Dr. Michael Gillespie Doctor of Chiropractic It is necessary to understand normal anatomy and healthy biomechanical relationships to accurately evaluate orthopedic and neurological conditions. Understand the relationship between structure and function. Anatomical and biomechanical variants can be present with a particular patient. Patient History Orthopedic and Inspection / observation Neurologic Testing Diagnostic Imaging Functional Testing Palpation Range of Motion Evaluate progress. Share information with other practitioners. Insurance records. Malpractice. Subjective – Patient History Objective – Observation and Testing Assessment – Based on compilation of findings Plan – Further testing and / or treatment A thorough patient history can often lead to a proper diagnosis with no further testing. Emphasize the aspect of the patient history with the greatest clinical significance. Acquire all of the patient’s history whether or not something seems relevant at the time. Keep the patient focused on the problem. Listen carefully. Do not lead the patient towards answers. Question and Answer Format. Written Forms Dialogue between patient and examiner. Identify other problems that are either directly or indirectly related to the presenting complaint. Address the patient’s fears and concerns. Develop rapport. Keep the patient focused on the presenting problem. Onset of complaint Provoking or Palliative concerns Quality of pain Radiation to particular areas Site and Severity of complaint Time frame complaint Family History Occupational History Social History General Appearance Functional Status Body Type Postural deviations Gait Muscle guarding Compensatory movements Assistant devices Skin Subcutaneous tissue Bony structure Bruising Scarring Trauma or surgery Changes in color Vascular changes of inflammation Vascular deficiency – pallor or cyanosis Pigmented areas / Hairy areas Change in texture Open wounds – traumatic or insidious Asymmetry MM lack symmetry Irregular Borders MM have notched, indented, scalloped, or indistinct borders Color Changes MM have uneven coloration, may contain several colors Diameter MM are typically greater than 6mm (0.25 in) Elevation Evaluate for inflammation and swelling Atrophy Increase in size Edema, articular effusion, muscle hypertrophy Nodules, lymph nodes, or cysts Compare b/l symmetry, utilize circumferential measurements Evaluate bony structure when gait or range of motion is altered. Evaluate the spine Scoliosis Kyphosis Lordosis Pelvic tilt Shoulder height Evaluate for congenital and traumatic bone deformities Palpate the patient in conjunction with inspection. Begin with a light touch. Dysesthesia. Hypoesthesia. Hyperesthesia. Anesthesia. Evaluate skin temperature High – inflammation Low – vascular insufficiency Adhesions Subcutaneous soft tissue – fat, fascia, tendons, muscles, ligaments, joint capsules, nerves, blood vessels. Palpate with more pressure than with skin. Palpate for tenderness and swelling or edema. Grade I - Patient complains of pain Grade II - Patient complains of pain and winces Grade III - Patient winces and withdraws the joint Grade IV – Patient will not allow palpation of the joint Immediately after injury, hard and warm Contains blood 8 to 24 hours after an injury, boggy or spongy Contains synovial fluid Tough and dry Callus Thickened and leathery Chronic swelling Soft and fluctuating Acute Hard Bone Thick and slow moving Pitting edema Palpate for pulse rate, rhythm, and amplitude Normal healthy resting pulse rate for an adult is 60 – 100 bpm Detection of alignment problems Dislocations, luxations, subluxations, fractures Identify ligaments and tendons that attach to the bones Detect bony enlargements Passive Active Resisted The examiner moves the body part without the patient’s help. Note normal, increased, or decreased movement. Note pain. Capsular or ligamentous lesion on side of movement and / or muscular lesion on side opposite of movement. 1. Normal mobility with no pain. No lesion – normal joint. 2. Normal mobility with pain. Minor ligament sprain or capsular lesion. 3. Hypomobility with no pain. Adhesion. 4. Hypomobility with pain. Acute ligament sprain or capsular lesion. Guarding from muscle spasm. 5. Hypermobility with no pain. Complete tear with no fibers intact where pain can be elcited. 6. Hypermobility with pain. Partial tear with some fibers still intact. Sprain - A sprain is an injury involving the stretching or tearing of a ligament (tissue that connects bone to bone) or a joint capsule, which help provide joint stability. Strain - Strains are injuries that involve the stretching or tearing of a musculo-tendinous (muscle and tendon) structure. Evaluate for end feel after determining the degree of passive range of motion. Passively move the joint to the end of its range of motion and then apply slight overpressure to the joint. Table 1-1 Page 6 Yields information regarding the patient’s general ability and willingness to use a body part. Assessment value is limited. Note the degree of motion as well as pain elicited. Crepitus should be noted. Inclinometers and goniometers are used to measure range of motion. Resisted range of motion assesses musculotendinous and neurologic structures. Musculotendinous injuries tend to be more painful than they are weak. Neurologic injuries tend to be more weak than they are painful. 5 – Complete range of motion against gravity with full resistance. 4 – Complete range of motion against gravity with some resistance. 3 – Complete range of motion against gravity. 2 – Complete range of motion with gravity eliminated. 1 – Evidence of slight contractility. 0 – no evidence of contractility. Strong with no pain – Normal. Strong with pain – lesion of muscle or tendon. Weak and painless – neurological lesion or complete rupture of a tendon or muscle. Weak and painful – partial tear of muscle or tendon. Fracture, neoplasm, and acute inflammation are possibilities.