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Principles and Concepts
Principles and Concepts
1
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2 Chapter 1 Principles and Concepts
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Chapter 1 Principles and Concepts 3
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4 Chapter 1 Principles and Concepts
Sensory
Physiological Affective
Intensity
Location Quality Mood state
Onset Pattern Anxiety
Duration Depression
Etiology Well-being
Syndrome
PAIN
Figure 1-1 The dimensions of pain. (Redrawn from Petty NJ, Moore AP: Neuromusculoskeletal examination and assessment: a handbook for
therapists, London, 1998, Churchill-Livingstone, p. 8.)
7. Where was the pain or other symptoms when the patient sensitization manifests itself as widespread hypersen-
first had the complaint? Pain is subjective, and its sitivity to such physical, mental, and emotional stress-
manifestations are unique to each individual. It is a ors as touch, mechanical pressure, noise, bright light,
complex experience involving several dimensions temperature, and medication.14,15
(Figure 1-1).10 If the intensity of the pain or symp- Has the pain moved or spread? The location and
toms is such that the patient is unable to move in a spread of pain may be marked on a body chart, which
certain direction or hold a particular posture because is part of the assessment sheet (see Appendix 1-1).
of the symptoms, the symptoms are said to be severe. The examiner should ask the patient to point to
If the symptoms or pain become progressively worse exactly where the pain was and where it is now. Are
with movement or the longer a position is held, the trigger points present? Trigger points are localized
symptoms are said to be irritable.11,12 Acute pain is areas of hyperirritability within the tissues; they are
new pain that is often severe, continuous, and perhaps tender to compression, are often accompanied by
disabling and is of sufficient quality or duration that tight bands of tissue, and, if sufficiently hypersensi-
the patient seeks help. Acute injuries tend to be more tive, may give rise to referred pain that is steady, deep,
irritable resulting in pain earlier in the movement, or and aching. These trigger points can lead to a diag-
minimal activity will bring on symptoms, and often nosis, because pressure on them reproduces the
the pain will remain after movement has stopped.3 patient’s symptoms. Trigger points are not found in
Chronic pain is more aggravating, is not as intense, normal muscles.16
has been experienced before, and in many cases, the In general, the area of pain enlarges or becomes
patient knows how to deal with it. Acute pain is more more distal as the lesion worsens and becomes smaller
often accompanied by anxiety, whereas chronic pain or more localized as it improves. Some examiners call
is associated with depression.13 When tissue has been the former peripheralization of symptoms and the
damaged, substances are released leading to inflam- latter, centralization of symptoms.17–19 The more
mation and peripheral sensitization of the nocicep- distal and superficial the problem, the more accu-
tors (also called primary hyperalgesia) resulting in rately the patient can determine the location of the
localized pain. If the injury does not follow a normal pain. In the case of referred pain, the patient usually
healing pathway and becomes chronic, central sen- points out a general area; with a localized lesion, the
sitization (also called secondary hyperalgesia) patient points to a specific location. Referred pain
may occur. Peripheral sensitization is a local phenom- tends to be felt deeply; its boundaries are indistinct,
enon whereas central sensitization is a more central and it radiates segmentally without crossing the
process involving the spinal cord and brain. Central midline. The term, referred pain, means that the pain
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Chapter 1 Principles and Concepts 5
is felt at a site other than the injured tissue because TABLE 1-2
the same or adjacent neural segments supply the
Differentiation of Systemic and Musculoskeletal Pain
referred site. Pain also may shift as the lesion shifts.
For example, with an internal derangement of the Systemic Musculoskeletal
knee, pain may occur in flexion one time and in • Disturbs sleep • Generally lessens at
extension another time if it is caused by a loose body • Deep aching or throbbing night
within the joint. The examiner must clearly under- • Reduced by pressure • Sharp or superficial
stand where the patient feels the pain. For example, • Constant or waves of pain ache
does the pain occur only at the end of the ROM, in and spasm • Usually decreases with
part of the range, or throughout the ROM?9 • Is not aggravated by cessation of activity
8. What are the exact movements or activities that cause mechanical stress • Usually continuous or
pain? At this stage, the examiner should not ask the • Associated with the intermittent
patient to do the movements or activities; this will following: • Is aggravated by
Jaundice mechanical stress
take place during the examination. However, the Migratory arthralgias
examiner should remember which movements the Skin rash
patient says are painful so that when the examination Fatigue
cessation of the activity, does the pain stay the same, Generalized weakness
or how long does it take for the pain to return to its Cyclic and progressive
previous level? Are there any other factors that aggra- symptoms
Tumors
vate or help to relieve the pain? Do these activities
History of infection
alter the intensity of the pain? The answers to these
questions give the examiner some idea of the irritabil-
ity of the joint. They also help the examiner to dif- From Meadows JT: Orthopedic differential diagnosis in physical
therapy—a case study approach, New York, 1999, McGraw Hill, p. 100.
ferentiate between musculoskeletal or mechanical Reproduced with permission of the McGraw-Hill Companies.
pain and systemic pain, which is pain arising from one
of the body’s systems other than the musculoskeletal
system (Table 1-2).18 Functionally, pain can be subacute conditions have been present for 10 days to
divided into different levels, especially for repetitive 7 weeks, and chronic conditions or symptoms have
stress conditions. been present for longer than 7 weeks. In acute on
chronic cases, the injured tissues usually have been
reinjured. This knowledge is also beneficial in terms of
how vigorously the patient can be examined. For
Pain and Its Relation to Severity of Repetitive example, the more acute the condition, the less stress
Stress Activity the examiner is able to apply to the joints and tissues
during the assessment. A full examination may not be
• Level 1: Pain after specific activity
• Level 2: Pain at start of activity resolving with warm-up possible in very acute conditions. In that case, the
• Level 3: Pain during and after specific activity that does not affect examiner must select those procedures of assessment
performance that will give the greatest amount of information with
• Level 4: Pain during and after specific activity that does affect the least stress to the patient. Does the patient protect
performance or support the injured part? If so, this behavior signi-
• Level 5: Pain with activities of daily living (ADLs) fies discomfort and fear of pain if the part moves,
• Level 6: Constant dull aching pain at rest that does not usually indicating a more acute condition.
disturb sleep 10. Has the condition occurred before? If so, what was the
• Level 7: Dull aching pain that does disturb sleep onset like the first time? Where was the site of the
NOTE: Level 7 indicates highest level of severity. original condition, and has there been any radiation
(spread) of the symptoms? If the patient is feeling
better, how long did the recovery take? Did any treat-
9. How long has the problem existed? What are the dura- ment relieve symptoms? Does the current problem
tion and frequency of the symptoms? Answers to these appear to be the same as the previous problem, or is
questions help the examiner to determine whether the it different? If it is different, how is it different?
condition is acute, subacute, chronic, or acute on Answers to these questions help the examiner to
chronic and to develop some understanding of the determine the location and severity of the injury.
patient’s tolerance to pain. Generally, acute condi- 11. Has there been an injury to another part of the kinetic
tions are those that have been present for 7 to 10 days, chain as well? For example, foot problems can lead
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6 Chapter 1 Principles and Concepts
to knee, hip, pelvic, and/or spinal problems; elbow helping. Are pain or other symptoms associated with
problems may contribute to shoulder problems; and other physiological functions? For example, is the
hip problems can contribute to knee problems. pain worse with menstruation? If so, when did the
12. Are the intensity, duration, or frequency of pain or patient last have a pelvic examination? Questions
other symptoms increasing? These changes usually such as these may give the examiner an indication of
mean the condition is getting worse. A decrease in what is causing the problem or what factors may
pain or other symptoms usually means the condition affect the problem. It is often worthwhile to give the
is improving. Is the pain static? If so, how long has patient a pain questionnaire, visual analog scale
it been that way? This question may help the exam- (VAS), numerical rating scale, box scale, or verbal
iner to determine the present state of the problem. rating scale that can be completed while the patient
These factors may become important in treatment is waiting to be assessed.20,21 The McGill-Melzack
and may help to determine whether a treatment is pain questionnaire and its short form (Figures 1-2
Figure 1-2 McGill-Melzack pain questionnaire. (From Melzack R: The McGill pain questionnaire: major properties and scoring methods. Pain
1:280–281, 1975.)
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Chapter 1 Principles and Concepts 7
1. THROBBING 0) 1) 2) 3)
2. SHOOTING 0) 1) 2) 3)
3. STABBING 0) 1) 2) 3)
4. SHARP 0) 1) 2) 3)
5. CRAMPING 0) 1) 2) 3)
6. GNAWING 0) 1) 2) 3)
7. HOT-BURNING 0) 1) 2) 3)
8. ACHING 0) 1) 2) 3)
9. HEAVY 0) 1) 2) 3)
10. TENDER 0) 1) 2) 3)
11. SPLITTING 0) 1) 2) 3)
12. TIRING-EXHAUSTING 0) 1) 2) 3)
13. SICKENING 0) 1) 2) 3)
14. FEARFUL 0) 1) 2) 3)
15. PUNISHING-CRUEL 0) 1) 2) 3)
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8 Chapter 1 Principles and Concepts
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Chapter 1 Principles and Concepts 9
when the structures are stretched or pinched. Each developed to determine if neuropathic causes domi-
of these specific tissue pains is sometimes grouped as nate the pain experience.31 Somatic pain, on the
neuropathic pain and follows specific anatomical other hand, is a severe chronic or aching pain that is
pathways and affect specific anatomical structures.18 inconsistent with injury or pathology to specific ana-
The Leeds Assessment of Neuropathic Symptoms tomical structures and cannot be explained by any
and Signs (LANSS) Pain Scale (Figure 1-6) has been physical cause because the sensory input can come
from so many different structures supplied by the
TABLE 1-3 same nerve root.12 Superficial somatic pain may be
localized, but deep somatic pain is more diffuse and
Pain Descriptions and Related Structures may be referred.32 On examination, somatic pain may
Type of Pain Structure be reproduced, but visceral pain is not reproduced by
movement.32
Cramping, dull, aching Muscle 16. What types of sensations does the patient feel, and where
Dull, aching Ligament, joint capsule
are these abnormal sensations? If the problem is in
Sharp, shooting Nerve root
Sharp, bright, lightning-like Nerve
bone, there usually is very little radiation of pain. If
Burning, pressure-like, Sympathetic nerve pressure is applied to a nerve root, radicular pain
stinging, aching (radiating pain) results from pressure on the dura
Deep, nagging, dull Bone mater, which is the outermost covering of the spinal
Sharp, severe, intolerable Fracture cord. If there is pressure on the nerve trunk, no pain
Throbbing, diffuse Vasculature occurs, but there is paresthesia, or an abnormal sensa-
tion, such as a “pins and needles” feeling or tingling.
1) Does your pain feel like strange, unpleasant sensations in your skin? Words like a) NO, normal sensation in both areas ..................................... (0)
pricking, tingling, pins and needles might describe these sensations.
b) YES, allodynia in painful area only ....................................... (5)
a) NO - My pain doesn’t really feel like this ...................................... (0)
b) YES - I get these sensations quite a lot ....................................... (5) 2) ALTERED PIN-PRICK THRESHOLD
Determine the pin-prick threshold by comparing the response to a 23 gauge
2) Does your pain make the skin in the painful area look different from normal? (blue) needle mounted inside a 2 ml syringe barrel placed gently on to the skin in
Words like mottled or looking more red or pink might describe the appearance. a non-painful and then painful areas.
a) NO - My pain doesn’t affect the colour of my skin ........................ (0) If a sharp pin prick is felt in the non-painful area, but a different sensation is
experienced in the painful area (e.g., none/blunt only [raised PPT] or a very
b) YES - I’ve noticed that the pain does make my skin look different from normal ..... (5) painful sensation [lowered PPT]), an altered PPT is present.
3) Does your pain make the affected skin abnormally sensitive to touch? Getting If a pinprick is not felt in either area, mount the syringe onto the needle to
unpleasant sensations when lightly stroking the skin, or getting pain when increase the weight and repeat.
wearing tight clothes might describe the abnormal sensitivity.
a) NO, equal sensation in both areas ........................................ (0)
a) NO - My pain doesn’t make my skin abnormally sensitive in that area ........... (0)
b) YES, altered PPT in painful area ........................................... (3)
b) YES - My skin seems abnormally sensitive to touch in that area .................... (3)
4) Does your pain come on suddenly and in bursts for no apparent reason when you’re
still. Words like electric shocks, jumping, and bursting describe these sensations. SCORING:
a) NO - My pain doesn’t really feel like this ............................................. (0) Add values in parentheses for sensory description and examination findings to obtain
overall score.
b) YES - I get these sensations quite a lot ............................................... (2)
5) Does your pain feel as if the skin temperature in the painful area has changed TOTAL SCORE (maximum 24) .................................
abnormally? Words like hot and burning describe these sensations
a) NO - I don’t really get these sensations ............................................... (0) If score <12, neuropathic mechanisms are unlikely to be contribution to the patient’s pain.
Figure 1-6 The Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) Pain Scale. (Modified from Bennett M: The LANSS Pain
Scale: the Leeds assessment of neuropathic symptoms and signs, Pain 92:156–157, 2001.)
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10 Chapter 1 Principles and Concepts
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Chapter 1 Principles and Concepts 11
studies35,36 but is equally applicable to other joints. psychogenic pain.3,39,40 Thus, psychosocial aspects
This concept states that injury to structures on one can play a significant role with injury.41–44 Because of
side of a joint leading to instability can, at the same the importance of these psychosocial aspects related
time, cause injury to structures on the other side or to movement, questionnaires such as the Fear-
other parts of the joint. Thus, an anterior shoulder Avoidance Beliefs Questionnaire (FABQ)45 (Figure
dislocation can lead to injury of the posterior capsule. 1-8) and the Tampa Scale for Kinesiophobia46–49 have
Similarly, anterolateral rotary instability of the knee been developed. Most of the studies related to the
leads to injury to posterior structures (e.g., arcuate- psychosocial aspects of injury have been related to
popliteus complex, posterior capsule) as well as ante- the low back but could be used for other joints. The
rior (e.g., anterior cruciate ligament) and lateral focus of these questionnaires is on the patient’s beliefs
(e.g., lateral collateral ligament) structures. Thus, the about how physical activity and work affect his or her
examiner must be aware of potential injuries on the injury and pain.42,50,51 Table 1-4 outlines some of the
opposite side of the joint even if symptoms are pre- psychological processes affecting pain.42 These pro-
dominantly on one side, especially when the mecha- cesses have been divided into different colored “flags”
nism of injury is trauma. (Table 1-5), but it is important to note that these
18. Has the patient experienced any bilateral spinal cord psychological flags, other than the red flag, are dif-
symptoms, fainting, or drop attacks? Is bladder func- ferent from pathological “flags” previously men-
tion normal? Is there any “saddle” involvement tioned.44 Waddell and Main37 consider illness behavior
(abnormal sensation in the perianal region, buttocks, normal with patients who are exhibiting both a physi-
and superior aspect of the posterior thighs) or vertigo? cal problem and varying degrees of illness behavior
“Vertigo” and “dizziness” are terms often used syn- (Table 1-6). In these cases, it may be beneficial to
onymously, although vertigo usually indicates more determine the level of psychological stress or to refer
severe symptoms. The terms describe a swaying, spin- the patient to another appropriate health care profes-
ning sensation accompanied by feelings of unsteadi- sional.38 When symptoms (such as, pain) appear to
ness and loss of balance. These symptoms indicate be exaggerated, the examiner must also consider the
severe neurological problems, such as cervical possibility that the patient is malingering. Malinger-
myelopathy, which must be dealt with carefully and ing implies trying to obtain a particular gain by a
can (e.g., in cases of altered bladder function) be conscious effort to deceive.52
emergency conditions potentially requiring surgery.
Drop attacks occur when the patient suddenly falls
without warning or provocation but remains con-
scious.18 It is caused by neurological dysfunction Reactions to Stress
especially in the brain.
• Aches and pains
19. Are there any changes in the color of the limb? Ischemic
• Anxiety
changes resulting from circulatory problems may • Changed appetite
include white, brittle skin; loss of hair; and abnormal • Chronic fatigue
nails on the foot or hand. Conditions such as reflex • Difficulty concentrating
sympathetic dystrophy, which is an autonomic nerve • Difficulty sleeping
response to trauma, however minor, can cause these • Irritability and impatience
symptoms, as can circulatory problems such as • Loss of interest and enjoyment in life
Raynaud’s disease. • Muscle tension (headaches)
20. Has the patient been experiencing any life or economic • Sweaty hands
stresses? These psychological stressors are sometimes • Trembling
considered to be yellow flags that alter both the • Withdrawal
assessment and subsequent treatment.37,38 Divorce,
marital problems, financial problems, or job stress or
insecurity can contribute to increasing the pain or 21. Does the patient have any chronic or serious systemic
symptoms because of psychological stress. What illnesses or adverse social habits (e.g., smoking, drink-
support systems and resources are available? Are there ing) that may influence the course of the pathology or
any cultural issues one should be aware of? Does the the treatment? In some cases, the examiner may use
patient have an easily accessible living environment? a medical history screening form (Figure 1-9) to
Each of these issues may increase stress to the patient. determine the presence of conditions that may affect
Pain is often accentuated in patients with anxiety, treatment or require referral to another health care
depression, or hysteria, or patients may exaggerate professional.
their symptoms (symptom magnification) in the 22. Is there anything in the family or developmental history
absence of objective signs, which may be called that may be related, such as tumors, arthritis, heart
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12 Chapter 1 Principles and Concepts
Here are some of the things which other patients have told us about their pain. For each statement please
circle any number from 0 to 6 to say how much physical activities such as bending, lifting, walking, or
driving affect or would affect your back pain.
The following statements are about how your normal work affects or would affect your back pain
Completely Unsure Completely
disagree agree
6. My pain was caused by my work or by an accident at work ................ 0 1 2 3 4 5 6
7. My work aggravated my pain ............................................................... 0 1 2 3 4 5 6
8. I have a claim for compensation for my pain ........................................ 0 1 2 3 4 5 6
9. My work is too heavy for me ................................................................. 0 1 2 3 4 5 6
10. My work makes or would make my pain worse .................................. 0 1 2 3 4 5 6
11. My work might harm my back ............................................................. 0 1 2 3 4 5 6
12. I should not do my normal work with my present pain ........................ 0 1 2 3 4 5 6
13. I cannot do my normal work with my present pain .............................. 0 1 2 3 4 5 6
14. I cannot do my normal work till my pain is treated .............................. 0 1 2 3 4 5 6
15. I do not think that I will be back to my normal work within 3 months. 0 1 2 3 4 5 6
16. I do not think that I will ever be able to go back to that work ............... 0 1 2 3 4 5 6
Scoring:
fear-avoidance beliefs about work (scale 1) = (points for item 6) + (points for item 7) + (points for item 9) + (points for item 10)
+ (points for item 11) + (points for item 12) + (points for item 15)
fear-avoidance beliefs about physical activity (scale 2) = (points for item 2) + (points for item 3) + (points for item 4)
+ (points for item 5)
Interpretation:
• The higher the scale scores the greater the degree of fear and avoidance beliefs shown by the patient.
Figure 1-8 Fear-Avoidance Beliefs Questionnaire (FABQ). (Modified from Waddell G, Newton M, Henderson I, et al: A fear-avoidance beliefs
questionnaire [FABQ] and the role of fear-avoidance beliefs in chronic low back pain and disability. Pain 52:166, 1993.)
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Chapter 1 Principles and Concepts 13
TABLE 1-4
Modified from Linton SJ, Shaw WS: Impact of psychological factors in the experience of pain. Phys Ther 91:703, 2011.
TABLE 1-5
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14 Chapter 1 Principles and Concepts
TABLE 1-6
Symptoms
Pain Musculoskeletal or neurologic distribution Whole leg pain
Pain at the tip of the tailbone
Numbness Dermatomal Whole leg numbness
Weakness Myotomal Whole leg giving way
Time pattern Varies with time and activity Never free of pain
Response to treatment Variable benefit Intolerance of treatments
Emergency hospitalization
Signs
Tenderness Musculoskeletal distribution Superficial
Nonanatomic
Axial loading Neck pain Low back pain
Simulated rotation Nerve root pain Low back pain
Straight leg raising Limited on formal examination Marked improvement with distraction
No improvement on distraction
Motor Myotomal Regional, jerky, giving way
Sensory Dermatomal Regional
From Waddell G, Main CJ: Illness behavior. In Waddell G, editor: The back pain revolution, Edinburgh, 1998, Churchill Livingstone, p. 162.
disease, diabetes, allergies, and congenital anomalies? review. If analgesics or anti-inflammatories were
Some disease processes and pathologies have a famil- taken just before the patient’s visit for the assessment,
ial incidence. some symptoms may be masked.
23. Has the patient undergone an x-ray examination or 25. Does the patient have a history of surgery or past/present
other imaging techniques? If so, x-ray overexposure illness? If so, when was the surgery performed, what
must be considered; if not, an x-ray examination may was the site of operation, and what condition was
help yield a diagnosis. being treated? Sometimes, the condition the exam-
24. Has the patient been receiving analgesic, steroid, or any iner is asked to treat is the result of the surgery.
other medication? If so, for how long? High dosages of Has the patient ever been hospitalized? If so, why?
steroids taken for long periods may lead to problems, Health conditions such as high blood pressure, heart
such as osteoporosis. Has the patient been taking any and circulatory problems, and systemic diseases
other medication that is pertinent? Anticoagulants (e.g., diabetes) should be noted because of their
(such as, aspirin or anticoagulant therapy) increase effect on healing, exercise prescription, and func-
the chance of bruising or hemarthrosis because the tional activities.3
clotting mechanism is altered. Patients may not Taking an accurate, detailed history is very important.
regard over-the-counter formulations, birth control Listen to the patient—he or she is telling you what is
pills, and so on as medications. If such medications wrong! With experience, the examiner should be able to
have been taken for a long period, their use may not make a preliminary “working” diagnosis from the
seem pertinent to the patient. How long has the history alone. The observation and examination phases of
patient been taking the medication? When did he or the assessment are then used to confirm, alter, or refute
she last take the medication? Did the medication the possible diagnoses. What an examiner looks for in
help?53 It is also important to determine whether observation and tests for in examination is often related
medication is being taken for the condition under to what she or he has found when taking a history.
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Chapter 1 Principles and Concepts 15
Date:
Patient's Name: DOB: Age:
Diagnosis: Date of Onset:
Physician: Therapist: Precautions:
Medical History Do Not Complete, For Clinician
Have you or any immediate family member Relation to Date of Current
ever been told you have: Circle one: Patient Onset Status
Cancer Yes No
Diabetes Yes No
Hypoglycemia Yes No
Hypertension or high blood pressure Yes No
Heart disease Yes No
Angina or chest pain Yes No
Shortness of breath Yes No
Stroke Yes No
Kidney disease/stones Yes No
Urinary tract infection Yes No
Allergies Yes No
Asthma, hay fever Yes No
Rheumatic/scarlet fever Yes No
Hepatitis/jaundice Yes No
Cirrhosis/liver disease Yes No
Polio Yes No
Chronic bronchitis Yes No
Pneumonia Yes No
Emphysema Yes No
Migraine headaches Yes No
Anemia Yes No
Ulcers/stomach problems Yes No
Arthritis/gout Yes No
Other Yes No
Medical Testing
1. Are you taking any prescription or over-the-counter medications? Yes No
If yes, please list:
2. Have you had any x-rays, sonograms, computed tomography (CT) Yes No
scans, or magnetic resonance imaging (MRI) done recently?
If yes, when? Where? Results?
3. Have you had any laboratory work done recently (urinalysis or blood tests)? Yes No
If yes, when? Where? Results?
4. Please list any operations that you have ever had and the date(s) of surgery.
Surgery/Date:
General Health
1. Have you had any recent illnesses within the last 3 weeks (e.g., colds, Yes No
influenza, bladder or kidney infection)?
Figure 1-9 Medical history screening card. (From Goodman CC, Snyder TK: Differential diagnosis in physical therapy, Philadelphia, 1990, WB
Saunders.) Continued
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16 Chapter 1 Principles and Concepts
2. Have you noticed any lumps or thickening of skin or muscle anywhere Yes No
on your body?
3. Do you have any sores that have not healed or any changes in size, Yes No
shape, or color of a wart or mole?
4. Have you had any unexplained weight loss in the last month? Yes No
5. Do you smoke or chew tobacco? Yes No
If yes, how many packs/day?
For how many months or years?
6. How much alcohol do you drink in the course of a week?
7. How much caffeine to you consume daily (including soft drinks, coffee,
tea, or chocolate)?
8. Are you on any special diet prescribed by a physician? Yes No
Special Questions for Women
1. Last Pap smear:
2. Last breast examination:
3. Do you perform a monthly self-breast examination? Yes No
4. Do you take birth control pills or do you use an intrauterine device (IUD)? Yes No
Special Questions for Men
1. Do you ever have difficulty with urination (e.g., difficulty in starting or Yes No
continuing flow or a very slow flow or urine)?
2. Do you ever have blood in your urine? Yes No
3. Do you ever have pain on urination? Yes No
Work Environment
1. Occupation:
2. Does your job involve:
prolonged sitting (e.g., desk, computer, driving) Yes No
prolonged standing (e.g., equipment operator, sales clerk) Yes No
prolonged walking (e.g., mill worker, delivery service) Yes No
use of large or small equipment (e.g., telephone, fork lift, typewriter, Yes No
drill press, cash register)
lifting, bending, twisting, climbing, turning Yes No
exposure to chemicals or gases Yes No
other: please describe
3. Do you use any special supports:
back cushion, neck cushion Yes No
back brace, corset Yes No
other kind of brace or support for any body part Yes No
For Clinician
Vital signs:
Resting pulse rate:
Oral temperature:
Blood pressure: 1st reading: 2nd reading:
Position: Extremity:
Figure 1-9, cont’d
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Chapter 1 Principles and Concepts 17
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18 Chapter 1 Principles and Concepts
probably hypomobile and/or hypermobile structures 8. Are there any scars that indicate recent injury or
affecting the pelvic position. The three questions are: surgery? Recent scars are red because they are still
1) Can the patient get into the “neutral pelvis” posi- healing and contain capillaries; older scars are white
tion? (If not, why not?) and primarily avascular. Fibers of the dermis (skin)
2) Can the patient hold the “neutral pelvis” position tend to run in one direction, along so-called cleavage
while doing distal dynamic movement? (If not, or tension lines. Lacerations or surgical cuts along
why not?) these lines produce less scarring. Cuts across joint
3) Can the patient control the dynamic “neutral flexion lines frequently produce excessive (hypertro-
pelvis” while doing dynamic movement (e.g., phic) scarring. Some individuals are also prone to
walking, running, jumping)? keloid (excessive) or hypertrophic scarring. Hyper-
If the answer to any of these questions is “no,” the trophic scars are scars that have excessive scar tissue
examiner should consider adding pelvic “core muscle” but stay within the margins of the wound. Keloid
control activities to any treatment protocol. scars expand beyond the margins of the wound. Are
7. Are the color and texture of the skin normal? Does there any callosities, blisters, or inflamed bursae,
the appearance of the skin differ in the area of pain indicative of excessive pressure or friction to the skin?
or symptoms, compared with other areas of the body? Are there any sinuses that may indicate infection? If
Ecchymosis or bruising indicates bleeding under the so, are the sinuses draining or dry?
skin from injury to tissues (Figure 1-10). In some 9. Is there any crepitus, snapping, or abnormal sound
cases, this ecchymosis may track away from the injury in the joints when the patient moves them? Sounds,
site because of gravity. Trophic changes in the skin by themselves, do not necessarily indicate pathology.
resulting from peripheral nerve lesions include loss of Sounds on movement only become significant when
skin elasticity, shiny skin, hair loss on the skin, and they are related to the patient’s symptoms. Crepitus
skin that breaks down easily and heals slowly. The may vary from a loud grinding noise to a squeaking
nails may become brittle and ridged. Skin disorders noise. Snapping, especially if not painful, may be
(such as, psoriasis) may affect joints (psoriatic arthri- caused by a tendon moving over a bony protuber-
tis). Cyanosis, or a bluish color to the skin, is usually ance. Clicking is sometimes heard in the temporo-
an indication of poor blood perfusion. Redness indi- mandibular joint and may be an indication of early
cates increased blood flow or inflammation. nonsymptomatic pathology.
10. Is there any heat, swelling, or redness in the area
being observed? All of these signs along with pain
and loss of function are indications of inflammation
or an active inflammatory condition.
11. What attitude does the patient appear to have toward
the condition or toward the examiner? Is the patient
apprehensive, restless, resentful, or depressed? These
questions give the examiner some indication of the
patient’s psychological state and how he or she will
respond to the examination and treatment.
12. What is the patient’s facial expression? Does the
patient appear to be apprehensive, in discomfort, or
lacking sleep?
13. Is the patient willing to move? Are patterns of move-
ment normal? If not, how are they abnormal? Any
alteration should be noted and included in the obser-
vation portion of the assessment.
On completion of the observation phase of the assess-
ment, the examiner should return to the original prelimi-
nary working diagnosis made at the end of the history to
see if any alteration in the diagnosis should be made with
the additional information found in this phase.
EXAMINATION
Figure 1-10 Ecchymosis around the knee following rupture of the Principles
quadriceps and dislocation of the patella. Note how the ecchymosis is
tracking distally toward the foot because of gravity from the leg hanging Because the examination portion of the assessment
dependent. involves touching the patient and may, in some cases,
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Chapter 1 Principles and Concepts 19
cause the patient discomfort, the examiner must obtain a 5. During AROM, if the ROM is full, overpressure may
valid consent to perform the examination before it be carefully applied to determine the end feel of the
begins. A valid consent must be voluntary, must cover joint. This often negates the need to do passive
the procedures to be done (informed consent), and the movements.
patient must be legally competent to give the consent 6. Each active, passive, or resisted isometric movement
(Appendix 1-2).55,56 may be repeated several times or held (sustained)
The examination is used to confirm or refute the sus- for a certain amount of time to see whether symp-
pected diagnosis, which is based on the history and obser- toms increase or decrease, whether a different pattern
vation. The examination must be performed systematically of movement results, whether there is increased
with the examiner looking for a consistent pattern of signs weakness, or whether there is possible vascular insuf-
and symptoms that leads to a differential diagnosis. Special ficiency. This repetitive or sustained activity is espe-
care must be taken if the condition of the joint is irritable cially important if the patient has complained that
or acute. This is especially true if the area is in severe repetitive movement or sustained postures alter
spasm or if the patient complains of severe unremitting symptoms.
pain that is not affected by position or medication, severe 7. Resisted isometric movements are done with the joint
night pain, severe pain with no history of injury, or non- in a neutral or resting position so that stress on the
mechanical behavior of the joint. inert tissues is minimal. Any symptoms produced by
the movement are then more likely to be caused by
problems with contractile tissue.
8. For passive range of motion (PROM) or ligamentous
tests, it is not only the degree (i.e., the amount) of
Red Flags in Examination Indicating the Need the opening but also the quality (i.e., the end feel)
for Medical Consultation57 of the opening that is important.
9. When the examiner is testing the ligaments, the
• Severe unremitting pain appropriate stress is applied gently and repeated
• Pain unaffected by medication or position several times. The stress is increased up to but not
• Severe night pain beyond the point of pain, thereby demonstrating
• Severe pain with no history of injury maximum instability without causing muscle
• Severe spasm
spasm.
• Inability to urinate or hold urine
10. When testing myotomes (groups of muscles supplied
• Elevated temperature (especially if prolonged)
• Psychological overlay by a single nerve root), each contraction is held for
a minimum of 5 seconds to see whether weakness
becomes evident. Myotomal weakness takes time to
develop.
11. At the completion of an assessment, because a good
In the examination portion of the assessment, a number examination commonly involves stressing different
of principles must be followed. tissues, the examiner must warn the patient that
1. Unless bilateral movement is required, the normal symptoms may exacerbate as a result of the assess-
side is tested first. Testing the normal side first allows ment. This will prevent the patient from thinking
the examiner to establish a baseline for normal move- any initial treatment may have made the patient
ment for the joint being tested58 and shows the worse and thus be hesitant to return for further
patient what to expect, resulting in increased patient treatments.
confidence and less patient apprehension when the 12. If, at the conclusion of the examination, the examiner
injured side is tested. has found that the patient has shown unusual signs
2. The patient does active movements before the exam- and symptoms or if the condition appears to be
iner does passive movements. Passive movements are beyond his or her scope of practice, the examiner
followed by resisted isometric movements (see later should not hesitate to refer the patient to another
discussion). In this way, the examiner has a better appropriate health care professional.
idea of what the patient thinks he or she can do
before the structures are fully tested.
Vital Signs
3. Any movements that are painful are done last, if pos-
sible, to prevent an overflow of painful symptoms In some cases, the examiner may want to begin the exami-
to the next movement that, in reality, may be nation by taking the patient’s vital signs to establish
symptom free. the patient’s baseline physiological parameters and vital
4. If active range of motion (AROM) is not full, over- signs (Table 1-7) and review the medical history screen-
pressure is applied only with extreme care to prevent ing card (see Figure 1-9). These include the pulse (most
the exacerbation of symptoms. commonly the radial pulse at the wrist is used), blood
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20 Chapter 1 Principles and Concepts
TABLE 1-7
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Chapter 1 Principles and Concepts 21
TABLE 1-8
From Kaplan NM, Deveraux RB, Miller HS: Systemic hyperextension. Med Sci Sports Exerc 26:S269, 1994.
TABLE 1-9
Reprinted, by permission, from McGrew CA: Clinical implications of the AHA preparticipation cardiovascular screening guidelines. Athletic Ther
Today 5(4):55, 2000.
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22 Chapter 1 Principles and Concepts
History
Observation
DECISION:
Spinal joints or peripheral joint problem?
Active movements
Passive movements Cervical
Peripheral joint scan Resisted isometric or lumbar
Scanning Myotomes movements spine Scanning
Examination Sensory scan Peripheral joint scan Examination
Myotomes
Sensory scan
DECISION:
Spinal joints or peripheral joint problem?
Special tests (for specific spinal area) Special tests (for specific peripheral joint)
Joint play (Sensory tests*)
Palpation (Reflexes*)
Imaging techniques Joint play
Palpation
Imaging techniques
Figure 1-11 The scanning examination used to rule out referral of symptoms from the spine. A, Spinal assessment (i.e., based on the history, the
clinician feels the problem is in the spine). B, Peripheral joint assessment (i.e., based on the history, the clinician feels the problem is in a peripheral
joint). (*These are done if scanning examination is not done.)
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Chapter 1 Principles and Concepts 23
sensory scanning examination (sensory scan) can be per- cord and nerve roots of the body and those arising from
formed that may include the appropriate reflexes, the peripheral nerves. The scanning examination helps to
sensory distributions of the dermatomes and peripheral determine whether the pathology is caused by tissues
nerve distribution, and selected neurodynamic tests (e.g., innervated by a nerve root or peripheral nerve that is
upper limb tension test, slump test) if the examiner sus- referring symptoms distally.
pects some neurological involvement. At this point, the The nerve root is that portion of a peripheral nerve
examiner makes a decision or an “educated guess” as to that “connects” the nerve to the spinal cord. Nerve roots
whether the problem is in the cervical spine, lumbar spine, arise from each level of the spinal cord (e.g., C3, C4),
or the peripheral joint, based on the information gained. and many, but not all, intermingle in a plexus (brachial,
Once the decision is made, the examiner either completes lumbar, or lumbosacral) to form different peripheral
the spinal assessment (in the case of a suspected spinal nerves (Figure 1-12). This arrangement can result in a
problem) or turns instead to completing the assessment single nerve root supplying more than one peripheral
of the appropriate peripheral joint (see Figure 1-11). The nerve. For example, the median nerve is derived from the
scanning examination should add no more than 5 or 10 C6, C7, C8, and T1 nerve roots, whereas the ulnar nerve
minutes to the assessment. is derived from C7, C8, and T1 (Table 1-10). For this
The idea of the scanning examination was developed reason, if pressure is applied to the nerve root, the distri-
by James Cyriax,1 who also, more than any other author, bution of the sensation or motor function is often felt or
originated the concepts of “contractile” and “inert” exhibited in more than one peripheral nerve distribution
tissue, “end feel,” and “capsular patterns” and contrib- (Table 1-11). Therefore, although the symptoms seen in
uted greatly to development of a comprehensive and sys- a nerve root lesion (e.g., paresthesia, pain, muscle weak-
tematic physical examination of the moving parts of the ness) may be similar to those seen in peripheral nerves,
body. Although several of his constructs and paradigms the signs (e.g., area of paresthesia, where pain occurs,
have been questioned,62–64 the basic principles of ensuring which muscles are weak) are commonly different. The
that all tissues are tested remains sound. examiner must be able to differentiate a dermatome
(nerve root) from the sensory distribution of a peripheral
Spinal Cord and Nerve Roots nerve, and a myotome (nerve root) from muscles supplied
To further comprehend and ensure the value of the scan- by a specific peripheral nerve. In addition, neurological
ning examination, the examiner must have a clear under- signs and symptoms, such as paresthesia and pain, may
standing of signs and symptoms arising from the spinal result from inflammation or irritation of tissues, such as
Roots
Contribution to
phrenic nerve
Dorsal
Trunks scapular From C4
nerve C5
Suprascapular nerve C5
Subdivisions
Nerve to C6
subclavius
Cords C6
per C7
Up
ior C7
ter
st.
An dle C8
Mid
Po
Lateral
pectoral nerve Anterior
ior we
r
s ter Lo T1 T1
al Po
er
Nerves Lat
Posterior
or r Long thoracic nerve
steri io
Po ter
An
Musculocutaneous
nerve l
dia
Me
Axillary nerve 1st rib
Radial nerve Medial pectoral nerve
Medial brachial cutaneous nerve
Median nerve Medial antebrachial cutaneous nerve
Ulnar nerve Upper subscapular nerve
Thoracodorsal nerve
Lower subscapular nerve
Figure 1-12 The brachial plexus. (From Neuman DA: Kinesiology of the musculoskeletal system—foundations for rehabilitation, St Louis, 2010,
Mosby Elsevier, p. 150.)
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24 Chapter 1 Principles and Concepts
TABLE 1-11
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Chapter 1 Principles and Concepts 25
TABLE 1-11
vessels, dura mater, periosteum, ligaments, and interver- because slight differences and variabilities occur with
tebral discs, among many other structures. each patient, and dermatomes also exhibit a great deal
The sensory distribution of each nerve root is called of overlap.67,68 The variability in dermatomes was aptly
the dermatome. A dermatome is defined as the area of demonstrated by Keegan and Garrett in 1948 (Figure
skin supplied by a single nerve root. The area innervated 1-14).69 The overlap may be demonstrated by the fact
by a nerve root is larger than that innervated by a periph- that, in the thoracic spine, the loss of one dermatome
eral nerve.66 The descriptions of dermatomes in the fol- often goes unnoticed because of the overlap of the
lowing chapters should be considered as examples only, adjacent dermatomes.
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26 Chapter 1 Principles and Concepts
Vertebral artery Sympathetic ganglion nerve leads to complete paralysis of the muscles
supplied by that nerve, especially if the injury results in
Ventral nerve root Gray ramus
communicans an axonotmesis or neurotmesis, and the weakness there-
Facet (apophyseal) fore is evident right away. Differences in the amount of
joint Costal process resulting paralysis arise from the fact that more than one
myotome contributes to the formation of a muscle
Ventral ramus of
spinal nerve embryologically.
A sclerotome is an area of bone or fascia supplied by
Transverse
process a single nerve root (Figure 1-15). As with dermatomes,
sclerotomes can show a great deal of variability among
Dorsal ramus of
spinal nerve individuals.
It is the complex nature of the dermatomes, myo-
Spinal ganglion tomes, and sclerotomes supplied by the nerve root that
Spinal cord can lead to referred pain, which is pain felt in a part of
the body that is usually a considerable distance from the
Dura mater Dorsal nerve root
tissues that have caused it. Referred pain is explained as
an error in perception on the part of the brain. Usually,
pain can be referred into the appropriate myotome, der-
Figure 1-13 Spinal cord, nerve root portions, and spinal nerve in the
matome, or sclerotome from any somatic or visceral tissue
cervical spine and their relation to the vertebra and vertebral artery.
innervated by a nerve root, but, confusingly, it sometimes
is not referred according to a specific pattern.70 It is not
understood why this occurs, but clinically it has been
Spinal nerve roots have a poorly developed epineu- found to be so.
rium and lack a perineurium. This development makes Many theories of the mechanism of referred pain have
the nerve root more susceptible to compressive forces, been developed, but none has been proven conclusively.
tensile deformation, chemical irritants (e.g., alcohol, lead, Generally, referred pain may involve one or more of the
arsenic), and metabolic abnormalities. For example, com- following mechanisms:
pression of the nerve root could occur with a posterolat- 1. Misinterpretation by the brain as to the source of the
eral intervertebral disc herniation, a “burner” or stretching painful impulses
of the nerve roots or the brachial plexus in a football 2. Inability of the brain to interpret a summation of
player or alcoholic neuritis in an alcoholic. Pressure on noxious stimuli from various sources
nerve roots leads to loss of muscle tone and mass, but the 3. Disturbance of the internuncial pool by afferent nerve
loss is often not as obvious as when pressure is applied to impulses.
a peripheral nerve. Because the peripheral nerve that Referral of pain is a common occurrence in problems
innervates the muscle is usually supplied by more than associated with the musculoskeletal system. Pain is often
one nerve root, more muscle fibers are likely to be affected felt at points remote from the site of the lesion. The site
and wasting or atrophy is more evident if the peripheral to which pain is referred is an indicator of the segment
nerve itself is damaged. In addition, the pattern of weak- that is at fault: it indicates that one of the structures
ness (i.e., which muscles are affected) is different for an innervated by a specific nerve root is causing signs and
injury to a nerve root and to a peripheral nerve, because symptoms in other tissues supplied by that same nerve
a nerve root supplies more than one peripheral nerve. root. For example, pain in the L5 dermatome could arise
Pressure on a peripheral nerve resulting in a neuropraxia from irritation around the L5 nerve root, from an L5 disc
leads to temporary nonfunction of the nerve. With this causing pressure on the L5 nerve root, from facet joint
type of injury, there is primarily motor involvement, with involvement at L4–L5 causing irritation of the L5 nerve
little sensory or autonomic involvement, and although root, from any muscle supplied by the L5 nerve root, or
weakness may be demonstrated, muscle atrophy may not from any visceral structures having L5 innervation.
be evident. With more severe peripheral nerve lesions Referred pain tends to be felt deeply; its boundaries are
(e.g., axonotmesis and neurotmesis), atrophy is evident. indistinct, and it radiates segmentally without crossing
Myotomes are defined as groups of muscles supplied the midline. Radicular or radiating pain, a form of
by a single nerve root. A lesion of a single nerve root is referred pain, is a sharp, shooting pain felt in a derma-
usually associated with paresis (incomplete paralysis) of tome, myotome, or sclerotome because of direct involve-
the myotome (muscles) supplied by that nerve root. It ment of or damage to a spinal nerve or nerve root.53
therefore takes time for any weakness to become evident A radiculopathy refers to radiating paresthesia, numb-
on resisted isometric or myotome testing, and for this ness or weakness but not pain.71 A myelopathy is a neu-
reason, the isometric testing of myotomes is held for at rogenic disorder involving the spinal cord or brain and
least 5 seconds. On the other hand, a lesion of a peripheral resulting in an upper motor neuron lesion; the patterns
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Chapter 1 Principles and Concepts 27
C8
Anterior Anterior
SHERRINGTON BOLK
Posterior Posterior
Anterior Anterior
HEAD FOERSTER
Posterior Posterior
S1
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28 Chapter 1 Principles and Concepts
C5 C4
C5
C6
C7 L2
C8
L4
L4
C7
L2 C7
L5
S2
C8
L4 S1 Radiculopathy
C8 (nerve root lesion)
L3
L5
Plexopathy
(brachial plexus lesion)
L4
L5 L3 Neuropathy
(peripheral nerve lesion)
L4
S1
L4
L5 L5
S2
of pain or symptoms are different from that of radicular nerves therefore are most commonly affected by pressure,
pain, and often both upper and lower limbs are affected traction, friction, anoxia, or cutting. Examples include
(Figure 1-16). pressure on the median nerve in the carpal tunnel, trac-
tion to the common peroneal nerve at the head of the
Peripheral Nerves fibula during a lateral ankle sprain, friction to the ulnar
Peripheral nerves are a unique type of “inert” tissue (see nerve in the cubital tunnel, anoxia of the anterior tibial
the later discussion) in that they are not contractile tissue, nerve in a compartment syndrome, and cutting of the
but they are necessary for the normal functioning of vol- radial nerve with a fracture of the humeral shaft. Cooling,
untary muscle. The examiner must be aware of potential freezing, and thermal or electrical injury may also affect
injury to nervous tissue when examining both contractile peripheral nerves.
and inert tissue. Table 1-12 shows some of the tissue Nerve injuries are usually classified by the systems
changes that result when a peripheral nerve lesion occurs. of Seddon72 or Sunderland.73 Seddon, whose system is
In peripheral nerves, the epineurium consists of a loose most commonly used, classified nerve injuries into neu-
areolar connective tissue matrix surrounding the nerve ropraxia (most common), axonotmesis, and neurotmesis
fiber. It allows changes in growth length of the bundled (Table 1-13). Sunderland followed a similar system but
nerve fibers (funiculi) without allowing the bundles to be divided axonotmesis and neurotmesis into different levels
strained. The perineurium protects the nerve bundles by or degrees (Table 1-14). Any examination of a joint must
acting as a diffusion barrier to irritants and provides include a thorough peripheral nerve examination, espe-
tensile strength and elasticity to the nerve. Peripheral cially if there are neurological signs and symptoms. The
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Chapter 1 Principles and Concepts 29
TABLE 1-12
Signs and Symptoms of Mixed Peripheral Nerve (Lower Motor Neuron) Lesions*
Motor Sensory Sympathetic
• Flaccid paralysis • Loss of or abnormal sensation • Loss of sweat glands
• Loss of reflexes • Loss of vasomotor tone: warm flushed (dryness)
• Muscle wasting and atrophy (early); cold, white (later) • Loss of pilomotor response
• Lost synergic action of muscles • Skin may be scaly (early); thin, smooth,
• Fibrosis, contractures, and adhesions and shiny (later)
• Joint weakness and instability • Shallower skin creases
• Decreased range of motion and • Nail changes (striations, ridges, dry, brittle,
stiffness abnormal curving, luster lost)
• Disuse osteoporosis of bone • Ulceration
• Growth affected
TABLE 1-13
Data from Seddon HJ: Three types of nerve injury. Brain 66:17–28, 1943.
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30 Chapter 1 Principles and Concepts
TABLE 1-15
Comparison of Signs and Symptoms for C7 Nerve Root Lesion and Median Nerve Lesion at Elbow
C7 Nerve Root Median Nerve
Sensory alteration Lateral arm and forearm to index, Palmar aspect of thumb, index, middle, and half of
long, and ring fingers on palmar and ring finger
dorsal aspect Dorsal aspect of index, middle, and possibly half of
ring finger
Motor alteration Triceps Pronator teres
Wrist flexors Wrist flexors (lateral half of flexor digitorum profundus)
Wrist extensors (rarely) Palmaris longus
Pronator quadratus
Flexor pollicis longus and brevis
Abductor pollicis brevis
Opponens pollicis
Lateral two lumbricals
Reflex alteration Triceps may be affected None*
Paresthesia Index, long and ring fingers on palmar Same as sensory alternation
and dorsal aspect
*No “common” reflexes are affected; if the examiner tested the tendon reflexes of the muscles listed, they would be affected.
the examiner to differentiate between a peripheral nerve would be disrupted. In addition, diseased nerves are
lesion and a nerve root lesion. (An example is shown in more susceptible to injury; thus, the presence of systemic
Table 1-15.) If electromyographic studies are to be used disease (e.g., diabetes, thyroid dysfunction) may make the
to determine the grade of nerve injury, denervation nerve more susceptible to compression somewhere along
cannot be evaluated for at least 3 weeks after injury to its path.75 Finally, the signs and symptoms could poten-
allow wallerian degeneration to occur and to allow regen- tially be arising from both a nerve root lesion and a
eration (if any) to begin.77–79 Muscle wasting usually peripheral nerve lesion. Only with meticulous assessment
becomes obvious after 4 to 6 weeks and progresses to can the clinician delineate where the true problems lie,
reach its maximum by about 12 weeks following injury. which may be due to trauma, degeneration, or anatomical
Circulatory changes after nerve injury vary with time. In anomalies.
the initial or early stages, the skin is warm, but after about Similarly, the loss of extensibility of the nervous tissue
3 weeks, the skin becomes cooler as a result of decreased at one site may produce increasing tensile loads when the
circulation. Because of the decreased circulation and peripheral nerve or nerve root is stretched, leading
altered cell metabolism, trophic changes occur to the skin to mechanical dysfunction.85 This is the principle behind
and nails. the neural tension or neurodynamic tests, such as the
When assessing a patient, the examiner must also be straight leg raise, slump test, and upper limb tension
aware of what has been called the double-crush syn- test,85–87 and may provide a partial explanation for lesions,
drome or double-entrapment neuropathy.80–83 The theory such as cervical spine lesions mimicking tennis elbow and
of this lesion (which has not yet been proved but has carpal tunnel syndrome. These tests put neural tissue
clinical supporting evidence) is that, whereas compression (e.g., neuraxis of the central nervous system [CNS],
or pathology at one point along a peripheral nerve or meninges, nerve roots, peripheral nerves) under tension
nerve root may not be sufficient to cause signs and symp- when they are performed and may duplicate symptoms
toms, compression or pathology at two or more points that result during functional activity.85,87,88 For example,
may lead to a cumulative effect that results in apparent sitting in a car is closely mimicked by the action of the
signs and symptoms.84 Because of this cumulative slump test and straight leg raising. However, they often
effect, signs and symptoms may indicate one area of do not, by themselves, indicate where the problem lies.
involvement (e.g., the carpal tunnel), whereas other areas Further testing (e.g., nerve conduction tests, electromy-
(e.g., cervical spine, brachial plexus, thoracic outlet) may ography [EMG]) may be needed to determine the exact
be contributing to the problem. Similarly, cervical lesions site of the problem.
may be involved in tennis elbow (lateral epicondylitis) Neural tissue moves toward the joint at which elonga-
syndromes. Upton and McComas80 believed that com- tion is initiated. Thus, if cervical flexion is initiated, the
pression proximally on the nerve trunk could increase the nerve roots, even those in the lumbar spine, move toward
vulnerability of the peripheral nerves or nerve roots at the cervical spine. Likewise, flexion of the whole spine
distal points along their paths because axonal transport causes movement toward the lumbar spine, and extension
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Chapter 1 Principles and Concepts 31
of the knee or dorsiflexion of the foot causes neural move- (again, a scanning examination is performed); or when
ment toward the knee or ankle.85,87,88 These “tension the joint to be assessed is too acutely injured or irritable
points” can potentially help determine where the restric- to do the total systematic examination.
tion to movement is occurring. Normally, tension tests If there is an organic lesion, some active, passive, or
are not painful, although the patient is often aware of resisted isometric movements will be abnormal or painful,
increased tension or discomfort in the spine or the limb. and others will not. Negative findings must balance posi-
As tension tests indicate neural mobility and sensitivity to tive ones, and the examination must be extensive enough
mechanical stresses, they are considered positive only if to allow characteristic patterns to emerge. Determination
they reproduce the patient’s symptoms, or if the patient’s of the problem is not made on the strength of the first
response is altered by movement of a body part distal positive finding; it is made only after it is clear that there
to where the symptoms are felt (e.g., foot dorsiflexion are no other contradictory signs. Movements may be
causing symptoms in the lumbar spine), or if there is repeated several times quickly to rule out any problem,
asymmetry in the response.85 When doing tension tests, such as vascular insufficiency, or if the patient has indi-
the examiner should note the angle or position at which cated in the history that repetitive movements increase
the restriction occurs and what the resistance feels like. the symptoms. Likewise, sustained postures may be held
With irritable conditions, only those parts of the test that for several seconds or combined movements may be per-
are needed to cause positive results should be performed. formed if the history indicates increased symptoms with
For example, in the slump test, if neck flexion and slump- those postures or movements.
ing cause positive signs, there is no need to cause further Contractile tissues may have tension placed on them
discomfort to the patient by doing knee extension and by stretching or contraction.1 These structures include
foot dorsiflexion. the muscles, their tendons, and their attachments into the
In the examination, testing of neurological tissue bone. Nervous tissues and their associated sheaths also
occurs during active, passive, and resisted isometric move- have tension put on them by stretching and pinching, as
ment, as well as during functional testing, specific tests, do inert tissues. Inert tissues include all structures that
reflexes, and cutaneous distribution and palpation. would not be considered contractile or neurological, such
as joint capsules, ligaments, bursae, blood vessels, carti-
lage, and dura mater. Table 1-16 demonstrates differen-
Examination of Specific Joints
tial diagnosis of injuries to contractile tissue (strains and
The examiner should use an unchanging, systematic paratenonitis) and inert tissue (sprains). Some examiners
approach to the examination that varies only slightly to separate vascular tissues from the other inert tissues;
elaborate certain clues given by the history or by asym- however, for the most part, when doing a musculoskeletal
metric responses. For example, if the history is character- examination, they can be grouped with the other inert
istic of a disc lesion, the examination should be a detailed tissues with the understanding that they do present their
one of all the tissues that may be affected by the disc and own unique signs and symptoms.
a brief one of all the other joints to exclude contradictory When doing movement testing, the examiner should
signs. If the history suggests arthritis of the hip, the note whether pain or restriction predominate. If pain
examination should be a detailed one of the hip and a predominates, the condition is more acute, and gentler
brief one of the other joints—again, to exclude contradic- assessment and treatment are required. If restriction
tory signs. As the movements are tested, the examiner is predominates, the condition is subacute, or chronic,
looking sometimes for the patient’s subjective responses and more vigorous assessment and treatment can be
and sometimes for clinical objective findings. For example, performed.
if examination of the cervical spine shows clear signs of a
disc problem, as the examination is continued down the Active Movements
arm, the examiner looks more for muscle weakness (objec- Active movements (AROM) are “actively” performed by
tive) rather than for elicitation of pain (subjective). In the patient’s voluntary muscles and have their own special
contrast, if the history suggests a muscle lesion, pain will value in that they combine tests of joint range, control,
probably be provoked when the arm is examined. In muscle power, and the patient’s willingness to perform
either case, the structures expected to be normal are not the movement. These movements are sometimes referred
omitted from the examination. There are only a few situ- to as physiological movements. The end of active
ations in which deviation from this systematic routine movement is sometimes referred to as the physiological
should occur: when there is uncertainty about where the barrier. Contractile, nervous, and inert tissues are
pathology lies (in which case, a scanning examination involved or moved during active movements. When active
must be performed with combined assessment of the movements occur, one or more rigid structures (bones)
spine and one or more peripheral joints); when there is move, and such movement results in movement of all
no history of trauma or indication of pathology in a spe- structures that attach to or are in close proximity to that
cific joint yet the patient complains of pain in that joint bone. Although active movements are usually the first
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32 Chapter 1 Principles and Concepts
TABLE 1-16
movements done, they either are not performed at all or In this case, only those movements that provide the most
are performed with caution during fracture healing or if useful information should be performed. The examiner
the movement could put stress on newly repaired soft should note the rhythm of movement along with any
tissues. The examiner should note which movements, if pain, limitation, or unusual (e.g., instability jog) or trick
any, cause pain or other symptoms and the amount and movements that occur. Trick movements are modified
quality of pain that results. For example, small, unguarded movements that the patient consciously or unconsciously
movements causing intense pain indicate an acute, irri- uses to accomplish what the examiner has asked the
table joint. If the condition is very irritable or acute, it patient to do. For example, in the presence of deltoid
may not be possible to elicit all the movements desired. paralysis, if the examiner asks the patient to abduct the
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Chapter 1 Principles and Concepts 33
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34 Chapter 1 Principles and Concepts
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Chapter 1 Principles and Concepts 35
same amount in each direction (e.g., capsular pattern). only be tested with extreme care. A proper evaluation of
Pathomechanical hypomobility occurs as a result of end feel can help the examiner to assess the type of
joint trauma (micro or macro) leading to restriction in pathology present, determine a prognosis for the condi-
one or more directions.18 Hypermobility is not the same tion, and learn the severity or stage of the problem. By
as instability. Instability covers a wide range of pathologi- determining if pain or restriction is the main problem, the
cal hypermobility. Although there are tests to demon- examiner can determine if a more gentle treatment should
strate general hypermobility, these tests should be be given (pain predominating) or a more vigorous treat-
interpreted with caution because patients demonstrate a ment (restriction predominantly). The end feel sensations
wide range of variability between joints and within that the examiner experiences are subjective, so intrarater
joints.110,111 With careful assessment, one often finds that reliability tends to be good, whereas interrater reliability
a joint may be hypermobile in one direction and hypo- is poor.62 Many clinicians develop their own classification
mobile in another direction. It must also be remembered with the most common ones used63 developed by Cyriax,1
that evidence of hypomobility or hypermobility does not Kaltenborn,92 and Paris.112
necessarily indicate a pathological state in the person Cyriax described three classic normal end feels:1
being assessed. The examiner should attempt to deter- • Bone-to-Bone. This is a “hard,” unyielding sensation
mine the cause of the limitation (e.g., pain, spasm, that is painless. An example of normal bone-to-bone
adhesions, compression) or hypermobility (e.g., injury, end feel is elbow extension.
occupational, genetic, disease) and the quality of the • Soft-Tissue Approximation. With this type of end feel,
movement (e.g., lead pipe, cogwheel). there is a yielding compression (mushy feel) that stops
End Feel.1 When assessing passive movement, the further movement. Examples are elbow and knee
examiner should apply overpressure at the end of the flexion, in which movement is stopped by compression
ROM to determine the quality of end feel (the sensation of the soft tissues, primarily the muscles. In a particu-
the examiner “feels” in the joint as it reaches the end of larly slim person with little muscle bulk, the end feel
the ROM) of each passive movement (Table 1-17). Care of elbow flexion may be bone-to-bone.
must be taken when testing end feel, however, to be sure • Tissue Stretch. There is a hard or firm (springy) type
that severe symptoms are not provoked. If the patient is of movement with a slight give. Toward the end of
able to hold a position at the end of the physiological ROM, there is a feeling of springy or elastic resistance.
ROM (end range of active movement) without provoking The normal tissue stretch end feel has a feeling of
symptoms or if the symptoms ease quickly after returning “rising tension or stiffness.” This changing tension has
to the resting position, then the end feel can be tested. led to this end feel sometimes being divided into two
Pain with pathological end feels is common.63 If, however, types: elastic (soft) and capsular (hard). This feeling
the patient has severe pain at end range, end feel should depends on the thickness and type of tissue being
stretched, and it may be very elastic, as in the Achilles
tendon stretch, or slightly elastic, as in wrist flexion
TABLE 1-17 (tissue stretch), or hard as in knee extension. A hard
Normal and Abnormal End Feels end feel is firm with a definite stopping point, whereas
soft end feel implies a softer end feel without a definite
End Feel Example stopping place.113 Tissue stretch is the most common
Normal type of normal end feel; it is found when the capsule
Bone to bone Elbow extension and ligaments are the primary restraints to movement.
Soft tissue approximation Knee flexion Examples are lateral rotation of the shoulder, and knee
Tissue stretch Ankle dorsiflexion, shoulder and metacarpophalangeal joint extension.
lateral rotation, finger In addition to the three normal types of end feel,
extension Cyriax described five classic abnormal end feels, several
of which have subdivisions and each of which is com-
Abnormal monly associated with some degree of pain or restricted
Early muscle spasm Protective spasm following movement.1,114
injury
• Muscle Spasm. This end feel is invoked by movement,
Late muscle spasm Spasm due to instability or pain
with a sudden dramatic arrest of movement often
“Mushy” tissue stretch Tight muscle
Spasticity Upper motor neuron lesion accompanied by pain. The end feel is sudden and hard.
Hard capsular Frozen shoulder Cyriax called this a “vibrant twang.”1 Some examiners
Soft capsular Synovitis, soft tissue edema divide muscle spasm into different parts. Early muscle
Bone to bone Osteophyte formation spasm occurs early in the ROM, almost as soon as
Empty Acute subacromial bursitis movement starts; this type of muscle spasm is associ-
Springy block Meniscus tear ated with inflammation and is seen in more acute
conditions. Late muscle spasm occurs at or near the
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36 Chapter 1 Principles and Concepts
end of the ROM. It is usually caused by instability and found in joints with menisci. There is a rebound effect
the resulting irritability caused by movement. An with a thick stretching feel although it is not as stretchy
example is muscle spasm occurring during the appre- as a hard capsular end feel, and it usually indicates an
hension test for anterior dislocation of the shoulder. internal derangement within the joint. A springy block
Both types of muscle spasm are the result of the sub- end feel may be found with a torn meniscus of a knee
conscious efforts of the body to protect the injured when it is locked or unable to go into full extension.
joint or structure, and their occurrence may be related Capsular Patterns.1 With passive movement, a full ROM
to how quickly the examiner does the movement. must be carried out in several directions. A short, too-soft
Spasticity is slightly different and is seen with upper movement in the midrange does not achieve the proper
motor neuron lesions. It is a form of muscle hyperto- results or elicit potential findings. In addition to evaluat-
nicity that offers increased resistance to stretch involv- ing the end feel, the examiner must look at the pattern
ing primarily the flexors in the upper limb and extensors of limitation or restriction. If the capsule of the joint is
in the lower limb and may be associated with muscle affected, the pattern of limitation is the feature that indi-
weakness. The Ashworth scale is sometimes used to cates the presence of a capsular pattern in the joint. This
measure spasticity and resistance to passive movement, pattern is the result of a total joint reaction, with muscle
but its reliability has been questioned.115,116 A tight spasm, capsular contraction (the most common cause),
muscle may give its own unique end feel. This is and generalized osteophyte formation being possible
similar to normal tissue stretch, but it does not have mechanisms at fault. Each joint has a characteristic pattern
as great an elastic feel. of limitation. The presence of this capsular pattern does
• Capsular. Although this end feel is similar to tissue not indicate the type of joint involvement; only an analysis
stretch, it does not occur where one would expect (i.e., of the end feel can do that. Only joints that are controlled
it occurs earlier in the ROM), and it tends to have a by muscles have a capsular pattern; joints, such as the
thicker feel to it. ROM is obviously reduced, and the sacroiliac and distal tibiofibular joints, do not exhibit a
capsule can be postulated to be at fault. Muscle spasm capsular pattern. Dutton pointed out that capsular pat-
usually does not occur in conjunction with the capsular terns are based on empirical findings rather than research,
type of end feel except if the movement is fast and the and this may be the reason capsular patterns may be dif-
joint acute. Some examiners divide this end feel into ferent or inconsistent.3 In fact, Hayes et al.62 felt the
hard capsular, in which the end feel has a thicker pattern of limitation was useful but the proportional limi-
stretching quality to it, and soft capsular (boggy), tation concept should not be used. Table 1-18 illustrates
which is similar to normal tissue stretch end feel but some of the common capsular patterns seen in joints.
with a restricted ROM. The hard capsular end feel is Noncapsular Patterns.1 The examiner must also be aware
seen in more chronic conditions or in full-blown cap- of noncapsular patterns, for example, a limitation that
sular patterns. The limitation comes on rather abruptly exists but does not correspond to the classic capsular
after a smooth, friction-free movement. The soft cap- pattern for that joint. In the shoulder, abduction may be
sular end feel is more often seen in acute conditions restricted but with very little rotational restriction (e.g.,
with stiffness occurring early in the range and increas- subacromial bursitis). Although a total capsular reaction
ing until the end of range is reached. Maitland calls this is absent, there are other possibilities, such as ligamentous
“resistance through range.”117 Some authors interpret adhesions, in which only part of a capsule or the accessory
this soft, boggy end feel as being the result of synovitis, ligaments are involved. There may be a local restriction
soft-tissue edema, or hemarthrosis.118 Major injury to in one direction, often accompanied by pain, and full,
ligaments and the capsule often causes a soft end feel pain-free ROM in all other directions. A second possibility
until the tension is taken up by other structures.119 is internal derangement, which commonly affects only
• Bone-to-Bone. This abnormal end feel is similar to the certain joints, such as the knee, ankle, and elbow. Intra-
normal bone-to-bone type, but the restriction occurs capsular fragments may interfere with the normal sequence
before the end of ROM would normally occur or of motion. Movements causing impingement of the frag-
where a bone-to-bone end feel would not be expected. ments will be limited, whereas other motions will be free.
An example is a bone-to-bone end feel in the cervical In the knee, for example, a torn meniscus may cause a
spine resulting from osteophyte formation. blocking of extension, but flexion is usually free. Loose
• Empty. The empty end feel is detected when movement bodies cause limitation when they are caught between
produces considerable pain. The movement cannot be articular surfaces. A third possibility is extra-articular
performed or stops because of the pain, although no lesions. These lesions are revealed by disproportionate
real mechanical resistance is being detected. Examples limitation, extra-articular adhesions, or an acutely inflamed
include an acute subacromial bursitis or a tumor. structure limiting movement in a particular direction. For
Patients often have difficulty describing the empty end example, limited straight leg raising in the lumbar disc
feel, and there is no muscle spasm involved. syndrome is referred to as a constant length phenome-
• Springy Block. Similar to a tissue stretch, this occurs non. This phenomenon results when the limitation of
where one would not expect it to occur; it tends to be movement in one joint depends on the position in which
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Chapter 1 Principles and Concepts 37
TABLE 1-18
another joint is held. The restricted tissue (in this case, functional testing, selected special tests, joint play testing,
the sciatic nerve) must lie outside the joint or joints (in and palpation.
this case, hip and knee) being tested. The constant length Inert tissue refers to all tissue that is not considered
phenomenon may also result from muscle adhesions that contractile or neurological. Four classic patterns may be
cause restriction of motion. seen in lesions of inert issue, according to the ROM avail-
Inert Tissue.1 After the active and passive movements able (or restriction present) and the amount of pain
are completed, the examiner should be able to determine produced.1
whether there are problems with any of the inert tissues. 1. If the range of movement is full and there is no pain,
The examiner makes such a determination by judging the there is no lesion of the inert tissues being tested by
degree of pain and the limitation of movement within the that passive movement; however, there may be lesions
joint. For lesions of inert tissue, the examiner may find of inert tissue in other directions or around other
that active and passive movements are painful in the same joints.
direction. Usually pain occurs as the limitation of motion 2. The next possible pattern is one of pain and limita-
approaches. Resisted isometric movements (discussed tion of movement in every direction. In this pattern,
later) are not usually painful unless some compression is the entire joint is affected, indicating arthritis or cap-
occurring. During the examination, inert tissues are tested sulitis. Each joint has its own capsular pattern (see
or stressed during active and passive movements, Table 1-18), and the amount of limitation is not
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38 Chapter 1 Principles and Concepts
usually the same in each direction; however, although Resisted Isometric Movements
there is a set pattern for each joint, other directions Resisted isometric movements are the movements tested
may also be affected. All movements of the joint may last in the examination of the joints. This type of move-
be affected, but the motions described for the capsular ment consists of a strong, static (isometric), voluntary
pattern usually occur in the particular order listed. For muscle contraction, and it is used primarily to determine
example, the capsular pattern of the shoulder is lateral whether the contractile tissue is the tissue at fault, although
rotation most limited, followed by abduction and the nerve supplying the muscle is also tested. If the
medial rotation. In early capsular patterns, only one muscle, its tendon, or the bone into which they insert is
movement may be restricted; this movement is usually at fault, pain and weakness result; the amount of pain and
the one that has the potential for the greatest restric- weakness is related to the degree of injury and the patient’s
tion. For example, in an early capsular pattern of the pain threshold. If movement is allowed to occur at the
shoulder, only lateral rotation may be limited, and the joint, inert tissue around the joint will also move, and it
limitation may be slight. will not be clear whether any resulting pain arises from
3. A patient with a lesion of inert tissue may experience contractile or inert tissues. The joint, therefore, is put in
pain and limitation or excessive movement in some a neutral or resting position (see Table 1-35 later) so that
directions but not in others, as in a ligament sprain or minimal tension is placed on the inert tissue. The patient
local capsular adhesion. In other words, a noncapsular is asked to contract the muscle as strongly as possible
pattern is presented. Movements that stretch, pinch, while the examiner resists to prevent any movement from
or move the affected structure cause the pain. Internal occurring and to ensure that the patient is using maximum
derangement that results in the blocking of a joint is effort. To keep movement to a minimum, it is best for
another example of a lesion of inert tissue that pro- the examiner to position the joint properly in the resting
duces a variable pattern. Extra-articular limitation position and then to say to the patient, “Don’t let me
occurs when a lesion outside the joint affects the move you.” In this way, the examiner can ensure that the
movement of that joint. Because these movements contraction is isometric and can control the amount of
pinch or stretch the involved structure (e.g., bursitis force exerted. Movement cannot be completely elimi-
in the buttock, acute subacromial bursitis), pain and nated, but this method minimizes it. Some compression
limitation of movement occur on stretch or compres- of the inert tissues (e.g., cartilage) occurs with the con-
sion of these structures. If a structure such as a liga- traction, and there may be some joint shear as well, but
ment has been torn, the ROM may increase if swelling it will be minimal if done as described.
is minimal, especially right after injury, indicating If, as advocated, this isometric hold method is used,
instability (pathological hypermobility) of the joint then movement against this resistance would require
and can be seen in spinal or peripheral joints. Swelling muscle strength of grade 3 to 5 on the muscle test grading
often masks instability because it puts the tissues under scale (Table 1-19).121 If the muscle strength is less than
tension. Pathological hypermobility, if present, results grade 3, then the methods advocated in muscle testing
in greater than normal movement at the joint, causes manuals must be used.117,122 If the examiner is having dif-
pain, puts neurogenic structures at risk, and can result ficulty differentiating between grade 4 and grade 5, an
in progressive deformity and degeneration.120 eccentric break method of muscle testing may be used.
4. The final inert tissue pattern is limited movement that This method starts as an isometric contraction, but then
is pain free. The end feel for this type of condition is the examiner applies sufficient force to cause an eccentric
often of the abnormal bone-to-bone type, and it contraction or a “break” in the patient’s isometric con-
usually indicates a symptomless osteoarthritis—that is, traction. This method provides a more recognizable
osteophytes are present and restrict movement, but threshold for maximum isometric contraction.121 It must
they are not pinching or compressing any sensitive be recognized, however, that all three methods are subjec-
structures. If this situation is encountered, it should tive for normal and good values. When a muscle is tested
be left alone because it is not causing the patient any in the resting position, it is usually being tested in its posi-
problem other than restricted ROM and attempts at tion of optimum length so that maximum force, if neces-
treatment could lead to further problems. sary, can be elicited. In some cases, however, a muscle,
because of pathology, may become lengthened or short-
ened leading to weakness when tested in the normal
resting position. Testing a muscle in the fully lengthened
Patterns of Inert Tissue Lesions position tightens the inert components of muscle and puts
more stress on the contractile tissues, whereas testing it in
• Pain-free, full range of motion (ROM) a shortened position puts it in its weakest position. Kendall
• Pain and limited ROM in every direction et al.,123 for example, called muscle weakness that results
• Pain and excessive or limited ROM in some directions
from muscle lengthening stretch weakness or positional
• Pain-free, limited ROM
weakness. Thus, if the examiner has found ROM to be
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Chapter 1 Principles and Concepts 39
TABLE 1-19
Examiner Observations During Resisted Isometric
Muscle Test Grading Movement
Grade Value Movement Grade
• Whether the contraction causes pain and, if it does, the pain’s
5+ Normal Complete ROM against gravity intensity and quality
(100%) with maximal resistance • Strength of the contraction
4 Good (75%) Complete ROM against gravity • Type of contraction causing problem (e.g., concentric, isometric,
with some (moderate) resistance eccentric, econcentric)
3+ Fair + Complete ROM against gravity
with minimal resistance
3 Fair (50%) Complete ROM against gravity lesion, or a lesion or disease (myopathy) of the muscle,
3– Fair – Some but not complete ROM its tendons, or the bony insertions themselves. For the
against gravity first four of these causes, the system of muscle test grading
2+ Poor + Initiates motion against gravity may be used. For nerve root lesions, myotome testing is
2 Poor (25%) Complete ROM with gravity
the method of choice. When testing for muscle lesions,
eliminated
2– Poor – Initiates motion if gravity is
it is more appropriate to test the resisted movements
eliminated isometrically first, to determine which movements are
1 Trace Evidence of slight contractility but painful, then perform individual muscle tests, as advo-
no joint motion cated in texts such as that of Daniels and Worthingham,122
0 Zero No contraction palpated to determine exactly which muscle is at fault.
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40 Chapter 1 Principles and Concepts
Contractile Tissue.1 With resisted isometric testing, the or the nervous tissue supplying that contractile unit,
examiner is looking for problems of contractile tissue, regardless of how tender the muscles may be when
which consists of muscles, their tendons, attachments touched. The muscles and nerves function painlessly
(e.g., bone), and the nervous tissue supplying the con- and are not the source of the patient’s discomfort.
tractile tissue. Both active movements and resisted iso- 2. Movement that is strong and painful indicates a local
metric testing demonstrate symptoms if contractile tissue lesion of the muscle or tendon. Such a lesion could be
is affected. Other parts of the examination, which will test a first- or second-degree muscle strain. The amount
contractile tissue, include passive movement, functional of strength is usually determined by the amount of
testing, specific special tests, and palpation. Usually, pain the patient feels on contraction, which results
passive movements are normal—that is, passive move- from reflex inhibition that leads to weakness or cog-
ments are full and pain free, although pain may be exhib- wheel contractions. A second-degree strain produces
ited at the end of the ROM when the contractile or greater weakness and more pain than a first-degree
nervous tissue is stretched. If contractile tissue has been strain. Similarly, tendinosis, tendinitis, paratenonitis,
injured, active movement is painful in one direction (con- or paratenonitis with tendinosis (Table 1-20) all may
traction) and passive movement, if painful, is painful in lead to contractions that are strong (relative) and
the opposite direction (stretch). Resisted isometric testing painful, but one that is not usually as strong as on the
is painful in the same direction as active movement. If the good side; and the pain is in or around the tendon,
muscles are tested as previously described, not all move- not the muscle.124,125 If there is a partial avulsion frac-
ments will be found to be affected, except in patients with ture, again, the movement will be strong and painful.
psychogenic pain and sometimes in patients with an acute However, if the avulsion is complete, the movement
joint lesion, in which even a small amount of tension on will be weak and painful (see later discussion). Typi-
the muscles around the joint provokes pain. However, if cally, there is no primary limitation of passive move-
the joint lesion is acutely severe, passive movements ment when contractile tissue is injured although
(when tested) will be markedly affected, and there will be end range may be painful (stretch), except, for example,
no confusion as to where the lesion lies. As with inert in the case of a gross muscle tear with hematoma
tissue, four classic patterns have been identified with where the muscle, which is often in spasm, is being
lesions of contractile and nervous tissue.1 (In this case, stretched. In this case, the patient may develop joint
however, one is dealing with pain and strength rather stiffness secondary to disuse. This is often caused by
than pain and altered ROM.) protective muscle spasm of adjacent muscles that
1. Movement that is strong and pain free indicates that allow, for example, some joint contracture to be super-
there is no lesion of the contractile unit being tested imposed on the muscle lesion. This stiffness then takes
TABLE 1-20
From Khan KM, Cook JL, Bonar F, et al: Histopathology of common tendinopathies—update and implications for clinical management. Sports
Med 27:399, 1999.
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Chapter 1 Principles and Concepts 41
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42 Chapter 1 Principles and Concepts
TABLE 1-21
Tight Weak
Functional Division of Muscle Groups* hypertonic lengthened
postural phasic
Muscles Prone to Tightness Muscles Prone to Weakness muscles muscles
(Postural Muscles) (Phasic Muscles)
• Gastrocnemius and soleus • Peronei JOINT(S)
• Tibialis posterior • Tibialis anterior
• Short hip adductors • Vastus medialis and Weak Tight
• Hamstrings lateralis lengthened hypertonic
• Rectus femoris • Gluteus maximus, phasic postural
• Iliopsoas medius, and minimus muscles muscles
• Tensor fasciae latae • Rectus abdominis
• Piriformis • External oblique Figure 1-18 Postural and phasic muscle response to pathology producing
• Erector spinae (especially • Serratus anterior “crossed syndromes.”
lumbar, thoracolumbar, • Rhomboids
and cervical portions) • Lower portion of
• Quadratus lumborum trapezius
Concentric Cocontraction Concentric
• Pectoralis major • Short cervical flexors Action 1:
(stabilization)
• Upper portion of • Extensors of upper Isometric Isometric
trapezius limb
• Levator scapulae Smooth
• Sternocleidomastoid Action 2: harmonized
• Scalenes Eccentric motion Concentric
• Flexors of the upper limb brake
Figure 1-19 Force couple action.
Modified from Jull G, Janda V: Muscles and motor control in low back
pain. In Twomey LT, Taylor JR, editors: Physical therapy for the low
back: clinics in physical therapy, New York, 1987, Churchill Living- either by co-contraction to stabilize a joint, or by one
stone, p. 258. group acting concentrically and the opposing group
*Janda considers all other muscles neutral.
acting eccentrically to cause a controlled joint motion that
is smooth and harmonized (Figure 1-19).130 Pathology to
TABLE 1-22 one of the force couple muscles or to one of the force
Characteristics of Postural and Phasic Muscle Groups couples acting about a joint can lead to muscle imbalance,
instability, and loss of smooth coordinated movement.
Muscles Prone to Tightness Muscles Prone to Weakness
(Postural Muscles) (Phasic Muscles) Other Findings During Movement Testing
Predominantly postural Primarily phasic function When carrying out the examination of the joints, the
function examiner must be aware of other findings that may
Associated with flexor Associated with extensor become evident and may help to determine the nature
reflexes reflexes and location of the problem. For example, it should be
Primarily two-joint muscles Primarily one-joint muscles noted whether there is excessive ROM (hypermobility or
Readily activated with Not readily activated with laxity) within the joints. Comparison of the normal side
movement (shorter movement (longer with the involved side of the body gives some indication
chronaxie) chronaxie)
as to whether the findings on the affected side would be
Tendency to tightness, Tendency to hypotonia,
considered normal. For example, an apparently excessive
hypertonia, shortening, inhibition, or weakness
or contractures range (laxity) may just be the normal ROM for that
Resistance to atrophy Atrophy occurs easily patient. It must also be remembered that joints on the
nondominant side tend to be more flexible than those on
Modified from Jull G, Janda V: Muscles and motor control in low the dominant side.
back pain. In Twomey LT, Taylor JR, editors: Physical therapy for It is also important to note whether a painful arc is
the low back: clinics in physical therapy, New York, 1987, Churchill present; this finding indicates that an internal structure is
Livingstone.
being squeezed or pinched in part of the ROM. Sounds
(such as, crepitus, clicking, or snapping) should be noted.
at chronic joint injuries as both types of muscles tend to To be pathologically significant however, these sounds
be present and require different treatment approaches. must be related to the patient’s symptoms. They may be
In addition, the examiner should always consider caused by structures slipping over one another (e.g.,
the action of force couples surrounding a joint. Force tendons slipping over bone), loose bodies or arthritic
couples are counteracting groups of muscles functioning changes in the joint, abnormal movement of structures
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Chapter 1 Principles and Concepts 43
(e.g., meniscus click on opening or closing of the tem- of specific movement patterns of active, passive, and
poromandibular joint), or a tear in a structure (e.g., a tear resisted isometric movements used to differentiate
in the triangular cartilaginous disc of the wrist). Pain at between inert, neurological, and contractile tissue. Func-
the extreme of ROM may be caused by squeezing or tional assessment may involve task analysis, observation
stretching of structures around the joint or even in the of certain patient activities, or a detailed evaluation of the
joint, especially if the movement takes the joint into its effect of the injury or disability on the patient’s ability to
close packed position. function in everyday life. Reiman and Manske132 have
organized functional tests into different levels of difficulty
for assessment purposes (Table 1-23). Determining what
Functional Assessment
the patient hopes is an appropriate functional outcome,
Functional assessment plays an important role in the eval- and determining what the patient can and cannot do
uation of the patient.131 It is different from the analysis functionally can be extremely important in the choice of
TABLE 1-23
Level II
Assessment primarily at the level of impairment • Anthropometric measurements (e.g., body mass index, girth and
height measurements)
• Muscle length
• Manual muscle testing
• ROM
• Sensation
• Joint play
Level III
Assessment primarily at the level of static • Static posture
observation/posture/balance • Static balance (bilateral and single-leg balance static assessment)
Level IV
Assessment primarily at the level of dynamic • Dynamic posture (i.e., posture of individual as he or she performs
posture, general movement patterns, and movements required)
single plane dynamic balance • General movement patterns (e.g., walking, transfer movements)
• Dynamic balance predominantly in one plane of movement without
quality assessment (e.g., functional reach test, tandem walking)
Level V
Assessment primarily at the level of movement • Assessment of movement patterns the individual performs with his or
patterns encountered during higher level her primary tasks (e.g., specific sport, occupational, and other tasks)
tasks and/or multi-planar dynamic balance • Four square step
Level VI
Assessment primarily at the level of specific • Functional movement screen
movement patterns • Movement impairment syndrome assessment
Continued
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44 Chapter 1 Principles and Concepts
TABLE 1-23
Level VIII
Assessment primarily at the level of PPM • Aerobic endurance testing one or more of the following:
occurring predominantly in one plane of 1-mile walk
Vertical jump
Level IX
Assessment primarily at the level of PPM • Jump and hop testing in multiple planes of movement or requiring
occurring predominantly in multiple planes multiple jumps or hops for one or more of the following:
of movement and/or requiring explosive Side-hop
Hexagon jump
Figure-eight hop
Carioca drill
Illinois agility
Three-cone drill
T-test
Zigzag run
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Chapter 1 Principles and Concepts 45
TABLE 1-23
Level XI
Assessment primarily at the level of replication • Functional capacity evaluation
of the specific tasks performed during the • Firefighting “ability test”
individual’s sport/occupation/daily activity • BEAST90
and/or clustering of PPM that replicate • Functional abilities test
component(s) of the sport/occupation/
daily activity
Level XII
Cumulative assessment (FPT) including Assessment forward and backward along the functional continuum
performance assessment (quantitative utilizing each parameter of function (i.e., impairment, performance
and qualitative) with self-report and measures, and self-report measures) as necessary
biopsychosocial measures
Modified from Reiman MP, Manske RC: The assessment of function: how is it measured? A clinical perspective. J Man Manip Ther 19:95–97,
2011.
1RM, One repetition maximum; ADL, activity of daily living; BEAST90, ball-sport endurance and sprint test; FPT, functional performance testing;
PPM, performance-based measures; ROM, range of motion.
treatments that will be successful. Primarily, functional factors (e.g., strength, power, flexibility) that are needed
assessment helps the examiner establish what is important to perform the activities must be considered. For example,
to the patient and the patient’s expectations. It commonly if the patient is seated normally while a history is taken, the
represents a measurement of a whole-body task perfor- examiner knows the patient has the functional ROM
mance ability, as opposed to isolated examination of a (agility) for sitting with 90° of hip and knee flexion. Table
joint. That being said, Preston et al.133 recommend that 1-24 lists some functional outcome measures that should
functional assessment should involve joint-specific ques- be considered. The activities should be simple, patient-
tions and activity level questions along with general health oriented, and based on coordinated functional movement
questions. These may be in one questionnaire or in several of the joints, and they should be activities the patient wants
instruments. Because it is part of each individual joint to do. Although most functional outcomes or tests are
assessed, the functional testing should demonstrate subjective, this does not make them any less effective.134
whether an isolated impairment affects the patient’s ability The functional assessment is important to determine
to perform everyday activities. the effect of the condition or injury on the patient’s daily
The examiner should attempt to establish what func- life, including his or her sex life. Functional impairment
tional factors are important to the patient. For example, may be slightly annoying or completely disabling for the
functional testing may include movements under differ- patient. Functional activities that should be tested, if
ent loads to determine the patient’s ability to work or appropriate, include self-care activities, such as walking,
play. Likewise, repeated movements and sustained pos- dressing, daily hygiene (e.g., washing, bathing, shaving,
tures may be necessary for work, recreational, or social combing hair), eating, and going to the bathroom; rec-
activities. In some cases, movements at different speeds reational activities, such as reading, sewing, watching tele-
or under different loads may be necessary to determine vision, gardening, and playing a musical instrument; and
pathology.94 A traumatic shoulder instability, for example, other activities, such as driving, dialing a telephone,
may not be evident in a swimmer except when he or she getting groceries, preparing meals, and hanging clothes.
is actually doing the activity at the speed and load at Goldstein nicely divided activities of human function into
which the activity is done in the water. four broad areas, which are then broken down into more
Because functional testing relates to the effect of the discrete levels (Table 1-25).135 The examiner should con-
injury on the patient’s life, those activities that cause symp- sider which of these are important to the patient and
toms, those that are restricted by symptoms, and the ensure that they are considered in the assessment. Figure
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46 Chapter 1 Principles and Concepts
TABLE 1-24 1-20 shows some of the daily living skills and mobility
questions that may be of concern to both the examiner
Examples of Functional and Clinical Outcomes
and the patient. The short musculoskeletal function
Clinical Outcomes Functional Outcomes assessment (SMFA) helps to determine how much the
• Strength • Power patient is bothered by functional problems (Figure
• Range of motion • Agility 1-21).136 Other functional assessment tool examples that
• Proprioception • Kinesthetic awareness are available include the functional capacity evaluation
• Endurance • Endurance (muscular and (FCE),135 the functional independence measure (FIM),137
(muscular) cardiovascular) the physical performance test,138 the functional status
• Swelling • Speed test,139 the arthritis impact measurement scale (AIMS
• Pain • Activity specificity 2),140 the functional assessment tool (FAT),141 the SF-36
• Psychological • Pain
Health Status Survey,142,143 the Sickness Impact Profile,144
overlay • Skill level required for activity
• Psychological preparedness
the SMFA Questionnaire,145 and the Sock Test.146 The
• Daily living skills particular tool used depends on the needs of the patient
and the presenting pathological problem.
TABLE 1-25
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Chapter 1 Principles and Concepts 47
TABLE 1-25
Data from Goldstein TS: Functional Rehabilitation in Orthopedics, Gaithersburg, MD, 1995, Aspen Pub. Inc., pp. 19–23.
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48 Chapter 1 Principles and Concepts
Numerical scoring systems are often used as part of demonstrates tests that could be used in an examination
the functional assessment and often play a role in clinical of simulated activities of daily living (ADLs).161 Similar
prediction rules (also called clinical decision rules or charts can and have been developed for almost all
risk scores) that quantify different parts of the history, joints of the body. However, many of these numerical
physical examination, and laboratory results in making a scoring systems have been developed from the clinician’s
diagnosis or prognosis.148–152 By combining the different perspective rather than from what the patient thinks is
findings, it is felt that a clinician’s diagnostic accuracy is important.
increased.5,131,148,153–155 The Ottawa Ankle and Foot Rules Functional tests may also be used as provocative tests
and the Pittsburgh Knee Rules are examples of clinical to bring on the symptoms the patient has complained
prediction rules.95,156 of or to determine how the patient is progressing or
The numerical scoring systems are often more related whether he or she is ready to return to activity. Examples
to function as it applies to a specific joint and often a of these tests include the hop test and disco test for the
specific activity rather than to the whole body (Figure knee. These tests, in reality, could be used for all the
1-22),157 and for many, functional assessment plays only weight-bearing (lower limb) joints. However, it must be
a small part. With these numerical systems, the clinician remembered that many of these provocative or stress tests
must ensure that the scoring systems really measure what are designed for very active persons and are not suitable
they say they measure. To be effective, a numerical scoring for all populations.
system must demonstrate universality, practicality, reli-
ability, reproducibility, effectiveness, and inclusiveness,
Special (Diagnostic) Tests
and it must have been validated.158 The terminology and
methods must be described precisely; the criteria should After the examiner has completed the history, observation,
be related to functional outcome (what the patient and evaluation of movement, special tests may be per-
desires) rather than clinical outcome (what the clinician formed for the involved joint. Many special tests are
desires), and the measures must be sensitive enough to available for each joint to determine whether a particular
show a difference.159 Figure 1-23 shows a functional type of disease, condition, or injury is present. They are
assessment involving the entire upper limb.160 Table 1-26 Text continued on p. 53
Figure 1-20 Daily living skill and mobility questions for function assessment. (Modified from Convery FR, Minteer MA, Amiel D, et al: Poly-
articular disability: a functional assessment. Arch Phys Med Rehab 58[11]:498, 1977.)
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Chapter 1 Principles and Concepts 49
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50 Chapter 1 Principles and Concepts
Figure 1-21 Short Musculoskeletal Function Assessment (SMFA). (From Swiontkowski MF, Engelberg R, Martin DP, et al: Short musculoskeletal
function assessment questionnaire: the validity, reliability, and responsiveness. J Bone Joint Surg Am 81[9]: 1256–1258, 1999.)
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Chapter 1 Principles and Concepts 51
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52 Chapter 1 Principles and Concepts
Figure 1-22 Shoulder evaluation form. (Modified from Rowe CR: The shoulder, Edinburgh, 1988, Churchill Livingstone, p. 632.)
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Chapter 1 Principles and Concepts 53
TABLE 1-26
Modified from Potvin AR, Tourtellotte WW, Dailey JS, et al: Simulated activities of daily living examination. Arch Phys Med Rehab 53:478, 1972.
sometimes called clinical accessory, provocative, motion, reliable, valid, sensitive, or specific. In this book, the
palpation, or structural tests. These tests, although strongly author has highlighted key tests that the clinician should
suggestive of a particular disease or condition when they practice, become comfortable with, and become confi-
yield positive results, do not necessarily rule out the disease dent in their use because the value of these tests has been
or condition when they yield negative results. This will demonstrated clinically (via examiner experience) and/or
depend on the sensitivity and specificity of each test as well statistically to show that they contribute to determining
as the skill and experience of the clinician. what the problem is. It is better to learn one or two tests
Special tests should seldom be used in isolation or as well and to be confident and proficient in their use rather
“stand alone” tests. They should only be considered as than learning all the possible tests used to confirm a
part of an overall clinical assessment that includes history, certain pathology. The following key (“Key to Classifying
observation, and the rest of the examination.162,163 One Special Tests”) has been developed to give an indication
of the problems with special tests is that many clinicians, whether the author feels it is worthwhile to learn to do
especially those with less experience, hope that any special the test based on present evidence and the clinician’s
tests they use will give them a definitive answer as to what experience. That being said, even the tests with a icon
is wrong. Although a special test may give a definitive will or can be ineffective if the conditions outlined in the
answer, more commonly it does not, but combined with following green box are not met. Without these condi-
the other information from the assessment, a clearer tions being met, even the best test may fail to confirm
picture of the problem arises. No physical test is 100% the diagnosis regardless of its utility score, QUADUS
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54 Chapter 1 Principles and Concepts
Figure 1-23 Upper extremity function test. (Modified by permission of the publisher from Carroll D: A quantitative test of upper extremity func-
tion. J Chron Dis 18:482, 1965. Copyright © 1965 by Elsevier Science.)
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Chapter 1 Principles and Concepts 55
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56 Chapter 1 Principles and Concepts
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Chapter 1 Principles and Concepts 57
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58 Chapter 1 Principles and Concepts
TABLE 1-29
Adapted from Quinn J: Introduction to the musculoskeletal system. In Meschan I: Synopsis of analysis of roentgen signs in general radiology, Phila-
delphia, 1976, W.B. Saunders Co., p. 27.
N, Normal; O, occasionally; R, rarely; ↑, increased; ↓, decreased.
TABLE 1-30
From Curran JF, Ellman MH, Brown NL: Rheumatologic aspects of painful conditions affecting the shoulder. Clin Orthop Relat Res 173:28, 1983.
*Inflammatory fluids will clot and should be collected in heparin-containing tubes. All group 2 or 3 fluids should be cultured if the diagnosis is
uncertain.
TABLE 1-31
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Chapter 1 Principles and Concepts 59
examiner must take care not to confuse this reaction with excessive on both sides, especially in young people, unless
the pathological response. The two most commonly a central lesion is suspected. Exercise just before testing
tested pathological reflexes are the Babinski reflex (lower or patient anxiety or tenseness may lead to accentuated
limb) and the Hoffman reflex (upper limb). tendon reflexes.87 Hyporeflexia or areflexia indicates a
To be of clinical significance, findings must show lesion of a peripheral nerve or spinal nerve root as a result
asymmetry between bilateral reflexes unless there is a of impingement, entrapment, or injury. Examples would
central lesion. The eliciting of reflexes often depends on be nerve root compression, cauda equina syndrome, or
the skill of the examiner. The examiner should not be peripheral neuropathy. Hyporeflexia or areflexia may be
overly concerned if the reflexes are absent, diminished, or seen in the absence of muscle weakness or atrophy because
of the involvement of the efferent loop of the reflex arc
in the reflex. Hyperactive or exaggerated reflexes (hyper-
TABLE 1-32 reflexia) indicate upper motor neuron lesions as seen in
Superficial Reflexes neurological disease and cerebral or brain stem impair-
ment. If a disc herniation and compression occur above
Pertinent Central the cervical enlargement in the cervical spine, the reflexes
Nervous System
of the upper extremity are exaggerated. If the cervical
Reflex Normal Response Segment
enlargement is involved (which is more commonly the
Upper abdominal Umbilicus moves up T7–T9 case), then some reflexes are exaggerated and some are
and toward area decreased.188
being stroked
Lower abdominal Umbilicus moves T11–T12
down and toward
area being stroked
Cremasteric Scrotum elevates T12, L1
Deep Tendon Reflex Grading
Plantar Flexion of toes S1–S2
0—Absent (areflexia)
Gluteal Skin tenses in gluteal L4–L5, S1–S3
1—Diminished (hyporeflexia)
area
2—Average (normal)
Anal Contraction of anal S2–S4
3—Exaggerated (brisk)
sphincter muscles
4—Clonus, very brisk (hyperreflexia)
TABLE 1-33
Pathological Reflexes*
Reflex Elicitation Positive Response Pathology
†
Babinski Stroking of lateral aspect of sole of Extension of big toe and fanning of Pyramidal tract lesion
foot four small toes Organic hemiplegia
Normal reaction in newborns
Chaddock’s Stroking of lateral side of foot Same response as above Pyramidal tract lesion
beneath lateral malleolus
Oppenheim’s Stroking of anteromedial tibial surface Same response as above Pyramidal tract lesion
Gordon’s Squeezing of calf muscles firmly Same response as above Pyramidal tract lesion
Piotrowski’s Percussion of tibialis anterior muscle Dorsiflexion and supination of foot Organic disease of central
nervous system
Brudzinski Passive flexion of one lower limb Similar movement occurs in Meningitis
opposite limb
Hoffman “Flicking” of terminal phalanx of Reflex flexion of distal phalanx of Increased irritability
(Digital)‡ index, middle, or ring finger thumb and of distal phalanx of of sensory nerves in
index or middle finger (whichever tetany
one was not “flicked”) Pyramidal tract lesion
Rossolimo’s Tapping of the plantar surface of toes Plantar flexion of toes Pyramidal tract lesion
Schaeffer’s Pinching of Achilles tendon in middle Flexion of foot and toes Organic hemiplegia
third
*Bilateral positive response indicates an upper motor neuron lesion. Unilateral positive response may indicate a lower motor neuron lesion.
†
Test most commonly performed in lower limb.
‡
Test most commonly performed in upper limb.
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60 Chapter 1 Principles and Concepts
At the same time, the examiner can perform a sensory TABLE 1-34
scanning examination by checking the cutaneous distri-
Nerve Fiber Classification
bution of the various peripheral nerves and the derma-
tomes around the joint being examined. The sensory Axon Conduction
examination is performed for several reasons. First, it is Sensory Diameter Velocity
used to determine the extent of sensory loss, whether that Axons (µm) (m/sec) Innervation
loss is caused by nerve root lesions, peripheral nerve Ia (Aα) 12–22 65–130 Muscle spindles
lesions, or compressive tunnel syndromes. Second, (annulospiral endings)
because function is often tied to sensation, it is used to Ib (Aα) 12–22 65–130 Golgi tendon organs
determine the degree of functional impairment. Third, II (Aβ) 5–15 20–90 Pressure, touch, vibration
because sensory function returns before motor function, (flower spray endings)
it can be used to determine nerve recovery after injury or III (Aδ) 2–10 6–45 Temperature, fast pain
repair as well as when reeducation can commence. Also, IV (C) 0.2–1.5 0.2–2.0 Slow pain, visceral,
temperature, crude
if sensory function remains after injury to the spinal cord,
touch
it is a good indication that some motor function, at least,
will be restored.189 Finally, it is part of the total assessment
and is often necessary for medicolegal reasons. Although
the sensory distribution of peripheral nerves may vary
from person to person, they tend to be more consistent other sharp object. Only light tapping should be used.
than dermatomes.69,190 The examiner must be able to dif- About 2 seconds should elapse between each stimulus to
ferentiate between sensory loss involving a nerve root avoid summation. It is the group II afferent fibers (Table
(dermatome) and that involving a peripheral nerve (see 1-34) that are being tested. Perception to pin prick may
Table 1-15 for an example). range from absence of awareness, through pressure sensa-
The sensory examination begins with a quick scan of tion, hyperanalgesia with or without radiation, localiza-
sensation. To do this, the examiner runs his or her relaxed tion, and sensation of sharpness, to normal perception.
hands relatively firmly over the skin to be tested bilaterally If desired, the examiner may also test other sensations.
and asks the patient whether there are any differences in Two test tubes (one with hot water, one with cold) are
sensation. The patient’s eyes may be open for the scan. used to assess sensitivity to temperature (lateral spinotha-
If the patient notes any differences in sensation between lamic tract and group III fibers), one containing hot
the affected and unaffected sides, then a more detailed water and one containing cold water. A normal response
sensory assessment is performed. The examiner should to this test does not necessarily mean that the patient has
note the patient’s ability to perceive the sensation being normal temperature sensation. Rather, the patient can
tested and the difference, if any, between the two sides distinguish between hot and cold, each at one level in the
of the body. In addition, distal and proximal sensitivities range, but not necessarily between different degrees of
should be compared for each form of sensation tested. hot and cold. Sensitivity to vibration (i.e., how long until
During the detailed sensory testing, the patient should vibration stops) may be tested by holding a tuning fork
keep his or her eyes closed so that the results will indicate (usually 30- or 256-cps tuning forks are used) against
the patient’s perception and interpretation of the stimuli, bony prominences; this tests the integrity of group II
not what the patient sees happening. With the detailed fibers and the dorsal column and medial lemniscal systems.
sensory testing, the examiner marks out, or delineates, the Deep pressure pain (group II Aβ fibers) can be tested by
specific area of altered sensation and then correlates the squeezing the Achilles tendon, the trapezius muscle, or
area with the known dermatome and peripheral nerve the web space between the thumb and index finger or by
distribution. The examiner must be aware, however, that applying a knuckle to the sternum. To test proprioception
the abnormal sensation does not necessarily come from and motion (i.e., the skin and joint receptors, muscle
the indicated nerve root or peripheral nerve; because of spindles, dorsal column and medial lemniscal systems, and
referred pain, it may come from any structure supplied by group I and II fibers), the patient’s fingers or toes are
that nerve root. In some cases, the paresthesia may involve passively moved, and the patient is asked to indicate the
no specific pattern, or it may involve the entire circumfer- direction of movement and final position while keeping
ence of a limb. This “opera glove” or “stocking” pares- the eyes closed. To ensure that pressure on the patient’s
thesia or anesthesia may result from vascular insufficiency skin cannot be used as a clue to direction of movement,
or systemic disease. the test digit should be grasped between the examiner’s
Superficial tactile (light touch) sensation, which is thumb and index finger.
commonly the first sensation affected, can be tested with Cortical and discriminatory sensations may be tested
a wisp of cotton, soft hairbrush, or small paint or makeup by two-point discrimination, point localization, texture
brush. Superficial pain can be tested with a flagged pin discrimination, stereognostic function (i.e., identification
(holding a piece of tape attached to a pin), pinwheel, or of familiar objects held in the hand), and graphesthesia
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Chapter 1 Principles and Concepts 61
(i.e., recognition of letters or numbers written with a position) is one of minimal congruency between the
blunt object on the patient’s palms or other body parts). articular surfaces and the joint capsule with the ligaments
These techniques also test the integrity of the dorsal being in the position of greatest laxity and passive sepa-
column and lemniscal systems. ration of the joint surfaces being the greatest. This posi-
tion may be the anatomical resting position, which is
usually considered in the midrange, or it may be just
Joint Play Movements
outside the range of pain and spasm. The advantage of
All synovial and secondary cartilaginous joints, to some the loose packed position is that the joint surface contact
extent, are capable of an active ROM, termed “voluntary areas are reduced and are always changing to decrease
movement” (also called active physiological movement) friction and erosion in the joints. The position also pro-
through the action of muscles crossing over the joint. In vides proper joint lubrication and allows the arthrokine-
addition, there is a small ROM that can be obtained only matic movements of spin, slide, and roll. It is therefore
passively by the examiner; this movement is called joint the most common position used for treatment using
play or accessory movement. These accessory move- joint play mobilizations. Examples of resting positions
ments are not under voluntary control; they are necessary, are shown in Table 1-35.
however, for full painless function of the joint and full
ROM of the joint. Joint dysfunction signifies a loss of Close Packed (Synarthrodial) Position
joint play movement. The close packed position should be avoided as much as
The existence of joint play movement is necessary possible during an assessment except to stabilize an adja-
for full, pain-free voluntary movement to occur. An cent joint, because in this position, the majority of joint
essential part of the detailed assessment of any joint structures are under maximum tension. In this position,
includes an examination of its joint play movements. If the two joint surfaces fit together precisely—that is, they
any joint play movement is found to be absent or are fully congruent. The joint surfaces are tightly com-
decreased, this movement must be restored before the pressed; the ligaments and capsule of the joint are maxi-
patient can regain functional voluntary movement. In mally tight; and the joint surfaces cannot be separated
most joints, this movement is normally less than 4 mm by distractive forces. It is the position of maximum joint
in any one direction. stability. Thus, this position is commonly used during
In some cases, joint play movements may be similar to treatment to stabilize the joint, if an adjacent joint is
or the same as movements tested during passive move- being treated. Ligaments, bone, or other joint structures,
ments or ligamentous testing. This is most obvious in if injured, become more painful as the close packed
joints that have minimal movement and in joints that do position is approached. If a joint is swollen, the close
not have muscles acting directly on them, such as the packed position cannot be achieved.119 In the close packed
sacroiliac joints and superior tibiofibular joints. position, no accessory movement is possible. Examples of
the close packed positions of most joints are shown in
Table 1-36.
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62 Chapter 1 Principles and Concepts
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Chapter 1 Principles and Concepts 63
• Differences in tissue tension and texture • Comes on soon after injury → blood
• Differences in tissue thickness • Comes on after 8 to 24 hours → synovial
• Abnormalities • Boggy, spongy feeling → synovial
• Tenderness • Harder, tense feeling with warmth → blood
• Temperature variation • Tough, dry → callus
• Pulses, tremors, and fasciculations • Leathery thickening → chronic
• Pathological state of tissues • Soft, fluctuating → acute
• Dryness or excessive moisture • Hard → bone
• Abnormal sensation • Thick, slow-moving → pitting edema
body part. It may be the result of bone thickening, 5. Determine joint tenderness by applying firm pressure
synovial membrane thickening, or fluid accumulation to the joint. The pressure should always be applied
in and around the joint. It may be intracellular or with care, especially in the acute phase.
extracellular (edema), intracapsular or extracapsular.
Swelling may be localized (encapsulated), which may
indicate intra-articular swelling, a cyst, or a swollen
bursa. Visualization of swelling depends on the depth
Grading Tenderness When Palpating
of the tissue (a swollen olecranon bursa is more
obvious than a swollen psoas bursa) and the looseness • Grade I—Patient complains of pain
of the tissues (swelling is more evident on the dorsum • Grade II—Patient complains of pain and winces
of the hand than on the palmar aspect because the • Grade III—Patient winces and withdraws the joint
dorsal tissues are not “held down” to adjacent tissue). • Grade IV—Patient will not allow palpation of the joint
Swelling that develops immediately or within 2 to 4
hours of injury is probably caused by blood extravasa-
tion into the tissues (ecchymosis) or joint. Swelling
that becomes evident after 8 to 24 hours is caused 6. Feel variations in temperature. This determination is
by inflammation and, in a joint, by synovial swelling. usually best done by using the back of the examiner’s
Bony or hard swelling may be caused by osteophytes hand or fingers and comparing both sides. Joints tend
or new bone formation (e.g., in myositis ossificans). to be warm in the acute phase, in the presence of
Soft-tissue swelling such as edematous synovium infection, with blood swelling, after exercise, or if
produces a boggy, spongy feeling (like soft sponge they have been covered (for example, with an elastic
rubber), whereas fluid swelling is a softer and more bandage).
mobile, fluctuating feeling. Blood swelling is usually 7. Feel pulses, tremors, and fasciculations. Fascicula-
a harder, thick, gel-like feeling, and the overlying skin tions result from contraction of a number of muscle
is usually warmer. Pus is thick and less fluctuant; the cells innervated by a single motor axon. The contrac-
overlying skin is warm, and the temperature is usually tions are localized, are usually subconscious, and do
elevated. Older, longstanding soft-tissue swelling not involve the whole muscle. Tremors are involun-
(such as, a skin callus) feels like tough, dry leather. tary movements in which agonist and antagonist
Synovial hypertrophy has a hard, thick feeling to it muscle groups contract to cause rhythmic move-
with little give. The more leathery the thickening ments of a joint. Pulses indicate circulatory suffi-
feels, the more likely it is to be chronic and caused ciency and should be tested for rhythm and strength
by local symptoms. Softer thickenings tend to be if circulatory problems are suspected. Table 1-37
more acute and associated with recent symptoms.117 indicates the more commonly palpated pulses that
Pitting edema is thick and slow moving, leaving an may be used to determine circulatory sufficiency and
indentation after pressure is applied and removed. It location.
is commonly caused by circulatory stasis and is most 8. Determine the pathological state of the tissues in and
commonly seen in the distal extremities. Long-lasting around the joint. The examiner should note any ten-
swelling may cause reflex inhibition of the muscles derness, tissue thickening, or other signs or symp-
around the joint, leading to atrophy and weakness. toms that would indicate pathology. Painful scars or
Blood swelling within a joint is usually aspirated neuromas may be diagnosed using the thumbnail
because of the irritating and damaging effect it has test. This test involves running the dorsum of
on the joint cartilage. the thumbnail over the scar. If this action elicits a
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64 Chapter 1 Principles and Concepts
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Chapter 1 Principles and Concepts 65
Radiolucent Image
Rules to Minimize Errors When Taking X-Rays210
Air 1. If possible, the patient should be awake
2. The x-ray beam must be perpendicular to the anatomical region
Fat
being examined
radiodensity
radiodensity
3. The x-ray source should be the farthest possible distance from the
Decreasing
Increasing
Water
region being examined (minimal distance: 2.75 m)
Bone
Contrast media
Heavy metals
Uses of Plain Film Radiography201
Radiopaque Image
• Fractures
Figure 1-24 Radiographic density (shades of gray) as related to object • Arthritis
radiodensity. Note that the shade may vary depending on thickness of • Bone tumors
tissue. (From Richardson JK, Iglarsh ZA: Clinical orthopaedic physical • Skeletal dysplasia
therapy, Philadelphia, 1995, WB Saunders, p. 630.)
commonly, AP and lateral projections. Two views are ankylosing spondylitis, or tumors and structural body
necessary because x-rays take planar images; so all struc- abnormalities such as developmental anomalies, arthritis,
tures in the path of the x-ray beam are superimposed on and metabolic bone diseases. Thus, the main purpose of
each other, and abnormalities may be difficult to evaluate x-ray films is to determine the state of bone and its sur-
with only one view. Two views give information concern- rounding soft tissue. Bone remodelling (the taking up
ing the dimensions of a structure, whether foreign bodies [osteoblastic action] and removal [osteoclastic action] of
or lesions are present and their location, and to determine bone) goes on continuously in the body with the rate of
the alignment of fractures.203 Other views may be change being the result of several factors, such as disuse,
obtained, depending on clinical circumstances and spe- aging or disease. If removal occurs quicker than uptake,
cific needs.205–208 In the lumbar spine, AP, lateral, and then osteoporosis (decrease in bone mass) results.
oblique views are commonly taken. Remodelling is related to Wolff’s law, which states that
X-rays are part of the electromagnetic spectrum and changes in form and function of bone is followed by
have the ability to penetrate tissue to varying degrees. changes in its internal structure or that bone responds
X-ray imaging is based on the principle that different (like any tissue) to the stress and strain placed on it. For
tissues have different densities and produce images in dif- x-ray films, osteoporosis (similar to other conditions such
ferent shades of gray.209 The greater the density of the as osteomalacia) results in an increase in radiolucency.
tissue, the less penetration of x-rays there is, and the This increased radiolucency is called osteopenia.
whiter its image appears on the film (Figure 1-24). In Commonly, an ABCDs search pattern is used when
order of descending degree of density are the following looking at radiological images (Table 1-38).203 With soft-
structures: metal, bone, soft tissue, water, fat, and tissue injuries, clinical findings should take precedence
air. These differences give the six basic densities on the over x-ray findings. It is desirable to know whether an
x-ray plate. x-ray has been taken so that the examiner can obtain the
When viewing the x-rays, the examiner must identify films if necessary. The examiner should be aware of
the film, noting the name, age, date, and sex of the obvious and unusual x-ray findings that distract attention
patient, and the examiner must identify the type of pro- from other tissue that is actually the cause of the pain;
jection taken (e.g., AP, lateral, tunnel, skyline, weight- such x-ray abnormalities are significant only if clinical
bearing, stress-type). Rules that should be kept in mind examination bears out their relevance. With experience,
to minimize diagnostic errors when taking radiographs the examiner becomes able to detect many important
are outlined in the following box. soft-tissue changes on x-ray examination, such as effusion
The x-ray plates that are developed after exposure in joints, tendinous calcifications, ectopic bone in muscle,
to the roentgen rays enables the examiner to see any tissue displaced by tumor, and the presence of air or
fractures, dislocations, foreign bodies, or radiopaque foreign body material in the tissues. Radiographs may also
substances that may be present. The main function be used to indicate bone loss. For osteoporosis to be
of plain x-ray examination is to rule out or exclude frac- evident on x-ray, approximately 30% to 35% of the bone
tures or serious disease such as infection (osteomyelitis), must be lost (Figure 1-25). Cortical thickness can be
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66 Chapter 1 Principles and Concepts
TABLE 1-38
Modified from McKinnis LN: Fundamentals of musculoskeletal imaging, Philadelphia, 2005, F.A. Davis, pp. 40–41.
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Chapter 1 Principles and Concepts 67
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68 Chapter 1 Principles and Concepts
A B C
Figure 1-27 X-ray films showing skeletal maturity. A, Male, newborn. B, Male, 5-years-old. C, Female, 17-years-old.
Arthrography
Arthrography is an invasive technique in which air, a
water-soluble contrast material containing iodine, or a
combination of the two (double contrast) is injected into
a joint space, and a radiograph is taken of the joint. The
air or contrast material outlines the structures within the
joint or communicating with the joint (Figure 1-28). It
is especially useful in detecting abnormal joint and bursal
communications, synovial abnormalities, articular carti-
lage lesions, and the extent of or pathology to the
capsule.203 It is used primarily in the hip, knee, ankle, Figure 1-28 Normal arthrogram, shoulder in lateral rotation. Note
shoulder, elbow, and wrist.205 the good dependent fold (wide arrow) and the outline of the bicipital
tendon (narrow arrow). (From Neviaser TJ: Arthrography of the shoul-
der. Orthop Clin North Am 11:209, 1980.)
Uses of Arthrography201
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Chapter 1 Principles and Concepts 69
TABLE 1-39
From Sanders JO, Khoury JG, Kishan S, et al: Predicting scoliosis progression from skeletal maturity: a simplified classification during adolescence.
J Bone Joint Surg Am 90(3):541, 2008.
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70 Chapter 1 Principles and Concepts
A B
Figure 1-29 Occlusion of brachial artery. A, Arteriogram of a young man with a previously reduced elbow dislocation and an ischemic hand
shows an occluded brachial artery. B, A later film shows fresh clot (arrow) in the brachial artery and reconstituted radial and ulnar arteries. Primary
repair and thrombectomy treated the ischemic symptoms. (From McLean G, Frieman DB: Angiography of skeletal disease. Orthop Clin North Am
14:267, 1983.)
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Chapter 1 Principles and Concepts 71
A B
C D
Figure 1-32 A, Normal computed tomographic (CT) image at the level of the mid acetabulum obtained with soft-tissue window settings shows the
homogenous, intermediate signal of musculature. a, Common femoral artery; gd, gluteus medius; gn, gluteus minimus; gx, gluteus maximus; ip,
iliopsoas; oi, obturator internus; ra, rectus abdominis; rf, rectus femoris; s, sartorius; t, tensor fascia lata; v, common femoral vein. B, Axial CT at
bone window settings reveals improved delineation of cortical and medullary osseous detail. Note anterior and posterior semilunar acetabular articular
surfaces and the central nonarticular acetabular fossa. C, Normal midacetabular T1-weighted axial 0.4-T magnetic resonance image (MRI) (TR,
600 msec; TE, 20 msec) of a different patient shows a normal, high-signal-intensity image of fatty marrow (adult pattern) and subcutaneous tissue,
low-signal-intensity image of muscle, and absence of signal in the cortical bone. The thin articular hyaline cartilage is of intermediate signal intensity
(arrow). D, T2-weighted MRI (TR, 2,000 msec; TE, 80 msec) shows decreasing high signal intensity in fatty marrow and subcutaneous tissue with
increased signal intensity in the fluid-filled urinary bladder. (From Pitt MJ, Lund PJ, Speer DP: Imaging of the pelvis and hip. Orthop Clin North
Am 21[3]:553, 1990.)
to show one small area or plane in focus with other areas cross-sectional area in one plane is viewed with each scan,
or planes appearing fuzzy or blurred. The conventional multiple images or scans are taken to get a complete view
tomogram is seldom used today except when subtle bone of the area.34 CT arthrography may be used to enhance
density alterations are sought. assessment of intra-articular structures and may be used
The CT scan involves the same thin cross sections or for patients who cannot tolerate conventional MRI.
“slices” taken at specific levels (Figure 1-32). CT scans
produce cross-sectional images based on x-ray attenua-
tion. Because of computer enhancement, CT produces
superior tissue contrast resolution compared with con- Uses of Computed Tomography Scans201
ventional x-rays, thus enabling greater details of subtle
• Complex fractures
bone pathology.198,214 CT provides excellent bony archi- • Comminuted fractures
tecture detail and has good resolution of soft-tissue struc- • Intra-articular fragments
tures.204 Its disadvantages include limited scanning plane, • Fracture healing (e.g., non-union)
cost, exposure to radiation (dosage similar to or greater • Bone tumors
than that of plain x-rays), alteration of the image by arti-
facts, and degradation of soft-tissue resolution in obese
people.34,205 The CT scan, or computed axial tomography Single photon emission computed tomography
(CAT) scan, is a radiological technique that may be used (SPECT) scanning is a specialized type of CT scanning
to assess for disc protrusions, facet disease, or spinal used in orthopedics primarily to detect spondylolysis.204
stenosis.215 The technique may also be used to assess
complex fractures, especially those involving joints, dislo- Radionuclide Scanning (Scintigraphy)216
cations, patellofemoral alignment and tracking, osteone- With bone scans (osteoscintigraphy), chemicals labeled
crosis, tumors, and osteomyelitis. Because only a small with radioactive isotopes (radioactive tracers) such as
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72 Chapter 1 Principles and Concepts
A B C
Figure 1-33 Whole body bone scans. A, Normal adult anterior scan. B, Normal adult posterior scan. C, Posterior scan showing joint involvement
of rheumatoid arthritis. (From Goldstein HA: Bone scintigraphy. Orthop Clin North Am 14:244, 250, 1983.)
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Chapter 1 Principles and Concepts 73
Fluoroscopy
Fluoroscopy is a technique that is used to show motion
in joints through x-ray imaging; it also may be used as a
guidance technique for injections (e.g., in discography).
It is only rarely used because of the amount of radiation
exposure. It is sometimes used to position fracture frag-
Figure 1-35 Normal discogram shown with barium paste. (From ments and to demonstrate abnormal motion.
Farfan HF: Mechanical disorders of the low back, Philadelphia, 1973,
Lea & Febiger, p. 96.) Diagnostic Ultrasound
Like therapeutic ultrasound, diagnostic ultrasound
alters tissue water content.34,213 MRI offers excellent tissue involves transmission of high-frequency sound waves (5
contrast, is multiplanar (i.e., can image in any plane), and to 10 MHz) into the tissues by a transducer through a
has no known adverse effects. In some patients, claustro- coupling agent with calculation of the time it takes for
phobia is a problem, and artifacts may result if the patient the echo to return to the transducer from different inter-
does not remain still.211 For musculoskeletal conditions, faces. The depth of the structure is determined, and an
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74 Chapter 1 Principles and Concepts
A B
C
Figure 1-36 Magnetic resonance T1-weighted coronal oblique images from anterior (A) to posterior (C). A, Acromion; AC, acromioclavicular
joint; C, coracoid; D, deltoid muscle; G, glenoid of scapula; H, humerus; IS, infraspinatus muscle; ist, infraspinatus tendon; SB. subscapularis muscle;
sbt, subscapularis tendon; sdb, subdeltoid-subacromial bursa; SS, supraspinatus muscle; sst, supraspinatus tendon; T, trapezius muscle. (From Mayer
SJ, Dalinka MK: Magnetic resonance imaging of the shoulder. Orthop Clin North Am 21:500, 1990.)
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Chapter 1 Principles and Concepts 75
A B
Figure 1-38 Xeroradiography. A, Normal examination. Note the ability to demonstrate both soft tissues and bony structures on a single examina-
tion. The halo effect (arrow) around the bony cortices is an example of edge enhancement. B, Hyperparathyroid bone changes shown on xerora-
diography. The subperiosteal bone resorption (arrow) and distal tuft erosion are well shown. (A, From Weissman BN, Sledge CB: Orthopedic
radiology, Philadelphia, 1986, WB Saunders, p. 11. B, From Seltzer SE, Weissman BN, Finberg HJ, et al: Improved diagnostic imaging in joint
diseases. Semin Arthritis Rheum 11[3]:315, 1982.)
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76 Chapter 1 Principles and Concepts
TABLE 1-40
Modified from Goodman CC, Snyder TE: Differential diagnosis in physical therapy, ed 2, Philadelphia, 1995, W.B. Saunders Co., p. 539.
*“Pain” associated with vascular claudication may also be described as an “aching,” “cramping,” or “tired” feeling.
TABLE 1-41
Differential Diagnosis of Contractile Tissue (Muscle) and Inert Tissue (Ligament) Pathology
Muscle Ligament
Mechanism of Injury Overstretching (overload) Overstretching (overload)
Crushing (pinching)
Contributing Factors Muscle fatigue Muscle fatigue
Poor reciprocal muscle strength Hypermobility
Inflexibility
Inadequate warm-up
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Chapter 1 Principles and Concepts 77
TABLE 1-41
Differential Diagnosis of Contractile Tissue (Muscle) and Inert Tissue (Ligament) Pathology—cont’d
Muscle Ligament
Active Movement Pain on contraction (1°, 2°) Pain on stretch or compression (1°, 2°)
Pain on stretch (1°, 2°) No pain on stretch (3°)
No pain on contraction (3°) ROM decreased
Weakness on contraction (1°, 2°, 3°)
Passive Movement Pain on stretch Pain on stretch (1°, 2°)
Pain on compression No pain on stretch (3°)
ROM decreased
Resisted Isometric Movement Pain on contraction (1°, 2°) No pain (1°, 2°, 3°)
No pain on contraction (3°)
Weakness on contraction (1°, 2°, 3°)
Special Tests If test isolates muscle, weakness and pain If test isolates ligament, ROM and pain
on contraction (1°, 2°) or weakness affected
and no pain on contraction (3°)
Reflexes Normal unless 3° Normal
Cutaneous Distribution Normal Normal
Joint Play Movement Normal Increased ROM, unless restricted by
(in Resting Position) swelling
Palpation Point tenderness at site of injury Point tenderness at site of injury
Gap if palpated early Gap if palpated early
Swelling (blood—ecchymosis late) Swelling (blood/synovial fluid)
Spasm
Diagnostic Imaging MRI, arthrogram, and CT scan show MRI, arthrogram, and CT scan show lesion
lesion Stress x-ray shows increased ROM
CT, Computed tomography; MRI, magnetic resonance imaging; ROM, range of motion.
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82 Chapter 1 Principles and Concepts
APPENDIX 1-1
Example of an Assessment Form
HISTORY
OBSERVATION (POSTURE)
NEUROLOGICAL TESTS
EXAMINATION
SPECIAL TESTS
PALPATION
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Chapter 1 Principles and Concepts 83
APPENDIX 1-2
Example of Informed Consent/Patient Authorization
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