COURSE STRUCTURE

1. The Assessment (Ax): how to do an orthopedic assessment

2. Modalities
3. The spine: cervical (cs), thoracic(ts), lumbar(ls) and the sacro-iliac joint (SIJ),
4. The upper extremity (UE): shoulder, elbow, wrist,
5. The lower extremity (LE): Hip, Knee, Ankle
ORTHOPEDIC ASSESSMENT
LEARNING OUTCOMES
• You must be able to describe what the following are, and how to use them:
• 1. What is SOAP?
• 2. What is subjective information?
• 3. What is objective information?
• 4. What is assessment information?
• 5. What is a plan?
• 6. What does treatment information comprise of?
• 7. Pain (types, stages of healing)
• 8. Tissue injury (types, differential diagnosis)
• 9. What is ROM, AAROM, PROM ?
• 10. What is RROM?
• 11. What is MMT?
ORTHOPEDIC ASSESSMENT
OBJECTIVE ASSESSMENT

WHAT IS AN OBJECTIVE ASSESSMENT??

• This is information obtained by you with out bias. It is observable, reliable,
reproduceable data you collect. It includes but is not limited to the following:
1. OBSERVATION
2. PALPATION
3. MOTION ASSESSEMENT
4. NEUROLOGICAL ASSESSMENT
5. SPECIAL TESTS ASSESSMENT
OTHOPEDIC ASSESSMENT
OBJECTIVE ASSESSMENT - OBSERVATION

WHAT IS OBSERVATION??

 General appearance (standing posture, sitting posture, gait)

 Mobility (gait, assistive devices, stairs)
 Bony and soft tissue appearance, foot-wear
 ROM (functional) ie. How do they sit, squat, do ADL’s (activities of daily living)
OTHOPEDIC ASSESSMENT
OBJECTIVE ASSESSMENT - PALPATION

WHAT IS PALPATION??

• Palpation consists of but is not limited to the following:

 Temperature, texture, tone, tenderness of the skin and underlying tissues

 Anatomical review of muscles, sinews, channels
 Feeling for swelling, pain, inflammation, myospasm, scar tissue, bony changes etc.
OTHOPEDIC ASSESSMENT
OBJECTIVE ASSESSMENT - MOTION

WHAT IS MOTION??

Motion assessment consists of the following:

1. ROM, PROM, AAROM (range of motion, passive range of motion, active assisted range of motion)
2. RROM (Resisted ROM)
3. MMT (manual muscle testing)

• Let’s discuss these in more detail …

OTHOPEDIC ASSESSMENT
OBJECTIVE ASSESSMENT – OBSERVATION: ROM

WHAT IS ROM??
OBJECTIVE ASSESSMENT
MOTION
Range of Motion (ROM)
• The amount of movement that
occurs at a joint

http://36.media.tumblr.com/6d8942058dcf2622aa7a853c73a49c59/tumblr_mf9ddk7gkQ1qgrnh8o1_400.jpg
OBJECTIVE ASSESSMENT
MOTION
Structures that Affect ROM:

• Muscles
• Joint surfaces
• Capsules
• Ligaments
• Fascia
• Blood vessels
• Nerves
OBJECTIVE ASSESSMENT
MOTION
Decreased ROM can be caused by:

• Systemic diseases
• Joint pathology
• Neurological conditions
• Muscular conditions
• Surgery
• Trauma
• Inactivity
• Immobilization
OBJECTIVE ASSESSMENT
MOTION
How is ROM Described?

• Terms such as flexion, extension, abduction, adduction, IR (internal rotation), ER

(external rotation) are used to describe the range
• Degrees are measured with a Goniometer
OBJECTIVE ASSESSMENT
MOTION
Three types of ROM

• Passive range of motion (PROM)

• Active range of motion (AROM)

• Active-assisted range of motion (AAROM)

OBJECTIVE ASSESSMENT
MOTION
PROM

• Movement within the unrestricted ROM for a segment/joint

• Produced by an external force (gravity, machine, person)
• No voluntary action
 OBJECTIVE ASSESSMENT
MOTION
Active Range of Motion (AROM)

Movement of a segment/joint
http://www.milfordathleticclub.org/images/elbow-1.gif
within the unrestricted ROM
that is produced
by active contraction of the
muscles crossing that joint
OBJECTIVE ASSESSMENT
MOTION
Active-Assistive Range of Motion
(AAROM)

• Type of active range of motion where assistance is

provided manually or mechanically by an outside
force because the muscles need assistance to
complete the motion

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q=tbn:ANd9GcRffq7bHYSvkINT_8t2DPRWy-
2uFw0kyw5I62Q4P1cVZkf9EQgSgw

https://i.ytimg.com/vi/8iCj6Q1t6p8/hqdefault.jpg
ROM Video
• https://www.youtube.com/watch?v=cE5lv_AhP-E&feature=related
OTHOPEDIC ASSESSMENT
OBJECTIVE ASSESSEMENT: MOTION

WHAT IS RROM??
OBJECTIVE ASSESSMENT
MOTION - RROM

 RROM is a Resisted isometric contraction test designed for specific muscles. Isometric
contraction means the muscle is activated but there is no movement around the joint.
 Typically hold position for 3-5 seconds
 It provides information on strength of a myotome, specific muscle, contractile tissue
health, pain and progression of rehab
OBJECTVIE ASSESSMENT
MOTION - RROM

• https://www.physio-pedia.com/Resisted_Isometric_Movement_Testing
OBJECTIVE ASSESSMENT
MOTION - MMT

WHAT IS MMT??

 MMT is manual muscle testing where muscle strength is tested throughout its range,
with gravity and with gravity eliminated
 Provides information on strength of muscle, muscle groups, health of contractile tissue,
pain and progression of rehab
Graded out of 5. Graded from no muscle contraction to able to do full ROM with
maximum resistance
Assessment
Protocol
for MMT
MMT
• https://www.physio-pedia.com/Muscle_Strength_Testing
ORTHOPEDIC ASSESSMENT
OBJECTIVE ASSESSMENT - MOTION

So, how does this assessment of motion guide our understanding?

The amount of movement, the presence of pain, the ability to withstand a force lets us know
what tissues may be involved in the injury.
Let’s look at this more closely at tissue damage, stages of healing and differential
diagnosis of pain…
Tissue Damage

WHAT ARE THE TYPES OF TISSUE DAMAGE??

1. Muscle Injury
2. Tendon Injury
3. Ligament injury
4. Bone injury
5. Joint injury
6. Nerve injury
Healing Times

Exercise Muscle Soreness •0-3 Days

•Grade 1 : 0-3 days

Muscle Strain
•Grade 2 : 4 days – 3 months
•Grade 3 : 3 weeks – 6 months

Ligament Sprain •Grade 1 : 0-3 days

•Grade 2 : 3 weeks – 6 months
•Grade 3 : 5 weeks – 1 year

Tendon •Tendinitis : 3 – 7 weeks

•Tendinosis : 3 weeks – 6 months
•Laceration : 5 weeks to 6 months

Articular Cartilage •2 months – 2 years

Bone •5 weeks – 3 months

Tissue Damage
Muscle Injury

Muscles are contractile tissue

Muscle Cramp – involuntary muscle contraction
Muscle Strain – tearing of the muscle fibers (1st, 2nd, 3rd)
Muscle contusion – bruising that can be within or outside of the muscle fibers
Degenerative muscular disease
Tissue Damage
Tendon Injury

• Tendons are contractile tissues that connect muscle to bone

• Tendinopathy is a chronic injury of the tissue
• Tenosynovitis is an inflammation of the tendon sheath
• Tendinosis is a non-inflammatory degeneration of the tendon or its sheath
• Tendonitis is an inflammatory condition of the tendon
• Avulsion: tendon tears off at boney insertion
• Tear: partial, full thickness tears
Tissue Damage
Ligament Injury

• Non- contractile tissue that connects bone to bone

• Sprain: tearing of the tissue (1st, 2nd, 3rd degree)
• Avulsion: tears off the bone

• Note: first degree tear = micro tears, pain but no loss of function, second degree tear =
moderate tears with pain and partial loss of function, third degree tear = full tear, pain,
full loss of function
Tissue Damage
Joint Injury

• Joint capsule disorders (ligament tissue)

• Joint degeneration (cartilage and boney changes)
• Bone chips
• Inflammatory disorders (immune disorders, arthritis)
Tissue Damage
Bone Injury

• Fractures (simple, compound, spiral, comminuted, stress)

• Chips
• Boney overgrowth
• contusions
Tissue Damage
Nerve Injury

• Compression
• Neuropathy
• Disease process (MS, DM)
• Traumatic injuries to the central nervous system or peripheral nervous system
Tissue Healing

Acute: Stage One (3-5 minutes)

• Amount of damage and immediate reaction to tissue trauma
• Damage tissues, extravasated blood from the injury
• Blood vessels constrict
Acute: Stage Two (0-3 days)
• Quickly follows previous stage
• Inflammatory response (vasodilation, increased blood flow, fluid accumulation, enzymatic chemical
reaction and increased pain from cellular response and fluid pressure)
• Cardinal signs: pain, red, edema, heat, loss of function
Tissue Healing

Sub Acute: Stage One - Repair/Fibroplasia (4-28 days)

• Scar tissue formed and capillaries grow into wound in a process called angiogenesis
• Established healing occurs 10-17 days
Sub Acute and Chronic – Rehabilitation (15-60+ days)
• Maturation of the collagen tissues and an increase in soft tissue strength, range of motion
and function
(note: chronic is usually recognized as a condition that has been present for 3 months or
longer)
Tissue Specific Differential Diagnosis

HOW DO WE INTERPRET THE PAIN??

• Muscle injury
• Ligament injury
• Joint injury
• Bone injury
• Nerve injury
• Visceral injury
Tissue Specific Differential
Muscle Injury

• In the acute stage you will have pain at rest

• As the healing progresses one may have pain because of stage of injury/healing, or
because contractile tissue is stressed.
• Pain will occur with:
Palpation
AROM
AAROM
RROM
MMT
 Tissue Specific Differential
Ligament Injury
• Acute stage - pain may be present pain with rest
• Palpation – pain may be present
• Pain with stretching of the ligament, especially with over pressure. Why?? Pain occurs with
stressing of the non-contractile ligamentous tissue or when the bones it is supporting get stressed.
• AROM – pain with end range
• PROM – pain with end range
• AAROM – pain with end range
• RROM – may not have pain
• MMT – may not have pain

Note: with ligament injury their maybe instability or a clunking sensation

Tissue Specific Differential
Joint Injury

• Acute stage - pain may be present pain with rest

• Palpation – pain may be present
• Pain with stressing of the joint, especially with over pressure. Why?? Pain occurs with stressing of the non-
contractile ligamentous tissue or when the bones it is supporting get stressed.
• AROM – pain with end range
• PROM – pain with end range
• AAROM – pain with end range
• RROM – may not have pain
• MMT – may not have pain
Note: Pain occurs because joint is not working to its biomechanical specifications/demands
Tissue Specific Differential
Bone Injury (fractures and chips)

• Acute stage - pain may be present pain with rest

• Palpation – pain may be present .
• AROM – pain may occur
• PROM – pain may occur
• AAROM – pain may occur
• RROM – pain may occur
• MMT – pain may occur
• Pain will occur when bone moves against surrounding tissues or the instability of the bone causes
trauma
Tissue Specific Differential
Nerve Injury

• ROM and strength may or may not be affected depending upon if nerve has impacted the
muscle
• Paresthesia, shooting pain, pain reproduced with stretch or compression of nerve,
weakness or muscle wasting may be present, myotome or dermatomes may be affected,
reflexes may be affected
Tissue Specific Differential
Visceral Injury

• Will not affect ROM or strength

• Deep, achy often poorly localized
• Writhing, cramping pain
• Often not changed by change in body position
• Ex. Appendix, Gallbladder, Myocardial infarction referral
ORTHOPEDIC ASSESSMENT
OBJECTIVE ASSESSMENT

BACK TO SOAP!
We have looked at
Observation
Palpation
Motion (including ROM, Strength & differential diagnosis of tissue damage)

Let’s now look at neurological assessment

ORTHOPEDIC ASSESSMENT
OBJECTIVE ASSESSMENT - Neurovascular screen

• Dermatome (sharp, dull, fine, hot, cold)

• Myotome
• Reflexes
• Cranial nerves
• Pathologic reflexes
• Proprioception
• Pulses
• Nail bed or skin blanching
Neurovascular
Screen
ORTHOPEDIC ASSESSMENT
OBJECTIVE ASSESSMENT - Neurovascular screen

Dermatome
• An area of skin that is supplied by a single spinal nerve. They relay sensation from a particular
region of the skin to the brain
Myotome
• Group of muscles that a single spinal nerve innervates
Reflexes (DTR: deep tendon reflexes)
• An involuntary movement in response to a stimulus due to the reflex arc. Generally, a decreased
reflex indicates a peripheral or lower motor neuron lesion, and an increased reflex indicates a
central or upper motor neuron lesion.
ORTHOPEDIC ASSESSMENT
OBJECTIVE ASSESSMENT -Neurovascular screen

Cranial Nerves
 Emerge directly from brain as opposed to spinal nerves
 Reflexes involving 12 cranial nerves
Pathological Reflexes
 Babinski, clonus
Proprioception
 The sense of the body segments in relation to other body parts
 Heel to shin, finger to nose, placing, RAM (rapidly alternating movement)
Also - Pulses, Blanching
• Vascular competency
ORTHOPEDIC ASSESSMENT
OBJECTIVE ASSESSMENT – Outcome measures & Special
tests

• Orthopedic tests
• Diagnostic imaging
• Lab tests

SO WHAT ARE THESE??

There are many many tests, the following are some examples…
ORTHOPEDIC ASSESSMENT
OBJECTIVE ASSESSMENT – OUTCOME MEASURES

• ADL's (activities of daily living)

• Patient Specific Functional Scale
• http://www.tac.vic.gov.au/__data/assets/pdf_file/0020/27317/Patient-specific.pdf
ORTHOPEDIC ASSESSMENT
OBJECTIVE ASSESSMENT – OUTCOME MEASURES

Outcome measures for flexibility…

• AROM (Active range of motion)

• PROM (Passive range of motion)
ORTHOPEDIC ASSESSMENT
OBJECTIVE ASSESSMENT – OUTCOME MEASURES

Outcome measures for Strength

• Manual muscle testing (MMT)

• Grip strength:
Hand-held Dynamometer, measure 3 times holding for 3-5 seconds and take the
average score
Measured in pounds/force or kg/force
ORTHOPEDIC ASSESSMENT
OBJECTIVE ASSESSMENT – OUTCOME MEASURES

Outcome measures for mobility and CV endurance

• Walking test
• Timed up & go
• 2-minute walk test
• Running test
• Biking test
ORTHOPEDIC ASSESSMENT
ASSESSMENT

 The assessment is where you formalize your objective findings by creating a problem list.
 Make sure you stay within your scope of practice
 You can only make a TCM diagnosis or objective assessment
Ex.
 1. pain in anterior aspect of right shoulder 6/10 at rest
 2. decreased Flexion Right shoulder – 100 degrees
 3. positive test for shoulder tendon pathology
 4. positive for Right shoulder Bi syndrome
ORTHOPEDIC ASSESSMENT
PLAN

 The plan includes the patient’s treatment plan and SMART goals
 Must include recommendations for frequency, duration and type of treatment to be
provided

Let’s talk a bit more about SMART goals

ORTHOPEDIC ASSESSMENT
PLAN – SMART GOALS

• Goals are vital to assessing and tracking your patient’s progress. They need to be …
SMART
• Specific- detailed & focused
• Measurable- quantifiable & concrete criteria for measuring progress
• Attainable- can it be achieved
• Realistic – realistic goal
• Time sensitive – appropriate to injury, age, goal
 ex. Patient to achieve 180 degrees of shoulder flexion in 4 weeks.
Summary

In summary, we looked at…

1. Course and class structure
2. SOAP notes
3. Subjective information (including the importance of pain)
4. Objective information (including ROM, strength, tissue healing, tissue damage,
differential diagnosis for tissue damage, observation, palpation, neurological and
special tests)
5. Assessment
6. Plan (including SMART goals)