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