EEI 10/14a MSK Examination Flashcards
Importance of diagnosis and PT
It provides communication between PT and physician and insurance
Medical world differential diagnosis
- pathoanatomic Dx - ballpark > helps us inform prognosis
- anatomically based
- pathologically based
- can be non-musculoskeletal as well
PT world differential diagnosis
- movement diagnosis
- impairment based
- impairment drives Rx (prescription)
- based on the assumption that impairments relate to limitations in functional activity and participation
- non musculoskeletal: decreased endurance; generalized weakness
what drives PT treatment
- Dx/Pathology
- Impairment
- ICF
- Movement System
- Cyriax
- Maitland
Diagnosis/pathology vs Impairment
Diagnosis = one pathology
-impairment varies within the pathology
for example, you could have 100 people who have strokes, but not all of them would have the same symptoms/impairments
ICF model that drives PT treatment
Impairments are related to activity, but the correlation is NOT near 1, it’s a huge assumption to think that an impairment would be directly related to their activity limitation
ICF Model break down for PT treatment with impairments
- Health Condition: Diabetic neuropathy
- Body Structure/Function Impairment: Neuropathy in the legs yielding balance impairment
- Activity Limitation: trouble walking/going up stairs
- Participation Restriction: difficulty driving (more integrated in community/some social role)
- Environmental Factor: location of their house/needing a car
- Personal Factor: Motivation
Movement system model that drives PT treatment
- Impairments lie within Motion, Force, Motor Control, and Energy
- Movement task is analyzed as either normal or abnormal based on CASSS
- Hypothesis about impairment is made
- Specific tests and measures are determined
- Evaluation and movement diagnosis is completed
- Interventions
- Qualitative observation targets are defined
Cyriax approach to examination
- Orthopedic medicine = nonsurgical orthopedic specialist
- Diagnosis is by selective tension
- reproduce CC Sx (symptoms) by applying tension to find which tissue has the lesion
comparable sign
Maitland (a follower of Cyriax)
- reproduce the patient’s CC with a movement, position, or test (on exam findings***)
- record as a measure of progression for the patient
Cyriax approach to examination with musculoskeletal tissues
- all are capable of producing pain by themselves
1. Contractile: directly responsible for producing movement (muscle, tendon, tenoperiosteal jct)
2. inert: not capable of producing movement by themselves (capsule, ligament, menisci, bone, bursa)
can cartialge be a direct source of Sx’s?
No, cartilage cannot be a direct source of symptoms because they are void of nerves and vessels
what is the goal of the cyriax test
to diagnose the locatin of the symptomatic lesion
–can be applied to virtually all musculoskeletal regions (works better at the extremities and not at the spine)
Approach to examination after history
- AROM
- PROM
- Isometric Resistance
AROM in examination
-Always start with AROM except when there is a muscle or tendon tear where it isn’t safe to actively contract.
Track:
A. Ability and willingness to move
B. Quality of Motion - CASSS
C. Range (amount), Pain (symptoms), painful arc (pain in the middle of the arc of motion)
differentiate between ability and willingness to move of a patient
Ability - can move body, but it hurts so much that they are not able
Willingness - can’t move body, but patient tries to
What causes changes in CASSS?
Force, Energy, Motion, or Motor Control Issues
What is the painful arc?
pain in the middle of motion
-something is transiently getting stressed/pinched
PROM in examination
- Sequence of pain/limitation (Cyriax)
- Capsular
- Non-capsular
- End Feel
Different scales of irritability
- High: pain prior to resistance (end feel) - treat pain
2. Low: resistance (end feel) prior to pain - treat the limitation/motion restriction
when do you treat limitation/motion restriction of a patient?
when there is low irritability and the patient is able to feel resistance (end feel) prior to pain
Sequence of Pain/Limitaiton (Cyriax)
the more inflamed the tissue, the earlier the pain comes on, the less inflamed, the less force needs to be used to produce pain (not time based)
- pain before end range (Acute)
- pain at end range (sub-acute)
- pain with overpressure (chronic)
- irritiability (per Maitland)
Capsular PROM impairment testing in examination
- predictable pattern of loss of motion for a specific joint
- decreased PROM is a proportional loss
- indicates involvement of an entire joint
classic example of a passive capsular impairment testing in examination
- Shoulder loss at GH joint – ER > ABD > Flex/IR
- Hip jt loss – IR > (Flex, Ext, ABD)
- Ankle jt loss – Plantar Flex > Dorsiflex
Non-capsular PROM impairment testing in examination
- something other than the whole joint
- decreased PROM not in capsular pattern
- isolated ligament adhesion
Examples of non-capsular PROM impairment testing in examination
- internal derangement (something floating around in the joint that’s not supposed to be there - meniscal tear in knee)
- extraarticular tissue (tight muscle that is producing a loss of motion, in a non-capsular pattern)
- GH jt loss: ABD > ER seen with impingement syndrome
PROM End Feels
- Capsular
- Spasm
- Empty
- Bony
- Tissue Approximation
- Springy Block
Capsular end feel
leathery end feel, most joints, firm stop with a little bit of give to it
Spasm end feel
muscle contraction stops motion
Empty end feel
PT stops out of mercy, patient is hurting so much that you stop, but more motion would’ve been available
Bony end feel
Elbow extension, bone on bone - no give
Tissue approximation end feel
Knee flexion, calf onto thigh muscle; elbow flexion
Springy block end feel
meniscal injury has a bounce to it
Lag
when AROM < PROM; there is a problem with force production either because of:
- weak muscle
- peripheral nerve damage
- cortically (in the brain) the muscle is not being driven
Isometric Resistance with joint in mid range
- isolate stress as much as possible to the contractile tissue/tendon
- Findings can be:
a. Strong/Painless
b. Strong/Painful (most common in outpatient! Usually tendinopathy)
c. weak/painless
d. weak/painful
why is isometric resistance tested in midrange?
minimize stress to inert structures (inert structures are not on tension, selectively stressing the muscle and tendon unit)
describe a strong/painless result from isometric resistance test
normal
describe a strong/painful result from an isometric resistance test
- Minor lesion in contractile unit
- Usually tendonitis
- Minor muscle strain (hamstrings would be more common as a muscle strain than tendinopathy)
describe a weak/painless result from an isometric resistance test
- Complete tear
- Neurologic
- -Spinal (nerve root)
- -Peripheral nerve
describe a weak/painful result from an isometric resistance test
- Partial tear (in muscle tendon unit)
- Occult fracture - less common (hidden/missed fracture)
- Other
palpation during an examination
-never start with palpation, use it to confirm what the exam has already shown
special tests for examination
- joint play
- other clinical exams
- imaging, EMG
irritability
- High
- Low
High irritability
-Severe pain
-Sx’s easily provoked
-No control of Sx’s
-Acute trauma
-Treatment goals
>Control Sx’s
> Stress Relief
>No End range
Low irritability
-Less pain
-Sx’s controlled
-Sx’s more predictable
-Treatment Goals
>Address impairments
>Stretching
Strengthening
