Assessment exam Flashcards
Piriformis Syndrome
Interview:
* Pain usually on one side
* Pain and paresthesia in posterior thigh, projecting to calf and sole of foot; numbness in foot; potential loss of proprioception or mm strength in lower leg – sciatic nerve
* Pain in glutes, lower back, hip and posterior thigh
* Pain increased by sitting/positions with prologued hip flexion, adduction, and medial rotation
* Symptoms aggravated by activity
* Pain decreases with external rotation
Assessment:
- Posture:
o Limb guarding on affected side
o Affected foot externally rotated
o Frequent shifting of weight
o Possible hyperlordosis - Gait:
o Antalgic gait (less weight bearing on affected side)
o External rotation of the affected hip
o Possible ataxic gait if nerve compression is causing altered sensation to the sole of the foot - Palpation:
o FR in glutes
o HT and trigger points and tenderness in piriformis, glutes, QL, iliopsoas, quads
o Adhesions in affected buttock
o Possible edema in lower affected limb - Range of Motion:
o AF ROM of hip – decreased internal rotation with pain on affected
o PR ROM of hip – decreased internal rotation with pain on affected
o AR ROM of hip – positive for weakness and pain on affected side in external rotation - Neuro:
o No findings in dermatomes, myotomes, or deep tendon reflexes - Ortho tests:
o Piriformis length test is positive with less than 45 degrees
o Pace test is positive for weakness and pain
Rule out:
* Nerve root compression of lumbar spine
o No findings when I do neuro testing
ITB Contracture
Interview:
* Sit a lot and knee is often in flexion
* May have foot in pronation frequently (flat feet, runner on slanted track)
* Does something that shortens IT band for extended periods of time such as frequently standing on one leg
* Gradual onset
* Worse with activity
* Achey
* Along lateral side of thigh
Assessment:
- Posture:
o Well-defined IT band may create an indentation in the lateral aspect of the affected thigh
o Unilateral – lateral pelvic tilt that is low on the affected side
o Bilateral – anterior pelvic tilt and hyperlordosis
o Knee on the affected side may have valgus orientation
o Pes planus may be on affected side - Gait:
o Antalgic gait - Palpation:
o Tenderness along IT band, especially along distal 1/3 and greater trochanter
o Affected IT band is thickened with fascial restrictions
o Unilateral – increased tone and trigger points in TFL and glute max on affected side; increased tone may be present in iliopsoas and adductors of non-affected side - Range of motion: STATE MAIN FINDING FOR TARGET JOINT
o Clear knee and thoracolumbar spine
o AF ROM of knee
Painful extension (always painful with friction syndrome)
o AF ROM of coxal
Reduced extension and adduction of hip
o PR ROM of knee
Painful extension at lateral aspect
o AR ROM of coxal
FTL, rec fem, glute max, glute med, iliopsoas and - Stronger TFL, hip flexors and glute max
- Weaker glute med
- Ortho test:
o Modified Ober’s test – straight leg (includes IT band)
Rule Out:
* Friction syndrome
o Noble’s test
Thoracic Outlet Syndrome
Interview:
* Neuronal:
o Numbness and tingling into upper limb and hand – primarily on ulnar side but can be whole hand
o Aching or throbbing, diffuse
o Aggravated by hanging arm down, lifting heavy objects, hand above head
o Gradual increase in motor weakness, loss of fine motor skills, difficulty gripping
* Vascular:
o Hand or arm is cold
o May go pale or blue
o Arm may feel heavy or boggy
o In extreme cases, necrosis of fingertips
o All neuronal symptoms
Assessment:
- Posture:
o Dropping shoulder on affected side
o Head forward posture
o Hyperkyphosis - Palpation:
o Chronic stages – muscle wasting in hand; intrinsic hand, hypothenar, and sometimes thenar mm
o Tenderness, HT, and trigger points in scalenes, pec minor, and subclavius mm
o FR in anterolateral neck, shoulder, and upper arm
o Edema may be present with vascular compression
o Hand may be cool - Neuro:
o do testing, but no findings - Ortho tests:
o Scalenes – Adson’s – client seated, find pulse, client looks at you, extend and laterally rotate arm while client extends neck, client takes deep breath, hold for 10-15 seconds – diminished pulse and increase in symptoms
o Costoclavicular – Eden’s – standing client, find pulse, instruct client to bring shoulder as far into retraction and depression – diminished pulse and increase in symptoms – vascular symptoms
o Pec Minor – Wright’s – seated client, find pulse, passively abduct and laterally rotate arm to 180 degrees, slightly extend arm – diminished pulse and increase in symptoms – vascular symptoms
o Pec minor length test
Rule Out:
* Carpal Tunnel
o Phalen’s
Frozen Shoulder
Stage 1
Interview:
* Gradual onset of pain and stiffness not typically due to trauma
* Stiffness sets in 2-3 weeks after initial pain
* Can’t lay on it
* Hurts badly at night
* Can’t internally rotate, externally rotate, and abduct due to pain
* Pain in outer aspect of the shoulder and the deltoid insertion referring down to elbow
Assessment:
- Posture:
o Possible hyperkyphosis
o Possible forward head posture
o Affect shoulder is elevated and protracted
o GH is medially rotated - Gait:
o Decreased arm swing on the affected side - Palpation:
o FR in anterior and posterior shoulder girdle
o HT, trigger points, and tenderness in shoulder gridle mm (deltoid, rotator cuff mm, upper trap, pec major/minor) - ROM to shoulder
o AF – limited range due to pain in external rotation, abduction, and internal rotation
o PR – limited range in abduction, external rotation, and internal rotation – empty end feel due to pain OR muscle guarding – no over pressure if there is pain
o AR – pain-free and strong
Clear above and below joints
Unaffected side first
Perform limited ranges last
Mention capsular pattern is external rotation, abduction, and internal rotation - Ortho test:
o Passive relaxed abduction test:
Positive – capsular tightness and leathery end feel at 90 to 129 degrees of abduction and 1:1 ratio of movement of scapula
o Apley’s scratch
Positive decrease ROM of affected shoulder in lateral rotation and abduction
Rule Out:
o Supraspinatus tendonitis
Empty can test
Frozen Shoulder
Stage 2
Interview:
* Started with progressive pain and stiffness not always due to trauma, but pain has begun to diminish
* Stiffness and loss of ROM in internal rotation, external rotation, and abduction are chief complaints
Assessment:
- Posture:
o Possible hyperkyphosis
o Possible forward head posture
o Affect shoulder is elevated and protracted
o GH is medially rotated - Gait:
o Decreased arm swing on the affected side - Palpation:
o FR in anterior and posterior shoulder girdle
o HT, trigger points, and tenderness in shoulder gridle mm (deltoid, rotator cuff mm, upper trap, pec major/minor) - ROM to shoulder:
o AF – limited range due to capsular pattern and pain in external rotation, abduction, and internal rotation
o PR – limited range due to capsular pattern and pain in abduction, external rotation, and internal rotation – leathery end feel found during over pressure
o AR – close to normal strength. Little pain in unrestricted ranges. Possible decrease in strength in external rotation
Clear above and below joints
Unaffected side first
Perform limited ranges last
Mention capsular pattern is external rotation, abduction, and internal rotation - Ortho tests:
o Passive relaxed abduction test:
Positive – capsular tightness and leathery end feel at 90 to 129 degrees of abduction and 1:1 ratio of movement of scapula
o Apley’s scratch
Positive decrease ROM of affected shoulder in lateral rotation and abduction
Rule Out:
o Supraspinatus tendonitis
Empty can test
Hyperlordosis
Interview:
* Low back pain – lumbar area
* May say they are pregnant or recently pregnant
* May have had abdominal or lumbar surgery
* Lots of sitting
Assessment:
- Posture – lateral view:
o Possible slight ankle plantarflexion
o Possible slight knee hyperextension
o Hip joints flexed
o Bilateral anterior pelvic tilt is greater than 10 degrees in females and greater than 5 degrees in males
o Lumbar lordotic curve increased
o Often there is compensatory hyperkyphosis and head forward posture
Look at all sides, palpate - Palpation:
o Tenderness, HT, and trigger points in lumbar ESGs, QLs, iliopsoas, TFL, and rec fem
o FR in lumbar region and TFL - Range of motion: PICK ONE JOINT
o AF ROM of coxal jt
Decreased extension
o PR ROM of coxal jt
Decreased extension with empty end feel
o AR ROM of coxal jt
Reduced strength in extension
o AF ROM of thoracolumbar spine
Decrease lumbar flexion
Painful lumbar extension - Ortho test (perform one or two):
o Ely’s
Positive bilaterally for short rec fem
o Thomas
Positive bilaterally for short hip flexors
Rule Out:
* Facet joint irritation or nerve root compression of lumbar spine
o Kemp’s
TMJD
Interview:
* Potential direct head, face or TMJ joint trauma
* Popping, clicking, grinding in jaw
* Locking of jaw
* Possible dental issues such as tooth loss
* Pain when pressing on jaw
* Very stressed
* Headaches
* Grinding teeth during sleep
* Clenching jaw
* Excessive gum chewing
* May be genetic
Assessment:
- Posture:
o Anterior view:
Shoulders may be elevated or one may be higher than the other
Face is assessed: - Observe levels of external auditory meatus, frontal ridges, zygomatic arches, angles of the mandibles, and alignment of teeth and jaw
- Masseter or temporalis mm may be clenched
o Lateral view:
Antalgic head forward posture
Increased cervical lordotic curve
Mandibular protraction or retraction
Protracted scapula
o Posterior view:
Lateral head tilt - Palpation:
o Tenderness in mm of mastication, anterior to TMJ and inside anterior aspect of external auditory meatus
o Possible heat and edema at affected TMJ
o Mm may be fibrosed
o Popping, clicking or crepitus of affected jt
o HT and trigger points in mm of mastication, neck, upper traps, suboccipitals, scalenes, upper ESGs, and intercostals - ROM of TMJ:
o AF – limited ROM due to pain in all ranges, palpate to feel for clicking and symmetry of movement
Clear below
Limited due to pain if muscular
Limited to restriction of joint if capsular
I would not choose to do PR or AR ROM as it can cause the jaw to lock - Ortho tests:
o Look for S- or C-wobble because of mm or capsular issues
S-wobble – muscle issue
C-wobble – capsular issue
o Three knuckle test
Non-dominant hand – less than 2-3 knuckles is positive
Rule Out:
* Went to the dentist – no cavities/problems with teeth
Plantar Fasciitis
Interview:
* Pain during first steps of the day, or when starting an activity after rest
* Pain on the medial, distal surface of calcaneus
* Pain when beginning walking or during long walks
* Can work on a hard surface or wears workbooks
* Potential recent increase in activity
* Gradual increase of symptoms – no trauma
Assessment:
- Posture:
o Excessive pronation
o Potential signs of swelling in the medial longitudinal arch - Gait:
o Pain is worse during toe-off stage
o Possible excessive external rotation of hip - Palpation:
o Unaffected side first
o Pain at medial, distal surface of calcaneus
o Potentially could be warm if inflamed
o Thickening and adhesions on calcaneus and into middle of foot - ROM:
o AF and PR ROM of ankle
Decreased in dorsiflexion
o AR ROM
Weakness or pain in plantarflexion
o Active and passive extension of toes is painful due to stretching of plantar fascia - Ortho tests:
o Gastrocnemius and soleus length test
Positive
Perform on both sides, know degrees needed to confirm test – dorsiflexion less than 20 degrees
Rule Out:
* Morton’s neuroma
o Morton’s neuroma squish test
Hyperkyphosis
Interview:
* Mid neck and back pain
* Tightness/soreness in neck, shoulders, pecs, and upper back
* Frequent sitting, tech neck
* Occupation that requires a lot of sitting
* Curled up while sleeping on side
* Possible shallow breathing
* Achey and stiff
* Sadness
Assessment:
- Posture:
o Increased thoracic kyphotic curve
o Head forward posture
o Protracted scapula
o Medially rotate GH bilaterally - Palpation:
o Fascial restrictions in bilateral anterior chest, posterior neck
o HT and trigger points in pec major/minor, subclavius, SCM, upper traps, suboccipitals, levator scapula, scalenes
o Hypomobility in thoracic vertebra and ribs - ROM:
o AF ROM of GH
Decreased flexion, external rotation
o PR ROM of GH
Decreased flexion, external rotation
Normal end feel
o AR ROM of GH
Possible decrease in strength with external rotation
o AF ROM of cervical
Decreased flexion and lateral flexion
o PR ROM of cervical
Decreased flexion and lateral flexion
Normal end feel
o AR ROM of cervical
Weakness in flexion - Ortho test (perform one or two):
o Pec major length test
Positive – arm remains at or above level of table
o Rhomboid strength test
Positive – client is unable to sustain the position against gravity or meet the therapist’s resistance
Rule Out:
* Facet joint irritation or nerve root compression of cervical spine
o Compression test and spurling’s
Carpal Tunnel
Interview:
* Numbness and tingling into the median distribution – “my hand falls asleep”
* Pain local to the wrist. Increasing the wrist activity makes it worse.
* Nocturnal symptoms
* Relieves with shaking of the hand
* Weakness and clumsiness of the hand; in progressed cases there may be thenar muscle atrophy
Assessment:
- Palpation:
o Possible signs of inflammation and heat local to wrist
o In chronic cases, possible ischemia
o Tenderness local to carpal tunnel at insertions at the carpal bones and over median nerve
o Boggy local to wrist
o Forearm mm are often dense
o HT and FR of the forearm mm due to overuse and trigger points are present
o In later stages, atrophy of thenar mm is present - ROM
o AF ROM
Decreased range in flexion, extension and possibly ulnar deviation
o PR ROM
Decreased range in flexion, extension and possible ulnar deviation
Empty end feel
o AR ROM
Strong and pain-free
Weakness in abductor pollicis brevis (with chronic CTS) - Neuro testing
o No findings - Ortho tests:
o Phalen’s
Rule Out:
* Neuro testing to rule out cervical nerve root compression
Scoliosis
Assessment:
* Posture:
o Varies depending on type of curve
C-curve
* Anterior:
o Lower ASIS on convex side or pelvic torsion
o Rib humping on convex side
* Lateral:
o Knee hyperextension
o Increased anterior pelvic tilt on convex side
* Posterior:
o Possible cervical compensatory curve
o Higher acromioclavicular joint on convex side
o Scapula on convex side is higher and possibly winged
o Difference in medial border of scapula and spine from left and right
o Iliac crest higher on concave side
o Asymmetrical negative space between torso and arms
o PSIS
Lateral pelvic tilt – PSIS is LOW on dropped side
Pelvic torsion – PSIS is HIGH on the anteriorly rotated, short-leg side
* S- curve:
o Anterior:
- Gait:
o Decreased arm swing
o Foot may collapse n=inward on stance - Palpation:
o Temperature – normal
o Texture – fibrosing on concave side
o Tenderness – point tender in ESG, QLs, intercostals, traps, glutes
o Tone – HT in ESG, QLs, intercostals, traps, glutes - ROM:
o AF ROM of thoracolumbar spine
Decreased ROM toward convex side in lateral flexion and flexion
o PR ROM
Decreased ROM in hip extension with anterior pelvic tilt
o PR ROM of shoulder
Decreased external rotation
o PR ROM of spine
Decreased ROM in all ranges
o AR ROM of thoracolumbar spine
Weakness in flexion and lateral flexion on concave side
o AR ROM of coxal
Weakness in extension, abduction, adduction, lateral rotation with ant pelvic tilt
Weakness in all ranges with lateral pelvic tilt
o Ortho test:
Functional vs structural scoliosis test
Rule out:
* Facet joint irritation with kemps
Torticollis
Assessment:
* Posture:
o Presentation of wry neck
o Head forward
o Increased thoracic and lordotic curves
o Hip flexion
o Anterior pelvic tilt
- Palpation:
o Temperature – heat with inflammation or cool due to ischemia
o Texture – ropey in upper/mid traps, scalenes, SCM, lev scap, rhomboids
o Tenderness – point tender to upper/mid traps, scalenes, SCM, lev scap, rhomboids
o Tone – HT to upper/mid traps, scalenes, SCM, lev scap, rhomboids - ROM:
o AF ROM of neck
Painful and very restricted when moving out of torticollis position - Flexion, lateral flexion, and rotation
o PR ROM of neck
Painful and very restricted when moving out of torticollis position - Flexion, lateral flexion, and rotation
Muscle spasm end feel
o Don’t do AR ROM when spasm is present
Rule out:
* Rule out whiplash with interview
Whiplash
Interview questions:
* Direction vehicle hit from?
* Where was the seat-belt worn?
* Previous injuries?
* Hit head?
* When injuries/symptoms occurred?
* Insurance claim?
* Neuro?
Assessment:
* Posture:
o Head forward
o Shoulders elevated/bilateral mm guarding
- Gait:
o Antalgic
o Reduced arm swing on affected side - Palpation:
o Temp – heat decreasing to cool with chronic
o Texture – firm edema (acute), adhesions (subacute/chronic)
o Tenderness – local point tenderness
o Tone – spasm (acute) to HT/trigger points in subacute/chronic, possible atrophy in chronic - ROM: ONLY DO AF ROM IN ACUTE
o AF ROM of neck
Pain and decreased ROM
o PR ROM of neck
Pain and decreased ROM with tissue stretch or empty end feel
o AR ROM of neck
Weakness and pain indicating a strain of rhomboids, mid trap, neck flexors - Neuro:
o Yes, if neuro symptoms noted in interview in stage 3 only
Do I refer out at this point? Yes, or get doctor’s clearance
Rule out:
* Ortho tests:
o Vertebral artery test –Before any assessment if there is neck trauma and subsequent neuro symptoms
Negative
o Spurling’s to rule out cervical nerve root compression
Negative
Pes Planus
Assessment:
- Posture:
o Mild – 4-6 degrees of hindfoot valgus
o Moderate – 6-10 degrees of hindfoot valgus
o Severe – 10-15 degrees of hindfoot valgus
o Achilles tendon has valgus orientation
o Possible internal tibial torsion
o Valgus at knee
o Internal rotation at hip
o Medial arch is flattened and foot is pronated
o Valgus orientation of the first metatarsal jt – possible bunion
o Forefoot may be abducted - Gait:
o Pronation occurs 15 to 20% into contact phase
o Pronation occurs through stance phase - Palpation:
o Tenderness at spring ligament, navicular, calcaneal attachment of the long planta ligament and plantar fascia, the first and second metatarsal heads and the first MTP joint
o Tenderness in mm and tendons of leg
o Areas of local heat on the 1st MTP jt with bunions
o Texture of the skin over the talar head and the 1st and 2nd metatarsal heads may be thick and rough
o Intrinsic foot mm, tib ant, tib post, and long toe flexors are HT and lengthened
o Gastrocs, soleus, fib long and brev and tertius are HT and short
o Trigger points in fib long and brev - ROM:
o AF ROM
Dorsiflexion of ankle may be limited in severe cases
o PR ROM
??
o AR ROM
