Clinical diagnosis of soft tissue lesions

4


Clinical diagnosis of soft tissue lesions



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Introduction


The major part of this book is about making a clinical diagnosis: a system of clinical reasoning leading to a proper diagnosis. The final stage of the diagnostic procedure is the precise anatomical description of the lesion, for example: supraspinatus tendinitis at the superficial aspect of the tenoperiosteal junction, chronic subdeltoid bursitis, lesion at the origin of the extensor carpi radialis brevis muscle, periostitis at the anteroinferior surface of the fibula, annular disc protrusion at the L4–L5 level irritating the fifth lumbar nerve root.


During the last decades, new technology has revolutionized diagnosis and decision making in orthopaedic medicine. Previously, soft tissue lesions were characterised by a lack of objective findings. This has changed dramatically since the arrival of sonography, computed tomography and magnetic resonance imaging (MRI). These new techniques can demonstrate anatomical changes in soft tissues and therefore contribute significantly to the understanding of non-osseous orthopaedic lesions. However, they do not make clinical assessment redundant. Contrary to popular belief, diagnosis is not made by only looking at the result of a technical investigation. In the best case, an anatomical picture may be the ultimate confirmation of the clinical diagnosis. If imaging is undertaken too early during the diagnostic process it will create more problems and questions than it resolves, and often puts the examiner on the wrong track and leads to wrong therapeutic decisions.


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


Another shortcoming of technical investigations is that they only detect an anatomical lesion (defect, swelling or other structural changes) and not the functional deficiency (weakness, limitation, laxity). In other words, the behaviour of the tissue during activity is not assessed.


For all these reasons, there is no place for high-tech visualization techniques in the beginning of the diagnostic process and they should never be used as screening tests. A biased examiner who is looking for a particular lesion will often find that lesion, whether it is responsible for the complaints or not. Too many and too early technical investigations substantially increase the cost of medical care but do not give a better outcome. On the contrary, in the hands of an unprofessional doctor, high-tech investigations are potentially dangerous as they may lead to major, unwanted and unnecessary surgery.



Principles of diagnostic procedure in orthopaedic medicine


Clinical examination is all about behaviour of the tissues involved. The examiner must have a very good knowledge of the behaviour of the lesions that he is dealing with and of the behaviour of the normal tissue. Tissue behaviour is described by the patient during the inquiry and checked by the examiner during the functional examination. Looking for tissue behaviour, the following general principles are important.



1 Look for ‘inherent likelihoods’


Some things are likely to happen

Soft tissue lesions behave in a very typical way and the examiner will therefore regularly be faced with the same history and the same response to functional testing. The symptoms and signs are closely related to the lesion present. The examiner should therefore try to recognize ‘inherent likelihoods’, a term defined as the sequence of symptoms and/or signs that belong to the clinical picture of a certain pathological disorder and that are likely to be found, more or less in a sequence which is typical for that disorder.


For example: in the history, a patient with lumbar pain may mention that on some days the pain spreads down the lower limb; tennis elbow is characterized by sudden twinges when objects are picked up; and in lumbar disc lesions pain may shift from one side to the other.


Functional examination can also show some inherent likelihoods. When resisted extension of the wrist hurts at the elbow, a tennis elbow is suspect and can be confirmed by positive responses to resisted extension of the wrist with the fingers held actively flexed and to resisted radial deviation of the wrist. In tendinitis at the radial insertion of the brachial biceps, apart from pain on resisted flexion and supination of the elbow, full passive pronation is also painful. In L5 sciatica, pins and needles in the medial three toes may be accompanied by numbness in the same area and by weakness of the extensor hallucis longus and peroneal muscles.


The examiner who has a knowledge of what is likely to happen should recognize this and compare the pattern to the ‘unlikelihoods’ presented by some patients, which indicate either a non-organic lesion, a somatic but non-orthopaedic problem or an unusual lesion. These inherent probabilities can of course only be recognized if the clinical examination is performed thoroughly.




3 Avoid palpation as much as possible


The function of the different tissues is known

Although palpation is very often used as a diagnostic procedure, it is unreliable for several reasons:



It is easy to understand that, in these circumstances, palpation offers no help at all or, even worse, may misdirect the examiner.


Diagnosis, therefore, rests largely on the correlation of a series of semi-subjective data, obtained from a proper functional examination – an indirect approach. By assessing the function of each tissue in turn and interpreting the signs in the light of the anatomical knowledge, the examiner should be able to come to a correct description of the lesion.


The patient is asked to answer some very precise questions. A patient with an organic lesion exactly describes what is felt and gives the examiner a fairly precise clinical picture. The neurotic or malingering patient will feel the need to embellish so as to give a colourful description of suffering rather than of the symptoms.



4 Functional testing: the principle of ‘selective tension’


The soft tissues can be put under tension

The different tissues of the moving parts can be subjected to strain which may increase the pain and tests are used to elicit or influence the patient’s symptoms.


The possibility of making a diagnosis by selective tension depends largely on the characteristics of each tissue and on its capacity either to contract or to become stretched.


Muscles and tendons may be stressed by isometric contraction of the muscle or by passive stretching in the opposite direction. By contrast, ligaments and joint capsules can be put under tension by passive stretch.


If a certain test is positive, in that it provokes the symptom for which the patient consults, it establishes the relationship between the structure that becomes stretched, squeezed or contracted and the lesion.


It is important to try to use movements that put tension on one structure only, so that interpretation is as simple as possible. If a movement tests more than one tissue, accessory tests or palpation may be required to obtain further information that can differentiate between potential causes. For example, when testing the lateral ligaments at the ankle, a combined movement of passive plantar flexion and inversion is performed. If this is positive and, later in the examination, passive internal rotation at the mid-tarsal joints is negative, involvement of the calcaneocuboid ligament is excluded. In examination of the shoulder, painful resisted flexion of the elbow incriminates either the biceps or brachialis muscle; if resisted supination of the elbow is also positive, the lesion lies in the biceps muscle.




6 Distinguish between inert and contractile tissues



Contractile structure

The complex of muscle origin, muscle belly, musculotendinous junction, body of tendon, tenoperiosteal junction and also the bone adjacent to the attachment of the tendon are considered clinically as contractile (Fig. 4.1).



The only worthwhile method of testing these structures is by maximal contraction against resistance. The movement should be performed isometrically so that the applied tension, which causes pain, falls only on the muscle and the structures attached to it.


Passive movement in the opposite direction, which stretches the contractile tissue, can also elicit the pain but cannot be used as a specific test for it because non-contractile tissues are also stretched. For example, a lesion in the subscapularis tendon at the shoulder gives rise to pain on resisted internal rotation. Full passive external rotation may also hurt. This sign fits the clinical picture of subscapularis tendinitis but has neither diagnostic nor localizing value because the passive movement also stretches the anterior joint capsule and the pectoralis major muscle and tendon.


However, a pain elicited by resisted movement does not invariably mean that a contractile tissue is at fault. If the bone close to the tendinous insertion is affected (fracture or other bony disorder), pain is evoked by the pull of the muscle. A contraction may also squeeze an underlying structure such as a lymphatic gland or bursa. When such tissues are inflamed, squeezing may evoke pain. The same applies when there is a disorder adjacent to muscles, for example an abscess. This explains why, for example, contraction of the sternocleidomastoid muscle may be painful in glandular fever and why contraction of the gluteal muscles can hurt in a trochanteric bursitis.



Inert structure

An inert structure does not possess an inherent capacity to contract and relax and can thus be tested only by passive stretching or squeezing. The inert tissues are shown in Box 4.1.


Active movements may also stretch or squeeze an inert structure but, because they also activate the contractile tissues, interpretation is subject to ambiguity and they cannot be used to test inert structures. For example, during active elevation of the arm, many muscles are in action (deltoid, supraspinatus, serratus anterior, trapezius). At the same time, certain parts of the joint capsule and some ligaments are stretched (acromioclavicular, sternoclavicular, conoid and trapezoid ligaments) and other structures are compressed (subacromial bursa, inferior acromioclavicular ligament, tendinous insertions of supraspinatus, infraspinatus, subscapularis and biceps).



7 Concentrate on ‘the’ pain


‘The’ pain is that pain for which the patient consults

When tests evoke pain, the examiner must make sure that this is the pain that is the patient’s complaint. It is possible that some movements elicit pain in a certain area and that other tests provoke another pain in another region: one of these will be recognized by the patient as the presenting symptom. The examiner should then concentrate on this pain alone.


The situation often occurs because combined lesions are quite common. A patient may come to see the doctor with pain down the arm. If, after the history has been taken, it is not clear whether the pain originates either from the cervical spine or shoulder girdle or from the shoulder itself, the preliminary examination aims to clarify the situation. It may show some discomfort at the base of the neck when cervical movements are tested (especially in middle-aged and elderly people) but if only shoulder movements elicit the pain complained of, then this pain (‘the’ pain) is the primary problem; the other pain (‘a’ pain) is secondary. The arm pain will, of course, be dealt with first and only when this problem is solved is the other problem (if still present) approached.


Difficulties may arise in hypersensitive patients who report every tension they experience and for which they use different words: ‘it hurts, it aches, it pulls, it stretches, …’.



8 The patient’s cooperation is vital


The patient knows the symptoms

The patient’s cooperation is essential, and it is vital that the questions put are understood. Details are sought on what activities have an influence on the symptoms and how symptoms behave over time. Except in psychologically disturbed patients, the more precise the questioning, the easier it is to obtain accurate answers. The patient must realize that, during functional examination, the examiner is looking for tests or movements that elicit symptoms. Most difficulties arise with those who are in constant pain, in that they tend to answer every question positively. It is the task of the examiner to explain carefully that movements that alter the pain are being sought. Not only tests that make the pain worse (a frequent occurrence) but also those that decrease the pain are considered important.




10 Keep the balance between credulity and excessive scepticism


Objectivity is a fair attitude

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).


Although the examiner must be on guard against feigned illness, great care must also be taken to maintain a dispassionate attitude during the clinical encounter. The diagnosis of ‘psychogenic pain’ must not be made too quickly. Only when many inherent unlikelihoods are encountered during the history and functional examination should the examiner be suspicious about the veracity of the patient’s story. Also, the discovery of a series of lesions is self-contradictory, because the development of several problems at the same time is most unlikely.



11 Request technical investigations only when necessary


Looking is not a substitute for thinking

Clinical testing is the first approach in orthopaedic medicine. Technical investigations, although sometimes very valuable, are only asked for in some situations:




image Warning


Incorporated into this system of clinical evaluation are warning signs: certain symptoms or combination of symptoms and signs indicate that something unprecedented is taking place and so alert the examiner to the possible presence of a potentially serious condition. Possible warning signs are, for example, pain in the upper lumbar area, deficit of more than one nerve root in the cervical spine, or a capsular pattern of the hip in children.


The presence of such warning signs will put the examiner on guard and indicate accessory clinical tests, further technical investigations or reference to a neurologist, an internist, a cardiologist or an oncologist.


These warning signs will be discussed further in later chapters.



Clinical evaluation



History


History is of prime importance in reaching a diagnosis. It is so well known as a method of determining symptoms that most examiners fail to realize how much information can be gained from it.


Patients are the best source of information in that they are suffering from the lesion and can best report precisely what is felt. It is then the examiner’s task to translate the subjective symptoms into anatomical and functional conclusions.


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


History taking is a slow business that requires time, patience and concentration; the examiner must do everything possible to gain the maximal detailed information. Vague, general description of the complaints should not be accepted but precise and detailed answers sought.


Most patients, and certainly when they are frank, are able to provide precise answers to the examiner’s questions or can spontaneously give a well-structured, detailed and chronological account. They try to be as helpful as possible and are visibly pleased to talk to an interested physician. However, taking the history becomes more difficult in those who cannot express themselves or give a disjointed story. It is the examiner’s task then to make sure that the right questions are asked in order to get useful answers. The same applies to talkative patients who try to be too helpful by adding all manner of irrelevant details. In these circumstances the examiner should concentrate on the important items only and bring the patient back to the point whenever there is a digression.


Patients with a clinical presentation that may rest in non-organic causes try to escape from precise questioning. They offer a garbled story full of internal contradictions.




Remarks

Questions should be asked in such a way that the account of the symptoms is given in chronological order which enables the examiner to get an idea of the duration and behaviour of the condition present. Knowledge of different dermatomes and of the possible likelihoods will help in interpretation of the evolution of the patient’s symptoms.


Leading questions should be avoided, because they suggest to the patient what answer is expected. The questions should be neutral, so that the patient has to think about what is felt. An honest patient will have no problems in giving exact answers; one who dissembles has the opportunity to make mistakes and display inconsistencies.


Examples of questions that should be recast are as follows:



When there is a relationship between the patient’s symptoms and rest, exertion, certain activities or certain postures, then it is probable that the patient suffers from a lesion of the locomotor system. The main exceptions are angina and intermittent claudication. Questions should therefore be asked about the movements and positions that evoke, increase or influence symptoms, for example:



Some information can be obtained only from the history, and not from any other diagnostic procedure. For example, to ascertain the stage of shoulder arthritis, to find out whether a displaced fragment of cartilage is stable or unstable, to determine whether sciatica is caused by a primary or secondary posterolateral disc protrusion, depends on the answers to some very specific questions. These are not only diagnostically important but also have a prognostic value and can determine correct treatment.


For lesions of the knee or spine, the history is of extreme importance; the examiner must go into great detail and if this is done the diagnosis becomes apparent. For example, a patient may mention that pain started in the centre of the back, soon spreading unilaterally towards the buttock, and later radiating down the lower limb into the lateral border of the foot and the two little toes while at the same time pain in the back and buttock disappeared. After a while pins and needles began to occur in the same toes and additionally they would go numb. The patient has revealed everything: the normal evolution of a protruded fragment of disc at the L5–S1 level, compressing the first sacral nerve root, is immediately apparent.


In some other joints, such as the shoulder, the history matters less but examination will disclose the lesion.



Taking the history



Age, sex, profession, hobbies and sports

Some disorders are confined to certain age groups so that the age of the patient may indicate diagnostic possibilities. For example, a patient of 14 who mentions internal derangement at the knee probably suffers from osteochondritis dissecans. The same story in a patient of 20 suggests a meniscal problem and at 60 years points to a loose body in an arthrotic joint. The same applies to the hip: trouble at the age of 5 is probably due to Perthes’ disease; at 15 it could be the result of a slipped epiphysis; at 30 ankylosing spondylitis is a possibility; and at 50 arthrosis is more likely. A similar age distinction applies in root pain of cervical origin: under the age of 35 it is extremely rare that this is caused by a disc protrusion.


Certain disorders are more typical for men (e.g. primary sciatica and ankylosing spondylitis) and others occur more often in women (e.g. de Quervain’s disease and the first rib, thoracic outlet syndrome).


The profession of the patient may sometimes give an idea about the causative strains that have acted on the affected joint. Also it may – in conjunction with hobbies or sports – have an influence on the decisions to be taken on treatment. Treatment for acute lumbago will be different in an employee who sits most of the day than in a docker who has to do heavy work; a patient with regular attacks of sudden backache will be advised against tennis, a sport full of quick movements.



Initial symptoms

The examiner should get an accurate picture of the moment the symptoms first appeared. The patient should be encouraged to recall that period and questions should proceed from that first instant.


The onset of the symptoms has to be clear. If they came on after an injury, a very detailed description of the accident should be elicited. The events immediately following the accident must be ascertained, in that compensation may be claimed because of inadequate or inappropriate management. The subsequent condition of the joint may not allow complete examination and therefore an idea of the direction of the forces acting on that joint and the position in which the joint was held at the moment of the accident are essential and will give a notion of the possible structures affected. The knee is an important example. In a ‘sprained’ knee the inflammatory reaction that follows the accident is so spectacular (swelling, limitation of movement) that proper functional testing becomes difficult, which means that in the acute phase the examiner has to rely mainly on the history to get an idea of what has happened. If the pain is felt at the medial aspect of the joint and the patient mentions a valgus injury, the medial collateral ligament or the medial meniscus are most likely to have been damaged.


Swelling of a joint after an injury may have come on immediately, in which case blood is the cause, or after a few hours, which is typically the result of a reactive effusion.


When the patient mentions a spontaneous onset, this may be either sudden or gradual. Apart from diagnosis this distinction may have therapeutic consequences. Backache, as the result of disc protrusion, that comes on suddenly is annular and requires manipulation, whereas a gradual onset suggests nuclear displacement, which is treated with traction.


The patient must exactly define the first localization of the symptoms. The area where the pain was first felt very often lies quite close to the site of lesion, referred pain usually coming on later. This does not apply to ‘pins and needles’. They are mostly felt distally in the limb, from wherever along its length the nerve is affected.


Questions are also asked about what influenced the symptoms. The examiner looks for a relationship between activities, movements or posture and the symptoms.



Progression/evolution

The symptoms may be present without interruption from their onset. However, it is also possible that the patient describes a recurrence (see Box 4.2).



Box 4.2   Evolution of symptoms



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The progression of symptoms since their first onset is ascertained. The condition may have continued uninterrupted, in which case details are asked about the development of the severity of the symptoms and of the localization of pain. If the latter has remained unchanged from the beginning, this indicates that the lesion is quite stable and not evolving. When pain has diminished it usually indicates an improvement, although there are conditions (e.g. nerve root atrophy and certain cases of mononeuritis), in which the pain disappears long before the condition has resolved. Pain becomes worse as the condition progresses: in such circumstances it is important to know the length of time for which it has been present. This has diagnostic significance: it is clear that conditions such as metastases have quite a short time course. In contrast, slowly worsening pain is characteristic of some other conditions such as a neurofibroma. When the patient describes intermittent pain, details are sought about the occasions on which pain is felt. Nocturnal pain, for example, suggests an inflammatory condition.


A very important distinction should be made between the following definitions.




Shifting pain

Pain coming on in one place as it leaves another indicates a shifting lesion.


This extremely significant phenomenon is well known in internal medicine: for example, when a renal calculus moves from the kidney down the ureter to the bladder and urethra, the pain experienced will follow the displacement. Pain is felt in the loin first, then in the iliac fossa, later in the groin and finally in the genitals. When the pain leaves one point, it is felt in another instead.


The same happens in soft tissue lesions. A good example is central backache, which becomes unilateral, then later on shifts to the buttock and finally to the lower limb – the backache has become sciatica. This shift can only be explained as follows: a structure lying in the midline and originally compressing the dura mater (backache) has shifted to one side and now compresses the dural sleeve of the nerve root (root pain). To be able to shift, that structure has to lie in a cavity and, because the pain was originally central, this has to be a central cavity. The only structure lying in a central cavity and able to change its position is the intervertebral disc: there is no other possibility (Fig. 4.2).



The same situation is encountered when a loose fragment of cartilage moves within a peripheral joint as, for example, often happens in the knee. Dependent on the position of the loose body in the joint space, the pain can be felt at the inner aspect, anteriorly or posteriorly and on other occasions even at the lateral side. Such moving pain indicates a moving lesion.



Expanding pain

This is synonymous with an expanding lesion – one that grows, for example a tumour. When it appears in another region the pain does not leave the area where it originated. It spreads, even beyond the boundaries of dermatomes. A patient may describe a pain that begins in the centre of the back and then becomes bilateral. It spreads to one buttock, and later to both, also increasing in the back. Later it spreads to one leg and even subsequently to both, while still becoming worse in the back as well as in the lower limbs. Such a course is one of expanding pain, as the lesion becomes more extensive.



image Warning


An expanding pain, in which pain spreads but does not regress at the original site (in the way that a shifting pain does), is indicative of an expanding lesion and is usually the manifestation of a serious condition.


Another course is recurrence. Certain disorders, such as those causing internal derangement or of rheumatoid type, have a recurrent character. Some occur suddenly, others more gradually. If the symptoms occur intermittently, it is important to know whether the patient is or is not free of pain between attacks, because this has both prognostic and therapeutic consequences. Freedom from symptoms for a certain period of time suggests that the same may happen again. In internal derangement, regular recurrence implies that the loose fragment of cartilage or bone is unstable, in which case the maintenance of reduction will be the main concern of the therapist. A patient who is doing heavy work and who gets lumbago every 2 years must be regarded as having a stable lumbar disc which is completely different from a man with a light job who gets lumbago three times a year. In the first case reduction suffices, whereas the second will need other prophylactic measures to maintain the disc in place.


The onset of pain may vary from one attack to another. Backache that starts suddenly on some occasions, but gradually on others, very strongly suggests discal trouble. The localization of the pain may also change from one attack to another: it may be felt on one side of the body or of a joint and on the next occasion on the other side. This shifting pain is very typical of internal derangement, although there are some other conditions that may present the same picture (e.g. alternating buttock pain in sacroiliac arthritis caused by ankylosing spondylitis and alternating headache in migraine).



Actual symptoms

After having built up a complete picture of the patient’s symptoms, information is sought about what is experienced at the time of interview.


Most patients consult the doctor because they have pain but other symptoms may also be described: pins and needles, numbness, limitation of movement, twinges, weakness and vertigo. These are sometimes forgotten by the patient and therefore the examiner must inquire about them. Every symptom must be given due weight and examined in detail.



Pain (Box 4.3)

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.



Box 4.3   Pain




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



Box 4.4   Characteristics of mechanical and inflammatory pain



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The severity of pain may be a determinant of the type of treatment that is chosen. For example, although sciatica without neurological deficit is not immediately an indication for surgery, discectomy may become the treatment of choice when the pain has become unbearable.


Finally, localization has some diagnostic significance. Pain may be felt centrally (on the midline), bilaterally or unilaterally. Central and bilateral pain usually point towards a lesion lying in the midline. A bilateral lesion is another possibility, but this is much less frequent. It should be realized, however, that central symptoms do not arise from a unilateral structure. And, although some structures lie very close to the midline (facet joints, costovertebral joints, erector spinae muscles), they are still unilateral and can only give rise to symptoms felt unilaterally. Unilateral pain originates in a unilateral structure or, when dealing with the spine, in a central structure that moved to one side and compresses nerve tissue unilaterally (e.g. a disc).


When the lesion is in the locomotor system, there should still be a relationship between symptoms and rest, exertion, activities, movements or posture. When coughing, sneezing or breathing hurts in an area other than in the chest, the dura mater could very well be responsible. Dural pain can be felt in the trunk far beyond the relevant dermatome.


Of special interest to the examiner are ‘twinges’: sudden short bouts of pain, which last only one second and are often associated with momentary functional incapacity. The occurrence of painful twinges may be the result of one of the following:







Paraesthesia

Non-painful sensory disturbances, paraesthesia, are strongly indicative of a condition that originates in a nerve (Box 4.5). They may result from an intrinsic lesion (primary neuritis or secondary polyneuropathy) or from an extrinsic cause (compression). They may also vary in quality and in intensity. In orthopaedic medicine the variation lies between numbness and real pins and needles. It is very often described as ‘tingling’.



Box 4.5   Paraesthesia



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The moment the patient mentions the presence of pins and needles, the examiner should go into detail and ask the following questions:



In entrapment neuropathies, knowledge of what brings the pins and needles on will show whether a compression phenomenon or the release phenomenon is acting (see pp. 26–27). For example, pressure on a small distal nerve gives rise to paraesthesia and analgesia in the cutaneous area of that nerve during the time of compression (e.g. meralgia paraesthetica). However, when a nerve trunk or nerve plexus becomes compressed, the paraesthesia are felt in a larger area, corresponding with the territory of that nerve and occur only after the compression has ceased (e.g. thoracic outlet syndrome). Nerve root compression results in segmental pain and paraesthesia felt within the corresponding dermatome (e.g. sciatica). Multisegmental bilateral paraesthesia indicates a lesion in the spinal cord.


It must be remembered that the site of compression always lies proximal to the proximal extent of the paraesthesia. They are usually felt in the distal part of the extremities. The more accurately the patient describes the area, the more distal the compression lies.


A paraesthesia-like feeling, especially vague tingling, may be experienced in some circulatory conditions, such as Raynaud’s syndrome, but this is usually accompanied by changing of the colour of the skin in the distal part of the limb.



Functional disability

Often, functional disability is complained of. It comprises limitation of movement, internal derangement, weakness and incoordination and instability.







Further questions

Other questions, if appropriate, are asked about similar symptoms, past or present, in other parts of the body, especially other joints (see Box 4.6). If the answer is positive, conditions such as rheumatoid arthritis, spondylitic arthritis, Reiter’s disease and gout should be suspected and further examination is required.



Box 4.6   Inflammatory disorders



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Disorders of rheumatoid type (rheumatoid arthritis, lupus erythematosus, systemic sclerosis, dermatomyositis) are characterized by the symmetrical joint involvement, usually of the small joints (e.g. metacarpophalangeal joints). Arthritis of reactive type (e.g. peripheral joint involvement in ankylosing spondylitis, ulcerative colitis, Reiter’s disease, sarcoidosis or psoriatic arthritis) affects a few large joints (e.g. shoulder, hip or knee) asymmetrically (Fig. 4.3).



Questions about the general state of health are asked to find out whether there is the possibility of a serious disorder (e.g. cancer).


The patient should also reveal present medication, and a doctor or therapist who considers manipulation should make sure that the patient is not taking anticoagulants: these are a contraindication because of the danger of haemorrhage.


Inquiries should also be made about previous treatments, which may give some idea of the chance of success of the proposed therapy. Previous surgery, its timing and indication are noted – it is not impossible that the present condition is the outcome of previous intervention (Box 4.7).



Box 4.7   Summary of history




1. Age, sex, profession, hobbies, sports


2. Initial symptoms:



3. Progression/evolution:



4. Actual symptoms:

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Jun 5, 2016 | Posted by in ORTHOPEDIC | Comments Off on Clinical diagnosis of soft tissue lesions
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