Overview
- Inspection/Observation
- Range of Motion
- Resisted isometric muscle test
- Neurological test
- Funcional Measures
- Special tests
- Palpation
Observation
Expose the area and offer to drape
- compare affected and non-affected sides (looks for asymmetries)
- Look for signs of inflammation-redness, swelling, bruising
- Loof for signs of deformity
Visually inspect areas above and bleow the affected body region
- E.g. Shoulder Ax: shoulder+ Cx & Tx spine
- E.g. Ankle Ax: foot & knee
Posture assessment
- Positions specific to their problem (e.g. pain while sitting at a desk–>observe sitting posture)
- Use a top-down/bottom-up approach to maintain consistency (e.g. head, neck, shoulders, Tx, Lx)
- View multiple angles- side, front, back
Why observation is important?
This information will help me determine the baseline of the Pt.
Are they in an acute stage? (any signs of swelling, redness or bruising)
It will also give me strong pre-post treatment outcome measure (e.g. swelling looks decreased after cryotherapy?)
The postural Ax can help me determine if there is a correlation between the Pt’s condition/injury and posture. If necessary, postural correction and ergonomics can be included in the treatment plan.
Range of Motion
Assess affected joints, including the joints above and below the affected area (e.g. shoulder pain- assess Cx, Tx, elbow)
* Start with AROM, if AROM is WNL & pain-free, no further ROM testing is required
* If painful/limited AROM, proceed to PROM and assess end feel
CAUTION with AROM/PROM (must be pain free) if acute inflammation/infection
* If ROM deficits are noted–>investigate specific ROM limitations using goniometry measurement
Why ROM assessment is important?
It is important to understand the Pt’s limitations to movement.
This will help me with my PT diagnosis as well as my treatment plan, especially when deciding which exercises are appropriate for the Pt.
ROM assessment can give me information about the following:
- Limited AROM+normal PROM–>contractile (muscle weakness/tear)–>reisisted isometric testing
- Limited AROM & PROM–> non-contractile issue (joint stiffness, bursitis, capsular contracture)–>joint end-feel testing
- End feels for each joint–>determine if it is pathological or normal
–>Eg: Knee flexion normal=soft tissue approximation–>now capsular–>abnormal and can give me information that can help me with my PT diagnosis
Resisted Isometric and why is this imformation important
- Assess whether an injury involves contractile or non-contractile tissue
Following issue can be suspected with different result of testing
* Strong & painless= No lesion in contractile tissue
* Strong & painful= Minor lesion in part of the muscle/tendon
* Weak & painless= nervous problem, complete rupture of muscle/tendon, disuse atrophy
* Weak & painful= fracture, partial tear of muscle/tendon, inflammation inhibiting contraction, neoplasm
- Test and track the Pt’s strength at a certain joint angle
–>If muscle weakness is noted or suspected, graded strength testing can also be performed using MMT
Pt may not have strenght at a given ROM
E.g. resisted shoulder end-range Abd and ER. In this case, resisted isometrics in this motion can be used as a tool to assess progress through rehabilitation.
Condition to be cautious about resisted isometric testing
Acute injury
- Weigh the benefits and risks of performing resisted isoemtric testing
- Consider if the information gathered from resisted isometric testinc would make you change your clinical impression/treatment paln
- If you feel it is necessary in order to make your clinical impression–>explain this in the rationale
Severe pain
- pain can interfere with accurate muscle testing results and further aggravate the Pt’s discomfort
Joint instability
-If the joint stability is compromised due to conditions like ligament laxity, joint hypermobility or recent dislocation
- It may be CI to perform resisted isometric muscle testing–>potentially lead to further joint damagne or instability
Recent surgery
- After certain types of surgery, resisted isometric muscle testing might be CI during early stage of recovery.
- Important to liaise with the surgeon–>determine post surgical precautions & determine when resisted muscle testing would be safe to use and track patient progress
Infection
- Active infection in muscle/joint being tested–>increase the risk of spreading the infection
Resisted isometrics or not?
Inversion ankle sprain 1 day ago
ankle significan brusing and swelling
can walk with 1/10 pain
Do resisted isometric:
- help determine whether the Pt has injured a contractile/non-contractile tissue
- Pain over lat. malleolus could be related to injury of ATFL/peroneal muscle
- Once I determine the cause of the Pt’s pain, I could better manage their injury
- My treatmenat plan would differ if it was a contractile issue (muscle strain), vs a non-contractile issue (ligament sprain)
Dun do resisted isometric
- Pt injury was 1 days ago–>area would be acute and irritable
- Treatment plan for the first few days would focus on managing inflammation and swelling
- Determining if the injury invovle contractile/non-contractile tissue–> would not change the initial treatment drastically
Resisted isometrics or not?
Calf pain started 2 months ago, pain worse at the end of the day and is eased by stretching and resting
Do resisted isometric:
- important to help assess whether the Pt’s pain is from a contractile or non-contractile lesion
- the information gained would help determine my phyisotherapy diagnosis and create my treatment plan
- we want to assess strength and pain with contraction without movingthe ankle or knee
- Strong+painless= no lesion in contractile tissue
- Strong+painful= minor lesion in part of the muscle/tendon and its attachment
- Weak+painless= nervous system disorder, complete rupture of muscle or tendon, or disuse atrophy
- Weak+painful= fracture, partial rupture of muscle or tendon, inflammation inhibiting contraction, neoplasm
Resisted isometric or not?
back injury 5 days ago
- Assess whether the injury involves contractile or non-contractile tissue.
- Given the acute nature, I am choosing not to include this in my assessment as I have enough infromation from other tests and in the case. - Resisted isometric can test and or track the Pt strength at a given joint range
- But since this is in the axial spine, I am going to include more functional testing instead of lumbar-specific motions to determine my clinical impression for this patient.
Neurological Tests
- Myotomes
- Dermatomes
- Reflexes
–>Deep tendon reflexes (hypo= PNS issue vs hyper= CNS issue)- Biceps brachii (C5-6)
- Brachioradialis (C6)
- Tricep brachii (C7-8)
- Patella (L2-4)
- Achilles (S1-2)
–>Long tract (CNS issue) - Babinski, Clonus
- Neurodynamic testing (SLR, slump, prone knee bend, ULTT)
- Provocative (Lx/Cx compression/distraction)
- Sensation test (e.g. light touch, temperature)
Why neurological tests are important?
- The information will give me information on whether the issue is local or a referral
I would conduct neurological test in the following situation
- Unclear MOI–>a gradual onset of pain over lat. forearm
- Presence of neurological signs/sympoms–> Pt complains of weakness/tingling & numbness in left arm
- Inury to axial skeleton–> WAD/lumbar muscle strain
Functional Measures
Make tests meaningful to Pt
gather info from a subjective interveiw/detail regarding functional impariements within the case
2-3 formal outcome measures
Consider stage of healing and appropriateness
Job specifitc
- Sitting/standing tolerance, lifting (above head, waist level, etc.), carrying
Sport/hobby specific
- Jumping/running/dribbling/shooting
Mobility
- Bed mobility, supine to sit, sit to stand, transfers, ambulation, stairs, getting down/up from the floor, getting in/out of the car
Balance
- Timed single-leg balance, eyes closed balance
ADL specific
- Dressing, folding laundary, putting away dishes
Why functional measures is important?
- It is importatn to identify what is important to the individual to support physical, social and psychological well-being.
- Functional tests assess performance abilities and provide insight into functional imitations
- This information can help me determine treatment options and timelines to have them safely participate in their sports, occupation, or recreation without functional limitations.
Special Test
- Perform any special test–>specific to the case and the Pt’s know or suspected condition
E.g. lateral elbow pain
- Lateral epicondylagia (Cozen’s, Maudsley’s, Mills)
- Cervical referral pain (spurling’s, compression/distraction, ULTT)
- Thoracic outlet (allen’s, adson’s)
Why special tests are important?
- They can be used to rule in or out certain pathologies.
- Using these tests can help me establish a PT diagnosis and select appropriate interventions
Palpation
- I would palpate the area of concern to confirm my PT diagnosis
Why palpation is important
Palpation is a great final step in my objective assessment as I can confirm my physiotherapy diagnosis by palpation.
E.g. if I suspect knee OA, I could palpatie the joint line to assess for tenderness
