Trigger points Very localized areas of hyperirritability within the tissues They are tender to compression, are often

en accompanied by tight bands of tissue Referred Pain Pain is felt at a site other than the injured tissue because the referred site is supplied by the same or adjacent neural segments It radiates segmentally without crossing the midline Duration of Condition: 1. Acute been present for 7-10 days 2. Subacute present for 10 days 7 weeks 3. Chronic present for longer than 7 weeks Type of Pain Cramping, dull, aching Sharp, shooting Sharp, bright, lightning-like Burning, pressure-like, stinging, aching Deep, nagging, dull Sharp, severe, intolerable Throbbing, diffuse Structures Muscle Nerve root Nerve Sympathetic nerve Bone Fracture Vasculature

Locking joint cannot be fully extended (meniscal tear) Pseudolocking joint cannot be fully extended one time and does not flex the next time (loose body in within the joint) Giving way caused by reflex inhibition of the muscles, so that the patient feels that the limb will buckle if weight is placed on it. Mechanical (pathological) instability refers to loss of control of the small joint movements that occur when the patient attempts to stabilize the joints during movement. Clinical instability (pathological hypermobility) refers to excessive gross movement in a joint Laxity (hypermobility) non pathological states hypermobility Voluntary instability initiated by muscle contraction Involuntary instability result of positioning Principles of Examination Test normal (uninvolved) side first Active movements first, then passive movements, then resisted isometric movements Painful movements are done last Apply overpressure with care Repeat or sustain movements if history indicates Do resisted isometric movements in a resting position With passive movements and ligamentous testing, both the degree and quality of opening are important With ligamentous testing, repeat with increasing stress With myotome testing, contractions must be held for 5 seconds Warn of possible exacerbations Refer if necessary Scanning Examination is used when: There is no history of trauma There are radicular signs There is trauma with radicular signs There is altered sensation in the limb There are spinal cord (long track) signs Patient presents with abnormal patterns There is suspected psychogenic pain In the upper part of the body, the scanning examination begins with the cervical spine and includes the temporomandibular joints, the entire scapular area, the shoulder region, and the upper limbs to the fingers. In the lower part of the body, the examination begins at the lumbar spine and continues to the toes.

Spinal cord and nerve roots Nerve roots: portion of a peripheral nerve that connects the nerve to the spinal cord; made up of anterior and posterior portions that unite near or in the intervertebral foramen to form a single nerve root or spinal nerve 31 nerve root: 8 cervical, 12 thoracic, 5 lumbar, 5 sacral and 1 coccygeal Spinal nerve roots have a poorly developed epineurium and lack a perineurium Dermatome area of skin supplied by a single nerve root Myotome groups of muscles supplied by a single nerve root Sclerotome area of bone or fascia supplied by a single nerve root

Radicular/radiating pain form of referred pain, felt in a dermatome, myotome or sclerotome because of direct involvement of a spinal nerve or nerve root Myelopathy neurogenic disorder involving the spinal cord or brain and resulting in an upper motor neuron lesion Mononeuropathy vs polyneuropathy Grade of Injury Neuropraxia (sunderland 10) Definition Transient physiological block caused by ischemia from pressure or stretch of the nerve with no wallerian degeneration Signs and Symptoms Pain No or minimal muscle wasting Muscle weakness Numbness Proprioception affected Recovery time: minutes to days Pain Muscle wasting evident Complete motor, sensory and sympathetic functions lost Recovery time: months (axons regenerate at rate of 1 inch/mos, or 1 mm/day) Sensation is restored before motor function No pain (anesthesia) Muscle wasting Complete motor, sensory and sympathetic functions lost Recovery time: months and only with surgery

Axonotmesis (Sunderland 20 and 30)

Internal architecture of nerve root preserved, but axons are so badly damaged that wallerian degeneration occurs

Neurotmesis (sunderland 40 and 50)

Structure of nerve is destroyed by cutting, severe scarring, or prolonged severe compression

End Feel examiner feels at the joint as it reaches the end of the ROM Normal end feel: 1. Hard bone-bone approximation 2. Soft soft tissue approximation 3. Firm tissue stretch Abnormal end feel: 1. Muscle spasm invoked by movement with a sudden dramatic arrest of movement often accompanied by pain 2. Capsular very similar to tissue stretch (firm), it does not occur when one would expect 3. Bone-to-bone similar to hard end feel , but the restriction or sensation of restriction occurs before the end of ROM would normally occur 4. Empty detected when considerable pain is produced by movement 5. Springy block similar to tissue stretch (firm), this occurs when one would not expect it to occur, it tends to be found in joints with menisci. There is a rebound effect Capsular Pattern pattern of limitation or restriction of the joints Causes of Muscle Weakness: 1. Muscle strain 2. Pain/reflex inhibitions 3. Peripheral nerve injury 4. Nerve root lesion (myotome) 5. Upper motor neuron lesion 6. Tendon pathology 7. Avulsion 8. Psychologic overlay Signs and Symptoms of Upper motor Neuron Lesion: Spasticity Hypertonicity Hyperreflexia (DTR) Positive pathologic reflexes Absent or reduced superficial reflexes Extensor plantar response (bilateral) Uses of Special Test: 1. To confirm a tentative diagnosis 2. To make a differential diagnosis 3. To differentiate between structures 4. To understand unusual signs

5.

To unravel difficult signs and symptoms

Classification of Synovial Fluid: Type Appearance Group 1 Clear yellow Group 2 Cloudy Group 3 Thick exudate, brownish Group 4 hemorrhagic

Significance Noninflammatory states, trauma Inflammatory arthritis: excludes most patients with osteoarthritis Septic arthritis; occasionally seen in gout Trauma, bleeding disorders, tumors, fractures

Nerve Fiber Classification Sensory Axons Innervation Ia (A alpha) Muscle spindles (annulospiral endings) Ib (A alpha) GTO II (A beta) Pressure, touch, vibration (flower spray endings) III (A delta) Temperature, fast pain IV (C) Slow pain, visceral, temperature, crude touch Loose Packed (Resting) Position one of minimal congruency between the articular surfaces and the joint capsule, with the ligaments being in the position of greatest laxity and passive separation of the joint surfaces being the greatest Closed Packed (Synarthrodial) Position majority of joint structures are under maximum tension; two joint surfaces fit together precisely; they are fully congruent. The joint surfaces are tightly compressed; the ligaments and capsule of the joint are maximally tight; and the joint surfaces cannot be separated by distracting forces When Palpating, the examiner should note: Differences in tissue tension and texture Differences in tissue thickness Abnormalities Tenderness Temperature variation Pulses, tremors, fasciculations Pathological state of tissue Dryness or excessive moisture Abnormal sensation Grading Tenderness on Palpation Grade 1 patient complains of pain Grade 2 patient complains of pain and winces Grade 3 patient winces and withdraws the joint Grade 4 patient will not allow palpation of the joint Common Circulatory Pulse Location: Carotid Brachial Radial Ulnar Femoral Popliteal Posterior tibial Dorsalis pedis