ORTHOPEDIC PHYSICAL ASSESSMENT
BY DR/ KHALED ALSAYANI
Total Musculoskeletal
Assessment
• Patient history
• Observation
• Examination of movement
• Special tests
• Reflexes and cutaneous distribution
• Joint play movements
• Palpation
• Diagnostic imaging.
PATIENT HISTORY
A complete medical and injury history should be taken and
written to ensure reliability
Often the examiner can make the diagnosis by simply
listening to the patient
In any musculoskeletal assessment, the examiner should
seek answers to the following pertinent questions;
1. What is the patient’s age and sex?
2. What is the patient’s occupation?
3. Why has the patient come for help?
(history of the present illness or chief complaint)
4. Was there any inciting trauma (macrotrauma) or
repetitive activity (microtrauma)?
5. Was the onset of the problem slow or sudden?
6. Where are the symptoms that bother the patient?
7. Where was the pain or other symptoms when the patient
first had the complaint?
Has the pain moved or spread?
8. What are the exact movements or activities that cause pain?
9. How long has the problem existed? What are the duration
and frequency of the symptoms?
10. Has the condition occurred before?
11. Has there been an injury to another part of the kinetic chain as well?
12. Are the intensity, duration, or frequency of pain or other symptoms
increasing?
13. Is the pain constant, periodic, episodic (occurring with certain
activities), or occasional?
14. Is the pain associated with rest? Activity? Certain postures? Visceral
function? Time of day?
15. What type or quality of pain is exhibited?
16. What types of sensations does the patient feel, and where are these
abnormal sensations?
17. Does a joint exhibit locking, unlocking, twinges, instability, or
giving way?
18. Has the patient experienced any bilateral spinal cord symptoms,
fainting, or drop attacks?
19. Are there any changes in the color of the limb?
20. Has the patient been experiencing any life or economic stresses?
21. Does the patient have any chronic or serious systemic illnesses or
adverse social habits?
22. Is there anything in the family or developmental history that may be
related?
23. Has the patient undergone an x-ray examination or other imaging
techniques?
24. Has the patient been receiving analgesic, steroid, or any other
medication? If so, for how long?
25. Does the patient have a history of surgery or past/present illness?
OBSERVATION
In an assessment, observation is the “looking” or inspection
phase.
Its purpose is to gain information on visible defects,
functional deficits, and abnormalities of alignment.
1. What is the normal body alignment?
2. Is there any obvious deformity?
3. Are the bony contours of the body normal and symmetric, or is
there an obvious deviation?
4. Are the soft-tissue contours (e.g., muscle, skin, fat) normal and
symmetric? Is there any obvious muscle wasting
5. Are the limb positions equal and symmetric?
6. Because pelvic position plays such an important role in correct posture
of the whole body, the examiner should determine if the patient can
position the pelvis in the “neutral pelvis” position
7. Are the color and texture of the skin normal?
8. Are there any scars that indicate recent injury or surgery?
9. Is there any crepitus, snapping, or abnormal sound in the joints when
the patient moves them?
10. Is there any heat, swelling, or redness in the area being observed?
11. What attitude does the patient appear to have toward the
condition or toward the examiner?
12. What is the patient’s facial expression?
13. Is the patient willing to move? Are patterns of movement
normal? If not, how are they abnormal?
EXAMINATION
Vital Signs
Scanning Examination
throughout the assessment, the examiner looks for two sets
of data:
(1) what the patient feels (subjective) and
(2) responses that can be measured or are found by the
examiner (objective).
When to Use the Scanning Examination
• There is no history of trauma
• There are radicular signs
• There is trauma with radicular signs
• There is altered sensation in the limb
• There are spinal cord (“long track”) signs
• The patient presents with abnormal patterns
• There is suspected psychogenic pain
Examination of Specific Joints
Active Movements
Examiner Observations During Active Movement
• When and where during each of the movements the onset of pain
occurs
• Whether the movement increases the intensity and quality of the pain
• The reaction of the patient to pain
• The amount of observable restriction and its nature
• The pattern of movement
• The rhythm and quality of movement
• The movement of associated joints
• The willingness of the patient to move the part
Passive Movements
Examiner Observations During Passive Movement
• When and where during each of the movements the pain
begins
• Whether the movement increases the intensity and quality of
pain
• The pattern of limitation of movement
• The end feel of movement
• The movement of associated joints
• The range of motion available
muscle strength
Signs and Symptoms of Myopathy (Muscle
Disease)
• Difficulty lifting
• Difficulty walking
• Myotonia (inability of muscle to relax)
• Cramps
• Pain (myalgia)
• Progressive weakness
• Myoglobinuria
Causes of Muscle Weakness
• Muscle strain
• Pain/reflex inhibition
• Peripheral nerve injury
• Nerve root lesion (myotome)
• Upper motor neuron lesion (even when muscle shows
increased tone)
• Tendon pathology
• Avulsion
• Psychological overlay
Special Test
Special Test Considerations
Any special test, regardless of its classification, can be
positively or negatively affected by the:
• Patient’s ability to relax
• Presence of pain and the patient’s perception of the pain
• Presence of patient apprehension
• Skill of the clinician
• Ability and confidence of the clinician
Special Test Uses
• To confirm a tentative diagnosis
• To make a differential diagnosis
• To differentiate between structures
• To understand unusual signs
• To unravel difficult signs and symptoms
Reflexes
Joint Play Movements
Mennell’s Rules for Joint Play Testing
• The patient should be relaxed and fully supported
• The examiner should be relaxed and should use a firm but
comfortable grasp
• One joint should be examined at a time
• One movement should be examined at a time
• The unaffected side should be tested first
• One articular surface is stabilized, while the other surface is moved
• Movements must be normal and not forced
• Movements should not cause undue discomfort
Palpation
Examiner Observations When Palpating a Patient
• Differences in tissue tension and texture
• Differences in tissue thickness
• Abnormalities
• Tenderness
• Temperature variation
• Pulses, tremors, and fasciculations
• Pathological state of tissues
• Dryness or excessive moisture
• Abnormal sensation
Swelling
• Comes on soon after injury → blood
• Comes on after 8 to 24 hours → synovial
• Boggy, spongy feeling → synovial
• Harder, tense feeling with warmth → blood
• Tough, dry → callus
• Leathery thickening → chronic
• Soft, fluctuating → acute
• Hard → bone
• Thick, slow-moving → pitting edema
Grading Tenderness When Palpating
• Grade I—Patient complains of pain
• Grade II—Patient complains of pain and winces
• Grade III—Patient winces and withdraws the joint
• Grade IV—Patient will not allow palpation of the joint
Diagnostic Imaging
Reasons for Ordering Diagnostic Imaging
• To confirm a diagnosis
• To establish a diagnosis
• To determine the severity of injury
• To determine the progression of a disease
• To determine the stage of healing
• To enhance patient treatment
• To determine anatomical alignment
Uses of Plain Film Radiography
• Fractures
• Arthritis
• Bone tumors
• Skeletal dysplasia
Examiner Observations When Viewing an X-Ray Film
• Overall size and shape of bone
• Local size and shape of bone
• Number of bones
• Alignment of bones
• Thickness of the cortex
• Trabecular pattern of the bone
• General density of the entire bone
• Local density change
• Margins of local lesions
• Any break in continuity of the bone
• Any periosteal change
• Any soft-tissue change (e.g., gross swelling, periosteal
elevation, visibility of fat pads)
• Relation among bones
• Thickness of the cartilage (cartilage space within joints)
• Width and symmetry of joint space
• Contour and density of subchondral bone
Tomography and Computed
Tomography
Uses of Computed Tomography Scans
• Complex fractures • Comminuted fractures
• Intra-articular fragments
• Fracture healing (e.g., non-union)
• Bone tumors
Radionuclide Scanning
(Scintigraphy
Uses of Scintigraphy
• Skeletal metastases
• Stress fractures
• Osteomyelitis
Discography
The technique of discography
involves injecting a small
amount of radiopaque dye
into the nucleus pulposus of
an intervertebral disc
Magnetic Resonance Imaging
Uses of Magnetic Resonance Imaging
• Intra-articular structures (e.g.,
meniscus, loose bodies)
• Musculotendinous injury
• Joint instability
• Osteomyelitis
• Fractures
• Stress injury
• Disc disease
• Soft tissue tumors
• Skeletal malformations
• Bone bruises
Diagnostic Ultrasound
Uses of Ultrasonography
• Hip dysplasia in children
• Joint effusion
• Tendon pathology
• Ligament tears
• Soft tissue tumors
• Vascular disease
