Ortho Eval and Intervention Cyriax Principles

principles of diagnosis through selective testing of structures

using a mechanical approach to diagnosis soft tissue lesions/injuries based on the tissues being divided into contractile and inert structures

contractile structure include

muscle, muscle tendon junction, tendon, tendon periosteal junction (anything put under tension when the muscle contracts)

inert structures include

all other soft tissue - ligaments, joint capsules, bursae, dura, nerve root and peripheral nerves, fascias, skin

method of diagnosis

try to reproduce pain by sequentially testing active, passive and resisted movement

active movement

place stress on both inert and contractile - informative of pain but not diagnostically informative

passive movements

test inert structures

resisted movements

test all contractile structures - requires isometric test at midrange of motion to not stretch the inert structures

if active and resisted movement is painful in one direction, and passive movement is painfree in the same direction

contractile tissue is at fault

in cases where a contractile tissue can be placed under tension with movement in the opposite direction, and the movement produces pain

compliment to the diagnostic process of muscle

minor injuries, in exception, may

not be painful with active movement where resistance is low

if active and passive movement is painful in one direction and resisted movement is painfree in the same direction

inert structure is at fault

the process of determining the inert structure is at fault rarely leads to

a specific diagnosis - but rules out contractile structures, need additional tests to determine the specific structure at fault

method of testing for contractile tissues

perform resisted motion, applying tension, palpation

performing resisted motion

hold joint in mid-range of available motion so that the related capsule ligaments and inert tissues are relaxed, make/break test with isometric muscle action, examiner stabilizes to reduce compensations from other muscles, test muscle groups first, then narrow down to specific muscles within the group

applying tension

confirmation may be possible through passive stretching of involved contractile structures - only effective for certain muscles

palpation

once contractile unit is identified, the muscle or tendon can be palpated for further confirmation and help determine exact location of injury (only applicable for certain muscles)

muscle is strong and painless

contractile tissues are normal

muscle is strong and painful

minor lesion of some part of the muscle or tendon is likely present

muscle is weak and painless

possibilities include a complete rupture of muscle or tendon, a neurological disorder (minor/partial to complete paralysis), atrophy

two congruous resisted movements are painful

injury is present in the muscle tendon/unit that contributes to these 2 actions (flexor carpi ulnaris example)

when 2 incompatible movements hurt

a single muscle/tendon injury is improbable

several/all resisted movements are painful

causes could include: severe injury where more than one muscle/tendon unit is injured, patient injury affects inert structure that is placed under stress with activation of any surrounding muscle/tendon units (stress fracture), or biopsychosocial presentations where the patient expresses pain with all movement tested (peripheral/central sensitization, anxiety)

muscle is painful on repetition

potential cause is vascular issue leading to local ischemia

end feels help determine

cause of limitation of motion and help in selection of preferred interventions to improve motion - appreicate the quality of resistance to movement

physiological end feel

joints have a characteristic normal end-feel which is dependent on the anatomy of the joint and the direction of the movement

pathological end feel

end feel is of another quality than is characteristic for that joint, or is normal but occurs too early or late in range of motion

types of physiological end feel

cartilaginous, soft tissue approximation, tissue stretch: muscular, capsular, ligamentous

cartilaginous

sudden stop but not hard, bone on bone with cartilage layer between

soft tissue approximation

soft, spongy - adipose or muscle tissue limited movement

muscular end feel

elastic resistance with slight discomfort (smaller muscles have less resistance, larger muscles have more resistance)

capsular end feel

hardish arrest of movement with some give in it - unfolding/gliding of fibers

ligamentous end feel

firm arrest of movement with no give or creep - regularly aligned fibers

pathological end feels

muscle spasm, capsular, bone to bone, empty, springy rebound, pannus, loose

muscle spasm end feel

sudden dramatic arrest of movement "vibrant twang" - involuntary muscle guarding

address muscle spasm end feel with

decreasing the involuntary guarding via a variety of modalities, dont try to stretch it out (tightness isnt the problem)

capsular end feel - pathological

capsule is more fibrotic in nature, can occur earlier in range than normal capsular end feel

address capsular end feel with

joint mobilization and stretching

bone to bone end feel

sudden hard stop short of normal range of motion, common with falling fractures

address bone to bone end feel with

no improvement of motion is expected

empty (painful) endfeel

soft, not limited mechanically - no resistance because had to stop before end range - continuing would bring on muscle guarding

address empty end feel with

decrease pain with movement - dont stretch

springy rebound endfeel

attributed to intraarticular structures - often need surgery or live with it

pannus endfeel

soft, crunchy squelch from inflammation and thickening of synovial lining of the capsule

address pannus endfeel with

decreasing inflammation (dont stretch)

loose endfeel

absence of/diminished resistance via ligamentous injury - indicative of excessive motion

address loose endfeel with

stabilization

capsular pattern

sequence of movement from most to least limited when an entire capsule is shortened

capsular pattern is not the same as

capsular end feel

painful arc

pain at the middle of the range of motion (active or passive) (not diagnostic)

pain at one extreme of range

likely due to a structure being stretched or compressed, is compressed prevent end range of motion, if a limited structure is being stretched try controlled stretching

joint crepitus

heard or felt - gives information on the state of joint gliding surfaces

fine joint crepitus

suggests slight roughening of cartilaginous articular surfaces

coarse joint crepitus

suggests considerable fragmentation of the articular cartilage

articular cartilage is not

innervated - so pain may not be reflective of crepitus (unless it causes increased pressure on subchondral bone, etc)

tendon creptius

heard or felt - occurs with tendons having a sheath or passing through a tunnel

fine tendon crepitus

suggests slight fibrotic changes to tendon

coarse tendon crepitus

suggests extensive fibrotic changes to the tendon

crepitus may never

fully disappear, but can reduce the pain to allow it to be tolerable to live with

"pop" at the time of injury

not diagnostic, can mean many things (ruptured ligament or tendon, dislocation/subluxation of the joint, fracture)

snapping

not diagnostic, usually attributed to a tendon catching on a bony prominence and then slipping over it, occurs more with active motion (can be due to improper mechanics or rupture of restraining structures)

AROM tells us

willingness to move, first impression or strength and amount of movement, and if there is pain with movement

if AROM caused pain, ask

if PROM is painful (yes = noncontractile, no= contractile)

if AROM is limited, ask

is PROM limited (yes = tightness or pain, no=weakness)

tightness is determined by

endfeel

if AROM caused pain, and PROM is not painful

test RROM (test regardless), if RROM is painful it is a contractile structure - use MMT to determine