ASSESSMENT PROCEDURE Test for back and leg pain.

Lasegues test (straight leg raising) to check a herniated nucleus pulposes. Ask the client lie flat and raise each relaxed leg independently to the point of pain. At the point, dorsiflex the clients foot. Note the degree of elevation when pain occurs, the distribution and character ogff the pain, and the results from dorsiflexion of the foot. Measure leg length. I f you suspect that the client has one leg longer than the other, measure them. Ask the client to lie down with legs extended. With a tape, measure the distance between the anterior superior iliac spine and the medial malleolus, crossing the tape on the medial side of the knee (true leg length).

NORMAL FINDINGS Pain not reproduced. Patient is able to raise leg to 90 degree angle. Mild pain of the hamstring is a common finding and does not indicate sciatic pain.

ABNORMAL FINDINGS Pain is reproduced. Pain that shoots and radiates down one or both legs (sciatica) below the knees may be due to a herniated intervertebral disc. Continuous, aching pain at night not relieved by rest may be from metastases. Lower back pain with tenderness and limited ROM is common in osteoporosis.

Measurements are equal or within 1 cm. if the legs still look unequal, assess the apparent leg length by measuring from a nonfixed point (umbilicus) to a fixed point (medial malleolus) on each leg.

Unequal leg lengths are associated with scoliosis. Equal true leg lengths are seen with abnormalities in the structure or position of the hips and pelvis.

SHOULDER, ARMS, AND ELBOWS Inspection and Palpation ASSESSMENT PROCEDURE Inspect and palpate shoulders and arms. With the client standing or sitting, inspect anteriorly and posteriorly symmetry, color, swelling, and masses. Palpate for tenderness, swelling, or heat. Anteriorly palpate the clavicle, acromioclavicular joint, sub acromial are, and the biceps. Posteriorly plapate the glenohumeral joint, coracoids area, and the scapular area. Test ROM. Explain to the client that you will be assessing his range of motion (consisting of flexion, extension, adduction, abduction, and motion NORMAL FINDINGS Shoulders are symmetrically round, no redness, swelling, or deformity or heat. Muscles are fully developed. Clavicles and scapulae are even and symmetric. The client reports no tenderness. ABNORMAL FINDINGS Flat, hollow, or less rounded shoulders are seen with dislocation. Muscle atrophy is seen with nerve or muscle damage or lack of use. Tenderness, swelling, and heat may be noted with shoulder strains, sprains, arthritis, bursitis, and degenerative joint disease.

Extend of forward flexion should be 180 degrees; hyperextension, 50 degrees; adduction, 50 degrees; and abduction 180 degrees.

Painful and limited abduction accompanied by muscle weakness and atrophy are seen with a rotator cuff tear. Client has sharp catches of pain when

against resistance.) ask client to stand with both arms straight down at sides. Next ask him to move the arms forward (flexion), then backward with elbows straight. Then have the client bring both hands together overhead, elbows straight, followed by moving both hands in front of the body past the midline with elbows straight (this tests adduction and abduction) In a continuous motion, have the client bring the hands together behind the head with elbows flexed (this tests external rotation) and behind the back (internal rotation). Repeat these maneuvers against resistance.

Extent of external and internal rotation should be about 90 degrees, respectively. The client can flex, extend, adduct, abduct, rotate, and shrug shoulders against resistance.

bringing hands overhead when he or she rotator cuff tendinitis. Chronic pain and severe limitation of all shoulder motions are seen with calcifies tendinitis. Inability to shrug shoulders against resistance is seen with a lesion of cranial nerve XI (spinal accessory). Decreased muscle strength is seen with muscle or joint disease.

ELBOWS Inspection and Palpation ASSESSMENT PROCEDURE NORMAL FINDINGS Inspect for size, shape, Elbows are symmetric without deformities, redness, or deformities, redness, or swelling swelling. Inspect elbows in both flexed and extended positions. With the elbow relaxed and Nontender; without nodules. flexed about 70 degrees, use your thumb and middle fingers to palpate the olecranon process and epicondyles. ABNORMAL FINDINGS Redness, heat, and swelling may be seen with bursitis of the olecranon process due to trauma or arthritis. Firm, nontender, subcutaneous nodules may be palpated in rheumatoid arthritis or rheumatic fever. Tenderness or pain over the epicondyles may be palpated in epicondylitis (tennis elbow) due to repetitive movements of the forearm or wrists.

Test ROM. Ask the client to perform the following movements to test flexion, extension, pronation, supination, and ROM. Flex the elbow and bring the hand to the forehead. Straighten the elbow. Then hold arm out, turn the

Normal ranges of motion are 160 Decreased ROM against degrees of flexion; 180 degrees resistance is seen with joint or of extension. 90 degrees of music disease or injury. pronation. 90 degrees of supination. Some clients may lack 5 to 10 degrees or have hyperextension. The client should have full ROM

palm down, then turn the palm against resistance. up. Last have the client repeat the movement against your resistance.

WRISTS Inspection and Palpation ASSESSMENT PROCEDURE NORMAL FINDINGS Inspect wrist size, shape, Wrists are symmetric without symmetry, color and swelling. redness, or swelling. They are Then palpate for tenderness and nontender and free of nodules. nodules. ABNORMAL FINDINGS Swelling is seen with rheumatoid arthritis. Tenderness and nodules may be seen with rheumatoid arthritis. A nontender, round, enlarged, swollen, fluid-filled cyst (ganglion) may be noted on the wrists. in Snuffbox tenderness may indicate a scaphoid fracture, which is often the result of falling on an outstretched hand. Ulnar deviation of the wrist and fingers with limited ROM is often seen in rheumatoid arthritis. Increased pain with extension of the wrist against resistance is seen in epicondylitis of the lateral side of the elbow. Increased pain with flexion of the wrist against resistance is seen in epicondylitis of the medial side of the elbow. Decreased muscle strength is noted with muscle and joint disease.

Palpate the anatomic snuffbox (the hollow area on the back of the wrist at the base of the fully extended thumb). Test ROM. Ask the client to bend wrist down and back (flexion and extension). Next have the client hold the wrist straight and move the hand outward and inward (deviation). Repeat these maneuvers against resistance.

No tenderness palpated anatomic snuffbox.

Normal ranges of motion are 90 degrees. Flexion; 70 degrees, hyperextension; 55 degrees, ulnar deviation; and 20 degrees, radial deviation. Client should have full ROM against resistance. Unequal lengths of the ulna and radius have been found in some ethnic groups.

Test for carpal tunnel syndrome. Perform Phalens test. Ask the No tingling, numbness, or pain client to place the backs of both result from Phalens test or from hands against each other while Tinels test. flexing the wrists 90 degrees downward. Have the client hold this position for 60 seconds. Optionally test for Tinels sign.

After either test, client may report tingling, numbness, and pain with carpal tunnel syndrome. Median nerve entrapped in the carpal tunnel results in pain, numbness, and impaired

With your finger, percuss lightly over the median nerve(located on the inner aspect of the wrist).

function of the hand and fingers.

HANDS AND FINGERS Inspection and Palpation ASSESSMENT PROCEDURE Inspect size, shape, symmetry, swelling, and color. Palpate the fingers from the distal end proximally, noting tenderness, swelling, boney prominence, nodules or crepitus of each interphalangeal joint. Assess the metacarpophalangeal joint by squeezing the hand from each side between your thumb and fingers. Palpate each metacarpal of the hand, noting tenderness and swelling. Test ROM. Ask the client to spread the fingers apart, make a fist, bend the fingers down and then up, move the thumb away from other fingers and then touch the thumb to the base of the small fingers. Repeat these maneuvers against resistance. NORMAL FINDINGS Hands and fingers are symmetric, nontender, and without nodules. Fingers lie in straight line. No swelling or deformities. Rounded protuberance noted next to the thumb over the thenar prominence. Smaller protuberance seen adjacent to the small finger. ABNORMAL FINDINGS Swollen, stiff, tender finger joints are seen in acute rheumatoid arthritis. Boutonniere deformity and swan-neck deformity are seen in long term rheumatoid arthritis. Atrophy of the thenar prominence may be evident in carpal tunnel syndrome. In osteoarthritis, hard, painless nodules may be seen over the distal interphalangeal joints and over the proximal interphalangeal joints (Bouchards nodes). Inability to extend the ring and little fingers is seen in Dupuytrens contracture. Painful extension of a finger may be seen in tenosynovitis of the flexor tendon sheathes. Decreased muscle strength against resistance is associated with muscle and joint disease.

Normal ranges are 20 degrees of abduction, full adduction of fingers, 90 degrees of flexion, and 30 degrees of hyperextension. The thumb should easily move away from other fingers and 50 degrees of thumb flexion is normal. The client normally has full ROM against resistance.

HIPS Inspection and Palpation ASSESSMENT PROCEDURE With the client standing, inspect symmetry and shape of hips. Palpate for stability, tenderness, and crepitus. NORMAL FINDINGS Buttocks are equally sized; iliac crests are symmetric in height. Hips are stable, nontender, and without crepitus. ABNORMAL FINDINGS Instability, inability to stand, and/or a deformed hip area are indicative of as fractured hip. Tenderness, edema, decreased ROM, and crepitus are seen in hip inflammation and degenerative joint disease.

Test ROM. With the client Normal ROM: 90 degrees of hip supine, ask the client traise flexion with knee straight and extended leg. 120 degrees of hip flexion with the knee bent and the other leg remaining straight. Clincal Tip: if the client has had a total hip replacement, do not test ROM unless the physician gives permission to do so. This is done to reduce the risk of dislocating the hip prosthesis. Move extended leg away from Normal ROM: midline of body as far as possible (adduction and abduction). 45 degrees to 50 degrees of Bend knee and turn leg inward abduction; 20 degrees to 30 (rotation) and then outward degrees of adduction. (rotation). Ask the client to lie prone and lift 40 degrees internal hip rotation. extended leg off table. 45 degrees external hip rotation. Alternatively, ask the client to 15 degrees hip hyperextension. stand and swing extended leg backward. Full ROM against resistance. Repeat these maneuvers against resistance.

Inability to abduct hip is a common sign of hip disease.

Pain and a decrease in internal hip rotation may be a sign of osteoarthritis or femoral neck stress fracture. Pain on palpation of the greater trochanter and pain as the client moves from standing to lying down may indicate bursitis of the hip. Decrease muscle strength against resistance is seen in muscle and joint disease.

KNEES Inspection and Palpation ASSESSMENT PROCEDURE With the client supine then sitting with knees dangling, inspect for size, shape, symmetry, swelling, deformities, and alignment. Observe for quadriceps muscle atrophy. Palpate for tenderness, warmth, consistency, and nodules. Begin palpation with 10 cm above the patella, using your fingers and thumb to move downward toward the knee. ABNORMAL FINDINGS Knees turn in with knock knees (genu valgum) and turn out with bowed legs (genu varum). Swelling above or next to the patella may indicate fluid in the knee joint or thickening opf the Some older clients may have a synovial membrane. bowlegged appearance because of decreased muscle control. Tenderness and warmth with a boggy consistency may be Nontender and cool. Muscle symptoms of synovitis. firm. No nodules. Assymetrical muscular development in the quadriceps may indicate atrophy. Test for swelling. If you notice No bulge or fluid appears on Bulge of fluid appears on medial swelling, perform the bulge test medial side of knee. side of knee with a small amount to determine if the swelling is of joint effusion. NORMAL FINDINGS Knees asymmetric, hollows present on both sides of the patella, no swelling or deformities. Lower leg in alignment with upper leg.

due to accumulation of fluid in the knee. The bulge test helps to detect small amounts of fluid in the knee. With the client in a supine position, use the ball of your hand firmly to stroke the medial side of the knee upward, three to four times, to displace any accumulated fluid. Then press on the lateral side of the knee and look for a bulge on the medial side of the knee. Perform the ballottement test. It helps to detect large amount s of fluid in the knee. With the client in a supine position, firmly press your nondominant thumb and index finger on each side of the patella. This displaces fkuid in the suprapatellar bursa located between femur and patella. Then with your dominant fingers, push the patella down on the femur. Feel for fluid wave or click. Palpate the tibioefemoral space. As you compress the patella, slide it distally against the underlying femur. Note crepitus or pain. Test ROM. Ask the client to Bend each knee up (flexion) toward buttocks or back. Straighten knee (extension/hyperextensi on). Walk normally. Repeat these maneuvers against resistance. Test for pain and injury. If the client complains of a giving in or locking of the knee, perform McMurrays test. With the client in the supine position, ask the client to flex one knee and hip. Then place your thumb and

No movement of patella noted. Fluid wave or click palpated with Patella rests firmly over femur. large amounts of joint effusion, a positive ballottement test may be present with meniscal tears.

There is no pain on examination. Crepitus may be present.

Normal ranges: 120 degrees to 130 degrees of flexion; 0 degrees of extension to 15 degrees of hyperextension. Client should have full ROM against resistance.

Osteoarthritis is characterized by a decreased ROM with synovial thickening and crepitation. Flexion contractures of the knee are characterized by an inability of to extend knee fully. Decreased muscle strength against resistance is seen in muscle and joint disease. Pain or clicking is indicative of a torn meniscus of the knee.

No pain or clicking noted.

index finger of one hand on either side of the knee. Use your other hand to hold t he heel of the foot up. Rotate the lower, leg and foot laterally. Slowly extend the knee, noting pain or clicking. Repeat, rotating lower leg and foot medially. Again note pain or clicking.

ANKLES AND FOOT Inspection and Palpation ASSESSMENT PROCEDURE NORMAL FINDINGS With the client sitting, standing, Toes usually point forward and and walking, inspect position, lie flat; however, they may point alignment, shape, and skin. in (pes varus) or point out (pes valgus). Toes and feet are in alignment with the lower leg. Smooth, rounded medial malleolar prominences with prominent heels and metatarsophalangeal joints. Skin is smooth and free of corns and calluses. Longitudinal arch; most of weight bearing is on foot midline. ABNORMAL FINDINGS A laterally deviated great toe with possible overlapping of the second toe and possible formation of an enlarged, painful, inflames bursa (bunion) on the medial side is seen with hallux valgus. Common abnormalities include feet with no arches (pes palnus or flatfeet), feet ith high arches (pes cavus); painful thickening of the over bony prominences and at pressure pints (calluses); and painful warts (verruca vulgaris) that often occur under a callus (plantar warts). No pain, heat, swelling, or Tender, painful, reddened, hot, nodules are noted. and swollen metatarsophalangeal joint of the great toe is seen in gouty arthritis. Nodules of the posterior ankle may be palpated with rheumatoid arthritis. Pain and tenderness or the metatarsophalangeal joints are seen in inflammation of the joints, rheumatoid arthritis, and degenerative joint disease. Tenderness of the calcaneus of the bottom of the foot may indicate plantar fasciitis.

Palpate ankles and feet for tenderness, heat, swelling, or nodules. Palpate the toes from the toes from the distal end proximally; noting tenderness, swelling, boney prominences, nodules, or crepitus of each interphalangeal joint. Assess the metatarsophalangeal joints by squeezing the foot form each side with your thumb and fingers. Palpate each metatarsal, noting swelling of tenderness. Palpate the plantar area (bottom) of the foot noting pain or swelling.

Test ROM. Ask the client to: Point toes upward (dorsiflexion) and then downward (plantar flexion). Turn soles outward (eversion) and then inward (inversion). Rotate foot outward (abduction) and then inward (adduction). Turn toes under foot (flexion) and then upward (extension). Repeat these maneuvers against resistance.

Normal ranges: 20 degrees dorsiflexion of ankle and foot; 45 degrees plantar flexion of ankle and foot. 20 degrees of eversion; 30degrees of inversion. 10 degrees of abduction; 20 degrees of adduction. 40 degrees of flexion; 40 degrees of extension. Client has full ROM against resistance.

Decreased strength against resistance is seen in muscle and joint disease. Hyperextension of the metatarsophalangeal joint of the proximal interphalangeal joint is apparent in hammer toe. Decreased strength against resistance is common in muscle and joint disease.