A System of Orthopaedic Medicine

A System of Orthopaedic Medicine april 1995



This book is based entirely on the Cyriax approach to orthopaedic medicine. James Cyriax (1904-1985), "the father of Orthopaedic Medicine", devoted his whole life to developing a logical system of clinical examination designed to elicit accurate diagnoses of locomotor disorders. His system is founded on a few elementary theories: Referred Pain and Selective Tension - an injured structure hurts when tension is put on its fibres. A detailed clinical examination using these simple principles outlines clinical patterns that are interpreted on the basis of the known facts of applied anatomy and physiology. Logical conclusions can then be drawn regarding diagnosis, treatment and spontaneous recovery.
The authors of this book were trained by Dr. Cyriax and subsequently taught with him until his death in 1985. Ever since, they continued his work, and as far as possible improved it. The fact that they are all practitioners, using the system in their daily clinical work has helped to add considerable complementary clinical experience.

Orthopaedic Medicine has traditionally been a grossly neglected section of medical education despite the large number of patients, suffering from non-surgical orthopaedic conditions. Any family practitioner will confirm that between a fifth and a quarter of his work consists of patients complaining of pain in the musculoskeletal system. This combination of inadequate education and a high incidence of leads to a large number of patients for whom there is no clear diagnosis nor proper treatment. Chronicity, neurosis and compensation claims are then, in many cases, inevitable consequences.

In recent years another trend has had a major impact on orthopaedic medicine. Outstanding advances, such as computed axial tomography (CAT), magnetic resonance imaging (MRI), arthroscopy and echography have undoubtedly enhanced the clinician's ability to see very detailed anatomical images and structures. However, these procedures are not unmixed blessings. Too often they are employed unquestioningly before a good clinical diagnosis has been established and may contribute needlessly to the escalating costs of health care. More important, the 'lesions' these investigations reveal are often not the real cause of the problem and may seriously mislead the examiner resulting in either inappropriate or potentially harmful treatment for the patient. Technology has become in many cases a substitute for clinical skills and he ability to diagnose and think remains poor.

An accurate clinical diagnosis is the first and most important obligation for every doctor and therapist. Since these skills are not formally taught , the main purpose of this book is to provide a systematic approach to clinical examination which can lead to accurate diagnosis. The method described is logical and consists of assessing in turn the function of each moving tissue, the positive and negative responses forming a pattern. The system relies entirely on basic clinical skills and requires none of the apparatus found only in hospitals. For this reason it will be of particular value to family doctors, physiotherapists, rheumatologists, orthopaedic surgeons and particularly those working in sports medicine. Especial emphasis is given to differential diagnosis. Warning signs are highlighted so as to warn both examiner and therapist for possible pitfalls and therapeutic hazards.

Most of the described treatment techniques were devised by Cyriax. They are: injections, infiltrations and deep transverse massage for muscular, tendinous and ligamentous lesions; manipulation for some ligamentous disorders and for reducing displaced fragments of cartilage in the different joints; traction for some types of lumbar disorder and capsular stretching for some capsular disorders. Although there may be many alternative equally effective treatments practised by others, the authors have confide themselves to those with which they have considerable personal experience. The treatments described here are simple and have through time confirmed their effectiveness. For any treatment to be successful, accurate diagnosis must be followed by carefully focused therapy to the affected area. For this reason considerable detail is given on the correct performance of each therapeutic technique supported by numerous clear, explanatory photographs and diagrams.

Finally we wish to accentuate the importance of the co-operation between physician and (physio)therapist. The system of orthopaedic medicine promoted in this book requires teamwork. Both doctor and therapist examine the patient in the same way, speak the same language and share their assessments and diagnoses. As to the treatment, some disorders will respond better to physical treatment and others will require a medical approach but both professions need to know what the possibilities, modalities and potential results are.