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Assessment and Evaluation
Mazyad Alotaibi
Assessment and Evaluation
• Good assessment is dependent upon:
– Knowledge of functional anatomy
– History
– Complete examination
Evaluation
• Structure governs function
– Anatomy is the structure
– Biomechanics/physiology are the function
Evaluation Purpose
• Develop database to establish Patient’s level
of function
• Plan a treatment program and establish
outcomes
• Evaluate results of treatment program
• Modify treatment program
Clinical Evaluation Sequence
•
•
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History
Inspection
Palpation
Functional Testing
• A/P/ROM
• Ligamentous Testing
• Special Tests
• Neurological Testing
History
• Most important portion of exam
– Any special test should confirm what is learned
in the history
• Key questions(identify forces on the body)
– Acute Injury= What is the mechanism
– Chronic Injury= Are there changes in treatment
routines/equipment/posture
History
• Mechanism
– How did injury occur
• Macrotrauma (single traumatic force)
• Microtrauma (accumulation of repeated forces)
• Relevant Sounds or sensations
– Pop
– “Giving Way”
• Location of symptoms
– Localized
– Referred(pain from another source)
– Isolated vs. diffuse
• Onset and duration of symptoms
– Immediate pain v. chronic
– Classification for overuse injuries
• Stage 1
– Pain after activity
• Stage 2
– Pain during/after activity
• Stage 3
– Constant pain
• Description of symptoms
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–
–
–
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Sharp/dull/achy
Intermittent v. constant
Weakness
Paresthesia (numbness/tingling)
Dysfunction/ inability to perform activity
• Change in symptoms
– Intensity change with specific motions,
postures, treatment, modalities, medications
• Previous history
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–
–
–
–
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Previous injury
When did previous episode occur
Who evaluated and treated injury
Diagnosis
Course of treatment/rehab/surgery performed
Did previous treatment plan decrease symptoms
• Related history to opposite body part
– Previous history of injury to uninvolved side
• General health status
– congenital abnormality/disease
Inspection
• Gait
• Gross Deformity
fracture/discoloration/serious bleeding
• Swelling (localized v. diffuse)
• Bilateral Symmetry
• Discoloration
• Keloids (surgical scars)
• Infection
– Redness/warmth/pus/swelling/red streaks/lymph nodes
Girth Measurements
• Swelling
– Identify joint line using bony landmarks
• Atrophy
– Make incremental marks (2,4,6 inch) from jt. line
• Lay tape symmetrically around body
• Take 3 measurement and record average
• Repeat and record for uninjured limb
Palpation
• Detect tissue damage
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–
–
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Bones (rule out fracture)
Ligaments/tendons
Soft tissue
Pulses
• Point tenderness
– Visualize structure which lie beneath fingers
– Compare bilaterally
• Trigger Points
– Palpated points in muscle which refer pain to
another body area
• Change in tissue density (or feel of tissue)
may indicate:
–
–
–
–
–
Muscle spasm
Hemorrhage
Edema
Scarring
Myositis ossificans
• Crepitus- repeated crackling sensations or
sound emanating from the joint or tissue
• Symmetry
– Compare muscle tone, bony prominence
• Increased tissue temperature
– Indicates active inflammatory process
Range of Motion (ROM)
• Helps to assess functional status
• Compare bilaterally
• Test joints proximal and distal to injured
area
Functional Testing
AROM
Contraindications:
immature fracture sites
newly repaired
Cardinal Planes (test all planes of ROM)
Painful ARC
compression within range
Functional Testing
PROM
• Quantity of available movement
• “End feel” reach limit of available ROM
• Most accurate method is with goniometry
measurements
Normal End Feel
Physiological
Hard
Soft
Firm
Bone contacting bone
elbow extension
Soft tissue approximation
elbow flexion
Capsule stretch(ext of MCP jt)
Ligament Stretch
(forearm supination)
Muscle Stretch
(hip flexion with knee extended)
Abnormal End Feel
Pathological
Soft
Firm
Hard
Empty
Soft tissue edema
synovitis
Capsular,muscular,
ligamentous shortening
osteoarthritis
Fracture
Bursitis, Joint inflammation
Functional Testing
RROM
• Two types of testing
– Manual muscle testing
– Break test
• Contraindications for RROM
– Patient is unable to voluntarily contract injured
muscle
– Patient is unable to perform AROM
– Underlying fracture site is not healed
– Involved tissues are not yet healed
• Manual Resistance
– Stabilize limb proximally
– Resistance provided distally on bone to which
muscle attaches
– Watch for compensation
Grading system for Manual
Muscle Testing
• 0/5
• 1/5
Zero
Trace
• 2/5
Poor
• 3/5
Fair
• 4/5
• 5/5
Good
Normal
No contraction
Palpable contraction
No muscle movement
Able to move body part
through gravity eliminated
Move against gravity
throughout ROM
Moderate resistance
Maximal resistance
Clinical Significance
• Strength
Pain
Finding
– Good
– Good
None
Present
– Weak
– Weak
Present
None
Normal
Minor soft tissue
injury
Major injury
Neurological or
Rupture or Chronic
Ligamentous and Capsular
Testing
Ligamentous testing
compare bilaterally
compare with baseline measures
correct positioning
(if incorrect positioning may lead to
false results)
Special Tests
• Specific procedures applied to joint to
determine presence of injury
• Unique to each structure
• Bilateral comparison
Neurological (Referred Pain)
• Involves Upper/lower quarter screen of:
– Sensory (dermatome)
– Motor (myotome)
– DTR (Deep Tendon Reflex)
Sensory Testing
– Bilateral
– Dermatone
• Area of skin innervated by a single nerve root
– Slight stroke over area/pin prick
– Sharp v. dull
– Hot v. cold
Motor Testing
Manuel Muscle Testing