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Clinical
Reasoning in
Musculoskeletal
Practice
SECOND EDITION
MARK A JONES BSc(Psych)

PT GradDipManipTher MAppSc
Senior Lecturer, Program Director, Master of Advanced Clinical Physiotherapy,
School of Health Sciences, University of South Australia, Adelaide, Australia
DARREN A RIVETT BAppSc(Phty)

GradDipManipTher MAppSc(ManipPhty) PhD
Professor, School of Health Sciences, University of Newcastle, Callaghan,
New South Wales, Australia
FOREWORD BY
ANN MOORE CBE

Professor Emerita, School of Health Sciences,
University of Brighton, Brighton, UK
Director of the Council for Allied Health Professions Research (CAHPR)
Edinburgh London New York Oxford Philadelphia St Louis Sydney Toronto 2019
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Notices
Knowledge and best practice in this field are constantly changing. As new research and experience
broaden our understanding, changes in research methods, professional practices, or medical treatment
may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating
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Contents
Foreword viii
Preface ix
Contributors xi
Introduction xv
SECTION 1
Key Theory Informing Clinical Reasoning in
Musculoskeletal Practice 1
1 Clinical Reasoning: Fast and Slow Thinking in Musculoskeletal
Practice 2
Mark A. Jones
2 Understanding Pain in Order to Treat Patients in Pain 32

Mark J. Catley • G. Lorimer Moseley • Mark A. Jones
3 Influence of Stress, Coping and Social Factors on Pain and Disability in

Amy S. Hammerich • Susan A. Scherer • Mark A. Jones
4 Assessment, Reasoning and Management of Psychological Factors in

Jason M. Beneciuk • Steven Z. George • Mark A. Jones
5 Clinical Prediction Rules: Their Benefits and Limitations in Clinical

Reasoning 89
Robin Haskins • Chad E. Cook • Peter G. Osmotherly • Darren A. Rivett
SECTION 2
Clinical Reasoning in Action: Case Studies From Expert
Musculoskeletal Practitioners 104
6 A Multifaceted Presentation of Knee Pain in a 40-Year-Old Woman 105
Jenny McConnell • Darren A. Rivett
7 Lateral Elbow Pain With Cervical and Nerve-Related Components 118

Robert J. Nee • Michel W. Coppieters • Mark A. Jones
8 Nonspecific Low Back Pain: Manipulation as the Approach to

Management 137
Timothy W. Flynn • Bill Egan • Darren A. Rivett • Mark A. Jones
9 Chronic Facial Pain in a 24-Year-Old University Student: Touch-Based

Therapy Accessed via Auditory Pathways 150
G. Lorimer Moseley • Mark A. Jones
v
vi Contents
10 Targeting Treatment Distally at the Foot for Bilateral Persistent

Patellofemoral Pain in a 23-Year-Old: A New Answer to an Old
Problem? 164
Mark Matthews • Bill Vicenzino • Darren A. Rivett
11 Post-Partum Thoracolumbar Pain With Associated Diastasis Rectus

Abdominis 179
Diane G. Lee • Mark A. Jones
12 A Construction Project Manager With Insidious Onset of Lateral Hip

Pain 198
Alison Grimaldi • Rebecca Mellor • Kim L. Bennell • Darren A. Rivett
13 A Pain Science Approach to Postoperative Lumbar Surgery

Rehabilitation 220
Adriaan Louw • Ina Diener • Mark A. Jones
14 A Lawyer With Whiplash 241

Gwendolen Jull • Michele Sterling • Darren A. Rivett • Mark A. Jones
15 Management of Profound Pain and Functional Deficits From Achilles

Insertional Tendinopathy 259
Ebonie Rio • Sean Docking • Jill Cook • Mark A. Jones
16 Cervicogenic Headache 276

Toby Hall • Darren A. Rivett • Mark A. Jones
17 Shoulder Pain: To Operate or Not to Operate? 294

Jeremy Lewis • Eric J. Hegedus • Mark A. Jones
18 Post-Traumatic Neck Pain, Headache and Knee Pain Following a

Cycling Accident 318
Rafael Torres Cueco • Darren A. Rivett • Mark A. Jones
19 Orofacial, Nasal Respiratory and Lower-Quarter Symptoms in a

Complex Presentation With Dental Malocclusion and Facial
Scoliosis 347
Harry J. M. von Piekartz • Mariano Rocabado • Mark A. Jones
20 Cervical Radiculopathy With Neurological Deficit 373

Helen Clare • Stephen May • Darren A. Rivett
21 Incontinence in an International Hockey Player 385

Patricia Neumann • Judith Thompson • Mark A. Jones
22 Neck and Upper Extremity Pain in a Female Office Assistant: Where

Does the Problem Lie? 405
Jodi L. Young • Joshua A. Cleland • Darren A. Rivett • Mark A. Jones
23 Managing a Chronic Whiplash Problem When the Patient Lives 900

Kilometres Away 421
Jochen Schomacher • Mark A. Jones
24 A Professional Football Career Lost: Chronic Low Back Pain in a

22 Year Old 443
Peter O’Sullivan • Darren A. Rivett
Contents vii
25 Applying Contemporary Pain Neuroscience for a Patient With

Maladaptive Central Sensitization Pain 455
Jo Nijs • Margot De Kooning • Anneleen Malfliet • Mark A. Jones
26 Thoracic Spine Pain in a Soccer Player: A Combined Movement Theory

Approach 471
Christopher McCarthy • Darren A. Rivett
27 Incorporating Biomechanical Data in the Analysis of a University

Student With Shoulder Pain and Scapula Dyskinesis 483
Ricardo Matias • Mark A. Jones
28 Acute Exacerbation of Chronic Low Back Pain With Right-Leg

Numbness in a Crop Farmer 504
Christopher R. Showalter • Darren A. Rivett • Mark A. Jones
29 Physical Therapy Chosen over Lumbar Microdiscectomy: A Functional

Movement Systems Approach 526
Kyle A. Matsel • Kyle Kiesel • Gray Cook • Mark A. Jones
30 A 30-Year History of Left-Sided ‘Chronic Sciatica’ 552

Alan J. Taylor • Roger Kerry • Darren A. Rivett
SECTION 3
Learning and Facilitating Clinical Reasoning 561
31 Strategies to Facilitate Clinical Reasoning Development 562
Nicole Christensen • Mark A. Jones • Darren A. Rivett
APPENDIX 1 Clinical Reasoning Reflection Form 583

APPENDIX 2 Clinical Reasoning Reflection Worksheet 586
Index 601
Foreword
This book, Clinical Reasoning in Musculoskeletal Practice, is the second edition of a book
published in 2004 by Mark Jones and Darren Rivett. The title of the first version was
Clinical Reasoning for Manual Therapists. It is very welcome to see the development of this
title – recognizing the spread of approaches that musculoskeletal physiotherapists now
take in addition to manual therapy which is still an important and fundamental approach.
The book is of extreme relevance and importance to all practitioners dealing with
musculoskeletal issues in clinical practice on a daily basis. The book is also highly relevant
for clinical educators; academics focused on musculoskeletal science and practice in
educational, as well as clinical settings; and, of course, for students, whether at undergraduate
or postgraduate level.
It is exciting to see how clinical reasoning and decision-making theories have developed
over the last 15 years or so, and this book captures these theoretical developments and
also captures the clinical relevance and applications of these theories. Mark Jones and
Darren Rivett have very successfully brought together 52 authors who are well known in
the field of musculoskeletal physiotherapy. Importantly, the authors are based in 12 countries
from across the world, which thus represents an international perspective on clinical
reasoning.
The book contains three sections. Section 1 contains five chapters which focus on key
theories which inform clinical reasoning in musculoskeletal practice. This section is a
fundamental read before moving on into the next section: ‘Clinical Reasoning in Action:
Case Studies From Musculoskeletal Practitioners’. Section 2 consists of 25 chapters with
each one focusing on a different musculoskeletal condition and demonstrating considerable
complexities. Each case study includes a history of the patient’s condition, examination
findings, their treatment approaches, and their outcomes. In addition Mark Jones and
Darren Rivett worked with the lead author of each of these chapters to explore their clinical
reasoning throughout the case study, and finally, they provide a clinical reasoning commentary
which links the clinician’s reasoning to the five theoretical chapters in Section 1.
Finally, Chapter 31 (Section 3) is a very useful chapter on strategies to facilitate clinical
reasoning development, and readers will also find the two appendices very helpful in
practice, as they contain a clinical reflection form and a clinical reasoning reflection
worksheet.
This book is certainly a must-read for all those interested in musculoskeletal practice,
and I would like to thank Mark and Darren for producing such a valuable contribution
to the musculoskeletal field. I would also like to thank all the contributors to the book,
who provide important insights and inspiration for us all.
Professor Emerita Ann P Moore CBE PhD FCSP FMACP Dip TP Cert Ed.
School of Health Sciences, University of Brighton, Brighton, UK
viii
Preface
We published our first edition of Clinical Reasoning for Manual Therapists, focused on making
expert clinical reasoning explicit through case studies, in 2004. Clearly there was a great
need for such a resource, both in formal musculoskeletal educational programs and as a
stimulus for informal professional development in clinical reasoning, as the book has been
widely adopted internationally and has stood the test of time. Since then, however, there
has been significant continued growth in the research evidence musculoskeletal clinicians
are expected to know and use and an increase in the understanding of pain science.
Associated with this growth in empirical research and understanding of pain has been a
parallel increase in the emphasis on psychosocial assessment, pain education and cognitive-
behavioural management. Of course, the clinical reasoning theory has also accordingly
adapted and progressed in this time.
The political pressure for research- and evidence-based practice is greater than ever,
increasingly in an attempt to justify cost-cutting measures in health care. This is despite
the plethora of systematic reviews now available concluding, more often than not, that
there is insufficient high-level research to judge what managements are best. Similarly, the
relatively recent rise in musculoskeletal practice of clinical prediction rules – statistically
derived clinical tools designed to assist in decision making – has generated much interest,
particularly amongst less experienced clinicians and those not well versed in clinical reasoning.
However, there is growing concern that clinical prediction rules are being adopted as a
‘lazy man’s’ substitute for clinical reasoning and are being prematurely adopted by clinicians
and required by funding bodies despite usually not having been fully validated and scientifi-
cally demonstrated to have a positive impact.
Conversely, pain science and chronic pain or disability research convincingly highlight
the importance of musculoskeletal practitioners increasing their skills in psychosocial
assessment and management. Although formal classroom education in these areas is increasing
at the pre- and post-professional levels, it is still arguably less developed and often not
well integrated into the clinical practice components of the curriculum. A key challenge
to musculoskeletal education and clinical practice is to strengthen this important area
without diminishing the knowledge and procedural skills essential to ‘hands-on’ physical
assessment and treatment. Indeed, physiotherapy ‘hands-on’ procedural skills may be
under threat from those who promote education (e.g. in pain management) as a replacement
for established physical therapies, rather than something that needs to be integrated with
those same therapies (Jull and Moore, 2012; Edwards and Jones, 2013). Arguably, skilled
clinical reasoning is more important than ever because of the external pressures for greater
efficiency and quality patient outcomes.
In this book, the theory underpinning clinical reasoning has been significantly expanded
from the previous edition to include the following completely new chapters:
Chapter 1: Clinical reasoning: fast and slow thinking in musculoskeletal practice
Chapter 2: Understanding pain in order to treat patients in pain
Chapter 3: Influence of stress, coping and social factors on pain and disability in musculo
skeletal practice
Chapter 4: Assessment, reasoning and management of psychological factors in musculoskeletal
practice
Chapter 5: Clinical prediction rules: their benefits and limitations in clinical reasoning
Chapter 31: Strategies to facilitate clinical reasoning development
Aside from these six theory chapters, the bulk of the book is comprised of 25 new case
study chapters of real patients, presented from their initial appointment through to discharge.
In each case chapter, Mark and/or Darren worked with the clinical authors to explore their
clinical reasoning throughout the case, then provided a Clinical Reasoning Commentary
that links aspects of the clinical authors’ reasoning to the theory chapters. The overarching
ix
x Preface
aim is to ‘bring to life’ the clinical reasoning theory and underpinning sciences in the
context of a real-world clinical problem. Contributing clinical authors were invited on the
basis of their world-renowned expertise in the case area, with representation of both spinal
and peripheral musculoskeletal cases, multiple clinical approaches and authors from around
the globe. Although the ‘hypothesis categories’ framework presented in Chapter 1 was
used as the basis for the majority of questions asked of clinical authors, they were not
provided with this or any of the other theory chapters when writing their cases or answering
the Reasoning Questions – that is, they were not prompted or required to conform to any
of the theory presented in the first five chapters.
With such a diverse group of contributing clinical authors, there are, understandably,
differences in the examination information obtained and forms of treatment used. However,
despite this variability, there is considerable similarity across the cases with respect to their
thoroughness in examination, scope of clinical reasoning and individually tailored manage-
ment, informed by both research and experience-based evidence. Although the language
used to report the cases and answer the Reasoning Questions also varies somewhat across
the cases, consistent with the clinical reasoning promoted in the theory chapters, the reasoning
presented throughout the cases is also holistic, biopsychosocial, collaborative and patient
centred. Attention to both the physical and the psychosocial presentation is consistently
evident, along with management that promotes patient understanding and self-efficacy.
It should be apparent by now to the discerning reader why we have modified the title
of the book from the original Clinical Reasoning for Manual Therapists to Clinical Reasoning
in Musculoskeletal Practice in this edition. The breadth of clinical practice in the musculoskeletal
field has clearly changed significantly since 2004, and the title change is an attempt to
reflect just that while still embracing manual therapy as a core skill for the musculoskeletal
practitioner.
Finally, we would like to express our sincere gratitude to the many contributing authors,
both of the theoretical chapters and of the clinical reasoning cases. Although the gestation
of this second edition has been rather more protracted than anticipated, they have uniformly
demonstrated great patience and ongoing enthusiasm for this new edition of the book.
Mark A. Jones
Adelaide, Australia, 2019
Darren A. Rivett
Newcastle, Australia, 2019
REFERENCES
Edwards, I., Jones, M., 2013. Movement in our thinking and our practice. Manual Ther 18 (2), 93–95.
Jull, G., Moore, A., 2012. Hands on, hands off? The swings in musculoskeletal physiotherapy practice. Man Ther
17 (3), 199–200.
Contributors
Jason M. Beneciuk DPT PhD MPH Jill Cook BAppSci(Phty)

Research Assistant Professor, Department PGDip(Manips) PhD
of Physical Therapy, College of Public GradCertHigherEd
Health and Health Professions, University Professor, La Trobe University Sport and
of Florida, Gainesville, Florida; Clinical Exercise Medicine Centre, La Trobe
Research Scientist, Brooks Rehabilitation, University, Bundoora, Victoria, Australia
Jacksonville, Florida, USA
Michel W. Coppieters PT PhD
Kim L. Bennell BAppSci(Physio) PhD Professor, Menzies Foundation Professor
Redmond Barry Distinguished Professor, of Allied Health Research, Griffith
Centre for Health, Exercise and Sports University, Brisbane and Gold Coast,
Medicine, Department of Physiotherapy, Queensland, Australia; Professor,
University of Melbourne, Melbourne, Amsterdam Movement Sciences, Faculty
Victoria, Australia of Behavioural and Movement Sciences,
Vrije Universiteit Amsterdam, Amsterdam,
Mark J. Catley BPhysio(Hons) PhD The Netherlands
Lecturer, School of Health Sciences,
University of South Australia, Adelaide, Margot De Kooning PhD
Australia Researcher, Department of Physiotherapy,
Human Physiology and Anatomy (KIMA),
Nicole Christensen BS BA PT Faculty of Physical Education and
MAppSc PhD Physiotherapy, Vrije Universiteit Brussel
Professor and Chair, Department of (VUB), Brussels, Belgium; Physiotherapist,
Physical Therapy, Samuel Merritt Department of Physical Medicine and
University, Oakland, California, USA Physiotherapy, University Hospital
Brussels, Brussels, Belgium; Member, Pain
Helen Clare DipPhty in Motion International Research Group
GradDipManipTher MAppSc
DipMD&T PhD FACP Ina Diener BSc(Physio) PhD
Director of Education, McKenzie Institute Part-Time Senior Lecturer, Stellenbosch
International, Sydney, New South Wales, University, Stellenbosch and University
Australia of the Western Cape, Cape Town,
South Africa
Joshua A. Cleland PT PhD
Professor, Franklin Pierce University, Sean Docking BHSc(Hons) PhD
Physical Therapy Program, Manchester, Postdoctoral Research Fellow, La Trobe
New Hampshire, USA University Sport and Exercise Medicine
Centre, La Trobe University, Bundoora,
Chad E. Cook PT PhD FAAOMPT Victoria, Australia
Professor and Program Director, Duke
Doctor of Physical Therapy Program, Bill Egan PT DPT OCS FAAOMPT
Duke University School of Medicine, Associate Professor of Instruction,
Duke Clinical Research Institute, Department of Physical Therapy, College
Durham, North Carolina, USA of Public Health, Temple University,
Philadelphia, Pennsylvania, USA
Gray Cook MSPT OCS CSCS
Founder, Functional Movement Systems,
Chatham, Virginia, USA
xi
xii Contributors
Timothy W. Flynn PT PhD OCS Gwendolen Jull AO MPhty PhD FACP

FAAOMPT FAPTA Emeritus Professor, Physiotherapy, School
Professor of Physical Therapy, South of Health and Rehabilitation Sciences,
College, Knoxville, Tennessee; Owner & University of Queensland, Brisbane,
Clinician, Colorado In Motion, Fort Australia
Collins, Colorado, USA
Roger Kerry PhD FMACP
Steven Z. George PT PhD FAPTA Associate Professor, Division of
Professor and Director of Musculoskeletal Physiotherapy and Rehabilitation
Research, Duke Clinical Research Institute Sciences, University of Nottingham,
and Vice Chair of Clinical Research, Nottingham, UK
Department of Orthopaedic Surgery,
Duke University School of Medicine, Kyle Kiesel PT PhD
Durham, North Carolina, USA Professor and Chair of Physical Therapy,
College of Education and Health
Alison Grimaldi BPhty MPhty(Sports) Sciences, University of Evansville,
PhD Evansville, Indiana, USA
Adjunct Research Fellow, University of
Queensland, Brisbane, Queensland; Diane G. Lee BSR FCAMT CGIMS
Practice Principal, Physiotec, Brisbane, Clinician and Consultant, Diane Lee &
Australia Associates, Surrey, British Columbia;
Curriculum Developer and Lead
Toby Hall PT PHD MSc FACP Instructor, Learn with Diane Lee, Surrey,
Adjunct Associate Professor, School of British Columbia, Canada
Physiotherapy and Exercise Science,
Curtin University, Perth; Senior Teaching Jeremy Lewis PhD FCSP
Fellow, The University of Western Professor of Musculoskeletal Research,
Australia, Perth, Australia University of Hertfordshire, Hertfordshire,
UK; Consultant Physiotherapist, MSK
Amy S. Hammerich PT DPT PhD Sonographer and Independent Prescriber,
OCS GCS FAAOMPT Central London Community Healthcare
Associate Professor, School of Physical NHS Trust, London, UK
Therapy, Regis University, Denver,
Colorado, USA Adriaan Louw PT PhD
Owner and CEO, International Spine and
Robin Haskins BPhty(Hons) PhD Pain Institute, Story City, Iowa, USA
Physiotherapist, John Hunter Hospital,
Newcastle, New South Wales; Conjoint Anneleen Malfliet PT MSc
Lecturer, School of Health Sciences, Physiotherapist, Research Foundation
University of Newcastle, Callaghan, – Flanders (FWO), Brussels; PhD
New South Wales, Australia Researcher, Vrije Universiteit Brussel
(VUB), Brussels, and Ghent University,
Eric J. Hegedus PT DPT PhD OCS Ghent; Physiotherapist, University
Professor and Chair, High Point Hospital Brussels, Brussels, Belgium;
University, Department of Physical Member, Pain in Motion International
Therapy, High Point, North Carolina, Research Group
USA
Ricardo Matias PT PhD
Mark A. Jones BSc(Psych) PT Researcher, Champalimaud Research,
GradDipManipTher MAppSc Champalimaud Centre for the Unknown,
Senior Lecturer, Program Director, Master Lisbon; Lecturer, Physiotherapy
of Advanced Clinical Physiotherapy, Department, School of Health,
School of Health Sciences, University of Polytechnic Institute of Setúbal, Setúbal,
South Australia, Adelaide, Australia Portugal
Contributors xiii
Kyle A. Matsel PT DPT SCS CSCS Jo Nijs PT MT PhD

Assistant Professor of Physical Therapy, Professor of Physiotherapy and
University of Evansville, Evansville, Physiology, Department of Physiotherapy,
Indiana, USA Anatomy and Human Physiology, Faculty
of Physical Education and Physiotherapy,
Mark Matthews MPhty(Musc) BPhty Vrije Universiteit Brussel (VUB), Brussels,
PhD candidate, University of Queensland, Belgium; Member, Pain in Motion
Brisbane, Australia International Research Group
Stephen May MA MSc PhD FCSP Peter G. Osmotherly BSc

Reader in Physiotherapy, Sheffield Hallam GradDipPhty MMedSci(ClinEpi) PhD
University, Sheffield, South Yorkshire, UK Senior Lecturer in Physiotherapy,
University of Newcastle, Callaghan,
Christopher McCarthy New South Wales, Australia
PGDip(Biomech) PGDip(ManTher)
PGDip(Phty) PhD FMACP FCSP Peter O’Sullivan DipPhysio
Clinical Fellow, Manchester School of GradDipManipTher PhD FACP
Physiotherapy, Manchester Metropolitan Professor, School of Physiotherapy and
University, Manchester, UK Exercise Science, Curtin University, Perth,
Australia
Jenny McConnell AM BAppSci(Phty)
GradDipManTher MBiomedEng FACP Ebonie Rio BAppSci BPhysio(Hons)
Practice Principal, McConnell MSportsPhysio PhD
Physiotherapy Group, Mosman, Postdoctoral Research Fellow, La Trobe
New South Wales, Australia University Sport and Exercise Medicine
Centre, La Trobe University, Bundoora,
Rebecca Mellor BPhty(Hons) Victoria, Australia
MPhty(Musc) PhD
NHMRC Senior Academic Research Darren A. Rivett BAppSc(Phty)
Officer, School of Health and GradDipManipTher
Rehabilitation Sciences, University of MAppSc(ManipPhty) PhD
Queensland, Brisbane, Queensland, Professor, School of Health Sciences,
Australia University of Newcastle, Callaghan,
New South Wales, Australia
G. Lorimer Moseley DSc PhD FAHMS
FACP HonFPMANZCA HonMAPA Mariano Rocabado PT DPT PhD
Professor of Clinical Neuroscience and Professor, Faculty of Dentistry, University
Foundation Chair in Physiotherapy, of Chile; Director, Rocabado Institute,
University of South Australia, Adelaide; Santiago, Chile
NHMRC Principal Research Fellow
Susan A. Scherer PT PhD
Robert J. Nee PT PhD MAppSc Professor, Rueckert-Hartman College of
Professor, School of Physical Therapy and Health Professions, Regis University,
Athletic Training, Pacific University, Denver, Colorado, USA
Hillsboro, Oregon, USA
Jochen Schomacher PT OMT MCMK
Patricia Neumann DipPhysio PhD DPT BSc MSc PhD
FACP Freelance teacher of physiotherapy and
Lecturer, School of Health Sciences, manual therapy, Erlenbach ZH,
University of South Australia, Adelaide, Switzerland
Australia
xiv Contributors
Christopher R. Showalter PT DPT OCS Bill Vicenzino BPhty

FAAOMPT GradDipSportsPhty MSc PhD
Owner and Program Director, MAPS Professor of Sports Physiotherapy, School
Fellowship in Orthopedic Manual of Health and Rehabilitation Sciences,
Therapy, Mattituck, New York, USA University of Queensland, Brisbane,
Queensland, Australia
Michele Sterling BPhty MPhty
GradDipManipPhysio PhD FACP Harry J. M. von Piekartz BSc MSc PT
Director, NHMRC Centre of Research MT PhD
Excellence in Road Traffic Injury Professor of Physiotherapy and Study
Recovery; Associate Director, Recover Director, Master of Science
Injury Research Centre, University of musculoskeletal Programm, University of
Queensland, Herston, Queensland, Applied Science, Osnabrück, Germany;
Australia Senior Lecturer in Musculoskeletal
Therapy, International Maitland Teacher
Alan J. Taylor MSc MCSP Association (IMTA), Cranial Facial
Assistant Professor, Physiotherapy and Therapy Academy (CRAFTA) and Neuro
Rehabilitation, Faculty of Medicine & Orthopaedic Institute (NOI); private
Health Sciences, University of practitioner in specialized musculoskeletal
Nottingham, Nottingham, UK therapy, Ootmarsum, the Netherlands
Judith Thompson DipPhysio Jodi L. Young PT DPT OCS FAAOMPT

PGDip(Continence & Women’s Associate Professor of Physical Therapy,
Health) PhD FACP A.T. Still University, Mesa, Arizona, USA
Lecturer, Faculty of Health Sciences,
School of Physiotherapy and Exercise
Science, Curtin University, Perth,
Australia
Rafael Torres Cueco PT PhD

Professor, Department of Physiotherapy,
University of Valencia, Spain; Director of
Master’s Program on Manual Therapy,
University of Valencia; President and
founder of the Spanish Society of
Physiotherapy and Pain (Sociedad
Española de Fisioterapia y Dolor SEFID);
Facilitator, WCPT Physical Therapy Pain
Network; Instructor, Neuro Orthopaedic
Institute (NOI); Member of the Spanish
Pain Society
Introduction
This new edition of our book is intended for all clinicians in musculoskeletal practice who
wish to improve their skills in clinical reasoning and decision-making by learning from
the reasoning of some of the most acclaimed clinicians in the world and by ensuring the
knowledge supporting their reasoning is comprehensive and contemporary. Musculoskeletal
practitioners all along the spectrum of clinical expertise and experience will benefit from
integrating the latest theory and science as they engage in reasoning through detailed and
varied clinical cases. The book can stand alone as a resource or can be used in a comple-
mentary manner with other learning materials, and it lends itself to both individual study
and group learning activities designed to promote the learning of clinical reasoning.
Transformative learning theory (Cranton, 2006; Mezirow 2009, 2012) refers to the
process by which we use critical reflection to transform prior, taken-for-granted understandings
to make them more inclusive, open, reflective and discriminating. For the focus in this
book on improving your clinical reasoning skills, this requires an awareness of your current
understanding of reasoning and a critical reflection on clinical reasoning in practice as a
means of transforming your clinical understanding and potentially your clinical practice.
The initial new theory chapters on clinical reasoning; pain science; stress, coping and
social factors; psychological factors; and clinical prediction rules provide important knowledge
to underpin contemporary biopsychosocially based clinical reasoning in musculoskeletal
practice. As discussed in Chapters 1 and 5, human bias can undermine our judgements.
To reduce bias and improve clinical reasoning, it is critical to first understand your own
clinical reasoning, including the processes involved, different foci of reasoning attended
to and factors influencing clinical reasoning proficiency. In addition to the theory chapters,
the 25 new cases throughout this book should promote reflection and improve your
understanding of your own clinical reasoning as you compare your reasoning as each case
unfolds to that of the expert clinical authors, with accompanying reasoning commentary
linking back to the theory chapters. This should facilitate an improved breadth, depth and
accuracy of your clinical reasoning and clinical decisions, with the final chapter providing
further strategies to develop your clinical reasoning skills in an ongoing manner. We see
clinical reasoning as an essential professional competency and believe we need to study
and practice clinical reasoning alongside our other professional competencies.
Practising clinical reasoning, by reading the cases and reasoning explored through the
cases in this book (along with other strategies for facilitating clinical reasoning discussed
in Chapter 31), will improve your underpinning understanding and hopefully your own
clinical reasoning skills in actual clinical practice. To optimize that learning, the cases
should not simply be read passively. As Mezirow (2012) highlights, transformative learning
requires participation in constructive discourse to use the experience (and reasoning) of
others to elicit reflection and awareness of your own reasoning and associated assumptions.
Constructive discourse can occur by attempting to answer the Reasoning Questions posed
throughout the cases prior to reading the expert clinicians’ Answers to Reasoning Questions
and by comparing and critiquing your reasoning with the reasoning put forward during
the case. Even more stimulating and probably more beneficial is to engage in constructive
discourse of a case and its associated reasoning in small groups of two or more practitioners
or students.
Clinical reasoning in musculoskeletal practice is not an exact science with absolute
correct and incorrect judgements. That is, it is not essential to agree with all the reasoning
explained throughout the cases. What is important is that all cases present their assessment
and management with explicit reasoning for what is done. When comparing your own
reasoning to the case reasoning of the expert clinical authors, especially where differences
exist, readers should consider assumptions being made (both in the case reasoning and
your own) in assessments (e.g. information obtained versus not obtained), assessment
analysis (e.g. hypothesis substantiation and alternative hypotheses), management (e.g.
xv
xvi Introduction
clinical and research support provided, and alternative management options) and outcome
re-assessment (e.g. breadth of self-report and physical measures informing treatment progres-
sion and success generally). Rather than simply attempting to pick holes in the clinical
approach taken and the reasoning provided, readers are encouraged to suspend judgement
and ‘try on’ the different points of view put forward. This sort of open-minded constructive
discourse is important to both consolidating and varying your own perspectives. Practising
clinical reasoning through the cases in this manner will assist your application of the theory
covered in Chapters 1–5 and 31, to your reasoning in clinical practice, improving both
your integration of that theory and your clinical reasoning proficiency.
REFERENCES
Cranton, P., 2006. Understanding and Promoting Transformative Learning: A Guide for Educators of Adults,
second ed. Jossey-Bass Wiley, San Francisco, CA.
Mezirow, J., 2009. Transformative learning theory. In: Mezirow, J., Taylor, E.W., Associates (Eds.), Transformative
Learning in Practice: Insights From Community, Workplace, and Higher Education. Jossey-Bass Wiley, San
Francisco, CA, pp. 18–31.
Mezirow, J., 2012. Learning to think like an adult. Core concepts of transformative theory. In: Taylor, E.W.,
Cranton, P., Associates (Eds.), The Handbook of Transformative Learning: Theory, Research, and Practice.
Jossey-Bass, San Francisco, CA, pp. 73–95.
SECTION 1
Key Theory Informing
Clinical Reasoning in
1
1
Clinical Reasoning: Fast
and Slow Thinking in
Mark A. Jones
Introduction
In this chapter clinical reasoning in musculoskeletal practice is presented as being multi-
dimensional and involving fast, intuitive first impressions and slow, more analytical
deliberations. It is hypothesis oriented, dialectic, collaborative and reflective. Skilled clinical
reasoning contributes to clinicians’ learning and to the transformation of existing perspectives.
The scope of clinical reasoning is presented through discussion of three key frameworks:
(1) biopsychosocial philosophy of practice, (2) clinical reasoning strategies and (3) hypothesis
categories. Cognitive processes involved in clinical reasoning (e.g. deduction, induction,
abduction) are explained, and key factors influencing skilled clinical reasoning and expertise
are discussed, including critical thinking, metacognition, knowledge organization, data
collection and procedural skills, and patient–therapist therapeutic alliance. Lateral thinking
is proposed as important to the generation of new ideas.
Why do we need to study and practice clinical reasoning? Nobel Laureate Daniel
Kahneman highlights the numerous biases of human judgment that occur due to quick
judgments and a lack of analytical thinking. He describes two broad forms of thinking:
fast (System 1) thinking characterized by automatic and effortless first impressions and
intuition (as with tacit pattern recognition) and slow (System 2) thinking characterized
by analytical deliberations requiring more attention, time and effort (Kahneman, 2011).
Both of these fictitious1 systems operate together, with System 1 running automatically and
System 2 normally in a low-effort mode. Our System 1 quick impressions receive minimal
scrutiny from our slower System 2 analysis, and if endorsed, those initial impressions
and intuitions turn into beliefs that lead to actions. More simply, you accept your fast
impressions as representing a prior belief without further scrutiny (note that this is true
for patients as well as clinicians). However, when System 1 runs into difficulty, as when
the representativeness of a finding (e.g. within a patient’s story, physical assessment or
outcome re-assessment) is unclear, contradictory or not what you expected, System 2 is
called upon for more attentive processing.
A wide range of errors (e.g. poor, inaccurate judgments) can be attributed to quick first
impressions and decisions based on insufficient information and lack of further deliberation.
For example, consider the following puzzle (Kahneman, 2011, p. 44) and your first
impression/intuition (without formally trying to solve it):
A bat and ball cost $1.10.

The bat costs one dollar more than the ball.
How much does the ball cost?
1
Kahneman highlights that his Systems 1 and 2 are fictitious in the sense that they are not systems in the convention
of entities with interacting aspects that can be simply attributed to one part of the brain or another. He explains
that the value of this distinction relates to the aptitude of our mind to better understand constructs presented
as stories with active agents, in this case Systems 1 and 2.
2
1 Clinical Reasoning: Fast and Slow Thinking in Musculoskeletal Practice 3
The quick, intuitive and wrong answer is 10 cents2 (50% of Harvard, MIT and Princeton
students studied got this wrong; 80% of students from less prestigious universities)
(Kahneman, 2011). Although heuristics, or shortcuts in thinking, work well in many
circumstances, if they go unchecked by more deliberative thinking, as with this example,
errors will occur.
When you consider that every patient cue perceived (verbal, visual, kinaesthetic) undergoes
some level of System 1 and/or System 2 processing, it is easy to appreciate the potential
for analogous errors in musculoskeletal clinical reasoning. For example:
Acromioclavicular joint (ACJ) pain is provoked with shoulder movement into horizontal
flexion.
Horizontal flexion provokes ACJ-area pain on active-movement testing.
The patient’s pain is due to nociception in the ACJ.
The patient reports mid-thoracic pain consistently provoked after sitting to eat lunch.
The patient reports sitting in fully slouched position when eating lunch.
Mid-thoracic pain is due to nociception associated with slouched sitting at lunch.
Inappropriate pain beliefs and cognitions contribute to nociplastic pain sensitization.

A patient has inappropriate pain beliefs and cognitions.
The patient has nociplastic pain sensitization.
These examples illustrate errors of deduction. Nociception from other structures can
be responsible for ACJ-area pain (e.g. subacromial tissues); other predisposing factors
than slouched sitting can precipitate mid-thoracic pain (e.g. gallbladder nociception
secondary to eating fatty foods); and inappropriate pain beliefs and cognitions can
also exist with nociceptive dominant pain. Although you may believe your System 2
would not uncritically endorse these System 1 conclusions without obtaining further
supporting information, it is a bit disheartening to contemplate the large number of
biases evidenced in health-related and non-health-related human judgment that Kahne-
man and others (e.g. Croskerry, 2003; Hogarth, 2005; Kahneman et al., 1982; Lehrer,
2009; Schwartz and Elstein, 2008) report. Some examples easily recognizable in clinical
practice include the following:
• The ‘priming’ influence of prior information (e.g. diagnosis provided in a referral, imaging
findings, influence of a recent publication or course)
• ‘Confirmation bias’, or the tendency to attend to and collect data that confirm existing
hypotheses
• ‘Memory bias’ of a spectacular successful outcome
• ‘Overestimation of representativeness’, as with the probability of a diagnosis given a
finding being confused with the probability of a finding given a diagnosis
• ‘Conservatism or stickiness’, where initial impressions and hypotheses are not revised
in the face of subsequent non-supporting information
The greater the coherence of our fast-thinking impressions, the more likely we are
to jump to conclusions without further System 2 analysis. Unfortunately, humans are
prone to find and accept coherence on the basis of limited information, so much so
that Kahneman (2011, p. 86) has characterized this trait associated with many of our
biases as ‘What You See Is All There Is’, that is, the assumption or acceptance that
the information at hand is all that is available. You build a story (explanation) from
the information you have, and if it is a good, coherent story, you believe it. Paradoxi-
cally, coherent stories are easier to construct when there is less information to make
sense of.
Although fast thinking is the source of many of our errors, ironically, it is also the
source of most of what we do right. When you break down the overall synthesis and
analysis of a patient’s presentation and consider the vast number of first-impression, fast-
thinking judgments that lead up to and inform our understanding of patients and their
2
If a ball is 10 cents and a bat is one dollar more ($1.10), then together they would be $1.20, not $1.10. The
ball is 5 cents.
4 SECTION 1 Key Theory Informing Clinical Reasoning in Musculoskeletal Practice
problems (e.g. quick recognition of when a patient’s telling of his or her story requires
clarification; patient discomfort and emotions; observed postural, movement and control
impairments; when additional physical testing is required for physical differentiation, etc.),
the ubiquity of our fast thinking is obvious. With appropriate training and experience, we
learn to effectively use our fast thinking to recognize potentially significant cues, interpret
contextualized meanings, recognize when clarification and further testing are required
to refine interpretations, and identify appropriate actions and solutions. The key is not
to deny the use of initial impressions and fast thinking but to build our skill with this
through quality practice and to be aware of the pitfalls and common errors of bias. One
of the foremost researchers in problem solving, Herbert Simon (also a Nobel Laureate),
perhaps best known for his seminal problem-solving research with chess masters, explains
intuition as ‘nothing more and nothing less than recognition’ (Simon, 1992, p. 155). That
is, accurate intuitions of experts are best explained by the effects of prolonged practice.
Although we articulate our judgments and make decisions through our analytical
thinking, that is not to say this system is without error. Our slow analytical thinking will
often simply endorse or rationalize ideas generated through our fast thinking (Kahneman,
2011). Research has demonstrated that experts function largely on pattern recognition
(e.g. Boshuizen and Schmidt, 2008; Jensen et al., 2007; Kaufman et al. 2008; Schwartz
and Elstein, 2008) and that overanalyzing also leads to errors in judgment (Lehrer, 2009;
Schwartz and Elstein, 2008). However, although not flawless, our slow analytical thinking
provides a backup, a check for our fast first impressions and pattern recognition that
reduces error and as such needs to be understood and developed, especially in areas of
uncertainty and complexity.
Kahneman concludes that humans need help to make more accurate judgments and
better decisions. We need to study and practice clinical reasoning, alongside our other
professional competencies, to improve the accuracy of both our fast and slow thinking.
Key Point
All thinking, including musculoskeletal clinical reasoning, involves a combination
of fast System 1 first impressions, inductions or pattern recognition and slow
System 2 deliberations, testing of hypotheses and deductions. Although errors
occur in both fast and slow thinking, bias in human judgment necessitates the use
of slow analytical thinking, particularly in areas of uncertainty and complexity, to
minimize error. An understanding of clinical reasoning and practice doing clinical
reasoning are needed to improve clinical reasoning proficiency and enhance the
application of core musculoskeletal-associated theory to clinical practice.
The Scope of Clinical Reasoning

Clinical reasoning can be defined as a reflective process of inquiry and analysis carried
out by a health professional in collaboration with the patient with the aim of understanding
the patient, the patient’s context and the patient’s clinical problem(s) in order to guide
evidence-based practice (Brooker, 2013, supplied by Mark Jones). Although more extensive
definitions are available (see Christensen and Nordstrom, 2013; Higgs and Jones, 2008),
this captures the broad essence of what we hope to promote in this book.
Musculoskeletal clinicians work with a multitude of problem presentations in a variety
of clinical practice environments (e.g. outpatient clinics, private practices, hospital- or
outpatient-based rehabilitation and pain unit teams, sports settings, home care and industrial
work sites). The clinical presentations they encounter are, therefore, varied, ranging from
discrete, well-defined problems amenable to technical solutions to complex, multifactorial
problems with uniqueness to the individual that defy the technical rationality of simply
applying a ‘proven’ protocol of management. Schön (1987, p. 3) characterizes this continuum
of professional practice as existing between the ‘high, hard ground of technical rationality’
and ‘the swampy lowland’ where ‘messy, confusing problems defy technical solution’. To
practise at both ends of the continuum clinicians must have good propositional (scholarly,
research based) and non-propositional (professional craft) knowledge as well as advanced
technical skills to solve problems of a discrete, well-defined nature. However, to understand
and manage successfully the ‘swampy lowland’ of complex patient problems requires a rich
blend of biopsychosocial knowledge and professional know-how, combined with personal

awareness of your own philosophy of practice, potential biases and diagnostic, procedural
and teaching skills. Contemporary musculoskeletal clinicians must have a high level of
knowledge and skills across a comprehensive range of competencies, including assessment,
management, communication (including teaching, negotiating, counselling), documentation
and professional, legal and ethical comportment. Effective performance within and across
these competencies requires a broad perspective of what constitutes health and disability
and equally broad skills in both diagnostic and non-diagnostic clinical reasoning.
Clinical Reasoning in a
Biopsychosocial Framework
The biopsychosocial framework was originally put forward by Engel (1977). As depicted
in the World Health Organization (WHO) International Classification of Functioning,
Disability and Health (ICF) model (WHO, 2001) (Fig. 1.1) the biopsychosocial perspective
recognizes that disability is the result of the cumulative effects of the biological health
condition (disease, illness, pathology, disorder), external environmental influences (e.g.
physical, social, economic, political, etc.) and internal personal influences (e.g. age, gender,
education, beliefs, culture, coping style, self-efficacy, etc.). This is in contrast to the reductionist
biomedical model that previously dominated medicine and musculoskeletal practice where
disease and illness were primarily attributed to pathogens, genetic or developmental
abnormalities or injury. By understanding disability as also being socially constructed, the
health professions, including musculoskeletal practice, expanded or made more explicit
the need for clinicians to understand all potential biopsychosocial influences and integrate
that understanding into their existing assessments, reasoning and management (e.g. Borrell-
Carrió et al., 2004; Edwards and Jones, 2007a, 2007b; Epstein and Borrell-Carrió, 2005;
Imrie, 2004; Jones et al., 2002; Jones and Edwards, 2008).
The contribution of psychosocial factors to the development, and particularly the
maintenance, of patients’ pain and disability and clinicians’ assessments of their patients’
psychosocial status is the focus of Chapters 3 and 4. For the purpose of this chapter, the
biopsychosocial framework illustrated in Fig. 1.1 is used to highlight the scope of knowledge,
skills and clinical reasoning required to fully understand our patients’ problems and our
patients themselves (i.e. the person behind the problem). The boxes across the middle of
the diagram depict the patient’s clinical presentation, incorporating physical impairments
of body functions and structures, restrictions and capabilities in functional activities and
restrictions and capabilities in the patient’s ability to participate in life situations (e.g. work,
family, sport, leisure) that collectively make up the patient’s disability. Bidirectional arrows
between the clinical presentation and the biomedical, environmental and personal influences
Health condition
(disorder or disease)
Body functions and Activities Participation

structures Capabilities and Capabilities and restrictions
e.g. physical impairments restrictions in function e.g. work, recreation, social
Environmental factors Personal factors

e.g. physical, social, e.g. education, beliefs,
economic, political, home culture, coping style,
and workplace conditions self-efficacy
Fig. 1.1 Adaptation of World Health Organization (WHO) International Classification of Functioning,
Disability and Health (ICF) framework. (Reproduced with permission [WHO, 2001, p. 18].)
reflect the reciprocal relationship whereby each has the potential to influence the other
(Borrell-Carrió et al., 2004; Duncan, 2000; Pincus, 2004). For example, where traditionally
functional restrictions, physical impairments and pain would have been conceptualized
as the end result of a specific injury/pathology or syndrome, the reciprocal arrows highlight
that these also can be associated with and even maintained by environmental and personal
influences. A holistic understanding of a patient’s clinical presentation therefore necessitates
attention and analysis of the patient’s physical health, environmental and personal factors.
Although musculoskeletal clinicians are generally well educated to assess and manage the
physical and many environmental dimensions of the patient’s health condition, formal
education and experience assessing, analysing and managing psychological and social
factors contributing to both acute and chronic pain is often less developed and less structured
(e.g. Barlow, 2012; Bishop and Foster, 2005; Foster and Delitto, 2011; Main and George,
2011; Overmeer et al., 2005; Sanders et al., 2013; Singla et al., 2014). The sociological
dimension of psychosocial in particular is generally given less attention as a factor contributing
to the pain experience (Blyth et al., 2007). A growing body of literature is now available
informing musculoskeletal clinicians’ psychosocial assessment and management (e.g. French
and Sim, 2004; Hasenbring et al., 2012; Johnson and Moores, 2006; Jones and Edwards,
2008; Keefe et al., 2006; Main et al., 2008; Muncey, 2002; Schultz et al., 2002; also see
Chapters 3 and 4) with literature also explicitly relating the WHO ICF to categorization
of clinical problems, clinical reasoning and management (e.g. Allet et al., 2008; Childs
et al., 2008; Cibulka et al., 2009; Edwards and Jones, 2007a; Escorpizo et al., 2010; Jette,
2006; McPoil et al., 2008; Steiner et al., 2002).
Being able to practice within a biopsychosocial framework requires different sets of
knowledge and clinical skills to be able to understand both the biological problems and
the environmental and personal factors that may predispose to the development or contribute
to the maintenance of the patient’s pain and disability experiences. As such, a distinction
can be made between understanding and managing the biological problem to effect change
versus understanding and interacting with the person to effect change. To assist clinicians’
application of biopsychosocial practice, we have promoted our evolving use of two frameworks
for guiding the focus of clinical reasoning required (clinical reasoning strategies) and the
categories of decisions required (hypothesis categories) (Edwards et al., 2004a; Jones,
1987, 2014; Jones et al., 2008).
Key Point
Conceptualizing disability as the cumulative effects of the biological health
condition (disease, illness, pathology, disorder), environmental influences (e.g.
physical and social) and personal influences (e.g. beliefs, culture, socio-economic,
education) highlights the scope of knowledge, skills and clinical reasoning
required to practice in a biopsychosocial framework. Musculoskeletal clinicians
are traditionally well educated in the assessment and management of physical and
environmental factors contributing to patients’ disabilities; however, formal
education and experience assessing, analysing and managing psychological and
social factors are often less developed and less structured. Psychosocial assessment
and management feature in varying degrees within the case studies of this book.
Attention to how psychosocial factors are screened, the reasoning used to
determine their contribution to individual patients’ clinical presentations and how
they are addressed in management will assist clinicians in further developing this
important component of their biopsychosocial practice.
Focus of Our Clinical Reasoning: Clinical

Reasoning Strategies
When students first consider clinical reasoning in musculoskeletal practice, they typically
only focus on diagnosis, with diagnosis itself often limited to categorizing the type of
problem, injury or pathology. When all potential influences present in the biopsychosocial
perspective (Fig. 1.1) are considered, as well as the reasoning required in the corresponding
management of identified influences, then clearly reasoning about diagnosis represents

only a portion of the reasoning that actually occurs in clinical practice. Research and theoretical
propositions across a range of health professions (e.g. physiotherapy, medicine, nursing,
occupational therapy) have identified explicit foci of clinical reasoning, including diagnostic
reasoning, narrative reasoning, procedural reasoning, interactive reasoning, collaborative
reasoning, predictive reasoning, ethical reasoning and teaching as reasoning (Higgs and
Jones, 2008). Edwards and colleagues (Edwards, 2000; Edwards et al., 2004a) investigated
the clinical reasoning of expert physiotherapists in three different fields of physiotherapy
(musculoskeletal, neurological and domiciliary/home health care) and found that these
physiotherapists employed a range of ‘clinical reasoning strategies’ despite the differing
emphases of their examinations and management. The following clinical reasoning strategies
were each associated with a range of diverse clinical actions:
Diagnostic reasoning: Reasoning underpinning the formation of a musculoskeletal practice
diagnosis related to functional limitation(s) and associated physical and movement
impairments with consideration of pain type, tissue pathology and the broad scope of
potential contributing factors.
Narrative reasoning: Reasoning associated with understanding patients’ pain, illness and/
or disability experiences. This incorporates their understanding (including personal
meaning) of their problem(s) and effects on their lives; their expectations regarding
management; associated cognitions and emotions; their ability to cope; and the effects
these personal perspectives have on their clinical presentation, particularly whether they
are facilitating or obstructing their recovery.
Reasoning about procedure: Reasoning underpinning the selection, implementation and
progression of treatment procedures. Although clinical guidelines provide broad direction,
typically focusing only on diagnostic categorization, practising clinicians need to adaptively
reason how best to apply those guidelines to patients’ individual presentations and goals.
Progression of treatment is mostly then guided by judicious outcome re-assessment that
attends to impairment and function-/disability-related outcomes.
Interactive reasoning: Reasoning guiding the purposeful establishment and ongoing
management of clinician–patient rapport (discussed further under Factors Influencing
Reasoning).
Collaborative reasoning: The shared decision-making between patient and clinician (and
others) as a therapeutic alliance in the interpretation of examination findings, setting of
goals and priorities, and implementation and progression of treatment (see Edwards
et al. [2004b] and Trede and Higgs [2008] for further detail).
Reasoning about teaching: Reasoning associated with the planning, execution and evaluation
of individualized and context sensitive strategies to facilitate change, including facilitating
motivation for change, facilitating conceptual change in understanding and beliefs (e.g.
regarding medical and musculoskeletal diagnosis and pain), facilitation of constructive
coping strategies, and facilitation of improved physical performance, activity and participa-
tion capabilities (e.g. rehabilitative exercises, conditioning, sport technique, activity
pacing and graded exposure).
Predictive reasoning: Reasoning utilized in judgments regarding effects of specific interven-
tions and overall prognosis. Although prognostic judgments regarding whether
musculoskeletal therapy can help and expected time frame are not precise, a thorough
reasoning consideration of biological, environmental and personal factors that recognizes
both facilitators and barriers (i.e. positives and negatives in a patient’s presentation), as
well as what is and isn’t modifiable, will assist this reasoning strategy.
Ethical reasoning: Reasoning underpinning the recognition and resolution of ethical
dilemmas which impinge upon patients’ ability to make decisions concerning their
health and upon the conduct of treatment and its desired goals (see Edwards et al.
[2005] and Edwards and Delany [2019] for further detail).
Consideration of these diagnostic and non-diagnostic foci of reasoning assist by highlighting
the broad scope of clinical reasoning we should be aware of, critique and strive to improve.
The complexity of our reasoning is further evident in the finding that expert physiotherapists
have been shown to dialectically move in their reasoning between contrasting biological
and psychosocial poles in a fluid and seemingly effortless manner (Edwards, 2000; Edwards
et al., 2004a). For example, a diagnostic test may elicit a patient response reflecting fear
of movement underpinned by inappropriate beliefs and cognitions regarding their diagnosis,
pathology and/or pain. Sensitivity, specificity and likelihood ratios of the diagnostic test
inform the likelihood of having that condition. At the same time, the expert clinician
perceives the more qualitative patient expressions of fear, tempering their diagnostic analysis
and dialectically shifting their reasoning from biological to psychosocial.
Attending to patients’ psychosocial status alongside physical/diagnostic findings is essential.
It is not possible to fully understand a patient’s pain and disability experience without a
comprehensive physical examination that reveals the extent of physical impairment and
disability they have to cope with. Similarly, psychosocial assessment will not only inform
diagnostic reasoning, but it also enables identification of unhelpful perspectives that need
to be addressed in management for both acute and chronic presentations. Although the
clinical reasoning strategies provide a framework to assist students and practicing clinicians
recognize the different foci of reasoning required, it is also helpful to recognize the different
categories of clinical decisions required within these different reasoning strategies.
Key Point
Diagnostic reasoning represents only one focus of clinical reasoning in
musculoskeletal practice. Expert clinicians have been shown to employ a range of
‘clinical reasoning strategies’ incorporating different foci of reasoning including
diagnostic reasoning, narrative reasoning, reasoning about procedure, interactive
reasoning, collaborative reasoning, reasoning about teaching, predictive reasoning
and ethical reasoning. Experts are able to dialectically move in their clinical
reasoning between the biological and psychosocial poles of the biopsychosocial
framework in accordance with emerging patient information. Awareness, critique
and practice in all areas of clinical reasoning are important to developing expertise
in clinical practice.
Categories of Clinical Decisions Required:

Hypothesis Categories
It seems obvious that clinicians should know the purpose of every question they ask their
patients and every physical assessment they conduct. That is, what do you want to find
out, and what decision will that information inform? It is not necessary or even appropriate
to stipulate a definitive list of decisions all clinicians must consider, as this would only
stifle the independent and creative thinking important to the evolution of our professions.
However, a minimum list of categories of decisions that can/should be considered is helpful
to those learning and reflecting on their clinical reasoning because it provides them with
initial guidance to understand the purpose of their questions and physical assessments,
encourages breadth of reasoning beyond diagnosis and creates a framework in which
clinical knowledge can be organized as it relates to decisions that must be made (i.e.
diagnosing, understanding psychosocial influences, determining therapeutic interventions,
establishing rapport/therapeutic alliance, collaborating, teaching, prognosis and managing
ethical dilemmas). What follows is a list of ‘hypothesis categories’ initially proposed by
Jones (1987) that has continued to evolve through professional discussion to this current
format (Table 1.1). Research evidence regarding musculoskeletal clinicians’ focus of clinical
reasoning, including reasoning across and within these different categories, is available
(e.g. Barlow, 2012; Doody and McAteer, 2002; Edwards et al., 2004a; Jensen, 2007; Rivett
and Higgs, 1997; Smart and Doody, 2006). This, combined with reflective discourse from
experienced clinicians and clinical educators, broadly supports the relevance and use of
these particular hypothesis categories. Nevertheless, these specific hypothesis categories
are not being recommended for uncritical use by all clinicians, and whatever categories
of decisions are adopted should continually be reviewed to ensure they reflect contemporary
health care and musculoskeletal practice.
TA BL E 1 .1
HYPOTHESIS CATEGORIES
• Activity and participation capability and restriction
• Patients’ perspectives on their experiences and social influences (psychosocial status)
• Pain type
• Sources of symptoms
• Pathology
• Impairments in body function or structure
• Contributing factors to the development and maintenance of the problem
• Precautions and contraindications to physical examination and treatment
• Management/treatment selection and progression
• Prognosis
Activity and Participation Capability and Restriction

Patients’ activity capabilities and restrictions directly relate to the ICF framework of health
and disability presented in Fig. 1.1 and refer to the patient’s functional abilities and restric-
tions (e.g. walking, lifting, sitting, etc.) that are volunteered and further screened for. To
gain a complete picture, it is important the clinician identifies those activities the patient
is capable of alongside those that are restricted.
Patients’ participation capabilities and restrictions refer to the patient’s abilities and
restrictions to participate in life situations (e.g. work, recreation/sport, family, etc.). Again,
determining participation capabilities, including modified participation (e.g. modified work
duties), is important because this will contribute to other decisions such as prognosis and
management. Note that identifying patients’ activity and participation restrictions and
capabilities, either through interview or through questionnaire, does not really qualify as
formulating ‘hypotheses’ in the sense that these are not clinicians’ judgments or deductions;
rather, they are simply essential information to obtain in order to understand the extent
of the patient’s disability and quality of life. They are included in the hypothesis categories
framework simply to facilitate attention to these critical aspects of the patient’s pain/
disability experience. Later, when making judgments about pain type, the proportionality
of activity and participation restrictions and the physical impairments/pathology identified
through examination will need to be considered. When activity and participation restrictions
are out of proportion to identified physical impairments and pathology, then it may reflect
a nociplastic pain type (IASP Taxonomy 2017; Nijs et al., 2015; Smart et al., 2012c; Woolf,
2011), and it is likely the patient’s psychosocial status will be negatively contributing to
the patient’s disability.
Patient Perspectives on Their Experiences and Social

Influences (Psychosocial Status)
Patients’ perspectives on their experiences and social influences relate to the patient’s
psychosocial status, which the clinician needs to assess and understand. Musculoskeletal
clinicians’ psychosocial assessment is discussed in more detail in Chapters 3 and 4. But
briefly, psychosocial assessment incorporates such things as:
• What are the patient’s perspectives of their pain/disability experience?
• Understanding / beliefs regarding their problem, its diagnosis, about pain (for example,
with respect to: seriousness, changeability and controllability) AND what is the basis
of those beliefs (i.e. why do they think that)?
• What are their expectations and beliefs about management and their role in manage-
ment? What are their specific goals?
• How they are coping, emotionally (e.g., anger, depressive symptoms, feelings of vulner-
ability, etc.) and behaviorally? Do they have any specific coping strategies (e.g. medica-
tion, rest, alcohol, exercise, avoidance), and if so, are they effective?
• What are the patient’s social circumstances (e.g. education / health literacy, culture,
living, work, friends, etc.) and what is their perception of support:
• How does the patient think they are perceived by their partner, workmates and
employer, and how does this affect their self-concept, self-efficacy and pain/disability
experience?
• Is change important to the patient? What is their self-efficacy to positively contribute
to change? What tasks do they currently believe they can perform? What tasks do they
believe they will be able to return to following management?
In the clinical reasoning strategies framework presented earlier, hypotheses regarding
psychosocial status fit within narrative reasoning focused on understanding patients’ pain,
illness and/or disability experiences. When assessing understanding of their problem (e.g.
diagnosis, pain), this is not simply their superficial understanding (e.g. what the doctor
told them or what they have read); rather, it refers to what meaning they attach to that
understanding (e.g. likely recovery, fear of further damage, etc.).
Pain Type
Understanding pain, including types of pain, differences between acute and chronic pain,
referred pain and the associated neurophysiology, is essential knowledge to musculoskeletal
clinicians. For this knowledge to be useful in clinical practice, it then must be linked to
clinical reasoning, for example, clinical patterns of different pain types and the implications
to precautions in assessment and management, management strategies and prognosis.
Chapter 2 provides an overview of contemporary pain science understanding linked to
clinical reasoning. For the purposes of this chapter, pain type is discussed as a hypothesis
category because of its overarching importance to these other reasoning decisions, especially
management.
The three main types of pain musculoskeletal clinicians need to be able to assess for and
recognize include nociceptive pain (with and without inflammation), neuropathic pain and
nociplastic pain3 (e.g. Gifford et al., 2006; IASP Taxonomy 2017; Nijs et al., 2014b; Woolf,
2011, 2014). Nociceptive pain is protective and refers to pain that is associated with actual
or threatened damage to non-neural tissue and involves activation of peripheral nociceptors
(IASP Taxonomy 2017). Nociceptive inflammatory pain occurs with tissue damage, and/or
immune cell activation in the case of systemic inflammation, facilitating repair by causing
pain hypersensitivity until healing occurs (Woolf, 2010). Neuropathic pain refers to pain
arising as a direct consequence of a lesion or disease affecting the somatosensory system
and can be further differentiated into peripheral or central neuropathic pain depending
on the anatomic location of the lesion (IASP Taxonomy 2017; Jensen et al., 2011; Treede
et al., 2008). Nociplastic pain is dysfunctional pain associated with altered nociceptive
processing in the central nervous system in the absence of overt peripheral drivers such
as tissue injury or neuropathy. Nociplastic pain has been demonstrated in a wide range of
conditions commonly treated by musculoskeletal clinicians, including non-specific chronic
back pain, complex regional pain syndrome, chronic fatigue syndrome, fibromyalgia, post-
surgical pain, and visceral pain hypersensitivity syndromes (Ashina et al., 2005; Clauw
2015; Coombes et al., 2012; Fernandez-Carnero et al., 2009; Lluch Girbés et al., 2013;
Meeus et al., 2012; Nijs et al., 2012a; Perrotta et al., 2010; Price et al., 2002; Roussel et al.,
2013; Woolf, 2011). The hypersensitivity manifests as increased responsiveness to a variety
of stimuli, including mechanical pressure, chemical substances, light, sound, cold, heat,
stress and electrical, with links to a range of CNS dysfunctions, as discussed in Chapter 2.
Although both subjective and physical clinical features of pain types have been reported
(Bielefeldt and Gebhart, 2006; Mayer et al., 2012; Nijs et al., 2010; Nijs et al. 2015;
Schaible, 2006; Smart et al., 2012a, 2012b, 2012c; Treede et al., 2008; Woolf, 2011),
diagnostic criteria and biomarkers of nociplastic pain are still not definitive (Kosek et al.,
3
Through most of the writing of this book this third pain type was called “maladaptive central nervous system
sensitization”. This was changed to “nociplastic” in the final stages of writing to be consistent with the IASP
change in terminology. However, it is acknowledged the new term is controversial and may change again in
the future.
2016; Vardeh, Mannion & Woolf, 2016; Woolf, 2011, 2014). As such, when clinical
features of different pain types co-exist, differentiation is challenging. This is particularly
true for initial appointments where the full picture of the patient’s presentation (subjective,
imaging, physical findings) is still emerging. For example, the full pain experience, including
initial screening for adverse psychosocial factors by interview and/or questionnaire, often
is not fully revealed at the first appointment. As clinician–patient rapport develops and
time allows for questionnaire responses to be explored and clarified, a fuller picture will
usually become available. Both physical and psychosocial stress can contribute to neuroim-
mune system dysregulation and thus contribute to pain hypersensitization. Clarification
of apparent overlap in pain mechanisms (e.g. nociception with and without sensitization)
may be assisted through outcome re-assessments of targeted treatment interventions over
a defined period of time. That is, nociplastic pain occurs in response to both internal and
external inputs, including cognitive and emotional modulation (e.g. thoughts, beliefs, fears,
anxiety) and can be triggered, but not maintained, by nociception from pathological,
inflamed or overloaded tissues if present, enabling increased sensitivity (or decreased load
tolerance) to co-exist with somatic and visceral nociception. While pain type informs
management, the mechanisms and contributors that underpin pain type can differ and
change over time. As such, hypotheses about the dominant pain type may change as further
information comes to light. Short-term treatments and re-assessments to potentially relevant
physical impairments may assist in establishing how much an apparent sensitization is
being driven by the symptomatic physical impairments or other co-existing cognitions,
emotions and life stressors. Although interventions directed at musculoskeletal tissues have
central modulatory influences (e.g. Cagnie et al., 2013; Nijs et al., 2011a, 2012a; Schmid
et al., 2008; Smith et al., 2013, 2014; Vincenzino et al., 2007b; Zusman, 2008), they are
unlikely to be sufficient on their own to resolve persistent nociplastic pain. However, when
physical impairments and associated disability underpin psychological stress and negative
cognitions, skilled physical and environmental management would be expected to improve
if not resolve negative psyche and disability. When both physical and cognitive/affective
factors appear to contribute to maintained pain and disability, management would logically
address both. In contrast, successful management for dominant nociplastic pain and persistent
pain memories maintained by psychosocial factors will likely require combinations of
pharmacotherapy and cognitive-behavioural strategies through pain neuroscience education,
facilitation of active coping strategies, graded activity and exercise (Louw et al., 2011;
Moseley, 2004; Moseley & Butler, 2017; Nijs et al., 2011a, 2011b, 2012b, 2014a; Turk
and Flor, 2006; Zusman, 2008) and is unlikely to be helped by traditional tissue-based
approaches. The importance of recognizing clinical features of nociplastic pain is also
evident when hypothesizing about potential nociceptive tissue pathology or sources based
on joint, muscle and soft tissue assessments. Nociplastic pain can create local false-positive
provocation of symptoms suggestive of tissue pathology (Gifford, 1998; Nijs et al., 2010)
illustrating the influence of one hypothesis category (e.g. pain type) on another (e.g. source
of symptoms) and the complexity of clinical reasoning required.
Source of Symptoms
Although the majority of patients with musculoskeletal problems present with pain as a
symptom, they also present with other symptoms such as hyper-/hypoesthesias, paraesthesias,
dysesthesias, vascular associated symptoms, stiffness, weakness, joint sensations (e.g.
instability, clicking, locking) and urinary urgency and incontinence, among others. Patients
in other areas of clinical practice (e.g. neurological, cardiorespiratory) present with additional
symptoms characteristic of disorders of those systems. Consequently, as discussed under
General Health Screening, it is important thorough screening occurs for other symptoms
beyond the patient’s main complaint to ensure that relevant symptoms not spontaneously
volunteered and that relevant health comorbidities are not missed.
When patients do present with pain, and when a nociceptive ‘pain type’ is hypothesized,
then it is appropriate to reason further regarding potential sources of nociception. Although
validation of the source of nociception on the basis of a clinical examination alone is often
limited, biological and clinical knowledge of pain distribution, patterns of provocation
and relief and common mechanisms of onset enables clinicians to hypothesize about the
likely sources of nociception. The accuracy of this aspect of diagnosis is significantly better
with some types of problems (e.g. muscle and ligament injuries) than others (e.g. low back
pain). However, even when a specific tissue cannot be confirmed, broader hypotheses
about body regions (e.g. spine versus shoulder or hip) are still helpful in differential
questioning and testing through the subjective and physical examination.
As an example of generating hypotheses regarding possible sources of nociception for
a patient’s symptoms based on the area of symptoms, consider the body chart in Table 1.2
depicting a common area of shoulder pain and the potential nociceptive, neuropathic and
visceral sources of nociception that should be considered.
TA B L E 1 . 2
BODY CHART DEPICTING AN EXAMPLE OF SYMPTOM LOCATION AND

THE POTENTIAL NOCICEPTIVE, NEUROPATHIC AND VISCERAL
SOURCES THAT SHOULD BE CONSIDERED FOR THAT SYMPTOM AREA
Potential Potential Nociceptive Potential Nociceptive

Potential Local Neuropathic Sources of Somatic Sources of Visceral
Nociceptive Sources Sources Referral Referral
• Glenohumeral • Axillary nerve • Any C5/C6 motion • Visceral structures
periarticular • Suprascapular segment structures with common
(rotator interval nerve (muscle, posterior innervation to
structures, capsule • C3–C7 nerve intervertebral joint) shoulder (e.g. phrenic
and ligaments) roots • Any somatic nerve C3–C5
• Glenohumeral structure sharing the innervates diaphragm,
intra-articular C5–C6 innervation pericardium,
(glenoid labrum, gallbladder, pancreas)
biceps attachment, • Visceral structures
joint surface) capable of irritating
• Subacromial space diaphragm (heart,
(rotator cuff, spleen [L], kidneys,
biceps, bursa, pancreas, gallbladder
coraco-acromial [R], liver [R])
ligament, acromion)
• Acromioclavicular
joint
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to men and such things to bestir herself very greatly, so she only put on her
next most becoming gown and descended languidly to find the people.
Her friend saw her first and made a little dive at her through the circle of
youths around her, and bore her to them with quite an air of triumph. And
then, while she was trying to hear the names and remember where they came
from, she suddenly saw a Harvard man coming toward her, and looking very
much surprised and intensely happy, and somewhat embarrassed. She had
just time to wish she had put on the other gown, when the bell for the
concert sounded and everybody began to rush down the corridor. Somehow
they got left behind the others, and as the place was crowded and they did
not seem to care much for the celebrated violinist, who really played
exceptionally well that evening, they considerately took seats against the
wall behind everybody, where they could talk to their hearts’ content.
And they really must have talked quite a good deal, for when the last bell
sounded for all the visitors to go and the driver of the big college sleigh
(which was really an omnibus on runners) was shouting himself hoarse in
the “centre” and in nervous asides assuring the excited and aggrieved
passengers already assembled and waiting that they would all be late for the
last train that night if the remaining few did not hurry up—while all of this
was going on, the Harvard man was still sitting with her on the pedestal of a
plaster statue in a darkened corner of a corridor, assuring her that they could
be married just as soon as the finals were over, and that though he was sure
to be made a marshal he would not wait for Class Day for anything which he
could then think of under the sun, and that instead of sending out invitations
to a spread in Beck, he would give his friends a delightful shock by
substituting his wedding cards for them, and while the other fellows were
working like beavers at the Tree, or filling dance cards for their friends, or
wearing themselves to shreds dancing with their friends’ friends, they could
be in a boat half-way over to the other side. And she was saying she didn’t
think she would come back after Christmas so as to have plenty of time to
get her gowns and things ready, and that she did not think she was really and
truly fitted for college life; which he interrupted to assure her that he was
certain she already knew vastly more than he did, and that he would
telegraph her mother and father about the whole thing before he slept, and
that if the answer was favorable he would send her some flowers the next
day as a token. And then when the coachman’s patience had quite given out
and they heard the sleigh go dashing away from under the porte-cochère,
before she could realize it he had kissed her once quickly and jumped down
the steps four at a time, and was out of the door tearing after the vanishing
coach.
The next afternoon Miss Wright received an enormous box full of Mabel
Morrison roses, and her tailor-made friend, not understanding the
significance of the flowers, thought it was rather shabby on her part not to
offer her some. About the same time of day the Harvard man sent a long and
explicit telegram to the agent of the Cunard Line for the very best stateroom
on a steamer sailing on or about the 20th of the next June, and blushed
boyishly and then laughed a little at its “previousness,” as he signed the
application for “Mr. and Mrs. Roger Pervere, New York,” six months before
his wedding-day.
AN EPISODE
J UDGE CAHILL drew his chair a trifle nearer the fire and the tall,
muscular young man who was with him, and who bore so striking a
resemblance to him as to be unmistakably his son, dropped into one
opposite. They had finished their late dinner and were on the way to the
library, but the elder man had paused before the big chimney-piece, standing
meditatively for a few moments, and had finally seated himself comfortably
and evidently with no immediate intention of proceeding to the library
beyond.
“The whole arrangement is just what I have planned and hoped for all my
life,” he said at length, with a bright look at the young man opposite. “And
we have a capital chance of talking it over together to-night. It is rather
lucky that your aunt is away for a few days, Dana. Your sister will be
delighted. You must write to her at once that it is un fait accompli and that
she must leave college for over Sunday and come in and celebrate with us!”
“Oh! it will doubtless seem a mere trifle to Louise in comparison with her
own arduous duties and tasks,” responded young Cahill, laughing a little and
offering a cigar to his father, who refused it with a slight shake of his fine,
white head.
“If you don’t mind, I’ll smoke one,” he said, lighting his own.
“Oh! I don’t mind at all,” said the elder man; and then absently and sadly,
as he pushed the thick, silvery hair back from his forehead with a quick
decisive motion habitual with him:
“I wish your mother could have lived to see this, Dana!”
The younger man made an inarticulate murmur of assent and regret, and
then they both sat silent, staring into the crackling logs, while the butler
moved noiselessly about, putting a decanter and glasses on the table and
turning down the lamp a bit and folding back the screen. The younger man
was making a rather unsuccessful attempt to recall his mother. He
remembered her vaguely as a boy of eight remembers, and she had always
seemed to him rather like some beautiful woman of whom he had read than
his own mother; and the portrait of her in the drawing-room, although he
could recall every feature, every line of it, was like the picture of any other
beautiful woman he might have seen in a gallery abroad or the year’s
Academy. At last he looked up, and shaking the ash from his cigar, said,
with rather an effort—
“You have been most kind, sir. I scarcely think I deserve so much at your
hands. I shall try to be all you wish.”
Judge Cahill looked quickly around. “That’s right! that’s right, my boy!”
he said heartily, and with a touch of surprise in his voice. “You have always
been what I wished—not very studious, perhaps”—he laughed indulgently,
“but you always stood fairly well at the University, and although you have
doubtless done a great many things of which I know nothing and of which I
do not wish to know,” he added quickly and decidedly, “still I believe you
have lived a life which you have no need to be ashamed of. I know that you
are honest, and truthful, and straight, and that I can trust you, and that the
responsibilities which you are to assume will make you even more upright
and ‘square,’ if possible.”
He glanced admiringly and affectionately at the athletic young figure
sitting easily before him, at the well-shaped head and pleasant blue eyes and
finely-cut mouth of the young man.
“You might have been so different,” went on the older man, musingly,
and with a certain whimsicality. “You might never have been willing to go
through the University; or worse still, you might never have been able to get
through; or you might have made debts that even I would not have felt
willing or able to pay; or you might have been unwilling to supplement your
college education with the years of travel which I thought necessary; or you
might have had so decided a dislike for the law that it would have been
impossible for me to take you in the firm as I am now so delighted, so proud
to do; or you might have married too soon and ruined your life. In short, you
might have been a disappointment—and you are not.”
The young man shifted his position a little, and tumbled the burnt end of
his cigar into the ash-tray at his elbow.
“You are very kind, sir,” he repeated. “I am not quite equal to telling you
just how kind you seem to me, and how proud I am to be the junior member
of the firm. I feel a legal enthusiasm kindling within me which I am sure will
land me on the Supreme Bench some day!” And then he went on more
seriously, and with an anxious note in his voice. “But I hope you are not
deceiving yourself about me, sir. If you remember, you did have to pay debts
for me at the University, and there was one time when I thought active
measures would be taken to prevent my finishing my course even if I had
been quite inclined to continue, as indeed I was; and I am not very clever,
and shall never be at the head of my profession as you are, sir!”
Judge Cahill leaned back and laughed easily.
“I had quite forgotten those little incidents, Dana!” he said, “and do you
know, it seems to me that we are unusually complimentary and effusive to
each other to-night. I am congratulating myself on having such a son, and
you on having me for your father! Well—it is not a bad idea. A little more
demonstration in our family will not hurt anything.” He paused slightly, and
then added: “Your mother was not very demonstrative.”
Again young Cahill murmured an assent as he looked reflectively into the
fire. He could just remember that she had not seemed very fond of himself.
“But Louise is demonstrative enough,” he said, at length.
“Yes—yes, indeed,” replied his father, readily. “Louise is very
affectionate and enthusiastic. She seems tremendously interested in her
college—much more so than you were in yours,” he added with another
laugh.
Dana Cahill got up leisurely, and stood by the chimney-piece thrusting
his hands in his pockets and looking thoughtfully into the fire.
“I am thinking, sir,” he began, hesitatingly, “of what you have said about
my having lived straight. I want to be fair about it. I have lived better than
some. I have done nothing to be ashamed of, as you said, sir, and I cannot
think of anything just now to speak of which would illustrate my point. But I
cannot help thinking that your ideals and principles are so much higher and
purer than those of most young men of to-day, that I may have fallen short of
them in a great many ways of which you do not dream.” He moved back
uneasily to his chair and dropped into it. “I do not mean in the more vital
questions. I have done nothing dishonorable, nothing that I could not afford
to do according to the world’s standard.”
The elder man looked at him, and a shade of annoyance and uneasiness
crept into his face.
“Well?” he asked, finally.
Young Cahill looked up, and his frank, boyish face wore a rather
perplexed, troubled expression.
“Well,” he said, “that’s all—unless—” he stopped suddenly and lit
another cigar rather nervously.
“Unless what?” insisted the elder man, the uneasiness and annoyance
betraying themselves in his voice.
“But,” he added, quickly; “don’t tell me anything that you might later
regret telling, or anything very disagreeable if you can help it, for I confess
you have been so satisfactory, so thoroughly all that I wanted my son to be,
that I shrink from hearing anything to your detriment.”
“I don’t know that it is exactly to my detriment, for after all, I was
thinking of a particular case to illustrate what I said a while ago, and I am
pretty sure that most of the men I know wouldn’t think seriously of it for a
moment; but I acknowledge that I have never felt satisfied with myself about
it all.” He threw back his head and stared fixedly at the ceiling for a moment,
and then burst out laughing.
“By Jove, sir! we are getting demonstrative,” he said. “Do you feel
yourself equal to being a father confessor besides just an ordinary father?”
Judge Cahill smiled in a perfunctory way.
“If your conscience is in such a bad way as to need confessing, Dana, I
shall be very glad to hear, although I, of course, cannot give you absolution.”
Cahill paused a moment.
“That’s so, sir,” he said, finally. “After all it is hardly worth while
troubling you about such a small thing, and one that happened so long ago,
and which is settled now, rightly or wrongly, forever.”
He stood up as if to say good-night, but the elder man did not rise and sat
looking thoughtfully at the blaze with the uneasy, surprised look still on his
face.
“It is not about business? nothing that affects your character for honesty
and fair dealing?” he said at length, interrogatively.
“Oh, no!” replied Cahill, quickly.
Judge Cahill looked inexpressively relieved. He poured out a little wine
and drank it off quickly, as if he had experienced some moment of sharp
emotion which had left him faint. The younger man noticed the action and
went on hastily.
“It was nothing—only about a girl whom you never heard of, and myself
—something that happens to two-thirds of the men one meets—it is really of
little consequence, though it has worried me, and since I have spoken of it at
all, I may as well tell you about it, sir.”
But it was a very fragmentary story that he told and the facts, as he
reviewed them hastily, seemed absurdly commonplace and inadequate to the
amount of worry he had given himself.
“It was five years ago, sir, you remember, just after I left college, and
went out to Nevada for the summer with Lord Deveridge and the rest of that
English syndicate. It was when they bought ‘The Bish’ mine, you know. Of
course we went about a great deal. They were so afraid of being swindled,
and there had been such pots of money lost out there by English syndicates,
that they determined to investigate fully and take every precaution. So they
went around trying to sift things out, and there were a great many
complications of all sorts which occasioned a great deal of delay, and there
were so many conflicting rumors about the value of the mine, that I began to
think they were never going to wind up things. Deveridge and I got awfully
tired of pottering around after all sorts of men, meeting an expert geologist
here and a committee there, and never getting at anything; so we finally
decided to cut the whole thing for two weeks and go off on a little shooting
expedition. Two or three others joined us, and we had magnificent sport for
four days—and then I sprained my bad ankle again.” He stopped suddenly.
“It is very curious how things happen,” he said at length, with a little laugh.
“If it hadn’t rained the morning of the Springfield game, the ground
wouldn’t have been wet and I wouldn’t have slipped in that last scrimmage,
and my ankle wouldn’t have been sprained, and I wouldn’t have wrenched it
on that mountain road, and I wouldn’t have been laid up two weeks in the
house with her, and none of this would have happened.”
But the elder man was in no mood for trifling.
“You were saying——?” he began, anxiously.
“That I hurt my ankle and had to limp to the nearest inhabited place and
stay there until it got better. Of course the others went on. They were coming
back that way and stopped for me. I was all broken up at not being able to
enjoy the shooting, but my ankle gave me so much trouble at first that I
didn’t have a great deal of time to think about it; and then it began to dawn
on me that she—the daughter I mean—was unusually pretty and refined and
quite different from her parents seemingly, and—and—there was nothing
else to do, sir, and I am afraid that I acted as most young men would act
under similar circumstances.”
“You mean,” said his father, with an uncompromising directness which
Cahill thought rather brutal and unnecessary, “you mean that you made love
to the girl?”
The young man nodded.
“She was very pretty, you know, and it was only for a short time, and she
must have seen—have realized—that there was a difference, that there was
nothing to it. It was only the most incipient flirtation—the same thing that
goes on at Bar Harbor and the Pier and Newport among a different class of
people.”
Judge Cahill said nothing, rather to the young man’s discomfiture, so he
ran on, hurriedly:
“They were very poor, and I paid them liberally for what they did for me.
I confess I rather lost my head about the girl for a week! She was strikingly
pretty, but she had only the most elementary education and was absurdly
unconventional. Of course it was nothing, sir, and I don’t flatter myself that
she felt any worse when I left than I did—at least she never made any sign,”
he added, meditatively.
“I can see how, from your point of view, it appeared nothing, Dana,” said
the elder man, gravely, at length. “But I hope this is the only episode of the
kind in your life,” he continued, after a moment’s pause.
The younger man stood up with a rather relieved look on his face.
“Indeed it is, sir! and I think the fact that I have let it worry me so much
is proof that I am a novice at it. The whole thing was so unimportant that I
feel rather ridiculous for having spoken of it. There was never anything
serious in the affair, and of course, sir, I did not dream—I knew it would be
impossible to bring her here. You—my sister——” he stopped and looked
around him rather helplessly.
“Of course,” assented the elder man, readily. “I am glad you got yourself
so cleanly out of such an entanglement. As you say, it was commonplace and
unimportant. Have you ever heard anything of her since?”
“O, no! I saw her for two weeks and then we parted with mutual regret,
and that was all, sir! Your too complimentary remarks recalled the whole
episode to my mind, and made me feel rather hypocritical, for I confess that
I consider that sort of thing extremely caddish. There’s no excuse for it.”
“There is not, indeed,” assented the elder man, rising. “And it has further
surprised me, because you have always seemed rather indifferent to women,
Dana—almost too much so. Well—I am glad you told me. Your life has been
clean, indeed, if you have no worse things to tell of than a two weeks’
flirtation with a little Western girl!” He laughed again—a deep, hearty laugh,
with a relieved ring in it.
“Good-night!” he said. “To-morrow you will please get to the office
promptly as a junior member should! ‘Cahill, Crosby, and Cahill’ sounds
very imposing, doesn’t it, Dana? much more so than merely ‘Cahill and
Crosby.’ I’m delighted, my boy! And it is especially good to think that you
are back with me. What with your college life and travels, and law study, I
have hardly seen anything of you for ten years, and at my age one cannot
spare ten years—it is too big a slice out of the little cake left! Good-night!”
“Good-night, sir!” responded the young man, heartily, as he held the door
open for his father to pass into the library.
And then he reseated himself before the fire and smoked another cigar
and recalled a great many details that had somehow slipped his memory
when talking to his father, and he felt distinctly relieved and glad to get away
from his own thoughts when he remembered an engagement which took him
out immediately.
At Easter Miss Louise Cahill left college to spend the vacation at her
home in Boston. It was possibly because she was small and blond and quite
irrepressible that her most intimate friend, Edith Minot, of Baltimore, whom
she brought home with her, was tall and rather stately, with a dark, severe
beauty quite in contrast to that of Miss Cahill. They were alike, however, in
a great many ways, in their young enthusiasms and in their devotion to art—
they worshipped Israels and Blommers and Herzog—and in their vast
interest in electrical inventions and discoveries, and in their sympathy with
whatever was weak or ill or oppressed, and in modern charities and college
settlements. They had been great friends at college, where Miss Minot had
taken her degree the year before, but they had seen little of each other since,
Miss Cahill having returned to finish her college course and Miss Minot
having been abroad until late in the fall, and having then been much taken up
with the social life of Baltimore.
Miss Cahill was very much afraid that society had spoiled Miss Minot,
and that she would be less interested in art for art’s sake, and in university
extensions and college settlements and organized charitable work. She was
therefore much delighted and very enthusiastic to find that her friend was not
at all changed in the ten months of absence, but that in the midst of her
travels and social pleasures she had contrived to devote a great deal of time
to the things that had always interested her, and that she had studied the
Guild Hall Loan Exhibit and the East End with equal enthusiasm, while in
London, and was greatly interested in Nikola Tesla’s latest experiments and
in college settlements. It was the college settlements that interested her most,
however.
“But I think,” she explained earnestly that evening to her friend and
young Cahill, after the Judge and his sister had gone into the library—“I
think that although there are more interesting and dreadful things to be
contended with at the Chicago Settlement, and although Rivington Street is
on a much larger scale, still I think I like the Boston College Settlement the
most. Perhaps it’s because I know it better, or because it is not quite in the
slummiest slums, or because I’m so interested in my protégée there—at any
rate, I like it best.”
Miss Cahill looked plaintively at her brother.
“Just think, Dana, when Edith was at college she used to spend her
Christmas vacations in Tyler Street. Don’t you think she’s very brave and
good? I’m sure I’m only too glad to give my money, and I’m greatly
interested in it, and awfully pleased when the others go; but I don’t think I
could possibly stay there myself! And I actually believe she came near
refusing my invitation to come here, because she thought she ought to go to
the settlement!”
Cahill laughed easily.
“That is hard on us, Miss Minot. Think of having to compete in
attractions with the college settlement, and only just managing to come out
ahead!” He was not thinking very much of what he was saying—he was
looking at the sombre, beautiful eyes, with the lids slightly lowered over
them, and the sensitively cut lips and air of thorough breeding of the girl
before him; and he was saying to himself that he had been singularly
unfortunate to have always been away in Japan, or at the law school, or in
Paris, when Miss Minot had visited his sister.
A little touch of color crept into the clear pallor of the girl’s cheeks.
“How unkind of you and Louise!” she exclaimed, smiling. “You must
know there could be no question of what was nicest to me. I’m very sorry
that I like dances and the opera and luncheons and all that so much, but it is
so, and the people at the college settlement are very good to let me come in
now and then, and try to help a little and ease my conscience a little for all
its self-indulgence and worldly pleasures. So you must not think better of me
than you should!”
“Don’t believe her, Dana!” interposed Miss Cahill, indignantly. “She does
it all because she’s so awfully good, and she never brags about it as I would
do, I’m sure, and they all adore her down there, and the little boys beg for
her flowers, and the little girls have to be kissed, and the teachers are always
delighted to see her,” she ran on, breathlessly and triumphantly.
Miss Minot looked up. “I do love the little children and they interest me
tremendously,” she said. She leaned forward eagerly, and appealed to Cahill.
“Don’t you see,” she said, “how easy it is to become interested in that sort of
thing? One doesn’t have to be particularly religiously inclined or even
ordinarily good—it’s just the human nature of it which touches one so. You
ought to see them,” she went on, still appealing to Cahill. “They are so
interested and amused in their ‘clubs,’ which meet different afternoons in the
week, and they are so anxious to get in even before the others leave! I have
seen them climbing up in the windows to get a look at the good times the
others were having, and waiting about at the door in the cold until that ‘club’
should have gone home and left the warm rooms and the playthings, and the
cheerful, bright teachers to them. It rather puts our society functions to
shame, where no one goes to a reception until the receiving hours are half
over, or to the opera until next to the last act.”
“And you ought to see how fond they are of her,” insisted Miss Cahill,
admiringly. “She lets them get on her prettiest gowns and muss her, and she
is so patient! I keep at a distance, and tell them they are very good and I
hope they are having a nice time.”
Cahill laughed.
“Philanthropy made easy, is what suits you, Louise!”
“But it isn’t philanthropy at all,” objected Miss Minot, “unless it’s
philanthropy to us outsiders to be allowed to go and help and share a little of
the pleasure and culture of our selfish lives. Really you ought to see the
children,” she went on, eagerly. “I don’t believe Palmer Cox’s brownies or
‘pigs in clover’ are such favorites anywhere else, and you wouldn’t imagine
how interesting the making of a pin-cushion cover could be; and I never
thought ‘Daisy Bell,’ and ‘Sweet Marie,’ and ‘Mollie and the Baby and I,’
were really pretty tunes until I heard a little girls’ club singing them in
excellent tune, and with an appreciation of the sentiments quite astonishing.”
Cahill nodded a trifle absently. He decided that he had never seen any
girl’s face quite as lovely or that appealed to him so as this girl’s, and that
she was very different from most of his sister’s college friends, who were
such serious young women and who rather over-awed him, and with whom
he was never entirely at his ease.
“And then the women in the evening! They like the singing best, I think.
It is wonderful to watch them when she sings for them, and I think her voice
never sounds so beautiful as then.”
Cahill looked up interrogatively.
“She?” he said.
“It’s her protégée, Dana,” interposed Miss Cahill. “Edith won’t tell you
the straight of it, so I shall. Edith found her already at the settlement. She
was awfully poor, but she had this glorious voice and she was trying to
support herself, and earn enough to have her voice trained. And she would
come over Sunday evenings—she lived near the settlement—and sing for the
men and women. You ought to see how they appreciate it and how they
listen to her quite quietly, as if astonished and charmed into silence. She is
nearly as poor as they, and it is all she can do for them, she says—I forget
what she did, type-writing or something—and she was going to an awfully
bad teacher and getting her voice ruined, and so Edith made friends with her
in that way. She has now sent her to Alden and really supports her so she can
devote herself entirely to her music.”
Miss Minot glanced quickly up in a little embarrassed way.
“Louise is terrible!” she said, laughing. “But you cannot imagine how
wonderfully beautiful her voice is. It is one of those naturally perfect voices
—she had always sung, but never suspected what an extraordinary gift she
had until two or three years ago. It’s such a tremendous satisfaction to do
something for a voice like that. One gets so tired spending on one’s self and
cultivating one’s own little society voice, that can just be heard across the
drawing-room if everyone keeps quite still! Alden says she will be ready for
Marchesi in six months, and for the Grand Opera in a year.”
“And one of these days, when she is a great prima donna and has married
a marquis, or a count at least, she will come back and patronize you and send
you a box for the matinée!” remarked Cahill.
Miss Minot shook her head smilingly.
“You are very cynical and you don’t know her in the least. She is very
beautiful and very fine and most grateful—absurdly grateful.”
“And she adores Edith,” put in Miss Cahill. “She has been her only friend
and confidant, and she worships her and treats her as if she were a goddess,
and I believe she would have her hands chopped off or her eyes burned out,
or be executed quite cheerfully, to show her devotion.”
Miss Minot looked openly amused. “I don’t know about all that, I’m
sure!” she said, “but I don’t think she would patronize me. Besides it would
not be strange if she were cynical and hard like yourself, Mr. Cahill,” she
went on smiling over at him, “for she has had a great deal of trouble
already.” The girl pushed her chair back a little, and her fine, earnest face
grew grave and perplexed.
Miss Cahill gave a little gasp. “I knew she had a history, Edith! She looks
like it. She is awfully pretty,” she went on, turning to her brother. “I have
seen her several times at the settlement, but we are not friends yet—I doubt
if she even knows my name. I would like to know her, though—there is
something so sad about her eyes and mouth, and her voice makes one cry.”
“And Alden—you know Alden, Mr. Cahill?—well, he’s rather brutal,
sometimes—thinks only of his art—and he told her one day that she was
particularly fortunate to have had a great trouble in her life, and that it would
do more for her voice than ten years of training. You ought to have seen how
she looked at him! But men are brutal; it was a man who made her suffer
first. She only told me part of the story, I don’t quite understand, but I know
it nearly broke her heart, young as she was, and that she will never get over
it or be the same again. I am not sure,” went on the girl thoughtfully, “it was
before she came to Boston, but I don’t know the details, and of course I
could ask no questions. She met him quite a while ago, out West, I believe,
where she lived, and she thought he loved her, he led her to believe so, and
she loved him, I know. He must have been quite different from the men she
had known. He had everything and she nothing. It was a sort of King
Cophetua and the Beggar Maid episode, only the king was not kingly at all,
and when the time came for him to go, he left her quite calmly.”
Her face was flushed now and her eyes wide open and shining with the
indignation she felt. It struck Cahill again that she was the handsomest girl
he had ever seen, and he liked her so—aroused and animated—even better
than coldly beautiful. He was not listening very much to what she was
saying, but he was watching her quietly and intently, the nobly poised head
and low forehead with the hair growing so beautifully on it, and the rounded
chin and firm, rather square jaw. As he looked at her the conviction was
borne in upon him that she was a girl who would be capable of entire
devotion or utter renunciation, and that she would be implacable if her
confidence were once destroyed.
“It must be a fine thing for a man to do,” she went on, scornfully, “to
make a girl love him and believe him nobler, and better, and stronger than he
is, and then to undeceive her so cruelly! And a girl like this one, too! That
was the worst of it. It is bad enough when the girl and the man have equal
chances—when they know each other’s weapons and skill, and when they
can retire gracefully and before it is too late, or when they are already so
scarred up that one wound more makes no difference. But when the
advantages are all on one side—when one is so much stronger than the
other! It may be because I am so fond of this girl, or it may be because I am
even yet unused to the world’s ways, and the four years spent in college and
away from such things may have made me super-sensitive, but however it
may be, it seems a despicable thing to me!” She stopped short, and the
indignation and scorn in her voice rang out sharply.
Cahill moved uneasily and looked around him. He had been so absorbed
in watching the girl’s face that he had hardly taken in what she had been
saying, but in some vague way he felt jarred and restless.
“And then,” continued Miss Minot, “if only she did not take it as she does
—if she were only angry, or indifferent, or revengeful even—but she loves
him still and she would do anything for him. She would be capable to-
morrow of sacrificing herself and her love if she thought it would make him
happier. Such devotion is as rare as genius.”
Miss Cahill leaned far forward, tracing out the delicate inlaid pattern of
the table with the point of her silver letter-opener.
“If I were engaged to a man,” she said, thoughtfully, “and were to
discover that he had treated a girl so, I would give him up, no matter what it
cost me.”
“And you, Miss Minot?” said Cahill, “what would you do?” He felt a
sudden, sharp curiosity as to her answer, and a vague apprehension of what
she would say. The girl lifted her head proudly.
“It would not be any effort for me to give such a man up,” she said,
quietly.
Cahill stood up restlessly. This girl had touched upon something which he
would have liked to forget. Of course it had been greatly different in his
case, he assured himself, but he felt uneasy and sore. And then he smiled.
There was something which struck him as pathetically amusing in the
seriousness of these two girls. They were so young and untried and utterly
unworldly, and they took such a tragic view of such a common-place affair,
and were so ready to be sacrificed for their high ideals and principles.
“You are very severe,” he said at length, with a rather forced laugh. “If
we are all to be judged like that it will go hard with us.” But he could
attempt no excuse or explanation with the girl’s beautiful, indignant eyes
upon him, and presently the talk drifted off in other channels.
It was about two weeks after this that Cahill began to realize just how
deeply in love he was with Edith Minot. She had interested him from the
first, and her very dissimilarity from most of the society girls he knew, the
nobility and seriousness of her nature beneath a rather cold and conventional
manner, and the young purity of her presence had struck him as being the
finest and most attractive things he had ever seen. He had been with her a
great deal in the two weeks she had spent with his sister, and he had had a
great many opportunities of finding out just how superior she was to most
girls, how witty and clever she could be, and what native dignity and fine
simplicity of character she possessed, and how sincere and truthful she was.
They had gone together to teas and receptions, and small dances, and the
numerous post-Easter weddings, and the fact that she was his sister’s guest
made it very easy for him to see a great deal of her without any gossip or
talk. But delightful as all that had been, he was glad now that she was going
back in a few days to her own people, and that he could go down in a
decently short time and tell her what he could not tell her in his father’s
house and which he had found so hard to withhold. The uncertainty in which
he was as to whether she cared for him or not made him restless and very
properly despondent, although he sometimes fancied that she was less cold
to him than to the others, and that if she talked with him about certain things
of particular interest to her, it was because she valued his opinion and
friendship. And he was much pleased and very flattered when she appealed
to him about her different schemes, and was even ready to sacrifice their last
day to the college settlement.
“I really must go to Tyler Street to-day,” Miss Minot had said. “It’s my
last chance. I have been very selfish, and have been having entirely too good
a time. Why, I haven’t even seen my boys or heard the Prima Donna
Contessa!” She turned and smiled at Cahill as she spoke. “By the way,” she
continued, “why don’t you and Louise come with me and hear her sing? I
have sent her a note telling her to meet me at the settlement at four o’clock,
and I know she will be only too pleased to sing for us. It is quite wonderful,
you know.”
“Of course we will go,” assented Miss Cahill briskly, while her brother
aquiesced cheerfully, if less enthusiastically. It occurred to him that it would
be as well for him not to be alone with Miss Minot any more, if he intended
to hold to his resolution of not speaking just yet.
It was rather late when they started for the settlement, and by the time
they had walked down Tyler Street from Kneeland—they left the carriage at
the corner of Kneeland—they found that it was quite four and time for a
club, the members of which were enthusiastically crowding around the door
waiting for permission to enter, and playing leap-frog and tag and
imperilling life and limb by walking on the spiked iron fence in their frantic
attempts to see in the windows. But when they caught sight of Miss Minot
they stopped playing and jumped down from the fence and threw away their
shinny sticks, and began to all talk at once at her, and to tell her what they
had been doing during the winter, and that they hadn’t been absent from
school but twice or ten times, or not at all, as the case happened to be, and
they all seemed to have had a surprising number of deadly diseases, of which
fact they were inordinately proud; and there were several still on the waiting
list, who wanted her to intercede for them to have their names put in the club
books, so they could go in and have a good time with the others; to all of
which, and a great deal more, she listened sympathetically and interestedly.
And as she stood so, the eager, softened expression on her face, laughing and
talking with the children crowding around her, the boys grabbing at her
hands and the little girls touching shyly the gown she wore, it seemed to
Cahill that he had never seen her quite so lovely and lovable. He felt an
amused sort of jealousy as he saw her run lightly up the steps with her slim
hands held tightly by two very dirty and very affectionate little boys, with
the rest swarming after her and hemming her in; and when the front door
was finally opened and she and his sister disappeared with them into the
rooms beyond, he felt rather aggrieved and out of it.
He found himself in a narrow little hall and was just wondering what he
should do with his hat and stick, when she came out from the inner room,
closing the door behind her. She was laughing in a breathless, pleased way,
and her face had a little flush on it as she turned to him.
“Please take off my coat,” she gasped, leaning against the balustrade of
the steep little stairs. “I’m going to amuse them until the Prima Donna comes
—she isn’t here, at least I don’t see her anywhere. Louise is playing for them
now.” Cahill could just catch the sounds of a piano above the shrill laughter
of the children. They were quite alone in the little hallway, and as he bent
down to take off her coat, a sudden, wild impulse overcame him. He forgot
everything except that he loved her and must tell her so, and he held her
tightly while he spoke rapidly and earnestly. It suddenly seemed
preposterous to him that he could have dreamed of waiting another week to
find out whether she loved him or not; she must tell him then and there, he
said, quick, before anyone came. And although she did not, in fact, tell him
anything at all, he was so content with her eyes as she turned toward him
that, bending down, he gave her one quick kiss after another.
And then the sound of the piano ceased and they heard a scramble of
running feet at the door, which was thrown open by Miss Cahill.
“Where are you? come in!” she cried.
As Cahill and Miss Minot went into the room beyond, a girl came slowly
down the stairs which they had just left. Her face was pitifully white and
drawn, and there was a scared, surprised look in her eyes which was not
good to see. When she reached the lowest step she stopped thoughtfully,
leaning heavily against the stairs’ rail.
“I saw them,” she said, softly and tremulously to herself. “I saw them,
and there is no possibility of a mistake. I don’t understand anything about it
—how it has happened—but it was he—it was he! If she loves him—and she
does love him—I saw it in her face, there is but one thing for me to do—
there is no other way now.” She put both hands on the banister and swayed
slightly toward it in her effort to control herself. “She has been everything to
me, has done everything for me. And if I love him—and I do love him!—
there is a million times more necessity for me to do it.” Her lips worked
painfully and silently for a moment.
An instant later she had crossed the narrow passageway, and throwing
open the door, stood there smiling faintly, with the hurt, frightened look still
on her pale face. Miss Minot was the first to see her. She moved toward her,
swiftly catching both the girl’s hands in her own, and dragging her forward
to where Cahill and his sister were standing.
“The Prima Donna Contessa!” she said, gayly. “May I introduce Miss
Cahill, Mr. Cahill——” but she stopped suddenly, for she saw Cahill take a
step forward while a dull red suffused his face.
“You!” he said—“you!” His voice sounded an octave higher than usual
and there was a queer, excited ring to it.
The girl drew back in a puzzled, half-offended way. But Cahill left his
sister’s side and crossed quickly to where the girl was standing.
“Great heavens!—you!—aren’t you—?” he began, but the girl interrupted
him quickly.
“Excuse me,” she said, in a politely distant tone.
“Don’t pretend—” he began again with a curious insistance in his voice;
and then he stopped, putting his hand heavily on the back of a chair near him
and looking at Miss Minot and the girl standing beside her. An agony of
apprehension took hold upon him.
The girl made a little gesture of surprise and turned proudly and
indifferently to Miss Minot.
“I don’t think I understand,” she said quietly to her.
The nonplussed, vacant look on her face made Cahill hesitate. He looked
fixedly at her. The red had left his face now and it showed a strange pallor.
He was just conscious of the cold, astonished look on Miss Minot’s face, and
that his sister was staring blankly at him. He pulled himself together sharply.
“I beg your pardon,” he said, with slow difficulty. “I have made a stupid
mistake—I thought—” he stopped and drew a sharp breath.
The girl’s eyes met his steadily for a moment, and then she smiled again
slightly.
“Oh, certainly,” she said, easily. “I have reminded so many people of so
many other people that I am getting quite used to it! Resemblances are so
often deceiving.”
Cahill looked at her in a curiously relieved way.
“And here we are, standing talking,” she ran on, “while the children are
waiting to sing! They have learned some very pretty Easter hymns. You shall
hear them.”
She spoke rapidly and directly to Cahill as though she wished to prevent
him from talking, and her voice sounded strained and monotonous. She went
over to the piano quickly and seated herself, and presently, when the children
had got through their songs, she began to sing alone, and that evening both
Miss Minot and Miss Cahill agreed enthusiastically that she had never sung
like that before, and that if the director of the Grand Opera had heard her he
would have signed a contract with her on the spot.
Miss Minot was rather disappointed that Cahill did not seem more
impressed.
“I don’t believe you enjoyed it half as much as I thought you would,” she
said, reproachfully to him. It was late, and they were just leaving the
drawing-room, but he had held her back for an instant while the others
passed on into the big hall.
“And isn’t she lovely and a great artist?” she insisted.
Cahill looked down at the severely beautiful face beside him, and for an
instant the feeling of dread and apprehension which had swept over him that
afternoon returned with redoubled force. He felt again the sudden, awful
shock the sight of that girl’s face had been to him, the intense relief on
discovering his mistake. He realized acutely and for the first time just how
impossible it would ever be to tell her of that episode in his life which the
girl’s face had recalled, and which he had once felt impelled to tell his father,
and he determined to make up to her in every way that a man can, for his
silence. The possibility which had faced him for a moment, of losing her,
had made her inexpressibly dear to him, and in that instant he had realized
passionately all that the loss of her would mean to him. He had felt
unutterably glad that the danger had been averted and that she need never
know. He did not mean to deceive her, but as he held her hand and looked at
her, he had but one thought, one fierce desire—to keep that look of trust and
happiness forever on her earnest and beautiful face. He leaned forward
slightly.
“How can I tell anything about any other woman when you are there?” he
said, argumentatively, smiling at her. “You didn’t expect me to take much
interest in the timbre of her voice or her trill when you had just told me——”
“Oh, yes—I know—I never told you anything,” objected the girl,
laughing and drawing away her hands. “And you were so dramatic—so
curious when you met her, that if I had—known you longer, I think
absolutely I would have demanded an explanation. Isn’t that what they say
in books—‘demand an explanation?’ ”
He shook his head. “I don’t know what they say in books. No book ever
told me anything about this!”
The girl turned her shining, happy eyes upon him.
“How unutterably silly of me,” she said, breathlessly. “For a moment you
said she was so like someone, and she had told me her story, I hardly know
what I thought—imagined.” She spoke in little, broken pauses, and as she
finished she laid her hand timidly on Cahill’s arm. “You said she reminded
you of——”
The young man laughed happily. “The mere idea!” he said, touching her
hands softly, and then he added lightly, as they moved toward the door:
“What she reminded me of was an episode in my life that happened long ago
and which was very uninteresting and unimportant.”

Clinical Reasoning in Musculoskeletal Practice 2Nd Edition Mark A Jones Full Chapter

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Clinical Reasoning in Musculoskeletal Practice 2Nd Edition Mark A Jones Full Chapter

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Clinical Reasoning in Musculoskeletal

Practice 2nd Edition Mark A. Jones

Content Strategist: Poppy Garraway, Serena Castelnovo

MARK A JONES BSc(Psych)

DARREN A RIVETT BAppSc(Phty)

ANN MOORE CBE

First edition 2004

British Library Cataloguing in Publication Data

Library of Congress Cataloging in Publication Data

2 Understanding Pain in Order to Treat Patients in Pain 32

3 Influence of Stress, Coping and Social Factors on Pain and Disability in

4 Assessment, Reasoning and Management of Psychological Factors in

5 Clinical Prediction Rules: Their Benefits and Limitations in Clinical

7 Lateral Elbow Pain With Cervical and Nerve-Related Components 118

8 Nonspecific Low Back Pain: Manipulation as the Approach to

9 Chronic Facial Pain in a 24-Year-Old University Student: Touch-Based

10 Targeting Treatment Distally at the Foot for Bilateral Persistent

11 Post-Partum Thoracolumbar Pain With Associated Diastasis Rectus

12 A Construction Project Manager With Insidious Onset of Lateral Hip

13 A Pain Science Approach to Postoperative Lumbar Surgery

14 A Lawyer With Whiplash 241

15 Management of Profound Pain and Functional Deficits From Achilles

16 Cervicogenic Headache 276

17 Shoulder Pain: To Operate or Not to Operate? 294

18 Post-Traumatic Neck Pain, Headache and Knee Pain Following a

19 Orofacial, Nasal Respiratory and Lower-Quarter Symptoms in a

20 Cervical Radiculopathy With Neurological Deficit 373

21 Incontinence in an International Hockey Player 385

22 Neck and Upper Extremity Pain in a Female Office Assistant: Where

23 Managing a Chronic Whiplash Problem When the Patient Lives 900

24 A Professional Football Career Lost: Chronic Low Back Pain in a

25 Applying Contemporary Pain Neuroscience for a Patient With

26 Thoracic Spine Pain in a Soccer Player: A Combined Movement Theory

27 Incorporating Biomechanical Data in the Analysis of a University

28 Acute Exacerbation of Chronic Low Back Pain With Right-Leg

29 Physical Therapy Chosen over Lumbar Microdiscectomy: A Functional

30 A 30-Year History of Left-Sided ‘Chronic Sciatica’ 552

APPENDIX 1 Clinical Reasoning Reflection Form 583

Jason M. Beneciuk DPT PhD MPH Jill Cook BAppSci(Phty)

Timothy W. Flynn PT PhD OCS Gwendolen Jull AO MPhty PhD FACP

Kyle A. Matsel PT DPT SCS CSCS Jo Nijs PT MT PhD

Stephen May MA MSc PhD FCSP Peter G. Osmotherly BSc

Christopher R. Showalter PT DPT OCS Bill Vicenzino BPhty

Judith Thompson DipPhysio Jodi L. Young PT DPT OCS FAAOMPT

Rafael Torres Cueco PT PhD

A bat and ball cost $1.10.

Inappropriate pain beliefs and cognitions contribute to nociplastic pain sensitization.

The Scope of Clinical Reasoning

blend of biopsychosocial knowledge and professional know-how, combined with personal

Body functions and Activities Participation

Environmental factors Personal factors

Focus of Our Clinical Reasoning: Clinical

management of identified influences, then clearly reasoning about diagnosis represents

Categories of Clinical Decisions Required:

Activity and Participation Capability and Restriction

Patient Perspectives on Their Experiences and Social

BODY CHART DEPICTING AN EXAMPLE OF SYMPTOM LOCATION AND

Potential Potential Nociceptive Potential Nociceptive

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