PHYSICAL

EXAMINATION
Prepared and Delivered By
Ambreen Asghar(M.Sc P.T.)
Lecture # 2
Compiled from Chapter#3 of NMSK Examination and Assessment
LEARNING OBJECTIVES
 At the end of this lecture the student will be
able to assess the patient physically and can
co-relate the objective assessment with
subjective assessment.
 Aim: To determine what structure(s) and/or
factor(s) are responsible for producing the
patient’s symptoms.
 The physical examination ‘is not simply the
indiscriminate application of routine tests,
but rather should be seen as an extension of
the subjective examination…. for specifically
testing hypotheses considered from the
subjective examination’.
 Two assumptions are made when carrying out
the physical examination:
 If symptoms are reproduced or eased then
the test has somewhat effected the
structures at fault.
 If an abnormality is detected in a structure,
which theoretically could refer symptoms to
the symptomatic area, then that structure is
suspected to be a source of the symptoms;
and is fully examined in the physical
examination. The abnormality is described as
a comparable sign.
PHYSICAL EXAMINATION STEP
BY STEP
 OBSERVATION
 Informal Observation: the clinician should
observe the patient in dynamic and static
situations; the quality of movement is noted,
as are the postural characteristics and fascial
expression. The observation starts at the
beginning of the subjective examination but
continues throughout the rest of the
subjective and physical examinations.
 *AIDS/COLLARS/STICKS.
FORMAL OBSERVATION
 OBSERVATION OF POSTURE
 Upper crossed syndrome: Where there is
elevation and protraction of the shoulders,
rotation and abduction of the scapulae and
forward head posture.
 Lower crossed syndrome: where there is an
anteriorly rotated pelvis, an increased
lumbar lordosis and slight flexion of the hips.
 The kyphosis-lordosis posture:
 Layer syndrome: there are alternate layers of
hypertrophic and hypotrophic muscles when
the patient is viewed from behind. There is
weakness of the lower stabilizers of the
scapula, lumbosacral errector spinae, gluteus
maximus, rectus abdominis and transversus
abdominis; there is hypertrophy of the
cervical errector spinae, upper trapezius,
levator scapulae, thoracolumbar errector
spinae and hamstrings.
 The flat back posture: which is characterized
by a slightly extended cervical spine, flexion
of the upper part of the thoracic spine (the
lower part is straight), absent lumbar
lordosis, a posterior pelvic tilt and extension
of the hip joints and slight plantarflexion of
the ankle joints. This is thought to be due to
elongated and weak hip flexors and short,
strong hamstrings.
 The sway back posture, which is characterized by
a forward head posture, slightly extended
cervical spine, increased flexion and posterior
displacement of the upper trunk, flexion of the
lumbar spine, posterior pelvic tilt, hyperextended
hip joints with anterior displacement of the
pelvis, hyperextended knee joints and neutral
ankle joints. This posture is thought to be due to
elongated and weak hip flexors, external
obliques, upper back extensors and neck flexors,
short and strong hamstrings and upper fibres of
the internal oblique abdominal muscles, and
strong, but not short, lumbar paraspinal muscles.
 The handedness posture: it is characterized
for right-handed individuals, as a low right
shoulder, adducted scapulae with the right
scapula depressed, a thoracolumbar curve
convex to the left, lateral pelvic tilt (high on
the right), right hip joint adducted with
slight medial rotation, and the left hip joint
abducted with some pronation of the right
foot. There is the appearance of a longer
right leg.
 Other postural presentations may include
skin creases at various levels.
 Any abnormal asymmetry in posture can be
corrected to determine its relevance to the
patient’s problem.
 Sustained postures and habitual movements
are thought to have a major role in the
development of dysfunction.
OBSERVATION OF MUSCLE
FORM
 Observe muscle shape, bulk and tone
 Compare left and right sides
 The handedness, level and frequency of
physical activity may produce differences in
muscle bulk between sides.
 Muscles produce and control movement, and
normal movement is dependent on the
strength and flexibility of the agonist and
antagonist muscles acting over a joint.
 Postural muscles are thought to shorten under
stress, while phasic muscles become weak.
OBSERVATION OF THE SOFT
TISSUES
 The local and general soft tissues can be
observed, noting the color and texture of the
skin, presence of scars, abnormal skin
creases suggesting and underlying deformity,
swelling of the soft tissues or effusion of the
joints. Skin color and texture can indicate
the state of the circulation, the state of the
patient’s general health, sympathetic
changes such as increased sweating, bruising
and the presence of other diseases.
EXAMPLES:
 Peripheral nerve lesions may result in shiny
skin that has lost its elasticity and hair, and
nails may become brittle and ridged; such as
with complex regional pain syndrome
(previously called reflex sympathetic
dystrophy). Scars may indicate injury or
surgery and will be red if recent and white
and avascular if old.
OBSERVATION OF GAIT
 Applicable for spinal & lower limb problems.
 Observes the gait from the front, behind and at
the side, looking at the pelvis, hips, knees, ankles
and feet. Common abnormalities of gait include:
 An antalgic gait due to pain at the hip, knee or
foot, characterized by a shortened stance phase
of the affected limb as compared with the non
affected limb.
 An arthrogenic gait, which occurs with hip or
knee fusion and is characterized by exaggerated
plantar flexion of the opposite ankle and
circumduction of the stiff leg to clear the toes.
 A gluteus maximus gait due to weakness of this
muscle, producing a posterior thoracic
movement during the stance phase to maintain
hip extension.
 Trendelenburg’s sign, which is due to weakness
of gluteus medius, congenital dislocation of the
hip or coxa vara, causing an excessive lateral
movement of the thorax towards the affected
limb during its stance phase of the gait cycle.
 A short leg gait producing a lateral shift of the
trunk towards the affected side during the
stance phase.
 A drop foot gait due to weakness of the ankle
and foot dorsiflexors, which causes the
patient to lift the knee higher than the
unaffected limb.
 A stiff knee or hip gait, where the patient
lifts the affected leg higher than the
unaffected leg in order to clear the ground.
OBSERVATION OF THE PATIENT’S
ATTITUDE AND FEELINGS
 The age, gender and ethnicity of patients
and their cultural, occupational and social
backgrounds will all affect the attitudes and
feelings they have towards themselves, their
condition and the clinician.
JOINT INTEGRITY TESTS
 These are specific tests to determine the
stability of the joint and will often be carried
out early in the examination, as any
instability found will affect, and may
contraindicate, further testing. Specific tests
will be described in the relevant chapters.