Musculoskeletal Physical Examination of the Lower Limb Flashcards
MODELS OF ASSESSMENT
What is the pathology based model?
traditional medical model
MODELS OF ASSESSMENT
What does the pathology based model use to classify clinical phenomena into diagnostic labels?
clinical tests
MODELS OF ASSESSMENT
What does the pathology based model give little insight into?
Severity, irritability, nature, or stage of disorder
MODELS OF ASSESSMENT
What happens with the “impairment” based assessment model?
Examination findings drive selection of various treatments (and creates signs) –> what you find upon examination is what shapes the type of treatment prescribed.
MODELS OF ASSESSMENT
What is important about the relationship between the impairment the symptoms?
the relationship between the two is of greater importance than the label of the diagnosis. (impairment causes the symptoms?)
AIMS OF PHYSICAL EXAMINATION (PE)
what does PE confirm/ reformulate?
the diagnostic hypothesis(es) made from the patient interview
AIMS OF PHYSICAL EXAMINATION (PE)
what does PE find?
a comparable sign/ asterisk sign
- establish disorder = musc
- implicate specific structures
AIMS OF PHYSICAL EXAMINATION (PE)
Determines…
Possible predisposing/ contributing physical factors (that leads to the injury)
AIMS OF PHYSICAL EXAMINATION (PE)
Guides…
selection of safe & effective treatment techniques
AIMS OF PHYSICAL EXAMINATION (PE)
Documents…
Outcome measures
Elements of PE
- observation (initial palpation)
- fctnal mvmts
- active mvmts
- passive mvmts (physiological & accessory)
- adjacent joints
- muscle tests (recruitment, strength, length)
- special tests e.g. ortho tests
- neuro tests
- neural tissue mechanosensitivity tests
- palpation (final)
PE considerations
1.
Move through different positions systematically
Why is it good to move through different positions?
- standing –> sitting (supine/ sidelying/ prone)
- more efficient
- less demand on patient
Why should you consider acute/ traumatic?
- diagnosis may already be established
- may need to limit examination (on pain etc.)
Why should you consider overuse/ gradual onset?
- strong consideration of intrinsic & extrinsic contributing factors
- may consider referral (e.g. pronation ++ –> podiatrist)
When do you start observing patient?
as soon as they enter the room
What do you observe?
- total body posture
- overall postural type
- gross changes in skin, muscle contours, body alignment
Local area observation elements:
- deformity
- swelling
- skin colour
- muscle wasting
- muscle spasm
- muscle imbalance
- traumatic/ surgical scars
Must observe
Willingness to move
Guarding/ protecting?
Must observe;
Correction of protective deformities
- are postural abnormalities/ alignment associated with patient’s symptoms
- adaptive/ maladaptive?
What do you look for in functional tests?
Movement/ activity that patient associates with symptoms / aggravating activity
- gait speed
Note in Fx:
- phase of movement in which symptom is felt
- behaviour of symptoms during activity/ movement (pain change? etc)
What are you testing for in palpation?
- temperature
- swelling
- tone of muscles (i.e. any tears?)
- other signs of inflammation –> redness
- bony abnormalities
- soft tissue thickening
- tenderness in soft tissues, muscles & insertions (tendons)
Purpose of AROM
find movement impairments with signs (pain, resistance, spasm, etc) that are comparable with the patient’s symptoms & disability
AROM consists of:
Patient performance of physiological movements along axes e.g. flexion, abduction etc.
AROM looking for:
- willingness to move
- quality of movement
- range of movement
- symptom response
What do we record for Active Movements?
- point of onset of pain/ increase in pain
- limit of AROM & if pain-free to overpressure
- pattern of movement/ Quality of movement
- compare with the other side
Overpressure purpose
additional stress testing to use if symptoms have not been provoked further
What is overpressure?
a moderate degree of oscillating pressure applied at limit of range
How do the oscillations in overpressure move?
gently but increasingly into limit of movement
What is the joint classed as in overpressure?
not classed as normal unless relatively firm overpressure can be applied painlessly
Purpose of Passive Movements (PROM)
To differentiate between contractile and non-contractile sources of symptoms ( e.g. joint vs muscle/tendon)
What do Passive Movements consist of?
- physiological movements
- accessory movements
What are you assessing with PROM?
- willingness to be moved
- quality of movement
- range of movement
- symptom response (symptoms that are normal, symptoms that reproduce the patient’s symptoms)
Passive Physiological movement (PPM)
movements that a person can carry out actively e.g. ankle DF
Passive Accessory movement (PAM)
Movements that a person cannot perform independently but are necessary for joint movement e.g. roll, spin, slide/glide & distraction, compression
What’s a common example of PAM?
anteroposterior glide of talus during ankle DF
What does normal ROM include?
active & passive ranges
What is ‘end-feel’?
term used to describe the sensation the examiner feels in the joint as it reaches end of range during passive movement
Why is end-feel important?
Very important diagnostic skill in detecting abnormal/ dysfunctional movement
What does end-feel feel like?
Bony, soft tissue, capsular, spasm
What do we record with passive movements?
- point of onset of pain/ increase of pain
- limit of PROM & if pain-free to overpressure
- pattern of movement/ Quality of movement
- compare with other side
Can adjacent joints refer pain/ symptoms to the area of primary problem?
yes
Can adjacent jts have altered function that is a predisposing factor to presenting problem?
yes
Can adjacent jts be injured at the same time as presenting problem?
yes
Can adjacent jts be affected by dysfunction in the presenting area?
Yes
e.g. signs of disuse, stiffness
What should you do first when diagnosing the injury?
clear joints above and below the painful one/ those with components which may refer symptoms
What do you use when clearing the joints above and below the painful one?
- guided active movements with overpressure at the end of range
- active & specific passive test
Adjacent jts tests
What is the active test for the hip joint?
Squat
What is the passive test for the hip jt?
Hip Quadrant or F/Add
What is the active test for the knee jt?
squat
What is the active test for the ankle?
squat
What is the passive test for the ankle?
DF + OP, PF + OP, Inf tib/fib PA/AP
What are the two types of muscle tests?
Quantitaive & Qualitative
What are the 2 types of quantitative muscle tests?
- strength testing
- muscle length tests
What are the types of strength tests?
- MMT (through range)
- hand held dynamometry
- isotonic/ isokinetic testing
What are the types of qualitative tests?
- functional muscle testing
- resisted iso contractions
- recruitment/ activation patterns
What grades are the MMT reliable for?
<3
What grades do you use hand held dynamometry to quantify iso muscle strength?
> 3
What are the different muscle length tests?
- SLR
- 90-90 test
- Ely test
- Gastrocnemius & soleus
- Thomas test
What is functional muscle testing?
Endurance testing/ inner range holds
What do you assess with a resisted/ static isometric contraction (SMT)?
whether the muscle/ tendon is a source of pain?
What does SMT provide?
quick screen of general strength
What is a SMT?
standardised test procedure
What do you avoid if there is pain from the joint?
joint movement
What do you do to test the joint if there is pain?
test in a position where all joint structures are most relaxed.
What are resisted/ static isometric contractions muscle tests used for?
to determine focal point of muscle injury
When are the SMT (static muscle tests) included?
in the objective examination as special tests for specific areas
What do you look to do with SMT?
reproduce symptoms
Is there a strength grade assigned to SMT?
no
What do you use SMT with?
other techniques e.g. palpation & length to achieve DD of muscle
MUSCLE CONTROL TESTS
What is the recruitment/ activation pattern of hip extension?
Glute max –> hamstrings (often dominant in hip/ lower limb dysfunction)
MUSCLE CONTROL TESTS
What is the recruitment pattern of knee extension?
VL &VMO simultaneously (often VMO delay in dysfunction of the knee)
What are the muscle qualities associated with muscle condition?
- strength
- endurance
- power
- length
What are the muscle qualities associated with muscle control?
- balance
- co-ordination –> proprioception
What do special tests depend on?
area examined and its unique anatomy & function
What are the 3 orthopaedic tests?
- ligament stress tests
- capsule tests
- dynamic instability tests
What are the 2 types of tests of the nervous system?
- neurological (first)
- neurodynamic (second)
Neurological examination
- someone comes in with symptoms
–> tests nerve conduction & function (e.g. dermatomes, reflexes, strength)
Neurodynamic examination
more specific examination
–> tests nerve movement throughout the body
What is palpation used for?
- to help confirm your diagnosis
- to confirm the extent of injury e.g. size of haematoma
- to help rule out other structures
When is palpation used?
final
DD’S (1)
Order of DD’s & testing (yes series)
Is active ROM full and painfree?
YES
Can you add overpressire?
YES
Clearing test -ve?
YES
Possibly non MSK/ referred?
–> Further testing: sustained, combined/ increased load?
DD’s (2)
Is AROM full and painfree?
YES
Can you add overpressure?
NO
Passive accessories -ve?
NO
Passive tissue (articular, tendoligamentous, neural?)
–> further testing: SOT? Neurodynamic?
DD’s (3)
Is AROM full and painfree?
NO
is PROM full and painfree?
YES
Iso restricted musc tests -ve?
NO
Active tissue (muscle pathology?)
–> further testing SOT, Neurodynamic?
–>Further testing MMT? recruitment? Functional testing? SOT?
DD’s (4)
is AROM full and painfree?
NO
Is PROM full and painfree?
NO
Passive accessories -ve?
NO
Passive tissue (articular, tendolig, neural)
–> further testing: sustained/ combined/ increased load & SOT/ Neurodynamic?
What do you typically measure?
- tests that reproduce symptoms
- variable that you expect to change with treatment/ intervention
- tests which are meaningful to the patient
IMPAIRMENTS AND ASSESSMENT
What is the clinical measurement for pain?
visual analogue scale (VAS)
IMPAIRMENTS AND ASSESSMENT
What is the clinical measurement for decreased hip ROM?
Goniometry – UG, inclinometer
IMPAIRMENTS AND ASSESSMENT
What is the clinical measurement for decreased muscle strength?
MMT, dynamometry
IMPAIRMENTS AND ASSESSMENT
What is the clinical measurement for decreased balance?
timed one leg balance test
Functional reach test
IMPAIRMENTS AND ASSESSMENT
What is the clinical measurement for impaired gait?
Gait assessment
10MWT
IMPAIRMENTS AND ASSESSMENT
What is the clinical measurement for poor posture & trunk strength ?
postural assessment
core stability testing
IMPAIRMENTS AND ASSESSMENT
What is the clinical measurement for reduced fitness?
Cardiovascular assessment
DIAGNOSIS OF MUSCLE/ TENDON PATHOLOGY
Clinical Test & test response
What is the test response for physiological movement?
PROM > AROM
DIAGNOSIS OF MUSCLE/ TENDON PATHOLOGY
Clinical Test & test response
Accessory movement
NAD
DIAGNOSIS OF MUSCLE/ TENDON PATHOLOGY
Clinical Test & test response
Palpation
Tender at site of lesion
DIAGNOSIS OF MUSCLE/ TENDON PATHOLOGY
Clinical Test & test response
Isometric tests
Provocative of symptoms
DIAGNOSIS OF MUSCLE/ TENDON PATHOLOGY
Clinical Test & test response
Muscle length tests
Possible reproduction of symptoms
DIAGNOSIS OF JOINT PATHOLOGY
Clinical Test & test response
Physiological movement
AROM = PROM and both reduced
altered end feel, earlier in range
symptom reprod
DIAGNOSIS OF MUSCLE/ TENDON PATHOLOGY
Clinical Test & test response
Accessory movement
Reduced range/ stiffness, altered end feel, painful
Where normal, consider muscle shortening as cause of restricted range
DIAGNOSIS OF MUSCLE/ TENDON PATHOLOGY
Clinical Test & test response
Palpation
Difficult to palpate joint structures
DIAGNOSIS OF MUSCLE/ TENDON PATHOLOGY
Clinical Test & test response
Isometric tests
No Pain
Pain if joint very sensitive (may compress jt)
DIAGNOSIS OF MUSCLE/ TENDON PATHOLOGY
Clinical Test & test response
Muscle length tests
Not valid when PROM limited
What things should you have at the end of the PE?
- clear idea of contraindictaions/ precautions to physio
- provisional diagnosis (pathoanatomical and/or clinical) to guide selection of tremant techniques
- determined short & long term goals of treatment
- established clear & quantitative outcomes on which to continually evaluate effectiveness of treatment
- established timeframes in which goals can be achieved
What does the prognosis (timeframe) depend on?
- age
- general health & lifestyle
- compliance & self
- severity & irritability of the injury
- extent of tissue damage & other associated injuries
- extent of PE
- normal healing process
What should goal setting always be?
with the patient
Goals should be…
SMART
Features of the PE
- consent for PE gained
- further interpretation
- confirm MSK problem
- confirm hypothesis
- determine impairments
