Musculoskeletal Assessment (Principles and Concepts for Physiotherapists)

Sreeraj S R
Musculoskeletal Assessment
Principles and Concepts for Physiotherapists
DR SREERAJ S R, PH.D.

Sreeraj S R
When to assess?
• On first patient contact
• During the treatment
• Following each treatment
• At the beginning of each new treatment
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Assessment
Examination
AROM
PROM
Resisted Motion
Neurological Testing
Leg Length
History
• Onset,
• Provoking &
alleviating
factors,
• Quality,
• Radiation,
• Severity,
• Timing
(duration) of
symptoms
Palpation
Heat
Tenderness
Oedema
Muscle Spasm Muscle Wasting
Special Tests
Observation
Gait
Posture
Leg length
discrepancies
Muscle Wasting
Other soft
tissues

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1. What is the patient’s age and sex?
2. What is the patient’s occupation?
3. Why has the patient come for help?
4. Was there any inciting trauma (macro trauma) or repetitive activity (micro trauma)?
5. Was the onset of the problem slow or sudden?
6. Where are the symptoms that bother the patient?
7. Where was the pain or other symptoms when the patient first had the complaint?
8. What are the exact movements or activities that cause pain?
9. How long has the problem existed?
10. Has the condition occurred before?
11. Has there been an injury to another part of the kinetic chain as well?
12. Are the intensity, duration, or frequency of pain or other symptoms increasing?
13. Is the pain constant, periodic, episodic (occurring with certain activities), or
occasional?
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14. Is the pain associated with rest, Activity, Certain postures, Time of day?
15. What type or quality of pain is exhibited?
16. What types of sensations does the patient feel, and where are these abnormal
sensations?
17. Does a joint exhibit locking, unlocking, instability, or giving way?
18. Has the patient experienced any bilateral spinal cord symptoms, fainting, or drop
attacks?
19. Are there any changes in the color of the limb?
20. Has the patient been experiencing any life or economic stresses?
21. Does the patient have any chronic or serious systemic illnesses?
22. Adverse social habits (e.g., smoking, drinking)?
23. Is there anything in the family or developmental history that may be related?
24. Has the patient undergone an x-ray examination or other imaging techniques?
25. Has the patient been receiving analgesic, steroid, or any other medication?
26. Does the patient have a history of surgery or past/present illness?
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Subjective Assessment
• Demographics: name, age, height, weight.
• Chief Complaint (CC): the major health problem or concern, and its time course
• History of the present illness (HOPI): details about the complaints, enumerated in the CC
• Past medical history (PMH):
• Past Surgical History (PSH): any previous surgery/operations (sometimes distinguished as ),
• Family History: especially those relevant to the patient's chief complaint.
• Congenital: Childhood diseases/Defects by Birth
• Co-Morbidities: Diabetes, Hypertension, Obesity and any current ongoing illness.
• Social history: Has the condition had an impact on their job? Is the job having a role on this
condition? Is their BADL & IADL affected? Enquire living arrangements, occupation, marital
status, number of children, recreational activities, habits.
• Drug History: Regular and acute medications (including those prescribed by doctors, over-
the-counter or alternative medicine)

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Pain History
• Onset of the event: whether the onset was sudden, gradual or part of an
ongoing chronic problem
• Provocation: Aggravating or relieving factors.
• Quality of the pain: Type, such as sharp, dull, crushing OR burning.
Pattern, such as intermittent OR constant.
• Region and radiation: Where the pain is localized or radiates to any other
area.
• Severity: The pain score (NPRS on a scale of 0 to 10, VAS, Wong-Baker
faces pain scale).
• Diurnal pattern: Do the symptoms worsen/improve/ remain constant at
different times of the day? Is it affecting sleep pattern?
• Time (history): How long the condition has been going on and how it has
changed since onset (better, worse, different symptoms)
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Sreeraj S R
Differentiation of Pain
• Systemic
 Disturbs sleep
 Deep aching or throbbing
 Reduced by pressure
 Constant or waves of pain and
spasm
 Is not aggravated by mechanical
stress
• Musculoskeletal
 Generally, lessens at night
 Sharp or superficial ache
 Usually decreases with cessation of
activity
 Usually continuous or intermittent
 Is aggravated by mechanical stress

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Systemic Pain Patterns
9
Donatelli RA. Orthopaedic Physical Therapy, 4th Edition (2010)

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Pain Descriptions and Related Structures
Type of Pain Structure
Cramping, dull, aching Muscle
Dull, aching Ligament, joint capsule
Sharp, shooting Nerve root
Sharp, bright, lightning-like Nerve
Burning, pressure-like,
stinging, aching
Sympathetic nerve
Deep, nagging, dull Bone
Sharp, severe, intolerable Fracture
Throbbing, diffuse Vasculature
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Pain Scales
• The McGill Pain Questionnaire (MPQ) is a self-reporting measure
of pain used for patients. It assesses both quality and intensity of
subjective pain.
• Child Revised Impact of Events Scale (CRIES) often used for infants 6
months old and younger and is widely used in the neonatal
intensive care setting.
• The COMFORT Scale is a pain scale that may be used by a
healthcare provider when a person cannot describe or rate their
pain.
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Red Flag Signs
Cancer:
 Persistent pain at night.
 Constant pain anywhere in the body.
 Unexplained weight loss (e.g., 4.5 to
6.8 kg in 2 weeks or less).
 Loss of appetite.
 Unusual lumps or growths.
 Unwarranted fatigue
Cardiovascular:
 Shortness of breath.
 Dizziness.
 Pain or 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).

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Red Flag Signs
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.
Neurological:
 Changes in hearing.
 Frequent or severe headaches with
no history of injury.
(Cont.…) Neurological:
 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
 Bladder rétention/incontinence,
 Bowel incontinence
 Saddle anesthesia

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Objective Assessment
• Observation
• When the patient is not aware of the observation.
• Occur anytime during the examination or history interview,
• Palpation
• Is a method of feeling with the fingers or hands during a physical
examination.
• Examination
• Examines a patient for any possible medical signs or symptoms of
a medical condition.
• Special Tests
• Provide us with greater diagnostic accuracy
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Observation
• Gait
• Posture
• Deformity
• Bulk/Girth
• Skin & Nails
• Artefacts
• Sensorium
• Orientation
• Ambulatory Status
• Body Build
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Posture
• Standing and sitting posture.
• Look for symmetry (folds/creases, etc.)?
• Do they have a kyphotic, lordotic, scoliotic posture?
• Do they lean and prop to one side?
• Do they become uncomfortable quickly?
• Do they have a good base of support?
• Is there rotation at the hips?
• Are the feet excessively turned in or out?
• Is one knee bent in standing?
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Gait
• What are the feet doing?
• Heel strike
• Foot Flat – is there excess pronation or supination?
• Toe off – is dorsiflexion/planatar flexion achieved or did they compensate?
• Swing phase – do the toes clear the ground satisfactorily?
• Are they facing the direction of travel
• What are the hips doing?
• Are the hips level through the gait cycle or do they bob up and down (Trendelenburg gait)?
• Are they rotating at all?
• What is the upper body doing?
• Are the arms swinging?
• Is the body rotating normally?
• What does the patient’s face look like – are they in pain?
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Deformity
• Look for attitude of the limb.
• Structural deformities are
present even at rest.
• Functional deformities are the
result of assumed postures and
disappear when posture is
changed.
• Dynamic deformities are caused
by muscle action and are present
when muscles contract or joints
move.
Example: foot drop apparent on
walking.
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Example: Structural vs Functional deformities
https://musculoskeletalkey.com/thoracic-assessment/

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Bulk/Girth
• Girth (circumference) measurements allow for a general assessment of
effusion and atrophy.
• Swelling within the knee joint is measured grossly by a girth measurement
taken at the joint line.
• Measurements taken at 5 cm and 20 cm proximal to the base of the patella
and 15 cm distal to the apex of the patella can provide an indirect indication of
atrophy in the VMO segment, quadriceps femoris muscle, and calf muscles,
respectively.
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Skin & Nails
Skin Discolorations.
• Pallor
• Erythema
• Cyanosis:
• Jaundice/Icterus:
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Pallor
• Paleness of skin & mucous membrane either as a result of diminished
circulating RBCs or diminished blood supply.
• Sites
• Lower palpable conjunctiva
• Tongue
• Soft palate
• Palm & nails
• Causes
• Anemia
• Vasoconstrictions
• Vitamin D deficiency
• emotional shock or stress
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Erythema
• Reddish coloration of the skin.
• Due to a rush of blood to the surface of the skin.
• Usually associated with a fever, infection, inflammation, allergic
reactions, or radiation.
• Non blanching red areas are strongly indicative of an impending
pressure ulcer and should be addressed immediately.
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Cyanosis
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CENTRAL PERIPHERAL
Mechanism
Diminished arterial O2
saturation
Diminished flow of blood to the
local part
Sites
On skin & mucous membrane
(tongue, lips, cheeks)
On skin only
Temperature of limb Warm Cold
Clubbing Usually associated Not associated
Local heat Cyanosis remains Cyanosis abolished
Breathing pure O2 Cyanosis decreases Cyanosis persists
• Bluish tone to the skin.
• This is due to low concentration of oxygen in the blood (hypoxemia).
• Can be central or peripherally due to cold exposure.

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Jaundice/Icterus
• Yellow tint to the skin,
mucous membranes or the
sclera of the eye.
• This is due to increased
levels of serum bilirubin in the
blood, sign of liver
inflammation.
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Topical Changes
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Ecchymosis
around the knee
following rupture
of the
quadriceps
Rheumatoid nodules. B,
Large nodules may
develop in the olecranon
bursa
Cellulitis of the leg.
Diffuse, acute,
infection of the skin
and subcutaneous
tissue

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Topical Changes
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Skin and nail
fold lesions
Gouty tophi
represent
deposits of urate
crystals
Psorialic anhritis, with
swelling of the distal
interphalangeal
joint and pitting in the
adjacent fingernails.
Evans RC. 2008.

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Pressure Ulcers
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Stage I Stage II Stage III Stage IV
• Fails to blanch with
pressure,
• Changes in
• Temperature
• consistency,
• pain or itching),
• color change
(red, blue, or
purple on darker
skin)
• The skin forms a
blister or sore.
• Ulceration involving
the epidermis,
dermis, or both
• Full-thickness skin
loss
• necrosis of
subcutaneous tissue
that may extend to
underlying muscle
• Stage III +
• damage to
underlying muscle,
bone, and
sometimes tendons
and joints
Bickley LS, 2017

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Gangrene
• Ischemic necrosis of the skin and
subcutaneous tissues creates a
blackened, atrophic eschar.
• Moist Gangrene: Results from an
untreated/poorly treated infection
in the body.
• Serious and life threatening
• Dry Gangrene: If the primary
problem is arterial insufficiency,
the lesions are atrophic and dry.
• If it does not become infected
and progress to wet gangrene,
usually does not
cause sepsis or death.
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Dry Skin
• Xerosis: Dry skin
• Anhydrosis: Dry feet
• Loss of adequate sebaceous and/or sweat gland function leads to
excessive drying of the skin.
• The skin is dry, often cracked and leathery in texture.
• CLINICAL OCCURRENCE:
• Anticholinergic drugs,
• denervation in peripheral neuropathies such as diabetes.
• Normal aging results in progressively more xerotic skin.
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Anhydrosis: Dry feet
Xerosis: Dry skin

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Skin Texture
• Quality of the feel of the skin.
• Smooth, soft or velvety skin
texture: Hyperthyroidism
• Very rough skin:
long-standing hypothyroidism
• Fibrosis or hardening:
• Lipodermatosclerosis: a gradual fibrotic
thickening of the skin in the ankle and
distal leg, is a classic sign of chronic
venous insufficiency.
• Scleroderma: an autoimmune disease.
• Scarring: from previous trauma.
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Lipodermatosclerosis
Scleroderma
https://dermnetnz.org/topics/lipodermatosclerosis/
https://www.yourveininstitute.com/vein-conditions/lipodermatosclerosis/

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Skin Moisture
• Skin typically has a slightly moist quality to it.
• Very dry: may indicate hypothyroidism, Chronic arterial
insufficiency .
• overly moist: may signal anxiety or a condition called
hyperhidrosis.
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Skin Elasticity/ Turgor
• Destruction or disruption of the elastic fibers in the skin results in decreased
elasticity.
• Skin appears wrinkled
• CLINICAL OCCURRENCE:
• Sun exposure (solar elastosis),
• actinic cutaneous atrophy,
• excessive stretching of the skin (e.g., pregnancy, obesity)
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Turgor
• Turgor is a measure of the skin’s
elasticity and hydration status.
• Test:
• Gently pinch and pull up the skin
slightly, then release.
• If the skin takes longer than 3
seconds to return to normal,
• is a strong indication that the
patient is moderately to severely
dehydrated.
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Fruth SJ. 2018

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Scars
• Injury to the
• epidermis can heal without scarring, with pigmentation.
• dermis results in scarring.
• subcutaneous fat and muscle can result in visible depressions or masses.
• All cutaneous scars are
• initially raised and red;
• they fade through pink to a pallid hypopigmented hue over months to years
as the vascularity of the fibrous tissue diminishes.
• Sutured wounds produce thin scars because there is a minimum of bridging
fibrosis.
• Wounds healing by secondary intention leave wide, inelastic scars like burns.
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Keloids and Hypertrophic Scars
• Keloid scars are cutaneous
conditions resulting from scar
tissue overgrowth.
• Often, these become bigger than
the size of the initial wound area.
• Hypertrophic Scars are less
severe than their keloi. Form as a
result of collagen overproduction.
More common
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Nails
• Nails should be
• somewhat pliable,
• have a uniform arced shape,
• smooth in surface texture, and
• have a pinkish nail plate that is uniform in color.
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Clubbing nails
• The base of the nail and nail bed
develop a domelike shape and the
distal phalanx becomes bulbous.
• Potential Associated Systemic
Conditions
• Chronic heart disease
• Cystic fibrosis
• Oxygen deprivation
• Chronic pulmonary disease
(specifically lung cancer)
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https://en.wikipedia.org/wiki/Nail_clubbing#Diagnosis

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Clubbing nails
• Schamroth sign:
• Lack of a window (gap)
between the fingers, when
the digits from each hand are
placed together with the top
of both hands touching.
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https://www.dailymail.co.uk/health/article-7727429/Simple-finger-test-reveal-cancer.html

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Clubbing nails
Grade Description
Grade 1 Softening of nail beds
Grade 2 Obliteration of the angle between the nail and the
nail bed
Grade 3 Parrot beak or Drumstick appearance. Swelling
of subcutaneous tissues over the base of nail.
Skin tense, shiny & wet. Increased nail curvature.
Grade 4 Hypertrophic pulmonary osteoarthropathy
causing pain & swelling of hand & wrist.
Swelling of fingers in all directions.
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Grade 2 & >

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Artefacts
• Observe for any walking aids, braces, orthotics, catheter, bandages, etc. in
situ?
• If yes,
• How well do they fit?
• Any red markings, inflammation, infection etc.?
• Is the subject use stick/ frame properly?
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Sensorium
• Ability of the brain to receive and interpret sensory stimuli.
• Good Sensorium = Alertness + Awareness
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Level of Consciousness
Alert : awake and attentive to normal stimulation
Lethargic : drowsy, may fall asleep if not stimulated
Obtunded : difficult to arouse, frequently confused when awake
Stupor : responds only to strong, noxious stimuli but returns to
unconscious state
Coma : cannot be aroused

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Glasgow Coma Scale
• It is a clinical scale to assess a patient’s “depth and duration of impaired
consciousness and coma”.
• GCS score = E + M + V
• Eye opening (E), Motor response (M), and Verbal response (V)
• maximum score of 15 and a minimum score of 3.
• In intubated patients, the maximum GCS score is 10T and the minimum score
is 2T
• Mild head injuries: GCS score of 13-15
• Moderate head injuries: 9-12
• severe head injury: GCS score of 8 or less.
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Orientation
• Orientation is often assessed as part of a mental status test to evaluate
a person's level of awareness of person, place, time, and situation.
• x1: Oriented to Person.
• x2: Oriented to Person and Place.
• x3: Oriented to Person, Place, and Time.
• x4: Oriented to Person, Place, Time, and Situation.
• Example: If AAOx3,
• The first “A” means “Awake”.
• The second “A” means “Alert”.
• The “O” means “Oriented”
• to Person, Place, and Time.
• Don’t use these letters if the patient is not alert and oriented.
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Mini-Mental State Examination (MMSE)
• The Mini-Mental State Exam (MMSE) is a widely used test of
cognitive function among the elderly.
• It includes tests of
• orientation,
• attention,
• memory,
• language and
• visual-spatial skills.
• Access here:
• https://www.oxfordmedicaleducation.com/geriatrics/mini-mental-state-examination-mmse/
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Ambulatory Status
• Note patient’s mode of locomotion.
• wheelchair,
• ambulatory with or without assistive device,
• bedridden,
• bed bound etc.
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Body Type: The 3 Somatotypes
• William H. Sheldon introduced the
concept of body types, or
somatotypes, in the 1940s.
• Ectomorphic thin, prominence of
structures from ectoderm
• Mesomorphic muscular, prominence
of structures from mesoderm
• Endomorphic heavy, fat body built,
prominence of structures from
endoderm
• These are generalizations and can be
of two or even all three somatotype
mix.
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https://www.muscleandstrength.com/articles/body-types-ectomorph-mesomorph-
endomorph.html

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BMI
• The BMI is a convenient method used to broadly categorize a person
as underweight, normal weight, overweight, or obese based on tissue mass
(muscle, fat, and bone) and height.
• Universally expressed in units of kg/m2
• Formula:
1. weight (kg) / [height (m)]2
2. weight (kg) / [height (cm)]2 x 10,000
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BMI
BMI Adults
Class Value range
Underweight : <18.5 kg/m2
Normal weight : 18.5 to 24.9 kg/m2
Overweight : 25 to 29.9 kg/m2
Obesity class I : 30 to 34.9 kg/m2
Obesity class II : 35 to 39.9 kg/m2
Obesity class III : > 40 kg/m2
BMI Children
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Posture
52
Kendall F P, 2005
Ideal Kypholordotic Flat Back
Lordotic

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Posture
• Basic Concepts of Physical Examination
• Jeffrey M. Gross – Musculoskeletal Examination
• For ABNORMAL POSTURES

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Posture: Posterior
Head & Neck
• Lateral flexion of the neck can result
from shortened muscles such as the
upper fibers of the trapezius, levator
scapulae, sternocleidomastoid, and
scalene muscles.
• Higher positioning of the ear on one the
side.
• Shoulder/neck flexion to the side of the
pain.
• Faulty spine alignment as in cervical
scoliosis.
• Neck rotation due to tight contralateral
sternocleidomastoid muscle, tight
scalenes and levator scapulae muscle
on ipsilateral side
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Ear Level Cx Spine Alignment
Cx Rotation

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Posture: Posterior
Shoulder
• Tightness of Levator Scapulae and
upper trapezius
• Muscle weakness (e.g., Stroke)
dropping shoulder.
• Dominant shoulder slightly
depressed and protracted.
• Neck pain elevate the shoulder to
reduce discomfort.
• Increase or decrease in muscle
tone due increased activity or
inactivity, respectively.
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Shoulder level
Example

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Posture: Posterior
Scapular Level
• Protracted shoulder relates to
elongated and weak Rhomboids
and the lower Trapezius.
• Severe retraction can be due to
hypertrophy of Rhomboids.
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Posture: Posterior
Scapular Rotation
• In upward rotation the medial border
and inferior angle are abducted from
the spine, lengthening the rhomboid
major and shortening the rhomboid
minor and levator scapulae.
• With downward rotation, the medial
border and inferior angle are
adducted towards the spine,
shortening the rhomboid major and
lengthening the rhomboid minor and
levator scapulae.
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Do

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Posture: Posterior
Inferior Angle of the Scapula
• The inferior angle is elevated
when the whole scapula is
elevated.
• Muscles of scapular elevation may
be shorter on the side of the
elevation such as upper fibers of
the trapezius and levator
scapulae.
• An elevated clavicle on same side
can be observed in anterior view.
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Example

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Winging of the Scapula
• Visible protrusion of the inferior angle and
the medial border of the scapula.
• Scapular winging indicates injury to:
1. the long thoracic nerve, which
controls the serratus anterior muscle
2. the dorsal scapular nerve, which
controls the rhomboid muscles
3. the spinal accessory nerve, which
controls the trapezius muscle
• And also
4. Tightness of Pectoralis Minor.
60

Sreeraj S R
Posture: Posterior
Thoracic Spine
• A scoliosis is defined as a
frontal plane lateral flexion
deviation of the spine.
• Causes can be
1. Congenital
2. Traumatic
3. Leg Length Discrepancy
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Posture: Posterior
Thoracic Cage
• Check the positioning of the
thoracic cage for rotation, and/or
shift to one side.
• Muscle Length Corresponding to
Rotation of the Trunk;
1. Internal oblique. Ipsilateral
2. External oblique. Contralateral
3. Lumbar erector spinae.
Contralateral
4. Neck rotation. Contralateral
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The right scapula appears not only more
prominent and closer to the observer.

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Posture: Posterior
Skin Creases
• Look for Skin Creases and its
symmetry on both sides.
• More or deeper creases on the
right side of the trunk may indicate
a shortened quadratus lumborum
on that side.
63
Scoliosis, posterior view
https://doctorlib.info/pediatric/visual-diagnosis-treatment-
pediatrics/37.html

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Posture: Posterior
Upper Limb Position
• Observe for the space formed between
the client’s arm and body.
• The arm on the side showing greater
space is abducted more.
• The possible reasons for larger space
between the left arm and the trunk in
standing is;
1. Short supraspinatus and/or the
deltoid.
2. The client is laterally flexed to that
side with a shorter quadratus
lumborum.
3. Pelvis is laterally tilted upwards on
the side to which she is flexed.
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Sreeraj S R
Posture: Posterior
Elbow Position
• Observe olecranon process for
symmetry of both the elbows.
• Look for;
1. Dropped, elevated or Internally
rotated shoulder;
2. laterally flexed trunk and space
between the arm and body
3. position of the client’s hands
• An internally rotated humerus might
contribute to shoulder pain caused by
the impingement of soft tissues.
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Sreeraj S R
Posture: Posterior
Hand Position
• Observe the position of the client’s
hands
• The more of the palm you can see,
the more internally rotated the
humerus is.
• Causes can be ;
1. Shoulder pain.
2. Tight and/or Overactive muscles:
Pec Major/Minor, Subclavius,
Latissimus Dorsi, Upper Trapezius,
Serratus Anterior and Anterior
Deltoid.
3. Weak and/or Inhibited muscles:
Mid/lower trapezius, Rhomboids.
•
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Sreeraj S R
Posture: Posterior
Lumbar Spine
• Observe for a straight lumbar
spine, or evidence of scoliosis.
• Also, skin creases on the waists.
• A scoliotic curvature may indicate;
• a disc herniation,
• muscle spasm,
• scoliosis,
• muscle imbalance or
• lateral flexion due to lateral
pelvis tilt.
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Posture: Posterior
Pelvic Rim
• Check to see whether the pelvis is level
or any lateral tilting.
• To compensate for a raised pelvis, a
client may have increased lateral flexion
of the lumbar spine to the raised side,
with the appearance of skin creases.
• Possible Effects of a Laterally Tilted
Pelvis;
1. Lumbar spine Flexed & concave to
the raised side.
2. Short quadratus lumborum and
erector spinae on same side.
3. hip is adducted on raised side and
abducted on contralateral side.
4. Accordingly Short hip adductors and
opposite hip abductors
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adducted
abducted

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Posture: Posterior
PSIS
• Check for lateral tilt of the pelvis
by placing your thumbs just
beneath the sacral dimple and
gauging whether the PSIS points
are level or not
• The subject is in standing.
• In this photo, the position of the
dimples suggests that the person’s
right PSIS is higher than his left
PSIS.
69

Sreeraj S R
Posture: Posterior
Pelvis
70

Sreeraj S R
Posture: Posterior
Buttock Crease
• Can consider only if the client is
willing to expose.
• Uneven creases can be due to;
1. Clients who bear weight more
on one side of the body than
the other may have a deeper
buttock crease on that side.
2. laterally tilted pelvises with a
deeper buttock crease on the
raised side.
3. leg length discrepancies.
71
Normal Rt. femur longer Rt. tibia longer

Sreeraj S R
Posture: Posterior
Posterior Knees
• If the posterior knee is prominent,
with the popliteus muscle seeming
to protrude slightly, what do you
suspect?
• client might be hyperextending
knee.
• Deep venous thrombosis
(DVT)
• Popliteal aneurysm
• Baker cyst
• Gastrocnemius tear
72
Right knee genu valgum Right knee Genu varum

Sreeraj S R
Posture: Posterior
Calf Midline
• Imaginary vertical line running from
the knee crease to the Achilles
tendon.
• A line that appears to be lateral
(rather than central) on the calf could
be due to an internally rotated hip or
a tibia that is medially rotated against
the femur on that side.
• A line that appears to be medial
(rather than central) on the calf
indicates the opposite.
• Look also, at the shape and bulk of
your client’s calf muscles.
73

Sreeraj S R
Posture: Posterior
Achilles Tendon, Malleoli, Foot Position
• Draw a line vertically down the
Achilles tendon, over the
calcaneus and to the floor.
• Look at the change in malleoli and
calcaneal bones change position
in pes valgus or pes varus.
74
Normal Pes valgus Pes varus

Sreeraj S R
Posture: Lateral
Head Position
• A forward head posture affects the
neck, chest and arms.
• Here the head is positioned ahead of
the body.
• Look for change in lordotic curve is
present or not.
• Cervical extensor muscles such as
levator scapulae are lengthened and
weak in the absence of increased
lordotic curve, .
• FHP increases the strain placed on
posterior cervical soft tissues leading
to upper back pain.
75
http://koreabizwire.com/diagnoses-of-forward-head-posture-up-by-300000-in-5-years/112198

Sreeraj S R
Posture: Lateral
Neck & Thorax
• Does the neck have the look for lordotic
curve normal or exaggerated.
• An exaggerated lordotic curve in the
cervical spine often accompanies a
kyphotic posture.
• Prolonged Cx lordotic posture can lead to
adhesions between joint capsules and
surrounding soft tissues resulting in a
decrease in range of movement.
• Prolonged compression of cervical
vertebrae leads to osteophytes in this
region.
76

Sreeraj S R
Posture: Lateral
Neck & Thorax
• The thoracic cavity may be diminished with
associated shortened intercostals,
pectorals, adductors, and internal rotators
of the shoulders.
• Muscles that are often weak in a kyphotic
posture include the thoracic spine
extensors and the middle and lower fibers
of the trapezius.
• The cervical extensor muscles are brought
closer together and are therefore likely to
be shortened and weak, and
• the neck flexor muscles are likely to be
lengthened and weak.
• Kyphosis or Dowager’s Hump
77
Dowager’s Hump

Sreeraj S R
Posture: Lateral
Shoulder Position
• Does the shoulder sit nicely in line with the ear?
• Does it appear protracted, the arm falling into internal rotation?
• Or is the client in military-style posture?
• Shoulder protraction is associated with lengthened and weak rhomboids,
middle and lower fibers of the trapezius, extensors of the thoracic spine and
tight pectorals and intercostals.
• An internally rotated humerus suggests shortness of medial rotators of
shoulder.
• Retracted shoulders may have a reverse of this.
• Also look for protracted shoulder on one side and a retracted shoulder on the
other side.
78

Sreeraj S R
Posture: Lateral
Abdomen
• In a normal, healthy person, the
abdomen should be flat.
• Protrusion of the abdomen;
1. could be a pregnancy or
2. the result of increased lumbar
lordosis, or
3. could be excess adipose tissue
due to overweight or
4. depressed chest sometimes
appear to have a protruding
abdomen.
79

Sreeraj S R
Posture: Lateral
Lumbar Spine and Pelvis
80
Kendall F P, 2005
Ideal Kypholordotic Flat Back
Lordotic

Sreeraj S R
Posture: Lateral
Lumbar Spine
• Factors Corresponding to Anterior and Posterior
Pelvic Tilt:
81
Anterior pelvic tilt Posterior pelvic tilt
The ASIS are held anterior to
the
pubis
The ASIS are held posterior to
the pubis
Increased lordosis Decreased lordosis
Extensors of the lumbar spine
are short and strong
Hip extensors are short and
strong
Rectus abdominis and
Hip extensors are long and
weak
Hip flexors are long and weak
Weak
abdominal
Tight erector
spinae
Weak gluteus
maximus
Tight
iliopsoas
Lower Cross
Syndrome

Sreeraj S R
Posture: Lateral
Knees
• Flexed knees are associated with tight
hamstrings and popliteus muscles and
weak quadriceps and soleus muscles.
• Causes increase in flexion at the hip and
dorsiflexion at the ankle joint.
• Causes
 a loose body within the joint may
prevent full extension;
 the pain of chondromalacia patella
may be aggravated by full extension.
 Clients who are hypermobile often
hyperextend
82
Normal Flexed Hyperextended

Sreeraj S R
Posture: Lateral
Knees
• Hyperextended knees are associated
with tight quadriceps leading to
anterior knee pain as the patella is
pushed against the femur in standing
and
• lengthened hamstrings.
• There might be increased stress on
the posterior aspect of the joint
capsule.
• Also associated with decreased
dorsiflexion.
83

Sreeraj S R
Posture: Lateral
Ankles
• Increased dorsiflexion in standing is observed in clients who stand with
flexed knees.
1. There is shortened tibialis anterior and
2. increased pressure to the anterior aspect of the ankle retinaculum.
• Decreased dorsiflexion is associated with
1. shortened quadriceps and
2. increased pressure to the anterior of the knee joint.
• There might be pain and early degenerative joint changes due to uneven
distribution of ground reaction forces through the tibiae.
84

Sreeraj S R
Posture: Lateral
Feet
85
Normal Pes Planus Pes Cavus

Sreeraj S R
Posture: Anterior
Face
• Look for facial symmetry.
• Some of the reasons for asymmetry are;
• Individual’s genetics.
• Facial scars, trauma or injury
• Bell’s palsy
• Stroke.
• Temperomandibular joint ankylosis
• Facial tumors
• Torticollis
• Cleft lip
86

Sreeraj S R
Posture: Anterior
Head Position
• Normally the nose should be in the midline along with the manubrium, sternum
and umbilicus.
• Both ear lobes should be at the same height.
• Some of the reasons for altered head position are;
• Prolonged work-related positioning.
• Severe lateral flexion with or without rotation, combined with heightened
tone in the sternocleidomastoid, could indicate torticollis.
• An injury to the neck.
87

Sreeraj S R
Posture: Anterior
Muscle Tone
• Look for more prominence of muscle of neck, chest, and shoulders on one side
compared to the other.
• Reasons could be Poor posture, wrong sleeping position, Repetitive neck
movements, Injuries while lifting weights, sports, whiplash etc. and Torticollis
• Pay particular attention to the sternocleidomastoid, the scalene and the upper fibres
of the trapezius.
• Enquire whether the increased tone symptomatic or not?
• Increased tone in respiratory muscles can be associated with long-term respiratory
conditions such as COPD.
• Atrophy, on the other hand, indicates disuse due to injury, immobilization, lack of
physical activity, age, malnutrition, neurological conditions.
88

Sreeraj S R
Posture: Anterior
Clavicles
• Observe angle, contour and
symmetry of the clavicles.
• Sharply angled clavicles indicate
elevated shoulders.
• It is normal for the clavicle on the
dominant side to be lower than
that on the non-dominant side.
• Uneven contours could indicate a
fracture that has healed in mal-
alignment, a more recent injury
such as a ruptured AC joint etc.
89
Asymmetrical clavicle level

Sreeraj S R
Posture: Anterior
Shoulder
• Look for shoulders level and muscle
symmetry.
• It is common for the shoulder of the
dominant hand to be slightly lower
than the other.
• Elevation of shoulder is an indication
for guarding an injury in the shoulder
or in the neck.
• Depression of the shoulder plus
indentation in the contour of the
deltoid is observed in people with
subluxation at the glenohumeral joint.
90
Prominent trapezius
Deltoid atrophy of the left shoulder.

Sreeraj S R
Posture: Anterior
Chest
• The thorax may shift laterally or rotate
relative to the neck and pelvis.
• Look whether the sternum appear in
the midline, rib cage position in
relation to pelvis and rotation of rib
cage.
• The lateral shift of thorax might be
due to sciatica, scoliosis, habitual
postural anomaly etc.
• When the thorax rotates,
compensatory changes occur in the
neck and lumbar spine.
91

Sreeraj S R
Posture: Anterior
Carrying Angle
• The carrying angle is the angle
formed between the long axis of
the humerus and the long axis of
the forearm.
• In males, a normal angle is 5 to 10
degrees;
• In females, a normal angle is 10 to
15 degrees
92
Axis of forearm
Axis of forearm
Carrying
angle

Sreeraj S R
Posture: Anterior
Arms, Hands and Wrists
• Observe for the space formed between
the client’s arm and body.
• The arm on the side showing greater
space is abducted more.
• The possible reasons for larger space
between the left arm and the trunk in
standing is;
1. Short supraspinatus and/or the
deltoid.
2. The client is laterally flexed to that
side with a shorter quadratus
lumborum.
3. Pelvis is laterally tilted upwards on
the side to which she is flexed.
• In hand and wrist;
• Look for swollen, inflamed and often
misshapen joints in the fingers: sign of
RA.
• Obvious muscle wasting may be due to
nerve damage or impairment.
• Discolouration can indicate poor blood
flow to the extremities, which is
common in conditions such as
diabetes.
93

Sreeraj S R
Posture: Anterior
Abdomen
• Observe for umbilicus position
in the midline along with the
sternum and pubic symphysis.
• If not look for rotation of the
thorax and pelvis.
• The rotation of the umbilicus
could also be because of
shortening in the iliopsoas
muscles on the same side.
94

Sreeraj S R
Posture: Anterior
Pelvis
• The anterior superior iliac spines (ASIS)
of the pelvis should be level.
• To compensate for a raised pelvis, a
client may have increased lateral flexion
of the lumbar spine to the raised side,
with the appearance of skin creases.
• Possible Effects of a Laterally Tilted
Pelvis;
1. Lumbar spine Flexed & concave to
the raised side.
2. Short quadratus lumborum and
erector spinae on same side.
3. hip is adducted on raised side and
abducted on contralateral side.
4. Accordingly Short hip adductors and
opposite hip abductors
95

Sreeraj S R
Posture: Anterior
Pelvis
• Look for pelvic rotation.
• Normal pelvis with both ASIS aligned.
Knees face forwards. There is equal
pressure beneath the medial and lateral
sides of the foot.
• The whole pelvis is rotated to the right.
Knees no longer face forwards. There is
increased pressure on the lateral side of
the right foot.
• The whole pelvis is rotated to the left.
Knees no longer face forwards. There is
increased pressure on the lateral side of
the left foot.
96
Normal Rt. rotated Lt. rotated

Sreeraj S R
Posture: Anterior
Knees
• With client standing with the feet
together, look for genu valgum or
genu varum
• Osteoarthritic changes or
degradation of menisci.
• Overstretching of soft tissues is
likely on the opposite side and
increased pressure on the same
side of the knee.
97

Sreeraj S R
Posture: Anterior
Knees
• Q angle measures the angle
between the rectus
femoris/quadriceps muscle and
the patellar tendon.
• A typical Q angle is 12 degrees for
men and 17 degrees for women.
• Q angle is increased by:
1. genu valgum
2. increased femoral anteversion
3. external tibial torsion
4. laterally positioned tibial tuberosity
5. increased pronation of the foot
98
ASIS
Midpoint of the patella
Tibial tubercle
Q angle

Sreeraj S R
Posture: Anterior
Knees
• When stands with the feet turned out slightly, the patella will also face
outwards slightly, but should still be aligned over the joint.
• However, when there is rotation in the femur, the tibia or both, the patella no
longer faces forwards.
• Clients who stand with the knees hyperextended often compress the patellae
against the femurs, and the patellae slant downwards rather than facing
straight ahead.
99

Sreeraj S R
Posture: Anterior
Patellar Position
• The patella should be positioned in
line with the tibial tuberosity.
• Reasons could be:
1. weak quadriceps
2. imbalance in strength between
hamstrings and quadriceps (called the
H:Q ratio
3. Overweight
4. turned-in knees/knock knees/valgus
5. flat feet
6. high-arched foot
7. structural problems in your knees or leg
alignment, such as a shallow trochlear
groove
100

Sreeraj S R
Posture: Anterior
Ankles & Foot
• The medial malleoli should be level with each
other, and the lateral malleoli should be level
with each other.
• The feet slightly turned out to the same angle,
equidistant from an imaginary plumb line.
• Changes Associated With Toe-Out and Toe-In
Foot Positions;
101
Toe-out position Toe-in position
Externally rotated hip
joint.
Internally rotated hip
joint.
Lateral tibial torsion. Medial tibial torsion.
External rotators of the
femur and iliotibial band
might
be shortened.
Internal rotators of the
femur might
be shortened.
The Fick angle is approximately 12° to
18°

Sreeraj S R
Palpation
• Palpation Guidelines
• Note differences in tissue tension, muscle tone & texture
• Note differences in tissue thickness
• Identify palpable anomalies
• Define areas of tenderness
• Temperature variations
• Dryness, excessive moisture
• Abnormal sensation
• Remember!! Palpate uninvolved part first and painful areas last
103

Sreeraj S R
Tenderness
• Tenderness Scale/Grading
104
Grading Response
0 : No tenderness.
I : Tenderness to palpation WITHOUT grimace or flinch.
II : Tenderness WITH grimace &/or flinch to palpation.
III : Tenderness with WITHDRAWAL + "Jump Sign".
IV : Withdrawal + "Jump Sign" to non-noxious stimuli

Sreeraj S R
Heat
• Palpate for any heat in the area with the dorsum of your hand.
• Is there heat along with swelling, or redness in the area being
observed?
• All these signs along with pain and loss of function are
indications of an active inflammatory condition.
105

Sreeraj S R
Oedema
• Edema is defined as a palpable swelling produced by an accumulation of fluid in the intercellular tissue
that results from an abnormal expansion in interstitial fluid volume.
History
1. Timing of the edema- since when?
• Acute swelling of a limb over a period of less than 72 hours is more characteristic
of DVT, cellulitis, internal rupture, acute compartment syndrome from trauma, or recent initiation of
calcium channel blockers.
• The chronic accumulation of more generalized edema is due to the onset or exacerbation of chronic
systemic conditions, such as CHF, renal disease, or hepatic disease.
2. Unilateral or bilateral edema:
• Unilateral edema can result from DVT, venous insufficiency, venous and ), lymphatic obstruction.
• Bilateral or generalized swelling suggests a systemic cause, such as CHF, pulmonary hypertension,
chronic renal or hepatic disease, or severe malnutrition.
3. Changes of edema with position
107

Sreeraj S R
Oedema
108
Pitting edema
DV
T

Sreeraj S R
Oedema
• Methods to Quantitatively Assess Peripheral Edema
1. Volume measurements (with a water volumeter)
2. Girth measurements (with a tape measure).
a. Circumferential Method
b. Figure-of-Eight method

Sreeraj S R
Oedema
110
Press firmly with your thumb for at least 2 seconds on each extremity,
• Over the dorsum of the foot
• Behind the medial malleolus
• Lower calf above the medial malleolus
Grade 0 : No clinical oedema
Grade 1 : Slight pitting (2 mm depth) with no visible distortion that rebounds immediately.
Grade 2 : Somewhat deeper pit (4 mm) with no readily detectable distortion that rebounds in fewer than
15 seconds.
Grade 3 : Noticeably deep pit (6 mm) with the dependent extremity full and swollen that takes up to 30
seconds to rebound.
Grade 4 : Very deep pit (8 mm) with the dependent extremity grossly distorted that takes more than 30
seconds to rebound.
Grading of Edema

Sreeraj S R
Muscle Spasm
• Muscle guarding / spasm minimize movement and stabilize the area of
injury often acting as a splint.
• The most common signs and symptoms of muscle spasm are pain,
tightness, and restricted motion.
• Muscle spasm can be confirmed by muscle palpation.
• Recognize muscle guarding as stiffness resisting any movement.
• Compare with the normal side.

Sreeraj S R
Range of Motion
• Factors That Can Affect Range of Motion
• Age
• Gender
• Body Mass Index
• Disease
• Occupation/Recreation
• Culture
113

Sreeraj S R
Active Range of Motion
• Gives an idea of the willingness and ability of the patient to move the part.
• May indicate affection of either contractile or non contractile tissue or both.
• Observe for
• patient’s willingness to move,
• coordination and motor control,
• muscular force production, and
• potential limiting factors (such as pain or a structural restriction).
• If a patient demonstrates pain-free, unrestricted AROM within the expected range,
further assessment of that joint motion is likely not necessary.
• Any motion that is limited or reproduces the patient’s symptoms requires further
investigation.
114

Sreeraj S R
• Look for Functional motion
• They typically involves a combination of motion in all three planes.
• For example, touching the opposite shoulder involves a
combination of shoulder flexion, adduction, and internal rotation.
• It is possible that motion is relatively normal when assessed using
planar motions, but abnormal (painful or limited) during multiplanar
motion.
115

Sreeraj S R
• Possible reasons for limited ROM includes,
• intra-articular blocks (such as a bone fragment, cartilage flap, or
a bony malformation),
• joint effusion,
• edema,
• capsular tightness,
• lack of muscle length,
• excessive muscular or adipose tissue, and
• inadequate force production of the prime movers.
116

Sreeraj S R
Passive Range of Motion
• If a limitation is noted during AROM, passive assessment of that motion should
occur.
• Stresses non-contractile tissues, and to a lesser degree, contractile tissues
• Passive motion requires that the patient be as relaxed as possible.
• PROM provide information about,
• The integrity of joint surfaces
• The extensibility of the capsule, ligaments, and muscle surrounding the
joint
• The irritability of local tissues and
• The full excursion allowed by a joint for any given motion.
117

Sreeraj S R
PROM: Hypermobility
• Normal mobility is relative.
• For example, gymnasts tend to be classed as lax (nonpathological
hypermobility) in most joints, whereas elderly persons tend to be classed as
hypomobile.
• Certain conditions such as Ehlers-Danlos syndrome, Marfan syndrome and
Benign joint hypermobility syndrome may cause Hyper ROM.
• The Beighton score is a popular screening technique for hypermobility.
118

Sreeraj S R
The Beighton score
Left Right Total
1 Passive dorsiflexion and hyperextension of the fifth MCP joint
beyond 90°
1 1 2
2 Passive apposition of the thumb to the flexor aspect of the forearm 1 1 2
3 Passive hyperextension of the elbow beyond 10° 1 1 2
4 Passive hyperextension of the knee beyond 10° 1 1 2
5 Active forward flexion of the trunk with the knees fully extended so
that the palms of the hands rest flat on the floor
1 1
Grand Total 9
119
• A Beighton score of 4/9 or greater (either currently or historically) is considered a major criteria
• A Beighton score of 1, 2 or 3/9 is considered minor criteria

Sreeraj S R
PROM: Hypomobility
• The examiner must determine whether there is any limitation of range
(hypomobility).
• Myofascial hypomobility results from adaptive shortening or hypertonicity of
the muscles or from posttraumatic adhesions or scarring.
• Pericapsular hypomobility has a capsular or ligamentous origin and may
result from adhesions, scarring, arthritis, arthrosis, fibrosis, or tissue
adaptation.
• Pathomechanical hypomobility occurs as a result of joint trauma (micro or
macro) leading to restriction in one or more directions
120

Sreeraj S R
PROM: Joint End Feel
• Normal End Feels
121
Feel Description Example
Hard Bone-to-Bone Elbow extension
Soft Soft Tissue Approximation Elbow or knee flexion
Firm
Muscular stretch Hip flexion with the knee straight (passive elastic tension
of hamstring muscles
Capsular stretch Extension of metacarpophalangeal joints of fingers
(tension in the anteriorcapsule)
Ligamentous stretch Forearm supination (tension in the palmar radioulnar
ligament of the inferior radioulnar joint, interosseous
membrane, oblique cord)

Sreeraj S R
PROM: Joint End Feel
• Abnormal End Feels:
Occurs sooner or later in the
ROM than is usual
122
End Feel Example
Soft
Soft tissue edema
Synovitis
Firm
Increased muscular tonus
Capsular, muscular, ligamentous shortening
Hard
Chondromalacia
Osteoarthritis
Myositis ossificans
Fracture
Loose bodies in joint
Empty
Acute joint inflammation
Bursitis
Abscess
Fracture
Psychogenic disorder

Sreeraj S R
Performing End Feel
• Passive ROM and end feel must be performed slowly and carefully.
• Secure stabilization of the proximal bone is critical to prevent crosstalk.
• Be sure that severe symptoms are not provoked.
• End feel can be tested if,
• The patient can hold a position actively at the end of the physiological ROM,
• The symptoms ease quickly after returning to the resting position.
• If the patient has severe pain at the end range, end feel should only be tested with
extreme care.
123

Sreeraj S R
Capsular and Noncapsular Patterns
• Joints display a pattern of movement limitation which is unique to a
particular joint caused by dysfunction in the joint capsule.
• This movement restriction is called the joint capsular pattern.
124

Sreeraj S R
Capsular Pattern: TM & U/L Joints
Joints Restricted Motion
Temporomandibular Limitation of mouth opening
Glenohumeral Lat. rotn., abd.,med. rotn
Elbow Flxn. extn.
Forearm Equal limitation of supination and pronation
Wrist Equal limitation of Flxn. Extn.
CMC Digit 1 Abd. Ext.
MCP & IP Flxn., extn.
125

Sreeraj S R
Capsular Pattern: L/L Joints
Joints Restricted Motion
Hip Med. rotn. flxn. abd. extn
Knee Flxn. extn
Ankle Plantar flxn. dorsi flxn.
Subtalar Inversion, eversion
Midtarsal Add., med. rotn.
MTP digit 1 Extn. flxn.
MTP digit 2-5 Flxn. extn.
IP Extn. flxn.
126

Sreeraj S R
Joint Play or Accessory Movement
• Not under voluntary control but they are necessary, for full painless function of
the joint and full ROM of the joint.
• Joint dysfunction signifies a loss of joint play movement.
• Joint play mobilization should be done in a loose packed position
• Loose packed (resting) position: the position at which the joint is under
the least amount of stress (capsule, ligaments, bone contact).
• Close packed position: the position in which most joint structures are
under maximum tension.
127

Sreeraj S R
• Mennell’s Rules for Joint Play Testing (Magee DJ, 2014)
1. The patient should be relaxed and fully supported
2. The examiner should be relaxed and should use a firm but comfortable
grasp
3. One joint should be examined at a time
4. One movement should be examined at a time
5. The unaffected side should be tested first
6. One articular surface is stabilized, while the other surface is moved
7. Movements must be normal and not forced
8. Movements should not cause undue discomfort
129

Sreeraj S R
• Joint Play assessment grading:
130
Motion Extend of Restriction Grade Intervention
Hypomobility
No movement (ankylosis) 0 Surgery (?)
Considerable decreased movement 1 Manipulation
Slight decreased movement 2 Mobilization
Normal Normal 3
Hypermobility
Slight increased movement 4 Exercise
Considerable increased movement 5 Brace/Exercise
Complete instability 6 Surgery

Sreeraj S R
Resisted Isometric Movements
• Stresses contractile tissues
• Isometric contraction of specific muscles
• "Neutral" joint position - don't allow joint motion
• Possible Responses & Reasons
131
Type of response Possible tissues involved
Strong and pain free : No lesion of the contractile unit
Strong and painful : First- or second-degree local lesion
Weak and painful : Major lesion of a muscle, tendon OR a fracture
Weak and pain free : A third-degree strain, complete avulsion #, peripheral nerve or nerve
root involvement.

Sreeraj S R
Contractile vs Non-Contractile lesions
Contractile Non contractile
Muscle with its tendons and attachments Bones, joint capsules, ligaments, bursae,
Fasciae, nerve roots
Active and passive movements are restricted in
opposite directions.
Active and passive movements are restricted in
the same direction.
Passive joint play movements are normal and
symptom free.
Passive joint play movements produce or
increase symptoms and are restricted.
Resisted movements produce or increase
symptoms.
Resisted movements are symptom free.
132

Sreeraj S R
Muscle Strength Grading
• Medical Research Council (MRC) Manual Muscle Testing scale
aka Oxford scale
133
MRC Scale Explanation
0 : No contraction
1 : Flickering contraction
2 : Full Range of Motion with eliminated gravity
3 : Full Range of Motion with Against gravity
4 : Full Range of Motion with Against gravity with minimal resistance
5 : Full Range of Motion with Against gravity with maximal resistance

Sreeraj S R
Limb Length Discrepancy
• A limb length discrepancy is a difference between the lengths of the arms or legs.
• Patients who have differences of 3.5 to 4 percent of total leg length i.e. about 4 cm or
1.5 inches in an average adult, may limp or have other difficulties when walking.
• Because these differences require the patient to exert more effort to walk, he or she
may tire easily
• Leg length discrepancy can be divided into 2 etiological groups:
1. True LLD, defined as those who are associated with shortening of bony
structures, and
2. Apparent LLD, defined as those who are the result of altered mechanics of the
lower extremities.
• Methods used for Assessing Leg-length Difference
• Tape measure
• Standing on Blocks
• Imaging Methods
134

Sreeraj S R
135
• Tape measure
• A “true” leg length from the anterior
superior iliac spine (ASIS) to the
medial malleolus.
• Before taking true LL, measure the
distance from the ASIS on the left and
right sides to the umbilicus, to
ascertain if any pelvic rotation is
present.
• If a difference in the two
measurements is found, the pelvic
rotations need to be corrected before
a reassessment is done
Apparent LL
True LL

Sreeraj S R
• Tape measure
• The “apparent” leg length is
measured from the umbilicus
to the medial malleolus.
136
Apparent LL
True LL

Sreeraj S R
• Standing on Blocks
• Placing blocks of known height
beneath the heel of the short leg
to level the pelvis allows “indirect”
measurement of leg length
discrepancy.
137

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Neurological Examination: L/L
Motor Examination Sensory Examination
Movement Nerve Root
Hip flexion/IR/adduction L2/L3
Hip extension/ER/abduction L4/5
Knee extension L3
Ankle dorsiflexion L4
Big toe extension L5
Ankle plantarflexion S1
Bladder and rectum S4
http://nothinbutapeanut.com/?page_id=577#Lower_Limb_Reflexes

Sreeraj S R
Neurological Examination: U/L
Motor Examination Sensory Examination
140
Movement Nerve Root
Neck Flexion C1-C2
Neck Lateral flexion C3, CN XI
Shoulder Elevation C4, CN XI
Shoulder Abd., LR, Flex. C5
Shoulder Flex. C5, C6
Elbow flexion/Wrist Extension C6
Elbow extension/Wrist flexion C7
Thumb extension C8
Finger Abduction & Adduction T1

Sreeraj S R
Reflexes
• Reflexes tested include the
following:
1. Biceps (by C5 and C6)
2. Radial brachialis (by C6)
3. Triceps (by C7)
4. Distal finger flexors (by C8)
5. Quadriceps knee jerk (by L4)
6. Ankle jerk (by S1)
7. Jaw jerk (by 5th cranial nerve)
141
Grade Response
0 No evidence of contraction
1+ Decreased, hypo-reflexic. generally
associated with LMN
2+ Normal
3+ Hyperreflexia is often attributed to UMN.
4+ Clonus: Repetitive shortening of the muscle
after a single stimulation
This grading system is rather subjective.

Sreeraj S R
Normal Gait
Initial swing Mid swing Terminal swing
Normal Gait (swing phase 40%)
Initial Contact Loading
Response
Mid
stance
Terminal Stance Pre
swing
Normal gait (stance phase 60%)

Sreeraj S R
Distance Parameters in Young Healthy Adults
Parameter Definition Range of Values
Stride length The distance between ground contact of one foot and the
subsequent ground contact of the same foot
1.33 to 1.63 m
Step length The distance between ground contact of one foot and the
subsequent ground contact of the opposite foot
0.70 to 0.81m
Step width/base
of support
The perpendicular distance between similar points on
both feet measured during two consecutive steps
0.61 to 9.0 cm
Foot angle Angle between the long axis of the foot and the line of
forward progression
5.1 to 6.8 degrees
143

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Temporal Parameters in Young Healthy Adults
Parameter Definition Range of Values
Stride time Time in seconds from ground contact of one foot to ground
contact of the same foot
1.00 to 1.12
Speed / velocity Distance/time, usually reported in m/sec 0.82–1.60 m/sec
Cadence Steps per minute 100–131
Stance time Time in seconds that the reference foot is on the ground during
a gait cycle
0.63 to 0.67
Swing time Time in seconds that the reference foot is off the ground during
a gait cycle
0.39 to 0.40
Double support
time
Time in seconds during the gait cycle that two feet are in
contact with the ground
0.11 to 0.141
Single support
time
Time in seconds during the gait cycle that one foot is in contact
with the ground
144

Sreeraj S R
Pathological Gait
• Gait abnormalities fall into following functional categories.
1. Deformity,
2. Muscle weakness,
3. Sensory Loss
4. Pain
5. Impaired Motor Control (Spasticity)
6. Leg length discrepancy
145

Sreeraj S R
Types of pathological gait
1. Due to pain – Antalgic or limping gait – (Psoatic Gait)
2. Due to neurological disturbance – Muscular paralysis
a) Spastic (Circumductory Gait, Scissoring Gait, Dragging or Paralytic Gait,
Robotic Gait[Quadriplegic]) and
b) Flaccid (Lurching Gait, Waddaling Gait, Gluteus Maximus Gait, Quadriceps
Gait, Foot Drop or Stapping Gait,)
c) Cerebellar dysfunction (Ataxic Gait)
d) Loss of kinesthetic sensation (Stamping Gait)
e) Basal ganglia dysfunction (Festinating Gait)
146

Sreeraj S R
Types of pathological gait
• Due to abnormal deformities –
a. Equinus gait
b. Equinovarous gait
c. Calcaneal gait
d. Knock & bow knee gait
e. Genu recurvatum gait
• Due to Leg Length Discrepancy (LLD)
a. Equinus gait
147

Sreeraj S R
Antalgic gait
• Position of minimal intraarticular pressure with movement for
• the ankle, the minimal pressure posture is 15° plantar flexion.
• The knee has an arc between 30° and 45° flexion, while
• the hip's position of least pressure is 30° flexion
• Characteristic features:
• Decreased in duration of stance phase of the affected limb (unable of weight
bear due to pain)
• There is a lack of weight shift laterally over the stance limb and to keep
weight off the involved limb
• Decrease in stance phase in affected side will result in a decrease in swing
phase of sound limb.
148

Sreeraj S R
Psoatic gait
• Psoas bursa may be inflamed & edematous, which cause limitation
of movement due to pain & produce a typical gait.
• Hip externally rotated
• Hip adducted
• Knee in slight flexion
• This process seems to relieve tension of the muscle & hence
relieve the inflamed structures.
149

Sreeraj S R
Gluteus maximus gait
• The gluteus maximus act as a restraint for forward progression.
• The trunk quickly shifts posteriorly at heel strike (initial contact).
• This will shift the body’s COG posteriorly over the gluteus
maximus, moving the line of force posterior to the hip joints.
• With foot in contact with floor, this requires less muscle strength to
maintain the hip in extension during stance phase.
• This shifting is referred to as a “Rocking Horse Gait” because of
the extreme backward-forward movement of the trunk.
150

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Gluteus Medius Gait: Unilateral
• It is also known as “Trendelenberg gait” or “Lurching Gait” when one
side affected.
• The individual shifts the trunk over the affected side during
stance phase.
• When right gluteus medius or hip abductor is weak it cause two
thing:
• The body leans over the left leg during stance phase of the left
leg, and
• Right side of the pelvis will drop when the right leg leaves the
ground & begins swing phase.
• Shifting the trunk over the affected side is an attempt to reduce the
amount of strength required of the gluteus medius to stabilize the
pelvis.
151

Sreeraj S R
Gluteus Medius Gait: Bilateral
• waddling or duck gait.
• The patient lurch to both sides while walking.
• The body sways from side to side on a wide base with excessive
shoulder swing.
• E.g., Muscular dystrophy
152

Sreeraj S R
Quadriceps gait
• Quadriceps action is needed during heel strike & foot flat when
there is a flexion movement acting at the knee.
• Quadriceps weakness/ paralysis will lead to buckling of the
knee during gait & thus loss of balance.
• Patient can compensate this if he has normal hip extensor &
plantar flexors.
153

Sreeraj S R
Quadriceps gait
• Compensation:
• With quadriceps weakness, the individual may lean forward over the
quadriceps at the early part of stance phase, as weight is being shifted
on to the stance leg.
• Normally, the line of force falls behind the knee, requiring quadriceps action
to keep the knee from buckling.
• By leaning forward at the hip, the COG is shifted forward & the line of
force now falls in front of the knee.
• This will force the knee backward into extension.
154

Sreeraj S R
Quadriceps gait
• Another compensatory manoeuvre to use is
the hip extensors & ankle plantar flexors in a
closed chain action to pull the knee into
extension at heel strike (initial contact).
• In addition, the person may physically push
on the anterior thigh during stance phase,
holding the knee in extension.
155

Sreeraj S R
Genu Recurvatum Gait
• When hamstrings are weak, 2 things may happen
1. During stance phase, the knee will go into excessive
hyperextension, referred to as “genu recurvatum” gait.
2. During the deceleration (terminal swing) part of swing
phase, without the hamstrings to slow down the swing
forward of the lower leg, the knee will snap into
extension.
156

Sreeraj S R
Hemiplegic Gait
• With spastic pattern of hemiplegic leg
• Hip into extension, adduction & medial rotation
• Knee in extension, though often unstable
• Ankle in drop foot.
• In order to clear the foot from the ground the hip & knee should
flex.
• But the spastic muscles won’t allow the hip & knee to flex for the
floor clearance.
• So, the patient hikes hip & bring the affected leg by making a half
circle i.e., circumduction of the leg.
• Hence the gait is known as “Circumductory Gait”.
• Usually, there will be no reciprocal arm swing.
• Step length tends to be lengthened on the involved side & shortened
on the uninvolved side.
157

Sreeraj S R
Scissoring gait
• It results from spasticity of bilateral adductor muscle
of hip.
• One leg crosses directly over the other with each
step like crossing the blades of a scissor.
• E.g., Cerebral Palsy
158

Sreeraj S R
Dragging or paraplegic gait
• There is spasticity of both hip & knee extensors & ankle
plantar flexors.
• In order to clear the ground, the patient has to drag his both lower
limb, swings them & place it forward.
159

Sreeraj S R
Cerebral Ataxic or Drunkard’s Gait
• Abnormal function of cerebellum result in a disturbance of normal
mechanism controlling balance & therefore patient walks with
wider BOS.
• The wider BOS creates a larger side to side deviation of
COG.
• This result in irregularly swinging sideways to a tendency to fall
with each steps.
• Hence it is known as “Reeling Gait”.
160

Sreeraj S R
Sensory Ataxic Gait
• This is a typical gait pattern seen in patients affected by tabes dorsalis.
• It is a degenerative disease affecting the posterior horn cells & posterior
column of the spinal cord.
• Because of lesion, the proprioceptive impulse won't reach the
cerebellum.
• The patient will loss his joint sense & position for his limb on space.
• Because of loss of joint sense, the patient abnormally raises his leg
(high step), jerks it forward to strike the ground with a stamp.
• So, it is also called as “Stamping Gait”.
• The patient compensated this loss of joint position sense by vision.
• So, his head will be down while he is walking.
161

Sreeraj S R
Short Shuffling or Festinate Gait
• Normal function at basal ganglia are:
• Control of muscle tone
• Planning & programming of normal movements.
• Control of associated movements like reciprocal arm swing.
• Typical example for basal ganglia lesion is parkinsonism.
• Because of rigidity, all the joint will go for a flexion position with spine stooping
forward.
• This posture displaces the COG anteriorly.
• In order to keep the COG within the BOS, the patient will have nunmber of small
shuffling steps.
• Due to loss of voluntary control over the movement, they loses balance & walks
faster as if he is chasing the COG.
• So, it is called as “Festinate Gait”.
• Since his shuffling steps, it is otherwise called as “Shuffling Gait”
162

Sreeraj S R
Foot Drop or Slapping Gait
• This is due to dorsiflexor weakness caused by paralysis of
common peroneal nerve.
• There won't be normal heel strike, instead the foot meets ground
as a whole with a slapping sound.
• So, it is also known as “Slapping gait”.
163

Sreeraj S R
High Stepping Gait
• Due to plantarflexion of the ankle, there will be relatively
lengthening at the leading extremity.
• So, to clear the ground the patient lift the limb too high.
• Hence the gait get s its another name i.e. “High Stepping Gait”
164

Sreeraj S R
Equinus Gait
• Equinus = Horse
• Because of paralysis of dorsiflexor which result in plantar flexor
contracture.
• The patients will walk on his toes (toe walking).
• Other cause may be compensation by plantar flexion for a
short leg.
165

Sreeraj S R
Unequal Leg Length
• Leg length discrepancy (LLD) are divided into;
• Minimal leg length discrepancy
• Moderate leg length discrepancy
• Severe leg length discrepancy
166

Sreeraj S R
Minimal leg length discrepancy
• Compensation occurs by dropping the pelvis on the affected
side.
• The person may compensate by leaning over shorter leg (up to 3
cm can be accommodated with these adoption).
167

Sreeraj S R
Moderate leg length discrepancy
• Approx between 3 & 5 cm, dropping the pelvis on the affected
side will no longer be effective.
• A longer leg is needed, so the person usually walks on the ball of
the foot on the involved (shorter) side.
• This is called an “Equinus Gait”.
168

Sreeraj S R
Severe leg length discrepancy
• It is usually discrepancy of more than 5 cm.
• The person may compensate in a variety of ways.
• Dropping the pelvis and walking in an equinus gait plus flexing the
knee on the uninvolved side is often used.
169

Sreeraj S R
Equinovarus gait
• There will be ankle plantar flexion & subtalar inversion.
• So, the patient will be walking on the outer border of the foot.
• E.g., CETV
170

Sreeraj S R
Calcaneal Gait
• Result from dorsiflexor contracture.
• The patient will be walking on his heel (heel walking)
• It is characterized by greater amounts of ankle dorsiflexion &
knee flexion during stance & a shorter step length on the affected
side.
• Single-limb support duration is shortened because of the
difficulty of stabilizing the tibia & the knee.
171

Sreeraj S R
Knock Knee Gait
• It is also known as genu valgum gait.
• Due to decreased physiological valgus of knee.
• Both the knee face each other widening the BOS.
172

Sreeraj S R
Bow Leg Gait
• It is also known as genu varum gait.
• Knee face outwards.
• Due to increase increased physiological valgus of knee.
• The legs will be in a bowed position.
173

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FUNCTIONAL ANALYSIS
• Barthel's index of activities of daily living (BAI)
• Functional Independence Measure (FIM)
174

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References
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2. Southorn N. The Student’s Companion to Physiotherapy E-Book : a Survival Guide. 1st ed. Churchill Livingstone; 2010.
3. UFO Themes. Thoracic Assessment [Internet]. Musculoskeletal Key. 2019 [cited 2021 Feb 3]. Available from: https://musculoskeletalkey.com/thoracic-assessment/
4. Bickley LS, Szilagyi PG, Hoffman RM. Chapter 6, The Skin, Hair, and Nails. In: Bates’ pocket guide to physical examination and history taking. 12th ed. Philadelphia: Wolters Kluwer;
2017. p. 173–114.
5. Fruth SJ. Chapter 8. Integumentary Examination. In: Fundamentals of the physical therapy examination : patient interview and tests & measures. Burlington, MA: Jones & Bartlett
Learning; 2018. p. 175–208.
6. Evans RC. Illustrated orthopedic physical assessment. 3rd ed. Edinburgh: Mosby; 2008.
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9. Christensen B. Glasgow Coma Scale - Adult: Adult Glasgow Coma Scale [Internet]. Medscape.com. Medscape; 2019 [cited 2021 Feb 11]. Available from: https://tinyurl.com/4obdb37h
10. https://www.facebook.com/verywell. What Does Oriented x1, x2, x3 and x4 Mean in Dementia? [Internet]. Verywell Health. 2019 [cited 2021 Feb 11]. Available from:
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11. Weir CB, Jan A. BMI Classification Percentile And Cut Off Points. [Updated 2020 Jul 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available
from: https://www.ncbi.nlm.nih.gov/books/NBK541070/
12. End-Feel [Internet]. Physiopedia. 2014 [cited 2021 Feb 16]. Available from: https://www.physio-pedia.com/End-Feel
13. Gray H, Williams PL, Warwick R. Gray’s anatomy. 36th ed. Philadelphia: Saunders; 1986.
14. Sabharwal S, Kumar A. Methods for assessing leg length discrepancy. Clin Orthop Relat Res. 2008;466(12):2910-2922. doi:10.1007/s11999-008-0524-9
15. Nakanowatari T, Suzukamo Y, Suga T, Okii A, Fujii G, Izumi S-I. True or Apparent Leg Length Discrepancy. Journal of Geriatric Physical Therapy [Internet]. 2013 Oct [cited 2021 Feb
26];36(4):169–74. Available from: https://tinyurl.com/4kf6ya4f
16. Curvature of the Back - Visual Diagnosis and Treatment in Pediatrics, 3 Ed. [Internet]. Doctorlib.info. 2011 [cited 2021 Mar 1]. Available from: https://doctorlib.info/pediatric/visual-
diagnosis-treatment-pediatrics/37.html
17. Ratan Khuman. Gait normal & abnormal [Internet]. Slideshare.net. 2012 [cited 2021 Apr 20]. Available from: https://www.slideshare.net/prkhuman/gait-normal-abnormal
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