ASSESSMENT MUSCULOSKELETAL ASSESSMENT

BY JULIAN HATCHER, MCSP

A CLINICAL ORTHOPAEDIC EXAMINATION The following subheadings make the whole clinical assessment easier to breakdown for the purpose of greater understanding. This is the stage where an unknown client enters your clinic, requiring your professional services. After introducing yourself, you need to sit down with the client and glean a subjective history from them. n The subjective history is literally exploring what the client feels has happened to them and how it is affecting them now. n The objective examination, which comes after this, allows the therapist to perform a series of objective tests – namely passive and resisted movements. The process of assessment is

essentially putting together several pieces of a puzzle, and then standing back to try to recognise the picture. It is rare that assessment yields every piece, so some sound anatomical knowledge and clinical reasoning skills will be needed for more complex patterns of clinical findings, and it is this particular skill that is hardest to gain. The therapist looks for specific key elements (e.g. onset, behaviour and symptoms) in much the same way that a detective looks for key elements in any investigation (e.g. motive, opportunity, forensic evidence). Diagnosis is not, therefore, made on the basis of a single positive finding, but on a pattern of clinical features.

SUBJECTIVE EXAMINATION Observation Face, posture and gait This is the first stage and it is particularly important to gauge how much pain and discomfort the client is in; one of the most accurate ways of

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MUSCULOSKELETAL ASSESSMENT

PART 2: CLINICAL ORTHOPAEDIC EXAMINATION

doing this is to observe their face when they walk in the clinic and when you introduce yourself to them. At this point they are unaware that you may be observing them and will tend to act in a more natural manner. The face can give clear indications of pain whether severe or prolonged and may also give an idea of whether they have had disturbed sleep! It is a good opportunity to observe their posture also and the way they move and walk. Someone with an ankle problem may walk on their heel with a relatively fixed and extended knee, whilst someone with a knee problem may well walk on their toes in order to prevent full knee extension.

SUBJECTIVE HISTORY The next stage is to take the subjective history. Several questions need to be asked in order to help with the diagnostic process. The order of questions is ultimately a personal preference and does not have to follow the format set out below. It is worth noting however that it is highly likely that as a therapist you will need to ask someone to get relatively undressed, you are also going to invade their ‘personal space’ by physically handling their limbs or body in some manner. Given these considerations it is really important to gain some rapport with the client as quickly as possible so asking them questions about themselves that are more general (but no less important) in nature early may be a good tactic. You can then follow

up with the more personal questions towards the end of the subjective interview. It may also be helpful as an aide memoir to use the following keywords as a template interview as these are linked together as pairs.

Age and occupation Age is a useful starting point because it helps establish rapport but it may also offer some clues as to the injury, for example, slipped epiphysis in young adolescent boys, or degenerative conditions in the over 50s. Paired with age is occupation,

it is important to establish exactly what the client does for a living. Are they a professional athlete, or are they a recreational athlete. Either way what you need to establish is what activity levels you have to get them back to as part of your treatment plan. It goes without saying that a professional athlete is likely to require more rehabilitation than that of an office worker who plays a little tennis at weekends. Equally it needs to be established whether work or recreational activity may have any impact on the current injury – either causative or preventing recovery in some way.

Site and spread Asking the client to indicate where they feel their problem is can be enlightening as it may indicate whether the problem is a local one, or referred from elsewhere in the body. If one

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