Musculoskeletal examination

Musculoskeletal Examination
Advances and Related Evidence
Soundararajan K
11/14/2019 K. Soundararajan, MPT, SRIHER 1

Contents of Topic
1. Screening
2. Mobility testing
3. Muscle performance
4. Concepts based evaluation

Introduction
• Examination is systematic process by which a
therapist obtains information about a patient’s
problem(s) ultimately to formulate a Somatic
diagnosis and determine whether these problems
can be appropriately treated by PT interventions.
• If treatment of identified problems does not fall
within the scope of PT practice then referral

Evaluations must be sufficiently
comprehensive to provide information
necessary to make or verify a treating
diagnosis, identify patient/client goals,
develop a plan of care, and guide treatment
and re-evaluations as needed. (APTA,2014)

Therapeutic Exercise
Foundations And Techniques
F I F T H E D I T I O N
Carolyn Kisner

Pain
“An unpleasant sensory and emotional
experience associated with actual or
potential tissue damage, or described in
terms of tissue damage, or both."
International Association for the Study of Pain (IASP)

Risk factors that may alter pain and
pain perception
• Biomedical
• Psychosocial or Behavioural
• Social and Economical
• Professional/ Work-related
(Woolf CJ, 2006)

VISERAL PAIN
Noxious stimulation within an organ
Inflammatory in origin
Viscera is insensitive to mechanical stimuli
E.g.- Pathology in heart
Stomach lesion
Renal calculi

MUSCULOSKELETAL PAIN
1.Nociceptive
2.Peripheral neuropathic
3.Central pain
(Lidbeck, 2002; Smart et al., 2008,2010)

Central sensitisation pain has been
operationally defined as an amplification of
neural signalling within CNS that elicits pain
hypersensitivity
(Woolf, 2011)

Multisegmental reference of pain

Psychosocial factors
• Unrecognizable signs & symptoms
• Poor cooperation
• Over enthusiasm
• Contradictory signs
• Seek answer expected of them

Screening examination designed to
• Narrow source(s) of symptoms to a specific
body region ( tissue at fault).
• Identify red flags , along with the history
findings, suggest PT initiate a patient
referral/consultation.
• Identify primary contributing impairments
related to patient’s symptoms, functional
limitations, and disability.

• Determine which body regions or body
systems require amore detailed examination
during the initial or subsequent visits.
• Improve rehabilitation outcomes by avoiding
inaccurate diagnoses or by the timely referral
to other practitioners.
• Provide guidance, along with history findings,
regarding specific interventions that may help
or contraindicated

PRE MANIPULATIVE
SCREENING

Red flags(Moore et al 2005):
Contraindications to OMT interventions:
• Multi-level nerve root pathology
• Worsening neurological function
• Unremitting, severe, non-mechanical pain
• Unremitting night pain (preventing patient from
falling asleep)
• Relevant recent trauma
• Upper motor neuron lesions
• Spinal cord damage

Precautions to OMT interventions
• Local infection , Inflammatory disease
• Active cancer /History of cancer
• Long-term steroid use / Osteoporosis
• Systemically unwell ,Hypermobility syndromes
• Connective tissue disease
• A first sudden episode before age 18 or after age 55
• Cervical anomalies
• Throat infections in children
• Recent manipulation by another health professional

Serious conditions which may mimic
musculoskeletal dysfunction in the
early stages
• CAD (e.g. vertebrobasilar insufficiency due to
dissection) (Kerry et al, 2008)
• Upper cervical instability (Niere and Torney,
2004), that could compromise the vascular
and neurological structures.

Physical examination
• Blood pressure
• Cranio vertebral ligament testing
• Neurological examination
• Positional testing (Provocative positional
testing )
• Palpation of the carotid artery
CHECK FOR : VASCULAR OR NEUROLOGICAL

NEUROLOGICAL TESTING
•Reflexes
•Dermatomes
•Myotomes
•Cranial / peripheral nerve assessment
•Pathological reflexes

Observation
• General
• Specific
• Palpation
-osseous
-myofascial
- muscular
- functional

Gait Analysis

• Subjective
Our observation of gait is a subjective
measure that we can use. We might ask the
individual to walk normally, on insides and
outsides of feet, in a straight line, running. All
the time looking to compare sides and
understanding of "normal".

Objective
Quantitative method
• Video Analysis and Treadmill
• Electronic and Computerized Apparatus
• Electronic Pedometers
• Satellite Positioning System

Qualitative methods
• Rancho Los Amigos Hospital Rating List
• Ten Meter Walking Test
• 6 Minute Walk Test
• 2 Minute Walk Test
• Dynamic Gait Index
• Emory Functional Ambulation Profile
• Timed Up and Go Test This test is statistically
associated with falling in men, but not in women.
• Functional Ambulation Categories
• Tinetti-Test

Specific observation

Osseous palpation

Myofascial Evaluation
Static posture
 Leg length
 Pelvic symmetry
 Sacral positioning
Dynamic Posture
 C/s Rom
 B Shoulder Abd
 Trunk Mobility
 LE ROM
 Hip ext
 Knee Flx

Myofascial Evaluation
• Palpation
– Superior – inferior glides
– Medial – lateral glides
– Clockwise –Counter-clockwise glides
– Joints: Compression - distraction

Functional Palpating Brachialis

Functional Palpating Brachioradialis

Joint mobility Testing
• Joint integrity and mobility represent the
structure and function of the joint and are
classified in biomechanical terms as
arthrokinematic motion.
• Joint mobility is the capacity of the joint to be
moved passively, evaluating the structure and
integrity of the joint surface in addition to
periarticular soft tissue characteristics.

• The physical therapist uses tests and measures to
assess accessory joint movements (movements
not under voluntary control), including the
existence of either excessive motion
(hypermobility) or limited motion (hypomobility).
• Responses monitored at rest, during activity, and
after activity may indicate the presence or
severity of an impairment, activity limitation, or
participation restriction.

Joint Play
- movement not under voluntary control (passive)
- can not be achieved by active muscular
contraction
versus
Component Movement
- involuntary obligatory joint motion occurring
outside the joint accompanies active motion
– i.e. - scapulohumeral rhythm

• Joint Positions and Congruence
• Resting Position
• Closed Pack Position
• Capsular pattern

TISSUES
INERT
•Tested through passive movements
•Capsule,ligaments,menisci,bursa,fascia,duramater
& Dural nerve root sleeve, tendon at rest
•Creates passive tension
CONTRACTILE
•Tested through active with resistance
•Muscle, Musculo-tendinous Junction, tendon,
teno-osseous

PATTERNS OF LESION-INERT TISSUE
•Pain free full ROM
•Pain & limited ROM in every direction
•Pain & excessive/limited ROM in some
direction
•Pain free limited ROM

RESISTED ISOMETRIC TESTING
1. Whether the contraction causes pain and, if
it does, the pain's intensity and quality
2. Strength of the contraction
3. Type of contraction causing problem
(concentric, isometric,eccentric, econcentric)

MUSCLE STRENGTH / POWER TESTING

MUSCLE ENDURANCE TESTING

• McGill core endurance test
• Plank hold test
• Static squad test
• Maximal push test

McGill core endurance test
1.Trunk flexor test (TFT)

2.Trunk extensor test (TET)

3. Lateral musculature test and right lateral
musculature test

Static squad test

Maximal push test

Pressure feedback

TESTS FOR MUSCLE LENGTH

RELIABILITY OF MUSCLE LENGTH
TESTING
• No research exists as to the reliability of
measurements of muscle length of upper
extremity.
• Such research would be quite valuable for the
clinician attempting to provide an upper
extremity flexibility examination.

TESTS FOR MUSCLE LENGTH:
HAMSTRINGS
Sit and Reach Test

• Wang et al.3 6 reported intratester reliability of
measurements of the length of the
gastrocnemius muscle (measured supine) and of
the soleus muscle (measured prone) in 10
subjects.
• Results indicated a reliability correlation (ICC) for
gastrocnemius muscle length of .98 for both the
dominant and non-dominant limb;
• the soleus reliability correlations (ICC) were .93
for the dominant limb and .94 for the non-
dominant limb.

Special test

Outcome measures

FUNCTIONAL ASSESSMENT

PHYSICAL DIAGNOSIS
• Clinical grouping-SIN,Momentary or End range
• Source of problem-joint,inert,contractile &
nervous tissue

Various Concept
Based Examination
Introduction

The Cyriax Approach

Examination
• Subjective
• Objective
Inspection: deformity, colour, wasting,
swelling
Palpation: heat, swelling, synovial thickening – not
tenderness

• Condition at rest
• Active movements
–Test for inert and contractile tissue
–Check for: pain, power, range, painful arc, willingness
• Passive movements
–Test inert tissue
–Check for: pain, range, end feel, crepitus, capsular pattern

• Resisted Movements
– Test contractile tissue
– Check for: pain and power
• Neurological tests
• Palpation
– To localise exact site of lesion
• Objective tests
– Blood, X-ray, EMG, scan

Mobilisations
• Grade A – passive movements within painfree
range
• Grade B - passive movements to end of joint
range
• Grade C - passive movements to end of joint
range & overpressure of minimal amplitude

COMBINED MOVEMENTS

LUMBAR SPINE
• Physical test and observations
Gait

Patient category
• Acute
• Sub acute
• Chronic

References

Thank you

Musculoskeletal examination

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