1. Ackowledgments IntroductionPART I CHAPTERxi XlllMusculoskeletal Complaints 1General Approach to Musculoskeletal Complaints3Context 3 General Stra tegy 4 History 8 Examination 20 Management 26 Appendix 1- 1 42 Appendix 1-2 42 Appendix 1-3 44 CHAPTER2Neck and Neck! Arm Complaints453Temporomandibular ComplaintsContext 77 General Strategy 77 Relevant Anatomy and Biomechanics 78 Evaluation 79 Management 82 Selected TMJ Disorders 86 Appendix 3- 1 88Thoracic Spine Complaints895Scoliosis105Context 105 General Strategy 105 Idiopathic Scoliosis Etiology 106 Evaluation 107 Management 115 Summary 11 9 Appendix 5-1 123 CHAPTER774Context 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 CHAPTERContext 45 General Strategy 46 Relevant Anatomy and Biomechanics 51 Evaluation 53 Management 60 Selected Causes of Cervical Spine Pain 68 Appendix 2-1 72 Neck Diagnosis Table 75 CHAPTERCHAPTER6Lumbopelvic Complaints127Context 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 CHAPTER7Shoulder Girdle Complaints175C ontext 175 General Strategy 176v

2. Appendix 8-1 237 Elbow and Forearm Diagnosis Table 238 CHAPTER9Wrist and Forearm ComplaintsCHAPTER241Context 241 General Strategy 241 Relevant Anatomy and Biomcchanics 243 Evaluation 244 Management 251 Selected Disorders of the Wrist and Forearm 254 Appendix 9-1 26514PART II CHAPTER10Finger and Thumb ComplaintsCHAPTERHip, Groin, and Thigh Complaints295Context 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 CHAPTER12Knee ComplaintsContext 321 General Strategy 322 Relevant Anatomy and Biomechanics 323 Evaluation 325 Management 336viContentsNeurologic Complaints 15Weakness421Context 42 J General Strategy 421 Relevant AnatolllY and Physiology 423 Evaluation 423 Management 429 Selected Neurologic and l1uscular Diseases 433 Appendix 15-1 438 CHAPTER11381267Context 267 General Strategy 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 CHAPTERFoot and Ankle ComplaintsContext 3Rl General Strategy 381 Relevant Anatomy and Biomechanics 382 Evaluation 385 Management 392 Selected Foot Disorders 404 Appendix 14-1 412 Foot/Ankle/Lower Leg Diagnosis Table 414CHAPTER32116Numbness, Tingling, and Pain439Context 439 General Strategy 439 Relevant Anatomy 44 J Evaluation 442 Management 447 Appendix 16-1 449 Appendix 16-2 449 17Headache451Context 4.5 1 General Strategy 452 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 3. Relevant Anatomy and Physiology 510 Evaluation 510 Management 512 Appendix 19-1 517 Appendix 19-2 51 7 PART III CHAPTER20Context 575 General Strategy 575 Relevant Physiology and Anatomy 575 Evaluation 577 Management 578 Selected Causes of Lower Leg Swelling 580 Appendix 25-1 583General Concerns Depression521 CHAPTERContext 521 General Strategy 521 Terminology and Classification 522 Evaluation 524 Management 525 Appendix 20-1 528 Appendix 20-2 528 CHAPTER21Fatigue22Fever531CHAPTERCHAPTER54723Sleep and Related Complaints27Skin Problems59355328Vaccination: A Brief Overview603Context 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 CHAPTERContext 553 General Strategy 553 Relevant Anatomy and Physiology 554 Classification System 555 Evaluation 556585Context 593 General Strategy 596 Evaluation 597 Management 601 Appendix 27-1 601Context 547 General Strategy 548 Relevant Physiology 548 Hyperthermia 548 Evaluation 549 Management 551 Appendix 22-1 552 CHAPTERLymphadenopathyContext 585 General Strategy 585 Relevant Anatomy and Physiology 586 Evaluation 586 Management 587 Selected Causes of Lymphadenopathy 589 Appendix 26-1 591Context 531 General Strategy 531 General Discussion 532 Evaluation 533 Management 535 Selected Disorders Presenting as Fatigue 538 Appendix 21-1 544 CHAPTER2629Weight Loss613Context 613 General Strategy 613 Relevant Physiology 614 Evaluation 614 Management 616 Appendix 29-1 619 Contentsvii 4. Management 631 Appendix 31-1 633PART IV CHAPTERCHAPTERGastrointestinal Complaints32Abdominal Pain637Context 637 General Strategy 637 Relevant Anatomy and Physiology 638 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 CHAPTER33Constipation665Context 665 General Strategy 665 Relevant Anatomy and Physiology 666 Evaluation 667 Management 669 Appendix 33-1 673 CHAPTER34DiarrheaContext 675 General Strategy 67 5 Relevant Anatomy and Physiology 678 Evaluation 678 Management 680 Appendix 34-1 683PART V CHAPTERUrinary Incontinence and Voiding DysfunctionContext 687 General Strategy 687 Relevant Anatomy and Physiology 689viiiContentsPART VI CHAPTER705Cardiopulmonary Complaints38Syncope/Presyncope713Context 713 Genera l Strategy 713 Relevant Physiology 713 Evaluation 7 14 Management 716 Appendix 38-1 716 39Chest Pain717Context 717 General Strategy 717 Relevant Anatomy and Physiology 717 Evalu ation 722 Managen1ent 724 Selected Causes of Chest Pain 726 Appendix 39-1 734 Appendix 39-2 734 CHAPTER40Palpitations735Context 735 General Strategy 735 Relevant Anatomy and Physiology 736 Evaluation 736 Management 739 Possible Causes of Palpitations 742 Appendix 40-1 743Genitourinary Complaints 35Vaginal BleedingContext 705 Genera l Strategy 705 Relevant Anatomy and Physiology 705 Evaluation 706 Management 706 Appendix 37-1 709CHAPTER67537687 CHAPTER41Dyspnea (Difficulty Breathing)Context 745 General Strategy 745745 5. Appendix 42-1 770PART VII CHAPTER43Relevant Anatomy 825 Evaluation 826 Management 826 Appendix48-1 826Head and Face Complaints Eye Complaints775 CHAPTERContext 775 Review of General Terminology 77 5 General Strategy 776 Evaluation 777 Management 780 Selected Causes of Vision Loss 784 Appendix 43-1 788 Appendix 43-2 788 CHAPTER44Facial Pain45Ear PainPART VIII 791CHAPTER799CHAPTERHearing lossContext 809 General Strategy 809 Relevant Anatomy and Physiology 810 Evaluation 810 Management 812 Selected Causes of Hearing Loss 816SOSpecial Conditions Diabetes Mellitus83351Thyroid Dysfunction845Context 845 General Strategy 845 Relevant Physiology 846 Evaluation 846 La bora tory Testing and Managemen t 847 Selected Thyroid Disorders 849 Appendix 51-1 852 CHAPTER46827Context 833 General Strategy 834 Relevant Physiology 834 Evaluation 836 Management 838 Appendix 50-1 842 Appendix 50-2 842Context 799 General Strategy 799 Relevant Anatomy and Physiology 799 Evaluation 800 Management 801 Selected Causes of Ear Pain 805 Appendix 45-1 808 Appendix 45-2 808 CHAPTERSore ThroatContext 827 General Strategy 827 Evaluation 828 Management 829 Appendix 49-1 830Context 79 1 General Strategy 791 Relevant Neurology 792 Evaluation 792 Management 793 Facial Pain Caused by Neuralgias 796 Appendix 44--1 797 CHAPTER4980952853HyperlipidemiaContext 853 General Strategy 853 Relevant Physiology 854 Evaluation 854 Management 857 Appendix 52-1 865 Appendix 52-2 865 Contentsix 6. 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 CHAPTER55The Geriatric PatientContext 933 General Strategy 935 Relevant Anatomy and Physiology 937 Evaluation 940 Focused Concerns 944xContentsAppendix Pharmacology for the Chiropractor: How ~edications ~ay Affect Patient Presentation and ~anagement Outcomes 933993Concensus Document for the Operationally Defined Use ofI.CD. Codes: Palmer Chiropractic College West Clinics1027Index1029 7. AcknowledgmentsI 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 8. IntroductionWhat 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 9. 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., DACBSPxivIntroduction 10. WEBSITESChiropractic 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.govNational 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.htmlDatabases 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.caIntroductionxv 11. 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 regionshave 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 12. IIIsoft 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 myofascitisIIIjoint arthritis subluxation/fixation (chiropractic) synovitis infection joint mice dislocation/subluxation (medical)IIIIIIDetermine whether the mechanism is one of overuse. III IIIIIIIIIIII IIIIIIHistoryIIIIIIIs the complaint traumatic? Is there a history of overuse) Is the onset insidious?Clarify the type of complaint. IIIIIIIs 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.IIIIII4If 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 ComplaintsAre 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 IIIIII IIIClarify the mechanism if traumatic (for extremities see Table 1-1). IIIAre 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.IIIIIIIn 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.IIIWith 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. 13. Acromioclavicular separation Dislocation Fall onto top of shoulderS houlder pointer Acromioclavicular separation Distal clavicular fractureT ractioninjury to armPlexus injury Medical subluxationElbow Direct fall on tip of elbow or fall on hand with elbow ftexedOlecranon fractureFallon hand with extended elbowRadial head fractureH yperextension injuryto elbowElbow dislocationSevere valgusstressCapitellum fractureSupracondylar fracture in children Avulsion of medial epicondyle Medial collateral ligament sprain or rupture Sudden traction offorearmRadial head subluxationWrist/hand Fallondorsifiexed handNavicular fracture E piphyseal and torus fracturesin children Carpal dislocation,or instabilityHyperextension or abduction of thumbGamekeeper'sthum b(ulnar collateral ligament damage)Axial compression of thumbBennett's fracture DislocationHyperextension of fingerVolar plate injury Jersey finger (rupture of fiexor digitorum profundus) DislocationHyperftexion of fingerAvulsion of central slip Mallet finger (rupture of extensor tendon)Valgus/varusstress injuryto fingerCollateral ligament orvolar plate injuryAxial compressionCapsular irritation FractureHip Fallon hipFracture Synovitis (co ntinued)General Approach to Musculoskeletal Complaints5 14. Blow to anterior knee/patellaIrritation of plica Patellar fracture Bursitis Infrapatellar fat padirritationV algusforceMedial collateral ligament tear Pesanserine strainRotational injury with foot fi xed on groundM eniscusRotational injury with avalgus forceAnterior cruciate ligament, meniscus,medial collateral ligamentFoot/ankle Plantarfiexion, inversion of ankleAnkle sprain with possible ass ociated bifurcate ligament damage, fracture, or peroneal tendon snapping from torn retinaculumEversion injury to ankleDeltoid ligament sprainor rupture Fracture DislocationH yperextensionof great toeTurf-toe injury toc ular ligaments apsL anding on heelsFat 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.6Musculoskeletal ComplaintsManagement 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. 15. TABLE1-2Synovial Fluid ExaminationCle arN ormal Group I (Noninfiammatory)DJD TraumaTransparentYellowTransparentYellow to opalescentTransparent to opaqYellowto greenOpaqueOteochondritis dissecans s PVS Osteochondromatosis Neuropathic arthropathy Group II (Infiammatory)RA Active crystal-induced (gout,pseudo-gout) Seronegatives (AS, Reiter's psoriatic) Enteropathic (lBD) Rheumatic feverCro::JS LE~Scleroderma~: -c -cTuberculosis(3~= a~c: ~c: "~ro "" ~ '" ,-.a3-c'" ~.'-IG III roup (Purulent)P yogenic bacterial infectionNote. 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 16. 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-8Musculoskeletal Complaintsmary 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 17. 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 tissuestructures. 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 General Approach to Musculoskeletal Complaints9 18. cLE 'l~3Selected Arthritic Disorderss:: ~ c::~ro '"Degenerative~Primary Osteoarthritis~S' 3-a." ~.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 handsOften 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 OsteoarthritisAge of Onset- > 25 y/o Gender Predominance-Equal Common Joints Involved-GH,AC, SI, hip, elbow, knee, foot, hanCause 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 OsteoarthritisAge ofOnset-40-50 y/o Gender Predominance-Female Common Joints Involved-Interphalangeal joints of handInfiammatory 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 DiseaseAge 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 involvementRange 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 19. TABLESelected Arthritic Disorders (continued)1-~' 'ri!i'TypeD iffuse IdiopathicSkeletal Hyperostosis (DISH) (synonyms ankylosing hyperostosis, Forestier's disease)FeaturesAge of Onset- 50y/o andolder Gender Predominance- Male Common Joints Involved-Spine; predominantlyT7 -T11 (calcific tudinalligament) with 30% peripheral joint involvementF 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) ArthropathyAge of Onset - Va ria ble Gender Predominance- Variable (ommon Joints Involved- Knee,hip,ankle,spine,shoulder,elbowVariable 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, C'> ro::> ~~ :l>' -0 -0Synoviochondrometaplasia (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" defora ,., QJ=r-o~c:: ~ c::~~~ ~b' 3-057 ~.-Age ofOnset- 30- 50y/o Gender Predominance-Male to female ratio= 31 (ommon Joints Involved-Knee,hip,ankle,elbow, wris tInflammatory Positive for Rheumatoid Factor (Seropositive) Rheumatoid Arthritis (RA)Age ofOnset-25-55 y/o Gender Predominance- Female tomale ratio = 2/3: 1 (ommon Joints Involved- Hand, foot, wrist, knee, elbow, G joint H spine (atlantoaxial) 20. ~Selected Arthritic Disorders (continued)s: ~ c::~~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 leChronicArthritiSAgeofOnset- 5- 10y/o Gender Predominance-Variable basedon specific dis order (ommon Joints Involved-Hand,foot, wrist, knee, elbow, heel,h~~b' 3-0 ~.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 fracturesNegative 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 heelComplaintsoftenbeg 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. 21. TABLE1-3Selected Arthritic Disorders (continued)Type Reiter's SyndromeFeaturesAge 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 extremityUrethritisand 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 soriaticO 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,C'> ft) ::> ft)~ >--0 -030 ylo (in females, postmenopausal) Gender Predominance- Male Common Joints Involved- First MTP joint of foot, feet,ankl e ,anFirst 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,wristCCPD 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 25. TABLE1-3..Selected Arthritic Disorders (continued)Type HydroxyapatiteDeposition Diseasefeatures Age of Onset - 40- 70 y/0 Gender Predominance- Equal Common Joints Involved-Shoulder, hip, cervical spineT 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 arcoidosisAge of Onset - 20- 40 Y /0 Gender Predominance- Equal Common Joints Involved-Hands, wrists,andfeetThis 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'" '" ~ ::::lRare 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.-0 -0o ~=~o:s: ~c:~'" '" ~ ~b'3-0~C:~Age of Onset - 40- 60 y1 0 Gender Predominance - Male to female ratio = 10:1 to 201 Common Joints Involved -Hip, knee, shoulder,wrist,handAlkaptonuria(OchronOSis)Age ofOnse-30- 40 ylo (present at birth though) Gender Predominance- Male equal to fema le (ommon Joints Involved- Spine,hip, and kneeAn 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 26. ... 00TABLE1-3Selected Arthritic Disorders (continued)~~c::~~~~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,ankleb' 3-cCi> ~.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 rthropathyAge ofOnset-2- 3ylo Gender Predominance-Male Common Joints Involved-Knee and elbow commonlyaffected appendicular jointscan be affectedHemophilia 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.InfectiousArthritis 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 27. TABLE1-3Selected Arthritic Disorders (continued)Hyperlipidemiac-. ro :::l ro~ :>""0 ""0a ,.., '" =r ..... o$:~.:::~~ro~~b'3 ;;:;-""0~.10 28. 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 E1-4.Selective Tension ApproachArth ritis! ca psu litisPainful at limit of rangePainful at limit of rangeUsually painless within range of motionOften specific capsular pattern of one or two restricted movement patternsTendinitis TendinosisVariablePa inon stretchPainful, especially if contracted in stretched positionInsertion of tendon is often tender or slightly proximal to insertionTendon ruptureNoneFull;painlessWeak; painlessNote displaced muscle bellyLigament sprainDecreased;limited by painPain on stability challengePainless iffull rupture,painful if partialOverpressure laxity may indicate degree of damageMuscle strainPainful,often midrangePassive stretch may increase painIf resistance is sufficient, pain is producedCheck with resistance throughout full range of movementIntraarticular bodySudden onset of pain in aspecific range of motionSudden onset of pain in aspecific range of motion is also possibleUsually painlessAn"arc" of pain with a"catching" or blockage is highly suggestiveAcute bursitis (deep)Painful in most directionsEmpty end-feel is often presentIsometric testing is often painfulPositional relief is less common than with muscle/tendon injuryKey. ROM range of motion20Musculoskeletal Complaints 29. Bone Tumor-primary or metastatic Os teoch 0ndros i5/apo physitis Fracture Stress fracture Osteopenia (osteoporosis) OsteomyelitisSoftTissue Muscle Strain or ruptureRadiographMRI or CT, bone scan for metastasis (nonspecific)Local tenderness and radiographPossible bone scanPalpation, percussion, tuning fork, radiographCT or possibly MRIPalpation, percussion, radiog ra phBone scan, SPECT scan;quantified CT, dual-energy absorptiometryRadiographQuantified CT, dual-energy absorptiometryRadiographMRIActive resistanceFor rupture,sonography,or MRITrigger pointsPalpationNoneAtrophyObservationE lectrodiagnostic studiesMyositis ossificansPalpation, radiographCTMuscular dystrophyMuscle testing, LDH on labElectrodiagnostic studiesTendi nitis/tendi nosisStretch and contractionSonographyParatenonitisS tretchSonography or MRIRuptureLack of passive tension effectS onography or MRIS tability testingMRIPalpationMRI or bursographyPalpationNoneCharacteristic Joint involvement,laboratory findings including rheumatoid factor, HLA-B27, ANA, and radiographic characteristicsCT for bone, MRI for soft tissue involvementSubluxation/fixation (chiropractic)P alpation, indirect radiographic findingsCT for facet joints (research only)SynovitisCapsular pattern of res trictionMRI,Joint aspirationJoint miceRestrictedROM, radiographCT or MRIDislocation/subluxation (medical)Observation and radiographCTTendonLigament Sprain or ruptureBursa BursitisFascia MyofascitisJoint ArthritisKey. 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.General Approach to Musculoskeletal Complaints21 30. 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. 22Musculoskeletal Complaintsextension. 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 31. NoNo...6AROM and PROM increased; resisted movement is painless and strong?7Pain on resisted movement, especially in a fully stretched position?Consider Yes---. hypermobility.8 YesConsider tendinitis or tenosynovitis.No No~129 10Ligament challenge reveals abnormal movement (may be painful or painless)?Consider muscle strain. movement at midrange?Yes-.. Ligament sprain.No...I13If multiple muscles are painful, consider vascular compromise, fibromyalgia , or psychologic problems. 1415PROM is decreased and painful?Painful arc with AROM or PROM with a specific pattern of movement?Yes-.16Consider 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?No18 Yes19PROM 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 .I20Consider bony blockage often due to advanced degenerative jOint changes.22AROM is normal; PROM is painful at endrange?23Ye~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. General Approach to Musculoskeletal Complaints23 32. 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 weaknessEXHIBIT '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).24Musculoskeletal Complaints 33. 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 andalso 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. IORadiography 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: IIIV7hat are the risks to the patient?IIIWhat is the cost? Are there less expensive methods of arriving at the same diagnosis?IIIiVhat 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 IIIIIIII IIIII III III IIIsignificant trauma suspicion of cancer (unexplained weight loss, prior history of cancer, patients over age 50 years) suspicion of infection (fever of unknown origin above 100F 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 General Approach to Musculoskeletal Complaints25 34. .. 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: IIIIIIIIIIIIIIIRadiography-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. IIIIIIIIIInitial 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 treat26Musculoskeletal Complaintsment 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 35. TABLE1...6Magnetic Resonance Imaging for the ChiropractorMRI 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 3daysH ydrocephalus Brain atrophyFracture 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 calcificationsSpinal stenosisOccult fracture of avertebra Complex fracture of avertebra Bony foraminal encroachmentLarge lumbar herniation Spinal stenosisOccult fracture H ypertrophic bonyovergrowth or spurring Bony foraminal encroachment Spondylolysis E valuation of posterior element fusionRotator cuff tearSubtle glenoid labrumtear Evaluation afthe glenohumeral ligamentsMeniscal tearE valuationof the m eniscus following previousmeniscectomy Evaluation of the articular cartilageMRI 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 abscessMRI 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 tumorMRI 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, CaliforniaGeneral Approach to Musculoskeletal Complaints27 36. Figure 1-2Passive Care Management-AlgorithmMusculoskeletal condition meeting inclusion criteria for passive care (A)32 PRICE Protect-rest-iceYes----. compress-elevate (up to 72 hours after onset)Presence of active inflamation or acute pain?No4f---------1~(No9~_ _L-_-----8Evidence of hypomobility or hypermobility?--Yes~es~ J:~inflammation and5Manage 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 116No 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 algorithmYes----+~Diminished~Nol7CONSIDER: Potential chronic inflammatory disorders or pain behavior. Discharge or refer.12 DischargeAnnotations (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 stabilizationSource. Rep rinted from D. L. Nelson, Top ics in Clinical Chiropractic, Vol. 1, No.4, p. 75, 1994, Aspen Publishers, Inc28Musculoskeletal Complaints 37. Physiotherapy Approaches for Musculoskeletal ComplaintsPulse WidthPulse RateHigh FrequencyHigh75-100 8 days? Severe pain? More than four previous episodes? Preexisting structural or pathological conditions? NoYes---.Recovery time increased by 1.5 to 2 times; 9-16 weeks of decreasing treatment frequency102-6 weeks of patient education and active care for strength and endurance as needed and as clinical status permits112-6 weeks of patient education and active care for strength and endurance as needed and as clinical status permits 12No anticipated delay in recovery. Treat to preepisode status 6-8 weeks, up to three times per week1413 Maximum clinical and functional improvement?Yes------.Discharge and/or elective care (C)1615 Complicated case factors identified?Yes------.(D)Move to algorithm for complicated cases (Figure 1-4)17 Continued failure to achieve desired outcomesdischarge or referralGeneral Approach to Musculoskeletal Complaints31 40. Figure 1-4Subacute/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 weeks4 23No-.iSymptoms prolonged> 6, < 16 weeksChronic EPisode, I Symptoms> 16 weeks1-. - - - . . . . .-Passive care including CMT for exacerbations only, pm - Supervised rehabilitation and lifestyle changesIYes15Subacute Episode Symptoms> 6, < 16 weeks1 ---86 Supportive care using passive procedures (including CMT) may be necessaryPassive care including CMT not generally to exceed twice weekly Active care, dissuasion of pain behavior, education, exercises, and/or rehabilitation Supportive care inappropriate107 Is patient insincere or noncompliant with care/treatment?9Is patient insincere or noncompliant with care/ treatment?Discharge or referralNoNo1211 Continue to preepisode status 6-16 weeks therapy goalDischarge and/or elective care(A)13May not return to prelnjury status. Consider declaration of maximum therapeutic benefit. (A)Source: Reprinted from D T. Hansen, Topics in Clinical32Musculoskeletal ComplaintsVol. 1, NoA, p. 74, 1994,tspen Publishers, Inc. 41. 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 General Approach to Musculoskeletal Complaints33 42. figure 1-5Active 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 efforts32 Evidence of joint hypomobility?4Manage with: Active assisted ROM, PNF, active ROM, and/or continued passive ROM (2 to 8 weeks)YesGo to Active Exercise -yes-----. Algorithm (Figure 1-6)Evidence of improved mobility?No15Evaluate for potential permanent joint changes and adjust long-term goalsNo76 Evidence of joint hypermobility?Yes8Manage for: Support to prevent tissue damage and stabilization exercises (8) (4 to 16 weeks)Evidence of improved stability?YeGo to Active Exercise AlgorithmNo~9Consider. Permanent InstabilityNo10 Evidence of deconditioned soft tissue?11No-----.1513Reduce endurance capacity?NoProprioception or balance deficitsNo--.DischargeYes 12Go to Active Exercise AlgorithmManage with: High repetition w/resistance; interval/circuit training; cardiovascular training; to treatment goalSource: Reprinted from D. L. Nelson, Topics In34Musculoskeletal Complaints14 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. 43. Figure 1-6Active Care: Exercise-AlgorithmMusculoskeletal condition responsive to passive and/or active management32 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 toleranceGo to Box 20r DischargeYes54 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 Assess for compliance Retest for toleranceYes76 Patient tolerates: Short-arc dynamic exerciseNo~(High rep , low weight) (1-3 sets/12-20 reps)Consider: Additional 1 to 3 weeks of manual resistance through ROM Assess for compliance Retest for toleranceGo to Box 4 or DischargeYes9 Patient tolerates: Extended ROM, moderate resistance, 2-4 sets/8-12 reps, multijoint motions, and progressive resistance?NoYesConsider: Additional 1 to 3 weeks of short-arc dynamic exercise Assess for compliance Retest for toleranceGo to Box60r Discharge11Patient tolerates: Heavy resistance, 3-5 sets/5-8 reps , work hardening?No~Consider: Additional 1 to 3 weeks of Go to extended ROM, r---_I Box 8 or moderate resistance Discharge Assess for compliance Retest for toleranceYes112Discharge 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.General Approach to Musculoskeletal Complaints35 44. i.JA'6ll,8' SetThe Daily Adjustable Progressive Resistance Exercise (DAPRE) Approach,"', :,weight 1/2 working weight 3/4 working weig ht Full working weight4MaximumA djusted working weight (basedon3rd set)Maximum U thefollowing tableto determine working weight for 4th set (Based on 3rd set numberof repetitions) se Full working weight (3rd s of the next training session isbased on number of repetitionsperformed in the4th set et)l"!'o.ofRepetitions 0-2F~r4tbSet~,gtm~xt5essionFu}Ii,o!~ngW~ght,Decrease 5-10 IbDecrease 5-10 Ib3-4Decrease 0-51bThe same5-6The sameIncrease 5-10 Ib7-10Increase 5- 1 Ib 0Increase 5-151b11 or m oreIncrease 1 0-151bIncrease 10-20 IbEXHIBIT 1-5Eccentric Exercise Protocols General Comments Eccentrics are usually begun in the subacute phase of healing. Although there is some disagreement, the initial phase begins somewhere between 3 and 7 days after injury depending on severity. The superiority of eccentrics over concentrics occurs only during the first 19 days postinjury. A load of up to 20% above a one-repetition maximum is considered safe. It is suggested by the literature to perform between 3 and 20 repetitions with a three-set maximum; two to three times per week. Two times per week will probably prevent delayed-onset muscle soreness (DOMS). Rest periods are not as important due to the low oxygen demand. Somewhere between 30 seconds to 1 minute is sufficient. Training begins with slow progressing to faster repetitions. Two concerns are chance of overload injury and DOMS. Generally, there are three phases of training. An exa mple for the lower extremity follows : 1. Two-leg concentric/eccentric training is followed by two-leg concentric/injured leg eccentric work. 2. Slow, submaximal, single-leg eccentrics are performed. The first two phases are usually completed in 3 weeks or less. 3. Functional eccentrics are performed in preparation for plyometrics. This phase usually takes 2 to 3 weeks to complete. Functional Eccentrics for the Lower Extremity A sample of a functional eccentric program would include the following: 1. One-leg step-up onto 12-inch stool; noninvolved leg steps up first, down last 2. One-leg step-up; involved leg steps up first, down last 3. Repeat with I8-inch step height 4. Slow quarter squats 5. Rapid quarter squats 6. Slow parallel squats 7. Rapid parallel squats36Musculoskeletal Complaints 45. Curwin and Stanish l7 Eccentric Protocol for TendinitisfTendinosis 1. Static stretching for 15-30 seconds is repeated three to five times. 2. Eccentric exercise is begun with gravity or light weights. For the first 2 days they are performed slowly. During days 3-5 they are performed at moderate speed. On days 6 and 7 the exercises are performed quickly. Three sets of 10 are performed. 3. After the eccentric phase, a repeat of the static stretching phase is performed. 4. Follow with 5-10 minutes of icing. Curwin and Stanish feel that there should be some pain felt in the third set. Ifnot, the resistance should be increased slightly. If pain is felt in the first two sets, weight should be decreased slightly.EXHIBIT 1-6Advanced Training Approaches Russian Stimulation Protocol III Place one electrode over the muscle and one over the associated nerve root. III Use a 2500-Hz carrier wave; modulate at 50 pulses per second. III Increase intensity to patient tolerance. III Use la-second maximum contraction with 50-second rest periods equaling 10 contractions in 10 minutes. III Use three to five treatments per week for 5 to 7 weeks for a total of 2 3 to 35 treatments (2-day rest period per week). III Protocol is used one time per year, best at night and not before or after strenuous exercise. Plyometrics for the Lower Extremity II