INTRODUCTION

The evaluation for treatment consultation between a physician and a patient is at the center of all orthopedic practice activities.

From the moment of the first encounter with a patient, the physician is simultaneously observing and examining the movements and mannerisms of the patient, as well as listening to what is being said. The physician is trying to piece together the nature of the patient’s orthopedic problem.

The purpose of orthopedic evaluation is twofold. First, it allows the patient to present the problem, and second, it enables the physician to triage the nature of the problem and develop a course of action. In this context, the physician must always learn what has brought the patient to the consultation. In some cases a patient visits the orthopedic specialist because of referral by or on the advice of a third party. The diagnostic process is also complex, given that the physician needs to establish the physical issues that are of greatest importance to the patient and that are most disrupting to the activities of daily living, as well as try to differentiate the anatomic and pathologic aspects of any disease that might be present.

The history provides much information about the pathologic process involved and the impact of the condition on the patient, whereas the orthopedic physical examination is essential to define the anatomic structures involved; together these processes allow differentiation of orthopedic disorders into various categories.

Health care providers assess patients every day in clinical practice. Commonly, clinical practice is impossible without structured assessments and tests. Examination procedures look straightforward; results are either positive or negative. However, all assessment and testing in clinical practice is based on the assumption of uncertainty: Does the patient have a disease? The probability of a particular disease can be established only by performing a test from a chain of tests.

The accuracy of a test for detecting a disease or a condition is determined by sensitivity and specificity. A high sensitivity (or a high specificity) does not suffice to make a test useful in clinical practice; a test should be as sensitive as possible. The sensitivity and specificity of examination procedures and tests can often be found in the literature. Sensitivity and specificity are important characteristics of evidence-based physical assessment procedures but only in the context of a specific disease or condition.

The probability of a disease or condition after having performed a test (Bayes theorem) is dependent on two factors: (1) the specificity and sensitivity of the procedure (test characteristics) and (2) the probability of the disease or condition before conducting the procedure. Interpretation of Bayes theorem is that the probability of having a disease is not only dependent on the test or examination procedure result and the characteristics of the procedure, but also dependent on how likely the existence of the disease before the procedure is actually conducted. This factor is dependent on the prevalence of the disease.

The decision of whether to perform a new test depends on the result of the previous test. Procedures with the lowest burden, risk, and costs for the patient are performed first, and those with the highest burden, risk, or costs are reserved for certain patients in which the prior probability is highest. Examination procedures in the context of a low prior probability of disease are rarely, if ever, informative, with the yield of diagnostic testing that will increase the prior probability approximating 50%. Very experienced clinicians intuitively apply these rules and arrange their diagnostic process in such a way that the highest possible yield (a highly probable diagnosis) will be obtained at the lowest possible burden, risk, and cost for the patient. Less-experienced clinicians may learn from experienced colleagues by recalling Bayes theorem and implementing its principles in everyday clinical practice.

Health care providers cannot function adequately without physical examination procedures. In the real world, examiners accomplish clinical practice appropriately without a detailed knowledge of the principles of tests. However, the benefits from physical testing can be easily increased by recognizing that these tests do nothing more than increase the probability of a certain condition or diagnosis. Test results are never infallible.

From the moment of the first encounter with a patient, the examiner is simultaneously observing and examining the movements and mannerisms of the patient, as well as listening to what is being said. The diagnostic process is complex; the examiner needs to establish the physical issues that are of greatest importance to the patient (those most disrupting to the activities of daily living) and try to differentiate the anatomic and pathologic aspects of any disease or injury that might be present.

The history provides much information about what difficulties the patient is experiencing and the impact of these on the patient. Orthopedic examination is essential to define the structures involved; together, these processes allow differentiation of orthopedic disorders into various diagnostic categories (Box 1-1).

HISTORY

A carefully elicited history is a most crucial element in orthopedic assessment. An experienced examiner can form an idea of the extent and magnitude simply from the patient’s history. In the modern era of electronic patient medical record keeping, the examiner has new tools and methods for not only capturing patient information, but also tracking clinically significant changes.

CHIEF COMPLAINT

Patients who have more than one complaint, such as those with pain of spinal origin coupled with other body region symptoms or extremity problems, must be guided in ranking the complaints in priority. Although patients occasionally seek attention for stiffness or some other joint-related complaint, most patients with musculoskeletal conditions do so for reasons related to pain, especially when it compromises the activities of daily living.

OBSERVATION AND INSPECTION

A useful approach in clinical examination of the neuromusculoskeletal system is to seek answers to the Critical 5 questions for an orthopedic specialist. Once all five questions are answered, a differential diagnosis can usually be established (Box 1-2).

The physician needs to learn what exacerbates or relieves the symptom pattern. Equally important is how long the complaints have existed (Table 1-1).

PALPATION

Palpation is the process of assessing the physical characteristics of joints and contiguous structures by touching or feeling the patient’s body. The purpose of palpation is to locate and substantiate areas of tenderness, swelling, and abnormal muscle tone. Palpation allows the examiner to identify a localized increase or decrease in surface temperature and the presence of induration and mass. Palpation is classically performed with the fingertips, or with the blunt end of a cotton-tip applicator. However, instruments can be used in percussion (gently tapping with a reflex hammer), with vibration (using a C-128 tuning fork), or with the blunt end of a cotton-tip applicator.

NEUROLOGIC EVALUATION

The neurologic evaluation involves locating the lesion; testing deep tendon, superficial, and pathologic reflexes; testing cranial nerve and brainstem function; measuring body parts (mensuration); grading muscular strength; and testing the gross sensory modalities.

PAIN AND PATTERNS OF PAIN

Pain that arises with activity and decreases with rest is likely to have mechanical causes. The pain may be position dependent; most cases of mechanical spinal pain have both a provocative and a palliative arc of motion.

LOCAL VERSUS REFERRED PAIN

Patients with referred pain often point to large generalized areas, whereas patients with localized lesions can be more specific. A patient complaining of unrelenting spinal pain, demonstrating full, pain-free range of motion, presents a problem. The patient likely has either viscerosomatic pain, which mandates further diagnostic testing, or pain resulting from a psychosocial cause. If referred pain from a diseased organ system is mimicking a local orthopedic problem, the examiner should not hesitate to order appropriate tests.

VITAL SIGNS

Vital signs include the brachial blood pressure, peripheral pulse rate, respiration rate, height, weight, and vital capacity. The instrumentation for these measurements includes stethoscopes, spirometers, scales, tape measures, and blood pressure cuffs.

RANGE OF MOTION

Of all the orthopedic tests that an examiner can perform on a patient, none is more crucial than range-of-motion (ROM) testing of the affected articulation. ROM testing often reveals the origin of the patient’s discomfort because movement may reproduce the pain. The patient is examined symmetrically for active motion of all the joints that may be involved in the dysfunction or injury. The examiner then takes the patient through passive ROM, evaluating the end-feel (i.e., springiness) of the affected joint.

STABILITY TESTING

Because clinical examination reveals the degree of ligamentous or joint sprain (Table 1-2), the examiner must be able to test accurately for joint instability. Stability testing moves joint and periarticular structures through their respective arcs and end-range motions. Stability testing involves stressing ligamentous tissues and joint capsules.

MUSCULAR ASSESSMENT

Movement restrictions in a joint’s passive ROM are not exclusively articular. Muscular hypertonicity limits passive movement and often occurs in association with articular lesions (joint dysfunction). Chronic joint problems are also commonly associated with myofascitis.

CLINICAL LABORATORY