J.AYYAPPAN, M.P.

T (ORTHO)

ORTHOPAEDIC physical ASSESSMENT

Date:

Subjective assessment
Name: Age: Gender: Occupation: Address: IP/OP no Chief Complaint:

Place:

History taking Present History:

Allowed to narrate history Date of onset of symptoms Mechanism of injury Mode of onset Condition Improved, Stationary, Deteriorated Muscular weakness Current treatment

J.AYYAPPAN, M.P.T (ORTHO)

Past History: Relevant previous medical problem to present condition
Examples Trauma Joint injuries Neurological problem Any history of Tuberculosis Bronchial Asthma Blood Pressure Diabetes Cardiac Problems Enquiry made for any accidental injury

Family History :
Hereditary Consanguinity

Personal History :
Cigarettes Alcoholic Number/day ,How long (Pack years) Amount/day ,Duration

Socio-economic History: Social status-some of the disease common in slum area

Affordability : Economic status of the patients

Drug History :
Present medication patient is on

J.AYYAPPAN, M.P.T (ORTHO)

Pain Assessment:
Nature of the pain:
1. Burning-patient used to say burning. Ex -nerve involvement (sympathetic) 2. Electric shock- it is same like electric shock. Ex-compression on nerve 3. Pin prick-pain will be feel like prickling with needle. Ex- nerve compression 4. Needle insertion-it is familiar with everyone .Ex- nerve problem

Course:
1. Radiating pain- pain will be there in the course of the nerve- Radiculopathy 2. Localized- local pain-local injury

Types of pain:1. Dull ache-slow pain, Ex-ligament and muscle injury, Cumulative trauma disorder, Some chronic condition 2. Sharpe- Fast pain Ex-fracture- acute injuries 3. Diffused diffused pattern. Ex- muscle injury, blunted injuries 4. Unidentified cannot localized by patient. Ex- peripheral plasticity

Duration of symptoms:
From onset to present

Intensity: Subjective quantification:

Visual Analog Scale Magill pain questionnaire

Objective Quantification:
Pain pressure algometer Submaximal exertional tourniquet test

J.AYYAPPAN, M.P.T (ORTHO)

Aggravating factor:
Activities, pressure, stretching

Relieving factors:
Rest , pain medication

Objective Examination
On Observation:
General Condition of patient Poor, Good, Fair built

Muscle wasting- long term case Edema: soft spongy edema- recent fluid collection
Hard brownie edema- chronic lymphatic edema

Any bandages, Scars Area extent Attitude of the Limbs Supine, Sitting, Standing Type of gait: ask the patient to walk Bony contours: compare to normal side Deformities: any abnormal bony protrusion On Palpation:
You can do three layers of palpation. Layer 1- you can palpate the skin less pressure. Layer 2- you can palpate the fascia, adipose tissue & muscle- moderate pressure. Layer 3- you can palpate the bony contour more pressure.

J.AYYAPPAN, M.P.T (ORTHO)

Tenderness :
Grading Grade 1 - Patient complains of pain Grade 2 - Patient complains of pain & winces Grade 3 - Patient winces & withdraws Grade 4 - Patient will not allow palpation of the joint

Tissue tension and texture :

Temperature variation of skin- inflammation Spasm Type of skin Dry or Excessive moisture Scar Adherent / Non Adherent Swelling

Points to be considered while assessing swelling

Comes on soon after injury Blood Comes on after 8 to 24 hours Synovial Blood Boggy, spongy feeling Synovial Harder, tense feeling ,with warmth Tough, dry Callus Leathery thickening Hard Bone Pitting edema Chronic Soft fluctuating Acute Thick, slow-moving Bruit or Thrill with edema- Active Hemorrhage

Crepitus, Abnormal sounds

J.AYYAPPAN, M.P.T (ORTHO)

On Examination:

Vital Signs :

Motor Assessment
Range of Motion (ROM) Active - When and where pain starts Whether movement increases pain - Pattern of movement , Trick movements Passive - When and where pain starts - Whether movement increases pain Pattern of movement D/F between range of motion available

End Feel
Normal: Bone to Bone - elbow extension Soft Tissue Approximation -elbow flexion , knee flexion Tissue Stretch- hip flexion, Abnormal : Early Muscle Spasm acute severe injury Late Muscle Spasm joint pain Hard Capsular PA shoulder

Soft Capsular - capsulities Bone to Bone Empty pain Springy Block muscle tightness myosities ossificans

Capsular Patterns :
Normal capsular pattern Abnormal capsular pattern

J.AYYAPPAN, M.P.T (ORTHO)

Manual Muscle Testing : MRC Grading Resisted Isometrics On contraction causes pain and, if it does, pain s intensity & quality - Strength of contraction Type of contraction causing problem (concentric, isometric, eccentric) Joint movements Loose packed position Close packed position

Sensory Assessment
Superficial Sensations - Pain, Temperature, Light touch, Pressure Deep Sensations Movement sense Position sense Combined Sensations Stereognosis, Barrognosis Tactile Localization, Two Point Discrimination, Grapesthesia MRC Grading S0 : No sensation S1 : Deep Proprioception S2 : Skin touch, pain thermal sensation S3 : S2 with accurate localization but deficient stereognosis, cold sensitivity, hypersensitivity often present S3+ : Object and texture recognition but not normal sensation, good but not normal two point discrimination S4 : Normal sensations

J.AYYAPPAN, M.P.T (ORTHO)

Reflexes
Superficial Reflexes Corneal, Abdominal, Plantar, Cremasteric Deep Reflexes Biceps, Triceps, Babinski Reflex, Knee Jerk, Ankle Jerk Clonus : Grading 0 : Absent 1 : Diminished 2 : Normal 3 : Brisk 4 : Exaggerated

Dermatomes & Myotomes : Limb Length Discrepancies

Apparent Length True Length

Peripheral scanning examination: Assess the proximal and distal joints to the affected area
Ex- Double crush syndrome

Special Tests:
See the annexure

Functional Assessment : Using any one of the functional assessment scale

Ambulation o Gait or Wheel Chair o Independent or Dependent - Transfers

J.AYYAPPAN, M.P.T (ORTHO)

Gait Assessment
Type of gait Stride length Step length

ADL: BADL- Basic activities of daily living Eg- bathing, eating, FIM scale Any other functional assessment scale Investigations:
X-ray, CT scan, MRI, BMD, Global skeletal scan, Arthroscopy

IADL- Instrumental Activities of daily livings Eg- cooking, combing, home making

Clinical Impression:
Medical diagnosis/Pathological study

Differential Diagnosis:
Rule out the inappropriate conditions

Findings to make Final Impression:

Positive points should support your diagnosis Provisional diagnosis: Your diagnosis Based on your own assessment, functional limitation of the patients, and area of the involvement. Eg; lateral Elbow paintennis elbow, Tone dysfunction and movement disorder in half of the body- hemiplegia Do not write your diagnosis based on tissue pathology

J.AYYAPPAN, M.P.T (ORTHO)

Goals: Short Term Long Term Treatment Plan: Electric Modalities Manipulation Exercises Splints & Assistive Devices Home Programme:

J.AYYAPPAN, M.P.T (ORTHO)

SPECIAL ORTHOPAEDIC TESTS

Shoulder:
Yergason s Test Lippman s Test Supraspinatus Test (Empty Can Test) Drop Arm Test (Codman s Test) Neer Impingement Test Roos Test Wright Test Adson Test Allen s Test Upper Limb Tension Test (ULTT) ULTT 1 ULTT 2 ULTT 3 ULTT 4 - Rotator Complex Supraspinatus & Biceps Tendon - Thoracic Outlet Syndrome - Thoracic Outlet Syndrome - Thoracic Outlet Syndrome - Thoracic Outlet Syndrome Median nerve & anterior interosseous nerve C5, 6, 7, Median nerve, Musculocutaneous nerve & axillary nerve - Radial nerve - C8, T1, Ulnar nerve Apprehension Test Rockwood Test Dugas Test Posterior Apprehension Test Push Pull Test Sulcus Test Clunk Test - Anterior Shoulder Dislocation - Anterior Shoulder Instability - Anterior Shoulder Dislocation - Posterior Shoulder Dislocation - Posterior Shoulder Dislocation - Inferior Shoulder Instability - Labral Tear Speed Test - Bicipital Tendinitis (Biceps or Straight Arm Test) - Bicipital Tendinitis - Bicipital Tendinitis - Supraspinatus Tear

J.AYYAPPAN, M.P.T (ORTHO)

Forearm, Wrist & Hand:

Finketsein s Test Sweater Finger Test Bunnel-Litter Test Phalen s Test Reverse Phalen s Test Froment s Sign

Abductor Pollicis Longus & Extensor Pollicis Longus Tenosynovitis Ruptured Flexor Digitorum Profundus - Tight Intrinsics - Carpal Tunnel Syndrome - Carpal Tunnel Syndrome Paralysis of Adductor Pollicis Longus

Pelvis: Approximation Test

Gapping Test Sacroiliac Rocking Test (SI Strain) SLR (Lascgucs Test) Gaenslen s Test

Prone Knee Bend Test Yeoman s Test

Possible SI Lesion or Sprain Posterior SI Ligaments - Sprain Anterior SI Ligaments - Sacrotuberous Ligaments - SI Problems - I/P SI Lesion or Hip Pathology or Lumbar Pathology - For D/F Diagnosis

Hip: Patrick s Test

(FABER or Figure Four Test) Stinchfield Test Thomas Test Rectus Femoris Contracture Test Ober s Test Piriformis Test

- Hip Joint? Iliopsoas Spasm - Hip Joint Pathology - Hip Flexion Contracture - For Rectus Femoris - TFL Contracture - Piriformis Syndrome

J.AYYAPPAN, M.P.T (ORTHO)

Knee: Valgus Stress Test
Varus Stress Test Lachman Test Anterior Drawer Sign Posterior Drawer Sign McMurray Test Apley s Test Bounce Home Test Mediopatellar Plica Test Fluctuation Test Patellar Tap Test Clarke s Sign McConnell Test Q-Angle or Patellofemoral Angle Fairbank s Apprehension Test - Medial Collateral Ligament - Lateral Collateral Ligament - Anterior Cruciate Ligament - Anterior Cruciate Ligament - Posterior Cruciate Ligament - Meniscal Tear - Meniscal or Ligamentous? - Meniscal Injury - Mediopatellar Plica - Swelling - Swelling - Patellofemoral Dysfunction - Chondromalacia Patella - Patellofemoral Dysfunction - Dislocation of Patella

Ankle: Anterior Drawer Test

Talar Tilt Thompson s Test

Anterior Talofibular Ligament Injury - Calcaneofibular Ligament - Achilles Tendon Rupture

Cervical Spine: Foraminal

Compression (Sparling s Test) ULTT s Shoulder Depression Test & Abduction Test Jackson s Compression Test Valsalva Tests Vertebral Artery Test (Cervical Quadrant Test)

- Cervical Radiculitis

D/F Diagnosis Compression of nerve roots or Brachial Plexus Lesion Pressure on nerve root Herniated disc / Tumour / Osteophyte Compression of Vertebral Artery

Thoracic Spine: Slump Test

Impingement of Dura & Spinal Cord / Nerve Roots

J.AYYAPPAN, M.P.T (ORTHO)

Lumbar Spine: Slump Test
SLR (Basic), 2, 3, 4, Crossed SLR Valsalva Maneuver Schober s Test Stoop Test - For Neuromeningeal Tract - Sciatic, Tibial, Sural, Common Peroneal, Disc Prolapse - Increased Intrathecal Pressure Measure Flexion of Lumbar Spine Neurogenic Intermittent Claudication

Tests for Malingering:

Hoover Test Burns Test

- Malingering for Back Pain - Malingering for Back Pain