Clinical diagnosis of soft tissue lesions

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Clinical diagnosis of soft tissue lesions

Chapter contents

Introduction

The major part of this book is about making a clinical diagnosis: a system of clinical reasoning leading to a proper diagnosis. The final stage of the diagnostic procedure is the precise anatomical description of the lesion, for example: supraspinatus tendinitis at the superficial aspect of the tenoperiosteal junction, chronic subdeltoid bursitis, lesion at the origin of the extensor carpi radialis brevis muscle, periostitis at the anteroinferior surface of the fibula, annular disc protrusion at the L4–L5 level irritating the fifth lumbar nerve root.

During the last decades, new technology has revolutionized diagnosis and decision making in orthopaedic medicine. Previously, soft tissue lesions were characterised by a lack of objective findings. This has changed dramatically since the arrival of sonography, computed tomography and magnetic resonance imaging (MRI). These new techniques can demonstrate anatomical changes in soft tissues and therefore contribute significantly to the understanding of non-osseous orthopaedic lesions. However, they do not make clinical assessment redundant. Contrary to popular belief, diagnosis is not made by only looking at the result of a technical investigation. In the best case, an anatomical picture may be the ultimate confirmation of the clinical diagnosis. If imaging is undertaken too early during the diagnostic process it will create more problems and questions than it resolves, and often puts the examiner on the wrong track and leads to wrong therapeutic decisions.

First of all, not every detected anatomical lesion causes pain or dysfunction. Asymptomatic lesions do exist and are present in numbers that are much larger than previously assumed: asymptomatic herniations in cervical, thoracic and lumbar spine are present in up to 50% of the population.1,2,3 Also the high prevalence of rotator cuff tears in elderly asymptomatic individuals is very well known.^4,5 It is estimated that in the general population, approximately two-thirds of all rotator cuff tears are asymptomatic.^6,7 Large numbers of asymptomatic lesions have also been demonstrated in the knee. A recent MRI study on asymptomatic soccer players demonstrated one or more MRI abnormalities in no less than 64%. Another study with MRI scans performed on the knees of asymptomatic male professional basketball players demonstrated an overall prevalence of articular cartilage lesions of 47.5%⁸ and meniscal lesions of 20%.⁹

Another shortcoming of technical investigations is that they only detect an anatomical lesion (defect, swelling or other structural changes) and not the functional deficiency (weakness, limitation, laxity). In other words, the behaviour of the tissue during activity is not assessed.

For all these reasons, there is no place for high-tech visualization techniques in the beginning of the diagnostic process and they should never be used as screening tests. A biased examiner who is looking for a particular lesion will often find that lesion, whether it is responsible for the complaints or not. Too many and too early technical investigations substantially increase the cost of medical care but do not give a better outcome. On the contrary, in the hands of an unprofessional doctor, high-tech investigations are potentially dangerous as they may lead to major, unwanted and unnecessary surgery.

Principles of diagnostic procedure in orthopaedic medicine

Clinical examination is all about behaviour of the tissues involved. The examiner must have a very good knowledge of the behaviour of the lesions that he is dealing with and of the behaviour of the normal tissue. Tissue behaviour is described by the patient during the inquiry and checked by the examiner during the functional examination. Looking for tissue behaviour, the following general principles are important.

1 Look for ‘inherent likelihoods’

Some things are likely to happen

Soft tissue lesions behave in a very typical way and the examiner will therefore regularly be faced with the same history and the same response to functional testing. The symptoms and signs are closely related to the lesion present. The examiner should therefore try to recognize ‘inherent likelihoods’, a term defined as the sequence of symptoms and/or signs that belong to the clinical picture of a certain pathological disorder and that are likely to be found, more or less in a sequence which is typical for that disorder.

For example: in the history, a patient with lumbar pain may mention that on some days the pain spreads down the lower limb; tennis elbow is characterized by sudden twinges when objects are picked up; and in lumbar disc lesions pain may shift from one side to the other.

Functional examination can also show some inherent likelihoods. When resisted extension of the wrist hurts at the elbow, a tennis elbow is suspect and can be confirmed by positive responses to resisted extension of the wrist with the fingers held actively flexed and to resisted radial deviation of the wrist. In tendinitis at the radial insertion of the brachial biceps, apart from pain on resisted flexion and supination of the elbow, full passive pronation is also painful. In L5 sciatica, pins and needles in the medial three toes may be accompanied by numbness in the same area and by weakness of the extensor hallucis longus and peroneal muscles.

The examiner who has a knowledge of what is likely to happen should recognize this and compare the pattern to the ‘unlikelihoods’ presented by some patients, which indicate either a non-organic lesion, a somatic but non-orthopaedic problem or an unusual lesion. These inherent probabilities can of course only be recognized if the clinical examination is performed thoroughly.

2 Look for objective physical signs

Examination of the moving parts is an exercise in applied anatomy

The examination should include questioning (history taking) and testing which provokes or elicits symptoms and/or signs that can be assessed, judged and interpreted as objectively as possible.

The soft tissues of the locomotor system have the advantage that their functional anatomy is well known. It is clear how joints behave, how capsules and ligaments guide and limit movements, how muscles function and what movements they provoke.

Therefore, examination of the moving parts is an exercise in applied anatomy. Each tissue or group of tissues in turn must be tested and the answer interpreted in the light of the anatomical possibilities.

3 Avoid palpation as much as possible

The function of the different tissues is known

Although palpation is very often used as a diagnostic procedure, it is unreliable for several reasons:

• Some regions in the body are always tender to touch (e.g. lesser tuberosity at the shoulder, lateral epicondyle at the elbow, border of the trapezius muscle).

• Some structures lie too deeply and cannot be reached by the palpating finger (e.g. capsule of the hip joint, cruciate ligaments at the knee).

• The painful area does not always correspond to the site of the lesion (referred pain) and referred dural tenderness is sometimes present.

• Some patients with altered perception or desire to deceive the examiner may produce misleading responses.

It is easy to understand that, in these circumstances, palpation offers no help at all or, even worse, may misdirect the examiner.

Diagnosis, therefore, rests largely on the correlation of a series of semi-subjective data, obtained from a proper functional examination – an indirect approach. By assessing the function of each tissue in turn and interpreting the signs in the light of the anatomical knowledge, the examiner should be able to come to a correct description of the lesion.

The patient is asked to answer some very precise questions. A patient with an organic lesion exactly describes what is felt and gives the examiner a fairly precise clinical picture. The neurotic or malingering patient will feel the need to embellish so as to give a colourful description of suffering rather than of the symptoms.

4 Functional testing: the principle of ‘selective tension’

The soft tissues can be put under tension

The different tissues of the moving parts can be subjected to strain which may increase the pain and tests are used to elicit or influence the patient’s symptoms.

The possibility of making a diagnosis by selective tension depends largely on the characteristics of each tissue and on its capacity either to contract or to become stretched.

Muscles and tendons may be stressed by isometric contraction of the muscle or by passive stretching in the opposite direction. By contrast, ligaments and joint capsules can be put under tension by passive stretch.

If a certain test is positive, in that it provokes the symptom for which the patient consults, it establishes the relationship between the structure that becomes stretched, squeezed or contracted and the lesion.

It is important to try to use movements that put tension on one structure only, so that interpretation is as simple as possible. If a movement tests more than one tissue, accessory tests or palpation may be required to obtain further information that can differentiate between potential causes. For example, when testing the lateral ligaments at the ankle, a combined movement of passive plantar flexion and inversion is performed. If this is positive and, later in the examination, passive internal rotation at the mid-tarsal joints is negative, involvement of the calcaneocuboid ligament is excluded. In examination of the shoulder, painful resisted flexion of the elbow incriminates either the biceps or brachialis muscle; if resisted supination of the elbow is also positive, the lesion lies in the biceps muscle.

5 Use physiological movements as much as possible

Normal movements may become disturbed

This approach has some advantages:

• The structures that participate in the movement are well known (applied anatomy).

• The movements are easily controllable and reproducible. Pain may be provoked, but also limitation can be seen and weakness is not difficult to detect. The inter- and intra-tester reliability is quite high.10–15

• Patterns can be found: pain patterns, patterns of limitation and patterns of weakness. The recognition of a known pattern confirms the symptoms and signs presented.¹⁶

6 Distinguish between inert and contractile tissues

Soft tissues are either inert or contractile

This distinction is one of the pillars on which the whole system of orthopaedic medicine rests. The soft tissues of the locomotor system can be divided on the one hand into tissues that can contract (the contractile structures) and on the other hand, tissues that do not possess this capacity (the non-contractile or inert structures) (Box 4.1).

Box 4.1 Inert and contractile tissues

Contractile structure

The complex of muscle origin, muscle belly, musculotendinous junction, body of tendon, tenoperiosteal junction and also the bone adjacent to the attachment of the tendon are considered clinically as contractile (Fig. 4.1).

Fig 4.1 Contractile structures – the musculotendinous unit: 1, tendon; 2, muscle belly; 3, musculotendinous junction; 4, insertion.

The only worthwhile method of testing these structures is by maximal contraction against resistance. The movement should be performed isometrically so that the applied tension, which causes pain, falls only on the muscle and the structures attached to it.

Passive movement in the opposite direction, which stretches the contractile tissue, can also elicit the pain but cannot be used as a specific test for it because non-contractile tissues are also stretched. For example, a lesion in the subscapularis tendon at the shoulder gives rise to pain on resisted internal rotation. Full passive external rotation may also hurt. This sign fits the clinical picture of subscapularis tendinitis but has neither diagnostic nor localizing value because the passive movement also stretches the anterior joint capsule and the pectoralis major muscle and tendon.

However, a pain elicited by resisted movement does not invariably mean that a contractile tissue is at fault. If the bone close to the tendinous insertion is affected (fracture or other bony disorder), pain is evoked by the pull of the muscle. A contraction may also squeeze an underlying structure such as a lymphatic gland or bursa. When such tissues are inflamed, squeezing may evoke pain. The same applies when there is a disorder adjacent to muscles, for example an abscess. This explains why, for example, contraction of the sternocleidomastoid muscle may be painful in glandular fever and why contraction of the gluteal muscles can hurt in a trochanteric bursitis.

Inert structure

An inert structure does not possess an inherent capacity to contract and relax and can thus be tested only by passive stretching or squeezing. The inert tissues are shown in Box 4.1.

Active movements may also stretch or squeeze an inert structure but, because they also activate the contractile tissues, interpretation is subject to ambiguity and they cannot be used to test inert structures. For example, during active elevation of the arm, many muscles are in action (deltoid, supraspinatus, serratus anterior, trapezius). At the same time, certain parts of the joint capsule and some ligaments are stretched (acromioclavicular, sternoclavicular, conoid and trapezoid ligaments) and other structures are compressed (subacromial bursa, inferior acromioclavicular ligament, tendinous insertions of supraspinatus, infraspinatus, subscapularis and biceps).

7 Concentrate on ‘the’ pain

‘The’ pain is that pain for which the patient consults

When tests evoke pain, the examiner must make sure that this is the pain that is the patient’s complaint. It is possible that some movements elicit pain in a certain area and that other tests provoke another pain in another region: one of these will be recognized by the patient as the presenting symptom. The examiner should then concentrate on this pain alone.

The situation often occurs because combined lesions are quite common. A patient may come to see the doctor with pain down the arm. If, after the history has been taken, it is not clear whether the pain originates either from the cervical spine or shoulder girdle or from the shoulder itself, the preliminary examination aims to clarify the situation. It may show some discomfort at the base of the neck when cervical movements are tested (especially in middle-aged and elderly people) but if only shoulder movements elicit the pain complained of, then this pain (‘the’ pain) is the primary problem; the other pain (‘a’ pain) is secondary. The arm pain will, of course, be dealt with first and only when this problem is solved is the other problem (if still present) approached.

Difficulties may arise in hypersensitive patients who report every tension they experience and for which they use different words: ‘it hurts, it aches, it pulls, it stretches, …’.

8 The patient’s cooperation is vital

The patient knows the symptoms

The patient’s cooperation is essential, and it is vital that the questions put are understood. Details are sought on what activities have an influence on the symptoms and how symptoms behave over time. Except in psychologically disturbed patients, the more precise the questioning, the easier it is to obtain accurate answers. The patient must realize that, during functional examination, the examiner is looking for tests or movements that elicit symptoms. Most difficulties arise with those who are in constant pain, in that they tend to answer every question positively. It is the task of the examiner to explain carefully that movements that alter the pain are being sought. Not only tests that make the pain worse (a frequent occurrence) but also those that decrease the pain are considered important.

9 Take into account the patient’s personality

The patient is a person

The history in particular will give an idea about the patient’s personality. The reaction to pain can be assessed and a picture built up of the extent of disability. The findings can then be related to what is actually found when the examination takes place.

The view obtained from the history and physical examination may have therapeutic significance: for example, most patients can cope with active treatment such as manipulation or deep transverse massage but the clinician may obtain a ‘perception’ for those who cannot.

10 Keep the balance between credulity and excessive scepticism

Objectivity is a fair attitude

Orthopaedic medical disorders produce symptoms and signs that may be difficult to analyse objectively. Patients who have a reason to assume disorders for some type of personal gain, therefore, commonly use clinical features in the locomotor system to try to establish their credibility (see online chapter Psychogenic pain).

Although the examiner must be on guard against feigned illness, great care must also be taken to maintain a dispassionate attitude during the clinical encounter. The diagnosis of ‘psychogenic pain’ must not be made too quickly. Only when many inherent unlikelihoods are encountered during the history and functional examination should the examiner be suspicious about the veracity of the patient’s story. Also, the discovery of a series of lesions is self-contradictory, because the development of several problems at the same time is most unlikely.

11 Request technical investigations only when necessary

Looking is not a substitute for thinking

Clinical testing is the first approach in orthopaedic medicine. Technical investigations, although sometimes very valuable, are only asked for in some situations:

• To exclude major lesions for which the functional testing has not been sufficient.

• To exclude contra-indications for some therapeutical actions (manipulations or infiltrations).

• To confirm the tentative diagnosis made after the clinical examination.

Warning

Incorporated into this system of clinical evaluation are warning signs: certain symptoms or combination of symptoms and signs indicate that something unprecedented is taking place and so alert the examiner to the possible presence of a potentially serious condition. Possible warning signs are, for example, pain in the upper lumbar area, deficit of more than one nerve root in the cervical spine, or a capsular pattern of the hip in children.

The presence of such warning signs will put the examiner on guard and indicate accessory clinical tests, further technical investigations or reference to a neurologist, an internist, a cardiologist or an oncologist.

These warning signs will be discussed further in later chapters.

Clinical evaluation

History

History is of prime importance in reaching a diagnosis. It is so well known as a method of determining symptoms that most examiners fail to realize how much information can be gained from it.

Patients are the best source of information in that they are suffering from the lesion and can best report precisely what is felt. It is then the examiner’s task to translate the subjective symptoms into anatomical and functional conclusions.

Cyriax said: ‘Every patient contains a truth. He will proffer the data on which diagnosis rests. The doctor must adopt a conscious humility, not towards the patient, but towards the truth concealed within the patient, if his interpretations are regularly to prove correct’.¹⁷

History taking is a slow business that requires time, patience and concentration; the examiner must do everything possible to gain the maximal detailed information. Vague, general description of the complaints should not be accepted but precise and detailed answers sought.

Most patients, and certainly when they are frank, are able to provide precise answers to the examiner’s questions or can spontaneously give a well-structured, detailed and chronological account. They try to be as helpful as possible and are visibly pleased to talk to an interested physician. However, taking the history becomes more difficult in those who cannot express themselves or give a disjointed story. It is the examiner’s task then to make sure that the right questions are asked in order to get useful answers. The same applies to talkative patients who try to be too helpful by adding all manner of irrelevant details. In these circumstances the examiner should concentrate on the important items only and bring the patient back to the point whenever there is a digression.

Patients with a clinical presentation that may rest in non-organic causes try to escape from precise questioning. They offer a garbled story full of internal contradictions.

Remarks

Questions should be asked in such a way that the account of the symptoms is given in chronological order which enables the examiner to get an idea of the duration and behaviour of the condition present. Knowledge of different dermatomes and of the possible likelihoods will help in interpretation of the evolution of the patient’s symptoms.

Leading questions should be avoided, because they suggest to the patient what answer is expected. The questions should be neutral, so that the patient has to think about what is felt. An honest patient will have no problems in giving exact answers; one who dissembles has the opportunity to make mistakes and display inconsistencies.

Examples of questions that should be recast are as follows:

• Not: does the pain spread down your leg?

But: does the pain spread at all?

If so, where to?

• Not: is it painful to cough?

But: what happens when you cough?

• Not: is it painful to bend forwards?

But: does anything bring the pain on?

• Not: do you feel pins and needles in your hand?

But: have you got any pins and needles?

And if so, where?

When there is a relationship between the patient’s symptoms and rest, exertion, certain activities or certain postures, then it is probable that the patient suffers from a lesion of the locomotor system. The main exceptions are angina and intermittent claudication. Questions should therefore be asked about the movements and positions that evoke, increase or influence symptoms, for example:

• What brings the symptoms on?

• What makes the symptoms disappear?

Some information can be obtained only from the history, and not from any other diagnostic procedure. For example, to ascertain the stage of shoulder arthritis, to find out whether a displaced fragment of cartilage is stable or unstable, to determine whether sciatica is caused by a primary or secondary posterolateral disc protrusion, depends on the answers to some very specific questions. These are not only diagnostically important but also have a prognostic value and can determine correct treatment.

For lesions of the knee or spine, the history is of extreme importance; the examiner must go into great detail and if this is done the diagnosis becomes apparent. For example, a patient may mention that pain started in the centre of the back, soon spreading unilaterally towards the buttock, and later radiating down the lower limb into the lateral border of the foot and the two little toes while at the same time pain in the back and buttock disappeared. After a while pins and needles began to occur in the same toes and additionally they would go numb. The patient has revealed everything: the normal evolution of a protruded fragment of disc at the L5–S1 level, compressing the first sacral nerve root, is immediately apparent.

In some other joints, such as the shoulder, the history matters less but examination will disclose the lesion.

Taking the history

Box 4.2 Evolution of symptoms

The progression of symptoms since their first onset is ascertained. The condition may have continued uninterrupted, in which case details are asked about the development of the severity of the symptoms and of the localization of pain. If the latter has remained unchanged from the beginning, this indicates that the lesion is quite stable and not evolving. When pain has diminished it usually indicates an improvement, although there are conditions (e.g. nerve root atrophy and certain cases of mononeuritis), in which the pain disappears long before the condition has resolved. Pain becomes worse as the condition progresses: in such circumstances it is important to know the length of time for which it has been present. This has diagnostic significance: it is clear that conditions such as metastases have quite a short time course. In contrast, slowly worsening pain is characteristic of some other conditions such as a neurofibroma. When the patient describes intermittent pain, details are sought about the occasions on which pain is felt. Nocturnal pain, for example, suggests an inflammatory condition.

A very important distinction should be made between the following definitions.

Reference of pain

Referred pain is a very typical feature in non-osseus lesions of the locomotor system. It is mostly segmental and thus experienced in a single dermatome, which indicates the segment in which the lesion should be sought. Reference of pain is influenced by the severity of the lesion: the more severe it becomes, so giving rise to a stronger stimulus, the further distally does the pain (usually) spread. The reverse also holds: reduction in the distal distribution is synonymous with improvement.18,19

It is therefore always important not to forget the question: ‘Where was the pain originally and where has it spread since?’

Shifting pain

Pain coming on in one place as it leaves another indicates a shifting lesion.

This extremely significant phenomenon is well known in internal medicine: for example, when a renal calculus moves from the kidney down the ureter to the bladder and urethra, the pain experienced will follow the displacement. Pain is felt in the loin first, then in the iliac fossa, later in the groin and finally in the genitals. When the pain leaves one point, it is felt in another instead.

The same happens in soft tissue lesions. A good example is central backache, which becomes unilateral, then later on shifts to the buttock and finally to the lower limb – the backache has become sciatica. This shift can only be explained as follows: a structure lying in the midline and originally compressing the dura mater (backache) has shifted to one side and now compresses the dural sleeve of the nerve root (root pain). To be able to shift, that structure has to lie in a cavity and, because the pain was originally central, this has to be a central cavity. The only structure lying in a central cavity and able to change its position is the intervertebral disc: there is no other possibility (Fig. 4.2).

Fig 4.2 Shifting pain: posterocentral disc protrusion causing central backache (a); shifts to posterolateral position causing unilateral sciatica (b).

The same situation is encountered when a loose fragment of cartilage moves within a peripheral joint as, for example, often happens in the knee. Dependent on the position of the loose body in the joint space, the pain can be felt at the inner aspect, anteriorly or posteriorly and on other occasions even at the lateral side. Such moving pain indicates a moving lesion.

Expanding pain

This is synonymous with an expanding lesion – one that grows, for example a tumour. When it appears in another region the pain does not leave the area where it originated. It spreads, even beyond the boundaries of dermatomes. A patient may describe a pain that begins in the centre of the back and then becomes bilateral. It spreads to one buttock, and later to both, also increasing in the back. Later it spreads to one leg and even subsequently to both, while still becoming worse in the back as well as in the lower limbs. Such a course is one of expanding pain, as the lesion becomes more extensive.

Warning

An expanding pain, in which pain spreads but does not regress at the original site (in the way that a shifting pain does), is indicative of an expanding lesion and is usually the manifestation of a serious condition.

Another course is recurrence. Certain disorders, such as those causing internal derangement or of rheumatoid type, have a recurrent character. Some occur suddenly, others more gradually. If the symptoms occur intermittently, it is important to know whether the patient is or is not free of pain between attacks, because this has both prognostic and therapeutic consequences. Freedom from symptoms for a certain period of time suggests that the same may happen again. In internal derangement, regular recurrence implies that the loose fragment of cartilage or bone is unstable, in which case the maintenance of reduction will be the main concern of the therapist. A patient who is doing heavy work and who gets lumbago every 2 years must be regarded as having a stable lumbar disc which is completely different from a man with a light job who gets lumbago three times a year. In the first case reduction suffices, whereas the second will need other prophylactic measures to maintain the disc in place.

The onset of pain may vary from one attack to another. Backache that starts suddenly on some occasions, but gradually on others, very strongly suggests discal trouble. The localization of the pain may also change from one attack to another: it may be felt on one side of the body or of a joint and on the next occasion on the other side. This shifting pain is very typical of internal derangement, although there are some other conditions that may present the same picture (e.g. alternating buttock pain in sacroiliac arthritis caused by ankylosing spondylitis and alternating headache in migraine).

Actual symptoms

After having built up a complete picture of the patient’s symptoms, information is sought about what is experienced at the time of interview.

Most patients consult the doctor because they have pain but other symptoms may also be described: pins and needles, numbness, limitation of movement, twinges, weakness and vertigo. These are sometimes forgotten by the patient and therefore the examiner must inquire about them. Every symptom must be given due weight and examined in detail.

Pain (Box 4.3)

There are many different ways of describing pain: it is amazing how much variation patients can achieve in their vocabulary and how many different descriptive terms can be used for the different sensations perceived. The reason lies in the fact that pain is mainly an unpleasant emotional state that is aroused by unusual patterns of activity in specific nociceptive afferent systems. The evocation of this emotional disturbance is contingent upon projection to the frontal cortex.20,21 The nature of the pain may have some diagnostic value: everybody knows the throbbing pain of migraine, the stabbing pain of lumbago or the burning sensation of neuralgic conditions. Although the way the patient describes the pain may sometimes point to a certain disorder, it can also indicate the emotional involvement of the patient with the lesion.

Box 4.3 Pain

• Description

• Character: mechanical

inflammatory

• Severity: therapeutic consequences

• Localization: diagnostic significance

Pain may have either a mechanical or an inflammatory character (Box 4.4). Mechanical pain (e.g. in arthrosis) is characterized by pain and stiffness at the beginning of a movement; augmentation when load is put on the joint; pain at the end of the day and absence of pain at rest, although moving in bed may also be uncomfortable. Inflammatory pain (e.g. rheumatoid arthritis, gout or infectious arthritis) wakes the patient at night and gives rise to frank stiffness early in the day.²²

Box 4.4 Characteristics of mechanical and inflammatory pain

The severity of pain may be a determinant of the type of treatment that is chosen. For example, although sciatica without neurological deficit is not immediately an indication for surgery, discectomy may become the treatment of choice when the pain has become unbearable.

Finally, localization has some diagnostic significance. Pain may be felt centrally (on the midline), bilaterally or unilaterally. Central and bilateral pain usually point towards a lesion lying in the midline. A bilateral lesion is another possibility, but this is much less frequent. It should be realized, however, that central symptoms do not arise from a unilateral structure. And, although some structures lie very close to the midline (facet joints, costovertebral joints, erector spinae muscles), they are still unilateral and can only give rise to symptoms felt unilaterally. Unilateral pain originates in a unilateral structure or, when dealing with the spine, in a central structure that moved to one side and compresses nerve tissue unilaterally (e.g. a disc).

When the lesion is in the locomotor system, there should still be a relationship between symptoms and rest, exertion, activities, movements or posture. When coughing, sneezing or breathing hurts in an area other than in the chest, the dura mater could very well be responsible. Dural pain can be felt in the trunk far beyond the relevant dermatome.

Of special interest to the examiner are ‘twinges’: sudden short bouts of pain, which last only one second and are often associated with momentary functional incapacity. The occurrence of painful twinges may be the result of one of the following:

• Internal derangement

• Tendinous

• Neurological.

A momentary subluxation of a loose fragment of cartilage in a joint

This happens quite often in the lumbar spine, the knee and the hip and less frequently in the elbow, ankle and subtalar joints. If there are any signs found during clinical examination, they will be articular – a non-capsular pattern (see p. 74). The combination of twinges and articular signs is pathognomonic of the existence of internal derangement.

A tendinous lesion

The patient recounts that, especially when the tendon is involved in movement, there are bouts of painful momentary weakness which arrest movement. This is common in tennis elbow, where the lesion lies at the origin of the extensor carpi radialis brevis muscle from the lateral epicondyle. It also occurs, although less frequently, in tendinitis at the shoulder, especially of the supraspinatus.

A neurological condition

These include tabes, post-herpetic or trigeminal neuralgia and Morton’s metatarsalgia.

Paraesthesia

Non-painful sensory disturbances, paraesthesia, are strongly indicative of a condition that originates in a nerve (Box 4.5). They may result from an intrinsic lesion (primary neuritis or secondary polyneuropathy) or from an extrinsic cause (compression). They may also vary in quality and in intensity. In orthopaedic medicine the variation lies between numbness and real pins and needles. It is very often described as ‘tingling’.

Box 4.5 Paraesthesia

The moment the patient mentions the presence of pins and needles, the examiner should go into detail and ask the following questions:

• What brings on the pins and needles?

• What makes them disappear?

• How far proximally do they extend?

• Where exactly are they felt?

In entrapment neuropathies, knowledge of what brings the pins and needles on will show whether a compression phenomenon or the release phenomenon is acting (see pp. 26–27). For example, pressure on a small distal nerve gives rise to paraesthesia and analgesia in the cutaneous area of that nerve during the time of compression (e.g. meralgia paraesthetica). However, when a nerve trunk or nerve plexus becomes compressed, the paraesthesia are felt in a larger area, corresponding with the territory of that nerve and occur only after the compression has ceased (e.g. thoracic outlet syndrome). Nerve root compression results in segmental pain and paraesthesia felt within the corresponding dermatome (e.g. sciatica). Multisegmental bilateral paraesthesia indicates a lesion in the spinal cord.

It must be remembered that the site of compression always lies proximal to the proximal extent of the paraesthesia. They are usually felt in the distal part of the extremities. The more accurately the patient describes the area, the more distal the compression lies.

A paraesthesia-like feeling, especially vague tingling, may be experienced in some circulatory conditions, such as Raynaud’s syndrome, but this is usually accompanied by changing of the colour of the skin in the distal part of the limb.

Functional disability

Often, functional disability is complained of. It comprises limitation of movement, internal derangement, weakness and incoordination and instability.

Limitation of movement

When limitation of movement is mentioned, its nature will have to be determined during the functional examination: limitation of active movements only, or limitation of both active and passive movements, and in this case whether it is of the capsular or of the non-capsular type. End-feel at the end of the passive movements and the relationship between pain and end-feel must also be ascertained (see pp. 73–74).

Internal derangement

Symptoms caused by internal derangement are irregular in nature. There are moments when the joint feels normal and that the patient is able to do everything, and other occasions when the joint does not work well. Typical symptoms are sudden twinges, shifting pain, giving way of the limb, locking of the joint and a feeling of insecurity.

If the answer to the question ‘Does the joint lock?’ is positive, further inquiry should make clear in what position locking occurs and how it is released. For example, a knee that locks in extension and unlocks spontaneously suggests a loose body, and one that locks in flexion and has to be unlocked manipulatively is a meniscal problem.

Weakness

This symptom should lead the examiner to concentrate during the examination on both active and resisted movements to see if the weakness is physically apparent or not. If weakness is confirmed, the distinction has to be made between a lesion in the muscle itself (e.g. atrophy or rupture) or in the nervous system, which is more often the case.

Incoordination and instability

These complaints are indications that something is amiss with either deep (proprioceptive) sensibility, the vestibular system or the cerebellum.

Further questions

Other questions, if appropriate, are asked about similar symptoms, past or present, in other parts of the body, especially other joints (see Box 4.6). If the answer is positive, conditions such as rheumatoid arthritis, spondylitic arthritis, Reiter’s disease and gout should be suspected and further examination is required.

Box 4.6 Inflammatory disorders

Disorders of rheumatoid type (rheumatoid arthritis, lupus erythematosus, systemic sclerosis, dermatomyositis) are characterized by the symmetrical joint involvement, usually of the small joints (e.g. metacarpophalangeal joints). Arthritis of reactive type (e.g. peripheral joint involvement in ankylosing spondylitis, ulcerative colitis, Reiter’s disease, sarcoidosis or psoriatic arthritis) affects a few large joints (e.g. shoulder, hip or knee) asymmetrically (Fig. 4.3).

Fig 4.3 Patterns of: (a) reactive arthritis; (b) rheumatoid arthritis.

Questions about the general state of health are asked to find out whether there is the possibility of a serious disorder (e.g. cancer).

The patient should also reveal present medication, and a doctor or therapist who considers manipulation should make sure that the patient is not taking anticoagulants: these are a contraindication because of the danger of haemorrhage.

Inquiries should also be made about previous treatments, which may give some idea of the chance of success of the proposed therapy. Previous surgery, its timing and indication are noted – it is not impossible that the present condition is the outcome of previous intervention (Box 4.7).

Inspection

Inspection begins the moment the patient enters the room. If gait is disturbed, the way of walking may be diagnostic. An experienced examiner usually has the analytical ability to recognize, for example, the following typical patterns: a subluxated meniscus at the knee; a ‘tennis leg’; the elderly patient with arthrosis of the hip; acute lumbago; a spastic gait; the patient with parkinsonism; a Trendelenburg gait; a drop foot; a ruptured Achilles tendon; and finally the patient with a non-physical condition.

Further features may be noted while the history is taken. A normally seated patient should have at least 90° flexion at hip and knee which is later confirmed on functional examination. The face may reveal the extent of pain or may disclose parkinsonism. The attitude in which a limb is held during the inquiry may be informative. Finally, the way the patient takes off clothes and shoes can provide further information on disability.

Deformities or deviations are easily seen: for example, in acute torticollis or in lumbago, the patient stands with the head or the lumbar spine held in deviation, usually towards one side. Real deformities can be the result of one or more fractures. Pathological fractures of a vertebral body lead to angular kyphosis or, if they occur at several levels, to a ‘shortened’ patient. Every examiner knows the typical kyphosis of adolescent osteochondrosis. Other examples are genu valgum and varum, which may be physiological up to a certain age but are pathological in adults. The presence of a deformity is not always relevant. It is quite possible that it has nothing to do with the presenting condition. A short leg or a long-standing scoliosis are very often seen but occur in asymptomatic as well as in symptomatic patients.

Soft tissues, such as skin and muscles, may show abnormalities. The colour of the skin may be different from that of other parts of the body: red in inflammation, blue when a haematoma is present or when a venous disorder has developed, white in arterial problems. Visible muscle wasting may be obvious. If swelling is present, the examiner should ascertain whether it is general and diffuse or localized.

An inflammatory condition may show quite spectacular signs such as redness of the skin, swelling and warmth.

Preliminary examination

After having taken the history and amassed evidence from inspection, the examiner should have an idea of which part of the body the symptoms originate from. Regional examination follows. When the history alone is not diagnostic, so that doubt over the origin or localization exists, a quick survey of the tissues forming the relevant segment may be necessary.

This ‘preliminary’ examination (Fig. 4.4) includes tests for the different joints. For example, the preliminary examination for pain down the arm includes tests for the cervical spine, shoulder girdle, shoulder, elbow, wrist and hand (Table 4.1).

Table 4.1

Movements tested in the preliminary examination of the upper limb

Root	Region	Type
C1	Neck movements	Active
		Resisted
C2–C4	Shoulder movements	Active
		Resisted
C5	Arm movements
	Shoulder	Active
		Resisted
C6–C7	Elbow	Passive
		Resisted
	Wrist	Resisted
C8	Thumb	Resisted
T1	Fingers	Resisted

Fig 4.4 Role of the preliminary examination.

When some tests are positive and indicate that the lesion lies about a certain joint, this joint will then be tested more rigorously. When no abnormalities are found, it is assumed that the lesion lies outside the moving parts. If all movements hurt, or when the patient presents a contradictory pattern, the question of a psychogenic disorder arises.

Functional examination

In lesions lying within the locomotor system, pain is brought on mainly by tension. Therefore, during examination the different tissues are selectively put under tension and the results noted.

As the function of the different tissues is well known, functional testing is really an exercise in applied anatomy. This indirect approach to diagnosis is purely mechanical.

The examination used is standardized, which permits a systematic search for signs in such a way that, with a minimum of tests, maximum information is obtained. Too many tests in the standard examination can confuse the examiner and make interpretation very difficult.

This does not imply that the diagnosis will always be reached after the standard functional examination. It may sometimes be necessary to add accessory tests (see pp. 66–67).

Procedure

The purpose of functional examination is to reach a decision on which structure is affected. However, even that may be insufficient. In a patient with a shoulder problem it is not enough to say that there is a lesion in the brachial biceps muscle: is it in the long head or the short head? In a lesion of the long head, is it localized in the bicipital groove or in its intra-articular course or at its insertion at the glenoid? Therefore, once the structure at fault is known, the next step must be to determine exactly where, within that structure, the lesion lies.

Examination is usually performed on both sides. Certainly, if the range of a passive movement is assessed, it has to be compared with the contralateral normal joint. When muscle strength is evaluated, comparison with the non-affected side is again necessary.

The patient as well as the examiner should adopt a good position from which to start. When passive movements are performed, the examiner must make sure that they can be done until the end of range (if present) is reached: movement should not be limited by the examiner’s body, or by the couch or even by clothing. For resisted movements, which are done isometrically, the examiner’s position must be such that the examiner can exert more power than the patient can. It may be of interest to put the patient in front of a mirror so that reactions can be observed.

The movements that are used to test the different structures should be ‘pure’ ones, i.e. testing only one structure or one group of structures at a time. This facilitates subsequent interpretation.

Questions asked during examination should be as neutral as possible. The examiner must not impose on the patient an expected answer. Questions such as ‘Does this movement hurt?’ or ‘Is this painful?’ should be avoided. It is better to say ‘How is that?’ and ask the patient to report anything experienced. It must also be understood that the examiner is looking for tests that elicit the symptoms or, if they are constant, those that influence them.

Movements

The functional examination contains active movements, which are not always necessary, passive tests and movements against resistance. Positive tests are always repeated on the opposite side in order to compare the normal with the abnormal.

Active movements

Active movements are mainly used to determine quickly the area from which symptoms originate and what structures to test in detail with passive and/or resisted movements (Box 4.8).

Box 4.8 Aims of testing active movements

• To ascertain patient’s willingness and ability

• To determine range

• To assess muscle power

Examination by active movements goes against the principle of trying to test one structure at a time. When a limb is actively moved, muscles, tendons, ligaments, bursae and capsule are all put under stress. In consequence such tests are non-specific and therefore not always necessary. However, they can be of interest because they suggest what the patient is able and willing to do. In most cases, they also give an idea of the range of movement possible (normal, limited or excessive) and of muscle power. They are always executed first to provide a criterion with which to compare subsequent passive and resisted movements.

When a normal range is later found on passive testing and normal muscle strength is apparent when tested against resistance, there is no reason for any abnormality or restriction of active movements. Thus if, in these circumstances, it is claimed that the active movement cannot be done, there must be refusal, either involuntary (psychogenic) or voluntary (intention to deceive). There are, of course, organic lesions where a discrepancy exists between active and passive or resisted movement but only within certain limits. For example, a mononeuritis of the long thoracic nerve, leading to weakness of the serratus anterior muscle, can make full active elevation of the arm impossible even though the passive range and muscle power of the shoulder are normal. A further example is total rupture of the Achilles tendon, in which resisted plantiflexion is weak and active movement impossible despite the range of passive movement at the ankle remaining unaltered.

Active movements are usually required when the spine (cervical, thoracic and lumbar), the shoulder girdle and the shoulder are examined but they may also be tested at any other joints if they can supply additional information.

Passive movements (Fig. 4.5)

These tests are meant to examine the inert tissues. The information they give is precise, provided they are performed correctly. The patient should completely relax the muscles and let the examiner do the movement. It is important to realize that non-inert tissues may also be stretched by the manœuvre: if this gives rise to pain, it must be determined whether there is a ‘contractile tissue pattern’, in which case active contraction in the opposite direction will also be painful (see pp. 77).

Fig 4.5 Passive movements.

The criteria for passive testing are pain, range and end-feel (Box 4.9).

Box 4.9 Aims of testing passive movements

• To assess pain

• To determine range

• To characterize end-feel

Pain

The patient must understand that the examiner is looking for ‘the’ pain – the reason for presentation – and that each time this pain is evoked or influenced a response is required. When straight-leg raising is performed in a patient with low back pain radiating down the posterior aspect of the thigh, the examiner must make sure that the sensation felt during the test is the exact pain complained of and not just a tight feeling in shortened hamstring muscles.

Pain evoked by a certain movement requires the further information of exactly where it is and at what stage of the movement. Pain may come on at a certain moment but the movement is not necessarily limited. For example, straight-leg raising may become painful at 60° but continue to full range without increased discomfort. Excessive gentleness may fail to elicit information. Passive movements must be performed as comfortably as possible for the patient but, if a proper answer can only be obtained by pushing a bit harder and thus hurting the patient, this should be done. It would be a diagnostic error to interpret a perfectly full movement as being limited by a few degrees, if the movement was stopped because of pain. The same applies to a painful arc. This may be so uncomfortable that the patient cannot get beyond it by active movement. If an arc is suspected, a harder push during passive movement may succeed and show its presence. Interpretation would be totally different: on the one hand, limitation of movement and, on the other hand, full range with a painful arc.

The presence of joint signs in root lesions is a misleading phenomenon. When a cervical or lumbar nerve root becomes compressed as the result of a disc protrusion, passive movement in a neighbouring joint may occasionally affect the root pain. Thus passive movements for the shoulder joint may hurt at the end of range so focusing attention on the shoulder. As pain of cervical origin is also felt down the arm the picture becomes very confused. The same occurs in lumbar root pain; passive hip movements are not limited but they may influence the pain when they are brought to full range – they are probably capable at their extreme of altering the tension on the nerve roots in a minor way, analogous to straight-leg raising.

Amplitude

The range of movement is noted and is always compared to the unaffected side. The response should be interpreted in the light of the patient’s age and general condition.

Limited movement requires the examiner to ascertain whether the limitation is in all directions or only in some directions or in one direction only. If only one movement is reduced, a ‘proportionate’ or a ‘disproportionate’ limitation may be present (see p. 76).

Pain at full range suggests that the pain is provoked by stretching or pinching of the affected structure. The localization of the pain will very often be indicative.

Excessive range may be pathological but laxity is sometimes purely physiological: for example, most women can hyperextend the elbow. When a joint moves further than is normally accepted, great care must be taken that the symptoms are not too readily ascribed to that phenomenon. Hypermobility with a normal end-feel is usually not of significance.

End-feel

This is a term typical of Cyriax. It describes the sensation that the examiner experiences at the end of the passive movement. The hand that performs the passive movement is not only motor but also sensory. When the movement comes to the end the examiner should assess the sensation. When no limitation is present the end-feel is at the end of the normal range. When limitation exists, the end-feel is judged at the end of the possible range.

End-feel is diagnostically important as it gives an idea of the structure or condition that stops the movement.²³ In addition it has therapeutic consequences. Especially during attempted spinal manipulations, the sensation imparted to the operator’s hand will indicate whether or not to proceed. Likewise, in the shoulder or hip, the decision whether to undertake capsular stretching depends on end-feel.

For accurate judgement of the nature of end-feel, experience is required. Passive movement should be executed with extreme gentleness, especially during the final degrees of range. The moment resistance is first noted, the rate of movement is reduced so that the feeling can be assessed before movement comes to a complete stop. In normal circumstances each joint movement has a characteristic end-feel, which can be considered as ‘physiological’. In pathological conditions, end-feel may change. The examiner should know what the normal feeling of each (passive) movement of a joint is like in order to be able to judge every change in end-feel.

Physiological end-feel

This can be hard, elastic or related to tissue approximation:

• Hard: the movement comes to an abrupt stop, either because two bony surfaces meet (bone-to-bone end-feel) or because a ligamentous structure prevents further movement (Fig. 4.6a). Extension of the elbow has a bone-to-bone end-feel, because the main factor that stops the movement is the engagement of the olecranon process in the olecranon fossa. Extension of the knee also has a hard stop, though less clearly direct than the elbow; here, the main structure that stops movement is the posterior cruciate ligament, which does not stretch.

Fig 4.6 Hard (a), elastic (b) and soft tissue approximation; (c) end-feels.

• Elastic: at the end of range the examiner feels resistance but further stretching over a few degrees is possible (Fig. 4.6b). The feeling is one of two pieces of tough rubber being squeezed together or of a piece of thick leather being stretched. This end-feel is typical of a normal joint capsule and is felt during most rotation movements in shoulder, elbow, hip, knee, cervical and thoracic spine. The tern ‘elastic’ has the same meaning as ‘capsular’.

• Tissue approximation: this end-feel is normal in those movements where extra-articular soft tissues engage against each other (Fig. 4.6c). Flexion at elbow and knee give this ‘soft’, ‘muscular’ end-feel. At the elbow the muscles of the forearm come in contact with the biceps and at the knee the calf muscles engage against the hamstrings. This ‘extra-articular’ end-feel does not occur in patients with poorly developed muscles: they present an ‘articular’ end-feel, either hard or elastic.

Pathological end-feel

A number of types of end-feel are pathological.

• Too hard: the normal elastic, or tissue approximation, end-feel may become harder when the quality of the tissue that stops the movement alters under the influence of pathological conditions. This change very often accompanies limitation of movement because of capsular contracture, osteophytic outcrops of bone, myositis ossificans or a malunited fracture close to the joint. Dependent on the condition, the end-feel may vary from a slight increase in hardness (early arthrosis) to a bony block (ankylosing spondylitis). The latter forms a contraindication to further stretching (i.e. during manipulation).

• Too soft: in those instances where a hard end-feel is expected, the movement may come to a soft stop. This is especially the case in a loose body blocking a movement as may happen at the elbow: extension is limited by a few degrees with a soft end-feel.

• Muscle spasm: this involuntary muscular contraction usually indicates severe disorder. The muscles contract with a sudden, vibrant ‘twang’ even when the movement is performed very gently. This is reflex protective spasm and may happen in acute conditions, such as arthritis in the acute stage. It may also be a sign of more serious lesions such as recent fracture (e.g. scaphoid fracture at the wrist) or secondary deposits (e.g. in a cervical vertebra). Such an end-feel is always an absolute contraindication to manipulation.

• Empty: movement may be so painful that the patient begs the examiner to desist. The latter feels that further movement would be possible because there is no organic resistance but stops the movement because of the perceived pain or out of sympathy for the patient. Further forcing would result in active voluntary muscular contraction. This situation always indicates a serious problem. Acute bursitis, extra-articular abscess or neoplasm is a possibility, but there is nothing wrong with the joint itself. This end-feel may also indicate laxity in a joint or a non-organic lesion. In the latter case there is initial strong resistance, which yields to sustained pressure, disclosing a full range of motion.

• Springy block: this finding always indicates internal derangement: when part of an intra-articular cartilaginous tissue displaces, it may prevent a full range of movement which leads to a rebound at the extreme of the possible range. The commonest examples are a displaced meniscal fragment in the knee and a buckled end-plate in the lumbar spine.

• Crisp: this is typical for a disc protrusion and is best felt in the cervical spine. The feeling is the result of small involuntary muscular contraction at the end of the possible range, known as ‘muscle guarding’. The condition is not acute, as a result of which there is no real muscle spasm.

• Soggy: this end-feel is seldom encountered and can be situated somewhere between a soft and an empty feeling. It is typical of rheumatoid arthritis in the upper cervical joints and is a strong contra-indication to manipulation.

Relationship between pain and end-feel

It is also important to look for the relationship between the moment of appearance of pain and that of the end-feel. Usually the pain comes on at the same time as the end of range is sensed (Fig. 4.7). Earlier pain implies that the joint is in a very irritated state which has therapeutic implications.

Fig 4.7 Relationship between pain and end-feel.

Resisted movements

Movements against resistance are performed isometrically. The joint is put in a neutral position and should not move when resistance is applied. This method ensures that stress on inert tissues is minimal or absent.

The position of the examiner must be such that the force exerted by the patient can be resisted. A maximal contraction is asked for and held for a few seconds. Counterpressure is therefore taken by the other hand at the opposite side. For example, to test resisted extension of the neck, one hand is put on the occiput and another hand on the sternum (Fig. 4.8). Similarly, to test resisted flexion, one hand is placed on the forehead and the other between the scapulae.

Fig 4.8 Resisted extension of the neck.

The criteria when testing against resistance are pain and strength (Box 4.10).

Box 4.10 Aims of testing resisted movements

• To assess pain

• To determine muscle strength

Fig 4.9 Resisted movements.

Pain

In a lesion that lies in the contractile tissue, the pain should be elicited during the contraction. In mild disorders the test may initially be negative but repetition of the movement may eventually provoke symptoms. Similarly, slight muscular or tendinous problems may give pain only during exertion and resisted movements may remain painless. If pain cannot be elicited by repetitive contractions, the patient should be seen and tested in the circumstances when pain is experienced. The resisted movements may then be found positive.

There are cases of tendinitis in which the pain is only felt when the patient relaxes after muscle contraction. This is not uncommon and can also be interpreted as a positive resisted movement.

A positive answer on resisted movement is usually only one – but the most important – part of a ‘contractile tissue pattern’ in which the passive movement that stretches or pinches the affected part is also painful.

The examiner must be aware of inert tissue lesions that can become painfully squeezed or moved by muscular contraction (e.g. gluteal bursitis).

Strength

The movement should be strong, but weakness may occur and an experienced examiner will immediately have an idea of what is the cause. It may be the result of pain; in that instance, the examiner feels a sudden cessation of power – the patient stops the contraction when the pain is felt. This often happens in partial muscular or tendinous ruptures when sufficient fibres are torn to diminish strength.

In total contractile tissue ruptures, there will not be pain but complete absence of muscle power. This pattern is completely different from a neurological weakness. Here there still is a force that has to be overcome: the examiner is stronger than the patient and so can push the patient’s limb away while still feeling continuing resistance. The latter can vary from an almost normal sensation – slight paresis – to very little (scarcely detectable) force – complete paralysis. This may be the result of a lesion that has completely stopped motor innervation or it may be a consequence of the patient’s refusal to undergo the manœuvre.

Accessory tests

After a well-balanced basic functional examination, interpretation of the pattern that emerges should, in most cases, make it possible to single out the tissue at fault. Difficulties are, of course, encountered and further accessory testing is then required to reach a precise diagnosis, to positively confirm an existing but tentative diagnosis or to disclose the precise point affected within the structure.

An important feature is that a distinction should be made between standard functional examination and accessory tests. The basic examination is always done in its entirety, whereas the accessory tests are applied selectively (Box 4.11).

Box 4.11 Aims of accessory tests

• To differentiate within a group of structures

• To confirm a tentative diagnosis

• To unravel a difficult pattern

• To extend a negative examination

• To make a differential diagnosis

• To understand unusual signs

It is wrong to do accessory tests without a prior idea of the nature of the problem, and in the hope that more tests would automatically provide more complete information. On the contrary, the more tests the more confusing the picture may become and in the end the ‘wood cannot be seen for the trees’. Accessory tests therefore should be goal-oriented. They are performed in the following circumstances.

After testing a group of structures

When a resisted movement has tested a group of structures, further differentiation is sometimes necessary to find in exactly which structure the lesion lies.

In ‘tennis elbow’, resisted extension of the wrist is painful. To find out whether the lesion lies in the extensors of either the wrist or of the fingers the test is repeated with the fingers held actively flexed, so inhibiting the finger extensors. A negative answer implicates the wrist extensors, which can then be differentiated by executing resisted radial and resisted ulnar deviation: when resisted ulnar deviation hurts, the extensor carpi ulnaris is at fault; whereas if resisted radial deviation is painful, the lesion clearly lies in one of the radial extensors of the wrist – true tennis elbow. Whether the tendinitis is situated at the extensor carpi radialis longus or brevis cannot be found by further testing – palpation is called for.

The same applies to the hamstring muscles. A muscular or tendinous lesion about the knee will give rise to pain on resisted flexion. Differentiation between either (a) the femoral biceps or (b) the semitendinosus and semimembranosus is achieved by testing resisted external and internal rotation. Positive lateral rotation incriminates the biceps and medial rotation draws attention to the other two muscles. Palpation identifies exactly where the lesion lies.

To confirm a tentative diagnosis

An accessory test may help, especially in uncommon conditions, to confirm a tentative diagnosis. For example, when the diagnosis of mononeuritis of the spinal accessory nerve has been suspected, weakness on resisted scapular approximation will show the diagnosis to be correct.

In difficult cases

A clinical picture can sometimes be difficult to interpret and accessory tests may then resolve doubt. When pain is thought to be due to squeezing of a structure, diagnostic traction may help to confirm this. For example, in difficult cases of internal derangement of the cervical spine, pain and/or paraesthesia can be temporarily abolished by applying manual or mechanical traction. Traction on the arm can diminish pain in subacromial bursitis.

When the functional examination is negative

A negative examination does not necessarily mean that a lesion is absent. There may be a problem in a neighbouring tissue which was not systematically tested in the standard examination. A negative shoulder examination, for example, invites the examiner to test the coracobrachialis muscle. In anterior knee pain a negative examination is followed by tests of the patellofemoral joint.

In differential diagnosis

Different conditions may give rise to similar positive answers. An accessory test can then help to elucidate which structure is at fault. For example, limitation of external rotation at the shoulder is the primary sign of anterior capsular contraction as well as of a subcoracoid bursitis. Passive external rotation with the arm held in abduction will be positive in a capsular lesion and negative when a bursitis is present.

A test for distant pain can be performed when a lesion lies in a long bone. When a fracture is suspected on the dorsal aspect of a rib, pressure on the anterior aspect or on the sternum may provoke the pain. This technique can also be used to differentiate a rib problem, a lesion in an intercostal muscle or at a costovertebral joint.

When unusual signs are found

Discrepancies between individual findings on functional examination may suggest an unusual and possibly serious lesion, a psychogenic problem or an attempt to deceive. In the former, the patient is sent for further specialized examination. When neurosis or deception is suspected, the patient is subjected to a number of accessory tests: additional movements that cannot possibly influence the alleged symptoms or repetition of tests in other positions. The opportunity for the patient to make mistakes is thus presented, which in a positive way can confirm the examiner’s suspicion (see online chapter Psychogenic pain).

Palpation

Palpation can be a very useful aid to diagnosis when performed at the right moment. However, it is frequently done too early in the examination, with the risk of an incorrect diagnosis. When, after functional testing, the examiner has interpreted the different movements and the pattern that emerged, and still thinks that more information could be forthcoming about the lesion, palpation is undertaken. Abnormal sensations that are imparted to the hand in a stationary as well as in a moving joint are sought.

Palpation of the stationary joint

During palpation of a motionless joint (Fig. 4.10a) the examiner may assess temperature (either warmth or cold), swelling, synovial thickening or structural changes. Palpation may also elicit tenderness.

Fig 4.10 Palpation of (A) the stationary and (B) the moving joint.

Warmth

Warmth is best palpated with the dorsum of the hand and may be diffuse or localized. Spurious warmth can be the result of a rubefacient ointment or of a bandage that has been removed just before examination. Otherwise, warmth always indicates activity. The lesion may be osseous (e.g. fracture or metastases) or articular (e.g. arthritis, haemarthrosis, loose body, or a disorder of a meniscus or ligament) or tendinous (e.g. rheumatoid-type tendinitis). A purely mechanical tendinitis will not cause any warmth. When the warmth occurs suddenly and twinges are also present, this indicates persistent subluxation of a fragment of cartilage. The heat may or may not diminish when the joint is kept still. Sometimes (e.g. in loose body) the warmth may be elicited merely by the examination.

Cold

When the extremity feels cold an arterial problem is suspected. Palpation will then follow for arterial pulsations. Cold may also occur during an attack of sciatica, especially that which causes muscular weakness. When the foot becomes cold only after exertion, the probable cause is an iliac thrombosis. The cause may also be neurological.

Swelling

Swelling is the result of an articular reaction to a lesion and may be localized or generalized. Swelling that came on after injury may be the outcome of haemorrhage or effusion. If it is caused by bleeding, the joint fills up within a few minutes; effusion develops over a few hours. Blood also fluctuates: the swelling moves en bloc. The presence of pus is exceptional and indicates an infection with microorganisms. Periarthritic oedema may pit. In a localized swelling, its consistency should be ascertained: a soft swelling indicates subcutaneous clear fluid or a thickened bursa, a fluctuating mass may result from a haematoma or from a mucocele and a hard but still fluctuant swelling is typical of a cyst or a ganglion. When the consistency is bony the cause is usually a callus, a bony subluxation (e.g. capitate bone at the wrist or cuboid bone in the midfoot), an osteophytic outcrop or any other bony deformity which results from a destructive process (e.g. osteitis deformans, neoplasm).

Thickening of the synovial membrane

This is found in rheumatoid, bacterial or inflammatory arthritis (e.g. gout, tuberculosis, gonorrhoea, Reiter’s disease, ulcerative colitis, spondylitic arthritis or psoriatic arthritis). It is absent in mechanical conditions, such as traumatic arthritis, post-immobilizational arthritis and arthrosis. To palpate capsular thickening, the examiner has to seek the reflexion of the membrane where it overlies a bony prominence.

Gaps

A gap may be palpated at the site of the rupture of a muscle or tendon.

Tenderness

Palpation for tenderness is sometimes performed to determine the exact localization of a lesion. For this purpose, it is done only in a structure that has already been found, by clinical examination, to be affected and only when it is within reach of the finger. Eliciting tenderness is only necessary when, after clinical examination, the diagnosis still lacks precision. When a localizing sign has been found, palpation is of course superfluous. To search for tenderness is of much more value in a distal joint (wrist, hand, ankle, foot) than in a proximal joint (trunk, shoulder, hip), because the localization of the pain is much more accurate.

Difficulties may arise when two tissues overlap and when no certainty exists whether the lesion lies in the superficial or a deep structure. This situation arises most in the chest and abdomen. To ascertain whether the tenderness lies in a superficial or a deep muscle or in another structure (e.g. a viscus), palpation is performed during contraction and relaxation of the superficial muscle. Greater pain when the superficial muscle is tense suggests that the muscle is at fault, the converse that deeper structures are affected.

Other misleading phenomena are the presence of either a ‘referred’ tenderness or an ‘associated’ tenderness.

Localized, deep referred tenderness may occur within a painful region, for example, as the result of compression of the dura mater usually by a small displaced fragment of the intervertebral disc. This phenomenon is described in Chapter 1 and can be very deceptive unless the examiner is familiar with the rules of pain reference.

Associated tenderness is a very well-localized tender area very close to the site of the lesion. There is a relation between the two because both pain and tenderness disappear when the patient is cured. Associated tenderness is most common at the wrist and the elbow. In de Quervain’s disease – tenovaginitis of the abductor longus and extensor brevis muscles at the wrist – the styloid process of the radius is extremely tender, as is the posterior aspect of the lateral epicondyle in tennis elbow, especially when the lesion lies at the tenoperiosteal origin of the extensor carpi radialis brevis.

Negative palpation does not necessarily mean that the diagnosis is wrong, except perhaps in very superficial lesions, because there are tissues that are not explicitly tender when affected (e.g. the supraspinatus tendon).

Pulsation

Palpation for pulsation in the arteries may have an important diagnostic value and is indicated when symptoms are mentioned or signs are found that point to a vascular condition (e.g. claudication, a cold limb, or blue or white skin).

Palpation of the moving joint

Next, the moving joint is palpated. The examiner may either experience crepitus or clicks, or can assess end-feel or mobility (see Fig. 4.10b).

Crepitus

Crepitus always indicates a pathological situation. It can often be heard and can also be felt by the palpating hand placed on the moving part during active or passive movement. There are circumstances in which the crepitus is only felt during a movement against resistance. Crepitus may be articular, tendinous, muscular, osseous or bursal.

Articular crepitus

Crepitus which originates from the joint surfaces gives an idea of their ability to glide over one another. Fine crepitus indicates slight roughening and occurs in mild arthrosis or in long-standing rheumatoid arthritis. The latter gives rise to the characteristic ‘silken’ crepitus. Coarse grating is felt in advanced arthrosis and results from considerable fragmentation of the cartilaginous surface. In severe arthrosis the cartilage has wholly worn through which leads to intermittent creaking of bone against bone (‘cogwheel’ phenomenon).

Tendinous crepitus

Crepitus in relation to a tendon establishes tenosynovitis. Fine silky crepitus occurs in acute mechanical cases as the result of a traumatic roughening of the tendon surface and of the inner aspect of the tendon sheath. Coarse crepitus is felt in chronic rheumatoid or tuberculous tenosynovitis.

Muscular crepitus

This is observed in two situations only:

• Tenosynovitis of the two extensors and of the long abductor of the thumb in the distal part of the forearm is usually accompanied by crepitus that can be felt locally. The crepitus is, however, sometimes felt throughout the muscle bellies, possibly as far up as the elbow (see p. 524).

• Localized crepitus is usually felt in a lesion at the musculotendinous junction of the tibialis anterior muscle.

Osseous crepitus

A fracture may crepitate when the limb is moved and the two ends of the fractured bone move against each other but, except in pathological fractures, an attempt to elicit crepitus usually causes so much pain that it should not be done.

Bursal crepitus

Subdeltoid bursitis is the characteristic situation. Some time after a bursitis with effusion has subsided, creaking on moving the arm can be felt (see Shoulder, p. 333).

Scapulothoracic crepitus

This is unique. The posterior thoracic wall can become roughened at an area just beyond the lateral edge of the iliocostal muscle, with localized crepitus felt on shoulder movement (see the online chapter The shoulder girdle: Disorders of the inert structures.

Clicks

Clicks can be produced in several ways. Certain tests on clinical examination or certain manœuvres during a manipulative session may provoke movement of an intra-articular fragment of cartilage. This often happens when a loose body is present in a joint (e.g. knee or elbow) or when a meniscus subluxates (e.g. knee or jaw) or a fragment of disc moves (e.g. spinal joints). Clicking during a manipulative manœuvre is of interest in that it is often associated with an improvement of the physical signs, clearly indicating that a block to movement has been removed. In ligamentous laxity (as can be seen in subluxation of the clavicular joint, in capsular overstretching of the shoulder, or in rupture of the medial collateral ligament at the knee), a click is produced when one bone moves in relation to its fellow. Irrelevant clicks also appear, for example painless clicking of a costal cartilage or a patellar click during active extension of the knee.

End-feel

End-feel can be assessed when a passive movement comes to a stop. It is either physiological or pathological and has important diagnostic and therapeutic consequences (see pp. 64–65).

Hypermobility and hypomobility

These are terms that are currently used by osteopaths and manual therapists.24–25 During their so-called ‘segmental examination’ they claim to be able to feel the difference in mobility between different, mostly spinal, joints.²⁶ To establish hyper- or hypomobility would afford an excellent guide to the level of the lesion if it were always at the joint in which the fault lay, which is not in fact the case. Moreover, these findings are so subjective that they are not verifiable or reproducible. It has been shown on different occasions that even experienced osteopaths or therapists cannot agree about the findings.^27–31 The main mistake, however, consists in attributing diagnostic significance to such differences in mobility. When movement in a hypomobile or hypermobile joint strongly evokes the patient’s symptoms, this has to be considered as the best criterion and clearly shows where the lesion must lie. However, when the abnormal mobility does not elicit the known symptoms, the problem clearly has nothing to do with the hypermobile joint.^32–34 Furthermore, there are no universal standards to determine abnormal mobility. What is normal for one person can be abnormal for another. Hypermobility can be physiological up to a certain level, especially in women, and hypomobility can also be considered as normal, particularly in the elderly. When hypermobility gives rise to symptoms, then and then only can it be considered as pathological. The terms ‘laxity’ and ‘instability’ are then used. The end-feel will add greatly to this conclusion.

Diagnostic infiltration or aspiration

Diagnostic local anaesthesia

When faced with lesions of the locomotor system, a diagnostic infiltration with a weak local anaesthetic is extremely valuable and most effective in confirming the diagnosis. There is no other comparably effective test. By using infiltration in every suitable case, the physician makes the patient the judge of the correctness of the diagnosis.

Between 2 and 10 ml of a weak local anaesthetic (e.g. procaine 0.5%) is infiltrated at the assumed site of the lesion. Five minutes later the movements that were previously positive are retested. This allows the patient to determine whether the infiltration has altered the pain. When the tests have become completely or partly negative, the exact site of the lesion has clearly been reached, confirming the diagnosis. When the tests are still as painful or as limited as before, the wrong place was infiltrated, i.e. the diagnosis is wrong.

This approach is useful in the following circumstances:

• When the examiner is not certain about a diagnosis or when the examiner wants positive confirmation of a tentative diagnosis, the induction of a local anaesthetic may help.

• For lesions in the extremities, infiltration is particularly useful and gives reliable answers. However, it is not useful on the posterior aspect of the trunk: paraspinal infiltrations may give temporary relief but have no diagnostic value.

• In difficult cases this approach may be the final ‘court of appeal’.

Aspiration

From the diagnostic point of view it is often important to aspirate a swollen joint or a diffuse extra-articular swelling in order to ascertain what sort of fluid is present.

Technical investigations

It should be stressed again that there still remains a huge discrepancy between discovered anatomical changes and existing pain and disability. During the last decades the medical profession has focused on, and been fascinated by, techniques of imaging that can clearly show existing anatomical aberrations. However, very often, these anatomical changes are not the source of the pain because they appear to exist also in large groups of symptomless individuals. For example, the prevalence of herniated lumbar discs in a normal asymptomatic population ranges from 35%–50%.35–41 Evidence of cervical discopathy is also found in asymptomatic subjects^42–44 and there is not always good concordance between the different imaging techniques.⁴⁵ In the shoulder, echography can discover partial thickness and full thickness ruptures of the rotator cuff even in large asymptomatic groups.^46–49 The finding of asymptomatic anatomical changes in knee joints during arthroscopy is not uncommon.^50,51

In orthopaedic medicine, technical examinations are not routinely performed but are instead used only when necessary to refine the clinical diagnosis, to exclude certain lesions or to clarify differential diagnosis. They are always undertaken when the history and/or functional examination have revealed warning signs (Box 4.12).

Box 4.12 Technical investigations

Only when necessary:

• To refine the clinical diagnosis

• To exclude certain lesions

• To clarify differential diagnosis

• When warning signs are present

The clinician should not ascribe too much diagnostic importance to technical investigations – a positive answer does not always identify with certainty the condition present. The reverse also holds: a negative picture does not always mean that there is nothing wrong. Knowing when to ignore a positively or negatively misleading picture comes only from proper clinical examination (see Box 4.13). The latter always remains the most important of the tools available and it is far more dangerous to omit a proper clinical examination and rely on technical investigations than to do the reverse.

Later chapters outline when and when not to fall back on technical investigations and complement the clinical findings.

Interpretation

Interpretation is only possible if the clinical examination has been performed correctly: a detailed history, followed by inspection and a careful functional examination. Every part of the examination may be important, and consequently a complete examination should be carried out on each occasion. Cyriax stated ‘Omission of part of this examination, because the diagnosis seems obvious or to save time, is the common source of error’.⁵² Examining patients may become a routine and repetitive, with the same features being frequently encountered so that it is tempting to omit that part of the examination which is expected to be negative. By doing this, the presence of a double lesion can easily be overlooked or, even worse, the signs of an uncommon (possibly serious?) disorder (one of the classic ‘warning signs’) may be missed.

The functional examination gives positive answers balanced by negative ones, the latter corroborating the former. A pattern is found, which may be capsular, non-capsular, muscular or partly or fully articular, and this has to be interpreted so that logical conclusions of incontestable validity are drawn. Interpretation requires experience because examination is subjective and such features as weakness, end-feel and resistance can only be interpreted by comparison, which needs time and patience.

In practice one of a number of patterns can emerge (see Box 4.14).

Impairment of active movements

In combination with impairment of passive movements

The response to active movements (Fig. 4.11) may correspond with that found on passive testing. When an active movement is found to be painful, passive movement in the same direction will usually be more painful. In this case, the passive movement must be considered as the important one and the response to it is used for interpretation (see pp. 73–77). When the active movement is limited, passive movement is usually also restricted, although it should be possible to go a little further in the limited direction.

Fig 4.11 Response to active movements.

In combination with impairment of resisted movements

When an active movement hurts and the same movement performed against resistance is also painful, the latter has to be considered as being most important (see pp. 77–78). Limitation of an active movement and not of the corresponding passive one indicates gross weakness. The same movement performed against resistance usually also proves to be weak. Sometimes, however, other (accessory) tests against resistance must be done to uncover the lesion.

In isolation

One or more active movements are limited but are full range on passive movement

This occurs when one or more muscles are out of action. The resisted movements aimed to test the same muscles will also be weak. Weakness is quite often encountered in orthopaedic medical disorders. It may be of organic type or functional type (Fig. 4.12).

Fig 4.12 Classification of weakness.

Functional palsies are mostly psychogenic. Organic palsies are the result of either an anatomical pathological condition or of a physiopathological (usually biochemical) lesion. The cause may be intrinsic or extrinsic.

Intrinsic (myogenic) lesions are the result of either a structural disorder, such as a severe partial or a total rupture of muscle or tendon, myopathy (e.g. muscular dystrophy or myositis) or a biochemical disorder (e.g. myasthenia gravis or paroxysmal palsies). Extrinsic (neurogenic) lesions may be either central or peripheral (Table 4.2).

Table 4.2

Differences between central and peripheral palsies

Central	Peripheral
Muscular hypertonus	Muscular hypotonus
Hyperreflexia	Hyporeflexia
No muscular atrophy	Muscular atrophy
Upper skin reflexes disappear
Lower skin reflexes appear