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Trigger points

Very localized areas of hyperirritability within the tissues They are tender to compression, are often accompanied by tight bands of tissue

Referred Pain

Pain is felt at a site other than the injured tissue because the referred site is supplied by the same or adjacent neural segments It radiates segmentally without crossing the midline

Duration of Condition:1. Acutebeen present for 7-10 days2. Subacutepresent for 10 days7 weeks3. Chronicpresent for longer than 7 weeks

Type of Pain Structures

Cramping, dull, aching Muscle

Sharp, shooting Nerve root

Sharp, bright, lightning-like Nerve

Burning, pressure-like, stinging, aching Sympathetic nerve

Deep, nagging, dull Bone

Sharp, severe, intolerable Fracture

Throbbing, diffuse Vasculature

Lockingjoint cannot be fully extended (meniscal tear)

Pseudolockingjoint cannot be fully extended one time and does not flex the next time (loose body in within the joint)

Giving waycaused by reflex inhibition of the muscles, so that the patient feels that the limb will buckle if weight is placed on it.Mechanical (pathological) instabilityrefers to loss of control of the small joint movements that occur when the patient attempts to stabilize the

joints during movement.Clinical instability (pathological hypermobility)refers to excessive gross movement in a joint

Laxity (hypermobility)non pathological states hypermobility

Voluntary instabilityinitiated by muscle contractionInvoluntary instabilityresult of positioning

Principles of Examination

Test normal (uninvolved) side first Active movements first, then passive movements, then resisted isometric movements Painful movements are done last Apply overpressure with care Repeat or sustain movements if history indicates Do resisted isometric movements in a resting position With passive movements and ligamentous testing, both the degree and quality of opening are important With ligamentous testing, repeat with increasing stress With myotome testing, contractions must be held for 5 seconds Warn of possible exacerbations Refer if necessary

Scanning Examination is used when:

There is no history of trauma There are radicular signs There is trauma with radicular signs There is altered sensation in the limb There are spinal cord (long track) signs Patient presents with abnormal patterns There is suspected psychogenic pain- In the upper part of the body, the scanning examination begins with the cervical spine and includes the temporomandibular joints, the

entire scapular area, the shoulder region, and the upper limbs to the fingers. In the lower part of the body, the examination begins at

the lumbar spine and continues to the toes.

Spinal cord and nerve roots

- Nerve roots: portion of a peripheral nerve that connects the nerve to the spinal cord; made up of anterior and posterior portions thatunite near or in the intervertebral foramen to form a single nerve root or spinal nerve

- 31 nerve root: 8 cervical, 12 thoracic, 5 lumbar, 5 sacral and 1 coccygeal- Spinal nerve roots have a poorly developed epineurium and lack a perineurium

Dermatomearea of skin supplied by a single nerve root

Myotomegroups of muscles supplied by a single nerve rootSclerotomearea of bone or fascia supplied by a single nerve root

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Radicular/radiating painform of referred pain, felt in a dermatome, myotome or sclerotome because of direct involvement of a spinal nerve or

nerve rootMyelopathyneurogenic disorder involving the spinal cord or brain and resulting in an upper motor neuron lesion

Mononeuropathy vs polyneuropathy

Grade of Injury Definition Signs and Symptoms

Neuropraxia

(sunderland 10

)

Transient physiological block caused by ischemia from pressure or stretch of

the nerve with no wallerian degeneration

Pain

No or minimal muscle wastingMuscle weakness

Numbness

Proprioception affectedRecovery time: minutes to days

Axonotmesis

(Sunderland 20 and 30)

Internal architecture of nerve root preserved, but axons are so badly damaged

that wallerian degeneration occurs

Pain

Muscle wasting evidentComplete motor, sensory and

sympathetic functions lost

Recovery time: months (axonsregenerate at rate of 1 inch/mos, or

1 mm/day)

Sensation is restored before motorfunction

Neurotmesis

(sunderland 40 and 50)

Structure of nerve is destroyed by cutting, severe scarring, or prolonged severe

compression

No pain (anesthesia)

Muscle wasting

Complete motor, sensory andsympathetic functions lost

Recovery time: months and onlywith surgery

End Feelexaminer feels at the joint as it reaches the end of the ROM

Normal end feel:

1. Hardbone-bone approximation2. Softsoft tissue approximation3. Firmtissue stretch

Abnormal end feel:1. Muscle spasminvoked by movement with a sudden dramatic arrest of movement often accompanied by pain2. Capsularvery similar to tissue stretch (firm), it does not occur when one would expect3. Bone-to-bonesimilar to hard end feel , but the restriction or sensation of restriction occurs before the end of ROM would normally

occur

4. Emptydetected when considerable pain is produced by movement5. Springy blocksimilar to tissue stretch (firm), this occurs when one would not expect it to occur, it tends to be found in joints withmenisci. There is a rebound effect

Capsular Patternpattern of limitation or restriction of the joints

Causes of Muscle Weakness:

1. Muscle strain2. Pain/reflex inhibitions3. Peripheral nerve injury4. Nerve root lesion (myotome)5. Upper motor neuron lesion6. Tendon pathology7. Avulsion8. Psychologic overlay

Signs and Symptoms of Upper motor Neuron Lesion:

- Spasticity- Hypertonicity- Hyperreflexia (DTR)- Positive pathologic reflexes- Absent or reduced superficial reflexes- Extensor plantar response (bilateral)

Uses of Special Test:1. To confirm a tentative diagnosis2. To make a differential diagnosis3. To differentiate between structures4. To understand unusual signs

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5. To unravel difficult signs and symptomsClassification of Synovial Fluid:

Type Appearance Significance

Group 1 Clear yellow Noninflammatory states, trauma

Group 2 Cloudy Inflammatory arthritis: excludes most patients with osteoarthritis

Group 3 Thick exudate, brownish Septic arthritis; occasionally seen in gout

Group 4 hemorrhagic Trauma, bleeding disorders, tumors, fractures

Nerve Fiber Classification

Sensory Axons Innervation

Ia (A alpha) Muscle spindles (annulospiral endings)

Ib (A alpha) GTO

II (A beta) Pressure, touch, vibration (flower spray endings)

III (A delta) Temperature, fast pain

IV (C) Slow pain, visceral, temperature, crude touch

Loose Packed (Resting) Positionone of minimal congruency between the articular surfaces and the joint capsule, with the ligaments being in

the position of greatest laxity and passive separation of the joint surfaces being the greatest

Closed Packed (Synarthrodial) Positionmajority of joint structures are under maximum tension; two joint surfaces fit together precisely; they

are fully congruent. The joint surfaces are tightly compressed; the ligaments and capsule of the joint are maximally tight; and the joint surfaces

cannot be separated by distracting forces

When Palpating, the examiner should note:- Differences in tissue tension and texture- Differences in tissue thickness- Abnormalities- Tenderness- Temperature variation- Pulses, tremors, fasciculations- Pathological state of tissue- Dryness or excessive moisture- Abnormal sensation

Grading Tenderness on Palpation

Grade 1patient complains of pain

Grade 2patient complains of pain and winces

Grade 3patient winces and withdraws the joint

Grade 4patient will not allow palpation of the joint

Common Circulatory Pulse Location:- Carotid- Brachial- Radial- Ulnar- Femoral- Popliteal- Posterior tibial- Dorsalis pedis