Principles of Cyriax Orthopedic Medicine I. Characteristics of referred pain a) Two main characteristics 1.Frequently the site of the pain is not the site of the lesion 2.There are no objective findings in Lab, imaging b) Rules of referred pain 1.Does not cross the midline Except)A central disc protrusion could cause central or bilateral pain. 2.Segmental distribution Any structure of C5-origin would cause pain in the C5-dermatome. 3.Reference mainly in a distal direction 4.The lesion does not necessarily lie in the painful area 5.Many soft tissues can cause referred pain 6.The pain is felt anywhere in the dermatome, not necessarily in the entire dermatome 7.Discrepancies between dermatomes and myotomes A muscular structure does not lie necessarily underneath its dermatome. Examples : . thumb and index finger lie in the C6-dermatome ; the muscles in the hand are of C8- and T1-origin. eight areas where the skin and the underlying structures do not have the same embryological origin : The head The skin of the mandible has originated at the front of the neck(C2) ; the skull and the entire face above the mouth are developed from the back of the neck.(Cr5) The scapular area The scapula and its muscles (including the latissimus dorsi) are derived from the middle and lower cervical segments ; yet the skin overlying them and the ribs beneath them have a thoracic origin. This means in practice that an upper thoracic pain can have a cervical or scapular origin if it radiates to the shoulder and the arm ; however, we think of an upper thoracic origin if the pain radiates to the front of the chest. The pectoral area the intercostal muscles, the ribs and the skin have a thoracic origin, whereas the pectoral muscles are lower cervical structures. The intrathoracic area The diaphragm is a C3/C4-structure (shoulder pain) ; the heart is T1-T2-T3. myocardial pain may spread to the entire arm, as far as the ulnar border of the hand. The hand Therefore, a The skin at the radial side is of C5/C6-origin, but covers thenar and interosseous muscles of C8/T1origin. The buttock The skin of the upper buttock is L1-L2-L3 and covers gluteal muscles of L4/S1-origin. The thigh It is only seldom that a patient with L4- or L5-nerve root compression states that his pain moved from the buttock to the lower leg omitting the thigh. Generally, he feels also a pain in the thigh ; the reason therefore is that the L4- and L5-dermatomes originate in the thigh. The scrotum When pain is felt in the scrotum, we should think of the following levels : S4 (skin) and T11-T12-L1 (testicle). c) Factors affecting reference of pain 1. The strength of the stimulus The stronger the stimulus, the more reference we can expect. 2. The position of the lesion within the dermatome If proximal : much possibility of distal reference. 3. The depth of the affected structure The deeper the structure, the more reference we can expect. A more superficial structure causes less reference. 4. The nature of the affected structure Rule : the first pain is always felt near the site of the lesion. (Hence an interesting question in the history : where did your pain start ?) Exception : nerve (e.g. a primary posterolateral protrusion : see chapter lumbar spine) II. Dura mater Exception to the rule of segmental reference : Dura mater = extrasegmental reference of pain and tenderness. What does that mean ? a) Pain Let’s imagine a cervical disc protrusion compressing the C7-nerve root. 1. Slight pressure on the dural sleeve causes pain in the C7-dermatome. 2. More pressure, reaching the parenchyma : pain AND paraesthesia. 3. Stronger pressure, through dural sleeve and parenchyma, on the nerve fibres : deficit (motor, sensory, jerks). Motor deficit : resisted elbow extension and wrist flexion are weak ; the other motor tests are negative. Sensory deficit : in the fingers (2)-3-4. Jerks : biceps and brachioradialis jerks are normal ; triceps jerk is sluggish. b) Tenderness The tenderness that can be found on palpation is not always reliable. We should consider the possibility of extrasegmentally referred tenderness. III. Diagnosis a) Introduction A palpatory examination without previous functional examination is to be avoided,why?. 1. 2. 3. 4. Some structures are normally tender (insertion of biceps on radius), some lesions lie too deeply extrasegmental tenderness from the dura mater, and some patients are malingerers. b) Inherent likelihoods/unliklihood When history and/or clinical examination are too different from what was expected, this becomes an inherent Unlikelihood. c) History The history can be more important than the clinical examination. . neutral questions : we do not suggest anything to the patient. Chronological order important to know where the pain started, because in most cases this is quite near to the site of the lesion. . Recurrences : . What influences symptoms ? Is there a relation between the symptoms and certain positions, movements, activities ? This is what we expect in a lesion of the locomotor system. . Age, profession : . Pain : uni- or bilateral. (Remember : a unilateral structure can only cause unilateral pain.) . Shifting or expanding pain !! Shifting pain :ex) a lumbar disc protrusion Expanding pain:ex) metastases. d) Clinical examination . A correct starting position . We interpret THE pain and should not be misled by A (second) pain.. . We distinguish between inert and contractile structures. Inert : capsule, disc, meniscus, ligament, fascia, dura mater, nerves, bursa. Contractile : muscle belly, body of tendon, musculotendinous junction, tenoperiosteal junction. A clinical examination is composed of an 1. inspection, 2. functional examination and 3. palpation. 2. Functional examination . Active movements : Active tests do not enable us to differentiate between inert and contractile structures. an active test does inform us about the patient’s willingness. . Passive movements :the integrity of the inert structures. We look for pain, range of movement and end-feel. . Resisted tests (maximal isometric contractions from a neutral position) examine the contractile structures. We assess pain and muscle strength. . The presence of a painful arc indicates a momentary pinching of a sensitive structure.A painful arc is often a localizing sign. 3. Palpation . Abnormal findings a) At rest : warmth, fluid, synovial thickening b) On movement : crepitus, end-feel. End-feel . Normal / physiological - Hard : e.g. elbow extension, knee extension - Capsular (elastic) : e.g. rotations at shoulder, elbow, hip - Extra-articular (tissue approximation) : flexion at elbow, hip. . Pathological - Too hard : e.g. osteoarthrosis - Too soft : e.g. loose body in the elbow joint - Muscle spasm (involuntary muscle contraction) : e.g. arthritis - Empty (voluntary muscle contraction, not always the same range) : e.g. abscess - Springy block : e.g. meniscus subluxation. e) Interpretation of tests 1. Lesion of an inert structure passive tests are positive, while all the resisted tests are negative (ideal situation). D/DX between the joint capsule and the other inert structures ; . The capsular pattern: osteoarthrosis or some sort of arthritis. Every joint has its own capsular pattern. A capsular pattern only exists in joints under muscular control The various capsular patterns Jaw Increasing limitation of mouth opening. Cervical spine Equal limitation of extension, both side flexions and both rotations. Flexion is the best movement. Shoulder Limitation of abduction, more limitation of lateral rotation, less limitation of medial rotation. Elbow Limitation of extension, more limitation of flexion. Lower radio-ulnar joint Pain on passive pro- and supination, no limitation. Wrist Equal limitation of flexion and extension. Trapezio-first metacarpal joint Limitation of abduction and extension, no limitation of flexion. Thumb and finger joints Flexion more limited than extension. Thoracic spine Equal limitation of both rotations. Lumbar spine Equal limitation of extension and both side flexions. Hip Gross limitation of medial rotation and abduction ; flexion more limited than extension. Knee Limitation of extension, more limitation of flexion. Ankle joint Limitation of dorsiflexion, more limitation of plantiflexion. Talocalcanean joint Increasing limitation of varus, in the end fixation in full valgus. Midtarsal joints Limitation of dorsiflexion, plantiflexion, adduction and medial rotation ; no limitation of abduction and lateral rotation. First metatarsophalangeal joint Limitation of plantiflexion with more limitation of dorsiflexion. II-V metatarsophalangeal joints Variable. Fixation in extension with flexed IP joints. . The non-capsular pattern is any other combination. Ligamentous adhesions ONE movement is SLIGHTLY limited by LOCALIZED pain. Internal derangement(loose body, meniscus, disc) A joint partially blocked and partially free. E.g. meniscus subluxation at the knee, acute torticollis. Extra-articular limitation(muscle belly) GROSS limitation in ONE direction, with normal movement in all other directions. Example : passive knee flexion markedly limited in case of a lesion in the quadriceps muscle belly (because of muscle spasm). 2. Lesion of a contractile structure One or more positive resisted tests (Other possibilities are : fracture, compression of an abscess or a bursa, and psychogenic disorders.) . Pain + Strength - 2 - - nerve lesion complete rupture 3 + gross lesion 1 Lesion minor lesion partial rupture 4 all - somatic lesion - hypersensitivity 3. Differential diagnosis At the end of the clinical examination, an accurate assessment of the findings is needed. We have already dealt with two possibilities : a lesion of an inert structure and a lesion of a contractile structure. Other possibilities are : Active range limited/passive range normal We think of the following possibilities : muscle or tendon (complete rupture) nerve : peripheral neuritis psychogenic disorder (anterior poliomyelitis, cerebrovascular accident). Hypermobility Capsuloligamentous laxity in : acromioclavicular, sternoclavicular, sacroiliac, sacrococcygeal joints, symphysis pubis, collateral and cruciate ligaments at the knee, tibiofibular mortice and calcaneofibular ligaments. Bony block Limitation of range with a bony end-feel, because something hard stops the movement : without pain : probably a neuropathic arthropathy with some pain: osteophytosis, myositis ossificans, a malunited fracture. No movement is possible Intense muscle spasm in a bacterial arthritis ; fibrous or bony ankylosis. A snap occurs . “Frictional tendinitis” : a tendon catches against an exostosis and slips over it (peronei, hip, long head of biceps). . Osteoma : this catching against a tendon may be the first sign. . A small semi-membranosus bursa may slip over a tendon on knee flexion. . Trigger finger. A crack is heard A normal phenomenon on traction, especially at the fingers. A click is palpable E.g. : - loose body - ligamentous laxity. Crepitus E.g. : - wear and tear of the gliding surfaces of a joint : fine or coarse crepitus, or creaking of bone against bone when the articular cartilage has worn through completely - tenosynovitis fine crepitus : mechanical coarse crepitus : rheumatoid or tuberculous - myosynovitis (musculotendinous junction) of the extensor pollicis brevis and longus and the abductor pollicis longus muscles at the forearm (tunnels 1+3) and the tibialis anterior muscle. f) Other diagnostic procedures Localization of a lesion in two overlapping structure Distant pressure a lesion in a long bone, Diagnostic traction a nerve root compression by a disc protrusion, Aspiration Intra-articular fluid : blood or clear liquid ? g) Misleading phenomena Referred pain Extrasegmental dural reference. Associated tenderness A nearby structure can be more tender than the lesion itself. - type 2 tennis elbow (origin of extensor carpi radialis brevis muscle) : posterior aspect of the epicondyle -de Quervain’s disease : radial styloid process. Articular signs in root compression E.g. : - cervical posterolateral protrusion : pain, no limitation, on passive shoulder movements Palpation The more distally a lesion lies, the more reliable information palpation affords. Roughly, the value of palpation is as follows : - often misleading : trunk, shoulder, hip - useful : knee, elbow - important : hand, foot.. h) Local anaesthesia As diagnosis i) Failure to arrive at a diagnosis When, in the presence of a good examination technique, a correct diagnosis cannot be reached, the following possibilities should be brought in mind. Slight pain The lesion is minimal. Very severe pain Here there may be too many positive tests. Lesion outside the sphere of orthopaedic medicine Obviously, a visceral Real difficult cases Anterior thorax-abdomen pain : visceral <---> PPLP or dural compression. Minor orthopaedic lesion with a psychogenic overlay : experimental treatment for 1-2 weeks. Double lesion (supra- and infraspinatus ; neck + shoulder) : - treat the easiest lesion first - treat the most frequent lesion first - treat the most obvious lesion first - treat the most painful lesion first. In conclusion, we should always work along the following lines, in the precise order : 1. Local lesion or referred pain ? 2. Inert or contractile structure ? 3. Capsular or non-capsular pattern ? 4. Palpation ? Remark : palpation occurs only after the functional examination. IV. Trauma to soft tissues : principles of treatment a) General remarks Rest in itself is not to be recommended. we should abate it as much as possible, perhaps with deep friction or with triamcinolone infiltration. . b) Minor muscular tears deep transverse friction, in most cases, will be the best treatment For three large muscle groups (quadriceps, hamstrings, calf muscles) the principles of treatment are as follows : - Acute stage : infiltration of a local anaesthetic deep friction + active and electricalcontractions - Chronic stage : deep friction + active and electrical contractions. For a lesion in a musculotendinous junction (in the entire body) the treatment is always deep friction. c) Tendinous lesions Tendinitis . The lesion often lies at the tenoperiosteal junction, less often in the body of the tendon. . Many such lesions are of the “self-perpetuating inflammation” type. . Two treatments have to be considered : infiltration of triamcinolone : quick result but a rather high rate of recurrence deep friction : takes more time, but there are fewer recurrences. Tenosynovitis, tenovaginitis . Triamcinolone, (deep friction). d) Minor ligamentous sprains Acute sprain . To reduce the post-traumatic inflammation : deep friction or triamcinolone. . To prevent the formation of adhesions : deep friction and progressive mobilization. Chronic sprain . Under the analgesic influence of the deep friction, adhesions are ruptured by manipulation ; the patient maintaines the new range of movement. For a lesion of the medial collateral ligament at the knee and the lateral ankle ligaments (anterior talofibular, calcaneocuboid and calcaneofibular ligaments) we proceed as follows : acute sprain - progressive deep friction : 30”-3’-5’-7’-10’ - progressive mobilization, without causing any pain - marching. V DEEP TRANSVERSE FRICTION a) Effect . Traumatic hyperaemia. . Movement of the affected structure, which prevents or destroys adhesions. . Stimulation of mechanoreceptors, which produces a quantity of afferent impulses with, as a result, a temporary analgesia. b) Indications . Muscular, tendinous and ligamentous lesions (sometimes deep friction is the only possible treatment). c) Contraindications . Calcification . Rheumatoid tendinous lesions . Local sepsis. . Skin diseases. d) Technique . Exact localization. . No movement between finger and skin (possibly cleanse the skin with alcohol or use a thin layer of cotton-wool between finger and skin). . Transverse. . Sufficient amplitude : we move over-up-and again over the structure. . Sufficient depth. . Starting position : lesion accessible to the finger tendons with a tendon sheath generally in a stretched position, just like ligaments muscle bellies always in a shortened position. . Various grips are used, according to the nature and the position of the lesion. . Economy of effort : an arm movement instead of a small finger movement (is so much more comfortable to the patient and to the therapist) a two-phase movement : active phase and relaxation. Always try to keep your own finger joints slightly flexed. e) Duration, frequency . For most lesions 3 times/week is a good frequency : mostly 15’ per session . There are two exceptions where a different strategy is used : the medial collateral ligament of the knee and the lateral ankle ligaments. Here, the deep friction is given in a progressive way. . The treatment can be ended when the patient is symptomfree and the functional examination has become negative Exception : quadriceps and hamstrings muscle bellies. To avoid recurrences, the treatment has to be continued for another week after full clinical recovery. f) Normal execution : one or more fingers are put onto the lesion, reinforced by one or more fingers. A reserve of skin is taken in the opposite direction, pressure is applied and the active phase of the DF is then a movement towards ourselves. In most cases, this is a large arm movement and not a small finger movement, with all our finger joints slightly flexed. The relaxation phase then follows into the opposite direction. VI. Pressure on nerves Neuritis The conduction along a nerve can be disturbed in two ways : - due to a parenchymatous lesion (“neuritis”) - due to pressure on the nerve from outside (“entrapment neuropathy”). In both cases paraesthesia are provoked. History A first information is the upper end of the paraesthesia. It is interesting to know how far proximally the paraesthesia are felt, because the site of compression lies even further proximally. Distal pressure on a small nerve . Numbness in the cutaneous area of the nerve. . One aspect (front or back, inner or outer). . Sharp edge. . Possibly an anaesthetic centre. Nerve trunk . Pins and needles in the cutaneous area of the nerve. . One aspect. . Vague edge. . Release phenomenon : the paraesthesia only appear after the compression has ceased. There is a clear relation between the duration of the compression and the length of the interval between cessation of compression and appearance of paraesthesia. The nervous structures in the distal half of the upper limb constitute an exception to the release phenomenon. . Stroking the paraesthetic area and moving the paraesthetic fingers can provoke the paraesthesia. Nerve root . Compression phenomenon, i.e. the symptoms appear when the nervous structure is compressed. . There is a segmental reference (dermatome) of pain and/or paraesthesia. . Stroking the paraesthetic area can provoke the paraesthesia. . Pain is the first symptom ; if pressure increases, paraesthesia are added. This sequence is relevant and important. Suppose the patient has paraesthesia without any premonitory pain ; in this case the lesion has to be sought elsewhere along the nerve. Spinal cord . Extrasegmental reference of paraesthesia. For finding the exact site of compression in an entrapment neuropathy, the history is extremely important. As far as examination is concerned, there are seven groups of signs, which rarely exist together. At times, the examination is completely negative and the diagnosis is established on the history, the objectivity of the patient and the absence of signs suggesting other pathology. Pain on stretching the nerve Examples : straight-leg raising, L3-stretch. Provocation of pins and needles In neuritis, the paraesthesia are very irregular and unrelated to movement. upon a nerve the paraesthesia can be provoked in two ways : . by active movement of the paraesthetic finger (= “entrapment”, not neuritis) In external pressure . by distant movement (= localizing meaning, e.g. shoulder elevation in a thoracic outlet syndrome with paraesthesia in the hand). Tenderness and swelling of a nerve sheath Both these elements are almost always present. pressure provokes the symptoms. E.g. : ulnar nerve at the elbow median nerve in the carpal tunnel If possible, we seek the point where neuroma in acute metatarsalgia (Morton). Postural deformity E.g. : lumbar lateral deviation. Neurological deficit Greater pressure through the dural sleeve and the perineurium results in conduction deficit in the nervous fibres. Local anaesthesia For example, if we can anaesthetize the dural sleeve, this is a good method of confirming a tentative diagnosis. After a couple of minutes the symptoms disappear and, depending on the individual, remain absent for a brief period. In many cases there is even a lasting effect. Steroid infiltration If, after steroid infiltration, the symptoms disappear, this has also a diagnostic meaning. In case of a carpal tunnel syndrome, the relief can last for weeks or months; or even be permanent.
