Essential Orthopaedics 2Nd Edition Mark D Miller Full Chapter PDF
Essential Orthopaedics 2Nd Edition Mark D Miller Full Chapter PDF
Essential Orthopaedics 2Nd Edition Mark D Miller Full Chapter PDF
Mark D. Miller
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Essential Orthopaedics
Second Edition
Mark D. Miller, MD
S. Ward Casscells Professor of Orthopaedic Surgery
Department of Orthopaedics
University of Virginia
Charlottesville, Virginia
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ESSENTIAL ORTHOPAEDICS, SECOND EDITION ISBN: 978-0-323-56894-4
Copyright © 2020 by Elsevier, Inc. All rights reserved.
No part of this publication may be reproduced or transmitted in any form or by any means, electronic or
mechanical, including photocopying, recording, or any information storage and retrieval system, without
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This book and the individual contributions contained in it are protected under copyright by the Publisher
(other than as may be noted herein).
Notice
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and
using any information, methods, compounds or experiments described herein. Because of rapid
advances in the medical sciences, in particular, independent verification of diagnoses and drug dosages
should be made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors,
editors or contributors for any injury and/or damage to persons or property as a matter of products
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Printed in China
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To Ann Etchison, a smart lady and a great wife.
MDM
To my wife, Melissa, for her love, patience, and support. To my children, Abby, Hannah,
Eliza, and JD, for their sacrifice and understanding. And to the memory of my parents for
the inspiration to live a life of service.
JMM
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Contributors
Sonya Ahmed, MD Laurie Archbald-Pannone, David J. Berkoff, MD
Co-Director MD, MPH, AGSF, FACP Clinical Professor of Orthopedics and
Private Practice Associate Professor of Internal Medicine Emergency Medicine
Nilssen Orthopedics University of Virginia University of North Carolina Chapel Hill
Pensacola, Florida Charlottesville, Virginia Chapel Hill, North Carolina
James Alex, MD Anthony J. Archual, MD Anthony Beutler, MD
Algone Sports and Regenerative Medicine Resident Physician NCC Sports Medicine Fellowship
Wasilla, Alaska Department of Plastic Surgery Director
University of Virginia Injury Prevention Research Laboratory
R. Todd Allen, MD, PhD Charlottesville, Virginia CHAMP Consortium Professor
Associate Professor of Orthopaedic
Department of Family Medicine
Surgery Michael Argyle, DO Uniformed Services University
Director, UCSD Spine Surgery Fellowship Sports Medicine Physician
Bethesda, Maryland
University of California San Diego 18th Medical Group
Health System U.S. Air Force Matthew H. Blake, MD
San Diego, California Kadena Air Base, Japan Director of Sports Medicine
Department of Orthopedics and Sports
Annunziato Amendola, MD Joseph Armen, DO Medicine
Professor of Orthopaedic Surgery Team Physician, Student Health Services
Avera McKennan Hospital & University
Chief, Division of Sports Medicine Sports Medicine Fellowship Program
Health Center
Duke University Director
Sioux Falls, South Dakota
Durham, North Carolina Department of Family Medicine
East Carolina University Jeffrey D. Boatright, MD, MS
Nicholas Anastasio, MD Greenville, North Carolina Division of Hand and Upper Extremity
Department of Physical Medicine &
Surgery
Rehabilitation Keith Bachmann, MD Department of Orthopaedic Surgery
University of Virginia Assistant Professor of Orthopaedic
University of Virginia
Charlottesville, Virginia Surgery
Charlottesville, Virginia
University of Virginia
Bradley M. Anderson Charlottesville, Virginia Benjamin Boswell, DO
Research Assistant
ED Physician, Sports Medicine Fellow
Rothman Institute Spine Section Geoffrey S. Baer, MD, PhD Primary Care Sports Medicine Fellowship
Philadelphia, Pennsylvania Associate Professor of Orthopedics
Duke University
and Rehabilitation
D. Greg Anderson, MD Durham, North Carolina
University of Wisconsin
Professor of Orthopaedic Surgery
Madison, Wisconsin Seth Bowman, MD
Thomas Jefferson University
Hand Fellow
Philadelphia, Pennsylvania Kaku Barkoh, MD Department of Plastic Surgery
Spine Surgery Fellow
Kelley Anderson, DO, CAQSM University of Virginia
Department of Orthopaedic Surgery
Assistant Professor of Orthopedics Charlottesville, Virginia
University of Southern California
University of Pittsburgh;
Los Angeles, California Robert Boykin, MD
Primary Care Sports Medicine Physician
Staff Physician
University of Pittsburgh Medical Center Michael A. Beasley, MD Blue Ridge Division
Pittsburgh, Pennsylvania Instructor of Orthopedics
EmergeOrtho
Harvard Medical School;
Mark W. Anderson, MD Asheville, North Carolina
Division of Sports Medicine
Professor of Radiology and Orthopaedic
Boston Children’s Hospital Rebecca Breslow, MD
Surgery
Boston, Massachusetts Associate Physician, Primary Care
Department of Radiology
Sports Medicine
University of Virginia Anthony J. Bell, MD Department of Orthopaedics
Charlottesville, Virginia Assistant Professor of Orthopaedic
Brigham and Women’s Hospital
Surgery and Rehabilitation
Boston, Massachusetts
University of Florida College of Medicine
Jacksonville, Florida
iv
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Contributors
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Contributors
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Contributors
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Contributors
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Contributors
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Contributors
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Contributors
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Video Contents
Chapter 104 Trigger Finger Injection
Section 2 Video 104.1 Trigger Finger Injection
The Shoulder Chapter 105 Digital Blocks
Chapter 25 Overview of the Shoulder Video 105.1 Digital Block (Finger)
Video 25.1 Shoulder Joint Examination
Chapter 28 Multidirectional Shoulder Instability Section 5
Video 28.1 Shoulder Apprehension and Relocation Tests The Spine
Chapter 30 Superior Labral Injuries Chapter 106 Overview of the Spine
Video 30.1 The O’Brien Test Video 106.1 Spine Examination
Video 30.2 Load and Shift Test of the Shoulder
Chapter 33 Shoulder Impingement Syndrome Section 6
Video 33.1 Impingement Tests
The Pelvis/Hip
Chapter 34 Rotator Cuff Tear
Video 34.1 Shoulder Strength Testing Chapter 118 Physical Examination of the Hip and Pelvis
Chapter 48 Glenohumeral Joint Injection Video 118.1 Hip Joint Examination
Video 48.1 Glenohumeral Joint Injection Video 118.2 Ober Test
Chapter 49 Subacromial Injection
Video 49.1 Subacromial Injection Section 7
Chapter 50 Acromioclavicular Injection
The Knee and Lower Leg
Video 50.1 Acromioclavicular (AC) Joint Injection Chapter 141 Overview of the Knee and Lower Leg
Video 141.1 Knee Joint Examination
Section 3 Chapter 142 Anterior Cruciate Ligament Injury
The Elbow Video 142.1 Lachman Test
Video 142.1 Pivot Shift Test
Chapter 52 Overview of the Elbow
Video 52.1 Elbow Joint Examination Chapter 143 Posterior Cruciate Ligament Injury
Video 143.1 Posterior Drawer Test
Chapter 67 Injection or Aspiration of the Elbow Joint
Video 67.1 Elbow Joint Aspiration/Injection Chapter 144 Medial Collateral Ligament Injury
Video 144.1 Varus and Valgus Stress Tests
Chapter 68 Lateral Epicondylitis (Tennis Elbow) Injection
Video 68.1 Lateral Elbow Injection Chapter 148 Meniscus Tears
Video 148.1 McMurray’s Test
Chapter 69 M edial Epicondylitis (Golfer’s Elbow)
Injection Chapter 166 Knee Aspiration and/or Injection Technique
Video 69.1 Medial Elbow Joint Injection Video 166.1 Knee Joint Injection
Chapter 70 Olecranon Bursa Aspiration/Injection Chapter 167 P repatellar Bursa Aspiration and/or
Video 70.1 Olecranon Bursa Aspiration/Injection Injection Technique
Video 167.1 P
repatellar Bursa Aspiration/Injection
Section 4 Chapter 168 Pes Anserine Bursa Injection Technique
Video 168.1 Pes Anserine Bursa Aspiration/Injection
The Wrist and Hand
Chapter 71 Overview of the Wrist and Hand Section 8
Video 71.1 Wrist and Hand Evaluation The Ankle and Foot
Video 71.2 The Allen Test
Chapter 76 de Quervain Tenosynovitis Chapter 171 Overview of the Ankle and Foot
Video 76.1 Finkelstein Test Video 171.1 Ankle Joint Examination
Chapter 79 Carpal Tunnel Syndrome Chapter 201 Ankle Aspiration and/or Injection Technique
Video 79.1 Special Tests for Carpal Tunnel Syndrome Video 201.1 Ankle Injection
Chapter 100 d e Quervain/First Dorsal Compartment Chapter 202 Plantar Fascia Injection
Injection Video 202.1 Plantar Fascia Injection
Video 100.1 de Quervain Injection Chapter 203 Morton Neuroma Injection
Chapter 102 Carpal Tunnel Injection Video 203.1 Morton Neuroma Injection
Video 102.1 Carpal Tunnel Injection
Chapter 103 Carpometacarpal Injection
Video 103.1 Carpometacarpal (CMC) Injection xix
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1 Section 1 General Principles
Welcome to what we hope will be the most comprehensive graphic that will direct you to likely diagnoses based on the
and useful textbook of orthopaedics you will ever own. location of the patient’s symptoms or findings. The following
Appreciating that the vast majority of orthopaedic care takes pages include a review of regional anatomy, pertinent history
place not in the orthopaedic surgeon’s office or operating that is characteristic for each anatomic area, a review of
room, but rather in a myriad of primary care settings, this specific physical examination techniques, and practical
work is designed to be a user-friendly reference to assist management of imaging strategies.
primary care physicians, physician’s assistants, nurse prac- Within each specific topic chapter you will find a consistent
titioners, physical therapists, and athletic trainers. Having a format designed to aid efficiency in finding the information
reliable, thorough resource of clinical information is essential that you need as quickly as possible. After alternative condition
to ensure timely and appropriate management of all orthopaedic names and ICD-10-CM codes are provided, topic headings
concerns. As such, we have produced Essential Orthopaedics include Key Concepts, History, Physical Examination, Imaging,
to be your go-to resource in the clinic or the training room. Additional Tests (if applicable), Differential Diagnosis, Treatment,
The new edition also brings some exciting updates such as Troubleshooting, Patient Instructions, Considerations in Special
ICD-10-CM codes for the most common orthopaedic condi- Populations, and Suggested Reading. We have placed great
tions, current concept updates, new composite figures, and emphasis on including multiple drawings, photographs, and
even some new chapters to highlight the changes in the field. radiologic images to enhance the quality of each topic. In
As you peruse the text, you will find that the initial sections addition, we have added an accompanying DVD that covers
are devoted to a number of general topics important to in great detail the key orthopaedic physical examination
orthopaedic care. A review of orthopaedic anatomy and techniques and procedures that any provider should know.
terminology is followed by information on the nuances of We want you to feel comfortable that you have seen what
radiologic evaluation of orthopaedic conditions. Subsequent you need to provide great care.
chapters are dedicated to such vital topics as pharmacology, It is our sincere hope that you will find the latest edition
impairment and disability, and principles of rehabilitation. of Essential Orthopaedics to be the finest orthopaedic reference
Additional chapters are dedicated to special populations and for primary care providers of all types. Having a comprehensive
conditions such as the obese, elderly, pediatric, and female reference designed for rapid access of information is crucial
and pregnant patients, and those with multiple comorbid for busy practitioners. This text will help you find the right
conditions, arthritides, and trauma. answer quickly and will help enhance your comfort with
The remainder of the text is divided into major anatomic orthopaedic diagnosis, management, and appropriate referral.
groups: shoulder, elbow, wrist/hand, spine, pelvis/hip, knee Musculoskeletal care accounts for a sizable percentage of
and lower leg, and ankle and foot, with a special section medical encounters; let Essential Orthopaedics help enhance
dedicated to pediatrics. Each section begins with an anatomic the care of every orthopaedic patient whom you see.
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Chapter 2 Orthopaedic Terminology 1
Chapter 2 Orthopaedic Terminology
Siobhan M. Statuta
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1 Section 1 General Principles
• Type II: Physeal fracture that extends into the metaphysis. • Eversion: Rotation of the foot or ankle outward away from
• Type III: Physeal fracture that extends into the epiphysis. midline.
• Type IV: Fracture that involves the metaphysis, physis • Inversion: Rotation of the foot or ankle inward toward
and epiphysis. midline.
• Type V: Crush-type fracture that involves compression • Pronation: Rotary movement described at the wrist, where
of the epiphyseal plate. the palm of the hand rotates from a superior facing position
• Spondylolisthesis: The abnormal anterior or posterior to one facing inferiorly. Similarly, at the ankle, the plantar
translation of one vertebral body with respect to another. aspect of the foot rotates outward or laterally.
• Spondylolysis: A fracture of the pars interarticularis of the • Supination: Rotary movement described at the wrist, where
vertebra usually due to repetitive stress. The lower lumbar the palm of the hand rotates from an inferior facing position
vertebrae are most frequently affected. to one facing superiorly. Similarly, at the ankle, the plantar
• Sprain: An injury to the ligaments that support a joint. aspect of the foot rotates inward or medially.
Mild injuries involve microscopic tearing; moderate injuries • Valgus: Anatomic alignment of a joint where the distal
involve partial tearing of the ligament; severe insults involve portion is angulated away from the midline (i.e., knock
complete disruption of the ligament. knees).
• Strain: An injury to muscle or tendon around or attached to • Varus: Anatomic alignment of a joint where the distal portion
a joint. Grading scale is similar to sprains with mild injuries is angulated toward the midline (i.e., bowlegs).
involving microscopic tearing, moderate injuries involving
partial tearing of the muscle or tendon, and severe injuries
resulting in complete disruption of muscle or tendon fibers. Treatment
• Stress fracture: Microscopic fractures in bone caused by • Arthrocentesis: Aspiration of synovial fluid from a joint.
isolated repetitive forces to a focal area. Bony breakdown • Arthroscopy: A surgical technique that uses a small camera
occurs more rapidly than repair due to overuse or lack of (arthroscope) in a joint space for the diagnosis and treatment
recovery time. of joint-related conditions.
• Subluxation: Partial dislocation of the articular surfaces of • Dry needling: Technique in which needles are inserted into
a joint. myofascial trigger points with the goal of improving muscle
• Syndesmotic ankle (“high ankle”) sprain: Ankle sprain result- tension and pain.
ing in injury to the syndesmotic ligament that connects the • Iontophoresis: Process by which an electrical current is used
tibia and fibula superior to the ankle joint proper. These to deliver a drug (often a corticosteroid) to the surrounding
injuries are generally more severe than routine ankle sprains. soft tissues or joint transdermally.
• Tendinitis: Acute inflammation of a tendon. Symptoms are • Physical therapy: The branch of medicine that specializes
typically present for several weeks. Commonly affected in treatment, prevention, and functional optimization of
sites include the shoulder, knee, elbow, and heel. disorders of the musculoskeletal system. It encompasses
• Tendinosis/tendinopathy: Degenerative breakdown of numerous treatment modalities including mobilization,
the tendon and abnormal vascularization due to chronic, strengthening, flexibility, massage, heat, and dry needling.
repetitive stress. Symptoms are often present for several • Rehabilitation: The process of restoring one’s health
weeks to months. functionality.
• Tenosynovitis: Inflammation of a tendon sheath. This
can occur concomitantly with tendon involvement or Suggested Readings
independently. Armstrong AD, Hubbard MC, eds. Essentials of Musculoskeletal Care. 5th
ed. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2016.
Miller MD, Thompson SR, eds. DeLee & Drez’s Orthopaedic Sports
Movement Medicine: Principles and Practice. 4th ed. Philadelphia: Elsevier; 2015.
• Abduction: Movement away from the body’s midline. Thompson JC. Netter’s Concise Orthopaedic Anatomy. 2nd ed (Updated
• Adduction: Movement toward the body’s midline. Edition). Philadelphia: Elsevier; 2015.
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Chapter 3 Imaging of the Musculoskeletal System 1
Chapter 3 Imaging of the
Musculoskeletal System
Mark W. Anderson
A B
Fig 3.1 Radiography: Soft-tissue contrast. Lateral radiograph
of the knee demonstrates dark, lucent air (A); dark gray fat in Fig 3.2 Radiography: Importance of obtaining more than one
Hoffa fat pad (arrow); intermediate gray fluid in the suprapatellar view. (A) Posteroanterior radiograph of the finger demonstrates
bursa (F) related to a large joint effusion (note the similarity in a transverse fracture of the distal phalanx that does not appear
density between the fluid and the hamstring muscles [M] pos- to involve its articular surface (arrow). (B) Corresponding lateral
teriorly); and the relatively dense bones (related to their calcium view reveals intra-articular extension and mild distraction along
content). the fracture line. 5
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1 Section 1 General Principles
A B
Fig 3.3 Radiography: Tumor and arthritis. (A) Frontal view of the shoulder reveals a coarse, sclerotic intramedullary lesion within the
proximal humerus, compatible with a chondroid neoplasm, most likely an enchondroma. (B) Posteroanterior radiograph of the foot
demonstrates classic findings of gout involving the first metatarsophalangeal joint including large marginal and para-articular erosions,
calcific densities in the adjacent soft-tissue tophus, and relative sparing of the joint space.
Weaknesses
• Pathology of the medullary cavity (bone contusion, occult
fracture, medullary tumor) (Fig. 3.5)
• Soft-tissue pathology
• Uses ionizing radiation
Computed Tomography
• Technique: An x-ray source is rotated around the patient,
who is lying on a moving gantry, resulting in image “slices”
in the transaxial plane.
• The data from these slices can then be viewed as axial
images or used to create reformatted images in any plane
(typically sagittal and coronal planes).
• Can be combined with intravenous (IV) contrast, which
results in increased density (enhancement) in vessels and
hypervascular tissues owing to its iodine content
Strengths
Fig 3.4 Radiography: Joint prosthesis. Frontal radiograph of the
• Tomographic depiction of anatomy allowing for two- and left hip shows prosthetic discontinuity of the femoral component
three-dimensional reformatted images (Fig. 3.6) at the junction of its head and neck with resulting superolateral
• Depiction of complex fractures, especially those involving migration of the proximal femur.
the spine and flat bones (pelvis and scapula) (Fig. 3.7)
• Evaluation of fracture healing
• Postoperative evaluation of the degree of fusion or hardware
complications (Fig. 3.8)
• Can be combined with intrathecal or intra-articular con-
trast (computed tomography [CT] myelography and CT
6 arthrography, respectively) (Fig. 3.9)
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Chapter 3 Imaging of the Musculoskeletal System 1
A B
Fig 3.5 Radiography: occult fracture. (A) No discrete fracture is evident on this posteroanterior view of the wrist obtained after injury.
(B) Coronal T1-weighted magnetic resonance image reveals numerous nondisplaced, low-signal-intensity fracture lines within the
distal radius.
A B
Fig 3.6 Computed tomography: Reformatted images. (A) Thin-slice computed tomography images obtained in the axial plane were
combined to create this two-dimensional sagittal reconstructed image of the cervical spine. (B) A three-dimensional reformatted
image of the pelvis depicts prominent diastasis of the symphysis pubis and less prominent widening of the right sacroiliac joint.
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1 Section 1 General Principles
Fig 3.7 Computed tomography: Complex fractures. Coronal, Fig 3.9 Computed tomography arthrogram. Coronal reformat-
two-dimensional reformatted image from a computed tomography ted image from a computed tomography arthrogram of the left
scan of the pelvis demonstrates an essentially nondisplaced, hip reveals a small cartilage flap along the medial femoral head
comminuted right acetabular fracture (arrows). (arrow).
A B
Fig 3.8 Computed tomography: Postoperative assessment. (A) and (B) Adjacent coronal reformatted images of the wrist reveal a
8 nondisplaced scaphoid fracture transfixed with a surgical screw. Note the lack of metal-related artifact.
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Chapter 3 Imaging of the Musculoskeletal System 1
• Pathologic processes typically show increased metabolic
activity and increased 18F-fluorodeoxyglucose uptake.
• This modality also has theoretical value for the evaluation of a
variety of neoplastic, infectious, and inflammatory conditions
of the musculoskeletal system. Although promising results
have been reported for some indications, the number of
studies has been limited to date, and further investigation
is needed.
Strengths
• Whole-body imaging allows rapid assessment of the entire
skeleton; this is the study of choice to evaluate possible
skeletal metastases.
• Provides physiologic information regarding the activity of
a bone lesion (Fig. 3.12)
• High sensitivity
Weaknesses
Fig 3.10 Dual energy computed tomography (CT): Gout. Color- • Relatively low specificity.
coded coronal reformatted image from a dual energy CT examina- • Any process resulting in increased bone turnover (infection,
tion demonstrates extensive monosodium urate deposition (green tumor, fracture) may result in a focus of increased activity.
foci) throughout the wrist. • False-negative examinations may occur in the initial 24 to
48 hours, especially in elderly patients.
• Insensitive for detecting multiple myeloma (plain radiographs
are actually better for this purpose).
• Poor soft-tissue evaluation.
• Produces ionizing radiation.
A B
Fig 3.11 Computed tomography versus magnetic resonance imaging for a tibial plateau fracture. (A) Coronal reformatted computed
tomography image of the knee reveals a very small cortical lucency (arrowhead) in the tibial plateau at the site of a nondisplaced
fracture that is much better demonstrated using MRI as indicated by the arrow in (B), a coronal T1-weighted image. 9
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1 Section 1 General Principles
A B
Fig 3.12 Bone scan. (A) Anterior and posterior whole-body bone scan images reveal focal uptake at the thoracolumbar junction
(arrow) at the site of a pathologic fracture related to a vertebral metastasis. (B) Spot images of the lower legs from a bone scan in
a different patient show abnormal uptake in the right mid-tibia at the site of a stress fracture (arrow).
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Chapter 3 Imaging of the Musculoskeletal System 1
A B
Fig 3.13 Ultrasonography: Tendons. (A) Longitudinal sonogram of a normal Achilles tendon (arrows). (B) Longitudinal scan of the
Achilles tendon in a different patient demonstrates diffuse thickening of the tendon (arrows) and an area of high-grade partial tearing
(arrowheads).
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1 Section 1 General Principles
A B
Fig 3.16 Magnetic resonance imaging: T1- and T2-weighted images. Sagittal T1-weighted (A) and T2-weighted (B) images of the
lumbar spine illustrate the characteristic signal characteristics of fluid. Note the low signal intensity of the cerebrospinal fluid on the
T1-weighted image and bright signal on the T2-weighted scan.
A B
Fig 3.17 Magnetic resonance imaging: Osteomyelitis. Sagittal T1-weighted (A) and T2-weighted (B) images of the foot reveal
abnormal, fluidlike signal throughout the marrow of the proximal and distal phalanges of the great toe compatible with osteomyelitis
in this diabetic patient who had an adjacent cutaneous ulcer.
12
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Chapter 3 Imaging of the Musculoskeletal System 1
A B
Fig 3.18 Magnetic resonance imaging: Use of intravenous contrast. (A) Coronal T1-weighted image before intravenous contrast
administration shows no abnormality. (B) Coronal T1-weighted fat-saturated postcontrast image demonstrates prominent synovial
enhancement throughout the joints of the hand and wrist, compatible with an inflammatory (rheumatoid) arthritis.
• Because of the strong magnetic field involved, contraindica- • The test of choice for evaluating neurologic deficits related
tions to MRI include the presence of a cardiac pacemaker, a to spinal trauma or neoplasm.
metallic foreign body in the orbit, certain vascular aneurysm • Can be combined with gadolinium-based contrast agents
clips and cochlear implants, and a metallic fragment (e.g., injected either intravenously (to highlight tissues with
bullet) of unknown composition near a vital structure (e.g., increased vascularity) or directly into a joint (magnetic
spinal cord, heart), among other items. As a result, each resonance arthrography) (Fig. 3.22, see also Fig. 3.18).
patient should undergo a thorough screening process prior • No ionizing radiation.
to scanning.
Weaknesses
Strengths • Fractures of the posterior elements of the spine are difficult
• Images can be obtained in any plane and provide superb to detect with MRI.
soft-tissue contrast, anatomic detail, and simultaneous dem- • Assessment of fracture healing.
onstration of bones and soft tissues. As a result, it is the best • Hardware (depending on type, may produce severe artifact,
single modality for evaluating most types of musculoskeletal obscuring adjacent tissues) (Fig. 3.23).
pathology (Fig. 3.19, see also Figs. 3.17 to 3.18).
• The most sensitive modality for detecting marrow pathol-
ogy (neoplastic marrow infiltration, bone contusion, occult Imaging Algorithms
fracture, tumor) (Figs. 3.20 and 3.21). • Please see Figs. 3.24 to 3.28.
13
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1 Section 1 General Principles
A B
C
Fig 3.19 Magnetic resonance imaging: Ligament injuries. (A) Sagittal T2-weighted image with fat saturation demonstrates a complete
rupture of the anterior cruciate ligament. Note the high signal edema and hemorrhage in the central intercondylar notch, as well as
the absence of discernible ligament fibers. (B) A normal anterior cruciate ligament with taut, parallel fibers (arrow) is shown for
comparison. (C) Coronal T2-weighted image with fat saturation shows a partial tear of the proximal medial collateral ligament (arrow).
Note the intact ligament fibers distally (arrowhead).
14
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Chapter 3 Imaging of the Musculoskeletal System 1
A B
Fig 3.20 Magnetic resonance imaging: radiographically occult fracture. Sagittal (A) and coronal (B) T1-weighted images of the knee
reveal a nondisplaced fracture in the lower pole of the patella (arrows). The fracture was not visible on radiographs. (This is the same
patient as in Fig. 3.1.)
A B
C
Fig 3.21 Magnetic resonance imaging: bone tumor. (A) Anteroposterior radiograph of the pelvis reveals subtle lucency in the right
acetabulum (arrow) that could be potentially missed owing to the degree of diffuse osteopenia. Coronal T1-weighted (B) and fat- 15
saturated T2-weighted (C) images demonstrate the lesion to much better advantage (arrows).
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1 Section 1 General Principles
A B
Fig 3.22 Magnetic resonance arthrography. (A) Axial T1-weighted image of the shoulder after an intra-articular injection of a dilute
gadolinium solution reveals a posterior labral tear (large arrow). Note also the normal labrum (small arrow) and middle glenohumeral
ligament (arrowhead) anteriorly. (B) Oblique sagittal T1-weighted image with fat saturation confirms the posterior labral tear (arrow).
Skeletal
trauma
Radiographs
Fig 3.23 Magnetic resonance imaging: Metal artifact. Sagittal Focal lesion:
T2-weighted image of the knee after anterior cruciate ligament bone
reconstruction demonstrates the normal anterior cruciate ligament Radiographs
graft (arrowheads), as well as prominent low-signal artifacts related
to associated metal hardware (arrows). Note how these partially Normal, but high
degree of clinical Abnormal
obscure and distort adjacent tissues.
suspicion
Abnormal
MRI MRI
Detection and Bone Local staging
local staging scan
Distant
staging
Normal Stop
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Chapter 3 Imaging of the Musculoskeletal System 1
Focal lesion: Suggested Readings
soft tissue Ahn JM, El-Khoury GY. Role of magnetic resonance imaging in
Radiographs musculoskeletal trauma. Top Magn Reson Imaging. 2007;18:155–168.
Look for calcifications, Collin D, Geijer M, Gothlin JH. Computed tomography compared to
relationship to bone magnetic resonance imaging in occult or suspect hip fractures. A
retrospective study in 44 patients. Eur Radiol. 2016;26:3932–3938.
Duet M, Pouchot J, Liote F, Faraggi M. Role for positron emission
Possible cyst? Probable solid mass tomography in skeletal diseases. Joint Bone Spine. 2007;74:14–23.
Geijer M, El-Khoury GY. MDCT in the evaluation of skeletal trauma: prin-
ciples, protocols, and clinical applications. Emerg Radiol. 2006;13:7–18.
Imhof H, Mang T. Advances in musculoskeletal radiology: multidetector
Ultrasound Solid computed tomography. Orthop Clin North Am. 2006;37:287–298.
MRI
Characterization Khoury V, Cardinal E, Bureau NJ. Musculoskeletal sonography: a
Stop or local staging dynamic tool for usual and unusual disorders. AJR Am J Roentgenol.
Cyst
aspirate 2007;188:W63–W73.
Kransdorf MJ, Bridges MD. Current developments and recent advances
in musculoskeletal tumor imaging. Semin Musculoskelet Radiol.
Fig 3.26 Focal lesion: Soft-tissue algorithm. 2013;17:145–155.
Lalam RK, Cassar-Pullicino VN, Tins BJ. Magnetic resonance imaging
of appendicular musculoskeletal infection. Top Magn Reson Imaging.
2007;18:177–191.
Possible skeletal Love C, Din AS, Tomas MB, et al. Radionuclide bone imaging: an illustrative
metastases review. Radiographics. 2003;23:341–358.
Bone scan Mhuircheartaigh NN, Kerr JM, Murray JG. MR imaging of traumatic spinal
injuries. Semin Musculoskelet Radiol. 2006;10:293–307.
Nacey NC, Geeslin MG, Miller GW, Pierce JL. Magnetic resonance imaging
of the knee: an overview and update of conventional and state of the
art imaging. J Magn Reson Imaging. 2017;45:1257–1275.
Nicholau S, Yong-Hing CJ, Galea-Soler S, et al. Dual–energy CT as a
potential new diagnostic tool in the management of gout in the acute
MRI setting. AJR Am J Roentgenol. 2010;194:1072–1078.
Spine and pelvis Radiography Papp DR, Khanna AJ, McCarthy EF, et al. Magnetic resonance imaging
of positive area(s) for of soft-tissue tumors: determinate and indeterminate lesions. J Bone
further characterization Joint Surg Am. 2007;89A(suppl 3):103–115.
Schoenfeld AJ, Bono CM, McGuire KJ, et al. Computed tomography alone
Image-
versus computed tomography and magnetic resonance imaging in the
guided
biopsy identification of occult injuries to the cervical spine: a meta-analysis.
J Trauma. 2010;68:109–114.
Fig 3.27 Possible skeletal metastases algorithm. Tuite MJ, Small KM. Imaging evaluation of nonacute shoulder pain. AJR
Am J Roentgenol. 2017;209:525–533.
Turecki MB, Taljanovic MS, Stubbs AY, et al. Imaging of musculoskeletal
soft tissue infections. Skeletal Radiol. 2010;39:957–971.
Vande Berg B, Malghem J, Maldague B, Lecouvet F. Multi-detector CT
Low back pain Clinical “red flags?” imaging in the postoperative orthopedic patient with metal hardware.
Neurologic findings, signs of infection, Eur J Radiol. 2006;60:470–479.
history of trauma, known primary neoplasm
Yes No
17
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1 Section 1 General Principles
Chapter 4 Rehabilitation
Jeffrey G. Jenkins, Sara N. Raiser, Justin L. Weppner
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Chapter 4 Rehabilitation 1
• A rapid increase in force can cause injury. • Proprioceptive exercises seek to improve joint position
• This type of stretching has been largely abandoned as sense and thereby prevent injury.
a training technique. • For example, a tilt or wobble board is commonly used
after ankle ligamentous injury to reduce the incidence
Neuromuscular Facilitation of recurrence.
• Seeks to improve function through improved efficiency of
the interplay between the nervous and musculoskeletal Exercise Prescription
systems • A prescription for therapeutic exercise with a therapist
• Neuromuscular facilitation techniques in flexibility training: should always include the following components:
• Isometric or concentric contraction of the musculoten- • Diagnosis
dinous unit followed by a passive or static stretch • Frequency of treatment (i.e., number of sessions per
• Prestretch contraction of muscle facilitates relaxation week)
and flexibility. • Specific exercises required
• Examples include hold-relax and contract-relax • Precautions (includes restrictions on weight bearing and
techniques limb movement, as well as identification of significant
tissue damage or other factors that may interfere with
Plyometrics performance of specific exercises)
• Performance of brief explosive maneuvers consisting of • Contraindicated exercises or modalities (should include
an eccentric muscle contraction followed immediately by any specific motions, positions, or modalities that should
a concentric contraction be avoided to ensure appropriate tissue healing and
• This technique is primarily employed in the training of patient safety without incurring further injury)
athletes. • Ideally, individual exercises are further defined by:
• Should be approached with caution under the supervi- • Mode: specific type of exercise (e.g., closed chain
sion of a trained therapist and begun at an elementary quadriceps strengthening)
level • Intensity: relative physiologic difficulty of the exercise
• Some studies demonstrate a decreased risk of serious (this is often best described in terms of the patient’s
injury during sports activity among athletes who receive rating of perceived exertion, ranging from very light to
plyometric training (e.g., reduction in the incidence of knee very hard)
injuries in female athletes participating in a jump training • Duration: length of an exercise session
program). • Frequency: number of sessions per day/week
• Progression: increase in activity expected over the course
Proprioceptive Training of training
• Background:
• Proprioceptive deficits have been shown to result from
Modalities: Heat, Cold, Pressure,
and predispose to injury.
• Impairment of joint proprioception is believed to influ- Electrotherapy
ence progressive joint deterioration associated with both • Physical agents: use of physical forces to produce beneficial
rheumatoid arthritis and osteoarthritis. therapeutic effects (see Fig. 4.1) 19
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1 Section 1 General Principles
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Chapter 4 Rehabilitation 1
• Used for desensitization and vasogenic reflex effects • Effective as an adjunct to passive stretching in the
• Mostly used on hands or feet; typical indications include treatment and prevention of contractures
rheumatoid arthritis and sympathetically mediated pain • Myofascial release
(reflex sympathetic dystrophy) • Applies prolonged light pressure specifically oriented
with regard to fascial planes
Traction • Typically combined with passive range of motion
• Technique used to stretch soft tissues and to separate joint techniques to stretch focal areas of muscle or fascial
surfaces or bone fragments by the use of a pulling force. tightness
• Based on available medical evidence, therapeutic use of • Contraindications:
spinal traction is generally limited to the cervical spine. • Should not be performed in patients with known malig-
• The efficacy of lumbar traction is controversial. nancies, open wounds, thrombophlebitis, or infected
• Traction has been shown to lengthen the intervertebral tissues
space up to 1 to 2 mm, but the lengthening is transient.
• Decreases muscle spasm, possibly by inducing fatigue in Electrotherapy
the paravertebral musculature • Transcutaneous electrical nerve stimulation (TENS)
• May decrease neuroforaminal narrowing and associated • Most common direct therapeutic application of electrical
radicular pain current
• The patient should be positioned in 20 to 30 degrees of • Used for its analgesic properties
cervical flexion during traction to optimize the effect on • The unit uses superficial skin electrodes to apply small
the neural foramina. electrical currents to the body.
• Therapeutic benefit is usually obtained with 25 pounds of • Theorized to provide analgesia via the gate control theory
traction (this includes the 10 pounds required to counterbal- of pain, in which stimulation of large myelinated afferent
ance the weight of the head). nerve fibers block the transmission of pain signals by
• The duration of a treatment session is typically 20 minutes. small, unmyelinated fibers (C, A delta) at the spinal cord
• The best results are obtained when a trained therapist level
administers manual traction in a controlled setting. • Signal amplitudes generally do not exceed 100 mA.
• Home cervical traction devices can be used (these typically • With initiation of treatment, TENS use is typically taught
use a pulley system over a door, and a bag filled with 20 and monitored by a physical therapist. Once the patient
pounds of sand or water). is competent and confident in using the device (electrode
• Home cervical traction devices should not be used without placement, stimulator settings, duration of treatments),
previous training and observation by a trained therapist or the unit can be used independently, outside the medical
physician. or therapy setting.
• Heat (hot packs) is helpful in decreasing muscle contraction • Common indications include posttraumatic/postsurgical
and maximizing the benefit of treatment. pain, diabetic neuropathic pain, chronic musculoskeletal
• Contraindications: pain, peripheral nerve injury, sympathetically mediated
• Cervical ligamentous instability resulting from conditions pain/reflex sympathetic dystrophy, and phantom limb
such as rheumatoid arthritis, achondroplastic dwarfism, pain.
Marfan syndrome, or previous trauma • Iontophoresis
• Documented or suspected tumor in the vicinity of the • Uses electrical fields to drive therapeutic agents through
spine the skin into underlying soft tissue
• Infectious process in the spine • Treatments in the musculoskeletal patient population
• Spinal osteopenia typically use antiinflammatory agents and/or local
• Pregnancy anesthetics.
• Cervical spinal traction should not be administered with • Conditions commonly treated include plantar fasciitis,
the neck in extension, particularly in patients with a history tendinitis, and bursitis.
of vertebrobasilar insufficiency. • Most physical therapists are trained in this technique,
although not all have access to the necessary equipment.
Therapeutic Massage • It is worth noting that, in most cases, injection enables
• Causes therapeutic soft-tissue changes as a direct result a more efficient delivery of a greater concentration of
of the manual forces exerted on the patient by a trained the therapeutic agent in question.
therapist • Electrical stimulation (E-stim)
• Specific techniques can be helpful for musculoskeletal • At higher intensities than those used in TENS, E-stim
patients: can be used to maintain muscle bulk and strength.
• Deep friction massage • Useful for immobilized limbs and for paretic muscles
• Used to prevent and break up adhesions after muscle after nerve injury.
injury • Evidence does not suggest that E-stim can strengthen
• Friction is applied transversely across muscle fibers otherwise healthy muscle.
or tendons. • Relative contraindications to E-stim include implanted or
• Soft-tissue mobilization temporary stimulators (pacemakers, intrathecal pumps,
• Forceful massage performed with the fascia and spinal cord stimulators, etc.), congestive heart failure,
muscle in a lengthened position pregnancy, skin sensitivity to electrodes, and actively 21
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1 Section 1 General Principles
healing wounds near the stimulation site. Stimulation • There is some evidence that use of a semirigid ankle
over the carotid sinus is also highly discouraged due orthosis can decrease the risk of ligamentous injury in
to the propensity for vagal response. athletes, particularly those with a history of sprain.
Orthoses
• An orthosis is an external device that is worn to restrict or When to Refer
assist movement. Examples include braces and splints. • To a significant extent, the primary physician’s own per-
• Orthoses are typically prescribed and used for one or more sonal comfort level in managing a rehabilitation program
of the following reasons: determines the need for referral. However, some indications
• To rest or immobilize the body part: reduce inflammation, for referral include:
prevent further injury • Patient’s inability to progress functionally with the current
• To prevent contracture: minimize loss of range of motion therapy regimen
in a joint or limb • Suboptimally controlled acute or chronic pain
• To correct deformity: typically in conjunction with therapy • Painful or functionally disabling spasticity
or surgery • Neuromuscular or musculoskeletal comorbidities (e.g.,
• To promote exercise: encourage strengthening of certain stroke, spinal cord injury, cerebral palsy, multiple scle-
muscles and/or correct muscle imbalances rosis, rheumatoid arthritis, fibromyalgia, and chronic
• To improve function pain syndromes) that can compound functional deficits
• Orthoses can be subdivided into static and dynamic devices. and/or complicate the process of progressing toward
• Static orthoses keep underlying body parts from moving, functional goals
thereby encouraging rest and healing via immobilization
while preventing or minimizing deformity.
• Dynamic orthoses have internal or external power Patient Instructions
sources that encourage restoration and/or control of • Your active participation in the rehabilitation process is the
joint movements. most important factor in determining the success of the
• Orthoses are often named for the body parts that they program.
incorporate (e.g., ankle-foot orthosis and wrist-hand • Be involved in the development of functional goals for your
orthosis). rehabilitation program.
• Prescriptions for orthotics should include the type (defined • Follow physician and physical therapist instructions as
by incorporated limb segments/body parts) and a static/ closely as possible.
dynamic classification. If a dynamic orthosis is to be used, • Give feedback to care providers as to the effectiveness of
the prescription should specifically identify the motion(s) interventions as well as any side effects of treatment.
to be assisted or inhibited. • Do not continue to do exercises or use modalities that
• Prefabricated, off-the-shelf orthotics can be effectively used worsen your symptoms or condition without checking with
in the treatment of most orthopedic injuries. Frequently your physician.
encountered examples include knee and ankle braces
prescribed for ligamentous injury or wrist splints for carpal
tunnel syndrome. Considerations in Special Populations
• In special populations (e.g., hand trauma, nerve injury, • Hand injuries
partial limb loss, severe deformity), orthoses should be • Whenever possible, a rehabilitation program for hand or
custom fitted by an orthotist or an appropriately trained wrist dysfunction should involve evaluation and treatment
occupational therapist. of the patient by a certified hand therapist.
• Orthotic use should generally be restricted to injured • Swelling will occur after any surgery or injury to the
or dysfunctional limbs. Prophylactic bracing of joints is hand. Orthoses can potentially aggravate edema, and
controversial. their use must be carefully monitored during this stage
• Indications for orthoses include: of rehabilitation to prevent loss of function.
• Trauma (e.g., fracture, joint sprain) • Sensory deficits
• Surgery (e.g., tendon repair, joint reconstruction) • For obvious reasons, physical modalities and orthotic
• Central or peripheral nervous system pathology (e.g., devices should be used with great caution in patients
weakness, spasticity) with sensory deficits (e.g., peripheral neuropathies,
• Painful disorders (e.g., rheumatoid arthritis, carpal tunnel central nervous system disorders). Orthotic pressure
syndrome) over insensate areas must be minimized, and cryotherapy
• Orthoses and sports of these areas is contraindicated.
• There is no compelling evidence in the literature to • Pregnancy
support the use of prophylactic knee bracing in football • The safety of some physical modalities, including TENS
players. In fact, both the American Academy of Pediatrics and E-stim, has not been established in patients who are
and the American Academy of Orthopaedic Surgeons pregnant. Therapeutic US is absolutely contraindicated
have advised against the routine use of prophylactic over the low back and abdomen of a pregnant woman.
knee bracing in football, in part due to data that actually • Diabetes
showed an increase in anterior cruciate ligament injuries • Many patients with diabetes will experience a decrease in
22 in brace wearers. blood glucose levels when beginning a new therapeutic
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Chapter 4 Rehabilitation 1
exercise regimen. Levels should be monitored closely American Society of Hand Therapists (ASHT). Splint Nomenclature Task
and medications adjusted as necessary to avoid Force: Splint Classification System. Garner, NC: ASHT; 1991.
hypoglycemia. Hennessey WJ, Uustal H. Lower limb orthoses. In: Cifu DX, eds. Braddom’s
Physical Medicine and Rehabilitation. 5th ed. Philadelphia: Elsevier;
• Elderly
2016:249–274.
• Where possible, therapeutic exercise modalities pre-
Kelly BM, Patel AT, Dodge CV. Upper limb orthotic devices. In: Cifu
scribed for patients who are elderly should be chosen DX, eds. Braddom’s Physical Medicine and Rehabilitation. 5th ed.
to minimize stress on the bones and joints. Philadelphia: Elsevier; 2016:225–248.
• Pain Wilder RP, Jenkins JG, Panchang P, Statuta S. Therapeutic exercise. In:
• Pain is not a contraindication to therapeutic exercise, Cifu DX, eds. Braddom’s Physical Medicine and Rehabilitation. 5th
physical modalities, or the use of orthotic devices. ed. Philadelphia: Elsevier; 2016:321–346.
However, significant worsening of pain or onset of Wolf CJ, Brault JS. Manipulation, traction, and massage. In: Cifu DX, eds.
new pain after initiation of treatment demands further Braddom’s Physical Medicine and Rehabilitation. 5th ed. Philadelphia:
investigation and/or referral. Elsevier; 2016:347–367.
Suggested Readings
Alfano AP. Physical modalities in sports medicine. In: O’Connor FG, Sallis
RE, Wilder RP, St. Pierre P, eds. Sports Medicine: Just the Facts.
New York: McGraw-Hill; 2005:405–411.
23
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1 Section 1 General Principles
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Chapter 5 Special Populations: Geriatrics 1
• Often geriatric patients are on multiple medications, and
BOX 5.1 Activities of Daily Living
polypharmacy (>3 medications) is frequent in this popula-
• Dressing tion. The addition of any new medication, as well as the
• Eating dose, frequency, and duration of the medication, must
• Ambulating account for the geriatric patient’s comorbidities and other
• Toileting medications.
• Hygiene • A geriatrician can assist in the management of medica-
tions and comorbidities associated with elderly patients.
Studies have shown that the rate of delirium is decreased
in postoperative units that comanage elderly patients with
patient is more likely to present with tendinoses such as geriatric physicians and an interdisciplinary team.
rotator cuff strains, medial epicondylitis, and Achilles
tendinitis.
Benefits of Exercise in the
• Geriatric patients are also more likely to have degenerative
meniscus tears because of age-related collagen changes. Geriatric Patient
• Muscle strains are also common in the geriatric population • Exercise can impact the rate and extent of functional decline.
secondary to a decrease in flexibility. • It is recommended that geriatric patients have approximately
• Due to decrease in bone density, geriatric patients are at 30 minutes of exercise at least 5 days each week.
risk from spontaneous, nontraumatic, or minimally traumatic • Exercise programs that include balance, flexibility, and
fractures. strength exercises have been shown to significantly reduce
the number of falls in the geriatric population.
• Light to moderate exercise training has been shown to
Treating Chronic Osteoarthritis Pain in the decrease systolic blood pressure.
Geriatric Patient • Endurance training is associated with improved insulin
• Due to physiologic changes with normal aging, medication sensitivity, and regular exercise has been shown to decrease
administration must be adjusted in the geriatric patient, as depressive symptoms.
compared with a younger patient. • Weight-bearing exercise has been shown to attenuate bone
• In 2015 the American Geriatrics Society updated the Beers density loss in several studies.
Criteria for medications to use with extreme caution in • A regular exercise program has been shown to improve
older adults. OA pain and improve function in this population.
• Due to age-related renal changes, nonsteroidal antiinflam-
matory drugs (NSAIDs) are not recommended for long-term
Promoting Safe Exercise for the
use in the geriatric population. NSAIDs can be helpful
for short-course treatment of acute pain or inflammation. Geriatric Patient
Adverse effects commonly associated with NSAID use in • To promote safe exercise, a preparticipation screening
the geriatric population include acute kidney injury, gastric evaluation can assess for cardiovascular risk factors prior
bleeding, and peripheral edema. to initiating or escalating an exercise program.
• Acetaminophen can be used safely in the treatment of • Established cardiovascular screening guidelines for masters’
chronic arthritis pain in the geriatric patient. Regular dosing level athletes should be followed with particular attention
of scheduled acetaminophen can decrease pain level and to key clinical risks such as family history of sudden
act as a “narcotic-sparing medication” in chronic and death, exertional syncope, exertional dyspnea, chest pain,
postoperative pain control. Maximum dosing of acetamino- or hypertension. The cardiovascular exam should focus
phen in the geriatric patient is 3000 mg a day in divided on identification and characterization of heart murmurs,
doses of 1000 mg TID. All formulations of acetaminophen peripheral pulse quality, and stigmata of Marfan’s syndrome.
must be accounted for and be less than 3000 mg in any • Geriatric patients can work under direct monitoring of a
1 day. physical therapist or personal trainer to first establish an exer-
• Geriatric patients who are acutely ill are at risk for delirium cise regimen before transitioning to working independently.
from a variety of factors, including hospitalization, dehy- • After medical clearance for exercise, prescribe an exercise
dration, medications, and postoperative state. Although regimen that is consistent with that individual’s cognitive
pain medication, especially narcotic medication, can be and functional abilities.
associated with delirium, untreated pain is also associated • Proper hydration and nutrition must be maintained
with delirium. for optimal function. Hydration is especially important due
• Short-course narcotic pain medication at appropriate dosing to a decrease in thirst perception that is part of normal
can be used in the geriatric population with close monitoring aging.
for side effects. Narcotic-induced constipation is a common
side effect in this population and can be treated with a
Exercise Prescriptions for the
promotility stimulant laxative such as senna.
• A key principle in dosing medication in elderly population is Geriatric Patient
“start low, go slow.” Start a medication at a low therapeutic • After cardiac clearance, an exercise prescription is an
dose and slowly titrate up while reevaluating for effect and excellent way to promote a healthy lifestyle in an elderly
adverse effects in the geriatric patient. patient. 25
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1 Section 1 General Principles
26
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Chapter 6 Special Populations: Disabled 1
Chapter 6 Special Populations:
Disabled
David Hryvniak, Jason Kirkbride
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1 Section 1 General Principles
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Chapter 6 Special Populations: Disabled 1
Pueschel SM, Scola FH, Perry CD, Pezzullo JC. Atlanto-axial instability Vallaint PM, Bezzubyk I, Daley ME. Psychological impact of sport on
in children with Down syndrome. Pediatr Radiol. 1981;10:129– disabled athletes. Psychol Rep. 1985;56:923.
132. Warms C, Belza B, Whitney J. Correlates of physical activity in adults with
Storheim K, Zwart J. Musculoskeletal disorders and the Global Burden mobility limitations. Fam Community Health. 2007;30(2 suppl):S5–S16.
of Disease study. Ann Rheum Dis. 2014;73:949–950. World Health Organization. The Burden of Musculoskeletal Conditions
U.S. Department of Health and Human Services. The Surgeon General’s at the Start of the New Millennium. Technical Report Series 919.
Call to Action to Improve Health and Wellness of Persons with Dis- Geneva: World Health Organization; 2003.
abilities. Rockville, MD: U.S. Department of Health and Human Services, World Health Organization. International Classification of Functioning,
Office of the Surgeon General; 2005. Disability and Health: ICF. Geneva: World Health Organization; 2001.
29
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1 Section 1 General Principles
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Chapter 7 Special Populations: Pediatrics 1
TABLE 7.1 Numbers of High School–Age American skill sports such as football, basketball, soccer, and field
Boys and Girls Involved in Organized hockey.
Sports • Can accept increasing emphasis on game tactics and
strategy
Group 1971 1996 2006 2016 Many changes occurring during puberty can affect children’s
Boys 3,670,000 3,700,000 4,321,000 4,560,000 athletic performance. The exact timing of these changes can
Girls 294,000 2,500,000 3,022,000 3,400,000 be affected by genetics, endocrine function, nutritional status,
and amounts and types of exercise.
Total 3,960,000 6,200,000 7,342,000 7,960,000
Athletic and Sports Issues of Puberty
population and (2) professional baseball players surveyed Co-Ed Youth Teams
did not feel sport specialization was required prior to high • Muscle strength, speed, and skills are usually nearly equal
school to master their skills (as indicated in an early sport in boys and girls until age 10 to 11 years, and sports
specialization article [Wilhelm et al., 2017]). activities can still be coeducational due to these similarities.
• Girls generally begin their pubertal changes at approximately
10 years of age, approximately 2 years before boys.
Growth and Maturation • By age 12 to 13 years, pubertal differences start to affect
• Preparedness for particular sports, capabilities for training, the skill and strength involved in sports, and depending
and skills development are all directly related to age-specific on the sport, these differences may affect whether girls
maturation in children’s neuromuscular, cardiovascular, and and boys should continue to play and compete together.
cognitive systems.
• By age 6 years, most children have acquired sufficient Physiologic Changes of Puberty
physical skills to participate in some organized sports. • Capacities for both aerobic and anaerobic exercise are
• Gaining experience in a variety of sports is important for beginning to increase, which allow longer and more intense
the young athlete to enable them to acquire a mix of skill periods of exercise to be tolerated.
sets and to keep physical activity interesting and fun. • Aerobic capacity: Greater maximum oxygen uptake
(VO2max)
Developmental Levels and Readiness for Sports • Due to increases in pulmonary ventilation and cardiac
at Various Prepubertal Ages output and to more efficient extraction and use of
• Selection of appropriate athletic activities for children should oxygen by muscle
be guided by knowledge of the developmental skills and • Anaerobic capacity: allows for short, intense bursts of
limitations of specific age groups. activity
• Note: The downside of these physiologic changes is that
Ages 3 to 5 Years although pubertal children are less limited by body fatigue
• Focus on learning basic skills such as running, swimming, and can thus exercise longer, they are also more capable
tumbling, throwing, and catching. of overexercising, which can lead to overuse injuries.
• It is recommended that direct competition should be
avoided; fun play should be emphasized. Musculoskeletal Changes of Puberty
• Changing body contours during early puberty can lead
Ages 6 to 9 Years to physical awkwardness, which may be associated with
• Focus on developing fundamental sports skills with limited increased chances of injury, especially in early adolescence
emphasis on direct competition. when new skills have not caught up with new capacities
• To learn additional fundamental skills and work toward and new growth.
a transition to direct competition, sports like swimming, • Flexibility and joint hypermobility are increased, which
running, and gymnastics can be tried. increases the risk of glenohumeral and patellar subluxation
• Note: Children have a short attention span, limited and dislocation.
memory development, and do not easily make rapid
decisions; they need simple, flexible rules and short Bone Density and Calcium Needs
instruction times. • During early puberty, bone mineral density begins to increase
in both boys and girls.
Ages 10 to 12 Years (Prepubertal Years) • The calcium needs of all adolescents are great during puberty,
• With the mastery of basic skills, children can now compete due to the deposition of calcium into rapidly growing bone.
in activities and are able to learn more complex motor skill • Adolescents accrue 40% of their eventual adult bone
patterns. mass during puberty.
• Children begin to develop their sense of confidence, • Recommended calcium intake for adolescents is 1300 mg/
esteem, and self-awareness. At these ages, body day (amenorrheic females may need up to 1500 mg/day).
image and popularity are distinguished, and successful
mastery of new skills become closely linked to child’s Linear Growth
self-esteem. • Linear growth begins first in the long bones of the extremities
• They have the cognitive, social, and emotional maturity and can contribute to a temporary clumsiness that can
to handle modest competitive pressure and complex have an impact on the athletic performance of younger 31
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1 Section 1 General Principles
TABLE 7.2 Average Timing of Pubertal Changes in • There has been a recent increase of training facilities
Linear Growth (Height) focusing on proper lifting and sports-related techniques,
rather than growth and power, at younger ages.
Specific Pubertal • Young athletes, regardless of gender, should avoid power
Change Girls Boys
lifting until the growth plates are closed, due to an associ-
Increasing height 9 years 11 years ated with avulsion fractures at the growth plates.
velocity begins
Peak height 9 cm/year, at 10 cm/year, at Weight Increases During Puberty
velocity and Tanner Tanner • Puberty-related weight increases account for approximately
timing stage 2–3 stage 3–4 50% of adult total body weight.
Duration of 24–36 months 24–36 months Weight Changes in Girls
growth spurt
• Lean body mass decreases during puberty to 75% of the
Average age at 14 years 16 years total body weight, due to increases in body fat.
complete • Maximum weight velocity occurs approximately 6 months
skeletal maturity before their linear growth (height) spurt.
• Hip enlargement decreases waist-to-hip ratio.
Body Image
adolescents (Table 7.2). The child who previously exhibited • Body image concerns in young female athletes may arise
strong skills may suddenly appear to be less coordinated. because of higher levels of fat in this population.
Puberty-related increases in height velocity usually begin • Sports where low body fat is valued include dancing,
in girls at approximately 9 years of age and in boys at gymnastics, cheerleading, figure skating.
approximately 11 years of age. • Loss of self-esteem and eating disorders are a particular
• The preadolescent and adolescent growth spurt, which risk in this age group.
can last for 24 to 36 months, accounts for approximately
20% of final adult height. Weight Changes in Boys
• Lead body mass increases to approximately 90% of total
Epiphyseal Growth Plates and Other Vulnerable body weight due to higher androgen levels.
Anatomic Sites • On average, boys end up with 1.5 times the lean body
• In early puberty, areas of rapid cell production include mass and one-half the body fat of girls.
(1) articular surfaces, (2) physes (growth plates), and (3) • Muscle mass accounts for 54% of boys’ body weight,
apophyses. The relative weakness of these areas compared making the average male athletes stronger and faster than
to adjacent ligaments, tendons, and bone make these sites the average female athletes.
more susceptible to injury, including fracture.
• Articular Surfaces
• Examples include osteochondritis dissecans and patel- Training and Conditioning
lofemoral syndrome. • The purpose of all athletic training programs for young
• Physes and Apophyses athletes should include improvement of skills, speed, flex-
• Physes are responsible for the linear growth of bones, ibility, strength, conditioning, maintenance of good nutrition,
while apophyses are responsible for growth at tendinous and attention to hydration.
insertion sites. • Benefits of training and conditioning include greater
• Physeal fractures represent 15-30% of all childhood muscle strength, power, and coordination and a lower
fractures. risk of athletic injuries (especially knee injuries).
• Apophysites include Sever disease (calcaneus), Osgood- • Training is a noncompetitive (or less competitive)
Schlatter and Sinding-Larsen-Johansson diseases means of improving conditioning, strength, and
(Chapter 221), and Iselins disease (fifth metatarsal). coordination.
• Physeal and epiphyseal injuries include little league • Training can improve athletic performance, increase
shoulder (Chapter 218), little league elbow (Chapter 219), bone density, promote weight loss, and enhance
and spondylolysis and spondylolisthesis (Chapter 223). children’s self-esteem.
• These are self-limited and usually resolve with a • Training can promote a healthy lifestyle that can last
temporary reduction in activity. into adulthood.
• Additional injuries can result from overuse, lack of skills,
lack of appropriate protective equipment, improperly learned Training Guidelines
(or taught) techniques, and/or excessive performance • Successful training programs should include qualified adult
expectations. supervision, no/low weight to focus on technique, and
enjoyment.
Injury Prevention • Age: No minimum age for participation in a youth
• Regular conditioning, stretching regimens, and light strength resistance training program
training can be particularly beneficial in prevention of injuries • Need emotional maturity to accept and follow direc-
32 (especially lower extremity injuries). tions (~7 to 8 years old)
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Chapter 7 Special Populations: Pediatrics 1
• Instruction: Training should include sufficient instruction Benjamin HJ, Glow KM. Strength training for children and adolescents: what
and supervision in proper techniques and equipment can physicians recommend? Physician Sports Med. 2003;31:19–25.
use. Coon ER, Young PC, Quinonez RA, et al. Update on pediatric overuse.
Pediatrics. 2017;139(2).
• Adult supervisors should stress positive attitude,
Feeley BT, Agel J, Laprade RF. When is it too early for single sport
character building, teamwork, and safety.
specialization? Am J Sports Med. 2015;44(1):234–241.
• Results: Improvement of baseline strength and muscle Greydanus DE, Patel DR, Pratt HD. Essential Adolescent Medicine. New
tone by 40-50% over a 6-week period. York: McGraw Hill Professional; 2011.
• Prepubertal athletes: training increases strength and Kraemer WJ. Strength Training for Young Athletes. Champaign, IL: Human
neuromuscular adaption but will not result in muscle Kinetics; 2005.
hypertrophy. Marques A, Santos R, Ekelund U, Sardinha LB. Association between
• Pubescent athletes: training will result in larger muscle physical activity, sedentary time, and healthy fitness in youth. Med
mass, due to increasing testosterone, especially with Sci Sports Exerc. 2015;47(3):575–580.
increasing weights and resistances. Metzl JD. Sports Medicine in the Pediatric Office. Elk Grove Village, IL:
American Academy of Pediatrics; 2017.
• Conditioning: should start at least 6 weeks before
Metzl JD, Shookhoff C. The Young Athlete: A Sports Doctor’s Complete
beginning a sports season.
Guide for Parents. New York: Time Warner; 2002.
• Two to three times per week on nonconsecutive Patel DR, Soares N, Wells K. Neurodevelopmental readiness of children
days (to allow a day of rest between sessions) for participation in sports. Transl Pediatr. 2017;6(3):167–173.
• Warm-ups and cool-downs, including stretching, Rosenbloom C. Youth athletes: nourishing young bodies and minds.
should be part of each session. Nutr Today. 2016;51(5):221–227.
• One to 3 sets of 6 to 15 repetitions with light weights Stracciolini A, Casciano R, Friedman HL, et al. A closer look at overuse
on a variety of exercises, starting with a small number injuries in the pediatric athlete. Clin J Sport Med. 2015;25(1):30–35.
of exercises Strasburger VC, Brown RT, Braverman PK. Adolescent Medicine: A
• Gradual increase in weights, number of repetitions, Handbook for Primary Care. Philadelphia: Wolters Kluwer; 2015.
Wilhelm A, Choi C, Deitch J. Early sport specialization: effectiveness and
and number of exercises
risk of injury in professional baseball players. Orthop J Sports Med.
• Core exercise should be supplemented by some
2017;5(9):232596711772892.
form of cardiovascular activity for 30 to 40 minutes
three to four times weekly.
Suggested Readings
Anderson SJ, Harris SS. Care of the young athlete. Elk Grove Village,
IL: American Academy of Pediatrics; 2010.
33
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2021. For personal use only. No other uses without permission. Copyright ©2021. Elsevier Inc. All rights reserved.
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at the Italian opera in Paris; but the only foundation for such a report
seems to be that it was not uncommon for violinist composers of that
period to enlist the aid of their friends in writing for the orchestra.
Viotti was a broadly educated musician, whose experience with
orchestras was wide.
Second in importance to the concertos are the duets for two violins
written during his stay in Hamburg. These are considered second in
musical charm only to Spohr’s pieces in the same manner. That
Viotti was somewhat low in spirit when he was at work on them,
exiled as he was from London and Paris, is shown by the few words
prefixed to one of the sets, ‘This work is fruit of the leisure which
misfortune has brought me. Some pieces came to me in grief, others
in hope.’
The list of the men who came to him for instruction while he was in
Paris contains names that even today have an imposing ring. Most
prominent among them are Rode, Cartier, and Durand. And among
those who were not actually his pupils but who accepted him as their
ideal and modelled themselves after him were Rodolphe Kreutzer
and Pierre Baillot. These men are the very fountain head of most
violin music and playing of the nineteenth century. They set the
standard of excellence in style and technique by which Spohr and
later Vieuxtemps ruled themselves.
IV
Before considering their work, the development of violin music in
Germany during the eighteenth century must be noticed. The
influence of the Italians was not less strong here than in France.
Both Biber and Strungk had come under it in the late seventeenth
century, Strungk being, as we know, personally acquainted with
Corelli and at one time associating closely with him in Rome. The
German violinists of the eighteenth century either went to Italy to
study, or came under the influence of various Italians who passed
through the chief German cities on concert tours.
Most conspicuous among those who were actually his pupils was
Johann Gottlieb Graun, brother of the still familiar Carl Heinrich. But
Graun was not content with instruction in Germany alone, and
betook himself to Tartini in Padua. After his return to his native land,
he eventually found his place at the court of Frederick the Great,
who was still crown prince. With him at this time were Quantz, the
flute player, and Franz Benda. After the accession of Frederick to the
throne of Prussia, Graun was made first violin and concert master in
the royal orchestra; and he held this place until his death in 1771.
His compositions, like all others for the violin at this period, are
hardly more than imitations of the Italian masterpieces. And like
Pisendel, his importance is in the improvement of the state of
instrumental music in Germany, and especially of the orchestra at
Berlin.
His successor in this royal orchestra was Franz Benda, who, not only
by reason of the romantic wanderings of his life, is one of the most
interesting figures in the history of music in Germany during the
eighteenth century. His father, Hans Georg, had been a sort of
wandering player, as well as a weaver; and his brothers, Johann,
Georg, and Joseph, were all musicians who won a high place in their
day. Georg was perhaps the most distinguished of the family, but in
the history of violin-music Franz occupies a more important place.
His playing was admired for its warm, singing quality, which showed
to such advantages in all slow movements that musicians would
come long distances to hear him play an adagio. Burney heard him
in 1772 and was impressed by the true feeling in his playing. Burney,
too, mentioned that in all Benda’s compositions for the violin there
were no passages which should not be played in a singing and
expressive manner. He went on to say that Benda’s playing was
distinguished in this quality from that of Tartini, Somis, and Veracini,
and that it was something all his own which he had acquired in his
early association with singers.
His works for the violin are numerous, but only a small part of them
was published, and this posthumously. In spite of the often lovely
melodies in the slow movements they have not been able to outlive
their own day. Wasielewski calls attention to the general use of
conventional arpeggio figures in the long movements, which,
characteristic of a great deal of contemporary music for the violin,
may have been written with the idea of offering good technical
exercise in the art of bowing.
Among Benda’s many pupils the two most significant are his own
son, Carl, and Friedrich Wilhelm Rust. The former seems to have
inherited a great part of his father’s skill and style. The sonatas of the
latter are among the best compositions written in Germany for the
violin in the second half of the eighteenth century. Rust died in
February, 1798. His name is remembered as much for his sonatas
for pianoforte as for his violin compositions. Another pupil, Carl
Haack, lived until September, 1819, and thus was able to carry the
Benda tradition over into the nineteenth century. On the whole Franz
Benda may be said to have founded a school of violin playing in
Berlin which has influenced the growth of music for that instrument in
Germany. Its chief characteristic was the care given to simplicity and
straightforwardness, especially in the playing of slow movements
and melodies, which stands out quite distinctly against the current of
more or less specious virtuosity running across the century.
V
Meanwhile about the orchestra at Mannheim there was a band of
gifted young men whose importance in the development of the
symphony and other allied forms has been but recently recognized,
and now, it seems, can hardly be overestimated. The most
remarkable of these was J. C. Stamitz, a Bohemian born in 1719,
who died when less than forty years old. His great accomplishments
in the domains of orchestral music have been explained elsewhere
in this series. In the matter of violin music he can hardly be said to
show any unusual independence of the Italians, but in the meagre
accounts of his life there is enough to show that he was a great
violinist. He was the teacher of his two sons, Carl (1746-1801) and
Anton (b. 1753), the latter of whom apparently grew up in Paris,
where the father, by the way, had been well known at the house of
La Pouplinière. Anton, as we shall see, was the teacher of Rodolphe
Kreutzer, already mentioned as one of the great teachers at the
Paris Conservatory in the first of the nineteenth century.
In Vienna the Italian influence was supreme down to nearly the end
of the century. The first of the Viennese violinists to win an
international and a lasting renown was Karl Ditters von Dittersdorf (b.
1739), the friend of Haydn and Gluck. Though two of his teachers,
König and Ziegler, were Austrians, a third, who perfected him, was
an Italian, Trani. Through Trani Dittersdorf became familiar with the
works of Corelli, Tartini, and Ferrari, after which he formed his own
style. Practically the first German to draw a circle of pupils about him
was Anton Wranitzky (b. 1761). Among his pupils the most
distinguished was Ignaz Schuppanzigh, who, as the leader of the
Schuppanzigh quartet, won for himself an immortal fame, and really
set the model for most quartet playing throughout the nineteenth
century. He was the son of a professor at the Realschule in Vienna.
From boyhood he showed a zeal for music, at first making himself a
master of the viola. At the time Beethoven was studying counterpoint
with Albrechtsberger he was taking lessons on the viola with
Schuppanzigh. Later, however, Schuppanzigh gave up the viola for
the violin. His most distinguished work was as a quartet leader, but
he won fame as a solo player as well; and when the palace of Prince
Rasoumowsky was burned in 1815, he went off on a concert tour
through Germany, Poland and Russia which lasted many years. He
was a friend not only of Beethoven, but of Haydn, Mozart, and of
Schubert as well; and was the principal means of bringing the
quartet music of these masters to the knowledge of the Viennese
public. He died of paralysis, March 2, 1830. Among his pupils the
most famous was Mayseder, at one time a member of the quartet.
VI
Before concluding this chapter and passing on to a discussion of the
development of violin music in the nineteenth century a few words
must be said of the compositions for the violin by those great
masters who were not first and foremost violinists. Among these,
four may claim our attention: Handel, Bach, Haydn, and Mozart.
Handel is not known to have given much time to the violin, but it is
said that when he chose to play on it, his tone was both strong and
beautiful. He wrote relatively little music for it. Twelve so-called solo
sonatas with figured bass (harpsichord or viol) were published in
1732 as opus 1. Of these only three are for the violin: the third, tenth,
and twelfth. The others are for flute. Apart from a few characteristic
violin figures, chiefly of the rocking variety, these solo sonatas might
very well do for clavier with equal effect. There is the sane, broad
mood in them all which one associates with Handel. In the edition of
Handel’s works by the German Handel Society, there are three
additional sonatas for violin—in D major, A major, and E major.
These seem to be of somewhat later origin than the others, but they
are in the same form, beginning with a slow movement, followed by
allegro, largo, and final allegro, as in most of the cyclical
compositions of that time. One cannot deny to these sonatas a
manly dignity and charm. They are in every way plausible as only
Handel knows how to be; yet they have neither the grace of Corelli,
nor the deep feeling of Bach. One may suspect them of being, like
the pieces for clavier, tossed off easily from his pen to make a little
money. What is remarkable is that sure as one might be of this, one
would yet pay to hear them.
There are besides these solo sonatas for violin or flute and figured
bass, nine sonatas for two violins, or violin and flute with figured
bass, and seven sonatas, opus 5, for two instruments, probably
intended for two violins.
But the polyphonic style of the sonatas for violin alone is peculiarly a
German inheritance. Walter and Biber were conspicuous for the use
of double stops and an approach to polyphonic style. Most
remarkable of all was a pupil of the old Danish organist, Buxtehude,
Nikolaus Bruhns (1665-1697), who was able to play two parts on his
violin and at the same time add one or two more with his feet on the
organ pedals. Though Corelli touched gently upon the polyphonic
style in the movements of the first six of his solo sonatas, the
polyphonic style was maintained mostly by the Germans. As Bach
would write chorus, fugue, or concerto in this style, so did he write
for the violin alone.
Of the six works the first three are sonatas, in the sense of the
sonate da chiesa of Corelli, serious and not conspicuously
rhythmical. The last three are properly suites, for they consist of
dance movements. The most astonishing of all the pieces is the
Chaconne, at the end of the second suite. Here Bach has woven a
series of variations over a simple, yet beautiful, ground, which finds
an equal only in the great Passacaglia for the organ.
There are besides these sonatas for violin alone, six sonatas for
harpsichord and violin, which are among the most beautiful of his
compositions; and a sonata in E minor and a fugue in G minor for
violin with figured bass. It is interesting to note that the six sonatas
for harpsichord and violin differ from similar works by Corelli and by
Handel. Here there is no affair with the figured bass; but the part for
the harpsichord is elaborately constructed, and truly, from the point
of view of texture, more important than that for the violin.
Bach wrote at least five concertos for one or two violins during his
stay at Cöthen. One of these is included among the six concertos
dedicated to the Margrave of Brandenburg. All of these have been
rearranged for harpsichord, and apparently among the harpsichord
concertos there are three which were originally for violin but have not
survived in that shape. The concertos, even more than the sonatas,
are not essentially violin music, but are really organ music. The style
is constantly polyphonic and the violin solos hardly stand out
sufficiently to add a contrasting spot of color to the whole. Bach’s
great work for the violin was the set of six solo sonatas. These must
indeed be reckoned, wholly apart from the instrument, as among the
great masterpieces in the musical literature of the world.
The young Mozart was hardly less proficient on the violin than he
was on the harpsichord, a fact not surprising in view of his father’s
recognized skill as a teacher in this special branch of music. But he
seems to have treated his violin with indifference and after his
departure from Salzburg for Paris to have quite neglected his
practice, much to his father’s concern. The most important of his
compositions for the violin are the five concertos written in Salzburg
in 1775. They were probably written for his own use, but just how
closely in conjunction with the visit of the Archduke Maximilian to
Salzburg in April of that year cannot be stated positively. Several
serenades and the little opera, Il re pastore, were written for the fêtes
given in honor of the same young prince. The concertos belong to
the same period. In Köchel’s Index they are numbers 207, 211, 216,
218, and 219. A sixth, belonging to a somewhat later date, bears the
number 268. Of these the first in B-flat was completed on April 14,
1775, the second, in D, June 14, the third, in G, September 12, the
fourth, in D, in October, and the fifth, in A, quite at the end of the
year.
On the other hand, we have found the violin masters like Corelli and
Tartini writing sonatas for violin, with figured bass for harpsichord,
lute, or even viol. Such sonatas were often called solo sonatas, as in
the case of those of Handel, recently mentioned. The accompanying
instrument had no function but to add harmonies, and a touch of
imitation in the written bass part, here and there.
Between these two extremes lies the sonata with harpsichord
obbligato, that is to say, with a harpsichord part which was not an
accompaniment but an essential part of the whole. In these cases
the music was generally polyphonic in character. The violin might
carry one or two parts of the music, the harpsichord two or three.
Very frequently, if the instruments played together no more than
three parts, the composition was called a Trio. The sonatas by J. S.
Bach for harpsichord and violin are of this character. Though the
harpsichord carries on more of the music than the violin, both
instruments are necessary to the complete rendering of the music.
Mozart must have frequently added improvised parts for the violin to
many of his sonatas written expressly for the keyboard instrument.
Among his earliest works one finds sonatas for clavecin with a free
part for violin, for violin or flute, for violin or flute and 'cello. Oftenest
the added part does little more than duplicate the melody of the part
for clavecin, with here and there an imitation or a progression of
thirds or sixths. But among his later works are sonatas for pianoforte
with added accompaniment for violin in which the two instruments
contribute something like an equal share to the music, which are the
ancestors of the sonatas for violin and piano by Beethoven, Brahms,
and César Franck. Among the most important of these are six
published in November, 1781, as opus 2. In Köchel’s Index they bear
the numbers 376, 296, 377, 378, 379, and 380. The greatest of them
is that in C major, K. 296, with its serious and rich opening adagio, its
first allegro in Mozart’s favorite G minor, and the beautiful variations
forming the last movement. Four more sonatas, of equal musical
value, were published respectively in 1784, 1785, 1787, and 1788.
VII
Looking back over the eighteenth century one cannot but be
impressed by the independent growth of violin music. The Italians
contributed far more than all the other nationalities to this steady
growth, partly because of their native love for melody and for sheer,
simple beauty of sound. The intellectual broadening of forms, the
intensifying of emotional expressiveness by means of rich and
poignant harmonies, concerned them far less than the perfecting of a
suave and wholly beautiful style which might give to the most singing
of all instruments a chance to reveal its precious and almost unique
qualities. This accounts for the calm, classic beauty of their music,
which especially in the case of Corelli and Tartini does not suffer by
changes that have since come in style and the technique of
structure.
Perhaps only in the case of Chopin can one point to such a pure and
in a sense isolated ideal in the development of music for a single
instrument, unless the organ works of Bach offer another exception.
And already in the course of the eighteenth century one finds here
and there violin music that has more than a special significance. The
sonatas for unaccompanied violin by Bach must be regarded first as
music, then as music for the violin. The style in which they were
written is not a style which has grown out of the nature of the
instrument. They have not served and perhaps cannot serve as a
model for perfect adaptation of means to an end. Bach himself was
willing to regard the ideas in them as fit for expression through other
instruments. But the works of Corelli, Tartini, Nardini and Viotti are
works which no other instrument than that for which they were
written may pretend to present. And so beautiful is the line of melody
in them, so warm the tones which they call upon, that there is
scarcely need of even the harmonies of the figured bass to make
them complete.
[50] See ‘W. A. Mozart,’ by T. de Wyzewa and G. de St. Foix, Paris, 1912.
Appendix II, Vol. II, p. 428.
CHAPTER XIII
VIOLIN MUSIC IN THE NINETEENTH
CENTURY
The perfection of the bow and of the classical technique—The
French school: Kreutzer, Rode, and Baillot—Paganini: his
predecessors, his life and fame, his playing, and his compositions
—Ludwig Spohr: his style and his compositions; his pupils—
Viennese violinists: Franz Clement, Mayseder, Boehm, Ernst and
others—The Belgian school: De Bériot and Vieuxtemps—Other
violinist composers: Wieniawski, Molique, Joachim, Sarasate, Ole
Bull; music of the violinist-composers in general—Violin music of
the great masters.
The art of violin music in the nineteenth century had its head in
Paris. Few violinists with the exception of Paganini developed their
powers without the model set them by the great French violinists at
the beginning of the century. Most of them owed more than can be
determined to the influence of Viotti. Even Spohr, who with more or
less controversial spirit, wrote of the French violinists as old-
fashioned, modelled himself pretty closely upon Rode; and therefore
even Spohr is but a descendant of the old classical Italian school.
I
Something may now be said of these men, whose activities have
without exception the glaring background of the horrors of the
French Revolution. Though Kreutzer was of German descent, he
was born in Versailles (1766) and spent the greater part of his life in
and about Paris, intimately associated with French styles and
institutions. Apart from early lessons received from his father, he
seems to have been for a time under the care of Anton Stamitz, son
of Johann Stamitz. At the Chapelle du Roi, to which organization he
obtained admittance through the influence of Marie Antoinette, he
had the occasion of hearing Viotti. The great Italian influenced him
no less than he influenced his young contemporaries in Paris.
Concerning his activities as a composer of operas little need be said,
though one or two of his ballets, especially Paul et Virginie and Le
Carnaval de Venise, held the stage for some years. As a player he
ranks among the most famous of the era. His duets with Rode
roused the public to great enthusiasm. In 1798 he was in Vienna in
the suite of General Bernadotte, and here made the acquaintance of
Beethoven. Subsequently Beethoven dedicated the sonata for violin
and piano (opus 47) to Kreutzer.