Examination &

Evaluation in
Orthopedic Physical
Therapy

Superior University
Principles & Concepts
• A musculoskeletal assessment requires a proper and thorough
systematic examination of the patient
• A correct diagnosis depends on a knowledge of functional anatomy,
an accurate patient history, diligent observation, and a thorough
examination
• The differential diagnosis process involves the use of clinical signs
and symptoms, physical examination, a knowledge of pathology and
mechanisms of injury, provocative and palpation (motion) tests, and
laboratory and diagnostic imaging techniques
Principles & Concepts
• One of the more common assessment recording techniques is the
problem-oriented medical records method, which uses “SOAP” notes
• SOAP stands for the four parts of the assessment:
• Subjective
• Objective
• Assessment
• Plan
Principles & Concepts
• Regardless of which system is selected for assessment, the examiner
should establish a sequential method to ensure that nothing is
overlooked
• The assessment must be
• organized
• comprehensive
• reproducible
• In general, the examiner compares one side of the body, which is
assumed to be normal, with the other side of the body, which is
abnormal or injured
Principles & Concepts
• Total Musculoskeletal Assessment
• Patient history
• Observation
• Examination of movement
• Special tests
• Reflexes and cutaneous distribution
• Joint play movements
• Palpation
• Diagnostic imaging
PATIENT HISTORY
Patient History
• Often the examiner can make the diagnosis by simply listening to the patient.
• Even if the diagnosis is obvious, the history provides valuable information about
the disorder, its present state, its prognosis, and the appropriate treatment.
• The history also enables the examiner to determine the type of person the
patient is, his or her language and cognitive ability
• The patient’s ability to articulate, any treatment the patient has received, and
the behavior of the injury.
• Past medical history should include any major illnesses, surgery, accidents, or
allergies..
• Lifestyle habit patterns, including sleep patterns, stress, workload, and
recreational pursuits, should also be noted
Patient History
• It is important that the examiner politely but firmly keeps the patient
focused and discourages irrelevant information
• Examiner should listen for any potential red flag signs and symptoms
that would indicate the problem is not a musculoskeletal one or a
more serious problem that should be referred to the appropriate
health care professional
Red Flag Findings in Patient
History
Cancer
• Persistent pain at night, Constant pain anywhere in the body, Unexplained weight loss (e.g., 4.5 to 6.8 kg [10 to 15 lbs]
in 2 weeks or less)
• Loss of appetite
• Unusual lumps or growths
• Unwarranted fatigue
• Cardiovascular
• Shortness of breath
• Dizziness
• Pain or a feeling of heaviness in the chest
• Pulsating pain anywhere in the body Constant and severe pain in lower leg (calf) or arm
• Discolored or painful feet
• Swelling (no history of injury)
• Gastrointestinal/ Genitourinary
• Frequent or severe abdominal pain
• Frequent heartburn or indigestion
• Frequent nausea or vomiting
• Change in or problems with bowel and/or bladder function (e.g., urinary tract infection)
• Unusual menstrual irregularities
Red Flag Findings in Patient
History
Miscellaneous
• Fever or night sweats
• Recent severe emotional disturbances
• Swelling or redness in any joint with no history of injury
• Pregnancy
Neurological
• Changes in hearing
• Frequent or severe headaches with no history of injury
• Problems with swallowing or changes in speech
• Changes in vision (e.g., blurriness or loss of sight)
• Problems with balance, coordination, or falling Faint spells (drop attacks)
• Sudden weakness
Yellow Flag Findings
• Yellow Flag Findings in Patient History That Indicate a More Extensive Examination May Be Required
• Abnormal signs and symptoms (unusual patterns of complaint)
• Bilateral symptoms
• Symptoms peripheralizing
• Neurological symptoms (nerve root or peripheral nerve)
• Multiple nerve root involvement
• Abnormal sensation patterns (do not follow dermatome or peripheral
nerve patterns)
• Saddle anesthesia
• Upper motor neuron symptoms (spinal cord) signs
• Fainting
• Drop attacks
• Vertigo
• Autonomic nervous system symptoms
• Progressive weakness
• Progressive gait disturbances
• Multiple inflamed joints
• Psychosocial stresses
Patient History
What is the patient’s age and sex
• various growth disorders, such as Legg-Perthes disease or
Scheuermann disease, are seen in adolescents or teenagers
• Degenerative conditions, such as osteoarthritis and osteoporosis, are
more likely to be seen in an older population.
• Shoulder impingement in young people (15 to 35 years) is more likely
to result from muscle weakness
Patient History
• What is the patient’s occupation?
• history of the present illness or chief complaint
• Was there any inciting trauma (macrotrauma) or repetitive activity
(microtrauma)?
• What was the mechanism of injury, and were there any predisposing
factors?
Patient History
• Was the onset of the problem slow or sudden?
• Did the condition start as an insidious, mild ache, progress to continuous
pain
If inciting trauma has occurred, it is often relatively easy to
determine
the location of the problem.
• Does the pain get worse as the day progresses?
• Was the sudden onset caused by trauma,
• was it sudden with locking because of muscle spasm (spasm lock) or pain
Patient History
Where are the symptoms that bother the patient?
• If possible, have the patient point to the area.
• Does the patient point to a specific structure or a more general area?
• The latter may indicate a more severe condition or referral of symptoms (yellow flag).
Patient History
• Where was the pain or other symptoms when the patient first had the complaint?
• Acute pain is new pain that is often severe, continuous, and perhaps disabling and is of
sufficient quality or duration that the patient seeks help.
• Acute injuries tend to be more irritable resulting in pain earlier in the movement, or minimal
activity will bring on symptoms, and often the pain will remain after movement has stopped.
• Chronic pain is more aggravating, is not as intense, has been experienced before, and in
many cases, the patient knows how to deal with it.
• Acute pain is more often accompanied by anxiety, whereas chronic pain is associated with
depression.
• When tissue has been damaged, substances are released leading to inflammation and
peripheral sensitization of the nociceptors (also called primary hyperalgesia) resulting in
localized pain.
• If the injury does not follow a normal healing pathway and becomes chronic, central
sensitization (also called secondary hyperalgesia) may occur.
Patient History
• What are the exact movements or activities that cause pain?
• Pain and Its Relation to Severity of Repetitive Stress Activity
• Level 1: Pain after specific activity
• Level 2: Pain at start of activity resolving with warm-up
• Level 3: Pain during and after specific activity that does not affect
performance
• Level 4: Pain during and after specific activity that does affect performance
• Level 5: Pain with activities of daily living (ADLs)
• Level 6: Constant dull aching pain at rest that does not disturb sleep
• Level 7: Dull aching pain that does disturb sleep
NOTE: Level 7 indicates highest level of severity.
Patient History
Patient History
• Has the condition occurred before?
• If so, what was the onset like the first time?
• Where was the site of the original condition, and has there been any
radiation (spread) of the symptoms?
• If the patient is feeling better, how long did the recovery take?
• Did any treatment relieve symptoms?
• Does the current problem appear to be the same as the previous
problem, or is it different?
Patient History
• Has there been an injury to another part of the kinetic chain as well
• Are the intensity, duration, or frequency of pain or other symptoms
increasing?
Patient History
Patient History
Patient History
Patient History
• Is the pain constant, periodic, episodic (occurring with certain activities), or
occasional?
• Constant pain suggests chemical irritation, tumors, or possibly visceral lesions..
• If periodic or occasional pain is present, the examiner should try to determine
the activity, position, or posture that irritates or brings on the symptoms, because
this may help determine what tissues are at fault. This type of pain is more likely
to be mechanical and related to movement and stress.
• Episodic pain is related to specific activities. At the same time, the examiner
should be observing the patient.
• Does the patient appear to be in constant pain? Does the patient appear to be
lacking sleep because of pain? Does the patient move around a great deal in an
attempt to find a comfortable position?
Patient History
• Is the pain associated with rest? Activity? Certain postures? Visceral
function? Time of day?
Patient History
• What type or quality of pain is exhibited
Patient History
• What types of sensations does the patient feel, and where are these
abnormal sensations ?
• Does a joint exhibit locking, unlocking, twinges, instability, or giving
way?
Patient History
Has the patient experienced any bilateral spinal cord symptoms, fainting, or
drop attacks?
• Is bladder function normal?
• Is there any “saddle” involvement (abnormal sensation in the perianal region, buttocks, and
superior aspect of the posterior thighs) or vertigo? “Vertigo” and “dizziness” are terms
often used synonymously, although vertigo usually indicates more severe symptoms.
• The terms describe a swaying, spinning sensation accompanied by feelings of unsteadiness
and loss of balance.
• These symptoms indicate severe neurological problems, such as cervical myelopathy, which
must be dealt with carefully and can (e.g., in cases of altered bladder function) be
emergency conditions potentially requiring surgery.
• Drop attacks occur when the patient suddenly falls without warning or provocation but
remains conscious.
Patient History
Are there any changes in the color of the limb?
• Ischemic changes resulting from circulatory problems may include
white, brittle skin; loss of hair; and abnormal nails on the foot or
hand.
• Conditions such as reflex sympathetic dystrophy, which is an
autonomic nerve response to trauma, however minor, can cause
these symptoms, as can circulatory problems such as Raynaud’s
disease.
Patient History
• Has the patient been experiencing any life or economic stresses?
Patient History
• Does the patient have any chronic or serious systemic illnesses or
adverse social habits (e.g., smoking, drinking) that may influence the
course of the pathology or the treatment?
• Has the patient undergone an x-ray examination or other imaging
techniques
• Has the patient been receiving analgesic, steroid, or any other
medication?
• Does the patient have a history of surgery or past/present illness?
Listen to the patient—he or she is telling
you what is wrong!
OBSERVATIONS
OBSERVATIONS

• In an assessment, observation is the “looking” or inspection phase

• Its purpose is to gain information on visible defects, functional
deficits, and abnormalities of alignment
OBSERVATION
• What is the normal body alignment?
• Anteriorly, the nose, xiphisternum, and umbilicus should be in a straight
line
• From the side, the tip of the ear, the tip of the acromion, the high point
of the iliac crest, and the lateral malleolus (anterior aspect) should be in
a straight line.
• Is there any obvious deformity?
• Structural Deformities
• Functional Deformities
• Dynamic Deformities
OBSERVATION
• Are the bony contours of the body normal and symmetric, or is there
an obvious deviation?
• Are the soft-tissue contours (e.g., muscle, skin, fat) normal and
symmetric? Is there any obvious muscle wasting?
• Are the limb positions equal and symmetric? The examiner should
compare limb size, shape, position, any atrophy, color, and
temperature
• Are the color and texture of the skin normal? Does the appearance of
the skin differ in the area of pain or symptoms, compared with other
areas of the body?
OBSERVATION
• Are there any scars that indicate recent injury or surgery? Recent
scars are red because they are still healing and contain capillaries;
older scars are white and primarily avascular.
• Is there any crepitus, snapping, or abnormal sound in the joints when
the patient moves them? Sounds, by themselves, do not necessarily
indicate pathology
• Is there any heat, swelling, or redness in the area being observed?
• All of these signs along with pain and loss of function are indications
of inflammation or an active inflammatory condition
OBSERVATION
• What is the patient’s facial expression?
• Does the patient appear to be apprehensive, in discomfort, or lacking
sleep?
• Is the patient willing to move?
• Are patterns of movement normal? If not, how are they abnormal?
• Any alteration should be noted and included in the observation
portion of the assessment
EXAMINATION
EXAMINATION
• Unless bilateral movement is required, the normal side is tested first.
• Testing the normal side first allows the examiner to establish a
baseline for normal movement for the joint being tested
• The patient does active movements before the examiner does
passive movements
• Any movements that are painful are done last, if possible, to prevent
an overflow of painful symptoms to the next movement that, in
reality, may be symptom free.
• Each active, passive, or resisted isometric movement may be
repeated several times or held (sustained) for a certain amount of
time to see whether symptoms increase or decrease
Vital Sign
EXAMINATION
Principles of EXAMINATION
Examination of Specific Joints
• Active Movements

• Passive Movements
Capsular Pattern
Muscle Testing
Functional Assessment
Reflexes and Cutaneous Distribution
• Superficial Reflex

• Deep Reflex
Class Activity
Write down the pathological reflexes
Joint Play Movements
• Loose Packed (Resting) Position
To test joint play movement, the examiner places the joint in its resting
position, which is the position in its ROM at which the joint is under the
least amount of stress; it is also the position in which the joint capsule has
its greatest capacity
• Close Packed (Synarthrodial) Position
The close packed position should be avoided as much as possible during
an assessment except to stabilize an adjacent joint, because in this
position, the majority of joint structures are under maximum tension. In
this position, the two joint surfaces fit together precisely—that is, they are
fully congruent
Questions
Thanks