Musculoskeletal Examination (10/14a) [Examination]

Question 1

Medical World vs PT World

Answer 1

Medical

• tissue/pathology based
• pathoanatomy
• often directs general treatment approach and informs prognosis

PT

• impairments/movement based
• usually dictates what we do with a patient

Question 2

Medical World - Pathoanatomic Diagnosis

Answer 2

Anatomically based

Pathology based

What tissue is affected?

Pathology drives Rx

Non musculoskeletal

Question 3

Pathoanatomy vs Impairments

Answer 3

Fractured Radius vs Wrist Joint Stiffness

Rotator Cuff Tear vs Shoulder Weakness

Lateral Ankle Sprain vs Joint Instability

Knee Osteoarthritis vs Knee Pain/Effusion

Achilles Tendinitis vs Heel Pain/Tightness

Question 4

PT World - Movement Diagnosis

Answer 4

Impairment based

What is/are the primary impairment(s)?

What is causing them?

Impairment drives Rx

Based on the assumption that impairments relate to limitations in functional activity and participation

Question 5

Are impairments and activity limitations always correlated?

Answer 5

No, not always directly correlated

make sure you find out what the patient cares about being able to do

correlation often below 0.5

Question 6

Using Patient Management Model for Diff Dx

Answer 6

Functional Movement Task
- use CASSS

Observation

Hypotheses about Dysfunction

Specific Tests and Measures

Evaluation and Movement Diagnosis

Interventions

Reobserve

Question 7

Cyriax - Diagnosis by Selective Tension

Answer 7

Identify the tissue with the “lesion”

Reproduce chief complaint symptoms by applying tension

Question 8

Maitland - Diagnosis by Comparable Sign

Answer 8

Reproduction of the patient’s chief complaint with a movement, position, or test

Asterix on exam findings, compared over time

Developed system of vertebral manipulation

Question 9

Musculoskeletal Tissues - Contractile

Answer 9

Muscle and tendon

and tenoperiosteal junction

Question 10

Musculoskeletal Tissues - Inert

Answer 10

(not capable of producing movement)

Capsule, ligament, menisci, bone, bursa

Cartilage isn’t on the list since it isn’t a direct source of symptoms

Question 11

Cyriax Examination - Overview

Answer 11

“Selective tissue tension”

Based on the notion that the “lesion” can be localized by selectively applying tensile stress to various tissues in a systematic way

Goal is to diagnose the location of the symptomatic “lesion”

Can be applied to virtually all musculoskeletal regions — works better at some than others (extremities vs spine)

Most won’t use it for the spine since it doesn’t work as well for it

Question 12

Cyriax Examination - Steps

Answer 12

AROM → PROM → Isometric Resistance

AROM — ability / willingness to move

PROM — passive tension inert & contractile

Isometric Resistance — active tension, contractile only

Question 13

Cyriax Steps - AROM

Answer 13

Ability and willingness to move

Quality of motion

Range, pain, painful arc

Question 14

Painful Arc

Answer 14

pain in the middle of a ROM (EX: common with shoulder)

tend to mean something is transiently getting stressed/pinched

Question 15

Cyriax Steps - PROM Sequence of Pain/Limitation

Answer 15

pain before end-range (acute)

pain at end-range (subacute)

pain with overpressure (chronic)

Irritability (per Maitland)

• High: pain prior to resistance/end feel → treat pain
• Low: resistance/end feel prior to pain → treat limitation

Question 16

Cyriax Steps - PROM Capsular Patterns

Answer 16

predictable pattern of PROM for a specific joint

PROM is a proportional loss

Indicates involvement of entire joint

Arthritis, synovitis, capsulitis

EXAMPLES
Glenohumeral joint loss
- Lose more ER > Abd > Flex/IR

Hip joint loss
- Lose more IR > (Flex, Ext, Abd)

Knee joint loss
- Lose more Flex > Ext

Ankle joint loss
- Lose more Plantar Flex > Dorsiflex

Question 17

Cyriax Steps - PROM Noncapsular Patterns

Answer 17

PROM not in capsular pattern
something other than entire joint

isolated ligament adhesion, internal derangement, extra- articular tissue

Internal derangement = something floating around in the joint that doesn’t belong there, such as a piece of tissue (EX: meniscal tear)

EXAMPLE
GH jt loss
- Lose more Abd>ER
- seen with impingement syndrome

Question 18

Cyriax Steps - PROM End Feels

Answer 18

capsular
spasm
empty
bony
tissue approximation
springy block

Question 19

Cyriax Steps - Isometric Resistance

Answer 19

No joint movement

Midrange — minimize stress to inert structures

4 types of findings with neutral joint

Question 20

Cyriax Steps - Isometric Resistance Findings

Answer 20

Strong / Painless = Normal
- strong = getting adequate contraction

Strong / Painful

• minor lesion in contractile unit
• usually tendinitis
• minor muscle strain

Weak / Painless

• complete tear
• neurologic (spinal nerve root, peripheral nerve)

Weak / Painful

• partial tear
• occult fracture

Question 21

Summary of Cyriax Approach to Examination

Answer 21

AROM → PROM → Isometric Resistance

Palpation

Special Tests

• joint play (accessory motion)
• other clinical exams (sensory, reflexes, ectc)
• imaging, EMG

Functional Tests

Question 22

High Irritability

Answer 22

DESCRIPTION

• severe pain
• symptoms (sx) easily provoked
• no control of sx’s
• acute trauma

TREATMENT

• control sx’s
• stress relief
• no end range

Question 23

Low Irritability

Answer 23

DESCRIPTION

• less pain
• sx’s controlled
• sx’s more predictable

TREATMENT

• address impairments
• stretching
• strengthening