Pocket Guide to Msukculoskeletal Assessment by RICHARD f. BAXlfR

- - - - - - - - - - - - - - 95 Wilson-Barstow maneuver first for (L improved symmetry E. Sensation I 1. Dermatomes 2. Nerve fields co F. Palpation 1. Pubic tubercles/rami 2. Inguinal ligament 3. ASIS 4. Iliac crest 5. Greater trochanter 6. Surrounding soft tissue/muscle G. Joint play 1. Long axis and lateral distraction 2. Compression IV. Sidelying A. GMMT 1. Hip abd (test both supine if status poor or below) 2. Hip add (test both supine if status poor or below) B. Special tests 1. ITB: Ober's test Prone A. AROM 1. Hip ext (10-20 deg) B. GMMT 1. Hip ext C. Special tests (as applicable) 1. Anteversion: Craig's test 2. Coxa vara or dislocation: Nelaton's line and Bryant's triangle D. Sensation 1. Dermatomes 2. Nerve fields

d I SPECIAL TESTS FOR THE HIP Test Proce Test Detects Pt supine with one leg off e Thomas's test' Hip flex contracture (tight while flexing iliopsoas, rectus femoris, TFLI with hands, a Rectus femoris 1ight rectus femoris Method 1: sa tightness test' LE with knee Gber's test' 1ight TFL or ITS Method 21EIy passively fiex Sidelying with obliterate any is then held stabilized. Ex pulls PI's thig line with bod

IdlH 8 CD OJ rn <Xi :--J 0) 01 ~ W N \"\"D Q.) (fJ (fJ (fJ (j) Q.) \"\"D U (\") (\") (\") n GJc-, 0 (\") (fJ .Q....). 3 ro::r0 (j) (fJ :::J 0 3 ..... o'C :::JQ.) ro..... .....:::J (j) .....Q. ~. Q.) Q.) (\") -CD, 0 :::J ..... .....:::J:::J0 C 0::r(Q Q.) 0- (\") CD (\") 0::r ::r(j) s3. .......... -<0 (j)(j) Q.) --+, ;::<: :::J ~. :::J -CD, (j) (Q ..... --(j) CD c :::J CD 3 Q. C 0 :::J (j) (\") CD edure Positive Sign Straight leg rises off table th back fiat on table and resting end of table with knee extended Method 1: flexed knee extends and is pulled up from table other hip, pulling knee to chest Method 2: hip on same side spontaneously flexes and holding LE remains abducted and does not fall to table ame as Thomas's test except tests ContinI/cd\" fiexed y's testl: Pt prone. Examiner xes PI's knee h LE flexed at hip and knee to y lumbar lordosis. Affected knee in 90 deg flex while pelvis is xaminer passively abducts and gh/hip posteriorly until thigh is in dy

<c.o0 Test Proced I SPECIAL TESTS FOR THE HIP Continued Method 1: Pt Test Detects Examiner perfo Method 21mo Hamstring tightness Tight hamstrings PI supine and test'\" flex. Pt then a examiner uses Sign of buttock' Lesion in buttock and not in formed by fem lumbar spine that is causing Scouring test' radicular pain PI supine. Exa limitation exis Percussion test Hip joint pathology le.g, DJD, to see if more Faber's test (Patrick's avascular necrosisl test)' Pt supine with Hip stress fracture applies axial l Hip joint or Sl joint problem PI supine. Exa Pt supine. Exa on opposite kn abd toward ta Trendelenburg's test Stability of hip and ability of hip Pt stands on o Craig's test' abductors to stabilize pelvis on femur Pt prone with Nelaton's line' Measures femoral anteversion and rotates' hip me Bryant's triangle8 indirectly measures hip stability is parallel with motion. Degree Dislocated hip, coxa vara based on angl Dislocated hip, coxa vara Pt prone. Imag tuberosity to A trochanter sho imaginary line Pt supine. Ima table. Seconda trochanter par to first line. M line to table. <.0 <.0

dure Positive Sign supine with back flat on table. Method 1: straight leg being raised should raise at orms SLR test. least 80 deg from table odified active-knee-extension test): Method 2: compare with opposite LE; although holds thigh so hip is in 90 deg reported as a valid alternative to SLR test, no actively extends knee while normative data exist for adults to author's s goniometer to measure angle knowledge mur and tibia. Reproduction of radicular-type pain, even when knee aminer performs SLR test. If is flexed sts on SLR, examiner flexes knee e hip flex can occur. Exquisite pain reproduced in hip/groin and crepitus h hip flexed 90 deg. Examiner Exquisite hip/groin pain load and circumducts Pt's hip. Pain, muscle spasm, or limited motion aminer strikes heel. Positive findings with overpressure are indicative of SI dysfunction aminer places Pt's foot of test LE nee. Test extremity is lowered in able. one leg PelvIs on opposite side drops {unaffected side drops, and affected side shifts laterallyl knee flexed 90 deg. Examiner Anteversion greater than 20 deg, more common in ed and lat until greater trochanter females than males h table or reaches limit of ee of anteversion then estimated Greater trochanter palpated well above this line le of LE to vertical. Distance of secondary line from table greater on ginary line drawn from ischial involved side than uninvolved side ASIS of same side. Tip of ould lie on or below this e. aginary line drawn from ASIS to dary line drawn through greater rallel to table and perpendicular Measure distance from secondary

oo Test Proced III SPECIAL TESTS FOR THE HIP Continued PI supine. Exa med malleolus Test Detects (see belowl. R tested with Pt True leg length' Leg length Thumbs placed heights of thu Apparent leg length10 Lateral pelvic tilt (could be AP rotated) Pt supine. Exa Wilson-Barstow tip of xiphoid maneuver l1 Used for symmetrization before leg malleolus length measurement Pt supine. Exa palpates med knees and then pelvis from tab and examiner compares posi can then be us distal portion o I TREATMENT OPTIONS FOR THE HIP Special Condition Hx/Symptoms Signs/ DJD Groin or greater trochanter pain (especially Increase Trochanteric bursitis with weight bearing!. may also extend into lat Increase or posterior thigh to knee position Iliopectineal bursitis Insidious onset ROM lim Increased Sx with cold weather o.... AM stiffness and night ache Tendern trochan May be insidious, or Pt may report specific May ha event of feeling a \"pop\" as ITB snapped over test lor greater trochanter May have HID direct blow to hip Tendern Pain in lat hip that may refer along lat thigh Increase to knee passive Increased Sx with stairs, walking uphill, or May ha side lying on involved side Insidious onset Pain in groin or femoral triangle

dure Positive Sign Difference in measurements greater than 1-1.5 cm aminer measures ASIS to tip of s. Use Wilson-Barstow maneuver Difference in measurements Relative length of tibia may be No positive sign. This is used to ensure symmetry t prone and knee flexed 90 deg. before measuring leg length d on sales of feet Note relative umbs aminer measures distance from process or umbilicus to med aminer stands at PI's feet and malleoli with thumbs. Pt flexes n pushes off with heels to lift ble. Pt returns pelvis to table, passively extends PI's knees and itions of malleoli. Tape measure sed to measure from ASIS to of med malleolus /Objective Findings Treatment Options ed Sx after activity Iwalking, runningi ARDM ed Sx when hip in closed pack Maintain flexibility n, positive scouring or Faber's tests Decrease stress on hip with activity Ilose weight, mitations in a capsular pattern exercise in a swimming pool, use assistive devices such as a canei ness to palpation directly over greater Strengthen hip ext rotators and abductors nter ave positive Dber's test or Faber's Acute' relative rest. ice, NSAIDs, avoid AGG, phonophoresisliontophoresis, ultrasound both) Subacute/chronic: begin ITB stretching If conservative Rx fails, refer Pt to orthopedic surgeon; orthopedic surgeon may inject or surgically excise bursa ness to palpation in femoral triangle Acute.' relative rest, ice, NSAlDs, phonophoresis, ultrasound ed Sx with resisted hip flex and full Subacutelchronic: hip flexor stretching e hip ext COllfllllWr! ~ ave positive Faber's test

o N I TREATMENT OPTIONS FOR THE HIP Continued Special Condition Hx/Symptoms Signs/ Piriformis syndrome Pt may have Sx similar to radiculopathy, with Positive pain Isharp/burning) in buttocks (unilateral) tenderne Legg-Calve-Perthes extending down LE Increase disease PI may report that sitting or sitting in poorly cushioned chair reproduces Sx Antalgic Slipped capital femoral Pt has d epiphysis Groin, med thigh, and/or med knee pain Radiogr Iwithout knee pathology) femoral Sx in 3 to 8 year olds and in males most common Antalgic PI's hip Insidious onset or may follow trauma when h Sx in males during puberty and obese Pts Radiogr most common Hip &/or med thigh pain Meralgia paresthetica Pain/paresthesia In lat and antenor thigh R/O rad (entrapment of lat Pt may have had direct blow to iliac crest! Pt may femoral cutaneous ASIS as it pa nervel Overuse of abdominal muscles from sit-ups Palpate Pt may wear tight belt or pants, causing Sx ligamen Pubic ramus stress Fx Groin pain of insidious onset Antalgic Femoral neck stress Fx Commonly occurs in short individual who Tendern overstrides to keep up with others when Possibl walking/running le.g., military formationj Bone s Aggravated by activity and relieved by rest Positive Groin, hip, and/or med thigh pain of insidious Bone s onset Recent Increase In physical activity/training Aggravated by activity and relieved by rest o-w-'

/Objective Findings Treatment Options e SLR, positive sign of the buttock, Ultrasound, piriformis stretching ess to palpation in sciatic notch Avoid AGG ed Sx with hip ER or resisted ER If Sx fail to resolve/improve after 2-3 wk, may consider referral to orthopedic surgeon or pain clinic c gait for injection decreased ROM in abd, IR, and flex Refer Pt to orthopedic surgeon raphs show flattened or resorbed head Refer Pt to orthopedic surgeon c gait automatically externally rotates he/she flexes hip raph confirms diculopathy from back Avoid AGG be obese (putting pressure on nerve Eventually subsides on own asses over ASISI May use ice for anesthetic benefit. Modalities and e along iliac crest/ASIS and inguinal soft tissue mobilization if entrapment suspected nt in attempt to reproduce Sx rather than trauma ic gait Rest and crutches ness to palpation on pubic ramus After Sx subside, change training methods/schedule. ly adductor spasm Return to physical conditioning gradually scan consistent with stress Fx e percussion test Rest scan consistent with stress Fx Pt should be on crutches immediately because continued full weight bearing and physical activity may result in displaced femoral neck Fx and disruption of blood supply to femoral head

104-------------- References 1. Magee DJ: Orthopedic Physical Assessment, 3rd ed. Philadelphia, WB Saunders, 1997. 2. Ober FR The role of the iliotibial band and fascia lata as a factor in the causation of low-back disabilities and sciatica J Bone Joint Surg Am 18:105-110, 1936. 3. Kendall FP, McCreary EK Muscles: Testing and Function, 3rd ed. Philadelphia, Williams & Wilkins, 1983 4. Gajdosik R, Lusin G: Hamstring muscle tightness: Reliability of an active-knee-extension test. Phys Ther 631085-1090, 1983 5. Gajdosik RL, Rieck MA, Sullivan DK, Wightman SE: Comparison of four clinical tests for assessing hamstring muscle length. J Orthop Sports Phys Ther 18:614-618, 1993. 6. Cameron DM, Bohannon RW: Relationship between active knee extension and active straight leg raise test measurements. J Orthop Sports Phys Ther 17:257-260, 1993. 7. Maitland GD: Peripheral Manipulation, 3rd ed. Boston, Butterworth-Heinemann, 1991. co 8. Beetham Wp, Pollwy HF, Slocumb CH, Weaver WF: Physical Examination of the Joints. Philadelphia, WB Saunders, 1965. 9. Adams JC: Outline of Orthopaedics, 9th ed. London, Churchill Livingstone, 1968. 10. Hoppenfeld S: Physical Examination of the Spine and Extremities. Norwalk, CT, Appleton & Lange, 1976. 11. Woerman AL: Evaluation and treatment of dysfunction in the lumbar-pelvic-hip complex. In Donatelli R, Wooden MJ (eds): Orthopaedic Physical Therapy New York, Churchill Livingstone, 1989. Bibliography Barton PM: Piriformis syndrome A rational approach to management. Pain 47:345-352, 1991. Bunnell WP: Legg-Calve-Perthes disease. Pediatr Rev 7:299-304, 1986. Hertling D, Kessler RM: Management of Common Musculoskeletal Disorders. Physical Therapy Principles and Methods, 2nd ed. Philadelphia, JB Lippincott, 1990. Jankiewicz JJ, Hennrikus WL, Houkom JA: The appearance of the piriformis muscle syndrome in computed tomography and magnetic resonance imaging: A case report and review of the literature. Clin Orthop 262:205-209, 1991.

105 Kisner C, Colby LA: Therapeutic Exercise Foundations and Techniques, 2nd ed. Philadelphia, FA Davis, 1990. Schoenecker PL: Legg-Calve-Perthes disease: A review paper. Orthop Rev 15:561-574,1986. 0... J: co



IiIr-------------107 ~ KNH Subjective w . ati w Z Pt Hx (region specific): Functional limitations. locking/popping/giving- ~ way. swelling (if trauma. did it swell and how quickly) t If traumatic. was there a \"pop\" at the time of the injury? t Type of shoes (especially runners and running shoes): proper type. age of shoes. wear pattern t SQ, if applicable

108 - - - - - - - - - - - - - - Objective Examination I. Standing A. R/O spine pathology B. Observation 1. Gait 2. Posture (e.g., genu recurvatum, genu valgum, genu varum) 3. Function (e.g., squat, 1-leg hop) II. Sitting A. GMMT 1. Knee ext (test sidelying if status poor) III. Supine A. R/O ankle or hip pathology B. Observation 1. Posture (e.g., quadriceps angle, leg length differences, other alignment problems) 7'\\ 2. Measure or grade effusion Z m m C. AROM 1. Knee flex (135-145 deg) 2. Knee ext (0 deg) D. Special tests (as applicable) 1. Ligament: Lachman's test, varus and valgus tests at 0 and 30 deg, anterior and posterior drawer tests, pivot-shift test, flex-rot drawer test, ER-recurvatum test 2. Meniscus: McMurray's test, bounce home test, joint line tenderness, Apley's grinding test 3. Patellofemoral: apprehension test, grind test (Clarke's sign) 4. ITB: Noble's compression test, Ober's test 5. Plica: Swelling/effusion, tenderness over plica with palpation 6. OCD: Wilson's test E. Sensation

-------------109 1. Dermatomes (see Appendix A) w 2. Nerve fields F. Palpation w 1. Specific anatomic landmarks/ligaments, Z including joint line ~ G. Joint play 1. AP and med/lat movement of tibia on the femur 2. Superior/inferior and med/lat movement of the patella 3. AP movement of the fibula on the tibia IV. Prone A. GMMT 1. Knee flex (test side lying if status poor or below) B. Palpation 1. Posterior knee complex

.......... Tes o L SPECIAL TESTS FOR THE KNEE Test Detects Tests for Anterior Instability Compromised ACl (straight Pt s lachman's test (modifiedl' instabilityl unde prox Anterior drawer test (also with Compromised ACl (with IR and ER. dista tibial IR and ERP may indicate anterolateral and dista anteromedial rotary instability, 20-3 Pivot-shift testH respectivelYI PI s Anterolateral rotary instability 90 d (structures impl icated as stab compromised are ACL, lCl, tibia posterolateral capsule, the arcuate Easy complex, and ITBI Pt s opp tibia valg knee Flex-rot drawer test' Anterolateral rotary instability (same Pt su structures implicated as in pivot- unde Jerk test of Hughston' (reverse shift test) While pivot-shift test) exam Anterolateral rotary instability (same on le Tests for Posterior Instability structures implicated as in pivot- Posterior drawer test (also with shift testl Pt su tibial IR and ER)' hand Compromised PCl (with tibia in IR and a ER-recurvatum test' and ER; may also indicate exten posteromedial and posterolateral Valgus and varus stress tests at rotary instability, respectively) Pt su flexed odeg knee ext' Posterolateral rotary instability Exam ............... (structures involved include PCl, poste arcuate ligament. lCl, and IR an posterolateral capsulel Pt su Compromised PCl in addition to toes MCl or lCl quad Pt su holds place med

st Procedure Positive Sign supine. Examiner places knee and leg Excessive displacement of tibia compared er PI's thigh for support Examiner holds with uninvolved knee ximal hand over knee, palpating joint line; al hand is used to pull up on tibia just Excessive displacement of tibia compared al to joint PI's knee should be flexed with uninvolved knee 30 deg during test Tibia subluxes while femur externally rotates; supine. Hip flexed 45 deg and knee flexed then at 30-40 deg of flex, tibia suddenly deg with feet flat on table. Examiner jumps/reduces bilizes PI's foot and pulls anteriorly on a. Also perform with tibia in IR and ER. y test to perform. supine. Examiner grasps heel with posite hand placed laterally on proximal a just distal to knee. Examiner applies gus stress and internally rotates tibia as e is moved from full ext to flex. upine. Examiner holds leg (with foot Femur falls back posteriorly and externally er arm) and flexes PI's knee 20-30 deg. rotates while examiner is holding PI's leg and le keeping tibia in neutral rotation, foot with knee flexed. When examiner then miner then applies posterior drawer force applies a posterior drawer force on PI's leg, eg to cause reduced position. femur reduces and internally rotates. upine. Examiner grasps foot with one Sudden subluxation or \"jerk\" of tibial plateau d and just distal to knee with other hand at 20-30 deg knee flex applies valgus stress with IR of tibia and nds knee from 60 deg flex to 0 deg. upine with hip flexed 45 deg and knee Excessive tibial displacement compared with d 90 deg with foot flat on table. PI's uninvolved knee miner stabilizes PI's foot and pushes eriorly on tibia. Also perform with tibial Knee assumes position of slight recurvatum, nd ER. and tibia externally rotates. Involved kneel tibia appears to have tibial vara. upine. Examiner grasps both of PI's great and lifts feet from table (Pt told to relax Excessive med and/or lat gapping compared driceps). with PI's uninvolved knee upine with knee in full ext Examiner Con/iwud ~ s PI's foot under arm for support and es one hand along joint line and applies and lat force.

• SPECIAL TESTS FOR THE KNEE Continued Test Test Detects PI su flexed Sag sign' Compromised PCl (straight shoul instability) PI su Godfrey's sign' Compromised PCl (straight on so instabilityl that must Tests for Medial and lateral Torn MCl. Straight instability with Instability knee fully extended also indicates PI su Valgus stress test (at 0 and 30 torn PCL. for s line a deg~ Torn lCl Straight instability with oppo knee fully extended also indicates Varus stress test lat 0 and 30 torn PCL. Pt su for s deg~ line a oppo Test· for Meni cal Tears Posterior meniscal tears PI s McMurray's test10lI han Torn meniscus palp Apley's grinding test\" Torn meniscus or loose body in knee app kne Bounce home test\" PI p Miscellaneous Tests hard Apprehension test\" tibia Grind test (Clarke's sign!' Pt s han ~ kne ~ Patellar subluxation or hypermobility PI s w (with propensity for subluxation or or s dislocationl forc Patellofemoral joint disorder Ie. g., Exa DJD, patellofemoral pain syndrome, sup chondromalacia patellae! Pt g

t Procedure Positive Sign upine with hip flexed 45 deg, knees Tibia sags posteriorly compared with d 90 deg, and feet flat on table. PI uninvolved knee. ld relax muscles of LEo Tibia sags posteriorly compared with upine. Examiner holds legs or places legs uninvolved knee, similar to SAG sign, above omething for support le.g., stool! such PI's hips and knees are flexed 90 deg. PI relax lE muscles. upine. Examiner holds PI's foot under arm Excessive med gapping compared with PI's support and places one hand along joint uninvolved knee and applies inward (medl pressure with osite hand. Excessive lat gapping compared with PI's uninvolved knee upine. Examiner holds PI's foot under arm support and places one hand along joint and applies outward (lat! pressure with osite hand. supine. Examiner grasps heel with one Palpable click/pop and pain along joint line nd and places other hand on knee, pating joint line (med and lat). Examiner Eliciting exquisite joint line pain: med pain plies full lA, then EA, as examiner takes ee from full flex to 90 deg. = med meniscus, lat pain = lat meniscus prone. leg flexed 90 deg. Examiner leans Failure of knee to reach full ext and d on heel to compress menisci, rotating exhibiting elastic resistance to further ext a internally and externally. supine. Examiner holds tibia with both nds and fully flexes PI's knee, then allows ee to passively extend. sitting with knees fully extended on table Pt feels like patella may dislocate and shows supine. Examiner applies med and lat apprehension ce to patella. Pain in patellofemoral joint. (However, many aminer places web space of hand just Pts feel pain with this test. I perior to patella while applying pressure. gently and gradually contracts quadriceps. COlili/JIut! ~

I SPECIAL TESTS FOR THE KNEE Continued Test Test Detects Pt si table Wilson's test' DCD exam tibia Noble's compression test\" ITS friction syndrome existing at lat med Dber's test\" knee Pt su Tight TFl or ITS flexe over epico Pt si oblit is th stab exte with 11 TREATMENT OPTIONS FOR THE KNEE Signs/Ob Special Condition Hx/Symptoms ACl deficiency/tear H/D valgus or hyperextension force to knee Positive an If contact injury PI holds kn H/D quick stop, landing with knee fully involved lE extended, or sharp cut with noncontact injury Rarely an i mensical in H/D audible \"pop\" Immediate effusion MCl deficiency/tear H/D valgus force to knee through contact or Pt mayor noncontact injury deg, depen PI C/O med knee pain Tenderness -' -' U1

t Procedure Positive Sign itting with knee flexed over edge of Exquisite pain with this motion at approx 30 e. Pt then actively extends knee while deg of flex, then no pain when tibia is miner internally rotates PI's tibia IIR of externally rotated puts tibial spine against lat surface of femoral condyle, a classic site of DCDI. upine. Knee flexed 90 deg with hip Exquisite pain over distal ITS at point of ed. Examiner applies pressure with thumb pressure 30 deg before full knee ext ITS just proximal to lat femoral ondyle, and Pt actively extends knee. I idelying with lE flexed at hip and knee to lE remains abducted and does not fall to terate any lumbar lordosis. Affected knee table. hen held in 90 deg of flex while pelvis is bilized. Examiner passively abducts and ends PI's thigh/hip until thigh is in line h body. bjective Findings Treatment Options nterior instability tests Acute: relative rest. ice, elevation, NSAIDs nee in slight flex and unable to bear weight on to reduce effusion; brace and crutches E isolated injury; look for Sx of MCl and Subacute: Quadriceps and hamstring sets, njury SlR, hip ADD/A8D may not have positive valgus stress test at 30 Progress to isotonic, closed-chain, and nding on severity isokinetic hamstring and quadriceps s over MCl and/or attachments strengthening; plyometrics; functional exercises for return to sport. Pt also needs referral to orthopedic surgeon Most facilities have their own postsurgical protocol if surgery is required Acute: relative rest. ice, elevation, NSAIDs; brace and crutches Subacute: Quadriceps and hamstring sets, SlR, hip add/abd, stationary bike When Pt has 90 deg knee flex, begin isotonic PREs and closed-chain exercises for quadriceps and hamstring strengthening When PI has full knee ROM, begin functional running program

TREATMENT OPTIONS FOR THE KNEE Continued Signs/Ob Special Condition Hx/Symptoms LCL deficiency/tear H/D varus force to knee through contact or PI mayor ma noncontact injury deg, dependin Pt C/O lat knee pain Tenderness o Differentiate or positive N ITS friction syndrome H/D increase in running distance, intensity, Positive Nobl duration, or frequency Imost likely) Pain over lat knee Tenderness w Differentiate Patellofemoral pain Pain around/under \"kneecap\" Positive or ne IPFPS, RPPS, PFJS) Tender with p Pt may describe crepitus beneath/around Pain with com \"kneecap\" Ascending stairs especially aggravates Sx Prolonged sitting with knees flexed may aggravate Sx Imovie-goer's sign) Patellar subluxation/ H/D valgus force and/or rot force to knee Positive appre dislocation Patellar hyper Med knee tenderness due to tearing of med patellar retinacular fibers More common in females

bjective Findings Treatment Options ay not have positive varus stress test at 30 Acute: relative rest, ice, elevation, NSAIDs; ng on severity brace and crutches over LCL and/or attachments Subacute: Duadriceps and hamstring sets, SLR, hip add/abd, stationary bike from ITB friction syndrome IH/D overuse and/ Noble's compression test) Progress to isotonic, PREs, and closed-chain exercises for quadriceps and hamstring strengthening As Pt continues to improve, progress to functional running program and return to sport activities le's compression test. positive Dber's test Relative rest. ice, NSAIDs, phonophoresis/ iontophoresis with palpation around lat femoral epicondyle from LCL sprain/tear ITS stretching Attempt to correct contributing biomechanical factors Pt education to avoid future training errors and ensure that running shoes are not worn out egative grind test IClarke's signl Acute: relative rest. Ice, NSAIDs initially; may palpation beneath med and/or lat borders consider patellar taping away from painful mpression of patella patellar margin Check for abnormal biomechanics Ipes ehension test planus, patellar tilt or hypo/hypermobility, rmobility, effusion excessive Q-angle, tight hamstrings/calf/ITS) Subacute: quadriceps sets, SLR, hamstring/ calf/ITS stretching; progress to short-arc quadriceps and one-quarter wall squats/ slides, standing quadriceps sets, pain free leg press Also may consider backward walking on treadmill to strengthen quadriceps without increasing patellofemoral joint compressive forces Acute: relative rest, ice, elevation, brace Subacute.' quadriceps sets, SLR, hip add Progress to short-arc quadriceps, one-quarter wall squats, forward and lat step-ups Ifocus on VMD) backward walking on treadmill, functional training COlltilllled ...

........ (Xl • TREATMENT OPTIONS FOR THE KNEE Continued \" I Signs/Obj Special Condition Hx/Symptoms Symptomatic plica Pain over med or lat femoral epicondyle Tender band o Pain with activity lat femoral co Snapping sensation Must differen Arthroscopy is Patellar tendinitis H/D running, jumping, kicking, or climbing Tenderness w (\"jumper's knee\"l Sx located along patellar tendon along patellar tubercle Single-leg hop Possibly crepit Osgood-Schlatter Occurs in children around puberty Exostosis caus disease/syndrome Pain at tibial tubercle Point tenderne Increased Sx w Prepatellar bursitis H/O acute blow to patella Increased tibia Painful focal swelling Tenderness an Pes anserinus bursitis Possible H/O blow to med proximal tibia Tenderness an Ikneel or overuse forming pes a Painful area over tendons forming pes Resisted hip a anserinus Be careful to ........ <.0

jective Findings Treatment Options or palpable cord from patella across med or Acute: relative rest, NSAIDs, ice, ondyle phonophoresis/iontophoresis ntiate from patellofemoral pain s \"gold standard\" for Ox Subacute/chronic: quadriceps strengthening and stretching with palpation at inferior pole of patella or If unresolving, may require arthroscopic r tendon, including insertion at the tibial excision by orthopedic surgeon pping increases specific Sx at tendon Acute: relative rest, ice, NSAIDs, itus in tendon with ROM phonophoresis/iontophoresis Pt education on how to avoid future incidences (proper trainingl Subacute/chronic: progress back to full function sing enlarged tibial tubercle Relative rest ess at tibial tubercle Decrease athletic activity lusually resolves as with activity and decreased Sx with rest skeletal system matures, but enlarged tibial al tubercle pain with resisted knee ext tubercle remains) Quadriceps stretching and strengthening le.g., nd swelling directly on patella sets, SlR) as pain subsides nd swelling directly over region of tendons Relative rest, ice, compression, NSAlOs, anserinus phonophoresis/iontophoresis add; may increase Sx Stubborn cases may require aspiration by R/O Mel sprain/tear or med menicsal tear orthopedic physician or excision Relative rest, ice, NSAIDs, phonophoresis/ iontophoresis Stubborn cases may require injection, aspiration, or excision by orthopedic physician

120 - - - - - - - - - - - - - References 1. Jonson T, Although B, Peterson L, Renstrom P: Clinical diagnosis of ruptures of the anterior cruciate ligament: A comparative study of the Lachman test and the anterior drawer sign. Am J Sports Med 10 100-102, 1982. 2. Weatherwax RJ: Anterior drawer sign. Clin Orthop 154:318-319, 1981 3. Fetto JF, Marshall JL: Injury to the anterior cruciate ligament producing the pivot-shift sign: An experimental study on cadaver specimens. J Bone Joint Surg Am 61 :710-713, 1979. 4. Galway HR, Macintosh DL: The lateral pivot shift: A symptom and sign of anterior cruciate ligament insufficiency. Clin Orthop 147:45-50, 1980. 5. Tamea CD, Henning CE: Pathomechanics of the pivot shift maneuver: An instant center of analysis. Am J Sports Med 9:31-37,1981. 6. Katz JW, Fingeroth RJ: The diagnostic accuracy of ruptures of the anterior cruciate ligament comparing the Lachman test, the anterior drawer sign, and the pivot-shift test in acute and chronic knee injuries. Am J Sports Med 14:88-91, 1986. 7. Magee DJ: Orthopedic Physical Assessment, 3rd ed. Philadelphia, WB Saunders, 1997 A 8. Muller W: The Knee: Form, Function, and Ligament Z m Reconstruction. New York, Springer-Verlag, 1983. m 9. Hughston JC, Norwood LA: The posterolateral drawer test and external rotation recurvatum test for posterolateral rotary instability of the knee. Clin Orthop 147:82-87, 1980. 10. McMurray TP: The semilunar cartilage. Br J Surg 29:407-414,1942. 11. Stratford PW, Binkley J: A review of the McMurray test: Definition, interpretation, and clinical usefulness J Orthop Sports Phys Ther 22116-120, 1995. 12. Apley AG: The diagnosis of meniscus injuries. J Bone Joint Surg Br 2978-84, 1947. 13. Hoppenfeld S: Physical Examination of the Spine and Extremities. Norwalk, CT, Appleton & Lange, 1976. 14. Hughston JC, Walsh WM, Puddu G: Patellar Subluxation and Dislocation. Philadelphia, WB Saunders, 1984. 15. Noble HB, Hajek MR, Porter M: Diagnosis and treatment of iliotibial band tightness in runners. Phys Sportsmed 10:67-74, 1982. 16. Ober FR: The role of the iliotibial band and fascia lata as a factor in the causation of low-back disabilities and sciatica. J Bone Joint Surg Am 18105-110,1936.

--------------121 il liogr:l.)h 1 w w Cherf J, Paulos LE: Bracing for patellar instability. Clin Sports Med 9:813-820, 1990. Z Doucette SA, Goble EM: The effect of exercise on patellar ~ tracking in lateral patellar compression syndrome. Am J Sports Med 20:434-440. Ficat RP: Disorders of the Patella-femoral Joint. Baltimore, Williams & Wilkins, 1977. Flynn TW, Soutas-Little RW Patellofemoral joint compressive forces in forward and backward running. J Orthop Sports Phys Ther 21 :277-281, 1985. Hertling D, Kessler RM: Management of Common Musculoskeletal Disorders: Physical Therapy Principles and Methods, 2nd ed. Philadelphia, JB Lippincott, 1990. Kisner C, Colby LA: Therapeutic Exercise: Foundations and Techniques, 2nd ed. Philadelphia, FA Davis, 1990. McConnell J: The management of chondromalacia patellae A long term solution. Aust J Physiother 32:215-223, 1986. Noble HB, Hajek MR, Porter M: Diagnosis and treatment of iliotibial band tightness in runners. Phys Sportsmed 10:67-74, 1982. Reider B, Sathy MR, Talkington J, et al: Treatment of isolated medial collateral ligament injuries in athletes with early functional rehabilitation: A five-year follow-up study. Am J Sports Med 22:470-477,1993. Thabit G, Micheli LJ: Patellofemoral pain in the pediatric patient. Orthop Clin North Am 23:567-585, 1992 Tindel NL, Nisonson B: The plica syndrome. Orthop Clin North Am 23:613-618,1992. Zappala FG, Taffel CB, Scuderi GR: Rehabilitation of patellofemoral joint disorders. Orthop Clin North Am 23:555-566, 1992.



m.----------123 fOOl ANO ANKl[ Subjective ill Evaluation -l ~ t Pt Hx (region specific): Locking/ popping/ giving-way, type shoes/ Z« wear pattern «oz oof- t How does walking on various ter- rain affect swelling? LL t For runners/joggers, how long has Pt been a .C..l jogger and what is jogging surface? t Describe workout type/intensity/duration

124-------------- Objective Evaluation I Standing A. R/O spine pathology B. Observation 1. Gait 2. Posture (e.g., pes planus/cavus, calcaneal varus/valgus, genu varus/valgus/ recurvatum, tibial torsion) 3. Function a. Toe walking (Sl-S2) b. Heel walking (L4-S1) C. GMMT 1. Ankle PF (Single leg-heel raise'; test sidelying if status poor or worse) aa\"T1 II. Sitting A. Special tests (as applicable) ---1 »z 1. Kleiger's test o »z III. Supine A. R/O knee, hip pathology A r m B. Measure swelling/effusion C. AROM 1. Ankle OF (10-15 deg) 2. Ankle PF (45-55 deg) 3. Ankle inv (30-40 deg) 4. Ankle ev (15-25 deg) D. Special tests (as applicable) 1. Ligament (ATFl): anterior drawer test 2. Diastasis/syndesmotic sprain: squeeze test 3. Stress fracture: metatarsal loading test 4. Deep vein thrombophlebitis: Homans' sign 5. Other: Morton's neuroma test E. Sensation 1. Dermatomes (see Appendix A) 2. Nerve fields

------------125 F. Palpation W 1. Dorsal pedal and posterior tibial artery -l pulses ~ 2. Specific anatomic landmarks/ligaments Z« G. Joint play: AP glide and long-axis distraction oz« IV. Sidelymg aaf- A. GMMT LL 1. Ankle inv/ev (test supine if status poor or worse) o.... B. Special tests (as applicable) 1. Ligament (CFl): talar tilt test C. Joint play 1. Medial and lateral tilt tests V. Prone A. Observation 1. Posture (forefoot/rearfoot/varus/valgus) B. Special tests (as applicable) 1. Ligament (ATFl): anterior drawer test 2. Achilles tendon: Thompson's test

II SPECIAL TESTS FOR THE FOOT AND ANKLE Te Test Detects Pt Single leg-heel raise' Ankle PF strength ex RO Anterior drawer (ankle stabilityl Compromised anterior talofibular lig Pt test' Compromised calcaneofibular lig ov Ex Talar tilt (inv stress test)\" pu th or Pt Ex ab Kleiger's test' Compromised deltoid lig (MCl) PI Squeeze test' 5 ta Compromised interosseous lig, also on ER stress test' known as syndesmotic ankle sprain la Homans' sign' Compromised interosseous lig, also Pt known as syndesmotic ankle sprain Ex in Deep vein thrombophlebitis tib as re Pt kn po in E P P

est Procedure Positive Sign t standing on test limb with knee Test grades xtended. Pt raises heel from floor through Normal and good: Pt completes four to OM of PF five times with good form and no apparent fatigue t prone with foot and ankle extending Fair: Pt plantar flexes ankle sufficiently to ver edge of table and foot in 20 deg PF clear heel from floor xaminer stabilizes tibia and fibula and Poor and worse: Tested sidelying ushes calcaneus forward with other hand; his can also be performed with Pt sitting Increased anterior translation compared with r supine and pulling calcaneus forward. uninvolved ankle. At same time, vacuum effect is seen in which skin on both sides of t supine or sidelying. PI's foot in neutral. Achilles tendon is drawn inward (when xaminer tilts talus side to side in add and sitting or supine, \"dimples\" may appear to bd (inv and ev of footl form anteriorly because of vacuum effectI. Increase in talar tilt compared with uninvolved ankle, accompanied by lateral \"dimpling\" of skin around lat malleolus and soft end-feel I sitting with knee flexed over edge of Med and lat pain, and examiner may feel able 90 deg. Examiner stabilizes leg with talus displace from med malleolus ne hand and grasps foot and rotates it aterally (ER). Exquisite pain reproduced during test in vicinity of distal syndesmosis or ankle joint t sitting with leg over edge of table. Examiner places hands on PI's leg approx 6 Exquisite pain reproduced over anterior or nches inferior to knee and compresses posterior tibiofibular lig and over bia and fibula with heels of both hands, interosseous membrane s if to bring them together, and then Exquisite pain in calf eleases COlltiillwd ... Pt sitting with leg over edge of table and nee flexed 90 deg and ankle in neutral osition. Examiner applies ER stress to nvolved foot and ankle. Examiner palpates deep between heads of PI's gastrocnemius or forcibly dorsiflexes PI's ankle when knee is fully extended

Nco Te • SPECIAL TESTS FOR THE FOOT AND ANKLE Continued Pt Test Detects on lat Thompson's test' Ruptured Achilles tendon Ex Vibration test Stress Fx str su Metatarsal loading test Stress Fx in metatarsal sim Test for Morton's neuroma' Morton's neuroma Ex fin (ax Ex be Ex an I TREATMENT OPTIONS FOR THE FOOT AND ANKLE Special Condition Hx/Symptoms Sig Achilles tendinitis, acute Painful Achilles tendon, crepitus Ach Hee Pt reports increased Sx with ankl running, jumping, stair climbing Rest decreases Sx Achilles tendinitis, chronic Chronic achilles tendon pain {Pt may Nod have continued to exercise through pain for monthsl May Rem both N (0

est Procedure Positive Sign Absence of ankle PF {present but significantly gets in quadruped position (on all foursl reduced PF may represent partial tear) n table. Examiner squeezes calf (med and Exquisite pain at suspected stress Fx site t sides of gastrocnemius). Reproduction of Pt's Sx xaminer places tuning fork on suspected ress Fx site. Ultrasound 1100%) over Reproduction of Pt's Sx le.g., exquisite pain, uspected stress Fx may also be used for burning, shooting, tinglingl milar effect. xaminer grasps metatarsal head with ngers and pushes it toward calcaneus xial loadingl. xaminer grasps two metatarsal heads, etween which is the suspected neuroma. xaminer moves metatarsal heads back nd forth while compressing them together. gns/Objective Findings Treatment Options hilles tendon tender to palpation Relative rest. ice, heel lift, NSAIDs, el raises and forced phonophoresis/iontophoresis le OF reproduces Sx Subacute: gentle calf stretching, transverse dules in achilles tendon friction massage (TFMI; may consider y have partial rupture eccentric training program after Sx subside member to perform Thompson's test for ISAIDI h acute and chronic conditions Correct biomechanical problems that may be contributing Heel lift, TFM May require 4-6 mo of decreased activity Calf stretching Strengthening anterior muscle group May consider eccentric training program (SAlOl Correct biomechanical problems that may be contributing May require surgery if no improvement 'Y( , fIJI I

ow • TREATMENT OPTIONS FOR THE FOOT AND ANKLE Continued Special Condition Hx/Symptoms I Sig Achilles tendon rupture H/O rapid eccentric loading (e.g., Pos jumping, sprinting, stair climbing) Ob ..Severe bet mid Pt may preapinoritn haecahriinllegsatenpdoopn. or Exq it is feeling as though struck from calc behind at time of injury Pt LE Plantar fasciitis Often coexists with calcaneal spurs Tend Pain in AM with first few steps calc

gns/Objective Findings Treatment Options sitive Thompson's test Refer Pt to orthopedic surgeon bservable gap may be present beneath skin Pt may be treated operatively or tween ends of ruptured tendon in nonoperatively dsubstance rupture quisite tenderness at rupture site whether Nonoperative Rx: involves casting in PF (6-10 is midsubstance or at insertion into wk) initially. After cast removed, Rx aimed at caneus restoring AROM. Strengthening is then also unable to perform a toe raise on involved progressed carefully from isometrics through isotonics and isokinetics. Eccentric loading/ strengthening should also be part of later stages of rehabilitation. Some authorities do not recommend this option for an active, athletic patient' Possible rehabilitation approach after operative Rx: Week 1: ice, NWB, AROM out of splint Week 2: ice, NWB, AROM out of splint, isometric inv/ev, gather towel with toes, mobilize scar Week 3: begin PWB in cam-walker or cast with walking boot; if no cast, AROM, der over plantar foot and/or plantar gentle calf/Achilles stretch with towel, caneus isometric PF/OF/inv/ev, begin light isotonic PF/OF/inv/ev with tubing (10 repetitionsi Week 4--6: progress PWB up to FWB by week 6, AROM, progress calf/achilles stretching (may begin standing stretch). progress isotonic strengthening, proprioception Week 6-12: FWB in footwear with high heel such as boots, progress stretching, continue isotonics and add toe raises with both LEs Week 12 +. progress all exercises and prudently progress walk to jog; pool exercises Use modalities as needed to assist rehab Decrease activity, NSAIOs, phonophoresis/ iontophoresis Orthoses/low-dye taping Plantar fascia, gastrocnemius, and soleus muscle stretch Pt education to wear supportive shoes at all times and avoid walking barefoot or in sandals Night splints for recalcitrant cases (ollIiIJUt / ..

-> W N I TREATMENT OPTIONS FOR THE FOOT AND ANKLE Continued Special Condition Hx/Symptoms Sig I Stress Fx Vague insidious onset of Sx Com localized tenderness over bone calca Pain subsides with rest An overuse injury Tend Posi Compartment syndrome, acute Disproportionate pain with passive Asso (medical emergency) stretch and Paresthesia Compartment syndrome, chronic/ Muscle weakness Asso exercise induced Progresses rapidly (in 8-12 hr can cause permanent damagel Similar to acute but less intense pain No rapid progress Sx subside with rest Ankle sprain, grade I and 11* H/O trauma linv or ev forceI Swe Ankle sprain, grade 111* Mild to moderate pain and disability Ten H/O trauma {inv or ev forceI inju Severe pain and disability PTI Ma draw pres Ass and Swe Ten MC Pos test spra Pos Asse and w-w>

gns/Objective Findings Treatment Options mmon areas are metatarsals, tibia, Aest aneus Prescribe appropriate ambulatory status der directly over bone based on PI's Sx during weight bearing itive metatarsal loading or vibration tests NW8 exercise intially, progressing to weight- bearing exercise as Sx resolve ociated with severe trauma IFx), burns, Ensure Pt obtaining proper/sufficient nutrition excessive overuse Elevate to horizontal Monitor closely Notify physician/orthopedic surgeon immediately ociated with activity/exercise Increase flexibility Increase muscle endurance Correct mechanical fault Surgical release if continually problematic elling Acute: reduce swelling lice, elevate, compression tape/wrap, NSAIDs), crutches to nderness over lCl IATFl, CFL, PTFU in inv reduce weight bearing ury or MCl/deltoid lig (TNL, ATIL, TCL, IU in ev injury Subacute: AAOM lalphabet, pumping, inv, ev), isometric strengthening IDF, PF, inv, evl, wean ayor may not have positive anterior from crutches wer test or talar tilt test with laxity sent, but definite firm end-feel Chronic: Isotonic strengthening (OF, PF, inv, ev), calf stretch, balance/proprioceptive sess for presence of syndesmosis sprain training, agility/return to sport activity d A/O osteochondral Fx of talar dome Acute; reduce swelling (ice, elevate, elling compression tape/wrap, NSAIDsl crutches to reduce weight bearing, ankle stirrup brace nderness over lig comprising lCl linv) or Cl/deltoid lig (evl Subacute: AAOM (alphabet, pumping, inv, ev), isometric strengthening IDF, PF, inv, ev}, wean sitive anterior drawer test and talar tilt from crutches t both with soft/empty end-feel with lCl ain Chronic. isotonic strengthening IDF, PF, inv, evl, calf stretch, balance/proprioceptive sitive Kleiger's test with MCl sprain training, lace-up ankle brace for support in return to sport activities, agility/return to sess for presence of syndesmosis sprain sport activity A/O osteochondral Fx of talar dome If aggressive nonoperative Ax fails to restore stability, reconstructive surgery may be required

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------------135 References u , 1. Daniels L, Worthingham C: Muscle Testing: Techniques of ~ Manual Examination, 5th ed. Philadelphia, WB Saunders, 1986. \"< 2. Gungor T: A test for ankle instability: A brief report J Bone c Joint Surg Br 70:487, 1988. \"< 3. Magee DJ: Orthopedic Physical Assessment, 3rd ed. eel- Philadelphia, WB Saunders, 1997. u 4. Trevino SG, Davis P, Hecht PJ Management of acute and chronic lateral ligament injuries of the ankle. Orthop Clin North Am 25:1-16,1994. 5. Swain RA, Holt WS: Ankle injuries: Tips from sports medicine physicians. Postgrad Med 93:91-100,1993. 6. Boytim MJ, Fischer DA, Neumann L: Syndesmotic ankle sprains. Am J Sports Med 19:294-298, 1991. 7. Kelikian H, Kelikian AS: Disorders of the Ankle. Philadelphia, WB Saunders, 1985. 8. Calliet R Foot and Ankle Pain, 2nd ed. Philadelphia, FA Davis, 1983. 9 Cetti R, Christensen S, Ejsted R, et al: Operative versus nonoperative treatment of Achilles tendon rupture. Am J Sports Med 21791-799,1993. Bibliography Boytim MJ, Fischer DA, Neumann L: Syndesmotic ankle sprains. Am J Sports Med 19294-298. Calliet R: Foot and Ankle Pain, 2nd ed. Philadelphia, FA Davis, 1983 Clement DB, Taunton JE, Smart GW: Achilles tendinitis and peritendinitis Etiology and treatment Am J Sports Med 12179-184,1984. Cox JS: Surgical and nonsurgical treatment of acute ankle sprains. Clin Orthop 198118-126, 1985. Curwin S, Stanish WD: Tendinitis. Its Etiology and Treatment. Lexington, MA, DC Heath, 1984. Galloway MT, Jokl P, Dayton OW: Achilles tendon overuse injuries. Clin Sports Med 11 :771-780, 1992. Hertling D, Kessler RM: Management of Common Musculoskeletal Disorders.· Physical Therapy Principles and Methods, 2nd ed. Philadelphia, JB Lippincott, 1990. Mascaro TB, Swanson LE: Rehabilitation of the foot and ankle. Orthop Clin North Am 25147-160, 1994. Schepsis AA, Leach RE, Goryca J Plantar fasciitis: Etiology, treatment, surgical results, and review of the literature. Clin Orthbp 266: 185-196, 1991.

136 - - - - - - - - - - - - - - Seta JL, Brewster CE: Treatment approaches following foot and ankle injury. Clin Sports Med 13:695-718, 1994. Soma CA, Mandelbaum BR: Repair of acute Achilles tendon ruptures. Orthop Clin North Am 26:239-247, 1995. Swain RA, Holt WS: Ankle injuries: Tips from sports medicine physicians. Postgrad Med 93:91-100, 1993 Trevino SG, Davis P, Hecht PJ: Management of acute and chronic lateral ligament injuries of the ankle. Orthop Clin North Am 25:1-16,1994. Wapner KL. Sharkey PF: The use of night splints for treatment of recalcitrant plantar fasciitis. Foot Ankle 12: 135-137, 1991. \"o o --1 » oZ »z rA m

m.------------137 RfSPIRATORY fVAlUATlON Subjective z Evaluation o • Pt Hx (respiratory specific): age, ~ sex, diagnosis, vital signs, swal- lowing, nutritional status, chest ra- ::::> diographs, PFT tests, laboratory re- g-l ports on sputum, cough W • Smoking Hx, other environmental factors/expo- sures >oa:-: • Family/support system ~ a:: 0... (f) W a:: ......

138 - - - - - - - - - - - - - Objective Evaluation ObselvCltlon A. Posture B. Use of accessory muscles C. Furrowed brow D. Flaring nares E. Pursed-lip breathing F. Increased work to breathe G. Respiratory rate and depth ...... H. Cyanosis/clubbing of nails I. Pt's color (e.g., pallor, red, blue) ~ J. Supplemental devices (e.g., oxygen, m ventilatOr) (f) -0 K. Oxygen saturation (no exercise if <90%) ~ o~ II Cre t as f-' ment -~< A. Chest shape/size m B. Tone § C. Upright posturing r C ~ III Bre thing pattern oz A. Brain stem involvement B. Diaphragmatic C. Paradoxic D. Diaphragm only E. Upper accessory muscles only F. Asymmetric G. Shallow H. Irregular I. Work of breathing IV Phondtlon A. Length B. Voice intensity/quality C. Listen with the stethoscope for abnormal vocal resonance

- - - - - - - - - - - - - 139 V oug z A. Inspiration o B. Force buildup C. Expulsion ~ D. Production ~ vi M\"lnudl d essment ---.J A. Vital signs B. Auscultation (e.g., abnormal breath sounds, ~ rales, wheezing, pleural friction rub) C. PFTs (VC, Vt, FEV1, FRC) W D. Chest wall expansion measurement (i.e., level of axilla, fourth intercostal space, nipple >- line, and 10th rib) 0: VII Pdlp. tlon A. Check so: 1. Chest/thoracic and abdominal asymmetries 0: 2. Abnormal contours 0... 3. Lumps (f) 4. Masses W 5. Soft tissue swelling 0: 6. Efficacy of muscle contraction B. Percussion (i.e., placing finger over ...... intercostal spaces at symmetric lung segments from apex to base and tapping with opposite finger at each site): Is the sound resonant, dull, or flat? C. Pitting edema in the LEs Fc A. Monitor response when Pt is allowed activity (e.g., walking, wheel chair propulsion, ADLs) 'I i graph\" Cohen M, Michel TH: Cardiopulmonary Symptoms in Physical Therapy Practice. New York, Churchill Livingstone, 1988.

140 - - - - - - - - - - - - - Hobson L, Hammon WE: Chest assessment. In Frownfelter DL (ed): Chest Physical Therapy and Pulmonary Rehabilitation: An Interdisciplinary Approach, 2nd ed. Chicago, Year Book Medical Publishers, 1987. Scanlan CL: Chest physical therapy. In Scanlan CL, Spearman CB, Sheldon RL (eds): Egan's Fundamentals of Respiratory Care, 5th ed. St. Louis, CV Mosby, 1990. Wilkins RL: Physical assessment of the patient. In Scanlan CL, Spearman CB, Sheldon RL (eds): Egan's Fundamentals of Respiratory Care, 5th ed. St. Louis, CV Mosby, 1990. Youtsey JW: Basic pulmonary function measurements. In Scanlan CL, Spearman CB, Sheldon RL (eds): Egan's Fundamentals of Respiratory Care, 5th ed. St. Louis, CV Mosby, 1990. Zadai CC: Comprehensive physical therapy evaluation: Identifying ...... potential pulmonary limitations. In Zadai CC (ed): Pulmonary Management in Physical Therapy. New York, Churchill Livingstone, 1992 . ::0 m (f) -0 ::0 o~ :-:<0 :m;; r C ~ oz

16-----------141 INPATlfNT PHYSICAl THfRAPY CARDIAC fVAlUATION Subjective oz Evaluation ~ t Pt Hx (cardiac specific): age, sex, ::J diagnosis :-;l: t Are any Sx present today (chest/ neck/left shoulder/jaw pain; syn- W cope or dizziness)? U« o t Does Pt feel \"palpitation\" of the heart (i.e., u«a: \"pounding, stopping, jumping, or racing\" in the chest), fever, or chills? N... t Laboratory and ECG results t Has Pt had surgical intervention? t Nutritional status, smoking Hx, PMHx, PSHx, Meds t Other significant cardiac risk factors

142 - - - - - - - - - - - - - - Objective Evaluation Observation A. General appearance: Does Pt look ill? B. Edema in the extremities C. Posture (i.e., sternal or spinal deformities that may affect the heart) D. Cyanosis/clubbing of nails E. Supplemental devices (e.g., oxygen, ventilator) F. Congenital abnormalities ... II. Vital signs N A. Blood pressure: record blood pressure and pulse while Pt is sitting or reclining, standing »() before exercising, and during and after ::0 exercises/ambulation (if Pt is stable and has 0 :i> been cleared by physician to begin cardiac () rehabilitation) m ~ B. Pulse (beats per minute and regularity) r C C. Auscultation ~ a III. Breathing pattern z A. Dyspnea B. Wheezing C. Orthopnea D. Cheyne-Stokes breathing E. Overuse of accessory muscles F. Increased work of breathing IV Phonation A. Length B. Voice intensity/quality C. Listen with the stethoscope for abnormal vocal resonance V. Cough A. Inspiration B. Force buildup

-------------143 C. Expulsion D. Production (color of sputum) VI Function A. Bed mobility B. Transfers C. Ambulation Bibliography az Goldberger E: Essentials of Clinical Cardiology. Philadelphia, JB ~ Lippincott, 1990. ::J Hurst JW, Crawley IS, Morris DC, Dorney ER: The history: -.J Symptoms and past events related to cardiovascular disease. In Hurst JW, Schlant RC, Rackley CE, Sonnenblick EH, Wenger ~ NK (eds): The Heart: Arteries and Veins, 7th ed, vol 1. New York, McGraw-Hili, 1990:122-134. W Silverman ME Inspection of the patient. In Hurst JW, Schlant RC, U Rackley CE, Sonnenblick EH, Wenger NK ledsl: The Heart. Arteries and Veins, 7th ed, vol 1 New York, McGraw-Hili, <r: 1990:135-147. o a: Willerson JT: Physical examination of the patient with heart u<r: disease. In Sanford JP, Willerson JT, Sanders CA (eds): The Science and Practice of Clinical Medicine: Clinical Cardiology, N... vol 3. New York, Grune & Stratton, 1977:94-111.