Is It a Muscle or Joint Problem? Is It Local or Referred?
Editor’s Note: This column contains information deriving from Dr. Chaitow’s research for thethird edition of Palpation and Assessment Skills.
In Physical Therapy of the Cervical and Thoracic Spine, Janda has pointed out that since clinical evidence abounds that joint mobilization (thrust or gentle) influences the muscles in anatomic or functional relationships with a joint, it may well be that normalization of excessive muscle tone is what provides the benefit.3 By implication, normalization of muscle tone by other means (such as Muscle Energy Technique) would produce a beneficial outcome and joint normalization.
Since reduction in muscle spasm/contraction commonly results in a reduction in joint pain, the answer to many such problems would seem to lie in appropriate soft-tissue attention.
Can you test to see whether a patient’s problem is primarily joint or muscle? What clues can guide us to differentiate whether a patient’s pain derives from a soft-tissue or a joint problem? Kaltenborn suggested that we ask the following questions:4
- Does passive stretching (traction) of the painful area increase the level of pain? If so, it is probably of soft-tissue origin (extra-articular).
- Does compression of the painful area increase the pain? If so, it is probably of joint origin (intra-articular), involving tissues belonging to that joint.
- If active movement (controlled by the patient) in one direction produces pain (and/or is restricted), but passive movement (controlled by the therapist) in the opposite direction, also produces pain (and/or is restricted), contractile tissues (muscle, ligament, etc.) are involved. This can be confirmed by resisted tests, described below.
- If active and passive movement in the same direction produce pain (and/or restriction), joint dysfunction is likely a cause. This can be confirmed by use of traction and compression (and gliding) tests of the joint.
Resisted tests can be used to assess both strength and painful responses to muscle contraction, either from the muscle or its tendinous attachment. This involves producing a strong contraction of the suspected muscle, while the joint is kept immobile, starting somewhere near the midrange position. No joint motion should be allowed to occur. This is done following Test 3 above, to confirm a soft tissue dysfunction rather than a joint involvement.
Before performing a resisted test it is wise to perform a compression test (described later) to clear any suspicion of joint involvement. We should remember that in many instances, soft tissue dysfunction will accompany (precede, or follow on from) joint dysfunction. There are few joint conditions, acute or chronic, without some soft tissue involvement. The tests described above will give a strong indication as to whether the major involvement in such a situation is of soft or osseous structures.
An example of a joint assessment involving compression would be that described by Blower and Griffin for sacroiliac dysfunction.1 This suggests that if pain is produced in the sacrum and buttocks when pressure is applied over the lower half of the sacrum or the anterior superior iliac spines of a supine patient, the problem involves sacroiliac joint dysfunction. Soft-tissue dysfunction would not produce painful responses with this type of compression test.
But where does muscle pain come from? A Norwegian study involving more than 3,000 people showed that localized musculoskeletal pain is relatively rare and usually coexists with pain in other parts of the body.5 Knowledge of the patterns of distribution of trigger-point pain symptoms allows for a swift focusing on suitable sites in which to search for an offending trigger (if the pain is indeed coming from a myofascial trigger point). Alternatively, the discomfort could be a radicular symptom deriving from the spine. The functional limitations caused by trigger points include muscle weakness, poor coordination of movement, fatigue with activity, decreased work tolerance, lack of endurance and joint stiffness, as well as limitations in active and passive range of motion.2
Mense, et al. give clear guidelines as to what the practitioner needs to be aware of when seeking the source of muscular pain: “Because muscle pain and tenderness can be referred from trigger points, articular dysfunctions, and enthesitis [inflammation associated with musculotendinous junctions], the examiner must examine these sites for evidence of a condition that would cause referred muscle pain and tenderness.”6 They maintain that “local pain and tenderness in muscle is commonly caused by trigger points,” but suggest that it is necessary to separate such local pain from other possible sources. For example, in the case of joints, particularly the capsules, zygapophyseal (facet) joints: “The muscles crossing involved [blocked] joints are…likely to develop trigger points producing secondary muscle-induced pain because of the joint problem.”
Thus, ligaments and fascia must also be considered as sources of referred pain. Hopefully the advice of some of the experts I’ve quoted will be helpful.
- Blower P, Griffin A. Clinical sacroiliac tests in ankylosing spondylitis and other causes of low back pain; 2 studies. Ann Rheumat Dis 1984;43:192-5.
- Dommerholt J, Issa T. Differential diagnosis of fibromyalgia. In: Chaitow L, Fibromyalgia Syndrome: A Practitioner’s Guide To Treatment, 3rd Ed. Edinburgh: Churchill Livingstone, 2009.
- Janda V. In: Grant R, Physical Therapy of the Cervical and Thoracic Spine. New York: Churchill Livingstone, 1988.
- Kaltenborn F. Manual Mobilization of the Extremity Joints. Oslo: Olaf Novlis Bokhandel, 1980.
- Kamaleri Y, Natvig B, Ihlebaek CM, et al. Number of pain sites is associated with demographic, lifestyle, and health-related factors in the general population. Eur J Pain2008;12(6):742-8.
- Mense S, Simons D, Russell IJ. Muscle Pain. Philadelphia: Williams and Wilkins, 2001.