Orthopedic Examination - Continuing-ed.cc

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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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