Physiotherapy

1. ORTHOPEDIC PHYSICAL ASSESSMENT
BY DR/ KHALED ALSAYANI

2. Total Musculoskeletal
Assessment
 • Patient history
 • Observation
 • Examination of movement
 • Special tests
 • Reflexes and cutaneous distribution
 • Joint play movements
 • Palpation
 • Diagnostic imaging.

3. PATIENT HISTORY
 A complete medical and injury history should be
taken and written to ensure reliability
 Often the examiner can make the diagnosis by
simply listening to the patient

4.  In any musculoskeletal assessment, the examiner
should seek answers to the following pertinent
questions;
 1. What is the patient’s age and sex?
 2. What is the patient’s occupation? What does the
patient do at work? What is the working environment
like? What are the demands and postures assumed?
 3. Why has the patient come for help?
(history of the present illness or chief complaint)

5.  4. Was there any inciting trauma (macrotrauma) or
repetitive activity (microtrauma)? In other words,
what was the mechanism of injury, and were there
any predisposing factors?
 5. Was the onset of the problem slow or sudden? Did
the condition start as an insidious, mild ache and
then progress to continuous pain, or was there a
specific episode in which the body part was injured?
 6. Where are the symptoms that bother the patient?

6.  7. Where was the pain or other symptoms when the patient first
had the complaint?
 Has the pain moved or spread?
 8. What are the exact movements or activities that cause pain?
 9. How long has the problem existed? What are the duration
and frequency of the symptoms?
 10. Has the condition occurred before? If so, what was the
onset like the first time? Where was the site of the original
condition, and has there been any radiation (spread) of the
symptoms?

7.  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?
 14. Is the pain associated with rest? Activity? Certain
postures? Visceral function? Time of day?
 15. What type or quality of pain is exhibited?

9.  16. What types of sensations does the patient feel, and
where are these abnormal sensations?
 17. Does a joint exhibit locking, unlocking, twinges, 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?

10.  21. Does the patient have any chronic or serious systemic illnesses or
adverse social habits (e.g., smoking, drinking) that may influence the
course of the pathology or the treatment?
 22. Is there anything in the family or developmental history that may
be related, such as tumors, arthritis, heart disease, diabetes,
allergies, and congenital anomalies?
 23. Has the patient undergone an x-ray examination or other
imaging techniques?
 24. Has the patient been receiving analgesic, steroid, or any other
medication? If so, for how long?
 25. Does the patient have a history of surgery or past/present illness?

11. OBSERVATION
 In an assessment, observation is the “looking” or
inspection phase.
 Its purpose is to gain information on visible
defects, functional deficits, and abnormalities of
alignment.

12.  1. What is the normal body alignment?
 2. Is there any obvious deformity?
 3. Are the bony contours of the body normal and
symmetric, or is there an obvious deviation?
 4. Are the soft-tissue contours (e.g., muscle, skin, fat)
normal and symmetric? Is there any obvious muscle
wasting
 5. Are the limb positions equal and symmetric?

13. 6. Because pelvic position plays such an important role in correct
posture of the whole body, the examiner should determine if the
patient can position the pelvis in the “neutral pelvis” position
7. Are the color and texture of the skin normal?
8. Are there any scars that indicate recent injury or surgery?
9. Is there any crepitus, snapping, or abnormal sound in the joints
when the patient moves them?
10. Is there any heat, swelling, or redness in the area being
observed?

14. 11. What attitude does the patient appear to have
toward the condition or toward the examiner?
12. What is the patient’s facial expression?
13. Is the patient willing to move? Are patterns of
movement normal? If not, how are they abnormal?

15. EXAMINATION
Vital Signs

17. Scanning Examination
 hroughout the assessment, the examiner looks for
two sets of data:
 (1) what the patient feels (subjective) and
 (2) responses that can be measured or are found
by the examiner (objective).

18. When to Use the Scanning Examination
• There is no history of trauma
• There are radicular signs
• There is trauma with radicular signs
• There is altered sensation in the limb
• There are spinal cord (“long track”) signs
• The patient presents with abnormal patterns
• There is suspected psychogenic pain

19. C2 – neck flexion
C3 – neck extension
C4 – neck side flexion (left and right)
C5 – shoulder abduction
C6 – elbow flexion or forearm supination
C7 – elbow extension or wrist flexion
C8 – thumb extension or adduction and ulna deviation
T1 – finger abduction/adduction
L2 – hip flexion or adduction
L3 – knee extension
L4 – dorsi flexion at the ankle
L5 – big toe extension or ankle eversion
S1 – plantar flexion of the ankle or knee flexion.

21. Examination of Specific
Joints
 Active Movements
Examiner Observations During Active Movement
• When and where during each of the movements the onset
of pain occurs
• Whether the movement increases the intensity and quality
of the pain
• The reaction of the patient to pain
• The amount of observable restriction and its nature
• The pattern of movement
• The rhythm and quality of movement
• The movement of associated joints
• The willingness of the patient to move the part

22.  Passive Movements
Examiner Observations During Passive Movement
• When and where during each of the movements
the pain begins
• Whether the movement increases the intensity and
quality of pain
• The pattern of limitation of movement
• The end feel of movement
• The movement of associated joints
• The range of motion available

24.  muscle strength

25. Signs and Symptoms of Myopathy (Muscle
Disease)
• Difficulty lifting
• Difficulty walking
• Myotonia (inability of muscle to relax)
• Cramps
• Pain (myalgia)
• Progressive weakness
• Myoglobinuria

26. Causes of Muscle Weakness
• Muscle strain
• Pain/reflex inhibition
• Peripheral nerve injury
• Nerve root lesion (myotome)
• Upper motor neuron lesion (even when muscle
shows increased tone)
• Tendon pathology
• Avulsion
• Psychological overlay

27. Special Test
 Special Test Considerations
Any special test, regardless of its classification, can
be positively or negatively affected by the:
• Patient’s ability to relax
• Presence of pain and the patient’s perception of
the pain
• Presence of patient apprehension
• Skill of the clinician
• Ability and confidence of the clinician

28. Special Test Uses
• To confirm a tentative diagnosis
• To make a differential diagnosis
• To differentiate between structures
• To understand unusual signs
• To unravel difficult signs and symptoms

29. Reflexes

32. Joint Play Movements
Mennell’s Rules for Joint Play Testing
• The patient should be relaxed and fully supported
• The examiner should be relaxed and should use a firm
but comfortable grasp
• One joint should be examined at a time
• One movement should be examined at a time
• The unaffected side should be tested first
• One articular surface is stabilized, while the other
surface is moved
• Movements must be normal and not forced
• Movements should not cause undue discomfort

33. Palpation
Examiner Observations When Palpating a Patient
• Differences in tissue tension and texture
• Differences in tissue thickness
• Abnormalities
• Tenderness
• Temperature variation
• Pulses, tremors, and fasciculations
• Pathological state of tissues
• Dryness or excessive moisture
• Abnormal sensation

34. Swelling
• Comes on soon after injury → blood
• Comes on after 8 to 24 hours → synovial
• Boggy, spongy feeling → synovial
• Harder, tense feeling with warmth → blood
• Tough, dry → callus
• Leathery thickening → chronic
• Soft, fluctuating → acute
• Hard → bone
• Thick, slow-moving → pitting edema

35. Grading Tenderness When Palpating
• Grade I—Patient complains of pain
• Grade II—Patient complains of pain and winces
• Grade III—Patient winces and withdraws the joint
• Grade IV—Patient will not allow palpation of the
joint

36. Diagnostic Imaging
Reasons for Ordering Diagnostic Imaging
• To confirm a diagnosis
• To establish a diagnosis
• To determine the severity of injury
• To determine the progression of a disease
• To determine the stage of healing
• To enhance patient treatment
• To determine anatomical alignment

37. Uses of Plain Film Radiography
• Fractures
• Arthritis
• Bone tumors
• Skeletal dysplasia

38. Examiner Observations When Viewing an X-Ray Film
• Overall size and shape of bone
• Local size and shape of bone
• Number of bones
• Alignment of bones
• Thickness of the cortex
• Trabecular pattern of the bone
• General density of the entire bone
• Local density change

39. Margins of local lesions
• Any break in continuity of the bone
• Any periosteal change
• Any soft-tissue change (e.g., gross swelling,
periosteal elevation, visibility of fat pads)
• Relation among bones
• Thickness of the cartilage (cartilage space within
joints)
• Width and symmetry of joint space
• Contour and density of subchondral bone

40. Computed Tomography
Uses of Computed Tomography Scans
• Complex fractures
• Comminuted fractures
• Intra-articular fragments
• Fracture healing (e.g., non-union)
• Bone tumors

41. Radionuclide Scanning
(Scintigraphy
Uses of Scintigraphy
• Skeletal metastases
• Stress fractures
• Osteomyelitis

42. Discography
 The technique of
discography involves
injecting a small amount
of radiopaque dye into
the nucleus pulposus of
an intervertebral disc

43. Magnetic Resonance
Imaging
Uses of Magnetic Resonance
Imaging
• Intra-articular structures (e.g.,
meniscus, loose bodies)
• Musculotendinous injury
• Joint instability
• Osteomyelitis
• Fractures
• Stress injury
• Disc disease
• Soft tissue tumors
• Skeletal malformations
• Bone bruises

44. Diagnostic Ultrasound
Uses of Ultrasonography
• Hip dysplasia in children
• Joint effusion
• Tendon pathology
• Ligament tears
• Soft tissue tumors
• Vascular disease