ABC of Common Soft Tissue Disorders

Francis Morris, Jim Wardrope, Paul Hattam, Francis Morris, Jim Wardrope, Paul Hattam

• Publisher: Wiley-Blackwell
• Year: 2016
• ISBN:
  9781118799772
• Edition: 1
• Topic: Medicine
• Subtopic: Family Medicine & General Practice

Soft tissue problems are very common, with one in four people at any one time suffering with a musculoskeletal disorder. ABC of Soft Tissue Disorders is a practical, fully illustrated guide to their assessment and treatment. Structured by body part, each chapter provides guidance on assessment, treatment and management, and covers common conditions such as sprains and strains, tendinopathy, ligament injuries, and sciatica. With particular focus on shoulders, back and knee problems (reflecting the frequency and complexity of problems in these parts of the body), it provides guidance on the essential history and examination required to reach an accurate diagnosis. Written by an expert author team, ABC of Soft Tissue Disorders is important reading for all general practitioners, nurse practitioners, junior doctors and medical students working in a range of settings, including emergency, minor injury departments, as well as in orthopaedics and rheumatology.

Chapter 1
Introduction to Musculoskeletal Medicine

Jim Wardrope

Northern General Hospital, Sheffield, UK

Overview

• This chapter will review the structure of the musculoskeletal system and how the ‘human machine’ works.
• How the musculoskeletal system is modified by age and illness.
• A system is outlined for history, examination, investigations and note taking.
• The principles of management of injury to muscles, tendons, ligaments and nerves are examined.
• How best to restore function is discussed.

Introduction

Musculoskeletal conditions are one of the commonest presentations in general practice. One in four people at any one time will have a musculoskeletal problem. Such conditions are responsible for one in seven primary care consultations. Almost 50% of the population will have back pain in 1 year. The cost to society is huge.

These conditions are often regarded by doctors as ‘minor’ problems, but to patients they are often painful and disabling. Very occasionally apparently minor problems can be life threatening.

Structure and function: the body as a machine

The skeleton

Any machine needs a rigid framework. The main functions of this framework are to overcome the effects of gravity, to protect vital parts and to provide a network of levers to enable the effective application of force.

A crane shows these functions as well (Figure 1.1). It has a network of steel girders to give it height (overcome gravity) and a very long arm to provide a means of reaching and for the effective application of force. It has specialized areas for protection, for example the driver's cab (skull). The human skeleton is much more complex but the principles are the same. The ‘girders’ of the skeleton are the bones, designed by evolution to be strong, to have some elasticity but still to be light.

Figure 1.1 A crane is a very simple machine but has many elements in common with the human body. The human body is subject to the laws of mechanics like any other machine.

Joints

The crane has a few simple joints that allow movement, flexibility and a degree of shock absorption. At the base there is a circular joint to allow 360° motility in one plane. It comprises load-bearing surfaces, lubrication and constraining structures that hold the joint in place. The nearest human equivalent would be a ball-and-socket joint such as the shoulder. There are also hinge-type joints allowing motion in one plane (e.g. the elbow).

Human joints are much more complex and of greater variety (synovial, symphyseal and syndesmotic). These joints all have articular surfaces, and ligaments that connect the bones together, and also contain stretch receptors and associated muscles. They may also have specialized structures such as intra-articular cartilages that may assist in shock absorption or in joint stability.

Muscles and tendons

The powerhouse needs a fuel supply, oxygen, a method of converting the energy in the fuel to mechanical energy and a method of transmission of that energy to the skeleton. Skeletal muscle uses sugar as its main energy source backed up by glycogen to meet the peak action of the ‘pistons’ of the actin and myosin filaments that cause contraction (and relaxation).

The muscle exerts its force through tendons. Tendons are immensely strong yet also have elastic stretch. This stops them breaking at times of sudden loading (see Figure 1.2).

Figure 1.2 The human ‘combustion engine’. (a) Fuel in a car engine is combusted with oxygen to create a force that moves the piston and turns the crankshaft. (b) Glucose in muscle cells is respired to create the ATP that drives muscle contraction.

Reciprocal groups of muscles

An important concept is that with many active muscle movements there are opposing muscles which contract to allow a stable platform for the active muscle. Using the crane analogy, the large counterbalance weight is essential to prevent the crane toppling over when lifting a load (see Figure 1.1). A good example of this is tennis elbow. There is pain at the extensor origin when gripping. The main active muscles are the finger flexors; however, the extensors of the wrist have to contract to stabilize the wrist. Without this reciprocal action the wrist would flex and grip strength would be lost. This powerful reciprocal contraction causes stress at the origin of the wrist extensors at the lateral epicondyle (see Figure 1.3).

Figure 1.3 Reciprocal muscle contraction. In gripping the finger flexor muscles contact strongly. If the wrist extensors do not ‘brace’ the wrist then the wrist would also flex and grip would be very weak (a). Strong contraction of the wrist extensors allows the finger flexors to exert maximum power (b).

Nerves

All machines need a control system. The brain, the spinal cord and the motor and sensory nerves provide that control system.

Much of the control of movement is carried on at an unconscious level. The simplest example of unconscious control is the spinal stretch reflex. If a muscle is stretched, then receptors in the muscle and tendon are activated, and signals are passed up the sensory nerves to the spinal cord and hence to the motor neurones that fire to cause the reflex contraction. This reflex arc is subject to many other influences, both from within the spinal cord and descending from the cerebellum and the cerebral cortex and associated nuclei. However, it is a key concept in understandi...

Table of contents

• Cover
• ABC Series
• Title Page
• Copyright
• Table of Contents
• List of Contributors
• Chapter 1: Introduction to Musculoskeletal Medicine
• Chapter 2: Soft Tissue Problems of the Neck
• Chapter 3: Back Pain
• Chapter 4: Shoulder: Sub-acromial Pathology
• Chapter 5: Shoulder: The Articular Structures
• Chapter 6: Elbow
• Chapter 7: Soft Tissue Disorders at the Wrist
• Chapter 8: Soft Tissue Injuries of the Hand
• Chapter 9: Common Soft Tissue Disorders of the Hip
• Chapter 10: Soft Tissue Knee Injuries
• Chapter 11: Non-traumatic Knee Problems
• Chapter 12: Calf and Shin Problems
• Chapter 13: Soft Tissue Injuries of the Ankle
• Chapter 14: The Foot
• Index
• End User License Agreement