PHYSICAL

THERAPY
ASSESSMENT
FOR
ORTHOPAEDIC
CONDITIONS
 A musculoskeletal assessment requires proper and thorough
systemic examination.
 Correct diagnosis depends on,
 Knowledge of functional anatomy
 Accurate patient history.
 Proper observation

 Thorough examination.
 Differential diagnosis involve,
 The use of clinical signs and symptoms

 Physical examination
 Knowledge of pathology

 Mechanism of injury
 Diagnostic imaging techniques.
Several techniques and models used for
physical therapy assessment..
 Nagi Model

 ICIDH: International Classification of Impairment,

Disability and Handicap.
 International Classification of Functioning, Disability and
Health (ICF)
 International Classification of Diseases (ICD)
 International Classification of Health Interventions
(ICHI)- it is still under development.
Nagi Model
ICIDH

 The International Classification of Impairments, Disabilities

and Handicaps (ICIDH), developed in the 1970s, was issued
by the World Health Organization in 1980 as a tool for the
classification of the consequences of disease.
 It is a tool that is used to classify the types of interventions
applied in the course of treating patients.
 This information is collected and then analyzed to provide
insight into the population's level of health, as well as the
state of the country's health system.
 ICIDH-2(International Classification of Functioning,
Disability and Health, known as ICIDH-2)belongs to the
“family” of classifications developed by the World Health
Organization (WHO) for application to various aspects of
health.
 The WHO family of international classifications provides a
framework to code a wide range of information about health
(e.g. diagnosis, functioning and disability, reasons for
contact with health services) and uses a standardized
common language permitting communication about health
and health care across the world in various disciplines and
science
 The overall aim of the ICIDH-2 classification is to provide a
unified and standard language and framework for the
description of health and health-related states. The revised
classification defines components of health and some health-
related components of well-being (such as education and
labour)..
 The ICIDH-2 domains can, therefore, be seen as health
domains and health-related domains. These domains are
described from body, individual and societal perspectives by
two basic lists: (1) Body Functions and Structures; (2)
Activities and Participation
 Because of disability, the person experiences certain
disadvantages in day to day life. He is unable to play the role
expected in society.
 e.g. Taking an accident
 Accident…………………disease or disorder.
 Loss of foot……………...impairment.
 Can not walk…………….disability.
 Unemployed……………..handicap.
ICF Model

 The International Classification of Functioning, Disability

and Health (ICF) is a statistical tool for describing the lived
experience of functioning and its restrictions in the context
of diseases and other health conditions which are classified
in the International Statistical Classification of Diseases and
Related Health Problems (ICD).
Aims of ICF Model

 To provide a scientific basis for understanding and studying

health and health-related states, outcomes and determinants;
 To establish a common language for describing health and
health-related states in order to improve communication
between different users, such as health care workers,
researchers, policy-makers and the public, including people
with disabilities;
 To permit comparison of data across countries, health care
disciplines, services and time;
 To provide a systematic coding scheme for health
information systems
Components of the ICF

 ICF has two parts, each with two components:

 Part 1. Functioning and Disability

 (a) Body Functions and Structures

 (b) Activities and Participation

 Part 2. Contextual Factors

 (c) Environmental Factors

 (d) Personal Factors

Uses of ICF

At the individual level

 For the assessment of individuals
 For individual treatment planning
 For the evaluation of treatment and other interventions
 For communication among physicians, nurses,
physiotherapists, occupational therapists, other health
workers, social service workers, and community agencies
 For self-evaluation by consumers
At the institutional level
 For educational and training purposes

 For resource planning and development

 For quality improvement

 For management and outcome evaluation

 For managed care models of healthcare delivery
Interaction of Concepts
ICF 2001
Health Condition
(disorder/disease)

Body function&structure Activities Participation

(Impairment) (Limitation) (Restriction)

Environmental Personal
Factors Factors
ICF Components

Body Functions Activities Environmental

& & Factors
Structures Participation

Functions Capacity Barriers

Structures Performance Facilitators

Contextual Factors
Person Environment
 gender
 Products
 age  Institutions
 other health conditions  Social Norms
 coping style  Culture
 social background  Built-environment
 education  Political factors
 profession  Nature
 past experience
 character style
Body Functions and Structures
Mental functions
Sensory functions and pain
Voice and speech functions
Functions of the cardiovascular,
haematological, immunological and
respiratory systems
Functions of the digestive, metabolic
and endocrine systems
Genitourinary and reproductive
functions
Neuromusculoskeletal and
movement-related functions
Functions of the skin and related
structures
Structures of the nervous system
The eye, ear and related structures
Structures involved in voice and
speech
Structures of the cardiovascular,
immunological and respiratory
systems
Structures related to the digestive,
metabolic and endocrine systems
Structures related to the genitourinary
and reproductive systems
Structures related to movement
Skin and related structures
 Most common assessment recording technique is problem
oriented medical record method.
 That is SOAP
 SOAP stands for four parts of assessment.
1. Subjective
2. Objective
3. Assessment
4. Plan
 SOAP notes are a highly structured format for documenting
the progress of a patient during treatment and is only one of
many possible formats that could be used by a health
professional.
 They are entered in the patients medical record by healthcare
professionals to communicate information to other providers
of care, to provide evidence of patient contact and to inform
the Clinical Reasoning process.
 SOAP is an acronym for:
• Subjective - What the patient says about the problem / intervention.
• Objective - The therapists objective observations and treatment interventions
(e.g. ROM, Outcome Measures)
• Assessment - The therapists analysis of the various components of the
assessment.

• Plan - How the treatment will be developed to the reach the goals or objectives .
 SOAP notes were developed by Dr. Lawrence Weed in the
1960's at the University of Vermont as part of the Problem-
orientated medical record (POMR).
Advantages and Disadvantages

 Advantage

1.  widespread adoption

2. emphasises clear and well-organised documentation of

findings with a natural progression from collection of
relevant information to the assessment to the plan on how to
proceed.
 Disadvantages

1. too concise,

2. overuse of abbreviations and acronyms

3. lack of guidance on how to address functional outcomes or
goals.
 The American Physical Therapy Association provides general guidance on
what information should be included in Physical Therapist SOAP Notes:
• Self-report of the patient
• Details of the specific intervention provided
• Equipment used
• Changes in patient status

• Complications or adverse reactions

• Factors that change the intervention
• Progression towards stated goals

• Communication with other providers of care, the patient and their family
COMPONENTS OF A SOAP NOTE
Subjective

 describes the patients self-report of their current status in

terms of their function, disability, symptoms and history.
 It may also include information from the family or
caregivers and if exact phrasing is used, should be enclosed
in quotation marks.
 It allows the therapist to document the patients perception of
their condition as it relates to their progress in rehabilitation,
functional performance or quality of life.
Objective

 This section outlines the objective results of the re-

assessment, the progress towards functional goals and the
treatments performed.
 It should include details of the interventions, including
frequency, duration and equipment used.
 The therapist should indicate changes in the patient's status,
as well as communication with colleagues, family or carers.
Assessment

 This is potentially the most important legal note because this

is the therapists professional opinion in light of the
subjective and objective findings.
 It should explain the reasoning behind the decisions taken
and clarify and support the analytical thinking behind the
problem-solving process.
 Progress towards the stated goals are indicated, as well as
any factors affecting it that may require modification of the
frequency, duration or intervention itself. Adverse, as well as
positive responses should be documented.
Plan

 The therapist should report on what the patient's Home

exercise programme (HEP) will consist of, as well as the
steps to take in order to reach the functional goals.
 Changes to the intervention strategy are documented in this
section.
Subjective

 Chief Complaint (CC)

 The CC or presenting problem is reported by the patient. This can
be a symptom, condition, previous diagnosis or another short
statement that describes why the patient is presenting today. The
CC is similar to the title of a paper, allowing the reader to get a
sense of what the rest of the document will entail.
• Examples: chest pain, decreased appetite, shortness of breath.
 However, a patient may have multiple CC’s, and their first
complaint may not be the most significant one. Thus,
physicians should encourage patients to state all of their
problems, while paying attention to detail to discover the
most compelling problem. Identifying the main problem
must occur to perform effective and efficient diagnosis.
 History of Present Illness (HPI)
 The HPI begins with a simple one line opening statement
including the patient's age, sex and reason for the visit.
• Example: 47-year old female presenting with abdominal
pain.
  An acronym often used to organize the HPI is termed
“OLDCARTS”:
• Onset: When did the CC begin?

• Location: Where is the CC located?

• Duration: How long has the CC been going on for?

• Characterization: How does the patient describe the CC?

• Alleviating and Aggravating factors: What makes the CC
better? Worse?
• Radiation: Does the CC move or stay in one location?

• Temporal factor: Is the CC worse (or better) at a certain time

of the day?
• Severity: Using a scale of 1 to 10, 1 being the least, 10 being
the worst, how does the patient rate the CC?
 History

• Medical history: Pertinent current or past medical conditions

• Surgical history: Try to include the year of the surgery and surgeon if
possible.
• Family history: Include pertinent family history. Avoid documenting the
medical history of every person in the patient's family.
• Social History: An acronym that may be used here is HEADSS which
stands for Home and Environment; Education, Employment, Eating;
Activities; Drugs; Sexuality; and Suicide/Depression.
 Review of Systems (ROS)
 This is a system based list of questions that help uncover
symptoms not otherwise mentioned by the patient.
• General: Weight loss, decreased appetite
• Gastrointestinal: Abdominal pain, hematochezia

• Musculoskeletal: Toe pain, decreased right shoulder range of

motion
 Current Medications, Allergies
 Current medications and allergies may be listed under the
Subjective or Objective sections. However, it is important
that with any medication documented, to include the
medication name, dose, route, and how often. 
• Example: Motrin 600 mg orally every 4 to 6 hours for 5 days
Objective

• Vital signs
• Physical exam findings

• Laboratory data
• Imaging results

• Other diagnostic data

• Recognition and review of the documentation of other
clinicians.
 A common mistake is distinguishing between symptoms and
signs.
 Symptoms are the patient's subjective description and should
be documented under the subjective heading, while a sign is
an objective finding related to the associated symptom
reported by the patient. An example of this is a patient stating he has
“stomach pain,” which is a symptom, documented under the subjective heading. Versus
“abdominal tenderness to palpation,” an objective sign documented under the objective
heading.
Assessment

 Problem
 List the problem list in order of importance. A problem is often known as a
diagnosis
 Differential Diagnosis
 This is a list of the different possible diagnosis, from most to least likely, and
the thought process behind this list. This is where the decision-making process
is explained in depth. Included should be the possibility of other diagnoses that
may harm the patient, but are less likely.
• Example: Problem 1, Differential Diagnoses, Discussion, Plan for problem 1
(described in the plan below). Repeat for additional problem
Plan

 This section details the need for additional testing and

consultation with other clinicians to address the patient's
illnesses.
 It also addresses any additional steps being taken to treat the
patient.
 This section helps future physicians understand what needs
to be done next. For each problem:
• State which testing is needed and the rationale for choosing
each test to resolve diagnostic ambiguities; ideally what the
next step would be if positive or negative
• Therapy needed (medications)
• Specialist referral(s) or consults
• Patient education, counseling
 This method is especially useful in helping the examiner to
solve the problem.
 Total musculoskeletal Assessment includes,
 Patient history
 Observation
 Examination

 Special tests
 Reflexes and cutaneous distribution
 Joint play movement
 Palpation

 Diagnostic imaging.
Subjective Examination

 This includes,
 Speaking at a level and using terms the patient will
understand.
 Taking time to listen
 Being empathetic, interested, caring with patient and
being professional
 Name:
 Age:

 Gender:
 Address:

 Occupation:
 Chief Complain:
 Age:

 Many conditions occur within certain age ranges. For

example, various growth disorders 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 be due to muscle weakness, primarily in the
muscle controlling the scapula, whereas the condition in
older people (40+ years) is more likely due to degenerative
changes in the shoulder complex.
History Taking

 Present History

 onset of history

 Mechanism of injury
– Road side accident
– Direct injury
– Indirect injury
– Bending / twisting injury
– Rotational injury
+

 Mode of onset – Sudden/ Gradual/ Insidious/ Periodic

 Condition – Improved/ Stationary/ Deteriorated

 Current Treatment
 Past History
 Relevant previous medical problem to present condition

 History of other diseases & injuries

 Operations & Hospitalizations

 Medications
 Physiotherapy Treatment:
 Personal History
 Marital Status

 Personal Habits : Tobacco/ Cigarette smoking/ Alcohol

[Amount, Frequency and Duration]
 Family History
 Similar Problem in relatives:

 Hereditary Disease:
 Infections
 Socio-Economic Condition
 Social Status

 Educational Status
 Environment of Home

 Environment of Workplace
 Other Associated Diseases
 High BP

 Diabetes
 Any Allergies
 Vital Signs
 Heart Rate

 Blood Pressure
 Respiratory Rate

 Temperature
 History provides,

 Valuable information about the disorder,

 Its present state,

 Its prognosis,

 The appropriate treatment.

 Past medical history should include any major illnesses,
surgery, accidents, or allergies.
 The examiner should listen for any potential "red flag" signs
and symptoms that would indicate the problem is not a
musculoskeletal one and that the problem should be referred
to the appropriate health care professional.
 RED FLAG finding in patient history
that indicate need for referral to
physician
1. 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 lb] in 2 weeks or less)
 Loss of appetite
 Unusual lumps or growths

 Unwarranted fatigue
2. 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)
3. GASTROINTESTINAL/GENITOURINARY:
 Frequent or severe abdominal pain

 Frequent heartburn or indigestion

 Frequent nausea or vomiting

 Change in or problems with bladder function (e.g., urinary

tract infection)
 Unusual menstrual irregularities
4. MISCELLANEOUS:
 Fever or night sweats

 Recent severe emotional disturbances

 Swelling or redness in any joint with no history of injury

 Pregnancy
5. 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 finding in patient history that
indicate a more extensive examination may
required
 Abnormal signs and symptoms ( unsual patterns of
complaint)
 Bilateral symptoms

 Symptoms peripheralizing
 Neurological symptoms( nerve root or peripheral nerve)
 Multiple nerve root involvement
 Abnormal sensation patterns (do nt 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 disturbance
 Multiple inflamed joints

 Psychosocial stresses
 Circulatory or skin changes
PAIN ASSESSMENT
Course of Pain

Site of pain.

Radiating/localized
 If the area of pain enlarge or becomes more
distal as the lesion worsens – called
Peripheralization.
 If the area of pain becomes smaller or more
localized as it improves – called Centralization.
 If the pain is felt at a site other than the injured tissue
because the same or adjacent neural segments supply
the referred site – called as Referred pain.
 Referred pain tends to be felt deeply; its boundaries
are distinct, and it radiates segmentally without
crossing the midline.
PAIN DESCRIPTION AND RELATED STRUCTURE

Type of Pain Structure involved

Cramping , dull, aching Pain Muscle

Dull , aching pain Ligament, joint capsule

Sharp , shooting pain Nerve root pain

Sharp , bright, lightning like pain Nerve pain

Burning, pressure like stinging, Sympathetic nerve

aching pain
Type of Pain Structure involved

Deep, nagging pain Bone pain

Sharp, sever intolerable pain Fracture pain

Throbbing and diffuse pain Vasculature pain

Burning Pain Autonomic pain

 Duration of symptoms – from onset to present

 Intensity of pain:

 Subjective Quantification – VAS, NPRS, Mac Gill

pain Questionnaire
 Objective Quantification – pain pressure algometry,
 Aggravating Factors-

 Activities, Pressure, stretching

 With cessation of activity, does the pain stay the same

or how long to avoid an overflow painful syndromes.
 Relieving factors- rest, pain medication
 Pain at rest / pain that worse at the beginning of activities
than at the end implies acute inflammation.
 Pain that is not affected by rest / activities – indicates
bone pain or may be related to the organic or systemic
disorders such as cancer or disease of the viscera.
 Chronic pain may be because of,

 Fatigue

 Certain postures activities

 Intractable pain (hard to control or deal) at night may
indicate serious pathology eg. Tumor
 Symptoms of peripheral nerve entrapment (carpal tunnel
syndrome) and thoracic outlet syndrome tend to worse at
night.
 Pain / cramping with prolonged walking may indicate
lumbar spinal stenosis (neurogenic intermittent claudication)
or vascular problem (circulatory or vascular intermittent
claudication)
 Intervertibral disc pain is aggravated by sitting and bending
foreward.
 Facet joint pain is relieved by sitting and bending foreward
while aggravated by extension and rotation.
 Type of mattress / pillow patient is using???
 Too many pillows, pillows improperly positioned, or too soft
a mattress may also cause problem.
 Any abnormal Sensation:
 Pins and needles (Paresthesia) : it is an unpleasant
sensation that occurs without an apparent stimulus or
cause. It occurs because of pressure on the nerve trunk.
 Radiating Pain: if pressure is applied to a nerve root,
Radicular pain results from pressure on the dura mater,
which is outer most covering of spinal cord.
 Any other bilateral spinal cord symptoms/ fainting or drop
attacks?
 Vertigo – it may indicate more severe neurological
problem.
 Swaying, Spinning sensation accompanied by feeling of
unsteadiness and loss of balance.
 Theses also may indicate neurological problems such as,
cervical myelopathy.
 Drop attacks occur when patient suddenly falls without
warning or provocation but remains conscious.
 May be because of neurological problems related to the
brain.
OBJECTIVE EXAMIANTION
 Differentiation of systemic and
musculoskeletal pain
Musculoskeletal
Systemic
• Generally lessens at night
• Disturbs sleep
Sharp or superficial ache
• Deep aching or throbbing
• Usually decreases with
• Reduced by pressure
cessation of activity
• Constant or waves of pain
• Usually continuous or
and spasm
intermittent
• Is not aggravated by
• Is aggravated by mechanical
mechanical stress
stress
• Associated with: • Usually associated with
– Jaundice
– skin rash nothing specific
– fatigue
– weight loss
– low-grade fever
– generalized weakness
– cyclic and progressive
symptoms
– history of infection
ON OBSERVATION

 Purpose of an observation is to gain the information on

visible defects, functional defects and abnormalities of an
alignment.
 General condition of the patient: Poor/ good/ fair built.
 Posture of the patient/ body alignment in standing, sitting
and supine.
 As patient enters the assessment area, the examiner
should observe his/her gait.
 Normal body alignment:
 Anteriorly nose. Xiphisternum and umbilicus should be in
a straight line.
 From side, tip of the ear, tip of the acromion, the high
point of the iliac crest and lateral malleolus should be in
the same line.
 Any obvious deformity:
 It may take the form of restricted ROM. Eg. Flexion
deformity.
 Malalignment. Eg. Genu varum
 Alteration in the shape of the bone. Eg. Fracture
 Alteration in relationship of two articulating structure. Eg.
Subluxation / dislocation.
Deformities

 Structural deformity:
 Present even at rest.

 Eg. Torticollis, Fracture, Scoliosis, Kyphosis.

 Functional Deformity:
 Result of assumed posture.

 Disappear when posture is changed.

 Eg. Scoliosis due to a short leg seen in upright posture
but disappear on Forward flexion.
 Pes Planus [flat foot] on weight bearing may disappear
on non- weight bearing.
 Dynamic deformities:
 Caused by muscle action.

 Present when muscles contract or joint moves.

 So, not evident when the muscles are relaxed.

 Dynamic deformities are most likely to seen during the

examination phase.
 Bony contour:
 it should be normal and symmetrical.

 Any other obvious deviation.

 May any person have lower shoulder on the dominant
side.
 It may demonstrate a slight scoliosis of spine.
 Soft tissue contour:
[muscle/ skin/fat]
 Eg. Any muscle
wasting.
 Limb Position:
 Compare limb size, shape, position

 Any atrophy, color and temperature.

 Appearance of the skin differ in the area of pain /
symptoms.
 Any Ecchymosis / bruising
indicate, bleeding under the
skin from injury to tissue.
 Ecchymosis may track
distaly from the injury site
towards the foot because of
gravity.
 Any trophic changes: can result from peripheral nerve
lesion.
 Loss of skin elasticity

 Shiny skin
 Hair loss on skin

 Skin that breaks down easily and heals slowly.

 Nails may become brittle / ridged.
 Skin disorder like Psoriasis may affect joint.
 Cyanosis / bluish color to the skin usually indicate poor
blood perfusion.
 Redness may indicate increase blood flow/ inflammation.
 Scar may indicate recent injury / surgery.
 Recent scar are red because they are still healing and contain
capillaries.
 Old scar are white and primarily avascular.
 Cut across the flexion lines frequently produce excessive
scarring.
 Some individual are also prone to excessive [keloid] /
hypertrophic scarring.
 Hypertrophic scar have excessive scar tissue but stay within
the margin of the wound.
 Keloid scars expand beyond the margin of the wound.
Keloid Scar Brittle Nail
 Callosities / Blisters/ inflamed bursa indicative of excessive
pressure or friction to the skin.
 Any crepitus / snapping/ abnormal sounds in the joints.
 Crepitation : may vary from a loud grinding noise to a
squeaking noise.
 Snapping: may be caused by a tendon moving over a
bony protuberance.
 Clicking : sometimes heard in the temporomandibular
joint.
 It may indicative of early non-symptomatic pathology.
 Any redness or swelling with pain and loss of function are
indication of inflammation / active inflammatory
condition.
 Attitude of the patient:
 Apprehension / restless/ depressed

 It will indicate psychological state of patient.

 Facial expression is also indicative of any discomfort or
lacking sleep.
 Pattern of any other altered movement.
 "Red Flags" in Examination Indicating
Need for Medical Consultation

 Severe unremitting pain

 Pain unaffected by medication or position

 Severe night pain

 Severe pain with no history of injury

 Severe spasm
 Psychological overlay
ON PALPATION

 Palpation is an important assessment technique that must be

practiced, if it is to be used effectively.
 To palpate properly, the examiner must ensure that the area
to be palpated is as relaxed as possible.
 For that body part must be supported as much as possible.
 Discriminate differences in tissue tension.

 Eg. Effusion, spasm, muscle tone [Spasticity, Rigidity,

flaccidity]
 Spasticity: Muscle tonus in which there may be a collapse
of muscle tone during testing.
 Rigidity: Involuntary resistance being maintained during
passive movement and without collapse of the muscle.
 Flaccidity: there is no muscle tone.
 Difference in tissue texture:
 Palpate the direction of fibers or presence of fibrous
bands.
 Identify shape/ Structure/ tissue type.. So, detect
abnormality. Eg. Myositis ossificans.
 Tissue thickness / texture

 Check about whether it is pliable / soft/ resilient.

 Any other obvious swelling
 Edema : abnormal accumulation of fluid in the
intercellular spaces.
 Swelling : abnormal enlargement of body part.

 May be result of bone thickening, synovial membrane

thickening or fluid accumulation in and around the
joint.
 It may be intra or extra cellular or intra or extra
capsular.
 Swelling may be localized. [encapsulated] – indicate
intra articular swelling / cyst/ swollen bursa.
 Visualization of swelling depends on 1) Depth of the
tissue.
 Eg. Swollen Olecranon bursa is more obvious than a
swollen psoas bursa.
 2) looseness of the tissue: Swelling is more evident on
the dorsum of the hand than on the palmer aspect
because the dorsal tissue are not ‘held down’ to
adjacent tissue.
 Swelling
Comes on soon after injury Blood

Comes on after 8 to 24 hours Synovial eg. Inflammation in

synovial joint.
Boggy, Spongy feeling Synovial eg. Oedematous
synovium [like soft sponge rubber]
Harder, Tense, feeling with Blood [thick gel like feeling over
warmth lying skin is usually warmer]
Tough and dry Callus
 Swelling
Leathery thickening Chronic, older, longstanding soft tissue
swelling such as skin callus. [more
leathery the thickening feels more likely
to be chronic]
Soft and fluctuating Acute. [fluid swelling, more mobile]

Hard Bony [osteophytes / new bone formation

, myosities ossification]
Thick , slow moving Pitting edema. [caused by circulatory
stasis and seen in distal extremities.]
Long lasting swelling may cause reflex inhibition of the muscle
around the joint leading to atrophy and weakness.
 Tenderness

 It is determine by applying firm pressure to the joint.

Grading of Tenderness

1 Patient complains of pain

2 Patient complains of pain and winces

3 Patient winces and withdraws

4 Patient will not allow palpation of the joint.

Temperature
 Test with the dorsum of the hand or fingers and comparing
both sides.
 Joint tend to be warm in,

 The acute phase

 In the presence of infection

 With blood swelling

 After exercises
 If patient have covered with elastic bandage.
Pulse / Tremor
 Pulse : Indicate circulatory suficiency and should be tested
for rhythm and strength if circulatory problems are
suspected.
 Tremors are involuntary movements in which agonist and
antagonist muscle groups contract to cause rhythmic
movement of a joint.
Scar
 Painful scar / neuroma
 Diagnosed using thumbnail test.

 Running the dorsum of the thumbnail over the scar.

 If it elicit the sharp pain – indicate neuroma with scar.

 A neuroma is a painful condition, also referred to as a

“pinched nerve” or a nerve tumor.
Dryness / excessive moisture of the skin
 Eg. Acute gouty joints tend to be dry
 While septic joints tend to be moist.

 Nervous patient usually demonstrate increase moisture

[sweating] in the hand.
Any abnormal sensation
 Dysesthesia : Diminished sensation
 Hyperesthesia: Increase sensation

 Anesthesia: Absence of sensation.

 Fine crepitus: indicate roughening of the articular cartilage

 Course crepitus: indicate badly damage articular cartilage or

bone.
 Always uninvolved side should be palpated first
so that the patient has some idea of what to expect and to
enable the examiner to know what ‘normal feels’ like.
Examination
Principles of Examination
 Normal site is tested first.
 Baseline for normal movement for the joint being tested and
shows the patient what to expect. – Resulting in patient
confidence and less patient apprehension when the injury
side is tested.
 Do active movement (AROM) first then passive
movement (PROM) then resisted isometric movement
(RIM)
 Do the painful movement last.
 Apply overpressure with care to test end feel.

 Each active/passive or resisted isometric movement may be

repeated several times or held for a certain amount of time to
see whether symptoms increase or decrease.
 Resisted isometric movement are done with the joint in
neutral / resting position – so, that the inert tissue is minimal.
 For passive ROM or Ligamentous test not only the degree
of opening [amount] but quality of the opening [end feel] is
also important.
 While doing ligamentous test- appropriate stress is applied
gently and repeated several times.
 Stress is increased up but not beyond the point of pain.
 At the completion of an assessment, warn the patient of
possible exacerbation.
 Maintain the patient’s dignity.
 Refer if necessary.
Vital signs
 Pulse : most commonly radial pulse at the wrist is used.
 Blood pressure
 Respiratory rate

 Temperature [Normal 98.4 0 F or 370 C ]

 High blood pressure values should be checked several times
at 15 -30 minute interval with the patient resting in between
to determine whether the high reading is accurate or is being
caused by anxiety. [called white coat syndrome]
Scanning Examination

 This action enables the examiner to determine the nature and

site of the present symptoms and the patient’s response to
these symptoms.
 The scanning examination is a "quick look" or scan of a part
of the body involving the spine and extremities.
 It is used to rule out symptoms, which may be referred from
one part of the body to another.
 It is divided into two scans- 1) The upper limb scan and 2)
The lower limb scan.
 In the upper part of the body, the upper limb scanning
examination begins with the cervical spine and includes the
temporomandibular joints, the entire scapular area, the
shoulder region, and the upper limbs to the fingers.
 In the lower part of the body, the examination begins at the
lumbar spine and continues to the toes.
 The "scan" should add no more than 5 or 10 minutes to the
assessment.
Spinal cord and nerve roots
 It helps to determine whether the pathology is caused by
tissues innervated by a nerve root or peripheral nerve that is
referring symptoms distally.
 The nerve root is that portion of a peripheral nerve that
connects the nerve to the spinal cord.
 Nerve roots arise from each level of the spinal cord (e.g., C3,
C4), and many, but not all, intermingle in a plexus (brachial,
lumbar, or lumbosacral) to form different peripheral nerves.
 This arrangement can result in a single nerve root supplying
more than one peripheral nerve. For example, the median
nerve is derived from the C6, C7, C8, and T1 nerve roots.
 For this reason, if pressure is applied to the nerve root, the
distribution of the sensation or motor function is often felt or
exhibited in more than one peripheral nerve distribution.
Dermatome

 The sensory distribution of each nerve root is called the

dermatome.
 A dermatome is defined as the area of skin supplied by a
single nerve root.
Myotome
 They are defined as groups of muscles supplied by a single
nerve root.
 A lesion of a single nerve root is usually associated wit
paresis of the myotome (muscles) supplied by that nerve
root.
 It takes time for any weakness to become evident on resisted
isometric or myotome testing.
 Isometric testing of myotome is held for at least 5 seconds.
Sclerotome

 It is a area of bone or fascia supplied by a single nerve root.

 It is the complex nature of the dermatomes, myotome and
sclerotome supplied by the nerve root that can lead to
referred pain.
 Which is pain felt in a part of the body that is usually a
considerable distance from the tissue that have caused it.
 Referred pain is explained as an error in perception on the
part of the brain.
 Radicular or radiating pain, is a sharp, shooting pain felt
in a dermatome, myotome or sclerotome because of direct
involvement of spinal nerve or nerve root.
 A radiculopathy refers to radiating Paresthesia, numbness or
weakness but not a pain.
 A myelopathy is a neurological disorder involving the spinal
cord or brain and resulting in an upper motor neuron lesion.
 Injury to a single peripheral nerve is called as a
mononeuropathy. Eg. Injury to median nerve.
 Systemic disease may affect more than one peripheral nerve.
Which is called as polyneuropathy. eg,. Diabetes.
Examination of Specific joints

 Which involve,
 Active Movements

 Passive Movements
 Resisted Isometric Movements

 Functional Assessment.
ACTIVE MOVEMENTS

 They are actively performed by the patient’s voluntary

muscles action.
 They have their own special value in that they combine tests
of joint range, control muscle power, and patient’s
willingness to perform the movement.
 These movements are called as Physiological movements.
 The end of active movements is sometimes referred to as the
Physiological barrier.
 Note which movements cause pain or other symptoms.
 Amount of pain that results.

 Eg. Small, unguarded movement causing intense pain

indicate an acute, irritable joint.
 If condition is very irritable or acute, it may not be possible
to elicit all the movements desired.
 Note the rhythm of movement along with any pain,
limitation or unusual or trick movement occur.
 Trick movements are modified movements that the patient
consciously or unconsciously uses to accomplish what the
examiner asked the patient to do.
 Eg. Presence of deltoid paralysis, if the examiner asks the
patient to abduct the arm, the patient can accomplish this
movement by laterally rotating the shoulder and using the
biceps muscle to abduct the arm.
 What to observe during active movement?
 When and where during each of the movements the onset
of pain occurs.
 Whether the movement increases the intensity and quality
of the pain.
 The reaction of the patient to pain.

 The amount of observation restricted and its nature.

 The pattern of movement.
 The rhythm and quality of movement.

 The movement of associated joints

 The willingness of the patient to move the part.

 If the joints are not too reactive or irritable, over

pressure may carefully be applied at the end of the
active ROM.
 If the overpressure does not produce symptoms and the
end feel is normal, the movement is considered normal
and the examiner may decide that passive movements
are unnecessary.
PASSIVE MOVEMENT

 They are movements, where examiner puts the joint through

its ROM while the patient is relaxed.
 These movements are referred to as Anatomical
movements.
 The end of passive movements is sometimes referred to as
the Anatomical barrier.
 Normally physiological barrier occurs before the anatomical
barrier, so passive movements are always greater then active
movement.
 The movement should proceed through as full a range as
possible.
 Positioning the patient may have an effect on active and
passive ROM.
 Difference in ROM between active and passive movements
may be caused by muscle contraction or spasm, muscle
deficiency, neurological deficit, contracture or pain.
 Active/Passive ROM may be measured by,

 Goniometer
 Inclinometer
 Examiner estimation [eye balling]
 Measurement at different times show progression or
regression of the deformity.
What to observe during passive
movement?
 When / where during each of the movements the pain
begins?
 Whether the movement increases the intensity and quality of
pain?
 The pattern of limitation of movement.

 The end feel of the movement.

 The movement of associated joint.

 The range of motion available.

 Each movement must be compared with the same movement
in the opposite joint.
 Passive movement must be gentle.
 Determine whether there is any limitation of range –
Hypomobility.
 Excess of ROM – Hypermobility
 Hypermobile joints tend to be more susceptible to,
 Ligament sprain

 Joint effusion
 Chronic pain

 Recurrent injury
 Paratenonitis resulting from lack of control. [instability]
 Hypomobile joints are more susceptible to,
 Muscle strain

 Pinched nerve syndrome

 Paratenonitis resulting from overstress

 Myofascial hypomobility – result from,

 Adaptive shortening / Hypertonicity

 Posttraumatic adhesions / scarring

 Pericapsular hypomobility – it has capsular / ligamentous
origin. It results from,
 Adhesion

 Scarring
 Arthritis
 Arthrosis
 Fibrosis
 Tissue adaptation.
 Pathomechanical hypomobility – result of joint trauma.
[micro/ macro] leading to restriction in one or more
direction.
End feel
 During assessing passive movement the examiner should
apply overpressure at the end of the ROM to determine
quality of end feel.
 It is the sensation the examiner feels in the joint as it reaches
the end of the ROM.
 Care must be taken that severe symptoms are not provoked.
 Pain with pathological end feel is common.
Types of normal end feel by Cyriax.
End Feel Example
Bone to bone Elbow extension
•Hard to feel
•Unyielding sensation that is
painless

Soft tissue approximation Elbow/ Knee flexion in which

•Mushy feel movement is stopped by
•Yielding compression compression of the soft tissue.
Like Muscle.

Tissue stretch Achilles Stretch

•Hard / firm Wrist flexion
•Springy Knee extension
•Elastic resistance
 Normal tissue stretch divided in to two parts
 Elastic [soft] stretch – achilles stretch which is very
elastic while wrist flexion is slightly elastic.
 Capsular [Hard] stretch – knee extension.
 Tissue stretch is most common type of normal end feel
found when capsule and ligament are primary
restraints. Eg. Lateral rotation of shoulder
Abnormal End feel.
End feel Example
Early muscle Spasm Protective spasm following
•Occurs early in the ROM spasm.
Associated with inflammation
Seen in acute condition
Late muscle spasm Spasm resulting from
•Occur at or near the end ROM instability or pain.

Mushy tissue stretch Tight muscle

• Both muscle spasm are result of the subconscious effort of

the body to protect the injured joint or structure.

•Tight Muscle – it has own unique end feel. Similar to normal

tissue stretch.

•Spasticity – seen in UMNL. Form of muscle hypertonicity

that offers increased resistance to stretch. Primarily flexors in

UL and extensors in LL.

 Abnormal End feel.
End feel Example

Hard capsular Chronic condition

•Thicker stretching quality Frozen shoulder

Soft capsular Acute condition.

•Boggy stretch but with Synovitis
restricted ROM. Soft tissue edema

• Major injury to ligaments and the capsule often cause a soft

end feel until the tension is taken up by other structure
 Abnormal End feel.
End feel Example
Bone to bone Osteophytes formation in
cervical spine.

Empty Acute subacromial bursitis

•Movement cannot be Tumor
performed or stops because of
pain.

Springy Block Meniscus tear of knee when it

•Similar to tissue stretch is locked.
•Rebound effect with thick It indicate an internal
stretching feel. derangement within a joint
CAPSULAR PATTERNS
 Examiner must look at the patterns of limitation / restriction.

 If the capsule of the joint is affected, the pattern of limitation

is the feature that indicate the presence of a capsular pattern
in the joint.
 It is the result of total joint reaction caused by,

 Muscle spasm
 Capsular contraction
 Generalized osteophyte formation.
Joint Restriction

Temporomandibul Limitation of mouth opening

ar joint

Cervical spine Side flexion and rotation equally limited ,

extension.
Glenohumeral Lateral rotation, abduction, medial rotation.
joint
Elbow joint Flexion , extension

Wrist joint Flexion and extension equally limited.

Thoracic and Side flexion and rotation equally limited, extension

lumbar spine
Joint Restriction

Hip joint Flexion, abduction, medial

rotation.
Knee joint Flexion and extension

Ankle joint Plantar flexion and dorsiflexion

NON CAPSUALR PATTERN

 Limitation that exist but does not correspond to the classic

capsular pattern for that joint.
 Eg. Shoulder abduction may be restricted but with very little
rotational restriction, like in subacromial bursitis.
Causes of non capsular pattern
 Ligamentous adhesion in which only part of capsular or
accessory ligaments are involved.
 Internal derangement : affects only certain joints. Such as
knee, ankle, elbow.
 Eg. Torn meniscus may cause a blocking of extension but
flexion is usually free.
 Loose bodies cause limitation when they are caught
between articular surface.
 Extra articular lesion:
 Extra articular adhesions
 Acute inflamed structure limiting movement in a
particular direction.
 Eg. Limited SLR in the lumbar disc syndrome is referred
to as constant length phenomenon. In which limitation of
movement in one joint depends on the position in which
other joint is held.
RESISTED ISOMETRIC MOVEMENT
 These movements are tested last in the examination.
 This type of movement consists of strong, static [isometric],
voluntary muscle contraction.
 It is used primarily to determine whether the contractile
tissue is the tissue at fault.
 Nerve supplying muscle is also tested.
 The patient is asked to contract the muscle as strongly as
possible while the examiner resist to prevent any movement
from occurring and to ensure that the patient is using
maximum effort.
 To keep movement to a minimum, it is best for the examiner
to position the joint properly in the resting position and then
to say the patient “don’t let me move now”.
 What to observe during isometric movement?
 Whether the contraction causes pain and if it does, the
pain’s intensity and quality.
 Strength of the contraction
 Type of contraction causing problem, like concentric,
eccentric, isometric, isotonic etc…
Manual Muscle Testing
Grades Value Movement Grade

5+ Normal Complete ROM against gravity with maximum

(100%) resistance

4 Good Complete ROM against gravity with moderate

(75%) resistance

3+ Fair (+) Complete ROM against gravity with minimum

resistance

3 Fair Complete ROM against gravity.

(50%)
Manual Muscle Testing
Grades Value Movement Grade
3- Fair (-) Some but not complete ROM against gravity.

2+ Poor (+) Initiate motion against gravity

2 Poor Complete ROM with gravity eliminated.
(25%)
2- Poor (_) Initiate ROM if gravity is eliminated.

1 Trace Evidence of slight contractility but no joint

motion.
0 Zero No contraction palpated.
Causes of muscle weakness
 Muscle strain

 Pain
 Peripheral nerve injury
 Nerve root lesion
 UMNL
 Tendon pathology
 Avulsion

 Psychological overplay
Nerve root examination

 The examiner must be able to differentiate the dermatomes

from the sensory distribution of a peripheral nerve and a
Myotoms from muscles supplied by a specific peripheral
nerve.
 Dermatomes: the area of skin supplied by a single nerve
root.
 Area innervated by a nerve root is larger than that innervated
by a peripheral nerve.
 Myotoms: groups of muscle supplied by a single nerve root.
 A lesion of a single nerve root is usually associated with
paresis [incomplete paralysis] of muscles supplied by that
nerve root.
 Sclerotome: area of bone or fascia supplied by a single
nerve root.
NERVE ROOT DERMATOMES
MAYOTOMES
NERVE DERMATOME MYOTOMES
ROOT
C1 Vertex of the skull None

C2 Temple, forehead and Longus colli,

occiput sternocleidomastoid

C3 Entire neck, posterior Trapezius, splenius capitis

cheek, foreward under
mandible
C4 Shoulder area, clavicular Trapezius, levator
area, upper scapular area scapulae.
NERVE ROOT DERMATOMES
MAYOTOMES
NERVE DERMATOME MYOTOMES
ROOT
C5 Deltoid , anterior aspect of Supraspinatus,
entire arm to base of thumb infraspinatus, deltoid and
biceps
C6 Anterior arm, radial side of Biceps, supinator, wrist
hand to thumb and index extensor
finger
C7 Lateral arm and forearm to Triceps, wrist flexors
index, long and ring fingers

C8 Medial arm and forearm to Ulnar deviators, thumb

long , ring and little finger extensor and thumb
adductors
NERVE ROOT DERMATOMES
MAYOTOMES
NERVE DERMATOME MYOTOMES
ROOT
T1 Medial side of forearm to None
base of little finger

T2 Medial side of upper arm to None

medial elbow, pectoral and
midscapular areas
T3-T12 T3 –T6 upper thorax, T5-T7 None
costal margin, T8-T12
abdomen and lumbar
region.
L1 Back over trochanter, groin None
NERVE ROOT DERMATOMES
MAYOTOMES
NERVE DERMATOME MYOTOMES
ROOT
L2 Back, front of thigh to knee Psoas, hip adductors

L3 Back, upper buttocks, Psoas, quadriceps, thigh

anterior thigh and knee, atrophy
medial lower leg
L4 Medial buttock, lateral Tibialis anterior, extensor
thigh, medial leg, dorsum of hallucis
foot, big toe.
L5 Buttock, post. & lateral Extensor hallucis,
thigh, lateral aspect of leg, peroneals, gluteus medius,
dorsum of foot, medial half dorsiflexors, hamstring
of sole, 1st, 2nd 3rd toes and calf atrophy
NERVE ROOT DERMATOMES
MAYOTOMES
NERVE DERMATOME MYOTOMES
ROOT
S1 Buttock, thigh and leg Calf, hamstring, wasting of
posterior gluteals, peroneal. Plantar
flexors
S2 Same as S1 Same as S1 except
peroneals

S3 Groin, medial thigh to knee None

S4 Perineum , genitals, lower Bladder and rectum

sacrum
FUNCTIONAL ASSESSMENT
 Functional assessment may involve,
 Task analysis

 Observation of certain patient activities

 Detail assessment of the effect of the injury / disability on
the patient’s ability to function in everyday life.
 Functional assessment helps the examiner what is
important to the patient and the patient’s expectation.
 Functional activities that should be tested, includes
 Self care activities such as, walking, dressing, daily
hygiene [washing, bathing, shaving, combing hair]
 Eating, going to the bathroom, recreational activities such
as, reading, sewing, watching, television, gardening,
playing a musical instrument.
 Activities such as driving, dialing telephone, cooking,
hanging cloth etc…
 Scales used for functional assessment,
 SMFA : short musculoskeletal function assessment

 FCE: functional capacity evaluation

 AIMS: arthritis impact measurement scale

 FAT: functional assessment tool

 SF- 36- health status survey
REFLEX AND CUTANEOUS DISTRIBUTION

 Superficial reflexes
 Deep reflexes

 Pathological reflexes are checked.

 Done to an indication of the state of nerve or nerve roots
supplying the reflexes.
 If neurological system is thought to be normal, there is no
need to test the reflex or cutaneous distribution.
 Deep tendon reflex – also called muscle stretch reflexes.
 Tested with reflex hammer

 Superficial Reflexes- are provoked by superficial stroking ,

usually with a sharp object.
 Pathological reflex is not normally present except in the very
young < 5-7 months in whom the cerebrum is not developed
enough to suppress this reflex.
 Hyporeflexia – loss / abnormality of nerve conduction
causes diminution in reflex
 Areflexia – loss of reflex
 Aging also cause a decreases responses.
 UMNL causes,
 Spasticity

 Hyperreflexia
 Hypertonicity

 Extensor plantar response

 Reduced / absent superficial reflex

 Weakness of muscle distal to the lesion

 LMNL causes,
 Flaccidity

 Areflexia
 Hypotonicity

 Weakness
 Atrophy of involved muscle.
DEEP TENDON REFLEX GRADING
 0 – Absent [Areflexia]
 1 – Diminished [Hyporeflexia]

 2 – Average [Normal]
 3 – Exaggerated [Brisk]

 4 – Clonus, Very Brisk [Hyperreflexia]

common deep tendon reflexes
Reflex Site of Stimulation CNS Segments

Jaw Mandible Cranial N. V

Biceps Biceps tendon C5-C6

Brachioradialis Brachioradialis tendon / distal to C5-C6

the musculotendinous junction

Triceps Distal triceps tendon above the C7-C8

olecranon process
common deep tendon reflexes
Reflex Site of Stimulation CNS Segments

Patella Patellar tendon L3-L4

Medial and Semimembranosus and biceps L5, S1 and S1-

lateral femoris tendon S2
hamstring
Tibialis Tibialis posterior tendon behind L4-L5
posterior medial malleolus

achilles Achilles tendon S1-S2

SUPERFICIAL REFLEXES
REFLEX NORMAL RESPONSE CNS SEGMENTS

Upper Umbilicus moves up and T7-T9

abdominal towards area being stroked
Lower Umbilicus moves down and T11-T12
abdominal towards area being stroked
Cremasteric Scrotum elevates T12, L1

Plantar Flexion of toes S1-S2

Gluteal Skin tenses in gluteal area L4-L5, S1-S3

Anal Contraction of anal S2-S4

sphincter muscle
Joint Play Movement

 All synovial and secondary cartilaginous joints to some

extent, are capable of an active ROM, termed “voluntary
movements” also called as active physiological movement
through the action of muscles crossing over joint.
SPECIAL TESTS
 Special tests are available for each joint to determine
whether a particular type of disease , condition, or injury is
present.
 Also called as,
 Clinical accessory tests

 Provocative test
 Motion test

 Structural tests
 Special tests are used to,
 Confirm a tentative diagnosis

 Make a differential diagnosis

 Differentiate between structures

 Understand unusual signs

 Unravel difficult sign and symptoms
 In additional to special tests, the examiner may also make
use of laboratory tests ordered by a physician for specific
condition.
 Eg, osteomyelitis - +ve blood culture, elevated white blood
cells, increased ESR etc…
DIAGNOSIC IMAGING
 Used to confirm a clinical opinion, and must be interpreted
within the context of the whole examination.
 It includes,

 Plain film radiography

 Arthrography
 CT Scan
 MRI
 Diagnostic Ultrasound
what to observe when viewing an x-ray
 Overall size and shape of bone
 Local size and shape of bone

 Number of bones
 Alignment of bones

 Thickness of the cortex

 Trabecular pattern of the bone

 General density of the entire bone

 Any break in continuity of the bone
 Margins of the local lesion

 Width and symmetry of joint cartilage

 Contour and density of subchondral bone
 Provisional Diagnosis
 Aim / Goals of the treatment plane

 Make a Treatment plane

 Take regular Follow up of the patient.
THANK YOU