Approach to Musculoskeletal Approach to Musculoskeletal Pain patientsPain patients

Characteristics of soft tissue Characteristics of soft tissue lesionlesion

1.Discrepancy between the site of pain and the site of lesion(Referred Pain)

2.Lack of objective findings in X-ray or Labs.

Mechanism of Referred PainMechanism of Referred Pain--Convergence projection Convergence projection

theorytheory--Synaptic error at the level of spinal cord

afferent from somatic structures and related visceral structures synapse with the same spinal dorsal horn cell

(viscerosomatic convergence)

• Perceptional error at the sensory cortex

Rules of referred painRules of referred pain

Does not cross the midline (?)

Segmental

The pain is usually deep,achy, poorly localized

Reference mainly in a distal direction(?)

The lesion does not necessarily lie in the painful area

Many soft tissues can cause referred pain

The pain is felt anywhere in the dermatome, not necessarily in the entire dermatome

Discrepancies between dermatomes and myotomes

8 area

ExampleExample

-Thumb and index finger lie in the C6-dermatome ; the muscles in the thenar are of C8- and T1-origin

-upper buttock L1-2 dermatome;

gluteal muscles L4-S1

Segmental Development of Segmental Development of Soft TissueSoft Tissue

Dermatome(skin)

Myotome(muscle and other soft tissues)

Sclerotome(bone and fibrous septa)

Action Muscles NervesNerve Roots

Finger extensionExtensor digitorum, Extensor indicis, Extensor digiti minimi

Radial nerve (posterior interosseous nerve)

C7, C8

Thumb abduction in plane of palm Abductor pollicis longusRadial nerve (posterior interosseous nerve)

C7, C8

Finger abduction Dorsal interossei, Abductor digiti minimi Ulnar nerve C8, T1

Finger and thumb adduction in plane of palm

Adductor pollicis, Palmar interossei Ulnar nerve C8, T1

Thumb opposition Opponens pollicis Median nerve C8, T1

Thumb abduction perpendicular to plane of palm

Abductor pollicis brevis Median nerve C8, T1

Flexion at distal interphalangeal joints digits 2, 3

Flexor digitorum profundus to digits 2, 3 Median nerve C7, C8

Flexion at distal interphalangeal joints digits 4, 5

Flexor digitorum profundus to digits 4, 5 Ulnar nerve C7, C8

Wrist flexion and hand abduction Flexor carpi radialis Median nerve C6, C7

Wrist flexion and hand adduction Flexor carpi ulnaris Ulnar nerveC7, C8,

T1

Wrist extension and hand abduction

Extensor carpi radialis Radial nerve C5, C6

Elbow flexion (with forearm supinated)

Biceps, Brachialis Musculocutaneous nerve C5, C6

Elbow extension Triceps Radial nerve C6, C7, C8

Arm abduction at shoulder Deltoid Axillary nerve C5, C6

Action Muscles Nerves Nerve Roots

Hip flexion IliopsoasFemoral nerve, and L1-L3 nerve roots

L1, L2, L3, L4

Knee extension

Quadriceps Femoral nerve L2, L3, L4

Knee flexionHamstrings (semitendinosus, semimembranosus, biceps femoris) Sciatic nerve

L5, S1, S2

Leg abduction Gluteus medius, Gluteus minimus, Tensor fasciae latae

Superior gluteal nerve L4, L5, S1

Leg adductionObturator externus, Adductor longus, magnus, and brevis, Gracilis Obturator nerve L2, L3, L4

Toe dorsiflexion

Extensor hallucis longus, Extensor digitorum longus

Deep peroneal nerve L5, S1

Foot dorsiflexion Tibialis anterior Deep peroneal nerve L4, L5

Foot plantar flexion Triceps surae (gastrocnemius, soleus) Tibial nerve S1, S2

Foot eversion Peroneus longus, Peroneus brevis Superficial peroneal nerve L5, S1

Foot inversion Tibalis posterior Tibal nerve L4, L5

Factors affecting the degree Factors affecting the degree of reference of painof reference of pain

The strength of the stimulus

The stronger the stimulus, the more reference we can expect ,ie the less can the patient tell where it originates

useful in evaluation of treatment

ex: centralization/peripheralization

The position of the lesion within the dermatome

If proximal : much possibility of distal reference

The depth of the affected structure

The deeper the structure, the more reference we can expect

exception: bone;severe ,deep,well localized pain

The nature of the affected structure bone,periosteum ;deep localized pain

capsule,bursa,ligament,tendon;poorly localized pain not distinguishable

muscle: less reference than tendon

nerve: segmental or extrasegmental depending on site of compression

General Diagnostic Skim of General Diagnostic Skim of Musculoskeletal PainMusculoskeletal Pain

History

Clinical Examination:

Inspection

Functional Exam.

Standard orthopedic &

Neurological tests

Special tests

Dignostic Imaging

Labs.

HistoryHistory

Onset

Site(and Referring)

Frequency

Duration

Quality and quantity

Aggravating or relieving factors

Getting worse,better,unchanged

Any associated symptoms

Inherent likelihood

Should be neutral

Quality of painQuality of pain

Cramping,dull,aching; Muscle

Sharp,shooting; Nerve Root

Burning,pressure-like,stinging; Sympathetic nerve

Deep,sharp,severe; Fracture

Throbbing,diffuse; Vascular

Thing s to RememberThing s to Remember

-Reference of painseverity of lesion

-Shifting painmoving lesion(internal derangement)Ex: disc protrusion

-Expanding painserious lesionEx: spinal tumor

-Recurrenceunstable lesion requiring prophylactic maintenance therapy

twingetwinge

Internal derangement

Tendinous lesion

Neurological problem

Functional ExaminationFunctional Examination

To D/Dx between contractile and non-contractile tissue by Selective Tissue Tension tests

Look for patterns of pain, limitation,weakness

Sequence:

Active

Passive (with End-Feel by slight Over-

Pressure Technique)

Resistive (Isometric)

Palpation

Differential Diagnosis of Differential Diagnosis of Soft Tissue PainSoft Tissue Pain

Contractile tissue Pain

Non-contractile(Inert) tissue pain

Contractile tissuesContractile tissues

-Muscle belly,Musculotendinous junction,Tendon,Tenoperiosteal junction,Bone adjacent to the attatchment of tendon

-Best tested by isometrically resisted movement

Inert(nonInert(non--contractile ) contractile ) tissuestissues

-Joint capsule,Ligament,Bursa,

Aponeurosis,Fascia,Nervous tissues including Dura mater, Peripheral nerve,Dural sleeve of nerve root,Spinal cord

-Tested by passive stretch

Functional Examination Functional Examination PrinciplesPrinciples

Test bilaterally, normal side firstIn resistive test, resist at least 5 sec. to see weaknessIn resistive test, test must be done in physiologic neutral positionJoint end-feel test must be done several times slowly and carefully at the end range of passive movementNote Sx. Change, ROM, strength changeConcentrate on “The pain” not “a pain”

Active testActive test

do not enable us to differentiate between inert and contractile structures

To see:

Patient willingness

Range of movement

Muscle power

Passive TestPassive Test

provide information about the integrity of the inert structures

To see:

pain

range of movement

end-feel

EndEnd--FeelFeel

Sensation at the end range of passive movement(tested by slight overpressure)

Normal / physiological

- Hard : e.g. elbow extension, knee extension

- Capsular (elastic) : e.g. rotations at shoulder, elbow, hip,facet

- Extra-articular (tissue approximation) : flexion at elbow and hip

Pathological

- Too hard : e.g. osteoarthrosis

- Too soft : e.g. loose body in the elbow joint

- Muscle spasm (involuntary muscle contraction) : e.g. Acute arthritis

- Empty (voluntary muscle contraction, not always the same range) : e.g. Abscess,acute bursitis

- Springy block : e.g. meniscus subluxation

Capsular patternCapsular pattern

-characteristic propotion of limited range of all plane of movements to a particular joint

-best seen in osteoarthrosis or some sort of arthritis

-only exists in joints under muscular control

Ex: shoulder:

ext, rotation>abduction>int. rotation

Hip:

int. rotation>abduction>flexion>ext.rot

NonNon--capsular patterncapsular pattern

-ligament sprain(adhesion);

slight limitation and localized pain of one movement

-Internal derangement;

sudden limitation and pain one or several direction

-Extraarticular limitation;

GROSS limitation in ONE direction, with normal movement in all other directions

Resisted TestResisted Test

maximal isometric contractions from a neutral position

examine the contractile structures

To see:

Pain

weakness

Results of Resistive TestResults of Resistive Test

Strong&painless; normal

Strong&painful; minor lesion

Weak&painless;complete rupture or nerve lesion

Weak&painful;partial rupture or fracture

Pain to all resisted test;hypersensitivity

Pain on repetitive movement;claudication

PalpationPalpation

Static Palpation:

tissue texture changes

asymmetry of bony landmarks

Motion Palpation:

joint play

joint click

end-play

Neurological PainNeurological Pain

Nociceptive pain; frequent

Neuropathic pain; rare

Symptoms referred from Symptoms referred from pressure on the 4 different pressure on the 4 different

sites of nervous tissuesites of nervous tissuePain

nervi nervorum in the connective tissue of the nerve or in dura of the nerve root by mechanical force or chemical irritation from inflammation

Paresthesia

Pins and needles sense

pathognomonic of peripheral nerve lesion

Loss of Function

D/Dx between External cause and primary neuritis

provocation of P&N’s by movements

or stroking over the affected skin suggest external cause

Spinal cord

Dural sleeve of nerve root

Nerve trunk or plexus

Small peripheral nerve

Spinal cordSpinal cord

No pain

Bilateral paresthesia(pins and needles)

No effect of digital movement or skin stroking on pins and needles(P&N’s)

Nonsegmental distribution

Think of serious pathology

Sometimes UMN sign

Nerve root(Dural sleeve)Nerve root(Dural sleeve)

Dermatomal pain

Distal paresthesia according to dermatome

Pins and needles are compression phenomenon(on pressure->Sx)

Skin stroking provoke P&N’s,but not

digital movement

Typical progression of Typical progression of symptoms due to evolving disc symptoms due to evolving disc

lesionlesion

Pain-epidural sheath compression

Paresthesia- parenchymal tissue involve

Numbness and weakness-parenchymal damage cause loss of function

Symptoms according to Symptoms according to degree of compressiondegree of compression

① pain ( segmental pain ) ② pins & needles ③ numbness④motor & sensory deficit⑤only numbness

(n. sheath가 없는 부위 의 경우 )

① ② ③ ④ ⑤

Nerve Trunk or plexusNerve Trunk or plexus

No painP&N’s distal cutaneous area to the compressed nerveP&N’s are release phenomenon(off pressure->Sx)

exception:distal part of U/E

Ex: CTSSkin stroking and digital movement provoke P&N’sLMN sign

Ex: TOS

Release phenomenon

The longer compression

onset of P&N’s is more delayed

duration of P&N’s is longer

Small peripheral nerveSmall peripheral nerve

No pain

No weakness

Main Sx is numbness

Well defined edge

Central anesthesia

Dura Mater: exception to the Dura Mater: exception to the rule of segmental referencerule of segmental reference

extrasegmental reference of pain and tenderness

cause is unknown(maybe great overlap of sinuvertebral nerve innervation up to 8 segments)

pain can be midline or bilateral

Ex)

-pseudoangina from lower cervical disc protrusion

-incidental appendectomy from lower lumbar disc protrusion

Maybe

sclerotomal(Ligamentous) reference

Maybe chemical(epineural )inflammation

Extrasegmentally referred Extrasegmentally referred painpain

Cervical lesion

discodural; pain from C2(head)-

T6(interscapular),whole pectoral area not to U/E

discoradicular; pain according to dermatome(U/E)

Lower lumbar lesion

discodural: pain from lower thoracic,

lower abdomen,groin,buttock,

L/E(to the ankle)

discoradicular: pain according to dermatome(to the foot)

Extrasegmentally referred Extrasegmentally referred tendernesstenderness

localized tender spot in the painful area(called fibrositis/trigger point-meaning primary lesion in muscle) are not primary lesion ,but the extrasegmentally referred tenderness secondly to pressure on the dura mater(?)

Not just pressure on the nerve or dura

Vertebral joint dysfunction or visceral pathology

Peripheral or central sensitization

Consideration on tight Consideration on tight muscle or muscle spasmmuscle or muscle spasm

-According to Cyriax, Hackett, Dorman

muscle tightness is secondly manifestation of ligamentous laxity, joint dysfunction, disc pathology

-According to Travell, Gunn

impaired muscle function(balance) due to neuropathy can not provide support and relieve load on inert tissue, thus result in inert tissue overload and damage

Common site Common site

Cervical dural compression

referred tenderness in upper border of trapezius,scapular muscles,base of neck

Lower lumbar dural compression

referred tenderness in sacroiliac region and upper parts of buttock

Evidence(clinical)

shift of tender spot instantly after manipulation or

shift of tender spot toward midline after manipulation and improvement of functional tests

Types of TreatmentsTypes of Treatments

Active:

Exercise

Functional Rehabilitation for

Strength

Flexibility

Endurance(including cardiovascular)

Proprioception(balance)

Passive:

Manual therapy;

Manipulation

Mobilization

Soft tissue techniques(Massage,PIR/MET)

Traction

Physical modalities(thermal,electrical,hydro)

Needling(IMS,Acupuncture)

Injection or Infiltration

Orthosis

Therapeutic rest

Others:

Taping(athletic,kinesio,balance..)

Nutrition including herb

Biofeedback and other relaxationtherapy(yoga,PMR…)

Movement therapy;

Feldenkraise,Alexander,Pilates,Trager,Ashton,Rolfing….

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