ORTHOPEDIC ASSESSMENT

To complete a musculoskeletal assessment of a patient, a proper and

thorough systematic examination of the patient and the condition is required.

A correct diagnosis depends on a knowledge of functional anatomy, an

accurate patient history, diligent observation and a thorough examination.

The differential diagnosis process involves the use of clinical signs and
symptoms, physical examination, knowledge of pathology and the mechanics
of the injury, provocative and palpation tests and laboratory and diagnostic
imaging techniques.

One of the more common assessment recording methods used in the

problem oriented medical records method (POMR) is the use of the “SOAP”
module or technique.

SOAP stands for the four parts of the assessment.

- Subjective
- Objective
- Assessment
- Problem
Regardless of which system is selected for the assessment, the examiner or
the therapist performing the assessment should establish a sequential
method to ensure that nothing is overloaded.

The assessment must be organized, comprehensive and reproducible.

In general, the examiner or the therapist compares one side of the body,
which is assumed to be normal, with the other side of the body which is
abnormal or injured.

Need of Assessment:

 To determine the patients problems and to establish a treatment plan

 Subjective and Objective assessments are used o judge the efficacy of
the physiotherapy.
 To determine the lasting effect of the treatment or the effects that the
other activity may have had on the patients signs and symptoms.

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 Types of Assessment:

1. Subjective Assessment.
2. Objective Assessment.

SUBJECTIVE ASSESSMENT:

Name:

To know the identity of the patient.

Age:

The age of the patient plays a vital part in the assessment.

Many conditions occur within certain age ranges.

Ex. Various growth disorders such as Less-Perthes Disease or Schewrmanns

Disease are seen in adolescents or teenagers.

Degenerative diseases such as osteoporosis and osteoarthritis are more likely

to be seen in older people.

Sex:

Some conditions may be sex related – certain conditions are more commonly
found in females than in males.

Occupation:

Occupation related conditions are very common. The patients occupation

could play an important role in the assessment of the condition.

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Ex. A laborer probably has stronger muscles than a sedentary worker and
may be less likely to suffer a muscle strain.

However laborers are more susceptible to injury because of the types of jobs
they have. Habitual postures and repetitive strain caused by some
occupations may indicate the location or the source of the problem.

Marital Status:

The marital status of the individual is noted.

Socio Economic Status:

It helps to know the economic status of the patient and how far he can afford
the treatment.

Chief Complaints:

The patient is asked to describe in their own words as to what is bothering

then and the extent to which it bothers them.

This is important from a functional aspect and can help the examiner to
determine whether the patients expectations from the forthcoming treatment
are realistic.

History

Present Medical History:

The examiner should ask the mechanism of the injury and were there any
predisposing factors.

When asking questions about the mechanism of the injury, the examiner
must try to determine the direction and magnitude of the injury causing force
and how the force was applied.

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By carefully listening to the patient, the examiner can often determine the
structures which were injured and how severely were they injured by
knowing the force and mechanism of the injury.

The examiner should determine whether there were any predisposing,

unusual or new factors such as sustained postures or repetitive activities,
general health or familial or genetic problems that may have lead to the
problem.

Past Medical History:

The patient is asked if a similar condition has occurred before. If so he is

asked what was the onset like the first time. The site of the original condition
and any similar symptoms should be noted.

The following questions can be put forth to the patient:

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 similar
symptoms?

Did any treatment relieve the symptoms?

Does the current problem appear to be the same as the previous problem or
is it different?

Answer to these questions helps the examiner determine the location and
severity of the problem.

Family History:

The examiner should ask if anybody in the family has the same or similar
problems. This plays an important role as some conditions or diseases may
be hereditary.

Personal History:

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The examiner should ask if the patient has had any previous injuries or any
medical conditions. These may help the examiner come to a diagnosis or a
conclusion.

Surgical History:

The examiner should ask the patient if he has had any surgery before.

If yes, the following questions should be asked to the patient:

Where was the surgery performed?

What was the condition?

Sometimes, the conditions that the therapist treats are a result of surgery.

Associated Problems:

The examiner should find out if the patient is suffering from any other
disease.

Does the patient have any chronic or serious systemic illness that may
influence the course of the pathology or the treatment?

Pain History / Assessment:

- Intensity
- Duration
- Frequency
The patient should be asked if the Intensity, Duration and Frequency of the
pain are increasing.

These changes usually mean that the condition is getting worse. A decrease
in pain or other symptoms usually means that the condition is improving.

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Is the pain static? If so, how long has it been that way?

This question may help the examiner or the therapist to determine the
present status of the problem.

These factors may become important in treatment and may help to

determine whether a treatment is beneficial or not.

Pain or other symptoms are associated with other physiological functions.

Ex. Is the pain worse with menstruation? If so, when did the patient last
have a medical examination?

Questions such as these may give the examiner an indication of what is

causing the problem or what factors may affect the problem.

The patient is often provided with pain questionnaires like the McGill Pain
Questionnaire etc.

Onset:

a) Insidious Onset:
Insidious onset means that the patient’s symptoms appear without any
obvious cause.

Ex. Degenerative conditions such as Osteoarthritis. This type of conditions

often begins with a small amount of stiffness and pain.

b) Traumatic Onset:
Can the onset of symptoms be related to a particular injury?

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Ex. A valgus stretch of the knee may stretch the medial collateral ligament of
the knee.

Duration of the symptom:

Establish whether the pain and the symptoms are intermittent or constant. Is
the pain present all the time or does it come and goes depending on
activities or time of day?

Area of the symptoms:

It’s useful to record the area of the pain by using a body chart, because this
affords a quick visual reference.

Type of Pain:

Structures that cause pain:

a) Bone – deep, boring, localized, intolerable on weight bearing.

b) Nerve – sharp, bright, burning along with the course of the nerve
distribution.
c) Nerve Root – tightening sharp, radiating, pin and needle sensation
along the dermatomal pattern
d) Muscle – dull aching, deep, aggravated by particular muscle activity.
e) Inner Tissue – deep and dull and produces pain when tissue stretched.
f) Visceral – chronic, aching, referred.
g) Blood Vessel – diffused, aching, throbbing, pulsating pain.

Seasonal Pain:

Sometimes pain varies in different seasons.

a) Morning Pain – inflammatory conditions like OA, RA, Plantar Facialtis

b) Evening Pain – postural causes

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Aggravating and Relieving Factors:

Positional Factors: Most musculoskeletal pain is mechanical in origin and is

therefore made better or worse by adopting particular positions or postures
that either stretch or compress the structure that are giving rise to the pain.

Moreover aggravating and relieving factors/movements may provide the

physiotherapist with a clue as to the structure that is causing the pain.

Relationship of Symptom over Time:

It is useful to record the behavior of signs and symptoms over a 24hr period
or the diurnal pattern.

Do the symptoms keep the patient awake or awaken the patient regularly
during the night and at characteristic times of the day.

Ex. Chronic Osteoarthritis changes are characteristically painful and stiff

initially on arising from sleep.

Severity of the symptom:

The severity of the pain may be measured on a visual analogue scale or on a

numerical scale of 0-10 to quantify the pain, where 0 stands for no pain at all
and 10 is perceived by the patient as the worst pain imaginable.

Determining SIN Factors:

The SIN Factors are:

Severity

Irritability

Nature

Severity:

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 This can be quantified by the visual analogue scale or other valid pain
questionnaire. It can be recorded as high (Pain score of around 9-10)
Moderate (score around 4-6) or low (score around 1-3)

Irritability:

This is the time that the person has to perform the activity to increase the
pain and conversely how long it takes before the pain settles to its former
intensity.

It can be measured as high, moderate or low.

High – The aggravating factor causes the pain to increase very quickly and
then the pain takes long time to settle back.

Moderate – The aggravating factor takes longer to increase the symptom.

Low – The aggravating factor can be performed for a longer time before
exacerbating the patient’s symptom and then on stopping the activity the
symptoms subside rapidly.

Nature:

It is possible to hypothesize the nature of the condition following the

subjective history that whether the patient’s condition has a predominantly
inflammatory, traumatic, degenerative or mechanical cause.

Visual Analogue Scale:

The Visual Analogue Scale (VAS) is the most commonly used scale.

Here the patient is asked to rate the pain within 0 – 10.

0 – No Pain

5 – Moderate Pain

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10 – Severe Pain

0|___________5___________|10

The following questions have to be answered by the patient:

Is the pain constant, periodic, episodic or occasional?

Constant pain is suggestive of chemical irritation, tumors or possibly visceral

lesions.

Is the pain periodic or occasional?

The examiner should try to determine the activity, position, posture that
irritates or brings on the symptoms as this may help determine what tissues
are at fault.

This type of pain is more likely to be mechanical and related to movement

and stress.

Is the pain associated with rest, certain activity or certain postures or

visceral functions?

At what time does the pain occur?

Pain that decreases with rest usually indicates mechanical problems

interfering with movements such as adhesive capsulitis.

Morning pain with stiffness that improves with activity usually indicates
chronic inflammation and oedema.

Pain or aching as the day progresses usually indicates increased congestion

in a joint.

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Pain at rest and pain that is worse at the beginning of activity that at the end
implies acute inflammation.

Pain that is not affected by rest or activity usually indicates bone pain or
could be related to organic or systemic disorders such as the disease of the
viscera.

Chronic pain is often associated with multiple factors such as fatigue or

certain postures or activities.

What type or quality of pain is exhibited?

Here pain tends to be sharp, bright and burning and also tends to run in the
distribution of specific nerves.

Bone pain tends to be deep, boring and localized.

Vascular pain tends to be diffuse acting and poorly localized and may be
referred to other areas of the body.

Muscle pain is usually not localized and causes dull aching, aggravated and
may be referred to other areas.

Vital Signs:

The vital signs are:

- Temperature
- Blood Pressure
- Pulse Rate
- Respiratory Rate
The examiner should check all the vital signs because a patient with high
temperature is contraindicated for certain modalities of therapy. Also
hypertension patients should not be given heavy exercises.

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OBJECTIVE ASSESSMENT / OBSERVATIONS:

LEVEL OF CONCIOUSNESS (LOC):

The examiner must grade the patient according to the status during
examination.

There are six stages of LOC:

1) Confusion + Disorientation:
The patient is fully conscious. He is alert and co-operative. He is
incorrect to line / place / person.

2) Katatonic:
The patient is fully normal but is either mute / immobile /
unresponsive.

3) Delirium:
The patient is in a state of confusion and disorientation. He is out of
the surrounding but gives a spontaneous response.

4) Drowsiness:

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 The patient is half conscious and responds only to some stimuli by
moving.

5) Stupor:
The patient is completely unconscious and responds only to painful or
vigorous stimuli.

6) Comatose:
The patient is unconscious and has no response to any stimuli.

Body Alignments:

Anteriorly the nose, xiphisternum and the umbilicus should be in a straight

line.

From the side of the tip of the ear, the tip of the acromion, the high point of
the iliac crest and the lateral malleolus should be in a straight line.

Built:

The built of the patient is taken into consideration.

There are three types of body builts:

a) Ectomorphic
b) Mesomorphic
c) Endomorphic

Posture:

Observe any asymmetry of posture in standing, walking and sitting. Poor

posture is frequently a precursor to muscle imbalance, selective tightness
and weakness through over or underuse of specific muscles. Correction may
prevent recurrence or acceleration of specific pathologies.

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Deformities:

Deformities may take the form of restricted ROM (ex. Flexion deformities) or
malalignment (ex. Genu Varum). Alteration in the shape of a bone (ex.
Fracture) or alteration in the relationship of two articulating structures (ex.
Subluxation or dislocation).

Structured deformities are present even at rest.

Ex. Torticolis, Scoliosis and Kyphosis.

Fuctional deformities are the result of obtained postures and disappear when
postures are changed.

Ex. Scoliosis, due to a short leg when standing in an upright posture

disappears on forward flexion.

Dynamic deformities are caused by muscle acion and are present when
muscles contract or joints move.

Abnormal Bony / Soft Tissue Contours:

The body is not perfectly symmetric and deviation may have no clinical
implications.

Ex. Many people have a lowered shoulder on the dominant slide.

Scoliosis of the spine that is adjacent to the heart.

While checking for soft tissue contours, the following questions may be
answered:

Is there any obvious muscle wasting?

Is there any muscle spasm present?

Scar Formation:

Recent scars are red because they are still healing and older scars are white
and primarily a vascular.

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Skin Changes:

The examiner must see if there are any changes in the appearance of the
skin in the area of the pain.

Bruising indicates bleeding under the skin from injury to tissue.

Tropical changes in the skin, resulting from peripheral nervous lesions

include the loss of skin elasticity, shiny skin, hair loss on the skin and skin
that breaks down easily and heals slowly.

Increased redness indicates increased blood flow or inflammation.

Swelling:

Heat, swelling or redness in the area of the pain indicates inflammation or an

active inflammatory condition.

Crepitus:

Sounds by themselves, do not necessarily indicate pathology.

Sounds on movement are of immense significance.

Crepitus may vary from a loud grinding noise to a squinting noise.

Shaping especially if not painful may be caused by a tendon moving over a

bony protuberance.

Palpation:

Palpate for the following:

Tenderness

Heat (use the back of your hand which is more sensitive to heat changes)

Swelling

- Comes on soon after injury = blood

- Comes on after 8 to 24 hours = synovial
- Boggy, spongy feeling = synovial
- Hard = bone

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 - Tough, dry = callus
- Thick, slow moving = pitting oedema
Muscle Spasm

EXAMINATION:

Range Of Motion (ROM):

The range of movement is to be taken, both active and passive range of

motion is noted down for the patient.

1. ACTIVE (Physiological)
2. PASSIVE (Physiological & Accessory)

Movement may be broadly classified as:

Hypomobile – Normal – Hypermobile

ACTIVE ROM

- Physiological Movements
Ex. flexion, extension, abduction, adduction, internal and
external rotation, ankle dorsiflexion and plantarflexion, inversion
and eversion

- Compare with opposite limb

- Measured from 0 deg – anatomical position
- Active - measured first before passive
- The degree to which a joint can be moved by muscle contraction
- Active movement limited by – joint pain, joint stiffness, pain
from nearby fracture site and soft tissues, weakness from
associated muscles, swelling, apprehension
- Note: quality of movement, crepitus, painful range, looseness or
excessive range

PASSIVE ROM

- Physiological Movements

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 Ex. flexion, extension, abduction, adduction, internal and external
rotation

- Normal “End Feel” of joint movement may be:

Hard (bone to bone)

Springy (capsule/ligaments)

End Feel:

During active movement, the ROM is full.

Over pressure may be carefully applied to determine the full range of the
joint.

During passive movements the end feel is noted. Different joints and
different pathologies have different end feel. The quality of the resistance felt
at the end of range has been categorized by Cyriax (1982)

Ex. Bony block to movement or a hard feel is characteristic of arthritic

joints.

Capsular feel shows a hard arrest of movement.

An empty feel or no resistance offered at the end of range may be due to

severe pain associated with infection, active inflammation or a tumor.

Accessory Movements:

Ex. translatory gliding (anterior/posterior and medial/lateral),

traction/distraction (caudad/cephalocaudad)

Roll and Glide Principle

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Muscle Strength:

The muscle strength is determined by manual muscle testing (MMT).

The muscle grading is then done according to the tests.

- Ability to generate force against some resistance

- Isometric muscle tests – isolate tensile tissue
- Muscle grading chart – tests through range

Muscle Grade Description

5 – Normal Complete ROM against gravity with full resistance
4 – Good Complete ROM against gravity with some resistance
3 – Fair Complete ROM against gravity
2 – Poor Complete ROM with gravity eliminated
1 – Trace/Flicker Slight contraction, but no joint motion
0 – Nil No evidence of contraction

Isometrics:

Resisted isometric movements are the movements tested last in the

examination of the joint.

It is primarily done to determine whether the contractile tissue is the tissue

fault, although the nerve supplying the muscle is also tested.

Reflexes:

To check the state of the nerve and the nerve roots, deep tendon reflexes
are checked.

If the neurological system is thought to be normal then there is no need to

test for the reflexes.

Deep Tendon Reflexes are performed to test the integrity and the spinal
reflexes.

Reflex Elicitation Positive Response Pathology

Babinski’s Stroking of lateral Extension of the Pyramidal
aspect of the sole of great toe and the Tract Lesion
the foot small toe
Chaddock’s Stroking of lateral side Same response as Pyramidal

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 of the foot beneath above Tract Lesion
the lateral malleolus
Oppenhan’s Stroking of anterior Same response as Pyramidal
medial tibial surface above Tract Lesion
Bordon’s Squeezing of calf Same response as Pyramidal
muscles firmly above Tract Lesion
Rossolimos’s Tapping of plantar Plantar flexion of toes Pyramidal
surface of the toes Tract Lesion
Brudginshia’ Passive flexion of one Similar movement Meningitis
s limb occurs in the opposite
limb
Hoffman’s Flicking of terminal Flexion of distal Pyramidal
phalanx of index and phalanx of thumb and Tract Lesion
middle finger distal phalanx of
index

Common Deep Tendon Reflexes:

Reflex Site of Stimulus Normal Response CNS

Jaw Mandible Mouth Closes Cranial
Biceps Biceps Tendon Biceps Contraction C5-C6
Brachioradialis Brachioradialis Tendon Flexion of Elbow or C5-C6
Pronation of Forearm
Triceps Distal Triceps Tendon Elbow Extension C7-C8
Patella Patellar Tendon Leg Extension L3-L4
Medial Semimembranous Knee Flexion L5-S1
Hamstring Tendon
Lateral Biceps Femoris Tendon Knee Flexion S1-S2
Hamstring
Tibialis Tibialis Tendon near Plantar Flexion with L4-L5
Posterior Medial Malleolus Eversion
Achilles Achilles Tendon Plantar Flexion of Foot S1-S2

Superficial Reflexes:

Reflex Normal Response CNS

Segment

Upper Umbilicus up and towards the area being T7-T9

abdominal stroked
Lower Umbilicus moves down and towards area T11-T12
abdominal being stroked
Cremastric Scrotum elevates T12-L1

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 Plantar Flexion of toes S1-S2
Gluteal Skin tense in gluteal area L4,L5,S1,S2
Anal Contraction of anal sphincter muscle S2-S3

Muscle Tone:

The muscle tone is checked by performing passive movements.

There are three types of hypertonicity:

Lead Pipe: Resistance through-out the movement

Cog Wheel: Catch and Release phenomena. Intermittent resistance through-

out the movement.

Clasp Knife: Resistance at the beginning of movement but no resistance

through-out the movement.

Sensation:

Sensation tests are performed to check the intactness of the nerve and the
nerve roots of the parts.

There are three types of sensation:

b) Superficial Senses
- Touch
- Pain
- Temperature
- Pressure
The superficial senses can be tested using a device called the Seimm
Weinstein Monofilament. The temperature senses can be tested using
test-tubes containing hot (upto 45 degrees) and cold water (upto 5 degrees).

c) Deep Senses
- Kinesthesia
- Proprioception
- Vibration

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Kinesthesia and Proprioception can be tested by performing passive
movements with the patients eyes closed and then asking the patient to
repeat the movement on the unaffected limb.

Vibration is tested using at tuning fork.

d) Combined Cortical Senses

- Stereognosis – Object Recognition
- Barognosis – Weight Recognition
- Graphesthesia – Stimulus Recognition
- Double Simultaneous Stimulation – Tested using the therapists
fingers
- Two Point Discrimination – Tested using an Aesthesiomether or
a caliper type instrument
- Texture Recognition

Balance / Co-ordination:

The balance of the patient is checked and is graded. It can be done by the
Balance Berg Scale.

According to the Balance Berg Scale:

Grade I – Normal – Patient is able to maintain balance without support and

accept maximal challenge and can shift weight in all directions.

Grade II – Good – Patient is able to maintain balance without support but can
accept only moderate challenges and can shift weight in all directions but the
limitation is evident.

Grade III – Fair – Patient cannot tolerate challenges and cannot maintain
balance while shifting weight.

Grade IV – Poor – The patient requires support to maintain balance.

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Grade V – Very Poor – Zero – The patient requires maximal support to
maintain balance.

Limb Length:

The true and apparent limb length is measured to know whether there is any
limb length discrepancy.

The true length is measured from the Anterior Superior Iliac Spine (ASIS) to
the Medial Malleolus in the lower limb.

The true length is measured from the Acromion process to the Radial Styloid
process in the upper limb.

The apparent length is measured from the Umbilicus to the Medial Malleolus
in the lower limb.

Limb Girth Measurement:

Limb and Joint girth are measured to see the muscle wasting and the level of
effusion around the joint.

Limb or Joint Girth is measured by taking three measurements of the

circumference of the limb or the joint and then taking an average of all the
measurements.

ADL Analysis:

ADL Analysis involves task analysis of normal daily activity. It involves the
observation of certain patient activity or detailed evaluation of the effect of
injury or disability or the patients ability to function in everyday life.

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Differentiation Tests:

If a lesion is situated within a non-contractile structure such as ligament,

then both the active and passive movements will be painful and/or restricted
in the same direction. Both active and passive movements of inversion are
painful in case of sprained lateral ankle ligament.

If a lesion is within a contractile tissue such as muscle, then the active and
passive movements will be painful and/or restricted in opposite directions.

Ex. A ruptured quadriceps muscle will be painful or passive knee flexion

(stretch) and resisted knee extension (contraction)

Special Tests:

After the examination of the patient history, observation and evaluation of

movement, special tests may be performed. These tests are although
strongly suggestive of a particular disease or condition when they yield
positive results do not necessarily rule out the disease or condition when
they yield negative results.

Investigations:

Record the results of any investigations that the patient has undergone, case
notes, radiographic films and reports can be ordered and read.

X-Rays, MRI Scans, CAT Scans and Bone Scans:

Scans are now commonly used to aid the diagnosis of musculoskeletal

disorders.

X-Rays are useful extent of osteomyelitis, osteoporosis, and arthritis and to

identify fractures or dislocations.

CAT (Computerized Axial Tomography) may be used to identify the precise

level and extent of disc prolapse.

MRI (Magnetic Resonance Imaging) used to identify ligamentous or muscular

injury.

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Bone Scans are used to detect malignancy or diseases such as ankylosing
spondylitis and diagnosis of particular diseases such as RA, AS and
Osteomyelitis.

Other Investigations:

Investigation of other pathologies related to musculoskeletal conditions.

Provisional Diagnosis:

On the basis of assessment and the special tests that have been conducted,
the provisional diagnosis of the patient can be obtained and the treatment
can be planned accordingly.

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