Musculoskeletal Complaints Guide

Ackowledgments
Introduction

PART I
CHAPTER

xi
Xlll

Musculoskeletal Complaints
1

General Approach to Musculoskeletal
Complaints

3

Context 3
General Stra tegy 4
History 8
Examination 20
Management 26
Appendix 1- 1 42
Appendix 1-2 42
Appendix 1-3 44
CHAPTER

2

Neck and Neck! Arm Complaints

45

3

Temporomandibular Complaints

Context 77
General Strategy 77
Relevant Anatomy and Biomechanics 78
Evaluation 79
Management 82
Selected TMJ Disorders 86
Appendix 3- 1 88

Thoracic Spine Complaints

89

5

Scoliosis

105

Context 105
General Strategy 105
Idiopathic Scoliosis Etiology 106
Evaluation 107
Management 115
Summary 11 9
Appendix 5-1 123
CHAPTER

77

4

Context 89
General Strategy 89
Relevant Anatomy 90
Biomechanics 91
Evaluation 92
Management 95
Selected Disorders of the Thoracic Spine 99
Appendix4--1 102
Thoracic Diagnosis Table 103
CHAPTER

Context 45
General Strategy 46
Evaluation 53
Management 60
Selected Causes of Cervical Spine Pain 68
Appendix 2-1 72
Neck Diagnosis Table 75
CHAPTER

CHAPTER

6

Lumbopelvic Complaints

127

Context 127
General Strategy 12 8
Relevant Anatomy, Physiology, and
Biomechanics 12 8
Evaluation 131
~a nagement 147
Sel ected Disorders of the Low Back 157
Appendix 6-1 166
Low Back Diagnosis Table 171
CHAPTER

7

Shoulder Girdle Complaints

175

C ontext 175

v

Appendix 8-1 237
Elbow and Forearm Diagnosis Table 238
CHAPTER

9

Wrist and Forearm Complaints

CHAPTER

241

Context 241
Relevant Anatomy and Biomcchanics 243
Evaluation 244
Management 251
Selected Disorders of the Wrist and Forearm 254
Appendix 9-1 265

14

PART II
CHAPTER

10

Finger and Thumb Complaints

CHAPTER

Hip, Groin, and Thigh Complaints

295

Context 295
General Stratef.,'Y 295
Relevant Anatomy 296
Evaluation 298
Ivlanagement 303
Selected Disorders of the Hip, Groin, and
Thigh 307
Appendix 11-1 317
Hip Pain Diagnosis Table 318
CHAPTER

12

Knee Complaints

Context 321
Evaluation 325
Management 336

vi

Contents

Neurologic Complaints
15

Weakness

421

Context 42 J
Relevant AnatolllY and Physiology 423
Evaluation 423
Management 429
Selected Neurologic and l1uscular Diseases 433
Appendix 15-1 438
CHAPTER

11

381

267

Context 267
Relevant Clinical Anatomy 268
Evaluation 269
Management 273
Selected Disorders of the Finger, Thumb, and
Hand 280
Appendix 10-1 289
Vrist and Hand Diagnosis Table 291
CHAPTER

Foot and Ankle Complaints

Context 3Rl
Evaluation 385
Management 392
Selected Foot Disorders 404
Appendix 14-1 412
Foot/Ankle/Lower Leg Diagnosis Table 414

CHAPTER

321

16

Numbness, Tingling, and Pain

439

Context 439
Relevant Anatomy 44 J
Evaluation 442
Management 447
Appendix 16-1 449
Appendix 16-2 449
17

Headache

451

Context 4.5 1
Theories of Causation of Primary Headaches 454
Management 461
Selected Headache Disorders 468
Appendix 17-1 472
Appendix 17-2 472
Headache Diagnosis Matrix 477

Relevant Anatomy and Physiology 510
Evaluation 510
Management 512
Appendix 19-1 517
Appendix 19-2 51 7
PART III
CHAPTER

20

Context 575
Relevant Physiology and Anatomy 575
Evaluation 577
Management 578
Selected Causes of Lower Leg Swelling 580
Appendix 25-1 583

General Concerns
Depression

521
CHAPTER

Context 521
Terminology and Classification 522
Evaluation 524
Management 525
Appendix 20-1 528
Appendix 20-2 528
CHAPTER

21

Fatigue

22

Fever

531

CHAPTER

CHAPTER

547

23

Sleep and Related Complaints

27

Skin Problems

593

553

28

Vaccination: A Brief Overview

603

Context 603
OPV (Polio) 607
MMR (Focus on Measles) 607
DPT (Focus on Pertussis) 607
Summary 608
Some Childhood Diseases 609
Appendix 28-1 611
Appendix 28-2 611
CHAPTER

Context 553
Classification System 555
Evaluation 556

585

Context 593
Evaluation 597
Management 601
Appendix 27-1 601

Context 547
Relevant Physiology 548
Hyperthermia 548
Evaluation 549
Management 551
Appendix 22-1 552
CHAPTER

Lymphadenopathy

Context 585
Evaluation 586
Management 587
Selected Causes of Lymphadenopathy 589
Appendix 26-1 591

Context 531
General Discussion 532
Evaluation 533
Management 535
Selected Disorders Presenting as Fatigue 538
Appendix 21-1 544
CHAPTER

26

29

Weight Loss

613

Context 613
Evaluation 614
Management 616
Appendix 29-1 619
Contents

vii

Management 631
Appendix 31-1 633

PART IV
CHAPTER

CHAPTER

Gastrointestinal Complaints

32

Abdominal Pain

637

Context 637
Evaluation 640
Examination 645
Management 647
Selected Causes of Acute Abdominal Pain 651
Selected Causes of Recurrent Abdominal Pain 656
Appendix 32-1 662
Appendix 32 -2 662
CHAPTER

33

Constipation

665

Context 665
Evaluation 667
Management 669
Appendix 33-1 673
CHAPTER

34

Diarrhea

Context 675
General Strategy 67 5
Evaluation 678
Management 680
Appendix 34-1 683

PART V
CHAPTER

Urinary Incontinence and Voiding
Dysfunction

Context 687

viii

Contents

PART VI
CHAPTER

705

Cardiopulmonary Complaints

38

Syncope/Presyncope

713

Context 713
Genera l Strategy 713
Evaluation 7 14
Management 716
Appendix 38-1 716
39

Chest Pain

717

Context 717
Evalu ation 722
Managen1ent 724
Selected Causes of Chest Pain 726
Appendix 39-1 734
Appendix 39-2 734
CHAPTER

40

Palpitations

735

Context 735
Evaluation 736
Management 739
Possible Causes of Palpitations 742
Appendix 40-1 743

Genitourinary Complaints
35

Vaginal Bleeding

Context 705
Genera l Strategy 705
Evaluation 706
Management 706
Appendix 37-1 709

CHAPTER

675

37

687
CHAPTER

41

Dyspnea (Difficulty Breathing)

Context 745

745

Appendix 42-1 770

PART VII
CHAPTER

43

Relevant Anatomy 825
Evaluation 826
Management 826
Appendix48-1 826

Head and Face Complaints
Eye Complaints

775
CHAPTER

Context 775
Review of General Terminology 77 5
Evaluation 777
Management 780
Selected Causes of Vision Loss 784
Appendix 43-1 788
Appendix 43-2 788
CHAPTER

44

Facial Pain

45

Ear Pain

PART VIII
791

CHAPTER

799

CHAPTER

Hearing loss

Context 809
Evaluation 810
Management 812
Selected Causes of Hearing Loss 816

SO

Special Conditions
Diabetes Mellitus

833

51

Thyroid Dysfunction

845

Context 845
Evaluation 846
La bora tory Testing and Managemen t 847
Selected Thyroid Disorders 849
Appendix 51-1 852
CHAPTER

46

827

Context 833
Evaluation 836
Management 838
Appendix 50-1 842
Appendix 50-2 842

Context 799
Evaluation 800
Management 801
Selected Causes of Ear Pain 805
Appendix 45-1 808
Appendix 45-2 808
CHAPTER

Sore Throat

Context 827
Evaluation 828
Management 829
Appendix 49-1 830

Context 79 1
Relevant Neurology 792
Evaluation 792
Management 793
Facial Pain Caused by Neuralgias 796
Appendix 44--1 797
CHAPTER

49

809

52

853

Hyperlipidemia

Context 853
Evaluation 854
Management 857
Appendix 52-1 865
Appendix 52-2 865
Contents

ix

Sports-related Issues in the Young Patient 900
A Region-based Approach to Complaints and
Concerns ofPatientlParent 917
Appendix 54-1 929
Appendix 54-2 930
CHAPTER

55

The Geriatric Patient

Context 933
Evaluation 940
Focused Concerns 944

x

Contents

Appendix
Pharmacology for the Chiropractor:
How ~edications ~ay Affect Patient
Presentation and ~anagement Outcomes
933

993

Concensus Document for the Operationally
Defined Use ofI.CD. Codes: Palmer
Chiropractic College West Clinics

1027

Index

1029

Acknowledgments

I would like to express my apprecia tion to those who have
co ntributed to the editing of the firs t two editions. T his
includes many of the department chairs at variolls chiropractic colleges. In particular, my thanks go to Robert
Mootz, D. C., and D ominick Scuderi, D .C. Also, I would
like to thank the clinical professors at P almer College of
Chiropractic Nest for their help in developing the T.C.D.
(International Classification of Diseases) Code docu-

ment used in this text. Special thanks to Greg Snow, D .C.
Repeated thanks goes to John Boykin for his photography and advice. As usual, a task this size is not possibJe
without the dedication and hard work from th e editorial
and production staff at the publisher, J ones & Bartlett.
Special th anks to C hambers Moore,Jenny McIsaac, Anne
Spencer, Amy Rose,J ack Bruggeman, and everyone else
who assi sted in this project.

xi

Introduction

What would warrant a third edition? The mere fact that new information is being generated at an exponential rate may seem justification enough, yet another area of need is to refocus based on "trends"
in science and theories applied to disease and health. Additionally, as with the second edition, recommendations from readers have led to changes in format and design.
The most prevalent themes running through the current literature regarding the practice of health
professionals include among others:
• An evidence-based approach to evaluation and management of patients. The most recent trend
is a "best-practices" approach.

• The new knowledge provided by the human genome project and the discovery of the importance of the interaction between genes and the environment. For example, we now know that
patients respond to various medications differently because of genetic predisposition. Some involve having or not having a gene and some involve mutations of a given gene. This is also true
for certain sub-groups of patients at risk for various diseases including breast cancer and colorectal
cancer.
• The understanding that many diseases that were thought to be unrelated have a common underlying inflammatory process.
• Recent discoveries about the relationship among disease, diet, and lifestyle.
• The alarming rate of increase of obesity in the U.S.
• An increase in diabetes and hypertension resulting in the development of pre-diabetes and prehypertension threshold levels now used as initiating points for management.
As with the previous two editions, there continues to be a dedication to the most current research
regarding the recommendations for the use of evaluation and management tools. An enormous increase in the number of papers focusing on the reliability, sensitivity/specificity, and validity of a number of tests (in particular orthopedic tests) has emerged. With this new information, many traditionally
held approaches are being questioned. This focus on clinical research is a more appropriate evaluation of patients rather than a memorized list or ritualistic testing.
In the search for an evidence-based approach, no single profession or specialty is safe from scrutiny.
Some studies have questioned the value of chiropractic manipulation/adjusting versus other conservative approaches. Others question the use of surgery for conditions that apparently resolve on their
own or simply reach a level of improvement without surgical intervention similar to those patients havmg surgery.
WIthin chiropractic there has always been the background concern aboutvertebrobasilar accidents related to cervical adjustments. Researchers have redirected the spotlight on the need for a procedure (i.e.,
cervical adjustments/manipulation) to determine if it is "worth the risk" however rare. Most impo~
tantly, though, research has supported the rare occurrence of these events and exposed the poor SCIence which was used to magnify the effect unjustifiably raising it to the level of relatlVely common
xiii

of a specific code and/or criteria for commonly seen presentations. These are simply recommended
use guidelines and are not intended as broad-based consensus agreement among all chiropractors. Yet,
these tables may help identify key criteria for th e use of many commonly used codes, thereby allowing a more standardized approach.
Also add ed to this new edition are:
• Over 500 new references
• Tables that summarize over 100 additional disorders (less commonly seen emphasis) including:
.. Arthritides
• Myopathies
ill
Neuropathies
!II
Anemias
Ii!
Cancer/tumors
• Inherited disorders
• Summary pages for the following:
• Veretebrobasilar accidents (VBAs)
III
Vaccination issues
II!
Popular diets
II
Anti-Inflamm atory diet
As part of a best-practices approach, I have added some key websites after many of the chapters.
Following this introduction are some general websites related to chiropractic, for general searches,
and for evidence-based/guideline resources. T hese are essential for filling the gap between edi tions
of the text.
Thomas Souza, D.C., DACBSP

xiv

Introduction

WEBSITES

Chiropractic Websites
American Chiropractic Association
http://www.amerchiro.org/
International Chiropractic Association
http://www.chiropractic.org/

Evidence-Based Sites
Agency for Health Care Research and Quality
http://www.ahcpr.gov/
Cochrane Database
http://www.update-software.com!cochrane/
Center for Evidence-Based Medicine
http://www.cebm.netl
Evidence-Based Medicine
http://ebm.bmjjournals.com!

Practice Guideline Sites
Alberta Medical Association Clinical Practice Guidelines Program
http://www.albertadoctors.org/resources/
guideline.html
British Columbia Medical Services Plan: A list of
guidelines and protocols from the BC Ministry of
Health Services
http://www.hlth. gov. bc/calmsp/protoguides/
gps/index.html
Canadian Medical Association Clinical Practice
Guidelines (CPG) Infobase
http://mdm.calcpgsnewlcpgs/index.asp
Canadian Task Force Preventive Health Care,
Canadian Guide to Clinical Preventive Health
Care: Full text of the Task Force guidelines on screening and other preventive health measures
http://www.ctfphc.org
College of Physicians and Surgeons of Alberta:
The college is responsible for setting standards of
medical practice in Alberta
http://www.cpsa.ab.calpublicationsresources/
policies.asp
HSTAT: Full text of practice guidelines, consumer
information, and consensus statements from U.S. government agencies
http://text.n1m.nih.gov

National Guidelines Clearinghouse: Guidelines
from the U.S. Agency for Health Care Policy &
Research, the U.S. Preventive Services Task Force,
and other agencies
http://www.guidelines.gov
National electronic Library for Health (NeLH)
Guidelines Finder: A database containing over
600 UK national guidelines with links to Internet
downloadable versions
http://www.nelh.nhs. uk! guidelinesfinder
New Zealand Guidelines Group
http://www.nzgg.org.nz
Prodigy (Practical Support for Clinical Governance): Clinical guidance products from UKNHS
http://www. prodigy.nhs. uk!clinicalguidance
Rehabilitation Guidelines: Evidence-based rehabilitation guidelines from the University of Ottawa
http://www.health.uottawa.calEBCpg/english
Scottish Intercollegiate Guidelines Network (SIGN)
http://www.show.scot.nhs. uk! signlindex.html

Databases
PUB MED: www.ncbi.nlm.govlPub Med/
CINAHL: www.cinahl.com
MANTIS: www.health.index.com
COCHRANE LIBRARY:
www.update-software.com
DARE: http://agatha.york.ac_uk!darehp
CLINICAL EVIDENCE:
www.clinicalevidence.com
PEDro: www.cohs.usyd.edu.au
CAMPAIN TECHNOLOGY REPORTS:
www.campain.umm.edu.ris/ris/web.isa
HSTAT: http://hstat.n1m.nih. gov.!
HTA-UK: www.ncchta.orglhtapubs.htm
CCOHTA: www.ccohta.ca
GUIDE TO HEALTH TECHNOLOGY
ASSESSMENT ON THE WEB:
www.ahfmr.ab.ca

Introduction

xv

CONTEXT
The approach to a patient's musculoskeletal complaint is
a standardized, often sequential search for what can and
what cannot be managed by the examining doctor. There
is always an ultimate decision: rule in or rule out referable
conditions.
• The crucial decision with acute traumatic pain is to
rule out fracture (and its complications such as neural or vascular damage), dislocation, and gross
insta bili ty.
• The crucial decision with nontraumatic pain is to
rule out tumors, inflammatory arthritides, infections, or visceral referral.
There appears to be a misinterpretation regarding the
amount of information necessary to make diagnostic or
management decisions. One error is to think of aJl joints
as distinctly different because the names of structures,
disorders, or orthopaedic tests are different for each joint.
Another error is to make the assumption that the joint operates as an independent contractor without accowltability
to other joints. The first error leads to an overspecialization effort that often leaves the doctor unwilling to
attack the vast amount of individual infomlation for each
joint. The second error leads the examiner to an approach
that excludes important information that may contribute
to the diagnosis of a patient's complaint. Each is an error
in extremes: the first is that too much knowledge is assumed necessary; the second assumes that too little baseline information is needed for making diagnostic and
treatment decisions.
A general approach to evaluation of any joint (and surrounding structures) utilizes the perspective that a joint
is a joint. Although a specific joint may function differently because of its bony configuration, structurally, it is
composed generally of the same tissues. Most joint regions

have bone, ligaments, a capsule, cartilage and synovium,
surrounding tendons and muscles, associated bursae,
blood vessels, nerves, fat, and skin. All of these structures
may be injured by compression or stretch. Compression
may lead to fracture in bones or neural dysfunction in
nerves. Stretch leads to varying degrees of tendon/
muscle, ligament/capsule, neural/vascular, or bone/
epiphyseal damage ranging from minor disruption to full
rupture. Joints can be further divided into weight bearing and non-weight bearing. Non-weight-bearing joints
may be transformed into weight-bearing joints through
various positions such as handstands or falls with the upper extremity, hyperextension of the spine, or any axial
compression force to the joint. Weight-bearing joints
are generally more susceptible to chronic degeneration
and osteoarthritis.
Bones and joints are also susceptible to nonmechanical processes that involve seeding of infection or cancer
as well as the development of primary cancer and the immunologically based rhewuatoid and connective tissue disorders. Clues to rheumatoid and seronegative arthritides
include a pattern of involvement with a specific predilection to a joint or groups of joints coupled with laboratory
investigation.
The approach to evaluation of a neuromusculoskeletal complaint is also directed by a knowledge of common
conditions affecting specific structures (regardless of the
specific names). Following is a list of these structures and
the disorders or conditions most often encountered with
each:
• bone
• tumor, primary or metastatic
• osteochondrosis/apophysitis
• fracture
• osteopenia (osteoporosis)
• osteomyelitis
3

III

soft tissue
1. muscle
l!! strain or rupture
trigger points
atrophy
myositic ossificans
muscular dystrophy
rhabdomyositis
2. tendon
tendinitis
tendinosis
pa ra ten 0 ni tis
rupture
3.lig3ment
l!! sprain or rupture
4. bursa
bursitis
5. fascia
myofascitis

III

joint
• arthritis
• subluxation/fixation (chiropractic)
•
•
•
•

synovitis
infection
joint mice
dislocation/subluxation (medical)

III

III

Determine whether the mechanism is one of overuse.
III
III

III

III

III
III

III

History

III

III

Is the complaint traumatic?
Is there a history of overuse)
Is the onset insidious?

Clarify the type of complaint.
III

III

Is the complaint one of pain, numbness or tingling,
stiffness, looseness, crepitus, locking, or a combination of complaints?
Localize the compbint to anterior, posterior, medial, or lateral if applicable.

III

III

4

If there was a fall onto a specific region or structure
within that region, consider fracture, dislocation, or
contusion.
Determine whether there was an excessive valg'us
or varus force, internal or external rotation, or f1exMusculoskeletal Complaints

Are there associated spinal complaints or radiation
from the spine? Consider subluxation, nerve root
entrapment, or compression.
Does the patient have a diagnosis of another arthritide, systemic disorder such as diabetes, or past history of cancer'
Does the patient have "visceral" complaints such as
abdominal or chest pain, fever, weight loss, or other
complaints?

Evaluation
III

III
III

Clarify the mechanism if traumatic (for extremities see
Table 1-1).
III

Are there associated systemic signs of fever,
malaiselfatigue, lymphadenopathy, multiple affected areas, etc?
Are there local signs of inflammation including
swelling, heat, or redness?
Is there local deformity?
Is there associated weakness, numbness, tingling, or
other associated neurologic dysfunction?

Determine whether the patient has a current or past history or diagnosis of his or her complaint or other related
disorders.

III

III

In what position does the patient work?
Does the patient perform a repetitive movement
at work or during sports activities? Consider muscle strain, tendinitis, trigger points, or peripheral
nerve entrapment.

If insidious, determine the following:

GENEIUH STRATEGY
Clarify the onset.

ion or extension. Consider ligament/capsule or
muscle/tendon.
If there was sudden axial traction to the joint, consider sprain or subluxation.
If there was axial compression to the joint, consider
fracture or synovitis.

III

With trauma, palpate for points of tenderness and
test for neurovascular status distal to the site of injUly; obtain plain films to rule out the possibility of
fracture/ disloca tion.
Palpate for swelling, masses, and warmth.
Determine whether swelling is present and if so,
whether it is intra- or extra-articular. If extraarticular, attempt to differentiate between bursal
versus vascular inflammation.
If deformity or mass is evident, attempt to differentiate ben:veen soft versus bony tissue. The most
common soft-tissue causes would include lipomas,
neuromas, and ganglions (or other cyts), or fascial
herniation.

Acromioclavicular separation
Dislocation
Fall onto top of shoulder

S
houlder pointer
Acromioclavicular separation
Distal clavicular fracture

T
ractioninjury to arm

Plexus injury
Medical subluxation

Elbow
Direct fall on tip of elbow or fall on hand with elbow ftexed

Olecranon fracture

Fallon hand with extended elbow

Radial head fracture

H
yperextension injuryto elbow

Elbow dislocation

Severe valgusstress

Capitellum fracture

Supracondylar fracture in children
Avulsion of medial epicondyle
Medial collateral ligament sprain or rupture
Sudden traction offorearm

Radial head subluxation

Wrist/hand
Fallondorsifiexed hand

Navicular fracture
E
piphyseal and torus fracturesin children
Carpal dislocation,or instability

Hyperextension or abduction of thumb

Gamekeeper'sthum b(ulnar collateral ligament damage)

Axial compression of thumb

Bennett's fracture
Dislocation

Hyperextension of finger

Volar plate injury
Jersey finger (rupture of fiexor digitorum profundus)
Dislocation

Hyperftexion of finger

Avulsion of central slip
Mallet finger (rupture of extensor tendon)

Valgus/varusstress injuryto finger

Collateral ligament orvolar plate injury

Axial compression

Capsular irritation
Fracture

Hip
Fallon hip

Fracture
Synovitis
(co ntinued)

General Approach to Musculoskeletal Complaints

5

Blow to anterior knee/patella

Irritation of plica
Patellar fracture
Bursitis
Infrapatellar fat padirritation

V
algusforce

Medial collateral ligament tear
Pesanserine strain

Rotational injury with foot fi xed on ground

M
eniscus

Rotational injury with avalgus force

Anterior cruciate ligament, meniscus,medial collateral ligament

Foot/ankle
Plantarfiexion, inversion of ankle

Ankle sprain with possible ass
ociated bifurcate ligament damage, fracture,
or peroneal tendon snapping from torn retinaculum

Eversion injury to ankle

Deltoid ligament sprainor rupture
Fracture
Dislocation

H
yperextensionof great toe

Turf-toe injury toc ular ligaments
aps

L
anding on heels

Fat pad irritation
Ankle ortibial fracture

• With no history of trauma or overuse, consider the
use of special imaging, including MRl or CT; bone
scan for cancer seeding screen or for stress fracture; electrodiagnostic studies if persistent neurological findings are present; laboratory if systemic
findings are present; or synovial fluid analysis if
swelling is present or if an arthritide is suspected but
in need of differentiation (see Table 1-2)
• Palpate and challenge the ligaments and capsule of
the joint.
• Challenge the musculotendinous attachments with
stretch, contraction, and a combination of contraction in a stretched position.
• Measure the functional capaci ties of the region involved; determine any associated biomechanical
faults that may be contributing to the problem.

6


Management

• Refer fracture/dislocation, infection, and tumors
for orthopaedic management.
• Refer or comanage rheumatoid and connective tissue disorders.
• If the problem is one of instability without ligament rupture, stabilize the joint through an appropriate exercise program using a brace initially,
if necessary, to assist.
• If the problem is weakness, strengthen the associated muscle.
• Functionally retrain the individual for a return to daily
activities and occupational or sport requirements.
• Use manipulation/mobilization for articular
dysfunction.

TABLE

1-2

Synovial Fluid Examination

Cle
ar

N
ormal
Group I
(Noninfiammatory)

DJD
Trauma

Transparent

Yellow

Transparent

Yellow to opalescent

Transparent to opaq

Yellowto green

Opaque

Oteochondritis dissecans
s
PVS
Osteochondromatosis
Neuropathic arthropathy
Group II
(Infiammatory)

RA
Active crystal-induced
(gout,pseudo-gout)
Seronegatives (AS,
Reiter's psoriatic)
Enteropathic (lBD)
Rheumatic fever

C

ro

::J

S
LE

~

Scleroderma

~

:»
-c
-c

Tuberculosis

(3

~

=
a

~

c:
~

c:
"

~

ro
""
~
'"
,-.

a

3

-c

'"
~.

'-I

G III
roup
(Purulent)

P
yogenic bacterial
infection

Note. Joint aspiration findings for hemorrhagic causes including hemophilia, trauma (with or without fracture), neuropathic
,

Legend:WBC = white blood cell;PMN = polymorphonuclear leukocytes; P = pigmentedvillonodular synovitis; IBD = infla
VS

HISTORY
A mnemonic approach to the patient's complaints may be
helpful in organizing the vast number of possibilities.
Beginning with a description of the patient's complaint,
a list of common causes may be attached. WIRS Pain is
a mnemonic for weakness, instability, restricted movement, surface complaints, and pain.

Weakness
Weakness may be due to pain inhibition, muscle strain, or
neurologic interruption at the myoneural junction, peripheral nerve, nerve root, or spinal cord and above.
Weakness may be a misinterpretation by the patient when
instability or a "loose" joint is present or the patient has stiffness that must be overcome by increased muscularactivity.

Instability
Instability is due to either traumatic damage to ligamentous or muscular support or due to the inherent looseness
found in some individuals' joints. This inherent looseness
is usually global and can be identified in other joints or
acquired as a result of repetitive overstretch positioning.
Instability is most apparent when the joint is positioned
so that muscles have less mechanical advantage (e.g.,
overhead shoulder positions) or when a quick movement
demand is faster than the reaction time for the corresponding muscles (cutting or rotating knee movements).

Restricted Movement
Restricted movement may be due to pain, muscle spasm,
stretching of soft tissue contracture, or mechanical blockage by osteophytes, joint mice, fracture, or effusion.

Surface Complaints
Superficial complaints include skin lesions, cuts/
abrasions, swelling, and a patient's subjective sense of
numbness or paresthesias.

Pain
Pain is nonspecific; however, the cause usually will be revealed by combining a history of trauma, overuse, or insidious onset with associated complaints and significant
examination findings. It is important to determine local
pain versus referred pain. Following are some guidelines:
• Referred pain from scleratogenous sources:
Scleratogenous pain presents as a nondermatomal
pattern with no other hard neurologic findings such
as significant decrease in myotomal strength or
deep tendon reflex changes. Although the term is
used broadly, here we are referring mainly to facetand disc-generated pain.
• Referred pain from visceral sources: In most cases
a historical screening of patients will reveal pri-

8


mary or secondary visceral complaints. It is important to know the classic referral zones, such as
scapular/shoulder pain with cholelithiasis and medial arm pain with cardiac ischemia.
• Bone pain: Bone pain is deep pain, commonly worse
in the evening. Trauma may indicate an underlying
fracture requiring radiographic evaluation. An overuse history may be suggestive of a stress fracture
requiring a radiographic evaluation. If results of
the radiograph are negative, but a stress fracture is
still suspected, a bone scan is warranted.
A careful history will usually indicate the diagnosis or,
at the very least, narrow down the possibilities to two or
three. Physical examination and imaging studies more
often are used as a confirmation of one's suspicion(s).
Generalizing a history approach allows the doctor to address any complaint regardless of region. Generally speaking, damage to structures locally is due to (1) exceeding
the tensile stress ofligaments, capsule, muscles, and tendons; (2) compression of bone; (3) demineralization of
bone; or (4) intrinsic destructive processes involving
arthritides (e.g., pannus foonation with rheumatoid arthritis [RAJ, crystal deposition with gout or pseudogout), infections, or cancer. Although the first two categories are
almost always the result of trauma or overuse, the latter
two are more commonly insidious. Traumatic and overuse disorders are classically local with regard to signs and
symptoms, whereas arthritides and cancer are often either
generalized or stereotypical based on the type.
Suspicion of specific structures is based on a basic knowledge of what causes damage to any similar structure regardless of which region or joint is involved. Ligament or
capsular injury is often the result of excessive force on the
opposite side of the ligament/capsule. For example, a valgus stress (outside to inside force) to the knee will cause an
injury to the medial collateral ligament; a varus force, the
lateral collateral ligament. Although more dramatically
evident in an acute injury, it must be remembered that
low-level, chronic stresses are often the cause ofligamentous or capsular sprain. Muscle injury can be divided into
stretch injury and contraction injury. Often when ligaments are damaged, muscle/tendon groups are also involved. Muscle/tendons often act as static stabilizers simply
because when they cross the joint they are in the way when
outside forces stretch that joint. Additionally, muscles will
often contract in an attempt to protect the joint and either incur damage or impose more damage to the joint. This
occurs especially when a joint is in extension (such as the
knee and elbow) or in neutral (such as the wrist and ankle).
Contraction injury is divided into concentric and eccentric.
Usually an overexertion problem, concentric injury often
occurs when too heavy a weight is lifted or a sudden explosive muscle activity is required. Concentric injury occurs as the muscle is shortening. Eccentric injury occurs

while the muscle is lengthening. Although eccentric injury may occur with lifting, this pattern is frequently seen
with overuse or repetitive activity and/or injuries that
challenge the decelerator or stabilizer role of the muscle.
Tendons are susceptible primarily to overstrain from
a sudden, forceful muscle contraction or from overuse.
Occasionally, direct trauma may damage or inflame the
tendon or its sheath. Rheumatoid and connective tissue
disorders can also affect the synovial lining or paratenon.
Sometimes the use of various terminologies in the description of tendon disorders is confusing. Newer terminology replacing older nomenclature causes some of
this difficulty, coupled with new theories as to the types
of tendon pathology that occur related to its structure
and function. l Following is an updated list:
• Paratenonitis-This term is replacing tenosynovitis, tenovaginitis, and peritendinitis. It is characterized by inflammation of only the para tenon (lined
by synovium or not). Clinical signs are swelling,
pain, crepitation along the tendon, local tenderness , and warmth.
• Tendinitis-Now used in place of strain or tear of a
tendon. This term refers to symptomatic degeneration of a tendon with vascular disruption and an inflammatory repair response. Stages include: acute,
< 2 weeks; sub-acute, 4-6 weeks; and chronic,
> 6 weeks. Three subgroups include: (1) purely inflammatory with acute hemorrhage and tearing,
(2) inflammation that is in addition to preexisting
degeneration, and (3) calcification and tendinosis
that is chronic.
• Tendinosis-The newer term used to indicate intratendinous degeneration due to atrophy (due to
aging, microtraum a, vascular compromise, etc.).
This is considered noninflammatory with hypocelluJarity, variable vascular ingrowth, local necrosis,
and/or calcification, with accompanying fiber disorientation. Palpable nodules can be fonnd, such as
in the Achilles, with or without tenderness.
• Para tenonitis with tendinosis-This describes a
paratenon inflammation associated with intratendinosis degeneration. Unlike tendinosis, this
combination of pathologies presents clinically with
a possible palpable tendon nodule, with accompanying signs of swelling and inflammation.
Bursae are protective cushions placed strategically at
points of friction, particularly between muscle/tendon and
bone. Althongh there are standard bursae in most individuals, adventitious bursae may develop at sites of repetitive friction in individuals performing specific activities.
Bursae may be deep or superficial. Superficial bursae are
susceptible to direct traumatic forces. Deep bursae are
more susceptible to compression by bone or soft tissue

structures. Compression is often position specific such as
during overhead movements with the shoulder. Bursitis
may be secondary to other soft tissue involvement such
as calcific tendinitis.
"Vhen musculoskeletal pain does not have an obvious mechanical or traumatic cause, a search is initiated for myofascial disorders, artluitides, psychologic factors, connective
tissue disorders, cancer, and infection (see Table 1-3).
Arthritis has a "geriatric" connotation, yet it may affect any age group. The term simply means that the joint
is affected. Generally, arthritis is due to degeneration or
destruction that is age-related or trauma related, infectious, inflammatOlY, and/or autoimmune. Based on the
cause, arthritis may present as a monoarthopathy (i.e.,
single joint), oligoarthopathy (2-4 joints), or as a polyarthropathy (~ 5 joints). Vhen a single joint is involved,
gout (first toe), infectious (direct infection or indirect
spreading from another source such as gonococcal), or
trauma should be considered. Vhen multiple joints are
involved a distinction in thinking occurs differentiating
degenerative, inflammatory (primarily rheumatoid and
rheumatoid variants), and crystalline induced (primarily
gout, pseudo-gout, amyloidosis, etc.). Seronegatives and
enteropathic arthropathies tend to be oligoarticular,
whereas RA and LE tend to involve more joints.
When considering arthritis as a cause of joint pain, there
are several other general factors that when considered separately and then clustered together provide a good tool
for narrowing the large list of possibilities. The sequence
of how these factors are considered may change given the
presentation of the patient, yet the discussion will begin with
age. There are very few arthritides that affect the young.
Primarily, juvenile rheumatoid arthritis or arthritis secondary to other diseases would be considered. For the
young to middle-aged adult, primarily inflanunatOlY and/or
autoimmune arthritides are considered, including:
• Seronegative arthritides (i.e., negative for rheumatoid factor) including ankylosing spondylitis (AS),
Reiter's, and psoriatic
• Rheumatoid arthritis (RA)
• Scleroderma
• Lupus erythematosis (LE)
• Osteitis condensins illi
• Synoviochondrometaplasia
For onset in the senior, the primary considerations
include:
• Degenerative joint disease; osteoarthritis (OA)
• Diffuse idiopathic skeletal hyperostosis (DISH)
• Hypertrophic osteoarthropathy
• Gout
• Pseudogout; calcium pyrophosphate dihydrate
(CCPD) deposition disease

9

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Selected Arthritic Disorders

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Degenerative

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Primary Osteoarthritis

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Age of Onset-Generally > 45 y/o
Gender Predominance-Ratio offemale to male = 10:1
Common Joints Involved-Hips, knees,SI joint,AC joint, first MC
DIP joints of hands

Often initially asymptomatic;gradual increase in joint stiffness and p
apparent (e.g., Herberden's nodes in hands). May eventually lead to
instability.
Radiolographically:The distribution is asymmetric, with non-uniform
osteophyte formation,subchondral sclerosis (eburnation),subchond
Secondary Osteoarthritis

Age of Onset- > 25 y/o
Gender Predominance-Equal
Common Joints Involved-GH,AC, SI, hip, elbow, knee, foot, han

Cause is secondary to other disorders or diseases/injuries such as tra
tory arthritis, slipped epiphyses, dysplasias, fracture/dislocation, avas
sis,and acromegaly Similar radiographic presentation.

Erosive Osteoarthritis

Age ofOnset-40-50 y/o
Gender Predominance-Female
Common Joints Involved-Interphalangeal joints of hand

Infiammatory variant of DJD characterized by cartilage degeneration
tion. Acute episodes that appear similar to infiammatory/synovial a
evolve to subluxation and development of Herberden's nodes Radio
with additional finding of central erosions.

Degenerative Spine Disease

Age of Onset- > 30 y/o
Gender Predominance-Equal
Common Joints Involved-Specific spinal involvement at (5-C
with additional involvement of uncovertebral,costovertebral, discov
(facet) joint involvement

Range from asymptomatic to severely symptomatic with pain and s
clinical correlation is poor.May contribute to IVF narrowing and spin
findings include disc space narrowing, hypertrophy of smaller joints
tovertebral,synovial cysts,Schmorl's nodes,and intradiscal vacuum
In middle stages,joint and capsular laxity may lead to subluxation an

TABLE

Selected Arthritic Disorders (continued)

1-~'
'ri!i'

Type

D
iffuse IdiopathicSkeletal
Hyperostosis (DISH) (synonyms
ankylosing hyperostosis,
Forestier's disease)

Features

Age of Onset- 50y/o andolder
Gender Predominance- Male
Common Joints Involved-Spine; predominantlyT7 -T11 (calcific
tudinalligament) with 30% peripheral joint involvement

F in 25%of men and 15% of women> 50 y/o (common) Mayb
ound
symptomatic, similar complaints associatedwith D suchas stiffness
JD
tientsreport dsyphagia; occasional compla intsinvolving the Achilles t
wrist/forearm,plantar fascia, and quadriceps tendon (may find enthes
sponding sites);about aquarter of patientshave diabetes. Radiograph
perostosis primarily alongthe anterolateral aspect of spine ("fiowing w
of patients also have ossification of the PLL
,especiallyin thecervical s
N
euorpathic (Neurotrophic)
Arthropathy

Age of Onset - Va ria ble
Gender Predominance- Variable
(ommon Joints Involved- Knee,hip,ankle,spine,shoulder,elbow

Variable upper motor and lower motor lesions cause acombination o
and pain perception leading to joint destruction,Conditionsinclude sy
tabes dorsalis, mUltiple sclerosis, Charco-Marie-T disease, prolong
ooth
articular corticosteroids, pernicious anemia,and leprosy,among other
but related cause isspinal cord damageresulting inparaplegia or qua
in usually asymptomatic bony ankylosis,Radiographically neuropathic
joint collapse,pseudoarthrosis, fragmentation,and deformity,
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Synoviochondrometaplasia
(idiopathic synovial
osteochondromatosis)

Synoviochondrometaplasia, as the name implies, isasynovial metapla
form ation of cartilage that then form sloosebodies in the jointThis pro
pathicbut maybetheresult oftrauma.Thepatient will report increasin
tus,and locking due to theloosebodies. Radiographically the loose bo
radiopaque Sometimes erosion may occur as in the"apple-core" defor

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Age ofOnset- 30- 50y/o
Gender Predominance-Male to female ratio= 31
(ommon Joints Involved-Knee,hip,ankle,elbow, wris
t

Inflammatory
Positive for Rheumatoid Factor
(Seropositive)
Rheumatoid Arthritis (RA)

Gender Predominance- Female tomale ratio = 2/3: 1
(ommon Joints Involved- Hand, foot, wrist, knee, elbow, G joint
H
spine (atlantoaxial)

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RA (continued)

Asymmetric, bilatera l,polyarticular disorder of the synovial membra
swelling,and destruction.A involved areligaments,tendons, and b
lso
criteriaincludes: D
eformities s as Boutonniere swan-neck,phalan
uch
,
;m
ti
arthritismutalins orning s ffness that lastslonger thanone hour,s
eral joints (includingthePIPjoints, MCP joint,andwrist), rheum
atoid
rheumatoidfactor, andradiographicevidence that includes erosions
nia or both in hands or wrists or both. Needfour or more of the above
Additional symptoms may include fatigue, anorexia,weight loss,and
Special concern isfor a
tlanta-axia l instability due to ligament erosion
excessivem
ovement leadinatospinal cord compreSSion .

Juveni leChronicArthritiS

AgeofOnset- 5- 10y/o
Gender Predominance-Variable basedon specific dis
order
(ommon Joints Involved-Hand,foot, wrist, knee, elbow, heel,h

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Several types including:
• Juvenile-onset adult RA-s findings asRA
ame
• S disease- moreof as
till's
ystemicdisease
• J
uvenileons of s
et eronegative arthropathies-see each disorder
R iographicallysimilar with thepossible additionof growth dis
ad
epiphysea l c
ompression fractures

Negative for R
heuma F
toid actor
(Serone
gative)
A
nkylosing S
pondylitiS(AS
)

AgeofOnset-1 5- 35y/o
Gender Predominance-Maletofem ratio= 4:1to 10: 1
ale
(ommon Joints Involved- 51 thoracolumbar spi ne
joint,
,cervica
hip,shoulder,and heel

Complaintsoftenbeg inwith 51 and progress to low backandth
pain
Eventually therem be adecrease inchest expansion.P pheral joi
ay
eri
approximately50% a does radia pai nto the lower extremity.Are
s
ting
tis (20% of cas s a ins
e ), ortic ufficiency,aneu rysms, pulmonary fibrosi
SR
ctive
1 is.L
0idos aboratoryfindings include anincreased E during a p
andL factors; HLAB posltivein 80%(positivein 6-8%of gene
E
-27,
adiographicallythereare classicsigns, including s
ymmetrical involv
R
ligam calcifica
ent
tion,andmarginal syndesmophytes,eventuallylea
sign,andbamboospine.

TABLE

1-3


Type
Reiter's Syndrome

Features

Age ofonset- 15- 35 ylo
Gender Predominance- Male to female ratio = 51 to 50 1dep
Common Joints Involved-51 joint, foot,heel, ankle,knee, hip,sp
upper extremity

Urethritisand other eye complaintsoften following a5TD or gastroin
erratitis, kerratoderma,andkeratosisof nails may be found, Systemi
K
fever, weight loss, thrombophlebitis, or amyloidosis, Lab findings may
B27(75%),leukocytosis,anemia,and elevated ESRRadiographically
antlanto-axial instability, non marginal syndesmophytes Similar to p
digit may be involved (sausage finger) and enthesopathies are comm
aortic regurgitationin chroniccases,
P
soriatic

O about 5% of those with skin diseasehavethe joint involvement
nly
terns,yet many times the proximal and distallP joints are involved,A
lead to arthritis mutilans, Inaddition to possibly having scaly patches
extensor surfaces of [he kneesand elbows, patientsmayalso havena
ting' discoloration,and splintering In some caseshyperostosis occurs
lesions mayoccur in thehands and feet. Lab includes HLA-B27 antig
anemia,elevated ESR during activeperiods, occasionally elevated uri
Radiographically the involvement of the hands issimilarto RA, In ad
affected (sausage finger) and tuft resorption and proliferation (ivory
spine, nonmarginal syndesmophytes may be seen,

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Age ofonset- 20-50y/o
Gender Predominance-Generallyequal
Common Joints Involved-Hand,foot, 51 joint, thoracolumbar sp

Enteropathic(associated with
inflammatorybowel disease [IBO])

Age of Onset- Variable
Gender Predominance-V
ariable
Common Joints Involved-SI joint and spine;occasionally perip

Manyinflammatory disorders affecting the G tract mayresult inan a
I
seronegative arthritides. D
isorders include Crohn's,ulcerativecolitis,W
fections,including Salmonella,Shigella,a nd Yersinialntestinal bypas
lated.The frequency of IBO and AS isabout 15%. Laboratoryreveals H
with IBO and arthritis Radiographic findings are similarto AS, includi
the spine.

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TABLE

1-3


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Systemic Lupus Erythematosis (SLE)

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Gender Predominance-Female more than male
Common Joints Involved-Hand and osteonecrosis, specifical
condyles) and sometimes shoulder (humeral head)

Asystemic autoimmune disorder characterized by multi-system in
generalized findings such as fever, anorexia, weight loss, malaise, an
flammation occurs. Skin affects include rashes (e.g., butterfiy malar
mon.Like many patients with autoimmune rheumatoid conditions
and may rupture. Laboratory reveals anemia with leucopenia and p
ties (protein electrophoresis usually ordered due to globulin increas
and LE cells present Afalse-positive syphilis test may occur. Radiog
nonerosive yet deforming arthropathy is seen. Osteonecrosis may b
or due to treatment (corticosteroids)

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Scleroderma (progressive systemic
sclerosis)

Age ofOnset-20-30y/o
Common Joints Involved-Hand, wrist, foot,ribs,and, more rar

There are two types of this collagen-vascular disease one with syst
gressive) and one without (localized) Scleroderma is characterized
ple organs including skin, heart,lungs, kidneys, GI tract, and muscul
signs and symptoms are quite variable. Muscle weakness, including
phenomenon;hyperpigmentation;vitiligo and telangiectasias;and
of the skin of the face, hands,and feet Laboratory findings include a
(60-70%),positive RF (20-40%), positive ANA (35-96%),and a
ovial fiuid.Radiographically there are periarticular and subcutaneou
paraspinal, phalangeal tuft, and superior rib erosions.

Dermatomyositis and Polymyositis

Age ofOnset-5-1O y/o and again at 20-50 y/o
Gender Predominance--Female to male ratio = 21
Common Joints Involved-Soft tissues primarily of the thigh,


Dermatomyositis and Polymyositis
(continued)

Dermatomyositis affects skin and muscle, whereas, polymyositis a
affect is infiammation and degeneration of striated muscle with a
calcifications in soft tissue. Abou t half of patientshave arthritiswh
Raynaud'sphenomenon Disability occurs due toprogressive symm
weakness. Laboratoryfindings include CPK elevations and elevatio
els. EMG reveals aproximal myopathy as does muscle biopsy Radi
tissue atrophy coupled with s
heet-like soft tissue calcifications and
Like other infiammatory conditions, there is phalangeal tuft resorp

Mixed C
onnective Tissue Disease

Age ofOnset-20-50y/o
Common Joints Involved-Hand, wrist,and foot

Thisgroup of conditions isan overlap of several specificdiseases s
myositis, and scleroderma. L
aboratory finding sinclude specific find
presence of ribonuclease-sensitive extractable nuclear antigen. Ra
those for eachdisorder and include joint destruction with margina
calcification.
Hypertrophic Osteoarthropathy
(Marie-Bamberger syndrome or
pulmonary osteoarthropathy)

There is atriad of peripheral arthritis with clubbing of the fingers a
long bones.This process appears to be secondary to processes in th
commonly, bronchogenic carcinoma,and seems to be neurovascu
function. Patients often have sig nsonly ofthe underlying disorder.
clude the digital clubbingand long bone symmetrical periostitis.

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Age ofOnset-40-60 ylo
Gender Predominance-Primarily male
Common Joints Involved-Fingers(clubbing);periostitis in ti

Osteitis CondensinsIlli

Gender Predominance-Female to male ratio =91
(ommon Joints Involved-Sacroiliac

Thisbilateral disorder affects females probably through acombina
(hormonally induced) and mechanical stresses that lead tosclerot
chondral bone.The process is often asymptomaticWhen symptom
back pain with or without leg pam;however,caution must be take
late the radiographic changes to sym ptoms.The condition, if symp
marily self-limiting

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Type
OsteitisPubis

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Features
Age of Onset -Varies, but with females duringthereproductive
Gender Predominance- F
emale predominant
Common Joints Involved- Symphysis pubes

An inflammatory process seconda ryto trauma,pelvicsurgery, or ch
true if complicated by infection. Possibly due to intraosseous venous
tion Radiographicallyappearsas joint space widening, subchondral
porosis,and joint erosions.

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Metabolic
C l Deposition
rysta
Gout

Age ofOnset- >30 ylo
(in females, postmenopausal)
Gender Predominance- Male
Common Joints Involved- First MTP joint of foot, feet,ankl e
,an

First attack isoften sudden and nocturnal, affectingthe first MCP joi
excess alcohol or meat intakeJever is common duri ng the acute att
swollen.Desquamationand pruritisafter theacute attack are comm
deposits) appear after several attacks of gout and are found behind
prepatellar bursae, hands, and feetThere is adramatic response to N
ing theacute attacUhose with gout should be eva luated for associ
alcoholism, various neph ropathies, myeloproliferative disorders, hyp
sistance Occurrence in 2nd and 3rd decade indicates hereditary diso
thineguanine phosphoriboxyltransferase deficiency. H
yperuricemia
duringacute attacks; joint aspirationrevealscalcium urate crystals. R
struction with soft-tissue swelling and radioluscent spots (urate cry
Ca lcium Pyrophosphate Deposition
Disease ((CPD)

Age ofOnset- >50 ylo
Gender Predominance- Generally equal dependent on cause
Common Joints Involved-Knee, symphysispubis, hand,wrist

CCPD crystal depositioninsoft tissueoccurs due to trauma,several m
other causes The general term chondromcalcinosis isaSSOCiated with
include hemochromatosis, hyperparathyroid ism,och ronosis, diabete
Wilson's disease, among others.There are various sub-types such as
pseudorheumatoid arthritis, and pseudodegenerative J disease.
oint
pseudo-gout, may appearsimilar to gout; however it occursat alate
,
May be asymptomaticor symptomatic When symptomatic, pain an
piration revea lspyrophosphate crystals in synovial fiuid.ESRis eleva
Calcification of intra and extra-articular structures with eventual art
fragmentation

TABLE

1-3

..


Type
HydroxyapatiteDeposition Disease

features
Age of Onset - 40- 70 y/0
Gender Predominance- Equal
Common Joints Involved-Shoulder, hip, cervical spine

T idiopathic process resultsin calcium (hydroxiapatite) depoSition in
hiS
other periarticular soft tissue.In the spine thismay include nucleus pulp
Technically not an arthritis, pain is felt around joints. It is believed that sy
the process resolves (infiammation) rather than during thedeposition p
Radiographically, soft tissue opacities are seen around the joint
O
ther
S
arcoidosis

Age of Onset - 20- 40 Y
/0
Gender Predominance- Equal
Common Joints Involved-Hands, wrists,andfeet

This is systemic disease that produces noncaseating granulomas. It is m
Scandanavianand B populations. Generalized symptoms/signs pred
lack
grade fever, ra sh, lymphadenopathy, malaise, fatigue, arthralgias, and irit
tientshave L
ofgren's syndrome. Laboratory findings includeareverse A/
hypercalcemia,and apositive Kviem test S
keletal involvement occurs in
Radiographically,granulomasare seenin the perihylar region ofthe lun
fibrosis Injoints there may be circumscribed,lytic, intraosseous lesions.
Hemochromatosis
CI

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Rare disorder involvingdepOSition of iron into various tlssues.Triad inclu
cirrhosis,and diabetes mellitusWhen joints are affected there may be p
swelling; usually bilaterally; however, may beginin asingleJoint Labora
E andserum iron,increased saturation of plasma iron binding protein
SR
biopsy finding s Radiographically, usually bi lateral involvement with ost
tal deposition (50% of patients),and involvement of Mep joints.

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Age of Onset - 40- 60 y1
0
Gender Predominance - Male to female ratio = 10:1 to 201
Common Joints Involved -Hip, knee, shoulder,wrist,hand

Alkaptonuria(OchronOSis)

Age ofOnse-30- 40 ylo (present at birth though)
Gender Predominance- Male equal to fema le
(ommon Joints Involved- Spine,hip, and knee

An hereditarydisorder of tyrosinecharacterized by absence of homogen
leading to deposition in tissues throughout the body.The accumulation
oxidizes to form ablack pigment.Ochronosis (brown-black pig mentatio

...
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TABLE

1-3


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Alkaptonuria (Ochronosis)
(continued)

not usuallyseen until age 20),discoloration of urine and ochronotic
acute exacerbationsof arthriticpain inthe spine.Cartilage of nose an
brown but blue on transillumination.Renal and prostatestones arec
ingsincludeurinethat turnsblackonstanding,homogentisicacidin
there is accelerated D of the spinewith eventual bamboo spine
JD
,of
fication of the interspinous ligament.

Pigmented Villonodular S
ynovitis
(PVS)

Age of Onset- 20- 40 ylo
Gender Predominance-Male (slight)
Common Joints Involved- Knee, hip,elbow,ankle

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Asynovial proliferative disorder of unknown origin,although 50% o
tory oftrauma; usually occurs inone joint.ln the hand or foot atendo
giant cell tumorSlowly developing joint pain withassociated swellin
warmth.Aspirationmay reveal hemorrhage. Radiographically,a "pop
with initial preservation of joint space. C erosions with hemorrha
ystic
seen.MRI isdiagnostic.
H
emophillicA
rthropathy

Age ofOnset-2- 3ylo
Gender Predominance-Male
Common Joints Involved-Knee and elbow commonlyaffected
appendicular jointscan be affected

Hemophilia is agroup of disorders that share aproblem with clotting
dysfunctional blood coagulation.The result is bleeding throughout th
ternally as bruising,and prolonged bleeding, such as nose bleedsWi
cursand graduallycauses changes that include swelling,contracture
destruction.Due to the age of onset,radiographic findings Include ep
celerated skeletal maturation,and radioluscent joint effusions. At som
similar appearance radiographically tojuvenile rheumatoidarthritis.

Infectious

Arthritis may be secondary to bacterial, fungal, or viral infe
tration of svnovial or Deriarticular tissues.

There are anumber of risk factors for joint infections including older
patients over60 years of age) ;joint surgery; intravenousdrug use; alc
munosuppressive illnesses or use of immunosuppressivemedication
disease ofthe liver, lu ng, or kidney;skin infections; or malignancy.

F acutearthritis, the most commonbacterial cause in adultsisNeis
or
includeS
taphylococcusaureua, streptococci,and some gram-negati
P
suedomonas auroginosa,and Serratia marcescens.

For chronicarthritis, primarycauses include m
ycobacterium and fun

TABLE

1-3


Hyperlipidemia

c-.
ro
:::l
ro

~
:>

""0
""0

a
,..,
'"
=r
.....
o

$:

~

.:::

~

~

ro

~

~

b'

3
;;:;-

""0

~.

10

sociated systemic signs may help relate the arthritis to
disorders such as LE, scleroderma, enteropathic arthritides (i.e., arthritis associated with inflammatory bowel disease), and so on.
Assembling and applying this information, if a middleaged female presented with a polyarthropathy that included the hands but not the spine, without other systemic
involvement, RA would be high on the list of differentials.
If a young to middle-aged male presented with sacroiliac
pain, no spinal pain, and involvement of a finger, Reiter's
or AS would be high on the list of differentials.

EXAMINATION
Acute Traumatic Injury
An approach to acute injury evaluation initially focuses on
neurovascular status distal to and local to the injury site.

However complex the orthopaedic evaluation may become, the basics remain the same regardless of which joints
and/or surrounding structures are involved (Table 1-4).
Generally, orthopaedic testing attempts to (1) reproduce
a patient's complaint (i.e., elicit pain, provoke numbness/tingling, or reproduce popping or clicking); (2) reveal laxity; (3) demonstrate weakness; or (4) demonstrate
restriction (orthopaedic evaluation, in the context of a
chiropractor, also includes accessory motion evaluation
at a joint). The possible caveats to these attempts are that
pain may be due to many factors and is therefore nonspecific (localization and injury pattern help better define);
laxity may be normal for an individual (especially if bilateral) or pathologic; weakness may be due to reflex inhibition caused by pain (relatively nonspecific), laxity,
muscle injury, or neurologic damage; and restriction to
movement may be due to soft tissue or bony blockage.

TABL E

1-4.

Selective Tension Approach

Arth ritis! ca psu litis

Painful at limit of range

Painful at limit of range

Usually painless within range
of motion

Often specific capsular pattern
of one or two restricted
movement patterns

Tendinitis
Tendinosis

Variable

Pa inon stretch

Painful, especially if contracted
in stretched position

Insertion of tendon is often
tender or slightly proximal
to insertion

Tendon rupture

None

Full;painless

Weak; painless

Note displaced muscle belly

Ligament sprain

Decreased;limited by pain

Pain on stability challenge

Painless iffull rupture,painful if
partial

Overpressure laxity may indicate degree of damage

Muscle strain

Painful,often midrange

Passive stretch may increase
pain

If resistance is sufficient, pain is
produced

Check with resistance throughout full range of movement

Intraarticular body

Sudden onset of pain in aspecific range of motion

Sudden onset of pain in aspecific range of motion is also
possible

Usually painless

An"arc" of pain with a"catching" or blockage is highly
suggestive

Acute bursitis (deep)

Painful in most directions

Empty end-feel is often present

Isometric testing is often
painful

Positional relief is less common
than with muscle/tendon
injury

Key. ROM range of motion

20


Bone
Tumor-primary or metastatic
Os teoch 0ndros i5/apo physitis
Fracture
Stress fracture
Osteopenia (osteoporosis)
Osteomyelitis

SoftTissue
Muscle
Strain or rupture

Radiograph

MRI or CT, bone scan for metastasis (nonspecific)

Local tenderness and radiograph

Possible bone scan

Palpation, percussion, tuning fork, radiograph

CT or possibly MRI

Palpation, percussion, radiog ra ph

Bone scan, SPECT scan;quantified CT, dual-energy absorptiometry

Radiograph

Quantified CT, dual-energy absorptiometry

Radiograph

MRI

Active resistance

For rupture,sonography,or MRI

Trigger points

Palpation

None

Atrophy

Observation

E
lectrodiagnostic studies

Myositis ossificans

Palpation, radiograph

CT

Muscular dystrophy

Muscle testing, LDH on lab

Electrodiagnostic studies

Tendi nitis/tendi nosis

Stretch and contraction

Sonography

Paratenonitis

S
tretch

Sonography or MRI

Rupture

Lack of passive tension effect

S
onography or MRI

S
tability testing

MRI

Palpation

MRI or bursography

Palpation

None

Characteristic Joint involvement,laboratory findings
including rheumatoid factor, HLA-B27, ANA,
and radiographic characteristics

CT for bone, MRI for soft tissue involvement

Subluxation/fixation (chiropractic)

P
alpation, indirect radiographic findings

CT for facet joints (research only)

Synovitis

Capsular pattern of res
triction

MRI,Joint aspiration

Joint mice

RestrictedROM, radiograph

CT or MRI

Dislocation/subluxation (medical)

Observation and radiograph

CT

Tendon

Ligament
Sprain or rupture

Bursa
Bursitis

Fascia
Myofascitis

Joint
Arthritis

Key. MRI, magnetic resonance imaging;CT,computed tomography; LDH, lactate dehydrogenase; HLA, human leukocyte antigen;ANA,antinuclear antibodies; ROM,range of motion;SPECT, single
photon emission computed tomography.


21

main focus is to determine reproduction of a patient's complaint).
• Nerves-Tapping (i.e., Tinel's) and compression
are direct tests for superficial nerves; indirect tests
include motor and sensory evaluation of specific
peripheral nerves, nerve plexus, nerve root, or central nervous system (CNS) involvement including
muscle tests, deep tendon reflex testing, and sensory
testing with a pin/brush or pinwheel.
Palpation is a valuable tool when accessing superficial
tissues. Accessibility is limited, based on the joint and its
location. The fingers and toes are thin accessible structures, whereas the hip and shoulder are not. Direct palpation of ligaments and tendons may reveal tenderness.
Muscles may also be palpated for tenderness and possible associated referred patterns of pain. These trigger
points have been mapped by Travell and Simons. 2 Their
work serves as a road map for investigation.
The reliability of soft tissue palpation has been evaluated for the spine and the extremities. In general, it is evident that soft tissue palpation findings are not as reliable
as bony palpation among examiners. When specific sites
in the extremities are exposed through specific positioning, however, the reliability may increase. 3
Although orthopaedic testing is the standard for orthopaedists , more involved investigations are usually
added by the chiropractor and/or manual therapist. The
first is based on the work of Cyriax,4 which emphasizes
the "feel" of soft tissue palpation, especially at end-range.
Combined with this end-range determination, a selective
tension approach is incorporated using the responses to
active, active resisted, and passive movements to differentiate between contractile (muscle/tendon) and noncontractile (ligament/capsule and bursa) tissue. Another
approach is to challenge specifically each joint to determine fixation or hyper mobility. Finally, a functional approach to movement as proposed by Janda 5 and Lewit6
is often used. This approach addresses the quality of
movement and the "postural" tendencies toward imbalance of strength and flexibility of muscles.
22


extension.
• Capsular-This occurs with a tight, slightly elastic
feel such as occurs with full hip rotation. It is due
to tile elastic tension that develops in the joint capsule when stretched.
Abnormal end-feels include the following:
• Spasm-When muscle spasm is present, pain will
prevent full range of motion.
• Springy block or rebound-This occurs when there
is a mechanical blockage such as a torn meniscus in
the knee or labrum in the shoulder. The end-range
occurs before a full range of motion is attained.
• Empty-This occurs when there is an acute painful
process such as a bursitis. The patient prevents
movement to end-range.
• Loose-This end-feel is indicative of capsular or ligamentous damage and is in essence the end-feel
that is found with a positive ligament stability test.
Many examiners probably sense these different end-range
palpation findings. They have not categorized them , yet
interpret them intuitively.
Some examiners will equate timing of the onset of
pain on passive testing with staging of injury as follows:
• Pain felt before end-range is considered an acute
process that would obviate the application of vigorous therapy.
• Pain felt at the same time as end-range is indicative
of a subacute process and would be amenable to
gentle stretching and mobilization.
• Pain felt after end-range is indicative of a chronic
process that may respond to aggressive stretching
and manipulation.
By taking the patient through passive range of motion (PROM) and active range of motion CAROM) and
testing resisted motion, a clearer idea of contractile versus noncontractile tissue involvement may be appreciated (Figure 1-1 and Table 1-5).ltshould be evident mat

No

No

...

6

AROM and PROM
increased; resisted
movement is
painless and strong?

7

Pain on resisted
movement,
especially in a fully
stretched position?

Consider
Yes---. hypermobility.

8
Yes

Consider tendinitis or
tenosynovitis.

No
No

~

12

9
10

Ligament challenge
reveals abnormal
movement (may be
painful or painless)?

Consider muscle strain.
movement at
midrange?

Yes-.. Ligament sprain.

No

...

I

13

If multiple muscles are painful,
consider vascular compromise,
fibromyalgia , or psychologic
problems.
14

15

PROM is decreased
and painful?

Painful arc with
AROM or PROM with
a specific pattern of
movement?

Yes-.

16

Consider impingement or
Yes--.
an intraarticular loose
body.

No
Equal restriction in
both AROM and
PROM; however,
resisted motion in
available range is
painless and strong?

No

18
Yes

19

PROM increased
with post-isometric
relaxation attempt?

Yes--.

Consider muscle
splinting as cause
of decreased
ROM.

No

+

21
No injury evident or patient is
insincere or uncooperative. ...-No
Repeat testing .

I

20

Consider bony blockage
often due to advanced
degenerative jOint
changes.

22

AROM is
normal; PROM
is painful at endrange?

23

Ye~

Consider ligament or
capsular sprain or joint
subluxation/fixation.

Source. Reprinted from R. Henning er and D. T. Henson, Topics in Clinical Chiropractic, Vol. 1,No.4, p. 77,© 1994,Aspen Publishers, Inc.
·


23

interexaminer reliability using these methods. The interexaminer agreement was 90.5 % with a kappa statistic
ofO.875J
An extension of the selective tension approach is to
determine the effect of mild isometric contractions on
restricted range of motion. If a patient provides a mild resistance for several seconds to the agonist and antagonist pattern of restriction (e.g., flexion/extension) and
repeats this several times followed by an attempt at stretch
by the examiner, a distinction between soft tissue or bony
blockage to movement may be determined. For example,
if a patient presented with a restriction to abduction of the
shoulder, repetitive, reciprocal contraction (minimal contraction for 5 to 6 seconds) into abduction and adduc-

muscles are often tonic, posturally assigned. Certain
movement patterns are biased. For example, supination
is stronger than pronation and internal rotation of the
shoulder is stronger than external rotation. This bias is
in large part due to the size or number (or both) of muscles used in the movement pattern. Strength is also positionally dependent. Certain positions place at a
disadvantage some muscles of a synergistic group.
There is another perspective with regard to muscle
weakness and tightness that may affect evaluation and
eventually management. An observation by Janda 5 and
Lewitli is that there are crossed and layered patterns of
weakness and tightness. For example, in the low back it
is not uncommon to find a pattern of anterior weakness

EXHIBIT '1-'1
Postisometric Relaxation, Propioceptive Neuromuscular Facilitation (PNF) Hold and Relax,
and PNF Contract and Relax
Posrisometric Relaxation
III Stretch the affected muscle to patient tolerance.
III Maintain the stretch position while the patient isometrically contracts the muscle for 6 to 10 seconds at a
25% effort against doctor's resistance.
III Instlllct the patient to relax fully (taking in a deep breath and letting it out may help).
III Attempt a further stretch of the muscle with the patient relaxed.
III Repeat this procedure five or six times or until no further stretch seems possible (whichever comes first).
PJ'F Hold-Relax
III This technique is very similar to a postisometric relaxation approach; however, classically the patient
attempts a maximum contraction of either the agonist or antagonist.
III Caution must be used with maximal contractions. The author prefers to start with a postisometric approach
using a 25% contraction before proceeding to more forceful resistance.
PNF Contract-Relax
III This is a full isotonic contraction followed by a stretch into a new position.
III There are several variations of this technique. A popular one is called CRAC (contract-relax-antagonistcontract).

24


in the abdominal muscles associated with posterior tightness of the erector spinae (sagittal pattern). A vertical
pattern is illustrated by the association of the tight erector spinae's being sandwiched between weak gluteal muscles inferiorly and weak lower trapezius muscles superiorly.
These two planes create a "crossed" pattern whereby
tightness of the erector spinae is associated with tightness
of the iliopsoas, and weakness of the abdominal muscles
is associated with weakness of the gluteal muscles. This
pattern is relatively consistent throughout the body and
is a reflection of two concepts: (1) muscles that function
to resist the effects of gravity (postural muscles) have a tendency to become tight in sedentary people, and (2) muscles that function more dynamically are undelllsed and
become weak and prone to injury. Additionally, muscles
that cross more than one joint are prone toward tightness.
For example, the rectus femoris, which crosses the hip and
knee, is prone toward tightness, whereas the medialis
obliquus, which does not cross a joint and is primarily a
"dynamic" muscle, is often weak.
With the above concepts in mind, Lewit and Janda
have focused on an observation of quality of movement
with an emphasis on the timing and recruitment during
a movement pattern. Often these two concepts overlap
when the timing of the movement is a reflection of recruitment. For example, hip extension in a lying position requires a timing of contraction beginning with the
hamstrings. This is followed by gluteal contraction, then
erector spinae contraction. If the hamstrings or gluteals
do not participate, the erector spinae contract, causing a
weak contraction and a lordotic/compressive load to the
low back. In the neck, flexion may reveal all imbalance in
movement. If the patient's jaw juts forward at the beginning of the pattern, weak neck flexors with associated
"strong" sternocleidomastoids are indicated.

Accessory Motion
One of the indicators for manipulation or adjusting is
blockage of accessory motion. 9 Accessory motion is that
subtle amount of bone-on-bone movement that is not under voluntary control. For example, although the humerus
moves on the glenoid during abduction, there is a degree
of movement measured in millimeters that is necessary
yet not under the control of the shoulder abductor muscles. Detennining whether accessory motion is available involves placing tl1e joint in a specific position and attempting
passively to move one bone on another. If the end-feel is
springy, then joint play is available. If there is a perceived
restriction, however, movement at the joint may be restricted. It is important to distinguish between the endrange descriptions of CyriaxA and the end-feel of accessory
motion. Cyriax is referring to the end-range of an extremity
or spinal movement such as flexion, extension, abduction,
or adduction. Accessory motion is palpated at the joint
both with the joint in a neutral or open-packed position and

also with a coupled movement pattern taken to end-range
actively and passively. The joint would not be restricted by
the tension of the capsule or muscle with the neutral position method. The active and passive techniques take advantage of the end-range position to determine whether
the accompanying accessory motion is, in fact, occurring.
There are specific guidelines for both assessment and application of treatment to accessory motion barriers.
Specific patterns of extremity and spinal movement
are coupled with specific accessory motion so that restrictions in active movement may be indirectly an indicator of dysfunction of the accompanying accessory
motion. IO

Radiography and Special Imaging
V'hen making choices regarding the need for radiographs
or special imaging, it is important to keep one major
question in mind: Is there a reasonably high expectation
that the information provided by the study will dictate or
alter the type of treatment or dictate whether medical
referral is needed? If the answer is no, it is important to
delay ordering expensive, unnecessary studies at that
given time. As time passes, the answer to the question
may change. Some secondary issues with regard to further testing are as follows:
III

V7hat are the risks to the patient?

III

What is the cost? Are there less expensive methods
of arriving at the same diagnosis?

III

iVhat are the legal ramifications if the study or
studies are or are not performed?

The decision for the use of radiographs is based on
relative risk. Patients often can be categorized into highand low-risk groups by combining history and examination data. Many groups have developed similar standards
for absolute or relative indications for the need for radiographs. 1l - 13 Generally, for patients with joint pain, the
following are some suggested indicators:
III
III

II

III
II

III
III
III
III

significant trauma
suspicion of cancer (unexplained weight loss, prior
history of cancer, patients over age 50 years)
suspicion of infection (fever of unknown origin
above 100°F and/or chills, use of intravenous drugs,
recent urinary tract infection)
chronic corticosteroid use
drug or alcohol abuse
neuromotor deflcits
scoliosis
history of surgery to the involved region
laboratory indicators such as signifIcantly elevated
erythrocyte sedimentation rate, alkaline phosphatase, positive rheumatoid factor, monoclonal
spiking on electrophoresis

25

.. dermopathy suggestive of psoriasis, Reiter's syndrome, melanoma, and the like
.. lymphadenopathy
.. patients unresponsive to 1 month of conservative
care
II1II medicolegal requirements or concerns
Choice of imaging is based on the sensitivity and specificity of a given imaging tool, the cost, and the availability (see Table 1-5). In general:
III

III

III

III

III

Radiography-Signs of many conditions, including
cancer, fracture, infection, osteoporosis, and degeneration, often are visible. The degree of sensitivity is quite low with early disease, however.
Magnetic resonance imaging (MRI) is extremely
valuable in evaluating soft tissue such as tendons,
ligaments, and discs. In evaluating the volume of
tumor or infection involvement, MRI is also valuable. Spinal cord processes such as multiple sclerosis or syringomyelia are well visualized on MRI
(Table 1-6).
When attempting further to clarify the degree of
bony spinal stenosis, the extent of fracture, or other
bony processes, computed tomography (Gn is often a sensitive tool-better than MRI in many cases.
Recent cerebrovascular events and some tumors
are well visualized with CT.
When the search is for stress fracture, metastasis to
bone, or avascular necrosis, bone scans often provide valuable information.
vl1en determining the degree of osteoporosis in a
patient, dual x-ray radiographic absorptiometry is
more sensitive than standard radiography.

MANAGEMENT
Conservative management of a musculoskeletal problem
is based on several broad principles.
III

III

III

Initial management involves a greater degree of
passive care with a transition into active care dominance over time.
The goals for patient management vary based on the
acuteness of the problem.
Rehabilitation progresses in a sequence: passive
motion to active motion to active resisted motion
(begins with isometrics and progresses to isotonics)
to functional training.

Although traditionally it was the doctor's role to be
active and the patient's to be passive with treatment, it is
becoming clear that there is a point at which role switching is necessary. vVhen a patient has acute pain, the goal
is to reduce the pain and assist healing. Many of the treat26


ment methods used with acute pain employ procedures that
are doctor dependent. As the patient progTessively improves, there should be a focus on the patienes active participation in restoring normal function. Nelson 14 has
outlined some criteria for passive care (Figure 1-2). These
include a history of recent trauma, acute condition or flare
up, inflammation, or dependency behavior. There are
generally four types of care that may overlap, as follows:
1. Care for inflammation might include tl1e tra-

ditional approach of protection, rest, ice, and,
if appropriate, compression and elevation.
Modalities that are available include highvoltage galvanic stimulation, ultrasound, therapeutic heat, contrast baths, and nonsteroidal
anti-inflammatory drugs (NSAlDs), or enzyme
al terna tives.
2. Options for care for pain include manipulation,
mobilization, trigger-point therapy, transcutaneous electrical nerve stimulation (TENS), interferential stimulation, ice, cryotherapy,
acupuncture, and NSAlDs (1able 1-7).
3. Care for hypo mobility includes various forms of
stretch, manipulation, mobilization, and soft
tissue approaches such as myofascial release
techniques.
4. Care for hypermobility includes protection with
taping, casts, splints, or various braces.
Numerous techniques for stretching and soft tissue
pain control are used. Exhibits 1-2 through 1-4 outline
many of these approaches, including rhythmic stabilization, postisometric relaxation, proprioceptive neuromuscular facilitation (PNF) hold-relax and contract-relax
techniques, cross-friction massage, spray and stretch, and
myofascial release techniques (MRT or active resistive
technique [ARTJ15).
Recommendations for the frequency of manual therapy generally have been outlined by the Mercy Guidelines
(Figures 1-3 and 1-4).16 A brief summalY follows:
If the condition is acute «6 weeks) and uncomplicated (no red flags indicating referral), there may be
an initial trial treatment phase of 2 weeks at a frequency of three to five times per week.
.. At 2 weeks the case is reevaluated (unless there is
progressive worsening); ifimproving, the patient is
given an education program regarding activities of
daily living (ADL) and a graduated program of exercise and stretching, with treatment continuing
for up to 8 weeks depending on the patient's
Proo-ress'' if not improved.. a 2 -week trial with a difb
ferent treatment plan is suggested.
III If after the second 2-week trial tl1e patient has not
improved, consultation or referral is suggested.

III

TABLE

1...6

Magnetic Resonance Imaging for the Chiropractor

MRI Equal.to CT
.

·

t

:

MRI of the Head
Severe headaches
Visual disturbance
Sensory-neural hearing loss
Primary brain tumor
Metastatic brain tumor
Intracranial infection
Age-related CNS disease
Multiple sclerosis
Dementia
Chronic subdural hematoma
Posttraumatic evaluation of the brain
Intracranial hemorrhage older than 3days
Cerebral infarction older than 3days

H
ydrocephalus
Brain atrophy

Fracture of the calvaria
Fracture of the skull base
C
holesteatoma of inner ear
Intracranial hemorrhage 1-3 days old
Cerebral infarction 1- 3days old
Intracranial calcifications

Spinal stenosis

Occult fracture of avertebra
Complex fracture of avertebra
Bony foraminal encroachment

Large lumbar herniation
Spinal stenosis

Occult fracture
H
ypertrophic bonyovergrowth or spurring
Bony foraminal encroachment
Spondylolysis
E
valuation of posterior element fusion

Rotator cuff tear

Subtle glenoid labrumtear
Evaluation afthe glenohumeral ligaments

Meniscal tear

E
valuationof the m
eniscus following previousmeniscectomy
Evaluation of the articular cartilage

MRI ofthe Cervical and Thoracic Spines
Tumors or masses at the level of the foramen magnum
Chiari I malformation
Cervical or thoracic herniated disc
Posttraumaticsyrinx
Core or conus tumor
Acquired immunodeficiencysyndrome-related myelopathy
Multiple sclerosis of the spinal cord
Posttraumatic epidural hematoma
Epidural metastatic disease
Epidural abscess

MRI ofthe Lumbar Spine
Small lumbar herniation
Foraminal herniation
Interruption of the posterior longitudinal ligament
Root sleeve compression
Postoperative scar versus recurrent lumbar herniation
(with gadolinium)

MRI of the Shoulder
Posttraumatic bone bruise
Avascular necrosisof humeral head
Impingement syndrome
Lipoma (or soft tissue mass)
Tumor
Brachial plexus tumor

MRI ofthe Knee
Posttraumatic bone bruise
Osteochondritis dissecans
Anterior cruciate ligament tear
Posterior cruciate ligament tear
(ollateralligament tear
Patellar tendon abnormalities
Infection
Tumor
Source:Courtesyof Murray Solomon, MD, Redwood City, California


27

Figure 1-2

Passive Care Management-Algorithm

Musculoskeletal
condition meeting
inclusion criteria for
passive care (A)

3

2
PRICE
Protect-rest-iceYes----. compress-elevate
(up to 72 hours
after onset)

Presence of
active
inflamation or
acute pain?

No

4

f---------1~(

No

9

~_ _L-_-----8

Evidence of
hypomobility
or
hypermobility?

--Yes

~es~
J:~

inflammation
and

5

Manage for:
Hypomobility to
increase ROM (D)
or
Hypermobility for
stabilization (E)
(2 to 6 weeks)

Manage for:
Inflammation (8)
and/or pain (C)
(2 to 4 weeks)

10
Continued
evidence of
hypo mobility or
hypermobility?

No-+ Go to
box 11

6

No
Yes
Go to
active care
algorithm
(Figure 1-5)

11
Evidence of
deconditioned soft
tissue, reduced
endurance, or
compromised
balance/

Go to
Yes---+- active care
algorithm

Yes----+~

Diminished

~

No

l

7

CONSIDER:
Potential chronic
inflammatory disorders
or pain behavior.
Discharge or refer.

12
Discharge

Annotations
(A) -Passive care criteria: History of recent trauma, acute condition or flare up, inflammation, or dependency behavior
(B)-Care for inflammation: PRICE, high-voltage galvanic stimulation ultrasound, NSAIDs,contrast baths, therapeutic heat
(C)-Care for pain: Mobilization, manipulation, acupuncture, trigger-point therapy,TENS, interferential stimulation, NSAIDs, protection,
cryotherapy, heat
(D)-Care for hypomobility: Passive stretch,assisted stretch, mobilization, manipulation, soft tissue massage .
(E)-Care for hypermobility:Taping, elastic support, brace, splint, cast, surgical repair, begin active stabilization

Source.· Rep rinted from D. L. Nelson, Top ics in Clinical Chiropractic, Vol. 1, No.4, p. 75, © 1994, Aspen Publishers, Inc

28


Physiotherapy Approaches for Musculoskeletal Complaints

Pulse Width

Pulse Rate

High Frequency

High75-100

<200

Increase to discomfort

20 min.-24 hrs

Low Frequency

L Below 10
ow

200-300

Increase toelicit strong rhythmic contractions

30- 60 min.

T -1 50
ENS

150

Increase to titanic contraction

15min.

75-100

Increase to strong but comfortable contraction

20-60 min.

Brief and Intense

Am litude

Treatment Time

Galvanic: 1-5
Burst mode

50-100

of Stimulation

Mode

Treatment Effect

Time (min)

Reduce edema

Continuous

High 80-1 00

Sensory

20

Reduce muscle spasm

Continuous

High 80-120

Sensory/motor

20-30

Autonomic respons
e

Un interrupted/Pulsed

High 80-100

Sensory

20-30

Neuro/hormonal

Uninterrupted/Pulsed

L
ow2- 5

Motor (twitch)

30-60

Muscle pumping

S
urged 13

L
owJO-50

Motor

20-30

EXHIBIT 1-2

Rhythmic Stabilization
A variation of hold-relax, this technique uses a reciprocal contraction of the agonist and the antagonist following
the approach outlined below:
• Stretch the involved muscle to patient tolerance.
• Use a physician's contact on both sides of a joint.
• Ask the patient to contract with a 25 % contraction in the direction of agonist contraction for 5 to 8 seconds.
• Without resting, ask the patient to contract into the opposite direction for 5 to 8 seconds.
•
•
•
•

Repeat this procedure five or six times.
Ask the patient to relax.
Stretch into new position.
Repeat the above five or six times or until no more stretch appears available (whichever comes first) .

EXHIBIT 1-3

Cross-Friction Massage and Spray and Stretch
Cross-Friction Massage
Cross-friction massage is a technique popularized by Cyriax.4 The rationale behind its use is somewhat
dependent on the patient's presenting phase of injury. For example, in subacute injury the intent is to align
collagen for stronger scar formation. With chronic conditions the cross-friction approach is used to break up
adhesions and increase blood supply. A secondary effect of cross-friction massage is a pressure anesthesia, which
occurs after a couple minutes of application. There are several suggestions for the proper use of cross-friction
massage:
• It appears to be most effective with tendons and ligaments.

(continued)


29

EXHIBIT 1-3 (continued)

III

III
III
III
III

III

The tendon or ligament should be placed under slight tension (by stretching the involved structure) while
cross-friction is performed.
The contact is skin on skin with no lotion.
The pressure is applied as a transverse motion (90 0 to the involved structure).
Monitoring the patient every 2 minutes for a total of 6 to 9 minutes is recommended.
Prior to application, some practitioners recommended ice; others recommend moist heat for approximately
5 minutes.
Treatment is given every other day for 1 to 2 weeks (up to 4 weeks maximum).

Spray (Cold) and Stretch
Although the technique of using fluoromethane spray for stretching muscles was popularized by Travell and
Simons, I concerns over damage to the ozone layer and increasing unavailability of the spray have led to a return
to the use of ice. INith the use of either tool, the technique of application has several common protocol
components:
III The muscle being stretched is placed in a position of mild to moderate stretch. Maintain this stretch while
applying the cold stimulus.
III The cold stimulus is applied in a series oflinear strokes to the skin overlying the muscle and its associated
pain referral zone. This is applied in the direction of pain referral.
III Gradually increase the stretch while applying the cold.
III Following the stretch, the skin should be brief1y rewarmed with a moist heat pack.
III The muscle should then be put through a full range of motion, passively and then actively (this is an attempt
to avoid posttreatment soreness).

EXHIBIT 1-4

Myofascial Release Techniques (MRTs)
Several techniques have been developed and popularized under different technique names. ~Most techniques
involve a stripping motion of a muscle. A combination of these techniques is found with MRT (or ART) as
proposed by Leahy and Mock. 1s These techniques are best used when a muscle is determined to be dysfunctional.
This is accomplished through a combination of palpation, range of motion (ROM) findings, and muscle testing.
This technique is not intended for acute injury (within 24 to 36 hours) or for ligaments and tendons that respond
better to cross-fi'iction massage. In essence, this is an extension of other myofascial or trigger-point approaches.
Skin lotion should be used when possible. Following is a summary of this approach. There are four levels. Use
the highest level that patient tolerance permits.

Level 4
III Place the muscle in its shortest position.
III Apply a firm contact to the muscle just distal to the site of palpable adhesion.
III Ask the patient to move the limb actively through an antagonist pattern (if the joint is in extension, the
patient flexes), elongating the muscle.
III Always maintain a fixed contact on the patient so that the adhesions are forced under the contact point.
Level 3
III Place the muscle in its shortest position.
III Apply a firm contact to muscle just distal to the site of palpable adhesion.
III Passively move the limb through an antagonist pattern, elongating the muscle.
III llwavs maintain a fIxed contact on the patient so that the adhesions are forced under the contact point.
,

30


(continued on po e 33)

Figure 1-3
Uncomplicated Cases
Acute, recurrent, or
exacerbation of chronic
cases

Acute/Uncomplicated Cases-Algorithm

Annotations
(A)-In general, more aggressive in-office intervention may be necessary early.
(B)-Promotion of rest, elevation, active rest, and remobilization as needed.
(C)-Supportive maintenance care is inappropriate.
(D)-Complicated case factors may include radicular pain, anomalies, etc.

2
Initial trial of manual therapy
methods, 10-14 days;
three to five visits per week

Source.' Reprinted from D. T Hansen, Topics in Clinical Chiropractic, VaLl , No.4, p. 73, © 1994,
Aspen Publishers, Inc.

(A)
4
Second 2-week trial of
different treatment plan,
including spinal
manipulative theory

improvement and
lack of new

Yes

5

Instruction in activities of
daily living (ADL) and active
health care programs for
....-Ye
flexibility and strength
as clinical status
(B)
permits

7

6
Significant
documented
improvement?

No -----.

Discharge or Referral

8

9

Preconsultation duration of
symptoms> 8 days?
Severe pain?
More than four previous
episodes?
Preexisting structural or
pathological conditions?
No

Yes---.

Recovery time
increased by 1.5 to 2
times; 9-16 weeks of
decreasing treatment
frequency

10

2-6 weeks of patient
education and active care
for strength and endurance
as needed and
as clinical status permits

11

2-6 weeks of patient
education and active care
for strength and endurance
as needed and
as clinical status permits
12

No anticipated delay in
recovery.
Treat to preepisode status
6-8 weeks, up to three
times per week

14

13
Maximum clinical
and functional
improvement?

Yes------.

Discharge and/or
elective care
(C)

16

15
Complicated case
factors identified?

Yes------.

(D)

Move to algorithm for
complicated cases
(Figure 1-4)

17
Continued failure to achieve
desired outcomesdischarge or referral


31

Figure 1-4

Subacute/Chronic Complicated Cases-Algorithm
Annotation
(A)-Conditions that are exacerbated or recur, refer to algorithm for acute/uncomplicated cases (Figure 1-3).

Complicated Cases
Subacute or chronic;
symptoms> 6 weeks

4
2

3

No-.i

Symptoms
prolonged> 6,
< 16 weeks

Chronic EPisode,
I
Symptoms> 16 weeks

1-.
- - - . . . . .

-Passive care including
CMT for exacerbations
only, pm
- Supervised rehabilitation
and lifestyle changes

I

Yes

1

5

Subacute Episode
Symptoms> 6,
< 16 weeks

1
-

-

-

8

6
Supportive care using
passive procedures
(including CMT) may
be necessary

Passive care including
CMT not generally to
exceed twice weekly
Active care,
dissuasion of pain
behavior, education,
exercises, and/or
rehabilitation
Supportive care
inappropriate

10

7
Is patient
insincere or
noncompliant with
care/treatment?

9

Is patient insincere
or noncompliant
with care/
treatment?

Discharge or referral

No

No

12

11
Continue to preepisode
status 6-16 weeks
therapy goal

Discharge and/or
elective care

(A)

13

May not return to
pre·lnjury status.
Consider declaration of
maximum therapeutic
benefit.
(A)

Source: Reprinted from D T. Hansen, Topics in Clinical

32


Vol. 1, NoA, p. 74, © 1994,tspen Publishers, Inc.

EXHIBIT 1-4 (continued)

Level 2
• Place the muscle in a stretched position (creating tension).
• Apply muscle-stripping massage (along the direction of muscle fibers) using a broad contact, concentrating
on areas of adhesion).

Levell
• Place the muscle in a neutral position (no tension).
• Apply muscle-stripping massage, concentrating on areas of adhesion .
Treatment usually involves several passes over the muscle, treatment every other day, and resolution within the
first few treatments.
Adjunctive care involves prescription of exercises for the involved muscle, starting with facilitation.

• Cases that will likely have a prolonged recovery include those with symptoms lasting longer than
8 days, severe pain, more than four previous episodes,
or preexisting structural or pathologic conditions.
Active care criteria include decreasing pain and inflammation and an improvement in range of motion and
joint mobility (Figures 1-5 and 1-6). There is a phase
where passive and active care coexist. During this stage,
isometrics performed in limited arcs are helpful initiators
and facilitators for a progressive exercise program.
Progressing through a graded program involves setting
criteria for passing each stage. The most common criteria are range of motion, strength levels, and performance without pain.
Active care elements include training to increase range
of motion, strengthening primary and secondalY stabilizers of a given joint or region, increasing the endurance
capabilities of the muscles, proprioceptively training for
balance and reaction time, and finally, functionally training for a specific sport or occupational task. Each element involves different training strategies (Table 1-8 and
Exhibits 1-5 through 1-7).

Strength and Endurance
Strengthening begins with facilitation . This is accomplished either through isometrics performed at every 20°
to 30° or rhythmic stabilization using elastic tubing, performing very fast, short-arc movements for 60 seconds or
until fatigue or pain limits further performance.
Strengthening may then progress to holding end-range
isometrics with elastic tubing for several seconds, and
slowly releasing through the eccentric (negative) con-

traction. In some cases, these end-range isometrics may
be performed against gravity only first. If these elements
are strong and pain free, progressing to full-arc isotonics using weights or elastic tubing may be introduced. It
is best to begin with three to five sets of high repetitions
(12 to 20) using 50% to 70% of maximum weight. After
1 to 3 weeks of this training, progression through a more
vigorous strengthening program may be determined by
the daily ad justa ble progressive resistance exercise
(DAPRE) approach l 8 (although the exercises are performed evelY other day). This is a pyramid approach using lower weight with more repetitions and progressing
through sets to higher weight and fewer repetitions. The
last number of repetitions performed determines the
working weight for the next workout.

Proprioceptive Training
Proprioceptive training incorporates various balance devices such as wobble boards, giant exercise balls, and
minitrampolines. The intention is to have the body part
react to changing support as quickly as possible and to integrate the rest of the body in this attempt.
Functional Training
Functional training is based on the requirements of a
given sport or occupational activity and requires a knowledge of the biomechanics involved. Various PNF techniques may be employed. Simulated task performance is
another approach for occupational retraining.
Nutritional Support
The nutritional support needed for musculoskeletal healing is based on recommendations made by Gerber. 19

33

figure 1-5

Active Care Management-Algorithm
Annotations
(A)-Active care criteria: Decreasing pain and inflammation, tolerance to increasing activity,

Musculoskeletal
condition meeting
inclusion criteria for
active care (A)

improvement in joint motion, and favorable response to passive care
(B)-Stabilization exercises: Includes isometric and limited-arc dynamic efforts

3

2
Evidence of
joint hypomobility?

4

Manage with:
Active assisted ROM,
PNF, active ROM,
and/or continued
passive ROM
(2 to 8 weeks)

Yes

Go to
Active Exercise
-yes-----. Algorithm
(Figure 1-6)

Evidence of
improved
mobility?

No

1

5

Evaluate for potential
permanent joint changes
and adjust long-term
goals

No

7

6
Evidence
of joint
hypermobility?

Yes

8

Manage for:
Support to prevent tissue
damage and stabilization
exercises (8)
(4 to 16 weeks)

Evidence of
improved stability?

Ye

Go to
Active Exercise
Algorithm

No

~

9

Consider.
Permanent Instability

No

10
Evidence of
deconditioned
soft tissue?

11

No-----.

15

13

Reduce
endurance
capacity?

No

Proprioception or
balance deficits

No--.

Discharge

Yes
12

Go to
Active Exercise
Algorithm

Manage with:
High repetition w/resistance;
interval/circuit training;
cardiovascular training;
to treatment goal

Source: Reprinted from D. L. Nelson, Topics In

34


14
Manage with:
Balance board; gymnastic
balls; agility drills; plyometric
training; job/sport skills training;
I
to treatment goal

!

VoL 1, No.4, pp. 76-77, r,;,; 1994, ASDen Publishers, Inc.

Figure 1-6

Active Care: Exercise-Algorithm

Musculoskeletal
condition responsive
to passive and/or
active management

3

2
Patient tolerates:
Multiple-angle
isometrics for 2- to
4-week trial?

No~

Consider:
One 1- to 3-week tri al of
active ROM and
pain control
Assess for compliance
Retest for tolerance

Go to
Box 20r
Discharge

Yes

5

4
Patient tolerates:
Manual resistance
through pain-free
ROM?

No~

Consider:
Additional 1 to 3 weeks
Go to
of active ROM and
r---_I Box 2 or
isometrics
Discharge

Yes

7

6
Patient tolerates:
Short-arc dynamic
exercise

No~

(High rep , low weight)
(1-3 sets/12-20 reps)

Consider:
Additional 1 to 3 weeks of
manual resistance
through ROM

Go to
Box 4 or
Discharge

Yes

9
Patient tolerates:
Extended ROM,
moderate resistance,
2-4 sets/8-12 reps,
multijoint motions,
and progressive
resistance?

No

Yes

Consider:
short-arc dynamic exercise

Go to
Box60r
Discharge

11

Patient tolerates:
Heavy resistance,
3-5 sets/5-8 reps ,
work hardening?

No~

Consider:
Go to
extended ROM,
r---_I Box 8 or
moderate resistance
Discharge

Yes

1

12

Discharge or go
to Box 11 Active Care
Algorithm
(Figure 1-5)

Source. Reprin ted from D. L Nelson, Topics in Clinica l
Chiropractic, Vol. 1,No.4, p. n,© 1994,Aspen Publishers, Inc.


35

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