Patient history 88
4.1.1 Course of the disease 88
4.1.2 Localization 89
4.1.3 Trauma 89
4.1.4 Load, posture, and position 89
4.1.5 Non-mechanical factors 90
4.1.6 Psychological factors 90
4.1.7 Paroxysmal character 90
4.1.8 The significance of patient age 90
4.5 Examination of the pelvis 101
4.5.1 Screening examination 101
4.5.2 Pelvic obliquity 102
4.5.3 Pelvic distortion 102
4.5.4 Pelvic tilt 103
4.5.5 Restriction of the sacroiliac joint 103
4.5.6 Shear dysfunction (Greenman) (upslip and downslip) 106
4.5.7 Outflare and inflare 106
4.5.8 The pelvic floor and coccygeus muscle 106
4.5.9 The painful coccyx 107
4.5.10 Ligament pain 107
4.11 Examination of the temporomandibular joint 130
4.12 Examination of disturbances of balance 130
4.17 Retesting 153
4.18 Dysfunctions and the course of examination 153
4.19 Adjusting our thinking to the functional approach 154
4.20 Chain reactions of dysfunctions and motor programs 155
4.20.1 Function and chain reactions 155
4.20.2 Chain reactions in the light of developmental kinesiology 157
4.20.3 The pathomechanisms of chain reactions 159
4.20.4 Causes of chain reactions 160
4.20.5 The role of the diaphragm 160
4.20.6 Rotation of the trunk 161
4.20.7 Unilateral chains of dysfunction 161
4.20.8 Analysis of chain reactions 161
As in every other field of medicine, examination starts with taking the patient history. The model we shall take here is the diagnosis of vertebrogenic disturbances, which are among the most frequent type of dysfunction. Dysfunctions should not simply be diagnosed by a process of elimination; if we approach the task by ruling out all other possible causes of the lesions (especially pathomorphology) we cannot expect to arrive at helpful findings. Instead, diagnosis should be based on characteristic symptoms. Precise criteria for the patient history have been laid down by Gutzeit (1951).
Following the patient history, the next step is the physical examination. There is no clinical field in the whole of our experience in which the purely clinical examination plays such a decisive role; nor does any other make such high demands as the examination of motor function. The examination begins the moment the patient enters – the very first steps into the room, the way the patient sits down, even the way the patient undresses. It is important that patients should undress for the first examination (to their underwear, since most patients feel more at ease if they can keep their undergarments on, and so move more naturally). Present-day knowledge of functional inter-relationships shows it to be essential to study the entire locomotor system at the initial examination.
4.1. Patient history
4.1.1. Course of the disease
Unless we are dealing with a young patient, symptoms will usually have been present for some time; in most cases for years or decades, though sometimes in mild form, interspersed with periods of complete absence of pain. The frequency, duration, and intensity of the individual episodes are all relevant, but such details can often only be discovered by careful, specific questioning. For example, female patients will tend not to recall or mention low-back pain during menstruation unless specifically asked, because they consider this irrelevant. In contrast to this pattern, a short, progressive course should give rise to concern, especially if the patient is advanced in age.
4.1.2. Localization
Over the course of years, pain may occur in various different parts of the spine and locomotor system; it is exceptional for dysfunctions to remain confined to a single region. Again, specific questioning is usually needed to elicit this information. Patients presenting with headache will have little idea that there might be a connection between this and their low-back pain, any more than patients with lumbago will associate this with vertigo originating from the spinal column.
Patients may suffer from a number of complaints that might, if taken individually, be seen as having a variety of different causes, yet all have a common denominator in the spinal column or locomotor system. The greater the number of complaints a patient has – all of which, however different, could have a vertebral origin – the greater the likelihood that these are indeed vertebrogenic dysfunctions. This serves to confirm Gutzeit’s (1951) view that the spinal column is the link that runs like a bright red thread through a thoroughly varied list of different complaints.
Vertebrogenic pain is typically asymmetrical as between sides and often unilateral. This applies both to radicular pain and to reflex, referred pain such as headache or pseudovisceral pain. The asymmetry usually increases as a patient’s condition deteriorates, and decreases as it improves. If (in the case of dysfunctions) a unilateral pain spreads to become bilateral, this does not usually indicate deterioration.
4.1.3. Trauma
As has already been emphasized (in the discussion of pathogenesis), trauma is a significant factor in the etiology of vertebrogenic disturbances. If an accident features in the previous history it becomes all the more likely that the presenting complaint has a vertebral origin. Almost any kind of trauma, even if it ‘only’ affects the limbs, affects the spinal column. This is particularly so in the case of head injury. Nevertheless, it is well known that many patients tend to forget ‘minor’ injuries, serious as the consequences often turn out to be. Children who wrench their neck in an awkwardly performed somersault in a gymnastics lesson at school, or fall and sit down heavily, seldom suffer any painful consequences at the time; if they do, they compensate quickly. However there can be consequences, but they often appear very much later. It is therefore advisable not to accept straight away an answer that your patient cannot remember ever having had any accident. Instead, it should become a routine question to ask patients what sports they practice. To give a typical example: a patient who answered a direct question about injury by saying that he ‘never suffered any trauma’ replied to one about sport by saying that he had been a boxer!
4.1.4. Load, posture, and position
Function and its disturbances in the locomotor system are influenced by movement, load, posture, and position, especially if the position maintained is stressful. Therefore one of the most important points in recording the case history is to discover under what conditions the pain occurs. This is not only useful in arriving at a diagnosis, but also important from the point of view of prevention.
Details in the history such as these are essential, but often very difficult to discover from the patient. It does little good to ask what happened just before the onset of symptoms, because patients will give an answer based on all sorts of theories they have heard or formed for themselves. What we need to know are the circumstances in which pain was initially felt and which cause it to recur on a regular basis. Patients often find this very difficult to recall, thinking that it would not help to say, for example: ‘when I got up from my chair …’; ‘I was shaving, and when I tried to look more closely in the mirror …’; ‘… getting out of bed in the morning …’; ‘I was going to pick up a piece of paper from the floor …’; yet these are significant details.
It is also important to ask which position or movement gives relief. It is important to know whether pain is provoked by sudden movements, by an extended period of sustained, strenuous effort, or by an enforced position. Even apparently irrelevant details can be important. The point that has to be identified is whether a particular pain symptom occurs on bending slightly forward, as when working at a desk, or on maximum flexion, as when stooping to wipe a floor, or while straightening up from a stooping position. The mechanism behind the problem is very different in each case.
In this context too it is necessary to find out about patients’ work and sporting activities.
4.1.5. Non-mechanical factors
Dysfunctions of the locomotor system are not simply a mechanical problem, but involve every aspect that affects the reactive capacity of the body. The nervous system in particular plays a role, as can be seen in susceptibility to changes in the weather, to chills, and infectious diseases. This is especially so if these cause raised body temperature. Hormonal disturbances, the clearest effects of which are those experienced by women during menstruation, can also be important; allergy can likewise have an effect.
4.1.6. Psychological factors
Since, as we know, the locomotor system is subject to human will, and pain is the most frequent symptom of dysfunction, it is hardly surprising that psychological factors play an important part. Psychological involvement in no way excludes, but rather corroborates, the diagnosis of vertebrogenic dysfunction. It must be stressed that appropriate treatment of the dysfunction is the best means of easing the pain. It also provides the practitioner with the best means of dealing with the psychological problems. It is ultimately the course of the illness that indicates how significant the psychological factor is in the particular case. The psychological problems may ease when the patient’s pain is relieved, or may persist; they may even cause relapse as a result of increased muscle tension, and an inability to relax. This is particularly the case in masked depression.
One general principle needs to be stressed: we should guard against categorizing pain as psychological if patients are able to localize it accurately and if they give the same account of the symptoms each time they describe them. The conclusion we should draw in this case, assuming that no pathomorphological lesion is found, is that there is a dysfunction of the locomotor system. Signs that a problem is caused by purely psychological factors are these: if the patients are unable to localize the pain, if they constantly change their account, or if they cannot describe the pain. They are often confusing their psychological suffering with the pain.
4.1.7. Paroxysmal character
Gutzeit (1951) is entirely right when he describes the paroxysmal character of vertebrogenic complaints, especially if the symptoms involved are autonomic and vasomotor in nature: examples are headache, vertigo, pseudocardiac or other pseudovisceral problems. If the pain has the same, sustained intensity, for example headache, this tends to suggest another cause rather than a vertebral one. At the same time it should be pointed out that patients often speak of pain as being ‘constant’ when they are never completely free of it, although its intensity rises and falls paroxysmally with a certain frequency.
4.1.8. The significance of patient age
For differential diagnosis it is important to bear in mind that the age of the patient plays an important role. In adolescents we might expect to find ‘ordinary’ restrictions or juvenile osteochondrosis, and in slightly older patients, ankylosing spondylitis. In the middle-age group, the most common serious conditions are herniated disc and ‘ordinary’ dysfunctions. In older age groups, osteoporosis is the most important, especially in women; also osteoarthritis, especially of the hip and knee joints. In this older age group, malignant disease must also be considered, especially if the patient is over 50 years of age and the disease has followed a progressive course. True vertebrogenic disease tends to decrease after the age of 60, accompanied by a rise in the incidence of osteoarthritis of the limb joints.
4.2. The inspection: posture
The inspection usually begins with the dorsal aspect. The plumb line is positioned so as to fall between the heels. This is followed by the lateral and finally the frontal aspects. If possible the patient should also be assessed in the sitting position, again from all sides.
The inspection is the quickest way of gaining an overall impression so that the manual stage can be carried out in as targeted and economical a way as possible.
4.2.1. The dorsal aspect
The inspection begins with an assessment of overall posture, looking for any deviation from the plumb line and any asymmetries.
The next stage is the systematic inspection. Working upward from the feet, the specific points to examine are:
• the shape (roundness) and position of the heels
• the shape of the foot
• the shape and thickness of the Achilles tendons and the calves, observing their medial and lateral contours
• the position of the knees
• the shape of the thighs
• the height of the gluteal folds
• the tone of the gluteal muscles
• the course of the intergluteal cleft
• the shape of the hips: whether symmetrical or projecting to one side
• the waist
• the distance of the pendant arms from the trunk on either side.
Further details to examine are:
• the rhomboid of Michaelis between the dimples situated at the posterior superior iliac spines (PSIS), and further craniad, the prominence of the erector spinae muscles. Between these lie the spinous processes, set within a groove between these muscles. This may follow a vertical course, or may be found to deviate from the vertical
• the apex of the lordosis and the transition to kyphosis
• the position of the shoulder blades: how high, and, if prominent, how symmetrical
• the relative height and shape of the shoulders
• the quadratus lumborum and latissimus dorsi muscles; these form the lateral contour of the trunk up to the axilla. The superior border of the shoulders is formed by the deltoid and superior portion of the trapezius, and medially to these by the levator scapulae. The inspection should note whether the superior contour takes a concave or convex (hypertonic) course and observe whether there is symmetry
• the neck: note whether the neck deviates to one side or the other, and observe whether it is long, slim, or stocky
• the hair line: note whether this is well above the shoulders or low down as in basilar impression
• the head: look for any deviation. Does it deviate to the same side as the neck, or to the opposite side?
4.2.2. The lateral aspect
Inspection of the lateral aspect also begins with an assessment of posture as a whole. The center of gravity of the head should normally be above the shoulder girdle; more precisely the external auditory meatus should be vertically above the pelvic girdle and this in turn above the feet, so that a plumb line from the external auditory meatus falls approximately 2cm in front of the ankles and touches the scaphoid of the foot (navicular bone). During this inspection the patient’s gaze should be directed at an object at eye level.
It is extremely important to register a forward-drawn position, in which the head is in front of the shoulder girdle, and this in front of the pelvic girdle, with the pelvis above the anterior part of the foot.
It is important for diagnosis to note any tension of the muscles of the back, and especially of the back of the neck, which disappears on sitting.
When carrying out the systematic inspection, the examiner again works upward from the feet. Points to assess are:
• the shape of the lower leg and especially the knee: genu recurvatum is a sign of laxity
• the shape of the buttocks
• the lumbar curvature: note whether the apex of the lordosis is located at or above the lumbosacral junction. In cases of increased lordosis with flabby posture, the abdomen is seen to protrude; this is not always a sign of adiposity. This protrusion may be at its maximum at the navel; however, if there is a drooping belly the level may be much lower
• the level of the transition from lumbar lordosis to thoracic kyphosis: note whether the patient has a flat or round back; if the thoracic spine is flat there is frequently increased kyphosis at the cervicothoracic junction
• the shape of the spinal column
• the position of the shoulders: whether drawn forward or protruding.
Cervical lordosis largely depends on the shape of the thoracic spine. If the thoracic spine is flat, cervical lordosis may be completely absent. This is particularly seen in individuals of the athletic type with broad shoulders and a flat thoracic cage; similarly in ballet dancers. If the back is round, on the other hand, the thoracic kyphosis often continues into the lower cervical spine, with only the upper part of the cervical spine showing lordosis.
In flabby posture, exaggerated cervical lordosis is sometimes seen; the thyroid cartilage (and trachea) may protrude, giving the impression of an enlarged thyroid gland. This, however, disappears in the supine position.
In a forward-drawn posture there is frequently hyperlordosis in the craniocervical region.
4.2.3. The ventral aspect
At inspection of the ventral aspect the most striking features are asymmetries between one side and the other, especially those that fall into the category of hemihypertrophy. Working from caudal to cranial, the points to observe are:
• the position of the feet and their transverse and longitudinal arching
• the knees: varus or valgus alignment
• the thighs
• the lower abdomen. Note a protruding abdomen and also the navel; the position of the navel is important. Specific points to note are whether it is central, and whether it lies on the surface or at some depth. If the patient has a large abdominal circumference and the navel is deep-lying, this indicates corpulence, but if the abdomen is enlarged and the navel ‘floats’ in a superficial position, it is indicative of muscle weakness. The lateral contours of the abdominal wall are normally concave, but if the abdominal muscles are weak, the contour is convex bulging
• the epigastric angle: this may be obtuse or acute
• the sternum and pectoral muscles. It is mainly in male patients that these are easily seen
• the clavicles, noting how they move during inhalation and exhalation and the extent to which they participate in the movements of respiration (markedly or little). The depth of the supraclavicular fossae is important; these are deeper when the thoracic cage remains in an inspiratory position, as happens in emphysema, for example, or where there is a functional problem of faulty breathing. In this case there is also hypertonus of all the other upper fixators of the shoulder girdle, which is manifested as a ‘Gothic shoulders’ posture
• the position of the shoulders: asymmetry is almost the general rule
• the jugular fossa in the neck region between the medial ends of the clavicles, and the sternoclavicular joint: one joint is often found to be more prominent than the other, although this need not be clinically significant. The sternocleidomastoids can be seen either side of the jugular fossa; the lateral attachment of this muscle on the clavicle is usually less distinct. Between the sternocleidomastoids and the trapezius, some bundles of the scaleni may be visible in slim patients
• the thyroid cartilage: this can be seen more distinctly in males. Any lateral shift in its position is clinically very significant, since this indicates tension in one of the digastric muscles, drawing the hyoid to one side along with the thyroid cartilage. This observation is accompanied by distortion and asymmetry of the floor of the mouth, which is shallower on one side and deeper on the other
• hyperactivity of the masticatory muscles: this can often also be seen at rest. Another manifestation is that the patient’s mouth hardly opens during speech.
• the face: facial asymmetry is very frequent, and can be combined with asymmetry of bite and even ‘facial scoliosis.’ This in turn can be associated with scoliosis of the spinal column and hemiatrophy.
To summarize: inspection of the dorsal and ventral aspects enables the practitioner to detect asymmetries, either in the sense of relative weakness of one side (hemihypogenesis), or simply of the marked dominance of one side. Dominance is clearly recognized by the arm that is more powerful. In the lower limbs, the stance leg is more powerful and solid, though it is the swing leg that is dominant.
4.2.4. Inspection of the seated patient
Examination of the patient in the relaxed, sitting position can produce very different results from those obtained with the patient standing. This is particularly so with hypermobile subjects, in whom lumbar hyperlordosis standing changes to a kyphotic posture when seated and relaxed. This is accompanied by a forward-drawn neck and hyperlordosis at the atlanto-occipital and atlantoaxial joints. This is particularly important in subjects whose profession is mainly sedentary.
Inspection from above would reveal rotation of the shoulder girdle in relation to the pelvic girdle and the feet.
4.3. Palpation (soft-tissue examination)
Palpation is extremely important in the diagnosis of painful structures of the locomotor system and essential for all manipulative techniques. This examination therefore follows next, immediately after the inspection.
The first step in palpation is to place a hand (finger) onto the surface of the patient’s body, and then to focus one’s attention on the aspect to be tested: warmth, moisture, consistency (whether the surface is rough or smooth), mechanical properties (resistance, mobility, stretch capacity), and whether the examination causes the patient to feel pain.
Given that palpation is associated with touch, and this in turn with pressure, we might think that an objective way to perform it would be to use a pressure gauge. Sadly this idea is misleading; palpation is never a matter of mere (static) pressure, but a process that involves movement of the hands (fingers).
Whether attempting to penetrate down from the surface to underlying layers, or to examine some aspect of the tissue by feel, we are constantly moving tissue aside or drawing it apart. Palpation therefore involves a combination of alternating pressure and movement. It is registered using not only our pressure receptors but also, simultaneously, our proprioceptors.
Further, touch constantly evokes a reaction from the patient, and this reaction must also be registered. Feedback operates between the examiner and the patient, and is extremely important in diagnosis; a non-reproducible process of feedback is taking place between two systems.
Palpation is a method that reveals a great deal to the experienced examiner; a host of information that a technological instrument is incapable of providing. The fact that it is not reproducible frequently leads to its rejection as too subjective: however this is not only absurd on practical grounds but also theoretically untenable; computers that process information are in essence no more than imperfect copies of the nervous system. The information that we obtain from them is uncritically accepted as ‘objective’ while the original, the human brain and the hands that provide the sensory input of information, are rejected as unreliable. Yet there is already radiological evidence to demonstrate ‘palpatory illusions’ (see Figure 4.11).
The palpating hand has receptors to sense heat and cold, to distinguish pressure, motion, position, and tissue quality. No technological instrument is able to detect and integrate all these factors simultaneously. There is also a feedback process between practitioner and patient, both during diagnosis and during treatment.
4.3.1. Hyperalgesic zones
The quickest, most elegant method of finding a hyperalgesic zone (HAZ) is to run one’s fingers very lightly over the surface of the skin: heightened friction is felt at an HAZ on account of increased sweat production. The lighter the touch of the fingers, the more readily this is detected. The ‘barrier’ phenomenon is used when examining all the tissues of the locomotor system other than bones (see Figure 2.3). The points to note are:
• in the movement of a joint, the point at which the barrier is reached
• whether the barrier is normal or pathological.
A small area of skin can be examined by stretching it between the fingertips (the interdigital folds are an example) – a larger area is examined between the thumbs and the palms of the hands – always taking up the slack until the point where the barrier is engaged, and always comparing one side with the other (see Figure 6.56).
4.3.2. Subcutaneous tissue and fasciae
To examine – and also treat – subcutaneous connective tissue, including that in scar tissue and shortened muscles, the practitioner should create a fold (see Figure 6.57) and stretch (not squeeze) it until the barrier is reached. If it is not possible to create a fold, slight pressure alone is enough to arrive at this barrier.
In examining fasciae, the most useful characteristic to look for is their mobility against the underlying layer, that is mobility of the subcutaneous layer against the muscle and especially of the muscle against the bone. This mobility is examined as follows:
• The muscles of the back in the cranial or caudal direction, with the patient prone.
• The gluteal muscles in the cranial direction.
• The muscles around the thorax in the dorsoventral direction.
• The muscles of the neck around the longitudinal axis of the neck.
• The muscles of the limbs around their longitudinal axis (pp. 232–234).
The scalp also behaves in the same way as a fascia relative to the skull.
Resistance (pathological barrier) is often discovered at periosteal pain points when trying to shift the subperiosteal tissue in various directions, and an easing of the pain is achieved when mobility is restored. This applies particularly at the attachments of tendons and ligaments.
Bones that are linked not by joints but by connective tissue also move relative to one another. Examples are the metacarpal and metatarsal bones, and the fibula relative to the tibia. Testing of their mobility relative to each other often reveals pathological barriers, which are treated in analogous ways. Everything that has been said about soft-tissue lesions applies to active scars.
The soft tissues surround the muscular and articular structures everywhere, and need to move in harmony with them. The same principle also applies to the internal organs. For this reason, dysfunctions that are closely associated with the function of joints and muscles can be diagnosed in the soft tissue. It is the mobility and elasticity of the soft tissues that enable them to move, and there is a harmonious interplay between these and movement. This mobility has been little studied, but if it is disturbed, the neuromusculoskeletal system cannot function normally.
4.3.3. Trigger points
Palpation is the means of diagnosing the most characteristic change, the myofascial trigger point (TrP). Various terms for this exist in the literature; it is known, for example, under the names myogelosis, fibrositis, or local hypertonus. Here we shall apply the definition and terminology given by Travell & Simons (1999), who describe the TrP as a hyperirritative spot in skeletal muscle, which is associated with a hypersensitive palpable nodule in a taut band. A twitch reaction can be elicited by snapping palpation which can be registered by electromyography. At the same time the patient feels characteristic pain, which is accompanied by signs from the autonomic nervous system (see Figure 4.1 and Figure 4.2).
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| Figure 4.1 |
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| Figure 4.2 |
A muscle bundle in which there are TrPs contains some muscle fibers that are in a state of contraction, alongside others that are uncontracted (relaxed). If we succeed in relaxing the contracted fibers, using post-isometric relaxation, reciprocal inhibition, ‘spray and stretch’ or simple pressure, the problem usually disappears instantly, showing it to be a functional, reversible disturbance.
Recent studies show that the hardening derives from the part of the muscle fiber that is stretched, and that the nodule of contracted muscle is the actual myogelosis. These changes have also been demonstrated histologically (Windisch et al 2001), findings which indicate that there are also TrPs that are chronic and irreversible. These respond little to the reflex methods mentioned above, requiring instead aggressive therapy such as needling (see Chapter 6, p. 248).
Myofascial TrPs can also be studied objectively by means of electromyography (EMG) using monopolar needle electrodes. This method has successfully been used (Hong & Yu 1998; Hubbard & Berkoff 1993; Simons 2003) to show that what they were observing were end-plate potentials originating in TrPs.
Two kinds of TrP can be distinguished: active and latent. Active TrPs are those that give rise to pain, especially referred pain. Latent TrPs do not give rise to spontaneous pain, but are painful on palpation and participate, often decisively, in chain-reaction patterns.
Myofascial TrPs are not the only pain points that can be palpated; points of tenderness can also be found at the periosteum, in joint capsules, at attachment points of tendons and ligaments, and within muscles in the absence of any area of hardness. Since the hardened area forms part of the definition of a ‘TrP’ the term cannot strictly be applied in this case and instead it is best to use the term ‘tender point’ (TeP). These can also be the point of origin of referred pain. If the TeP is the attachment of a tendon, this is usually closely associated with the TrP of the corresponding muscle, the actual cause of the pain at the tendon attachment.
Characteristic muscular pain points are also present in system-wide disease, as for instance in fibromyalgia syndrome, but a particular feature of these is that there are no areas of hardness. There is also no twitch response, and these pain points do not respond to reflex relaxation.
Table 4.1 lists some muscle TrPs that are important for their diagnostic implications.
| Muscle | Clinical significance |
|---|---|
| Soleus | Pain at the Achilles tendon |
| Quadriceps femoris | Lesion in L4 segment; pain at the upper edge of the patella; ‘pseudo hip and/or knee pain’ |
| Tensor fasciae latae | Pain at the hip and at the superior border of the patella |
| Thigh adductors | Lesion in the hip joint; TrP in pelvic region |
| Iliacus | Lesion in S1 segment; coccyx; pseudovisceral pain |
| Piriformis | Lesion in L5 segment; ‘hip pain’ |
| Ischiocrural muscles | Lesion in segments L5, S1 (straight-leg raising test positive); pain at the ischial tuberosity and head of the fibula |
| Levator ani | Pain at the coccyx |
| Coccygeus | Low back pain; many chain reactions due to pelvic floor dysfunction |
| Erector spinae | Back pain in the corresponding segment |
| Psoas major | Pseudovisceral pain; restricted rotation of trunk |
| Quadratus lumborum | Acute lumbago; restricted rotation of trunk |
| Rectus abdominis | Tenderness at xiphoid process and pubic symphysis; pseudovisceral pain |
| Pectoralis major | Pain at chest wall; pseudocardiac pain |
| Pectoralis minor | Tender coracoid process, sternocostal joints, and superior thoracic aperture |
| Diaphragm | Chest pain; cervical syndrome |
| Transverse (middle) part of trapezius | Cervicobrachial and radicular syndromes |
| Subscapularis | Pain in the shoulder; in the arm; at the lesser tubercle; pseudocardiac pain |
| Supraspinatus, infraspinatus | Pain in the shoulder; in the arm; at the greater tubercle |
| Supinator, biceps brachii, forearm extensors | Radial (lateral) epicondylopathy |
| Triceps brachii | Pain in the axilla; epicondylopathy |
| Finger flexors | Ulnar (medial) epicondylopathy |
| Descending (superior) part of trapezius | Neck pain; headache and shoulder pain |
| Levator scapulae | Shoulder pain; headache; neck pain |
| Scalene muscles | Pain at Erb’s (supraclavicular) point; at the superior thoracic aperture |
| Craniocervical extensors | Upper cervical syndrome |
| Sternocleidomastoid | All cervical syndromes |
| Masticatory muscles | Earache; upper cervical syndrome |
4.3.4. Periosteal pain points
Numerous pain points on the periosteum are also found in most cases of dysfunctions of the locomotor system. The appearance and resolution of these pain points – as well as their treatment – play an important role in the course of the dysfunction.
Many periosteal pain points are sites of attachment of tendons or ligaments closely associated with TrPs in the muscles, and have the effect of producing increased tension there. This is called enthesopathy. On examination, mobility testing of the subperiosteal tissue against the underlying bone reveals characteristic resistance in one or more directions on the affected side as compared with the healthy side.
Pain points can also be found in the region of the vertebral and limb joints wherever these are accessible to palpation. At the spinal column this is particularly so in the cervical region. They are also found at the sternocostal joints and at the temporomandibular joint.
Table 4.2 lists the most important periosteal points and their clinical significance.
| Periosteal point | Clinical significance |
|---|---|
| Head of metatarsals | Metatarsalgia in the case of splay foot; also in the case of tarso-metatarsal restriction |
| Calcaneal spur | TrP of deep plantar flexors |
| Head of fibula | TrP in biceps femoris, tibialis posterior; restriction of fibular head; forward-drawn posture |
| Pes anserinus (tendinous expansions of muscles at medial border of tuberosity of tibia) | TrP in the hip adductors; osteoarthritis of hip joint |
| Insertion of collateral ligament | Lesion of a meniscus in the knee |
| Superior border of patella | TrP in quadriceps femoris and tensor fasciae latae |
| Ischial tuberosity | TrP in the ischiocrural muscles |
| Posterior superior iliac spine (PSIS) | Frequent but not specific |
| Lateral border of the pubic symphysis | TrP in the hip adductors; hip |
| Superior border of the pubic symphysis | TrP in the rectus abdominis; forward-drawn posture |
| Coccyx | TrP in the levator ani, tension in the gluteus maximus |
| Iliac crest | TrP in the gluteus medius and quadratus lumborum |
| Pain at spinous process | Hypermobility with TrP in the erector spinae muscles |
| Spinous process T4—T6 | Weakest region of erector spinae with TrP |
| Spinous process of C2 | Lesion in segments C2—C4; TrP in levator scapulae |
| Xiphoid process | TrP in rectus abdominis |
| Ribs in the medioclavicular line | TrP in pectoralis minor |
| Ribs in the axillary line | TrP in the serratus anterior |
| Sternoclavicular joint | TrP in the scalene muscles and superior parts of the pectoralis muscles |
| Sternum just below 1st rib | Sternocostal joint of 1st rib |
| Angle of ribs | TrP in subscapularis; restriction of ribs |
| Sternal end of clavicle | TrP in sternocleidomastoid |
| Pain at Erb’s point | TrP in scalene muscles; radicular syndromes |
| Transverse processes of atlas | TrP in sternocleidomastoid |
| Posterior margin of foramen magnum | Restriction of retroflexion at C0/C1; headache; migraine |
| Nuchal line | Referred pain from the short craniocervical extensors, insertion of splenii capitis muscles |
| Condylar process of mandible | TrP in masticatory muscles |
| Hyoid | TrP in digastric and mylohyoid muscles |
| Styloid process of radius | Lesion of the radioulnar joint |
| Radial (lateral) epicondyle | TrP in biceps, supinator, extensor muscles of the fingers |
| Ulnar (medial) epicondyle | TrP in flexor muscles of the fingers |
| Attachment of deltoid | TrP in deltoid; frozen shoulder |
4.3.5. Radicular syndromes
As already stressed, radiating pain alone (even mere paresthesia) are not sufficient for the diagnosis of a radicular syndrome. Conclusive evidence of radicular syndrome is provided by neurological deficit, the main signs being:
• hypesthesia
• localized hypotonia and/or atrophy
• muscle weakness
• decreased tendon and periosteal reflexes
• increased idiomuscular excitability.
Unless these signs are present we may suspect root lesion, but this requires further proof.
There are certain signs, however, which strongly suggest radicular syndrome, without being positive proof. These are if the pain and paresthesia radiate down to the fingers (or toes), especially if objective examination also finds increased resistance to stretching at the interdigital fold, and difficulty in the mobility relative to each other of the metacarpals (metatarsals) in the corresponding segment. If the straight-leg raising test produces a finding below 45°, this also raises suspicion. Another sign is when the patient reports that control of the limb feels different from usual.
The individual radicular syndromes are dealt with in Section 7.8.2. There is disagreement as to the dermatomes, and some individual variation has to be expected. The scheme we observe, particularly for the trunk, is that of Hansen & Schliack (1962) (see Figure 4.3 A–C and E); for the lower limbs, that of Keegan (1944) (see Figure 4.3 D). In radicular syndromes and herpes zoster, the authors work on the basis of Head zones (referred pain) findings. There is very credible evidence to support the existence of the cervicothoracic and the lumbosacral hiatus; this term describes the fact that segments C5–T1 are only found on the upper limbs and segments L2–S2 only on the lower limbs. This means that on the trunk, segment C4 is followed immediately by T2, and L2 by S2. These dermatome charts regularly show a ‘step’ on the trunk, approximately on the axillary line, which marks the boundary of the area supplied by the dorsal ramus and ventral ramus of the spinal nerve, and which is usually clearly observable in herpes zoster (see Figure 4.3).
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| Figure 4.3
The dermatomes. (A) Ventral aspect. (B) Dorsal aspect. (C) Lateral aspect of the trunk (after Hansen & Schliack 1962). (D) Lateral aspect of the lower limb (after Keegan 1944). (E) The perineum (after Hansen & Schliack 1962).
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4.3.6. Conclusion
There are many functional and reflex changes that correspond to nociceptive stimulation of the skin, subcutaneous tissues, and muscles, at the periosteum and the points of attachment of tendons and ligaments. These changes can be diagnosed clinically and can also be registered instrumentally, by means of thermography, measurement of electrical resistance, and EMG. These present a means of precise diagnosis by straightforward methods, so enabling targeted treatment.
4.4. Mobility testing
This section will deal with general principles only. The regular procedure should be to examine active and passive mobility and movement against resistance.
4.4.1. Active mobility
Active movement includes muscle activity and joint mobility in the absence of any influence on the part of the examiner. This corresponds to voluntary movement.
4.4.2. Movement against resistance
The force applied by the examiner may be less than, equal to, or greater than that used by the patient. The muscle contraction is then described as concentric, isometric, or eccentric. If testing is not performed isometrically, the movement against resistance can be performed isotonically (i.e. maintaining the same force) or isokinetically (i.e. at constant speed). The object of testing is to examine not only the force produced by the muscle but also the provocation of pain, and coordination.
4.4.3. Passive mobility
First and most obviously, the testing of passive movement examines joint function. Very considerable changes in joint function may be found, however, as a result of muscle tension. Findings fall into three categories: normal mobility, movement restriction, and hypermobility; this relates both to functional movement and to joint play (see Chapter 2).
The following changes should be looked for during examination:
• Restriction of the movement of a joint as compared with the contralateral joint or the neighboring spinal segment.
• Increased resistance during movement, particularly during the examination of joint play.
• Resistance to springing in the end-of-range position (i.e. at the barrier). Note whether this resistance is physiological or pathological, or whether it is found during functional movement or on testing of joint play.
Figar & Krausová (1975) were able to measure the resistance to springing using a resistance transducer. This was done in a restricted cervical segment before treatment, during manipulation, and after treatment (see Figure 4.4).
The spinal column
It is important when examining the spinal column to discover which of two neighboring segments is restricted. The question as to which of the paired joints is restricted is less important because the determining factor is the direction in which the treatment is applied.
The lumbar spine
It helps to picture the joints as positioned with the articular facets fully covering each other in retroflexion, but as being in their end position in anteflexion.
If anteflexion of a spinal joint is restricted, the spine deviates to the restricted side in anteflexion. If retroflexion is restricted, then also the spine deviates to the restricted side during retroflexion (see Figure 4.5). However, the deviation to one side that is observed is frequently the result of antalgic posture in order to relieve reflex pain, for example in radicular syndromes.
The cervical and thoracic spine
In the cervical and thoracic spine, it is (in theory) possible to discover on which side the restricted joint is by examining side-bending first in retroflexion and then in anteflexion.
If side-bending is more restricted in retroflexion, then the joint on the side to which the patient is bending is affected; if side-bending is more restricted on the opposite side, then it is the joint on the opposite side that is restricted.
4.5. Examination of the pelvis
Examination of the pelvis is usually preceded by screening assessment of the lower limbs, in particular since problems there can be the cause of pelvic obliquity.
4.5.1. Screening examination
Inspection
Points to observe are:
• deviation to one side
• unilateral prominence
• height of the buttocks
• irregularities of the rhomboid of Michaelis, which is formed by the dimples above the PSISs, the spinous process of L5, and the uppermost point of the intergluteal cleft.
Deviation of the upper end of the intergluteal cleft to one side is the result of asymmetrical positioning of the inferior end of the sacrum and coccyx.
Palpation
Palpation begins at the iliac crest, which the examiner can find by sliding the edge of his forefinger downward from the patient’s ribs. The reason this is important is that the iliac crest is often considerably higher than might be expected from the localization of the contours of the buttocks (often it is even just below the costal arch). A spirit level can be used to confirm the horizontal position of the pelvis (see Figure 4.6).
If the pelvis deviates to one side, this creates the impression that it is higher on the side toward which it deviates. This is because the examiner can easily contact the top of the iliac crest on the side to which the pelvis deviates, whereas on the other side the superior border of the iliac crest is hidden under the costal arch and has to be searched for. Working in a medioparavertebral direction, the examiner can then locate the PSISs.
The most reliable way to perform the palpation of the PSIS is from laterally and below, since this corresponds to the shape of the spines. The same approach is suited to the palpation of the anterior iliac spines.
If both the anterior and posterior iliac spines are at the same level on both sides, the pelvis is horizontal in the neutral position. A point worth mentioning here is that the rise in obesity has made palpation more difficult in many cases, and this is especially true when palpating the posterior iliac spines.
Deviation of the pelvis to one side can be the result of a difference in leg length; in this case the pelvis deviates to the higher side. More frequently it is the result of (usually minor) scolioses, the pelvis being horizontal. In the case of true pelvic obliquity the iliac crest and anterior and posterior iliac spines are lower on one side.
4.5.2. Pelvic obliquity
Measurement of leg length is more difficult than might be thought, because the head and neck of the femur are not externally evident. Pelvic obliquity is therefore the most reliable clinical sign of difference in leg length, unless there is a measurable difference in the length of the lower leg. However, this may be compensated by the length of the thigh.
Where there is a difference in leg length the pelvis is generally seen to deviate to the higher side if the patient stands with weight equally distributed on both legs. The shoulder is typically seen to be lower on the side where the pelvis is higher. The findings can be tested clinically by placing a block or heel insert under the shorter leg. When this is done the pelvis becomes horizontal and no longer deviates to one side, and the shoulders level out. However, this effect only takes place if any significant movement restrictions have already been resolved.
A check can be made at the same time by placing each of the patient’s feet separately onto a balance scale, and placing a heel insert under the shorter leg to equalize the length. This produces one of three possible results:
1. The difference remains the same.
2. The difference is equalized.
3. The difference increases.
The patient should be asked each time whether it is more comfortable with the heel insert, or whether it feels awkward. If the patient finds at the very least that the (unaccustomed!) heel insert does not feel awkward, the effect is seen to be favorable. Equalization of length can then be recommended, unless of course the patient has one flat foot. An X-ray check (with patient standing) is recommended to confirm the difference in leg length.
4.5.3. Pelvic distortion
This is a curious phenomenon which must be distinguished from pelvic obliquity. The dorsal inspection usually shows the pelvis to deviate to the right, with the appearance of being slightly rotated to the left.
Palpation of the iliac crests may show their height to be symmetrical laterally, but as the examiner’s palpating fingers (the edge of the forefingers) advance medially and approach the PSISs, they do not meet: one of the iliac spines (usually the right) lies higher than the other. This can be confirmed by direct palpation of the PSIS (from below).
The finding for the anterior iliac spines is the converse: here the right anterior superior iliac spine (ASIS) is usually lower than the left. The two ilia seem to be twisted relative to each other. There is always a discrepancy when the position of the ASIS, PSIS, and the iliac crests are compared. However, the difference at the anterior or posterior iliac spines, and at the iliac crests, can vary, so that it is not always easy to distinguish pelvic distortion from pelvic obliquity, especially if both changes are simultaneously present. In such cases it is advisable to begin by treating the pelvic distortion and then to repeat the process of measurement.
Another feature of pelvic distortion is the overtake phenomenon. On anteflexion the PSIS that is lower (usually the left) momentarily ‘overtakes’ the right. After 10–20seconds the finding reverts to what it was before. Cramer’s (1965) analysis of the mechanism involved (see Figure 3.12) appears best to match our understanding of what is happening. This also leads us to expect findings such as external rotation of the leg on the side of the ilium that is tilted so as to be lower posteriorly.
The aspect that now seems to us to be more significant is that of muscular dysfunctions which are associated with pelvic distortion and accompanied by asymmetrical muscle function. Pelvic distortion is always secondary, and the cause is usually located in the atlanto-occipital and atlantoaxial joints (see Chapter 2); the findings at the muscles are inconsistent.
4.5.4. Pelvic tilt
A third condition can be distinguished in addition to pelvic obliquity and pelvic distortion; this is pelvic tilt. To examine for this it is necessary to palpate the anterior and posterior superior iliac spines. The line between them is normally horizontal. In patients with a drooping belly the pelvis is usually tilted forward, and in patients with tension of the gluteal and ischiocrural muscles it is tilted backward.
4.5.5. Restriction of the sacroiliac joint
There is still a frequent tendency to overestimate the importance of restriction of the sacroiliac joint. One reason for this is the fact that there are no muscles between the sacrum and ilium, yet despite this, restrictions here were a relatively frequent finding, and this led to the assumption that this was a ‘pure’ joint restriction, with no involvement of muscle spasm or TrPs. However, this view has proved untenable, because it is often possible to release ‘indirect’ restrictions in the case of TrPs in the biceps femoris (head of the fibula), pelvic floor, piriformis muscle, and elsewhere, after which it is usually found that restrictions of the sacroiliac joint are also resolved. Such chain reactions indicate that most restrictions of the sacroiliac joint are secondary.
There is also a practical problem: diagnosis usually relies on palpation of the mobility of bony structures, which often lie under a considerable layer of fat and connective tissue. This reduces the reliability of comparative examination.
Testing for ‘overtake’
Testing for the overtake phenomenon, as described above in connection with pelvic distortion, is more difficult to assess in patients with a degree of adiposity. The changes observed in overtake, unlike those in pelvic distortion, are not transitory, but remain during anteflexion. Bear in mind that it is not possible to retain hold of the posterior iliac spine, since it disappears under the skin during anteflexion; it does not present the same surface in anteflexion, and of course, if the restriction is bilateral the test fails completely to reveal it.
The spine sign test
The ‘spine sign’ is a more successful test to use with non-adipose patients, following the method devised by Dejung (2003) (see Figure 4.7). The examiner sits behind the standing patient, placing one thumb on the posterior inferior iliac spine and the other on the spinous process of L5. The patient is then told to bend the knee and lower the hip on the side being examined. The normal finding is that the distance between the examiner’s two thumbs increases: the thumb on the iliac spine moves caudad and laterally while the thumb on the spinous process of L5 remains still. If there is restriction, the distance does not increase and the examiner can feel the laterally directed pressure of the spinous process of L5.
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| Figure 4.7 |
Springing test with patient supine
The remaining examination methods are all ‘springing’ tests. The springing test with the patient supine (see Figure 4.8) is much used. The examiner stands by the table and grasps the patient’s contralateral leg (which is bent, while the other remains extended) and adducts her leg until the pelvis begins to follow. This engages the barrier and sets up the position from which the test is performed. With the hand that is guiding the patient’s knee, the examiner exerts pressure in the longitudinal axis of the thigh in the direction of the PSIS, to take up the slack. The examiner then exerts springing pressure. The springing is palpated with the hand under the posterior iliac spine. Adduction (to the barrier) is usually measurably restricted on the affected side. This is a useful test to use as a screening examination and is simple to perform.
Springing test with patient in the side-lying position
This test produces a springing response of gapping (distraction) of the joint, so that the technique is also suitable for use in therapy (see Figure 4.9). The patient is side-lying with the uppermost leg bent, knee resting on the treatment table. The examiner’s caudad arm should be placed so that his forearm lies gently on the region of the ASIS and iliac crest, and is angled to point ventrally, medially, and cranially. Gliding pressure with a springing movement is then exerted on the ala of the ilium in the same direction. This has the effect of producing a dorsal gapping (distraction) of the sacroiliac joint. The thumb of the examiner’s other hand senses the springing motion between the PSIS and sacrum.
Springing test with patient prone
The superior portion of the sacroiliac joint is examined with the patient lying prone. The practitioner takes hold of the patient’s ASIS from the ventral side by curling the fingers of one hand around it, then lifts it slightly on taking up the slack, and shakes it upward with a springing movement. The thumb of his other hand is meanwhile used to palpate the sacrum, to sense whether it moves together with the ASIS. It will only do so if the joint is restricted (see Figure 4.10).
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| Figure 4.10 |
The inferior portion of the sacroiliac joint is examined by applying pressure with a springing movement to the inferior apex of the sacrum with the patient prone. Mobilization techniques, which are described in Chapter 6, can also be used for examination.
Test technique according to Rosina
The ‘traditional’ tests described so far all involve some degree of unreliability in view of the great number of obese patients. Lewit & Rosina (1999) has developed a technique that is also reliable when examining such patients.
Lewit & Rosina (1999) observed that, when the subject’s head is turned, the ASIS is displaced caudally on the side toward which the head turns. Following this observation we found that the opposite happens at the posterior iliac spines; in other words, that pelvic distortion occurs. On the side to which the head turns, the posterior border of the iliac crest also rises at the same time as the posterior iliac spine.
For this test the patient is standing. The examiner places the edges of the forefingers of both hands on the iliac crests, approaching them from the lateral aspect of the iliac crests in a medial direction just above the PSIS. The patient is then asked to rotate her head to the side.
After a few seconds’ latency, in a normal subject the examiner finds that the forefinger rises on the side to which the head is turned. Only very slight pressure from above is required in this test. The layer of fat on the iliac crest does not influence the result (Lewit & Rosina 1999). The effect is absent if there is restriction of the sacroiliac joint.
The mechanism involved in this test is unknown. Although the difference in height of the two iliac crests is very noticeable, no difference in their position can be demonstrated radiologically. The effect must therefore be due to a shifting of soft tissues, producing a palpatory illusion (see Figure 4.11).
On anteflexion with head turned, it is even possible to observe a transitory overtake phenomenon on the side that lies lower. There is no movement if the sacroiliac joint is restricted. (No explanation for this has been found.)
Pain points
There may be pain points at the upper margin of the sacroiliac joint, at the lower end of the joint, and also, more rarely, in the iliacus muscle, at the attachment point of the adductors at the symphysis (slightly positive Patrick’s sign) and above the posterior iliac spine, although these findings need not be present.
4.5.6. Shear dysfunction (Greenman) (upslip and downslip)
When there is tenderness at the superior border of the pubic symphysis and tenderness to pressure at the ischial tuberosities, the usual finding on palpation is that the medial end of the pubic bone is higher on the side that is painful, and that the ischial tuberosity is lower on the side where the gluteus maximus is tense. Clinically we have found these to be signs of a syndrome associated with tension (TrPs) of the rectus abdominis muscles, forward-drawn posture, tension of the erector spinae and neck extensors, gluteal muscles, and biceps femoris.
The sacroiliac joints do not themselves play any significant role in our experience. Curiously, the position of the symphysis and ischial tuberosities appears to be symmetrical when the patient is standing. Still more remarkably, after treatment the palpatory finding had normalized but the X-ray showed no evidence of change even though palpation had found changes of up to 2cm at the ischial tuberosities.
To try to find an explanation for this, X-rays were taken showing the examiner’s thumbs as they palpated before and after treatment. The result was clear: what had changed was not the position of the bones, but that of the examiner’s palpating thumbs (see Figure 4.11). In this way we were able to obtain evidence to document a ‘palpatory illusion.’
It must be remembered that bones are often overlain by a layer of soft tissues, including muscles, and this may sometimes be considerable. If painful disorders produce a change in tension in these tissues, that must exert an effect on the position of the fingers palpating the site. In the particular case described here, this would be taking place at the attachment of the rectus abdominis on the pubic symphysis and that of the biceps femoris at the ischial tuberosity.
The general principle to be drawn is that if there is asymmetry of tension in the soft tissues, a deviation in the position of the underlying bone (e.g. spinous processes) can generally be palpated; these are then found to be ‘repositioned’ once tension has been balanced. The same effect can be observed if cotton wool or foam rubber of varying thickness is wrapped around the corners of a matchbox and the object is then palpated with eyes closed: the shape of the matchbox is felt to be distorted.
4.5.7. Outflare and inflare
Greenman and Tait (1986) described an apparently isolated change in the position of the ASISs, which caused a distortion of the triangle formed by these iliac spines and the navel (see Figure 7.3). Our experience shows this change to be clinically important, and it is discussed in more detail in Chapter 7 (see Section 7.1.8). One iliac spine (usually the right) is usually found to be flatter and its distance from the navel to be greater (‘outflare’) than the other (usually the left), which is more prominent and closer to the navel (‘inflare’). At the same time, palpation shows tonus in the lower part of the abdomen on the flattened side to be (relatively) decreased, as compared with the other side.
In this case the finding is certainly not a palpatory illusion, because the tissue layer over the anterior iliac spine is very thin, and the asymmetrical positioning is clearly visible in slim patients. In adipose patients it is necessary to palpate it, since otherwise a clinically important lesion would be missed; one that is easy to treat.
The clinical significance (i.e. the effect of treatment) was for a long time a mystery, but we have recently been able to establish (Lewit & Olšanská, 2005) that this change is always associated with an asymmetrical internal rotation of the hip joint. This rotation is restricted on the side of the inflare and instantly becomes normal following treatment.
4.5.8. The pelvic floor and coccygeus muscle
Examination of the pelvis also includes palpation of the pelvic floor, the coccygeus muscle.
In 1989, Silverstolpe described a syndrome which he called ‘pelvic dysfunction.’ He performed the examination by exerting pressure next to the coccyx, in the direction of the sacrotuberous ligament, and this had the effect of provoking intense pain. The types of pain reported by the patients usually varied considerably and included visceral pain. In these patients he found extremely painful TrPs in the region of the thoracolumbar erector spinae muscles, and snapping palpation of the prone patient produced dorsiflexion of the lumbar spine and pelvis. By maintaining the (painful) pressure in the direction of the sacrotuberous ligament he was able to resolve most of the symptoms these patients were experiencing (see Figure 4.12).
If this palpation provokes pain, the examiner will sense distinct resistance; if the pressure is maintained, the resistance resolves. What this palpation has found is a TrP in the coccygeus muscle, the pelvic floor. The great significance of this finding is that the pelvic floor forms part of the deep stabilization system which gives rise to effects in the form of chain reactions in the entire locomotor system. This explains the importance of finding this TrP.
4.5.9. The painful coccyx
A coccyx that is tender to pressure should never be ignored, because it is a considerably more frequent contributory cause of low-back pain than coccygodynia. Palpation of the coccyx should therefore be carried out when diagnosing low-back pain.
Palpation of a painful coccyx can be more difficult than might be expected. The problem here is one of myotendinosis (insertion tendopathy) resulting from tension of the gluteus maximus and a TrP in the levator ani, which can be palpated quite easily via the rectum.
A tender coccyx is always ventrally curved. The pain point is typically on the ventral surface of the tip of the coccyx, so it is necessary to feel around for the ventrally curved coccyx, which produces resistance from the tense gluteus maximus. Mere touch is enough to provoke pain. Any strong pressure here is always painful and therefore misleading; only pain experienced at the tip of the coccyx is diagnostically useful. Patients often report pain at the coccyx when what they are experiencing is in fact referred pain from other pelvic structures, in which case pain points will also be found laterally (pelvic floor, lower sacroiliac joint, etc.).
In addition, a HAZ is often found in the sacral region, resembling a cushion of fat. There are often concomitant findings in the straight-leg raising test and Patrick’s test and a TrP in the iliacus muscle. In the history, the patient may report pain on sitting.
4.5.10. Ligament pain
A condition known as ‘ligament pain’ (Barbor 1964, Hackett 1956) tends to be found where there is sustained static load; this may be associated with sacroiliac restriction, especially if there is hypermobility. It particularly involves the iliolumbar and the sacroiliac ligaments.
The key to diagnosis is the ability to provoke pain, and the following technique is used. The patient lies supine on the table with one leg bent at the hip and knee. The examiner should stand beside the table. He grasps the patient’s bent leg at the knee and adducts the thigh, at the same time exerting pressure along the axis of the thigh to take up the slack (see Figure 4.13).
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| Figure 4.13 |
At about 90° of hip flexion, the maintenance of adduction tests primarily the iliolumbar ligament, and the patient will feel pain in the groin. At a hip flexion of 60–70° it is mainly the sacroiliac ligaments that are tested. This time, as the examiner maintains the adduction, the pain radiates down the leg in the S1 segment. It is important to ensure before testing the ligaments that there is no sacroiliac joint or lumbosacral restriction. The localization of the provoked pain is the main criterion for diagnosis.
Closer examination will show that in these patients adduction is restricted on the painful side. It is easy to measure this by looking at the distance between the adducted knee and the table. This degree of increased resistance cannot be due to ligaments alone. The fact that it is often resolved using post-isometric relaxation (PIR) suggests a muscular cause. The authors quoted above treat ligament pain with injections of hypertonic solutions at the attachments of the ligaments, and we have also treated this type of pain by means of straightforward needling. This we follow with PIR and reciprocal inhibition (RI), both of which are suitable methods for use in self-treatment.
If movement restriction is found on testing of the iliolumbar or sacroiliac ligaments, this is due to muscle tension, which can be treated by PIR and RI.
4.6. Examination of the lumbar spine
4.6.1. Screening examination of active movement
Retroflexion
Examination of the lumbar spine can properly be said to have begun with that of the pelvis. The examination starts with the patient standing, ideally in retroflexion, and the examiner should not only assess the overall range of motion but also observe whether the movement extends into the lumbosacral segment. In normal cases this is easily seen, because dorsiflexion is greatest in the lumbosacral segment, while the excursion in other directions of movement is greatest in the L4/L5 segment. The examiner can not only identify movement restriction, but also local hypermobility, which is seen as a sharp lordotic bend on retroflexion, often in the inferior-most part of the lumbar spine or at the thoracolumbar junction. If retroflexion is painful and inhibited without actual restriction, this may be a sign of TrPs in the rectus abdominis muscle with tenderness to pressure at the pubic symphysis, or pain at the spinous processes.
Side-bending
When examining side-bending, the examiner needs to ensure that the patient’s movement does not deviate in the forward or backward direction. He should then compare on both sides how far down the leg the patient’s arm extends when side-bending with arms and fingers extended. (Do the fingertips reach as far as a point above, or – more frequently – beyond the knee?) As the patient bends, the examiner notes whether the spinal column arches over in an even curve, or with a sharp bend at some point, or whether it remains stiff.
A further aspect to look for is rotation synkinesis, in which the pelvis rotates in the opposite direction to the side-bending as soon as the side-bending movement reaches the thoracolumbar junction. This movement is evidently determined by the rotation of the lumbar spine during side-bending.
Anteflexion
When examining anteflexion with the knees held straight, the examiner should test how close to the floor the patient’s fingertips reach with knees fully extended, and at the same time note the arch of the lumbar spine and the position of the pelvis; it is important to distinguish whether anteflexion happens mainly at the pelvis with minimal lumbar kyphosis, or whether the main action is flexion of the lumbar spine with shortened ischiocrural muscles. Certain kinds of flattening of the bend during anteflexion are common and can be normal variations. These occur at the thoracolumbar junction and at the lumbosacral junction.
The examiner compares the prominence of the transverse processes as well as that of the erector spinae muscles that are stretched over them. This provides a sign of rotation as found in scoliosis, or possible deviation to one side such as happens in radicular syndromes.
When measuring the distance between the reach of the fingertips and the floor it is important to note not only an increased fingertip–floor distance but also a negative measurement. If the patient is able to place the flat of her hand on the floor, this is a sign of hypermobility.
The patient’s body proportions should be noted, looking at the length of the trunk, legs, and arms.
Anteflexion can be painful, even when there is no restriction. One reason is the ‘painful arc’ described by Cyriax (1978): during anteflexion, often shortly after beginning to bend forward, the patient feels considerable pain. An evasive movement of the spinal column can often be seen, as if the patient is working around some obstacle, after which the action continues quite normally. On straightening again the pain reappears and there is an evasive reaction at the same point. This sign indicates disk herniation. It is also possible for the patient to carry out the anteflexion movement normally but experience the pain on straightening. This indicates joint restriction in retroflexion.
If the fingertip–floor distance is increased, movement restriction of the lumbar spine is not the only possible cause, since this finding may also be linked to a positive straight-leg raising test. Therefore, if an increased fingertip–floor distance is found, the examiner should also test anteflexion in the sitting position with knees bent. If anteflexion is also restricted in sitting, and mobility of the hip joints is normal, this localizes the disturbance to the lumbar spine.
Before testing the mobility of the individual motion segments of the lumbar spine it is advisable to examine muscles with TrPs that are characteristic for disturbances in particular motion segments (see Table 4.1).
4.6.2. Examination of individual motion segments
Palpation
The examination can begin with palpation. The fingertips are used to provoke pain at the spinous processes. Although the spinous process lies in the midline, careful palpation will show that it is only truly tender to pressure on one side.
Springing test
Following palpation, the springing test is applied. This examines resistance and also provokes pain in the deeper-lying structures (mainly the joints and disks), so that it is important to avoid testing the spinous processes at the same time. The thenar and hypothenar eminences of one hand are placed on the transverse processes, ‘bridging’ over the spinous process. The examiner exerts very slight pressure with the extended arm to take up the slack, followed by ‘springing’ pressure (see Figure 4.14).
Another method is to place the tips of the second and third fingers of one hand on the transverse processes from the caudal direction, then using the ulnar (medial) edge of the other hand to take up the contact, then taking up the slack and applying the springing pressure (see Figure 4.15).
The springing test is not totally specific to a particular segment. If there is joint restriction, increased resistance (an absence of springing) is felt after the slack has been taken up, and the patient may also experience pain. However, if the patient feels pain when springing of the segment is normal, this is a sign of disk pain.
Palpation of mobility
Carefully directed palpation of mobility serves to localize a hypomobile or hypermobile motion segment more precisely.
Retroflexion
Restricted retroflexion can be localized as follows to the segment affected: the patient is in the side-lying position on the treatment table, with hips and knees flexed at an angle of about 100°. The examiner stands facing the patient, and begins by fixing the upper vertebra of the segment to be examined. This is done by placing one finger of each hand, one on top of the other, on the spinous process. Using his thighs he should then exert pressure against the patient’s bent knees in the dorsal direction, toward the fingers that are holding the vertebra fixed (see Figure 4.16). Having taken up the slack, he applies springing pressure to the knees, taking up the impulse at his fingers.
In a normal case this is sensed as a slight dorsal shifting of the lower of the two vertebrae against the upper one that is fixed. This movement is not felt if there is restriction, as long as the examination is not being done forcefully. It has been shown radiologically that this is in fact a slight, localized dorsiflexion, not a shift.
It is extremely important when carrying out this technique that the application of very slight pressure to the patient’s knees to take up the slack by the fingers should be done in absolute synchrony. The examiner can achieve this by straightening his trunk, which forces his thighs forward to deliver the push to the patient’s knees at the same time as bringing his arms backward. This technique is one of the very few that can localize the restriction to one single segment. In 35 patients examined at random independently by two examiners familiar with that technique there was full agreement in 30 cases and only 5 disagreements (see Figure 4.16).
Retroflexion can also be examined with the patient in the side-lying position. The examiner should grasp the patient’s lower legs above the ankles and push them away from the neutral position in a dorsal direction, so flexing the lumbar spine dorsally. The fingers of the other hand palpate between the spinous processes as these approach one another. Resistance is felt if there is restriction (see Figure 4.17). It is important for the success of this technique to keep the patient’s ankles on the treatment table, and not to lift them, when exerting the push in the dorsal direction.
Anteflexion
Anteflexion of the lumbar spine is examined with the patient in the side-lying position, with knees flexed to the abdomen and positioned so to lie close to the edge of the treatment table.
The examiner stands facing the patient and fixes her thoracic region by placing one elbow on it from above. With his thighs, he exerts a push against the patient’s knees so as to produce kyphosis of the lumbar spine and take up the slack. With the other hand, which is resting on the patient’s buttocks, he now applies a springing pressure designed to create further kyphosis. At the same time, the fingers of the hand fixing the upper thoracic spine palpate the mobility, sensing the separation of the spinous processes of two neighboring vertebrae, or sensing the resistance if there is restriction (see Figure 4.18).
It is important for the practical success of this technique to ensure that the hand fixing the spinal column from above is used to take up the pressure delivered by the examiner’s other hand and thighs.
If the patient is very tall and the examiner small, this will make it impossible to reach the spinous processes of the lower lumbar spine with the same hand while it continues to fix the patient’s shoulder region. In that case it will be necessary to use the fingers of the hand on the patient’s buttocks both to palpate and to deliver the pressure.
Side-bending
The patient adopts the side-lying position for this examination. Her underneath leg should be bent at right angles both at the hip and at the knee, so that her lower legs lie parallel to the line of her trunk, knees protruding slightly over the edge of the table.
The examiner stands facing the patient, and grasps the underneath leg just above the ankle. As he does so, her other leg becomes more flexed, so that her foot is now behind the thigh of the underneath leg. With the thumb of the other hand, the examiner fixes the upper vertebra of the segment being examined, from above. The examiner should now raise the lower part of the patient’s underneath leg, like a lever operating from a point of support resting against his thigh, using this to side-bend the lumbar spine (see Figure 4.19).
The thumb of the other hand, which is on the spinous process of the upper vertebra in the segment being examined, is used to palpate movement (or resistance).
4.7. Examination of the thoracic spine
4.7.1. Screening examination of active movement
Examination begins with active movement. The patient should sit astride the end of the treatment table and bend backwards and then forwards, easing out the body as she does so; she should then bend to each side, and rotate to each side with a slightly kyphotic posture. This enables the examiner to note the angle between her shoulder girdle and the table, and to see clearly any irregularities in the line of the spinous processes.
A springing test is performed using the same technique as that described for the lumbar spine, with the patient lying prone (see Figure 4.14 and Figure 4.15). The spinous processes are palpated; this is best done with the patient seated in a kyphotic position (see Figure 4.20).
Mobility of the individual segments can be observed from the side with the patient prone, by means of deep inhalation and exhalation as described by Tesarová (1969). It is helpful if the patient is asked to inhale first into the abdomen and then into the chest. This enables the examiner to observe the rise and fall of the back and also the fan-like movement of the spinous processes as they expand and separate during inhalation and draw together during exhalation. If this movement is absent anywhere, this indicates joint restriction. This test cannot be applied in a case of pronounced clavicular breathing (in which the thorax is lifted during inhalation), because the chest wall is not being expanded.
4.7.2. Palpation of mobility
For the specific palpation of mobility the examiner should stand to one side behind the patient. The patient sits on the table with arms clasped behind the back of her neck.
Retroflexion
The patient’s elbows should be angled forward, and the examiner grasps them from below with one hand. With his other hand he should palpate with one finger between two spinous processes (see Figure 4.21). Then he should bring the patient’s thorax into retroflexion until the barrier is engaged, following this with a springing pressure.
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| Figure 4.21 |
In those locations where the spinous processes do not move toward each other, the examiner will simultaneously sense resistance if there is joint restriction. It is important in this technique to guide the patient’s trunk in such a way that the apex of the retroflexion occurs at the position of his palpating hand. This can be done if the patient is made to lean against the examiner’s body and the two move in concert.
4.7.3. Anteflexion
To examine anteflexion, practitioner and patient adopt the same position as for retroflexion; this time, however, the practitioner grasps the patient’s elbows from above. He should anteflex the patient’s trunk in kyphosis to take up the slack, and apply a springing pressure (see Figure 4.22), palpating between the spinous processes with the fingers of the other hand to sense the increase in tension during the springing pressure. No springing is felt if joint restriction is present. The hand which anteflexes the patient’s trunk also feels increased resistance, which makes the diagnosis easier.
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| Figure 4.22 |
Again, in this examination it is important to move the patient’s trunk in such a way that the point of maximum kyphosis is the site of palpation by the examiner’s other hand.
4.7.4. Side-bending
To examine side-bending the practitioner stands behind the patient, who is sitting. The practitioner should place one hand dorsally around the patient’s ribs at the level of the segment being examined, the thumb palpating between the spinous processes of the segment from laterally. He places his other hand at approximately shoulder height (according to the level of the segment being examined) on the other side, side-bending the patient’s upper body to engage the barrier (see Figure 4.23).
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| Figure 4.23 |
With his palpating hand the practitioner stabilizes the patient’s thorax while the thumb palpates the resistance to the springing pressure delivered by his other hand. Resistance is greater if there is joint restriction.
For this technique it is important for the fingers on the ribs to create a fulcrum as they support the patient’s trunk. At this point it seems as if the thumb will not be able to reach the spinous processes, but during the side-bending the thoracic spine rotates, which brings the spinous processes into contact with the palpating thumb.
If the patient has a very broad back (and the examiner has a very small hand), the following technique is more appropriate: the examiner should stand at the patient’s side, grasp her farther elbow, which is raised, and draw that elbow toward him. He uses the thumb of the other hand, from a lateral direction, to fix the spinous process of the lower vertebra in the segment being examined (see Figure 4.24).
4.7.5. Rotation
For this examination the patient should sit astride the end of the treatment table, with her back toward the examiner, and actively turn her trunk from one side to the other. The examiner compares the extent of rotation and notes any asymmetry.
On palpation (sometimes even on inspection) with the patient in slight kyphosis it is often found that the spinous processes in the region of the thoracolumbar junction do not move evenly to each side. In the past this was interpreted as a sign of restriction; however, this was disproved by Singer & Giles (1990) in a computed tomography (CT) study during rotation. Further, clinically it was then found that the rotation restriction to one side is muscular in origin; it is produced by TrPs in the thoracolumbar erector spinae, psoas major, and quadratus lumborum muscles, especially those on the contralateral side to the rotation restriction. The treatment we give to our patients, therefore, consists almost entirely in relaxation of these contralateral muscles. Because of the way that these muscles are linked, to relax just one of them is enough to normalize rotation (see Chapter 6).
4.8. Examination of the ribs
4.8.1. Screening examination
The examination continues with the thorax, including the ribs. Just as the spinous processes are palpated for tenderness when examining the thoracic spine, so it is the angle of the rib that is palpated when examining the ribs for pain points (Tilscher & Oblak 1974). The angle of the ribs is the most prominent part dorsally, situated laterally to the erector spinae muscles. It is accessed by abducting the scapula, which can be done by pressing the patient’s elbow against the thoracic cage on the same side.
Pain points at the angle of the rib must be differentiated from a frequently-found TrP in the middle part of the trapezius, which tenses like a tendon medially to its attachment to the scapula when this is fully adducted, and is also tender to pressure.
There is a pain point at the sternocostal joint that generally corresponds to pain points at the angle of the rib. (This is the point of attachment of the pectoralis minor muscle.)
The respiratory excursion of the ribs is examined by comparing rib movement on both sides during inhalation and exhalation, with the patient lying down. This movement should be assessed visually and by palpation of the area between the ribs. The patient should be asked to inhale and exhale deeply. When the excursion of the ribs is at its maximum it is easiest to assess whether the inhalation (or exhalation) stops sooner on the affected side than on the healthy side.
When the patient is supine, an overtake phenomenon is often observed in the region of the upper ribs. One rib is found to be slightly lower than its opposite number; during inhalation, the rib that had been lower ‘overtakes’ the other. This indicates joint restriction on the side that was ‘overtaken.’
The most useful method of examining the upper and middle ribs is the palpation of resistance during retroflexion as described by Kubis (1970). The patient is sitting. For this examination she should adopt the same position as was used to examine retroflexion of the thoracic spine, except that this time she should raise only the elbow on the side of the rib to be examined. This she raises to the maximum, placing her hand on the back of her head. The examiner stands on the other side, grasps the elbow from in front, and uses it to bend the patient’s trunk backwards. The pads of the fingers of his other hand take up contact with the angle of the rib under examination and offer resistance (see Figure 4.25).
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| Figure 4.25 |
The examiner applies pressure in a dorsal direction to the raised elbow, toward the fingertips of the other hand, to take up the slack, followed by springing pressure to test whether the springing of the joint at the end of range is normal.
It is important to support the patient’s body, and to guide the elbow in such a way that movement occurs only in the sagittal plane and that there is no rotation of the patient’s trunk.
When examining in the region of ribs 2–5 it is necessary to palpate through the shoulder blade, but this does not affect the quality of the palpation.
Putting pressure on the lower arch of the thorax (mainly the 10th rib) between two fingers from inside and outside is diagnostic for a ‘slipping rib’.
4.8.2. Examination of the first rib
The first rib occupies a special position, and dysfunction causes pain at the upper border of the shoulder and just below the clavicle, toward the sternal manubrium, where the first rib articulates with the sternum.
Restriction of the first rib is common. The simplest method of testing for this is to apply springing pressure from above, which is done as follows: the examiner should stand behind the patient, place the radial (lateral) edge of one forefinger on the first rib from above and apply slight pressure to take up the slack. This is followed by springing pressure, and the examiner can then sense whether there is any springing at the first rib.
Palpation of mobility is carried out by the following method. The patient is sitting. The examiner begins by drawing the patient toward him and placing the lateral edge of one forefinger on her clavicle, laterally to the neck, to create a fulcrum. The patient’s neck is rotated contralaterally and then inclined forward until resistance is felt (see Figure 4.26). If there is restriction of the first rib, this diagonal anteflexion will be markedly restricted as compared with the normal side.
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| Figure 4.26 |
There is a close link between restrictions of the first rib and dysfunctions of the cervicothoracic junction.
4.9. Examination of the cervical spine
4.9.1. Screening examination
This begins with inspection, concentrating in particular on head posture and symmetry, followed by palpation of the soft tissues and TrPs. The assessment of active movement looks at anteflexion, retroflexion, side-bending (inclining the ear toward the shoulder), and rotation to both sides. Examination against (isometric) resistance is also important in order to diagnose any muscular lesion, especially following an accident.
Palpation is done with the patient supine, her head beyond the end of the treatment table, slightly raised and supported against the examiner’s thighs (see Figure 4.27). In this position all the muscles are relaxed and the examiner can palpate not only the spinous processes but also the transverse and articular processes.
The supine position with head raised is necessary in order to palpate the short craniocervical extensors, posterior arch of the atlas, and posterior border of the foramen magnum, where important pain points are found. The pain points at the nuchal line are secondary.
In order to palpate the site of important pain points on the lateral aspect of the spinous process of C2, the examiner should incline the patient’s head to the opposite side. As he does so, it rotates toward his fingers, which he uses to palpate from a lateral position. The patient can be either sitting or lying down.
Palpation of the transverse process of the atlas is better carried out with the patient sitting, palpating from laterally and below, between the mastoid processes and the ascending ramus of the mandible. This transverse process is more prominent laterally than those of the other cervical vertebrae. Following this, the examiner should palpate TrPs in the two sternocleidomastoid muscles, between his thumb and forefinger.
Accurate localization of the spinous process of C7 can sometimes be important for precise orientation, since the examiner has to ensure that the process found is that of C7 which is not always the vertebra prominens. This is best done during retroflexion, placing a finger on each of two neighboring spinous processes at the cervicothoracic junction. During retroflexion the spinous process of C6 moves deeper, while that of C7 remains in the same place.
4.9.2. Examination of passive mobility
The assessment of passive mobility begins with a screening examination of the whole of the cervical spine. The patient is sitting and the examiner must fix (immobilize) the cervicothoracic junction so that any resistance, or indeed tenderness, can be detected.
Retroflexion and anteflexion
Retroflexion is examined as follows: the examiner should stand beside the patient and ease her head backward, testing springing of the cervicothoracic junction.
To test passive anteflexion the examiner should guide the patient’s chin toward the chest while holding the upper thoracic spine fixed from behind, and noting the tension.
The most common cause of restriction here is shortened neck muscles. If pain is felt at the start of anteflexion, this may indicate restriction of the atlanto-occipital and atlantoaxial joints; meningeal or radicular pain is typically felt during the course of anteflexion, and pain felt at the barrier, after a period of latency, is most probably ligament pain (see Section 7.6.1, Anteflexion headache, p. 332).
Side-bending
In order to test side-bending, the examiner should fix the shoulder from the side toward which the side-bending is performed and ease the patient’s ear down toward her shoulder, comparing mobility in both directions.
Rotation
This test is the most important for diagnosis.
Examination with patient sitting
The patient should be sitting erect. The examiner fixes her shoulder from in front, on the side away from that to which the patient’s head is to be turned, using his elbow to do so. As he turns her head, the examiner should note how close it is possible to bring the chin to the shoulder on either side (see Figure 4.28 A). Care must be taken to rotate the head accurately about a vertical axis.
An alternative method is to perform this test with hands crossed. To turn the patient’s head to the left, the examiner applies lateral pressure with the right hand to her chin, while his left hand guides the occiput to the right. The examiner should fix the patient’s right shoulder, using his forearm from behind (see Figure 4.28 B).
With the head in maximum anteflexion
To test rotation in maximum anteflexion the examiner stands behind the patient, who is sitting. With one hand on the occiput he should ease her head into maximum anteflexion, while using the fingers of the other hand to fix her chin.
In this position, rotation takes place almost entirely between the atlas and axis. It is particularly important in this case to ensure that the rotation takes place about the longitudinal axis of the cervical spine; the cervical spine will now be almost horizontal. This can only be achieved by ensuring that the main movement is that of the occiput from one side to the other, while the chin is held fixed as described (only the minutest amount of movement should be permitted).
Because the examiner sees only the patient’s occiput, he only sees the movement there, and so tends to move the chin. A warning must be given: when carrying out rotation in maximum anteflexion it is a serious mistake to exceed an angle of 45° in either direction.
With maximum forward nutation of the head
To test rotation with the patient’s chin drawn to its maximum extent towards the neck (forward nutation), the examiner stands behind the patient and eases her chin toward her neck, rotating her head as far as it will go to one side and then the other and at the same time applying slight traction. According to Jirout (1979b), rotation takes place almost exclusively in the C2/C3 motion segment.
Again it is important to ensure that rotation takes place about the correct axis, and this is done by moving mainly the occiput, and permitting the minimum of movement at the chin.
In retroflexion
In retroflexion the atlanto-occipital and atlantoaxial joints are locked and the examination looks at the region below C2/C3. The farther backward the cervical spine is inclined, the more the rotation takes place in the lower and cervicothoracic sections. Here, too, care has to be taken to ensure that rotation occurs about the longitudinal axis of the cervical spine.
The crossed-hand hold shown in Figure 4.28 B is helpful here. One hand simultaneously moves the chin to one side and raises it. Again, the chin should move only minimally, and it is mainly the occiput that is moved. Care should be taken not to permit any lateroflexion.
Having completed these investigations, which are designed essentially as a screening examination, we proceed to the examination of the individual motion segments.
4.9.3. Examination of the motion segments
Side-bending
This can be performed with the patient sitting or lying down. For each segment, the examiner inclines the patient’s head to the side with one hand while the other creates a fulcrum at the lower vertebra of the segment under examination; the examiner uses the edge of his forefinger to do this and the cervical spine is inclined over this fulcrum. With the hand that moves the patient’s head, the examiner then applies very slight pressure to take up the slack. Springing pressure is given to test springing at the end of range (resistance) as well as range of movement. The findings are compared with the other side and with neighboring segments.
With patient supine
For the examination in the supine position the patient’s head extends beyond the end of the table and is cradled in the examiner’s hand, slightly raised and rotated gently toward the contralateral side. When examining C1/C2, the cervical spine up to C2 should remain as far as possible in the neutral position, with only the head nutated to one side: to be precise, the head is rotated about an axis at the level of the root of the nose (see Figure 4.29 A).
For the lower segments the index which forms the fulcrum is lowered to the examined segment and the head side bent accordingly to take up the slack and to sense resistance against springing in end position (see Figure 4.29 B).
With patient sitting
For side-bending at the cervicothoracic junction, the patient must be sitting as erect as possible. Using the ulnar (medial) fingers of one hand in the region of the zygomatic bone, the examiner should bend the patient’s head backward and to the side, at the same time rotating it in the opposite direction to that of the side-bending. While performing this rotation, the examiner uses the thenar eminence of the other hand to contact and fix the spinous process of the upper vertebra of the pair in the segment being examined. With the thumb of the other hand, he applies springing pressure from the side to the spinous process of the lower vertebra of that segment and senses the resistance (see Figure 4.30).
With patient in the side-lying position
The examination is somewhat easier to perform with the patient in the side-lying position. The examiner should stand facing the patient, with his forearm under her head, his elbow supported on the table, and his hand cradling the patient’s occiput. The examiner should now push the supporting elbow forward on the table, so that his hand automatically produces a side-bending movement of the patient’s head combined with rotation to the opposite side. This is done until the barrier is engaged, when he applies springing pressure in the same direction. The thumb of his other hand meanwhile fixes the spinous process of the lower vertebra of the pair (see Figure 4.31).
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| Figure 4.31 |
The examiner will find it easier to perform this test with his knee supported on the treatment table.
Rotation
The patient is sitting, and the examiner stands behind her. He fixes the vertebral arch of the lower vertebra of the segment, from one articular process to the other, between the thumb and forefinger of one hand. With his other hand, he should rotate the patient’s head to the side (usually guiding it by the chin) until he senses resistance at the thumb or forefinger of the hand fixing the vertebral arch. He can then deliver slight springing pressure (see Figure 4.32).
The examination begins by fixing the axis and establishing the range of movement between atlas and axis; it then proceeds with C2/C3, and on down to C5/C6. The range of movement increases step-wise. If there is a restriction in a segment, this step increase is absent on one or both sides. This method can be used to register the movement found, which was successfully done by Berger (1990) by means of cervicomotography (see Figure 4.33).
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| Figure 4.33
Step diagram produced using cervicomotography according to Berger (1990). 1, Movement restriction between C1/C2 and C2/C3 (arrows), and hypermobility between C3/C4. 2, After mobilization, restriction between C2/C3 and hypermobility between C3/C4. 3, Normal finding after further treatment.
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The following points are important in order to perform this technique accurately:
• The vertebra that is fixed during the investigation must be held exactly in the neutral position.
• Only the minimum of force should be used to fix the vertebra, because as soon as the finger that is fixing (palpating) the vertebra reaches the articular process, a reflex response by the patient causes it to stop, which has the effect of determining the range of motion.
Another useful place to examine rotation is at the cervicothoracic junction. The examiner stands behind the patient, who is sitting erect on a low chair. The examiner takes hold of the patient’s head between his forearm and upper arm, so that her forehead rests in the crook of his elbow. With the little finger of the same hand, he should then span the arch of the upper vertebra of the segment being examined. The thumb of his other hand fixes the spinous process of the lower vertebra from the contralateral side (see Figure 4.34). Next the examiner should turn the patient’s head to take up the slack, and exert gentle springing pressure.
Shifting techniques
These techniques are used to examine joint play in the cervical spine in the ventrodorsal and laterolateral directions.
The patient should be sitting erect. The examiner stands at the side and takes hold of the patient’s head between his forearm and upper arm. The little finger of the same hand spans the vertebral arch of the upper vertebra of the segment to be tested. From this point, two methods are possible:
1. The examiner shifts the patient’s head backwards until the barrier is engaged, and then applies springing pressure. In this case he should fix the lower vertebra of the segment at the vertebral arch by holding it between thumb and forefinger.
2. The examiner side-shifts the patient’s head and that part of the cervical spine down as far as the upper vertebra of the segment, holding the lower vertebra of the pair fixed using either his thumb, working toward him, or his forefinger, away from him. Each time, on engaging the barrier he applies gentle springing pressure (see Figure 4.35).
This technique can be used to examine the segments from C2/C3 down to C5/C6 backward and to the side. It can also be used successfully, in the backward direction only, to test the occiput–atlas segment. In this case slight anteflexion of the head is advisable. The fixing hand grasps around the arch of the axis, but shifting is only possible between the atlas and the occipital condyles, not between the atlas and axis.
From C6 to T3, the shifting technique can be used successfully in the backward direction for diagnosis. The patient is sitting erect on a low chair. The examiner takes hold of the patient’s head between his forearm and upper arm, so that her forehead rests in the crook of his elbow. With the ipsilateral hand, he applies pressure in the dorsal direction to the patient’s trapezius muscle. The lower vertebra of the segment is fixed with the finger or the thumb of the other hand (see Figure 4.36).
The backward pressure applied to the shoulder muscles has the effect of delivering a dorsal push to the spinal column while fixation of the lower vertebra of the segment localizes it.
4.9.4. Testing of mobility between occiput and atlas
Anteflexion
The patient is supine. The examiner should place his hand, palm uppermost and completely relaxed, on the treatment table, allowing the patient’s occiput to rest in the palm. He should rest his thumb and forefinger on the superior, posterior border of the transverse process of the atlas to fix the vertebra from the cranial direction. The other hand is placed on the patient’s forehead and she is asked to look down toward the chin to engage the barrier (see Figure 4.37).
In this position, springing pressure is applied. This is done using the fingers on the transverse processes of the atlas, as the fingers release their hold, so that the examiner can verify how effective fixation of the atlas is. At that moment, anteflexion should increase.
Side-bending
The patient lies supine, head beyond the edge of the table. The examiner should take hold of the patient’s head and rotate it so as to lock the atlas/axis segment, then very gently carry out side-bending between the occiput and atlas sufficiently to engage the barrier, and apply springing pressure (see Figure 4.38). With older patients, head rotation need not exceed 50–60°.
Retroflexion
The patient lies supine, head well beyond the edge of the table. The examiner should take hold of the patient’s head by the chin and at the occiput, well up toward the top of the skull, then raise the head a little and rotate it so as to lock the rest of the cervical spine. In this position, the examiner should incline the head backward sufficiently to engage the barrier, and apply springing pressure (see Figure 4.39). The hand on the occiput needs to be placed high enough up the skull so that it does not obstruct retroflexion (this also applies during the mobilization).
This test is carried out once with the patient’s head rotated to the right, and once to the left.
Rotation
The patient is sitting erect. The examiner should stand behind the patient, place one hand on the patient’s cheek and, with this hand, rotate the patient’s head to one side. It is stabilized against the body of the examiner. Care should be taken to ensure that the head rotates about a vertical axis. Using the very minimum of force, the examiner should take up the slack and gently apply springing pressure, again with the absolute minimum of force. Springing is sensed with a fingertip of the other hand, placed on the transverse process of the atlas. If there is joint restriction, no springing is felt, either at the chin or at the transverse process of the atlas.
4.10. Examination of the limb joints
Dysfunctions of the locomotor system affect the limbs as much as they do the spinal column, and both are so closely linked that it is always hard to decide the location of the primary or more serious disturbance. As a result, the diagnosis and treatment of these disturbances are an important part of everyday practice.
Examination always begins with inspection, followed by active movement, then passive movement and movement against resistance, so as to differentiate between a disturbance of the joint and one of the muscle. Weakness in a muscle need not be the result of paresis; it may be caused by pain.
When examining passive movement, a distinction has to be made between functional movement and joint play. In disturbances of functional movement, we distinguish between a situation in which movement is affected within the joint itself, and one in which it is affected by an external obstruction (such as a disturbance of the subdeltoid bursa at the shoulder joint). In this case, mobility of the joint is restricted only in the direction in which the obstruction operates; for example abduction of the shoulder if there is a disturbance in the region of the subdeltoid bursa. In the other case, all the movements of the joint are affected; not to the same degree in every direction, but nevertheless a clear proportional relationship can be observed. This has been termed a ‘capsular pattern’ by Cyriax (1977). Every joint has its own characteristic capsular pattern, and it is this pattern that determines the diagnostic significance.
Movement restriction of the joint itself usually also involves restriction of joint play. Therefore this should always be examined; joint play and the re-establishment of joint play are fundamental to therapy. The technique used to examine joint play is identical to that used for joint mobilization performed for the purpose of therapy; it is therefore described in Chapter 6, in connection with therapy.
4.10.1. The shoulder
Active movement
Active movement can be further classified into the categories of abduction, adduction, internal rotation, anteflexion, and retroflexion.
The most commonly found disturbance, and also the most painful, is that of abduction. Pain is felt on movement within a circumscribed range, which can be overcome (the ‘painful arc’): the patient feels pain during abduction at a particular angle of less than 90°, but if it is possible to pass this point, abduction continues quite normally to the full extent. The cause of this lies in the fact that the head of the humerus and rotator cuff slip under the acromioclavicular ligament during abduction. This is enabled by the subdeltoid bursa. If there is a disturbance of the subdeltoid bursa or in the rotator cuff, this initially results in a transitory constraint; however, if the change is more advanced it leads to a painful, absolute, isolated barrier to abduction.
This is the interpretation given by Cyriax (1977) and is the basis of ‘impingement syndrome,’ and is widely accepted. Examination of patients with this clinical picture, that is impaired abduction but normal rotation with the arms in abduction, regularly presents lack of joint play as shown in Figure 4.42. After mobilization – restoring joint play – abduction is regularly restored (see Figure 6.13).
The explanation lies in the biomechanics of the glenohumeral joint as given by Latarjet (Testut 1928). On page 592 we read: ‘If the distal part of the humerus is lifted, its proximal part or its head slips down in the fossa glenoidalis; on the other hand, if the same extremity moves upward in the glenoid cavity then the humerus which was previously raised returns to its position of rest in adduction’ (see Figure 4.42).
‘Whatever the role of tears in the rotator cuff and/or changes in the bursa subdeltoacromialis, once joint play is restored, that is the normal biomechanics of the glenohumeral joint, the patient can abduct (lift his arm) normally and without pain.’
The most commonly found painful changes of muscle attachments in the region of the rotator cuff can be investigated by isometric contraction against resistance in the starting position.
Pain produced by the tension of abduction with the arm fully adducted (see Figure 4.40 A) indicates a lesion of the supraspinatus. Pain produced by the tension of external rotation (see Figure 4.40 B) indicates a disturbance of the infraspinatus.
The long biceps tendon can be palpated directly, but if the patient reports pain when this is done, it originates from the attachments at the crest of the greater or the lesser tubercle. A more reliable method is to provoke the pain by anteversion of the supinated arm, bent at the elbow, against resistance (see Figure 4.40 C). The subscapularis, the most important internal rotator muscle, has to be palpated deep inside the axilla.
Passive movement
If passive mobility is impaired at the shoulder joint itself (the scapulohumeral or glenohumeral joint), the characteristic capsular pattern observed is, according to Sachse (1995), the following: first and most commonly, abduction is restricted, followed by external rotation and then internal rotation. The starting position is with the arm adducted and elbow ventrally directed. The shoulder blade must be fixed, either from above (see Figure 4.68) or from the side at the inferior angle of the scapula.
External rotation
It is important when examining external rotation to ensure that the patient’s upper arm remains adducted and the elbow flexed at 90°. External rotation is usually examined on both sides at once (see Figure 4.41).
Internal rotation
Internal rotation is usually also examined on both sides at once, by drawing the patient’s thumbs upward behind her back and comparing the two sides. When this examination is performed, adduction produces a degree of retroflexion.
Abduction
In this case there is a characteristic disturbance of joint play: with the upper arm abducted at a right angle, the examiner applies slight pressure to the head of the humerus from above to engage the barrier, followed by springing pressure (see Figure 4.42). If there is a true capsular pattern and the patient is still able to abduct her arm to approximately 90°, joint play is normal, indicating that the frozen shoulder is not due to dysfunctional joint restriction but to reactive capsulitis.
If abduction alone is restricted, there is generally also a disturbance of joint play. In this case the head of the humerus cannot glide down from the narrow, upper part of the glenoid cavity as it needs to in abduction. It is important when performing this test to ensure that the pressure is applied at the correct point: on the head of the humerus, which is lateral to the apex of the deltoid (see Figure 4.42).
The acromioclavicular joint
Two more joints frequently cause shoulder pain: the acromioclavicular and the sternoclavicular. Disturbance of the former is very frequent, although its involvement is seldom recognized; however diagnosis is not difficult: adduction of the arm in front of the thorax causes the patient to feel pain and is restricted in comparison with the normal side. This is done by passively moving the elbow of the affected side toward the opposite shoulder. Direct palpation of the joint itself is also painful.
The sternoclavicular joint
Dysfunction of the sternoclavicular joint is a much less common condition. The patient experiences pain when moving the shoulder blades and on movements involving greater excursion of the shoulders; on palpation the joint is tender to pressure. The following points should be noted, however: tenderness of the medial end of the clavicle is also found in cases of myotendinosis of the sternocleidomastoid. Also, laterally below the clavicle is the joint between the first rib and the manubrium of the sternum, and this is tender to pressure in cases of restriction of the first rib.
The expression ‘periarthritis humeroscapularis’ or ‘shoulder periarthritis’ is still much used, but is meaningless and unhelpful as a description of frozen shoulder. Specific diagnosis of the disturbance is required.
4.10.2. The elbow
Disturbances of the elbow joint produce restriction in flexion and extension, with flexion being more markedly affected in accordance with the capsular pattern. The joint play here is a sideways (radial or ulnar) springing of the forearm, especially of the ulna relative to the upper arm. The elbow is also the location of the radioulnar joint, and it is here that pronation and supination take place.
The most frequently found clinical condition is pain at the epicondyles. There is tenderness on palpation involving application of pressure. If the radial epicondyle is affected, pain is produced by shaking hands or lifting a chair with the arm pronated. Lifting with the arm supinated is painful if it is the ulnar (medial) epicondyle.
4.10.3. The wrist
The wrist joint is complex, consisting of the radius and ulna, the carpal bones, and their articulations with the metacarpals.
In order to localize findings anatomically it is useful to know that the skin fold on the dorsal aspect of the wrist in dorsiflexion corresponds to the radiocarpal joint, and that the fold on the palmar aspect in palmarflexion corresponds to the carpometacarpal joints.
The general appearance of the wrist joint (articulatio radiocarpalis) is at first sight rather like an egg that is free to move around in every plane in the shallow joint socket of the radius. Its functional movements, in combination with the midcarpal joint (articulatio mediocarpalis), are in fact limited to dorsal extension and palmar flexion and radial and ulnar abduction. Rotation is entirely possible in terms of joint play, but as regards functional movement the muscles to perform active rotation are lacking.
The wrist joint and midcarpal joint each have a distinct role to play in dorsal extension and palmar flexion. Palmar flexion takes place mainly in the wrist joint, the proximal row of the carpal bones gliding in a dorsal direction relative to the radius. Dorsal extension takes place mainly in the midcarpal joint, the distal row of the carpal bones gliding in a palmar direction relative to the proximal row.
In ulnar abduction, the proximal row glides radially (laterally) relative to the radius.
Radial abduction involves the most complicated mechanism. The proximal end of the first metacarpal draws closer to the radius, and as it does so the lateral end of the scaphoid tips in the palmar direction. The trapezium and trapezoid glide in the palmar direction, rather as they do in dorsal extension. This explains why it is possible to perform radial abduction at the same time as dorsal extension, but not simultaneously with palmar flexion. In dorsal extension, ulnar abduction is prevented.
A further factor affecting ulnar abduction and, still more, radial abduction, is the mobility of the ulna relative to the radius. Radial abduction is accompanied by a synkinetic pronation of the forearm when the hand is kept in the same plane. Similarly, on ulnar abduction there is a corresponding slight supination. The radius also moves proximally relative to the ulna during radial abduction, and distally during ulnar abduction. Lateral movements in the wrist are therefore dependent on the mobility of the radius relative to the ulna. This is the main cause of certain frequently occurring painful conditions, such as pain at the radial styloid process or, less frequently, at the ulnar styloid process, tenosynovitis and persistent pain following fracture of the radius.
The cause of restricted abduction of the wrist in a radial (lateral) or ulnar (medial) direction is most frequently found in the radioulnar joints, most importantly at the elbow.
The metacarpophalangeal joints are in fact ball and socket joints, which permit movement in every plane, but the absence of rotator muscles means that only flexion, extension, and laterolateral movements are actively possible. The only exception is the saddle joint between the trapezium and first metacarpal. This joint permits movement in all three planes, whereas the first metacarpophalangeal joint only permits flexion and extension.
The interphalangeal joints are hinge joints, which permit only flexion and extension. Joint play in the finger joints is dealt with in Section 6.2.1.
4.10.4. The hip
Although the hip is a limb joint, clinically it is part of the pelvis, borne out by the fact that frequently the first symptom in lesions of the hip joint is low-back pain.
In disorders of the hip joint, the hip – and therefore also the knee – is in flexion; it is also in external rotation, which often has the effect of increasing the lumbar lordosis. This makes it possible to distinguish hip pain from acute lumbago at first glance. The distinction is still clearer in retroflexion.
The most constant sign to be looked for is Patrick’s sign (see Figure 4.43), and it is with this that the examination proper begins. The leg to be tested is flexed at hip and knee (‘frog-leg’ position). The test is positive if abduction of that leg is restricted.
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| Figure 4.43 |
The capsular pattern in dysfunction is first and most markedly restriction of internal rotation. This is tested with the patient supine, with the knee and hip flexed (see Figure 4.44) or with the patient lying prone with the hip straight (examining both sides at the same time). This is followed by an examination of extension (with the patient prone), of maximum flexion (patient supine), and finally external rotation. In addition, active abduction of the leg with the patient in the side-lying position is painful. The range of motion may be normal at first, but springing in the end position is painful.
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| Figure 4.44 |
The most important pain points are at the femoral head in the groin, the greater trochanter, and the attachment of the adductors on the pes anserinus of the tibia, which the patient experiences as pain in the knee. The articular head and socket being largely congruous, the only joint play is distraction.
4.10.5. The knee
The inspection of the knee should note:
• valgus or varus alignment
• genu recurvatum (back-knee)
• deterioration of fine structural features as in osteoarthritis
• the height of the hollows of the knees.
Again, asymmetry here can cause pelvic obliquity.
The knee, like the elbow, consists of two joints: it is made up of the true knee joint, between the femur and the tibia, and the joint between the tibia and fibula (the tibiofibular joint). The movements that take place at the knee joint are flexion, extension, and, when the knee is flexed, rotation.
There is considerable joint play, partly because the joint surfaces are incongruous, and partly on account of the articulation with the patella. The joint play consists of gliding in the ventrodorsal direction with the knee flexed, distraction, laterolateral shifting, and springing with the knee extended; also of craniocaudal and laterolateral shifting of the patella.
The joint pattern of the knee means that the first and most common restriction is that of flexion. This must therefore be examined first, by bringing the heel toward the buttock as far as it will go. It will be necessary to guide the patient’s heel so as to deviate slightly medially or laterally, to avoid obstruction of the approach caused by the substantial belly of the calf and ischiocrural muscles. Rotation between the upper and lower leg can also be examined when the patient’s knees are flexed.
The most important pain points are at the medial collateral ligament, in the hollow of the knee, at the superior border of the patella, and at the attachment of the patellar ligament (housemaid’s knee).
The tibiofibular joint participates in the rotation of the lower leg on the thigh. Passive movement can most accurately be examined by comparing the internal and external rotation of the feet with the patient prone and the knees flexed. The joint play consists of dorsomedial and ventrolateral rotation of the fibular head, and is best examined with the patient supine and with knees flexed.
Restriction of the head of the fibula is clinically very significant. The fibular head is the point of insertion of the biceps femoris, and restriction of the fibular head is regularly associated with a TrP in this muscle. This disturbs the fixation of the pelvis, affecting the abdominal and gluteal muscles and so overall posture (forward-drawn posture).
4.10.6. The foot
Some aspects have already been dealt with when discussing the inspection. Assessment of flat foot can be carried out most accurately and with equivalence on both sides by inserting the tip of the finger under the longitudinal arch from medially, pushing the fingertip inward, and comparing findings. The finger meets resistance sooner on the side that is flattened. If asymmetry is found, this is often the cause of pelvic obliquity. The patient should be asked to stand supported on the lateral edges of the foot; both iliac crests then become horizontally level.
Besides establishing the shape of the foot, a functional diagnosis is needed. For this, the examiner must observe the arch of the foot from medially, during walking. The point that needs to be checked is whether the arch of the foot is maintained or yields during the action of walking, irrespective of the degree of arching or flatness of the foot. In normal locomotion the heel strikes the ground first; the foot then uncurls, mainly along its lateral border, into pronation and pushes off with the aid of the toes. If the patient concentrates on the lateral border and tries to sense this during walking, this is often enough to restore the function of the foot.
The function of the toes in pushing off often suffers restriction. This insufficiency of the toe flexors is closely associated with splay foot. Véle’s test (personal communication) examines this. If the patient, standing barefoot, transfers her weight forward without going on tiptoe, this automatically (as a reflex response) produces flexion of the toes, evidently as a defensive action to prevent falling. This reflex is frequently absent, especially when there is weakness of the short flexors of the foot in the case of splay foot or S1 radicular syndrome. Therefore, in the case of splay foot, this synkinesis needs to be practiced. The patient is asked to rock rhythmically to and fro.
Hallux valgus is commonly found, representing a deviation of the great toe toward the lateral side of the foot as a result of wearing constricting shoes, and involving a weakness of the abductor hallucis. This muscle also supports the longitudinal arch of the foot, so that the patient has to learn (laboriously!) how to exercise the muscle. Shoes are a factor not only in hallux valgus, but also in causing the deficient function of the toes and so also for splay foot.
The best method of screening all the joints of the foot is to test rotation about its longitudinal axis. The patient is supine, the examined leg flexed with the heel resting on the table. The examiner grasps the foot with one hand at the first metatarsal head and the other at the fifth, and rotates it around the longitudinal axis, which passes through the talar head. If there is dysfunction in any of the foot joints, this rotation is impaired: either the foot deviates from the axis before the end of the rotation, or increased resistance is found if the axis of rotation is maintained.
The ankle joint (articulatio talocruralis) is a hinge joint which allows only the movements of dorsiflexion and plantarflexion. As a result of its joint pattern, the prime, most common restriction of this joint is dorsiflexion. This is generally examined with the patient’s knees flexed, because, with the knee extended, a short gastrocnemius muscle hinders dorsiflexion. Joint play consists of ventrodorsal shifting of the tibia and fibula against the talus, and distraction. It is important to realize that, when there is dysfunction of this joint, this is clearly shown by the joint play, while the range of functional movement often remains normal.
The joints of the foot include the subtalar (talocalcaneal) and talocalcaneonavicular joints between the talus, the calcaneus and the navicular bone, the transverse tarsal (Chopart’s) joint, and the tarsometatarsal (Lisfranc’s) joints between the tarsals and metatarsals. They enable active pronation and supination combined with eversion and inversion. Joint play in particular should be examined, and this is used for mobilization (see Section 6.2.2).
Examination of the toe joints is done in the same way as that of the finger joints. Although there is no articulation between the heads of the metatarsals, in the foot their free mobility one against the other is especially important. This mobility is often disturbed in painful splay foot and in radicular syndromes. The problem is due to a soft-tissue lesion between the metatarsals.
4.11. Examination of the temporomandibular joint
The temporomandibular joint forms a functional unit together with the masticatory muscles and muscles of the floor of the mouth, and it is of great importance, as can be seen from the term ‘mandibulocranial syndrome.’ In fact, the mandibulocranial syndrome can cause symptoms that are difficult to distinguish from craniocervical syndrome, including headache and even vertigo. When the main symptom is pain in the face, differential diagnosis is important to exclude trigeminal neuralgia. Pain in the region of the ear, and dysphagia, sometimes also tinnitus, are also typical symptoms.
An important diagnostic indication is tenderness to pressure of the capitulum in front of the tragus, on palpation from the direction of the external auditory meatus. This may intensify on opening and closing of the mouth. TrPs in the masticatory muscles are another important sign.
The functional movements of this joint are the opening and closing of the mouth, shifting the mandible from anterior to posterior and also laterally. Dysfunction causes restriction of mouth opening. It is normally possible to insert the width of three finger knuckles between the upper and lower incisors. Joint play consists of distraction and side-to-side movement.
TrPs can be found in the temporal region in the temporalis muscle, through the cheeks or from the mouth in the masseter muscle, behind the mandibular angle in the medial pterygoid muscle and, most frequently, in the lateral pterygoid in the mouth above the wisdom teeth; this TrP is most intensely painful. Tension in the floor of the mouth, caused by TrPs in the digastric and mylohyoid muscles, is also important. These are best diagnosed by palpation of resistance at the thyroid cartilage or at the hyoid, which is more difficult to perform. The tension on one side is often so considerable that lateral deviation of the thyroid cartilage is seen toward the side of the tension, as well as distortion of the floor of the mouth. The characteristic muscular imbalance is shortening of the masticatory muscles, with weakening of the muscles that govern the opening of the mouth. The main causes are a faulty bite, ill-fitting dentures, or trauma, or they may be functional and brought about by stress and grinding of the teeth (bruxism). Functional chain reactions are frequent, especially in the craniocervical region.
4.12. Examination of disturbances of balance
As has already been made clear (see Section 2.5), the spinal column plays a significant part in maintaining or disturbing balance; and it is therefore important to have straightforward methods of clinical examination to assess dysfunctions of the spinal column in cases of disturbed balance.
Hautant’s test seems the most suitable for this purpose. The patient is seated comfortably in a chair which supports her back, with eyes closed and both arms stretched forward. The examiner stands facing her, with his thumbs pointing at the patient’s fingertips (see Figure 4.45). This enables him to detect whether the patient’s arms deviate (not owing to rotation of the trunk) and then assess the role played by the cervical spine. The test is repeated with different positions of the head relative to the trunk and enables the examiner to recognize ‘pathogenic’ and also relief positions, by judging whether the deviation appears, increases, or disappears. Between each test, when the patient changes the position of her head, the examiner must hold her hands in neutral position to prevent deviation due to synkinesis of the arms. When testing each head position, the examiner should wait for about 5–10seconds to see whether deviation sets in or is spontaneously corrected.
This test has great advantages: being seated with the back supported, the patient feels safe even if dizziness occurs, and any deviation that is found is not caused by nervousness, as is often the case in Romberg’s test or Unterberger’s stepping test. The second advantage is that with the patient’s back leaning against a chair, the back is fixed and only side deviation of the arms is possible. There is no swaying to and fro as in disturbance of the labyrinth. If the patient is asked to turn her head when in the sitting position, this best enables the examiner to assess the role of the cervical spine. The reaction produced is so characteristic that it is possible to speak of a ‘cervical pattern’ (see Section 7.6.2). This examination is therefore indicated whenever the patient complains of disturbances of balance and also when the test standing on two scales produces a difference of more than 4kg.
Berger (1990) has constructed a simple technique to register this deviation: the patient is sitting with eyes closed; in one outstretched hand she holds a ballpoint pen and moves it from right to left and back for about 1cm each time on paper that is moving forward at a constant speed. In this way deviation can be registered for various head positions (see Figure 4.46). The test can be performed before and after treatment for comparison.
For the test using two scales, the patient is asked to stand with legs extended and to distribute her body weight equally on both, since otherwise it is natural to place more weight on the stance leg. What is tested is therefore the patient’s ability to estimate accurately the symmetrical distribution of body weight on the legs.
It is of course essential to make a distinction between the position of the head relative to the trunk and the position in space of the head and trunk together, that is to diagnose positional vertigo. To do so we must change the position of the patient’s head and trunk simultaneously (e.g. sitting up and lying down are done with the patient’s head in a neutral or rotated position; turning to one side or the other supine is done by turning the head and the rest of the body simultaneously). The positional vertigo produced in this way is true labyrinthine rotatory vertigo. Although it lasts only a few seconds, it is usually very intense, as can be seen from the patient’s reaction. The patient tends to close her eyes, so that it is not usually possible to see the nystagmus, which lasts only very briefly.
To determine the role of the vertebral artery in vertigo, the patient is examined in positions assumed to restrict blood flow in the artery on the contralateral side to the rotation. De Kleyn’s test is suitable for this. The patient is supine, with her head beyond the end of the treatment table. Rotation is examined in retroflexion. The examiner needs to wait to see whether the patient begins to experience vertigo; if her eyes are open, nystagmus will be seen. This test is particularly conclusive if there is no restriction in the position being tested, and all the symptoms can therefore be attributed to the disturbance of blood flow. If concomitant restriction is found, this should be treated and the test then repeated. If the result of the test is again positive, the cause must lie with the vertebral artery.
In some instances de Kleyn’s test may provoke positional vertigo. If this is observed the examiner should recognize the fact and follow either of two options, the first being to repeat the test at short intervals. In positional vertigo, adaptation soon occurs so that no vertigo is provoked. No such adaptation takes place if there is insufficiency of the vertebral artery. The other option is to maintain the test position and wait. Positional vertigo never lasts more than a few seconds, whereas the patient’s condition gets worse if there is insufficiency of the vertebral artery; this situation involves some degree of risk.
Differential diagnosis of vertigo can be considerably refined by using manual techniques.
4.13. Examination of muscle function
4.13.1. General principles
One fundamental difficulty of examination is undoubtedly the lack of established definitions as to what is to be considered normal. Diagnosis has to be based almost exclusively on clinical examination, since the alternative, electromyography, is so cumbersome and time-consuming that it is seldom practicable.
Clinical kinesiological examination
In addition to neurological screening, the examination should include:
• muscle strength (muscle tests)
• shortened muscles
• hypermobility
• overall tonus, mobility, and elasticity of the soft tissues including the fasciae
• posture, standing and sitting
• sensitivity, especially in the regions of the hands and feet
• simple movements
• gait, including tests of walking in unaccustomed posture such as on tiptoe or on the heels, or with arms raised or hanging down.
In the neurological examination the signs of special interest are those characteristic of minimal brain damage, such as marked asymmetry, especially of the face and the limbs, restlessness, clumsiness, agitation, and also minor deficits such as slight paresis, hypesthesia, and paresthesia.
Evaluation of muscle function
The muscle test was originally introduced to examine paresis of individual muscles or of muscle groups in such diseases as poliomyelitis. It essentially examines muscle strength during a simple coordinated movement. This enables the strength of one specific muscle or muscle group to be assessed. Standard conditions must be maintained, so that results are comparable. Results are graded as follows:
• 0: No muscle activity.
• 1: Muscle twitch without motor effect.
• 2: Muscle contraction enabling movement without resistance, therefore in the horizontal plane.
• 3: Movement against gravity.
• 4: Movement against moderate resistance.
• 5: Movement against maximum resistance.
Our patients are for the most part seeking treatment for painful conditions, and none of them apart from those with radicular syndromes are suffering from true paresis; consequently the values we find range between grades 4 and 5, and only the abdominal muscles and deep neck flexors occasionally exhibit weakening to grade 3. As a result, the degree of distinction that can be made using grades 4 and 5 is not fine enough to be useful for the assessment of our patients.
Without going into details, the examiner must bear in mind the following principles when performing the muscle test:
• The position of the patient must be constant.
• Resistance must remain constant throughout the movement.
• The direction and speed of movement should remain as constant as possible.
• The movement must above all be isotonic.
• Isometric resistance can also assess the degree of force in the muscle but does not assess coordination.
Some modification of the muscle function test therefore are helpful for our patients, who do not suffer from paresis. The most important techniques are described below. In the sections dealing with muscular stereotypes (see 2.9 and 4.15), a distinction is made in line with the work of Janda between those muscles with a tendency to weakness and laxity and those with a tendency to hyperactivity and shortening.
4.13.2. Examination of muscles with a tendency to weakness
The gluteus maximus
Before performing the classic muscle test we begin by examining active retroflexion (hyperextension) of the hip, with the patient prone in order to identify the patient’s accustomed stereotype (movement pattern; see Figure 4.47). Electromyography has established that, far from simply being a function of the gluteus maximus alone, retroflexion of the hip is carried out by the coordinated action of the ischiocrural muscles (knee flexors), gluteus maximus, and erector spinae. The major role is performed by the ischiocrural muscles, rather than the gluteus maximus. The action begins with contraction of the ischiocrural and gluteus maximus muscles, followed by the erector spinae on the contralateral and finally the ipsilateral side. It is therefore advisable to palpate the gluteus maximus and ischiocrural muscles with one hand, and the erectores spinae of both sides with the fingers of the other. In the frequent cases of an inhibited gluteus maximus, contraction is found to be retarded, so that it is passed over and the contraction of the ischiocrural muscles is immediately followed by an exaggerated contraction of the ipsilateral erector spinae. In the most severely disturbed movement patterns muscular contraction may start at the superior part of the trapezius.
The muscle test proper is performed with the patient prone, face down and knee flexed. Resistance to the extension of the hip is applied above the knee (see Figure 4.47 B).
If we wish to facilitate the gluteus maximus, the best approach is to examine retroflexion of the hip with the leg in external rotation (see Figure 4.47 C).
If the patient’s leg, in extension, is allowed to hang down beyond the edge of the treatment table so that the extension of the hip begins from that position, the examiner will see that the gluteus maximus does not contract until the leg is horizontal, whereas the ischiocrural muscles are active from the very beginning of the movement. The same applies in upright gait. On the other hand, when the person is getting up from a chair or climbing steps, the gluteus maximus contracts immediately.
The gluteus medius
The gluteus medius is examined with the patient in the side-lying position, her underneath leg flexed slightly. She should be asked to raise the uppermost leg laterally (i.e. upward from the table), completely spontaneously. The examiner should make no intervention at this stage, but instead observe whether she makes a true abduction (see Figure 4.48 A), or a combined movement, involving flexing of the hip and external rotation of the leg (see Figure 4.48 B). Only the first is genuine abduction, employing the true abductor muscles (gluteus medius and minimus) at the same time as contracting the tensor fasciae latae. The second reveals incoordination, in which there is substitution by the tensor fasciae latae. It is therefore advisable to palpate both the gluteus medius and the tensor fasciae latae during the examination. In incoordination there is also premature contraction of the quadratus lumborum, producing side-bending of the trunk rather than hip abduction.
The classic test is performed by applying resistance against the lower third of the thigh from laterally and above, at the same time fixing the pelvis in such a way as to prevent substitution by the quadratus lumborum (see Figure 4.48 C). Meanwhile, with the thumb and forefinger of the other hand, the examiner should palpate the gluteus medius and tensor fasciae latae.
The rectus abdominis
The classic test is performed with the patient supine, knees flexed, and arms clasped behind the back of her neck. The examiner fixes the patient’s lower limbs and pelvis. She is then asked to sit up, beginning by lifting her head, then her thorax, ‘curling up’ in the process.
For our purposes it is better if the patient sits up unaided with arms stretched forward (see Figure 4.49). This can only be done if the abdominal muscles are sufficiently strong. Very strong patients will even be able to sit up with arms clasped behind the back of the neck. Although bending the knees inhibits the hip flexors to some degree, sitting up is always the result of coordinated action together with the hip flexors. To examine the abdominal muscles alone, excluding the hip flexors, the examiner should place his hands under and behind the patient’s heels, telling her to press down onto his hands with her heels. Then she is asked to lift her head and her thorax in succession. The moment the patient starts using the hip flexors, the pressure of her heels on the examiner’s hands ceases. The stronger the abdominal muscles, the higher the patient can lift her head and trunk without relaxing the pressure of her heels.
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| Figure 4.49 |
The transversus abdominis
The transversus abdominis cannot be tested by means of a particular movement; the examiner simply has to observe whether the patient’s flanks are drawn inward during sitting up or rotation of the trunk. If the patient’s flanks bulge outward, this is a reliable sign of insufficiency. Another indication of insufficiency is seen when the patient’s abdomen bulges on lifting an object from a position of anteflexion.
The inferior (ascending) part of the trapezius
For this muscle test the patient should be prone, face down, and with the arm on the tested side stretched forward. With one hand, the examiner grasps the outstretched arm, and with the other he should grasp the inferior angle of the scapula, telling the patient to pull her arm and shoulder down in the caudal direction (see Figure 4.50).
For our purposes, the best way to diagnose incoordination is simply inspection. The patient is face down, with her arm against her body. She is then asked to draw one shoulder down in the caudal direction (i.e. in line with the muscle fibers). If the trapezius is weak, the inferior scapular angle moves medially like a hook and protrudes under the skin, as it does in winged scapula (scapula alata). This movement, which is normally forceful, can in this case be prevented easily by the thumb and forefinger of the examiner’s hand. The patient should be able to move the scapula in a caudal (and slightly medial) direction against resistance.
The serratus anterior
This muscle is tested with the patient on all fours. She should distribute her weight forward onto her arms rather than putting the weight on her knees, and her shoulder blades should be abducted. She can flex her elbows slightly as she does this (see Figure 4.51). She must then maintain this position while the examiner waits and observes. If the muscle is weak, then after a period of latency the medial border of the scapula lifts, leading to the appearance of slight winged scapula.
The deep flexors of the neck
The patient is supine and is told to lift her head in an arching movement, drawing her chin toward the jugular fossa. The examiner fixes the patient’s chest from above with one hand while the other, on her forehead, applies resistance (see Figure 4.52). If there is weakness of the deep neck flexors, a ventral shift of the head (incoordination) is seen, due to predominance of the sternocleidomastoid muscles.
There is a useful ‘quantitative’ test that can be applied: the patient is asked to raise her head as if reading (without lifting the thorax). If strength is normal, this position can be maintained for half a minute or even longer, but if the muscles are weak, the patient’s head sinks back down onto the treatment table after a few seconds.
To test the sternocleidomastoid muscles, the examiner should apply resistance to the ventral lifting of the head.
4.13.3. Examination of muscles with a tendency to shortening
Evaluation of those muscles that tend to hyperactivity and shortening – the ‘predominantly postural muscles’ identified by Janda (see Table 2.1, p. 28) – is essentially a matter of observing how far a muscle can be stretched without the use of force; as this is done in the same way as if taking up the slack in PIR, only those muscles for which the techniques differ are dealt with here.
The soleus
If this muscle is shortened, dorsiflexion of the ankle joint is restricted. This can be tested by asking the patient to squat down without raising her heel from the floor. If she has to lift her heels from the floor, then it is primarily the soleus that is shortened (see Figure 4.53).
If, as often happens, it is only the gastrocnemius that is shortened, dorsiflexion of the ankle joint is restricted with the knee extended but not with the knee flexed, and this can be shown quite simply by comparing dorsiflexion with the knee extended and flexed (see Figure 4.54). For this reason the mobility of the ankle joint should never be tested with the knees extended. The foot must be guided precisely at the lateral border while applying traction at the heel.
The ischiocrural muscles
The ischiocrural muscles are tested in the same way as in the straight-leg raising test. The patient is supine. The leg that is not being examined should be fixed on the table from above, and the other leg flexed at the hip, with the knee extended. The ischiocrural muscles are considered shortened if the extended leg cannot be flexed at the hip to an angle of 90°. All the patient feels in this case is tension in the hollow of the knee and in the thigh, but (unlike in radicular syndrome) no real pain.
Shortening of these muscles is the most frequent reason why a clinically healthy subject cannot touch the floor when bending forward with the arms and legs straight. This is most clearly evident when observed from the side: on anteflexion, considerable kyphosis of the lumbar spine is seen, but ventral inclination of the pelvis is inadequate.
The hip flexors
These comprise the iliopsoas, the rectus femoris, and the tensor fasciae latae. They are examined in the position for Mennell’s test. The patient is supine with the buttocks at the end of the table, and draws one knee toward her chest, close enough to flatten lumbar lordosis (see Figure 4.55). The other leg (the one to be tested) is allowed to hang down over the edge of the table. In this position some disturbances can be identified straight away by simple inspection: if the iliopsoas is shortened, the knee of the leg being tested will be raised. If the rectus femoris is shortened, the lower leg will not hang vertically; instead there will be an obtuse angle between the lower leg and thigh. If the tensor fasciae latae is shortened, the thigh will be slightly abducted and the patella will deviate slightly outward.
To evaluate the individual muscles, the examiner should reinforce fixation of the flexed knee (the one not being examined) from above with one hand. With the other hand, the examiner then:
• exerts pressure from above on the knee of the leg being tested in order to assess shortening of the iliopsoas
• applies lateral pressure to the slightly abducted knee. Premature resistance is felt and the tension can be seen in the iliotibial tract, as if in a groove on the lateral aspect of the thigh.
The lumbar erector spinae
Examination for a shortened lumbar erector spinae is carried out with the patient sitting, the knees flexed and the trunk in anteflexion. The patient’s hands should rest behind her body, palms uppermost and the back of her hands flat on the treatment table (see Figure 4.56 A). She is asked to draw her forehead to her knees. This cannot be done if the erector spinae muscles are shortened. However, other factors are also capable of preventing this: for example it is impossible if the patient’s trunk is long and her thighs short. Conversely, however, if the patient has a short trunk and long thighs, it is possible to perform the movement even if the muscles of the back are shortened. A modified version of the test is therefore more reliable: the patient, seated, fixes her pelvis by placing her hands on the iliac crests, and humps her spine to create lumbar kyphosis. If the lumbar part of the erector spinae is shortened, lumbar lordosis remains unaltered (see Figure 4.56 B).
The quadratus lumborum
Shortening of the quadratus lumborum can be identified on side-bending, but scoliosis or a difference in leg length can give a false impression of shortening of this muscle. Examination with the patient side-lying is more accurate; the patient should raise her upper body, supported on her elbow and forearm, so as to produce side-bending of the lumbar spine. The lower part of her trunk should remain on the table (see Figure 4.57); if necessary the examiner should fix the patient’s pelvis from above to prevent her from raising her trunk too far. If the quadratus lumborum is shortened, side-bending is reduced.
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| Figure 4.57 |
The muscles of the nuchal region
The technique used to test for shortening of the superior (descending) part of the trapezius, pectorales, and levator scapulae muscles is identical to that used in PIR treatment to take up the slack, and is described in the section dealing with this (see Section 6.8).
On inspection, shortening of the pectoralis is shown by increased thoracic kyphosis, shortening of the superior part of the muscle is shown by forward-drawn shoulders, and hypertonus of the superior part of the trapezius is revealed by the upwardly convex ‘Gothic’ shape of the shoulders (see Figure 4.58).
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| Figure 4.58 |
For rapid screening assessment, the muscles of the nuchal region are examined as follows. The patient should draw her chin to her chest (with mouth closed). If the muscles are short, the patient will be unable to do this, and a gap remains, which the examiner can measure in terms of fingers’ breadth. Short nuchal muscles are the most frequent cause of inability to bring the chin down on to the chest.
4.14. Examination of hypermobility
Not only weakness and tautness, but hypermobility, too, is mainly muscular in origin. The significance of hypermobility in pathogenesis has already been described (see Section 2.10); here we shall focus on diagnosis.
The guidelines in this respect have been set out by Sachse (1969) and enable the examiner to make the distinction between normal mobility, hypomobility, and hypermobility, all within the range of the normal. It is nevertheless important to bear in mind the great variability between individuals, and also between age groups. What may be considered hypermobile in an adult male may be perfectly normal in a female or a child. With this proviso in mind, it will be helpful in what follows to present the results not in the form of a continuous scale of measurements, but of three levels of mobility, A, B and C:
• A: hypomobile to normal
• B: slightly hypermobile
• C: marked hypermobility.
I also compare Sachse’s criteria with the data given by Kapandji (1974) and describe the technique.
4.14.1. The spinal column
The overall mobility of the spinal column on the basis of X-ray examination is 145° for anteflexion, 135° for retroflexion, 75° for side-bending, and 90–95° for rotation to each side, as found by Kapandji (1974). Clinically, each of these movements is measured separately.
One sign of hypermobility of the lumbar spine which is of particular clinical importance is this: hyperlordosis is seen when the patient is standing, and changes to hyperkyphosis when the patient adopts a relaxed sitting position.
The lumbar spine
Retroflexion
The average range of retroflexion is 35° according to Kapandji (1974). Clinical examination may show the maximum angle of retroflexion to be either lumbosacral or thoracolumbar. According to Sachse (1969) the test is carried out with the patient prone so as to exclude synkineses of the pelvis. The patient’s hands should be placed underneath her as support, flat on the table, and positioned so that her fingertips are immediately under her shoulders (see Figure 4.59 A). The examiner should fix her pelvis from above. The patient is asked to direct her gaze at the floor and to lift her upper body by the pressure of her arms, raising it as far as her lumbar spine will allow without involving any movement of the pelvis. The degree of movement can be read indirectly by looking at the internal angle of the elbow. Range A is up to 60°, range B up to 90°, and range C in excess of 90° (see Figure 4.59 B).
Anteflexion
The average range of anteflexion is 60° according to Kapandji (1974). When this is tested by having the patient bend to touch the floor, hip flexion is also tested, and if done with legs extended, this also tests the muscle stretch of the ischiocrural muscles (see Figure 4.60). Range A covers a finger–floor distance through to 0cm. Greater flexibility, through to the point where the patient is able to touch the floor with her knuckles, is classed as range B. Range C covers anything beyond this. The patient is sometimes even able to place the chest against the thighs. This examination has the disadvantage that it tests not only the kyphosis of the lumbar spine but also muscle stretch of the ischiocrural muscles. The following test can focus much more specifically on anteflexion of the trunk: for this the patient is in the sitting position and is asked to bend and try to touch her knees with her forehead. In this test, range A describes anteflexion that does not go beyond a forehead–knee distance of 10cm, range B covers anteflexion to the point where the patient can touch the knees with her forehead, and in range C the patient can put her forehead between her knees.
Side-bending
The lumbar spine allows side-bending of approximately 20° to each side; in the test devised by Sachse (1969) the patient stands with legs closely together and flexes to the side. The plumb line from the fold of the contralateral axilla reaches no further than the intergluteal cleft in range A. In B it reaches beyond this point as far as the middle of the buttock of the side toward which the patient is side-bending, while in C it reaches beyond the lateral aspect of the buttock (see Figure 4.61). When testing anteflexion and side-bending the examiner must take into account the mobility of the hips and, in particular, the body proportions of the patient: there may be ‘false’ hypermobility due to a long trunk and short legs. In anteflexion this impression can also be given if the patient has long arms.
Rotation
The range of lumbar rotation is given by Kapandji (1974) as 5°, which is not capable of being clinically tested.
The thoracic spine
Rotation
The figure given by Kapandji (1974) for trunk rotation is 35° to each side. The patient sits astride the end of the treatment table and fixes her shoulder girdle with her hands, which are clasped behind the nape of her neck. She is asked to turn to the right and left in succession, while the examiner ensures that the pelvis remains fixed. Up to 50° to each side is defined as range A, from 50–70° as range B, and beyond 70° as range C (see Figure 4.62).
We now know that rotation of the trunk produces simultaneous side-bending of the spinal column in a coupled movement, in which the lumbar spine also participates (see Section 3.4.1).
Anteflexion, retroflexion, and side-bending
Testing of anteflexion, retroflexion, and side-bending of the trunk also involve the thoracic spine. The examination of these movements (with the patient in the standing position) has already been described above as tests for the assessment of the lumbar spine.
Kapandji (1974) gives the range of movement for the thoracic spine as 45° in anteflexion, 25° in retroflexion, and 20° to each side in side-bending. If the examiner wishes to measure anteflexion and retroflexion of the thoracic spine clinically, this should be done with the patient sitting, asking her to hump her back and straighten up.
The cervical spine
Rotation
In the cervical spine, rotation can be measured clinically. According to Kapandji (1974), this movement is 50° to each side. When tested with the patient’s head in perfectly erect posture (see Figure 4.63), the degree of movement is assessed as range A when it is up to 70° to each side, B from 70–90°, and C when it is over 90°. When examined in this way the rotation also involves the upper thoracic spine. If the head is held slightly bent forward, this synkinesis can be eliminated.
4.14.2. The joints of the upper limb
The figures used in this section are those given by Sachse (1969).
The metacarpophalangeal joints
In passive dorsal extension (in which the interphalangeal joints may be bent), an average range of movement of up to 45° is assessed as A, between 45° and 60° as B, and measurements beyond this as C (see Figure 4.64).
The elbow
At the elbow joint, there is often a correlation between valgus alignment and hypermobility. The following test is based on this fact. The patient is asked to bend her elbows and place her forearms and hands firmly together in front of her. She should then extend her arms as much as she can without separating her elbows (see Figure 4.65). If the internal angle at the elbows remains less than 110°, this is assessed as range A, an angle of 110–135° is range B, and beyond this is range C.
The shoulder
For this test the patient is asked to bring the horizontally raised upper arm towards the shoulder of the opposite side. Range A mobility enables the patient to bring the elbow to the midline at most, range B from there to a point half way between the midline and the contralateral shoulder, and range C beyond this. In extreme cases the elbow may even reach the contralateral shoulder (see Figure 4.66).
Another test examines the patient’s ability to make both hands meet diagonally behind the back. The test is performed on both sides, and relates to the side of the hand approaching from below. The result is recorded as range A if the fingers do not touch or if the fingertips just come into contact, as range B if the patient’s fingers overlap, and as C if the fingers can be placed in the palm (see Figure 4.67). There must be no hyperlordosis of the spinal column.
The best way to test the mobility of the glenohumeral joint specifically is by means of passive abduction. If the examiner fixes the shoulder blade precisely in position from above, abduction of 90° is assessed as range A, from 90° to 110° as range B, and beyond this as range C (see Figure 4.68).
4.14.3. The joints of the lower limb
The knee
The knee joint is best tested by means of hyperextension. This is assessed as range A when the limit of this extension movement is at 0°. Hyperextension of up to 10° is range B, and extension beyond this is assessed as range C (see Figure 4.69).
The hip
To evaluate the hip joint, the most satisfactory method is to measure the combination of external and internal rotation with the hip flexed at 90°. Combined external and internal rotation of up to 90° is assessed as range A, between 90° and 120° as B, and more than 120° as C (see Figure 4.70).
4.15. Examination of coordinated movements (motor stereotypes)
Examination of individual muscle groups by means of simple movements in the muscle test and the variations on that test is followed by the study of more complex movements. We begin with assessment of posture (see Section 4.2).
Motor stereotypes are the result of conditioned and unconditioned reflexes and/or programs acquired in the course of ontogenesis.
4.15.1. Examination with the patient sitting
The patient is examined sitting on a height-adjustable stool. The examiner notes the position of the feet and the level of the iliac crests, the posture of the lumbar spine, and the tonus of the abdominal, paravertebral, and gluteal muscles. In correct sitting posture, the feet are flat on the floor and the iliac crests level; the lumbar lordosis should be flattened, and muscles only slightly tensed with the tonus evenly distributed (see Figure 4.71).
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| Figure 4.71 |
Anteflexion: stooping and straightening
For correct stooping, one leg moves forward in front of the other and the knee of that leg is bent. At the same time the trunk bends forward, the movement starting with the head, the body then curling up from caudal to cranial as the abdominal and gluteal muscles contract slightly (see Figure 4.72 A). The erector spinae contracts initially, but relaxes again at the point of maximum anteflexion.
As the body straightens up again, the knees are extended and at the same time the trunk uncurls, lifting first the lumbar spine, then the more cranial sections of the spine, and finally the head (see Figure 4.72 A). This action is brought about by contraction of the abdominal and gluteal muscles.
The whole of this movement is the result of coordinated activity by the muscles of the gluteal region, abdomen, and back. The knee of the forward leg is positioned under the thorax so that the center of gravity of the body constantly lies above this point of support. The trunk must never be raised stiffly like a ramrod, because this acts as a long lever and places great stress on the lumbosacral junction (see Figure 4.73 B). Nor must the abdomen be allowed to bulge.
Trunk rotation, sitting
This test mainly examines the thoracic spine and shoulder girdle. The patient is seated on a stool, holding a small book in her hands. Correct sitting posture is important. The shoulder girdle should be relaxed and posture erect, including the shoulders. The patient is now asked to place the book on a shelf behind her, at head height (see Figure 4.74). The examiner should observe the rotation of the trunk, which should be about a vertical axis, and check for coordinated activity of the back and abdominal muscles, fixation of the shoulder blades, and minimal tension in the superior part of the trapezius.
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| Figure 4.74 |
If performed properly, the rotation is seen as a fluid movement in which the pelvis and legs do not participate. There is only moderate activity of the abdominal and back muscles, the inferior angles of the scapula do not diverge, and the superior part of the trapezius remains relaxed.
Rotation of the head and neck
The examiner should begin by observing head posture with the patient standing and sitting. The normal posture is slightly lordotic, but this lordosis may be absent if the thoracic spine is flat. The angle between the mandible and neck should be about 90°. During head turning, the examiner observes neck rotation and also the cervical muscles and position of the shoulders (see Figure 4.75). If the movement is performed correctly, lordosis should not increase and there should be minimal side-bending. The sternocleidomastoid should not be overstrained, and neither shoulder should be drawn forward or lifted.
Raising the arms
When raising the arms, the patient also raises her shoulders and shoulder blades. This activates the upper fixators of the shoulder girdle, in particular the superior part of the trapezius and the levator scapulae, especially if fixation of the shoulder blades from below by the inferior part of the trapezius is insufficient (see Figure 6.152).
4.15.2. Examination with the patient standing erect
Weight carrying
Here the typical fault is a forward-drawn position of the head and a drawing forward of the shoulders, causing tension in the upper fixators of the shoulder girdle and muscles of the upper limbs (see Figure 4.76). If a weight is to be carried correctly, the shoulders should be behind the center of gravity of the body and the head and neck remain erect. When this is so, the hand carrying the weight is also relaxed.
Standing on one leg
The examiner should observe all the joints of the stance leg, the line and center of gravity of the body, the pelvis and iliac crests, the spinal column and muscle tension, especially that of the hip stabilizers (the gluteus medius and minimus).
In correct posture on one leg, all joints of the stance leg are in the line of gravity; the center of gravity moves forward as compared with stance on two legs, to the second and third metatarsal heads. The iliac crests remain horizontal, the physiological curvatures of the spine remain unchanged, and no scoliosis occurs. The hip stabilizers, in particular the abductors, contract on the side of the stance leg. The flexors and extensors of the lumbar spine (the abdominal and erector spinae muscles) and of the hip should contract evenly, as should the quadratus lumborum (see Figure 4.77 A).
If the abductors are weak, as is frequently found in patients with faulty posture, the patient raises the iliac crest on the side opposite to the stance leg (see Figure 4.77 B). Trendelenburg’s sign, in which the iliac crest is lowered, is mainly found in decompensated hip luxation and extreme muscle weakening.
Gait
In normal gait the steps are even and the weight is placed equally on each leg in turn. Each foot strikes the ground heel first, the entire foot then uncurling along its lateral edge to end in pronation and propulsion by the toes. The examiner should note the extension of the knees and hips.
The pelvis sways from side to side, remaining horizontal but rotating about a vertical axis; the excursion is more pronounced in women than in men. The spinal column curves from one side to the other in waves, the greatest excursion being at L3; there is some counter-excursion in the thoracic spine, the point of change occurring at the thoracolumbar junction, which remains vertically above the sacrum. The head should move very little and the arms should swing symmetrically (in right-handed individuals, slightly more on the left than the right). This movement comes from the shoulder, which rotates in the opposite direction to the pelvis. The shoulder blades are fixed against the back by the caudal fixator muscles. The body’s center of gravity shifts only slightly, from one side to the other and up and down; that is the person should neither waddle nor rock.
Significant asymmetries of gait are also clearly audible, especially if the patient is walking quickly.
Certain faults only become observable if the patient walks with eyes closed, on tiptoe, on the heels, or with upstretched arms.
If it is possible to examine patients in their typical working position (lifting weights, at the computer, at a machine or instrument, etc.), this can provide important insights.
4.15.3. Movement patterns of respiration
Although the prime purpose of respiration is the exchange of gases, it is the function of the locomotor system that underlies it. The muscles involved in breathing are in their turn extremely important for the function of the locomotor system, so much so that breathing patterns are considered the most important of all motor stereotypes (see Section 2.9.5).
Respiration can be examined starting with the patient at rest, supine. In the supine position, abdominal respiration should predominate. In erect posture, standing or sitting, the abdominal muscles must also perform their postural function during respiration, and this occurs when the thoracic cage widens, beginning from the waist. To find whether this is happening, the examiner should place his hands on the patient’s lower ribs on each side, and sense whether his hands are moved apart as the patient breathes in, or whether they move upward with no widening of the thorax (lifting of the thorax during inhalation – clavicular breathing – see Figure 4.78).
If this faulty breathing pattern is very pronounced, the thorax may remain permanently in the inhalation position and the lifting of the thorax during inhalation may be seen even at rest. In this case the sternocleidomastoid and scalene muscles and all the upper fixators of the shoulder girdle are found to be taut and the supraclavicular fossae are deep. In the most severe cases the patient may draw the abdomen in during inhalation (paradoxical respiration, see Figure 4.78). In these cases clavicular breathing can be evident even when the patient is lying down. In less severe cases it is only observed when the patient inhales deeply. This lifting of the thorax can also be asymmetrical; the shoulders are each lifted to a different extent and there is often weakness of the inferior part of the trapezius on the side that rises more.
Another consequence of the lifting of the thorax is that breathing is performed mainly by the contraction of the scalene muscles and the diaphragm is not sufficiently activated. The movement of the ventral wall of the thorax may even cause the diaphragm to be cranially angled; if this happens there will be no co-contraction of the diaphragm together with the abdominal muscles, and therefore no fixation of the thorax to the pelvis.
As Figure 4.78 also shows, the effect is not only to overload the cervical spine, but to lift the thorax away from the pelvis, so that there is no fixation of the lumbar spine. The photograph also shows the hypotonus in the region of the waist and lateral abdominal wall (see Section 2.9.5).
Therefore the tonus of the lateral abdominal wall should also be palpated and the patient asked to exert pressure against the examiner’s palpating fingers. The patient often finds this impossible to do. According to Kolář (2006), the following tests can then be performed:
• The patient lies supine with knees flexed. Resistance is applied to the knees and the patient asked to flex the knees further against the resistance; alternatively the patient, sitting erect, is asked to raise both knees against gravity. The examiner palpates the abdominal wall laterally at the waist. The lateral abdominal wall contracts (the patient can feel this by touch, and so can provide feedback), but the thorax should not rise as it does so.
• The patient lies supine and slowly lifts the head and trunk while the examiner palpates the medioclavicular line. As the neck is flexed, the abdominal wall begins to contract, and when the thorax is lifted, the lateral part of the abdominal wall contracts. The equivalent method with the patient prone is used to examine the extension of the head and shoulders as the muscles at the waist contract.
The close relationship between posture and respiration can be seen not least in the effect of a hunched sitting posture, which makes it difficult for the thoracic cage to expand and so leads to clavicular breathing. This kyphotic posture is associated with a forward-drawn position of the head, which is compensated by hyperlordosis of the cervical spine.
This close relationship is also shown by holding the breath during muscular effort (Valsalva maneuver); the body achieves maximum stability at the expense of respiration, as is done, for example, when delivering a tennis serve. Holding the breath is even maintained for the period of a short sprint: the body temporarily reinforces postural function at the expense of respiratory function.
Inhalation and exhalation have about the same duration; the patient should be able to extend that duration considerably, to at least 10seconds. (Professional singers should be able to sustain a breath for much longer.) A quiet breathing sound is heard, the sound coming from the nose. The nostrils expand during deep inhalation and narrow during exhalation.
In the prone position the progress of the respiratory wave can be observed traveling up from the lumbar spine to the upper part of the thoracic spine during deep breathing. This wave may be interrupted where there is a restriction. If there is a faulty breathing pattern the wave may be completely absent.
The close relationship between the locomotor system and breathing means that a faulty breathing pattern, especially clavicular breathing (in which the thorax is lifted during inhalation), is highly pathogenic. It should never be overlooked.
4.16. Syndromes
4.16.1. The lower crossed syndrome
In this syndrome there is imbalance of the following muscle groups:
• Weakness of the gluteus maximus; shortening of the hip flexors and tension of the ischiocrural muscles.
• Weakness of the gluteus medius, tension of the tensor fasciae latae, adductors, and quadratus lumborum.
There is also substitution for the weak gluteus maximus by the ischiocrural and erector spinae muscles, for the gluteus medius by the tensor fasciae latae and quadratus lumborum, and for the rectus abdominis by the hip flexors.
Clearly this syndrome renders the curling of the spinal column on lying down from a sitting position impossible. The main visible result of imbalance between the rectus abdominis and the lumbar erector spinae is lumbar hyperlordosis; if there is imbalance between the gluteus maximus and hip flexors, the hyperlordosis occurs at the lumbosacral junction. The psoas major does not only flex the hip but also brings about lordosis of the lumbar spine (‘psoas paradox’). There is also increased pelvic tilt (see Figure 4.79).
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| Figure 4.79 |
4.16.2. The upper crossed syndrome
There is imbalance in the following muscle groups:
• Between the upper and lower fixators of the shoulder girdle.
• Between the pectorales and the interscapular muscles.
• Between the deep neck flexors (longus colli, longus capitis, omohyoid, and thyrohyoid) and the neck extensors. There may be shortening of the superior part of the ligamentum nuchae with fixed lordosis in the upper cervical region.
The ascending part of the trapezius is extremely important for the fixation of the scapula. Activity of this muscle portion can produce reflex relaxation of the upper fixators. Tension of the pectoralis muscles leads to increased thoracic kyphosis and forward-drawn shoulders, as well as kyphosis of the lower part and hyperordosis of the upper part of the cervical spine.
The correct movement of arched anteflexion from a supine position is only possible if there is coordinated activity of the scalenes and deep neck flexors. If these are weak and the sternocleidomastoids hyperactive, there is ventral shifting of the head (incoordination). The cause that leads to weakness of the deep neck flexors is often weakness of the deep stabilizers of the lumbar spine. This is because the longus colli has its point of attachment here.
4.16.3. Stratification syndrome (according to Janda)
In this syndrome, alternating strata of hypertrophic and weak muscle groups are found: on the dorsal aspect, working in a caudocranial direction, we find fairly slim calves, but hypertrophic ischiocrural muscles; hypotrophic, lax gluteal muscles and underdeveloped lumbar erectores spinae, and above these the bulging hypertrophic, thoracolumbar erectores spinae; above these we find flabby interscapular muscles and hypertrophic, taut upper fixators of the shoulder girdle.
On the ventral aspect the inferior part of the abdominal wall bulges, but lateral to the rectus abdominis muscles there is a hollow corresponding to the taut obliquus abdominis muscles; lateral to this the abdominal wall may bulge again in the region of the waist (‘pseudohernia’).
The significance of the stratification syndrome lies in the alternation of sections marked by contraction and lax, hypermobile sections. Hypermobility in the region of the lumbosacral junction is especially pathogenic in its effect.
Dysfunction of the feet appears to play an important part here. Minor variations in balance are normally absorbed by the toes; in fact by the muscles of the foot and especially the calf. The function of the toes is often inhibited by the shoes, and the muscles of the thighs then take over the task of managing static balance.
There is a simple explanation for the fact that the interscapular muscles are often found to be weak, if we look at developmental kinesiology: in infants, the development of upright posture takes place in the form of two lordotic curvatures, and is brought about through the activity of the cervical and thoracolumbar erector spinae muscles. The weak point is at the place where the two meet, at T4 or T5.
4.17. Retesting
Clinical examination routinely provides a wealth of data to give us the information we need about dysfunctions, and therefore also to compare findings before and after therapy. The effects of such treatment are often instantaneous, by reflex response. Immediate, post-treatment testing, or retesting, is therefore a means of feedback, and is indispensable for all practitioners who want to use solid criteria. This plays the role of short-term evidence. Yet – with a few exceptions – this kind of instant check is simply not possible for other modalities such as pharmacotherapy, for example. Given the great variation in the course of patients’ complaints, there is great value in this. Nevertheless, however good the immediate effect, this must not be confused with actual therapeutic success, because patients are rarely suffering from a single dysfunction; the therapeutic effect depends to a great extent on how relevant the lesion is that we have treated. If treatment of that lesion achieves only a partial effect, there is no reason why we should not continue by treating a further lesion and retesting once more.
In principle, every abnormal finding at clinical examination can be compared by testing before and after treatment. Where the test involves actual measurement, such comparison can be especially useful; examples include the range of movement of joints or sections of the spinal column, and the straight-leg raising test. Side deviation in Hautant’s test can also be compared before and after. Even in radicular syndromes, an increase of strength in weakened muscles may be found on retesting (see 2.12 and 2.13). Routine testing before and after treatment can also be carried out for reflex changes such as muscle TrPs, HAZs, and mobility of fasciae, for example following therapies such as mobilization, needling, PIR, RI, or local anesthesia. Instrumental methods such as thermography may also be used.
Subjective statements by the patient are also valuable. Most patients seek treatment because they are suffering pain, so it matters that they should find relief after treatment. The practice of concluding treatment by letting patients palpate their pain points found during the examination is a helpful one; they can palpate them with their own hands and confirm for themselves that the symptoms have indeed improved or disappeared.
Testing also gives a useful indication as to the most suitable further therapy. The practitioner can test the application of a particular treatment approach. For example, if we wish to find out whether traction or the treatment of an active scar is indicated, we can test whether the planned approach brings immediate relief. An immediate (reflex) result can be useful evidence-based medicine that indicates the effectiveness of a particular method, although this should not be equated with therapeutic success.
4.18. Dysfunctions and the course of examination
The question to be answered is how to carry out a systematic examination of a patient suffering from dysfunctions. If we wish to draw up the medical report of a patient with functional disorders as described by Brügger (2001), what would this look like?
Having described the various clinical examination techniques, the next issue is how to proceed in practice; how to obtain useful results and avoid errors as far as is humanly possible.
The answer is not simple, as the object of examination – the locomotor system, including morphological changes and dysfunctions – is in fact the concern of many different fields of medicine. The locomotor system can in many ways be said to be a reflection of everything that is happening in the body. Some patients present with problems belonging to the field of internal medicine; others with neurological, orthopedic, or rheumatological complaints. Still others are in the fields of ear, nose, and throat, or gynecology. For some, the main problem lies in disturbed muscle function, for others, in disturbed joint mobility; yet others may be suffering from a great range of reflex changes.
To examine each patient from all of these aspects would demand far more time than is practicable, especially given the outpatient nature of most consultations. The problem is essentially that our focus of interest lies in dysfunctions for which there is no specific, established medical field, since they relate to the locomotor system as a whole.
4.19. Adjusting our thinking to the functional approach
The examination techniques described in detail so far deal with dysfunctions, as do the demanding techniques used in treatment. However, they can only be used effectively if we have a proper understanding of these disturbances of function. Practitioners need not only master the techniques but must adjust their thinking to understand in a functional way.
It is as important – and still more difficult – to adjust our thinking to the functional approach as to master the technical aspect of manual medicine.
The following points present in general terms the most important differences between the usual, pathomorphological understanding and the functional approach.
• The first and fundamental task in classification and differential diagnosis is to decide whether the particular case is primarily pathomorphological or primarily one of dysfunction.
• Function (physiology) is as real as is morphology (anatomy).
• If a disorder is mainly pathomorpholological, the task is to localize it and decide what precisely is affected. Function and dysfunction, on the other hand, are the result of the interplay of a whole chain of different structures which are variously located.
• The clinical picture correlates far more with the functional disturbances than with the pathomorphological changes. Consequently, pathological processes often do not manifest themselves until they cause dysfunction. Dysfunctions, on the other hand, can cause very marked clinical symptoms, even in the absence of any morphological changes.
• Thus: pathomorphological changes cause dysfunctions, which manifest themselves in clinical symptoms.
• Consequently, even pronounced pathomorphological findings can often exist without causing any clinical symptoms, and may even be clinically irrelevant (e.g. disk herniation at CT, scoliosis, or spondylolisthesis). Concomitant dysfunction, on the other hand, can be of decisive importance clinically.
• In such cases, if the pathomorphological changes are assumed to be the key to the disorder, therapy fails; on the other hand, even if the pathomorphological changes are clinically relevant, we still may improve the patient’s condition if we improve function – for example by rehabilitation. It is, however, necessary to be aware of the limits of what can be achieved. Compensation can occur, so should not be forgotten.
• In pathomorphological diagnosis, the aim is to localize the lesion exactly and to identify its nature (principle of localization).
• In diagnosing dysfunction, the aim is to identify the pathogenetic chain of reactions and to assess the interrelationships and relevance of the individual links (holistic principle).
• In pathological processes, the cause of pain lies in the nature of the lesion; in dysfunction, the cause of pain is mainly pathological tension brought about by the dysfunction.
• In pathomorphological conditions, if therapy is successful it is continued until healing is achieved. Alternatively a decision may be made to intervene surgically.
• If therapy is successful in conditions due to dysfunction, the next step is usually to treat another link in the pathogenetic chain. If the same lesion needs to be treated again, we should consider whether there is another link in the chain that is more relevant and requires treatment. Change of approach in therapy is therefore the norm.
• In pathomorphological conditions, success depends on drug treatment or surgery; success in dealing with dysfunctions depends on the relevance of the particular link in the pathogenetic chain we address at that moment.
• When treating dysfunction, the practitioner is lost – or rather his patient is – if he treats it at the point where pain is felt.
• Because dysfunctions are by definition reversible, the effect of treatment can be immediate, giving the impression of a miracle cure. This is by no means unusual; at times it is even what we would expect.
• Modern technology achieves wonders in dealing with pathomorphological lesions, but often fails when it turns to the treatment of dysfunction, where it is at best cumbersome. Clinical skill is decisive in such cases, but is often undervalued as ‘subjective’ and too little put into practice. As a result, too much stress is often placed on morphological changes, which may in fact be of little relevance.
• The psychological factor is important in all disease. In dysfunctions of the locomotor system, however, psychology is itself a link in the pathogenetic chain, because voluntary motor function is the effector of psychological activity. Here, too, pain is the main symptom, and tension and its relaxation play a very important role. Practitioners need to decide in each case how relevant the psychological factor is and how amenable it is to treatment.
• In pathomorphological conditions, the relationship between cause and effect tends to be clear. In dysfunctions, what had been the cause can often turn into the consequence. Pain, whatever its origin, will produce changes in movement patterns or stereotypes; these in turn cause dysfunction which perpetuates pain. Chronic tension and joint restriction cause impaired mobility of the fasciae, and resistance in the fasciae in turn becomes the cause of recurring joint restrictions.
• When dealing with pathomorphological conditions, it is easy to produce statistics, and such findings are indeed very important. The task is incomparably more difficult when dealing with dysfunctions. Even in diagnosis, the symptom can be the result of a long chain of various disturbances in various locations, and the relevance of each link can change. In therapy, if we have treated one link successfully, there would be no sense in repeating treatment there. If the symptoms continue, we treat another link in the chain, and so on. If at the end of the process the clinical symptoms have disappeared, there is no reason to conclude that the treatment of the first link contributed less to the success.
• The functional approach is difficult. We may compare function to the ‘software’ and structure to the ‘hardware’ of the system.
4.20. Chain reactions of dysfunctions and motor programs
4.20.1. Function and chain reactions
In view of the argument presented in the previous section, which emphasizes that dysfunctions normally affect the entire locomotor system, or at least the major part of it, we must turn to the question of how to approach the individual case. Experience has shown that if on examination we find ‘A’, we expect ‘B’, and must then test ‘C.’ What regularly occurring patterns or rules can we observe or expect? What can we take as our screening guidelines in the clinical situation?
The first test is based on the premise that these regularly occurring patterns are associated with certain basic functions of the locomotor system. Basic functions or programs relate to the following:
• Gait, and especially the lower limbs and pelvis.
• Body statics, and especially the trunk, neck, and head.
• Respiration, and especially the trunk and neck.
• Prehension, and especially the upper limbs and shoulder girdle.
The chain reactions of dysfunction envisaged here are given in Table 4.3. These do not claim to be complete; although these are the chains especially affected, the disturbance is not limited to the details listed. The intention is rather to provide some means of screening. Our understanding is further focused and extended by our insight into developmental kinesiology.
| Lower limb — gait — swing phase – extension | |
| Tension | Flexors of toes and foot, soleus, ischiocrural muscles, glutei, piriformis, levator ani, erector spinae |
| Painful points of attachment | Calcaneal spur, Achilles tendon, fibular head, ischial tuberosity, coccyx, iliac crest, greater trochanter of femur, spinous processes of L4—S1 |
| Joint dysfunction (restrictions) | Small joints of foot, ankle joint, fibular head, sacro-iliac joint, lower lumbar spine, (atlanto-occipital and atlanto-axial joints) |
| Lower limb — gait — stance phase — flexion | |
| Tension | Extensors of toes and foot, tibialis anterior, hip flexors, hip adductors, recti abdominis, thoracolumbar erector spinae |
| Painful points of attachment | Pes anserinus of tibia, patella, lesser trochanter of femur, superior border of pubic symphysis, xiphoid process |
| Joint dysfunction (restrictions) | Knee, hip, sacroiliac joint, superior lumbar spine, thoracolumbar junction (atlanto-occipital and atlanto-axial joints) |
| Trunk — body statics | |
| Tension in muscle pairs | Sternocleidomastoid and short craniocervical extensors |
| Scalenes+deep neck flexors+digastric and: trapezius+levator scapulae+masticatory muscles | |
| Iliopsoas+recti abdominis and: erector spinae+quadratus lumborum | |
| Painful points of attachment | Posterior arch of atlas, spinous process of C2, nuchal line, sternal end of clavicle, superior and medial border of scapula, xiphoid process, pubic symphysis, lower ribs, iliac crest |
| Joint dysfunction (restrictions) | Atlanto-occipital and atlanto-axial joints, cervicothoracic junction and upper ribs, thoracolumbar junction (trunk rotation), lumbosacral and sacroiliac junction, temporomandibular joint |
| Lifting the thorax during inhalation (clavicular breathing) | |
| Tension | Superior parts of abdominal muscles, pectoralis, scalene, diaphragm, sternocleidomastoid muscles, short craniocervical extensors, levator scapulae, superior part of trapezius |
| Painful points of attachment | Posterior arch and transverse processes of atlas, spinous process of C2, nuchal line, sternal end of clavicle, superior border of scapula, sternocostal joints and upper ribs |
| Joint dysfunction (restrictions) | Atlanto-occipital and atlanto-axial joints, cervicothoracic junction, upper ribs, thoracic spine |
| Upper limb — prehension — restricted flexion | |
| Tension | Extensors of fingers and wrist, thenar eminence, supinator, biceps brachii, triceps brachii, deltoid, supraspinatus, infraspinatus, upper fixators of scapula, interscapular muscles |
| Painful points of attachment | Radial styloid process, radial (lateral) epicondyle, attachment of supraspinatus and infraspinatus, attachment of levator scapulae, spinous process of C2 |
| Joint dysfunction (restrictions) | Elbow, acromioclavicular joint, middle cervical spine, cervicothoracic junction, upper ribs |
| Upper limb — prehension — restricted extension | |
| Tension | Flexors of fingers and wrist, pronators, subscapularis, pectoralis, sternocleidomastoid, scalene muscles |
| Painful points of attachment | Ulnar (medial) epicondyle, sternal end of clavicle, sternocostal joints, Erb’s point, transverse process of atlas |
| Joint dysfunction (restrictions) | Carpal bones, elbow, glenohumeral joint, cervicothoracic junction, atlanto–occipital and atlanto-axial joints |
| Head and neck — eating — speaking | |
| Tension | Masticatory, digastric, sternocleidomastoid muscles, craniocervical extensors, trapezius, levator scapulae, deep neck flexors, pectoralis muscles |
| Painful points of attachment | Hyoid, posterior arch and transverse processes of atlas, spinous process of C2, nuchal line, sternal end of clavicle, superior border of scapula, angle of upper ribs |
| Joint dysfunction (restrictions) | Temporomandibular joint, atlanto–occipital and atlanto-axial joints, cervicothoracic junction, upper ribs |
4.20.2. Chain reactions in the light of developmental kinesiology
What is said here follows on from Section 2.5.3, which describes the development of the co-contraction pattern of flexors and extensors, adductors and abductors, and external and internal rotators. As a prerequisite for human upright posture, antagonists developed into synergists, a development that can most clearly be seen at joints such as the knee and individual segments of the spinal column. This pattern appears yet more fundamental in the craniocaudal direction, with the formation of muscle chains in the sagittal plane beginning at the feet, connected through their points of attachment and stabilizing the spinal column just as a mast is stayed. These muscles, as pointed out by Richardson et al. (2004), are long, most of them spanning two or more joints.
This is the more important for the fact that the spinal column, unlike a mast, is jointed. Panjabi et al. (1992a) showed that the motion segments are unstable, and require the activity of the short, deep muscles of the back to stabilize them. If it were not for these muscles, the contraction of the long muscles would cause individual motion segments to buckle. Therefore, in parallel with the co-contraction pattern, there developed the system of the deep stabilizers. This includes not only the multifidi, but also, ventrally, the abdominal cavity and its walls: the diaphragm, transversus abdominis, and pelvic floor, sustaining intra-abdominal pressure. The importance of this stabilization function is so great that, in the action of raising the arm, the diaphragm or transversus abdominis contract before the deltoid (see Figure 4.80). We even observed a patient who was unable to raise her arm if her pelvis was not fixed, on account of paralysis of the deep muscles of the back. If her pelvis was fixed, however (in the sitting position), she was able to carry out the action without difficulty (Lewit & Horácek 2003).
 |
| Figure 4.80
EMG of the deltoid muscle and diaphragm on raising the arm: contraction of the diaphragm takes place in advance of contraction of the deltoid (modified after Richardson et al 2004). Pdi, transdiaphragmatic pressure; Pga, intra-abdominal pressure; Poes, intrathoracic pressure.
|
The development discussed so far has been that of the postural program, which takes place automatically and is also associated with the optimal positioning (centering) of the limbs. This development is completed in overall terms in the fourth month of life, but only fully completed at four years of age. As indicated previously in Section 2.6, in a considerable proportion of children this development does not proceed straightforwardly.
As soon as children learn movement, their own individual programming of movement patterns begins to take shape, in line with their particular interests and opportunities. The way this happens will become clearer if we use an example: playing tennis. On the basis of neurology we would expect the following: as soon as the player sees the ball, the image strikes the retina. From there, the stimulus travels to the diencephalon and is transmitted to the occipital lobe, from there to the parietal lobe, and finally to the motor cortex. From here, the neurons of the central nervous system communicate with the spinal cord and peripheral neurons with the muscles. There is then feedback via the posterior horn and the cerebellum. Assuming a transmission speed of 100m/s, the ball will be long since out of play.
The only way to understand this problem is once more by looking at the developmental process: first, we place the ball firmly in the child’s hands. (The child has successfully passed through the stage of postural development.) Then we carefully throw the ball to the child, who stands with hands ready to receive it. It takes some time before the child is actually able to catch the ball, first with both hands, then with just one. Only now do we give our child a tennis racquet for the next stage: learning to hit the ball. What has been happening during those years? The brain, that most accomplished computer of all, has constructed a program, and the moment the eye sees the ball, the program springs into action: the movements of eye, head, trunk, and limbs all take place automatically.
This understanding is extremely important in determining our practical approach. It clearly shows that the program involves the entire system. If a disturbance appears somewhere along its course, we must reprogram it. It also follows that symptoms, in this case dysfunctions, can appear in many places, and it is our job to discover which is the most important dysfunction, the one that is the key link in the chain reaction.
Understanding this development enables us to organize our approach in a rational way and draw up certain rules that describe how this system behaves as a whole. A good way to illustrate this ‘holistic’ approach is with reference to the programmed reaction of supporting oneself, for example with hand, elbow, or knee, in standing posture. As soon as we do this there is an instant change in our posture in every section of our locomotor system. This reaction must originate from the receptors of these points of support, which are also very important, according to Vojta & Peters (1992), as points of stimulation.
The only way that a programmed function can be directed is by the nervous system, by means of the musculature. Therefore we must take the muscles as our starting point if we wish to understand and analyze the chains of reaction. The function of the muscles is closely linked with that of the joints: the earlier discussion of TrPs made clear that these are linked with movement restrictions; this is manifested in practical terms in the use of neuromuscular techniques of treatment. In this context it becomes evident that TrPs in fact have the function of establishing stability at the cost of mobility.
They are found in antagonists in motion segments or limbs: adductors–abductors; extensors–flexors. In the case of fan-shaped muscles such as the pectoralis major, a section of the muscle corresponds to a particular section of the erector spinae. However, the antagonism is not limited to the particular segment: if, for example, an extensor is stimulated, this does not only inhibit its specific antagonist, but also the entire flexor system. As demonstrated by Brügger (2001), this effect is especially pronounced when the extensors of the fingers and toes are stimulated, since the density of receptors is particularly great in these locations. As an example, stimulation of the toe extensors can inhibit the activity of the ischiocrural muscles, with consequent weakening in the straight-leg raising test.
The co-activation pattern applies not only within the segment; it also serves to maintain upright posture. From their anchor point at the feet, the muscles and their attachments work together to maintain upright posture just as a mast is stayed by the rigging. Dysfunctions often produce TrPs in the muscle chains that form these ‘mast stays.’
TrPs are markers that trace out chain reactions, and these chain reactions also involve joints and soft tissues.
4.20.3. The pathomechanisms of chain reactions
A further principle can be drawn from developmental kinesiology: the developmentally older function is less susceptible to disturbance, and therefore predominates. In pain, exhaustion, aging, and the phenomena associated with paresis, the predominating model is that of the newborn. The same principle follows equally from the disturbances of movement pattern in the concept developed by Janda (see Table 2.1) and from Brügger’s (1971)‘sterno-symphyseal syndrome.’
In both these cases it is possible to speak of a chain reaction in which the flexors predominate. In Janda’s terms these are the ‘primarily postural muscles’; in terms of current knowledge they are the developmentally older muscle groups. Brügger’s (1971) explanation of the round-shouldered sitting position, however, is not based on muscular imbalance, but on the position of the joints: in sitting with thighs adducted, the pelvis tips backward, and if the arms are folded in front of the chest, it becomes impossible to straighten the thorax. This situation also shows the close relationship between joint function and muscle activity.
A further chain reaction in which the balance between flexors and extensors is disturbed is the forward-drawn posture when standing. On inclining forward, all the erector spinae muscles, including the nuchal muscles, become taut. Proof of this can be found by palpating one’s own neck muscles. If patients are found to have tense nuchal muscles in standing posture, and if restriction of the atlanto-occipital and atlantoaxial joints has been excluded, the following test is decisive: the patient whose nuchal (and back) muscles are tense when standing is asked to sit on a chair; the tension disappears on sitting excluding the role of the lower limbs. TrPs are generally found in the sternocleidomastoid and especially the rectus abdominis. There is often tenderness to pressure of the attachment points on the xiphoid process, inferior costal arch, and especially the superior border of the pubic symphysis, at least on one side. The chain usually continues on down to the ischiocrural muscles, especially the biceps femoris and its insertion at the fibular head, and there is generally restriction relative to the fibula. If the chain does not end here, there may be TrPs in the short toe flexors and short extensors with restrictions in Lisfranc’s (tarsometatarsal) joint. The most distal link in the chain is generally the decisive factor, and in many cases this is in the foot, which also belongs to the deep stabilization system.
The pathogenesis of this chain lies in the important role played by the powerful ischiocrural muscles in the fixation of the pelvis. If there is a TrP here, the fixation of the pelvis is disturbed and has to be compensated by the rectus abdominis and the gluteus maximus. The consequence of this is tension of the rectus abdominis in particular, and this helps cause the forward-drawn posture. Often such patients complain of headache and pain in the nape of the neck; the cause, however, often lies in the region of the patient’s feet.
4.20.4. Causes of chain reactions
The most frequent cause of chain reactions is dysfunction of the deep stabilizers. These form a chain in their own right, as was demonstrated by Richardson and coworkers (2004) in their electromyographic study of the contraction of the pelvic floor. The muscles involved are the diaphragm, the transversus abdominis, the pelvic floor, and the multifidi. TrPs can be palpated directly on the pelvic floor and diaphragm. In the case of disturbance here, the long muscles react with the emergence of TrPs in an attempt to compensate for the disturbed stability, a task to which they are little suited.
In the trunk region, the longissimus, quadratus lumborum, and psoas major, and sometimes the rectus abdominis, are the muscles involved. The irritability of the erector spinae is sometimes so marked that snapping palpation of a TrP in the thoracic portion sometimes produces a twitch reaction in the lumbar portion as well. This causes strong dorsiflexion of the pelvis, described by Silverstolpe (1989) hence called ‘S’ reflex.
Working in the cranial direction, the next muscles are the pectoralis and subscapularis, the upper fixators of the shoulder girdle, scalenes, sternocleidomastoid, short craniocervical extensors, and the masticatory and digastric muscles.
Working in the caudal direction, the next muscles are the hip adductors, the ischiocrural muscles, and quadriceps femoris; then in particular the soleus and painful Achilles tendon and the short muscles of the foot.
4.20.5. The role of the diaphragm
The diaphragm clearly seems to play a special role because it combines a postural function with that of respiration. This means that disturbance of the deep stabilizers is associated with faulty breathing, or, conversely, that correct breathing and good stabilization of the lumbar spine depend on the coordinated contraction of the diaphragm and abdominal wall.
According to Kolář (2006), this can be examined by means of the following tests: the patient is supine or sitting, thorax caudalized in exhalation. The examiner should fix the thorax in the exhalation position, simultaneously palpating the lateral abdominal wall at the waist. The patient is asked to exert pressure against the examiner’s palpating fingers. To facilitate this, the patient’s knees should be bent and, if the patient is supine, resistance is applied to the flexed knees. If the patient is sitting, the only action necessary is for the patient to lift the bent knees slightly; the lateral abdominal wall tenses at that moment. This tension should be maintained during inhalation to prevent clavicular breathing (in which the thorax is lifted during inhalation) and oblique positioning of the diaphragm. Contraction of the diaphragm is then concentric, and this counters the eccentric contraction of the transversus abdominis in particular. The examiner should at the same time ensure that there is contraction of the muscles of the lower abdomen, and to a lesser degree the upper abdomen, so that the navel does not move in the cranial direction.
If supine, the patient should slowly raise the head and to a slight degree also the trunk, and the examiner should palpate the lower ribs in the medioclavicular line. The raising of the patient’s head activates the abdominal muscles, so that the thorax remains caudalized. Further raising of the thorax causes activation of the lateral abdominal wall, even caudad to the navel. However, the abdomen should not bulge, either forward or laterally.
If prone, the patient should be asked to lift the head and bend upward to create a slight lordosis of the back. This should cause the erector spinae muscles and lateral abdominal wall to contract. If there is insufficiency of the muscles, there will be no contraction of the lateral abdominal wall, and if there is excessive activity of the thoracolumbar erector spinae, the shoulder blades will move craniad.
4.20.6. Rotation of the trunk
Trunk rotation is another function that is recent in developmental terms. As in the case of the deep stabilizers, a muscle chain is responsible for this movement. If trunk rotation is restricted, TrPs are found in the thoracolumbar erector spinae, quadratus lumborum, and psoas major, usually on the opposite side to the restricted rotation. Release of one of these three muscles is sufficient to remove the TrPs in the other two, whereupon trunk rotation becomes symmetrical again. This function is so important that, in cases where rotation of the cervical spine is also restricted, the treatment of trunk rotation frequently has the effect of normalizing findings at the cervical spine.
4.20.7. Unilateral chains of dysfunction
In very painful conditions such as radicular syndrome, a unilateral chain pattern tends to be observed. This involves the sternocleidomastoid, short craniocervical extensors, trapezius, pectoralis muscles, subscapularis, and erector spinae, and sometimes the iliacus and quadratus lumborum, piriformis, glutei, hip adductors, rectus femoris, and soleus, down to the TrPs and restrictions of the foot, though it may not include the deep stabilizers. If this is the case, the disturbance derives from the ‘deep’ short stabilizers of the foot, which can similarly elude voluntary control; for example the abductor pollicis brevis. Another very important feature here is this: in such unilateral chains, sensitivity is noticeably asymmetrical, both overall and, in particular, on the soles of the feet. This is clearly evident from the involuntary reaction to exteroceptive stimulation of the sole of the foot. In such cases this test of exteroceptive stimulation is decisive, meaning that the afferent disturbance is the most relevant link in the chain.
In addition there are shorter chains, which are of particular local significance. In the case of lateral (radial) epicondylopathies, these chains consist of TrPs of the extensors of the fingers and wrist, the supinator, the biceps brachii and tripceps brachii, all muscles with a point of attachment on the lateral epicondyle and with a role in prehension. Usually, however, these muscles are also linked with chains of dysfunction in the cervical spine. Even more important is insufficient fixation (stability) of the shoulder blade on the same side.
The syndrome of the superior thoracic aperture represents a chain of muscular and joint dysfunctions in its own right. This chain consists of the cervical spine, the scalenes, the upper fixators of the shoulder girdle, the pectoralis minor and subscapularis muscles, and the uppermost ribs and cervicothoracic junction, as a rule associated with clavicular breathing and therefore also with the deep stabilizers.
The soft tissues have for the most part been excluded from the discussion so far for the sake of clarity. However, fasciae that ‘stick,’ especially around the thorax, the back, and the scalp, can often play a decisive role in the chains. The most pathogenic soft tissue lesions are ‘active scars,’ which will be discussed in Chapter 5.
4.20.8. Analysis of chain reactions
Chain reactions are not always complete, and sometimes there may be more than one chain. Diagnosis seeks to find the most relevant link in the chain, since treatment of this key link will often normalize the entire chain, enabling therapy to be given in the most efficient way. Equally importantly, the practitioner needs to know the direction in which to proceed when planning further treatment. What, then, are the criteria to be used in this analysis?
• The patient history should give an indication as to which symptoms occurred early on and which later, and also which symptoms tend to recur and under what circumstances.
• The intensity of a given finding can be important.
• It is very important to identify whether the part affected is a key region, structure, or function. For example, the problem may affect the feet, the joints of the craniocervical region, structures of the deep stabilization system, faulty breathing, or an active scar; this is particularly important if the symptoms appeared shortly after trauma or an operation.
• Having decided on the treatment, the practitioner should of course check the effectiveness of therapy by re-examining the patient immediately afterwards.
• Therefore, diagnosis does not end until the first treatment procedure is given. If the expected effect is not achieved, the practitioner should turn to another link in the chain. The first treatment is often chosen with an eye to diagnosis, in order to establish the relevance of a particular link in the chain (i.e. that of a particular finding). In the case of active scars, this is the normal procedure. If these are found to be highly relevant, any other treatment would fail.
• Even if the first therapeutic/diagnostic procedure proves successful, this does not necessarily mean that another might not also be successful. If the chain reaction runs in one direction, this does not necessarily mean that it might not run in the opposite direction; these chains are not ‘one-way streets’ (Hermach 2007).
An understanding of chains of dysfunction is fundamental to a holistic approach to their treatment.
4.21. Differential diagnosis
4.21.1. Problems
As has already been mentioned, the locomotor system reacts to some degree to everything that happens in the body, and reflects it. As a result, clinical diagnosis is multifaceted and a highly responsible task.
The problems essentially fall into two fundamentally different categories. The first concerns conditions which to varying degrees involve the spinal column and locomotor system: headache, vertigo, and a number of visceral symptoms in which vertebrogenic disturbances regularly play a part, such as chest pain, pain in the abdominal cavity, dysmenorrhea, etc. In the case of these conditions the task is to decide the significance of the concomitant findings that usually exist in the locomotor system, and to determine whether they require treatment. This problem covers the whole field of medicine, and so can often only be solved with the collaboration of specialists in the relevant branches of medicine.
The second problem is the differential diagnosis of disturbances of the locomotor system and the spinal column itself. Here the task is to decide whether the lesion is a pathomorphological one or a dysfunction, or a combination of both. In that case there is the further decision as to which disturbance is currently the more relevant.
Errors in diagnosis may arise; in such cases inflammatory, metabolic, or neoplastic diseases may be involved. For this reason laboratory tests should always be carried out (including blood count and erythrocyte sedimentation rate), and X-rays requested if there is the least suspicion. Pathological processes can often be difficult to diagnose clinically in the early stages, so that the practitioner can only prescribe pain relief. In cases such as these where it is not yet possible to arrive at a diagnosis, treatment of dysfunctions using today’s techniques involves no more risk than analgesics, which are indeed more likely to produce undesired side effects.
The regular follow-up examinations given to patients during therapy mean that the warning comes from the course of the disease; the practitioner should be alert to warning signs such as repeated relapses, persistent failure of therapeutic measures to achieve much effect, and deterioration in the patient’s condition. However, it would be a mistake to overestimate the capacity of the test procedures used for these examinations. The practitioner should carry out testing directly after treatment to check the immediate effect; but it is wrong to suppose that a favorable finding, indicating success at this immediate stage, can be any proof that pathomorphological processes are not present. Even where there is pathomorphological disease, dysfunctions can develop and feed the symptoms at the moment when we are administering therapy. These may include restrictions and TrPs which it is quite legitimate to treat.
This is an appropriate point to describe typical sources of error and how they can be avoided. If, despite repeated treatment and self-treatment, restrictions and identical TrPs repeatedly occur in the same segment, the cause is either internal disease in a location corresponding to that segment, or a correspondingly located tumor or other pathological process in the region of the spinal column. For example, in a young patient, recurrence of a sacroiliac restriction, if bilateral, suggests sacroiliitis. Recurrent back pain in postmenopausal women, especially if it occurs following physical stress, suggests osteoporosis.
4.21.2. Case studies
A. F., carpenter, born 1915. This patient underwent surgery in 1959 for a painful tumor on the left thenar eminence, and for a Dupuytren’s contracture of the fourth finger on the left hand. In 1959, he began to experience pain in the back of the neck, with stiffness. The pain became increasingly severe and the patient was admitted to a neurological hospital at the beginning of 1961. A contrast study of the spinal column (myelography) yielded no particular findings, and the patient was therefore referred to us for manual therapy in May 1961. By the autumn of that year he had received treatment four times, and each time the success was only temporary. Despite the absence of neurological symptoms, and simply on the basis of the course of the illness, we recommended that the contrast investigation be repeated. On readmission to the neurological hospital in October 1961, the patient was found to have stiffness of the neck and he was holding his head in a fixed position slightly bent forward and permanently rotated to the right. Erb’s point on the right was tender to pressure, as were the spinous processes of C2–C4. Mobility of the head was restricted in all directions, but especially left rotation. The one other finding was a static, evidently functional, tremor of the right hand.
Pneumomyelography after injection of 30ml of air by the lumbar route, with the patient sitting and the head in maximum anteflexion, showed a well-defined tumor at C2. Cerebrospinal fluid albuminocytological dissociation was found. Symptoms of a radicular lesion at C8 appeared for the first time following the pneumomyelography. This striking finding led us to a diagnosis of neurinoma at C2, partially intradural and located on the ventral aspect of the cord. The patient underwent operation and a neurinoma of the spinal root of C2 was removed. The unbearable pain subsided immediately following the operation.
The conclusions to be drawn apply not only to other sections of the spinal column but also to restrictions in the craniocervical region with forced attitude of the head in the case of brain tumors with an occipital pressure cone; this behaves like an extramedullary tumor.
F. M., born 1914. This female patient was an unskilled worker. From September 1961 she complained of occipital headaches, repeatedly accompanied by vomiting. She was examined as an outpatient at the neurological hospital in November 1961, when cervicocranial headache was diagnosed. Manipulation was performed and brought instant relief from the pain, lasting about a month. At the follow-up examination at the end of December 1961 there was intense pain at the nape of the neck and the spinous process of C2 was tender to pressure. This time, manipulation brought no relief; injection of procaine at the pain point was then tried, also without success. At the next follow-up examination in mid February 1962 the patient was holding her head in a forced attitude in anteflexion and inclined to the left. Passive mobility testing of the head did not find any typical restriction, but merely found resistance; overcoming this produced a reaction of nausea. This suggested forced attitude of the head as a result of increased intracranial pressure.
Plain film X-ray of the head showed signs of increased intracranial pressure at the sella turcica. On hospital admission on 21st February 1961, the patient was entirely symptom free and the neurological findings and electroencephalogram (EEG) were normal. However, pneumoencephalography showed an occipital pressure cone. Only a very small amount of the air entered the third ventricle, and showed it to be displaced to the left. This finding led the hospital to perform angiography of the right internal carotid, which revealed a vascularized tumor in the right parietal region, located parasagittally and suspected to be a meningioma. Only after the pneumoencephalography did the beginnings of papilledema and slight disturbance in the EEG become evident. The patient underwent surgery in mid May 1962, and a falx meningioma of the right parietal region was removed.
In this case an occipital pressure cone initially caused a very ordinary cervicocranial syndrome that responded well to manipulation. Later came the development of the forced attitude, and it was important for the manual practitioner to distinguish this from restriction (the typical hard end-feel is absent).
A restriction that is not resolved either spontaneously or in response to treatment, and/or relapses within a short time, suggests visceral disease in the corresponding segment, or a tumor.
4.21.3. Common differential diagnoses
Acute pain
Chronic, relapsing symptoms are not the only type to give rise to differential diagnostic decisions; acute pain is another. This is especially so if the pain appears following accidents, and manual techniques can also be used to deliver first aid. The practitioner not only needs to be able to exclude fractures and dislocations, but also torn ligaments and joint capsules, hematomas, etc. Acute pain at the back of the neck, occurring together with severe headache, can be the result of subarachnoid hemorrhage. Since this is not a joint disturbance but an acute meningeal syndrome, the movement direction that is restricted is not rotation or side-bending but anteflexion of the head.
Herniated disk
Psychosomatic disorders
In patients whose main concern is pain, the practitioner very frequently has to decide to what extent psychological factors play a role; every instance of pain is also a psychological experience. Understandably, medical practitioners base their approach on the presence or absence of clinical signs in a condition that the patient describes as painful. Unfortunately, few doctors have the relevant specialist knowledge to diagnose and understand dysfunctions, which are the most frequent cause of pain. The key is this: if the patient is able to give a precise description and localization of the pain, and this information remains consistent on repeated questioning, it is unwise to dismiss it as merely psychological. In doubtful cases our guide is the course of the illness, based on observation over time and knowledge gained of the patient. These enable us to compare the clinical findings, and the changes that take place in them, with the patient’s own statements. In contrast, if the patient finds it difficult to describe or localize the pain at all precisely, and there are frequent changes in the patient’s statements, it is likely that the pain is (mainly) of psychological origin.
Masked depression
The problem posed by masked depression is an important one because it can indeed take the outward form of back pain and headache. This is because psychologically caused tension and tense posture do actually bring about painful dysfunctions, especially in the orofacial system and cervical region, and at the coccyx as a result of tension of the gluteal muscles and pelvic floor (levator ani). The diagnosis is hard to establish at the first examination; during the course of treatment it is found that after a short while the patient complains of fresh pain, and tension is found at the locations described. This should be a cue to ask targeted questions about whether the patient feels depressed or has experienced sorrow in the past. The most important question to ask is whether the patient suffers from disturbed sleep; the typical pattern of sleep disturbance is for the patient to fall asleep normally, but to wake in the (very) early hours of the morning and be unable to go back to sleep. A conclusive diagnosis is obtained by test prescription of mild antidepressive drugs.
Fibromyalgia syndrome
There is an essential distinction to be made between muscle pain that occurs in most cases of back pain in the form of TrPs on the one hand, and fibromyalgia syndrome, which has been much explored in the literature. This is a chronic systemic disease affecting mainly women. The painful muscles are found bilaterally; they are numerous, and not confined to the trunk, but also found on the limbs. The pain is accompanied by fatigue, and there is morning stiffness similar to that in rheumatoid arthritis. Patients suffer from sleep disturbance, especially of non-REM sleep. The combination of chronic pain, fatigue, and sleep disturbance is associated with a mood of depression. On palpation, the muscles that are painful either behave like TrPs or feel hypotonic and doughlike. Tenderness in hypotonic muscles is a particularly characteristic finding in this disorder. The laboratory findings are not characteristic and the pathogenesis unknown. The cause is thought to lie in a lowering of the pain threshold in the central nervous system. Mild antidepressants and carefully judged physical exercise are recommended as treatment. In our experience, there is some benefit in light massage that the patient experiences as pleasant, administered over fairly long periods of time. The usual analgesics are not very effective.
Inflammatory conditions
Inflammatory conditions also play a role. Rheumatoid arthritis is usually not difficult to recognize. This does not generally tend to affect the spinal column as often as it does the limbs, but this very fact makes it important to be aware of inflammatory, destructive lesions in the region of the atlas and axis. For this reason, where vertebrogenic symptoms appear in patients with existing rheumatoid arthritis, an X-ray should be performed.
Another condition that should particularly be borne in mind is ankylosing spondylitis. This should be considered in cases where the patient’s symptoms first occurred around the age of 20, from then on taking a progressive course without lasting periods of remission. Characteristically patients report pain at night, which regularly wakes them at the same time in the very early hours of the morning and forces them to get up and move about. The first clinical sign is generally recurrent sacroiliac restriction, often bilateral. The restriction soon extends to the entire lumbosacral segment, then to rotation of the trunk, and especially stiffening of the thoracic cage, where springing pressure elicits no springing. Consequently there is clavicular breathing and exaggerated abdominal breathing.
Laboratory findings are also important in the diagnosis of this condition. One such finding is the HLA-B27 antigen, which suggests a hereditary cause. The radiological findings are also significant; a positive finding in the X-ray of the sacroiliac joints shows the contours of the joints as ill-defined. In the early stages the joint space is widened, but later it may be ossified. On the spinal column, syndesmophytes develop and bridge the intervertebral disks, so that in the fully developed stage the anteroposterior film shows the spinal column as looking rather like a stick of bamboo. Typical as these radiological changes are, they may be absent. Diagnosis is especially difficult in female patients, because the disease often follows a milder course which does not then lead to stiffness. In males, progressive stiffness, gradually extending in the cranial direction, is the rule. This development can occur largely painlessly, in which case the impression is given that the disease did not begin until around age 40 or even later. The consequences are particularly severe for patients in whom the disease develops in the hip joints. In the early stage it is mainly the palpation findings that are characteristic. This fact makes it difficult to achieve early diagnosis, and calls for practice.
4.21.4. Conclusions
Perhaps the main point to be made in conclusion is that diagnosis of dysfunctions of the locomotor system is a new field of clinical medicine, and a difficult one. In differential diagnosis we need to be aware that in most cases, including structural changes, the earliest clinical manifestation takes the form of disturbed function. Moreover, patients referred for pain due to ‘mere’ disturbed function are usually dealt with as outpatients, who cannot be examined as thoroughly as those in a hospital ward, where the technical facilities available are also greater. The practitioner in charge of such cases must remain constantly aware of the innumerable pitfalls; nothing is more dangerous than a sense of infallibility. This section on differential diagnosis should also serve as a warning.
