orthopedic physical assessment
TRANSCRIPT
J.AYYAPPAN, M.P.T (ORTHO)
ORTHOPAEDIC physical ASSESSMENT Date:
Subjective assessment Place:
Name: Age: Gender: Occupation: Address: IP/OP no
Chief Complaint:
History taking
Present History:
• Allowed to narrate history
• Date of onset of symptoms
• Mechanism of injury
• Mode of onset
• Condition – Improved, Stationary, Deteriorated
• Muscular weakness
• Current treatment
J.AYYAPPAN, M.P.T (ORTHO)
Past History:
Relevant previous medical problem to present condition
Examples
• Trauma
• Joint injuries
• Neurological problem
• Any history of Tuberculosis
• Bronchial Asthma
• Blood Pressure
• Diabetes
• Cardiac Problems
• Enquiry made for any accidental injury
Family History :
Hereditary
Consanguinity
Personal History :
• Cigarettes – Number/day ,How long (Pack years)
• Alcoholic – Amount/day ,Duration
Socio-economic History:
Social status-some of the disease common in slum area
Affordability :
Economic status of the patients
Drug History :
Present medication patient is on
J.AYYAPPAN, M.P.T (ORTHO)
Pain Assessment:
Nature of the pain: 1. Burning-patient used to say burning. Ex -nerve involvement (sympathetic)
2. Electric shock- it is same like electric shock. Ex-compression on nerve
3. Pin prick-pain will be feel like prickling with needle. Ex- nerve compression
4. Needle insertion-it is familiar with everyone .Ex- nerve problem
Course: 1. Radiating pain- pain will be there in the course of the nerve- Radiculopathy
2. Localized- local pain-local injury
Types of pain:- 1. Dull ache-slow pain, Ex-ligament and muscle injury,
Cumulative trauma disorder, Some chronic condition
2. Sharpe- Fast pain Ex-fracture- acute injuries
3. Diffused – diffused pattern. Ex- muscle injury, blunted injuries
4. Unidentified –cannot localized by patient. Ex- peripheral plasticity
Duration of symptoms: From onset to present
Intensity: Subjective quantification:
Visual Analog Scale
Magill pain questionnaire
Objective Quantification:
Pain pressure algometer
Submaximal exertional tourniquet test
J.AYYAPPAN, M.P.T (ORTHO)
Aggravating factor:
Activities, pressure, stretching
Relieving factors:
Rest , pain medication
Objective Examination
On Observation: General Condition of patient – Poor, Good, Fair built
Muscle wasting- long term case
Edema: soft spongy edema- recent fluid collection
Hard brownie edema- chronic lymphatic edema
Any bandages, Scars – Area extent
Attitude of the Limbs – Supine, Sitting, Standing
Type of gait: ask the patient to walk
Bony contours: compare to normal side
Deformities: any abnormal bony protrusion
On Palpation:
You can do three layers of palpation.
Layer 1- you can palpate the skin –less pressure.
Layer 2- you can palpate the fascia, adipose tissue & muscle- moderate
pressure.
Layer 3- you can palpate the bony contour – more pressure.
J.AYYAPPAN, M.P.T (ORTHO)
Tenderness :
Grading
Grade 1 - Patient complains of pain
Grade 2 - Patient complains of pain & winces
Grade 3 - Patient winces & withdraws
Grade 4 - Patient will not allow palpation of the joint
Tissue tension and texture :
• Temperature variation of skin- inflammation
• Spasm
• Type of skin – Dry or Excessive moisture
• Scar – Adherent / Non Adherent
• Swelling
Points to be considered while assessing swelling
Ø Comes on soon after injury – Blood
Ø Comes on after 8 to 24 hours – Synovial
Ø Boggy, spongy feeling – Synovial
Ø Harder, tense feeling ,with warmth – Blood
Ø Bruit or Thrill with edema- Active Hemorrhage
Ø Tough, dry – Callus
Ø Leathery thickening – Chronic
Ø Soft fluctuating – Acute
Ø Hard – Bone
Ø Thick, slow-moving – Pitting edema
Ø Crepitus, Abnormal sounds
J.AYYAPPAN, M.P.T (ORTHO)
On Examination: Vital Signs :
Motor Assessment Range of Motion (ROM)
Active - When and where pain starts
Whether movement increases pain - Pattern of movement ,
Trick movements
Passive - When and where pain starts - Whether movement increases pain
Pattern of movement
D/F between range of motion available
End Feel
Normal:
Bone to Bone - elbow extension
Soft Tissue Approximation -elbow flexion , knee flexion
Tissue Stretch- hip flexion,
Abnormal :
Early Muscle Spasm – acute severe injury
Late Muscle Spasm – joint pain
Hard Capsular – PA shoulder
Soft Capsular - capsulities
Bone to Bone – myosities ossificans
Empty – pain
Springy Block – muscle tightness
Capsular Patterns :
Normal capsular pattern
Abnormal capsular pattern
J.AYYAPPAN, M.P.T (ORTHO)
Manual Muscle Testing :
MRC Grading
Resisted Isometrics
On contraction causes pain and, if it does, pain’s intensity & quality - Strength of contraction
Type of contraction causing problem (concentric, isometric, eccentric)
Joint movements
• Loose packed position • Close packed position
Sensory Assessment
Superficial Sensations - Pain, Temperature, Light touch, Pressure
Deep Sensations –
• Movement sense
• Position sense
Combined Sensations
• Stereognosis,
• Barrognosis
• Tactile Localization,
• Two Point Discrimination,
• Grapesthesia
MRC Grading
S0 : No sensation
S1 : Deep Proprioception
S2 : Skin touch, pain thermal sensation
S3 : S2 with accurate localization but deficient stereognosis, cold sensitivity,
hypersensitivity often present
S3+ : Object and texture recognition but not normal sensation, good but not normal two point
discrimination
S4 : Normal sensations
J.AYYAPPAN, M.P.T (ORTHO)
Reflexes
Superficial Reflexes
Corneal, Abdominal, Plantar, Cremasteric
Deep Reflexes
Biceps, Triceps, Babinski Reflex, Knee Jerk, Ankle Jerk
Clonus :
Grading
0 : Absent
1 : Diminished
2 : Normal
3 : Brisk
4 : Exaggerated
Dermatomes & Myotomes :
Limb Length Discrepancies
• Apparent Length
• True Length
Peripheral scanning examination:
Assess the proximal and distal joints to the affected area Ex- Double crush syndrome
Special Tests:
See the annexure
Functional Assessment :
Using any one of the functional assessment scale
Ambulation
o Gait or Wheel Chair
o Independent or Dependent - Transfers
J.AYYAPPAN, M.P.T (ORTHO)
Gait Assessment
• Type of gait
• Stride length
• Step length
ADL:
BADL- Basic activities of daily living Eg- bathing, eating,
IADL- Instrumental Activities of daily livings Eg- cooking, combing, home making
• FIM scale
• Any other functional assessment scale Investigations:
X-ray, CT scan, MRI, BMD, Global skeletal scan, Arthroscopy
Clinical Impression:
Medical diagnosis/Pathological study
Differential Diagnosis:
Rule out the inappropriate conditions
Findings to make Final Impression:
Positive points should support your diagnosis
Provisional diagnosis:
• Your diagnosis Based on your own assessment, functional limitation
of the patients, and area of the involvement. Eg; lateral Elbow pain-
tennis elbow, Tone dysfunction and movement disorder in half of the
body- hemiplegia
• Do not write your diagnosis based on tissue pathology
J.AYYAPPAN, M.P.T (ORTHO)
Goals: Short Term
Long Term
Treatment Plan: Electric Modalities
Manipulation
Exercises
Splints & Assistive Devices
Home Programme:
J.AYYAPPAN, M.P.T (ORTHO)
SPECIAL ORTHOPAEDIC TESTS À Shoulder: À Speed Test
(Biceps or Straight Arm Test)
- Bicipital Tendinitis
À Yergason’s Test - Bicipital Tendinitis
À Lippman’s Test - Bicipital Tendinitis
À Supraspinatus Test
(Empty Can Test)
- Supraspinatus Tear
À Drop Arm Test (Codman’s Test) - Rotator Complex
À Neer Impingement Test Supraspinatus & Biceps Tendon
À Roos Test - Thoracic Outlet Syndrome
À Wright Test - Thoracic Outlet Syndrome
À Adson Test - Thoracic Outlet Syndrome
À Allen’s Test - Thoracic Outlet Syndrome
À Upper Limb Tension Test (ULTT)
ULTT 1
ULTT 2
ULTT 3
ULTT 4
Median nerve & anterior interosseous
nerve
C5, 6, 7, Median nerve,
Musculocutaneous nerve & axillary
nerve
- Radial nerve
- C8, T1, Ulnar nerve
À Apprehension Test - Anterior Shoulder Dislocation
À Rockwood Test - Anterior Shoulder Instability
À Dugas Test - Anterior Shoulder Dislocation
À Posterior Apprehension Test - Posterior Shoulder Dislocation
À Push Pull Test - Posterior Shoulder Dislocation
À Sulcus Test - Inferior Shoulder Instability
À Clunk Test - Labral Tear
J.AYYAPPAN, M.P.T (ORTHO)
Forearm, Wrist & Hand: À Finketsein’s Test
Abductor Pollicis Longus & Extensor Pollicis Longus Tenosynovitis
À Sweater Finger Test Ruptured Flexor Digitorum Profundus À Bunnel-Litter Test - Tight Intrinsics À Phalen’s Test - Carpal Tunnel Syndrome À Reverse Phalen’s Test - Carpal Tunnel Syndrome À Froment’s Sign Paralysis of Adductor Pollicis Longus
Pelvis: À Approximation Test Possible SI Lesion or Sprain Posterior SI
Ligaments À Gapping Test - Sprain Anterior SI Ligaments À Sacroiliac Rocking Test (SI Strain) - Sacrotuberous Ligaments À SLR (Lascgucs Test) - SI Problems À Gaenslen’s Test - I/P SI Lesion or Hip Pathology or
Lumbar Pathology À Prone Knee Bend Test - For D/F Diagnosis À Yeoman’s Test
Hip: À Patrick’s Test (FABER or Figure Four Test)
- Hip Joint? Iliopsoas Spasm
À Stinchfield Test - Hip Joint Pathology À Thomas Test - Hip Flexion Contracture À Rectus Femoris Contracture Test - For Rectus Femoris À Ober’s Test - TFL Contracture À Piriformis Test - Piriformis Syndrome
J.AYYAPPAN, M.P.T (ORTHO)
Knee: À Valgus Stress Test - Medial Collateral Ligament À Varus Stress Test - Lateral Collateral Ligament À Lachman Test - Anterior Cruciate Ligament À Anterior Drawer Sign - Anterior Cruciate Ligament À Posterior Drawer Sign - Posterior Cruciate Ligament À McMurray Test - Meniscal Tear À Apley’s Test - Meniscal or Ligamentous? À Bounce Home Test - Meniscal Injury À Mediopatellar Plica Test - Mediopatellar Plica À Fluctuation Test - Swelling À Patellar Tap Test - Swelling À Clarke’s Sign - Patellofemoral Dysfunction À McConnell Test - Chondromalacia Patella À Q-Angle or Patellofemoral Angle - Patellofemoral Dysfunction À Fairbank’s Apprehension Test - Dislocation of Patella
Ankle: À Anterior Drawer Test Anterior Talofibular Ligament Injury À Talar Tilt - Calcaneofibular Ligament À Thompson’s Test - Achilles Tendon Rupture
Cervical Spine: À Foraminal Compression (Sparling’s Test)
- Cervical Radiculitis
À ULTT’s D/F Diagnosis À Shoulder Depression Test & Abduction
Test Compression of nerve roots or Brachial
Plexus Lesion À Jackson’s Compression Test Pressure on nerve root À Valsalva Tests Herniated disc / Tumour / Osteophyte À Vertebral Artery Test
(Cervical Quadrant Test) Compression of Vertebral Artery
Thoracic Spine: À Slump Test Impingement of Dura & Spinal Cord / Nerve Roots
J.AYYAPPAN, M.P.T (ORTHO)
Lumbar Spine: À Slump Test - For Neuromeningeal Tract À SLR (Basic), 2, 3, 4, Crossed SLR - Sciatic, Tibial, Sural, Common Peroneal,
Disc Prolapse À Valsalva Maneuver - Increased Intrathecal Pressure À Schober’s Test Measure Flexion of Lumbar Spine À Stoop Test Neurogenic Intermittent Claudication
Tests for Malingering: À Hoover Test
- Malingering for Back Pain
À Burns Test - Malingering for Back Pain