Overview of Orthopedic Medicine
by Richard I. Gracer, MD
reprinted from TLfDP, April, 1997
Orthopedic Medicine is the nonsurgical evaluation and
treatment of the moving parts of the body. It is a “low-tech,” hands-on
approach for diagnosing and treating musculoskeletal problems. Although
many of the treatments used by orthopedic physicians require medical
or osteopathic licensure, the diagnostic schema and many of the basic
treatment modalities are practical, effective, and easily integrated
into the practices of many other alternative therapists. In fact, many
of the treatments consist of deep friction massage, for which many manual
and physical therapists are trained and with which they are already
familiar. This overview will outline in highly compressed format the
basic tenets of the discipline and describe the major treatments used
by orthopedic physicians.
In later articles I will outline specific diagnostic
methods and treatments for specific problems. Before this is possible,
it is important that the basic thought processes, vocabulary, and strategies
of orthopedic medicine be explained.
The first physician to codify and extensively write
about modern Orthopedic Medicine was James Cyriax, MD (1904-1985), a
British orthopedist, who starting in the late 1930's, developed a method
of diagnosis and treatment that was based on logical, reproducible elements.
He devoted most of his life to research, educating others. He wrote
several textbooks that were, and for many, still are the “Bible” of
orthopedic medicine. He recognized, described, and codified the concepts
of selective tension and referred pain. He was one of the first to recognize
the intervertebral disc as an important cause of spinal and limb pain.
Others have written updated texts on his work.2
Cyriax believed that the disc was the cause of almost
all cervical, thoracic, and lumbar pain and that the spinal ligaments
and muscles, including the facets and sacroiliac joints, were uncommon
pain generators. He did not recognize the importance of spinal facet
and sacroiliac subluxations and actually developed a rationale for disproving
their importance. He perfected many specific manipulation techniques
with specific indications and contraindications for conditions that
he considered caused by disc lesions, which caused impingements of the
dura, nerve root sleeves, or the roots themselves. They are efficacious
and safe. We now believe that they affect other structures, as well
as disc lesions.
Since his death there has been much change in orthopedic
medical teaching. We stress the importance of ligamentous injuries and
joint dysfunctions. Many of the terms and concepts that I will present
(for example, tensegrity) are not from the original Cyriax schema.
Of all the newer concepts, the importance of the ligaments
in musculoskeletal function and dysfunction stands out as the most important.
We now know that chronic ligamentous strains, scarring, and laxity are
the basis for much of the chronic pain problems that we see. Milne Ongley,
MD studied with Cyriax and eventually moved to New Zealand. He developed
a methodology for the evaluation and treatment of many of these problems.
These were studied and then amplified by Thomas Dorman, MD, in his important
In the 1950s Hackett also described a similar system
and series of treatment techniques, which are currently used in updated
Janet Travell and others have written extensively on
myofascial pain and muscular trigger point treatment.5 These
were considered secondary phenomena by Cyriax and were not treated directly.
We now know that they are very important, and have integrated this body
of work into the comprehensive orthopedic medical model that we use
The effects of the sympathetic nervous system on musculoskeletal
function have been described in the osteopathic and chiropractic literature.
Regulation of this important complex depends upon spinal function as
well as activity in the autonomic ganglia. Neural therapy as described
by Huneke and taught in this country by Deitrich Klinghardt, M.D. has
become an important part of orthopedic medical teaching.
Many progressive orthopedic physicians now realize the
importance of nutrition and other complementary techniques in treating
musculoskeletal problems. Nutritional support, as well as the diagnosis
and treatment of underlying psycho-immuno-neuro-endocrinologic disorders
makes our treatments much more effective.
What follows is a brief description of the basic tenets
and methodologies of orthopedic medicine.
Selective Tension, Inert and Contractile Structures,
Joint End Feel, Capsular Pattern
Normal structures are painless when stretched or compressed;
abnormal ones are painful, or in the case of muscles, may be weak and/or
painful. By selectively stressing the various structures of a body part
in a systematic and reproducible manner, the problem is ascertained:
the pathology is in the structure that is painful.
Musculoskeletal structures are divided into inert and
contractile structures. Testing the inert structures, such as the joint
capsules and ligaments, requires a passive stretch of the joint tested.
In addition, if there is a decreased range of motion, the pattern of
movement loss and the “end-feel” of the joint range is evaluated to
determine if the pattern is “capsular or non-capsular.”
The capsular pattern occurs when there is inflammation,
as in rheumatoid, septic, gouty, or even traumatic arthritis or capsulitis,
or with osteoarthrosis. It is specific for each joint. For example,
in the shoulder, there is a decrease in lateral rotation with proportionally
less loss of elevation and even less of medial rotation. In addition,
the end feel of the lateral rotation is harder than the usual leathery
The non-capsular pattern is present when extra-articular
factors cause the decreased range. Causes include bursitis, loose body
in the joint, or joint subluxation.
Joint end-feel depends upon the structure limiting joint
range. The elbow joint has a hard end feel because the olecranon hits
the humerus, while flexion is soft, being limited by the biceps and
forearm musculature. Fingers extend only as far as their joint capsules
permit, giving them a leathery end-feel. In pathologic conditions these
end-feels change, as does the joint range itself.
The contractile structures include the muscle body,
musculotendinous junction, the tendon body, and the tenoperiosteal junction.
Lesions of these structures include muscle tears and tendonitis. Testing
requires that the joint be in neutral position and that the various
components be stressed by resisted testing of specific motions. Myofascial
trigger points are different structurally and functionally and are not
included in this classification.
Combining the results of these observations allows the
practitioner to make a tissue specific diagnosis, often narrowing the
problem to a small aspect of a structure. Treatment can then be directed
to a specific tissue site.
Pain is often experienced in a different place from
its source. The traditional medical example is cardiac pain, felt in
the arm. We call this referred pain. Sophisticated practitioners know
that pain is not the only phenomena that is referred. Tender points
in both muscles and ligaments (including fascial sheets), active and
latent trigger points, and even skin tenderness are common. A numb-like
sensation called “nulliness” is often referred from both ligamentous
and muscular lesions, as well as nervous structures.
The patterns of reference can be dermatomal, based on
the spinal roots; sclerotomal, referred from ligamentous structures;
myotomal, resulting from irritation within a muscle, including trigger
points; or from the dura, which may refer bilaterally and remotely.
Any of these reference types can cause any of the reference phenomena
Tensegrity, tension and integrity, is a newer orthopedic
medical concept, which was first coined by the famous architect Buckminster
Fuller in the 1920's. A suspension bridge is held up by flexible cables,
acting upon a rigid set of towers; geodesic domes stay up because of
tension in the cables that support the walls. In the body, bones act
as compressive elements, while the ligaments and fascia are the cables
(tension elements). If one of the cables in a bridge is cut, the others
must make up the difference. In addition, the direction of stress on
them changes. Therefore, if there is an injury or a shift in joint position,
other, often remote, structures are affected, frequently causing significant
and puzzling symptoms. Practically, the areas most affected are the
ligamentous attachments, where the most force is applied.
Role of Ligaments
The ligaments and fascial structures act as the major
tension elements of the body's tensegrity structure. They also store
potential energy and allow us to retrieve the work done, for example,
in rotating the spine from one side to the other while walking. When
irritated or injured they can cause local pain as well as remote phenomena,
such as myofascial trigger points (active and latent), nulliness, and
Lax or strained ligaments become painful more quickly
and cause more intense stimulation than normal ligaments that are stretched
through prolonged activities or posture. Each ligament has a specific
sclerotomal referral pattern. Ligaments become most symptomatic when
they are stressed in one position, such as in sitting or standing. Movement,
as in walking, constantly alters the forces and usually decreases or
relieves the referred sensation. Pain that results from prolonged position
is called “posain” (positional pain). Nulliness, or a combination of
both may also result. The patterns may include separate, unconnected
areas. In a given individual only one area or several may be involved.
The practitioner must know these patterns to make the correct diagnosis.
Weak or lax ligaments allow pathologic forces to act
upon other seemingly normal structures, altering body mechanics, and
ultimately producing even more confusing manifestations when these structures
refer symptoms themselves. Effective, long lasting treatment must be
directed to the site of the primary problem. This often confusing clinical
picture must be sorted out layer by layer, until the tissue specific
lesion is found and then treated.
The concept of tissue specific treatment requires that
a specific diagnosis be made first. It makes no sense to apply
the correct treatment to the wrong lesion, or the wrong treatment to
the correct lesion.
Ligament injuries and strains can often be treated by
small, selectively placed steroid and local anesthetic injections. Recent
studies indicate that electro-acupuncture at certain of these sites
is also effective. Non-physicians can often treat these with deep friction
massage, which specifically allows the therapist to break down scar
tissue and increase mobility. These techniques are lesion specific and
are not general massage to the area.
Joint restrictions and small disc protrusions can be
manipulated, using any one of several methods. Myofascial trigger points
are treated by direct, local anesthetic injection or by cold application
to overlying skin, followed by muscle stretching (Travell's “spray and
stretch” and now the newer “ice and stretch”).
If the ligaments are lax and weak, however, no amount
of exercise, massage, or medication can strengthen them. It is as if
a hinge of a door is loose. The problem may be with the door's opposite
edge hitting the door frame. If one lifts the door back into place,
it may be fine temporarily (for example, by manipulation), but the next
time it opens, the same problem will recur. What we need to do is fix
the hinge! Ligamentous laxity is a common perpetuating factor that can
only be treated if first, the diagnosis is made, and secondly, the correct
treatment is applied.
Mildly irritating solutions injected into lax ligaments
cause a fibroblastic reaction that, under the correct conditions, results
in the creation of new, stronger, flexible ligament tissue. We call
this proliferative therapy. To continue the analogy of the hinge, this
is the way to tighten it up. When there is better support, joints function
more efficiently, reducing the strain on other supporting structures,
thereby reducing the CNS input that leads to referred phenomena. There
have been two double-blind controlled studies of proliferative therapy
in treatment of chronic low back pain, which show its validity.6,7
In addition, human and animal studies show the morphologic and structural
effects of this treatment.8-10
After injection of a proliferant, an inflammation is
produced. This results in early phase granulocyte activity and release
of inflammatory cellular contents. This lasts about three days. Over
the next 10 days or so macrophages predominate. They release chemotactic
factors which attract fibroblasts and act as growth factors. Over the
next several days collagen starts to form, giving strength to the tissue.
At first this is a soupy mixture without structure. Soon, however, a
matrix forms, on which collagen is deposited. Macrophages are still
active and they uptake some of this new material. Over time the collagen
predominates and there is a gradual dehydration of the matrix with more
orderly collagen fibers. This eventually leads to new, stronger connective
tissue. The whole process may take several months. During this time
period external forces affect the eventual outcome of the final tissue
fiber both as to length and strength as well as to orientation and flexibility.
This works much in the same way as the bone remodeling that occurs after
The elegance of this process is that the body “decides”
which ligaments to strengthen depending upon the physical needs in each
Another effect of proliferative therapy is that the
nerve endings that often perpetuate pain and sympathetic overstimulation
are markedly decreased by the inflammatory process. The pain decreases
because of decreased painful afferent input, as well as because of improved
body mechanics and stability.
Orthopedic medicine offers a comprehensive way to explain
and treat musculoskeletal problems in a reproducible, logical way. By
treating the primary as well as the secondary causes of pain, and realizing
that the body will cure itself if allowed, problems can often be cured,
instead of palliated.
Non-physician practitioners can successfully use the
diagnostic principles and many of the treatments described. This knowledge
also allows for proper referral of those patients who need specific
Orthopedic Medical intervention to physicians, as well as referral by
physicians to well-trained manual therapists for the many modalities
in which they specialize.
Richard I. Gracer, MD
895 Moraga Road, #15
Lafayette, California 94549 USA
If you want more information about orthopedic medicine
or want a referral in your area to an orthopedic physician, call the
American Association of Orthopedic Medicine, 435 N. Michigan Ave., Suite
1717, Chicago, Illinois 60611-4067, Tel. 800-992-2063
1. Cyriax J. Illustrated Manual of Orthopedic Medicine,
Second Edition. London: Butterworth. This is the latest and most easily
read and used “pure” Cyriax-style textbook, but there are many older
editions of his two volume works that are more complete.
2. Ombregt, Bisschop, ter Veer, Van de Velde. A System
of Orthopedic Medicine. London: Saunders; 1995.
3. Dorman T. Diagnosis and Injection Techniques in
Orthopedic Medicine. Baltimore: Williams and Wilkins, out of print
– available from author at Paracelsus Clinic, 2505 S. 320th St., Ste.
#100, Federal Way, Washington 98003; email: TD@Paracelsusclinic.com;
4. Hackett G. Ligament and Tendon Relaxation Treated
by Prolotherapy. 3rd Ed. Springfield: Charles Thomas; 1958. An updated
version of this book is available through the American Association of
Orthopedic Medicine, 435 N. Michigan Ave., Suite 1717, Chicago, Illinois
60611-4067, Tel 800-992-8557.
5. Travell J, Simon. Myofascial Pain and Dysfunction.
Baltimore: Williams and Wilkins; 1983, volume 1: upper body, volume
6. Ongley M, Klein R, Dorman T, Eek B, Hubert L. A New
Approach to the Treatment of Chronic Low Back Pain. Lancet. 1987;2:143-146.
7. Klein R, Eek B, DeLong B, Mooney V. A Randomized
Double-Blind Trial of Dextrose-Glycerine-Phenol Injections for Chronic,
Low Back Pain. J Spinal Disord. 1993;6:23-33.
8. Liu Y, Tipton C, Matthes R, Bedford T, Maynard J,
Walmer H. An in situ study of the influence of a sclerosing solution
in rabbit medial collateral ligaments and its junction strength. Connect
Tissue Res. 1983; 11 :95-102.
9. Maynard J, Pedrini V, Pedrini-Mille A, Romanus B,
Ohlerking F. Morphological and biochemical effects of sodium morrhuate
on tendons. Journal of Orthopedic Research. 1985;3:236-248.
10. Klein R, Dorman T, Johnson C. Proliferant injections
for low back pain: histologic changes of injected ligaments and objective
measurements of lumbar spinal mobility before and after treatment. Journal
of Neurologic and Orthopedic Medicine and Surgery. 1989;10:123 126.
Richard I. Gracer, M.D. has been practicing orthopedic
medicine since 1979. He is board certified in Family Practice and Chronic
Pain Management. He is an active teacher, and currently is an Assistant
Clinical Professor of Community and Family Medicine at UC San Francisco
School of Medicine. He has taught orthopedic medical topics at many
seminars and courses both in North America and Europe. His current interest
is in the nutritional aspects of musculoskeletal disorders.