Observation

Acknowledgment

  • Dr. Joel Fuller

  • Dr. Niamh Moloney

2. Observation
Key Concepts

  • LOOK: The primary action in observation, referring to a thorough visual examination of the patient's entire physical presentation, involving an assessment of the overall posture, symmetry, movements, and any visible abnormalities. This initial assessment guides subsequent physical examination steps.

Types of Observation

Static Observation

  • Focus on identifying:

    • Postural Abnormalities or Asymmetry: Observing the alignment and posture of the body when standing, sitting, or lying still. Look for deviations such as scoliosis, kyphosis, lordosis, limb length discrepancies, pelvic tilt, valgum/varum deformities of the knees, and shoulder height differences.

    • Bony Abnormalities: Noticing any irregularities in bone structure, contour, or alignment. This includes exostoses, malunion of fractures, or gross deformities.

    • Example: Haglund's Deformity of the heel, characterized by a bony enlargement on the back of the heel bone (calcaneus).

    • Muscle Atrophy/Hypertrophy: Assessing the size and bulk of muscles. Atrophy (wasting away) may indicate disuse, nerve damage, or chronic conditions, while hypertrophy (enlargement) can suggest compensatory mechanisms or overuse.

    • Swelling: Noticing any areas of localized or generalized swelling (oedema) which may indicate acute injury (e.g., effusion), inflammation, infection, or systemic issues. Assess for joint effusions versus soft tissue swelling.

    • Skin Changes: Observing changes in skin color (e.g., erythema/redness, pallor, ecchymosis/bruising), texture (e.g., smooth, rough, scaly), temperature, integrity (e.g., open wounds, rashes, ulcers), and the presence of any trophic changes.

    • Scars: Presence of scars indicating previous injuries, surgeries, or conditions. Assess their size, location, adherence to underlying tissues, and potential impact on movement or sensation.

Dynamic Observation

  • Observe the movement causing the greatest functional disturbance, paying close attention to the quality and control of movement, not just the range:

    • Can the patient perform the movement?: Assess the patient's ability to execute particular movements, noting any limitations in range, speed, smoothness, or control.

    • Compensation Strategies Utilized: Identification of alternative movement patterns or strategies patients use to perform movements, which may indicate impairment, weakness, pain avoidance, or joint instability (e.g., Trendelenburg gait, shoulder hiking during arm elevation, trunk leaning).

    • Pain Behaviors: Observation of where and when the patient exhibits signs of pain, such as facial grimacing, guarding (protective muscle spasm), verbal cues, or hesitation during movement.

    • Effects of Corrections: Monitoring what happens when adjustments are made to the patient's posture or movement patterns. This helps determine if the dysfunction is modifiable and if the correction alleviates symptoms or improves movement quality.

3. Move
Active Movement Testing

  • Assessment of the range, quality, and symptom reproduction during active patient-initiated movement will be discussed in more detail in the next session. This typically includes looking for the patient's willingness to move, movement patterns, and symptom provocation.

4. Feel
Palpation

  • Definition: Palpation is the process of examining the body by touch, specifically to confirm or refute a preliminary hypothesis rather than to form the initial diagnosis. It involves using the hands and fingertips to detect size, shape, consistency, temperature, texture, and tenderness of anatomical structures.

  • Techniques:

    • Start Globally, Move Locally: Begin with a wide, general area to build rapport, assess overall tissue quality, and then gradually focus in on specific locations suspected of involvement. This prevents surprising the patient with a painful direct touch.

    • Cover Lateral, Superior, and Inferior Structures: Ensure comprehensive examination of all aspects of the joint or area of interest, systematically palpating structures surrounding the suspected pathology.

    • Use Bony Landmarks: Utilize identifiable bones, such as epicondyles, malleoli, or spinous processes, as precise reference points to accurately locate and palpate adjacent soft tissues, ligaments, and tendons.

    • Compare to the Other Side: Always compare findings to the contra-lateral, asymptomatic side of the body. This provides a baseline for what is normal for the individual and helps identify subtle differences in temperature, tenderness, or structure.

    • Be Systematic: Follow a methodical approach (e.g., starting superficial and moving deep, or proximal to distal) to ensure all relevant areas are examined thoroughly and consistently, reducing the chance of missing important findings.

    • Iterative Process: Palpation is not a one-time step. Reassess areas as needed based on new findings from observation, movement testing, or patient feedback. The examination continually refines the focus.

    • Identifying Symptoms: Look for one specific area that reproduces the patient's concordant (familiar) symptoms more so than others. Confirm findings through clear, open-ended patient feedback (e.g., "Does this feel like your pain?").

Possible Information Gain from Palpation

  • Skin Temperature: Assessing for abnormal warmth (indicating inflammation, infection, or increased vascularity) or coolness (suggesting poor circulation, chronic conditions, or nerve impingement).

  • Pain/Tenderness: Localizing specific pain areas and assessing the degree of tenderness. Differentiate between primary hyperalgesia (increased pain sensitivity at the site of injury), secondary hyperalgesia (increased pain sensitivity in surrounding uninjured tissue), and allodynia (pain from a stimulus that does not normally cause pain).

  • Bony Prominences/Deformation: Identifying fractures, dislocations, bony enlargements, crepitus, or structural changes that may be palpable.

  • Muscle Spasms/Tone/Trigger Points: Evaluating muscle condition, identifying areas of increased tone (hypertonicity, spasticity, rigidity), muscle guarding, and active or latent myofascial trigger points (taut bands with localized tenderness and possible referred pain).

  • Characteristics of Swelling/Oedema: Assessing the type, location, consistency (e.g., soft, firm, fluctuant, boggy), and presence of pitting (indicating fluid accumulation) of swelling or oedema. Differentiate between intra-articular effusion and extra-articular soft tissue oedema.

  • Neurological Deficits: Identifying areas of loss of sensation (anesthesia), altered sensation (paresthesia like numbness or tingling), or other neurological issues through light touch, sharp/dull discrimination, proprioception, or vibratory perception testing.

Purpose of Examination
Testing Conduction of Spinal Nerves

  • Indications for Assessment: Assessment of spinal nerve conduction is crucial when symptoms suggest nerve root irritation or compression (radiculopathy).

    • Pain in a dermatomal distribution: Pain, numbness, or tingling that follows the sensory distribution pattern of a specific spinal nerve root (e.g., sciatica down the leg in an S1 dermatome).

    • Radiating pain past the buttock (lumbar spine) or shoulder (cervical spine): Pain that extends distally into the limb, often indicating nerve root involvement rather than purely local soft tissue pain.

    • Altered sensations in upper or lower limbs: Patients reporting symptoms such as numbness, pins and needles (paresthesias), burning, or a sensation of weakness, which can be indicative of nerve compromise.

    • Pain in limbs potentially related to cervical or lumbar spine conditions: When limb pain cannot be explained by local pathology and presents with features consistent with a spinal origin.

Note for Semester B

  • The Neurological Exam, including detailed sensory, motor, and reflex testing, will be covered in more detail in Semester B.

Special Tests
Purpose

  • Special tests are specific diagnostic maneuvers designed to selectively stress or examine the involvement of specific structures (e.g., ligaments, tendons, menisci, labrum, nerves) in the periphery. They are used to further confirm or refute preliminary hypotheses developed during observation, palpation, and movement assessment, enhancing the diagnostic accuracy.

Examples of Special Tests

  • Knee Tests:

    • Lachman’s Test: Assesses the integrity of the anterior cruciate ligament (ACL). Performed with the knee in $20-30$ degrees of flexion, the examiner applies an anterior translation force posterior to the tibia while stabilizing the distal femur. A soft or absent end-feel with increased anterior translation indicates a positive test.

  • Shoulder Tests:

    • O’Brien’s Test (Active Compression Test): Evaluates for superior labral tear from anterior to posterior (SLAP lesion) or acromioclavicular (AC) joint pathology. The patient actively flexes the shoulder to 9090 degrees, adducts 10−1510-15 degrees, and internally rotates with the thumb pointing down. Resistance is applied. The test is repeated with the thumb pointing up (external rotation). Pain or a click felt deep inside the shoulder with internal rotation that is reduced with external rotation suggests a SLAP lesion. AC joint pain may also be elicited.

Note for Semester B

  • Specific tests for various joints and conditions will be taught in coming sessions, including their rationale, technique, and interpretation.

References

  • Magee DJ. Orthopedic Physical Assessment. 6th ed. London: Elsevier Health Sciences; 2014.

  • Richards KV, Beales DJ, Smith AJ, O’Sullivan PB, Straker LM. Neck posture clusters and their association with biopsychosocial factors and neck pain in Australian adolescents. Physical Therapy. 2016;96:1576-1587.

  • International Classification of Functioning, Disability and Health: ICF, 2001. World Health Organization Website. www.who.int/classifications/icf/en/. Updated January 27, 2017. Accessed July 17, 2017.