|In this glossary you will find an illustrative explanation of some keywords which are frequently used in research papers and, more general, in updated Orthopaedic Medicine Cyriax, as well as some summarized descriptions of certain clinical images and diagnostic procedures
General remark : sometimes I refer the reader to "Part I" and "Part II" for further information on that specific subject i.e. the two books "Orthopaedic Medicine Cyriax : updated value in daily practice, Part I and Part II "
I also refer to the interesting glossary of some other publications such as :
"Orthopaedic Medicine, a practical approach ; Kesson-Atkins, 2nd edition, Elsevier BH 2005" and
"The lumbar spine, mechanical diagnosis and therapy, volume one, McKenzie-May, Spinal publications New Zealand 2003"
The various capsular patterns
Capsular pattern Jaw
Increasing limitation of mouth opening.
Capsular pattern Cervical spine
Equal limitation of extension, both side flexions and both rotations. Flexion is the best movement.
Capsular pattern Shoulder
Limitation of abduction, more limitation of lateral rotation, less limitation of medial rotation.
Capsular pattern Elbow
Limitation of extension, more limitation of flexion.
Capsular pattern Lower radio-ulnar joint
Pain on passive pro- and supination, no limitation.
Capsular pattern Wrist
Equal limitation of flexion and extension.
Capsular pattern Trapezio-first metacarpal joint
Limitation of abduction and extension, no limitation of flexion.
Capsular pattern Thumb and finger joints
Flexion more limited than extension.
Capsular pattern Thoracic spine
Equal limitation of both rotations.
Capsular pattern Lumbar spine
Equal limitation of extension and both side flexions.
Capsular pattern Hip
Gross limitation of medial rotation and abduction ; flexion more limited than extension.
Capsular pattern Knee
Limitation of extension, more limitation of flexion.
Capsular pattern Ankle joint
Limitation of dorsiflexion, more limitation of plantiflexion.
Capsular pattern Talocalcanean joint
Increasing limitation of varus, in the end fixation in full valgus.
Capsular pattern Midtarsal joints
Limitation of dorsiflexion, plantiflexion, adduction and medial rotation ; no limitation of abduction and lateral rotation.
Capsular pattern First metatarsophalangeal joint
Limitation of plantiflexion with more limitation of dorsiflexion.
Capsular pattern II-V metatarsophalangeal joints
Variable. Fixation in extension with flexed IP-joints.
What's the clinical image of a carpal subluxation ?
The examination shows a slight limitation of extension ; when we continue the movement, pain is provoked. Passive flexion is not limited but after some time, it becomes painful because one or more of the dorsal ligaments get involved (due of overstretch because of the carpal subluxation, mostly os capitatum).
The treatment consists of manipulation first, to reduce the subluxed bone, and then the affected ligament(s) should be treated by deep friction massage.
Differential diagnosis includes the following disorders :
dorsal ganglion : this is soft and can be punctured
Kienböck's disease : an aseptic necrosis of the lunate bone. Occurs spontaneously or after trauma, in young patients ("twenties"), can cause constant pain, eventually weakness
a non-union fracture
an isolated osteoarthrosis.
In the last three cases medical imaging is needed.
Remark : a palmar carpal subluxation is a rare possibility too. Mostly the lunate bone subluxes causing a small limitation of flexion and perhaps partial compression on the median nerve.
(Part I, p83 , Part II, p15-17)
Carpal tunnel syndrome
In a carpal tunnel syndrome there is an irritation of the median nerve near the wrist.
First symptom : pins and needles and/or pain at the palmar aspect (and at the dorsal aspect of the distal phalanges) of the 3 ½ radial fingers.
Centralisation is a phenomenon by which distal limb pain emanating from the spine is immediately or eventually abolished in response to the deliberate application of loading strategies.
Such loading causes an abolition of peripheral pain that appears to progressively retreat in a proximal direction. As this occurs there may be a simultaneous development or increase in proximal pain. It only occurs in the derangement syndrome.
Centralisation is a very favourable phenomenon and is an indicator of good treatment outcome.
Whatever treatment is given to the patient, when centralisation is present this means that the treatment given is favourable.
Cervical spine facet joint infiltration
Cervical facet joint
PATIENT'S POSTURE The patient lies prone on the couch ; an assistant holds the patient's head in slight flexion and full side flexion away from the painful side.
PRODUCT 0.5 ml triamcinolone acetonide (10 mg/ml)
SYRINGE 1 ml tuberculin syringe
NEEDLE 0.6x30 mm (23 G 1 ¼)
TECHNIQUE At 2-2.5 cm from the midline the dorsal aspect of the facet joint is found. Here, the needle is inserted straight to it. If only bone is felt, it hits the lamina. It should then be slightly moved in another direction until the tip of the needle feels a tough ligament first, and cartilage afterwards. Then, the needle lies intra-articularly and the injection is given.
Chondromalacia versus recurrent patella luxation
Chondromalacia (weakening of the cartilage)
The patient describes dull pain during flexion and sitting with the knees flexed.
There is reduced patellar mobility, an increased Q-angle, an infacing patella and hypertrophy of the lateral retinaculum.
Crepitus can be felt during a squat movement.
Pain that has lasted for longer than 7 weeks.
In the majority this will be mechanical in nature, and non-mechanical in a minority.
Chronic pain states
Pain of long duration in which non-mechanical factors are important in pain maintenance.
These factors may relate to peripheral or central sensitisation or psychosocial factors, such as fear-avoidance, etc.
Symptoms are often widespread and aggravated by all activity, and patients display exaggerated pain behaviour and mistaken beliefs about movement and pain.
Intermittent claudication is rather a local expression of a general condition ; the cerebral and coronary arteries are likely to be involved.
Claudication in the calf has a very typical history and clinical image :
the patient can walk a certain distance but then, due to increasing pain in the calf he needs to stop ; after a few minutes rest the pain is gone and he can walk a similar distance again.
The basic functional examination of leg and foot will be negative.
(Part I, p165)
The process of clinical reasoning is imperative to reach a diagnosis as valid and as useful as possible.
We need to collect relevant and objective information from the history, inspection, functional examination and palpation. All procedures are discribed in the Cyriax Assessment Forms.
We provide one clinical reasoning assessment form per joint.
(Part I, p15)
Constant pain describes symptoms that are present throughout the patient's waking day, without any respite, even though it may vary in intensity.
This may be chemical or mechanical in origin, and may also exist in chronic pain states.
The entity muscle belly, musculotendinous junction, tendon and tenoperiosteal part are considered contractile.
They can be tested very well by using resited tests with a maximal isometrical contraction.
(Part I, p12-14)
The coronary ligaments are often lesioned during a flexion-rotation trauma.
Mostly the medial coronary ligament is affected.
In the coronary ligament, two sites are possible :
between the infrapatellar tendon and the MCL (nearly always)
just behind the MCL : this is a little zone that can be reached only with a portion of our palpating finger.
The coronary ligament reacts very well on deep friction massage
(See Part I, p135 ; Part II, p31)
Creep is a property of viscoelastic structures which consists of a small, almost imperceptible movement, occuring when a constant stress is applied for a prolonged period of time.
If a constant force is left applied to a collagenous structure for a prolonged period of time, further movement occurs. This movement is very slight, it happens slowly and is imperceptible.
Also possible in several situations :
* degeneration 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.
fine crepitation : mechanical cause
coarse crepitation : rheumatoid or tuberculous cause.
* 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.
Cross links are either weak intramolecular hydrogen bonds connecting molecules or stronger covalent intermolecular bonds connecting collagen fibrils and fibres.
The links provide connective tissue structures with tensile strength and the greater the number of cross links, the stronger the structure.
An abnormal number of cross links (adhesions) develops as a result of a stationary attitude of collagen fibres and is responsible for the toughness and resilience of scar tissue.
Cruciate ligament lesion
An anterior cruciate ligament lesion is frequently an isolated lesion. It can be the result of a hyperextension-medial rotation trauma (e.g. the athlete who, after a sprint, quickly decreases his speed and rotates his knee).
It can be a combined lesion as well, together with the MCL and the medial menisc.
An ACL lesion finally could cause a longitudinal meniscal tear. A total or a partial rupture doesn't necessarily lead to functional instability.
Cuboid rotation - manipulation
Subluxation of the cuboid bone in athletes, caused by too much traction of the peroneus longus tendon (the lateral border of the cuboid moves upwards and the medial border downwards ; it stays fixed in this position). This seems to occur in 4% of all foot problems seen in athletes.
In an asymptomatic state, individuals can move from an extreme position of flexion to an extreme position of extension without impediment.
In case of an internal derangement this curve reversal can become difficult or impossible.
Following a period of loading or repeated movements in one direction the opposite movement may become obstructed and recovery is slow, gradual and/or painful.
This disturbed curve reversal is very frequently seen in patients with a lumbar internal derangement. It is in fact a typical element from the history.
(More information ?)
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