Physical Examination

PT 6280
Clinical Assessment

Presented by Michelle Reinink, PT, DPT, OCS, CIMT

 Objectives
1. Describe components and special considerations involved in
taking a subjective history and the objective assessment.

1. Describe 3 examples of basic movement analysis done at

physical exam.

2. Demonstrate how to screen for sensory and strength deficits.

1. Show how to assess reflexes and interpret findings.

1. Interpret AROM and PROM findings from a physical exam.

 Outline
 Purpose of physical examination
 Screening; looking for indications of pathology
 Part 1. History and Subjective Evaluation
 Part 2. Objective Assessment
– Pain -Skin Integrity -Extremity girth

– General level of function -Sensation -Joint ROM

– Vital signs -Strength -Special Tests

– Red flags -Reflexes -Gait

 Our Focus:
The Human Movement System
The human movement system comprises the anatomic
structures and physiologic functions that interact to move
the body or its component parts.
http://www.apta.org/Vision.

Image credit:
Washington University
Program in Physical
Therapy
 Overview
 Screen before performing more definitive tests
– Systems review: musculoskeletal, integument,
neurological, cardiovascular
– Developing a working diagnosis

 Develop your own sequence/system

– ordered, comprehensive, and reproducible

 Typically compare 1 side of body to other

 Expect a variety of ‘normal’
Part 1. History & Subjective Evaluation
 Look to gain the patient’s understanding on
their state-of-condition
 Evaluate general level of cognition &
capabilities
 Listen, yet strive to keep their words succinct
Guiding vs. Open-ended questions
 Key Demographics
 Gender
 Age
 Language and Culture
 Activities (present and previous)
 Employment
 Previous history
 Hand dominance
 Pertinent Questions
 General health

 Chief complaint and current symptoms

(give added consideration to complaints of pain)

 Etiology
– Insidious vs. traumatic onset
– Mechanism of injury

 Past treatments
– Types, discuss success or failed efforts
 Note any statements related to impairments (example:
strength, flexibility, sensation, balance…)
 Pain (SINS assessment)
 Severity
– Rating
 VAS or NPRS (0-10)
 McGill or other Questionnaire relating to
perception or function

 Irritability
– Pattern over 24 hours
– What makes it better or worse?
 Pain (cont’d)
 Nature
 Types
Nerve pain- sharp, burning, running down nerve
distribution
Vascular pain- diffuse, aching, poorly localized,
sometimes referred
Bone pain- deep, localized
Muscle pain- dull & aching, aggravated by imposed
resistance, may be referred
 Stability
 Location of Pain
 Location
– Body diagram
– Inquire about surrounding joints
 Referred Pain
– Pain felt remote from site of lesion
 Not well localized, deep, and typically radiates
(refers) without crossing midline
– I.e. nerve root dermatome
 Due to ‘misperception’ on some level of CNS

 Document pain intensity and location

 Additional Diagnostics
(added background info & tests)

 Physician’s medical diagnosis

 Previous diagnostic studies

– MRI; X-rays; CT scan; Bone scan
– EMG; Nerve conduction studies
– and many others…
 Pain Assessment Activity
 2-3 min each:
 Pair up: 1 patient, 1 PT
 Patient: pretend to have an injury (use a
previous injury/pain of yours or someone
you know at a particular stage)
 PT: ask questions to understand: severity,
irritability, and nature of the symptoms
 PT be prepared to report your assessment
of the patient’s symptoms to the class
(severity, nature, irritability)
 Final decision on aggressiveness of exam
Process all information gathered, begin
to decide how best to proceed.

Practice under the premise of:

First, do no harm!
 Red Flags
Patient history or report of these items cause concern; may
indicate immediate need for medical consultation
 Inability to find a position of comfort
 Severe, constant night pain
 Symptoms are out of proportion to injury
 Unexplained weight loss
 Recent history of falls, sudden weakness
 Unexplained lack of coordination
 Constitutional symptoms
 Others…
Yellow Flags
Proceed, but exercise caution. Should these findings
persist, a more extensive examination may be required

 Abnormal signs & symptoms (e.g. multiple inflamed joints)

 Progressive weakness or gait disturbance
 New neurological symptoms or changes in cognition
 Circulatory or skin changes
 Significant psychosocial issues
 Back or neck pain with normal ROM and strength
 Atypical pattern of limited ROM
 Others…
 History/Subjective Exam

Use the information gathered

– To develop a working diagnosis

– To guide your objective assessment

 Part 2. Objective Examination

Things to Consider:
 Use screening methods consistent to meet
the needs, feelings, and responses of patient
 Keep the patient informed of your intentions
 Perform painful movements last; when
possible, test uninvolved side first
 Movement Analysis
(Functional Assessment)
 Gait
– Observe walking starting in waiting room
 Antalgic (painful)
 Deviation (ROM, weakness)
 Assistive devices
 Posture
– Different positions (standing, sitting, supine)
– Different views (A/P, lateral)
 Movement Analysis
(Functional Assessment)
 Protective movement patterns are easily observed, and
should be documented, as should inconsistencies
 Are the movement patterns consistent with patient’s pain
or mobility complaints?
 Consider challenging the movement with more repetitions
or weight to elicit “abnormal” movements
 If you correct the movement fault, does the pain improve?
 Vital Signs
 Pulse, BP, respiratory rate, temperature
 Be aware of normal ranges
 Skin Integrity
 Color
 Edema: acute vs. chronic (lymph) swelling
 Texture/mobility
 Abnormalities
– Fragility, ecchymosis, warmth and redness, shiny
appearance, etc…
 Sensation
 Assess to:
– Determine extent and cause of sensory loss
(see next slide)

– Determine degree / level of impairment

– Make prognostic evaluation of injury

 Sensory Rationale
Differentiate the source of nerve injury
 Nerve root injury
– Dermatome is the sensory distribution of skin supplied by
single nerve root, injury manifest in a dermatomal pattern
– Dermatomal patterns vary between individuals
– Seen as pain and/or paresthesia

 Peripheral nerve injury

– Localized of pain, paresthesia, & weakness
(set areas that presents consistent with a peripheral nerve injury)
 Assessment of Sensation
 Quick Screen
Assess with light finger touch. If deficits present, then:

 Perform more detailed sensory exam:

 While patient keeps eyes closed
 assess sensation of all extremities bilaterally
 record abnormal findings or asymmetrical differences
 complete sensation testing instructed next lecture
 Dermatome Screen
(assess bilaterally)

UE LE
C4: Along clavicle L2: Front mid-thigh

C5: Deltoid L3: Medial knee joint

C6: Thumb L4: Medial malleolus (ankle)

L5: Dorsum foot

C7: Middle finger
S1: Lateral heel/leg
C8: Little finger
S2: Popliteal fossa
T1: Ulnar forearm
 Demo and Practice
Quick Sensation Screen
 Screen for Muscle Strength

 Screen muscle strength to

get an idea of the patients
overall strength

 Test UE and LE myotome

muscle groups to get added
diagnostic information
 Strength Screenings
Demo 1) General strength screen
(bilateral assessment performed with pt sitting)
 Grip
 Shoulder elevation, abduction, IR, ER
 Elbow flexion, extension
 Hip flexion
 Knee extension/flexion
 Ankle dorsiflexion/plantarflexion

Demo 2) Myotome strength screen

(test strength of myotome muscle groups, see next 3 slides)
 Myotome Screen (assess bilaterally)

UE LE

C4: shoulder elevation L2: hip flexion

C5: shoulder abduction L3: knee extension

(elbow flexion)
L4: ankle dorsiflexion
C6: wrist extension
L5: hallux dorsiflexion
C7: elbow extension
S1: ankle plantar flexion
C8: finger flexion
S2: knee flexion
T1: finger abduction
 UE Myotome Screen
C4: Shoulder elevation (resist shldrs)
C5: Shoulder abduction or elbow flexion
C6: Wrist extension (stabilize forearm)
C7: Elbow extension at 90° (resist forearms)
C8: Finger Flexors
T1: Finger Abductors
 LE Myotome Screen
L2: Hip flexion (resist top of thigh)
L3: Knee extension (resist lower leg)
L4: Ankle dorsiflexion (resist dorsum of foot)
L5: Hallux dorsiflexion (resist distal phalanx)
S1: Ankle plantar flexors (standing, lift weight)
S2: Knee flexion (resist posterior leg)
 Potential Strength Findings
 Strong and painless
– Normal

 Strong and painful

– Local lesion of muscle or tendon (muscle strain)

 Weak and painful

– Indicates severe lesion around joint

 Weak and painless

– Neuro involvement or complete tendon rupture
 Practice both general and
myotomal strength screen for
the upper and lower extremities
 Assessment of Reflex Action

Provides info on integrity of the nervous system

Generally
• Diminished indicates a peripheral nervous system (PNS) problem

• Exaggerated indicates a central nervous system (CNS) problem

 Reflex Findings (rationale)
 Hypo-reflexia (diminished response)
– Indicate loss of nerve conduction, lesion of
peripheral nerve or spinal nerve root, may be
classified as lower motor neuron (LMN) lesion

 Hyper-reflexia (exaggerated response)

– Indicative of upper motor neuron (UMN) lesion.
More on this concept taught in lecture tomorrow
 Reflex Testing
Basic Instructions
 Patient should be positioned relaxed
 Place tendon on slight stretch (if possible)
 Tap tendon briskly

Tricks to enhance reflex response (if needed)

 Jendrassik maneuver
 Clench teeth
 Interlock (cross) legs
 Demo & Practice Reflex Testing
(Elicit & Compare Bilaterally)

• Biceps
• Brachioradialis
• Triceps
• Patella tendon
• Achilles tendon

See lab handout

 Extremity Girth

 Assess circumferential muscle girth

looking for atrophy

 Assess joint girth looking for swelling

 Screen Joint ROM

• Screen active range-of-motion (AROM) first

• AROM is movement which a patient performs
without assist
• If AROM is full and pain free, there may be no
reason to assess PROM (passive range of motion)

• How might you quickly screen AROM for:

• Shoulder
• Hip
• Knee
• Back
 AROM
The screen is easily performed-
Simply ask patient to move their injured joint through its full
available ROM

Shows:

Willingness and general ability to move

The patient’s reaction to joint movement

The amount and nature of restriction

Movement impairments
 Assess PROM
(examiner moves the injured joint)
 Look for the presence of pain
– Where in ROM; e.g. painful arc in the shoulder

 Presence of muscle guarding

– Spasm

 Presence of tone
– Spasticity

 Assess “end feel”

– Normal vs abnormal
 PROM End Feel

 Determine by applying overpressure to

a joint at its limit of available motion

 “End Feel” is what the examiner “feels”

 End Feel (cont’d)

Depending on the joint; three

descriptions of normal end feel
 Bone-to-bone: Hard, unyielding joint structure
compression that stops further movement

 Tissue-approximation: Yielding soft tissue

compression that stops further movement

 Tissue-stretch: Firm springy (slight give)

tissue-stretch that stops further movement
 End Feel (cont’d)
 Abnormal:ROM is reduced or end feel is
of abnormal quality
– Muscle spasm
 Invoked by movement, sudden painful arrest of movement
 Early- protective after injury; late-irritability, instability
– Capsular
 Thicker tissue stretch at abnormal place in ROM; frozen shoulder
– Bone-to-bone
 Osteophyte formation
– Empty
 Movement can’t be performed due to PAIN but no real restriction is
identified by the examiner
– Springy block
 Like tissue stretch, but unexpected place (menisci)
 Special Tests
 Orthopaedic
 Neurologic
 Specific to joint pathology and/or patient
presentation
 Test interpreted clinically, usually as being
positive or negative
 Example: “Straight Leg Raise” is positive for sciatica
when the test reproduces pain that radiates down the leg
consistent with patient’s original complaint of pain.
 Summary
 Part 1. History and Subjective: The ordered and systematic part of the Physical
Exam where the patient’s subjective report of the problem guides your exam and
diagnosis

 Part 2. Objective Assessment: Begins as a quick screen, then moves to specifically

evaluation at the level of impairment you intend to treat
 Advice
• Practice screening for strength, sensation
and reflexes on anyone who will let you!

• Know your anatomy! Review your

innervations.
Questions?