Structural vs Functional Approach in Musculoskeletal Pathologies Structural vs Functional Approach in Musculoskeletal Pathologies June 1 st, 2013 9:15-10:30.

Structural vs Functional Structural vs Functional Approach in Approach in

Musculoskeletal Musculoskeletal PathologiesPathologies

June 1June 1stst , 2013 , 20139:15-10:30 AM9:15-10:30 AM

Dr. Alban Merepeza BA. D.C. Dr. Alban Merepeza BA. D.C. www.porthopehealthcentre.comwww.porthopehealthcentre.com

Port Hope Ontario.Port Hope Ontario.

What is the difference between What is the difference between structural and functional structural and functional

pathologies?pathologies?How do you diagnose and treat How do you diagnose and treat

them?them?Why is it important that we (and Why is it important that we (and

you) understand both?you) understand both?Finally we will cover some specific Finally we will cover some specific

cases of these two kinds of cases of these two kinds of pathologies.pathologies.

Dr. Vladimir Janda MD (1923-2002)Dr. Vladimir Janda MD (1923-2002)Czech neurologistCzech neurologist

Observed two schools of thought in Observed two schools of thought in musculoskeletal medicine:musculoskeletal medicine:

Traditional structural approach based on Traditional structural approach based on anatomy and biomechanics..anatomy and biomechanics..

and and Functional approach is based on Functional approach is based on

understanding of the function of structures understanding of the function of structures and how they relate to each other in a and how they relate to each other in a system.system.

Structural pathologies are damages Structural pathologies are damages to any anatomical structure.to any anatomical structure.

Ex. A muscle tear on the bicep muscle Ex. A muscle tear on the bicep muscle during a bicep curl, a tear on the during a bicep curl, a tear on the hamstring muscles during sprinting, a hamstring muscles during sprinting, a fracture of the femur during a collision in a fracture of the femur during a collision in a football game, a sprain of the ligaments football game, a sprain of the ligaments on a ankle roll over ect.on a ankle roll over ect.

Orthopaedic medicine is influenced and Orthopaedic medicine is influenced and guided by a structural approach to guided by a structural approach to pathologies.pathologies.

It relies heavily on visualization of the It relies heavily on visualization of the structures through imagery such as x-structures through imagery such as x-rays, diagnostic ultrasound, MRI and CT rays, diagnostic ultrasound, MRI and CT Scans.Scans.

Clinicians then focus their treatment on Clinicians then focus their treatment on repairing these damaged structures.repairing these damaged structures.

This is done through immobilization (to This is done through immobilization (to allow healing), surgery and rehabilitation allow healing), surgery and rehabilitation (exercises). (exercises).

The structural approach is the foundation of The structural approach is the foundation of medical education and practice.medical education and practice.

In some cases however many of the In some cases however many of the diagnostic tests are inconclusive or diagnostic tests are inconclusive or negative for structural lesions (damage).negative for structural lesions (damage).

The clinicians in these cases have The clinicians in these cases have difficulties on coming up a diagnosis.difficulties on coming up a diagnosis.

More likely the cause of lesions then is More likely the cause of lesions then is functional.functional.

Dr. Janda defined functional Dr. Janda defined functional pathologies as impairment in the pathologies as impairment in the

ability of a structure or physiological ability of a structure or physiological to perform its function.to perform its function.

These type of pathologies are more difficult to These type of pathologies are more difficult to detect and diagnose.detect and diagnose.

This is not visualised through diagnostic imaging. This is not visualised through diagnostic imaging. MRI, x-rays US do not show structural damage.MRI, x-rays US do not show structural damage.

Clinicians must visualise and understand the Clinicians must visualise and understand the dysfunction by analyzing the complex dysfunction by analyzing the complex interaction of the structures and systems.interaction of the structures and systems.

Structural or Functional?Structural or Functional?

Chronic shoulder pain due to subacromial Chronic shoulder pain due to subacromial impingement is a common complaint.impingement is a common complaint.

This pathology can be structural (primary) or This pathology can be structural (primary) or functional (secondary).functional (secondary).

..

Structurally this can be caused by bony Structurally this can be caused by bony structures such as subacromial spurs structures such as subacromial spurs (bony projections from the acromion), (bony projections from the acromion), osteoarthritis spurs on the osteoarthritis spurs on the acromioclavicular joint, and variations in acromioclavicular joint, and variations in the shape of the acromion. the shape of the acromion.

These structural abnormalities reduce the These structural abnormalities reduce the space under the acromion and cause an space under the acromion and cause an impingement of the rotator cuff soft tissues impingement of the rotator cuff soft tissues causing pain.causing pain.

Structural approach to treatment in this case Structural approach to treatment in this case is to repair the damaged structure through is to repair the damaged structure through surgery.surgery.

Ex. -Remove the hooked acromion or Ex. -Remove the hooked acromion or remove the subacromion spurs. remove the subacromion spurs.

-Repair a torn rotator cuff.-Repair a torn rotator cuff.

What if patients has subacromial What if patients has subacromial impingement but x-rays, MRI, US are all impingement but x-rays, MRI, US are all negative?negative?

In this case it is a Functional subacromial In this case it is a Functional subacromial impingement .impingement .

There is typically weakness on the scapular There is typically weakness on the scapular muscle stabilizers and/or muscle muscle stabilizers and/or muscle imbalance which causes aberrant imbalance which causes aberrant movement and impingement as a result.movement and impingement as a result.

This requires a good understanding of the This requires a good understanding of the function and biomechanics of the shoulder function and biomechanics of the shoulder and the approach to treatment is and the approach to treatment is significantly different from the structural significantly different from the structural approach.approach.

As you can see this structural and As you can see this structural and functional pathology of the shoulder functional pathology of the shoulder presents differently and should be treated presents differently and should be treated differently.differently.

This understanding of the difference This understanding of the difference between the two is essential for clinicians’ between the two is essential for clinicians’ success. The clinicians who fail to employ success. The clinicians who fail to employ both approaches to their practice are both approaches to their practice are doomed to fail. doomed to fail.

Other functional pathologies explained.Other functional pathologies explained.

Jumper’s kneeJumper’s knee

Osgood-Schlatter DiseaseOsgood-Schlatter Disease

Plantar FasciitisPlantar Fasciitis

Lower-Cross SyndromeLower-Cross Syndrome

Upper-Crossed SyndromeUpper-Crossed Syndrome

Iliotibial Band SyndromeIliotibial Band Syndrome

Why do you need to know ?Why do you need to know ?

Because you are at the front line.Because you are at the front line.

Often the first professionals to notice Often the first professionals to notice pathologies. Therefore refer to the right pathologies. Therefore refer to the right professionals for care.professionals for care.

There is a time for “no pain no gain” and there is There is a time for “no pain no gain” and there is a time that you might need to modify your a time that you might need to modify your exercise, change intensity, duration and maybe exercise, change intensity, duration and maybe try different kind of exercise.try different kind of exercise.

Thank you !Thank you !