Musculoskeletal Examination & Evaluation Flashcards
8 performance expectations for entry to practice
- screen
- examine
- Evaluate
- Diagnose
- Prognosticate
- plan of care
- intervention
- outcomes
purpose of the examination
to reach to the proper diagnosis
How to reach the proper diagnosis through the examination?
systematic and complete
Aspects of the Examination? (7)
-patient history
-observation
-ROM/MMT
-Special tests
-Reflexes/Sensations
Accessory motions/ palpation
Question to ask for HPI/ Chief Complaint
- What brings pt to PT. pt describe in own words
- mechanism of injury (MOI)
- Pre-injury status
- Assistive devices/equipment
Mechanism of Injury
Trauma vs overuse: seek detail description
Examples of assistive devices/ equipment
braces, crutches, immobilizers, orthoses, splints
Questions to ask for onset
What happened/ mechanism of injury
Was onset insidious
Was onset related to a trauma: macro trauma
Was onset related to repetitive use: Microtrauma
When did onset occur
Macrotrauma
Onset related to a trauma
Microtrauma
Onset related to repetitive use
Questions to ask for Location
Where is the pain
Was initial location of pain different than current location of pain
Where is the pain follow up questions?
localized
non-specific/general/diffuse
peripheralization/centralization
referred pain
Was initial location of pain different than current location of pain follow up question?
has it moved or spread
Duration questions
How long has pain been present
Constant (chemical) vs intermittent (mechanical)
If intermittent, how long does pain last when present
What do you want to find out when asking how long pain has been present?
stage of healing: acute/subacute/chronic
-days,weeks, months, years
Questions to ask for Character
Patient descriptors
Is pain changing
What are patient descriptors
Sharp/ lancinating burning dull/aching deep/boring aching throbbing
what are aggravating conditions/ activities
- sitting/ standing (flex/ext)
- Walking/running
- lifting/carrying
- Stairs/jumping
- throwing
- ROM/ Resisted motions
What are relieving conditions/ activities
Resting (sitting, lying) vs moving
standing vs sitting
ice vs heat
position of comfort
What are examples of temporal component
Worse in am when waking
worse as day progresses
worse at beginning of an activity, relieved during activity
worse during the night
What can be used to assess Severity
Pain intensity VAS or NPRA
VAS
current, past 7 days (best. worst), most severe at any time
NPRS
Verbal rating on a 0-10 scale
Other questions to ask about patient history
- other symptoms
- previous episode
- previous treatment for condition
examples of other symptoms
locking, instability/ giving way, numbness/tingling
What information do you want to know about current functional level
- basic home ADLs
- Instrumental (community) ADLs
- Patients goals and expectations
Information you want to get from the physician
- sling, brace, immobilizer, orthoses
- WB status
- Post- operative protocol/ precautions
Information about environment
home/living environment
Information about occupational
job duties
information about past medical history
- medical/surgical history
- Systematic diseases
- Allergies
- Pregnancy
- anything else important
Do you want to know what medications they are taking?
Yes
What test and measures
EMG/NCV
Radiographic imaging: xray, MRI, CT scan
Why do you want so much details about patient history ?
- forms working diagnosis
- Differential diagnosis
- Indication of progress or decline
- Goal setting
- Insurance
- can help drive treatment/interventions
What systems should be reviewed?
Cardiovascular, integumentary, musculoskeletal, neuromuscular
Components of observation
- waiting room assessment
- Visibility
- Dominant eye
- View from ant. post, right and left
what are you looking for when assessing the pt in the waiting room?
Posture and gait
how do you want to approach posture?
top-down or bottom up
What are you looking at for posture
head position shoulder/ scapula positioning spine pelvis lower extremities
When observing head position what are you looking for
forward head, C/S rotation, side bending
When observing shoulder/scapula positioning what are you looking for
forward shoulders.
scapula protraction/retraction/elevation/ depression
When observing the spine what are you looking for
scoliosis
normal kyphosis/lordosis
When observing pelvis position what are you looking for
- level iliac crest/ obvious rotations
- Deviated umbilicus
- Excessive tilt
When observing the LE postures what are you looking for
- Hip/knee/ankle joint angles
- Varus/valgus/recurvatum
- rearfoot varus/ valgus
- pes planes, rectus, cavus
What are you observing for the integumentary system
color, texture, temperature
What are you observing the wound/incision for?
- stage of healing
- Exudate
- Scar: red/vascularized, white/ vascularized
what are you observing when there is swelling ?
- edema/effusion
- Masses
- Girth (swelling vs atrophy)
what are you examine with AROM
Physiological motion
what are the components to physiological motion ?
-cardinal planes of motion
what do you want to observe with AROM
- willingness to perform
- quality/ pattern of movement
- pain, where?
what are you examining with PROM
Anatomical motion
Is AROM or PROM usually greater?
PROM
what do you want to look for with PROM
- weakness, active insufficiency
- Pain
- Joint or muscle contractures
- Muscle spasticity
- compare uninvolved side. norm
What do you want to asses for in PROM
- Crepitus
- Joint motion/ muscle length
- Pain/pattern of pain to resistance
- End Feel
What are you looking at for joint motion for PROM
Excessive, normal, limited
What are some causes for Excessive joint motion for PROM
trauma/disease, repetitive exposure (pitcher), genetic predisposition
what are some causes for limited joint motion for PROM
Muscle length/spasm, pain, adhesions,
Pattern of restriction can be ?
capsular pattern or non capsular pattern
Motion restriction in a proportional pattern
capsular pattern (cyriax)
what indicates total joint irritation, capsular contraction, arthritis, arthrosis
capsular pattern (cyriax)
motion restriction doesn’t follow capsular pattern?
non capsular pattern
what indicates local restriction, ligamentous adhesions, internal derangement, extra-articular lesion ?
non capsular pattern
what is the stage of injury when there is pain before tissue resistance
acute
what is the stage of injury when there is pain at tissue resistance
sub acute
what is the stage of injury when there is pain with overpressure (if painfree at tissue resistance) tissue resistance
chronic
what is the stage of injury when there no pain with overpressure?
No injury
Normal End feels for PROM
soft
firm
hard
soft end feel
soft tissue approximation
Firm end feel
Tissue stretch (muscle or capsule)
Hard end feel
bone to bone (elbow)
Abnormal end feels
muscle spasm empty hard/bony springy block capsular
Empty end feel
restricted by pain
hard bony end feel
occurs early in ROM (ostephyte)
Springy block end feel
Typical of meniscal tear
Capsular end feel
Occurs with restricted ROM
What is a MIDRANGE examination
resisted isometrics
Resisted Isometrics asses for
contractile tissue and peripheral n
Is resisted Isometric a break test?
NO
Strong and painfree
uninvolved contractile tissue or supplying nerve
Strong and painful
Mild lesion of contractile tissue, 1st or 2nd degree strain, tendinopathy
weak and painfree
Rupture of tendon or neurological involvement
Weak and painful
Severe lesion around joint, fracture causes reflex inhibition
What does MMT interpret
Muscle STRENTH grade
what does resisted isometric interpret
Assessing contractile tissue and peripheral nerve INTEGRITY
Examples of examination of task analysis for LE
- sit/stand
- stair ascent/descent
- squat/lift
Examples of examination of task analysis for UE
- Lift/ reach
- Grooming/feeding
- Writing/ turning pages
- opening jars
Special test are selected by
specific to a joint or structure
Special tests are what in nature
provocative
What do special test confirms
suspected diagnosis
Special test assists with what?
differential diagnosis
Grade 1 sprain for ligamentous testing
increased pain, no increased joint laxity, end feel softer than unaffected side
Grade 2 sprain for ligamentous testing
increased pain, increased joint laxity, end feel softer than unaffected side
Grade 3 sprain for ligamentous testing
no pain/ minimal pain, increased joint laxity, hard or soft end feel
What are findings for deep tendon reflexes
hyporeflexia (LMNL, aging)
Areflexia (LMNL)
Hyperreflexia (UMNL)
what must be relaxed to perform DTR
patient
what must be on stretch to perform DTR
tendon
grading of 0 for DTR
Absent
grading of 1 for DTR
diminished
grading of 2 for DTR
Normal
grading of 3 for DTR
Increased/ exaggerated
grading of 4 for DTR
clonus
When screening for sensation what do you do
Light touch, side-to-side difference, dermatomal distribution
What do you look for when examining sensation
pain, pressure, temp
accessory motions
movement between joint surface
Osteokinematic motion
cardinal planes of motion
Normal accessory movement is necessary for what?
full pain free ROM
Accessory motion is also referred as?
joint play
When looking at accessory motions, how must one assess the joint?
resting, open, loose packed position
When performing accessory motion what do you have to do to the segments?
stabilize one and mobilize the other
during traction/distraction the movement is in what direction from the concave joint surface
perpendicular and away
movement for traction/distraction is through what
up to and slightly through tissue resistance
During glide movement is what to the concave joint surface
parallel
movement for glide is through what
up to and slightly through tissue resistance
What are you examine for accessory motions?
mobility and pain
what is mobility for accessory motions
based on how much excursion is present from the beginning position to tissue resistance
How is mobility measured for accessory motions
7 grades
Grade 0 for accessory motions
fused
Grade 1 for accessory motions
considerably hypo mobile
Grade2 for accessory motions
slightly hypo mobile
Grade 3 for accessory motions
normal
Grade 4 for accessory motions
slightly hyper mobile
Grade 5 for accessory motions
considerably hyper mobile
Grade 6 for accessory motions
unstable
interpretation of hypomobility, no pain
chronic joint contracture/adhesion
interpretation of hypomobility, pain
acute joint contracture/ adhesion. muscle guarding
interpretation of normal excursion, pain
minor sprain
interpretation of normal excursion, no pain
normal
interpretation of hypermobility, no pain
chronic joint laxity or partial ligament tear, acute/chronic complete ligament tear
interpretation of hypermobility, pain
acute joint laxity or partial ligament tear
pain with distraction means what?
joint capsule
Pain with compression means what ?
joint surface , shortening the capsule
why do you palpate ?
alignment, tissue tension/texture/thickness, warmth, tenderness, pulses
Palpation grading of 1
compliant of pain
Palpation grading of 2
compliant of pain & winces
Palpation grading of 3
Winces & withdraws
Palpation grading of 4
No palpation allowed
Why do we exam diagnostic imaging?
confirm vs establish diagnosis
Radiography
Bone integrity, cartilage thickness (joint space)
Arthography? CT Arthrography
Peripheral joints
MRI
Joint pathology, spinal/ neural structures
CT scan
disc/ facet, complex fractures
Diagnostic US
Soft tissue injuries/ masses
what four things do you want for goals
structure (ABCDE), measurable, meaningful/functional, timely
what does A mean for goals
Actor: who will accomplish the goal
what does B mean for goals
Behavior: the action, task, or function that the individual will be able to perform
what does C mean for goals
Circumstances: The context, circumstances, and support needed to perform the behavior
what does D mean for goals
Degree: a quantitative specification of performance
what does E mean for goals
Expected time: the time period within which the goal will be achieved
Short term goals are
time frame within therapy episode of care
Long term goals are expected to met what?
as a result of PT interventions
Each STG should have what?
appropriate intervention
Plan of care should include?
Frequency and duration patient input STG and its interventions direct intervention patient education discharge planning
Patient input should be based on what?
their expectations and previous experience with PT
Direct interventions include?
TE Neuromuscular re-education manual techniques functional training physical agents
Patient education includes?
HEP
posture/ergonomics/body mechanics
activity modification