Patient History and Interview
Before beginning the physical examination, it is important to gain as much information as possible about the patient's current condition and past medical history. This information will help to direct and focus the physical examination to an area and system of the body. Information on symptoms and functional ability will help to establish a baseline against which treatment effectiveness can be judged. It will also help ensure that the examination and subsequent treatment are conducted safely.
Typically, most of this information is obtained while interviewing the patient. However, utilizing other information sources can be very efficient and provide objectivity and details to supplement interview data. If the patient is hospitalized in an acute care or rehabilitation setting, the medical records, including admission reports, progress notes, medication sheets, surgical summaries, body imaging reports, and laboratory test results, should be available and sought out. Referral summaries from previous medical care settings that review prior treatment approaches and discuss functional status may also be included. Other members of the health care team can be consulted for their input.
Outpatients often arrive with only a general diagnosis from a referring physician, or may be self-referred. In such cases it will be helpful to ask the patient to complete a medical history questionnaire before the examination process. A medical history questionnaire should include space for the patient to note the chief problem and date of onset; diagnostic tests performed for the problem; name and date of all surgeries; all medications currently being taken; past or current treatment for the problem (including those initiated by patient); a checklist of common medical conditions the patient may have experienced; brief family medical history; and patient's age, occupation, and lifestyle questions pertaining to smoking, alcohol use, and exercise. Figure 4.1 provides an example of a medical history questionnaire. The Guide to Physical Therapy Practice also includes a detailed template for a patient self-administered health questionnaire.6
A thorough understanding of the patient's medical background is critical for selection and safe application of examination and treatment procedures. For example, a history of an MI would cause the therapist to limit and more closely monitor the patient during muscle performance testing. A history of diabetes mellitus (DM) would cause the therapist to suspect and test for potentially compromised peripheral vascular and peripheral nervous systems, and to possibly avoid the use of heat modalities during treatment.
Patient self-administered health questionnaires have been shown to be generally accurate when conducted in a general medicine7 and orthopedic outpatient settings.8 However, even if a patient completes a medical history questionnaire, it is important for the therapist to review and clarify the information with the patient. Sometimes important medical background and medication data are inadvertently forgotten as the patient focuses on current problems. Verbally reviewing the information with the patient may jog the patient's memory.
After reviewing the information gained from medical records, other health care providers, and the patientcompleted medical history questionnaire, the therapist is ready to begin the patient interview. Ideally, the patient interview should be conducted in a quiet, well-lit room that offers a measure of privacy. To encourage good communication, the therapist and patient should be at a similar eye level, facing each other, with a comfortable space between them—about 3 feet (91.44 cm) apart is customary in the United States. The patient should have the therapist's undivided attention; telephone calls and other interruptions should be avoided. The therapist may wish to have paper and pen available to record particular dates and information that is easily forgotten, but the interview should flow as an active conversation, not a dictation session. Repeated practice greatly improves the therapist's ability to listen, direct the interview, and establish a positive working relationship with the patient.
Over the course of the interview the therapist gains information about the patient's current complaints including onset, location, type and behavior of symptoms, current medications, previous treatments, secondary medical problems, medical history, and goals for the physical therapy episode of care. The patient's age and gender should be noted; some conditions are more common in particular age groups and genders. Often, detailed information about a patient's occupation, recreational activities, and social/living situation are required to understand the cause of the impairments, activity limitations, and to develop a relevant POC that focuses on the patient's goals. Open-ended, objective questions that do not promote biased answers should be used. For example, instead of asking "Is your right knee painful?" the therapist should ask, "Where are your symptoms located?" The therapist should carefully guide the interview to keep it focused on pertinent information and conclude in a timely manner. All questions should use conversational language rather than medical terminology so the patient easily understands the questions. The therapist should ask one question at a time and be sure to obtain a response before proceeding to other questions. Follow-up inquiries may be needed to clarify initial answers. It is important for the therapist to keep an open mind during the interview and not rush to conclusions about the patient's symptoms and diagnosis.
The following sequence is suggested as a way of organizing the interview. Similar information on general patient interviewing, that includes slight variations in format, can be found in texts by Talley and O'Connor,9 Hertling and Kessler,1 Paris,10 and Coulehan and Block.11
An example of a medical history recording form. (Courtesy of North Andover Physical Therapy Associates, North Andover, MA.)
The interview should begin with a general question such as "What brings you to physical therapy today?" or "What seems to be the problem?" If the patient is hospitalized the question may need to be rephrased to avoid having the patient retell the medical history to every health care provider. "I see from your medical chart that you fractured your hip and underwent a surgical repair yesterday. Is that what happened?" The patient should be given the opportunity to present the story. After the patient has concluded his or her statement, it is appropriate to say, "That's good. Now I have an idea of the problem. I have some other questions I need to ask to help me understand your problem better." Depending on the information provided by the patient, some of the following questions may be asked.
"How did this pain (swelling, limitation, problem, etc.) begin?" The therapist must know if the onset was sudden (e.g., caused by trauma such as a fall, blow, or skiing or motor vehicle accident). Specific information about the patient's body or body segment position at the time of trauma and the mechanism of injury will help to identify the structures involved. If the onset was more gradual or insidious, a systemic condition or chronic biomechanical problem may be more likely. A congenital onset is also a possibility.
"Where is your pain? Can you point to the location?" A body chart (Fig. 4.2) can be used to help identify and document the specific location of symptoms. The patient (or therapist with the patient's direction) can darken the involved area on the body chart using a pen or pencil. Often the location of the symptoms coincides with the location of the lesion. This is more likely if the lesion is in superficial and distal tissues. For example, a lesion in a superficial tendon near the ankle will usually cause pain over the tendon site. Lesions in deeper, more proximal tissues can refer pain distally following sclerotome (Fig. 4.3) or dermatome patterns. (Refer to Chapter 3, Examination of Sensory Function.)
This body chart can supplement the patient's verbal description of the location of the pain.
Sclerotomes from the anterior and posterior aspects of the body. (From Hertling and Kessler,1, p. 52 with permission.)
Referred pain may be perceived as originating from any or all tissues innervated by the same segmental spinal level in which the lesion is located. For example, pain due to OA of the hip is often felt in the anterior groin and thigh along the sclerotomes or dermatomes for L2 and L3. Considerable individual variation has been noted in dermatome and sclerotome patterns.12
"Has the pain changed in location? Spread to other areas? Become more focused?" Pain that is spreading usually indicates a worsening condition, whereas more focused symptoms indicate improvement. Changes in symptoms in relationship to varying body positions, activities, and treatments should be noted.
"How severe is the pain? Is the pain sharp? Dull? Throbbing?" A simple yet effective way to document pain severity is to ask the patient to rate his or her pain from 0 (no pain) to 10 (most severe pain imaginable) as illustrated in the numerical pain rating scale presented in Figure 4.4. A visual analog scale (Fig. 4.5) or thermometer pain scale (Fig. 4.6) can also be used if preferred. A checklist of adjectives like that found in the McGill Pain Questionnaire13 can clarify symptoms further (Fig. 4.7).
Two types of numerical pain rating scales.
Visual analog pain rating scale. The line is usually 10 cm in length. The patient's mark is measured from the left (no pain) end of the scale and is recorded in centimeters.
Thermometer pain rating scale. (From Brodie, DJ, et al: Evaluation of low back pain by patient questionnaires and therapist assessment. J Orthop Sport Phys Ther 11:528, 1990, with permission.)
The McGill Pain Questionnaire. The first 10 groups of words are somatic (describing what the pain feels like), 11–15 are affective, 16 is evaluative, and 17–20 miscellaneous.13
The adjectives used to describe pain may have diagnostic implications. Dull, aching pain may indicate muscle or joint lesions. Numbness, tingling, shooting pain, or burning sensations may indicate nervous system involvement. Deep, throbbing pain, or coolness in a body region may indicate vascular problems. Weakness, clumsiness, or incoordination may suggest muscle and possibly peripheral or central nervous system dysfunction.
"What makes your symptoms increase? Decrease?" Symptoms from musculoskeletal conditions typically vary in response to rest, activity, and body positions that either increase or decrease mechanical stress placed on the involved tissue. The behaviors of the symptoms help to establish a diagnosis and determine which treatment techniques are more likely to be effective. For example, pain from overuse syndromes such as tendonitis will decrease with rest, whereas joint stiffness caused by OA often increases following rest. If a patient reports that the sitting position reduces back pain, then the therapist will probably have more success in relieving the pain using back flexion rather than extension exercises.
Symptoms that do not vary with a change in activity or body position are rarely due to musculoskeletal lesions, and in fact are a "red flag" for more serious conditions such as space-occupying tumors and pathologies involving internal organs. Often patients will report that "nothing helps the pain." This statement should be fully explored with follow-up questions such as "Is your pain better or worse in the morning when you wake up from sleeping? Does your pain vary if you sleep on your back versus on your stomach?"
Behavior of Symptoms During the Last 48 Hours
It is important to understand the behavior of the symptoms during the past few days, not just at the current moment. Sometimes symptoms suddenly worsen or disappear at the time of the physical examination. A more accurate picture of the situation is told if the time frame spans 48 hours. "Are the symptoms getting better, worse, or staying the same?" The answer to this question will help inform the therapist about the effectiveness of future treatment. If the patient's pain has been steadily worsening over the last 48 hours and treatment stabilizes the pain, then the treatment may be deemed helpful. However, if the patient reports that the pain has been steadily improving over the last 48 hours and treatment stabilizes the pain, then the treatment may be deemed as detrimental.
Previous Care of this Problem
"What previous care has been sought for the problem? Who else (e.g., physician, therapist, athletic trainer, chiropractor) has treated the problem? What tests and treatments did they perform? What have you done to relieve the problem?" From these and similar questions, all previous exercises, physical modalities, manual treatments, medications, injections, orthotics, and surgical procedures should be delineated. The answers to these questions help the therapist decide if further medical referrals are needed, and focus on the most effective treatment for the condition. For example, a patient who fell 3 days ago is experiencing severe ankle pain and swelling. The patient borrowed a friend's crutches and has been self-treating the ankle with ice and elevation. The therapist would recommend that the patient be examined by a physician and have radiographs taken to rule out a fracture before physical therapy intervention. In another scenario, if a patient with adhesive capsulitis of the shoulder has been treated previously by a physical therapist with ultrasound and pendulum exercises without improvement, then other physical therapy interventions should be considered.
"Has this problem occurred before? How was it treated? How was it resolved?" Many musculoskeletal problems tend to recur with continued occupational, recreational, and daily activities if underlying biomechanical abnormalities, weaknesses, joint laxity, or tightness persists. Information about previous successful and unsuccessful treatments for similar past problems can help in treatment planning for the current problem.
A brief history should be obtained concerning medical problems and prior surgeries involving other body regions and systems. Conditions involving the cardiac, respiratory, neurological, vascular, metabolic, endocrine, gastrointestinal, genital urinary, visual, and dermatological systems should be noted. Having a patient complete a medical history questionnaire before the examination is an efficient means of obtaining this information, but the information should also be verified during the interview. Therapists also need to be aware of other conditions that mimic signs and symptoms often attributable to the musculoskeletal system. For example, inflammation of the gallbladder (cholecystitis) may result in right shoulder pain. However, shoulder pain related to cholecystitis typically will not increase with shoulder movements or resisted isometric testing of shoulder musculature, as would occur in the presence of Musculoskeletal conditions. Patients with cholecystitis would likely have additional symptoms such as upper abdominal discomfort, bloating, belching, nausea, and intolerance of fried foods. Knowledge of systemic human pathology allows the therapist to recognize conditions requiring additional physician evaluation and intervention. Boissonnault14 and Goodman and Snyder15 have provided useful information to assist physical therapists in screening for medical conditions.
The type, frequency, dose, and effect of medications the patient is taking should be noted. The use of analgesic or anti-inflammatory medications may reduce the intensity of symptoms at the time of the examination. Changes in the use of these medications may make it difficult to determine the effects of physical therapy treatment. The secondary effects of some medications may necessitate the modification of examination and treatment techniques. For example, prolonged use of corticosteroids is associated with osteopenia (reduced bone mass) and reduced tensile strength of ligaments. The therapist may need to limit manual force applied through the lever of long bones to prevent fracture or ligament tear. The use of anticoagulants may make the patient susceptible to contusions and hemarthrosis. Such patients should be closely monitored for bruising and joint swelling. The amount of force used in exercise and manual therapies may need to be reduced.
Social History and Occupational, Recreational, and Functional Status
Questions in this area might include the following: "What type of work do you do in and outside of the home? How has this problem affected your ability to perform your job? Care for your children? Play golf? Dress? Bathe?" Certain occupational and recreational activities may contribute to the problem or interfere with recovery. Strategies such as joint preservation techniques and use of assistive devices may need to be considered to allow performance of necessary tasks. Medical insurance companies often make treatment reimbursement decisions based on a patient's functional status as related to the medical problem. Figure 4.8 presents sample questions that can be used to quantify the impact of the problem on function. Detailed assessment instruments, such as the Katz Index of Independence in Activities of Daily Living, Outcome and Assessment Information Set (OASIS), and SF-36 have also been developed to quantify a patient's functional status. See Chapter 8, Examination of Function, for additional information on examination of function.
Questions used to rate a patient's function. The patient circles the percent of activity that he or she is able to perform.
"Do you have to climb stairs to get into your house? To reach the bedroom? Bathroom?" Characteristics of the home environment may determine whether a patient who uses an ambulatory assistive device requires instruction in stair activities before returning home. The condition of floors, size of halls and doorways, placement of furniture, and bathroom facilities will need to be considered for a patient using a wheelchair. A more detailed discussion of examination of the environment including the home, workplace, and community can be found in Chapter 9, Examination of the Environment.
"Do you live alone?" It is helpful to understand the patient's living situation to determine if others are available to assist with exercise programs, ambulation, and transfer activities. Some patients have responsibility for the care of children, elderly parents, or a disabled spouse or sibling. These responsibilities may need to be restructured to allow time for rest and recovery.
"Do you use tobacco products? Alcohol? Recreational drugs?" Cigarette smoking has been associated with decreased bone density, delayed bone healing after fractures, greater spinal disk degeneration, increased low back pain, and increased UE and LE musculoskeletal disorders. Use of alcohol and recreational drugs can lead to risk-taking behaviors resulting in increased incidence of injuries, or difficulty in safely performing functional activities and home exercise programs (HEPs). Therapists may wish to advise a patient to reduce the use of these substances and refer the patient to appropriate social services or self-help organizations for counseling.
Anticipated Goals, Expected Outcomes, and Time Frame of Recovery
Ask the following types of questions, as appropriate: "What do you hope will be the outcome of physical therapy treatment? When do you anticipate returning home? To work? To playing football?" These questions enable the therapist and patient to discuss and determine mutually agreed upon anticipated goals and expected outcomes. The therapist should not presume to know what issues are important to the patient. Answers to these questions help the therapist to determine whether the patient has realistic expectations or will need further patient education concerning his or her condition and typical recovery. For example, an elderly patient who suffered a fractured hip yesterday and is currently hospitalized may expect to remain in the acute care hospital for 2 weeks until he or she can independently ambulate and be independent in self-care. More realistic goals given current health insurance practices may need to be discussed, such as discharge from the hospital in 3 or 4 days to a rehabilitation or extended care facility for further nursing care, physical and occupational therapy, or discharge home with home health aides, visiting nurses, and home care physical and occupational therapists.
When the therapist has finished obtaining the above information, one final type of open-ended question needs to be asked: "Is there anything else you wish to tell me?" or "Is there anything else you think I should know concerning your condition that I have not asked about?" Most likely the patient will respond by saying that he or she has no further information to offer and believes you understand the problem clearly. Sometimes, though, a patient may take this opportunity to clarify a previous point or share a concern that is adding stress to his or her life. Without this type of question at the conclusion of the interview, important information that may affect treatment and recovery may be lost.
The information elicited with the questions discussed above may be supplemented with additional questions based on the specific region of the body being examined and suspected etiologies. The physical therapist's knowledge of anatomy, kinesiology, pathokinesiology, physiology, and pathophysiology, as well as the physical presentation and progression of Musculoskeletal conditions, provide the appropriate background on which to base and develop patient interview questions.
During the interview, the patient's orientation to person, place, and time as well as general arousal state and cognitive and communication abilities should be noted (see section titled Arousal, Attention, Orientation, and Cognition in Chapter 3, Examination of Sensory Function). If deficits in these areas are present, the examination may need to be modified to gain accurate information. The use of simple words, concise instructions, and task demonstrations may be helpful. Distractions in the environment should be kept to a minimum. Communication difficulties may be overcome through the use of foreign language interpreters, gestures, drawings, and language boards. Changes in medications, upright positioning, and access to natural light via windows and skylights may improve patient arousal and orientation to time. Depending on the type of deficit, the patient may benefit from an evaluation by a neurologist, neuropsychologist, speech-language pathologist, and/or occupational therapist.
If a patient's medical record or interview suggests a compromised cardiovascular system, then heart rate, blood pressure, and respiratory rate should be determined before beginning other physical examination procedures (see Chapter 2, Examination of Vital Signs). Patients who are getting out of bed for the first time following recent surgery or prolonged bedrest should routinely have vital signs taken to establish baseline values before movement.
Observation begins with the therapist's first contact with the patient, whether at bedside in the case of hospitalized patients, or in the waiting room for outpatients. The patient's general posture and ability to perform functional activities—change bed position, transfer from sitting to standing, ambulate to the examining room—provides information about the severity of symptoms, willingness to move, range of joint motion, and muscle strength. This information, although preliminary, helps to focus and individualize the physical examination. For example, a patient with a shoulder disorder who uses the UE to push off from a chair during transfers, stands with level bilateral shoulder height, and has an alternating arm swing during gait, would be expected to have milder symptoms, tolerate a more extensive examination, and have a greater range of motion (ROM) and muscle function than a patient who stands with an elevated scapula and protectively cradles the UE during transfers and gait. If functional difficulties and gait abnormalities were noted, detailed functional status and gait examinations would be performed later. See Chapter 8, Examination of Function, and Chapter 7, Examination of Gait, for additional information about these examination procedures.
To perform the physical examination and inspect specific areas of the body, the patient must be suitably dressed. Observation of the shoulders, elbows, or spine will require males to remove their shirt and females to wear only a bra or loose hospital gown that can be draped to expose the UE and back. To observe the LEs, patients should undress from the waist down, wearing only undergarments or shorts.
Once the patient is in the privacy of an examining room and appropriately disrobed, the therapist begins a careful inspection of the body region implicated in the interview as well as biomechanically related areas. The LEs and lumbar region, being intricately involved in weight-bearing activities, should be inspected as a functional unit. Likewise, conditions involving the shoulder require the examination of the cervical and thoracic regions, and vice versa. Visual inspection should focus on bone, soft tissue structures, skin, and nails. The therapist should view the body region anteriorly, posteriorly, and laterally. Often palpation, which is discussed in the next section, is combined with observation.
Bone shafts and joints are judged against normative models for symmetry, comparing one side of the body to the other. Contour and alignment should be considered. Common causes of changes in bone contour include acute fractures, callus formation or bone angulation owing to healed fractures, congenital variations, or bone hyperplasia at tendon insertions, and arthritis. Alignment differences can be due to the above conditions as well as muscle and soft tissue tightness, muscle weakness, muscle and ligament laxity, and joint dislocation.
For patients with musculoskeletal involvement, an examination for postural alignment is often indicated. From an anterior view both eyes, shoulders (acromion processes), iliac crests, anterior superior iliac spines, greater trochanters of the femur, patellae, and ankle medial malleoli should be horizontally level. Waist angles should be symmetrical. Patellae and feet should face anteriorly. Laterally the line of gravity should bisect the external auditory meatus, acromion process, greater trochanter, lie just posterior to the patella and approximately 2 inches (5 centimeters) anterior to the lateral malleolus (Fig. 4.9).16
The location of the line of gravity from the lateral view. (From Levangie and Norkin,16 with permission.)
The cervical and lumbar spine should exhibit normal lordotic curves, and the thoracic spine a normal kyphotic curve. From a posterior view the ear lobes, shoulders, inferior angles of the scapula, iliac crests, posterior superior iliac spines, greater trochanters, buttock and knee creases, and malleoli should be level.
The spine should be straight, with the medial borders of the scapula equidistant from the spine bilaterally. Varus and valgus deformities of the knee and calcaneus should be noted.
The size and contour of soft tissue structures should be inspected and compared bilaterally. An increase in size may indicate soft tissue edema, joint effusion, or muscle hypertrophy. A decrease in size often indicates muscle atrophy. A loss of soft tissue continuity can suggest a muscle rupture. Cysts, rheumatoid nodules, ganglia, and gouty tophi can all change soft tissue contour. Clubbing, in which the distal finger and nail become rounded (bulbous), is believed to be caused by chronic hypoxemia and is typically associated with cardiovascular and respiratory diseases or neurovascular abnormalities.9 Clubbing may also occur in the toes. Skin color and texture provide important clues to pathological conditions. Cyanosis, a blue discoloration of the skin and nail bed, indicates a lack of oxygen and excessive carbon dioxide in superficial blood vessels.9 Inspection of the tongue for cyanosis helps determine if the poor perfusion is due to central or peripheral causes. Pallor is noted with a decrease in blood flow or blood hemoglobin—for example, in situations such as peripheral vasoconstriction, shock, internal bleeding, and anemia. Erythema, a localized redness, usually indicates increased blood flow and inflammation. Generalized redness can suggest fever, sunburn, or carbon monoxide poisoning. Yellow skin tone may be due to increased carotene intake, or liver disease. Brown, highly pigmented, hairy areas sometimes overlay bony defects such as spina bifida. Open wounds should be measured and diagrammed in patient records. New scars will be red, and older scars will be white in color. Skin tissue thickenings such as calluses can indicate chronic overloading and stress. Thin, glossy skin with decreased elasticity and hair loss is often found with peripheral nerve lesions or neurovascular disorders.
It is suggested that palpation immediately follow or be integrated with observation and occur before other testing procedures. Other procedures may aggravate the patient's condition, making it more difficult to localize tenderness if palpation is performed later. The information gained from palpation will also help guide decision making about the need for additional test and measurements.
Palpation requires detailed knowledge of anatomy and a systematic approach. All structures on one body surface should be palpated before proceeding to another surface. For example, all structures on the anterior surface of the patient should be palpated before beginning to palpate structures on the posterior surface. The uninvolved side is palpated first to acquaint the patient with the procedure and, in some cases, to serve as a normative model for comparison. The therapist should develop a system of moving from superior to inferior structures, medial to lateral, or superior and then inferior from a joint line. Which direction the therapist moves is not important, but the palpation process should be consistent and thorough.
Palpation of bone, soft tissue structures, and the skin is performed by varying the therapist's tactile pressure and using various parts of the hands. Light tactile pressure allows palpation of superficial tissues like the skin, whereas more pressure is needed to palpate deeper structures such as bone. Usually the fingertips are used for palpation, but large, deeper structures such as the greater trochanter of the femur or borders of the scapula are easier to locate using the entire surface of the hand. Rolling the skin and soft tissue between the fingertips and thumb helps the therapist judge myofascial mobility. Changes in skin temperature may be easier to detect using the posterior surface of the therapist's hand. When moving from one area to another, the therapist's hand should stay in firm contact with the skin whenever possible to prevent a tickling sensation. The fingers should not "crawl" or "walk" across the skin.
During palpation the therapist seeks feedback from the patient to help localize painful structures. Some lesions in deep or proximal structures will refer symptoms to other body areas, but localized tenderness often helps to implicate particular structures. Localized skin temperature should be noted: cool temperatures suggest reduced circulation, whereas warmth indicates increased circulation and often inflammation. Skin and soft tissue density and extensibility should be considered. Often muscle spasms and adhesions in skin and connective tissue can be found with palpation. The quality (amplitude) of peripheral pulses will provide gross information on arterial blood supply. Bilateral edema in the ankles and legs that forms pits with tactile pressure (termed pitting edema) can indicate cardiac failure, liver, or renal conditions. Unilateral pitting edema is typically associated with obstruction of returning circulation.
Abnormalities noted during observation and palpation may be further documented with anthropometric measurements. Using a cloth or flexible plastic tape measure, limb lengths are measured from one bony landmark to another and compared bilaterally. For example, true leg length is commonly measured from the anterior superior iliac spine to the medial malleolus.
Circumferential measurements help substantiate joint effusion, edema, and muscle hypertrophy and atrophy. Typically, these measurements are taken at specified distances (inches or centimeters) above or below a bony landmark so they can be reliably reproduced during subsequent measurements. For example, circumference measurements of the upper arm should be taken at noted distances distal to the acromion process of the scapula or proximal to the olecranon process of the ulna. If measurements are needed of the hands or feet, volumetric measurements can be taken by submerging the distal extremity in a container of water and noting the volume of water that is displaced.
Joints and their related structures are examined by performing active and passive joint motions. Joint motion is a necessary component of most functional tasks. Numerous studies have identified the ROM needed in the LE to walk on level surfaces,17,18,19,20,21 ascend and descend stairs,21,22,23 rise from a chair,24,25,26 as well as squat, kneel, and sit crosslegged.27,28 The ROM needed in the UE to eat with a spoon29,30 and perform many UE activities31,32,33 has been examined. Careful examination of joint movement for ROM, end-feel, effect on symptoms, and pattern of restriction help identify and quantify impairments causing activity limitations, and determine which structures need treatment.34
The examination of joint motion begins by testing active range of motion (AROM). Active motion is the unassisted voluntary movement of a joint. The patient is asked to move a body part through the osteokinematic motions at the involved and other biomechanically related joints. Osteokinematics refers to the gross angular motions of the shafts of bones. These motions are described as occurring in the three cardinal planes of the body: flexion and extension in the sagittal plane, abduction and adduction in the frontal plane, and medial and lateral rotation in the transverse plane. For example, in an examination of the hip the patient would be asked to move the hip into flexion, extension, abduction, adduction, and medial and lateral rotation. Often flexion and extension of the knee, as well as flexion, extension, rotation, and lateral flexion of the lumbar spine, are tested, because knee and spine motions can affect hip function. Some therapists prefer to have the patient move in functional, combined motions rather than straight plane motions. For example, a patient would be asked to reach a hand behind the head to test shoulder abduction and medial rotation simultaneously rather than perform isolated, individual motions.
Active motion is a good musculoskeletal screening procedure to further focus the physical examination. The amount, quality, and pattern of motion, as well as the occurrence of pain and crepitus, should be noted. For purposes of musculoskeletal screening, AROM can be visually estimated to determine if motion is within functional limits (WFL); however, use of a goniometer is required for the more objective and accurate measurements needed to establish a pathological baseline and to evaluate treatment response. Normal ROM varies among individuals and is influenced by factors such as age and gender,35,36,37,38,39,40,41,42,43,44 as well as measurement methods.45,46,47,48,49,50 Ideally, to determine if ROM is impaired, the ROM values should be compared with those obtained with the same measurement methods from people of the same age and gender. Studies that provide normative values by age and gender have been summarized by Norkin and White.34 However, when particular values are not available, the therapist may need to compare ROM values to those of the patient's contralateral extremity or to average adult values from sources such as the American Academy of Orthopedic Surgeons51,52 and the American Medical Association.53 If the patient can complete AROM easily, without presenting pain or other symptoms, then further passive testing of that motion is usually unnecessary.
If, however, the amount of active motion is less than normal the therapist will not be able to isolate the cause without further testing. Capsule, ligament, muscle and soft tissue tightness, joint surface abnormalities, and muscle weakness are all capable of causing limitations in AROM. Pain during AROM may be due to the contracting, stretching, or pinching of contractile tissues such as muscles, tendons, and their attachments to bone, or due to the stretching or pinching of non-contractile tissues such as ligaments, joint capsules, and bursa.54 Variations in the quality and pattern of active motion can result from central and peripheral nervous system disorders and metabolic conditions, in addition to disorders involving musculoskeletal structures. So, although active motion is an effective screening procedure, positive findings require a variety of additional tests to identify the underlying etiology and thus enable effective treatment.
Passive motions are movements performed by the therapist without the assistance of the patient. The term passive range of motion (PROM) typically refers to the amount of osteokinematic motion available when the patient's joint is moved without the patient's assistance. Normally, PROM is slightly greater than AROM because joints have a small amount of motion at the end of the range that is not under voluntary control. This additional range helps to protect joint structures by allowing the joint to absorb extrinsic forces. Passive ROM is examined not only for amount of motion, but also for the motion's effect on symptoms, the type of tissue resistance felt by the therapist at the end of the motion (end-feel), and pattern of limitation.
Passive range of osteokinematic motions depends on the integrity of joint surfaces and the extensibility of the joint capsule, ligaments, muscles, tendons, and soft tissue. Limitations in PROM may be due to bone or joint abnormalities or tightness of soft tissue structures. Because the therapist provides the muscle force needed to perform PROM, rather than the patient, PROM (unlike AROM) does not depend on the patient's muscle strength and coordination.
Pain during PROM is often due to moving, stretching, or pinching of non-contractile structures. Pain occurring at the end of PROM may be due to stretching contractile structures, as well as non-contractile structures.
Pain during PROM is not due to the active shortening (contracting) of muscle and the resulting pull on tendon and bone attachments. By comparing active and passive motions that cause pain, and noting the location of the pain, the therapist gains important information about which injured tissues are involved.
For example, on examination a patient is found to have limited and painful active knee flexion. This pain and limitation may be due to a lesion in the hamstring muscles (including tendons and bone attachments), the quadriceps muscles (including patella tendon and bone attachments), tibiofemoral and patellofemoral joint surfaces, meniscus, joint capsule, collateral and cruciate ligaments, or various anterior and posterior bursa. If the patient had similar pain and limitation during passive ROM, the quadriceps muscles, tibiofemoral and patellofemoral joint surfaces, meniscus, joint capsule, collateral and cruciate ligaments, or various anterior bursa may be involved. The hamstring muscles would not be implicated as these structures are put on slack and relieved of tension during passive knee flexion. Careful consideration of patient history, observation and palpation findings, and the results of additional tests and measurements such as end-feel determination, capsular versus non-capsular joint limitation patterns, accessory joint motion tests, and ligament stress tests will help to isolate the involved structures. These additional tests are discussed later in this chapter. If, however, passive knee flexion ROM were now normal and pain free as compared to painful during active flexion, a lesion in the hamstring muscles would be likely. The performance of resisted isometric muscle contractions would be used to confirm the presence of a lesion in the hamstring muscles.
In the clinical setting, PROM is usually measured with universal goniometers (Fig. 4.10) or less frequently with inclinometers (Fig. 4.11A and B), tape measures, and flexible rulers. With the exception of screening examinations, visual estimates are not used because they are less accurate than measurements taken with goniometers.55,56 Both the beginning and the end of the motion are measured to identify the "range" of movement and are recorded using both the start and end values (e.g., 0°–110°) (Fig. 4.12).
A variety of metal and plastic universal goniometers in different sizes and shapes. All universal goniometers have a central "body" with a protractor and fulcrum to center over the patient's joint, as well as two "arms" to align with the patient's body parts. (From Norkin and White,34 with permission.)
An inclinometer, with a bubble to indicate the position of the goniometer relative to gravity, is used to measure the beginning (A) and end (B) of lumbar flexion ROM. (From Norkin and White,34, p. 387 with permission.)
Measurement of the beginning (A) and end (B) of shoulder flexion ROM with a universal goniometer. The universal goniometer is moving from 0° toward 180° during the motion. (From Norkin and White,34, p. 63 with permission.)
Using the most common notation system, the 0° to 180° system, all motions except rotation begin in anatomical position at 0° and progress toward 180°. For example, a motion that begins at 0° and ends at 135° would be recorded as 0°–135°. A ROM that does not start with 0° or ends prematurely indicates joint hypomobility. Joint hypermobility at the beginning of the range is noted by the inclusion of a zero (the normal starting position) between the starting and ending measurements. For example, if the elbow joint has 5° of hypermobility in extension and 140° of flexion, it would be recorded as 5°–0°–140°. Hypermobility at the end of the ROM is denoted by an ending value higher than normal. Measurement results are incorporated into narrative reports or recorded on specialized forms. Specialized ROM recording forms typically have joints and motions listed centrally, with multiple columns on the left and right sides to record the date, examiner's initials, and ROM values of serial measurements (Fig. 4.13). These forms readily allow comparison of serial measurements to assess patient progress. Norkin and White,34 Clarkson,57 and Reese and Bandy58 provide detailed descriptions of goniometric measurement procedures.
Range of motion recording form for the lower extremity. The multiple columns on either side of the centrally listed joints and motions are used to record the date, examiner's initials, and ROM values from serial measurements. (From Norkin and White,34 with permission.)
ROM measurements taken with a universal goniometer of the extremity joints generally have good to excellent reliability. Reliability does vary depending on the joint and motion being measured. Reliability studies that include ROM measurements of elbow motions with a universal goniometer are presented in Box 4.1 Evidence Summary. ROM measurements of UE joints have been found to be more reliable than measurements of the LE46,60,66 and spine.67,68,69 In an often cited study, Boone et al60 found the average standard deviation between measurements made on the same subjects by different testers to be 4.2° for UE motions and 5.2° for LE motions. These differences in reliability have been attributed to difficulties in measuring complex as compared to simple hinged joints, in palpating bony landmarks, and in moving heavy body parts.60,70 The use of standardized positions, stabilization of the body part proximal to the joint being tested, use of bony landmarks to align the goniometer, and repeated testing conducted by the same therapist (rather than multiple therapists) all help to improve the validity and reliability of goniometric measurements.46,56,71
Box 4.1 Evidence Summary Outcome Studies on Reliability of Using Universal Goniometer to Measure Elbow Range of Motion
|Reference ||Subjects ||Design/Intervention/Duration ||Results ||Comments |
|Hellebrandt et al,591949 ||77 patients || |
Repeated measures design AROM
1 highly experienced PT tester
8 average experienced PT testers
2 trials by same tester, time between trials not defined
|Highly experienced tester had mean difference between trials of 1.0° for flexion and 0.1° for extension. Sig difference between trials for flexion ||High intratester reliability. Sig difference not clinically important. No data on elbow motions for averageexperienced testers |
|Boone et al,60 1978 ||12 healthy males 26-54 years || |
Repeated measures design AROM
4 PT testers with 5-20 years of experience
3 trials by each tester in one session
1 weekly session for 4 weeks (4 sessions total)
|No sig difference between 3 trials by each tester in one session so session means used in intra- and intertester calculations. Sig difference between testers lntratester r = 0.94 SD = 0.2° Intertester r = 0.88 SD = 2.6° ||High intra- and intertester reliability. Intratester reliability higher than intertester reliability |
|Rothstein et al,46 1983 ||12 patients had elbow measured || |
Repeated measures design, blinded PROM; method not standardized.
12 PT testers with 1-4 years experience
3 types of universal goniometer: large metal, large plastic, small plastic 2 trials per goniometer per tester
2 testers evaluated each patient.
r = .95 - .99
ICC = .86. - .99
r = .89 - .97
ICC = .85 - .95
Mean of 2 trials:
r = .94 - .97
ICC = .89 - .96
|High intra- and intertester reliability. Intratester reliability slightly higher than intertester reliability. Minimal improvement in intertester reliability by using mean of 2 trials versus score from single trial (differences inlCCno. 0.12) |
|Grohmann,61 1983 ||1 healthy adult || |
Repeated measures design, blinded
Elbow held in 2 fixed positions: 1 obtuse and 1 acute angle.
40 PT student testers used over-the-joint and lateral methods to measure each position
1 trial daily for 4 days
|No sig difference between methods ||No difference in using over-the-joint method or lateral method of measuring elbow position |
|Walker et al,43 1984 ||4 healthy adults, 60 years || |
Repeated measures design, blinded.
Each tester performed
5 trials on each subject in one day.
|Intratester reliability r = 81 ||High intratester reliability |
|Fish and Wingate,62 1985 ||1 healthy adult || |
Repeated measures design, blinded
46 PT student testers measured with 2 instruments: plastic and steel goniometers
3 conditions: ALIGN = elbow in fixed position with landmarks noted, ASSIGN = elbow in fixed position with no landmarks, PROM = full range of passive flexion
|ALIGN plastic SD = 1.8° - 2.1° ALIGN steel SD = 2.0° - 2.6° ASSIGN plastic SD = 2.5° - 3.0° ASSIGN steel SD = 2.5° - 3.4° PROM plastic SD = 3.4° - 3.8° PROM steel SD = 3.9° - 4.2° ||Variability of scores increased as standardization of measurements decreased |
|Greene and Wolf,64 1989 ||20 healthy adults (10 males, 10 females) 18-55 years || |
Repeated measures design. AROM
1 PT tester
2 instruments: universal goniometer and pendulum goniometer
3 trials per instrument in a session
3 sessions within 2 weeks
Universal goniometer within-sessions:
Flexion: ICC = .94; SD = 1.2°; 95% CI = 3.0°; Extension: ICC = .95; SD = 1.0°; 95% CI = 1.9°; Both instruments had sig difference between sessions. Low correlation (r = .11 - .21) and sig difference between instruments within-sessions
High intratester reliability with universal goniometer in one session.
95% of time reliability within 2–3° if taken by same tester in one session.
Different instruments should not be used interchangeably.
|Goodwin et al,63 1992 ||23 healthy females, 18–31 years || |
Repeated measures design.
3 experienced testers.
3 instruments: universal goniometer, fluid goniometer, electrogoniometer.
Landmarks noted on skin.
3 trials per instrument by each tester in a session.
2 sessions 4 weeks apart.
|Universal goniometer intra-tester reliability between sessions: r = .61 - .92 ICC = .56 - .91. Difference in means between sessions = 0.9°; Average difference in means between testers = 5.1°; Sig differences and interactions between goniometers, testers, and sessions || |
Moderate to high intra-tester reliability between 2 sessions 4 weeks apart, depending on tester.
Differences between sessions smaller than differences between testers.
Different instruments should not be used interchangeably.
|Armstrong et al,65 1998 ||38 patients with history of surgery for upper extremity injury. 19 males, 19 females 14–72 years || |
Repeated measures design.
5 testers of varying experience.
2 instruments: universal goniometer and electrogoniometer.
2 trials per instrument by each tester on same day
|Universal goniometer: Intratester reliability for flexion: ICC = .55 - .98, mean difference between trials = 3.2°; 95% CI = 5.9° Extension: ICC = .45 - .98, mean difference = 3.5°; 95% CI = 6.6° Intertester reliability for flexion: ICC = .58 - .62, mean difference = 6.4°; 95% CI = 9.2°; Extension: ICC = .58 - .87, mean difference = 7.0°; 95% CI = 8.9° || |
Moderate to high intra-tester reliability. Moderate intertester reliability.
95% of time reliability within 6.7° if taken by same tester, and 9° if taken by different testers.
The end of each motion at each joint is limited from further movement by particular anatomical structures. The type of structure that limits a joint motion has a characteristic feel, which may be detected by the therapist performing the passive ROM. This feeling, which is experienced by the therapist as resistance, or a barrier to further motion, is called the end-feel. Cyriax and Cyriax,54 Kaltenborn,72 and Paris73 have described a variety of normal (physiological) and abnormal (pathological) end-feels. A summary of the types of end-feels has been adapted from the work of these authors. Normal end-feels are generally described as soft, firm, or hard (Table 4.1). A soft end-feel has a gradual increase in resistance as muscle, skin, and subcutaneous tissues are compressed between body parts.74 A firm end-feel has a more abrupt increase in resistance as compared to a soft end-feel. Firm end-feels include varying amounts of creep, or give, depending on whether the barrier to the end of the motion is the stretching of muscle, capsule, or ligamentous tissue. The firm end-feel with the most creep would be the rubbery resistance offered by the stretch of muscle tissue, and the least amount of creep would be provided by the stretch of ligamentous tissue. The firm end-feel created by the stretch of a joint capsule usually has a moderate amount of creep. A hard end-feel is abrupt; there is an immediate stop to movement as when bone contacts bone.
Table 4.1Normal End-Feels ||Download (.pdf) Table 4.1 Normal End-Feels
|End-Feel ||Structure ||Example |
|Soft ||Soft tissue approximation ||Knee flexion (contact between soft tissue of posterior leg and posterior thigh) |
|Firm ||Muscular stretch ||Hip flexion with the knee straight (passive elastic tension of hamstring muscles |
| ||Capsular stretch ||Extension of metacarpophalangeal joints of fingers (tension in the anterior capsule) |
| ||Ligamentous stretch ||Forearm supination (tension in the palmar radioulnar ligament of the inferior radioulnar joint, interosseous membrane, oblique cord) |
|Hard ||Bone contacting bone ||Elbow extension (contact between the olecranon process of the ulna and the olecranon fossa of the humérus) |
End-feels are considered to be abnormal when they occur sooner or later in the ROM than is typical, or if they are not the type of end-feel that is normally found for that joint motion. Abnormal end-feels have been associated with more pain than normal end-feels.75 Many abnormal, pathological end-feels have been described, but most can be categorized as variations of soft, firm, and hard end-feels (Table 4.2). An abnormal end-feel that cannot be categorized as soft, firm, or hard, is an empty end-feel. This term describes the inability of the therapist to detect any anatomical barrier to the end of the ROM. Rather, the patient through verbal or nonverbal cues indicates that no further motion should occur, usually because of pain.
Table 4.2Abnormal End-Feels ||Download (.pdf) Table 4.2 Abnormal End-Feels
|End-Feel || ||Examples |
|Soft ||Occurs sooner or later in the ROM than is usual, or in a joint that normally has a firm or hard end. Feels boggy, with fluid shift. ||Soft tissue edema Synovitis |
|Firm ||Occurs sooner or later in the ROM than is usual, or in a joint that normally has a soft or hard end. ||Increased muscular tonus Capsular, muscular, ligamentous shortening |
|Hard || |
Occurs sooner or later in the ROM than is usual, or in a joint that normally has a soft or firm end.
A grating or bony block is felt.
Loose bodies in joint
|Empty || |
No real end because pain prevents reaching end of ROM.
No resistance is felt except for patient's protective muscle splinting or muscle spasm.
Acute joint inflammation
The ability to determine the type of end-feel is important in helping the therapist identify the limiting structures and choose a focused and effective treatment. Developing this ability takes practice and sensitivity. Passive ROM, particularly toward the end of the motion, must be performed slowly and carefully. Secure stabilization of the bone proximal to the joint being tested is critical in preventing multiple joints and structures from moving and interfering with determination of the end-feel.76,77
Capsular Patterns of Restricted Motion
Cyriax and Cyriax54 initially described characteristic patterns of restricted joint ROM due to diffuse, intra-articular inflammation involving the entire joint capsule. These patterns of restricted motion, which usually involve multiple motions at a joint, are called capsular patterns. The restrictions do not involve the loss of a fixed number of degrees, but rather the loss of a proportion of one motion relative to another. Capsular patterns vary from joint to joint. Table 4.3 presents common capsular patterns as described by Cyriax and Cyriax54 and Kaltenborn.72 Although therapists have been using capsular patterns in clinical decision making for many years, studies are needed to test the hypotheses regarding the cause of capsular patterns and to determine the capsular pattern for each joint.78,79
Table 4.3Capsular Patterns of Extremity Joints ||Download (.pdf) Table 4.3 Capsular Patterns of Extremity Joints
|Shoulder (glenohumeral joint) || |
Maximum loss of external rotation
Moderate loss of abduction
Minimum loss of internal rotation
|Elbow complex ||Flexion loss is greater than extension loss |
|Forearm || |
Full and painless
Equally restricted in pronation and supination in presence of elbow restrictions
|Wrist ||Equal restrictions in flexion and extension |
Carpometacarpal joint 1
Carpometacarpal joints ll-V
Abduction and extension restriction
Equally restricted in all directions
|Upper extremity digits ||Flexion loss is greater than extension loss |
|Hip || |
Maximum loss of internal rotation, flexion, abduction
Minimal loss of extension
|Knee (tibiofemoral joint) ||Flexion loss is greater than extension loss |
|Ankle (talocrural joint) ||Plantarflexion loss is greater than extension loss |
|Subtalar joint ||Restricted varus motion |
|Midtarsal joint ||Restricted dorsiflexion, plantarflexion, abduction, and medial rotation |
Lower extremity digits
Metatarsalphalangeal joint 1
Metatarsalphalangeal joints II-V
Extension loss is greater than flexion
Variable, tend toward flexion restriction
Tend toward extension restriction
Hertling and Kessler,1 expanding on Cyriax's work, have suggested that capsular patterns are due to one of two general situations: (1) joint effusion or synovial inflammation or (2) relative capsular fibrosis. Joint effusion or synovial inflammation results in a capsular pattern of limitation by distending the entire joint capsule, causing the joint to maintain a position that allows the greatest intra-articular volume. Pain triggered by stretching the capsule, and muscle spasms that protect the capsule from further stretch, inhibit movement and cause a capsular pattern of restricted motion. The other general situation that causes capsular patterns is relative capsular fibrosis, seen in the resolution of acute capsular inflammation, chronic low-grade capsular inflammation, and immobilization of a joint. These conditions cause a decrease in the extensibility of the entire capsule owing to an increase in collagen content of the capsule relative to the mucopolysaccharide content, or from internal changes in the collagen tissue.
To plan an effective treatment, the therapist must determine whether the capsular pattern is caused by joint effusion/synovial inflammation or capsular fibrosis. If joint effusion or synovial inflammation is present, treatment methods typically focus on resolving the acute inflammation with rest, cold modalities, compression, elevation, joint mobilization using grade 1 sustained and grade 1 and 2 oscillations, gentle ROM exercise, and anti-inflammatory medications. Capsular fibrosis, a more chronic condition, can be treated with heat modalities, joint mobilization using grade 3 sustained stretch and grade 3 and 4 oscillations, passive stretching procedures, and more vigorous ROM exercises. Patient history, observation, palpation, and careful determination of end-feels will help establish the cause of the capsular pattern.
Noncapsular Patterns of Restricted Motion
Restricted passive ROM that is not proportioned similarly to a capsular pattern is called a noncapsular pattern of restricted motion.1,54 Noncapsular patterns usually involve only one or two motions of a joint, in contrast to capsular patterns, which involve all or most motions of a joint. Noncapsular patterns are caused by conditions involving structures other than the entire joint capsule. Internal joint derangement, adhesion of a part of a joint capsule, and extracapsular lesions such as ligament shortness, muscle strain, and muscle shortness are examples of conditions that can result in noncapsular patterns. For example, shortness of the iliopsoas muscle will result in the noncapsular pattern of limited passive hip extension; the passive range of other hip motions will not be affected. This is in contrast to the capsular pattern of the hip caused by diffuse joint effusion or capsular fibrosis, in which there is loss of passive internal rotation, flexion, and abduction.
The sole recognition of a noncapsular pattern is not enough to direct appropriate treatment. Information gained from the patient history, observation, palpation, active and passive ROM, end-feels, resisted isometric muscle tests, joint mobility tests, and special tests must be integrated to determine the most likely cause of the noncapsular pattern. For example, both chronic shortness and acute strain of the iliopsoas muscle may result in a noncapsular pattern of limited passive hip extension. However, those conditions will present differently in terms of patient history, pain during active and passive ROM, end-feel, and resisted isometric muscle tests, and will require different treatment approaches.
If passive ROM is found to be limited or painful, an examination of arthrokinematic motions in indicated. Arthrokinematics refers to the motion of joint surfaces. These motions, often called accessory or joint play motions, are used to determine joint mobility and integrity. Accessory joint motions are typically described as slides (or glides), spins, and rolls. A glide (slide) is a linear motion of one surface sliding over another (Fig. 4.14). A roll is a rotary motion similar to the bottom of a rocking chair rolling over the floor or a tire rolling over a road (Fig. 4.15). A spin is a rotary motion around a fixed point or axis (Fig. 4.16).
A glide (slide) is a type of linear accessory joint motion in which points on a moving joint surface comes in contact with new points on the opposing joint surface. (From Norkin and White,34 with permission.)
During a roll, new points on the moving joint surface come in contact with new points on the opposing surface. The axis of rotation also moves, in this case to the right. (From Norkin and White,34 with permission.)
A spin is an accessory joint motion in which all the points on the moving surface rotate around a fixed axis. (From Norkin and White,34, p. 4 with permission.)
Accessory motions usually occur in combination with each other and result in angular movement of the bone shaft, or osteokinematic motion. Kaltenborn72 refers to the combination of translatory glide and the rotary motion of rolling as roll-gliding. The combination of a roll and glide allows for increased ROM by postponing the joint compression and separation that would occur at either side of the joint during a pure rolling motion. The direction of the rolling and gliding components of roll-gliding depends on whether a concave or convex joint surface is moving. If a concave joint surface is moving, the gliding component occurs in the same direction as the rolling or angular movement of the shaft of the bone (Fig. 4.17). For example, during flexion of the knee with the femur fixed, the shaft of the tibia rolls posteriorly while the joint surface of the tibia also glides posteriorly. If a convex joint surface is moving, the gliding component occurs in the direction opposite to the rolling or angular movement of the shaft of the bone. As an example, during abduction of the glenohumeral joint, the shaft and humeral head roll cranially, while the contacting articular surface of the humeral head glides caudally. In the human body, roll-gliding is by far the most frequently occurring arthrokinematic motion, although there are several instances of pure spin motions. An example of a spin joint motion would be supination and pronation of the radius at the humeroradial joint.
Diagrammatic representation of the concave-convex rule. (A) If the joint surface of the moving bone is convex, gliding is in the opposite direction of the angular movement of the bone. (B) If the joint surface of the moving bone is concave, gliding is in the same direction as the angular movement of the bone. (From Norkin and White,34, p. 5 with permission.)
Normal arthrokinematic (accessory) motions are necessary for full and symptom-free osteokinematic motions. The careful examination of accessory motions helps to more specifically locate and treat the source of impaired osteokinematic motions. The patient cannot perform accessory motions actively because these motions are not under voluntary control. Rather, the therapist tests them passively. The accessory motions most commonly tested are translatory motions: glides that are parallel to the joint surfaces, and distractions and compressions that are perpendicular to the joint surfaces. Kaltenborn,72 Kisner and Colby,80 Edmund,81 and Hertling and Kessler1 describe specific testing and treatment techniques that focus on accessory motions—usually under the topic of joint mobilization. Careful attention must be given to general patient positioning, specific joint positioning, relaxation of surrounding muscles, stabilization of one joint surface, and mobilization of the other joint surface.
Accessory joint motions are examined for amount of motion, effect on symptoms, and end-feel. The ranges of accessory motions are very small and cannot be measured with goniometers or standard rulers. Rather, they are typically compared to the same motion on the contralateral side of the patient's body, or compared to the therapist's past experience in testing people of similar age and gender as the patient. Accessory motions are assigned a joint play mobility grade of 0 to 6.72 These mobility grades have implications for treatment (Table 4.4).1,81
Table 4.4Accessory Joint Motion Grades and Implications for Treatment ||Download (.pdf) Table 4.4 Accessory Joint Motion Grades and Implications for Treatment
|Grade ||Joint Status ||Implications for Treatment |
|0 ||Ankylosed ||Joint mobilization is not indicated; surgery should be considered. |
|1 ||Considerable hypomobility ||Grades 1 and 2: Joint mobilization to increase the extensibility of joint structures is indicated. Heat modalities before mobilization and ROM exercises after mobilization should be considered. |
|2 ||Slight hypomobility || |
|3 ||Normal ||Joint mobilization is not needed, because findings are normal. |
|4 ||Slight hypermobility ||Grades 4 and 5: Joint mobilization to increase joint extensibility is not indicated. Taping, bracing, strengthening exercises, and education regarding posture and positions to be avoided should be considered. |
|5 ||Considerable hypermobility || |
|6 ||Unstable ||Joint mobilization is not indicated; surgery should be considered. |
The testing accessory motions put stress on specific anatomical structures. A change in symptoms during the performance of an accessory motion helps to implicate particular structures. Distraction stresses the entire joint capsule and numerous ligaments surrounding and supporting the joint. Glides stress a specific part of the joint capsule and particular ligaments, depending on the direction of the glide and joint. Compression applies force to intracapsular structures such as meniscus, bone, cartilage, and projections of the synovial lining of the joint capsule into the joint space. Accessory motions are of such a small magnitude that they do not stress surrounding muscles. Angular changes in joint position that typically occur during osteokinematic ROM movements more effectively change the length of muscle tissue. Normal and abnormal end-feels noted during passive accessory motions are characterized as soft, firm, and hard. Similar to end-feels noted during passive osteokinematic motions, they help determine the limiting structures and guide treatment planning.
Muscle performance is the ability of a muscle to do work.6 Linear work is defined as force multiplied by distance, and rotational work is defined as torque (force multiplied by perpendicular distance from the axis of rotation) multiplied by arc of movement. Usually during a musculoskeletal examination, a component of muscle performance—muscle strength—is tested. Muscle strength, as described in the Guide to Physical Therapist Practice,6 is the force exerted by a muscle or group of muscles to overcome a resistance in one maximal effort. Clinical methods of determining muscle strength include manual muscle testing (MMT), handheld dynamometry, and isokinetic dynamometry. Depending on the patient, other characteristics related to muscle performance may also be tested. Muscle power is work produced per unit of time, or the product of strength and speed. Muscle endurance is the ability of the muscle to contract repeatedly over time. In addition to these quantitative measures, the patient's qualitative response in terms of changes in pain during resisted isometric testing is important in identifying musculotendinous lesions.
Resisted Isometric Testing
During the performance of active and passive ROM testing, a patient may complain of pain. The patient history, location of pain, and the pattern of painful motions may suggest a lesion in contractile tissues such as muscle or tendons and their insertions into bone, or involvement of inert tissues such as the joint surfaces, joint capsule, or ligaments. Resisted isometric testing can be used to further clarify which type of tissue, contractile or inert, is involved. Increased pain during a resisted isometric contraction, caused by shortening of the muscle and pulling on the tendon, helps to confirm the involvement of contractile tissues. Sometimes more pain is felt when the contraction is released and lengthening occurs; this would still be considered a positive finding for a lesion in contractile tissues. The lack of pain during resisted isometric testing, pain noted with limited accessory joint motions, a capsular pattern of joint restriction, or particular end-feels during PROM and accessory joint motions help to confirm the involvement of inert tissues. For example, bicipital tendinitis would be painful during resisted isometric testing of elbow flexion and shoulder flexion. An adhesive capsulitis of the glenohumeral joint would be painless during these same resisted isometric maneuvers.
Resisted isometric testing must be performed carefully to stress particular contractile tissue while avoiding stress to surrounding inert tissue. The therapist should place the patient's joint in a position midway through the ROM, so that minimal tension is put on inert structures. The body part proximal to the joint being tested must be well stabilized by the therapist to minimize extraneous muscle substitutions. The patient is then asked to hold the position while the therapist gradually applies resistance. Joint movement is strictly avoided. Although some compression of articular surfaces will occur during the isometric contraction, this does not usually present a problem in interpreting the results. However, a bursa located deep to the musculotendinous tissue will also be compressed. Although bursae are not considered to be connective tissue, pain will be felt during the isometric contraction if a bursa is inflamed. Fortunately, treatment for bursitis is similar to treatment for musculotendinous strains and inflammation.
In addition to determining the absence or presence of pain during the resisted isometric testing, the therapist should also note the strength of the muscle contraction. If weakness is found, more extensive testing of muscle strength should be performed using MMT or dynamometers. Muscle weakness may be due to many causes, including pathologies involving upper motor neurons, peripheral nerves, neuromuscular junctions, muscles, and tendons. Pain, fatigue, and disuse atrophy can also cause weakness. The pattern of muscle weakness will help to identify the site of the pathology and direct treatment. The patient history and the results of sensory, coordination, motor control, cardiopulmonary, and electromyography (EMG) testing will help clarify findings as well.
Several authors1,2,54 have suggested using the results of resisted isometric testing to determine the type of pathology. The strength of the muscle contraction (strong or weak) and the presence or absence of pain (painful or painless) are used to implicate possible pathologies (Table 4.5). Franklin et al82 have suggested that a resisted isometric test finding of "weak and painful" warrants expansion to include not only serious pathologies, but also relatively minor muscle damage and inflammation such as that induced by eccentric isokinetic exercise. Intratester and intertester reliability of resisted isometric testing have been examined to determine types of pathology in the shoulder and knee.83,84
Table 4.5Results of Resisted Isometric Testing ||Download (.pdf) Table 4.5 Results of Resisted Isometric Testing
|Findings ||Possible Pathologies |
|Strong and painless ||There is no lesion or neurological deficit involving the tested muscle and tendon. |
|Strong and painful ||There is a minor lesion of the tested muscle or tendon. |
|Weak and painless ||There is a disorder of the nervous system, neuromuscular junction, a complete rupture of the tested muscle or tendon, or disuse atrophy. |
|Weak and painful ||There is a serious, painful pathology such as a fracture or neoplasm. Other possibilities include an acute inflammatory process that inhibits muscle contraction, or a partial rupture of the tested muscle or tendon. |
Manual muscle testing was developed by Wright85 and Lovett86 beginning in 1912 as a means of testing and grading muscle strength based on gravity and manually applied resistance. Over the years others have described various MMT methods, but the two methods most frequently used in the United States are those proposed by Daniels and Worthingham87 and Kendall et al.88 Both methods, based on the works by Wright and Lovett, use arc of motion, gravity, and manually applied resistance by the therapist to test and determine muscle grades. Generally, the patient is positioned so that the muscle or muscle group being tested has to move or hold against the resistance of gravity. If this is well tolerated, the therapist applies manual resistance gradually to the distal end of the body part in which the muscle inserts, and in a direction opposite to the torque produced by the muscle(s) being tested.
In recent editions, both methods recommend applying manual resistance in the form of a break test in which the patient holds a joint position until the therapist gradually overpowers the patient and an eccentric contraction begins to occur. Both methods suggest that the break test occurs at the end of the ROM when testing one-joint muscles, and at mid-range when testing two-joint muscles. In addition, many therapists apply manual resistance while the patient moves through the ROM, in what is called a make test, or an active resistance test, so that the muscle's ability to contact concentrically against maximal resistance can also be determined. In the case of weaker muscles that cannot hold or move well against gravity, the patient is repositioned and attempts to move the body part through a gravity-minimized (horizontal) plane of motion. During all testing, stabilization of the body part on which the muscle originates and careful avoidance of substitution by other muscle groups are emphasized.
Although there are many similarities, there are some differences between these two popular MMT methods. Kendall et al88 propose to examine individual muscles insofar as practical, whereas the Daniels and Worthingham method87 examines muscle groups that perform particular joint motions. Some testing positions are similar but others vary between the two methods, with Daniels and Worthingham providing more instruction and emphasis on gravity-minimized positioning for weaker muscle groups. Daniels and Worthingham recommend that the patient move through the arc of motion when testing both against gravity and with gravity minimized. Kendall et al have the patient move through an arc of motion only when testing with gravity minimized; otherwise the patient is positioned against gravity at the middle or end of the ROM and asked to hold the position.
Both methods use a grading system based on the work of Lovett with categories of Normal, Good, Fair, Poor, Trace, and Zero. However, Kendall et al suggest a 0% to 100% or a 0 to 10 scale; Daniels and Worthingham suggest a 0 to 5 scale (Table 4.6). If numerical scoring is used, it is important to clarify which scale is being used by following the score with a slash indicating the maximal value of the scale. For example, a grade of Fair strength should be noted as 3/5 if using a 0 to 5 scale, or 5/10 if using a 0 to 10 scale. Results can be noted in a narrative report or on standardized recording forms (Fig. 4.18).
Table 4.6Manual Muscle Testing Grades ||Download (.pdf) Table 4.6 Manual Muscle Testing Grades
|Grades ||Grade Abbreviations ||0-5 Scale ||0-10 Scale ||Criteria |
|Normal ||N ||5 ||10 ||Full available ROM, against gravity, strong manual resistance |
|Good plus ||G+ ||4+ ||9 ||Full available ROM, against gravity, nearly strong manual resistance |
|Good ||G ||4 ||8 ||Full available ROM, against gravity, moderate manual resistance |
|Good minus ||G- ||4- ||7 ||Full available ROM, against gravity, nearly moderate manual resistance |
|Fair plus ||F+ ||3+ ||6 ||Full available ROM, against gravity, slight manual resistance |
|Fair ||F ||3 ||5 ||Full available ROM, against gravity, no resistance |
|Fair minus ||F- ||3- ||4 ||At least 50% but not full ROM, against gravity, no resistance |
|Poor plus ||P+ ||2+ ||3 ||Full available ROM, gravity minimized, slight manual resistance |
|Poor ||P ||2 ||2 ||Full available ROM, gravity minimized, no resistance |
|Poor minus ||P- ||2- ||1 ||At least 50% but not full ROM, gravity minimized, no resistance |
|Trace plus ||T+ ||1 + || ||Minimal observable motion (less than 50% ROM), gravity minimized, no resistance |
|Trace ||T ||1 ||T ||No observable motion, palpable muscle contraction, no resistance |
|Zero ||0 ||0 ||0 ||No observable or palpable muscle contraction |
An example of a manual muscle testing recording form. (From Hislop and Montgomery,87 with permission.)
It is important to note that these numerical scales indicate ordinal data, because the intervals between the numbers do not represent equal units of measure. The MMT grades of Good and Normal typically encompass a large range of muscle strength, whereas the grades of Fair, Poor, and Trace include a much narrower range. Sharrard,89 counting alpha motor neurons in spinal cords of individuals with poliomyelitis at the time of autopsy, found that muscles previously receiving a grade of Good had 50% of their innervated motor neurons, whereas muscles graded as Fair had only 15% of their motor neurons. Beasley90 noted that patients with poliomyelitis were graded as having Good, Fair, and Poor knee extension when they had on average only 43%, 9%, and 3% of the knee extension force of normal subjects, respectively. Andres et al,91 in a study of four muscle groups in patients with amyotrophic lateral sclerosis (ALS), found that the muscles were often graded as Normal until up to 50% of strength was lost.
The concurrent validity of MMT with muscle strength measured by handheld dynamometers (described in the following section) and strain gauges have been supported by many research studies. Schwartz et al92 studied 24 muscle groups in 122 patients with spinal cord injury (SCI) and noted correlation coefficients ranging from .59 to .94 between strength measured with MMT grades and handheld dynamometry. Other investigators have reported similar findings.91,93,94 However, several researchers have noted a wide range of strength values within a MMT grade and an overlap in strength values between adjacent MMT grades, especially in the grades of Good and Normal.92,94,95,96 Manual muscle testing has been shown to be less sensitive in detecting strength deficits in stronger muscles than in weaker muscles. Although more costly and time consuming than MMT, handheld dynamometry can be used to improve objectivity and sensitivity as needed. When muscles are strong enough to move against gravity and the dynamometer's lever arm, isokinetic dynamometry may also be used.
Generally, intratester reliability of MMT has been found to be good among trained therapists using established methods, with correlation coefficients ranging from .63 to .98.96,97,98 The results of studies on intertester reliability of MMT vary more widely. Several investigators98,99,100,101,102 report complete agreement in MMT grades between testers who examined the same patient to be the lowest, ranging from 28% to 75%. Using a 0–5 scale, agreement between testers within a half grade (plus or minus) was better, ranging from 50% to 97%. Using a 0–10 scale, agreement between testers within plus or minus one full grade was high, ranging from 89% to 100%. Correlation coefficients for intertester reliability ranged from .11 to .94.92,98,99,103 Training to standardize testing positions, stabilization, and grading criteria resulted in higher agreement and correlation coefficients between testers. Global strength scores that average MMT results from multiple muscle groups also resulted in higher reliability.98,103
Grade definitions modified from Kendall et al88 and Daniels and Worthingham87 are presented in Table 4.6 with additional criteria as to the amount of motion completed by the patient to delineate the grades of Fair minus, Poor minus, and Trace plus. The grades Fair plus through Normal depend on the therapist's interpretation of what is minimal, moderate, and maximal resistance. A Normal grade is typically equated with the normal strength for that muscle given the patient's age, gender, and body size. It should be noted that there is considerable variability in the amount of resistance that Normal muscles can be expected to hold against. For example, large muscles in the LE will normally hold against considerable force and be difficult to overpower during a break test, while small muscles of the hand will normally hold against less force and be easily overpowered during a break test. The application of resistance throughout the arc of motion (make test or active resistance test) in addition to resistance at only one point in the arc of motion (break test) may help in accurately judging a muscle's strength.
Handheld dynamometers (HHDs) are portable devices, placed between the therapist's hand and the patient's body, that measure mechanical force at the point of application (Fig. 4.19). Patients are typically asked to push against resistance in a maximal isometric contraction (make test), or hold a position until the resistance overpowers the muscle producing an eccentric contraction (break test). The force measured by the dynamometer will vary depending on the method of applying the resistance (make or break test), the patient's body position in relationship to gravity, joint angle, dynamometer placement on the patient (lever arm), stabilization to prevent muscle substitution, and the therapist's strength.104,105,106 Although force values determined with make and break tests are highly correlated, break tests usually result in greater force values than make tests,107,108 so they should not be used interchangeably.
To reduce the effect of moving a body segment's weight on force measurements, it is recommended that muscle groups be tested in gravity-minimized positions. For example, to test the strength of the hip abductors the patient would be positioned supine so that the muscle action would pull in a horizontal plane relative to the ground (see Fig. 4.19). Soderberg106 provides detailed information on recommended positions and procedures for HHD. The joint should also be positioned at an easily reproducible angle so that muscle length remains constant. The dynamometer is applied perpendicular to the body segment at an established location on the patient's body. When muscles contract they produce torque that creates angular joint motion. The therapist must apply sufficient resistance to oppose the patient's torque to ensure an isometric (make test), or an eccentric contraction (break test). To provide greater resistance than what can be achieved manually, the dynamometer can be attached to a fixed surface109,110 or an isokinetic dynamometer can be used with the speed set to 0°/sec.
Measurement of the strength of the left hip abductors with a handheld dynamometer. The handheld dynamometer measures force at the point of application, which should be converted to torque by multiplying the force by the distance from the joint axis.
Normative force values for particular muscle groups by age and gender have been reported;111,112,113,114,115 however, attention must be directed to replicating methods used in the normative studies to ensure appropriate comparisons. Some authors have also included regression equations to take into account body weight and height.111,112 Most normative studies have reported results in units of force such as pounds, newtons, or kilogram-force. However, these force values will vary depending on the length between the dynamometer's location on the patient's body to the joint axis of motion, or lever arm. A better method of comparison across people would be to use torque.105,115,116 To determine torque, the measured force is multiplied by the distance between the dynamometer's location and the joint axis. Examples of units of torque are foot-pounds, newton-meters, or kilogram-force (kgf) meters.
For patients with unilateral conditions, it may be helpful to compare results to that of the uninvolved extremity. Andrews et al112 found no statistically significant difference in force between the dominant and nondominant LEs using a HHD, but did find a difference between the dominant and nondominant UEs. In general, differences were between 0 and 4.5 pounds or between 0% and 11.2% of the average forces generated. Phillips et al111 found statistically significant differences in force between sides in a variety of upper and LE muscle groups ranging from 0.2% to 8.0%. Sapega117 has recommended that a difference in muscle force between sides of greater than 20% probably indicates abnormality, while a difference of 10% to 20% possibly indicates abnormality.
Muscle forces measured with HHD have been compared to forces measured with isokinetic dynamometers to evaluate concurrent validity. Most studies have found good to excellent validity with correlation coefficients ranging from .78 to .98.118,119,120 Several investigators have reported that HHD underestimates strength in large muscle groups such as the knee extensors,121,122 or when forces are greater than 196 to 250 newtons.118,123
Depending on the study, HHDs have demonstrated good to excellent intratester reliability, and poor to excellent intertester reliability.107,122,124,125,126,127,128,129,130 Several reviews of such reliability studies are available.106,131,132 Reliability seems to be better when testing the UEs than when testing the LEs and trunk,125,127 in particular, the measurements of ankle dorsiflexion and hip abduction.111,112,122,125 Agre et al124 found the standard deviation of the repeated measurements expressed as a percentage of the mean force measurements (coefficient of variation of replication) to be 5.1% to 8.3% for the UE muscle groups, and 11.3% to 17.8% for the LE muscle groups. Wang et al128 reported coefficient of variation of replication ranging from 4.2% to 7.4% for three LE muscle groups. Researchers believe some of the error in using HHDs is due to off-center loading of the dynamometer, difficulties in positioning and stabilization, and limitations in the strength and experience of the examiners.
Isokinetic dynamometers are stationary, electromechanical devices that control the velocity of a moving body segment by resisting and measuring the patient's effort so that the body segment cannot accelerate beyond the preset angular velocity (Fig. 4.20). For example, the velocity of a Cybex Humac Norm (Computer Sports Medicine, Inc., Stoughton, MA 02071) isokinetic dynamometer can be set from 0° to 500°/sec; the resistance, measured in torque, can be monitored up to 500 ft-lb, or 680 newton-meters.133 Speeds of 60°, 120°, and 180°/sec are commonly tested in relatively sedentary patients, whereas faster speeds may be warranted in trained individuals. Isokinetic dynamometers can be used to measure the torque produced during isometric (if the velocity is set to 0°/sec), concentric, and eccentric contractions. Isokinetic dynamometers, although expensive and cumbersome, are especially helpful in examining the performance of large, strong muscle groups. In such situations, MMT and HHDs are often insensitive to muscle performance abnormalities.90,105 Muscle groups acting at the knee, shoulder, back, and to a lesser extent the elbow and ankle are those most frequently tested with isokinetic devices.
An isokinetic dynamometer is being used to measure muscle performance characteristics of the right knee extensors (quadriceps). Peak torque is the most frequently noted characteristic. (Courtesy of Biodex Medical Systems, Inc., Shirley, NY 11967.)
Isokinetic dynamometers measure torque and ROM as a function of time. Muscle performance characteristics most often noted are peak (maximal) torque, and less frequently peak torque/body weight (Nm/kg), and average torque. Work measurements can be derived from the angular displacement and torque values. Power, which is work per unit time, also can be determined. Endurance (muscle fatigue) can be assessed by measuring the time required for peak torque to decrease by 50%.117 Other approaches to examining endurance include determining: the sum of work performed for 25 repetitions of a motion; and a ratio of the work performed in the last 5 repetitions divided by the work performed in the first 5 repetitions.134,135
Peak torque ratios of reciprocal (agonist-antagonist) muscle groups such as the hamstrings/quadriceps and external/internal rotators of the shoulder have been documented. However, careful corrections for the weight of the limb (gravity effects) are necessary to arrive at an accurate relationship.136,137,138,139 If gravity corrections are not utilized, the muscles assisted by gravity will exhibit erroneously high torque values, whereas the muscles that resist gravity will exhibit erroneously low torque values.
It has been suggested that submaximal patient effort can be detected by the increased variability of repeated measures of peak torque, average torque, and slope to peak torque in isometric and concentric contractions.140,141,142 However, research in this area has produced conflicting findings and demonstrated large errors in classifying effort into maximal and submaximal categories.138,143,144,145 Many factors such as patient pain, fear, or fatigue, and damp settings, preload forces, mechanical artifact, and acceleration and deceleration ramping can affect the variability of torque measurements. The use of isokinetic dynamometer records to form clinical opinions of patient effort is not advised.
To ensure the validity of isokinetic dynamometry measurements, calibration of the equipment is necessary and should be performed each day of testing, at the same speed and damp setting to be used during testing.138 Proper alignment of joint axis and machine axis, stabilization of proximal body parts, and gravity correction are needed. Several practice trials of the motion to acquaint the patient with the equipment and testing protocol is helpful, and at least one to three maximal test repetitions should be performed before recording measurements.146,147 It is important to note that torque values will vary with type of muscle contractions (isometric, concentric, eccentric) and changes in velocity settings, joint angle, patient position, test trials, rest intervals, patient feedback, and preload, damp, and ramping machine settings. For example, isometric contractions will result in higher torque values than concentric contractions in the same muscle group, whereas eccentric contractions will result in higher torque values than isometric contractions. Faster velocity settings during concentric contractions will result in lower torque values than slower velocity settings. All of these factors must be kept constant in order to effectively use repeat testing data to judge patient progress. Keating and Matyas,148 Rothstein et al,138 Davies et al,149 and Gaines and Talbot150 have presented information to improve the validity and reliability of isokinetic testing. Peak torque and work measurements in a variety of healthy and patient populations have shown good to excellent reliability for concentric contractions, and poor to good reliability for eccentric contractions.146,151,152,153,154,155,156,157,158,159,160,161 Recip rocal (agonist–antagonist) ratios have shown less reliability than peak torque measurements.161
Normative data on adults161,162,163,164,165,166,167,168 and children169,170,171,172,173,174 can provide a reference for evaluating and interpreting patient data. However, comparisons with published data are appropriate only when identical procedures and equipment are used, and tested populations are similar. Patient age, gender, weight, height, and athletic participation can affect recorded values. Out of necessity, the involved extremity is often compared to the contralateral extremity. Generally, studies have found no statistically significant difference between dominant and nondominant sides in torque measurements for muscles surrounding the knee joint,165,169,175,176,177 elbow,170,174 and shoulder.170,178 Alternatively, some studies have found differences due to side dominance for certain motions at the elbow and shoulder especially in highly skilled male athletes.174,179,180,181,182 A difference of at least 10% in torque values between opposing sides of the body has been suggested as an indicator of impairment.183,184 Others have noted imbalances of more than 10% between sides of the body in healthy populations. Further research is needed to establish the magnitude of difference between opposite limbs that would indicate impairment. At the present time it seems appropriate to use the guidelines provided by Sapega,117 suggesting that a difference in muscle force between sides of greater than 20% probably indicates abnormality, whereas a difference of 10% to 20% possibly indicates abnormality.
After completing the patient interview, observation, palpation, and examination of ROM, accessory motions, and muscle performance, the therapist may suspect the nature of the pathology. Special tests, designed to focus on specific conditions in a particular region of the body, may be helpful in confirming the diagnosis. A therapist would ordinarily choose to perform only those tests indicated by previous findings that are relevant to the area of the body being examined. False-positive and false-negative results are possible. However, a positive test finding in conjunction with other aspects of the examination would be highly suggestive of pathology. There are many special tests presented in the work of Hoppenfeld,3 Magee,2 Starky et al,5 and Konin et al.185
One category of special tests is used to determine the integrity of ligaments in supporting a joint. The therapist performs these ligamentous instability tests, also called ligament stress tests, on a relaxed, passive joint. These maneuvers are often similar to tests of accessory or joint play motions. Although these tests focus on ligament integrity, capsular integrity as well as dynamic muscle support may influence the results. If possible, results should be compared with those from the uninvolved, contralateral joint. The amount of laxity is usually graded from I to IV (Table 4.7).186 Examples of ligamentous instability tests include the Lachman test, which examines injury to the anterior cruciate ligament; the posterior drawer test, which examines damage to the posterior cruciate ligament of the knee; and the varus and valgus stress tests, which examine the integrity of collateral ligaments at the elbow and knee.2,3
Table 4.7Grading of Ligamentous Instability Tests ||Download (.pdf) Table 4.7 Grading of Ligamentous Instability Tests
|Grades ||Amount of Movement |
|I ||0-5 mm |
|II ||6-10 mm |
|III ||11-15 mm |
|IV ||>15 mm |
In addition to ligament instability tests, there are more general tests that examine joint subluxation and dislocation. These tests are often called apprehension tests because the patient is placed in a vulnerable joint position while being monitored for apprehension. For example, to test for a history of an anterior subluxation or dislocation of the glenohumeral joint, the shoulder is positioned in 90° of abduction and moved toward external rotation. These provocative tests are considered positive and should be stopped if they begin to elicit patient discomfort.
The length of muscles that cross and act at one joint can usually be examined in the process of testing PROM. However, some muscles cross and act at two or more joints. Some special tests examine the length of these multi-joint muscles. The Thomas test,34,88 which examines the length of one and two joint hip flexors; the Ober test,34,88 which focuses on the length of the tensor fascia lata; and the Bunnel-Littler test,3 which determines the role of the lumbricles, interossei, extensor digitorum, and joint capsule in limited flexion of the proximal interphalangeal joints of the hand, are examples of special muscle length tests.
Numerous special tests address common conditions affecting the integrity of muscle and tendon structures. These tests typically stretch or contract the inflamed or injured structure, resulting in pain if the tests are positive. For example, the Finkelstein test3 is used to examine inflammation of the tendons of the abductor pollicis longus and extensor pollicis brevis by stretching these structures over the wrist and thumb. The tennis elbow test3 has the patient isometrically contract the extensor carpi radialis muscles against manual resistance. Often the therapist will have previously noted pain, limitation, and possibly weakness during tests for ROM and muscle performance; special tests are used to clarify these earlier findings.
Another category of special tests reproduces the symptoms caused by irritation, compression, or restricted mobility of peripheral nerves. For example, the Tinnel test that involves manual tapping over superficial nerve sites is positive for nerve irritation and possible neuroma when pain, numbness, burning, or tingling sensations are elicited. The Phalen test for carpal tunnel syndrome places the wrist in full flexion for 60 to 90 seconds to reproduce pain and paresthesia due to compression of the median nerve by the transverse carpal ligament.2,3 Neurodynamic tests utilize sequential positioning of two or more joints to lengthen and mobilize neural tissue independent from surrounding non-neural structures.186,187,188 The ability to complete the sequence of joint positions is compared to the uninvolved side. Once symptoms are provoked, the examiner moves one of the joints out of the nerve lengthening position to determine if the symptoms are relieved and confirm the involvement of neural tissue. However, before conducting neurodynamic testing all joints in the sequence should be tested and cleared for joint and non-neural soft tissue limitations so as not to confound the results.189 An example of a neurodynamic test is the slump test which requires the sequential motions of thoracic, lumbar, and cervical spine flexion, hip flexion, ankle dorsiflexion, and knee extension to assess the mechanosensitivity of the spinal cord, cervical and lumbar nerve roots, and sciatic nerve.2,80,186 Additional neurodynamic tests have been developed to test the sciatic, femoral, obturator, and peroneal nerves in the LE, and median, radial, and ulnar nerves in the UE.2,80,186,187,189,190,191,192
In addition to palpating for the quality of arterial blood flow at the brachial, radial, femoral, popliteal, tibial, and dorsalis pedius pulses, special tests can be performed to examine the peripheral circulation of particular body regions. For example, the Allen test examines blood flow from the radial and ulnar arteries to the hand.2,3 Homan's sign utilizes ankle dorsiflexion, knee extension, and deep palpation to elicit calf pain, which would be suggestive of deep vein thrombophlebitis; however diagnostic reliability is limited.2,3
Additional Tests and Measurements
Depending on findings, other tests and measurements may be indicated. Many of these additional examination procedures are discussed in detail in other chapters of this book. For example, patient complaints of paresthesia or difficulty in muscle performance often indicate neurological involvement that calls for testing of superficial, deep, and proprioceptive sensations (see Chapter 3, Examination of Sensory Function), reflexes and motor tone (see Chapter 5, Examination of Motor Function: Motor Control and Motor Learning), and coordination and balance (see Chapter 6, Examination of Coordination and Balance). Data from these tests together with muscle performance results help to identify conditions affecting peripheral nerves, spinal nerve roots, and the CNS. Therapists must distinguish peripheral nerve versus nerve root patterns of sensory and motor innervation. Manual muscles testing textbooks, such as those by Kendall et al88 and Hislop and Montgomery,87 provide extensive information on innervation patterns. Figure 4.21 presents muscle testing recording forms that are helpful in recognizing impaired innervation patterns. Myotomes that are often included as parts of a musculoskeletal examination are shown in Table 4.8, and deep tendon reflexes are presented in Chapter 5, Examination of Motor Function: Motor Control and Motor Learning. Upper motor neuron lesions usually result in hyperreflexia, whereas lower motor neuron lesions involving the spinal nerve root or peripheral nerves usually cause hyporeflexia of deep tendon reflexes.
Manual muscle testing recording forms that aids in determining the site or level of a nerve lesion. (From Kendall et al,88 with permission.)
Table 4.8Myotomes2,3 ||Download (.pdf) Table 4.8 Myotomes2,3
|Level ||Upper Quarter Myotomes || |
| ||Action to Be Tested ||Muscle |
|C5 ||Shoulder abduction, shoulder flexion ||Deltoid |
|C5,C6 ||Elbow flexion ||Biceps |
| ||Wrist extension || |
Extensor carpi radialis longus
Extensor carpi radialis brevis
|C7 ||Elbow extension ||Triceps |
| ||Wrist flexion || |
Flexor carpi radialis
Flexor carpi ulnaris
|C8 ||Ulnar deviation ||Flexor carpi ulnaris Extensor carpi ulnaris |
|T1 ||Digit abduction/adduction ||Interossei |
|Level ||Lower Quarter Myotomes || |
| ||Action to Be Tested ||Muscle |
|L2,L3 ||Hip flexion ||lliopsoas |
|L2, L3, L4 ||Knee extension ||Quadriceps |
|L4 ||Ankle dorsiflexion ||Anterior tibialis |
|L5 ||Extension of great toe ||Extensor hallicus longus |
|SI ||Plantarflexion ||Gastrocnemius |
| ||Ankle eversion || |
Impairments in ROM, accessory joint motions, and motor performance may affect activities of daily living (ADL) and occupational and recreational activities. In such cases the examination of gait (see Chapter 7, Examination of Gait), functional abilities (see Chapter 8, Examination of Function), and environmental surroundings (see Chapter 9, Examination of the Environment) is often appropriate. Sometimes findings indicate the need for additional testing by other health professionals such as physician specialists, psychologists, speech-language pathologists, and occupational therapists.