General Orthopedic Examination Principles Flashcards
Tendinitis versus Tendinosis
Tendinitis is at microscopic tear a the muscle-tendon junction, usually attended by localized swelling and tenderness.
Tendinosis is usually results from a degenerative process and manifests as chronic irritation or inflammation at the tendon-bone interface.
Treatment for tendinitis
almost exclusively conservative, foucusing on reductin the inflammation process and underlying tissue stressess.
Initial treatment can include ice application, oral NSAID administration, iontophoresis, rest, and cortisone injection.
Treatment for tendinosis
focuses on a controlled eccentric training program, often is lengthy (10 to 12 weeks or more in some cases), and eventually may require surgical intervention to eliminated the diseased area of the bone-tendon interface.
Normal End-Feels
End-feel is the type of reistance felt by an examiner at the end range of a passive range of motion test
Bone-to-Bone - hard unyielding sensation that is painless (ex elbow extension)
Soft-tissue approximation - a yielding (mushy feel) that stops further movement - primarily stopped by muscle bulk (ex elbow flexion, knee flexion)
Capsular (Hard) - firm with a defintie stopping (ex Knee extension)
Elastic (Soft) - soft without a definite stopping point (Shoulder External rotation)
CAPSULAR and ELASTIC end-feels are both considered tissue stretch end-feels
Abnormal End-Feels
Muslce Spasms - Invoked by movements, with a sudden dramatic arrested by movement accompained by pain. This end-feel is sudden and hard!
Spatiscity - muscle resistance to stretch (Upper Motor Lesion), hypertonicity
Hard Capsular Abnormal End-Feel - thicker stretching quality and has restricted ROM (ex frozen shoulder, adhesive capsulitis)
Soft Capsular Abnormal End-Feel - normal tissue quality but restricted ROM (ex synovitis, hemearthrosis, soft-tissue edema)
Bone to Bone Abnormal End-Feel - similiar to normal bone to bone end-feel but felt prior to normal end ROM (ex osteophyte formation)
Empty - movment causes considerable pain (ex subacrominal bursitis or tumor)
Spring block - similiar to tissue stretch, occurs where it shouldn’t. A rebound effect with a thick stretching feel. Usually indicates an internal derangement (ex, torn meniscus)
What is selective tissue tension testing?
Must selectively stress each tissue from which complaint might arise
Contractile tissues - muscles, tendons, and tenoperiosteal insertion
Non-contractile (inert) tissues - joint capsules, ligaments, nerves and their sheaths, bursae, and cartilages
Sequence of ROM Testing
(1) Active Movements - gives an idea of the willingness and ability of the patient to move the part
(2) Passive Movements - stresses non-contractile tissues, and to a lesser degree, contractile tissues
(3) Resisted Isometric Contractions - Stresses contractile tissues
ROM and Pain General Interpretation
AROM and PROM exhibit pain in the same direction and is elicited at the limit of range (ROM). RROM is not painful: Suspect a non-contractile element (inert)
PROM is painful in one direction and AROM is painful in the opposite direction. RROM is painful: Suspect a contractile element (Exceptions: Tenosynovitis – long tendons of wrist and hand.)
RROM is painful: Suspect a contractile element
All movement is painful: Suspect psychogenic overlay or serious disease process or major lesion
Interpretation of RROM (Muscle Testing)
Strong and pain free- no pathology with that muscle-tendon element
Strong and painful- “minor” lesion of the muscle-tendon element (eg muscle strain, tendonitis)
Weak and painful - “serious” problem (eg fracture)
Weak and painless - complete tear of the muscle-tendon element or pathology in nerve supply to the element
Repetition painful - suspect vascular (arterial) involvement
Pain at extreme ROM - suspect a “pinchable” structure
Movement and Pain
Pain at extreme ROM - suspect a “pinchable” structure
Excessive ROM - suspect ligamentous laxity
No movement possible - psychogenic, gross lesion, bony block
Palpable Click - suspect a loose body
Crepitus - suspect articular surface involvement
Seqeuene of Pain
pain before motion barrier = acute
pain at motion barrier = sub-acute
pain when motion barrier is exceeded = chronic
pain in middle of range only = painful arc
Signs of Hemarthrosis
History of severe mechanical trauma
Acute and immediate excruciating pain
Visible redness
Extreme joint heat
Rapid swelling (3-4 hours)
Presence of a capsular pattern
Blood in joint = immediate referral!
Special Tests
are only meant to help guide your physical examination, not be the main source of your information.
let the patient’s subjective history and results of the rest of your exam guide which special tests you choose
Red Flags
Signs of serious pathology
Cauda equina syndrome
fracture,
tumour,
unremitting night pain
sudden weight loss of 10 pounds over 3 months
bladder & bowel incontinence
previous history of cancer
saddle anaesthesia
Outcome Measures
the result of a test that is used to objectively determine the baseline function of a patient at the beginning of treatment. Once treatment has commenced, the same instrument can be used to determine progress and treatment efficacy. With the move towards Evidence Based Practice (EBP) in the health sciences, objective measures of outcome are important to provide credible and reliable justification for treatment. The instrument should also be convenient to apply for the therapist and comfortable for the patient
