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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.

Basic Background

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 textbook.3

In the 1950s Hackett also described a similar system and series of treatment techniques, which are currently used in updated form.4

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 today.

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 end-feel.

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.

Referred Phenomena

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 listed above.

Tensegrity

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 pain.

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.

Treatment

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”).

Proliferative Therapy

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 fracture.

The elegance of this process is that the body “decides” which ligaments to strengthen depending upon the physical needs in each individual.

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.

Conclusions

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.

Correspondence:

Richard I. Gracer, MD
895 Moraga Road, #15
Lafayette, California 94549 USA
510-283 6590
Fax 510-283-2009
Email: RGRACER@IX.NETCOM.COM

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

References

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; fax 253-529-3104.

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 2: lower.

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.

Bio

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.



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