Laurie's Blogs.

I was listening to a podcast-video the other day, and it was a Question & Answer session for physical therapists.  So the question came in:  “How do you differentiate between muscle, soft tissue, or joint capsule in the case of loss of motion or stiffness?”  The panel proceeded to answer the question and came up with a number of pieces of advice.

What I found fascinating was that it required the panelists (and my own brain), to slow down and describe the actual thought processing required to differentiate between these things.  It made me realize, yet again, how much of the physio thought processing that I take for granted.  Years ago, I created a document called “Thinking Like a Physio”, that was intended to help veterinarians learn to think differently when approaching a case.  (i.e. What are the parts of the clinical exam that will tell you MORE than what the x-ray, MRI, CT, or US tells you!?  OR, tell you when you need to do an X-ray, MRI, CT, or US etc.)  

I’ve also heard it said, “Physical Therapists can’t diagnose.”  Well that’s BS as well.  Whether or not we can legally call it a ‘diagnosis’ is a different question, but can we come up with a CLINICAL DIAGNOSIS… Hell yes!  Better than most other practitioner groups out there – here’s some human paper that describe just that:  

1. https://www.ncbi.nlm.nih.gov/pubmed/19239599

2. https://www.ncbi.nlm.nih.gov/pubmed/17576177

3. https://www.ncbi.nlm.nih.gov/pubmed/3054944

4. https://www.ncbi.nlm.nih.gov/pubmed/15963232

Anyways, I’m already a bit off topic, let’s dive into the thought processing and some canine examples.  

So, when confronted with an area of reduced motion, I jump into joint glides first.  (So did most of the panelists on the podcast).  I would start with mid-range glides (i.e. joint play).  Is there a stiffness in mid-range?  Muscles and tendons don’t do that.  Think of your shoulder joint… and older arthritic shoulder joint.  It will be stiff before getting to end ranges when there is arthritis and the joint capsule has tightened.  

Next, you might look into ROM with an awareness of what muscles you are concurrently stretching.  For example, shoulder flexion also stretches the supraspinatus tendon, and somewhat the biceps tendon.  If you start a biceps tendon stretch with elbow extension before adding in shoulder flexion, you thereby look specifically at biceps tendon without implicating supraspinatus or the glenohumeral joint.  However, you can move into full glenohumeral extension without putting Teres Major, Latissiumus Dorsi, Deep Pectorals, or Long Head of Triceps on stretch if you block scapulothoracic motion.  

With these things in mind you also want to have assessed other joints or the opposite side to get an understanding of global joint laxity or stiffness.  How does this joint compare?  Some patients will be hypermobile everywhere and others may be stiff everywhere.  This must be factored in.

If you suspect muscle / tendon to be at fault of if the restricted or painful motion can indicate either joint or a soft tissue structure, then you can palpate the muscle, tendon, ligament to determine if it is painful.

Can you compare Active Range of Motion (AROM) to Passive Range of Motion (PROM)?  This is obviously easier to do in a human than a dog, but there are likely some tests you can do that look at AROM.  Can the dog sit and lie down square?  Those both require full hip, stifle, and tarsus flexion.  The canine shoulder doesn’t lend itself to much in the way of testing full AROM.  But I include this thought process as a general discussion point.  AROM can involve a myriad of compensations.  A patient can learn how to actively avoid end ranges of the joint by allowing other joints to move more, take on a slight variation in rotational positioning, or by allowing certain muscles or structures to stretch more in order to complete the task.  (i.e. think of the dog with dysplastic hips.  He/she may compensate with excessive tarsus or stifle extension at end stage stance phase, or circumduct the hip or externally rotate at the hip, or have more pelvis / flank side bending that accompanies hip extension at the walk.)  So, a reduction in PROM is most likely a joint issue.

Then of course, is our ‘pièce de résistance’, End Feels!  The end feel of a motion is one of the key factors in deciding if the problem is capsular (ligaments or joint capsule), soft tissue apposition (muscle or fat impeding further motion), springy (like a meniscal tear), spasm (which tends to indicate a more acute injury), elastic (tendon stretching), boney (think elbow extension here), empty (pain… without an endfeel, and needs further diagnostics), or facilitation (i.e. like when you test for shoulder abduction in a chronic medial shoulder hypermobility case, and you feel resistance to even go into abduction.)  End feels tell you so much about the joint you are testing.

With all of this in mind, it is likely that you can create a clinical diagnosis with which to guide your treatment or the need for a referral for a surgical consult or for further diagnostics.  

Happy clinical diagnosing out there this week!

Cheers,  Laurie