Clinical Orthopedic Rehabilitation Education. Objectives. ○ Discuss the goals
and components of the standard orthopedic examination. ○ Discuss the role of ...
Orthopedic Examination
Objectives
Jason Zafereo, PT, OCS, FAAOMPT Clinical Orthopedic Rehabilitation Education
Discuss the goals and components of the standard orthopedic examination Discuss the role of active and passive movement testing in examination Discuss the role of impairment-based testing in examination
Objectives Discuss the role of clinical special testing in examination Integrate impairment-based and pathology-based assessments into a clinical diagnosis
Concordant Sign
Pain or other symptoms identified on a pain drawing and verified as being reason for seeking care (Laslett) Any combination of pain, stiffness, spasm found upon examination comparable with patient’s symptoms (Maitland)
EXAM OVERVIEW
Goals of the Objective Exam
Establish the pathology or pain generator via provocation or relief of concordant sign – –
Contractile Noncontractile
Establish involvement of contributing impairments to concordant sign – – –
Stiffness Instability/Weakness Misalignment
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Examination Components
Pathology, Impairment DDx – Active movements
Effect of Movement on Concordant Sign
ROM Repeated
–
movements
– –
Passive movements
–
ROM Accessory
Establish mechanical nature to chief complaint Understand negative or positive effect of movement on chief complaint
–
mobility
– –
Irritability level of tissue Staging Prognosis Goals Treatment planning Objective means of re-evaluation
Examination Components
Impairment DDx – – –
Alignment Flexibility Strength
Pathology DDx – – – –
Special tests Palpation Muscle provocation testing Neurological testing
Principles of Movement Testing
Test joints closest to concordant sign, then go proximal and distal All movements are first performed actively Passive motion is tested when pain or stiffness is encountered during active range Accessory mobility is tested when passive physiological mobility is limited
MOVEMENT ANALYSIS
Principles of Movement Testing
Systematic Approach to testing –
–
–
–
Movement to the first point of pain Movement (if able) past the point of pain Movement repeated or sustained to determine if pain or range changes Passive overpressure at end range for joint clearance
“A joint’s movements can never be classed as normal unless firm over-pressure can be applied painlessly”
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Principles of Movement Testing
Principles of Accessory Mobility Testing
Direction of Testing Cardinal planes
–
–
Allows for comparison to established norms Allows for precision of reproduction
Combined planes –
–
–
Possibly more specific to concordant sign Takes in to account spinal coupling laws More functional
Principles of Selective Tension Testing
Capsular patterns differentiate between joint conditions and other inert structure lesions Passive movements test the function of the inert structures Isometric contractions test the function of the contractile tissue
Interpretation of Passive Movement Testing
Pathology/Impairment DDx –
Active (loaded) ROM more than 5deg limited compared to passive (unloaded) ROM in the same direction (Cyriax)
–
Apply spin, rolling or gliding at neutral joint position, mid range, and at physiological end range Assessment of the neutral zone and resistance (R1/R2) to motion at end range Graded as normal, hypermobile, or hypomobile (Kaltenborn)
Interpretation of Passive Movement Testing
Pathology DDx The Capsular Pattern –
–
–
Description
Empty
Abnormal--Unable to achieve end range due to pain
Spring block
Abnormal – Int. derangement; Rebound
Abrupt check
Abnormal--Restriction by mm spasm
Soft-tissue approximation
Normal where movement limited by soft tissue contact; Soft
Bone to Bone
Normal where bone limits movement; Hard
Capsular
Normal where capsule or ligament limits movement; Firm
Shoulder
ER, ABD, IR
Elbow
Flex, Ext
Wrist
Flex and Ext Equally
al. 2004)
Hip
Flex, ABD, IR
Evidence against for presence in hip OA (Klassbo
Knee
Flex, Ext
Ankle
PF, DF/Varus
Impairment DDx –
Pain before tissue resistance
–
Within-range pain or aberrant motion
–
Pain at tissue resistance
Improved interrater reliability when pain is assessed with abnormal end feel (Petersen and Hayes JOSPT 2000)
Ext; SB and Rot Equally
Interpretation of Active Movement Testing
Contractile tissue, Instability/weakness
Cyriax End Feel Classification
Capsular Pattern
Spine
and Harms-Ringdahl 2003, Bijl et al. 1998)
End Feel
Evidence for presence in knee OA (Fritz et al. 1998) Variability for presence in adhesive capsulitis (Mitsch et
Region
Acute inflammation
Weakness/motor control Stiffness
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Interpretation of Active and Passive Movement Testing Combined
Pathology DDx (Cyriax)
Pathology
Movement pattern
Noncontractile lesion
Active and Passive ROM equal and painful in same direction
Contractile lesion
Active and Passive ROM painful in opposite directions
Interpretation of Repeated Movement Testing
Pathology DDx Lumbar HNP –
Favorable outcomes for use of repeated movements in patients demonstrating centralization (Wetzel and Donelson 2003)
Interpretation of Accessory Mobility Testing
Summary of Movement Testing
Spinal PAs Pathology DDx
–
Reasonable interrater reliability for detecting level of symptomatic segment (Jull et
al. 1988, Behrsin and Andrews 1991)
– –
Impairment DDx –
Establish effect of movement on concordant sign Begin to establish pathology
–
Poor interrater reliability for detection of R1 (Bjornsdottir and
Repeated movements Capsular pattern Active and Passive movements/PAs
Begin to establish contributing impairments –
– –
–
Response to active movements End feel Loaded versus unloaded ROM PAs/Joint glides
Kumar 1997, Matyas and Bach 1985)
Principles of Alignment Testing
Inspection focused on impairments that can be changed or accommodated with treatment – –
IMPAIRMENT TESTING
– – – –
Spinal position Pelvic obliquity Scapular asymmetry Patellar alignment Leg length Foot position
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Interpretation of Alignment Testing
Relationship to pain (CLBP) –
Asymmetry, particularly pelvic, present in normals as often as abnormals (Fann 2002)
Reliability (Pelvis) –
Principles of Flexibility Testing
Poor interrater reliability (Dreyfus et al. 1996; Sturesson et al. 2000)
Articular asymmetry not a stand-alone finding for diagnosis or treatment
Principles of Flexibility Testing
Dorsal hyperactive musculature – – –
– –
–
Thomas test normal – – –
Ventral hyperactive musculature – – – – – – – – –
–
Low back/sacrum flat Posterior thigh on table Knee flexed 80deg Full posterior pelvic tilt Hip Abduction
Inter-rater reliability poor to fair (Peeler and Anderson 2007)
Hip adductors Rectus femoris TFL Iliopsoas Oblique abdominals Pec minor Scalenes SCM Biceps
Interpretation of Flexibility Testing Ober test normal – –
Thigh drops to horizontal Modified: Thigh drops below horizontal 10deg
Thomas test mistakes –
Principles of Flexibility Testing
Triceps surae Hamstrings Lumbar erector spinae Quadratus lumborum Middle and upper trapezius Levator scapulae
Interpretation of Flexibility Testing
Testing focused on muscles that cross or attach near the concordant sign Testing should include muscles prone to hypertonicity or dominance (Janda)
Modified creates more effective stretch (Wang et al. 2006)
Ober test mistakes – – –
Femoral internal rotation Hip flexion Pelvic drop
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Principles of Strength Testing
Testing focused on muscles that cross or attach near the concordant sign Testing should include muscles prone to weakness or inhibition (Janda)
Principles of Strength Testing
Dorsal hypotonic muscles – – – –
– –
Principles of Strength Testing
Ventral hypotonic muscles – – – – – –
Tibialis anterior Toe extensors Peronei Vasti Rectus abdominus Deep neck flexors
Gluteals Lower trapezius Serratus Supra- and infraspinatus Deltoid Triceps
Interpretation of Strength Testing
How to improve reliability (Frese et al. 1987; Ottenbacher et al. 2002) – Slow application of force – Use of handheld device – Elimination of +/above 3/5
Summary of Impairment Testing
Consider postural asymmetry that contributes to excess tissue loading and the patient’s inability to heal Look for crossed syndromes – –
PATH0LOGY TESTING
Flexibility testing Strength testing
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Principles of Pathology Testing
Look locally and remotely for structure(s) responsible for concordant sign Differential diagnosis – –
Contractile tissue Noncontractile tissue
Disc Joint Nerve
Interpretation of Special Testing
Clusters of tests can improve diagnostic accuracy – – – – – – –
Cervical radiculopathy Subacromial impingement Full-thickness rotator cuff tear Lateral epicondylalgia Carpal tunnel syndrome SI joint pathology Hip OA
Interpretation of Muscle Provocation Testing Classification
Description
Strong and Painless
Contractile tissue not involved
Strong and Painful
Minor contractile lesion
Weak and Painless
Complete rupture contractile tissue; neuro disorder
Weak and Painful
Major lesion in contractile tissue
All Painful
Sinister pathologies; affective disorder; gross capsular lesion
Painful on repetition
Intermittent claudication
Principles of Pathology Testing
Special Tests for ruling in suspected pathology should have high + LRs Special Tests for ruling out suspected pathology should have low – LRs Palpation used to define, not to find Muscle provocation testing should attempt to isolate one muscle at a time Neurological testing should be performed on all patients with suspected adverse neural tension
Interpretation of Palpation
Good interrater reliability for contractile tissue localization at shoulder, TMJ, knee (Wolf and Agrawal 2001; Manfredini et al. 2003; Cook et al. 2001)
Good diagnostic accuracy when palpation recreates concordant sign (Cyriax 1993)
Interpretation of Muscle Provocation Testing
Difficult to isolate one muscle at a time Even isometric contractions produce joint movement and tension Acceptable reliability and diagnostic accuracy for shoulder and knee (Pellecchia et al. 1996; Fritz et al. 1998)
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Interpretation of Neurological Testing
Diagnostic accuracy for cervical radiculopathy –
DTRs significantly better than pin prick for diff dx (Lauder et al.
Diagnostic accuracy for lumbar stenosis –
DTRs, pin-prick, and weakness offer small probability shift in diff dx (Katz et al. 1995)
Summary of Pathology Testing
2000)
Establish (as able) the patient’s primary pathology or pain generator Rule out pathologies that do not contribute to the concordant sign
Goals of the Objective Exam
Establish the pathology or pain generator – –
INTEGRATED DIAGNOSIS
Establish involvement of contributing impairments to concordant sign – – –
Pathology/Pain Generator
Provides “label” for concordant sign –
–
Determine appropriateness of conservative management Guides tissue-specific treatment
Useful for ruling out a pain-producing region or pathology
Contractile Noncontractile
Stiffness Instability/Weakness Misalignment
Pathology/Pain Generator
Contractile tissue –
ROM
– – –
Active and Passive ROM painful in opposite directions Active ROM more than 5deg limited compared to passive ROM in the same direction
+ Special tests for muscle/tendon Palpation consistent with concordant sign + Muscle provocation testing
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Pathology/Pain Generator
Non-contractile tissue ROM –
– – –
Active and Passive ROM equal and painful in same direction Restricted motion in capsular or characteristic pattern (joint) Spinal PA pain consistent with concordant sign Favorable response to repeated movements (disc)
Involvement of Contributing Impairments
The mechanical “cause” of the concordant sign –
–
Reduce tissue loading for complete healing Reduce rate of reinjury
Pathology/Pain Generator
Non-contractile joint – –
+ Cartilage or ligament testing Palpation consistent with concordant sign
Non-contractile disc
Non-contractile nerve
–
– – –
+ SLR testing + Neurodynamic testing Palpation consistent with concordant sign + or – Neurological testing
Impairments
Stiffness – – – – –
Weakness/Instability – – –
Decreased ROM and pain at end range with firm capsular end feel Capsular pattern or characteristic pattern of restriction Decreased size of neutral zone on accessory mobility testing Short and strong muscles in the region of pain Presence of positional faults Mid range pain or aberrant movement, improved with active assist or stabilization Pain and limited motion under load, improved when unloaded Long and weak muscles in the region of pain
Alignment – –
Long bone length Joint position
Combined Diagnoses
Pain generator or pathology associated with Regional impairments of – – –
Stiffness Weakness Malalignment
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