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MUSC 206 > Musculoskeletal Physical Examination of the Lower Limb > Flashcards

Musculoskeletal Physical Examination of the Lower Limb Flashcards

1
Q

MODELS OF ASSESSMENT
What is the pathology based model?

A

traditional medical model

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2
Q

MODELS OF ASSESSMENT
What does the pathology based model use to classify clinical phenomena into diagnostic labels?

A

clinical tests

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3
Q

MODELS OF ASSESSMENT
What does the pathology based model give little insight into?

A

Severity, irritability, nature, or stage of disorder

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4
Q

MODELS OF ASSESSMENT
What happens with the “impairment” based assessment model?

A

Examination findings drive selection of various treatments (and creates signs) –> what you find upon examination is what shapes the type of treatment prescribed.

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5
Q

MODELS OF ASSESSMENT
What is important about the relationship between the impairment the symptoms?

A

the relationship between the two is of greater importance than the label of the diagnosis. (impairment causes the symptoms?)

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6
Q

AIMS OF PHYSICAL EXAMINATION (PE)
what does PE confirm/ reformulate?

A

the diagnostic hypothesis(es) made from the patient interview

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7
Q

AIMS OF PHYSICAL EXAMINATION (PE)
what does PE find?

A

a comparable sign/ asterisk sign
- establish disorder = musc
- implicate specific structures

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8
Q

AIMS OF PHYSICAL EXAMINATION (PE)
Determines…

A

Possible predisposing/ contributing physical factors (that leads to the injury)

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9
Q

AIMS OF PHYSICAL EXAMINATION (PE)
Guides…

A

selection of safe & effective treatment techniques

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10
Q

AIMS OF PHYSICAL EXAMINATION (PE)
Documents…

A

Outcome measures

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11
Q

Elements of PE

A
  • 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)
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12
Q

PE considerations
1.

A

Move through different positions systematically

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13
Q

Why is it good to move through different positions?

A
  1. standing –> sitting (supine/ sidelying/ prone)
  2. more efficient
  3. less demand on patient
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14
Q

Why should you consider acute/ traumatic?

A
  • diagnosis may already be established
  • may need to limit examination (on pain etc.)
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15
Q

Why should you consider overuse/ gradual onset?

A
  • strong consideration of intrinsic & extrinsic contributing factors
  • may consider referral (e.g. pronation ++ –> podiatrist)
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16
Q

When do you start observing patient?

A

as soon as they enter the room

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17
Q

What do you observe?

A
  • total body posture
  • overall postural type
  • gross changes in skin, muscle contours, body alignment
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18
Q

Local area observation elements:

A
  • deformity
  • swelling
  • skin colour
  • muscle wasting
  • muscle spasm
  • muscle imbalance
  • traumatic/ surgical scars
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19
Q

Must observe
Willingness to move

A

Guarding/ protecting?

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20
Q

Must observe;
Correction of protective deformities

A
  • are postural abnormalities/ alignment associated with patient’s symptoms
  • adaptive/ maladaptive?
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21
Q

What do you look for in functional tests?

A

Movement/ activity that patient associates with symptoms / aggravating activity
- gait speed

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22
Q

Note in Fx:

A
  • phase of movement in which symptom is felt
  • behaviour of symptoms during activity/ movement (pain change? etc)
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23
Q

What are you testing for in palpation?

A
  • 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)
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24
Q

Purpose of AROM

A

find movement impairments with signs (pain, resistance, spasm, etc) that are comparable with the patient’s symptoms & disability

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25
Q

AROM consists of:

A

Patient performance of physiological movements along axes e.g. flexion, abduction etc.

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26
Q

AROM looking for:

A
  • willingness to move
  • quality of movement
  • range of movement
  • symptom response
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27
Q

What do we record for Active Movements?

A
  • 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
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28
Q

Overpressure purpose

A

additional stress testing to use if symptoms have not been provoked further

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29
Q

What is overpressure?

A

a moderate degree of oscillating pressure applied at limit of range

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30
Q

How do the oscillations in overpressure move?

A

gently but increasingly into limit of movement

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31
Q

What is the joint classed as in overpressure?

A

not classed as normal unless relatively firm overpressure can be applied painlessly

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32
Q

Purpose of Passive Movements (PROM)

A

To differentiate between contractile and non-contractile sources of symptoms ( e.g. joint vs muscle/tendon)

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33
Q

What do Passive Movements consist of?

A
  • physiological movements
  • accessory movements
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34
Q

What are you assessing with PROM?

A
  1. willingness to be moved
  2. quality of movement
  3. range of movement
  4. symptom response (symptoms that are normal, symptoms that reproduce the patient’s symptoms)
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35
Q

Passive Physiological movement (PPM)

A

movements that a person can carry out actively e.g. ankle DF

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36
Q

Passive Accessory movement (PAM)

A

Movements that a person cannot perform independently but are necessary for joint movement e.g. roll, spin, slide/glide & distraction, compression

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37
Q

What’s a common example of PAM?

A

anteroposterior glide of talus during ankle DF

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38
Q

What does normal ROM include?

A

active & passive ranges

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39
Q

What is ‘end-feel’?

A

term used to describe the sensation the examiner feels in the joint as it reaches end of range during passive movement

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40
Q

Why is end-feel important?

A

Very important diagnostic skill in detecting abnormal/ dysfunctional movement

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41
Q

What does end-feel feel like?

A

Bony, soft tissue, capsular, spasm

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42
Q

What do we record with passive movements?

A
  • 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
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43
Q

Can adjacent joints refer pain/ symptoms to the area of primary problem?

A

yes

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44
Q

Can adjacent jts have altered function that is a predisposing factor to presenting problem?

A

yes

45
Q

Can adjacent jts be injured at the same time as presenting problem?

A

yes

46
Q

Can adjacent jts be affected by dysfunction in the presenting area?

A

Yes
e.g. signs of disuse, stiffness

47
Q

What should you do first when diagnosing the injury?

A

clear joints above and below the painful one/ those with components which may refer symptoms

48
Q

What do you use when clearing the joints above and below the painful one?

A
  • guided active movements with overpressure at the end of range
  • active & specific passive test
49
Q

Adjacent jts tests
What is the active test for the hip joint?

A

Squat

50
Q

What is the passive test for the hip jt?

A

Hip Quadrant or F/Add

51
Q

What is the active test for the knee jt?

A

squat

52
Q

What is the active test for the ankle?

A

squat

53
Q

What is the passive test for the ankle?

A

DF + OP, PF + OP, Inf tib/fib PA/AP

54
Q

What are the two types of muscle tests?

A

Quantitaive & Qualitative

55
Q

What are the 2 types of quantitative muscle tests?

A
  1. strength testing
  2. muscle length tests
56
Q

What are the types of strength tests?

A
  • MMT (through range)
  • hand held dynamometry
  • isotonic/ isokinetic testing
57
Q

What are the types of qualitative tests?

A
  • functional muscle testing
  • resisted iso contractions
  • recruitment/ activation patterns
58
Q

What grades are the MMT reliable for?

A

<3

59
Q

What grades do you use hand held dynamometry to quantify iso muscle strength?

A

> 3

60
Q

What are the different muscle length tests?

A
  1. SLR
  2. 90-90 test
  3. Ely test
  4. Gastrocnemius & soleus
  5. Thomas test
61
Q

What is functional muscle testing?

A

Endurance testing/ inner range holds

62
Q

What do you assess with a resisted/ static isometric contraction (SMT)?

A

whether the muscle/ tendon is a source of pain?

63
Q

What does SMT provide?

A

quick screen of general strength

64
Q

What is a SMT?

A

standardised test procedure

65
Q

What do you avoid if there is pain from the joint?

A

joint movement

66
Q

What do you do to test the joint if there is pain?

A

test in a position where all joint structures are most relaxed.

67
Q

What are resisted/ static isometric contractions muscle tests used for?

A

to determine focal point of muscle injury

68
Q

When are the SMT (static muscle tests) included?

A

in the objective examination as special tests for specific areas

69
Q

What do you look to do with SMT?

A

reproduce symptoms

70
Q

Is there a strength grade assigned to SMT?

A

no

71
Q

What do you use SMT with?

A

other techniques e.g. palpation & length to achieve DD of muscle

72
Q

MUSCLE CONTROL TESTS
What is the recruitment/ activation pattern of hip extension?

A

Glute max –> hamstrings (often dominant in hip/ lower limb dysfunction)

73
Q

MUSCLE CONTROL TESTS
What is the recruitment pattern of knee extension?

A

VL &VMO simultaneously (often VMO delay in dysfunction of the knee)

74
Q

What are the muscle qualities associated with muscle condition?

A
  • strength
  • endurance
  • power
  • length
75
Q

What are the muscle qualities associated with muscle control?

A
  • balance
  • co-ordination –> proprioception
76
Q

What do special tests depend on?

A

area examined and its unique anatomy & function

77
Q

What are the 3 orthopaedic tests?

A
  • ligament stress tests
  • capsule tests
  • dynamic instability tests
78
Q

What are the 2 types of tests of the nervous system?

A
  1. neurological (first)
  2. neurodynamic (second)
79
Q

Neurological examination

A
  • someone comes in with symptoms
    –> tests nerve conduction & function (e.g. dermatomes, reflexes, strength)
80
Q

Neurodynamic examination

A

more specific examination
–> tests nerve movement throughout the body

81
Q

What is palpation used for?

A
  1. to help confirm your diagnosis
  2. to confirm the extent of injury e.g. size of haematoma
  3. to help rule out other structures
82
Q

When is palpation used?

A

final

83
Q

DD’S (1)
Order of DD’s & testing (yes series)

A

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?

84
Q

DD’s (2)

A

Is AROM full and painfree?
YES
Can you add overpressure?
NO
Passive accessories -ve?
NO
Passive tissue (articular, tendoligamentous, neural?)
–> further testing: SOT? Neurodynamic?

85
Q

DD’s (3)

A

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?

86
Q

DD’s (4)

A

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?

87
Q

What do you typically measure?

A
  1. tests that reproduce symptoms
  2. variable that you expect to change with treatment/ intervention
  3. tests which are meaningful to the patient
88
Q

IMPAIRMENTS AND ASSESSMENT
What is the clinical measurement for pain?

A

visual analogue scale (VAS)

89
Q

IMPAIRMENTS AND ASSESSMENT
What is the clinical measurement for decreased hip ROM?

A

Goniometry – UG, inclinometer

90
Q

IMPAIRMENTS AND ASSESSMENT
What is the clinical measurement for decreased muscle strength?

A

MMT, dynamometry

91
Q

IMPAIRMENTS AND ASSESSMENT
What is the clinical measurement for decreased balance?

A

timed one leg balance test
Functional reach test

92
Q

IMPAIRMENTS AND ASSESSMENT
What is the clinical measurement for impaired gait?

A

Gait assessment
10MWT

93
Q

IMPAIRMENTS AND ASSESSMENT
What is the clinical measurement for poor posture & trunk strength ?

A

postural assessment
core stability testing

94
Q

IMPAIRMENTS AND ASSESSMENT
What is the clinical measurement for reduced fitness?

A

Cardiovascular assessment

95
Q

DIAGNOSIS OF MUSCLE/ TENDON PATHOLOGY
Clinical Test & test response
What is the test response for physiological movement?

A

PROM > AROM

96
Q

DIAGNOSIS OF MUSCLE/ TENDON PATHOLOGY
Clinical Test & test response
Accessory movement

A

NAD

97
Q

DIAGNOSIS OF MUSCLE/ TENDON PATHOLOGY
Clinical Test & test response
Palpation

A

Tender at site of lesion

98
Q

DIAGNOSIS OF MUSCLE/ TENDON PATHOLOGY
Clinical Test & test response
Isometric tests

A

Provocative of symptoms

99
Q

DIAGNOSIS OF MUSCLE/ TENDON PATHOLOGY
Clinical Test & test response
Muscle length tests

A

Possible reproduction of symptoms

100
Q

DIAGNOSIS OF JOINT PATHOLOGY
Clinical Test & test response
Physiological movement

A

AROM = PROM and both reduced
altered end feel, earlier in range
symptom reprod

101
Q

DIAGNOSIS OF MUSCLE/ TENDON PATHOLOGY
Clinical Test & test response
Accessory movement

A

Reduced range/ stiffness, altered end feel, painful
Where normal, consider muscle shortening as cause of restricted range

102
Q

DIAGNOSIS OF MUSCLE/ TENDON PATHOLOGY
Clinical Test & test response
Palpation

A

Difficult to palpate joint structures

103
Q

DIAGNOSIS OF MUSCLE/ TENDON PATHOLOGY
Clinical Test & test response
Isometric tests

A

No Pain
Pain if joint very sensitive (may compress jt)

104
Q

DIAGNOSIS OF MUSCLE/ TENDON PATHOLOGY
Clinical Test & test response
Muscle length tests

A

Not valid when PROM limited

105
Q

What things should you have at the end of the PE?

A
  1. clear idea of contraindictaions/ precautions to physio
  2. provisional diagnosis (pathoanatomical and/or clinical) to guide selection of tremant techniques
  3. determined short & long term goals of treatment
  4. established clear & quantitative outcomes on which to continually evaluate effectiveness of treatment
  5. established timeframes in which goals can be achieved
106
Q

What does the prognosis (timeframe) depend on?

A
  1. age
  2. general health & lifestyle
  3. compliance & self
  4. severity & irritability of the injury
  5. extent of tissue damage & other associated injuries
  6. extent of PE
  7. normal healing process
107
Q

What should goal setting always be?

A

with the patient

108
Q

Goals should be…

A

SMART

109
Q

Features of the PE

A
  • consent for PE gained
  • further interpretation
  • confirm MSK problem
  • confirm hypothesis
  • determine impairments

MUSC 206 (5 decks)

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