4 First of all, not every detected anatomical lesion causes pain or dysfunction. Asymptomatic lesions do exist and are present in numbers that are much larger than previously assumed: asymptomatic herniations in cervical, thoracic and lumbar spine are present in up to 50% of the population.1,2,3 Also the high prevalence of rotator cuff tears in elderly asymptomatic individuals is very well known.4,5 It is estimated that in the general population, approximately two-thirds of all rotator cuff tears are asymptomatic.6,7 Large numbers of asymptomatic lesions have also been demonstrated in the knee. A recent MRI study on asymptomatic soccer players demonstrated one or more MRI abnormalities in no less than 64%. Another study with MRI scans performed on the knees of asymptomatic male professional basketball players demonstrated an overall prevalence of articular cartilage lesions of 47.5%8 and meniscal lesions of 20%.9 • Some regions in the body are always tender to touch (e.g. lesser tuberosity at the shoulder, lateral epicondyle at the elbow, border of the trapezius muscle). • Some structures lie too deeply and cannot be reached by the palpating finger (e.g. capsule of the hip joint, cruciate ligaments at the knee). • The painful area does not always correspond to the site of the lesion (referred pain) and referred dural tenderness is sometimes present. • Some patients with altered perception or desire to deceive the examiner may produce misleading responses. This approach has some advantages: • The structures that participate in the movement are well known (applied anatomy). • The movements are easily controllable and reproducible. Pain may be provoked, but also limitation can be seen and weakness is not difficult to detect. The inter- and intra-tester reliability is quite high.10–15 • Patterns can be found: pain patterns, patterns of limitation and patterns of weakness. The recognition of a known pattern confirms the symptoms and signs presented.16 Orthopaedic medical disorders produce symptoms and signs that may be difficult to analyse objectively. Patients who have a reason to assume disorders for some type of personal gain, therefore, commonly use clinical features in the locomotor system to try to establish their credibility (see online chapter Psychogenic pain). Cyriax said: ‘Every patient contains a truth. He will proffer the data on which diagnosis rests. The doctor must adopt a conscious humility, not towards the patient, but towards the truth concealed within the patient, if his interpretations are regularly to prove correct’.17 A very important distinction should be made between the following definitions. Referred pain is a very typical feature in non-osseus lesions of the locomotor system. It is mostly segmental and thus experienced in a single dermatome, which indicates the segment in which the lesion should be sought. Reference of pain is influenced by the severity of the lesion: the more severe it becomes, so giving rise to a stronger stimulus, the further distally does the pain (usually) spread. The reverse also holds: reduction in the distal distribution is synonymous with improvement.18,19 There are many different ways of describing pain: it is amazing how much variation patients can achieve in their vocabulary and how many different descriptive terms can be used for the different sensations perceived. The reason lies in the fact that pain is mainly an unpleasant emotional state that is aroused by unusual patterns of activity in specific nociceptive afferent systems. The evocation of this emotional disturbance is contingent upon projection to the frontal cortex.20,21 The nature of the pain may have some diagnostic value: everybody knows the throbbing pain of migraine, the stabbing pain of lumbago or the burning sensation of neuralgic conditions. Although the way the patient describes the pain may sometimes point to a certain disorder, it can also indicate the emotional involvement of the patient with the lesion. Pain may have either a mechanical or an inflammatory character (Box 4.4). Mechanical pain (e.g. in arthrosis) is characterized by pain and stiffness at the beginning of a movement; augmentation when load is put on the joint; pain at the end of the day and absence of pain at rest, although moving in bed may also be uncomfortable. Inflammatory pain (e.g. rheumatoid arthritis, gout or infectious arthritis) wakes the patient at night and gives rise to frank stiffness early in the day.22
Clinical diagnosis of soft tissue lesions
Introduction
Principles of diagnostic procedure in orthopaedic medicine
2 Look for objective physical signs
3 Avoid palpation as much as possible
The function of the different tissues is known
4 Functional testing: the principle of ‘selective tension’
5 Use physiological movements as much as possible
Normal movements may become disturbed
6 Distinguish between inert and contractile tissues
10 Keep the balance between credulity and excessive scepticism
Objectivity is a fair attitude
11 Request technical investigations only when necessary
Clinical evaluation
History
Taking the history
Progression/evolution
Reference of pain
Actual symptoms
Pain (Box 4.3)
Clinical diagnosis of soft tissue lesions
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