Resisted movements These put the contractile components under tension and give an idea of pain and strength (Fig. 6). Resisted tests must be performed to the maximum and should be isometric contractions in order to ensure that the inert structures are not stressed at the same time. In order to get maximum contraction, the joint needs to be in a relatively neutral position (to allow inert structures to be in a non-stretched position). This should be mid-range in order to allow the angle of force from the contractile unit to act in the most mechanically advantageous position, as well as allowing the optimum overlap between actin and myosin filaments for strong contraction. If only 90% strength is used, and the muscle lesion lies within the untested 10% of fibres, then a false negative result would be obtained by the test. Essentially, it should be

remembered that all tests, whether passive or resisted, are only as sensitive and specific as the therapist is at performing them; there is no substitute for practising assessment techniques.

Palpation Finally it may be appropriate to use palpation in order to further localise the lesion. Further additional tests may then also be carried out to aid this process in some cases. This simple form of assessment will allow the therapist to gain a good clinical impression of diagnosis in 90% of cases (Fig.7).

END-FEELS The normal feel to the end of passive joint range of motion is often called the end-feel.

Normal end-feels n Hard – usually due to bony opposition and feels like a solid immoveable block to movement (e.g. olecranon process meeting the olecranon fossa during full elbow extension) n Soft – usually due to soft-tissue opposition which feels like a squashing of a sponge (e.g. hamstrings meeting calf musculature during flexion of the knee) n Elastic – usually the most common end-feel for synovial joints and is associated with stretching of the joint capsule and the feeling of elastic recoil

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Referred pain, although complex in nature, can be said to follow some general rules (1): n Does not cross the mid-line of the body n Has a tendency to refer distally n Always refers segmentally (within a dermatome) n May be felt in part or all of a dermatome n Is often felt or perceived as being deep

Figure 7: Palpation

when releasing the tension (e.g. lateral rotation of the shoulder joint).

Abnormal end-feels Abnormal or pathological end-feels indicate the presence of pathology and tend to present as follows: n Springy – usually due to the presence of cartilage being trapped between joint surfaces and feels like a firm resistance to movement that has some give when pressure is increased (e.g. meniscus in knee flexion or extension) n Spasm – this is a hard end-feel caused by sudden activation of muscles in response to the movement through pain, or apprehension. It is different from a normal hard end-feel in that it is not always repeatable at the same point in the range of motion n Empty – this is when no end-range is actually reached either due to the onset of extreme pain, or because of major joint disruption (i.e. torn ligaments/capsule) which therefore offer no resistance to movement.

REFERRED PAIN Referred pain is described as an ‘error in perception’ i.e. pain which is perceived elsewhere than at its true site. The sensation of pain is an extremely complex phenomenon, and very subjective, however, certain aspects of pain perception are known (3): n Site of pain – this is sensed by the body in the sensory cortex of the brain n Memory of pain – this is sensed in the temporal lobes of the brain n Degree of pain – this is sensed in the frontal lobes (amount of tension in these frontal lobes may govern the patient’s response to pain)

Nature of referred pain Again simple rules help to make some sense of referred pain: n Usually, the deeper the site of lesion, the more vague the reference of pain and the greater the spread of reference n This is also true of the location of the lesion i.e. the more proximal, the more vague and increase in spread of reference. n In most cases, the stronger the stimulus, the increase in spread of reference.

CONCLUSION In the first part of this article, we have looked at the basic principles guiding musculoskeletal assessment, drawn attention to the types of things you should be looking to identify from the presentation of the soft tissues and discussed various aspects of pain presentation. In the next part we present a format for a clinical orthopaedic examination. This is a two-part examination involving firstly a subjective element followed by an objective element. Subjective assessment is a form of questioning which may have more than one correct answer (or more than one way of expressing the correct answer). Objective assessment on the other hand is a form of questioning which tends to have a single correct answer.

References 1. Cyriax J. A Textbook of Orthopaedic Medicine Volume 1: Diagnosis of soft tissue lesions. ISBN 0702009350. To order http://bit.ly/8X8fZd

online

2. Orthopaedic medicine seminars hosted by the Society of Orthopaedic Medicine and Association of Chartered Physiotherapists in Orthopaedic Medicine

3. Butler DS. Mobilisation of the Nervous System. ISBN 0443044007. To order http://bit.ly/ahgxR0

sportEX dynamics 2010;24(Apr):9-12