becomes truly apparent in the lateral view (Fig.2b)..


Palpation How useful is palpation in assessment and diagnosis? There is always a great temptation in assessing painful problems to go ahead and put a finger to the sore area and palpate. The problem here is that not all pain is felt at the site of origin, hence palpation can very often deceive. Soft tissues have the habit of referring pain to other areas, often on a segmental basis. Referred pain is not too confusing if following the simple “rules” that appear towards the end of this article.


Direct treatment to the source It should be obvious that any treatment needs to be directed at the source of origin, and not necessarily the site of symptoms. There are however, certain circumstances when the latter may be appropriate, but it cannot be assumed to be enough. For example, a client suffering with referred pain from tennis elbow (lateral epicondylitis) may require treatment to the source of problem, i.e. the bone-tendon junction, but may also benefit from pain relieving modalities such as TENS (transcutaneous electrical nerve stimulation). In this case, the treatment electrodes may be placed around the area of referred pain, not just the causal site.


Treatment should benefit the tissue Treatment should have a beneficial effect on the particular tissues. Again this sounds obvious, but too often therapists have been guilty of performing treatments without really taking this into full consideration. The aims of treatment, therefore, should be to influence the cause of symptoms, not just relieve the symptoms.


DECISIONS FOR ASSESSMENT In the quest for diagnosis, there are some primary decisions to be made even before the assessment can begin: n About which joint does the lesion lie? n In what sort of tissue does the lesion lie e.g. contractile or inert? n Is the pain reproduced by the test? The first question should really


be answered by the initial subjective history. If the right sorts of questions are asked, then an initial impression


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may become evident, at least to the extent where the therapist can decide which joint assessment to perform. The next two questions are


answered by applying the Cyriax principle of selective tissue tensioning (1). Each tissue is selectively stressed, whilst at the same time not allowing any tension to occur at other tissues. Tissues are conveniently divided into two tissue types: n Contractile tissues - muscle, tendon and corresponding musculo-tendinous and teno-osseous junctions n Inert tissues - bone, cartilage, ligaments, capsule, bursa, fascia, nerve root and dura mater.


Capsular patterns One of the inert structures, the joint’s fibrous capsule, also displays an additional characteristic that is significant in diagnosis. Cyriax observed that joints lost range of motion in predictable ways - which he termed capsular patterns. When the capsule of a joint becomes inflamed, whether by trauma, infection or degeneration, it contracts and restricts the available range of movement in a set pattern. This pattern is the same for that joint but may be different for different joints, for example, shoulders display the same capsular pattern as each other, yet this differs from all knees. A loss of range not in common with the known capsular pattern is called a non- capsular pattern (see figure 3 for a list of capsular patterns for each joint).


JOINT MOVEMENTS AND PALPATION There are three types of joint movement: n Active n Passive n Resisted


Active movements Active movements are often not very helpful in diagnosis as all tissues are under tension simultaneously. They can, however, give an indication of willingness to move, in addition to onset of pain, available range and end-feel to joint motion (Fig.4).


Passive movements These stress the inert structures mainly, and provide an indication of onset of pain, range and end-feel. Passive movements should be exactly


CAUSE OF SYMPTOMS


TREATMENT SHOULD INFLUENCE THE


Figure 4: Active shoulder flexion


that - movements where the client is relaxed and does not attempt to help or join in with the movement. If this happens, then the client would be recruiting the contractile tissues which may give a false positive result (Fig.5).


Figure 5: Passive knee flexion


Figure 6: Resisted knee extension 11


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