Orthopedic Physical Assessment, 7e

1549 Pages·2020·117.839 MB·English

by  David J. Magee BPT PhD CM, Robert C. Manske PT DPT SCS MEd ATC CSCS

SEVENTH EDITION
ORTHOPEDIC
PHYSICAL
ASSESSMENT
David J. Magee, PhD, BPT, CM
Professor Emeritus
Department of Physical Therapy
Faculty of Rehabilitation Medicine
University of Alberta
Edmonton, Alberta, Canada
Robert C. Manske, PT, DPT, MEd, SCS, ATC, CSCS
Professor
Wichita State University
Department of Physical Therapy
Via Christi Ascension Orthopedic and Sports Physical Therapy
Wichita, Kansas, United States
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ORTHOPEDIC PHYSICAL ASSESSMENT, SEVENTH EDITION ISBN: 978- 0- 323- 52299- 1
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Dedication
Bernice Sharon Magee
1945–2019
“My Rock and the Family’s Glue”
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Preface to the Seventh Edition
In 2014, when I completed the 6th edition of Orthopedic new tests and figures, especially in the area of concussions
Physical Assessment, I thought it would be the last revision and assessment of the hip. The tables on the reliability
that I would do. Fortunately, I have been given an oppor- and validity of many of the special tests and the examples
tunity by Elsevier to do a 7th edition of the book and to of many functional tests have been moved to the Student
work with the individual who will take over as author/edi- Consult website, where they are available electronically
tor of Orthopedic Physical Assessment–Dr. Robert Manske, for those who want them. Reliability studies for testing
who will work with my irreplaceable developmental edi- show variability in their outcomes, so key tests are high-
tor, Bev Evjen, on any future editions. With the support lighted using different icons because the value of the tests
of Elsevier, I believe the book is in good hands. have been demonstrated clinically and/or statistically
I remember when the first edition was printed and that they contribute to determining what the problem is.
Elsevier told me they were going to print a first run of Hopefully, this will help students and clinicians determine
8000 copies. All I could think about was “how long would which tests could be effective depending on the pathol-
it take to sell 8000 copies when I only taught 40 physical ogy being presented. These special tests do not replace a
therapy students a year?” The book went through three good history or examination.
printings in the first year and the rest, as they say, “is his- This book, as the title suggests, is about assessing for
tory!” To do something in your life and have it succeed musculoskeletal pathology. It is not a pathology textbook.
well beyond all of one’s expectations, hopes, and dreams As part of the Musculoskeletal Rehabilitation Series,
has been very gratifying and hugely rewarding. The sup- the companion book to Orthopedic Physical Assessment
port of people who have provided input and constructive is Pathology and Interventions in Musculoskeletal
criticism is greatly appreciated and their input has contrib- Rehabilitation, which goes into much greater detail on
uted greatly to the book. The support of these people, my pathological conditions and their treatment. As “book-
models for the photos in the book, my students, and my ends” to these two books, Scientific Foundations and
family are greatly appreciated. Principles of Practice in Musculoskeletal Rehabilitation
When the first edition was published in 1987, I hoped provides information on healing of different tissue types,
at that time that I would be able to develop a series of pain and aging, and the principles of different types of
books that would meet the needs of rehabilitation clini- practice to treat different musculoskeletal tissue types;
cians in the area of musculoskeletal conditions. With the while Athletic and Sport Issues in Musculoskeletal
assistance of the other editors, James Zachazewski, Sandy Rehabilitation deals with more acute injuries and issues
Quillen, and Rob Manske, and with a number of experts in related to the more active individual, specific groups, and
their respective fields, my dream became a reality with the specific activities as they relate to sport.
Musculoskeletal Rehabilitation Series, with Orthopedic
Physical Assessment being the cornerstone of the book series. David J. Magee, PhD, BPT, CM
In this edition of Orthopedic Physical Assessment, infor- 2020
mation has been updated in all of the chapters with several
iv
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Acknowledgments
The writing of a book such as this, although undertaken Our photographer, Brian Gavriloff, whose photo-
by two people, is, in reality, the bringing together of ideas, graphic talents added immeasurably to the book.
concepts, and teachings developed and put forward by Dr. Andrew Porter for many of the radiographic
colleagues, friends, clinicians, and experts in the field of images he provided for the diagnostic imaging portions
musculoskeletal assessment. When the book was first pub- of the book.
lished in 1987, I had no idea of how successful it would Our models, Tanya Beasley, Paul Caines, Lee-A nne
be. It has succeeded in becoming more than I could have Clayholt, Carolyn Crowell, Michelle Cuthbert, Vanessa
ever imagined in seven languages. de Oliveira Furino, Devon Fraser, Ian Hallworth,
In particular, for this edition, I would like to thank the Nathaniel Hay, Sarah Kazmir, Megan Lange, Tysen
following people: LeBlanc, Dolly Magee, Shawn Magee, Theo Magee,
My family, especially my wife, Bernice, for putting up Tommy Magee, Harry Magee, Henry Magee, Nicole
with my moods and idiosyncrasies, especially at 4 a.m.! Nieberding, Judy Sara, Paula Shoemaker, Holly
Bev Evjen, our irreplaceable developmental editor and Stevens, Ben Stout, Brandon Thome, Veronica Toy,
friend. Without her help, encouragement, persistence, Joan Matthews- White, and Yung Yung Wong, whose
and eye for detail, this edition, as with previous editions patience and agreement to be models for the many explan-
and in fact the whole Musculoskeletal Rehabilitation atory photographs and videos is very much appreciated.
Series, would not be what it is. Brent Davis, Luke Kriley, and Jameson Fay, who
Rob Manske, who has agreed to author Orthopedic researched and updated the tables of psychometric prop-
Physical Assessment going forward. I believe the book is erties of the Special Tests for this edition.
in good hands and will be well looked after in the future. My colleagues, who contributed ideas, suggestions,
Judy Chepeha, who has acted as the clinician model radiographs, and photographs, and who typed and
through five editions of the book. Her support and will- reviewed the manuscripts.
ingness to be part of the book has greatly enhanced it and The people at WB Saunders (Elsevier), especially
added consistency to the book. Kathy Falk who has guided me and supported me
Our undergraduate, graduate, and postgraduate through several editions and Lauren Willis, Sarah Vora,
students from Canada, the United States, Brazil, Chile, and Rachel McMullen for their ideas, suggestions, assis-
and Japan, who provided us with many ideas for revi- tance, and patience for this edition.
sions, collected many of the articles used as references, My teachers, colleagues, and mentors, who encour-
and helped us with many of the tables. aged me to pursue my chosen career.
The many authors and publishers, who were kind To these people and many others—thank you for your
enough to allow us to use their photographs, drawings, help, ideas, and encouragement. Your support played a
and tables in the text so that explanations could be clearer large part in the success and completion of this book.
and more easily understood. Without these additions, the
book would not be what we hoped for. David J. Magee, PhD, BPT, CM
Ted Huff and Jodie Bernard, our medical illustrators, 2020
whose skills and attention to detail have made a signifi-
cant contribution to the success of Orthopedic Physical
Assessment.
v
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Acknowledgments
I would first and foremost like to thank David Magee for would not work without Bev’s unyielding friendship,
allowing me to help with this 7th edition of Orthopedic attention to detail, persistence, and amazing organiza-
Physical Assessment. I commonly refer to this text as the tional skills. She is an amazingly, wonderful person who is
“Orthopedic Bible.” I feel extremely blessed to have always looking out for our best interests. Thank you, Bev!
David mentor me through the process of revising a book Thirdly, I would like to thank the faculty, staff,
of this magnitude and significance. Despite many unex- and students at Wichita State University where I have
pected events during this revision, David has always been worked for the last 23 years, all of my many colleagues
gracious, kind, and patient with me through this process. I have worked with at various Via Christi–Ascension
It is never easy to give up control. However, he has slowly locations in Wichita over the last 25 years, and past
and patiently handed me pieces of rope, bit by bit, making and present patients who allow me to use the various
sure that he did not give me enough to hang myself. He tests from this book to help determine their orthopedic
has taught me so much more than he will ever realize— issues. They all drive me to continue to enhance my edu-
things like taking pride in your work, overall work ethic, cation and become not only a better teacher, but more
attention to detail, dependability, fairness, honesty, integ- importantly a better clinician. You are all incredibly tal-
rity, and humility to name just a few. The 7th edition of ented therapists and staff and your friendship means so
Orthopedic Physical Assessment with David and Bev will much to me.
probably be one of my proudest work accomplishments. Finally, thank you to my beautiful wife, Julie, and
Secondly, I want to thank Bev Evjen. David told me our unbelievable children, Rachael, Halle, and Tyler.
many years ago when we worked on our Athletic and Sport Thank you for adding so much to my life.
Issues book, how important Bev is to Orthopedic Physical
Assessment and the whole Musculoskeletal Rehabilitation Robert C. Manske, PT, DPT, MEd, SCS, ATC, CSCS
Series. That was a complete understatement. This process 2020
vi
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CHAPTER 1
Principles and Concepts
A musculoskeletal assessment requires a proper and thor- examiner should focus attention on only one aspect of the
ough systematic examination of the patient. A correct assessment at a time, for example, ensuring a thorough
diagnosis depends on a knowledge of functional anatomy, history is taken before completing the examination com-
an accurate patient history, diligent observation, and a ponent. When assessing an individual joint, the examiner
thorough examination. The differential diagnosis process must look at the joint and injury in the context of how the
involves the use of clinical signs and symptoms, physi- injury may affect other joints in the kinetic chain. These
cal examination, a knowledge of pathology and mecha- other joints may demonstrate changes as they try to com-
nisms of injury, provocative and palpation (motion) tests, pensate for the injured joint.
and laboratory and diagnostic imaging techniques. It is Each chapter ends with a summary, or précis, of the
only through a complete and systematic assessment that assessment procedures identified in that chapter. This
an accurate diagnosis can be made. The purpose of the section enables the examiner to quickly review the perti-
assessment should be to fully and clearly understand the nent steps of assessment for the joint or structure being
patient’s problems, from the patient’s perspective as well assessed. For further information, the examiner can refer
as the clinician’s, and the physical basis for the symptoms to the more detailed sections of the chapter.
that have caused the patient to complain. As James Cyriax
stated, “Diagnosis is only a matter of applying one’s
Total Musculoskeletal Assessment
anatomy.”1
One of the more common assessment recording tech-
• Patient history
niques is the problem- oriented medical records method,
• Observation
which uses “SOAP” notes.2 SOAP stands for the four
• Examination of movement
parts of the assessment: Subjective, Objective, Assessment, • Special tests
and Plan. This method is especially useful in helping the • Reflexes and cutaneous distribution
examiner to solve a problem. In this book, the subjective • Joint play movements
portion of the assessment is covered under the heading • Palpation
Patient History, objective under Observation, and assess- • Diagnostic imaging
ment under Examination.
Although the text deals primarily with musculoskeletal
Patient History
physical assessment on an outpatient basis, it can easily be
adapted to evaluate inpatients. The primary difference is Ideally, the environment for the assessment should be pri-
in adapting the assessment to the needs of a bedridden vate and as free of distractions as possible. The examiner
patient. Often, an inpatient’s diagnosis has been made should always introduce himself or herself to the patient
previously, and any continuing assessment is modified to and then sit beside or in front of the patient to enhance
determine how the patient’s condition is responding to the notion that the examiner is focused on the patient.
treatment. Likewise, an outpatient is assessed continu- Showing kindness and respect help to create an environ-
ally during treatment, and the assessment is modified to ment that facilitates the exchange of information.3
reflect the patient’s response to treatment. A complete medical and injury history should be taken
Regardless of which system is selected for assessment, and written to ensure reliability. This requires effective
the examiner should establish a sequential method to and efficient communication on the part of the examiner
ensure that nothing is overlooked. The assessment must and the ability to develop a good rapport with the patient
be organized, comprehensive, and reproducible. In gen- and, in some cases, family members and other members of
eral, the examiner compares one side of the body, which the health care team. This includes speaking at a level and
is assumed to be normal, with the other side of the body, using terms the patient will understand (common sense
which is abnormal or injured. For this reason, the exam- questions); taking the time to listen; and being empathic,
iner must come to understand and know the wide vari- interested, caring, and professional.4 Naturally, empha-
ability in what is considered normal. In addition, the sis in taking the history should be placed on the portion
1
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publication.
2 Chapter 1 Principles and Concepts
of the assessment that has the greatest clinical relevance. TABLE 1.1
Often the examiner can make the diagnosis by simply
Red Flag Findings in Patient History That Indicate
listening to the patient.5,6 This really means the patient,
Need for Referral to Physician
with the appropriate prompting, will tell the clinician
about the complex symptoms that leads the clinician to Cancer • Persistent pain at night
make the appropriate diagnosis.6 No subject areas should • Constant pain anywhere in the body
• Unexplained weight loss (e.g.,
be skipped. Repetition helps the examiner to become
4.5–6.8 kg [10–15 lbs] in 2 weeks or
familiar with the characteristic history of the patient’s
less) (5% or more in 4 weeks)
complaints so that unusual deviation, which often indi-
• Loss of appetite
cates problems, is noticed immediately. Even if the diag-
• Unusual lumps or growths
nosis is obvious, the history provides valuable information
• Unwarranted fatigue
about the disorder, its present state, its prognosis, and the • Change in bowel or bladder habits
appropriate treatment. The history also enables the exam- • Sores that will not heal
iner to determine the type of person the patient is, his • Unusual bleeding or discharge
or her language and cognitive ability, the patient’s abil- • Obvious change in wart or mole
ity to articulate, any treatment the patient has received, • Nagging cough or hoarseness
and the behavior of the injury. In addition to the history Cardiovascular • Shortness of breath
• Dizziness
of the present illness or injury, the examiner should note
• Pain or a feeling of heaviness in the
relevant past history, treatment, and results. Past medical
chest
history should include any major illnesses, surgery, acci-
• Pulsating pain anywhere in the body
dents, or allergies. In some cases, it may be necessary to
• Constant and severe pain in lower leg
delve into the social and family histories of the patient if
(calf) or arm
they appear relevant. Lifestyle habit patterns, including • Discolored or painful feet
sleep patterns, stress, workload, and recreational pursuits, • Swelling (no history of injury)
should also be noted. Gastrointestinal/ • Frequent or severe abdominal pain
It is important that the examiner politely but firmly keeps Genitourinary • Frequent heartburn or indigestion
the patient focused and discourages irrelevant information. • Frequent nausea or vomiting
Questions and answers should provide practical informa- • Change in or problems with bowel
and/or bladder function (e.g.,
tion about the problem. In addition, the examiner should
urinary tract infection), incontinence
listen for any potential red flag signs and symptoms (Table
• Unusual menstrual irregularities
1.1) that would indicate the problem is not a musculoskel-
Miscellaneous • Fever or night sweats
etal one or could be more serious pathology that should
• Recent severe emotional disturbances
be referred to the appropriate health care professional.7–9
• Swelling or redness in any joint with
Serious systemic pathology may be indicated by sweating, no history of injury
pallor/flushing, sallow/jaundiced complexion, tremors/ • Pregnancy
shaking, increased body temperature, and altered blood Neurological • Changes in hearing
pressure. A lone red flag would not necessarily indicate • Frequent or severe headaches with
serious pathology. It should be considered in the context no history of injury
of the individual’s history and the findings of assessment.9 • Problems with swallowing or changes
in speech
Yellow flag signs and symptoms are also important for
• Changes in vision (e.g., blurriness or
the examiner to note as they denote problems that may be
loss of sight)
more severe or may involve more than one area requiring
• Problems with balance, coordination,
a more extensive examination, or they may relate to cau-
or falling
tions and contraindications to treatment that the examiner
• Fainting spells (drop attacks)
might have to consider, or they may indicate overlying psy- • Sudden weakness
chosocial issues that may affect treatment.10 • Bilateral pins and needles
The patient’s history is usually taken in an orderly
sequence. It offers the patient an opportunity to describe Adapted from Stith JS, Sahrmann SA, Dixon KK, et al: Curriculum to
the problem and the limitations caused by the problem prepare diagnosticians in physical therapy, J Phys Ther Educ 9:50, 1995.
as he or she perceives them. To achieve a good func-
tional outcome, it is essential that the clinician heed to affects the patient’s quality of life.11 The clinician should
the patient’s concerns and expectations for treatment. ask questions that are easy to understand and should not
After all, the history is the patient’s report of his or her lead the patient. For example, the examiner should not
own condition. Sometimes, patients’ reported outcomes say, “Does this increase your pain?” It would be better
are included as part of the history. These outcomes give to say, “Does this alter your pain in any way?” The exam-
the status of the patient’s health and problems and are iner should ask one question at a time and receive an
given directly by the patient and how the problem(s) answer to each question before proceeding with another
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Chapter 1 Principles and Concepts 3
they are not used to. Habitual postures and repetitive
Yellow Flag Findings in Patient History That strain caused by some occupations may indicate the
Indicate a More Extensive Examination May Be location or source of the problem.
Required
3. Why has the patient come for help? This is often re-
• Abnormal signs and symptoms (unusual patterns of complaint) ferred to as the history of the present illness or
• Bilateral symptoms chief complaint.3 This part of the history provides
• Symptoms peripheralizing an opportunity for patients to describe in their own
• Neurological symptoms (nerve root or peripheral nerve) words what is bothering them and the extent to
• Multiple nerve root involvement which it bothers them. It is important for the clini-
• Abnormal sensation patterns (do not follow dermatome or peripheral
cian to determine what the patient wants to be able
nerve patterns)
to do functionally and what the patient is unable to
• Saddle anesthesia
do functionally. In other words, is there a functional
• Upper motor neuron symptoms (spinal cord) signs
limitation? It is often this functional limitation that
• Fainting
leads the patient to seek help. It is also essential to en-
• Drop attacks
• Vertigo sure that the clinician knows what is important to the
• Autonomic nervous system symptoms patient in terms of outcome, whether the patient’s
• Progressive weakness expectations for the following treatment are realistic,
• Progressive gait disturbances and what direction functional treatment should take
• Multiple inflamed joints to ensure the patient can, if at all possible, return to
• Psychosocial stresses his or her previous level of activity or realize his or
• Circulatory or skin changes
her expected outcome.13
4. Was there any inciting trauma (macrotrauma) or re-
question. Open- ended questions ask for narrative infor- petitive activity (microtrauma)? In other words, what
mation; closed or direct questions ask for specific infor- was the mechanism of injury, and were there any
mation. Direct questions are often used to fill in details predisposing factors? If the patient was in a motor ve-
of information given in open-e nded questions, and they hicle accident, for example, was the patient the driver
frequently require only a one- word answer, such as yes or the passenger? Was he or she the cause of the ac-
or no. In any musculoskeletal assessment, the examiner cident? What part of the car was hit? How fast were
should seek answers to the following pertinent questions. the cars going? Was the patient wearing a seat belt?
1. W hat is the patient’s age and sex? Many conditions When asking questions about the mechanism(s) of in-
occur within certain age ranges. For example, vari- jury, the examiner must try to determine the direction
ous growth disorders, such as Legg- Perthes disease and magnitude of the injuring force and how the force
or Scheuermann disease, are seen in adolescents or was applied. By carefully listening to the patient, the
teenagers. Degenerative conditions, such as osteoar- examiner can often determine which structures were
thritis and osteoporosis, are more likely to be seen injured and how severely by knowing the force and
in an older population. Shoulder impingement in mechanism of injury. For example, anterior disloca-
young people (15 to 35 years) is more likely to result tions of the shoulder usually occur when the arm is ab-
from muscle weakness, primarily in the muscles con- ducted and laterally rotated beyond the normal range
trolling the scapula, whereas the condition in older of motion (ROM), and the “terrible triad” injury to
people (40+ years) is more likely to be the result the knee (i.e., medial collateral ligament, anterior cru-
of degenerative changes in the shoulder complex. ciate ligament, and medial meniscus injury) usually re-
Some conditions show sex and even race differences. sults from a blow to the lateral side of the knee while
For example, some cancers are more prevalent in the knee is flexed, the full weight of the patient is on
men (e.g., prostate, bladder), whereas others occur the knee, and the foot is fixed. Likewise, the examiner
more frequently in women (e.g., cervical, breast), should determine whether there were any predispos-
yet still others are more common in white people. ing, unusual, or new factors (e.g., sustained postures
2. W hat is the patient’s occupation? What does the pa- or repetitive activities, general health, or familial or ge-
tient do at work? What is the working environment netic problems) that may have led to the problem.14
like? What are the demands and postures assumed?12 5. Was the onset of the problem slow or sudden? Did the
For example, a laborer probably has stronger mus- condition start as an insidious, mild ache and then
cles than a sedentary worker and may be less likely progress to continuous pain, or was there a specific
to suffer a muscle strain. However, laborers are more episode in which the body part was injured? If in-
susceptible to injury because of the types of jobs citing trauma has occurred, it is often relatively easy
they have. Because sedentary workers usually have to determine the location of the problem. Does the
no need for high levels of muscle strength, they may pain get worse as the day progresses? Was the sud-
overstress their muscles or joints on weekends be- den onset caused by trauma, or was it sudden with
cause of overactivity or participation in activity that locking because of muscle spasm (spasm lock) or
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publication.
4 Chapter 1 Principles and Concepts
Sensory
Physiological Affective
Intensity
Location Quality Mood state
Onset Pattern Anxiety
Duration Depression
Etiology Well-being
Syndrome
PAIN
Cognitive Behavioral Sociocultural-Ethnocultural
Meaning of pain Communication Family and social life
View of self Interpersonal interaction Work and home responsibilities
Coping skills and strategies Physical activity Recreation and leisure
Previous treatment Pain behaviours Environmental factors
Attitudes and beliefs Medications Attitudes and beliefs
Factors influencing pain Interventions Social influences
Sleep
Fig. 1.1 The dimensions of pain. (Redrawn from Petty NJ, Moore AP: Neuromusculoskeletal examination and assessment: a handbook for therapists,
London, 1998, Churchill- Livingstone, p 8.)
pain? Is there anything that relieves the symptoms? Chronic pain is more aggravating, is not as intense,
Knowledge of these facts helps the examiner to make and has been experienced before, and in many cases,
a differential diagnosis. the patient knows how to deal with it. Acute pain is
6. W here are the symptoms that bother the patient? If pos- more often accompanied by anxiety, whereas chron-
sible, have the patient point to the area. Does the ic pain is associated with depression.19 When tissue
patient point to a specific structure or a more general has been damaged, substances are released leading
area? The latter may indicate a more severe condi- to inflammation and peripheral sensitization of the
tion or referral of symptoms (yellow flag). The way nociceptors (also called primary hyperalgesia) re-
in which the patient describes the symptoms often sulting in localized pain. If the injury does not fol-
helps to delineate problems. Has the dominant or low a normal healing pathway and becomes chronic,
nondominant side been injured? Injury to the domi- central sensitization (also called secondary hyper-
nant side may lead to greater functional limitations. algesia) may occur. Peripheral sensitization is a local
Are the problems local (e.g., a sprain) or systemic phenomenon, whereas central sensitization is a more
(e.g., rheumatoid arthritis)? central process involving the spinal cord and brain.
7. W here was the pain or other symptoms when the pa- Central sensitization manifests itself as widespread
tient first had the complaint? Pain is subjective, and hypersensitivity to such physical, mental, and emo-
its manifestations are unique to each individual. It tional stressors as touch, mechanical pressure, noise,
is a complex experience involving several dimensions bright light, temperature, and medication.20,21
(Fig. 1.1).15,16 If the intensity of the pain or symp- Has the pain moved or spread? The location and
toms is such that the patient is unable to move in a spread of pain may be marked on a body chart, which
certain direction or hold a particular posture because is part of the assessment sheet (eAppendix 1.1). The
of the symptoms, the symptoms are said to be severe. examiner should ask the patient to point to exactly
If the symptoms or pain become progressively worse where the pain was and where it is now. Are trigger
with movement or the longer a position is held, the points present? Trigger points are localized areas of
symptoms are said to be irritable.17,18 Acute pain is hyperirritability within the tissues; they are tender to
new pain that is often severe, continuous, and perhaps compression, are often accompanied by tight bands
disabling and is of sufficient quality or duration that of tissue, and, if sufficiently hypersensitive, may give
the patient seeks help. Acute injuries tend to be more rise to referred pain that is steady, deep, and aching.
irritable resulting in pain earlier in the movement, or These trigger points can lead to a diagnosis, because
minimal activity will bring on symptoms, and often pressure on them reproduces the patient’s symptoms.
the pain will remain after movement has stopped.4 Trigger points are not found in normal muscles.22
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