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.

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.

The function of the different tissues is known

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

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.

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.

Normal movements may become disturbed

This approach has some advantages:

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).

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).

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).

‘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, …’.

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.

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.

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.

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:

• Not: does the pain spread down your leg?

• Not: is it painful to cough?

• Not: is it painful to bend forwards?

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

• What brings the symptoms on?

• What makes the symptoms disappear?

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).

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.

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).

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.

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

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:

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’.

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

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.