments. Verhaar et al ( 1 99 6 ) conducted a prospective rand omized trial of10 6 patients with tennis elbow. They com pared the effects of corticosteroid in jections with Cyriax physiotherapy (i.e. deep transverse frictions followed by Mills' manipulation - see below) . Both groups showed signi fi cant improvement at 6 weeks, with the injection group demonstrating better results. However, at I-year follow-up there was no significant difference between the groups, with 1 7 patients in the injection group and 14 patients i n the physiotherapy group going on to eventual surgery. There were no adverse side-effects in either group. The authors reached the conclusion that, although corti costeroid injectio ns alleviate pain in the short term, they do not address the cause of the condition. Since corticos teroid injection is more time-efficient than physiotherapy (three visits m aximum for the injection group; 12 visits for the physiotherapy group), it was considered to be the more effective treatment in the short term. However, as mentioned above, the effect of corticosteroid injecti on on healing at different stages is uncertai n. Assende l ft et al ( 1 996), on reviewing the literature, deter mined that the existing evidence on effectiveness, optimal ti ming of injections, composition of injection fluid and adverse effects of injections is not conclusive, although they ap pear to be safe and effective in the short teon (2-6 weeks). 111 ree injections seem to be the recommended
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maxi mum in several reviews, with post-injection pa in and subcutaneous atrophy being the adverse side-effects. Drechsler et al ( 1 997) compared two treatment regimes, a 'standard' treatme nt group exposed to several interventions i ncludi ng transverse frictions and a neu ral tension group exposed to mobilization of the radial nerve. The results showed no significant difference for any variable tested and the authors then attempted to validate the study through group analysis, incorporating further variables. While admi tting that the study could have been confounded by these additions, they nevertheless con cluded that neural and joint mobilizations together were supe rior to 'standard' treatment techniques. Newcomer et al (2001 ) conducted a randomized con trolled double-bl ind trial on 39 subjects with symptoms present for less than 4 weeks. The experimental group received corticosteroid inject ion and rehabilitation, the control group sham injection and rehabilitation. The authors recorded that there was no significant change in the experimen tal group and that subjects improved over time with the rehabilitation programme. They concluded that injections were not justified in patients who had symptoms for less than 4 weeks and that rehabilitation should be the first l i ne of treatment. Smidt et al (2002b) showed short-term rel ief for cortico steroid i njection, but physiotherapy consisting of ultra sound, deep transverse frictions and exercise was more effective i n the long term, as was advice and pain medica tion from a fam ily practitioner. However, there was no evi dence of standardization of injection ted1nique or of the way the physiotherapy programme was managed ( Hart 2002). Smidt et al (2003) evaluated curre nt evidence of the effectiveness of physiotherapy for tennis elbow, identify ing 23 ra ndomized controlled trials. Little evidence was found to either support or refute the use of physiother apy. Lack of evidence was judged to be due to low statis tical power, inadequate validity and insufficient reported data. There is a need to standardize outcome measures, to increase sample sizes and to include short, medium and long-term follow-up. A few valid studies were identified which suggested the potential effectiveness of some COm monly used treatments. Ultrasound may be better than placebo in allev iating pain; ultrasou nd with transverse frictions may be more effective than laser; and stretching, muscle conditioning and occupational exercises may be better than ultrasound with transverse flictions. Nimgade et al (2005) provided an updated review, concluding that i njections worl( best i n the first 2-3 months of onset and that after 3 months act ive physio therapy is better than i n jection but no better than rest. Physiotherapy was noted as better in the long term if patients are willing to wait for the improvement. A later ra ndomized study by Bisset et al (2006) com pared mobilization with movement and exercise, corticos teroid injection, or wait and see for tennis elbow, noting outcomes at 6 and 52 weeks. Corticosteroid in ject ion
demonstrated better outcomes at 6 weeks but at 52 weeks the physiotherapy approach had superior benefit when compared to the other two groups. Tonks et al (2006) conducted a simila r study, but also i ncluding steroid injection with physiotherapy, and on the basis of their results advocated that steroid injection alone should be given as the first line of treatment for patients demanding a quick return to daily activit ies. In summary, relative rest and time will eventually improve function but the use of early active i n terventions, includi ng steroid i njection and physiotherapy modalities, may speed recovery ( Nimgade et al 2005) . From this discussion the authors ackn owledge that the ev idence to support the use of tra nsverse frictions and Mills' ma nipulation is weak, but i t should also be empha sized that these techniques have not been proven to be ineffective. I t is interesting to note that the earlier studies tended to address inflammatory components rather than the degenerative features of tennis elbow. As studies con ti nue to exami ne the degenerative nature of the lesion, more substa ntial support for treatment may emerge. Davidson et al ( 1 9 97) and Gehlsen et al ( 1998) show some interesting support for the use of augmented soft tissue mobilizations in animal studies. Pressures, similar to those delivered by deep transverse frictions, are applied to promote the heali ng process in tendinopathy, which provides a stimulus for further investigation into t rans verse frictions. The controlled applicat ion o f microtrauma through pressure is thought to promote fibroblastic activity leading to repa i r in the absence of inAam mation (see Ch. 4). Greenfield & Webster (2002) demonstrate the lack of consensus on the best practice for the treatment of tennis elbow, but with well over half of the respo ndents choos ing transverse frictions and Mills' manipulation, positive clin ica l results can be assumed. As mentioned above, Cyriax ( 1 982) and Cyriax & Cyriax ( 1993) describe four possible sites of the lesion: •
•
• •
Teno-osseous junction (en thesis) - mainly extensor carpi radialis brevis Supracondylar ridge - origin of extensor carpi radialis longus Body of the common extensor tendon The muscle bellies.
Tennis el bow at the teno-osseous ju nction Cyriax ( 1 982) and Cyriax & Cyriax (1993) describe the teno-osseous ju nction (enthesis) as the most com mon tennis elbow lesion, suggesting 90% occurrence at this site. As mentioned above, however, this may be an over estimation. Pain is local ized to the common extensor tendon at the teno-osseous junction, mai nly affecting the extensor carpi rad ialis brevis on the anterolateral aspect of the lateral epicondyle of the humerus. The facet for attachment of the common extensor tendon faces ante riorly and is approximately the size of the patient's little
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finger nail. The cho ice o f trea t m e n t may be corticosteroid i n j ection o r M i l ls' m a n i p u l a t i o n . The i nflammatory model o f dHonic tendi no pathy is under debate and the j usti fication for corticosteroid i njec tion is d i fficu l t i n the absence o f i n flammation. Khan & Cook
(2000)
admowledge that c l i nical experience and
some studies show that corticosteroid i n j ecti on produces short-term relief o f pa i n in these lesions, a l though the mech a nisms for this pain relief are currentl y n o t known. Corticosteroid
injecti o n
for tennis el bow at
the
teno
osseous s i te is therefore s ti l l current.ly recom mended as an appropriate treatment. Once rendered pain-free, the patient, t hrough normal movement, will encourage al ignment of fi b res and mobi l i ty o f the scac H owever, i njection should not be considered to be a panacea and a n entire managem e n t programme, i nc l u d i n g activity mod i fication and supports o r braces, should be ad hered to (Gabel
1999).
Figure 6,25 Injection of tennis elbow, teno-osseous site.
Injection o f tennis elbow, teno-osseous site Suggested needle size: 25G x 5/8 in (0.5 x 1 6 mm) orange needle Dose: 1 0 mg triamcinolone acetonide in a total vo l u me of 1 m L
Support the patien t w i t h the forearm resting o n a p i l l ow, the el bow flexed to approxi m a t e l y ( Fig.
6.25 ) .
90°
a nd fu l l y supi nated
I d e n t i fy the area o f tende rness over the teno
osseous j u n ction o f the common exte nsor tendon with the a n terolateral aspect of the lateral epicondyle. I nsert t h e needle from a n a n terior d i rection, perpendicular to the facet, and d e l iver the i n j ection by a peppering technique ( Fig.
6.26).
Figure 6.26 Inje ct io n of tennis elbow, teno-osseous Site, s howing direction of approach and needle positi on
The patient is advised to m a i n t a i n a period o f
rel ative rest for approxi mately
2 weeks fol lowi n g inject i o n .
Corticosteroid i njections do h a v e t he adva n t age i n t h a t t h e y a r e re l atively e a s y a n d q u i c k to a d m i n ister, are ch eap,
He suggested that fo rcing the restdcted movement ( now known as M i l ls' m a n i p u l a t i o n ) could be curati ve.
and speci a l ist referral is not necessary. An a lterna tive trea t m e n t to corticosteroid i n ject ion is to aim to elo ngate t.he sca r tissue by ru p t u r i n g adhes i o n s w i t h i n the teno-osseous junct i o n , t h u s m a k i n g t h e area
I
M i lls' manipulation (cited i n Cyriax 1984, Cyriax & Cyria x 1 993)
m o b i l e a n d p a i n - free. Th is is a c h i eved by a M i l ls' m a n ip u l atio n , wh ich m u s t be fo l l owed by s t retch i n g exercises
The area should first be prepared by transverse fri ctions to
to m a i n ta i n t h e le ngt h e n i n g ach i eved . Before t h e M i l ls'
produce a n a n al gesic effect before applying the tech n i que.
m a n i pu l a t i o n can be performed, the teno-osseous j u nc
Pos i t i o n the patient co m fo rtably with the el bow ful ly
t i o n is prepared by deep transverse fricti ons to prod uce
s u p i n ated a nd i n 90 ° of flexi on; t h is exposes the tendon
an a n algesic e ffect, in p reparation fo r the m a ni p u l a tive
by a ll o w i n g i t to ru n d i rectly fo rward from the a n terior
tec h n ique.
aspect o f t h e epicondyle. Locate the a n tero l a teral aspect
G. Percival M i l ls described t h is technique for the treat ment o f ten n is elbow in the British Medical Journal i n
( 1 9 28).
O n exa m i n ing patients with tennis el bow, h e
o f the l a teral epicondyle a nd i d e n t i fy the area o f tender ness ( Fig.
6.27).
App l y deep tra nsverse frictions w i t h the
side o f the t h u m b t i p, app lying the pressure in a poste
6.28).
found that o n co m b i ned pronation a n d wrist a n d finger
r i o r d i rection o n to the teno-osseous j u nction ( Fig.
flexi o n the elbow j o i n t co u l d not achieve fu l l extension.
M a i n t a i n t h i s pressure w h i le i m parting deep transverse
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Figure 6. 27 Tra nsverse frictions for tennis el bow, teno osseous site.
figure 6.29 M i l ls' man ipulation, starting position
frict ions in a d i rection towards your fingers, which s h o u l d be positioned arou nd t h e postero me d i a l side of the e l bow for cou n t erpressu re. The M i l ls' manipulation is performed i m m ediately after the transverse frictions, providing the patient has a fu l l range of passive elbow extension, demonstrated during the c l i nical exa m ination process . .If the patient does not h ave fu l l passive elbow extension on examination, the manipula tive thrust w i l l affect the elbow j o i n t, rather than the com mon extensor tendon, possibly causing a traumatic arth ritis. Position the patient o n a chair with a back rest. Stand behind the patient: •
Support t h e pat ient's arm u n d er the crook of t h e e l bow w i th t h e s h ou l der j o i n t abducted to 900 and medially rotated . The fo rearm w i ll auto matically fal l
figure 6.28 Transverse frictions for tennis e l bow, teno osseous site, showing site of anterolateral facet on the lateral epicondyle of the h u merus, and the d i rection of ap plication.
i nt o prona t i o n ( Fig. 6 . 2 9 ) . •
Place the t h u m b of your other hand in t h e web space between the p a t i ent's thu m b and i ndex fi nger and
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a
Figure 6.30 (a--c) The thumb placed in the palm, fore arm pronated and wrist mainta ined i n full flexion.
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The e l bow
There s h o u l d be no reproduction of paraesthesiae d u r i ng t he tech n i q ue. This m a noeuvre i s u s u a l l y conducted o n ce o n l y at each t rea t ment session si nce it i s not a co m forta b l e procedure fo r the patient a n d t h e e ffects o f treat m e n t often become fu l l y apparent over the fol lowing few days. Between sessions the p a t i e n t is i nstructed to co n t i nu e stretc h i n g t h e tendon t o ma i n t a i n l e ngth a n d m o b i l i ty. A l though
m o re
research
is
required,
a
review
by
Stas i nopou los et al ( 2005 ) noted that a co m b i na t i o n o f eccentric strengthen i ng a n d stretc h i n g exercises achieved better res u l ts overa l l . The stretch ing exercises i ncluded t h e com ponen ts o f el bow eX1ension w i t h wrist flexi o n a n d u l na r dev i a t i o n . They a l s o com pared the o u tcomes from a home exercise or a supervised exercise progra m m e a nd, a l t hough the results were i nco n c l usive, t hey were a ble to suggest that overa l l a supervised exercise progra m m e achieved better results, i n co m b i n a t i o n w i t h the eccentric strengt hen i ng and stretch i ng exercises m e n t ioned above.
The resistant tennis el bow The short -term rel ie f ga i ned fro m e i t h e r i njection o r phys i o t herapy is a n i n d i cation t h a t the causative factors and ideal trea t m e n t for t e n n i s e l bow st i l l elude us. From c l i n ical experience, and w i t h some support fro m the d is cuss i o n above, i n j ection or physiotherapy seem to work wel l fo r u ncompl icated tennis elbow of recent onset. The c h ro n i c nature of t h e con d i t ion, however, means that most of us d o n o t see patients until t h e con d i t i o n is wel l estab l ished. The d i sappoi n t i ng results a n d recurrence o f sym ptoms i n d icate t h a t there m a y be o n e o r m o re com ponents i nvolved i n t e n n i s elbow. The gra d u a l o n set of t e n n i s el bow means t h a t prob l e m s Figure 6.31 Positioning of ha n d on poste rior aspect of extended elbow for application of the Grade C manipulation
c a n coexist w i t h i n t h e e l bow j o i n t a n d surro u n d i ng neural structures. Pa i n may restrict t h e range o f active move m e n t and t h e re lat ive i m m ob i l iza t i o n may produce a n associ ated capsu l a r pattern in t h e elbow j o i n t . S i m i l a r l y, dys fu nct i o n a t one s i t e can cause dysfunction a t o t h e rs and
•
fu l l y flex the patient's wTist and pronate the forearm
adverse neural tension can be a pri m a ry cause o r associ
(Fig. 6.30 a-c) .
ated cause of t e n n i s el bow (Yaxley & l u l l 1 99 3 ) . A cervical
Move the h a n d support i n g the crook of the e l bow
lesion ca n refer p a i n i n t o the fo rearm and m i m i c t e n n i s
onto the posterior su rface of the el bow j o i n t and,
el bow, or cervical syndromes can coexist w i t h a lesion a t
w h i l e m a i n t a i n i n g full wrist flexi o n and pronation,
t h e elbow.
extend the patient's e l bow u nti l you fee l all the slack h as been taken up in t h e tendon. •
•
The degenerat ive co m p o n e n t o f t e n n i s el bow is bel ieved to respond to a c o m b i n a t i o n of eccen tric strengt h e n i n g
Step sideways to stand behind the patient's head,
a n d stretch i ng exercises. As w i t h o t h e r tendi nopath ies,
taki ng care to prevent the patient from l ea n i ng
Stas i n o po u los et al
away either fo n"ards or s ideways, w h ich would reduce
t ra i n i ng progra m m e fo r 1 2 weeks and perseverance w i t h
( 2005 ) co nducted
their ecce n tric
the tension on the tendon ( Fig. 6.31 ) . Straighten yo u r
the
a r m i f possible b u t b e careful n o t t o lose t he wrist
to resolve t h e co n d i ti o n . The exercises should o n ly be
flexion.
stopped if the pa i n is very d isab l i ng and the gu idel i n e fo r
progra m m e s h o u l d
be expected
and
encou raged
Apply a m i n i m a l a m p l itude, h igh velocity thru s t
the treatment of tendi n o pathy can be offered that pat ients
( G rade C m a n i p u l a t i o n ) by s i m u l taneously s ide
s h o u l d work up to a level of pa i n that can be measured
flex i ng yo u r body away fro m your arms and p u s h i n g
on the visual a n a l ogue scale as 3 - 5 ( Ba h r et al 2006,
smartly downwards w i t h t h e hand over t h e pati ent's
Cook 4th I nterna t i o n a l Evidence-Based Physical Therapy
el bow.
Co n ference note 2008 ) .
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N e rve entrapment a t the e l bow may be a compl ica
1 994,
1 995) .
pad of your t h u m b aga i nst the lower third of the l a t
The rad i a l
eral supracondylar ridge ( Fig. 6 . 3 2 ) . D i rect the pressure
nerve d i vides i n to i t s term i n a l branches a t the el bow a n d
b ack aga i nst the ridge a n d i mpart the transverse fric
tion ( N o teboom et al
H artley
t h e posterior i n terosseous nerve passes between the deep
tions
and superfi c i a l head of s u p i nator. The upper edge o f the
advised
superfici a l head of s u p i n a to r is a t h ickened fi b rous b a n d
b u t no overuse or stretch i n g u n t i l p a i n - free on res isted
fo rm i ng a firm a r c h k n o w n as the arcade o f Frohse, w h i d)
testing.
in
a superior i n ferior d i rect i o n . where
functional
move m en ts
Re l a t ive rest is may
co n t i n ue,
provides a poss i b l e s i te for nerve entra p me n t . T h e musculotend i n ous, neura l , neurological a n d a rtiClI l a r c o m p o n e n ts s hould be assessed i n t h e resista n t t e n n i s el bow, a l t h ough t here i s l i ttle evidence i n the l i terature to co n fi rm that a d d ressi n g all poss i b l e components gives a ny better resu l ts . S o m e cases of t e n n i s el bow come to su rgery, i n vo l v i n g tenotomy of the extensor tendons a t
Transverse frictions to the body of the common extensor tendon (Cyriax 1984. Cyriax & Cyriax 1 993)
t h e l a te r a l epicondyle. Th is variety o f t e n n is e lbow is less co m m o n . The area
Transverse frictions to the origi n o f extensor carpi rad i a l is longus from the supracondylar ridge (Cyriax 1984. Cyriax & Cyriax 1993)
of tenderness is located in the region o f the radial head. I nj ection o f t h e tend o n i s c o n t roversial a n d t reatment is pre fera b l y by transverse fri c t i ons. Pos i t i o n the pat ient with the e l b ow suppo rted i n
6 . 3 3 ) . Locate the body of the tendon over the rad i a l head. I m part d eep t ra n sverse fri ctions across t h e fibres for
10 m i n Tra nsverse frictions a re the recom mended trea tment at
90 °
o f flexio n a n d t h e fo reann suppo rted i n pro n a t i o n ( Fig.
after some a n a l.gesia has taken effect . Relat ive rest
is advised where fu nctional movements may co n t i n ue,
this site. Posi t i o n the p a t i e n t w i t h the e l b ow su pported
b u t no overuse or st retch i ng u n t i l p a i n - free o n resisted
in 90° of flexi o n . Sit fac i n g the patient and p lace t h e
testi ng.
Figure 632 Transverse frictions f o r tennis e lbow
F igure 6. 33 Transverse frictions for te n n i s e lbow, body of the tendon.
,
supracondylar ridge.
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of t h rowing m a y c a u s e gol fer's e l bow as i t produces a
Transverse frictions to the muscle bel lies (Cyriax 1984, Cyriax & Cyriax 1993)
valgus stress at t h e el bow w h i ch has to be supported by t h e flexor m uscles ( Ho 1 9 9 5 ) . O n exa m i n a t i o n , p a i n o n resisted wrist flexio n w i th t h e elbow extended reproduces the patient's pa i n .
The lesion is i n the bell ies o f t h e common extensor muscles lyi ng deep to the brach i o rad ial is. Th is tends to present as a n acute les i o n fo l l owi ng u naccustomed activ ity b u t p a i n may a l so refer i n to the a rea from an acute l es i o n at the co m m o n extensor orig i n . Trea t m e n t with tran sverse fricLions is usual ly successful a n d the lesion set t l es quickly. Posi t i o n the patient w i t h t h e forearm supported w i t h the e l b ow flexed to 9 0 0 a nd t h e fo rearm i n the m i d-pos i tion (Fig. 6 . 3 4 ) . Palpate for the s i te o f the lesion d e e p t o b ra c h i o rad i a l is. G rasp t h e a ffected m uscle fi b res between a fi nger and t h u m b J nd i m part the transverse frictions by a p i nch i ng pressure appl ied up and down in a superior i n ferior d i rect i o n . Relative rest is advised where fu nctional movements may conti nue, but no overuse o r stretc h i n g u n t i l p a i n - free o n resisted testi ng.
The tendons i nvolved i n golfer's e l bow contro l move m e n t at two j o i nts and are susce p t i b l e to overuse t h rough overl oad. S t retchi ng, valgus fo rces a n d i n t rinsic forces fro m muscle co ntrac t i o n a l l contribute to the co n d i t i o n (Safran
1 9 9 5 ) . I n t h e degenera t i ve process o f golfer's
e l bow tendi nosis is evident ra ther tha n the acute i n fl a m m atory cha nges o f tendi nopathy ( Be n n ett 1 9 9 4 , Patten 1995). Go l fer's e l b ow, genera l l y speaking, is a less co m p l i cated co n d i t i o n to treat than t e n n i s elbow, but coexiste n t u l n a r neuritis (cubital t u n n e l syndrome) m a y produce med i a l e l b ow p a i n w i t h tende rness a n d paraesthesia i n t h e d is tri b u t i o n of the u l n a r n e rve ( Kurvers & Verhaar 1 9 9 5 , O' Dlvye r & H o w i e 1 9 9 5 )
.
Some cases of go l fer's el bow
come to surgery, i nvol v i n g i ncision of the flexor tendons a round the m e d i a l epicondyle, denervat i o n o f the epi co ndyle and transposition of the ul nar nerve. There a re rwo s i tes fo r the lesion: teno-osseous s i te a n d muscu l otend i nous s ite.
Treatment of golfer's elbow The co m m o n flexor tendon takes o r i g i n fro m the anterior aspect o f the med ial epicondyle. Pa l p a t i o n will i d e n t i fy the site o f t h e les i o n . Trea t m e n t m a y be by ei ther cortico stero i d i n jection o r transverse fricti ons.
Teno-osseous site (enthesis)
Injection of golfer's elbow, teno-osseous site (Cyriax 1 984. Cyriax & Cyriax 1 993) Figure 6.34 Transverse frictions for tennis elbow. muscle bellies.
Golfer's elbow
Suggested needle s i z e : 25G x 5 / 8 in (0. 5 x 1 6 m m ) o r a n g e needle or 2 3 G x 1 i n (0 6 x 25 mm) blue needle Dose: 10 mg triamcinolone aceton ide i n a total volume of 1 mL
Al though not as c o m m o n as tennis elbow, go l fer's elbow has a s i m i l a r presentation, aetiol ogy, d i sease p rocess a n d m a nagement.
Pos i t i o n the patient with the elbow supported i n exten
The patient presents with a gradual onset o f p a i n on
sion a nd fu l l y su p i n ated. Locate the anterior aspect of
the medial aspect o f t h e a r m . This may radiate d istal ly,
the m e d i a l epicondyle and i d e n t i fy the a rea of tender
b u t i n general i t does not project as fa r a s the p a i n seen i n
ness ( Fig. 6 . 3 5 ) . I nsert the need le perpend icu l a r to t h e
tennis el bow. The pa i n i s aggravated b y use and the el bow
facet and del iver the i nject i o n b y a p e p p e r i n g tec h n i que
is often s t i ff after rest. Onset of sym ptoms may be asso
( Fig. 6 . 3 6 ) . Bear in m i n d the pos i t i o n o f the u l n a r nerve
ciated with occu pa t i o na l overuse, sport i ng activi ties (e.g.
b e h i n d the medial epico ndyle. The patient is advised to
te n n is, bowl i ng, archery) or h o b bies (e.g. k n i t t i ng, need le
m a i n ta i n a period o f re l a t ive rest for approxim ately 2
work) ( Rayan 1 9 9 2 , Ku rvers & Ve rhaar 1 9 9 5 ) . The m o t i o n
weeks fol l ow i n g i n ject i o n .
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Figure 6.37 Transverse frictions for golfer's el bow. teno osseous site.
Fig ure 6.35 Injection of golfer's elbow, teno-osseous site.
Figure 6.38 Transverse frictions for golfer's elbow. teno osseo us site. to g i ve an indication of the direction of a p p l ication
Muscu lotend inous site Figure 6.36 Injection of golfer's el bow. teno-osseous site. showing direction of a p p roach and needle position.
Transverse frictions for golfer's el bow, teno-osseous site (Cyri ax 1 984, Cyriax & Cyriax 1 993)
Transverse frictions for golfer's el bow, muscu lotendi nous site Transverse fri ctions are co nsidered to be the most effec tive treatment here (Cyriax 1 9 84, Cyriax & Cy r i ax 1 9 9 3 ) . Pos i t i o n yo u rse l f a n d t h e pa t i en t a s above arid, using t he index finger, move I cm d i s t a l l y to pa l pate t he mus culotendinous j u n ction a t t he i n fe r i o r edge o f the me d i a l
Position the pa t i en t i n supine lyi ng with t h e el bow sup
e p i con dyle ( Fi g. 6 . 3 9 ) . M a i n t a i n t h e pressure aga i n st the
ported i n extension and locate the area of tende rness on
bone and i m part the frictions lfansversely across the fibres
the anterior aspect of the med i a l epico n dyl e ( Fig. 6 . 3 7).
fo r lO m i n after t he analges i c effe ct has been ach i eved.
Using an i ndex finge r rei n forced by t he m iddle fi nger, a nd
Relative rest is advised where funct i o n a l movements may
th u m b fo r co u n terpressu re, i m p art t h e tran sverse frict ions
co n t i n ue. b u t no overuse or stretch i n g u n ti l pa i n -free on
by applying t he pressure down o n to the anterior aspect
resisted test i ng.
and sweepi n g t ran sve rsely across the fibres ( Fig. 6 . 3 8 ) . Te n
An alternat ive pos i t i o n may be used fo r t h e appl i cation
m i n u tes' deep transverse frict i o n s a re del ivered after the
of tran sverse frictions to b o t h si tes. The pa t i e n t is seated
ana lgesic e ffect has been achieved. Relative rest is advised
on the trea t m ent couch with the s ho u l de r in lateral rota
where fu nctional move m e n ts may contin ue, but n o over
t i on, t he elbow extended and the fo rea rm fully s u p i nated .
use or s t retch i n g u n t i l p a i n -free on resisted test i ng.
The c l i n i c i a n stands alo ngside and fa cing t he patient to
1 48
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Chapter
I 6 I
The elbow
Figure 6.39
Transverse frictions for golfer's elbow, musculotendinous junction. Figure 6.42
Injection of biceps insertion at the radial
tuberosi ty.
Figure 6.40
Transverse frictions for golfer's elbow, teno-osseous site (alternative position).
and resisted supination of the flexed elbow. Passive stretching into elbow extension can also cause pain. Excessive friction may cause inflammation of the sub tendinous biceps bursa and differential diagnosis from b icipital tendinopathy may be difficult. A muddled pres entation of signs is found, con firming the diagnosis of bursitis. Pain may be reproduced on resisted elbow flex ion, passive elbow extension and passive elbow prona tion, as the bursa is squeezed aga inst its i nsertion. An injection of corticosteroid is the treatment of choice for the i nsertion of biceps, si nce the tendon of insertion lies deeply.
-
Injection of the insertion of biceps at the radial tuberosity (Cyriax
1984,
Cyriax & Cyriax
1 993)
Suggested needle size: 23G x 1 in (0.6 x 25 mm) b lue needle Dose: 1 0 mg triamcinolone acetonide in a total volume of 1 mL
Figure 6.41 Transverse frictions for golfer's elbow, musculotendinous junction (Alternative position).
support the elbow in extension. Using the other hand, transverse frictions can then be applied transversely across the fibres at each site (Figs 6.4 0 and 6.41).
Biceps At the elbow, the lesion lies either in the muscle belJy or at the insertion onto the radial tuberosity. The patient complains of pain at the elbow on resisted elbow flexion
Position the patient in prone lying in the anatomical posi tion. Without changi ng the position of the glenohumeral joint, care fu l ly pronate the extended forearm keepi ng your thumb in contact with the radial head to confirm your position. Insert the needle between the radius and ulna approximately 2 cm d istal to the radiohumeral joint line until the resistance of the tendon i nsertion is felt ( fig. 6.4 2 ) . Deliver the injection by a peppering tech nique to the tendon and adjacent area if the bursa is also involved (Fig. 6.4 3 ) . The patient is advised to maintain a period of relative rest for approxim ately 2 weel(s follow ing injection.
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149
I 2 I
Lateral
Practice of orthopaedic medicine
-------
Figure 6.43 I nj ecti o n of biceps i nsertion at the radial
tuberos ity, showin g direction of a pproach and needle position
Figure 6.44 Transverse frictions to the insertion of biceps at the radial tuberosity. around the fo rearm to p rovide counterpressure. Del iver the transverse frictions by a l ternately rot a t i ng the patient's forearm be tween pronation and supi nati o n w h i l e main t a i n i ng the pressure against the rad i al tuberosi ty. I f the l es i o n lies i n the muscle bel ly, the general pri nci
Transverse frictions to the insertion of biceps at the radial tuberosity (Cyriax 1 984, Cyriax & Cyriax 1 993)
ples o f trea t m e n t can b e a p p l ied (see eh .
4).
Triceps D ista l ru p t u re of t h e triceps tendon due to forced over
Pos i t i o n t h e patient w ith t he el bow j o i n t flexed to
90°
l oa d i nt o ext e n s i o n i s uncom m o n . A triceps muscle lesion
a nd s u p i n a te d . With yo u r t h u m b, locate the i nsertion of
is a l s o ra re, but would present w i t h posterior el bow pain,
b iceps a t the ra d i al tuberosity and apply pressure aga i nst
i ncreased by resisted el bow exte n s i o n . The general princi
i t , deeply and l a teral l y ( Fig. 6 . 4 4 ) . Wrap your fingers
p les of treatment can be applied.
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Osteopa t h . Assoc. 9 3 , 7 7 8 - 7 8 8 . S m i d t, N , van d e r Wi n d t, D A , Asse n d e l ft, W.), e t a l , 2 0 0 2 a . I n terobserver reprod uci b i l i ty o f t h e assess m e n t o f severity o f co m p l a i n ts, grip strength and pressure pa i n t h reshold i n p a t i e n ts w i t h l a teral
M i l ls, G . P., 1 9 2 8 . Tre a t m e n t o f ten n is
e l bow Orthop. C l i n . N . A11 1 . 3 0
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7 The wrist and hand
CHAPTER CONTENTS Summary Anatomy Inert structures Contract i l e structures
Guide to surface marking and palpation
Extensor carpi radialis longus a n d brevis
153
tendi nopathy
177
1 53
Flexor c a r p i u l naris tendin opathy
1 78
154
Interosseous muscle lesions
1 78
156
Palmar aspect
156 1 57
Lateral aspect
1 57 158
Observation
1 58
History (subjective examination)
158
Inspection
1 59
Pal pation
1 59
State at rest
1 60
Examination by selective tension (objective examination)
Capsular lesions
1 60 164
Inferior (distal) radioulnar joint
1 64
Wrist Joint
1 65
Trapeziofi rst-meta carpal joint
166
Finger joints
Non-capsular lesions
Collateral ligaments at the wrist joint
170
Carpal tunnel synd rome
171
Fibrocartilage tears a n d meniscal lesions
173
Trigger finger or thumb
173
©2010 Eis
vier
This chapter takes a pragmatic approach to the identification of specific lesions and suggests localized treatment, which may form a component of overall management. The detailed but relevant anatomy that forms a basis for accurate treatment is presented. Treatment for individual lesions is discussed, with emphasis on the application of principles to less commonly encountered lesions.
167 168
De Quervain's tenosynovitis
Repetitive strain injury and work-related upper limb disorder have done much to focus the clinician on the differential diagnosis and causative factors of pain in the wrist and hand.
168
Subluxed carpal bone
Contractile lesions
176 1 76
153
Dorsal aspect
Comm entary on the examination
Intersection syndrome or oarsman's wrist Extensor carpi u l na ris tendi nopathy
ANATOMY Inert structures The
distal radioulnar joint
is a pivot
j o int between
174
the head of the ulna and the ulnar
174
Mechanically linked to the superior radioulnar joint, it is
Ltd
Copyrighted Material
n o tch
of the radius.
153
I
2
I
Pra c t ice of onhopaedic medicine
responsible for the movements of pronation (85 ) and supination (90°). A triangular fibrocartilaginous articular disc closes the d istal radioulnar joi n t i nferiorly and is the m a i n str uc t u re u n i ti n g the rad i us and ulna (Pal astanga et al 2006). It l ies in a horizontal plane, i ts apex attac h i ng to the u l n a r styloid and i ts base to the lower edge of the u l n a r n o t c h o f the radius. T h e d isc art iculates w i t h the l u nate when the hand is in u l nar deviation. It adds to tbe sta b i l ity of the joint and acts as an articular cus h io n for the u l n ar side of the carpus, absorbing compress ion, trac t ion and shearing forces but bei ng p rone to degenerative changes (Livengood 1992, Rettig 1994, Wright et al 1994, Steinberg & P l a ncher J 995). The movements of pronation and supination rotate the rad i us around the ulna. Supination is stronger, hence the thread of nuts and screws which are tigh tened by supina tion i n right-handed people. There are two rows of carpal bones; o n t he palmar aspec!' from the rad i a l to the u lnar side t hey a re: 0
scaphoid, lunate, triquetraI, pisiform trapezium, uapewid, capiUlte, hamate.
The carpal bones a l l a rt iculate w i t h their neighbours, except p is ifolm, which is a separate bone s i tuated on the f ro n t of the triquetra l . The i n tercarpa l joints are a l l sup poned by i n tercarpal ligaments. The wrist joint proper is a b i axial, e l l ipsoid joint between the d istal end of the radius and the articular d isc, and the p roximal row of carpal bones. However, the so-called wrist joi n t complex i n c ludes the midcarpal joint and has mobil i ty as wel l as stability, which is i mport a n t f o r the fu nc tion o f the hand. Movements are extension (passive, 85°), flexion (passive, 85°), u l nar deviation (passi ve, 45°) and rad i a l deviation (passive, 15°). The c l ose packed pos i t i o n of the wrist joint is fu l l extension. The j o i n ts are surrounded by a fibrous capsule, l ined w i t h synovial m e m bra ne and reinforced by col l ateral l iga m ents. Both c o l l a teral ligam ents pass from the appropr i ate styl oid process to the carpal bones on the med ia l and l ateral side of the carpus. A fi brocart i l agi nous meniscus projects into the j oi n t from the ulnar co l l ateral l igament. The metacarpophalangeal joints are e l l ipsoid; t h e inter phalangeal joints are h inge joints. Both are supported by pal mar and col l a teral l igam e n ts and t h e extensor ten dons and d igi tal expans ions support the dorsal surfaces of the joi nts. Flexor tendons are contained w i t h i n fibrous s heaths w h ic h have thickened areas known as p u l l eys which may provide a restr iCtion, p roducing 'trigger finger' (see p. 175). At the wrist and i n the hand, the tendons are con t a i ned w it h i n synovi a l sheaths (Stand ring 2009). The flexor retinacull.lm, a strong fibrous band, creates a fi b ro-osseous passage, the carpal tunnel, t h rough w h i ch pass the f lexor tendons of the digits, the med i a n nnve and vessels. The flexor reti n aculum has four p o i n ts of
attac h m e n t: the p is iform and hook of hamate med i a l ly and the tuberosity of t he scaphoid and ridge of trapezium l atera l ly. I ts attach ment onto the trapez i u m splits to form a separate compart ment for the tendon of flexor carpi radi a l is. The median nenJe e nters the carpal tunnel deep to pa l m a ris longus. It shares i ts compartment of the carpal tun nel with n i n e tendons comprising the four tendons of flexor d igitorum superfic ialis and the four tendons of f lexor d igitorum profundus, and flexor poll icis l ongus. On leaving the carpal tunnel it supp l ies the thenar mus c les before d i viding into four or five d igital branches. The trapeziofirst-meLacarpal joint (first carpomeUicarpal joint) is a sadd l e jo i n t w i t h a loose articular capsul e and extensive joint surfaces givi ng i t a wide range of move ment. The first metacarpal has been rotated med i a l ly for the movement of opposi t ion. Flexion and extensi o n occur in a p l ane para l l el to the p a l m of the hand, while abduct ion and adduction occur in a p lane at right angles to the palm of the hand (Fig. 7.1 a-d). The close packed position of t he t rapeziofirst-metacarpal joint is strong oppos ition, when great force is transmi tted to the joi n t . The fu nctionally opposed t h u m b is subjected to compressive stresses w h i ch make the joi nt vulnerable to degenerat ive osteoarthrosis. The radial artery passes under abductor pollicis lon gus and extensor pol l i cis brevis, crossing the snuffbox obl iquely towards the first dorsal interosseous muscle. Its pos i ti o n should be acknowledged so that it can be avoided when i njeC t ing the t rapeziofirst- metacarp a l joint.
Contracti l e structures (med i a n nerve CG-C7) is the most lateral superfic ial flexor tendon. It passes through its own fibro-osseous compartment on the lateral side or the car pal tunnel, to i nsert i n to the base of the second and t h i rd metacarpals. Palmaris longus ( median nerve C7-CS) passes over, not under, the flexor reti nacu l u m, to attach to the d istal part of the flexor retinaculum and the p a l m a r aponeurosis. Flexor digitorulII superficialis ( median nelve C7 -CS, TI) lies medial to pal maris l ongus, but is not as visible because i t l ies on a sl igh t ly deeper p l a ne. In the carpal tun nel the four tendons are contai ned w i t h in the same synovi a l s heath, with tendons to the t h i rd and fOllrth fin gers ly ing superficial to those to the second and fifth. The tendons d ivide to provide a passage for flexor digitorum p rof u ndus, before cont i n u i ng on to i nsert either sid� of the m iddle phala nx. Flexor carpi uillaris ( u l nar nelve C7-C8) is the most med i a l s uperficial f lexor tendon a nd can be easily traced onto i ts i nsert ion i nto pisiform. The tendon sends sl ips onwards as the pisohamate and p isofif th-metacarpal l igaments. The pisoh a m a te ligament converts t he space Flexor cm-pi radialis
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c
Figure 7.1 Movements of the metacarpophalangeal joint of the thumb: (a) flexion; (b) extension; (c) abduction; (d) adduction.
between pisiform and the hamate into a tunnel (tunnel of Guyon) for the passage of the ulnar vessels and nerves. Flexor pol/icis longus (median nerve C8, T 1) passes through the lateral side of the carpal tunnel and inserts into the pal Illar aspect of the base of the distal phalanx of the thumb. Flexor digitorum profundus (medial part supplied by the ulnar nerve; lateral part supplied by the median nerve C8, Tll divides into four tendons which lie deep to flexor digitorum superficialis in the carpal tunnel. They pass through tunnels created by superficialis and attach to the distal phalanx of each finger. The lumbricals are four small muscles which arise from the flexor digitorum profundus tendons and pass to the radial side of the dorsal digital expansions of each finger. With attachments that link flexor and extensor tendons, they function by fiexing the metacarpophalangeal joints and extending the interphalangeal joints. The first two lumbricals are supplied by the median nerve, the third and fourth by the ulnar nerve, C8, Tl. ExteTlsor carpi radialis longus (radial nerve C6-C7) and extensor carpi milialis brevis (posterior interosseous nerve C7-C8) pass deep to the tendons of abductor pollicis longus and extensor pollicis brevis, under the extensor retinaculum, to attach to the radial side of the base of the second and third metacarpals respectively.
£1:tensor digitontm (posterior interosseous nerve C7-C8) divides into four tendons which pass under the extensor retinaculum to insert into the dorsal digital expansions of the fingers. Extensor digiti minimi (posterior interosseous nerve C7-C8) inserts into the dorsal digital expansion of the little finger. Extensor carpi 1Iinaris (posterior interosseous nerve C7-C8) lies in a groove between the head of the ulna and the styloid process, under the extensor retinacu lum. It attaches to the medial side of the base of the fifth metacarpal. Abductor pollicis longus and exte1lsor pol/ids brevis (pos terior interosseous nerve C7-C8) become tendinous and superficial in the lower foream) where they cross the tendons of extensor carpi radialis longus and brevis at the intersection point. a site of potential friction. They occupy the same synovial sheath in the first compart ment of the extensor retinaculum and form the lateral border of the anatomical snuffbox. The abductor inserts into the base of the first metacarpal and the extensor into the base of the proximal phalanx. Because of its position, abductor pollicis longus has been considered both ana tomically and functionally a radial deviator of the wrist (Elliott 1 992a).
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Extensor pollicis tong liS (posterior interosseous nerve
the position of the wrist joint line, while the proximal
C7-C8) deviates around the ulnar side of the dorsal
crease (if present) marks the proximal extent of the flexor
tuberde of the radius, to pass to the base of the distal
tendon sheaths.
phalanx of the thumb. It forms the medial border of the
Consider the position of the bones which make up the two rows of carpal bones (Fig. 7.3). From the radial to the
anatomical snuffbox.
Extensor indicis (posterior interosseous nerve C7-C8) joins the ulnar side of the extensor digitorum tendon, passing to the index finger.
ulnar side, an easy way to remember the order is: simply learn the parts
triquetra!, pisiform
Tile dorsal interossei (ulnar nerve C8, Tl) are four bipennate muscles arising from adjacent sides of the
scaphoid, lunate,
trapezium, trapezoid,
that the ca rpus has
capitate, hamate
metacarpal bones and inserting into the dorsal digital expansion and base of the proximal phalanx of the appro priate finger. They are responsible for abducting the fin
----+----
gers from the midline of the middle finger. The palmar interossei (ulnar nerve C8, Tl) are four
Ulnar artery
smaller muscles originating from the palmar aspect of the metacarpal bones and inserting into the dorsal digital expansions of the appropriate finger. They are responsible for adducting the fingers towards the middle finger.
Ulna
Ulnar nerve Flexor carpi ---+-+-'f+ radius Median nerve -H--l#-H-+Ii
GUIDE TO SURFACE MARKING AND PALPATION
Tubercle of
I/,>"-
scaphoid
ligament
Ridge of trapezium
Pa lmar aspect (Fig. 7.2)
Pisometacarpal
First---/
Look for three creases (not distinct in evelyone) on the
ligament
metacarpal
Hook of hamale
palmar aspect of the lower foreaml. The distal wrist crease
Fifth
joins pisiform and the tubercle of the scaphoid, the bones
metacarpal
at the heel of the hand (Backhouse & Hutchings 1990), marking the proximal border of the flexor retinaculum. The middle crease joins the two styloid processes, marking
Pis iform
F i gure 7.2 Palmar aspect of the wrist showing positIOn of the flexor retinaculum, Its adjacent tendons and nerves.
Lunate
Triquetral
Capitate
Pi siform Hamate
Common carpometacarpal joint
�Y=�r::::=\\-.------::::"...--
Interosseous ligament Inter metacarpal ligaments
Figure 7.3 Bones of the hand. From Anatomy and Human Movement by Palastanga N, Fi eld D and Soames R 2006. Reprinted by permission of ElseVier Ltd .
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Palpate the rad ial and ulnar styloid processes at the wrist; the radial styloid extends slightly more distally than the ulnar styloid. Palpate pisiform, the pea-shaped sesamoid bone, which lies at the base of the hypothenar eminence, giving inser tion to flexor carpi ulnaris. Move a thumb approximately 1.5cm distally and diago nally from pisiform, in the diredion of tlle index finger. Lying
Ulna Inferior
Radius
joint line
Lister's tubercle
Capitate
Extensor policis
roughly in line wim me ring finger is me hooh of hattUlte. Palpate deeply and tenderness will confinn its presence.
longus
Extensor
Radially deviate the wrist to make the tuberosity of the scaphoid more prominent. (t lies at me base of the thenar
Extensor carpi radialis brevis
Third
eminence, close to the tendon of flexor carpi radialis. Move
Extensor carpi
a thumb from the tuberosity of the scaphoid, diagonally
radialis longus
and distally approximately 1 cm, to lie in line with the index finger, and feel the ridge of the trapeziuTII through the bulk of the thenar eminence. It is best felt with the wrist joint in extension and is tender to deep palpation. Joining the four points described above - pisiform, hook of hamate, tuberosity of scaphoid and ridge of tra pezium - gives the position of the flexor retinaCIIlum, which is approximately the size of your lhumb when placed horizontally across the proximal palm (Fig.
7.2).
Identify the superficial forearm flexor tendons as they cross tlle palmar aspect of the wrist from the radial to ulnar side. Flexor carpi radialis is the most lateral tendon.
Palmaris 101l8us passes over lhe flexor retinaculum and can be brought into prominence by opposing me thumb and little finger with the wrist flexed. Flexor digilOrum superficilllis, lying in a deeper plane, may not be readily
palpable, but flexor carpi ulnaris can be followed down to its insertion onto the pisiform. Palpate for tlle milial puLse on tll€ palmar aspect of the lower radius lateral to flexor carpi radialis. 'lbe ulrwf puLse can be palpated on me lower ulna, lateral to flexor carpi ulnaris. Consider the position of tlle Illedum nelve as it enters me carpal tunnel deep to palmaris longus. If palmaris longus is absent. oppose tlle mumb and little finger and me midline crease produced gives me position of the median nerve.
Figure 7.4 Dorsal aspect of the wrist. it can be traced to its insertion inlO the base of the distal phalanx of the mumb. The capitate is the largest carpal bone and is roughly the size of the patient's thumb nail. It is wider dorsally and is roughly peg-shaped. It is situaled in the centre of the carpus, articulating mainly wim tlle third metacarpal dis tally, tlle trapezoid laterally, t.he concavity formed by me scaphoid and lunate prox.imally (Steinberg & Plancher
1995,
Standring
2009). To locate the
position of me capitate, run your finger proximally down the shaft of the third metacarpal with the wrist in slight flexion and drop over me end into me shallow depression. Place the wrist in flexion with the thumb relaxed to allow the tendon of extensor pollicis longus to fall out of the way and lO expose the base of the metacarpals. Now palpate the insertions of extellSor carpi radialis longus and brevis onto the radial side of the base of the second and
third metacarpals respectively. The extensO( carpi radialis brevis is probably me easier of the two to feel. Palpate the insertion of extensor carpi ulnaris onto the medial side of the base of the fifth metacarpal.
Lateral aspect (Fig. 7.5)
Dorsal aspect (Fig. 7.4) Pronate the forearm and the head of the ulna can be seen
Pronate the forearm and make a fist. The fleshy eleva
as a rounded elevation in the distal forearm. Palpate to
tion seen at the distal end of the radius is formed by the
the ulnar side of the head and feel the tendon of exlellSor
musculotendinous junctions of abductor pol/icis 10llgllS
carpi ulnaris in the groove between the head of the ulna
and extel1sor pol/icis brevis as they wind around the lower
and the styloid process.
radius, crossing over lhe tendons of extensor carpi radialis
Palpate the illferior radioulnar joilll line, which lies approximately 1.5cm laterally from the ulnar styloid. Confirm its presence by passively gliding the head of the
longus and brevis at the intersection point. Locate
the
arlUwmical
snuffbox
thumb) which is bordered by the tendons of abductor pollicis longus and extensor po\licis brevis laterally and
ulna on the radius and feeling the joint line. On the lower end of the radius, palpate the dorsal
by extensor pollicis longus mediall}'. Palpate the radial
tubercle (of Lister) lying roughly in line with the index
styloid at the proximal end of the anatomical snuffbox
finger. The tubercle is grooved on either side by the pass
and the trapeziofirst-metacarpal joint at the distal end.
ing tendons. ExWIlSOT carpi radialis longus and brevis pass
Locate the tendons of abductor po\licis longus and
on its lateral side, while extePlSOT pol/icis 10l1glls passes on
extensor pollicis brevis; sometimes a V-shaped gap may
its medial side before taking a 450 turn laterally, where
be appreciated belween the two.
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to serious abnormalities or injuries. The painful hand may be held in an antalgic position, resting with the fingers par allel to each other and in a degree of flexion, the thumb in a neuu'al position Possibly, the ann swing may be absent from the gait pattern and the hand held stiffly against the
-\------ Radius
side or across the body. Difficulty with fine movement may be observed during undressing, indicating a problem with dexterity.
Extensor carpi----\--\r+ radiali s brevis Extensor carpi radialis longus
----"
1<-''11:
4'''<---- Abductor pollicis longus ��.---Extensor poliici s brevis
History (subjective examination) The age, occupation, sports, hobbies lind lifestyle of the patient may give an indication of the cause and a possi ble diagnosis, since most problems in the lower forearm involve arthritis, trauma or overuse. Mobile phone tex
Trapezio-first -----\��*=:4 metacarpal joint
ting and the use of hand-held gaming devices have joined the more traditional causative factors of overuse of scis
Extensor pollicis ----+--+-_+><_ longus
sors and keyboard, etc. The specific activities required in an occupation should be explored to expose the precise movements required of the upper limb, often repetitively for several hours a day. Racquet sports, golf, hockey, etc. can all give rise to symptoms in the wrist and hand result ing from the impact forces and positioning of the upper limb. The site of pain is usually well localized by the patient, with little spread, since these are peripheral joints and structures lying at the end of their respective dermatomes, with little scope for reference. The presence of paraesthe sia or any apparent reference of pain may suggest a more proximal lesion, and all proximal joints must be exam ined, including the cervical spine. A fractured scaphoid
Figure 7.5 Ten dons on the lateral aspect of th e wrist.
gives localized pain and point tenderness in the anatomi cal snuffbox, while X-ray investigation may not show evi·
Move the wrist into ulnar deviation and the scaphoid
dence of the fracture for several weeks (Livengood 1992).
can be palpated distal to the radial styloid; it moves with
The onset of the symptoms may be due to trauma, over
the hand, whereas the radial styloid does not. The scaphoid
use or arthritis. If the onset is traumatic in nature, the
can be grasped between your thumb posteriorly in the base
possibility of fracture should be eliminated. Frequently,
of the snuffbox and your index finger anteriorly.
a direct injury involving a fall on the outstretched hand
Move distally to palpate the trapezium lying between the scaphoid and the base of the first metacarpal.
may cause fracture of the scaphoid or subluxation of the capitate or lunate bones, and may also cause a traumatic
Palpate the tmpeziofirst·metacarpal joint line by run
arthritis with soft tissue sweJJing and contusion. Indirect
ning a thumb down the shaft of the first metacarpal into
injuIY may also occur from a rotational force or maximal
the anatomical snuffbox. 1"lex and extend the joint to
effort in racquet sportS (Rettig 1994).
check its location.
Most injuries at the wrist and hand develop from repeti
Palpate the first donal interosseous in the web between
tive overuse. Tendinopathy may result from frequent over
index finger and thumb; it can be made more prominent
stretching or unaccustomed activity. An overuse syndrome
by resisting abduction of the index finger.
occurs when the level of repeated microtrauma exceeds the tissue's ability to adapt (Rettig 1994). Tensional overload or abnormal shear stresses can cause microtrauma at any point in the musculotendinous or ligamentous unit. The
COMMENTARY ON THE EXAM INAT ION
syndromes of carpal tunnel and de Quervain's (see p. 171 & 174) may be associated with more proximal lesions, such as nerve entrapment or lesions of the cervical spine. A hyperextension injury to the thumb is a relatively
Observation
common sporting injury, producing a traumatic arthritis
Before proceeding with the history, a general observation
in either the trapeziofirst-metacarpal joint or the meta
of the patient's face, posture and gait will alert the examiner
carpo phalangeal joint. This may occur in sl
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thumb') or spons which involve ball-catching, e.g. volley ball, netball or goal-keeping in football.
Deformities of the fingers are commonly associated with rheumatoid arthritis or may result from forced
Arthritis in the hand may be innammatory, degenera
hyperextension injuries, as in wicket keepers, for example.
tive or traumatic. Rheumatoid arthritis is common in the
ff an extensor tendon is avulsed or torn from the distal
smaller joints and therefore readily affects the joints of
phalanx, a mallet finger occurs with nexion of the distal
the wrist and hand where deformity is characteristic; it is
interphalangeal joint. This can be associated with sport
usually bilaterally symmetrical. Any synovial space can be
ing injuries or may simply occur if the finger is forcibly
involved, including the tendon sheaths and bursae, as well
caught, while making the bed, for example. t\ bony swell
as the joints. luvenile chronic arthritis has less symmetrical
ing of the distal interphalangeal joint is a characteristic
joint jnvolvement than adult rheumatoid arthritis.
Pri mary
degenerative osteoarthrosis affects the trape
ziofirst-metacarpal joints and the distal interphalangeal joints more readily. These joints are subjected to stress in
deformiry known as a Heberden's node, associated with primary degenerative osteoarthrosis. Degenerative
osteoarthrosis
of
the
trapeziofirst
metacarpal joint produces a capsular pattern which may
the functional position and are used through all extremes
draw the thumb into a position of nexion and medial
of range, predisposing them to primary arthritis. Secondary
rotation with bony osteophytes obvious at the base of
degenerative osteoarthrosis can affect any joint.
the thumb. Dupuytren's contracture is a deformity with
The duration of symptoms indicates the stage of the
contraction of the palmar fascia, causing nexion of plin
lesion in the innammatory process. Overuse syndromes
cipally the ring and little fingers. Clubbed fingers may be
have a gradual onset with symptoms present for many
indicative of systemic disease.
Rheumatoid arthritis and acute episodes of
Colour changes, which may indicate circulatory involve
degenerative osteoarthrosis tend to have periods of remis
ment, should be further investigated by palpating for the
sion and exacerbation while traumatic lesions may be of
arterial pulses. The fingers, in particular, can give clues to
fairly short duration.
serious underlying pathology and the colour and shape
months.
The symptoms alld behaIJiollr need to be considered. The
of the fingers and nails should be noted. Bruising may be
behaviour of the pain indicates the nature of the lesion,
apparent, resulting from direct trauma, and may be asso
with mechanical lesions eased by rest and aggravated
ciated with abrasions on the palm due to a fall on the
by activity. Overuse lesions are worsened by repetition
outstretched hand.
of the mechanism of trauma. The nature of the pain is
Muscle wasting may be obvious in the nattening of the
also important: is it localized or vaguely diffuse, deep or
thenar muscles, producing the ape-like hand with the
superficial, sharp, burning, aching, constant or intermit
thumb moving back in line with the other fingers. This
tent, getting worse or better, or staying the same?
indicates involvement of the median nerve in the carpal
The other symptoms described by the patient could
tunnel or possibly cervical nerve root pressure. Similarly,
include paraesthesia. An accurate description of these asso
the ulnar nerve or lower cervical nerve root compression
ciated symptoms is relevant to the source of pressure or
involves the hypothenar eminence, and if the intrinsic
nerve entrapment. The distribution of pins and needles
muscles are involved a claw hand develops. fnvolvement
and whether or not they possess edge and/or aspect helps
of the radial nerve affects the wrist extensors and pro
to determine their origin. Stiffness of the hand may be rel
duces a dropped wrist.
evant to arthritis or ligamentous lesions and it is therefore
Swelling indicates active innammation and the wrist
appropriate to know the daily pattern of the symptoms.
may be fixed in t.he mid-position due to the presence of a
Heat, coldness, sweating, dtyness and other sensory changes
joint effusion. Contusions with swelling are due to direct
may also be relevant, suggesting the vasomotor changes of
trauma. Excessive friction of the skin causes callus and
Raynaud's disease or renex sympathetic dystrophy.
blister formation, e.g. rowing and gymnastics. Ganglia
An indicatjon of past medical history, other joint involve
are mucus-filled cysts, which are commonly seen around
ment alld mediwtiolls will establish whether contraindica
the wrist, particularly on the dorsum of the hand. They
tions to treatment techniques e.-ust. As well as past medical
are common between the second and fourth decades of
history, establish any ongoing conditions and treatment.
life (Smith & Wernick
Explore other previous or current musculoskeletal prob
burst or require surgical excision. Rheumatoid nodules
lems with previous episodes of the current complaint, any
may be present.
1994)
and if symptomatic may be
treatment given and the outcome of treatment.
Pal pation
Inspection
Since these are peripheral joints, palpation for signs of
Fracture or dislocation commonly occurs with a fall on
activity is conducted. Temperature changes are assessed and
the outstretched hand and shows obvious bony deform
heaL indicates an active innammation, while cold may indi
ity and swelling. SublLLxation, e.g. of the capitate, may be
cate circulatory problems (Fig. 7.6). ft may be appropriate
seen as a bump on the dorsum of the hand with the wrist
to palpate the ulnar and/or radial pulse (Fig. 7.7). Synovial
in nexion.
thickening is usually palpated on the dorsum of the wrist
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Figure 7.6 Palpation for heat
Figure 7.8 Palpation for synov ial thickening.
Examination by selective tension (objective examination) The suggested sequence for the objective examination will now be given, followed by a commentalY including the reasoning in performing the movements and the signifi cance of the possible findings. Comparison should always be made with the other side.
Inferior radioulnar joint •
Passive p ronation (Fig. 7 9 )
•
Passive supination (Fig. 7.10 )
Wrist joint
Figure 7.7 Palpation for radial pulse
(Fig.
7.8). Swelling
is usually obselved around the wrist
where it may be fusiform, unilateral or bilateral. Other swellings, such as nodules or ganglia, can be palpated to assess whether they are hard or soft.
•
Passive flexion (Fig. 7.11 )
•
Passive extension (Fi g . 7.12 )
•
Passive ulnar deviation (Fig. 713 )
•
Passive radial deviation (Fig. 7.14 )
•
Resisted flexion (Fig. 7.15)
•
Resisted extension (Fig. 716)
•
Resisted u l n a r deviation (Fig. 717) .
•
Resisted radial devia tion (Fig. 7 1 . 8)
Trapeziofirst-metacarpal joint •
State at rest Before any movements are performed, the state at rest is esta blished to provide a baseline for subsequent comparison.
l.
Passive extension and adduction (Fig. 7 19 . ) ReSisted fleXion (Fig 7 20 )
•
ReSisted extension (Fig 7.21)
•
ReSisted abduction (Fig 722 . )
•
ReSisted adduction (Fig 7.23 )
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Interossei •
•
Resisted fi nger abduction for dorsal interossei (Fig. 724) Resisted fi nger adduction for palmar interossei (Fig. 725)
Palpation •
Once a diagnosis has been made, the structure at fault is palpated for the exact site of the lesion
Fingers •
L
_
Passive and resisted testing of the fingers is not :r�ormed routinely
Figure 7. 11 Passive flexion.
r Figure 7,9 Passive pronation. Figure 7.12 Passive extension .
Figure 7.10 Passive supination.
Figure 7.1 3 Passive ul nar deviation.
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Fig u re 7.14 Passive radial deviation.
Figure 7.17 Resisted u l nar deviation.
Figure 7.15 Resisted flexion.
Figure 7.18 Resisted radial deviatio n .
Fig u re 7.16 Resisted extension .
Figure 7.19 Passive extension and adduction o f the thumb.
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Figure 7.20
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Resisted thumb flexio n .
Figure 7.23 Resisted
thumb adduction.
Figure 7.21 Resisted thumb extension.
Figure 7.24 Resisted finger
Figure 7.22 Resisted thumb abdudion.
Figure 7.25 Resisted addudion
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a
bduc tio n for d orsa l interossei.
for palmar interossei.
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The inferior radioulnar joint gives pain felt at the wrist and is assessed using two passive movements, passive pro nation and supination, looking for pain, range of move ment, end-feel and the presence of the capsular pattern. Both rotations normally have an elastic end-feel. The wrist joint is then assessed by four passive move ments, looking for pain, range of movement and end-feel. Passive flexion normally has an elastic end-feel due to tis sue tension and passive extension a hard end-feel, while both deviations normally display an elastic end-feel. The presence of the capsular pattern indicates the existence of arthritis; the non-capsular pattern rna)' be due to a subluxed carpal bone, e.g. the capitate, or collateral ligament strain. The contractile structures at the wrist are assessed by resisted tests looking for pain and power. A positive find ing requires palpation of the appropriate anatomical structure to establish the exact site of the lesion. The tra peziofirst-metacarpal joint is assessed by passive applica tion of one combined movement, passive extension and adduction, which is always painful if the capsular pattern is present. The contractile structures around the thumb are assessed by resisted tests looking for pain and power. Resisted flexion assesses flexor pollicis longus, resisted extension assesses extensor pollicis longus and brevis, resisted abduction assesses abductor pollicis longus and resisted add uction assesses adductor pollicis. The interossei are assessed by 1\"0 resisted tests looking for pain and power. Resisted finger abduction assesses lhe dorsal interossei and resisted finger adduction assesses the palmar interossei. Passive and resisted movements of the fingers are not part of the routine examination, but included if necessary. Passive movements may establish the capsular patlerns described below.
Infe rio r (distal) radioulnar joint The inferior radioulnar joint is most commonly affected by rheumatoid arthritis. capsular pattern of the inferior radioulnar joint •
Pain at
end
of range
of both rotat io n s
.
Injection of the i nferior rad ioulnar joint (Cyriax 1984, Cyriax & Cyriax 1993)
Suggested needle blue needle
size: 2SG x 1 in (0.6 x 2S mm)
Dose: 10-20 mg triamcinolone acetonide in a
total volume of 0.5
ml
Position the patient with the Forearm supported in full pronation. Identify the inferior radioulnar joint line and insert the needle, which may need to be angled, into the joint (Fig. 7.26). Give the injection as a bolus once intra capsular (Fig. 7.27). The patient is ildvised to maintain a period of relative rest for approximately 2 weeks follow ing injection.
CAP SULAR LES IONS The presence of the capsular pattern at the joints indicates arthritis. Rheumatoid arthritis more readily affects the smaller joints and is seen as symmetrical involvement of the joints in the wrist and hand with deformity character istic of the condition. Primary degenerative osteoanJlrosis affects the trapeziofirst-metacarpal and distal interphalan geal joints more readily. The thumb may be flexed towards the palm of the hand by the contracted anterior joint capsule and the distal interphalangeal joints of the fingers may show the characteristic Heberden's nodes. Trauma may produce traumatic arthritis and fracture of a carpal bone should be eliminated. Arthritis in the wrist and hand responds to cortico steroid injection but Grade B mobilization is appropriate for limitation of movement associated with degenerative arthritis; an allernative treatment for the trapeziofirst metacarpal joint is described below.
Figure 7.26 Injection
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the inferior radioul nar
joint.
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I 7 I
The wrist and hand
Figure 7.27 Injection of the inferior radioulnar joint showing
direclion of ap proach and needle position.
Figure 7.28 Injection of the wrist joi n t .
Wrist joint The wrist joint is most commonly affected by rheumalOid arthri tis and trauma t i c art h r itis.
Wrist joint Capsular pattern of the wrist joint •
Equal limitation of flexion and exte nsion.
•
Eventual fixation in the mid-position.
Injection of the wrist j oint Suggested needle size: 23G x 1 i n
(0.6
x 25 mm)
blue needle Dose: 20-30 mg triamcinolone aceto nide in a total volume o f 3 mL
Figure 7.29 I njection of t h e wrist jOint showing direction of
Position the patient with the wrist su ppo r ted and the forearm in fu l l p ro na tion ( Fig.
7.28).
approach and needle posit i o n .
Locate a point of
en try, which may be at either side of t he extensor carpi
wrist, o r if degeneration is su fficient t o prevent access t o
radialis brevis tendon.
t he j oint, make two or t h ree needle insertions a n d pepper
Give the injection a s a bolus once the need le is int ra· capsular (Fig.
7.29).
Alterna tively,
in the rheu matoid
the area of synovial thickening with a series of withd raw als a nd reinsertions. This technique is not co mfortable
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the p a t i e n t . The p a t i e n t is advised t o mai n t a i n a period of re lat ive rest fo r approxi mately 2 weeks fo l l ow i ng i njecti o n .
Trapeziofirst-metacar pal joi nt The p a t i e n t com p l a i ns of pain and tenderness at the base of the t h u m b and o n u s i ng the th umb u nder co mpres s i o n , e.g. wri t i ng, grippi ng. It is a cond i ti o n co mm on in m i d d l e-aged women ( Li vengood 1 9 9 2 ) and X- ray con finns the di agnosis. An ax ial comp ress ion test appl ies l ongi t u d i n a l press ure d own t h e s h a ft of the fi rs t metacar pal to grind the a rt icular s urfaces together. [f pos i t ive, i t confirms t h e d i agnosis o f a rt h ri t is a n d d i ffe ren tiates the con d i t i o n from d e Quelvain's tenosynovi t is (see below ) . A grad i n g system i s used t o assess t h e s t age of degenera t i o n and to gui d e the treat m e n t approach. An e l a s t i c end feel on tes t i ng the l i m i ted move m e n ts ind icates t h at the
Figure 7.30 Injection of the trapeziof i rst-metacarpal joint.
lesion is l i kely to res pond to fri cti ons and stJetches to the j o i n t, i n clud i ng d istract i o n . A h a rd e r end-feel i n d i cates i nject ion a s the treat ment of choice. [n the persistence of pa i n w i t h severe l i m i ta t i o n o f fu nc t i o n an orthopaed ic o p i n i o n is appropriate a n d su rgery may be i n d icated .
capsular pattern of the trapeziofirst-metacarpal joint
l-
Most limitation of extension.
Co n fi r m a t i o n o f the ca psular l i m itation can be made by asking the pat i e n t to put t h e hands i nt o the prayer pos i t i o n and spread i ng t he t h u m bs, comparing the two sides.
Injection of the trapeziofirst-metacarpal joint (Cyriax 1 984, Cyriax & Cyriax 1 993) Suggested needle size 25G x 5 / 8 in (0. 5 x 1 6 mm) orange needle Dose:
1 0-20
mg triamcinolone acetonide in a
Figure 7 . 3 1 Injection of the trapeziofirst-metacarpal j Oint
total volume of 0. 5 - 0 . 7 5 mL
Pos i t i o n
t h e patient with
the hand
showing di rection of a p p roach and needle position
res t i n g co m forta
bly. The patient can a p p l y a degree of distract i o n to the a ffected t h u m b ( Fig.
7.30).
I d e n ti fy the j o i n t l i ne by run
n i n g you r t h umb down the fi rst metacarpal i lllo t h e a na tomical s n u ffbox to locate the j o i n t l i ne. In sert the need le i l l to the j o i n t and give the i njection as a bo lu s ( Fig.
Transverse frictions to t he anterior capsular ligament of t he trapeziofirst - metacarpal joint ( C yriax 1 984, Cyriax & Cyriax 1 993)
7 .31 ) .
A l te r n a t i vely, i f t h e t h e n a r emi nence i s flattened, i d e n t i fy
Place the t h u m b comfortably i n to extens ion and adduc
t h e j o i n t l i n e a n teriorly. [n e i t her case, osteophyte for
tion. Apply deep U-ansve rse fri ctions with t h e thumb or
m a t i o n may m a ke the injection d i ffi cu l t . The patient is
i ndex finger rei n forced by the m i d d l e finger ( Fig. 7 . 3 2 ) .
advised to mai n t<1 i n a period of re l a t i ve rest fo r approxi
D i rect the fri ct i o n down onto the a n terior capsu l a r l i ga
ma tely 2 weeks fo l l ow ing i n jection
ment a n d apply t h e sweep transversely across the fibres.
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Figure 7.33 Injection of the metacarpophalangeal joint.
Transverse frictions to the a nterior capsular ligament of the trapeziofirst-metacarpal joint.
Figure 7.32
Maintain the technique for lO min a fter achieving a n analgesic effect. The principles for stretching capsular adhesions ca n be a pplied, e.g. Grade B mobilization, and d istraction is a useful technique to apply to this joint.
Finger joints Capsular pattern of the finger joints
le
. _.....J Slightly more limitation of flexion than ext e ns io n _ _____
Figure 7.34 Injection of the metacarpophalangeal joint showing direction of a p p roach and needle position .
I njection of the finger joi nts
Suggested ne edle size: 2 5G x 5 / 8 in (0 5 x 1 6 m m) orange needle Dose: 5-1 0 mg triamcinolone acetonide in a total volume of 0 . 5 - 0 . 7 5 m L
Identi fy the affected joint. W i th knowledge o f the posi t ion of the tendons and ligaments around it, find a point of convenient access, usually on the dorsal aspect avoid ing the digital expansions (Figs 7.33 and 7.35). Angle the needle obliquely and, once intra-articular, give the injection as a bolus (Figs 7.34 and 7.36). The patient is advised to maintain a peri o d of relative rest for approxi mately 2 weeks following injection.
Figure 7.3S
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Injection of t h e interphalangeal joint.
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Reducti on of the capitate (Saunders 2000) Locate the capi tate
by
shaft of the adjacent dis thu mb, re i n forced
ru n n ing a t h u m b down the
the t h i rd metacarpal to its base and onto pl aced cap i tate ( Fig. 7 . 3 7 ) . Place one by
the
other, on top of the ca pitate ( Fig. 7 . 3 8 ) , and wrap
you r fingers c o m fortably around the patient's thenar and hypothenar e m i nences ( Fig. 7 . 3 9 ) . P l acing your l i ttle fin ger i n t o the web between the
pat ient's
t h u m b and i n d ex finger w i l l prevent you from
Aexi ng t h e pati ent's wrist during
the tech ni que.
Pos i t i o n the patient's proxi m a l row of carpal bones l evel w i t h the edge of t he coucll . Ins t ruct an ass istant to
fix
Figure 7.36 Inject ion of the i nterphalangeal joint showing
this
prox i m a l row of carpal bones with
the
web of the
d irection of approach and needle position.
NO N-CAPSU LAR LESIONS Subl uxed carpal bone The ca pit ate i s particu l a rly prone to dorsal subl uxation or d i s p l acement because i t is rough ly peg-shap ed,
with
i ts
dorsa l su rface s l i ghtly wider t h a n its palmar surface. The l u n a te s i ts be t"" e en scaphoid a n d triquetral, and end of th e ra d i us and
the
the
lower
articu l a r d i sc, and may d i s place
anteriorly when the wrist i s fo rced i n to extension ( N orris 2004 ) . Posterior d i s p l a cements may a lso occur. E i ther bone may d isplace, but co m m only
it is
the capitate.
The mechanism of i n j u ry involves a fal l on the outstretched hand or repeated co mpression through the extended wrist,
Figure 7.37 Palpating for the capitate bone at the base of
as occurs in gymnastics, fo r exa m p l e, causing the capitate
the third metaca rpa l .
to d isplace dorsal ly. The patient may com p l a i n of pain a n d l i m i ted movement a n d may b e concerned about t h e bump seen o n the dorsum of the hand. Occasionally a subluxed capitate may have been present for
a
long d u ration when
there is less chance of successful relocation . On exa m i n a t i o n t h e re is a non -capsu l a r pattern. Passive exten s i o n is pai n fu l and l i m i ted by a bony bl ock. Passive Aexion can us u a l ly achieve fu l l range, but the patient experiences pain at t h e end of range. A bony bum p may be obvious on passive flexion, but this should not be con fused w i t h the base of the t h i rd metacarpa l which is a l so pro m i ne n t . Diagnosis is dependent upon the ap propriate h i s tory and the presence of the non-capsular pattern .
The
p r i n c i p l e of trea t m e n t appl ied here is to relocate
the carpal bone by a thrust a p p l ied to the ca pit ate under strong tract i o n . I t should be e m p hasized t h a t th is i s a m o b i l ization techn ique pe rformed u n der strong tract ion, not a m a n i p u l ation at the end o f range. The tech n i que fo r
the
ca pi tate mob i l iz a t i o n w i l l be ex pla i n ed
here, but
ca n b e ada pted if another carpal bone is d i splace d .
it
Fig ure 7.38 Thumb position for the reduction of the capitate.
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Figure 7.39
I 7 I
The wrist and hand
Finger position for the reduction of the capitate. Figure 7.41
Figure 7.40
Body position for the reduction of the capitate.
Assistant's hand position for the reduction of the
capitate.
hand paral lel
to the edge of t h e couch a n d reinforced
with the other hand, to give counterp ressure (rig. 7 . 4 0 ) . Place
feet d i rectly
your
lean back to
app l y
under the p atient s '
strong traction (F i g. 7.4 1 ) .
hand and
A l l ow
this
traction to establish for a few seco nds to sepa rate the two rows of carpal bones. Apply
a
sharp t h rust downwa rds on
the c ap itate to assist its relocat ion. Re-examine
the palient
to assess the
res u l ts
and repeat
if necessaI)'. I f pain persists after relocation, the ligaments surround ing the cap ita te may be treated with deep transverse fric tions ( F i g . 7.4 2a,b).
Fig ure 7.42 Transverse fri ct ions to the capitate ligaments (a) hOflzontaly for vertical fibres and (b) vertically for h or i zo ntal fibres.
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Collateral ligaments at the wrist joint The collateral ligame nts may be sprained by a trau matic overstretchi n g of the w r i st j o i n t o r by repet itive microtrauma due to overuse. The condition may also be
transverse frictions, hav i ng placed the hand in a suitable position to gain access to the ligament ( Figs 7 . 43 - 7 . 4 8 ) . The pat i e n t is advised t o maintain a period o f relative rest for approximately 2 weeks following i njecti o n .
associated with rheumato i d arthritis. The pati e n t com plains of localized pain, and stretching the l igament by passive movement i n the opposite direct i o n reproduces this pai n . The ligame n t is tender to palpati o n . Rad ial collateral ligament sprain produces pain o n pas sive ulnar deviati o n and a sprained ulnar coll ateral liga ment produces pai n on passive rad ial deviat i o n . Either lesion may be treated by applying the principles of corti
Injection of the col lateral ligaments S u g gested needle size 2 5G x 5/8 in
(0.5
x
1 6 mm)
orange needle Dose: 1 0 mg triamcinolone acetonide i n a total volume of
0.5
mL
coster oid injection using a peppering tech n ique, or by deep
Figure 1.43 Injection of the r a d i a l collateral l i gament.
Figure 1.45 Injection of the ulnar collateral ligament.
Figure 1.44 Injection of the radial col lateral l i gament
F i g u re 1.46 Injection of the u l nar collateral ligament showing
showing direction of a p proach and needle position
d i rection of approach and needle position.
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Figure 7.47
Transverse fl·ictions to the rad ia l collateral l igament.
Figure 7.48
Transverse frictions to the ulnar collateral l igament.
Carpal tunnel syndrome The mech a n i s m of the l esion is u ncertain, but i nvolves some compression of the median nerve i n the carpal t u n nel . Mechanical and vascular factors are believed
to be involved, w i t h inflammation i ncreasi ng the size of structures lying w i t h i n the t u n nel, causing swel l i ng and com pression, or w i t h scarring a ffecting the peri n eural c i rculation (Anderson & Tichenor 1 994). The muscles o f the thenar eminence may be a ffected by denervation,
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abductor pollicis brevis in part icular, causing the thumb
numbness and tingling with i n 1 - 2 min. If symptoms are
to fall back i nto l i ne w i th the other digits a nd flattening
not reproduced wilhin 3 m i n the test may be considered
of the thenar e m inence.
to be negative (J-I oppenfe l d 1 9 76, Cailliet 1 9 90, Vargas
Anything which reduces the already tight space in the
Busquets 1 9 94, Hartl ey 1 9 9 5 , E k i m et al 2007 ) .
include
The 'link test' can b e applied t o assess m uscle strength ;
i n fl a m m a t i o n and swelling of any strudure within the
the thumb and in divi dual fi ngers are opposed in turn and
tunnel c o mpresses the nerve.
Intrinsic factors
tunneL or reduction of the size of the tunnel i tself: teno
the examiner attempts to break the link, which should not
synov itis,
be possi ble if the patient possesses normal muscle power.
hypothyroidism, diabetes melli tus, pregnancy,
obesity, rheumatoid arthritis a n d acrom egaly ( Kumar & Clar k 2 0 0 2 ) .
External factors i nclude trauma, pressure,
repetitive occupati onal or leisure adiviti es, repeated grip
Exa m i na t i on of the cervical spine and neural tension testing should be conducted if there is any suspici on that the lesio n lies m ore proxim ally.
ping or squeezing, excessive vibration from heavy machin ery,
keyboard use, knitting, woodworki ng, using power
t ools, or racquet sports. Bland (2007) refers to a strong genetic predisposition to carpal tunnel. syndrome. It occurs m ore comm o nly in women bet\"een the ages of 40 and 60, peaking i n the late 50s (N orris 2004, Bland 2007 ) . The presen ting sy m p t o m s and signs o f carp al tunnel synd rome are variable. The patient usually compla i ns of an aching, burn i ng sensa t i on, with t i ngling o r nu m b ness of t h e finger t ips. Paraesthesia is expetienced in the rad ial three and a half d igits o n the palmar surface. About 70% of patients exper ie nce numbness at night and 40% com plain of pai n radiating p r ox i m ally i nt o the lower forearm with si multaneous paraesthesia felt in the fi ngers ( S m ith & Wer nick
1 9 9 4 ) . The symp t o m s may wake pat i e n ts at
night and they may gain relief by shal
Treatment of ca rpal tunnel syndrome The
causative
fa ctors
sho u l d
be
discussed
with
the
patient and attempts made to avoid repetit ive adions. Symptoma tic relief may be gained from a corticosteroid i n j ec t i o n . The patient may be fitted with a wrist support splint to wear a t night, to avoid flexion, especially during pregna ncy. A review conducted by Marshall et al (2007) concluded that local co rticosteroid injec t i o n for carpal tunnel
syndro me
provi ded
greater
i mprovem e n t
in
symp t o m s 1 m o nth after inject i on c o mpared t o placebo and signi ficantly greater impr ovement than oral cortico ster o i d for up t o 3 m o n ths. There was l i t t l e consensus on the d ose i njected, h owever. If injection is unsuccessful or relief is short-ter m only, surgica l release of the flexor reti naculum
m ay be considered.
Significant weakness
of the thenar muscles will usually be an ind i ca t i o n for surgery.
On exam inat i o n, fla ttening of the thenar e m i nence may be observed if med i a n nerve c o m pression has occurred. Obj ective sensory l oss may be found i n prolonged cases of compressi o n w i t h weakness of the thenar muscles, especially abductor pollicis brevis, if the m ot or branch is
Injection of the carpal tunnel (Cyriax 1 984, Cyriax & Cyriax 1993)
involved. 1.3 1and (2007) o bserves that Tinel's sign and Phalen's
Suggested needle size: 2 3G x 1 in o r 1 X in
test are the m ost widely and recogn ized tests for confirm
(0 6
ing the diagnosis, although it should be recognized that
Dose: 2 0 mg triamCinolone acetonide
t hese tests are not perfect d iagnostic indicators. negative and false-positive rates have been
False
reported
x
2 5 / 3 0 mm) blue needle
of
bet\-veen 25 and 50% (see Hattam & Smeatham 2010). Nerve conduction studies show d i m i nished nerve veloc ity across the WTist in 90% of patients who go on to have
Posi t i o n the pati ent with the wrist supported· in exten
proven nerve c ompression at surgery (S mith & Wer nick
sion. Choose a point o f entry between the distal and
1 99 4 ) .
mi ddle wrist creases o n the u l nar side o f pal m a ris l o n
Tinel's sign for median nerve compression i n tlle carpal
gus. If palmaris longus is abse n t, oppose the thumb and
tunnel involves tapping the flexor ret in aculum. It is positive
l i t tle fi n ger t o produce a m id l i ne crease as a guide and
if pins and needles are elicited i n the radial three and a hal f
keep to the ulnar side (Fig. 7 . 4 9 ) . Angle the needle paral
digits ( H oppenfeld 1 9 76, Hartley 1 995, Ekim et aI 2007 ) .
lel to and between the flexor tend o ns, until it i s under
Phalen's test applies com pressio n t o t h e m e d i a n nerve
the flexor retinaculum, and give the injection as a bo lus
in the carpal tunneL achieved by maint a i n ing m ax i m u m
with in the t u n n el ( Fig. 7 . 5 0 ) . Be careful to check that
w r i s t flexion. The test i s posi tive if p i n s a n d needles are
t here is no paraesthesia before injecting to avoid i njury
reproduced. A n or m a l hand would develop t i ng l ing if this
t o the median nerve. The patient is advised to m a i nt a i n a
posi t i on were maintained f o r 10 m i n or m o re; a patient
period of relative rest for appr oxi m a tely 2 weeks foll ow
w i t h carpal tunnel sy ndrome w i l l report the onset of pain,
i n g injecti on.
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a n d clicking fel t on the u l n a r side of the wrist. On exami nation t h e click i n g may be appreciated by t h e examiner p a l pa t i n g the wrist while s i m u lt a n eously pronating a nd supinating t h e forearm. Passive u l na r devia t i o n may repro d u ce the pain, and point tenderness may be fel t ju st d is t a l t o the u l na r sryloid. To confirm diagn osis o f a mechan ical l es i o n of the intra-articu l a r compl ex, the wrist is placed into extension and u l n a r deviatio n, a n d axi al compressi o n i s a pp l ied to the u l n ar side of t h e wrist w h i l e t h e w ri s t i s passively c i rcumducted ( H attam & Smeatham 2 0 1 0 ) . Trea t m e n t may involve stro n g distraction to reduce poss i b l e displacement, or the patient may be referred fo r a r t h roscopy a n d excisio n .
Trigger finge r or t humb
Figure 7.49 Inj ec tio n o f t h e carpal t un nel
Trigger fi nger or t humb is a s n appi ng phenomenon pro ducing a painfu l catch as a fl exor tendon is ca ught at a thickened pu l l e y of the sheath d u ring fle xi o n and th en released d u ring fo rced extension ( S m i t h & Wernick 1 9 94, M u rphy et a l 1 9 9 5 ) . Palmar trauma or irritation can cause t h ickening of the tendon, sheath or a n n u l a r p u l l e y a n d a palpable nodule may exis t . S o m e 35% of cases i nvo lve t h e flexor p o llicis l o ngus t e n d o n a n d 50% involve the mid d l e o r r i n g fi nger flexor tendons (Smith & We r n i ck 1 9 9 4 ) . The co n d i t i o n may b e secondary t o systemic disease such as rheumatoid arthritis or diabetes me l litus. Treatment by co rticosteroid injed i o n can be cu rative, restoring pain less, smooth ful l range of movemen t to t h e d igit ( M u rphy e t a l 1 9 9 5 ) .
Injection o f trigger finger o r thumb Figure 7.50 I nj ect ion of the carpal t u n nel showing d i rection of a p p roach and needle positio n .
Suggested needle size : 25G x
5 / 8 i n (0 5
x 16 mm)
ora nge need le Dose: 1 0 mg triamcinolone aceto n ide in a total volume of 0 . 5 mL
Fib roca rtilage tears and meniscal lesions A tri a ngular fi b rocarti laginous d isc is related to the dis tal
rad i o u l na r j o i n t inferio rly and a fi brocart i la g i n o u s
I n sert the needle towards the thickened n o d u l e of t h e
meniscus projects i n t o t h e wrist j o i n t from the u l n ar col
a ffected t e n d o n o n t h e palmar surface. A n g l e t h e needle
l a teral liga ment. These i n t ra-a rticu l a r struct u res are prone
approximately 4 5 0 , dista l l y o r proxima l l y, with the bevel
to degenerative changes, tears a n d occasio n a l l y displace
o f the need le para l l e l to the tend o n . Avoid injec t i n g into
me n t . Trauma, such as a fal l o n the ou tstretched h a n d or
the t e n d o n a n d nodule i tself by w i t h d raw i n g back from
repetit ive joint overloading, ca n cause degeneration and
the substance of the t e n d o n s l ig h t l y u ntil a loss of resist
tears. Central o r radial tears are the most common ( Rettig
ance is appreciated, and d e l iver the i n jection slowly as
1 99 4 ) .
a b o l us ( Figs 7 . 5 1 and 7 . 5 2 ) . The patient is advised to
A mechanical lesion i nvolving a tear o r displacement o f a n y part of t h e i n t ra-art i cular complex presents with pain
maintain a period o f relative rest fo r approximately 2 weeks fo l l owing i nject i o n .
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i rri tabi l i ty or severity of the l esion, or corticosteroid injec tion delivered between the tendon and its sheath. A l l si tes are subjected to relative rest from overusing or aggravating factors fol lowi ng treatment. Com mon contracti l e lesions will be discussed.
De Querva in's tenosynovitis
Figure 7 . 5 1
Injection for trigger finger.
Figure 7.52 Injection for trigger finger showing direction of approach and needle position.
CON TRAC TILE LESIONS Tendi nopathy at the teno-osseous j u nction of a tendon and tenosynovitis affecting the tendon i n its sheath, as it runs under either the flexor or extensor retinacula, are com mo n lesions found a t the wrist and hand. Overuse is the most l i kely cause of the lesion, wh ich may be tend inopathy or tenosynovitis of a s ingle u n it, or part of an overa l l more com plex syndrome known as repetitive stra i n injury or work-related upper l imb disorder. Tendinopathy at the teno-osseous j u nction ca n be treated by i njection usi ng a peppering tech nique or tra ns· verse frictions. Tenosynovitis can be treated by transverse frictions appl ied with the tendon on a stretch to restore the g l i d i ng fu nction of the tendon sheath, graded accord ing to the
This com mon cond ition, original l y described in 1 895, is tenosynovit is i nvolving the tendons of abductor poll icis longus and extensor poll icis brevis in the first extensor compartment at the wrist ( E l liol\ 1 992a, Livengood 1 992, Rettig 1 994, I
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Injection for de Quervain's tenosynovitis
Suggested needle size: 2 5G x 5/8 in ( 0 . 5 x 1 6 mm) or a ng e needle Dose: 1 0 mg triamcinolone aceton ide in a total volume of 1 mL
Position t he patient i n silting, with the wrist supported, hold i ng the thumb in a degree of flexion and the wrist in u l nar deviation and s l ight extension. Identify the ten dons of abductor pollicis l ongus and extensor pol \ icis brevis and the V-s haped gap between t hem at the base of t h e fi rs t metacarpal. Insert the need l e between and paral lel to the two tendons ( Fig. 7.53). Give the i njection as a bolus i n t o the shared sheath ( Fig. 7 . 5 4 ) . If the i njection has been correctly placed a slight swel l i ng w i l l be seen around the tendons. The patient is advised to m a i n ta i n a period of relative rest for approx i m a tely 2 weeks fol l ow ing i njection.
Figure 7.53
I njection for de Querva i n 's tenosynovitis.
Transverse frictions for de Querva i n 's tenosynovitis Alternatively, deep transverse frictions may be applied. Place t.he thumb i nto flexion a n d u l n ar deviation at the wrist. to put the tendons on the stretch ( Fig. 7. 5 5 ) . D i rect the frictions down onto the tendons usi ng two fi ngers side by s ide and sweep transversely across the fi b res. Apply 1 0 min of deep transverse frictions after the analgesic
Figure 7.55
Figure 7.54 I nj ec t i on for de Quervain's tenosynovitis direction of approach and needle position.
showing
Tr a n sve rse frictions for de Querva i n 's tenosynovitis.
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e ffect is ach ieved. Re la tive rest is advised whe re functional movements may conlinue, but no overuse o r stretching until pain- free on resisted testing. A splint to support the thumb in the resting position may be helpful. As de Que rvain's te nosynovitis is a c h ronic lesion, it may fo rm part o f a synd rome involving occupationa l overuse and i t may be necessa ry to include a fu ll exami nation o f the cervica l spine and uppe r Jimb, includ ing neural tension. Al l components of the condition should be t reated app rop riate ly.
Intersection syndrome or oarsman 's wrist The inte rsection, or crossover, poi nt be tween the two sets of tendons (abductor pollicis longus/extensor pollicis b revis and extensor carpi rad i a lis longus/brevis ) occurs at a point on the radius approxima tely 4 cm proximal to the w list ( Livengood 1 992, Klug 1 9 9 5 ) . It is a point of poten tiill friction between lhe s t ructures it S they exe rt tension in di fferent directions. This could produce tenosynovitis of the tendons as t hey pass under the extensor retinaculum or, mo re commonly, infla mmation of the musculotendi nous junction in the lower fo rearm. Cyri 3.-'< ( 1 9 8 2 ) refe lTed to this as myosynovitis with crep itation of the muscle bellies, a condition which occa sionally also affects the tibialis anterior muscle. B rukner & Khan (2007) attribute the co ndition to burs itis between the two sets of tendons. The condition is provoked by overuse and the patients usually present with acute pain and the classical signs of in nammat ion, he al. redness, swelling and disturbed fun ction. Crepitation is usua l ly audible on movement but pain makes objective testing di fficult .
Figure 7_56 Transverse frictions lor in tersection syndrome.
rest is advised where functiona l movements may continue within the pain- free range, but no overuse or stretching unti l pa in- free o n resisted testing. This cond i tio n is com monly p rovoked again by ove ruse and lhe patient may need instru ction in manual handling tas ks and activity modi fication.
Principles of Injection for tendon lesions Suggested needle size: 2 5G
x
5 / 8 i n (0 5 x 1 6 m m )
o r a n g e needle Dose: 1 0 mg triamcinolone aceto nide in a total
of 1
volume
mL g iven as a bolus between the tendon
and its sheath given by peppering tech ni que a t the
Transverse frictions for intersection syndrome
teno-osseous junction
Treatment begins immediately with protection, rest and ice to cont ro l pain and inflammation. Gentle transve rse frict ions are give n, ideally on a daily basis, and the patient usually reco vers relatively quickly. Position the patient com fortably on a pil low. Identify the area of tenderness, w hich is obvious on the lowe r radial aspect of the fo rearm. Place a lhumb along t he length o f the painful tendons and by abduction and adduction of the thumb or p ronation and supination of you r forea rm, impart the frictions transversely across the fibres (Fig. 7 . 5 6 ) . Alte rnatively, all fo u r finger pads can be placed at right angles across the te ndons to impart the fri ctions t ransve rsely across the fibres. Begin gently to achieve the analgesic e ffect, the n fo llow this with approxi mately s ix good sweeps to produce move men t. Rela tive
Extensor carpi ulnaris tendinopathy After de Quervain's, tenosynovitis of extensor carpi ulna ris is the next most common tenosynovitis at the wrist (Klug 1 9 9 5 ) . Tenosynovitis or tendinopathy at the teno-osseous junction is usua lly due to repetitive overuse, sometimes occurring in the non-dominant hand of the tennis player w ho uses a double-handed backhand when the 'take back' invo l ves an extreme position of ulnar deviation (Rettig 1 9 9 4 ) . Direct t rauma may cause subluxation of the tendon from the groove between the head o f the ulna and the sty loid process ( Livengood 1 9 92, Rettig 1 9 94 ) . The patient
1 76
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Chapte r
Figure 7.57
I 7 I
The
wrist and hilnd
Injection for extensor carpi u lnaris at teno
osseous site.
Figure 7.59
Figure 7.58 Injection for extensor ca rp i ulnaris at teno osseous site showing d i recti o n of approach and needle position
Transverse frictions for extensor carpi u lnaris tenosynovitis.
com p l a i ns of pain ilnd clicking on the u l nar side of the wrist. When the extended wrist is active ly take n fro m rad ial [0 u l n a r deviation, the subluxation of the tendon can be observed and t h is wi l l help d i fferen t iate the cond i tion from a triangu l a r fibrocartilage or meniscal lesion. Treatment appl ies the tec h niques o f corticosteroid i njection, e ither i njecti ng between the tendon and sheath in tenosynovitis or peppering the insertion at the base of the fifth metacal"pal (Figs 7.57 and 7.58). Alternatively, transverse frictions can be used, with the tendon on the
stretcb i n tenosynovitis (Fig. 7.59) and agai nst the inser tion for the teno-osseous j u nction.
Extensor carpi rad i a l i s longus and brevi s tendinopathy The l esion is usua l ly at the teno-osseous j u nction where it is due to repetitive overuse, or it may be associated with a bony metacarpa l protuberilnce o r boss ( Rettig 1 994,
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F i gure 7.60 In j ec tio n for extensor carpi rad i a l i s longus or
brevis tendons at teno-osseous site.
F i g u re
7.62
Transverse friction s to extensor carpi ra d i a l is
longus or brevis tendons at teno-osseous site.
Figure
7.61
Injection for extensor carpi ra d i a l i s longus or
brevis tendons at teno-osseous site showing d i rection of approach and needle positio n
Bergman 1 9 9 5 ) . Pai D i s fel t on resisted wrist extensi o n and resisted ra d i a l devia ti o n . T h e p r i n ci p l es o f corticosteroid i n j ectioD o r transverse frictions are a p p l i ed to treat t he l es i o n . Posi tion the p a t i e n t w i t h the w r i s t i n flex i o n to expose the base of the metacar pals and to a l l ow the l o ng extensor tendon to the tl,um b 10
fa l l o u t o f t h e way. I d e n t i fy t h e site of the lesion b y pal
pation at the rad i a l s i d e of the base of e i t h e r t he second or t h i rd metacarpals ( Fig. 7 . 60 ) . Del iver the cort icosteroid i n ject i o n by a peppering tec h n i que ( Fig. 7 . 6 1 ), or d i rect the tra nsverse frict i o n s down o n to the i n sert i o n and sweep
Fig u re
7.63 Inject i o n for fl exo r carpi ulnaris tendi nopathy,
proximal si te.
Re mem ber t h e pos i t io n o f t h e u l n a r n erve, l y i ng just lateral to the ten d o n , so that you can avo id i t i [ i n j ecti ng. If a p p l y i n g transverse fri ctions at the proximal si te, d i rect your t h u m b down o n t o p i s i form ( Fig. 7 . 6 5 ) . W i t h the patient's l i l l i e fi n ge r flexed, to re l ax t h e hypothenar e m i n ence, apply t ransverse frict ions to the d i stal site ( Fig. 7 . 6 6 ) . Sweep tra nsversely across the fi b res at e i t h e r si te.
transversely across the fi bres ( Fig. 7 . 6 2 ) .
Flexor carpi ulnaris tendi no pathy
I nterosseous muscle lesions S t ra i n of the d o rsal i nt e rossei m o re commonly affects
I n sert i o n a l te n d i n o p athy can occur at t.he proxi m a l or
m u sicians and t e n n is p l ayers, for exa m pl e. The patient
d i s t a l teno-osseous j u n ct i o ns at the p is i fo r m . Treatment
presents w i t h a vague pain at t h e metacarpop h a l angeal
consists of a cort i costero i d i n j ect i o n d e l ivered by a pep
j o i n t or between the metacarpals w h ich is exacerbated by
peri ng tech n i q u e i nlO the lesion ( F igs 7.63 and 7 . 6 4 ) o r
repeated gri p p i n g ( Re l l ig 1 9 94 ) . Pa i D w i l l be reproduced
transverse frict i o ns .
by resisted a b d u c t i o n o f the appropriate fi nger.
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Figure 7.64 Injection for flexor carpi ulnaris tendinopathy, proximal site, showing direction of approach and needle position.
Figure 7.66 Transverse frictions to flexor carpi u l naris tendlnopathy, distal site.
figure 7,65, Transverse frictions to flexor carpi u l nans
tendinopathy, proximal site.
The treatment of choice i s transverse frictions. Palpa tion wi l l determ ine the si te, but i t is often from the origin o f the i n terosseous m uscle on one metacarpal. Direct your pressure against the metacarpal and perform the sweep para l lel to the sh aft ( Fig. 7 . 6 7 ) .
F i g u re 7 , 67
Transverse frictions to the dorsal interossei.
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ten osyn oviti s : a case study report u si ng an l\ u sLra l i an approach to man uaJ therapy. Phys. Th e r 74, 3 t 4 -3 2 6 . Backhouse, K M . , Hutchi ngs, RT, 1 9 9 0 . A
Co l o u r Atlas o f Su rface A n a t o m y -
C l i n ical and A p p l i e d . Wol fe M e d i c a l , Lon d o n . Bergman, A G , 1 9 9 5 .
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a r t h r i t i s patie nts w i th carpal t u n n e l syndrome. Swiss Med. WkJy. 1 3 7 ( 23 - 2 4 ) , 3 4 7 - 3 5 2 . EJ l io t t, B . G . , 1 9 9 2 a . t\bductor pol l ic i s longus - a c a s e o f m istaken i de n t i ty.
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I H a n d Su rg. 1 7 13,
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Assessment - Lower Quadrant. 2nd ed n . Mos by, London. H a ttam,
M a rs h a l l , S . , Ta rd i f. G . , Ashworth, N . , 2007. Loca l corticosteroid i n j ection fo r carp a l tunnel syndrome. Cochrane Database Syst. Rev. ( 2)CDOO I 5 5 4 . Mu rphy, D . , Failla, 1 M ., Koni uch, M . P.,
P., Smeatham, A , 2010.
Spec i a l Tests in M uscu l oskeletal Exa m i n a t i o n . Church i l l Livi ngstone, Edi n b u rgh. i-loppenfeld, S., 1 97 6 . Physical Exa mi n a t i o n o f the S p i n e a n d
fo r trigger finger.
Lon d o n . Shea, K G ., S h u m s ky, 1 . 13. , S h e a , OT, 1 9 9 1 . Sh ifting i n to wrist pain - de Querva i n 's d i sease a n d off-road m o u n t a i n b i k i ng. Physician Sports Med. 1 9 , 5 9 - 6 3 . S m i th, D . L. . Wern i c k, R . , 1 9 9 4 . Com m o n n o n a rt i c u l a r syndromes i n t h e elbow, wrist a n d h a n d . Postgra d . Med. 95, 1 7 3- 1 8 8. Stand ri ng. S., 2009. Gray's Anatomy: The Anatomical Basis of Cl i n ica l Practice, 4 0 t h e d n . C h u rc h i l l Livingstone, Ed i n b u rg h . Steinberg. B . D . , P l a nch er,
I<. D., 1 99 5 .
C l i n ical a n atomy of t h e wrist a n d e l b ow. Cl i n . Sports Med . 1 4 , 2 9 9 313. Ta n, M Y. , Low, CI <., ··I a n , S I < . , 1 9 9 4 .
1 9 9 5 . Steroid versus p l acebo i n j ection
a descri ptive error tha t can produce
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D . , Soa mes,
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De Quervain's tenosynov i t i s a nd gangl i o n over first dorsal e-'(tensor reti nacu l a r co mpartment. A n n . Aca d . M e d . 2 3 , 885-886. Va rgas Busquets, M . AV, 1 9 9 4 . H i storical com m entary: the wrist flexion test P h a l e n 's sign.
1 Hand Surg. 1 9 , 5 2 1 .
Weiss, A . P., Ake l m a n,
disease .. ). Hand Surg. 1 9A, 5 9 5-59 8 . Wright. TW., del Cha rco, M., Wheeler, D , 1 99 4 . I ncidence of l igament lesions and associated degenerative changes
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E, Tabatabai, M ,
1 99 4 . Treat m e n t of de Quervai n's
I. Hand Surg.
8 The cervical spine
Cervical arterial dysfunction and assessment 210
CHAPTER CONTENTS
181
Summary
181
Anatomy The jOints of the cervical spin e
1 83
Intervertebral d i scs
1 84
Ce rvical spinal n erves
1 85
Cervical arteries
1 86
Differential diagnosis
1 88
Mechanical ce rvical lesions
188
Other causes of head and neck pain, arm pain and associated s i gns and Cervical artery dysfunction
Commentary on the examination
216
Mechan ical cervical traction
217
Cont rai nd ications to mechanical cervical traction
219
SUMMARY
at the
cervical spine
symptoms
Advanced manoeuvres
1 89 1 93
194
Safety is of paramount importance in the application of manual techniques to the cervical spine. As a contribution to safety. this chapter begins with a summary of the key points of cervical anatomy. highlighting structures involved in the pre-treatment testing procedures and the treatment techniques themselves.
Observation
1 94
History (subjective exami natio n)
1 94
Differential diagnosis and the elements of clinical examination will be discussed. Patients
Inspection
196
with a mechanical lesion. and thus suitable for
State at res t
1 96
the treatments subsequently described. will be identified. The contraindications to treatment
1 96
will be emphasized and guidelines for safe practice will be given. since both are of vital
Examination by selective tension (objective examination)
Cervical lesions - a classification system of three clinical models
importance.
203
Clinical Model 1 : acute tort icollis
204
Clinical Model 2
204
Clinical Model 3: presen t i n g with referred arm symptoms
204
Treatment of cervical lesions
205
Contraindications
205
The cervical mobilization p rocedure
207
ANATOMY The spinal colu m n is a series of motion segments, each of which consists of an i nterbody joint and i ts two adja cent zygapophyseal joints. The resultant bony canal is
© 201 0 ElseVier Ltd
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Practice of orthopaedic medicine
p rotective, but while the structu ral arrangement of the lumbar s p i ne as a whole is suited to weight-bearing, move ment a nd stab i l i ty, the cervical spine is designed princi pally for mobility. The cervical spine is the most mobile area of the spine a nd its wide range a n d combinations of movement are related to cha nges i n the d i rection o f vision, the position i ng of the u pper l i mbs and hands, and locomotion. It is also an area of potential da nger as i t gives bony protec tion to major blood vessels that su pply the brain and the spinal cord (Taylor & Twomey 1994, Nord i n & Fra n kel 2001, Kerry & Taylor 2006) . Its mobil ity is at the expense of stability and i t has a close n euro physiological con nect i o n to the vestibular and visual systems. It can therefore be the source of a 'plethora of symptoms' (Kristjansson 2005) . Anatomica l ly a n d fundionally, the cervical spine can be div ided into two segments. The upper segment con sists of the atlas and the axis (el and e2 ) . Its structu re is designed fo r mobility, with approxi mately one-third of cervical flexio n and extension and over half of axial rota tion occurring at this level ( M e rcer & Bogd u k 2 0 0 1) . The lower segment consists of the rem a i n i ng cervical vertebrae ( e3 -e7), and co ntributes to overall mob i l i ty. The atlas ( el) is composed of two lateral masses, sup porting a rt icular facets, and their joi n i ng an teri o r and posterior arches. The s u perio r facets articul ate with the head at the atlanto-occipital joints and their condylar shape facilitates nodd i ng movements of the head (Netter 1987, Mercer & Bogd u k 2 0 0 1) . The inferior facets articu late with the axis at the atlantoaxial joillts where rotation is the principal movement. The axis (e2) has broad superior a rticular facets w hich support the lateral masses of the atlas and wh ich are responsible for bearing the axial load of the head a nd atlas, transm itting the load to the rest of the cervical spine. The axis supports the deliS or odontoid process on its superior su rface, the dens p rovi d i ng a pivot arou nd which the atJas rotates at the synovial median a t l a n toaxial joint (Mercer & Bogd uk 2001 ) . There is no i ntervertebral disc between the a tlas and axis. The i n te rn a l ligaments of the up per celvical segme n t a re part icularly importa n t to its stabi l i ty ( Fig. 8 . 1). The tectorial membrane is a superior extension of the pos te rior longitudinal ligament that covers the dens and i ts ligaments, acti ng as protection for the junction of the spi n al cord and t h e med u l la. The transverse ligament o f the a tlas is a strong horizo n t a l band with extensions passing vertically and horizontally from its midpoint to fo rm a l igamentous co mplex cal l ed the cruciform ligament. This, together with the apical ligament of the dens, is respon sible for keeping t h e dens in close contact with the atlas. Any i nsta b i l i ty in the upper cervical segment, e.g. as occurs with rheumatoid a rthritis, trauma or Down's syn d rome, is an absol u te contraindicatio n to orthopaedic medicine tec h n i ques.
Superior longitudinal
End of membrane
band of cruciform
tectoria (cut)
Anterior edge of foramen
ligament
magnum Transverse
Alar
process
ligament
of atlas Capsule of
Tran sve rs e __-I
atlantoaxial
ligament
joint
of atlas Inferior longitudinal
End of
band of cruciform
membrane
ligament
tectoria (cut)
Figure 8.1 Upper cerv ical Internal ligaments. From Functional of the Spine by Oliver J and Middleditch A. Reprinted by p er mi SSi o n of Elsevier Ltd. Anatomy
Foramen
Body
Pedicle Anterior tubercle Posterior tubercle Superior articular facet Lamina
Vertebral foramen
-/----- Bifid spinous p rocess
Figure 8.2 Typical cervical vertebra. From Anatomy and
Human Movement by Palastanga N, Field D and Soames R. Repr i n ted by permission of Elsevier Ltd.
The lower cervical segment co nsists of typical cervical vertebrae e3-e6 and the atypical e7 which is known as the vertebra promillel1.S because of its long spinous proc ess. A typical cervical vertebra consists of a small, broad, weight-bearing vertebral body (Fig. 8. 2), the superior s u r face of which is raised o n each s ide, rather l ike a bucket seat, to form ullciform processes. The unciform processes articu late w i t h corresponding facets on the vertebra above to fo rm the IlIIcovertebral joillts or the joints of Luschka. Posterioriy l ie two short pedic/es and two long, narrow laminae form i ng the vertebral arch which, together with the vertebral body, su rround a large, triangular vertebral canal. The lam i nae come together to form a bifid spillous process. Superior and inferior articular processes, at the ju nc tion of t he pedicles and laminae, articulate at the synovial zygapophyseal joinr.s wh ich form an a rticular p i llar on either side of the spi ne.
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The cervicaJ spine
Short, gutter-sha ped transverse processes slope antero
Vertebral body
laterally to transport the emerging nerve root. Theforamen Transverse process
transversarium, a distinctive feature in tlle transverse proc
esses on each side or the cervical vertebrae, houses the
Articular surface
ve rtebral artery.
�...,.-,-;-o.,-,.,.-,..,.....//t0f--- Joint capsule
The ligaments of the lower cervical segment assist sta bility and allow mobility. The aTiterior longitudinal liga ment protects the anterior aspect of the intervertebral
Uncovertebral joint
joints and, with other anterior soft tissues, limits cervical
I nte rve r tebral d is c
extension. The ligamentum Tluchae is a strong, fibroelastic sheet protecting the joints posterioriy and providing an intermuscular septum. The ligamentum flavurll is a highly elastic ligament linking adjacent laminae. In the cerv ical
Figure 8.3 Uncove rtebral jo ints. From Anatomy and Human
spine it allows separation or the vertebra e during nex
Movement by Palastanga N, Field D and Soa mes R. Reprinted
ion and assists the neck's return to tlle up right posture.
by permission of Elsevier Ltd .
Its elastic propel1ies also allow it to return to its original length, so preven t ing buckling into the s pinal canal where ( P rescller
it can sometimes compromise the spinal cord. Th e posterior longitudinal ligament passes from the axis to the sac rum and is at its broadest in the cervical spine
1998).
These fissures are absent in young child
ren and a p pear to develop in conjunction with the devel l opment of the uncifOr ll process.
where it covers the entire floor of the cervical vertebral
Once formed, the fissures in the annulus develop a
canal, supporting the disc and possibly preventing its
pseudocapsule in which vascularized synovial folds have
posterior displacement. It is taut in flexion and relaxed in
been seen. Prescl1er
extension Mercer & Bogduk
(1999) identi fy three distind
these fissures and the uncovertebral 'joint' to the develop
layers of the posterior longitudinal ligament. The deep
ment of the cervical lordosis resulting in a change in con
layer, consisting or short fibres, spans each intervertebral
figu ration and the magnitude of the loads t ransmitted
(1998)
relates the development o f
joint and extends in an alar (wing-shaped) pattern as far
through the cervical spine. This results in s t rong shear
as the posterior end of the base of the uncinate process,
forces being transmitted through t h e intervertebral disc,
where it is believed to compensate for a deficient poste
pa rticularly during rotation and s i d e flexion. C3-C5 are
rior annulus fibrosus.
the most loaded segments and it is at these levels t hat the fissures in t h e d isc fi rs t appear. The uncovertebra l joints also contlibute to mobility by
The joints of the cervical spine
prov iding a t ranslatory gliding component to flexion and
The joints of the lower cervical segment consist o f tl l e
extension as well as stabilizing the spine by limiting the
interbody joint anteriorly and the two zygapop hyseal
amount of side flexion. The gliding component produces
joints posterioriy. The interbody joint is made up of t h e
shear which extends ho rizontal fissuring of the disc medi
intervertebral joint and the uncovertebral joints. When
ally from the uncovertebral joints. This, togetller with the
stacked, the joints can be considered to form tllfee pil
degenerat.ive p rocess, may eventually produce a bipar
lars in a rriangular formation, t he vertebral bodies and
tite disc (see below) (Taylor & Twomey
uncinate processes fo rming the anterior column and the
Bogdllk
two articular pillars formed by the zygapophyseal joints a rranged posterioriy ( M ercer & Bogduk
1994,
Mercer &
1999).
The position of tlle uncovertebral joints gives bony protection to the nerve root from posterolateral disc dis
1999).
The illtervertebral joint is a sym physis formed between
placement. As synovial 'joints', degen eratjve changes can
t he relatively avascular intervertebral disc and the adjacent
have an effect on th e uncovertebral joints. Osteo phyte
vertebral bodies. The disc contributes to mobility and, as
formation on the uncinate proc ess occurs predominantly
it ages, assists the uncovertebral joints in providing trans
in the lower cervical segments. Posterior oSleophytes can
latory glide to the movements of nexion and extension
encroach on tlle intervertebral canal leading to compres
(see below).
sion of the emerging spinal nerve root, whe reas anterior
The uncover/eural joints (joints of Luschka) are rormed between the unciform processes and corresponding facets on the verteb ral body above (Fig.
8.3),
though tlleir exist
ence has been challenged ( Mercer & Bogduk
1999).
They
osteophytes may compress the vertebral artery. The zygapophyseal joints are sy novial plane joints with relatively lax fibrous capsules to facilitate movement. The articular facets are angled at approximately
450
to the ver
may be true synovial joints or adventitious fibrous joints
tical so that side f lexion and rotation of the lower cervical
which have developed through clefts or fissures in the lat
spine occur as a coupled movement. This angle of incli
eral corners or the annulus fibrosis of tlle intervertebral
nation adds to the component of translatory glide during
disc originally described by Hurbert von Luschka in
f l exion and extension (Taylor & Twomey
1858
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1994).
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Practic
number
of
intra-articular
structures
have
been
described, particularly vascular synovial folds, similar to the alar folds of the knee, as well as fat pads and menis coid structures, All are highly innervated and can be a potential source of pain (Taylor & Twomey Middleditch
2006) ,
1994 ,
Oliver &
As synovial joints, the zygapophy
seal joints are prone to degenerative changes and, being
Vertebra
---'1f-Spinous
placed nei\[ the exiting nerve root, osteophyte formation
process
may affect the size of the intervertebral foramen, Orthopaedic
medicine
treatment
was
traditionally
based on the discal model, but it should be remembered
Intervertebral disc
that any structure that receives a nerve supply can be a potential source of pain, Since the cervical spine is made up of individual motion segments, a lesion of one part of the segment will tend to influence the rest of that seg ment. Similarly, treatment directed to one part of a seg ment will affect the segment as a whole,
Intervertebral discs There are six cervical discs which facilitate and restrain
Figure 8.4 Cervical vertebrae, inter body j oint and posteri or el ements, From Anatomy a n d H u m a n Movement by Palastanga N , Field D and Soames R, Repri nted by permission of Elsevier Lt d ,
movement as well as transmit load from one vertebral body
(0
mately
the next (Fig,
5 mm
8,4),
Cervical discs are approxi
lhick (Palastanga et al
2006)
and the thinnest
of all the intervertebral discs, Each forms part of the ante rior wall of the intervertebral foramen and is thicker anteri orly, contributing to the cervical lordosis, The intervertebral disc consists of an annulus fibrosus, nucleus pulposus, and transitional superior and inferior vertebral end-plates, The difference in function between the lumbar and cervical spine and the traditionally accepted view that cervical discs are smaller versions of lumbar discs does not hold true, Mercer & Bogduk
(19 9 9 )
acknowledged
this in their investigation of the form of the human adult intervertebral cervical disc and its ligaments, At birth the nucleus consists of no more than
2 5%
of the entire disc
and it undergoes rapid degeneration with age so that, by the age of
30,
the nucleus is undistinguishable as such,
The structure of the
annulus fibrosus,
described by
Mercer & Bogduk (1999), is different anteriorly and pos teriorly
(Fig,
8.5).
The
anterolateral annulus
forms a
crescent shape when viewed from above, thicker in the median plane and thinner laterally, tapering out to the unciform processes. It forms a dense, anterior interosseous ligament. The fibres arise from the superior surface of the
Figure 8 . 5 Photograph showing the top view of a 39 yea r old cervical intervertebral disc. The annulus flbrosus (A F) i s thick a n d f i b rous, tapering p os teriorly towards t h e uncinate reg i on , Posteriorly the thin annulus f i b rosus (AF) is found only towards the midl ine, Central ly the nucleus p utposus (NP) appears as a fibroca rti l a g i nous core. From Grieve's Modern M a n u a l T h e rapy, 3rd edn by Boyli ng J D, l ull G A (eds), Reprinted by permission of Elsevier Ltd, -
lower vertebra, fanning out in an alar fashion laterally, but in the midline form a tightly interwoven pattern with fibres from opposite sides, not the true laminate structure as seen in the lumbar spine, A distance of
2 -3 mm
into the fibrocartilaginous core laterally at the uncover
from
tebral region, partially into the core in younger patients
the surface of the anterior annulus, collagen fibres have
but totally transecting the posterior two-thirds of the disc
been found embedded with proteoglycans and forming
in older specimens (bipartite disc). Covering the clefts in
a fibrocartilaginous mass which has a pearly appearance
the uncovertebral region is thin periosteofascial tissue, the
and the consistency of soap.
annul,ar fibres being deficient here,
On a deeper plane, the fibrocartilaginous mass becomes
The postelior
annulus demonstrates different features to
more homogeneous and less laminated, forming what
the anterior annulus, It consists of a thin layer of one set
the authors interpret as the nucleus of the disc. Clefts,
of vertically oriented collagen fibres, not more than
presumably the uncovertebral 'joints', are seen to extend
thick. passing between adjacent vertebrae and extending
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Chapter
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out as far as the unciform process on each side where no obl i que posterior a n n u lar fibres were fo und. Deep to this is the fibrocart ilaginous core. It wou ld appear that the deep layer of the posterior lo ngitudi n a l l igament, with short fibres spa n n i ng each i n tervertebral j o i nt, compensates for the lack of annular fibres in the poste rior pan of the d isc, supporting the nucleus posteriorly. I'osterolaterall y the alar fibres of t he posterior longitu d i nal li gament alone conta in the nucl eus and these may become lOrn or stretched by a bulging disc, or nuclear material may hern iate under or through them. The vertebral elld-plate offers protect ion by preventing the disc from bulging into the vertebral body. I t acts as a ' sem i perm the exchange of nutrients between the vertebra l body and the d isc. Cyriax (1982) stated that 'from a c l i n ical point of view nuclear protrusions fo rm only a small m i n o rity of cervi cal d isc displacemen ts'. He postulated that a true nuclear d isc lesion occurs only in adolescents and young adults, presenting as an acute torticol lis. H is hypothesis wou l d seem to be substantiated b y Taylor & Twomey (19 9 4 ) who suggested that early degenerat ion o f t h e cervical nucleus m a kes n uclear protJusion in the cervical spine un li kely, un less precipitated by severe trau m a . A centra l bar-like pro tll.lsion o f t h e a n n ulus was more l i kely to occur in the cervical spi ne. This a p peared to be refuted by the work of Mercer & Bogduk ( 1 9 9 9 ) d escribed ab ove, given the re latively c l eficient posterior cervical a n n u l us Identified. Perhilps, l ike l umbilf d iscs, herniated cervi cal d iscs may consist of degenerate nuclear ma teri a l . Postero lateral herniation of the d isc cou ld b e poss ible th rough the weak supporting alar fibres o f the poste rior 10ngitLId inai l iga ment i n the uncovertebral regi o n . Indeed, one speci men from the Mercer & Bogduk study (J 9 9 9 ) i l l ust rates a disc bulge and a herniation, both below their respecti ve alar fibres. The position of the u ncoverteb ral joints and the large vertebral canal in the cervical spine may both a lso exert a protective i n fluence on d isc movement. Degenerate cer vical discs may prolapse d i rectly posterioriy, encroach ing on the dura through the posterior longitud i na l l i ga ment, rather than latera l ly at the uncovertebral region, to affect the dural nerve root s leeve and underlying ne(\'e root i n the intervertebral ca nal. Alternatively, d iscal material may be reflected postero laterally in the vertebral canal by the stronger median part o f the posteri or longitudinal l iga ment to cause u n i lateral pressure on the dura. The triangular vertebral canal is at its l a rgest in t he cer vical spine and, even though the cervical cord is enlarged in this region, there may be room for a p ro lapse to be accommodated . Postero lateral p ro l a pse through the weaker alar portion in the uncovertebral region may encroach on the dura l nerve root sl eeve and underlying nerve root. However, it wo uld seem that only a very large posterolateral prolapse would be able 10 compress t he nerve root at the same leve l , un less there is canal stenosis
caused by osteophyte fo rmation, an i n fo l ding l igamen tum f1avum or congen ital factors. Si nce the extent of pain referral is thought to be related to the amount of pressure on the dura l nerve root sleeve (Mooney & Robertson 1976), brachi a l pain is not as com m o n ly associated w i t h cervical disc lesions as sciatica is w ith l umbar d isc lesions. D u ral pressure due to a cervical d isc tends to produce central or u n ilateral scapular pain. It is assumed that cerv sim il a r way to l u mbar d iscs, since no stud ies have refuted t h is as yet. Bogduk (1994a) acknowledged the pauciry of data on cervical discs but claimed t hat the few stud i es that had been done had been positi ve, demonstrating that the cervical d iscs do have iln i n nervation. In that respect, the data on cervical d iscs are in accord with those on lum bar d iscs. At least the outer third and possibly the outer half of the annu lus fibrosis receives a nerve supply from branches of a posterior longitudinal plexus, d erived from the celvical s i nuvertebral nerves, as wel l as from a s i m i l a r p l exus for med fro m cervical sym pathetic trunks a n d t h e vertebral nerves, and fro m penetrat ing branches from the vertebral nerve (Bogduk 1994a). Mendel et a l ( 19 92) fou n d evidence of ne rve fibres and mechano receptors in the posterolateral regi on o f the annulus. The cervical disc may produce eit her prim ary d isc pai n, pain due to the mechan ical effect of secondary co mpres sion of pai n-sensitive structures, or pa in associated with chem ical or i schaemic effects. The mecha nism o f pain produced by d isc disp l ace ment is covered in greater deta i l in Chapter 13 s i n ce m uch of the investigative work on pain production has been performed in the lumbar regio n and no studies have been identified that relate to the cervical spi ne. I f findings can be extrapolated to the cervical spine, d isc material i s thought to undergo a proc ess of degradation wh ich contributes to its h e rniation. The chemica l mediators of inflam mat ion may pl ay a rol e in t h e pathophysiology of cervical rad iculopathy ""h ich renders the ne rve root pa i n-sensitive (Kang et al 1 9 9 5 ) .
Cervical spinal nerves There are eight cervical s p i na l nerves, each approxi mately 1 cm lo ng. Each nerve, togeth er with the dorsal root ga n gli o n , occupies a large, f u n n e l-shaped in tervertebral fo ramen ( Fig. 8.6). The spillal lIel1Je is composed of one dorsal or posteri or nerve root and one an terior or ventral nerve root, the ventral n erve root em erging more cauda l ly from the d u ra mater (Tanaka et al 2000 ). The dorsal nelve root carries sensory fibres and the ventral nerve root, motor fibres. The spina l nerve occu pies o ne-fourth to one-th i rd of the i nte(\'ertebral foramen d i a meter and carries w i t h it an investment of the d u ra mater, the d u ra l nerve root sleeve. The d u ral n erve root sleeve is sens itive to pressure and produces pai n in a segmental d istrib ution. Cervical spinal nerves genera lly emerge horizonta l ly and therefore the nerve roots are vulnerab le t o pressure o n ly from the disc
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�---- Spinal cord Foramen
Sympalhetic
transversarium
ganglion
Ventral ramus
Grey ramus
of spinal nerve
communicans
Venlral nerve
Posterior tubercle
root
of transverse process
Spinal ganglion
Dorsal ramus of spinal nerve
'---Dura -mater
Superior facet Dorsal nerve root-_-.J
Figure 8.6 Formation of a spin al nerve. From Functional Anatomy of the Sp i ne b y O l iver J and permission of E lsevie r Ltd
Ventral root
Dorsal root ganglion
Figure 8.7 H or izon ta l d irection of emerging nerve roots. From Anatomy and H u m a n Movement by Palastanga N. Field D a n d Soames R. Reprinted by permission of Elsevier Ltd.
at that particular level, producing signs and symptoms i n o n e segment o n l y ( Fig. 8 . 7 ) . In dicat ion o f more than one nerve root involve ment shou ld be considered suspicious until proved otherwise. However. Tanaka et al (2000). in a cadaver study. showed that the roots be low CS reached their i n terver tebral fo ramen with i ncreas i ng obliq uity making co m pression of more than one ne rve root below this level poss i b l e. At the C7 -Tl d isc. 78% of specimens showed that the C8 nerve roots did not have any con tact with the disc at the en trance of the intervertebral fo ramen. whic h probably accounts for the low frequency of C8 radiculopathy. Nerve root compression was fo und to occur at the en trance of the i ntervertebral foramen and was determ i ned
Mi dd led itc h A Rep rinted
by
to be due to herniated d iscs and osteophytes i n the uncov ertebral region anteriorly. and to the superior articular process. ligamentum flavum and peri rad icu lar fibrous t is sue posteriorly (Tanaka et al 2000). Motor i mpairment, therefore. is suggesti ve of anterior com pression from a d isc prol apse or degenerative changes i n the u ncovertebral region. whereas se nsory change is ind icative of compres sion due to changes i n the posterior structures. Of course a large d isc prol apse or gross degenerative change. ante riorly or posteriorly. may compress both elements of the nerve root. After it leaves the intervertebral foramen. the spinal nerve root i m mediately d ivides i nto velltral and dorsal rami. The sinullertebral neme is a mixed sensory and sympathetic nerve. receiving origin from the ventral ramus and the grey ramus co mmunicans of the sympathetic system (F ig. 8.8). The nerve returns through the intervertebral foramen and gives off ascend i ng. descending and transverse branches to supply structu res at. above and below the segment (O liver & M iddleditch 2006. Palastanga et al 2006. Standring 2009). The structures it supplies i nclude the dura mater.. posterior longitudinal l igament and the outer part of the annulus of the i ntervertebral disc (Bogduk 1994b ) .
Cervical arteries Anato mical ly the vertebral artery is d ivided into the fol l ow ing fo ur sections. wh ich include two right-angled bends where it is vulnerable to i nternal and external factors which tend to compromise b lood flow (F ig. 8.9) (Ol iver & Middleditch 2006, Standring 2009): • •
Its origi n fro m the subclavian aL1ery Its passage through each foramen transversarium except C7. [n t h is section it gives off spinal branches
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Chapter
I 8 I
The cervical spine
which supply the spinal cord and its sheaths via the intervertebral foramen •
The first right-angled ben d, t u r n i n g medially to pass
•
The second right-angled bend, to turn vertically to
behind the lateral mass of the atlas enter the foramen magnum to unite with the other vertebral artelY to form the basilar artery, which passes on to contribute to the circle of W i l l i s. Anatomical anomalies and variations exist and com monly one vertebral artery is narrower than its partner. Cl i nical ly it is important to recognize vertebrobasilar signs and symptoms since these contraindicate certain cervical manoeuvres. The artery is elastic, particularly in its first alld third sections, which allow it to accommodate to movement. Degenerative changes in the artery itself, in the intervertebral canaL uncovertebral joints and zygapo physeal joints mal<e it vulnerable to blockage as well as possibly distorting its pathway
Figure 8.8 A sk etch of t h e innervation of the plexuses surround i n g a cervical intervertebral disc (based on Groen et al 1 990) The sin uvertebral nerves form a d e n se plexus accompanying the posterior longitudinal ligament (pll). Anteriorly, bra nches of the sympathetic trunk (st) s u p ply t he front of the disc a n d from a plexus acco mpanying th e anterior longitudinal ligament (all) vr ve n tr a l ramus, dr dorsal ramus, va vertebral a rtery, m prevertebral muscles. From Grieve's Modern Manual Thera py, 2nd edn by B oyli n g J D and Palastanga N. Reprinted by permission of Elsevier Ltd =
=
=
=
The internet! carotid artery arises from the bifurcation of the common carotid artery in the anterior cervical spine (Fig. 8.9). It supplies most of the ipsilateral cerebral hemisphere, the eye and accessory organs, the forehead and part of the nose. It ascends to enter the cranial cavity via the carotid canal and turns anteriorly to end by divid
ing into the anterior and m iddle cerebral arteries, which anastomose into the circle of Wil lis. The internal carotid arteries together provide the most significant proportion of blood to the brain, 80%, com pared with
Posterior communicating arteries
20%
passing through the posterior vertebral
,----Middle cerebral
Posterior cerebral arterie s--- ,
artery �--Anterior cerebral
Basilar artery----�
artery ___--- Internal carotid
Foramen ---,
artery in cavernous
magnum
sinus Left vertebral
-----._\
___ _ ._ ---'·w
artery Right vertebral-----Ir--<:::/-y artery Vertebral artery
carotid artery in carotid canal of temporal bone
--- -J--7�i:�
"'----Internal carotid artery in neck
Transverse process of sixth cervical
'----Thyroid cartilage
vertebra
'-----External carotid
Subclavian ---,.-._
artery
artery
'----- Common carotid artery "'-____ Brachiocephalic
artery
Figure 8.9 Pathway of vertebrobas ilar a rteries. From Anatomy a n d Human Movem ent by Palastanga N, Fi e ld D a n d Soames R. Reprinted by permiSSIOn of Elsevier Ltd.
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Practice of or t h o p a edi c medicine
artery system. Blood now is known to be innuenced by
which indicate a progression of the same condition. The
neck movements, particularly extension and less so rota
symptoms are age-related with a pattern of increasing frequency and severity.
tion (Rivett et al 1999, Kerry & Taylor 2006).
Eventually the nerve root may
become involved. The
anatomy
of the
zygapophyseal joint with its
intra-articular structures makes it susceptible to possible
Differential diagnosis at the
mechanical derangement. It is difficult to differentiate
cervical spine
pathology in the absence of neurological signs or symp
An understanding of the anatomy at the cervical spine,
toms, and primary disc lesions and zygapophyseal joint
together with a detailed history and examination of the
lesions appear to be similar in their presentation. Referral
patient, will help with the seleaion of patients suitable for
pain patterns arising from the zygapophyseal joints in
manual treatment and contribute to safe practice. The two
symptomatic subjects have been looked at by Cooper
areas of danger in this region are the cervical arteries and the
et al (2007) who found that there was referral into the
spinal cord, and certain signs and symptoms will become
neck but minimal reference into the arm. As mentioned
evident on e.,xamination which would exclude some patients
above, there are no similar studies for primary or second
from manual treatrnent techniques.
ary disc pain.
Similarly, there are other causes of ned< pain in which manual
treatment
techniques
are
either
contra-indi
While acknowledging the zygapophyseal and other pain-sensitive somatic structures as possible causes of
cated or not as appropriate. The following section will
pain, the approach in orthopaedic medicine is tradition
be divided into two pans. The first covers mechanical
ally based on the discal model.
lesions, which present a set of signs and symptoms that
Disc lesions in the cervical spine need to be reduced
help to establish diagnosis and to rationalize treatment
to prevent them contributing further to the degenerative
programmes. The second covers the other causes of neck
process. A central prolapse in particular may cause osteo
pain and associated signs and symptoms. On the whole,
phyte
these patients are not appropriate for treatment with
may evenlLlally threaten the spinal cord. Cyriax (1982)
manual orthopaedic medicine treatment techniques and
was emphatic in pointing out the danger of not reducing
require suitable referral.
an early, minor cervical disc lesion for this reason as there
formation
through ligamentous traction which
comes a time when manipulation will not have an effect and a point at which it may be dangerous. Elderly patients with osteophytic cord compression often report the onset
Mechanical cervical lesions
of paraesthesia associated with cervical extension and for
As well as being a primary source of pain, the disc, through prolapse into the vertebral or intelvertebral canal, can have a secondary effect on any pain-sensitive structure lying within. This effect can be mechanical through com pression and distortion, chemical through the inflam matory process and ischaemic through the pressure of oedema. For further information on these theories, the reader is referred to Chapter 13. Although the differences in the anatomy and function of the cervical and lum bar spine must be acknowledged, few studies have been unearthed to reflect patterns of radicular pain produc tion specific to the cervical spine, although conclusions
that reason it would seem that particular attention should be paid to restoring cervical extension which would act as an indicator that reduction had been effected. Cervical lesions produce a pattern of signs and symp toms and a set of clinical models has been established to aid diagnosis and establish treatment programmes. These are outlined later in this chapter. The models should be used as a general guide to the clinical diagnosis and treat ment of cervical lesions. All show a non-capsular pattern on examination. The following terminology will be used to describe disc lesions:
have been drawn in relation to myofascial pain patterns based on clinical observation. For the time being, cervical radicular pain patterns have been extrapolated from the lumbar model. A cen((al herniation of cervical disc material produces central and/or bilaterally referred symptoms. A unilat
Disc protrusion •
eral herniation produces unilaterally referred symptoms.
produc e primary disc pain since the outer annulus
Reference of pain arising from compression of the central
receives a nerve supply.
structures is characteristically multisegmental, i.e. over many segmen ts (see Ch.
1). I nvolvement of the
unilateral
structures, dural nerve root sleeve and/or the nerve root produces segmentally referred signs and symptoms. Since the disc degenerates early in the cervical spine, disc lesion.s
Degenerate disc material bulges into the weakened laminate structure of the annulus, where it can
Disc prolapse •
Discal material passes through
a
ruptured annulus and/
or posterior lo ngitudinal ligament into the vertebral canal or intervertebral canal where it has a secondary
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Chapter
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The cervical spine
often referred to as cervical spondylosis. However,
effect on pain-sensitive structures: the posterior
despite gross X-ray changes, there may be little in the
longitudinal ligament, dura mater, dural nerve root
way of symptoms.
sleeve, nerve root and dorsal root ganglion. The
It is possible to have a disc lesion in an older
sequela of this is sequestration of the elise.
degenerative neck, i.e. noncapsular pattern, superimposed onto a capsular pattern. The disc
Both forms of cervical disc lesion are suitable for
lesion can be treated with manual traction and
orthopaedic medicine manual techniques, providing no
the degenerative osteoarthrosis does not present a
contraindications exist.
contraindication to treatment in itself. However, rotation under traction should be avoided due to the close proximity of the degenerate zygapophyseal and uncovertebral joints to the course of the vertebral
Other causes of head and neck pain,
artelY (see below).
arm pain and associated si gns and symptoms
Degenerative changes in the uncovertebral joints lead to osteophyte formation which may encroach on the nerve root or adjacent vertebral arteries, causing
Generally, this group of conditions does not respond to the
problems through direct compression. Degenerative
manual techniques described in this chapter and indeed
changes of the synovial joints may alter or distort
some may be absolute contraindications. There may, how
the path of the vertebral artery, leading to possible
ever, be some overlap, particularly with the degenerative
compromise and symptoms.
conditions, and the techniques may be attempted pro •
vided contraindications have been eliminated.
Matutinal headaches may be due to ligamentous
contracture around the upper two cervical joints, the atJanto-occipital and atlantoaxial joints.
Arthritis in any joint presents with the capsular pattern.
A condition
called 'old man's matutinal headache' exists in which the patient, an elderly man, wakes every morning
capsular pattern of the cervical spine •
with a headache which usually eases after a few hours (Cyriax 1982). Mobilization techniques, particularly
Equal limitation of side fleXions.
•
Equal lirnitation of rotations.
•
So m e limitation of extension.
•
Usually full flexion
manual traction, may be appropriate for this condition. •
Tinnitus and vertigo may be associated symptoms
of degenerative osteoarthrosis of the cervical spine. They can respond well to the techniques, but the vertebrobasilar system must be ruled out as a cause of the symptoms.
ArthritL, occurs in synovial joints in the cervical spine and
•
Osteophytic root palsy produces a gradual onset
involves the zygapophyseal and uncovertebral joints. In
of aching in the arm, usually with paraesthesia,
the cervical spine the capsular pattern is demonstrated
as the osteophytes develop. The patient is usually
by the cervical spine as a whole. The limited movements
elderly and will have objective neurological signs of
have the 'hard' end-feel of arthritis. The pattern of sym
weakness in the arm affecting one nerve root only.
metrical limitation of the side flexions and rotations is
Since disc lesions presenting in this way are unusual
distinctive when compared with the asymmetrical pattern
in this age group, orthopaedic medicine techniques would be contraindicated.
of limitation seen in disc lesions. The early degeneration of the cervical intervel1ebral disc occurs concurrently with
•
Ceroical myelopathy may develop in association with
degenerative changes within the other joints. The his
degenerative changes in the cervical spine. Stenosis
tory will indicate the type of arthritis: degenerative osteo
of the central canal occurs through osteophytic
arthrosis, inflammatory or traumatic.
formation and hypertrophy and buckling of the
•
Degenerative osteoarthrosis involves damage to
ligamentum f1avum develops. The osteophytes, a disc
hyaline cartilage and subchondral bone with sclerosis
prolapse or a ligamentous fold may exert pressure
and osteophyte formation. Cervical movements
on the spinal cord and a gradual onset of symptoms
become limited in the capsular pattern. Stiffening
occurs with increasing disability. There may be pain,
of the neck is particularly evident on rotation when
dysaesthesia of the hands consisting of numbness
the patient may, for example, have difficulty in
and tingling, clumsiness and weakness of the hands,
reversing the car. Painful symptoms occur during
weakness and evidence of spasticity of the lower
acute exacerbations of the condition, precipitated by
limbs (Jenkins 1979, Connell & Wiesel 1992). The orthopaedic medicine treatment techniques described
trauma or overuse.
below would be contraindicated.
The upper cervical segments are particularly involved in the degenerative process, with marked loss of rotation. Degenerative changes in the neck are
•
ZygapophyseaJ joints could conceivably produce
symptoms individually and in isolation to the other
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j o i n ts in the segme n t . As synovial j o i n ts they are
elsewhere, and it most co mmonly affects t h e smal ler
prone to degenerative cha nges al ong with the oth er
peri pheral joi nts b i l ateral ly. However, i n patients w i t h
j o i n ts i n the segm e n t . A p r i l l et a l ( 1989) suggested
r h e u m a t o i d a rth ritis i t m a y be s i l e n t i n t h e cervical
t h a t d is t i nct patterns of p a i n referra l were associated
joi nts and there may b e no c l i n ica l evidence of
with i n d iv i d u a l cervical zygapophyseal j o i nts but
cervical spine i nvolve m e n t (Clark 1 994 ) . T h e mech a n i s m o f t he d isease i n t he s p i n a l
others have refu ted the existence of a facet synd ro me
j o i n t s i s t h e same as that s e e n i n peri p h e ra l j o i nts,
(Schwa rzer et al 1994 ) . •
Cervical or cervicogellic headache describes a p a i n
with ligament, cart i l age a n d bone destruct i o n .
perceived to origi n ate i n t h e head b u t whose sou rce
Th is loss of t h e support i ng i n frastructure of t h e
is i n the cervical s p i n e ( Bogd u k 1 992 ) . I t consists
spi ne, part icula rly of t h e upper cervical segment,
of an aching or deep pai n local ized to the neck,
is a pot e n t i a l hazard fo r signi ficant n e u rological
su boccip ital and fro ntal region, prec i p i t a ted or
i n volvement o f the bra i n s tem and cervical s p i n a l
aggrava ted by neck movements o r sust a i ned neck
cord . Atl a n t oaxial s u b l uxation is the most co m m o n
pos t u res, especi a l l y flex i o n . Th e re i s l i m i ta t i o n of
m a n i festation, but cranial set t l i ng (vertical i n trusion
passive neck movemen ts, cha nges in muscle contour,
of the dens) a n d subaxial subluxation may a lso occur
tex t u re or tone a n d a b normal tende rness of the
( C l a rk 1 994, Zeid man &. Ducker 1 994, M a t h ews
neck m uscles (Sjaastad 1 992, Beeton &. l u l l 1994,
1995 ) . Rheu matoid art hr i t is is t herefore an absol ute
l u l l 1 994a, 1 994b, N i l sson 1 995, Schoensee et al
co ntra i nd ica t i o n to orthopaedic medicine tech n i q u es.
1 99 5 ) . The upper t h ree celvical segments are most co m m o n ly i nvolved an d associated symptoms may
•
consist of nausea, visual d is t urbances, d i zziness or
causing i n fl a m m a t i o n in the cervical synovial j o i n ts
l i g ht-headed ness ( l u l l 1994a, 1994 b ) .
and t h e refore a capsu l a r pattern. This may occur
Kerry &. Taylor (2006) describe p a i n associated with
•
•
fo l lowing a w h i plash i n j u ry. O n ce the capsu l a r
carotid artery d issection that ca n present as ipsilateral
pattern h a s settl ed, there may b e evidence of a n
posterior neck p a i n and/or frontotemporal headache.
un derlying d isc lesion t o wh ich mob i l ization can be
There are many fo rms of headadle and the overl apping
carefu l ly a p p lied, provi d i ng there is no da mage to the
symptoms make it d i fficul t to isolate headache
vertebrobas i l a r syste m .
due to primary cervical dysfunction. Orthopaedic
•
Traumatic arthritis is produ ced by signi ficant trauma
•
Whip/ash i nj u ry occurs when a car is struck fro m
medicine trea tment techniques can be co nsidered as
beh ind, often w h i le the occu pa nts of t h e i n vo l ved car
a n option if the carotid a rtery dysfunction and other
a re u naware. A hyperextension i n j ury fo llowed by a
contraindications have been ruled out.
hyperflexion i n j u ry occurs. D u ri ng t h e hyperextension
Polymyalgia rheumatica a ffects the m i d d l e an d older
p h ase the a n terior structures, t h e i n t e rvertebral d i scs,
age group, wom e n more than m e n . [t presents as
a n terior lo ngit u d i n a l l iga ment a n d ante r i o r muscles
pa i n and s t i ffness i n t h e neck and shoulder g i r d l e
can be da maged or torn a nd the posterior structures
acc o m p a n i ed by fatigue, low-grade fever, d e p ression
com presse d . D u ri ng the hyperflexion phase the
and weight loss, and responds d ra m a t ical ly to s m a l l
dens may i m pact against t h e a t l as, a n d t h e atlanto
doses of o ra l corticosteroids ( H azel man 1 995 ) .
occ i p i ta l j o i n t, posterior l igaments and zygapophyseal
Gia11l cell arteritis or temporal arteritis is a cond it i o n
joi nts ca n be involved ( Bogd u k 1 9 8 6 ) . The a l a r and
closely related to polymyalgia rheumat ica . [ t is a
transverse l i gaments and the tectorial and posterior
vascul i t i s of u n known aetiology a ffecting the e l d e rly.
a t l a n to-occi p i t a l m e m b ranes can be d a m aged by
The p a t i e n t presents w i t h a severe temporal headache
w h i p l as h i nj u ry (!
and s calp t e n d e r n ess. The cond i t ion is treated
et al 2003 ) . Ge n e ral ly, a w h i p lash i n j u ry may produce
urge n t l y w i t h h igh-dose s t e roids, to prevent b l i nd ness
some pa in i n iti al ly, but it is not u n t i l later that the
( Hazel m a n 1995 ) .
l igam e n ts sti ffe n and produce a seco n d a ry capsular
Rheumatoid arthritis is an i n fl a m mato ry polyarth r i t i s,
pattern due to the tra u m a .
affecti ng fe ma les more th an ma les, with its onset usua l ly between the ages of 40 and 50.
[t
t e n ds to
S i g n i ficant bony or l iga mentous d a m age causes i m m ed i ate p a i n with a rel uctance to move the neck.
fol l ow a re l a ps i ng and re m i tting course. The synovi a l
X-ray evidence of cervical i nstab i l ity is an abso l u te
mem b ra n e becomes i n fl a m ed a n d th ickened to
co ntra i nd ication to orthopaed ic medicine tech n i q ues.
become co n t i n uous w i t h vascu l a r tissue - a co n d i t i o n
A h is t o ry of recent w h i p l as h i n jLl lY has been
k n o w n a s pannus. The p a n n u s causes typical
i de n tified as a poss i b l e risk fa ctor of vascu lar accident
destructive cha nges of l iga m e n ts, cart i l age and bone
( Kleyn h a ns &. Te rrett 1 9 8 5 ) .
(Wal ker 1 995 ) . Rheumatoid arth ri t is can also i nvolve extra - a rt ic u l a r soft t i ssues, e.g. Ach i l l es tendon,
Taylor &. Two mey ( 1 993 ) conducted a n au topsy study of neck spra i n s and showed clefts associated
plantar fascia ( K u m a r &. C l a r k 2002 ) .
with verte bral e n d - p l a te lesions i n trau ma victims.
I t is u ncommon fo r rheumatoid arth ritis t o affect t h e cervical j o i nts o n l y, w i t h out its m a n i festation
These were d i s t i nct from t h e u n covertebral clefts a n d cen t ra l fissu res associated w i t h degeneration of
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cervical d iscs. These so-called rim l esions i nvolved the avascular cart i l age end-plates and t h e o u ter a n n u l us and, in fu rther experiments, showed a poor response to healing. They may be responsib l e for the chron i c pain often associated with whip lash i n j u ri es. Posterior disc herniation through a damaged a n n u l us and haemarthrosis of the zygapophyseal joi nts were a lso observed i n the trauma victims and this is clin ically significa nt in treating the early w h i p lash. The acute spra i n of the j o i nts m a kes this an i rrita b l e lesion wh ich requires pain rel ief and reduction o f i n O ammation. Early mob i l ization - i n l i ne with t h e principles for acute l es ions l a i d o u t i n Chapter 4 may be appl ied, providing gross bony i n j ury and i nstab i l ity are not presen t . Evidence exists to support early mobilizat ion i n whiplash-type i n j u ries to avoid the ch ron ic pai n syndrome developi ng, with i ts associated psychosocial factors ( Mealy et al 1 9 86, McKin ney 1 98 9 ) . Current l i terature suggests that at 3 months, approximately one-third of subjects with wh ip lash injury w i l l have h igh levels of persisting pain and d isab i l i ty (Stewart et a l 2007). The Chartered Sociery of Physiotherapy has produced guidelines for the management of w h i p l ash associated disorder (WAD) fol l owing a review of the available evidence ( M oore et al 2005 ) . The guide l i nes a i m to support practice and to help both physiotherapists and patients to m a ke i n formed choices for con t i n uing management fol lowing assessment. The recommendations are s u m marized as fo llows: • In the acute stage (0-2 weeks after i njury) patients should be given education, active exercise, and advice on sel f-ma nagement ancl a return to normal activity as soon as possible. • In the subacute stage ( 2 - 1 2 weeks after i n j u ry) a m u lti moclal approach should be appl ied i ncluding postural training, manual tech niques and psychological su pport. There is evidence to support that com b i n ed mani pulation and mobilization, muscle retrai ning including deep O exor activiry, acupuncture, education, advice on coping strategies, TENS (transcutaneous electrical nerve sti m u lation), massage and soft tissue techn iques may contribute to pai n reduction. • I n the chronic stage ( more than 1 2 weel<s a fter i n j u ry) exercise therapy, m a n i pu lation a nd mob i l ization (wh ich may be co mbined) and m u lt idisci p l inary psychosocial packages may be effective. Tra i ned heal t h professionals (who are not necessar;ly psychologists) can give psychological support. Within the orthopaed ic medicine approach, gen t l e techniques have been devised for p a i n relief and return of function i n the acute stage, i.e. at an earl ier stage than that recommended by the gu idel ines. Two ra ndom ized control led trials relating
to m a n u a l mobil ization techn iques were scrutin ized i n the gu ideli nes and both were found to h ave flaws. The conclusion was that t here is no evidence regard ing the short- or long-term benefit of early mobil ization, However, Taylor & Kerry (2005) cite Cassidy et a l ( 1 9 9 2 ) and Bal taci et al ( 2001 ) to support the 'com monly held view' that mechanical pain o f acute onset responds wel l to early m a n i p u la t ion, a l though pai n arising from w h i p l ash i n j u ry is not specified. There does not appear to be evidence of no benefit. Sterl i ng & Kenardy (2008) l ool<ed at the heterogeneity of w h i plash and observe that it is i nappropriate to apply the same p rogra m m es of ma nagement to a ll i n d ivid uals s ince they display a ,vide range of d i fferen t characteristics and responses fol lowing the i n j u ry. They recom mend that more research n eeds to be done to be ab l e to identify features of the cond ition that may be identifiable at early assessment, particu larly as pred ictors of poor recovery, to a l low for more specific treatment d i rections. The techn i ques suggested below i nclude G rade A mobil ization, prov i d i n g there is no serious pathology. I n accordance with the guidelines, the patient is given the responsi b i l ity for self-management of the condition, and is i nstructed about posture and exercise, advice to avoid excessive relia nce on a col l a r, appropriate p i llow support and adequate analgesia. Serious, nOll-mechanical conditions may present with signs and symptoms similar to those of a mechanical presentation. For this reason, careful examinat.ion is necessary to eli m inate serious disease which would be colllraindicated for ortho paedic medicine treatment. Patients may present with local symptoms whidl are rarely provoked by movement or pos ture. On exam ination it may be di fficult to reproduce the symptoms. Other more generalized featu res may also be present, such as increasi ng and u nrelenting pain, night pain, weight loss, general malaise, fever, raised erythrocyte sedi mentation rate or other symptoms, e.g. cough. •
•
Spinal infections
may i nclude osteomyel i tis or epidural abscess. The organ ism responsible m ay be Staphylococcus lit/reus, Mycobacr.eri um tuberculosis or, rarely, Brucella (Kumar & Clark 2002 ) . Malignant disease is usually extradura l with bone metastases produced most commonly from primaries in the bronch us, breast, prostate, kidney or thyroid. The re may be a h istory of a gradu a l onset of pa i n and stiffness. the pai n tends to be u n relenting and night pain is usually a feature. The pain is not rel ieved by d i fferen t postures. O n exa m i n ation active movements produce pain and .l i m i tatiOIl in a l l d irections. The passive movements a re preven ted by the e nd-feel of a twang of m uscle spasm and resisted m ovements are painfu l a nd possibly weak. All of these signs and symp toInS are evidence of a gross l esion (Cyriax 1 9 8 2 ) .
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•
•
Practice of orthopaedic medicine
Neurological exa m i n a t io n may reveal excessive
Thoracic outlet syndrome, reflex sympathetic dystrophy
m uscle weakness i n volving several n e rve roots,
a n d worlz- reillted syndromes a l l present w i t h upper
possibly bi la teral l y, in cont rast to a disc lesion t h a t
l i m b signs and sy mp toms w h i ch are some t i m es
tends t o i nvolve o n e nerve r o o t o n l y ( M a t h ews 1995 ) .
d i ffic u l t to isol ate i n to a s i m p l e d iagnostic pattern,
Primary tumours (e.g. men i ngioma, neurofibroma,
pa rticu l a r ly if symptoms have been present fo r a
g l i o m a ) tend to present w i th a gradual onset of
l o ng t i me.
sy mptoms o f cord compression a n d pain i s n o t
•
compression, e n t ra p m e n t and/or postural
Pancoas t's tumour is carci noma i n the apex of t he
al tera t i o n s a ffecting the brac h i a l p l exus a nd its
l u ng wh ich may erode the ribs and involve the lower
acco m p a ny i n g neurovascu lar s t ructu res, a l t h ough
brach i a l plexus. I t accounts fo r o n l y 5% of bronch i a l
debate co n t i nues about i ts existence (Walsh
t u m o u rs. There i s severe p a i n i n t h e s h o u l d e r a n d
1994 ) . D i s t a l symptoms occur, us u a l l y due to
d o w n the m e d i a l aspect o f t h e a r m , w i t h evidence
compression of the lower t r u n k of t.he brach ial
of C8 an d/or Tl p a l sy, poss i b l e a t rophy of t h e u l n a r
p l exus (C8, Tl ), b u t t h e upper a nd m i d d l e t ru nks
aspect o f the h a n d a n d a reduced triceps reflex ( Pi tz
can also be involve d . The con d i tion may be
et a l 2004 ) . Cervical side flexion away from t h e
b i l atera l, w i t h a burn i ng, d u l l aching pa in a long
pai n fu l side may b e t h e o n l y li m i ted neck move m e n t,
t h e m e d i a l aspect of t h e fo rearm. D istal oedema
w i t h passive eleva t i o n of t h e s h o u l d e r on t h e
may be associated with activity, swea t i n g and
sy mptomatic s i d e a l so b e i n g pai n fu l ( Cy r i ax 1 9 8 2 ) .
heav i n ess, and c i rculatory cha nges may be seen
I n terruption of t h e sym p a th e t i c gangl ia c a n p roduce
i n the ha nds. Paraesthesia occurs as t he release
Horner's syn d rome - co nstriction o f the pupil a n d
phenomenon, coming on at n ight, some t i m e after t h e pressure has been released.
d rooping o f the eye l i d on t h e s i d e of the tumour ( Kum ar & C l a r k 200 2 ) .
•
involve m e n t . I t consists of persistent peripheral
consid ered as part of t h e c l i n ica l reaso n i ng requ i red in
b u r n i ng pai n and tend erness which is termed
d i ffere n t i a l d iagnosis:
hyperaesthesia (an a b normal response to p a i n ) or aJ\odynia ( p a i n in response to s t i m u l i that are not
Suprascapular, long thoracic and spinal accessory neuritis usually present w i t h p a i n i n the scapula a nd
upper arm of a p p roxi m a t e l y
3
nor m a l ly noxious ) . Vasomotor and sensolY cha nges
weeks' d u ra t i o n . 0 0
consist of sweati ng, colour cha nges and trop hic skin
exa m i n a t i on, t h e n e c k movements a r e fu l l a n d do
changes together with weakness, tremor, muscle
n o t reproduce the pai n . There is weakness of U1e
spasm an d contractures ( H errick 1995 ) .
a p p ropriate m uscles suppl ied by the affected nerve.
�
The cause may be u n known, or it may be d u e to
Worlz-related syndromes of Lhe upper limb are due
to repet it ive occu pational overuse, prod ucing
trauma or fol low a vira l i n fect i o n . Recovery is usual l y
muscu loskeletal sy mpto ms, once a cel1 a i n
sponta neous over approxi mately
th reshold of acti vity i s exceeded . Someti mes
•
•
•
Reflex sympathetic dystrophy describes a complex
d i sorder of u1e l i mbs with or wi thout obvious nerve
The fo l l owing cond i t i o n s are not serious b u t sho u l d be
•
Thoracic outlet sYlldrome is a term used fo r
usual ly a major feature.
6
weeks.
Suprascap ula r neuritis prod uces weakness of the
t h is may prese n t as a s i m p l e tenosynov i t i s o r
supraspi n a tus a n d i n fraspi natus muscles
t e n d i nopathy but m u c h more o ften i t presents
LOllg thoracic neuritis prod uces weakness of
as a ca t a l ogue of symptoms w h ich are non
t h e serratus an terior muscle a n d wi nging of t h e
speci fic. D i ffuse achi ng, s t i ffness, muscl e or j o i n t
sca p u l a
t i red n ess are present w i t h t h e chronic n a t u re o f
Spinal accessory neuritis produces weak ness of the
the co nd i t ion, perhaps l eading t o anxiety a nd
sternoclei d o m astoid and trapezius muscles
depression ( B i rd 1 99 5 ) . The sy mp toms h ere are
Neuralgic amyotrophy is an un usua l cause of severe
usually associated with factors t h a t a ffect t h e
pa in in the neck a n d sca p u l a r region w i t h a bizarre
v m o b i l ity and circu l a tion of t h e nervous system.
pattern of muscle weakness in the i n fras p i n a tus,
Each co m p o n e n t needs to be recognized a n d a
suprasp i n a t us, d e l toid, triceps and serratus a nterior
s u i t a b l e treat m e n t progra m m e est a b l ished. Neural
muscles. The cause of t h e co n d i t i o n i s u n known, but
tensiooing tech n i q u es can be a p p l i ed to assess
i t may fol l ow viral i n fection o r im m u n izat i o n a nd an
neural mobi l i ty which can be add ressed as part
a l l ergic basis is postulated (Kumar & Clark 2 0 0 2) . I t
of trea t m e n t and self- m a n age m e n t . Orthopaedic
usu a l l y recovers s p o n t aneously over several weeks o r
medicine tech n i q ues are not usu a l ly i ndicated
m o n t h s, a l t h ough recovery may b e more prolo nged
un less speci fic i d e n t i fi a b l e lesions are d i agnosed.
in some cases. •
The p a i n of s h i ngles ( herpes zoster) can precede the rash a nd cervical p a i n a nd headache have been
•
Fibromyalgia u su a l l y presents in women, as a
complex of va r i a b l e sy mptom s i nclu d in g widespread
reponed prior to the appearance o f vesicles i n the
m usculoskeletal pain of t h e neck, shoulders a n d
cervi ca l regi on.
u p p e r l i m bs . Fatigue, head ache, wa king unrefreshed,
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The cervical s p i ne
subjective d istal swe l l i ng, poor concentration, forgetfu l ness and weepiness have been described ( Doherty 1 99 5 ) . M u ltiple hyperalgesic tender spots and non-restorative sleep are the m a i n d i agnostic features of fi bromyalgia. There are several com ponen ts to management: they include the use of relaxation techn i ques, exercise, hydrotherapy, physiotherapy, acupuncture, muscle relaxants and drugs to i m prove the qual i ty of sleep. The condition is d i fficult to separate from endogenous depression and often responds to anti depressant medication ( E. l1uskisson, con ference note 1 99 5 ) . •
•
Cervical spine instability is controversial a nd d i fficult to d iagnose, and there do not appear to be va l i d or reliable tests to help with d i agnosis (Cook et a l 2005 ) . I nstabi l i ty may con tribute t o the c l i n ical presentation of various con d itions including cervicogenic headache, chronic w h i plash associated d isorder, rheumatoid arthritis, osteoarthritis and segmental degeneration. Trau m a, genetic predisposition (e.g Down's syndrome), d isc degeneration and surgery may comprom ise the stab i l izing mechanisms of the spine (Cook et al 2005 ) . I n some cases t h e i nstab i l i ty ca n b e potentia l ly l i fe t h reate n i ng as i n l axity of the transverse l iga m ent associated with rheu matoid arthritis or Down's syndrome where the odontoid peg may be hypoplasic or deformed. Subl uxation of the atlantoaxia l jOint and hype1l110bil ity of the atl a nto-occi p i ta l joint are associ ated with Down's syndrome and m ay occasionally l ead to compression of the spinal cord. Cl i nicians i nvolved in m a n i pu lation should be aware of this risk ( Pueschel et al 1 99 2 , Department of H ealth 1 9 95, Matsuda et aI 1 9 9 5 ) . U pper cervical i nstab i l ity h as been associated with l ocal ized atherosclerotic changes in the celvical vessels. The changes may be associated with repeated m icrotrauma as a result of i ncreased u pper cervical movement. This can be associated with connective tissue inflammatory d i sease, principally rheumatoid arthritis, or acute w h i p lash i n j u lY, as mentioned above ( Kerry & Taylor 2006). D rop attacks are sudden episodes of weakness i n t h e lower l i m bs, causing fal li n g without loss o f consciousness a n d co mplete recovery i n seconds or m i n utes. Drop attacks a re a symptom. not a d i agnosis, and t hey can have d iverse causes. They may be due to changes in tone in the lower l i m b originating i n t h e brainstem, a nd appear t o be related to transient ischaemic attacks ( Ku m a r & Clark 2002 ) . Any i nstability in the upper cervical segment - i.e congenital l igamentous laxity of the arJanto-occipital joint. deformed odontoid process, cervical spondylosis or a spondylolisthesis - can produce drop attacks (Cyria.x 1 982, H i nton et al 1 99 3 ) .
•
They m ay also be due t o t h e heart (a variant of syncope) or prob l ems with both the heart and c i rculation to the bra i n . Seizures and Men iere's disease can be associated with drop attacks and other rare causes have been reported ( H ai n 2009 ) . During the subjective exa m i n ation the patient m ust be questioned about drop attacks and the resu lt noted. Any h istory of drop attacks is a n absolute co ntraind ication to orthopaedic medicine treatment tech n i ques. f(1ippe/-Feil syndrome is associated with a l i mited range of cervical movement, short neck and low hairli ne. Patients usually h ave developmenta l abnorm a l i t i es, including congenital fusion of cervical vertebrae, w h i ch m ay predispose them to the risk of neuro l ogica l sequelae ( Pizzut i l l o et al 1 99 4 ) .
Cervica l a rtery dysfunction •
•
Vertebrobasilar insufficiency produces sym ptoms t h rough a reduced b lood flow in the vertebral arteries to the h i nd b ra i n . Patients often relate t heir sym ptoms to particular head posi tions such as looking u p (Toole & Tucker I % 0 ) . Anato m i ca l anomal ies a r e frequently seen i n t h e vertebral arteries and their cou rse t h rough the cervical foram e n transversariu m . Often the two arteries vary considerably in diameter ( M i tchel l & Mc Kay 1 9 9 5 ) a n d extrinsic o r i ntrinsic factors m ay decrease the l u men of the artery permanently or temporarily. Extrinsic factors i ndude degenerat.ive changes i n t.he i ntervertebral, zygapophyseal a n d u ncovertebra l joints, w i t h osteophyte formation, w h ich may com press or a l ter the course of the artery. I ntrinsic factors i nclude a rterial d isease a nd thrombosis. Wa l l e nberg's syndrome or lateral med u l l ary syndrome is probably the most recogn i zed syndrome of brainstem i n farction caused by vertebral artery pathology ( Fru m k i n & 8aloh 1 9 90, Kumar & Clark 2002 ) . The com mon site of i n jury to the vertebral artery fol lowing neck m a n i p u l ation is at the l evel of the atlan toaxial joint. I n j uries i nclude i n t i m a l tearing, d issecti o n or thrombus formation, i n t ra m u ral haematoma or vasospasm . D.izziness a n d nausea are the m a i n presenting sym ptoms of vertebrobasi lar i nsufficiency. H owever, sum sym ptoms a re a l so associated with celvical dysfu nction; therefore correct diagnOSis is i m portant. A fu l l l ist of possible signs and sym ptoms of vertebrobasilar insufficiency is given with the description of the test l a ter in this chapter. Carotid artery dissection can present suddenly and m ay arise from a s udden movement of the n eck i nvolving extension and rotation (Taylor & Kerry 2005 ) . I t typical ly presents with u n i l ateral upper cervical or a n terolateral neck pain with headache
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Practice of orthopaedic medicine
and/or sensitivity in the fro ntotemporal regi o n
the patient a nd to decide whether contrai n d i cations to treat
( Kerry & Tay lor 2006 ) . Homer's syndrome may
ment exist and/or whether onward referral is in d icated.
be present, associated with ptosis ( d roopi ng eye l i d ) , s u n ken eye, a smal l constricted p u p i l and fac i a l d ryness. Symptoms o f venebroba s i l a r artery
History (subjective examination) The history is particularly i m portant at the spinal joints.
i ns u ffi e n cy ( V B I ) may also be presen t .
Selection o f patients fo r orthopaedic med icine treatment teci1 n i ques relies o n the discal model of d iagnosis and cer tain aspects of the history wi l l assist i n this diagnosis as well
'Red flags' - cervical spine
as highl ighting patients with contra i n d ications to treatment. •
Yo u n g : Under 20
•
Elderly: First episode over 5 5
•
VBI/CAD symptoms
The age, occupa tion, sports, hobbies and lifestyle o f the
patient may give a n i n d ication o f the n a t u re of onset and i ts relationsh i p to habitu al postural prob l ems associated W i tll a particu l a r l i festyle.
•
Previous whipl ash/trauma
•
Past medical hi sto ry of m a l ig n a ncy
•
Constant progressive pain
•
Unremitting night pain
neck pa i n may be associated with a n acute tort i co l l i s,
•
Systemica lly u nwell
possibly a true nuclear d isc lesion.
•
Unexp la in ed weight loss
•
Drug abuse and HIV
•
Long-term systemic steroid use
•
Cough/sneeze increasing arm pain
•
The age of the patient is im portant, part icu l arly at t he celvi ca l spi ne, si nce the type of cervical disc l esion is related to age. I n the young p a t i e n t, child or adolescent,
Disc lesions tend to occur i n the mid d l e-age group, with posterior
Pa in g rad ua l ly worse n i n g over 3 mo nths
•
Inflammatory arthritis OsteopoenicJosteoporotic Down's syndrome
•
T1 weakness
•
Risk factors for atherosclerosis
may be ind ica
Degenerative ci1anges in the i n tervertebral, uncovertebral
H a b i t u a l postures can co n t r i b u te to postural adj ustment,
Side flexion away be in g only painful cervical movement Horn er's syndrome
35
t i ve of serious pathology and this should be excl uded.
Occupation, spo rts, hobbies and l i festy l e of the p a ti e nt
Arm pain under 35
Upper motor neurone signs
Arm p a i n presenting u nder t.he age of
may co n t r i b u t e to the p a t i e n t's signs and symptoms.
•
•
zygaphophysea l
and zygapop hysea l joi nts occur in the older neck.
•
•
herniation;
arm pain, d u e to a l a rge posterolateral d isc prolapse, usu
Neu rological signs and symptoms affecting more than one nerve root
•
posterolateral
a l l y occurs over the age of 35, through progressive prolapse.
•
•
or
j o i nt lesions are also prevalent in this age group. Referred
a l t e red b i o m echan ics and muscle i m bal ance. Examples a re provided by t h e head-forward posture of the visual d i s p l ay unit operator, the side-fl exed posture o f h o l d i n g the t e l e p h o n e i n t h e crook o f the n e c k to leave the h a n ds free, the flexed a n d rotated posture of t h e p l u m be r or b u i l der, or the head -extended posture a l lowi ng the arms to be used above the head i n the p a i n ter or electrici a n . Athl etes may ass u m e certa in postu res rela ted to the i r sport w h i ch may preci pi tate o r co ntrib ute to t h e i r p ro b l e m .
COMMENTARY ON TH E EXAMINATION
The site a n d spread of t h e symptoms give i m porta nt clues to d i agnosis i n the cervical s p i n e a n d highl ight the i m portance of u ndersta n d i ng the mech a n isms o f referred
Observation
p a i n i n a segmental or m u l t isegme ntal pattern. Pain may
Before proceed i n g with t h e his tory, a general observa t i o n
symptoms fe l t in the sca p u l a r area, chest, upper l i mb or
o f t h e patient's face, posture a n d gait is made, n o t i n g t h e
head. The s o l e presentation of i n ternal carotid artery dys
be l ocal ized to the
neck or occur in association with
posture of the n e c k and t h e carriage o f the head . Neck
Fu nct ion may be u n i lateral upper cervical or anterolateral
posture w i l l give a n i m mediate i nd i ca t i o n of the severity
neck p a i n and headache a n d/or sensitivity in the fro nto
and poss i b l e i rri ta b i l ity of the cond i t i o n, e.g. a wry neck
tem poral region ( Kerry & Taylor 2 0 0 6 ) .
associated with acute pain i n which the patient has devel
Nerve root compression i n the cervical s p i n e can o n ly occur at the levels at which the ne rve root can be com
o ped a n a n ta lgic postu re. The box above l ists the 'red flags' fo r the possible presence
p ressed. In the m i d and lower cervical regi ons the roots are
of serious pathology tlla t should be I istened fo r and identi
u nder threat from the i n tervertebral discs, u ncovertebral
fied t h roughout the subjective and objective exa mination.
jo i n ts and zyga pophyseal joi nts which fo rm the bou nda
I n isolation, many of the flags may have l i m ited significance
ries of the i n tervertebral fo ra men.
but it is for the cl i nician to consider the general profile of
not ru n in i n tervertebral fora m i na, therefore compressi o n
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and 2 nelve roots do
Chapter
I 8 I
The cervical spine
of these nelve roots is not the mechanism for up per cervi
the intrathecal p ressu re, and necl< pain produced with
cal pain.
any of these may indicate disc compression or tumour.
(t is important to establish the nature of the onset and
With regard to the latter, pain p roduced in the arm on
duration of the symptoms, not just of this current episode
coughing or sn eezing is considered to be a 'red flag', i.e.
of pain, but of all p revious episodes. Cervical disc lesions
a sign of serious spinal pathology, that warrants further
tend to be a progression of the same incident, and estab
investigation, and would prov i d e a contrai ndication to
lishing a histo lY of increasing and worsening episodes of
treatment. Paraesthesia may be related to n e rve root compres
pain assists diagnosis. The onset may be sudden or gradual. It may be precipi
sion . Sympathetic symptoms such as hot and cold feel
tated by a single incident, such as a whi plash inju ry due
ings, heaviness, puffiness or circulatory symptoms may
to a motor vehicle accident, or a sudden unguarded move
be related to nerve root compression or tho racic outlet
ment, such as missing a footing. I f traumatic in onset, the
syndrome, reflex sympathetic dystrophy or work- related
exact medlanism should be established: was it hyper flex
u pper limb disorder.
ion, hyperextension or excessive rotation ! If the condition
Other causes of neck pain and associated symptoms
developed gradually, is it associated with habitual postures,
should be eliminated, such as thoracic outlet syndrome,
or a change in posture, such as sleeping in a different bed! The patient with whiplash injUlY without serious bony complications p resents w ith pain felt at the time of the
which may produce similar sym ptoms to upper ce lvical syndromes. Sym ptoms may include facial pain, tinnitus, auditolY and visual disturbances.
trauma which settles. Twenty-four hou rs later, pain and
From the history, specific questions must be asked to
stiffness develop due to the ligamentous involvement
eliminate vertebrobasilar and carotid a rtery problems and
and muscular strain. The w h iplash patient who has severe
problems of instability in the u pper cervical joints, which
pain from the time of the trauma may have more serious
would contraindicate treatment. A desc ription of unilateral
u nderlying pathology, e.g. fracture and/or dislocation.
frontotem poral headache as 'unlik e any o Lher' should raise
Headache of sudden onset may be an indication of
concerns of intemal carotid dysfunction ( Kerry & Taylor
internal carotid artery dysfunction (Taylor & Kerry 2005,
2006). It is im portant to consider any risk factors for vas
Kerry & 'taylor 200 6).
cular disease, specifically atherosclerosis, that may help in
The duration of the symptoms helps to give a p rognosis
d i fferential diagnosis to distinguish pain associated with
of the patient's condition as well as providing an indicator
cervical a rte.ry d issection or to guide t reatment selection to
for serious pathology, being always on th e alert for possible
minim ize the poten tial risk from cervical techniques.
contraindications to treatment. General ly, the patient who
The risk factors for at herosclerosis includ e: hyperten
p resents with a short duration of symptoms responds bet
sion, raised blood cholesterol, l i p ids and free radicals, dia
ter to treatment. Disc pathology tends to be self-li miting
betes mellitus and genetic c l otting disorders or p ro pensity
and generally symptoms will resolve s pontaneously. With
to thrombus formation (tal
repeated episodes, however, this tends to take longer and
haul flight or s urgery ). Smo k ing, infection and di rect
longer. Nerve root compression may follow a mechanism
vessel trauma also provide an increased ris k of athero
3
sclerosis ( Kerry & Taylo r 2006). The list is extensive and
of spontaneous recovery in
or
4
months, p roviding the
patient loses the cent ral symptoms.
it could be argued that the risk factors a pply to a la rge
Recurrent symptoms may indicate a cervical disc lesion
proportion of the population. The advice is to consider
or degenerative arthrosis which tends to present with peri
the patient's
ods of exacerbation of symptoms I n flammatory arthritis
between ensuring patient safety and a pplying a p propriate
may present a similar pictu re, but it has usually manifested
treatment.
itself in other joints before involving the cervical spine. The symptollls and behaviour need to be conside red.
profile but to maintain a wise balance
Explore any complaint of dizziness, nausea, faintness, tinnitus or visual p roblems. Ask s pecific questions about
The behaviour of the pain will give an indication of the
dro p attacks, i.e. 'Do you ever fall to the ground without
irr itab iliry of the condition. Make a note of the daily pat
losing consciousness ?'. Establish the p resence of pins and
tern of the pain. If it is easier fi rst thin g in the morning
need les and numbness and note exactly where. Consider
and worse as the day goes on, easing up again with rest,
wheLher the distribution of Lhese symptoms fits with seg
this could indicate a comp ress ion p roblem or a postural
mental referral or is more a sympathetic featu re. Jt may
problem. If it is uncomfortable and s t i ff in Lhe morn
be p ertinent to ask about headaches, fatigue and stress, or
ing and painful on certain movements, this is indicative
blurred or dull vision.
of an active arthritis. It may be due to an acute episode
Other joint involvement will give an indication of previ
of degenerative osteoarthrosis, or inflamma tOIY a l1hritis
ous p ro blems which may o r may not be related. Look for
such as rheumatoid arthritis o r ankylosing spond yl i tis.
evidence of rheumatoid a rLhritis, usually in the smaller
Pain not at all relieved by rest and with unrelenting n ight
joints, remembering that the disease process may be quiet
pain indicates serious pathology such as tumour.
in the cervical spine. Ankylosing spondylitis usually sta rts
Of what other sy mptoms does the patient co m plain? Coughing, sneezing or straining cause an increase in
in t h e sacroi liac joint (s) and lumba r spine or hips. Note the p resence of generalized degenerative osteoarthrosis.
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Ask about pa s t medical h is tory and consider a ny serious i l l ness or operations. It is advisable to ask about previous trauma i nvolving the neck: a history of whiplash is con si dered a risk factor in vascu lar accidents ( K leynhans & Terret 1 9 85). Exp l ore previous s i m ilar episodes of neck pain ilnd any previous treatment. Check the medications currently taken by the patient, as anticoagula nts and l ong-term systemic steroid use may present a contraind ication to the treatment techniques. Ask about any pain-rel ieving d rugs to give an i n d ication o f how much pain con trol is req u i red by the patient. As anti depressants may also be prescribed fo r chro n ic pain they may give an ind ication o f the patient's general pain profile. Antistatins and anti hypertensive drugs should also be noted in relation to potential risk factors for d i agnosis and treat ment selection.
Articu'lar signs •
Active cervical extension (Fig. 8 . 1 0)
•
Active cervical right rotation (Fig. 8. 1 1 a)
•
Active cervical left rotation ( F i g . 8 . 1 1 b)
•
Active cerv ical ri g ht side flexion (Fig. 8. 1 2a)
•
Active cerv ical left side flexion (Fig . 8 . 1 2 b)
•
Active cervical flexion
•
Passive cervical extension (Fi g 8. 1 4)
•
Pass ive cervical right rotation
•
Passive cervical left rotat ion (Fig. 8 . 1 5 b)
•
Pass ive cerv ical r igh t side flexion ( F i g . 8. 1 6a)
•
Passive cerv ical left side flexion (Fig. 8 . 1 6b)
The patient should undress down to underwear to the waist, and be i n a good l ight. A general i nspection w i l l reveal a n y bony dejomliLy. The general spinal curvatures are ap preciated, assessi ng for any i ncreased or decreased cervical l ordosis, ti l t or rotation, abnorm a l i ties in the cer vicothoracic j u nction and u pper thoracic kyphosis, sco l io sis, or the presence o f an antalgic posture. Ab normal fa tty tissue sometimes develops over C7, in association with postural deform ity a t the cervicoth oracic junction, and this is known as a 'd owager's hump'. S i m i lar fatty tissue can often be seen i n rugby p layers in the fron t row of the seru m. The head carriage is also noted, l ooking fo r exces sive protraction or retraction. Colour changes and swelling wou ld not be expected in the cervical spine u n l ess associated with a h istory of d i rect trauma. A neuritis wou ld give the appropriate wast ing of the mus cles supplied by the nerve involved and the neck shoulder and scapular area should be assessed for obvious muscle wasting. Some unusual nerve pathologies produce bizarre patterns of bilateral asymmetrical wasting, e.g. neuralgic amyotrophy. I n disc pathology with nerve root com pres sion, muscle wasting may not be obvious on i nspection.
State at rest Before any movements are pe rformed, the state at rest is establ ished to provide a basel i ne for subsequent com parison.
Examination by selective tension (objective examination) The suggested sequence fo r the objective exa m ination w i l l now be given, fol l owed b y a commentary including the reason i ng i n performing the movements and the signifi cance of the possible fi n d i ngs.
.
(Fig. 8. 1 5a)
Resisted tests are not part of the routine examination, but may be appl ied here •
Inspection
(Fig. 8. 1 3)
Resisted cervical extension (Fig . 8 1 7)
•
Resisted cervical rotations (Fig . 8 . 1 8)
•
Resisted cerVical side flexions ( F i g . 8. 1 9)
•
Resisted cervical
flexion (Fig. 8 . 2 0)
Elimination of the shoulder joint •
Active shoulder elevation (Fig. 8 2 1 )
Resisted tests for objective neurological signs and alternative causes of arm pain; the main nerve roots are indicated in bold •
Shoulder elevation, trapezius (Fig. 8 22): spinal accessory nerve X I ( 3, 4
• •
•
•
Shoulder abduction, supraspinatus (Fig. 8.23): ( 4 , 5, 6 Shou lder add uction, latissimus dorSI, pectoralis major, teres major a n d minor (Fig. 8.24) ( 5, 6, 7, 8, T1 Shoulder lateral rotation, infraspinatus (Fig. 8 . 2 5 ) : (5, 6 Shou lder medial rotation, su bscapularis (Fig. 8 26), (5, 6
(Fig. 8 . 2 7) ( 5 , 6 (Fig. 8 28) ( 6 , 7, 8
•
E l bow flexion, biceps
•
Elbow extension, triceps
•
Wrist extensors (Fig. 8 29): ( 6, 7, 8
•
Wrist flexors (Fig. 8 30) (6, 7, 8, T 1
•
T h u m b add uctors, adductor brevis (Fig. 8. 3 1 ): ( 8 , T1
•
Fi nger add uctors, palmar i nterossei (Fig. 8 32): (8, T 1
Skin sensation (Fig,
8.33)
•
Thumb
•
I n dex, middle and ring fingers: ( 7
•
M i d d le, ring and little fingers: (8
and i n dex fll1ger: (6
(Fig. 8 . 33)
Reflexes •
Biceps ( F i g . 8 34) ( 5 , 6
•
Bra chio ra dia l is (Fig. 8. 35): ( 5, 6, 7
•
Tri ceps (Fig. 8
•
Plantar response (Fig. 8 37)
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Chapter
I 8 I
The cervi cal spi ne
Figure 8 . 1 0 Active extension.
I. ,
1 Figure 8 . 1 1 Active rotations .
Figure 8.1 2 Active s ide f lexions.
Figure 8.13 Active f lexio n .
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figure 8.14 Passive exten sion.
Figure 8 . 1 6 Passive side flexions.
figure 8. 1 5 Passive rotations.
Figure 8. 1 7 Resisted extension.
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Figure 8 . 1 8 Resisted rotations.
Figure 8 . 2 1 Active shoulder elevation to elimi nate the shou lder as a cause of pain.
Figure 8. 1 9 Resisted side flexions.
Figure 8.22 Resisted shoulder elevati on.
Figure 8.20 Resisted flexion.
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Figure 8.25 Resisted s ho ul der lateral rotat ion .
Figu re 8.23 Resisted shoulder abd uctio n .
Figure 8.26 Resisted shou lder medial rotation.
F i gure 8 . 2 4 Resisted shou lder a d d u ction.
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Figure 8.29 Resisted wrist extens i o n .
Fig ure 8.27 Resisted e l bow flexi o n .
Fig u re 8 . 30 Resisted wrist flexio n .
Fig u re 8.28 Resisted elbow extens i o n .
Figure 8 . 3 1 Resisted t h u m b adduct i o n .
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Figure 8 . 3 2 Resisted finger adduct i o n .
Figure 8.35 Brachioradialis reflex.
F i g u re 8 . 3 3 C hecking skin sensation .
F i g u re 8.36 Triceps ref l e x
Figure 8.34 Biceps reflex .
F i g u re 8.37 Plantar response.
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.
Chapter
I 8 I
The cervical spine
The routine examination of the cervical spine includes
The plantar response is assessed by stroking up the lateral
active, passive and resisted movements. Since the spinal
border of the sole of the foot and across the metatarsal heads.
joints are considered to be a potential focus for 'emo
If the response is extensor, i.e. upgoing, it is indicative of an
t i onal' symptoms, six active movements are conducted
upper motor neuron lesion. The normal response is flexor.
assessing willingness to move, range of movement and
The objective examination sequence provides a basic
pain. The capsular or non- capsular pattern may also
assessment framework to glean i m portant information
emerge from these active movements.
towards the selection of patients appropriate for the treat ment tedhniques used in orthopaedic medicine. It a l so highlights
Capsu l a r pattern of the cervica l spine
l.
Equal lim i tation o f ro tations.
•
Some limi tation of extens i o n .
•
Usu ally full flexion.
contraindications
Any other assessment
Equal lim itation of side flexions.
•
possible
and
provides
a
guide for the specific treatments to be used. procedures may be included
throughout the sequence or explored separately after wards, including vestibular apparatus tests for benign par oxysmal positional vertigo (BP PV), either to elicit extra
--------�
information for the purposes of the ap plicat ion of other treatment modalities, or to confirm findings necessitating patient referra l .
I n a non-capsular pattern of the cervical spine, some movements are lim ited and/or painful and others are full and pain-free. The presence of a non-capsular pattern indicates a possible disc displacement. Normally move ments at the cervical spine do not occur in isolation, but the examination procedure is conducted simply by assess ing the individual movemen t s. It should, however, be remembered that flexion and extension occur with a com ponent of translatory glide, while side flexion and rota tion occur as a coupled movem ent. The passive movements are assessed to determine the t r u e limitation of range of movement and the end-feel. The pattern of limited movements should be the same as that found on active movements, although the range may be slightly more. Normally passive extension has a hard end-feel, passive rotations an elastic end-feel and passive side flexions an elastic end-feel due to tissue ten sion. Passive flexion is not assessed because it would tend to aggravate the symptoms of disc lesion. The resisted tests are not part of the routine examina tion at the cervical spine, but should be ap plied if there is a history of trauma, e.g. for a muscle lesion, sLispected serious pathology such as fracture or
metastases,
or
i I I ness behaviour. The resisted tests also assess the Cl and 2 n erve roots. Resisted flexion may produce pain in a disc lesion since it causes compression. The shoulder joint complex is elim inated as a cause of pain by active elevation. If this is full range and pain-free, the shoulder can be eliminated from the exa m ination. Assessnll'nt for objective root signs is conducted by a series of resisted tests for the myotomes, looki ng for a pat tern of muscle weakness which would ind icate nerve root com pression. Since it is also impol1ant to el iminate other causes of arm pain, the musd e groups are also assessed, looking for alternative causes of pain. This explains why the sequence appears to test the same nelve roots several ti mes.
CERVICAL LESIONS - A CLASSIFICATION SYSTEM OF THREE CLIN ICAL MODELS In the past, treatment i n orthopaedic m edicine has been traditionally targeted at the disc, aiming to reduce dis placement, relieve pain and restore movement. However, there is a lack of confidence in these traditional pathoan· atomical diagnostic labels, since the cause of pain cannot be confidently loca l i zed to one specific structure ( Peake & Harte 2005 ) . Consequently, several authors have estab lished classifi cations to determine treat ment progranl m es and to predict prognosis ( Mc Kenzie Laslett & van Wijmen
1981,
Riddle
1 9 98,
Tseng et al 2006).
While not ideal, the p resentation of signs and sym p toms of cervical lesions has been classified here into clini cal models adapted from Cyriax's original theories. These models are judgment based and contribute to the clinical decision -making process to rationalize appropriate treat ment programmes, but are not intended to be restrictive. The reader is encouraged to be in.ventive, to draw on other experiences and to implement the a pproadh into their existing knowledge when putting a treatment progra mme together for individual patients. The t.reatment tedhniques described are by no means a cure-all for every case of neck pain.
H owever, uncom plicated lesions of recent onset
may respond well to the mobilization and manipulative tedhniques of orthopaedic medicine. The key is the selec tion of appropriate patients for treatment. For the purposes of the following classification of lesions, a cervical lesion presents with the following features: •
An onset of neck pain whidh may be in a
•
A typical medhanical history that describes pain
m ultisegmental or segmental distribution (see Ch.
A quick check of skin sensation to light touch is made looking for di fferences. Paraesthesia commonly affects the
1 9 99,
1)
distal end of the dermatomes and these are assessed, fol
aggravated by il ctivity and certain postures, such as
lowed by the biceps, brachioradialis and triceps reflexes.
sitting, and rel. ieved by rest and postures such as lying
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I 2 I •
•
•
•
Practice of o I1hopaedic med icine
Sym ptoms such as a cough or s neeze i ncreasing the pai n and possible paraesthesia i n a segm e ntal pattern No significant 'red' and 'ye l low flags' presen t in the h istory Exa m ination revea l i ng a no n-capsular pattern of move ment No contra i n d ications to treatment.
Clinical Model 1 : acute torti co l l i s
Factors from the subjective examination • •
•
• •
Adolescent or young adult M a i n ly central, or short b i lateral or u n i l atera l neck pain Patient usually wakes with severe onset of pain, not attributable to any preci pitating cause.
A n ta lgic posture Non-capsu lar pattern of pa i n fu l movements No neurological signs.
Factors from the subjective examination
•
•
• •
•
Cl inical Mode l 2
•
Factors from the subjective examina tion
•
A conve n ient shonhand fo r record i ng the fi n d i ngs of the objective exa m i nation can be found in Appendi.,'( 3 where the 'star diagram' is exp l a ined. Treatment consists of reassurance to both the patient and parents and progressive positi o n i ng out of the deform ity may exped ite reduct i o n . Pai n-rel ieving modal i ties m ay be applied, e.g. analgesics, electrotherapy, mas sage a nd gen t l e mobil ization. Gentle traction may be appl ied in the form of the 'bridging' technique and pro gressed to manual tract ion, depe n d i n g on irritabi l i ty. Tracti o n is applied i n l i ne with the d eformity i f the neu tral position ca n not be assumed. The co ndition usually resolves spontaneously i n 7-10 days. This treatment procedure can be app l ied to any acute/ irri table neck in the abse nce of cont raindications, e.g. the acute w h i p lash patient or the patient who fits classi fica tion of C l i n ical Model 2, but who has adopted an a ntalgic 'wry' neck and is too i rritable for the treatment regi me suggested below.
•
Cl i nica l Model 3 : presenting with referred arm symptoms
•
Factors from the objective examination •
Treatment of choice is to fol low the cervical manual traction and mobil ization routine described bel ow, pro viding no contraindications to treatment exist.
Cen tral, or short b i l ateral or u n i lateral neck or scapular p a i n Gradual or sudden onset Patient m ay or may not recal l the exact mode and time of onset.
Factors from the objective examination •
•
•
Non-capsular pattern of pai nful and l i m ited movements No neurological signs.
l'lo n-capsular pattern of movements producing neck a nd/or arm symptoms Root signs m ay be present, i . e. muscle weakness, absent or reduced reflexes.
The hypothesis is more readily rational ized h ere. Due to the nerve root i nvo lvement a l a rge posterolatera l prol apse of d isc material cou ld have occurred, producing pain referred i n to the arm through compression of the d ural nerve root sleeve or the nerve root i tself. Pain, therefore, is segmental in d istri bution. I f the nerve root is i nvolved, there w i l l be objective neurological signs. Since the nerve roots emerge horizonta l l y i n the cervical spi ne, only one nerve root should be invo lved in d isc lesions. The qual i ty of the pain helps to distinguish somatic and rad icu lar pain (see Ch. 1 ) . M u rphy (2006) presented a case report where a patient d evel o ped arm pain a fter cervica l m a n i p u l ation. I t was concluded that where cases of cervical hern i ated d isc do occu r, apparently after cervical manipulation, it is impossible to be sure that the worsen i ng sym ptoms actu a l ly resu l ted from the treatment or whether symptom progression occurred due to the natural h istory of the cond i t i o n . Van Z u n d e n et a l ( 2006) put forward the fol lowing c l i n ical tests as useful for the diagnosis of cervical rad icu lar pain: •
Factors from the objective examination •
Patient usually over the age of 35 I n itial presentation of central or u n i lateral neck a nd/ or scapular pain, fol l owed by referred arm pain (the central pain ceasing or d i m i n ishi ng) Sudden or gradual onset Often part of a h istory of increasi ng, worsen i ng episodes; therefore a progression of the above scenarios Patient may or may not recal l the exact ti me and mode of onset Patient may com p l a i n of root symptoms, i . e. paraesthesia felt in a segmental pattern.
•
Spurl i n g's test: reproduction of the patient's neck and/or arm pain by com b i n i ng extension of the spine with the head rotated towards the affected shoulder whi lst app lying axial compression. Shoulder abduction test: the arm pain is rel i eved when the patien t l i fts a hand above the head.
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Chapter •
I
I
8
The c{,.lVical sp i ne
In terms o f I ikely response to m a n i p u l a t i o n , the i d e a l
Axial manual tract i o n test: the a r m pain is rel ieved
p a t i e n t wi l l fit i n to t h e patter n of s i g n s a n d sym ptoms
by the a p p l icat ion of an axial tract i o n Force of approx i m a tely to- I S kg in s u p i n e lying.
that i n d icate C l i n i ca l Model 2 . In this m o d e l th ere w i l l be
They note t h a t all t h ree tests have a h igh speci ficiry b u t l o w se n s i t i v i ry b u t a r e valuable a i d s in t h e cl i n ical d i agno sis of a pat i e n t w i t h neck and arm p a i n n o n et h e less. Treat m e n t is a i med at reliev i ng p a i n . If n e u ro l ogical s igns are p resent,
m a n i p u l a t i o n is not strictly co n t ra
i n d icated prov i d ed the neurological signs a re m i n i mal and stable, i.e n o n -progressive, a n d that no o t h e r co n t ra i nd ica t i o ns exi st . l' l owever, the m o re peri phera l the s igns and symptoms, the less l i kely ma n i p u la t i o n is to succeed, and other mod a l i t ies, e.g m a n u a l or susta i n ed mech a n i c a l traction a n d m o b il i zati on, may be m o re effective i n rel ievi n g sym ptoms. An epi dural of corticostero i d and loca l anaesth e t i c may be i n d i cated, but t h is is a speci a l i s t procedure us u a l l y con ducted under u l t rasonogra phy. Si nce t h e n a t u ra l h i s t o ry o f d isc hern i a t i o n is one of recovery over t i m e w i t h o u t the i nterve n t i o n o f su rgery, a m echa n i s m o f spontaneous recovery may occur (Saal et al 1 9 96, Bush et a I 1 9 9 7 ) .
a h istory of sudden or gradual onset o f ce ntral, shol1 b i lat eral or u n i l a teral neck and/or scapu l a r pain. On exa m i na t i o n there is a n o n-caps u l a r pattem of l i m it ed move m e n t and no objective neuro l ogical signs. To be i d e a l i n terms of l i kely effectiveness of trea t m e n t , t h e sy mptoms s h o u l d be of rece n t o nset a n d h a v e m i n i ma l reference of pa i n . The more peri p h eral t h e sy m p toms, t h e less successful t h e tech niq ues described t e n d t o b e . Provided th ere a r e no co n t ra i nd ications to trea t m e n t , a regi me of cervical m o b i l iza t i o n is co m m enced. Tre a t m e n t tec h n i ques a r e c h o s e n based o n a conti nuous assessment a p p roach . Afte r every tec h n iq u e the pat i e nt's comparab l e signs a re reassessed . Fo l lowi ng each session of trea t m e n t, adv ice is given about neck care, general posture, s l ee p i n g postures a n d p i l l ows. M a i n t e n ance exercises are given i f they are appro p ri ate and the p a t i e n t i s sta rted o n a s e l f- h e l p progra m m e t o prevent recurrence. M o b i l iza t i o n and m a n i p u l a t i o n tec h n i q ues in ortho paedic med icine usually produce i m m e d iate res u l ls. One, t"vo or t h ree sessions of trea l m e n t wo u l d be expected.
TREATMENT OF CERVI CAL LESIONS I t is recom m e n d ed t h a t a course in orthopaed ic m e d i c i n e is attended b e fore the treatment tech n i ques below are a p p l i ed in c l i nical practice (see Appendix
l).
Trea t m e n t o f cervical l esion s depends o n t h e nature o f t h e pa i n and class i fi cation of t h e sy mptoms (see above ) . If the pain is su bacLlte, i . e. with low severiry and i rr i t a b i l i ty, a reg i m e o f m o b i l iza t i o n can be co m menced, progressi ng to m a n i p u l a t i o n if necessary. I f Lhe p a i n is acute, i . e. with h i gh seve rity and i rritab i l i ty, a ge n t l e r a p p roach to treat ment is adopted. In chronic cervical cond i t i ons, a th or
Ve rnon &. H u m p h reys ( 2 008) reviewed cha nge scores i n rando m ized co n t ro l l ed trials after o n e session o f m a n u a l therapy a n d fou n d moderate- t o h i gh-qu a l i ry ev id ence th at i m med i a te i m prove m e n ts were obta i n ed after o n e session o f m a n i p u l a t i o n . T h e evi de nce fo r m o b i l ization was less substa n t i a l w i t h fewer studies re porting s m a l l e r i m medi ate i m prove m e n ts . There was no evidence
fo r
a single session of m a n u a l tract i o n . I f a p a t i e n l is not respond ing to the approach, i l i s a b a n d o n ed a n d o l h e r m o b i l ization a n d trea t m e n t moda l it i es attem pted.
Contra indications
ough ex a m i na t i o n m ay reveal several co mponents to t ile
It
d i agnosis, adverse neura l tens i o n and m u scle i m b a l a nce,
co nt rai n d i ca t i ons and not h i ng can subst i t ute fo r a rigor
is i m possi ble to be absolutely defi n itive a b o u t a l l
fo r example, toget her w i t h underlying psychological fa c
ous assessment of the p res e n t i n g s i gns and sy m p toms a n d
tors such as anxiery and d e p ression. Al l co m p o n e n ts o f
a n accurate d i agnosi s of a mechanical cervical l es i o n .
Lhe patien t's co n d i t i o n must b e addressed a n d t h e ortho paed ic
med i c i n e
approach
and
treatment
tech n iques
'Red
flags'
are
s igns
and
sy m p t o m s
fou n d
in
the
p a t i e nl's subjective and objective exa m i n a t i o n that may
sh ould form o n l y part of t h e trea t m e n t p rogra m m e. Th e i r
i n d icate serious pathology and provide contra i n d i cations
use i s n o t i n tended t o b e exclusive.
to cervical m a n i p u l a l i o n (Green halgh &. S e l fe 2006, S i zer
Ve rnon et al ( 2007) cond ucted a review to explore the
et a l 2007) (see Red flags p . 1 9 4 ) .
effect of manual th erapy on p a t i e n ts w i t h chronic neck
The absolute co n t ra i n d ications a re h i ghl ighted i n t h e
p a i n, not due to wh i p l ash i n j u ry, and not i n cluding head
d iscuss i o n below but there are severa l re l a t i ve c o n t ra i n d i
ache or a nn p a i n . There was moderate- to h igh-q ual i ry
cat i o ns t h a t s h o u l d b e co nsidered a s wel l . It m a y be useful
evi dence that patients w i Lh t h e features descri bed show
to use Lhe m n e m onic 'COINS' ( a contract ion o f 'contra i n
cl i n ical i m p rove m e n t s from a cou rse of spinal m a n i p u la
d i catio ns' ) , a s a n aide-mernoire t o be a b l e to create m e n t a l
tion or mobil ization at 6, 1 2 and up to 104 weeks post
categories fo r the absol ute con tra i nd icati o n s : Circ u l a t o ry,
trea t m e n t . The patient w i t h more chro n i c neck p a i n is not
Osseous, Infla m m a to ry, Ne u ro l ogical and susp i cious fe a
usually p u t fo rward for the techn iques in t h i s text but the
t u res i n d icati ng Serious pathology. If the first and l ast two
review does sti mul ate th ought fo r t h e w i d e r appl ica t i o n
l e tters are pushed togelher as 'CONS', the cru c i a l need fo r
o f the ap proach.
conse n t is emp hasized.
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'COINS'
l
Circul atory : ���:���atory Neurological Serious •
•
•
--------�
The trea t m e n t reg i m e d i scussed i n t h is chapter i s abso l u tely contra i n d i ca ted i n t h e absence of informed patient consent. The patient s h o u l d be given a l l deta i l s of t h e i r d i agnosis togeth e r with t h e proposed trea t m e n t reg i m e a n d a d iscussion of t h e risks a n d benefits s h o u l d ensue to e n a b l e t h e m to give their i n formed consen t ( O p p e n h e i m e t a l 2005 ) . Consent i s t h e p a t i en t's agree m e n t, written or oral, for a h e a l th professional to pro vide care. I t m ay range fro m an active request by the p a t i e n t fo r a particu l a r trea t m e n t reg i m e to the passive accepta nce of t h e h e a l th p rofessional's advice. The proc ess of consent, w i t h i n the context of orthopaedic med i ci n e, is 'fl uid' rather than o n e i nsta nce i n t i me when t h e patient g i ves their consent. The patient i s constan t l y m o n i tored a n d feed back is actively requested. T h e treat m e n t p roced ures can be progressed or stopped a t t h e p a t i e n t's request o r i n response t o adverse reactions. Reassessment is cond ucted a fter each tech n iq u e and a j udgment made about proceedi ng. The patient h as a right to refuse consent a n d t h i s s h o u l d be respected and a lternat ive treatment options discussed. For fur ther i n formation o n consent, the reader i s referred to the Depart m e n t of H ea l t h website: www. d h . gov. u k/consent. Drop attacks a re an absolute contrai nd ication to the orthopaedic medicine cervicaJ mobil iza t ion proced ure, including m a n i p u l ation, si nce these may be ind icative of upper cervical instability or related to transient ischae mic attacks. S i m i larly, patients with a h istory of cerebro vlISwlar accident, transient ischaemic attacks or other tipper motor neuron lesions wou ld be contraindicated and other treatment m od a l ities shou l d be considered i f n eck pa i n is a feature i n t h ese patients. U pper cervical spine i nsta b i l i ty is a lso associated with Down's syndrome and active cervical rheumatoid arthritic changes. Liga mentous laxity m ay be a feature of pregnancy, making pregnancy a relative contra i nd ication to m a n i p u lation. A gradual onset of i ncreasing p a i n over 3 m o n ths may be ind icative of i nflam matory arthritis, wh ich may be a relative contra i ndication. A n kylosing spondyli tis and other spondyl oarthropath ies, for exam p l e, may not a ffect the cervical spi ne, in which case the cervical mobil iza tion regi m e d iscussed below wou l d not be contra i ndi cated 3Jld individual j udgments wou ld need to be made for each case. Rheumatoid arthritis, which usu a l ly affects the s m a l l e r j o i n ts symm etrical ly, may be progressi n g
subcl i ni ca l ly in the cervical spi ne; therefore the tech niq ues d iscussed below would be contraind icated. A subjective exa m i nation w i l l screen a patient fo r symp toms of vertebrobasilar insufficiellcy and, if present, the treatment regi me d iscussed below wou l d be abso lutely con traindicated . H owever, dizziness, a major symptom of vertebrobasilar insufficiency, is more co m monly a symp tom of cervical dysfunction. Reid & Rivett (2005) con ducted a systematic review of the effectiveness of manual therapy for cervicogenic d izziness and found that there was some evidence, th ough acknowledged as l i m i ted, to support the use of manual therapy in treating cervico genic d i zzi ness. Therefore accurate diagnosis is essential here i n order to prevent a large group of patients being denied a worthwh i l e treatment regime. The merits of the testing procedure for vertebrobasilar insufficiency w i l l be discussed below and currently it is advisable to conduct a recognized test before applyi n g manipulation. A positive vertebrobasi/ar test wou l d be an absol ute contraind ication to man ipulation. If the cause of dizziness cannot be ascer tai ned, it wou l d be wise to err on the side of caution. Suspicious features ind icative of non-mechan ical lesions would be an absolute con t raind ication to the orthopaedic medicine treatment regi me. These symptoms should not be considered in isolation but in the general context of the whole exam ination procedure and may i nclude unex plained weight loss, poor general health, pain unaffected by posture or activity, constant pain of which n ight pain is a feature and double root palsy and cord signs such as spastic gai t and/or abnormal plantar response. The patient with a past h istory of pri mary tumour is not strictly contra indicated, but d iagnosis of a mechan ical lesion must be certain before proceedi ng with the treatment regime si nce the pain of bony metastases may m i mic mechani cal pain. Suspicious findings occur in Pancoast's tumour (a tumour i n the ape.,'{ of the l ung) which may affect the lower trun ks of the brachial plexus resu lti ng i n medial arm pain and C8 and/or 1'1 palsy that may be evident as atrophy of the u l nar border of the hand and a reduced triceps refle.,'{ (Pitz et a l 2004 ) . Objective exa m i nation may reveal provo cation of pai n by side flexion away from the painful side as the o n ly positive cervical sign and this wou ld be an unu sual finding i n a cervical d isc lesion. Consider risk factors for atheroscl erosis and symptoms that could be associated with i nternal carotid artety dysfunction, i ncluding headache described as 'unl i ke any other' (Kerry & Taylor 2006). Sym ptoms of cervical d isc l esions can genera l ly be traced back to show a h i story of i n creasing and worsening e pisodes. Therefore cervical rad iculopathy genera l ly affects the over 35 age group. Of course, this can also occur in the younger age group, but d i agnosis is aga i n para mount, s i n ce this can be a suspicious feature associated with tumour. As in the lumbar spi n e, for the arm symp toms to be indicative of a m echanica l l esion, the cen tral sym ptoms a re expected to subside considerably at the onset of arm pain. The nerve roots emerge horizontal ly, cert a i n ly i n the upper cervical spine (see discussion i n the
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anatomy section); therefore mu l ti p l e nerve root involve ment should be cons idered susp i cious until the screening procedures in the subjective and obj ective examination con firm a mecha nical diagnosis. S imilarly, double nerve root involvement is unusual, particularly as the vertebral cana l in the cervical region is large and can more read ily accommodate a disc prolapse than in the lumbar spine. Bilateral arm signs and symptoms would therefore be an unusual p resentation of a mechanical lesion. I f, during the a p p l ication of manual traction, the patient experiences an onset of paraes t hesia i n a m u ltisegmental distrib ution, i.e. both hands, then the p rocedure s hould be stopped. Cyriax & Cyriax ( 1 993 ) suggested this phe nomenon 'is due to adherent dura, presumably therefore having implications for the mobility of the spinal cord, �nd a l ternative t reatment options should be explored. Cord signs, w h i c h may b e associated wilh cervical myelopathy, are an absolute con trai n dication to cervical ma nipulation. A central d is c prolapse may encroach o n t he dura mater producing bilateral symptoms; t h erefore central techniques might be appropr iate, but rotatory techniques under traction would not. The importance of reducing small uncom pl i cated disc lesions is important to prevent future degen e rative changes threatening the spi nal cord (Ombregt et al 2003). The acute cervical lesion is too irritab le for ma nipula tion but may well respond to mobiliza t i o n, particularly the bridging or manual traction tec h n ique described below. An antalgic posture ind icates severity. In radiculo pathy "vith m i n imal, stab le neurological s igns, ma nipu latio n is not contra ind i cated but m�y not be effective. Increas ing unstable neurological signs a re a contraindica tion as the prolapse could be increased.
A
history of recent trauma has been id ent i fied as a risk
factor in vertebrobasilar insufficiency due to damage to the l i ni ng of the verteb ral a rtery; therefore manipulation is contraindicated. Past history of trauma, head i n j u ry, fracture and previous surgery are all relative contra i n d ica t i ons and judgments will have to be made on individual cases. The drug history will identify the contraindication of all ticoagulatioll therapy to manipulation due to the risk of i ntraspinal bleed. The long-term use of sys temic steroid medica tion predisposes the pat i ent to osteoporosis; this and a known diagllosis of osteoporosis is a contraindica tion to man ipulation. Patients considered susceptible to osteoporosis may be relatively contraind icated a nd indi vidual judgments will need to be made. Caution s h o u l d b e ex l1ibited with
patients who have blood
c1o11ing
disord ers. Patients with psychosocial compo n ents, the so-called
T h e cervica l mobil ization proced u re It is importa nt to e m p hasize that the treatment tech niques in this section will b e described ca refu l l y in a step by-step fashion to enable their application. H owever, the profess i onal judgment and existing skill of the opera tor w ill allow each technique to b e adapted. Th e order of the techniques as they appear here merely provides a guide towards the development of skills at each stage and it is not n ecessarily an order of ef ficacy. [t is important to reassess the patient'S comparable signs constantly and to decide on the n ext step in the light of pat ient res ponse. [n this way the o rthopaedic m edici ne approach can properly be integrated i nt o exis t i n g practice as fresh decisions are made and the u nderlying hypoth esis is modified. It is t raditional to start each session with manual traction as this technique seems to achieve the greatest resp onse; if progression is requ ired then the other techniques are carried out, with a vertebrobasilar artery test conducted prior to the app l i cation of manipulation in each sessi on of treatment. Manipulat i o n as such, defined as a minimal ampli tude, high velocity t h rust at the end of range, is only car ried out if judgment deems it necessary. The mobil izat ion procedure suggested is usually sufficient to reduce most uncomplicated cervical lesions, i.e. with no neurological signs or symptoms. The benefit of this cervical mobilization procedure out weighs the small risk o f venebrobasilar complications but that is not to take the risk ligh lly. The �ppropriate steps to minimize this risk, suggested in the guidelines below, s hould always be taken, b u t debate continues on the true incidence of complications from cerv ical ma n i p ulation, and it has been ascertained that the tests themselves carry a degree of risk. The reader is recommended to check for the most recent developments before appl)'ing the techniques,
as
safety issues are in a state of change and the mosL up-co-date guidelines should be adhered La. The techniques involve t raction, slight extension of the head and somet i m es rotation, a n d these are the positions that have been implicated in caus i n g compromise of the vertebral arteries. H owever, it should be e m phasized that lhis is not the only area of danger in this region. The s pi nal cord is vulnerable to central disc herniation and t h ese same p ositions assist centralization of the hern iated disc material and aim to prevent further central displacement that could potent ially endanger the cord. It is not possible to say how many times each techn ique is to be attempted since the process of reassessment is the basis for each c l in i ca l decisi o n and the c i rcumsta nces vary in every clinical encounter. Nonetheless, a balance m llst
'yellow Hags', may be unsuitable fo r ma nipulation and
be found between s idestepping the question and provid
even t he mobilization regime may present a relat ive con
ing a recipe for trealment. Some guidance will be given in
traindication; a ga i n judgments will need to be made on individual cases. Safety recom me n dations for s p inal manipulative tech niques are included in Appen d x i 2.
terms of expectations, w i th respect t o the different states and stages of the conditions presented. Ceneral ly, the more acutely painful lesions require gen tle treatment, but reassurance and advice may be more
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Figure 8.38 B r i d g i n g tech n i q u e .
ap propriate i n the early stages wi thout the appl ication o f passive treatment. For the subacute o r less i rritable states, if the technique is helpi ng, it is repeated; i f no change occurs after a few attempts, the next techn ique is chosen; if the patie nt's signs and symptoms a re abol ished, treat ment should be stopped. O nce i m p rovement plateaus in each session, o r if the progress is uncerta in, the treatment is either modified to a n al ternative modal ity or ceased, with the patient being reassessed at the nex1 sess ion when a new status quo will have emerged. In general, lesions producing ce ntral or b i lateral pain should be t reated with central tech n iques, i .e. manual tract ion, tractio n with leverage, anteroposterior glide. Lesions prod ucing u n i l a teral pain are treated with manual traction, progressing to rotational mobil izations u nder tract ion and manipulation if necessary. The mon itoring that takes place d u ring this step-by-step progression of forces is most important t o safety.
Bridging technique
resting u nder the patien t's neck ( Fig. 8 . 3 8 ) . Make a bridge with the fi ngers and (est them u nder the occiput. Til t the hands i n to rad ial deviation, which tips the head sl igh t ly back, and pull, flexing your forearms by p u l l i ng you rself towards the patient, to apply m i n i ma l tracti o n . Hold the pu l l fo r a few seconds, accord i ng to patient comfort. Gently release and repeat as requ i red, grad ually applying more traction as the tissues rel ax. Th is technique can be adjusted and appl ied to differe nt spinal segm ental levels. The following mob i l ization procedure is appl ied to the cervical lesion that ideally fal ls into Clinical Model 2. Manual traction may also be appropriate in Clinical Models 1 and 3. The rotation techniques are not contraind icated for eitJ1er, but the lesion is possibly too i rritable and may be made worse. The patient who fal ls into Clinical Model 3 and d isplays root signs will probably not be helped by manipu lation, but again it is not a strict contraindication provided the neurological signs are not severe or progressive.
Manual traction (Cyriax 1 984)
The in dication for use is the patient w i th a h ighly i rritable lesion: an acute w h iplash inj ury; the acute torticol lis seen in Cl i n ical Model l a nd an acute p resentation of C l i nical Model 3. Progression to manual traction may be made as the i rrita b i l i ty o f the lesion is reduced. I t is a method of applying gentle traction and should nOt produce an increase i n sy mptoms. Position the patient supine on the couch a l ittle way down from the top edge. Sit on a chair a t the head of the couch and gen t l y adjust the patie nt's position so that yo ur fo rearms and elbows a re fu l ly supported, with you r hands
This is a l ways reco mmended as the fi rst tech nique to be performed in each t reatment session for the less i rrita ble or subacute neck. It is genera l l y comfo rtable for the patient and a l l ows both you and the patient to become used to the handling tech n i ques. It is often not neces sary to progress beyond this stage if positive results are achieved. After each tech nique a n i ncrease in range and/ o r decrease in symptoms is to be expected. Exp l a i n the tech n ique and its i ntention to the patient. All mob i l ization techniques a re carefully moni LOred
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by the operator for a change in sym ptoms. Patients are i nstructed to signal i f they wish the manoeuvre to stop for a ny reaso n. I t is i m portant that patients appreciate that they have cOl1trol over each manoeuvre - the fi n a l overpressu re of the G rade C manipulation (see below) is the o n ly exception to this - wh ich is why feedback on d iscomfort shou l d be obtai n ed fro m the patien t right up to the moment of its application. Raise the couch to be approxi mately level with you r h i ps. Position t h e p at i e n t i n supine w i t h their shoulders level with t h e head of the couch a n d su pport i ng their h ead in your hands. An assistant is needed to apply coun terpressure at the same time as you apply the manual traction, by restra i n i ng the movement of the patien t's shoulders, adopting a wal k-standing position at the side o f the couch. I f no assistant i s avai lable, restra i n i n g Cyriax 'horns' or non-s l i p malting may be used. Position one of your hands to cup the occiput or sup port just below the occiput, a l l owing the head to tip i n to sl ight extension; the cervical spine i tself should remain in a neutral position. The other hand rests comfortably arou nd the patien t's c h i n, avoid i n g the trachea, and your forearm l ies along the side of the face . Pl ace both feet d i rectly under the patien t's head and bend both you r knees. Lean out with straight arms to apply the traction usi ng body weight ( Fig. 8.39 ) . Perform the techn ique slow ly, al l owing the traction to esta b l ish for several seconds, then pull yourself back to the u pright position and release the traction. Sit the patient up slowly and re-exa m i n e the compara ble signs, before deci d i ng on the next ma noeuvre. Assess the patient's body weight compared with you r own. I f you a r e much heavier t h a n the patient do not apply ma.;xi m u m body weight. Less body we i ght can be ach ieved by positioning the feet a l i ttle fu rther back but the arms should sti l l be straightened . A patient with dentures should leave them in situ with some padding p laced between the teeth to help prevent d iscomfort or possi ble breakage. This tech ni que of manual traction is essential to most other manoeuvres and it is worthwh i le practisi ng it to gai n con fidence and competence. A patient class i fied as C l i n ical Model 3 who experi ences a red uction in s igns and symptoms after the a p p l i cation of manual traction can be progressed to sustained mechanical traction as described below, si nce i n the authors' clinical experience manual traction provides a short temporary e ffect with this model .
Manual traction plus rotation (Cyriax 1 984, Cyriax & Cyri ax 1 993)
Figure 8 . 3 9
Manual t racti on.
Figure 8.40
Hand pos i ti on i n g for
rotation to the right
traction plus
your right hand to be pos i t ioned arou nd the c h i n (Fig. 8 . 4 0 ) , and vice versa for a left rotation. Apply the traction as above. Allow i t to esta b lish for a few seconds, t h e n rotate i nto t h e l east pai n fu l rotation by side-flexing your body. Return to the mid -position and release the tract ion as above. Three variatjons of t h is techn ique ca n be a p p l i ed, and each is a progression of the other. •
The pain - free, or least painful, rotation is chosen fi rs t as this will be more comfortable for the patient. The hand holds are the same as above, with a right rotation requiring
manual
•
Grade A: m id-range rotation ( Fig. 8 . 4 1 ) G rade B: to end of ava i lable range (Fig. 8 . 4 2 ) . H ere it is so i m portant LO understand the nature of end-feel and LO be sensitive to any ab normal end-feel such as
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CERVICAL ARTERIAL DYSFUNCTI ON AND ASS ESSMENT
Figure 8.41
Manual traction plus rotation,
G rade A .
Figure 8.42 Manual traction plus rotation, Grade B , and position at which a G rade C manipulation is applied.
m uscle spasm, which suggests the tech n ique should be abandoned. If these two stages have proved unsuccessfu l. the pro cedu l'e is now repeated using the same ro utine through Grades A and B i nto the more pa i n fu l range o f rotati o n . Under traction, th is s h o u l d n o t produce an i ncrease i n sym p l'oms a n d a ny increase is an i nd ication t o stop. Aga in, progression is o n ly made to the next step i f necessary. I f this procedure has been foll owed, but the patient's pain is not resolved, a return can be m ade to the least pai n ful rotation to apply a Grade C man ipulation, and then to the m o re pai nfu l rotation i f necessary. I t is i m por til nt to note that it would be u nusual fo r the ful l rou t i ne to be fol lowed w i t h i n one treatment sess ion. •
Grade C: manipul ation, the final high veloci ty, m i n i ma l a m p l i tude thrust is appl ied at end of range. ( See the 'Guida nce fo r pre-manipulative testi ng of the cervical spine', based on Ba rker et 31 2001 , p. 2 1 2, before proceed ing to manipu l ation . )
S i nce the early 1 9 80s, the potential risl< to the cerebral blood flow fro m cervical mani pulation techniques has received growing publ icity in relation to i ncidents and accidents fo l lowi ng cervical m a n ipulalion ( J(rueger & O kaza ki 1 9 80, Wei nstein & Ca ntu 1 99 1 , S i nel & S m i t h 1 993, Rivett 1 994, Carey 1 995, S tern bach e t al 1 995, H a lveI' et a l 2003 ), Tra u m a to the vertebral or in tern al carotid arteries leadi ng to stroke is a rare but devastat ing com p l i cation of cervical man ipulation. Potential risk and precipitating factors have been suggested by various authors that are discussed here. Haldeman et al ( 1 999) assessed the Engl ish language l i terature from I 9GG to 1 9 93 to determine potential pre cipitating events and risl< factors, classifying vertebrobasi l a r d issection and occlusions as traumatic, spontaneous or caused by spinal manipulation. Spinal m a n i pu l ation was i mpl icated i n U S cases and most of these were extrapolated or generalized from retrospecti ve case reports. There was m i n i mal detailed i n formation on the magn i tude of forces appl ied or the type of manipulative procedure applied . Ernst ( 2007) conducted a systematic review of t h e l it erature to explore the adverse e ffects o f spinal m a n i pula tion. Most problems were reported for the celvical spine with vertebral artery d issections caused by rotational fo rces occurring most commonly at the a t l a n toaxial joint. Vascu la r accidents were a lso reported. I t was noted that chiropractors had the most i ncidents whi lst acl<nowledg i ng that they performed the greater nu m ber of manipula tions. I n context, however, a risk of 0 .000008% was put forward which c h i ropractors a rgue is l ess of a risk than gastric bleed i ng associated with the i ngest ion of non steroidal a n t i - i n fl a mm atory drugs, J(eny et al ( 2008 ) argue that valid data are not ava i l a b l e t o b e able t o esti mate the risl< from cervical mallual therapy, including manipu lation, a nd that the com pari son with the risks associated with m ed ications, such as no n-steroidal anti- i n flam matory drugs, should be vi ewed with caution. Magaray et a l ( 2004 ) analysed the results fro m a sur vey of 4 80 mem bers of the Austra l ian Physiotherapy Association and presented the risk of adverse effects From m a n i pulation i n a n ovel way, reponing one adverse effect per 1 77 . 5 therapist weeks for h igh velocity thrust tech n i q ues, which were mostly associated with sym ptoms of VB! . The total figure for adverse effects frorn a l l manual t herapy techniq ues appl ied to the cervical spine was 1 .3 8 adverse effects p e r therapist over a 2 -year period, i ,e, 0.01 per weei<. I n itiation for the venebral a rtery testi ng procedu res seems to stem fro m cadaver studies conducted by Brown & Ta tlow ( 1 9 G3 ) wh ich showed the contralateral vertebral artery to be someti mes occluded 011 rotation, extension
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or combi ned rotation and extensio n . More recent studies have demo nstrated confl icting resu lts on the effect of position of the cervical spine on blood flow i n the verte bral arteries, questioning the va l i d i ty and cl i n ical va lue of the pre-manipulative tests (Kerry & Taylor 2006, Kerry et al 2008). The vertebral artery is most VLl l neca b l e in its th ird sec tion, the atlanto-occipital region, where it takes two dght angled turns, one to pass behi n d t he lateral mass of the atlas and the second to enter the foramen magn u m . H e re the artery is relatively fixed and i m m o b i l e and m a n i pu l ation i nvolving rotation and/or extension has been i m p l i cated as a cause of vascu lar accident. The resu ltant shearing force on the arterial wall could lead to d i ssec tion, i ntramural haematoma and/or th rombus fo rmation. The test ing procedu res commonly consist of rotation and extension which cou ld be as hazardous as the m a n i p u la t ive tec h n i q ues themselves; therefore the rel ia b i l i ty and va lidity of the testing procedures has been questioned. Rivett ( 1 997) highl ighted a case of a negative verte bral artelY test despite complete occl usion. In contrast, Licht et al (2000) conducted a prospective study to assess vertebral a rtery blood flow i n patients with positive p re manipulative testing to i nvestigate whether, d espite the positive. test, chiropractors would co nsider treat ing such patients if the subsequent Doppler ul trasound was norm a l . The majority of chi ropractors surveyed agreed that they wou l d proceed with the m a n i pula tion if the Doppler u ltrasound was normal, despite the positive test. The study there fore concluded that a posi tive pre-manipulative test is not a n absolute contra ind ication to cervical man ipulation. Rivett et al (1999) conducted a two-grou p expe rimental p i lot study with a small sample of 20 subjects, to deter m i ne the effect of rotation or exte nsion on vertebral aneIY and i nternal carotid a rtery blood flow (the sustained posi tioning was held for u p to 60, which is not comparable with the short d uration that the position is assumed for the man ipulative procedu re ) . Some sUp pOI1 for the rel i ability o f pre-ma n i pulative test ing was demonstrated as sign i ficant changes occu rred in blood flow i n end-range positions i nvol v i ng contralateral rotation and extension. I t was concl uded that the scree n i ng p rocedu res may be usefu l tests of the adequacy of the collate ral circulation in preventing ischaemia i f the blood flow through one of the vertebral arteries was critica l l y reduced, for i nsta nce by cervical manipulation. M i tchell et al ( 2004 ) set out to see i f the rotation used in a sta ndard vertebrobas i l ar artery insufficiency (VBI) test was associated with a measurable cha nge in intracranial vertebral artery b lood flow i n young, healthy adults. The va l i d i ty, specificity and sensitivity of the VBI test had bee n questioned s ince the results of p revious blood flow stud ies had not been in agreement. Susta i ned , end-of-range, contralateral rotation of the cervica l s p i ne was shown to be associated with a significa n t decrease in m ean i n t ra cranial vertebral blood flow velocity, i rrespective of side.
Th is supported other reports of decreased bl ood flow i n both t h e i n t racra n ia l a n d extracra n ial artery. The a u thors recommended that m o b i l ization or m a n i p u l ation should not be carried out i m med iately a fter applying the test to ensure there is sufficient time for the l atent effect of the test to subsi d e. The rotation was held for 30 s, which is a standard t i m e for the test but not for the appl ication of end-ra nge rotation tech n iq ues (as appl ied i n orthopaed ic m ed icine) . This does h igh l ight the risk of the test itsel f and whether it is j usti fied prior to m o b i l ization as wel l as manipulation. Kerry et al (2008) stressed the point that stud i es p rovi d i n g i n formation on t h e effects on blood flow d u r i n g cer vical movem en ts in heal thy normals were a step towards estab lish ing the effect of b lood flow on cervica l a rtery sym ptoms but emphasized that there was l i ttle evidence of correlation between blood flow cha nges and symptoms of VBI . Reduced blood flow to the bra i n can be recorded but without signs of cereb ral ischaemia. The issue of false positives and negatives with i n the p re- m a n i p u lative test i ng procedures a l so a ffects the rel ia b i l ity of the tests. The a p p l icab i l i ty of hand-held Doppler u ltrasound u n i ts to assist in identi fy i ng flow dysfunction is a focus of ongoing research ( Kerry & Tayl o r 2 0 0 6 ) . The Austral ian Physiotherapy Association (fWA) was probably the fi rst group to in troduce a fomla l protocol for pre-man ipulative testing of the celvical spi n e; the proto col was publ ished i n the Australian Journal of Physiotherapy ( 1 988). A 'Guidance for pre-manipu lative testing of t he cer vical spine' ( Barker et al 2001 ) was devised as a joint ven ture between the Society of O rthopaed ic Medicine and the Manipu lation Associ ation of Chartered Physiotherapists and was published in Manual Therapy, the Journal of Orthopaedic M edicine and subsequently i n PhysioLherapy. The guidance a imed to gu ide the deciSion-making proc ess towards safe appl ication of cervical manipulation, to heighten awareness of the risks and compl ications, a nd to i m prove quality of care by i n form i ng of current best practice. A flowchart was p roduced on the basis of the guidance, wh ich h as been adapted i n Figure 8 . 4 3 to guide c l i ni ca l reason i ng and pre-treatment scree ni ng. However, the reader is strongly advised to asce rta i n the most up-to-date gu ideli nes in p lace at the t i me of read ing t h is text (see MACP website - http://www. m acpweb org) . The orig i n a l APA protocol has now been updated and the resu lts of the su rvey conducted by Magaray et a l ( 2004) ( a s mentioned above) fed i nto the review. T h e sur vey found that of the 480 mem bers who responded, two t h i rds found the protocol val u a b l e in their practice but j ust u nder a fifth used i t o n ly to satisfy legal req u i rements. The issue o f consent was looked at as part of the p rotocol . Approximately one-third of respondents a l ways i n fo rm ed the patient about potenti a l dangers of cervical manipu la tion and a th i rd (not necessari ly the same respondents) sought consent on every occasion at w h ich manipula tion was used. The t i m e taken to apply the p rotocol and
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Perform a detailed subjective examination including special screening questions to exclude cervical artery dysfunction (CAD)
Make a diagnosis and treatment plan based on clinical reasoning and
best available evidence
treatment plan
Absolute co ntraindication to manipulation
•
At the time of writing the advice is that a recognized pre-manipulation VBl test
should be conducted in each treatment session that is to include manipulation.
Figure 8.43 G U ida nce for pre-ma n i p u la tive testing of the f l owch a rt .
cervical spine
-
ga in consent was c ited as the main criticism of the pro tocol with the doubts concern i ng the val idity of the pre manipu lative tests and the possible deterrent to patients having the techn ique if too much was made of the risks especia l ly as the risks appear to be low. The survey drew out some honest insights fro m those who are expected to apply the protocol, which may resonate with other prac tising manual thera pists. The Man ipulation Association of Chartered Physio therapists ( MACP) com m issioned a review to begi n i n 2004 t o satisf)' a n uncertainty in those perform i ng man ual therapy rel a t i ng to the nature o f cervical spine arterial insufficiency, the risks o f manual therapy with respect to arterial co mpl ications, and to clarify the MACP's sta nce on pre-cervical spine treatment scree n i ng ( Kerry et al 2007 ) . The review was conducted by an i n terna tional body o f reviewers a n d a variety o f evidence sources were considered in categories relating to b lood flow studies, case reports, surveys and reviews, a nd haemodynam ic principles. The in itial docu ment created was published as a co nsultation document and input from a l l stakehol ders was encou raged. As an outcome, an evidence-based i n for mation document on 'Cervical Arterial Dysfunction and Manipulative Therapy' has been published on the MACP website ( h ttp:// www. macpweb.o rg) to guide c l i n ical rea so n i ng in the assess ment or neck pa i n and headache, especially with regard to the poss i b i l i ty of the existence of vascul a r dysfunction. The review itsel f has been publ ished in Manual Therapy ( Keny et al 2008). Kerry & Taylor (2006) widened the focus o f arterial dysfunction to include the in ternal carotid arteries. Their paper considered pathol ogies in both the vertebrobasilar arterial system (posterior system) and the i n ternal carotid arteries (anterior system) and described the l i kely c l i n ical prese ntations of both. If there is red uction of blood flow through the vertebral arteries, vertebrobasilar artelY i nsuf ficiency sym ptoms may be evident that they summarize as the '5 Ds' and '3 Ns': Dizziness; drop attacks; diplopia; dys arthria; dysphagia: Ataxia: Na usea; numbness, nystagmus. Principal symptoms and signs of i n ternal carotid artery dysfu nction i nclude pain in the neck, frontotemporal regio n or race; Horner's syndrome; t i n n i tus; cranial nerve palsies; l oss of vision and retinal i n farction. Transient ischaemic attack and stroke could be serious outcomes of both vertebral and internal carotid artery d issection. The benefit gain ed i n pa in rel ie f and restoration o f movement b y a n ��pertly applied manipu lative techn ique should not be sacri ficed in an attempt to be t O O cautious. Conflicting evidence of the risk versus the benefit can be fo und i n the l i terature. Refshauge et al (2002) postul ated that the risks outweigh the benefits whi l e l u l l et al (2002), i n response, suggested that many of their argu ments were biased or fl awed and did not support their recom men datio ns. Kerry et a l (2008) doubt the accuracy of
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The risk does neven hel ess exist and techniques i n volv ing traction and rotation have received criticism for being the most hazardous (Grant 1 98 8 ) . H owever, as discussed above, what is often not taken into account is that there are two potential danger areas w i t h i n the cervical spine: the cervical a rteries and the spinal cord. There can be risks in not treating cervical disc lesions as potential osteophyte formation arising fro m traction on the venebral end-plate could comprom ise the spinal cord. Kerry & Taylor ( 2006) appeal to manual therapists to be suspicious of cervical vascul a r pathology, especiall y i n cases of trauma or i n acute onset a n d where a head ache may be described as ' u n l i ke any other'. They recom mend the·expansion of manual therapy theory to i nclude haemodynamic principles: their rel ations h i p to move ment, a natomy and biomechan i cs and the i m p l ications for testing procedu res; looking for vascular risk factors and including cra n i a l nerve tests where i nternal carotid d issection is suspected. The non-systematic review conducted by I(eny et a l ( 2008) was t h e most up-to-date review at the t i m e o f writi ng. The term 'cervical arterial dysfunction' i s now fi rmly embedded in the consciousness of m uscu loskeletal practi tioners and the review exam i nes several l evel s of evidence to su pport a comprehensive d iscussion on the association between cervical spi ne manual therapy a nd cervical artery dysfu nction leading to cerebral ischaemic events. The review also searched for evidence relating to haemodyn a m i cs, anerial trau ma and vascular pathology, and blood flow studies. The review concl uded t hat there was little support for the value of pre-manipu lative screen ing tests i n i ndicat ing vascular patency or pred ict i ng i n j u ry. Th is view had previously been put forward by Th i e l & Rix ( 2005 ) . There is evidence to support the relationship between vascu l a r disease risk factors and cervical artery dysfunction (CA D ) and a broader view of t h e patient's healtb p ro fi l e is recommended. Headache and neck p a i n are com mon presenting signs of vascu l a r dissection and m ust at l east be considered as part of d i fferential d iagnosis, espec i a l l y in t he acute neck. I f there is a strong l il<el i hood of cervi ca l artery d issection, provocat ive pre-m a n i p u l ation tests should not be performed and the patient should be referred appropriately (Thiel & Rix 2005 ) . Si nce cervical artery haemodynam ics are i n fl uenced by movement as a whole, and not just by manipulative t h rust techniques, a form of vascu lar risk assessment should be considered prior to a l l manual therapy proce dures. Cl i nical reason i ng may be l i mited if only the ver tebral arteries are considered a nd there shou l d be a wider risk assessment per1aining to the whole cervical arterial system and the range of poss i b l e vascu lar pathol ogies. Before embark i ng on any cervical techn ique the clini cian is recommended to fol low the guida nce for safe prac tice as suggested below. The guidance has been devised to m i n i m ize the risk of compl ications fol lowi n g cervical
mobi l ization techniques. Several poi nts need to be con sidered before embarking on the testi ng regime. D izzi n ess is one of the first sym ptoms of vertebrobasi lar insufficiency, but i t is a lso a sym ptom associated with cervical dysfunction, cervicogen i c headaches, benign posi tional vertigo and i n ner ear problems. The vertebrobasilar artery system supplies the vestibular nuclei i n the bra i n stem and the l a byrinth of the inner ear (Grant 1 98 8 ) . A careful h istory w i l l assist diagnosis. If benign postural vertigo is suspected, d i agnosis can be confirmed by per forming H a l lp i ke - D ix positional testing wh ich, if posi t ive, demonstrates a characteristic torsional nystagmus when the head is rec l i ned and turned to the affected side ( Lempert et aJ 1 995, Magarey et al 2004, lohnson et al 2008 ) . The test should not be considered in iso lation, but in the con text of the w ho l e assessment procedure. Cervical traction is used as a techn ique by i tself, or i n conj unction wit.h mobilization a n d m a n ipulation. I t is used t o decomp ress the cervical joints, protecting t h e spinal cord fro m further posterior displacement of the d isc d u ring the techn ique. Traction is reco mmended as a fi rst ma noeuvre; it is relatively gentle and can be stopped i mmediately i f adverse effects are noted or reported. It often achieves an i ncrease in range and decrease in pain, making the addition of furt her tech n iques u nnecessary. Manipulation is only appl ied when a regime of m a n u a l traction and tracti on w i t h mobil izat.ion h a s fa iled t o b e e ffective. B y p rogressing t h e treatmen t i n this way, adverse vertebrobasilar artery symptoms should be picked up before a m a n ipulation is appl ied. As a foot note to t h is section there is some evidence that m a n ipulation to the t horacic spine may be usefu l i n the ma nagement of patients with neck pain due to the bio mechanical l i n k between the cervical and thoracic spi nes (Cleland et al 2005, Cleland et al 2007a, 2007 b ) . As risk of com pl ication is lower with a thoracic spine ma nipu l ation, thoracic m a ni p u l ation m ight be a suitable, safer a l ternat ive to cervical m a n i pu l ation.
G u idance for pre-man i pu l ative testing of the cervical spine The guidance for pre-manipulative testing ( Barker et al 2001 ) a i ms to identify patients with a potential risk of vascu lar accident i f the vertebral artery is com p rom ised. Rather than testi ng for venebrobasi l a r i nsufficiency, it aims to be a predictor of the abil ity of the col l ateral cir culation to m a i ntai n perfusion of the brain should the cervical arteries be occl uded. A detai led h istory, together with t he objective exa m i nation, establ ishes a d i agnosis. I f manipulation i s the treatment of choice, the c l i nician should d iscuss the risks and benefits of the proposed techn ique with the patient to gai n i n formed consent. The f10wcha n (see Fig. 8 . 4 3 ) is sel f-explanatory, a nd i t is cur ren t l y advised that a recognized pre-manipu lative test is
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The presence of d izzi ness, nausea, vo miting. sweating, pallor, blurred vision, dysart h ria, fa inting. tinnitus or par aest hesia in the head or arm or nystagmus consti tutes a positive test. The mai n symptoms and signs o f a posit ive vertebrobasi l a r artery test can be remembered using the five Ds: d izzi ness, d ip lopia, drop attacks, dysarthria and dysphagia - a useful aide-rnernoire attributed to Co man ( C rant 1 988, [(erry & Taylor 2006). If the test is fou nd to be positive, slide the patient back o nto the couch to remain lying i n supine to recover. Help the patient to sit up steadily and checl< by questioning and observation that the symptoms have subsided before term i nating the session, or continui ng with a suitable alternative treatment moda l ity. Fo llowing the recom mended gu ida nce is the current basis fo r ensuri ng maxi mum safety and preparation for the unexpected. The c l i n ician must take a l l due care while applyi ng the test and the trea tment tech n iques.
Figure 8.44 Vertebrobasilar artery test.
conducted in each trea tment session that is to i nclude cervical m a n ipulation. Some clin icians choose to apply the testing procedure prior to other cervical mobil ization tech niques, but this is not currently mandatory. Local pol icy sometimes drives the decision a n d justi fication should be available if the policy is cha l l e nged . The deci sion should be based o n c l i n ical j udgment i n the l ight of best available evidence and the reader is advised to keep abreast of deve lopments occurring i n t h e interven i ng t ime. Any recognized pre- manipulative testing procedure can be applied. Posi tions can in clude extension, com b i ned extension and rotation, the pre-manipulative posi tion or ro tation alone (Kerry & Taylor 2006 ) . Kerry et al ( 2008) observe that the extension element of testing has been removed from the new Austra l ian Physiotherapy Association protocol ( 2006) and appears to have taken i n to account that extension has been reported as the most influential movement for i n ternal carotid a rtery flow. The test described below places the patient's cervical spine in t h e s i m u lated pos ition for the manipulative p rocedu res. However, th is is a combined pos ition, wh ich is not exactly the same as the position fo r the i ndividual techniq ues, nor can the m a n i pu lative t h rust be simulated. Position the patient in supine lying with the shoulders level with the end of the couch . Support the head com fortably. Place the head i nto a degree of extension ( not ful l extension), with side flexion and rotation of the cervi cal spine ( Fig. 8 . 4 4 ) . [(eep t h e patient ta l king and the eyes open while m a i n ta i n i ng the position fo r 3 0 s u n l ess sym p toms are evoked before thi s ti me. A l l ow the patient to rest in neutral befo re repeating the test to the other side.
Anteroposterior glide under traction (Cyriax 1 984, Cyriax & Cyriax 1 993) Th is technique is appl ied if the symptoms have central ized and the range of movement has increased, but exten sion remains sl ightly l i m ited. The importance of fu l ly reducing a disc prolapse is based on the hypothesis that a s m a l l central bu lge, if left i n situ, wi l l gradua l l y cause l iga mentous traction and osteophyte formation, both of w hich have the potential to threaten the cord in later life. Therefore it aims to clear extension . Place the couch a l i ttle lower than h ip height. Position the patient supine on the couch as before, with an assist ant ready to apply counterpressure. Stand s ideways-on to the pat ient with both feet parallel and close to the couch, under the patient's head. One hand cups below the occiput and the forearm supports the weight of the h ead while cradl ing it against yo ur abdomen. The other hand is positio ned on the ch in to be a b l e to apply both traction and retraction ( Fig. 8 . 4 5 ) . Make a bridge by spreading your index finger and thumb. Apply the web to the chin and curl the rema i n i ng fi ngers so that they tllck a round and under the ch in (Fig. 8 . 46). Lean out sideways as fa r as poss i b l e to apply traction. Once traction is esta b lished, bend your knees and apply pressure over the chin, taking the ch in into maximum retraction to produce the anteroposterior gl ide wh ile avo i d i ng pressure fro m the knuckles against the larynx ( Fig. 8 . 4 7 ) . Al low the chin to return to neu tra l, avoid ing protracti o n, and release the traction. Sit the patient u p and reassess. If the manoeuvre has helped it can be repeated, this time lIsing several retractions.
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Figure 8.45 Anteroposterior glide under traction, starting posi ti on .
Fi gure 8.47 An teroposte rior glide under t rac t i o n, finishing position. The couch is again slightly lower than hip height, as for the position for the anteroposterior glide under trac tion technique described above. No traction is applied with the lateral glide. An assistant, when available, stands parallel to the couch and the patient l i es supine as above, but close to t.h e assistant. The assistant grasps the patient's op posite arm with both hands and holds the patient close to prevent lateral movement of the thorax. Cup the patient's head in both hands, fingers around the occiput and thumbs parallel with the mandible. Your thenar eminences should support just in front of the ears, resting comfortably over the temporomandibular joint (Fig. 8 . 4 9 ) . Bend your knees and position your abdomen against the patient's head but not enough to compress it.
Figure 8.46 Anteroposterior g lide u nder traction, hand position.
Apply the l ateral glide by rocking from foot to foot, grad ually i ncreasing the pressure of your thenar emi nences against the patient's head as the patient relaxes and more movement becomes available (Fig. 8 . 4 8 ) . To ensure that
Lateral glide
this is a rhythmical lateral gliding movement without side flexion, keep the patient's nose straight and apply gentle
This m anoeuvre i s used to relieve post-treatment soreness and to mobilize any residual t ightness in the neck. It may be useful in mobilizing restricted side flexion in particular.
pressure to the face as you move towards each side. A slight upward movement of the patient's head may occur as your weight moves from each leg.
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Advanced manoeuvres These are stmnger manoeuvres and it i s d e fi n i tely recom mended that they should be appl ied only after attending a n orthopaedic m ed icine course.
Traction with leverage (Cyriax 1 984, Cyriax & Cyriax 1 993) The ind ication for this tech nique is tJut stronger traction is required for central or bil ateral sym pto ms. Pos ition the patient in supine lying with the occiput level with the end of the couch. Cup the occi put and rest the back of your hand on the co uch. Apply manual trac tion as described previously. At the end of the technique, bend you r knees smartly to apply more Lraction, using your hand underneath as a p ivot ( Fig 8.50) . Maintain the traction as you straighten you r knees.
Manual traction plus rotation
Figure 8.48 La teral g lide.
This is the same techn i que as the rotation techn i que described previously, but i t applies a d i ffere nt hand-hold with the neck start i ng i n a degree of ro tation, which gives a stronger rotat ion overa l l . Start WitJl t h e patient's head turned i nto a s m a l l degree of rota tion before a p p lying the technique in order to secure a good grip . Cup your hand, pronate you r fore arm and pl ace it co mfortably on t h e side of the patient's
Figure 8.49 L a t era l g lide, hand position.
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The cervic� l spine side-flexed and moves the patient a l i ttle closer s o that the patie nt'S shoulder fits i n to the co rner of the couch . The ass istan t then reaches over to p l ace a hand over the patient's opposite shoulde r to fix it by holding o n to the top edge of the couch, s o resisting the side flexion move ment ( Fig. 8 . 5 2 ) . If you will b e moving towards the patien t's left side flexion, p l ace your left foot aga i nst the side o f the couch, or against the assistant's extended right foot. Lean out sideways to give tract ion, taking yo ur right foot off the floor ( rig. 8 . 5 3 ) . After a short pause to a l low the tract ion to take effect. swing yo ur body backwa rds, pivoting o n yo ur left foot and applying side flexi o n t o the patient's neck. The tech n ique can be performed as a Grade A ( m id range) or Grade B (to the end o f range ) . For the Grade C, whil st mainta ining control, apply a smart t hrust at the end of range and m a i ntain traction as you swing your body back to the straight p u l l position, when you can steadily put you r right foot to the floor and release the traction. As you practise this technique you will find that the momentu m of the movement will help ach ieve a smooth transition through the va rious stages. Take care not to perform the tech n ique too q u ickly or strongly w h ilst your ski lls i m prove. Reverse the assistant's position and the i nstructions if side flexi on towards the right side is i nd icated.
Mechanical cervical traction Figure 8 , 5 0 Traction with leverage.
face with the fingers under the chin, such that they face the d i rection of the rotat ion you are a i m i ng towards (Fig 8.51 ) . Stand with your feet rotated a l ittle in that same direction. Apply the manual traction and ro tation i n the p rogression reco mmended for the rota tion tech niq ues described above. (See Gu idance for pre-manipula tive test i n g, Fig. 8 . 4 3 , before proceed ing to manipulation.) --
Manual traction plus side flexion (Cyriax 1 984, Cyriax & Cyriax 1 993) If the rotations have not deared the symptoms, a side flexion techn ique can be applied . The technique can be progressed th rough the Grade A ( mid-range), Grade B (full range) and Grade C (man ipulation at the end o f range) as described for the rotations above. (See Guidance for pre-manipu lative testing, Fig. 8,43, before proceeding to manipulation.) AJways start by s ide-fl exing the patient away from the painful side. Position the patient as for manual tract i o n . An assista n t stands on t h e side to wh ich the neck w i l l b e
Cyriax did not advocate the use of cervical traction to the same exten t as l u mbar and was of the o p i nion that i t was used 'far too often' (Cyriax 1 98 2 ) . A systematic review of the l iterature o n the e fficacy of traction for neck and back pain was presented by van der H eijden et a l ( 1 9 95), but most of the selected studies proved to be of poor Ljual ity. No clear ind ica t ions of the effectiveness or i neffectiveness of tract ion cou ld be ascertained from t h i s stu dy. Peake &. Hal1e (2005) reviewed trials conducted between 1 9 6 6 and 2 0 0 4 , to u pdate (he review of v a n del' H e i j d e n et a l ( 1 995) but remarked that the evidence h a d n o t changed subs tantially s ince the earl ier review. They were unable to establish evidence either for or aga i nst the appl ication of cervical traction. I n spite of the lack of evidence to sup port the techniq ue, the authors suggest that apparent benefits m i ght be due to mobilization of the m uscle and connective tissue, in creased venous and lymphatic flow or psychol ogical i m p rovement. irrespective of any effect on the spi nal joints. H ickl i ng ( 1 9 72) described the a p p l ication of sustained cervical traction in either sitting ( cervical suspension) or lyi ng, and various studies have been publ ished t o exp lore the merits or d isadvantages of each . Celvical suspension, the application o f verti cal traction with the patie nt silt i ng, ap peared to be the cho ice of Cyriax, but it m ay a lso be appl ied in supine lying ( l ong tracti o n ) or incli ned h a l f lying . Colach is &. Strohm ( 1 9 6 5 ) quoted the paper of
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Fig ure 8.51 Manual traction plus rotati o n . The alter native hand position produces stronger rotation (Grade B shown)
Figure 8.52 Manual traction plus side flexion, hand position.
Cartland whicb mentioned I
traction impaired blood flow, a n d favoured intermittent
cervical suspension over long or horizontal traction :
tract ion . Deets e t 31 ( 1 9 7 7 ) men tion tbat Maitland had
•
the oppos i te view and preferred traction in sitting since
Convenience of application
•
Elimination of fric t i on
•
Accuracy of measuremen t
•
Facilitation of manipulation
his patien ts found it more comfortable. They also report that Crue found that greater foraminal sepa ration was ob served in the supine posi tion than in Sitti ng. Colachis & St rohm ( 1 9 6 5 ) , in a study of 10 normal
Stoddard (1 9 5 4 ) was critical of cervical suspension
medical students, found tbat the sepilration of the cervi·
since he observed that his patients found i t difficult to
cal vertebrae under t raction in creased with the an gle of
relax in this position. He also believed that sustained
flexion to the horizon tal of the rope ap plying the pull.
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I 8 I
The cervical spine
Readers must weigh up for themselves the pros and cons o f applyi ng tract ion in the sitting versus supine posi tion. The characteristics of the i n d ividual patie nts encou n tered wil l fo rm part of the decision-making process. Another factor i n the appl ication of cervical traction is the length of time for w h ich i t should be applied. Colachis & Strohm ( 1 % 5 ) noted that no fu rt her i ncrease of i ntervertebral separation occurred after 7 s of sus tai ned traction and ludovi tch ( 1 9 5 2 ) stated that the t i me of a p p lication should be decreased as greater forces were a p p l ied. H i ck l i ng ( 1 97 2 ) suggested that traction of 15-25 1 b ( 7 - 1 1 kg) should be co nti nued for between 1 5 and 2 5 m i n . This recom mendation is based o n empirical fi n d i ngs and more work needs to be done to establ ish the opti m u m duration of treat ment. The l iterature is u nclear i n its support of eitber sus tai ned or i ntermittent traction. Moeti & Marchetti ( 2 001 ) used i nterm ittent traction for patients with radicular sym ptoms and demonstrated that pati ents with symp toms of more than 1 2 weeks' duration had m i n i m a l i m p rovement, and those w i t h sym ptoms for less th an 1 2 weeks had a better outcome. Imp roved circulation, reduc tion of adhesions and red uction of pain via presynaptic i n h i bition at spinal cord level have been suggested as possible mecha n isms for i m provement due to i ntermit tent traction (Wong et a l 1 99 7 ) . Chung et al ( 2002) used MRI to eva l uate the reducibi l ity of cervical d isc herniation u nder traction on 29 patients and seven healthy vol u n teers. U s i n g a tract ion device which essentially consisted of a portable inflatable 'accord ion'-shaped neck col l ar to produce 30 Ib of traction force over 10 m i n, an i ncrease i n length o f the vertebral col u m n was demo nstrated i n both groups, and 21 patients had com plete o r partial reduction of the disc herniation.
Figure 8.53 Manual traction plus side flexion.
They found that the poundage applied had a compara tively greater effect on the joint separation and the maxi mum of 30 l b ( 1 4 kg) used in their i nvestigation had the greatest e ffect. judovitch ( 1 9 5 2 ) studied radiographs of the cervical spine under differe nt pound ages of traction and found that 25 l b ( 1 1 kg) of vertical traction straight· ened the ceJvical lordosis, while at 4 5 1 b ( 2 0 . 5 kg) a mean stretch of 5 111m was achieved in the cerv ical spi ne. Deets et al ( 1 977) cite a fu rther study of Colachis & Strohm which dem onstrated that the greatest elongation of the posterior portion of the disc was observed with the angle of rope pull at 3 5 0 to the horizontal. H ickling ( 1 972) recounted Cyriax's suggestion that cervical suspension should be just sufficient to l i ft the patient's buttocks from the chai r, i m plying that forces of near body weight were being applied. However, this was fo r a short duration of 1 -5 m i n . In lying, average treat ments ranged from 15 to 25 1 b ( 7 - 1 1 kg), accord ing to the size and overa l l response of the patient. The traction was appl ied horizontally or in s l ight flexion at an unspeci fied angle but with consideration for patient comfort and preference.
Contraindications to mechanical cervical traction These are l a rgely the same as fo r cervical m a n i p ulation and the reader is referred to the d iscussion on contra i n d i cations above. Care should be taken in applyi ng traction to the elderly and they must be thoroughly questioned for the presence of a ny contra ind ications. Most traction beds and mob i l e traction equ i pment of modern des ign have the fac i l i ty to apply cervical and l u m bar traction. A cervical harness i s required to rest under the occiput and chin, with straps or cord passing to a spreader bar above the head. There are several types of ha rness which nowadays a re made of washable m a terials, which a lso have the advantage of being pliable to give com fortable support. The simplest uses two padded rectangles which mould to the head as the traction is applied, but others a re made of more substantial m aterials and have adjustable clasps to accommodate the differing shapes of patients.
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The straps to the s p reader bar s h o u l d be l o ng enough
At the end of the trea tment time release the traction
to give s a fe clearance above the head. A rope passes fro m
slowly and observe the patient's response as you do so.
the central poi nt of the spreader bar via a pul ley or pu l
Let p a t i e n ts s i t fo r a moment o r two w h i l e they ro l l the
leys t o a fixing cleat i n m a n u a l ly app l i ed u n i ts, o r d i rectly
shoulders and relax the tissues, a n d al low them to get u p
i n to the hous ing of the automatic device.
when t h e y feel ready. Apply t h e cervical harness i n the same way as fo r s i n i ng traction Adj us t the angle of p u l l and select t h e a p p ropri
Technique
ate setting. Feedback from the patient will ensure that the
Exp l a i n the tech n i q u e carefu l ly t o t h e patient, m e n t i o n
tract i o n is strong and co m forta ble. There is a conve n t ion
i ng possible after-effects such a s s t i ffness o r tem porary
t h a t lesser weights a re a p p l i ed i n traction i n supine t h a n
i ncrease i n d i sco m fort, and ask for co nsent to proceed
i n the Sitting pos i t i o n, but for a lo nger time ( H ickl i ng
If applyi ng tract i o n in t h e sitting p os i tion, use a fi rm
1 9 7 2 ) . On thi s basis, weights of
5-7 kg
m ig h t be a p p l ied
cha ir w i t h comfortable back support. Pa t i e nts often l i ke
on the first treatment fo r 20 m i n, for exa mp le, i n creas i n g
to have t h e i r arms resting on two or t h re e p i l l ows on
t o 10 k g fo r 2 5 - 3 0 m i n at subsequent attendances.
t h e i r lap, both fo r support and to encou rage relaxat i o n .
Tract ion shou l d be appl ied, preferably, on a daily basis
I f a p p lying tracti o n i n s up i ne e n s u re that the patient i s
but weel<ends can b e exc luded to a l low a ny soft tissue d is
comforta b l e with o n e or two p i l l ows u nder t h e head a n d
co m fort from t h e a p p l ication of t h e h a rness to subsi de.
knees a s desired .
Patients may not be a b l e to attend d a i ly due to t i m e o r
P u t the cervical h a rness i n place u nd e r t h e jaw a n d occiput, prov i d i ng extra pa d d i ng i f necessary, a nd place
fi n ancial
constra i nts a n d t h e pressu res on
outpatient
departme nts may a lso deny this freq uency. However, i t i s
t issue between the patient and t h e h a rn ess, fo r reasons of
s t i l l appropriate to try the tec h n ique as frequently a s pos
hygiene. Attach the harness to t h e tract i o n u n i t and p lace
s i b l e si nce satisfactory res u l ts can s t i l l be achieved.
on the appropriate setti ng, consideri ng the patien t's s ize and general d e m e a n o u r.
I m p rovement usually occurs after two to fou r treat m e n ts and the whole treatment episode may be con t i n
Discuss the treatment t i m e with patients, explai ning tJlat the tJeat ment a i ms to be as 'long and strong' as is comfort
u e d over
a
2 - o r 3-weel< period i f necessa ry. I f there i s n o
change i n the symptoms a fter fou r treatments t h e posi
ab le, but they can call a halt to t.he trea tment at any time. I n
tion, the weight, angle of p u l l or the t i m e of appl i cation
practice, patients a r e usually comfortable Wi tJl about 1 5 m i n
may be adjusted, but if th ere is sti l l no change tJle tech
tranion at the first trea tment and even on subsequent
n i q u e s h o u l d be abando ned a n d another moda l i ty o r
attendances 20 m i n is usually the maxi mum requ i red.
course of action selected.
G ive patients sight of a c l ock and an alarm bell o r buzzer a n d a p p ly t h e traction steadi ly. Keep i n close con
Advice on
neck care a n d
posture s h o u l d
be given
to patients while they are u n d e rgoi ng treatment and
tact with the p a t i e n t while the traction is b e i ng ap pl ied,
an appropriate ge n t l e exercise progra mm e s hould be
since occasionally p a t i e n ts can become l ight- headed.
d evised.
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