Orthopaedic Assessment
University of Stellenbosch Physiotherapy
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Patient Information
Basic demographics and referral details
Interview
Main complaint, history of current condition
Onset of symptoms, progression, mechanism of injury, etc.
Timeline
| Date | Description |
|---|
Body Chart
Mark symptom areas on the body diagram
Anterior
Posterior
✕ Pain · //// Pins & Needles · ○ Numbness · ∷ Paraesthesia
Symptom Area Details
Area 1
0
Constant
Intermittent
Deep
Superficial
Area 2
0
Constant
Intermittent
Deep
Superficial
Area 3
0
Constant
Intermittent
Deep
Superficial
Area 4
0
Constant
Intermittent
Deep
Superficial
Previous & Social History
Past medical history and social context
Other similar problems, other relevant medical history
Home situation, family, work, transport, leisure, sport
Work, leisure, activities of daily living
Behaviour of Symptoms
24-hour pattern, aggravating and easing factors
24-Hour Behaviour
↑ Worsens
↓ Eases
No effect
Improved
Static
Worsened
Special Questions & Medication
Red flags, screening questions, current medications
General Health & Red Flags
Smoking
Alcohol
COPD
Diabetes
Hypertension
Osteoporosis
OA
RA
Cancer
TB
Wt loss
Dizziness, facial P&N/tingling, drop attacks, swallowing/speaking/vision problems
Negative
Positive
Bilateral symptoms, gait problems, bladder/bowel symptoms
Negative
Positive
Saddle anaesthesia, bladder/bowel symptoms (urgency, frequency)
Negative
Positive
Medication
| Type | Dosage | Effect |
|---|
X-rays & Investigations
| Area | Date | Findings |
|---|
e.g. McGill, Oswestry, LEFS, PSFS, PDI
Planning of Physical Evaluation
Structures to evaluate and contributing factors
| Area | Joints | Myofascial | Ligaments | Neurological | Other |
|---|
e.g. movement patterns, posture
SIN Factors
Yes
No
Yes
No
Mechanical
Inflammatory
Neural
Non-benign
Visceral
Other
Not SIN
SIN
Pain Mechanisms
Nociceptive somatic
Peripheral neurogenic
Visceral
Central neurogenic
Affective
Cognitive
Motor
Endocrine
Autonomic
Immune
Precautions & Contra-indications
Special Tests Before Evaluation
Babinski
VBI
DVT
Clonus
Joint stability
Observation & Function
Informal and formal observation, functional activities
Informal
Formal
Function
| Functional Activity | How Patient Does It / Missing Components |
|---|
Joint Tests
ROM, APM, PPM, joint stability
Active Physiological Movement (APM)
| Movement | ROM | Limitation / Area |
|---|
Passive Physiological Movement (PPM)
| Movement | ROM | Limitation / Area |
|---|
Joint Stability Tests
| Test | Tests For | Result |
|---|
Yes
No
Muscle Tests
Strength, length, and control
Muscle Strength Testing
| Muscle | Iso L | Iso R | Grade L | Grade R | Sx Response |
|---|
Stabilisers
| Muscle | Level |
|---|
Muscle Length Testing
| Muscle (R/L) | ROM | Interpretation |
|---|
Neurological Evaluation
Neural integrity, conduction, and neurodynamics
Neural Integrity / Conduction
Neurodynamics / Neural Mobility
| Test | Results (components, etc.) |
|---|
Palpation
Temperature, soft tissue, bony alignment, joint palpation
Normal
↑ Increased
↓ Decreased
Normal
↑ Increased
↓ Decreased
Soft Tissue & Bony Alignment
| Structure / Area | Left | Right |
|---|
Joint Palpation (PAM / PAIVM)
| Technique | Joint | L/R | ROM | Sx Response |
|---|
Yes
No
| Joint | Circumference L | Circumference R |
|---|
Movement Diagram
Draw the movement diagram for the comparable sign
Hypothesis & Comparable Signs
Clinical reasoning summary
Comparable Signs
| # | Comparable Sign |
|---|
Problem List
Functional limitations, impairments, and treatment plan
| Functional Problem / Activity Limitation | Missing Components / Signs & Symptoms | Underlying Reasons | Treatment Plan |
|---|
Goals
Short-term and long-term rehabilitation goals
Outcome Levels & Discharge
Functional outcome goals for discharge planning
0
Physiological Instability
I
Physiological Stability
II
Physiological Maintenance
III
Residential Re-integration
IV
Community Re-integration
V
Productive Activity
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