Orthopedic & Neurological Evaluation

1. Orthopedic & Neurological Evaluation Dr. Michael Gillespie Doctor of Chiropractic

2. Anatomic and Biomechanical Principles • 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.

3. Clinical Assessment Protocol • Patient History • Inspection / observation • Palpation • Range of Motion • Orthopedic and Neurologic Testing • Diagnostic Imaging • Functional Testing

4. Documentation • Evaluate progress. • Share information with other practitioners. • Insurance records. • Malpractice.

5. SOAP Notes • Subjective – Patient History • Objective – Observation and Testing • Assessment – Based on compilation of findings • Plan – Further testing and / or treatment

6. Patient History • 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.

7. Patient History • Keep the patient focused on the problem. • Listen carefully. • Do not lead the patient towards answers.

8. Closed-Ended History • Question and Answer Format. • Written Forms

9. Open-Ended History • 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.

10. OPQRST Mnemonic • Onset of complaint • Provoking or Palliative concerns • Quality of pain • Radiation to particular areas • Site and Severity of complaint • Time frame complaint

11. History – Other Factors • Family History • Occupational History • Social History

12. Observation / Inspection • General Appearance • Functional Status • Body Type • Postural deviations • Gait • Muscle guarding • Compensatory movements • Assistant devices

13. Inspection – three layers • Skin • Subcutaneous tissue • Bony structure

14. Skin Inspection • 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

15. Detection of Malignant Melanoma • 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

16. Subcutaneous Soft Tissue Inspection • 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

17. Bony Structure Inspection • 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

18. Genu Varus

19. Genu Valgus

20. Palpation • Palpate the patient in conjunction with inspection. • Begin with a light touch. • Dysesthesia. • Hypoesthesia. • Hyperesthesia. • Anesthesia.

21. Skin Palpation • Evaluate skin temperature • High – inflammation • Low – vascular insufficiency • Adhesions

22. Subcutaneous Soft Tissue Palpation • 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.

23. Tenderness Grading Scale • 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

24. Types of Swelling • 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

25. Types of Swelling • Thickened and leathery • Chronic swelling • Soft and fluctuating • Acute • Hard • Bone • Thick and slow moving • Pitting edema

26. Pulse • Palpate for pulse rate, rhythm, and amplitude • Normal healthy resting pulse rate for an adult is 60 – 100 bpm

27. Palpating Bony Structures • Detection of alignment problems • Dislocations, luxations, subluxations, fractures • Identify ligaments and tendons that attach to the bones • Detect bony enlargements

28. Range of Motion • Passive • Active • Resisted

29. Passive Range of Motion • 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.

30. Six Range of Motion Pain Variations • 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.

31. Six Range of Motion Pain Variations • 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.

32. Sprain Vs. Strain • 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.

33. End Feel • 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.

34. End Feel Evaluation Table 1-1 Page 6

35. Active Range of Motion • 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.

36. Inclinometer

37. Goniometer

38. Resisted 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.

39. Muscle Grading Scale • 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.

40. Resistant Range of Motion Reactions • 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.