MSK Assessment Flashcards
What is a subjective assessment?
- Initial assessment where we talk to our patients and gather information
- Discussions with other clinicians, family or carers
- Reading referrals or notes to gather initial information
What are the aims of your subjective assessment?
- Build rapport with your patient
- Gather information (to plan our objective assessment)
- Establish differential diagnoses
- Establish the main problems and patient’s goals / expectations.
- Evaluate patient awareness, knowledge and insight.
- Establish baseline subjective markers
What areas of subjective assessment should be included in MSK?
- History of present condition (HPC)
- Past medical history (PMH)
- Drug history (DH)
- Social history (SH)
- Patient goals / aims / expectations
- Differential diagnoses
What can interpersonal skills in a subjective assessment significantly contribute to?
- Patient and healthcare provider satisfaction
- Problem detection and diagnostic accuracy
- Patient adjustment to stress and illness,
- Patient recall of information and adherence to therapy plans
- Patient health outcomes
What percentage of clinicians can obtain their diagnostic info in a good subjective history?
60-80%
What percentage of subjective histories can lead to a final diagnosis?
76%
What are some expectations the patient may have from their assessment?
- Diagnosis
- Advice
- Exercises to help manage pain
- Reassurance
- Cure or resolution of their pain
- Reduction in their ain so they can self-manage
What is discovered during the History of Present Condition (HPC) section of a subjective assessment?
- Current symptoms
- Timeline
- Pattern of symptoms
- Treatment/investigations
- Mechanism of injury vs insidious onset
What is discovered during the Past Medical History (PMH) section of a subjective assessment?
- Previous operations, accidents or significant illnesses (THREADS)
- Relevant current medical conditions
- Specific ‘red flag conditions’
What is discovered during the Drug History (DH) section of a subjective assessment?
- Current medication (anticoagulation?, analgesics?)
- Significant past medication
- Specific ‘red flag’ medication
What is discovered during the Social Health (SH) section of a subjective assessment?
- Occupation
- Relevant social or family situations
- Hobbies & interests
How can we record signs & symptoms (S&S) in a clear, detailed and succinct way?
Body Chart
What are some symptoms that mean extra caution is needed?
- Excessive symptoms
- Neurological symptoms (P&N / numbness)
- Symptoms of instability
- Symptoms not matching MOI / problem
What are examples of signs & symptoms (S&S)?
- Pain
- Pins and needles
- Giving way
- Locking
- Stiffness
- Swelling
- Bruising
- Numbness
- Instability
- Clicking/popping/clunking
What questions would you ask about pain location?
- Exactly where is the pain?
- Can they point with one finger or is it the whole hand?
- Where does it start, where does it refer to?
- If there are more than one pain locations are they related?
- Is it deep or superficial (near the surface)?
- Do they come together or separately?
What information might we want to get about a patient’s pain?
- Severity
- Duration (when it started, how long each episode lasts, constant?)
What are non-verbal pain cues?
- Facial expression (grimace, redness/pale, clench teeth, shut eyes0
- Body language (deep breathing, withdraw from touch)
What are examples of words used to describe pain?
- Aching
- Throbbing
- Burning
- Shooting
- Prickling
- Lancing
- Stinging
What does night pain suggest in an assessment?
more severe pathologies
What does 24-hour pain pattern show in an assessment?
- Aids diagnosis
- AM pain + stiffness (indicate inflammatory)
What are (4) pain cautions to look out for?
- Non-mechanical pain: No clear aggravating factors or easing factors
- Unrelenting pain
- No 24-hour pattern: pain through the day and night
- Night pain: severe pain which prevents or wakes from sleep (Manageable night pain is not uncommon)
What do easing factors for pain show in an assessment?
- Aids diagnosis
What do aggravating factors for pain show in an assessment?
- Aids diagnosis
- Provides objective markers
What are ‘special’ questions to ask in an assessment?
Questions that help diagnose
- Any P&N/numbness?
- Any swelling?
- Any feelings of instability / locking / giving way?
- Any audible pops / clicking?
What are ‘red flag’ questions?
Questions that indicate more serious pathology
- Cauda equina symptoms
- PMH THREADS questions
What is SIN (pain)?
- Severity (low/moderate/high or VAS)
- Irritability (low/moderate/high)
- Nature (nociceptive (mechanical/inflammatory)/Neuropathic or peripheral neurogenic/central sensitisation))
- OR the origin of the pain
What is irritability (pain)?
a disorder’s susceptibility to become painful, how painful it becomes and the length of time this pain takes to subside.
(low/moderate/high)
What is nociceptive pain?
- Pain derived from tissues by mechanical or chemical processes.
- Most likely to be associated with an acute injury, with damaged and healing tissues and postural pain.
What is neuropathic/peripheral neurogenic pain?
- Pain derived from the nerve itself or its connective tissue by mechanical or chemical stimulation.
- Has characteristic qualities typical of nerve irritation and involvement including the sensation and behaviour of the pain
What is nociplastic pain/central sensitisation?
- Derived from a hyperactive and hypersensitised nervous system (where the stimulus would not normally trigger a pain response and can be strongly linked to stress and emotion).
- Can be a feedforward response where thoughts and feelings can elicit a pain response.
How will the subjective assessment and SIN factor affect an objective assessment?
- High impact MOI?
- Positive red flag questions?
- High pain score (severity)?
- High irritability?
- Pain nature?
+ Nociceptive
+ Neurogenic (peripheral neurogenic)
+ Nociplastic (central sensitisation)
How does an objective assessment in MSK outpatients flow?
- Observation
- AROM
- Clearing joints
- PROM
- Muscle tests
- Palpation
- Special tests to area
- Functional testing
- Nerve/Neuro tests (neuro integrity, neuro sensitivity)
- Outcome measures
Why do we need to clear joints in an objective assessment?
to ensure the pain is coming from the joint/area we think it is (and not referred from another joint/area)
How do we clear joints in an objective assessment?
- Verbally check for other areas of pain (e.g.: common referral areas)
- AROM + PROM with over pressure of joint above + below
What are special tests in an objective assessment?
tests that can be helpful determining the absence or presence of a disease
Why do we use special tests in an objective assessment?
to add another piece to the ‘diagnostic jigsaw’
What are considerations required for special tests during an objective assessment?
- Validity
- Reliability
- Sensitivity
- Specificity
What are neurological tests?
test the function or integrity of the peripheral nerves
What are functional tests?
complex objective tests which replicate activities of daily living (e.g.: jump, squat)
Outcome measures.
- Can be subjective or objective
- Need to consider reliability and validity
- Give us a baseline
- Monitor progress
- Motivate patients
- Justify onwards referrals or discharge decisions
What does the ‘snOut’ rule mean for an objective test?
a negative ‘snOut’ rules it out
(sensitivity + they don’t have it)
What does the ‘spIn’ rule mean for an objective test?
a positive ‘spIn’ rules it in
(specificity + they do have it)
What are some knee specific special questions for a subjective assessment?
Does the patient have or have they experienced any….
- Locking
- Swelling
- Giving way
- Clicking/clunking
- Any sound on injury (e.g.: popping)
- Pins and needles
What may true locking of the knee suggest about their injury?
suggests loose body or meniscal
What may pseudo locking of the knee suggest about their injury?
knee feels ‘sticky’ and like it may lock (but it doesn’t)
What is true locking of the knee like?
patient can’t physically move knee (have to move it with their hands for it to move again)
What may the time taken for swelling of the knee tell us about the injury?
Within hours = ACL rupture (or similar)
Over several hours = Meniscal
What does true giving way suggest about a patient’s knee injury?
Mechanical
- Meniscal tear
What does pseudo giving way suggest about a patient’s knee injury?
Knee weakness
- Hyperextension
Pain
- Muscle inhibition
What can a popping sound on injury tell us about the knee injury?
can indicate ACL rupture
What can pins & needles/ numbness suggest about an injury?
Indicates nerve involvement
- Is it peripheral nerve irritation perhaps a neuroma after trauma or following surgical incision or spinal referred pain?
What will be the findings on subjective assessment of an osteoarthritic knee?
- Insidious onset
- Gradually worsening though episodic.
Symptoms:
- Pain
- Stiffness
- Weakness
- Giving way
- Hot knee
- Clicking.
Functional limitations like a reduced ability to walk, kneel, squat.
What are the best diagnostic factors for patellofemoral pain syndrome (PFPS) following an objective assessment?
- Muscle weakness
- Muscle tightness
- Functional tests
What is patella tendinopathy pain aggravated by?
loading the tendon + quads activation
Who is patella tendinopathy most commonly seen in?
young males with a high prevalence in jumping sports
When do knee fractures occur?
result from high force sports trauma, falls or RTAs
How to fractures of the patella occur?
usually a direct trauma or deceleration injury
How do fractures of the tibial plateau occur?
usually a fall or high trauma event
How do fractures of the fibula head occur?
usually lateral impact
What are the Ottawa rules of the knee?
Knee X-ray only required when:
1. Age 55 or older
2. Isolated tenderness of patella
3. Tenderness at head of fibula
4. Inability to flex to 90 degrees
5. Inability to bear weight both immediately & in A&E
How are the collateral ligaments (MCL/LCL) typically injured?
through lateral forces to the side of the knee, creating a valgus or varus stress
Is the LCL or MCL more commonly injured and why?
MCL
- it’s less mobile (being partially attached to the medial meniscus)
How are knee ligament injuries graded?
Grade 1= few fibres torn
Grade 2 = more fibres torn
Grade 3 = complete tear
How do ACL ruptures most frequently occur?
Non-contact sports related injuries:
- Cutting
- Twisting
- Landing action
(where foot is plated on ground + knee pivots into adduction & medial rotation)
What specific tests are used to aid the diagnosis of an ACL injury?
- Anterior draw test
- Lachman’s test
- Positive sweep test (seen on examination due to intra-articular swelling)
Why are PCL injuries less common?
strong + prevent posterior translation of the tibia
How does PCL injury usually occur?
through hyperextension or a forceful AP translation of the tibia while in flexion
What are red flag pathologies and findings of the knee?
- Septic Osteoarthritis
- Wound infection
- Compartment syndrome
- Bone tumours
- Blocked movement
- Gross instability
- Non-mechanical pain
- Calf redness/heat/pain
How do you clear a joint?
Full AROM in all directions
- Helps to rule out other joints
- Helps to identify deficits which may be contributing to the patient’s symptoms.
If they have full pain free range of motion the clinician can apply overpressure.
(Do NOT apply over pressure if AROM is restricted/painful or condition is highly irritable.)
Weight bearing lunge test.
a functional measure of ROM (ankle dorsiflexion)
Foot parallel to wall. Bend knee to touch wall. Move foot as far back as possible with knee still touching wall. Measure distance.
What are some serious red flag pathologies?
- Fracture
- Infection
- Malignant
- Visceral
- Cauda Equina Syndrome
- Cervical Spine: Cervical artery dysfunction, cervical instability, cervical myleopathy
What are some key questions to ask patients (in relation to suspected/diagnosed cancer)?
- Over 50 years old
- Unexplained weight loss (> 5% over 6 months).
- Constant severe unremitting pain
- Night pain that prevents or disturbs sleep
- Thoracic pain
- Previous history of cancer
What questions do you need to ask your patient in relation to Cauda Equina Syndrome (CES)?
- Do you have pain down both legs (sciatica)?
- Have you noticed any changes in your bowel, bladder or sexual function?
- Do you have difficulty controlling your bowel or bladder?
- Can you feel your saddle area when you wipe?
- Have you noticed any disturbances in your walking?
What are some red flag questions when a patient has neurological symptoms?
- Do you have any P&N or numbness?
- Have you experienced any weakness or difficulty moving/controlling your body? (any loss of balance or coordination?)
- Do you experience muscle cramps or spasms?
What are some red flag questions when a patient has systemic symptoms?
- Have you had unexplained weight loss recently?
- Do you have a history of cancer?
- Have you experienced pain waking you at night and stopping you from getting back to sleep?
What is a red flag question for a patient who has had trauma or injury?
Have you recently experienced a significant trauma or injury?
What are red flag questions for a patient who is at risk of infection?
- Have you had a recent infection or operation?
- Do you have a fever or night sweats?
What are red flag questions for a patient who has had spinal trauma or injury?
- Have you recently experienced a significant trauma or injury to your back?
- Did your back pain start after a fall or accident?
What are red flag questions for a patient who you suspect has Cauda Equina Syndrome (CES)?
- Do you have severe pain down both legs?
- Have you noticed any changes in your bowel, bladder or sexual function?
- Do you have difficulty controlling your bowel or bladder?
- Can you feel your saddle area when you wipe?
- Have you noticed any disturbances in your walking?
What are red flag questions for a patient who has history of spinal infection?
- Have you had a recent infection or operation, especially one that involved the spine?
- Do you have a fever along with back pain?
What is a red flag question for a patient who has spinal inflammatory conditions?
Do you have any difficulty moving/stiffness in back or joints >30mins in the morning?
What is a red flag question for pathological lower limb vascular symptoms?
Have you noticed any changes in skin colour or temperature in your legs?
What are red flag questions for pathological lower limb joint swelling & deformity?
- Have you experienced any sudden swelling or deformity in your joints?
- Have you experienced any trauma?
- Do you have a history of joint diseases such as rheumatoid arthritis?
How do you assess dermatomes?
- Gently stroke skin with tissue over the dermatomes
- Compare both sides (find % of sensation reduction or some degree of quantification)
- Document sensation changes
What are you assessing for when looking at myotomes?
assessing for weakness (not pain)
What are the reasons for reduced ROM?
- Pain
- Swelling
- Scar tissue
- Ligament shortening
- Muscle Tightness
- Mechanical block (loose body/cartilage)
- Joint stiffness
What are some reasons for reduced ROM that you want to push hard to overcome?
- Ligament shortening
- Joint stiffness
- Muscle tightness
- Scar tissue
What are some reasons for reduced ROM that you want to push gently to overcome?
- Swelling
- Pain
What is a reason for reduced ROM that you don’t want to push to overcome?
- Mechanical block
When assessing muscle strength of hip adduction, what muscles are being assessed at 0 or 45 degrees of hip flexion?
- Adductor magnus
- Adductor longus
- Gracilis
When assessing muscle strength of hip adduction, what muscles are being assessed at 90 degrees of hip flexion?
Pectineus
How do you ‘resist’ muscles to assess strength of hip adduction muscles?
- Squeeze fist in between knees
- Pull/resist against one side
What are some functional tests for strength/stability of the hip?
- Single leg balance (Trendelenburg?)
- Squat (double/single leg)
- Bridge (double/single leg)
- Clam/hip abduction (single leg)
- Prone hip extension
What are (2) examples of capacity tests used to assess the hip?
- Hamstring – SL bridge to failure – expect 25 reps in runners
- Abductors / gluteal – Side lying leg lift to failure (watch for compensation)
What are the neural integrity tests?
- Dermatomes
- Myotomes
- Reflexes
What are the Upper Motor Neurone Lesion Tests?
- Clonus
- Babinski
How do you conduct a reflex assessment?
- Patient needs to be relaxed and comfortably supported
- A tendon reflex is elicited by briskly striking the tendon of a muscle which is on a slight stretch
Which segments are you assessing when conducting a reflex assessment on the Quads tendon?
L3/4
Which segments are you assessing when conducting a reflex assessment on the Achilles tendon?
L5/S1
What does a brisk/hyperactive reflex indicate?
Upper motor neuron pathology
What does a diminished/absent reflex indicate?
Lower motor neuron pathology
What can be done to help elicit reflexes?
‘Reinforcement’ - tense muscles
What are the contraindications to neurodynamic assessment?
- Malignancy
- Cauda equina / cord involvement
- Active inflammatory or infective disease
- Bone disease
- Joint instability, fracture or dislocation
What are the precautions to neurodynamic assessment?
- Rheumatoid Arthritis
- Osteoporosis
- Spondylolisthesis
- Hypermobility
- Pregnancy
- Vascular disorders
- Previous malignant disease
- Recent trauma
- Psychological issues.
How do you conduct a neurodynamic test?
- Test the pain free side first (baseline).
- Explain to patient what you’re looking for + when they should respond (“let me know as soon as you feel any pulling, stretching, tightness or pain”)
- Move slowly, adding components on one at a time
- Once the sensation is reported clarify what the patient can feel and where
- Remove a component at a joint away from the sensation to confirm neural
- Document range, response and final position
How do you conduct a straight leg raise?
Passive hip flexion with the knee in extension
What are the sensitising tests for a straight leg raise?
- Dorsiflexion
- Hip adduction
- Hip medial rotation
- Neck flexion
FADDIR & FABER tests are used to diagnose which intra-articular pathologies?
- Labral tears
- Femoroacetabular impingement (FAI)
- Osteoarthritis
What is the Keel StarTBack Tool?
The patient is asked to think about the last 2 weeks and tick “disagree” or “agree” for questions 1-8 and then give a scale for question 9.
- Back pain spread down the leg(s)
- Pain in the shoulder or neck at some time
- Only walked short distances due to back pain
- Dressed more slowly due to back pain
- “It is not safe for a person with a condition like mine to be physically active”
- “Worrying thoughts have been going through my mind a lot of the time”
- “I feel that my back pain is terrible and it’s never going to get any better”
- “In general, I have not enjoyed all the things I used to enjoy”
- How bothersome has your back pain been?
What is the femoral nerve slump test?
testing the top leg
How do you conduct the femoral nerve slump test?
- Lie on the opposite side to the one you want to test
- Patient holds the lower leg to their chest and flexes neck
- The uppermost knee if flexed and the hip extended.
How do you conduct a desensitising test during the femoral nerve slump test?
Cervical extension (should ease symptoms)
What are the aims when treating neurodynamic problems?
- Reduce the mechanosensitivity of the nervous system
- Restore its normal capabilities for movement
