JAMEST.S.MEADOWS Orthopedic Differential Diagnosis in PhysicalTherapy ACase StudyApproach T.S.MEADOWS -Orthopedic Differential Diagnosis in PhysicalTherapy proach Contents ~ ~ r e ~Introductionxiii Acknowledgmentsxvii Part: 1 General Principles of Different:ial Diagnosis1 Chapter 1:DifferentialDiagnosis:GeneralPrinciples3 Chapter 2:TheSubjectiveExamination7 Chapter 3: Observation35 Chapter 4: TheMusculoskeletalExamination53 Chapter 5: TheNeurological Tests71 Chapter 6: TheSpecial Tests77 Chapter 7:CancerandtheOrthopedic Therapist83 Chapter 8: Summaryof ChaptersIthrough799 Chapter 9: TheBiomechanical Evaluation109 Chapter 10: TheCervicalSpine121 Chapter 11:The ThoracicRegion183 Chapter 12:TheLumbarSpine193 Chapter 13: The Pelvis229 Part: IICase St:udies237 Cervical Case 1 Post-MVAChronicDizziness239 Cervical Case 2AFirst Instanceof Headaches andNeckPain243 98-49161 Cervical Case 3ASuddenOnsetof Neckand Arm Pain CIP WhileLifting245 v viContents Conten Cervical Case 4 A GoodorBad Prognosisin This Post-MVAPatient249 Cervical Case 5FacialImpact ina Post-MVAPatient253 Cervical Case 6NeckPainandVertigoDuringLifting257 Cervical Case 7AcuteTorticollisina10-YearOldBoy259 Cervical Case 8 Head Forward Postureand Arm Symptoms261 Cervical Case 9AcuteTorticollisina5-YearOld Girl263 Cervical Case 16 IsHer post-MVAHeadache Cervical Case 22 Vertebral Artery Injury: Cervical Case 10 HeadachesandNeckPain After a Fall265 Cervical Case 11Post-Manipulation Vertigo269 Cervical Case 12 Retro-OrbitalHeadaches271 Cervical Case 13Headachesand LowCervicalPain273 Cervical Case 14PinsandNeedles After aMVA275 Cervical Case 15LateralElbowPain279 ArisingFrom HerNeck?281 Cervical Case 17Medial Arm Paresthesia283 Cervical Case 18 HandParesthesia287 Cervical Case 19 "Frozen Shoulder?"289 Cervical Case 20 A ThirdCaseof Torticollis293 Cervical Case 21AHigh Speed Rear-EndCollision295 Wasit Preventable?299 Thoracic Case 1 70-Year-OldPatient withChest Pain301 Thoracic Case 2AnteriorChestPain303 Thoracic Case 360 YearOldPatientwith LowThoracicPain305 Thoracic Case 4Pain After PlayingSquash307 Part IJThoracic Case 5Pain AftertheFlu311 Thoracic Case 6"Tietze'sSyndrome?"313 Thoracic Case 7VisceralPain?315 h'ldex Thoracic Case 8Post-MVANeckandBack Pain317 :ontents Contents vii LUlnbopelvic Case 1 ARugbyInjury319 249 Lutnbopelvic Case 2TooLongDriving!323 253 LUlnbopelvic Case 3ANursewithBack and g257 LegPain-How Unusual327 0\"259 LUlnbopelvic Case 4TooLongStanding!331 Lutnbopelvic Case 5Buttock Pain After Gardening333 261 LUlnbopelvic Case 6LancinatingThighPain335 rI263 LUlnbopelvic Case 7Leg Aching339 :.ill 265 LUlnbopelvic Case 8TooLongSitting,Two!341 269 LUlnbopelvic Case 9ARunningInjury?345 271 LUlnbopelvic Case 10 AcuteSciatica347 273 LUlnbopelvic Case 11ADiscProlapseonMRI349 275 LUlnbopelvic Case 12EpisodicPainover 5 Years353 279 LUlnbopelvic Case 13AnklePain357 LUlnbopelvic Case 14 BilateralSciatica in 281 aPoliceOfficer359 283 LUlnbopelvic Case 15AFallontotheButtocks363 287 LUlnbopelvic Case 16 SevereCalf Pain365 289 LUlnbopelvic Case 17 LumbarSprain?367 293 LUlnbopelvic Case 18 Another Fall ontotheButtocks371 295 LUlnbopelvic Case 19 A20-Year-OldwithButtockPain375 LUlnbopelvic Case 20 Neural Adhesions?379299 LUlnbopelvic Case 21MultipleBackSurgeries381 n301 Lutnbopelvic Case 22 "DegenerativeDiskDisease?"385 303 Lutnbopelvic Case 23 VeryLocalBack Pain389 LUlnbopelvic Case 24 SacroiliacPain?391305 307 Part IIIDiagnosis and Resolution to Cases393311 313 315Index437 317 P r ~ Preface Theaimsof thisbook arethreefold.First,toprovide theundergraduate student with vicarious experiences thatwill temporarily fillthevoid that willlater be filled by the student's own experiences. Second, to offer therapists,whetherstudentsorvastlyexperienced,thechancetochallenge themselvesagainstcasehistoriesinprivatetosee howtheydo.I know thatself-testingissomethingthatfewphysicaltherapistscanpassup. Third,unusualcasesareexactlythat,unusual.Wedonotindividually havemanyopportunitiestoseemanypatientswithcancers,gastriculcers, kidney stones,hiatus hernias,and the like,sowe tend tomiss them because our orthopedicblinkersfocuseverythingintoorthopedicconditions.If this book does nothingmore than helpyourealize thatoddities have a way of presenting asthe mundane andthatwe have a way of perceivingwhatweexpect rather thanwhat is,itwillhavebeensuccessful. Thisisnota how-to book in theconventionalsenseof instruction in thetechniquesorexamination.Ingeneraleducationalterms,thisrequirementisdealtwithinschoolandinaplethoraof booksdesigned forexactlythispurpose.However,whatthestudentcannotgaininthe classroom is experience. During clinical placements, the student is quite correctlyrequiredtorotatethroughthevariousspecialtiesandsoreceives comparativelylittleexperienceinorthopedicsandoftennoneat allin orthopedic manualtherapy. The schools know that when the newly graduated therapistisreadytospecializein onearea,postgraduate programs are available.Unfortunately,other than clinical residencies,these classesstilllack whatismissinginthephysicaltherapyschool,handson experience.The object of thisbook istotrytoteach howtoanalyze andintegrateinformationgainedfromsubjectiveandobjectiveclinical examinations.Itwillhelpthestudentandpractitioneroforthopedic physicaltherapytodifferentiatepatientswithroutinediagnoses,treatmentplans,andresponsestotreatmentfromthosewhowillbea problem tothe therapist. These latter patients must be identified early sothat anonroutineapproachcanbetaken.If physicaltherapyisappropriate, auniqueapproach canbedesigned forthemoredifficult patient.If orthopedic therapyisdeemed inappropriate, thepatient can be returned to thephysicianasquicklyaspossible. Tosucceed inthese aims,thefirstsection of the book will consist of one clinical approach tothe evaluation of theneuromusculoskeletalsystem.Thefirstchaptergenerallydescribesthedifferentialdiagnostic ix xPreface Preface examination and discussesthe integration of the data generated from the examination.Fromthisintegration,thetherapistcaneithergeneratea working diagnosis and a management plan or determine that further clinicalexaminationisrequired.Forexample,fromthedifferentialdiagnosticexaminationa workingdiagnosismightbeanL4diskextrusion withL5spinalnervecompressionwithradiculopathy.Fromthisdiagnosis,a treatment plan can be madethat might consist of specificexercises,traction,rest,and soon,or inappropriate pathology might besuspectedandthepatientreturnedtothephysician.Alternatively,and usuallymorecommonly,aset of signsandsymptomsthatdonotlend themselvestoaspecificdiagnosisarefound.Inthiscasefurtherinformationisrequiredbeforeaspecifictreatmentplancanbearrivedat. Thisinformation isaffordedbythe biomechanical examination.Examplesof thetypeof diagnosisthatcanbearrivedatfromthebiomechanicalexaminationincludearightL4-5zygapophysealjointhypomobility,a right L3-4 torsionalinstability, or a left C5-6 zygapophyseal joint extensionhypermobility.From thisbiomechanicalevaluation,the therapist can initiate a specific exercise program, manual therapy,and/or stabilizationtreatments. Thedifferentialdiagnosticexamination,designedbyJamesCyriax, M.D.,willbe,withveryslightmodifications,possiblythemostcomprehensive and rational clinical examination of themusculoskeletal systeminusetoday.Themodificationsaresimplyadditionsthatwillincrease the breadth of the diagnosticscope.The examination isbased on our knowledge of the anatomy of the musculoskeletal system. The functionof eachsubset of thesystem,suchasthecontractiletissues(muscle,tendon,and tenoperiosteal junction), the inert tissues(joint capsule, ligament, dura, bone, and bursa), the vascular system (arteries and veins), and the neurological system (peripheral and central systems) isstressed. Theteststressisthefunctionof thesubsetappliedinasmuchasisolation fromtheother subsetsasispossible. Toalargeextent,theinterpretationandintegrationof thefindings willbe covered inthecasestudiesthemselves,wherethereisimmediaterelevancetotheclinical picture,ratherthanasanisolatedintellectual exercise. For example, paresthesia will be discussed in general terms inChapterIandmentionwillbemadeof itssignificance,but howthe patternof paresthesiasuggestscertainconditionswillbediscussedin detailinthediscussion of aparticular case. Someof thecasesinthisbookaregivenexactlyastheypresented; where these have been donated bycolleagues, due credit isgiven.Other casesarecompositesof caseswithroughedgessmoothed off or added *Cyriax J:Textbookof OrthopedicMedicine,8th ed.London,Balliere Tindall& Cassell, 1982. Pl'eface Prefacexi ~ d from the tosimplifyor complicatetheclinicalpicture.Thepurposeof thebook generatea istoprovide a learning tool,nottofaithfullyreproduce the clinical preurther clinsentationof eachpatient. ~ n t i a l diagFinally,thereaderwhohopestofindonlyexperimentallyvalidated kextrusion techniques will be disappointed. A book that confined itself to only those 1thisdiagassessment and treatment techniques that were criterion-validated would ecificexerbeaboutthree pages long. The material presented here does contain va19htbesuslidity,butitismostlyconstructivevalidity.Thedifferentialdiagnostic lti\ely,and assessmenttechniqueshavebeenfield-testedbythousandsof physical jo notlend therapistsaroundtheworld,whoseemtofindthemusefulinthatthey nher inforcontinuetousethem.Thismaynotbeaterriblyscientificperspective, arrivedat. but it isstill better than the supporting evidence for their invalidity. What :ion.Examthereaderwillget fromthis bookistheaccumulated experience of the thebiomeauthor,hiscolleaguesandhisteachersthathasbeen25yearsinthe jointhypo:apophyseal brewing.Takeitforwhatitis,theaccumulated clinicalimpressionsof numerousorthopedicphysical therapists. luation,the rapy.and/or nesCyriax, mostcom,keletal sys:hatwillin-isbasedon o.Thefuncssues(mus)intcapsule, s and veins), Iisstressed. Juchasisothefindings ~ isimrneditedintelleceneral terms buthowthe jiscussedin ypresented; given.Other off oradded ,iill &Cassell. The ( Diffe: Introduction The Orthopedic Physical Therapist's Differential Diagnosis Exantination Increasingly,physicaltherapistsarebeing called upontoactasscreeningprofessionalsfororthopedicpatients.Moreandmoretherapistsare legally entitled toprovideprimary carewhentheapparent safetynet of the physician referral isabsent. Ascommonly as,or perhapsmore commonly thanprimary contact,the familyphysician isrelying on the therapist to"assessand treat"rather thanfollowa predetermined diagnosis andasetformulaof therapy. The subject of physical therapists making differential diagnoses is controversial.Thereissomegenuineconcern forthepatienthere,butthere is also considerable turf protecting going on.From a patient concern perspective there is little totake issue with when the therapist makes the differentialdiagnoses.Ifthephysicianmakesareferralandthetherapist disagreeswiththeproffered diagnosisandsendsthepatientback,what harm hasbeen done? Isthe therapist capable of makinga differential diagnosis,or atleast recognizingred flagsandsendingthem tothephysician? In Britain a study wasundertaken comparing outcomes and patient satisfactionbetweenorthopedicphysicaltherapistslicensedtogive steroidinjectionsandorthopedicsurgeonsinahospitaloutpatientdepartment.Theabstractgavethe result asthis:"Anappropriatelytrained physiotherapistisaseffectiveasstaffgradesurgeonsinmanagingorthopedicout-patientsunlikelytobenefitfromsurgicalintervention."* Thereisnodoubtthatitisthephysician'sresponsibilitytoprovide aspreciseamedicaldiagnosisaspossibleandtocommunicatethatdiagnosistothepatientandthetherapist.However,thephysician'sresponsibilitytomakethediagnosisdoesnotabrogatethetherapist'sresponsibilitytoensurethatthatdiagnosisiscorrect andthatthereferral is appropriate. Withthe possible exception of postsurgical referrals from neuro- andorthopedicsurgeons,itisunusualtoreceiveapreciseand accuratediagnosisfromareferringphysician.Morecommonly,the *Weale AE,BannisterGC:Whoshouldseeorthopedicoutpatients-physiotherapistsor surgeons? AnnR Coli SurgEngl 72(Suppl2):71,1995. xiii xivIntroductionIntroduc prescriptionsimplystates"assess andtreat."Whenanonsurgicaldiagnosisisafforded,itisoftenof littlevaluetothetherapistasfarasthe determination of atreatmentregimenisconcerned.Such clinically valuelessdiagnosesincludelowback pain,acutelowback pain,shoulder impingement syndrome,rotator cuff syndrome,deranged knee,torticollis,back strain,chest wall pain, anklesprain,andsoforth.Thesetypes of "diagnoses" donothing more than regurgitate the patient's symptoms or themechanism of injuryor thearea of pain.Even apparently precise diagnoses such astennis elbow or the more technical lateral epicondylitis oftendonothelpindeterminingtreatment,astheyarenotprecise enough.Takeforanexamplelateralepicondylitis.Unlesstheexact locationisknown,effectivetreatmentcannotbecarriedout.Isitsupracondylar, epicondylar, inthe tendon body,or atthe myotendonous junction?Isitprimaryorsecondary? If itissecondary,doestheneckneed treatmentor istherea biomechanicalproblemattheelbowcausingor contributing tothesymptomatic lesion? Onlya detailed examination of thepatient,anin-depthanalysisof theinformationgenerated fromthe examination,andthesubsequentgenerationof adifferentialdiagnosis will provide thisinformation,which issovital toefficientand effective treatment. The problem iscompounded by directaccess. Insome countries, notablyAustraliaandtheUnitedKingdom,andinsomestatesand provincesin the United Statesand Canada, the therapist hastheright of directaccesstothepatientwithoutreferralfromthephysician.Inone ortwoof thesejurisdictionsintheUnitedStates,thissametherapist who can see the patient without referral does not have the righttomake adifferentialdiagnosis.Thisisobviouslyasillystateof affairs.How can anybodyof any discipline see patients asa primary care practitioner withoutmakinga diagnosis? Togetaround thisstupidity,thetherapists usethetermsphysicaltherapydiagnosisor functionaldiagnosis.So somehow,a disk prolapse ceasestoexistwhen it is examined bya therapistbutispresentwhenassessedbyaphysician.It isof courseimpossiblefortheorthopedictherapisttotreatanypatienteffectively,efficiently,or even ethically without previously examining the patient and coming tosome conclusion concerning thepatient's condition. Itistime torealizethatmakinga diagnosisiscommon toallhealthcare professionals involvedinthetreatmentof patients,not just physicians,andis not in and of itself practicing medicine. Regardless of what euphemisms arecurrently being employed toconform withstate,provincial,or even nationalregulationsregarding therightandabilityof thephysicaltherapisttomakeadifferentialdiagnosis,thatisexactlywhatwehaveto doinordertotreatthepatientappropriately. Todothis,thetherapistmustbeabletosortthroughthemassesof data generated during boththeobjectiveandsubjective examinations to reachaprovisionalworkingdiagnosisthatwillfacilitatetheformation .duction Introductionxv ~ - . j c a l diagsfarasthe nicallyvaln.shoulder ~ e . tonicolfhesetypes ;symptoms ntlyprecise picolldylitis notprecise heexactloIsitsupraonous junc~ neck need causingor mination of edfromthe aldiagnosis nd effective Juntries,no-statesand . theright of cianoInone netherapist ghttomake dfairs.How practitioner Ietherapists agllosis.So :d bya thercourseim'ectively,ef: patient and :m.Itis time careprofes:ians.andis euphemisms cia!.or even hysicalther. wehaveto Iemassesof minations to leformation of arationalmanagementplan.Thisplanshould be based on theclinical presentation of thepatient and thestate of theart information about thefunctionof thebody,thepathologicalprocessesthatthepatientis undergoing,andthetherapist's experienceandskilllevel. Thefollowingistheabstractof anarticlebyWeinstein*andisentirelyappropriateforphysicaltherapistsinanyfield,butespeciallyin orthopedictherapy. Cliniciansmustnotsimplydecidethata patient withsymptomsanda positivediagnostictesthasareasonforaspecifictreatment,and likewisecliniciansmustnotdecide thatapatientwithsymptomsand anegativetestdoesnothavea clinically importantproblem.Wemust alsoconsider thesensitivity,specificityandpredictivevalueof the diagnostictestandtheindividualcharacteristicsof thepatient. Treatment outcome dependsonmanyfactors.Point of service decisionsvs.population based decisionsareobviouslydifferent.Each patient presentstothetreatingpractitioner onagivenday,atagiven time,andit isthispicture uponwhichaplanof care isformulated. Inconclusion,themain reasonsfortheorthopedicphysicaltherapistto generateadifferentialdiagnosisare 1.Toidentifyinappropriate referrals. 2.Toidentifyconcurrent inappropriateconditionsaccompanyingan otherwiseappropriatereferral. 3.Togenerateaworkingdiagnosis. 4.Asaconsultationmeasurewhenrequestedfromanother physical therapistfromaphysicianand wherepermittedbystatutefroma lawyer,insurancecompany,or someother thirdparty. *WeinsteinIN:Consensussummaryofthediagnosisandtreatmentoflumbardisc herniation.Spine21(Suppl24):S75,1996. Ac II Ackno",ledgnlent:s Youdonotveryoftenget theopportunitytopubliclythankthosepeople towhomyouowea lifedebt.Of course,acknowledgmentsarenot forthegeneral readership,but forthepeople being thankedand forthe author. Also by namingspecificpeople,youdoat least havethe chance of their buyingthebook evenif nobodyelsedoes.Myapologiesinadvancetothereadersif thislist appearsoverlylong,but I intendtotake advantage of thisopportunity tothank these people.Of course,you can alwaystumthepage. I would like tothank all of the people who have over the years helped form thisversion of Jim Meadows and to remind them that there isprobablymoreblamethancreditintheachievement.Havingbeeninvolved inphysiotherapy(orphysicaltherapy,formyAmericancousins)for nearlythirtyyears,Ihavemetagreatnumberof people,mostlytoadvantage, who have had an impact on my professional development. Many ofthese people I am proud to know and number among my closest friends. TherearealsomanypeoplethatIhavenevermetinpersonbutwhose writingshaveshapedthewayIthinkandact.Unfortunately,thesheer number of people involved prohibits my naming them all,soI hope those whomI donot includewillforgivethelack of space andbelievethatit isnot that theyarenot important tome.However,tothosewhomI have not named,andyou knowwhoyouare,beassuredthatI dothank you. First,JamesCyriaxwhostarted mythinkingaboutwhatI wasactuallydoing.ThelateDavidLambwhowasascompleteaphysiotherapistasyoucouldevermeet.RolfLauvikwhofirstreallyshowedme howeffective manual therapy could be.Mike White who talkedmeinto takingtheCanadianmanualtherapyexamsandthenworkedhardto makesurethatI passedthem.Lani Alingtonwhocontinuallynagsand triestoimproveme,usuallybeyondthelimitsof herfrustration.Cliff Fowler whohasa pair of thebest handsinthebusinessandwhoisnot reluctant to call me anidiot when hefeelsit necessary.Erl Pettman who taughtmehowtoteach.DianeLeewhoisoneof themostproductive peopleIknowandwhohasmanagedtobalanceabusypersonallife with a rich understanding of her profession. Bob Sydenham whoisclinically and politically one of themost astute physiotherapists that I have metandGayeSydenhamwhohastoputupwithhim;Ioftenwonder who keepswindingher spring.Theyhavebothmadememoreof a political animalthanI ever wantedtobe.David Mageewho,tome,isthe xvii xviiiAcknowledgntents Ackno model that mostacademicsshould tryto emulate inthat hestrivesconstantlyforclinicalrelevance.Sharon Warrenwhoshowedmethatit is possibletobea researcher andretain hugeamountsof commonsense. RickAdamswho,whenitcomestoworkandourprofesison,hasno senseof moderation. Barrett DorkoandJohnMedeirosboth of whom I brushupagainstperiodicallyatalltoo-longintervalsbutwhomanage in a fewhourstoget meup and runningagain.PattyMayer,SueSaretski,and Gerry Bellows who keep me working and in touch with patients whenIaminCalgary.StanleyParistowhomthemanualtherapistsin theUnitedStatesoweamassivedebtof gratitudeandwhois,forme, theepitomeof effectiveness.GailMolloywhoisoneofthehardest workingofmycolleaguesandwho,byunconsciouslyputtingmeto shame, can get me to do things that I do not have time for.Lance Twomey whosharesthesamedistinctionthatDavidMageepossessesandisin everysenseagentlemanandtheonepersonIwouldliketobemore like. Mike Rogerswhohasa remarkablework ethicanda verystrongly developedsenseof right andwrong.Richard Bourassa whohasassited meonmanycoursesandwhohastolerated,toanamazing degree,my jokesathisexpense.Hehasdemonstratedtomewhat anethicaltherapist trulyis.Jim Doreewhodesignedandrunsmywebsite,andapparently doesn't know that there is only room for physiotherapy in our lives. MikeSuttonwhohasthegreatestnaturalenthusiasmandexuberance thatI haveevercomeacrossandwhoshowedmenottobeconcerned withwhat othersthought,providingyoubelievethat youaredoingthe rightthing.GwenParrottwhohasabsolutelynoproblemdisagreeing withmeandlettingmeknowitinnouncertaintermsandwhoconstantly challenges mefor thefacts;andtoher husband Jaimewhocontributestomy income via theoccasionalpoker gameinLouisville.My colleaguesat theNorth AmericanInstitute of Orthopedic Manual TherapyincludingBillTemes,AnnPorter-Hoke,KathyStupanski,Bill O'Grady,DavidDeppler,SteveAllen,KentandShariKyser,Alexa Dobbsandtherest of thegang. Therearemanymemorablypastandcurrentstudentswhohavekept andstilldokeepmeonmytoes.Innoparticular order theseinclude RebeccaLowe,PatChapman,DanaVansant,MarkDutton,AmyBrooks, Jeff Brosseau,ChuckHazel,JulieGallagher,BrianMacks,GrayCook, ShannonDoig,MaryGalatas,RandyHarms,BlaineMcKie,Dawn McConkey,ColleenMcDonald,JudyBlack,LorrieMaffy-Ward,Maureen Mooney, Roberto Pelosi, Myron Sorestad, Christine Wolcott, Suzanne Yakabowitch,PaulJozefczyk,FredSmit,MarcelGiguere,TaraConner, ChrisSoper,AudreyBjornstad,TerryBrown,AnneClouthier,Nathelie Savard,HeatherBryant,JanHodge,JoeKelly,GiseleLeBlanc,Ralph Simpson,KorrynWieseandmanymorewhosefacesIrememberbut whosenamessadly aregonefrommyever increasinglyevasive memory. iglUent:sAcknolNledglUent:sxix striYesconSteveZollo,McGraw-Hili'smedicalacquisitionseditorwhoconTIcthatitis vincedmethatthiswouldaneasyundertaking.Right!AnneSeitzof lffionsense. YorkGraphicswhose editing ensured that the book wasat least legible son.hasnototheEnglishreadingperson.Iwouldalsoliketothankthetwore1of whom I viewersof anearlydraftof thebook,ElizabethR.Ikeda,MS,PT As,homanage sistant Professor PhysicalTherapyDepartment,Universityof Montana ..SueSaretandRobert Johnson,MS,PT LoopSpine&SportsTherapyandclini\ i thpatients calfacultyattheDepartment of PhysicalTherapy,NorthwesternUnilherapistsin versity,whose ideasI took toheart and,for themost part,incorporated Jis.forme,into the book assuringa better product than it would have been without thehardest their recommendations. ltungmetoFinallyand most importantlytomyfamily-Sue,mywife,and AnnLeTwomeydrewand Matthew,mychildren.ItwasSue who motivatedmetowrite ,esandisin thisbook bysaying thatIcould buyanewcomputer if Ididso.Thank tobemoreyouall forputting upwithme atanytime but especially duringthepecrystronglyriodIwaswritingthisbook. )hasassited ;degree,my :thical thera:.andappar, in our lives. t exuberance )CLoncerned liedoingthe ldisagreeing adwhoconmewho conJuisville.My .1anual TherJpanski,Bill Kyser,Alexa hohavekept eincludeRe.-\myBrooks, .GrayCook, kKie.Dawn -Ward,MaulLon.Suzanne TaraConner, iller.Nathelie Blanc,Ralph cmemberbut lSiyememory. ,----s l s o u 8 u I O{ t ? 1 = J . u a J a J J I OJ O s a l d l ~ u l J d{ t ?J a u a9II Di: D i ~Ge TERI Differential Diagnosis: General Principles Theclinicaldifferentialdiagnosisisalwaysprovisionalandsubjectto change asfurther information from more objective studies such asblood testsandimagingbecomesavailableorastheresultsof theselected treatmentsarenoted.Spinal conditionsthat donothaveovertneuralor duralsignsorsymptomsaredifficulttodiagnoseexceptontheprovisionalbasisthattheselectedtreatmenthasitspredictedoutcome.For example,back painwithsomaticpain radiatingintothebuttockthat is not accompanied by neural or duralsignsor symptoms could be caused by a number of pathologies. These include a contained disk lesion,a zygapophyseal joint dysfunctionor inflammation,ligamentousor muscle tearing,injurytotheouteranulusfibrosis,compressionorotherfracture,bacterialinfection,orneoplasm.Someofthesepathologiesare muchmorecommonthanothers,andbythelawof probabilitiesalone youwouldprobablyberightmoreoftenthanwrongif yougenerated twoorthreediagnosesbasedonfrequencyof incidence.Eventaking intoaccounttheclinical findings,including other aspectsof thehistory andother objectivecues,thediagnosiscannotbeconsideredashaving 100%validity.Thebestyoucandoisgeneratea differentialdiagnosis inwhichyouhavethebest confidence.Evenimaging studieshelponly toconfirm a clinical diagnosis,given the rateof falsepositives andnegativesof MRIsandx-rays. 3 4Part: 1General Principles of Different:ial Diagnosis Chapt: Theorthopedicmanualtherapyexaminationconsistsof twoparts,a differentialdiagnosticexaminationandabiochemicalexamination.Of thetwo,thedifferentialdiagnosticexaminationisthemoreimportant becauseitconfirmsthatthepatientisappropriateforphysicaltherapy. Thebiomechanicalexaminationisvitalifspecificmanualtherapyor specificexerciseistobeadministered.Forthemostpart,thedifferentialdiagnosisisprovisional,dependingonfurther,moreobjectivetestingor,inretrospect,onthepatientrecoveringwithspecifictreatment. Many therapistslook onlyforred flagsonthedifferential diagnosisexaminationratherthanaspecificdiagnosis,andalthoughthisapproach isquitegood for precludinginappropriate patientsfromtreatment,it is of littlevalueinthegenerationof aspecifictreatmentplan. Anoverviewof theexaminationswould look likethis: Differential Diagnostic(Scan)Examination oHistory oObservation(inspection) oRoutineselectivetissuetensiontests oSpecialtests oPeripheraldifferentialscreeningexamination Biomechanical Examination oBiomechanicalscreeningtests oPassivephysiologicalmovements oPassiveaccessorymovements oNonligamentousarticularorsegmentalstabilitytests Thisbook willfocuson thedifferentialdiagnosis;biomechanicalevaluationistoocomprehensive a subject toincludehere,soonlytheprincipleswillbecovered. The differential diagnostic examination can be divided up asfollows: oSubjective oObservation oActivemovements oPassivemovements oResistedmovements oStress oDural oDermatome oMyotome oReflexes oSpecialtests a.Vertebralartery liagnosis n\o parts,a nination.Of important i.::altherapy. J therapyor thedifferen)jectivetesti.::treatment. liagnosis ex:lisapproach itis 1.

:hanicalevalon] ytheprinupasfollows: Chapter 1Differential Diagnosis: General Principles b.Upper limbtension c.Quadrant d.Phalan's e.Tinnel's f.Others THEUNIVERSlTY OFWESTFLORlOA 5 II Tl E" (R2 The Subjective Exantination Thehistoryisperhaps themostimportantpart of theclinical examinationof thepatient.Acarefulsubjectiveexaminationisthetoolmost likely touncover red and yellow flags. It will provide the examiner with importantinformationregardingthepatient'sproblem.Disabilities, symptoms,symptom behavior,irritability,and exacerbating,provoking, andrelievingfactorscanonlybeascertained fromthesubjective examination. Apast history of similar symptoms or nonmusculoskeletal conditionscanbe important inarousingtheexaminer'ssuspicionsthat the patient's problem may not be benign in nature or musculoskeletal in origin.Past treatments and the resultsof thesetreatmentsmay indicate the best routetofollowformanagement and what treatmentstoavoid.The historywillaffordinformationregardingthepatient'spersonality,attitudetowardhisor herproblem,andlikelihoodof compliancewiththe therapist's instructions regardingexercises,rest,activities,andsoforth. The followingsection of thischapter willlook at information generated fromthesubjectiveexaminationof thepatientandpossibleinterpretationsthatcanbeputuponitespeciallywhencombinedwithinformationgarnered fromtheobjectiveexaminations.Wewilllook first atquestionsthatpertaintoallregions,spinalandperipheral,andthen wewilldiscussregion-specifichistorytaking. Thepurposeof takinga historyistodetermine 1.Patient Profile oAge oGender oOccupation oLeisureactivities 7 BPart 1General Principles of Differential Diagnosis Chaph: 0Familystatus 0Past medicalhistory 0Current and past medications 2.Thepatient'ssymptomatology,including 0Onset 0Natureof symptoms 0Severityof symptoms 0Levelof irritability 0Exacerbatingandrelievingfactors 0Associatedfactors(diet,posture,activity,etc.) 3.Thepatient'slevelof disability 4.Thestressesthepatientmust beabletotolerateindaily activities 5.Anyother previousor currentmedical conditionsthatwillimpact ontheassessment or treatment 6.Anycurrentmedicationsthatmightimpact ontheassessment or treatment 7.Anyother past historyof a similar type 8.Anyother physicaltreatmentsforthisor othersimilarconditions andtheresultsof thesetreatments 9.Openingcommunicationchannelswiththepatient 10.Establishingaworkingrelationshipwiththe patient 11. Gaininganappreciationof thepatient'slikelycompliancewith programs 12. Gaininganappreciationof thepatient'sattitudetoward hisor her problem Thefollowingliststhemainquestionsthatneedtobeaskedmostpatients.Some areregionspecific.For example there islittle point inaskingabout dizzinesswhen the patient isattending for low back pain.The questionsonthelistwillbediscussedindetail,eitherinthegeneral principlessectionof historytakingorintheregion-specificexaminationsectionof thischapter. 1.Patient Profile oAge(old/young) oGender oOccupationanddescriptionof duties oLeisureactivitiesandtheirfrequencyandintensity oFamilystatus oPastmedicalhistory(cancer,diabetes,systemicarthritis, congenitalcollagendisorder) oCurrentandpast medications(steroids,NSAIDs,insulin, dizziness,provoking) oPastsurgeries(cancer,spinal,neurological) tiagnosisChapter 2The Subjective Examination 9 11\ . willimpact or I.:onditions with rd hisorher mostpapointinaskl.:k pain. The 1thegeneral lricexaminahrilis. lsulin. 2.Painand Paresthesm oOnset(traumatic/nontraumatic,immediate/delayed, insidious/sudden,cause/nocause) oLocation(steady/changing,local/extensive, segmental/nonsegmental,continuous/dissociated, shifting/expanding) oType(somatic,neurological) oSeverity(scaleof 10) oIrritability(howmuchstresstoirritateandhowmuchtimefor relief) oAggravating/abatingfactors(activities/postures,eating/diet, general/emotionalstress) oNocturnal(achingorsuddensharppain) oWorkrelatedornot oConstant,continuous,intermittent oEpisodic/nonepisodic 3.Other Symptomsand What ProvokesThem oDizziness(type1,2,or3) oVisualdisturbances(scotoma,hemi-/quadranopia,floaters, scintillations,blurring,tunnelvision) oTasteorsmelldisturbances oDysphagia(painful/painless) oAmnesia(traumatic/nontraumatic) oVomiting oCoughchanges(nonproductivetoproductive) oSputum changes(clear toyellowor green,freshoroldblood) oWeakness oClumsiness oGaitdisturbances(ataxia,staggering,tripping) oDropattacks oSyncope(frequency) oPhotophobia oPhonophobia oHypoacusia oHyperacusia oTinnitus(high/lowfrequency,unilaterallbilateral, pulsatile/nonpulsatile) oIntellectualimpairment(drowsiness,concentrationdifficulties) oBladder changes(retention/incontinence,color changes,odor changes) oBowelchanges(unabletoexpel,diarrhea,constipation,blood) oIncreasedsweating oDistalcolor changes(reddening,bluing,whitening) 10Part 1General Principles of Differential DiagnosisChapte Patient Profile oChangesin facialappearance(drooping,ptosis,reddening, enophthalmos,exophthalmos) oDysarthria(slurring) oDysphonia oHypoesthesia or anesthesia (unusualinthehistory) oHyperesthesia oIndigestion oRecent fever 4.MandatoryQuestions oDizziness oCranialnervesymptoms oLong tractsymptoms oBladder,bowel,orgenital dysfunction oOsteoporosis oVertebralarterysymptoms 5.PastEpisodesand Treatments oFrequency(increasing,steady,ordecreasing) oSymptomintensity(increasing,steady,or decreasing) oSymptomlocation(steadyor changing[spreading,shifting,or expanding]) oSeverity(increasing,steady,or decreasing) oIrritability(increasing,steady,or decreasing) oPast treatment(type,helped/worsened/unchanged) 6.Other Investigationsand Results OX-rays oMRl oMRA oCTscans oBonescans oScintillographs oPETscans oENG oEEG oEKG oEMG oNerveconductionstudies Thepatientprofileincludesgender,age,occupation,familystatus, leisureactivities,andpastandpresentmedicalconditionsandcurrent medications. )iagnosis Chapter 2The Subjective EXalnination11 kning, 19) or farnilystatus, andcurrent Age Children whoareinenough pain towarrant physical therapyshould alwaysbeviewedwithsuspicion.Forthemostpart,childrenrecover quicklyfromminorinjuries.Theytendnottohavethechronicproblemsthatadultssufferfrom,becausetheyhavenotyethadtheopportunity for cumulative stress or degeneration to take their toll,nor do they nonnallyhavethepsychologicalorfinancialbaggagethatgoeswith adultsandiscapableof complicatinganotherwiseuncomplicatedinjury,soachildcomplainingof ongoingpainmayhaveamoresevere injury than the trauma would suggest or be suffering froma serious disease.However,nowthatchildrenarebeingpushedharderandharder intovariousfonnsof competitivesports,weseemoreadulttypesof dysfunctioninchildrenthanpreviously.Consequently,adetailedhistorymust be takennot only of the immediate precursor but alsoof how involvedthechildisinsports,whatif anypreviousinjurieshaveoccurred,andhowtheyprogressed withtreatment. Theolderpatientis,of course,moredisposedtodegenerativeconditions,notonlyof themusculoskeletalsystembutalsoof othersystems.Cancerandcoronary,cerebral,andbrainsteminfarctsmayallbe factorsintheassessmentandtreatment of theolder patient.The ageof thepatient willalsogiveanidea of what therange of motion shouldbe whentheresultsof movementtestsareconsidered.Theolderpatient canbeexpectedtobea little stiffer thantheyounger,becausedegeneration increasingly becomesa factor.Ayoungperson whoisstiff everywhere has either veryhigh muscle tone or possibly a systemic joint condition.Amiddle-agedtoelderlywomanismorelikelytohavebreast cancerthanayoungoneoraman(themedianageatdiagnosisis57 yearsand islessthan1 per100,000 before 25years of ageascompared to397per100,000atage80).1 Gender Thiswillgivesomeindicationastopredisposition.Osteoporosisand gynecologicconditionsareeither moreprevalent inorexclusivetothe female;prostatitis,testicularcancer,andsoforthareexclusivetothe male.Lungcancer isabouttwoandahalf timesmore commonamong menthanamongwomenandhasa higher incidenceinthosewithpreviouspulmonarypathologiessuchassclerodenna andchronicobstructivepulmonarydisease.2 Breastcancerisabout146timesmorecommoninwomenthanmen.3 Acombinationofgenderandagewilloftensensitizethetherapist morethaneitheralone.A30-year-oldmanwithlowbackpainisless likelytohaveprostatecancerthanisa60-year-old.Amiddle-agedor elderlyfemaleismorelikelytohaveosteoporosisbecauseof thehormonaldeficienciesof menopause. 12Part 1General Principles of Differential Diagnosis Chapt Occupational and Leisure Activities Althoughtheinformationmaygivesomecluesabouttheunderlying causeof thepatient'sproblems,theneedtoknowexactlywhatthepatient doesforalivingismoreimportantinprognosticationandpostrehabilitation training. When can the patient goback toworkandfor how long(full- or part-time)? Willmodificationshavetobemadeinthepatient'sjobdescriptionorintheworkenvironment?Willretrainingbe necessary,andif sowhencanitbeginsafely?Toanswerthesequestions,inmanycasesatleast,asimple"Whatdoyoudoforaliving?" willnot suffice.especially in jobs that are a littlemoreunusualthanare thosenormallyencountered bythetherapist. Similarly,leisureactivitiesrequireadetaileddescriptionastotype andintensity.Isthisactivitylikelytohaveanadverseeffect on thepatient'sprogress,orcoulditbeusedasarehabilitationtool?If thepatient insists on continuing with the activityeventhoughthe therapist believesitwilllikelycauseproblems,thenanaccommodationmustbe reached.Delayingtheresumptionof theactivitymayhelp,especially whenthereisanydegreeof inflammationpresent.Reductioninitsintensitymayalsobeuseful.For example,agolferwiththoracicorlow back pain can be asked tonot drive the ball but to playthe shorter shots. Thismaynotbewhatthepatientwantstohear,butitatleastallows himor her topursuetheactivityevenif ina severelymodified fashion. Family Status Doesthepatienthavesupportathome,allowingthenecessaryrestor timetoexerciseathome?Canthepatientavoidadverseactivitiesat homebyhavingsomebodyelsedothem?Isthisaperiodofstressat home,whenlittle if anycooperation istobefound?Can the patient get somebody tohelp with the exercises if this isnecessary,or will you have tomodifythem? What aretheagesof thechildren,andhowmuch care must thepatient givetothem? If it isnecessary,the therapist must teach thepatient howtomodifypositions fornursingor changing infantsand dressing smaller children and torecruit older children totakeover some of thechores. Past and Present Medical Conditions Mostof thepatient'smedicalhistorywillbe of norelevancetous,and when this is recognized, questioning should be discontinued on that subject, because itbecomes aninvasionof the patient's privacy without any clinicalnecessity.However,weshouldlistenforahistoryof systemic arthritis,skinrashes,cancer,diabetes,coronaryconditions,or cerebral strokes. Asking about cancer canbea problem. Anymention of the disease tosome people generates panic,with the patients believing that you areaskingbecauseyouthinktheyhaveit.Toavoidthis,thequestion >iagnosis Chapter 2TheExatnination13 :underlying \\ hatthepa: illdpostre.indforhow .ieinthepa be " 1:1 eseques aliving?" -ualthanare 'Illastotype ,:[onthepa':Ifthepa be-lionmustbe ;'.especially :loninitsin)ra-:icorlow -horter shots. ::eastallows :fiedfashion. restor :.i-:ti\itiesat ofstressat hepatient get \\ illyou have Y,\muchcare L:':must teach infantsand ekeo\"ersome l-:etous,and ",:onthat suby without any yofsystemic l-,orcerebral ionof the dis that you ,thequestion can be put on a questionnairethat thepatient fillsout before seeing the therapist. A past history of cancer should always tellthe therapist toask questionsaboutpreviousscreeningformetastases(preferablyofthe physicianrather thanthepatient unlessthepatient volunteers theinformation).There isno point inworryingthepatient about something that maynot be anissue,but if screenings have not been done in at least the previous6months,thetherapistshouldbeconcernedandmorethana littlecriticalof theresultsof theobjectiveexamination.If cancerisa factor,askthepatient if heorsheisreceivingradiationtherapyor has receiveditrecently.Radiationtherapypatientsareoftenputontosystemic steroids fortheduration of the therapy,and of course thiswill alter collagenstrength. Diabetesmaycausearthropathies3 and neuropathies4 aswellasdelayingrecovery.Coronaryorcerebralvascularconditionsshouldlead the therapist tobe especially careful whentreatingcervical patients because theseconditionsare evidence of systemicatherosclerosisandthe vertebral artery may be similarly affected.Inaddition,anyexercise program needstobeplannedwiththeconditioninmind.Systemicarthritis,particularlyrheumatoidarthritisorankylosingspondylitis,should make thetherapist cautious,especially when treatingtheneck.Both of theseconditionsareintimatelylinkedwithatlantoaxialinstabilityand subluxation.5-7 If achild'sneckistobetreated,askaboutanyhistory of recurrent chest infections, because this can lead to Grisel's8 syndrome withitsaccompanyingtransverseligament laxity. Itispossiblethataheart conditionisproducingthe patient'ssymptoms.Heart pathology will often make itself feltthroughanache down thedeltoid and lateral border of the upper arm, mimicking shoulder joint pain.Itisof coursevitalthatprovokingorexacerbatingactivitiesbe discussed indetail. It isalsoworthnotingwhat,if anything,the patient hastosayabout congenitalanomalies.Becausealmostallcongenitalanomaliesareassociatedwithothersderivedfromthesameaffectedembryological block,9thepresence of ananomalyshould be pursued. Again,thisisof particularimportanceinthecervicalregion,whereacervicalribor Sprengle's deformity or polydactyly, for example, could alsoindicate an anomalyor anomaliesof thevertebralartery. Current: Medications Often patients forget to mention medical conditions but will tellyou that theyaretakingaparticular drug.Thisshouldleadyouback tothereasonfortakingthemedication.Inaddition,certainmedicationswillaffectyour treatment choices.For example,it isnot recommended toapplydeepfrictionstoorgivestrongexercisesforatendonor ligament that hasrecently(saythelast 3 weeks)been injected withsteroid.Cor14Part 1General Principles of Differential Diagnosis Chaptl tisoneinjectionsintothetissuewillweakenthecollageninjectedand may result inrupture. 10-12Systemicsteroidswillcause generalized collagenweakness,water retention,andgeneralized weaknessandtenderness,allof which canaffect the resultsof theexaminationandtheoutcomeofthetreatment.Anticoagulantsareacontraindicationto manipulationanddeeptransversefrictions.Aboutfourhundredmedicationsareknowntocausedizzinessasanadverseeffect.TheseincludeaspirinandotherNSAIDs,systemicsteroids,amminoglycosidic antibiotics,diuretics,andantianginals. 1314 Obviously,thesemustbe consideredwhenassessinga patient's dizziness. Pain and Paresthesia Painisthemostcommoncomplaintbringingapatientintothegeneralistorthopedictherapist.Painisasubjectivesymptomandvariesnot only from patient to patient for thesame stimulusbut from hour tohour andfromcontext tocontext. Atraumathatwilldisableoneperson will leaveanotherindifferent.Asaconsequence,painisnotsubjecttoobjective evaluation,and thepatient'sdescriptionisthe onlysource of informationthatthetherapisthaswhendeterminingitsqualities.Therefore,descriptions of itstype,location,behavior,intensity,andsoonare extremelyimportant inmakinga differentialdiagnosis. Onset Isthepainrelatedtotrauma?If so,wasitimmediateordelayed?An immediate onset of severepain often indicatesprofound tissuedamage suchasligamentousormusculartearingorfracture.Forexample,the immediateonsetof cervicalpainfollowingmotorvehicleaccidentsis recognizedfromanumberof retrospectiveandprospectivestudiesto indicateapoorprognosis.1 5 Adelayedonsetismorecommonlyencountered andisoften caused by the inflammatory process,which takes timetomakeitselffelt.Inadditiontopain,didthepatienthearany noisesatthetimeof theinjury?Cracking,tearing,orpoppingnoises could indicatesudden damage.Wasthereswelling,andwhendidit occur?Immediate,severeswelling isstronglysuggestive of hemarthrosis. Significantarticulartraumacausingpainbutnoswellingcouldmean thatthereisa rentinthecapsule,throughwhichtheinflammatoryexudateor blood isleaking. If thepainisnotrelated tooverttrauma,wasthereaparticularactivitythatcausedit?Occasionally,thepatientwillrelatethatthepain wastraumaticin origin,but furtherquestioningrevealsthatthetrauma wasveryminor compared with the degree of painand disability that the patient isexperiencing.Inthiscase,thetrauma maysimply be the final )iagnosisChapter 2The Subjective Examination15 injectedand eralized colcandtenderandtheout:1dicationto lndredmed~ t . Theseinnoglycosidic e"emustbe [0thegener1d\ariesnot hour to hour e personwill ubjecttoob,ource of inlities.Theremdso on are delayed?An .,.,.uedamage example,the ~ accidentsis \estudiesto !ITlTIlOnlyen. which takes .emhearany 'ppingnoises :1endiditochemarthrosis. :couldmean unmatoryex-particularacthatthepain atthetrauma bility that the y bethe final strawonthecamel'sback.Youmayneedtosearchforthefactorsthat stressedthefailedareasomuchthataminorstressfinisheditoff.The categoryintowhichmost patientsfallin generalorthopedic practiceis nontraumatic.The patient can relatenooverstressfulactivityor posture thateitherstartedorprovokedtheproblem.Thecausemayhavebeen liftingamoderateload,suddenlyturningthehead,wakingupwitha "crick" in the neck,or something equally innocuous. There aremore incidents of low back injury from lifting objects out of the back of the car than putting them in. Why? Probably because the lifter has driven somewhere andso predisposed thespine to injury.Life islike that: Wespend our youth and youngadulthoodpredisposingour bodies tofailurefrom injuriesthat on lessabusedmusculoskeletalsystems wouldbe insignificant.Whenweareafewyearsolder,disasterstrikes. The overusedterm overusesyndrome isanexample of nontraumatic pain. It suggests that simple overuse was the cause of the patient's symptomsanddisabilities.Insome cases, this isaccurate and the term isbeing used as it should be, but in a substantial number of instances (I would suggestthemajority),itisnotanaccuratedescriptor.Tenniselbowis anexcellent exampleof this.Apatientattendswithanepicondylar(or anyother type)tennis elbow thatisconfirmedonclinicalexamination. The patientisthenaskedabouthis job.Onbeingtoldthatheisacarpenterandspendsalargepart of hisdayhammeringnailsintoboards, the therapist is happy to lay the blame here and treat it asa primary tenniselbow.Thefactthatthepatient hadbeendoingthesame job inthe samewayfor15yearsdoesnot enter intotheequation.If youhammer allday,thatisoveruse.It isnotoveruseforanexperiencedcarpenter. Perhapsif thepatienthadonlybeendoingthe jobfor6months,if he had just come back froma monthonvacation,or if he hadchanged his hammerorthepositionhewashammeringin,primarytenniselbow might havebeen a reasonable deduction.However,it isnota goodidea toassumethatthemostobviousanswer isthecorrect one.Almost certainlysomething hadchanged, if not the job then something else.Some of thefactorsmentioned heremayobtain, or perhaps the patient'sneck wasdysfunctional.In the absence of a clear-cut case of unfamiliar overuse,thetherapistneedstolookforotherreasons.Apatientcomplaining of posterior thigh pain attended an orthopedic surgeon,who told her that shesuffered from a tom hamstring.Shesaid yes,she knew that, but whydidit tear?Hesaid it wasbecauseshewasa runner,towhichshe replied,"But Irunonbothlegs."Simplisticexplanationslikethatofferedto thisyoungladyaretherootcause of failuretoimprove or failuretomaintainimprovement.Inaddition,becarefulof casesinwhich thereisnoapparentcause.Thevastmajorityof thesepatientswillbe straightforward musculoskeletal problems, but it is fromthisgroup that thesystemicarthriticandcancer patientswillbedrawn. 16Part 1General Principles of Differential DiagnosisChaptf: Pain Quality Thenature or typeof painthepatient isexperiencing isvitalin assessingthecondition.Thereareanumberof differentclassificationsfor pain,butforthepurposesof differentialdiagnosisthefollowingisas goodasanyand better thanmost.Paincanbeclassified asneuropathic (neurological)or somatic(nonneurological).Experimentshavedemonstratedthatsimplecompressionof anuninjuredspinalnerveorspinal nerveroot(withtheexceptionof thedorsalrootganglion)doesnot resultinpain.The resultof simplecompressionexperimentallyisparesthesia,numbness,neurologicaldeficit,orallthree,butnotpain. 16,17 However,ithasbeendemonstrated thatcompressionor otherformsof irritationof previouslyinjuredspinalnervesornerverootscancause pain of a veryparticular type.Inaddition,it hasbeen postulated that intraneuralor perineuraledema mayproduce nerve rootischemia,which intummaycauseradicularsymptoms. 18 Thisradicularpainislancinating or shooting and lessthan one and a half inches in width, running down thelimbor around thetrunk. 19,20Asa consequence,therecognitionof radicularsymptomsisveryeasy.Itislancinatingpain,paresthetic, causalgic, or numb. Anysymptoms other than these cannot be ascribedtospinalnerveorrootcompressionorinflammation.Foran excellentshortdiscourseonthissubjectreadBogdukandTwomey.18 Nonneuropathicorsomaticpainisgenerallydescribedasaching.It canbeverysevereorverymild,butitisnotshootinginquality.Unfortunatelythistype of pain,whenfeltinthelegor arm,is inaccurately describedasroot pain.Based onexperimentaldata,it isnot.The nonneurologicalstructures-thedura,theexternalaspectof thedisk,the ligaments,periosteum,bone,andsoon-are nociceptiveandcangeneratethispain. 18,21It doesnothavetheelectricqualitycommonlydescribed whentrueradicular pain isexperienced. The argument hasbeen made that root painmaynotbe asdescribed hereand points to diabetic neuropathyandchronicrootpain,aswhena patient hasEMG or clinical evidencethattherewasa neuropathypresent butexperiences"nonneurological"pain.However,noevidencehasbeenpresentedthatthe painwasinfactcomingfromtheroot;itmayhavearisenfromsome other compromisedsomaticstructure. Typically,if theorthopedicpatientisexperiencinglancinatingroot pain,somaticpain isalsopresent,because thecompressing tissue,usuallythedisk,isalsocompressingtheduralsleeveof thenerveroot. 18 Somatic"sciatica"isfelteithercontinuouslyorwithposturessuchas sitting,whereasthezingingpainisveryintermittent(corningonsuddenlyduringtrunkflexion,forexample).Atothertimes,thelancinating pain is typically absent.Clinically,itseems that it would be prudent toacceptcurrentexperimentaldataandreservethetermroot painfor thosepatients presenting withlancinating pain or causalgia,asthiswill reducetheoverfrequencydiagnosisof rootcompressionandtheadDiagnosis italinassessificationsfor fllowingisas sneuropathic havedemonorspinal Idoesnot retallyisparesnotpain.16.17 ltherformsof OIScancause ulaled that in:hemia,which painislancirunning therecognigpain,pares: cannot beaslation.Foran ndTwomey.18 jasaching.It nquality.Vnisinaccurately not.Thenon-ithedisk,the andcangencommonlydement has been intsto diabetic DIG or clinieriences"non;cntedthatthe ;.enfromsome illcinatingroot ng tissue,usu18eroot. lSIuressuchas omingonsuds.thelancinatmIdbeprudent :lrootpainfor pa.asthiswill mandthead-Chapter 2TheExantination17 ministration of inappropriate treatments.On the other hand, it isnot beneficialtothepatienttomisdiagnoseadisklesionthatmightonlybe compressingtheduralsheathoftherootorspinalnerve,orapplying pressure totheundamagednervetissuewithoutcausinginflammation. Theriskisthatinappropriatetreatmentmaydamagethediskfurther, causingfrankcompressionwithneurologicaldeficit.Theabsenceof lancinatingpainorotherneurologicalsymptomsdoesnotprecludea diskherniationasthecauseof thepatient'sdisability.Asalways,the answertothequandarylieswiththerestof theexamination.Adiagnosisisnotbasedsolelyonthehistorybutonanalysisof alltheexaminationdata. Otherneurologicalconditionscausingpainhavetobeconsidered whentakingahistory.Thalamicpainsyndromes,herpeszoster(shingles),diabeticandotherneuropathies,polyneuropathies,andarachnoiditismay allbe erroneously referred tothephysical therapistintheir earlystages.Thedescription of pain fromneurologicalsourcessuchas thesetendstobemorevividthanthatof pain fromorthopedicsources, eventhosecausingspinalnerveorrootcompression.Descriptorsinclude stabbing,knifelike,a storm or shock,burning,bandlike, fleshtearing,andindescribable.It isbelievedthatthereasonforthisdifference indescriptorsbetweenneurologicalandsomaticcausesmaybethat dysesthesiaconfusesthepatient,whodoesnotknowhowtodescribe thistotallyunfamiliar sensation.22 Visceral referralof pain totheskinisbelieved to occur asa result of thesynapsing of primarysomaticsensoryneuronsandvisceralsensory neurons onto common secondary neurons of the dorsal horn of the spinal cord.23 Becauseof thedistributionofnociceptorsandpainfibers,visceralpainisgenerallyfelttobedifferentfrommusculoskeletalpain. Withtheexceptionof theparietalliningsof thecavities(pleural,peritoneal,andpericardial),nociceptorsaresparinglydistributedin the visceraandfastpainfibersareforallintentsandpurposesabsent.24 Asa consequence,thefastpainassociatedwiththemusculoskeletalsystem isnotcommoninvisceraldisordersunlessthecavityliningsareinvolved,astheymaybewithadvanceddisease.Visceralnoncavitypain isfrequentlydescribed asdeep,diffuse,and wavelike25 but also often in thesamewayasmusculoskeletalpain.Consequently,itbecomesdifficulttorelyonthequalityof paintodiscriminatebetweenpainarising fromtheviscera andthat coming froma musculoskeletalproblem.It is therefore very important that no definite conclusion be reached one way or theother untilfurtherinformationisobtained.Thisinformationmay wellbeforthcomingasthehistoryprogresses.Thepatientwhorelates thatthepainisassociatedwithdiet,eating,orthepositionassumed while eating is probably telling youthat a gastricdisorder exists.Cholycystitisorgastricorduodenalulcersmayallpresentinthismanner. However, remember that the patient issitting when eating,so makesure 18Part 1General Principles of Differential Diagnosis Chapter that youaskabout thechair andwhether sitting inthischair or one like itwhennoteatingcausesthesameproblem. Chest or shoulder pain on generalizedexertionsuch asrunning fora busorwalkingupstairsornonphysicalstressmaylikelybecausedby cardiacproblems.Ontheotherhand,pleuralpainfromadhesionsor pleuritiscan be extremelydifficult todifferentiate froma thoracicspine or rib dysfunction, because the structure isinnervated by fast pain fibers andsocanproduceamusculoskeletaltypeof pain.Thepleuraisalso attachedtotheribs,whichcomplicatestheobjectiveexaminationpicture,astrunkmotionwillprobablyreproducethepatient'spain. Location Becauseof themultiplicityof thelevelsinnervatingmosttissuesand thenumberof tissuesthatmightbethesource,thelocationof painis usuallyof littlevalueintheexact localization of thesourceof the pain. However,thesite of thepain maybeusefulinobtaininganideaof the embryologicallevelsfromwhichtheaffectedtissueisderived.Neither radicularnorsomaticpainsareconsistentintheirareasof spread.The referredareas of both neurologicalandsomatic sources of pain varybetweenindividualsaswellaswithinthesameindividual.andthelatter seeminglyisafunctionof theintensityof thestimulus.However,neurologicalsymptomsitesareabetterindicationof sourcethanaresomaticpainsites. Thedegreeof radiationisdirectlyrelatedtothreefactors: oStimulusintensity(thehigher theintensitythemorereferral) oStimuluscentrality(themorecentralthemoreradiation) oStimulussuperficiality(themoresuperficialthelessradiation) Consequently,thegreaterthedegreeof radiationthemorelikelyisthe chance thattheproblem isacuteand/or proximal,but,evenwiththediagnosticlimitationsplacedonusbythevagariesof pain,usefulinformationcanoften be gained fromthelocation of pain. Verylocalpain is verylikelytobefromastructureunderthepain area,and referredpain that isnot diffusemayindicatethespinalsegment fromwhichitisderived.It isthe therapist's job to judge howreliable the pain siteislikely tobeinaparticularcaseandtointegratethatinformationwithother datageneratedfromthehistoryandobjectiveexaminationstoproduce aworkinghypothesisaboutthepain'ssource. Grieve26 madethefollowingconclusionson painquality: 1. Allrootpainisreferredpain,butnotallreferredpainisrootpain. 2.Severereferredpainisnotnecessarilycaused byrootcompromise frominflammationor other formsof irritation. Jiagnosis Chapter 2The Subjective Exantination19 Iroronelike :unningfora :'C.:ausedby jdhesionsor loracicspine .s r pain fibers 'leuraisalso :-11 nationpic,pain. :rissuesand 0;1ofpainis e of rhepain. c.ideaof the l\ed.:-';either jspread.The pin \ary bemdthelatter ["weyer,neuthanareso-J:S: rereferral) radiation) likelyisthe r.withthediJ::-.:.-::-.. -\r:n:>;J5So JE:

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1.CameronRB(ed):PracticalOncology,p417.Norwalk, CT,Appleton&Lange,1994. 2.CameronRB(ed):PracticalOncology,pp189-190.Norwalk,CT,Appleton&Lange,1994. 3.Schumacher Jr HR(ed):PrimerontheRheumatic Dis eases,10thed.,pp191,243. Atlanta, ArthritisFoundation,1993. 4.Weiner WJ,Goetz,CG:Neurology fortheNon-Neurologist,3d ed.,pp166-167,1994. 5.Sharp J,Purser DW:Spontaneousatlantoaxialdislocation inankylosingspondylitisandrhematoid arthritis.Ann RheumDis20:47,1961. 6.StevensJCetal:Atlantoaxialsubluxationand cervial myelopathyinrheumatoidarthritis.QJMed40:391, 1971. 7.Boyle AC:Therheumatoid neck.ProcRSocMed 64:1161,1971. 8.Park WW et al:Thepharyngovetebralveins:ananatomic rationaleforGrisel'ssyndrome.JBone JointSurgAm 66:568,1984. 9.BealsRK et al:Anomaliesassociatedwith vertebralmalformations.Spine18: 1329,1993. 10.WigginsME et al:Healingcharacteristicsof atype1 collagenousstructure treatedwith corticosteroids. Am J Sports Med22:279,1994. 11.Oxlund H:The influence of alocalinjectionof cortisol on themechanicalpropertiesof tendonsandligaments and theindirect effectontheskin. Acta OrthopScand 51:231,1980. 12.Walsh WR etal:Effectsof adelayedsteroidinjectionon ligament healingusingarabbit medialcollateralligament model.Biomaterials16:905,1995. 13.SevyRW:Drugsasa causeof dizzinessandvertigo,in Dizzinessand Vertigo,AIFinestone (ed).Boston,John Wright,pp81-97,1982. 14.Ballantyne J,Ajodhia J:Iatrogenicdizziness,inVertigo, MRDix,10 Hood(eds).Chichester,UK,John Wiley, 1984. 15.Sturzzenegger Metal:The effectof accidentmechanismsand initialfindingsonthelong-termcourse of whiplashinjury.JNeurol242:443,1995. 16.McNab I:Themechanism of spondylogenicpain,inCervicalPain,CHisch, YZotterman(eds).Oxford,UK,Permagon,pp89-95,1972. 17.HoweIF etal:Mechanosensitivityof the dorsalrootgangliaand chronicallyinjuredaxons:aphysiologicalbasis forthe radicular painof nerveroot compression.Pain 3:25,1977. 18.Bogduk N,TwomeyLT:Clinical Anatomy of theLumbar Spine,2d ed.,pp151-159,1991. C2.-::-::-:= 5: IDiagnosis patientisvery ting.diarrhea, novement Jam of cortisol "andligaments ::.OnhopScand 'l.e:oidinjectionon .:cllateralligament andvertigo,in d,Boston,John inVertigo, ,1(.JohnWiley, :.:identmechate= courseof is. ,genicpain.inCer, Oxford,UK,Per::-:.edorsalrootgantysiological basis npression.Pain cmYof theLumbar Chal!t:er 2The Subiect:ive EXdluinat:ion33 SmythMJ,Wright V:Sciaticaandtheintervertebraldisc.30. Anexperimentalstudy.JBoneJointSurg Am40:1401, 1959. 31. :1),McCullochJA,WaddellG:Variationinof thelumbosacralmyotomeswithbonysegmentalanomalies. 32. J Bone JointSurgBr 62:475,1980. EIMahdiMAetal:Thespinalnerverootinnervation, anda newconceptof theclinicopathologicalinterrela33. tionsinbackpainandsciatica.Neurochirugia24: 137, 1981. 34. AdamsRDetal:Principlesof Neurology.6th ed.(CDROMversion).New York,McGraw-Hill,1998. 35. Wilson-PauwelsL etal:Autonomic Nerves,pp42-43. Hamilton,BCDecker,1997. 36. GoodmanCC,Snyder TE:Differential Diagnosisin PhysicalTherapy,2ded.,pp6-7. Philadelphia,WB Saunders,1995. 37. Holleb Aletal(eds):Textbookof ClinicalOncology, p 555.Atlanta, American Cancer Society,1991. 38. GrieveGP:Referredpainandother clinicalfeatures,in Grieve'sModernManualTherapy,2ded.,JDBoyling, 39. NPalastanga(eds).Edinburgh.ChurchillLivingstone, 1994. 40. WilliamsPL,WarwickR:Gray's Anatomy,36thed.Edinburgh,ChurchillLivingstone,1980. 41. " Cameron RB:PracticalOncology,p.Norwalk,CT,Appleton&Lange,1994. 42. :9.Holleb AIetal(eds):Textbookof ClinicalOncology.p. Atlanta,AmericanCancer Society,1991. HeadH:StudiesinNeurology,p 653.London,Oxford MedicalPublications,1920. CyriaxJ:Textbookof OrthopedicMedicine,8thed.London,Balliere Tindall&Cassell.1982. McKenzieRA:TheLumbar Spine:MechanicalDiagno sisand Therapy.Waikanae,NZ,SpinalPublicationsLtd., 1981. Weiner WJ,Goetz,CG:Neurology fortheNon-Neurologist,3d.ed.,p155.Philadelphia.JBLippincott,1994. GeorgeB,LaurianC:TheVertebral Artery:Pathology and Surgery.New York,Springer-Verlag.1987. AdamsRDetal:Principlesof Neurology,6thed.(CDROMversion).New York,McGraw-Hill,1998. Ausman JI et al:Posterior circulationrevascularization. Superficialtemporalarterytosuperior cerebellarartery anastomosis.JNeurosurg56:766,1982. PessinMSetal:Basilararterystenosis:middleanddistal segments.NeurolClin37: 1742,1987. KandalER,SwartzeJH:Principlesof NeuralScience,2d ed.,pp567-569.New York,Elsevier. AdamsRDetal:Principlesof Neurology,6thed.,Part4 (CD-ROMversion).New York,McGraw-Hill,1998. DalinkaMK etal:Theradiographicevaluationof spinal trauma.EmergMedClinNorth Am3:475. ReidDCetal:Etiologyandclinicalcourseof missed spinalfractures.J Trauma27:980. HuSSet al:Disorders,diseasesandinjuriesof thespine. inCurrentDiagnosis and TreatmentinOrthopedics, HBSkinner(ed).NorwalkCT,Appleton&Lange,1995. Db 3 Observation Amoredetaileddiscussionof whattolookforineachregionwillbe foundintheregion-specificexaminationsections.Ingeneral,theobservedphenomenonshouldbereadilyapparent;ifyoucannotseeit withinavery fewseconds,itisprobably notsignificant forthispart of theexamination.Lookforthefollowing: Gait Antalgiclimp Verticallimp Laterallimp Neurologicalgaits Ataxia(wide-basedorlateral) Trendelenberg Highstepping Foot drop Others Reducedor absent armswing Reducedor absent trunkrotation Static Posture Obviousposturalanteroposterior deviations (hyperlordosis/hyperkyphosis) Obviousposturaltransversedeviations(lateralshifts) Obviouspostural rotatorydeviations(rotoscoliosis) Torticollis Laterallean Atrophy Hypertrophy 35 Part 1General Principles of Differential Diagnosis 36 Surgicalscars Skincreases(anterior andposterior) Vertebralwedging Vertebralledging Edema Bruising Congenitalanomalies Sprengel's Klippel-Feilsyndrome Poly-,syn-,or adactyly Dwarfism Down'ssyndrome Birthmarks For amorecompletelist seepage000 Generalappearance Pupilaniscoria Ptosis Homer'ssigns Graynessoryellowness Nystagmus Facialdrooping Strabismus Cyanosis Speech,language,voice Dysphasia Dysarthria Dysphonia Gait Chapt Stan There area number of problems with assessing gait. There are too many areastoobserveatonetime.Oftenthereisnotenoughspaceavailable toallowthepatienttogetuptonormalwalkingspeeds.The patient is conscious that heor she is being watched,andartificialgait maybe executed. What aspect of the patient's bodyyouobserve dependsonwhat you arelookingfor.Remember that youarenotina gait labbutina clinic tryingtomakesurethat thepatient hasbeenappropriatelyreferredand thatyouwillgivethecorrect treatment.Gaitisaverysecondaryissue atthispoint in the examination and takeson more importance whenassessingnonroutinepatientswithnonorthopedicmanualtherapyconditionssuchasneurological disease,amputation, diabetes,andsoon.The typesof gaitdeviationdiscussedinthissectionarethosemorecommonlyseeninneurologicalconditionsandthoseusedtoassesspossiblecausesof theorthopedicproblem. DiagnosisChal!ter 3Observation 37 Inanantalgiclimpthereisashortenedstridelengthof theaffected limbwith the footusuallyturnedoutward.Of course,thisis notalways the case. Withan Achilles tendonitis,for example,patients will walk on their toes toavoidstretching theinjured area.Similarly,with a kneeinjurythatcausesaflexionposture,toewalkingisnecessarytogetthe foottothe ground. A lateral limp is recognized by watching the patient's shouldersduringgait.Theshoulderstendtodropdowntoonesideas the patient steps onto that leg.This mayindicate a short leg on that side. A vertical limp can best be seen bywatching the head bob upand down morethanisusual.Thisfrequentlysuggestsa longlegonthatside,as thebodyvaultsoverit.TheTrendelenberglimpisalaterallimpand againcanbestbeobservedbylookingattheshoulders.However,itis differentfromthelateral limpcausedbyleglengthdiscrepancyinthat thelimpoccursoncethepatientisonthelegatmidstanceratherthan atheelstrike.Generallya Trendelenberggaitsuggestsweaknessof the hip abductors of the weight-bearing leg for whatever reason. Ataxia takes manyforms;themost significant for theorthopedic therapist arelateral andwide-basedataxia.Lateral ataxia maybecausedbyvertebrobasilar ischemia(amongotherneurologicalconditions);wide-basedataxiais frequentlycausedbyvestibular disorders.A high-steppinggait isoften caused byneurological diseases that reduce proprioception,perhaps the mostnotoriousof whichisneurosyphiliswithatabeticgait.However, onepatient Isawhada unilateralhigh-steppinggait that hadlastedfor 15yearsanddisappearedalmostimmediatelywithsomesimpleexercises.Gofigure!Footdropisoftenheardbeforeitisseenandisaresultof paresisor paralysisof thedorsiflexorscausedbyperipheralor spinalnervepalsyor astroke. St:at:ic e aretoo many ,paceavailable Thepatient is aitmaybe exlsonwhatyou butina clinic lyreferredand econdaryissue :ancewhenastherapycondiandsoon.The 'semorecom)assesspossi-Posture Usuallywhatismeantbypostureisthepositiontakenupbythesubject inquiet standing,the lordoses and kyphoses.Of course, posture actuallymeansmuchmorethanthisandisbasicallyanyweight-bearing staticposition-sitting, standing,bending,andleaning.If wetakeitas itisusuallymeant,staticquietstanding,thenanumberof considerationshavetobe given.If wearegoingtoassessposturehaveweanadequateyardsticktomeasureourpatientagainst.Certainly,optimalor idealpostureshavebeenadvanced;perhaps FlorenceKendallhasbeen the most influential inthisarea. 1.2 Axialextension, inwhich thesubject attempts toline up,as much aspossible, the vertebrae soastominimize shearing forces,muscle activity, and ligamentous stress isthe most usual definitionof good posture,but isthisa good gold standard? EMG studies have consistently demonstrated that a freely adopted posture requires minimumandconsistentmuscleactivitybetweensubjects.3-7 Havea 38Part 1General Principles of Differential DiagnosisChapter 3 look at thegeneral population and at yourself.How many people doyou seemaintainingthisposture? It might be optimal,but itiscertainly not normalinthestatisticalor clinicalsenses.Evenif youdosubscribeto thisideal,isthereanormalvariationandisthisnormalvariationthe same for allbodytypes? The examinationof posture,whichonthesurfaceseemsstraightforward,isanythingbut. Tocomplicatethisfurther,itisextremelyunlikelythatthepatients whose posture youareobservingare intheir habitualstate.Theyarein pain,theyaredysfunctional,andanyalterationin posturemaywellbe occurringtorelievesomeof theirpain.It isnotreasonabletoassume thatapostureishabitualuntilyouhavereturnedthepatienttohisor herhabitualcondition.It wouldbebettertonotethepatient'sposture andlookforchangesasthepatient'sconditionimproves.Inaddition, bealittlemoreactiveinyourassessmentof posture;askpatientsto movethroughtherangeof posturesfromaxialextensiontoaxialflexion.If theyareabletodoso,youcanpresumethattheyaredoingso, atleasteverynowandthen,andthatatleasttheydonothaveafixed postural deficit.Later,once the immediate problem that hasbrought the patient toyouhasbeenaddressed,theposturalassessmentcan be done with the knowledge that it has more relevance. These results can be compared withyour initial results.If therehasbeen a dramatic change,itis reasonable to assume that theinitial posture wasmore probably a result of thepatient'ssymptomsratherthantheircause.Evenif youbelieve thatthere isa postural deficit,arethepatient'ssymptomsbeingcaused or aggravatedbythatdeficit? Althoughthereisa posturaldysfunction, itmaybecompletelyirrelevanttothatpatient. Lateralshiftingisa formof posturaldeficitbutismorelikelytobe directlyrelatedtothepatient'scomplaints.RobinMcKenziepopularized thesignificance of the lateral shift.McKenzie maintainsthatabout 50%of patientswithlowbackpainexhibitalateralshiftandgivesa numberof reasonsforthis,includingcongenitalanomaly,remotemechanicalcause,alterationof nucleusposition,andabnormal jointconfiguration. 8 Itisworthbearinginmindwhenfiguressuchasthisare used that the author's case load may be entirely different fromyours,so donotgettooupsetwhenyoufindyourselfatvariancewithsuchan author.If you finda lateral shift, isthere an element of rotation involved (thisisa rotoscoliosis) or doesthespine just reach out laterally without anyobviousrotation?Theformermaywellbepartof acongenitalor developmentalscoliosis.Equallyit maybecaused byazygopophyseal jointdysfunctionoradisklesion;therestof theexamwillindicate which.The straight shift is more likely to be caused bymechanical dysfunctions.If itcorrectseasilyandhasanormalendfeel,thecauseis likelytoberemote.If spasmintervenes,adisklesionoranacutezygapophyseal joint problem maybethecause.Spasmandreferred pain, particularlyif radicular innature,arelikelytobe caused bya disk heri3Observation39I Diagnosis . people do you iscertainly not 10subscribeto 11variationthe llch on thesurlatthepatients Lte.Theyare in remaywellbe abletoassume atienttohisor atienC sposture es.Inaddition, askpatientsto ntoaxialflexyaredoingso, athaveafixed hasbrought the :ntcanbedone Iltscan be comticchange,it is a result if youbelieve isbeingcaused -aldysfunction, orelikelyto be popularrainsthat about liftandgivesa Lly.remotemennal joint conuchasthisare fromyours, so ewithsuchan )tation involved nerally without a congenitalor zygopophyseal nwillindicate Ilechanical dyse1.thecauseis Dranacutezyjreferredpain, ibya disk herniationcompressing either thedural sleeve and/or thespinal nerve root. Resistance inthe formof a springy end feelmay indicate some fonnof transversediscal instability and may be fairlyeasily corrected. Alateral leanisrecognizedbythewholebody leaning tooneside fromthelegs, not just from the pelvis as in the case of the lateral shift. The usual cause isanipsilateralshort leg. Torticollis means "twisted neck." It may be painful or pain-free, fixed or correctable. The most common torticollis seen by the orthopedic therapistisfixedandpainful,anditrequirestreatment.Painlessandcorrectabletorticollises areoften theresult of visual disturbances(diplopia in particular)andhearingproblems9 but maybecaused byhysteria. Infantiletorticollismaybecausedbyanumberof thingsincluding difficult labor,breech deliveries,caesariandeliveries,sternomastoid tumors,orsimpleposturalandmuscleshortening.Thevastmajorityof cases respond tosimple stretching andpositioning, with only a very low percentage requiring surgery. Most benign infantile torticollises are congenital. 10Bemorecarefulof acquiredtorticollis,asthiscouldbethe resultof somemoreseriousdiseaseprocess.Childhoodtorticollisusuallyaffectschildrenbetweentheagesof 2and10.Insomethereisan orthopediccause,butinasubstantialnumberthecausemaybeinfectionwithinflammationof thecervicalglandsirritatingthesternomastoid,neurological disease,or neoplasm.Palpate thesubmandibular area fortendernessandenlargementof theglands,andif oneorbothare foundreturnthepatient tothephysician.Similarly,if noveryobvious biomechanical dysfunction is apparent with testing, again refer out. Adolescenttorticollisisthemostcommontype,usuallyaffectingchildren betweentheagesof 9and14YThisisaverypainfulconditionand noncorrectableontesting.Thereisoftenabiomechanicaldysfunction in the upper part of the neck.If thisisleft untreated,theacute painand rangedisturbancelastsabout10days.If treated,itlastsaboutaweek anda half!With carefultreatment (Iuseheat,manual cervical traction, asoftcollar,andlotsof reclining),about80%of thepainwilldisappear in lessthan24hours.If anadolescent presents withtorticollis that haslasted much more than10 daysor that isnot improving,thereisan increasedpossibilityof amoresinisterunderlyingpathology.12Adult torticollises are usually caused bystraightforward mechanical problems, althoughoccasionallyapresumptivediskprotrusionlargeenoughto causemechanicalproblemsbutbigenoughtocauseneuralsignswill giveaspringyendfeelandbeverydifficulttotreat. Muscle Atrophy and Hypertrophy Profoundatrophyin theabsenceof other obviouslong-standingneurologicalsignsisgenerallysuggestiveof lowermotorneurondiseaseor peripheralnervepalsy.Fasciculationoftengoesalongwithatrophy. 40Part 1General Principles of Differential Diagnosis Chapter 3 Lower motor neuron palsies tend toproduce coarse fasciculation;upper motor neuron problems produce fine atrophy. 13Upper motor neuron conditions tend to take much longer to produce atrophy, and nerve root compressionproducesonlyveryslightatrophybecauseofthemultisegmentalnatureof innervationtomostmuscles.Atrophycanalsooccur because of inhibition from painful joint lesions. Quadriceps wasting with meniscal injuriesisanexample. Considerthedistributionofthewasting.Doesitconformtoaperipheralnerve distributionor toa spinalsegment,or isitmultisegmentalornonsegmental?Thelasttwoareparticularlyworrisome,asthey couldindicateanupperorlowermotorneurondisease.Atrophyisof particularsignificanceif itoccursintheintrinsicmusclesof thehand or hands.It maybe thefirstindicationof a lower motor neurondisease becauselowcervicaldisklesionsrarelyproducepalsiesof thesemuscles.11 Unilateral atrophy of the hand intrinsics may occur aspart of thoracicoutletsyndromeorPancoast'ssyndrome,whicharecausedby trauma,breast,orapicallungcancerdisruptingthesympathetictransmissionatthestellate ganglionandthelower brachial plexus. Atrophy of the sternomastoid or,more usually,the trapezius musclessuggests an eleventh cranial nerve palsy, which in tum may be caused bya neuroma, occipital metastases, or fracture.Thiscertainlydemandsa cranial nerve examination.If other cranial nerve signsare evident,a brainstem injury or ischemia ispossible. If the atrophyisisolated, consideration must be giventoalesionof thenerveitself.If theatrophyfollowstrauma,an occipital fractureshould be ruled out,inwhich case, the nerve may have beenstretchedbythemechanicsof theinjury.If thereisnotrauma,a neuroma or metastaticcancer of the occiputarepossibilities. Isolated hypertrophy could be caused byoveruse in a muscle or musclestryingtosupportanunstableregion.Thisisparticularlycommon inthetibialisposteriorandanteriorastheytrytosupportanunstable foot.Of course,thehypertrophymaybemoreapparentthanreal,asit isinDuchenne'smuscular dystrophy.14 Surgical Scars and Creases Surgicalscarswillredirectthepatient'sattentiontopreviousmedical conditionsandtheir treatment,thereby jogging the memory.Most scars arenotrelevanttothepatient'scomplaints,butsome,eventhoughfar removedfromthesymptomaticregion,willbe.Thesearescarsfrom cancersurgery.Obviously,if youaretreatingthelowback andthepatient exhibits surgical scars, this will have a bearing onthe patient's condition,but more froma treatment perspective thana diagnosticone. Skincreasesofferinformationonhypermobilityandinstability,especially when these appear on movement. They are most commonly seen inthecervicothoracicjunctionandinthelumbarspineonextension. 11Diagnosis iculation;upper ltor neuron connerve root comithemultisegcanalsooccur pswasting with 'nformtoape.1multisegmenrisome,asthey . Atrophyisof lesof thehand neuron disease s of thesemus-Lfaspart of tho-arecausedby npathetictrans)lexus.Atrophy :lessuggests an ibya neuroma, a cranial nerve rainstem injury eration must be owstrauma,an nervemay have :snotrauma,a lities. muscle or musularlycommon onanunstable thanreal,asit e\iousmedical ory.~ o s t scars '\enthoughfar arescarsfrom .ckandthepae patient's congnosticone. instability,es:ommonly seen ~ onextension. Chal!ter 3Observation41 They are usually unilateral or if bilateral are seen at different levels,and theygenerallydepictextensionhypermobilityorrotatoryinstability. Lowabdominalanterior creasescanonlybeseen if theunderpantsare loweredinfront.Thiscreaseisalmostpathognomicof spondylolithesis.Be aware,though,that themere presenceof a creasedoesnot necessarilymeanthat instabilityispresent,and evenif it does,itdoesnot helpusdetermineif theinstabilityorhypermobilityisclinicallyrelevant. Local Bony Changes A local kyphus iswedging. It generally occurs with a compression fractureof thebodyof thevertebra.Often the patient cannot remember the injury,asitmayhaveoccurredin childhoodandbenothingmorethan a vague memoryof lowback pain. If the kyphus is painful topalpation, percussion,andthe application of a low-frequency tuning fork,becareful.If therewasnooverttrauma,thismaybeapathologicalfracture caused by osteoporosis, bone cancer, or some other bone disease. Ledging is a little different.Here thetherapist can run a finger down the spinousprocessandcome toonethat sticks outasitdoeswiththewedged vertebra,but on continuing downthespine,theother spinous processes arefoundtobelevel.Thiswouldsuggestthepresenceof adegenerative type of spondylolithesis inwhich the entire vertebra hasshifted forwardon thosebelow.Whenthere isa defect intheparsarticularis,this ledgemaynotbeseen,becausetheneuralarchisleftbehindandremainslevelwiththespinousprocessesbelow.Aretrospondylolisthesis wouldappear intheoppositeway,withthedip comingunderneathand continuingdownthespine. Bruising and Swelling These arenot commonlyseeninspinaltrauma but aresignificant when theydooccur.Bruising over themastoid iscalled Battle's signandfrequentlyindicatesfracturesof thetemporalor occipitalbones.Raccoon maskbruisingisbilateralblackeyessimilartothefeaturesonaraccoon'sfaceandisacompanionof facialfractures. 15 Bruisingoverthe erectorspinaeinthethoracicorlumbarspinemayindicatetearingof thesemuscles,mostusuallybydirectimpact.Shoulderinjuriesresultinginbruising running downthearmgenerally indicate a capsular tear or that a major muscle, such as the pectoralis major, biceps, or brachialis, istom initsbelly.Bruisingwithankleinversioninjuriescanoftenindicatehowsevere thedamageis.Extreme bruisingmaybecausedbya fracture.Bruising on the medial side of theankle with inversion injuries meansthatconsiderableinversionhasoccurred,allowingcompression of themedialtissues.Generallythemoreextensivethebruisingis,the moreseveretheinjury. I42Part 1General Principles of Differential Diagnosis Name of Defect Generalized Osteogenesisimperfecta Therearemanytypesof swelling,andsomearedifficulttosee,especially those around the spine and the shoulder. In the neck after trauma youmay seeswelling intheclavicular triangle or youmayhave topalpateforit.Inmyexperience,thesepatientstakea gooddeallongerto recover. Because itissodeep, the shoulder rarely demonstrates swelling aftertrauma,butwhenitdoes,recoveryisdifficult.Lumbarandthoracicedemaareextremelyrareanddifficulttojudge,butinkeeping withthemotto"If it'sunusual,itmusthaveanunusualetiology,"be careful.Swelling of thebuttock isnota good sign,especially in theabsenceofseveretrauma.Itmayindicateinfection,neoplasticdisease, fracture,andsoon.If thereisswelling,askthepatienthowlongafter thetrauma it came on.If itwas immediate, youare probably looking at ahemarthrosis;if delayed,simpleeffusion.If anentireregionisedematous,thecauseisreducedvenousreturn.If thisfollowedtrauma,it maysimply be disuseand a dependent position. If there wasnotrauma, other,moreseriouscauses couldinclude congestivecardiacfailureand deepveinthrombosis. Congenital AnOinalies Congenitalanomalies are important torecognizebecause inadditionto their directeffect onthe diagnosisandtreatment,theycan also indicate othermoreseriousdeficits.Thefollowingtablesaremadefrominformation from anarticle that looked at subjects with known vertebral malformationsforassociatedanomalies.It wasmoretherulethanotherwisethatthepresence of avertebralmalformationwasassociatedwith otheranomalies,usuallyfromthesameembryologicalblock.It isimportant because althoughthe presence of say,syndactyly,might notaffectthe patient's neck, the problem may beassociated with vertebral arteryanomalies. ClinicalFeatures Fragilesoftboneseasily fracturedor deformed,joint laxity Diaphysialaclasis(multiple exostosis)Cartilage-cappedmetaphysialexostosiswithdeficient remodelingandstuntedgrowth AchondroplasiaDefectivelongbonegrowthwithshortlimbs,dwarfing, andalargehead OsteopetrosisHarddensebonewithincreasedriskof fracture Gargoyl ism(Hurler'ssyndrome)Dwarfismwithkyphosiscausedbydeformedvertebrae, mentaldeficiency,largeliver andspleen Chapter 3 Craniocleido (amyoplasic Pseudohypertr dystrophY FibroplasiaFamilialhypor Cystinosis(ren '\Jeurofibromat syndrome; Hemophilia Gaucher'sdise Down'ssynd'o CentralNervous ,I ippel-Fei I S\r 5orengel'sdeio Cervicalrib -iem ivertebra 50inabifida'so -':,"1old-Chiari:r ::=1genitalintra ::stulasand" ::osectingaortc Limbs ::=-genital:- =comelia ::: -ot'ictionring LlDiagnosis leul ttosee,es after trauma layhavetopalldeallongerto strates swelling Imbarandthobutinkeeping a.letiology,"be :ially in theabplasticdisease, howlongafter ablylooking at regionisede)wedtrauma,it wasnotrauma, liacfailureand inadditionto enalsoindicate .defrominforvertebral mallIethanothercSsociatedwith llock.It isim. mightnotaf:hvertebralared,joint deficient ;.dwarfing, ure j\ertebrae, Chal?ter 3Observation43 =.:' "1iocleidodystosis multiplexcongenita amyoplasiacongenital =ocJdohypertrophicmuscular ::;\strophy = :-oplasiaossificansprogressiva hypohosphatemia -=.stinosis(renaltubularrickets) ',-:-urofibromatosis(Recklinghausen's svndrome) --:-mophilia .=:.ucher'sdisease ='::lwn'ssyndrome CentralNervousSystemTrunkand Spine ippel-Feilsyndrome ):Jrengel'sdeformity '=ervicalrib -1emivertebra )oinabifida(spinaldysraphism) -\rnold-Chiarimalformation Congenitalintracranialarteriovenous fistulasandhemangioma Dissectingaorticaneurysm Limbs Congenitalamputation Phocomelia Constrictionrings Impairedossificationof theskullwithdeficient clavicles Defectivedevelopment of themusclesresultinginstiff deformedjoints. Progressivemuscular weaknessbetweentheagesof 3to 6years Extopicossificationinthetrunkandlimbs,shortbigtoe Congenitalrickets(boneweakness) Rarifiedboneswithdeformity Cafeaulait spots,cutaneousfibromata,andcranialor peripheralnervepalsies Prolongedclotting times,leadingtohemarthrosisand softtissuebleeding Cystlikeappearanceof boneswithlargeliverandspleen Mentalandphysicalimpairment,micro- oradensia Shortstiffneckandlow hairlinecausedbyfused or deformedcervicalvertebrae Unilateral(usually)tetheredandhigh-scapular,no-neck appearance Usuallyasymptomaticbutmayresultinvascularor neurologicalthoracicoutlet syndrome Unilateralvertebraldefectleadingtoscoliosis Spinabifidaocculta,menigocele,ormyelocelemaybe asymptomaticorleadtolegdeformitiesand incontinencebecauseof neurologicalinvolvement; maybeassociatedwithhydrocephalus. Elongationof thecerebellumandmedullainto the spinalcanalwiththepotentialdevelopment of central neurologicalsignswithneckextensionor manipulationinadulthood. Varyinginsize,andcanoccuranywhereinthecranium; if largeenough,willcausepressuresignsand symptoms;mayenlargeorrupture,causingchildhood or adult symptoms,usuallybetweentheagesof 10 and31,but canbedelayedto50years;maysuffer frompulsatiletinnitus Severeinterscapularand/orchestand/orlumbarpain Partorallof alimbmissing Aplasiaof theproximalpartof thelimb withthedistal partpresent Limbordigit constrictionasif byapursestring;maybe associatedwithsyndactyly (continued) 44Part 1General Principles of Differential Diagnosis Chapter 3 AbsenceofradiusHanddeviatedlaterallybecauseoflackofsupport AbsenceofproximalarmmusclesTrapezius,deltoid,sternomastoid,and/orpectoralis major Madelung'sdeformityUlnaheaddislocatedfromtheradius,whichisbowed (dyschondrosteosis) SyndactylyFusedor webbingof twoormorefingers PolydactylyMorethanfivedigits Extrodacty IyLobster-clawhand Congenitaldislocationof thehipNeonataldislocationwithpossibleflattenedfemoral headinadulthood CoxavaraDefectivefemoralneckossificationwithreducedneck angle CongenitalshortfemurFootsmallandeverted;lateraltwodigitstogetherwith theirmetacarpalspossiblyabsent ClubfootFootinvertedandplantaflexedor evertedanddorsiflexed CurledtoeLateralangulationof oneormoretoes In a review of 218 subjects with known vertebral malformations Beals et al. 16 found that most malformations were associated with other anomalies(386vertebral and322 other anomalies),with 61 % of thesubjects showing multipleanomalies.Thesystemsaffectedwere oMusculoskeletal oNeurological oGenitourinary oOtolaryngeal oGastointestinal oCardiac oPulmonary The studyfounda prevalence of thoracic and lumbar anomalies(55.5% and 21 % respectively) with the cervical spine having about15% and the sacrumabout8%,givinganaverageof 1.77anomaliesper patient. AnolUalies Associated ""ith Vertebral MalforlUation Frequencyof DiagnosisNumberof Patients Cranialnervepalsy24(11 %) Upperlimbhypoplasia21(10%) Clubfeet20(10%) Lowerlimbhypoplasia19(9%) Dislocatedhip18(8%) IDiagnosis support 'ctoralis hisbowed jfemoral :iucedneck Igetherwith lddorsiflexed 'rmations Beals lthother anomof thesubjects malies(55.5% .It 15%and the :lCrpatient. fOI'mation of Patients Chal!ter 3Observation45 Sprengel'sdeformity18(8%) Hemifacialmicrosomia18(8%) Renalanomaly17(8%) Cardiacanomaly16(6%) Neurogenicincontinence15(7%) Inguinalhernia14(6%) Lowermotorneuronlesionof lower limb11(5%) Seizures5(2%) Source:FromRKBealset al:Anomaliesassociatedwithvertebralmalformations. Spine18:1329,1993. General Appearance PupilsAniscoria isthetermforasymmetricalpupils,either inside-tosideorinshape.Thepupilsshouldbewithin15%of thesamesizeas eachotherandround,andtheyshouldreactequallytolight,convergence,andsurprise. 17 Constriction of thepupils isa parasympathetic function in relation to increasinglightlevels.Theconstrictormusclesarecontrolledbythe Edinger-Westphal nucleus(part of thethird cranial nucleus) via the oculomotornerve;thedilatormusclesaresympatheticallyinnervatedby fibersfromthesuperior cervicalganglion.Thecontrolof pupildiameter isa coordinated effort between thesympathetic and parasympathetic systems,withtheparasympatheticsystemdominantsothatunderambientlightand environmental levels,thepupilstend toconstrict. If thereisasympatheticparalysis,theparasympathetictoneisunopposed and the constrictor musclesclose thepupil.Light reaction may absent,sluggish,or oscillating.Pathologies causing Horner'ssyndrome arethemostcommoncauseof thisconditionthattheGMT islikelyto encounter.Constriction of thepupilsalsooccurs duringconvergence of theeyesvia Brodman's area in the frontaland the Edinger-Westphal nucleuslobe,althoughtheexactmechanismisnotwellunderstood. Dilationof thepupilsoccurs,eitherasa result of reducedparasympathetic tone in reducing light conditions or from increasing sympathetic toneinthreatconditions.Abnormaldilationof thepupiliscausedby unopposedsympathetictone;generallybecauseof oculomotorparalysisorparesis.Inthesecases,thepupilfailstorespondnormallytothe absenceor reductionof light intheinitialpartof theconsensualreflex test or if the flashlight ismoved away from the eyes.Pupil dilation with ptosisisalmostpathognomicof oculomotor lesions. Addie's pupil isa tonicpupilwhosesize depends on itslast light environment.Itdoesnotreactnormallytolightreflextestingbutwill change its shape over time in different light conditions and once changed 46Part 1General Principles of Differential Diagnosis Chapter 3 maintainsitsdiameter.It respondsbetter duringconvergesthanit does to light stimulation,althoughstillabnormallyslowly,andtonear target testing.It isoftenassociatedwithsymmetricalorasymmetricaldeep tendon hyporeflexia andappearsto bea mild benign polyneuropathy. It hasnosignificancefortheorthopedictherapist. TheArgyle-Robertsonpupilisanirregularpupilthatdoesnotconstrict to light but does constrict on convergence or near vision.Itisspecifictoneurosyphilis. Thenear vision and light reflex discrepancywith regular pupilsisfoundwithconditionsother thansyphilis. PtosisPtosis ispathological depression of thesuperior eyelid such that itcoverspart of thepupil.Themusclesresponsible foropening the eye and maintaining it opened position are the levator palpebrae and Muller's muscle.Thelevatorpalpabraeisinnervatedbythethirdcranialnerve (oculomotor),becausethisnervecauseselevationof theeyeball.It is efficientthenthatthesameimpulsesthatresultinorbitelevationalso causesuperioreyelidelevation.Thesmall,sympatheticallyinnervated Muller'smusclesareattachedtotheinferiorandsuperiortarsals(fibrocartilaginousplatesintheeyelids).Whenthemusclecontracts,it pullsontheplateandcausestheeyelidtoraise. Paralysisor paresisof oneor bothof thesemusclescausesptosis. If anoculomotor paresis/paralysis ispresent, the ptosis isgenerally not capable of correction byeffort,because thelevator palpabraeisthelarger of the twomuscles.If asympathetic paralysisispresent (Horner'ssyndrome) the patient isusuallyable to elevate the eyelid on command and the ptosis ismost noticeable at rest. Because sympathetic paralysis leads tomiosisandoculomotortomydriasis,lookingfortheseasassociated signswillfurtherhelpdifferentiatethesourceof the ptosiS. 17 Fromanorthopedicperspective,ptosismaymeananeurovascular compromise. If the thalamus, reticular formation or the descending sympathetic nerve are affected, Horner's syndrome results and the ptosis will beaccompaniedbymiosis,facialreddening,anhydrosis,andenophthalmos,aswellasotherneighborhoodsigns.Otherpossiblesitesfor damagethatcouldcauseHorner'ssyndromearethethoracicoutflow, theinferiororthesuperiorcervicalganglion,oranywherealong thesympatheticchainintheneck.If thethirdnerveisimpairedthe ptosiswillbeassociatedwithpupildilationandextraocularparesisor paralysis. Horner'sSigns17 Thesearecausedbysympatheticparalysisor paresiscausedbya lesionaffectingoneof thefollowingstructures: oThalamus oReticular formation oDescendingsympatheticnerve 11Diagnosis 'gesthanitdoes Ddtonear target mmetricaldeep Ilyneuropathy.It 11doesnotconvision.It isspeiscrepancy with ilis. eyelid suchthat openingtheeye raeand Muller's cranialnerve Deeyeball.Itis Ielevationalso :allyinnervated tarsals(fi: Iecontracts,it :ausesptosis.If enerally not caraeisthelarger IHomer'ssyn1 command and paralysis leads easassociated )sis. 17 Ineurovascular symjthe ptosis will is.andenoph'ssiblesitesfor oracicoutflow, Iywherealong simpairedthe 'ularparesisor alysisorparelcrures: Cha]!ter 3Observation47 oCervicothoracicoutflow oInferior cervicalganglion oMiddlecervicalganglion oSuperior cervicalganglion Themostseriouslesionsarepreganglionic(rostraltotheinferiorcervicalganglion),but forthetherapistthereisnowayof clinicallydeterminingif alesionispre- orpostganglionic,soallpatientspresenting withHomer'ssyndromemustbeconsideredassufferingfromserious pathology until proven otherwise. The physician can detennine whether thisispre- or postganglionicbyinfusingtheeyewithcocaineandamphetaminesolutionsandwatchingfordilation. Theclinicalsignsof Horner'ssyndromeare oPtosis(smallbecause of paralysisof Muller'smuscle) oAnhydrosis(lack of sweating) oMiosis(constrictedpupil) oFacialflushing oApparent enopthalmos(retractionof theeyeball) Thereareanumberof causes,including oCervical lymphnodeinflammationortumor oPosterior fossatumors oTraumatooneof thecervicalganglion oDissectionof thecarotidartery oApical lung cancer invadingthelowerbrachialplexusand ganglion(Pancoast'ssyndrome) oBreast cancer invadingthelower brachialplexusand ganglion (Pancoast'ssyndrome) oSyringomyeliaandsyringobulbia oTrauma of thecervicothoracicoutflow oVertebrobasilar compromiselateralmedullary(Wallenberg's) syndrome oIdiopathic oHereditary(theirisisusuallya differentcolor bluefromthe otherside) Nystagmus17,18Nys