EVALUATING PATIENTS WITH MUSCULOSKELETAL PROBLEMS
THE ROLE OF THE THERAPIST
The Therapist as Clinical Decision-maker
When a patient comes to a therapist with a problem, that patient is
expecting the therapist to help alleviate or resolve the problem. To do so,
Understand and Clarify the Origin and the Extent of the Problem
- Understand and clarify the origin and the extent of the patientís
- Assess the impact of the problem on the various aspects of the
- Establish a baseline of the patientís functional ability by accurately
measuring and recording significant data;
- Establish patient-centered treatment strategies.
Does the therapist know the origin of the problem? Determine the onset,
including the mechanism of injury, acquire knowledge of circumstances
surrounding the injury (or injuries), the behavior of the problem, the
physician's intervention, including surgical procedures, etc. Isolate and
determine as much as possible the cause of the problem, and whether other
structures are involved.
Assess the Impact of the Problem on the Person's Life
Establish a baseline of the patientís functional ability by accurately
measuring and recording significant data. This also allows the therapist
measures against which to judge progress and assess effectiveness of the
- functional deficits: activities of daily living, work, and leisure;
- acute versus chronic: resolve, alleviate, or adapt.
Establish Patient-centered Treatment Strategies to restore premorbid
function as much as possible: incorporating the therapist's knowledge of
anatomy, physiology, and interventions into treatments focusing on the
patientís desired outcome(s). The therapist assists with and guides the
person's healing process.
THE MUSCULOSKELETAL EVALUATION
To make sound clinical decisions regarding their patients, therapists must
follow a structured approach. Part I of the Hypothesis Oriented Algorithm
for Clinicians (HOAC) proposed by Ecthernach and Rothstein (1989) provides
such a structure for the evaluation of a person with a musculoskeletal
Collecting Data: The Chart Review:
- Collect initial data (chart review, history, interview
- Generate a problem statement.
Establish goals with the patient (measurable and functional with time
- Perform physical examination (collect data on origin and extent of
problem and impact on patientís life).
- Generate a working hypothesis about the problem(s).
Correlate and interpret findings of the P.E. to determine a P.T
Diagnosis or Occupational Challenge
Refer to other practitioner (if therapist cannot generate a
- Plan reevaluation methodology (schedule dates for reevaluations)
- Plan treatment strategy based on hypothesis (overall treatment approach)
Obtain consultation, if needed.
- Plan tactics to implement strategy (specifics of treatment plan)
- Implement tactics (perform treatment)
* The physician's findings will provide valuable information
regarding the diagnosis, past history, and current status of all
major systems. Remember that the physician's diagnosis will be
somewhat different from your own.
- Physician's H & P, including the physician's diagnosis*
- Physician's orders
- X Ray findings
- Surgery Report**
- Lab findings
- EKG, Respiratory, Nurse's Notes, etc.
** Knowledge of the surgical intervention is crucial to the
evaluation and selection of treatment strategies. Awareness of
the anatomy that has been affected by the injury and by the
surgery, as well as how the structures heal is central to
effective and safe rehabilitation.
Collecting Data: The Patient Interview
The primary goals of acquiring a patient's history are to accurately
determine the origin of the person's problem and its impact on the person's
Remember to LISTEN to your patient, and let those responses guide your
interview. Maitlandís Philosophy of Interviewing Patients (1993):
The questions that the therapist asks should be, for the most part,
open-ended in that they require more than a yes or no response. This allows
patients to describe their circumstances in their own words.
- Make every effort to be as sure as is possible that you understand
what your patient is trying to tell you.
- Be ready to recognize from your patientsí communication any gaps they
leave which you the therapist should endeavor to fill by asking
- Make use of every possible opportunity to use your non-verbal
expressions to show your understanding and concern for the patient.
Acquiring information about the patientís problem:
Questions about the patientís problem follow the LOCIDAA format (Hicks &
- What brings you to physical therapy? (if not obvious)
If the person uses:
- Location: "Where is it located?" Indicate the primary area of pain.
Assess the Impact of the Problem on the Person's Life:
- a finger: indicates a small area, no spreading of
discomfort, problem probably not severe, relatively
superficial, or both.
- the whole hand: diffuse area as primary site : suggests
lesion is more severe, more deeply situated, or both
- a moving hand: spreading or radiating of the pain : if
along a well-defined pathway : dermatome: probably
nerve root problem
- general area, diffuse: most likely referred pain,
possibly visceral in origin
- Onset: "How and when did it occur?" (Include a description of the
mechanism and position of injury.)
How and when did the problem arise (mechanism of injury and date of
- Gradual versus sudden onset
- Sudden onset.
Position the person was in when the injury was acquired (whether
sudden or gradual onset).
Have you started any out-of-the-ordinary activities recently?
- Characteristics: "Describe your problem," "How does it feel (pain or
other symptoms) and how does it make you feel?" "Does your problem
occur at certain times?"
- Intensity: "How bad is your problem?" (What impact does this problem
have on your life? What are you unable to do because of this problem,
with respect to all aspects of your life: self-care, home, work, and
leisure?) Have the patient rank the problem, using a scale, such as 0
to 10 (give criteria for 0 and for 10, such as 0 = at its best, 10 =
at its worst).
- Duration: "If certain activities cause you pain, how long does it last
after you stop the activity ?" "Is it constant, or intermittent?"
- Aggravating factors: "What makes the problem worse?" "What do you
notice this problem to be associate with?" When do you typically feel
- Alleviating factors: "What makes the problem better?"
Questions about the person should focus on the activities that the person
performs and the environments in which they perform them. The activities
should address home, work, and leisure/play and should reflect a typical
day for the patient.
- "Tell me about yourself."
- "Tell me about your home life." (What physical activities do they have
to perform at home, describe the home environment, is the person
married, do they have children. etc.)
- "Tell me about your work." (What physical activities do they have to
perform, describe the work environment, etc.)
- "What do you like to do in your spare time?" (Describe the physical
activities and their environments related to hobbies, recreation,
- "Prioritize the activities from each of these areas that you want to
return to doing."
- "Describe your Ďtypical dayí before your problem and after your
During the interview and subsequent treatment, therapists continually seek
to gather information from their patients. When talking with patients,
consider Maitlandís "Keys to Successful Communication" (1993):
- What is it that this problem is keeping you from doing that you want
to get back to doing?" This is the patient's Outcome Statement. (Have
the patient prioritize those affected activities, from most to least
- "Do you have any other problems?"
- "What medications are you currently taking?"
- "Have you had any previous physical therapy?" (If yes, describe; was
- "How do you feel right now?"
- "Is there anything else you would like for me to know?"
Paralleling: the process of following the personís line of thinking and
following-up with related questions.
Keying: pay attention to "key" words that people may use to describe their
condition, often without realizing its significance.
THE PHYSICAL EXAMINATION
The goal of the physical examination is compare information from the
interview with physical findings, ultimately to identify the origin of a
personís problem and to establish a baseline of the person's functional
The Scanning Examination / Quadrant Screening
Although patients may come to a therapist with what appears to be a
joint-specific problem, it is very important that therapists do not develop
"tunnel vision." Many patient problems can arise from a central pathology
but present themselves with peripheral symptoms. Therapists must view the
patient as an entire system, evaluating the patient from a larger,
wholistic perspective first, then moving toward a more focused evaluation
of what appears to be the problematic area.
The scanning examination should briefly but accurately assess each region
of the quadrant.
For the Upper Quadrant / Upper Quarter: the TMJ, cervical spine, scapula,
shoulder, elbow, wrist, and hand.
For the Lower Quadrant / Lower Quarter: the lumbar spine, the sacroiliac
joint, hip, knee, ankle, and foot.
Beginning therapists should make it a habit to perform the scanning
examination on most of the patients that they see. Some exceptions:
patients whose surgical status would it inappropriate to perform a scanning
Once the therapist has ruled out more central or proximal problems, the
therapist can then perform an evaluation more specific to an area. This
Observation and Preliminary Palpation: observe the patient's hygiene,
emotional status, body build (slim, obese, cachectic, short stature, etc),
vital signs if indicated, deformities, or abnormalities in positioning of
body parts. Perform preliminary palpation of the area to evaluate tissue
warmth and texture.
- Observation and Preliminary Palpation
- Range of Motion and Selective Tissue Tension Tests consisting of:
- Active ROM
- Passive ROM for Noncontractile Structures (Joint play,
component motions, ligamentous stress tests, and end-feel)
- Resisted ROM for Contractile Structures
- Neurological Evaluation
- Mobility consisting of:
- Postural Control / Balance
- Special Tests / Differential Diagnostic Tests
- Performance of Functional Activities
Range of Motion and Selective Tissue Tension Tests: consists of specific
active, passive, and resisted movement tests that assess the status of each
of the component tissues of the physiological joint.
Assessing both noncontractile and contractile structures with ACTIVE
MOVEMENTS: test the general willingness and ability of the person to move
the part as well as overall quality of movement. Pain with active movements
suggests an irritated structure is being stretched, being pinched between
two structures, or an involved contractile tissue is being used. Note loss
of full range of motion, crepitus, pain, movement pattern etc.
- Noncontractile or inert structures: joint capsule, ligament, bursae,
nerves and their sheathes, cartilage, disks, dura mater.
- Contractile structures: muscle and tendon.
Assessing noncontractile structures with PASSIVE MOVEMENTS: tests the range
of movement available at the joint, end-feels of the joint, and whether
there is pain on movement. Emphasizes assessment of the
non-contractile/inert structures at the joint, primarily joint capsule and
ligament. A tear in a ligament is a sprain.
Joint Play and Component Motions: small passive motions not under
the patientís control that must be present at the joint to allow
full painless voluntary motion. Therapist evaluate these motions
when they suspect joint hypomobility and must differentiate
between restrictions due to capsular fibrosis versus muscular
Ligamentous stress tests: stress the major ligaments of a joint
in order to detect loss of ligamentous continuity, which may
result in joint hypermobility. The therapist will compare the
movement allowed by a ligament with that of the opposite joint,
then determine the degree of hypermobility.
End-feel: noted at extremes of painful or restricted movements.
End-feel is the quality of the resistance to movement that the
examiner feels when coming to the end point of a particular
movement. Some end-feels may be normal or pathologic, depending
upon the movement they accompany at a particular joint, and the
point in the range of movement at which they are felt. Other
end-feels are strictly pathologic (Magee, 1997, p.21).
- Bony end-feel: an abrupt, hard-feeling stop to movement due to the
anatomical structures of the joint limiting motion.
- Soft-tissue approximation end-feel: a soft end-feel where two soft
tissue structures contact on another, limiting further motion.
- Tissue stretch end-feel: a rubbery end-feel where a soft tissue limits
further motion at a joint.
Pain on movement of the joint: pain at the extremes of movement indicates
that a painful structure is being stretched or a painful structure is being
- Muscle-spasm end-feel: movement stops fairly abruptly, perhaps with
some "rebound" due to muscles contracting reflexively to prevent
further movement. Magee (1997) describes an early muscle spasm
end-feel as being protective in nature following an injury, and a late
muscle spasm end-feel as a result of joint instability.
- Capsular end-feel: this is a firm, "leathery" feeling. Magee (1997)
defines this end-feel as soft (indicating synovitis or soft tissue
edema) or hard (indicative of capsular fibrosis). Some capsular
end-feels are normal.
- MU>Bony end-feel: an abrupt, hard-feeling stop to movement due to a bone
fragment in the joint space.
- Empty end-feel: the examiner feels no restriction to movement, the
patient stops the movement due to severe pain.
- Springy block end-feel: a pronounced springy rebound at the end point
of movement. Typically caused by a mechanical block produced by a
loose body or displaced meniscus.
Assessing contractile structures with RESISTIVE MOVEMENTS: these assess the
status of musculotendinous tissue. Determines tears or inflammation of a
muscle or tendon. A tear in a muscle is a strain.
It is critical that therapists stress the muscle and tendon that they wish
to test without stressing non-contractile joint structures. Isolate the
specific muscle, and place it in a resting position (usually a
midposition). It is important to stabilize the part while
When performing resisted tests, determine whether the contraction is strong
or weak, and whether it is painful or painless. Weakness may be due to a
neurologic deficit or actual loss of continuity/tearing of the muscle or
tendon; a painful contraction signifies the presence of some pathology
involving the muscle or tendon.
Four possible findings on resisted tests:
Strong and painless: no lesion or neurologic deficit
involving the tested muscle or tendon.
Strong and painful: a minor lesion of the tested tendon
or muscle exists.
Weak and Painful: there may be a partial rupture of the
muscle or tendon, or may be the result of painful
inhibition of the muscle, as seen with a fracture or
Weak and painless: may be an interruption of the nerve
supply to the muscle being tested, correlate with the
neurologic test; or there may be a complete rupture of
the tendon or muscle (Magee, 1997, p. 23).
Depending on the patient's problem, therapists may choose to evaluate the
patient's strength via Manual Muscle Testing (MMT). Indications for
performing a MMT to assess muscular strength include:
- Weakness due to disuse/atrophy;
- To determine if postural and/or biomechanical deviations are linked to
muscular strength (certain muscles short and strong, others lengthened
When assessing neurologic function clinically, if you detect a deficit, you
can estimate the approximate site of the pathology by correlating the
extent of the deficit with peripheral nerve and segmental distributions.
Postural Control / Balance:
- Cutaneous Sensory Testing: check along the entire distribution of the
dermatomes for changes in sensation to light and deep pressures.
- Strength Testing: check for differences in strength or in quality of
contraction. To achieve this, the place the joint in a resting
position and apply resistance for five seconds.
- Deep Tendon Reflexes:
Evaluate and compare bilaterally and grade (Magee, 1997, p.36):
0 - 4 scale:
0/4 = no reflex (lower motor neuron lesion)
1/4 = diminished/sluggish
2/4 = average/normal
3/4 = exaggerated/hyperreflexive
4/4 = pathological/clonus (upper motor lesion)
- Neural Tension Tests: the nervous system attaches to surrounding
tissues in such a way that the tissues support the nerves, yet allow
for movement of the nerve to occur. Certain pathologies may restrict
this movement. Therapists can evaluate neural motion by putting the
patient in specific positions (Butler, 1989).
Coordination of Movement
Postural alignment / postural assessment: usually done in the scanning
examination. If the patient's problem dictates a more detailed
assessment, do it here. Perform a thorough biomechanical examination,
looking at static and dynamic alignment.
Performance of Functional Activities
Balance (Static and Dynamic)
Special Tests / Differential Diagnosis: a number of tests to confirm
or rule out problems caused by specific structures have been devised
and used by orthopedic physicians and by therapists. These tests apply
the concepts of biomechanics with a knowledge of anatomy of the
specific structure to implicate or rule out a pathology of a specific
Palpation: should consist of an organized inspection of bony
structures, soft tissues, and skin/integument with minimal position
changes. Therapists should routinely palpate during many aspects of
the physical examination, saving the more pain-provoking palpation
until the end of the P.E.
Bony structures: look for bony abnormalities.
Soft tissues: check for edema, wasting or atrophy of
muscles, and alterations in the general contours of the
Skin and nails: changes in color, changes in texture or
moisture, local scars, blemishes, abnormal hair patterns,
* Always examine bilaterally, use uninvolved side for
In addition to information provided by the person in regard to
limitations as a result of an injury/pathology, the therapist should
evaluate and measure the person's ability to perform functional tasks.
The tasks evaluated should be those that the person has identified and
prioritized. Measure limitations related to the patientís performance
of specific activities that are related to the personís desired
CORRELATION AND INTERPRETATION OF INFORMATION
The therapist will take the information that the patient has provided
in the interview, and correlate it with the findings of the physical
examination. Then the therapist determines a physical therapy
diagnosis / occupational challenge, sets goals based on the patientís
desired outcome, and devises and implements treatment strategies.
The Occupational Challenge and the Physical Therapy Diagnosis:
Is based on an evaluation that is congruent with our
education and licenses, that seeks out history, signs and
symptoms using tests we are qualified to use or request
(Magistro, Delitto, Guccione, Jette, & Sahrman, 1993).
Therapists determine the pathophysiology or impairment(s) by
correlating information from the evaluation (in which they ruled-in or
ruled-out certain structures) with knowledge of anatomy, physiology,
kinesiology, and pathology. The pathophysiology and/or impairment name
the origin and extent of the problem.
Names the pathophysiology, primary impairment, functional
limitation, and/or disability toward which the OT or PT will
direct treatment (Sahrman, 1988).
The functional limitation and/or disability describe the deficits
occurring because of a pathophysiological problem or impairment that
effect a person's ability to perform his or her usual activities.
Therapists determine functional limitations and disabilities from the
history provided by the patient or significant other, as well as by
the findings from the physical examination. (Cech & Martin, 1995).
When to Refer the Patient to Another Practitioner
Magee (1997) identifies several "red flag" findings that indicate the
need for the therapist to refer the patient to another, more
- Indications of Cancer: persistent pain at night; constant pain
anywhere in the body; unexplained weight loss of 10 - 15 pounds
or more in 2 weeks or less; loss of appetite; unwarranted
fatigue; pain along two or more cervical nerve roots
simultaneously; pain along three or more lumbar nerve roots.
- Indications of Cardiovascular problems: shortness of breath;
dizziness; pain or a feeling of heaviness in the chest; pulsating
pain anywhere in the body; constant and severe pain in the lower
leg, calf, or arm; discolored or painful feet.
- Potential GI / GU problems: frequent or severe abdominal pain;
frequent heartburn; frequent nausea and vomiting; change in
bladder function; unusual menstrual irregularities.
- Possible Neurological problems: changes in hearing; frequent or
severe headaches with no history of injury; problems with
swallowing or speech; changes in vision; balance problems;
fainting spells; sudden weakness.
- Other potential red flags: Fever or night sweats; recent severe
emotional disturbances; swelling or redness in any joint with no
history of injury; pregnancy.
Documentation of the initial evaluation should be structured (and
follow the systematic approach used in the evaluation), objective
(with measurements that can be reproduced), and documented treatment
should be such that it can be performed by another therapist.
The initial orthopedic evaluation, which consists of a thorough
history and physical examination, is but the first step in the
treatment process of people with musculoskeletal problems. A
reevaluation of the patientís status should always precede subsequent
treatments, addressing many, if not all, of the components addressed
in the initial evaluation. Therapists are continuously making clinical
decisions based on information they acquire from the evaluation,
working to guide the body's healing abilities to help the person
regain functional abilities that are important to them.
Table of Typical Findings Associated with Problems of Specific
Therapists should be alert to patterns of signs and symptoms, as well
as key words that the patient may use, which can provide clues to the
origin of the patient's problem.
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