the physical examination blueprint€¦ · the physical examination blueprint 4 introduction in...

THE PHYSICAL EXAMINATION BLUEPRINT

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THE

PHYSICAL EXAMINATION

BLUEPRINT

By Dr. Scott Gray

DR.SCOTT GRAY

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TABLE OF CONTENTS

Introduction ............................................................................................................................................ 4

About the Author................................................................................................................................... 6

Orthopaedic Examination Steps ........................................................................................................ 8

1. Initial Observation ........................................................................................................................ 9

2. History .......................................................................................................................................... 10

3. Pain Assessment ....................................................................................................................... 12

4. Neuro ........................................................................................................................................... 13

5. Structure: ..................................................................................................................................... 15

6. Palpation for Condition .............................................................................................................. 16

7. AROM .......................................................................................................................................... 17

8. PROM .......................................................................................................................................... 18

9. MSTT – Muscle Selective Tissue Tensioning Tests ............................................................ 20

10. MLT- Muscle Length Tests and Myofascial Analysis ......................................................... 21

11. MMT- Manual Muscle Testing ............................................................................................... 23

12. Special Test: ............................................................................................................................. 24

13. PFT- Palpation for Tenderness ............................................................................................. 25

14. Movement ................................................................................................................................. 26

15. Diagnosis .................................................................................................................................. 28

16. Prognosis .................................................................................................................................. 29

17. Intervention ............................................................................................................................... 30

Conclusion ........................................................................................................................................... 31


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INTRODUCTION

In this guide, I go into detail about exactly how I evaluate each and every single one

of my patients with a step-by-step approach. Right now, you may be wondering why

you need a structured examination process. After all, you’re an astute clinician –

surely you’ll pick up on any problems your clients may have?

A thorough and systematic examination should form the basis of any treatment plan

so that you can fully analyze and assess every patient to provide clinical reasoning

behind what you are doing and, more importantly, to ensure you do not miss

anything. As the saying goes, if you’re not assessing properly you are probably

treating by guessing.

It has been my experience as a young and aspiring clinician, that many therapists

don’t have a way of evaluating their patients systematically. As a result, sometimes

therapists get a correct diagnosis, while at other times, it is left up to pure chance.

This is why it is wise for any clinician to put system in place to assess their patients,

whether you use my template or one you have put together yourself to suit your

practice’s needs. My outline is not intended to be followed dogmatically per se, but it

lays a solid foundation of a sound orthopaedic, sport, and spine physical

examination.

As you follow the examination template below, think about the framework of what

you are doing. My approach is to start generally and then proceed to be more

particular and aggressive as the examination progresses. The steps laid out herein,

have been thoughtfully placed where they need to be to ensure no stage contradicts

another.

I hope once you’ve finished this book, you’ve found it useful. I’d love it if this was just

the beginning of a long lasting relationship between you and I. Let me know how I

can further help you by sending me an email with any questions or comments to:

[email protected]

mailto:[email protected]

DR.SCOTT GRAY

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COPYRIGHT NOTICE

© 2017 Scott Gray All Rights Reserved.

Any unauthorized use, sharing, reproduction, or distribution of these materials by any

means, electronic, mechanical, or otherwise is strictly prohibited. No portion of these

materials may be reproduced in any manner whatsoever, without the expressed and

written consent of the publisher, except for the use of brief quotations in a book

review. Published under United States copyright laws by Scott Gray.


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ABOUT THE AUTHOR

Dr. Scott Gray is a specialty trained expert Sport and Spine Manual Physical

Therapist. Each and every year he treats 1000s of patients with an array of sport and

spine injuries. He is highly sought out by many of his colleagues and is the go-to

person in his area for sport and spine conditions.

Dr. Scott Gray was a former division one athlete who missed half of his playing

career due to injury. Eventually, Dr. Gray was rehabilitated by an expert physio and

this experience led him to seek out a career in physical therapy.

Dr. Gray has traveled the world shadowing and learning from some of the best

clinicians to develop his clinical reasoning and to further his studies as much as

possible. He has trained under Dr. Stanley Paris and other skilled manual physical

therapists at the University of St. Augustine, Bill Hartman from I-FAST, Gary Gray

from the Gray Institute (no relation), as well as several other practitioners, and

ideologies of treatment and rehabilitation. He recently presented his research at the

International Federation of Orthopaedic and Manual Physical Therapy Conference in

Glasgow, Scotland.

Not only does Dr. Gray have a strong acumen in rehabilitation for orthopaedic and

sport conditions, he also has a background training athletes as a strength and

conditioning coach. He has worked with several elite athletes and studied under

some of the best coaches in the industry. He routinely applies his performance

DR.SCOTT GRAY

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background to successfully rehabilitate his patients, especially in enabling athletes

returning to sport.

He routinely writes on subjects of manual therapy, clinical reasoning, movement, and

sport and spine disorders. For further information about Scott, please go to

www.ScottGrayPT.com

http://www.scottgraypt.com/


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ORTHOPAEDIC EXAMINATION STEPS

There are seventeen steps in total that make up a thorough orthopaedic

examination:

1. Initial Observation

2. History

3. Pain and Psychosocial Assessment

4. Neurovascular

5. Structure

6. Palpation for Condition

7. AROM

8. PROM

9. MSTT

10. MLT

11. MMT

12. Special Test

13. PFT

14. Movement

15. Diagnosis

16. Prognosis

17. Intervention

DR.SCOTT GRAY

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1 Initial Observation

The examination of your patient should begin from the moment your patient walks

through the door. Your initial observations should include how your patient walks into

the clinic, gets into and out of their chair, etc. Right from the start, you can get a

sense of how your patient moves and how they perform their ADLs without them

taking notice. This gives you a chance to assess your patient initially without their

influencing the result. Sometimes you may see something noteworthy, while at other

times you won’t. However, it is a good habit to start looking at these things, just in

case.

Some other key things to ask yourself are how they are walking towards you in the

treatment room? Are they grimacing as they walk or stand? Are they putting their

weight on one leg more than the other? Is the shoulder guarded and placed by the

patient’s side?


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2 History

The patient history is the nuts and bolts of the examination. Usually with a thorough

history you can make the diagnosis alone! Therefore, it is important that you do not

skip or skim over this part.

Some of the key questions to ask to determine if an issue is musculoskeletal are:

A. Is your pain constant?

• If it is constant, it can mean a few things. If it is an acute injury,

they probably have inflammation and chemical pain that needs to

be taken into account. You also need to discern if there is a

psychosocial component to it, such as chronic pain. Finally, you

should consider if you are dealing with an MSK pathology or not.

Cancer and other forms of pathology either have pain all the time

or it is worst at night time.

• Sometimes you will find patients that have had constant pain for

over 2 or 3 years either because they have a serious injury that

hasn’t been treated (disc pathology) or they keep performing the

same repetitive task day-in and day-out that flairs them up. For

instance, I just treated a lady who has had LBP for 2 years. She

never sought treatment for the disc injury before and she is now

pain free after a few treatments. It would have been easy to write

DR.SCOTT GRAY

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her off as the pain being all in her head. For this reason, always

assess!

B. What makes your pain better and what makes it worse?

• This is probably the best question of all. You can usually depict

biomechanically what is going on with this question. This is one of

the many reasons why you need to know your biomechanics and

anatomy.

C. Mechanism of Injury? When did you injure yourself?

D. Is it getting better, staying the same, or worse?

E. Age and occupation or sport of patient?

-Certain diagnosis fall in a specific age group. For instance, I know my

athlete doesn’t have stenosis if they are 30 years old. Conversely, if my

patient who is 80 comes in with tingling and pain down the leg, they could

possibly have stenosis of the spine.

F. Is it better or worse in the morning or evening?

• Usually arthritis hurts worst in the morning and gets better as the

day progresses. Meanwhile, pain at night can be a red flag,

especially when sleeping, but you need to put this in context with

the history. Swelling and inflammation follows a circadian rhythm

and is usually worst at night too.

• Sometimes, too, a patient has recovered from the prior day’s

activities and feels pretty good, but then as the day proceeds they

have more pain, especially in certain postures. These types of

patients may need intervention with their workstation or adjust how

they are performing their work activities.


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3 Pain Assessment

Pain is subjective in nature and will vary from patient to patient but it does tell you

some valuable information. For instance, after filling out a McGill pain questionnaire,

if they show pain all over the body you are thinking of a potential psychosocial

component and a very sensitive nervous system. In contrast, an exact location pin-

pointed on their examination provides more insight and hypotheses of what may be

doing on.

The next step of this examination, especially for lower back and neck pain patients,

is to find out what their beliefs are about their pain? Does it stop them from being

active and social? Do they think that they can overcome this or do they feel limited

by their pain? This is a very key step in management of any MSK pathology and you

must discern what their beliefs are, and if they are faulty, you need to change them!

DR.SCOTT GRAY

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4 Neuro

The neuro examination is needed to help discern if there is a nervous system

component involved or an even more serious pathology such as a CNS disorder. For

these reasons, this is an important step in the examination process, but you will not

need to do this for every patient. Your history will tell you if you need to perform this

step of the evaluation. Sometimes I perform it anyway, even if I think there’s no

need, because it helps to establish credibility with the patient. If you’re more

thorough in your examination, the patient will develop trust because you have

established yourself as the expert.

The most common tests you will perform are deep tendon reflexes, sensation testing

light and deep, myotome strength, and neurodynamic testing. Although sensory and

reflexes results can vary and don’t tell the entire picture, they do provide some

insight, but I rely more on my myotome strength to discern neuro involvement in

addition to the SLUMP and ASLR testing, especially with suspected disc or other

neurodynamic pathology.

When testing sensory, your patient may have within normal limits light touch. but

don’t forget about testing the deep sensations such as vibration. This can be

particularly important for the older population with suspected stenosis. Last, but not

least, you want to make sure you do a babinski and clonus test at the end to ensure

no CNS involvement.

In regards to neurodynamics, these are tests to check if the nervous system is

altered by the mechanical interface, neural structure itself, or if the innervated tissues

that the nerve innervates are pathological. You probably have some familiarity with

some tests, such as testing ASLR, SLUMP, and upper limb neuro tests such as the

median nerve tests, but for further information check out Michael Shacklock’s book,

Clinical Neurodynamics, which can you can find in the “books” section on my site. In


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essence, you want to discern whether the nerve is sliding optimally. Is it a neural

tension dysfunction? Is the mechanical interface opening and closing optimally?

Here is some common DTR results and what they potentially mean when testing:

Hypo= Nerve compressed (bulging disc) or peripheral nerve injury

Normal= normal functioning nerve

Hyper= Nerve root is irritated (usually when chemicals from nucleus are on disc),

usually CNS involvement

DR.SCOTT GRAY

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5 Structure:

During your structural examination you want to take close look at a few things:

1. Body type

2. Potential Muscle Tightness and Weakness

3. Compensatory Postures

4. Muscle Wasting or Hypertrophy and Guarding

5. Structure: Pelvis height, spinal curves, foot position, femur position,

etc.

Have your patients stand statically. This gives you great insight on what muscles

may need lengthening and which ones will need strengthening. For instance, do they

have rounder shoulders, anterior pelvic tilt, femoral internal rotation, etc.?

It also tells you what body type the patient has. For instance, mesomorphs have

more muscle mass and will be stiffer in their joint and PROM examination.

Meanwhile, ectomorphs are usually more hypermobile.

Additionally, you can also look at the entire body to see how they carry their weight.

For instance, do they place more weight on one leg over the other? Are they

guarding and have a potential lateral shift?

Finally, you can also see if other serious things are going on, such as muscle

wasting which would be a red flag. Not good :-(


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6 Palpation for Condition

In this step of your examination, you need to place your hands on the affected area.

You are looking for warmth and swelling, muscle guarding and atrophy, and get an

overall sense of the state of the tissues to see if there is tissue damage.

DR.SCOTT GRAY

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7 AROM

When checking active ROM I usually do a quick screen of the shoulders, elbows,

wrists, spine, big toes, mid tarsal, subtalar joint, ankles, knees, and hips. Although

this may be unnecessary at times, I do it to get more information and it only takes a

few extra minutes.

Basically, we want to look at the following in this phase:

1. Compensatory or abnormal movement

2. Strength against gravity

3. Pain during and where at in motion

4. Potentially discern if a joint and surrounding articulations has enough

mobility to move

If I am treating a spine patient, in this phase I will add repeated movements and

holding of a static posture in either flexion or extension to discern their tolerance and

to see if it makes them better or worse. If the static positioning doesn’t seem to

produce or alleviate s/s then I will proceed to repeated flexion, extension, or rotation.

For further information, check out Robin McKenzie’s books (listed on my website)

and courses.


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8 PROM

A) Classical PROM

After discerning if there is a limitation in the active motion, I will then need to check

PROM classical. Classical PROM is also known as osteokinematic motion.

With osteokinematic motion, we want to look at the following:

1. Range of movement (quantity)

2. The quality of smoothness of the movement (end feel)

3. Did it reproduce the patient’s s/s and where at in the movement?

Some of the most common and normal end feels are:

1. Soft tissue approximation

2. Cartilaginous

3. Capsular

4. Ligament

5. Muscle

Some abnormal end feels would be:

1. Bony

2. Swelling or effusion

3. Abnormal muscle (muscle guarding)

4. Abnormal Capsule

5. Hypermobility

DR.SCOTT GRAY

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B) PROM Accessory

We can also take this a step further by directly testing the joint with arthokinematic

motion or joint glides. This will help discern if it is an intracapsular and joint issue.

Usually you will pick up joint hypomobility or hypermobility in this step of the

examination. The most common scale used to grade this mobility is the following:

0- Ankylosed

1. considerable hypomobility

2. slight hypermobility

3. normal

4. slight hyerpmobility

5. considerable hypermobility

6. unstable

In addition to checking for hypo- and hypermotilities, you can also discern end feel

here too.


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9 MSTT – Muscle Selective Tissue Tensioning Tests

It was James Cyriax who came up with this idea of selectively placing tension on

contractile tissue. In essence, it helps you discern if it is a tendonitis or tendonosis,

partial tear, or complete tear of the tissue.

Here are some common exam findings:

1. Strong and Pain free= Normal Tissue

2. Strong and Painful= Tendonitis/ Tendonosis

3. Weak and Painful= Partial Tear

4. Weak and Pain Free= Full Tear

Key Point: When testing the muscles in this stage, you want to place the joint in its

loose packed position so you do not stretch the capsule or any other inert tissue.

You also want to only resist with two fingers rather than your entire arm. This is a

sub-maximal contraction. You will resist maximally in the steps ahead.

DR.SCOTT GRAY

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10 MLT- Muscle Length Tests and Myofascial Analysis

In this stage of the examination, we want to look at the ability of the muscles to

lengthen and we also want to look at the connective and soft tissues.

Firstly, we want to be sure that the skin can move. If the skin doesn’t move, the ROM

will be limited. To discern this, do a quick skin roll by lifting and picking the skin up.

Next, we want to palpate the affected tissue to see if it is healthy. Like all other

tissue, the tissue must be able to slide and glide, lengthen, etc.

The most common pathology seen with muscles and soft tissue is:

1. Congestion- swelling and fluid stasis

2. Abnormal Tissue Tension- when moving the area, the myofasia tensions

or tightens

3. Scarring or Fibrosis – usually will feel like a leathery strap. This occurs

most frequently after an injury that didn’t heal appropriately.

After you have examined the above, you can now lengthen the myofascia in

question. However, we want to ensure that they have normal joint motion first hand

as you did in the earlier steps. If they didn’t have normal mobility in the prerequisite

stages, then you will not be able to test that muscle in question until you address the

joint limitation.

Some of the most common muscle length tests are:

1. Ober

2. Thomas Test

3. Hamstring

4. Pecks

5. Lats

6. Upper Trapezius

7. Levator Scapula

8. Adductors

9. Calves

10. Glutes and Piriformis


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Generally speaking, you can lengthen and test any muscle by lengthening it

proximally first then proceeding distally. For more information, check out Muscles

Testing and Function by Florence Kendall.

DR.SCOTT GRAY

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11 MMT- Manual Muscle Testing

If the muscles were weak and painful or weak and painless in your preceding step of

MSTT, you can skip testing the muscles with MMT. There is no reason to provide

more resistance if they already were determined weak by the MSTT.

MMTs are good because they help discern which muscles are weak and, better yet,

you can bias them by testing inner and outer ranges to help make a more accurate

diagnosis. For example, sometimes it is not always clear if it is muscle causing

someone’s pain or some other inert tissue or joint. For this reason, you may want to

test the muscle with the joint near closed packed and then test near the other end of

the spectrum, open packed.

Another good reason for using MMT is that you can see how the patient likes to

compensate and which muscles they prefer to recruit. For instance, if doing a hip

abduction MMT, many times the patient will internally rotate and flex at the hip using

TFL. This could potentially mean weakness of the hip abductors and external

rotators.

Finally, another way to test muscle strength is to test the muscles in a more

functional position. For example, I don’t like some of the MMT’s that Florence

Kendall has in her book, so I use a supine single leg bridge to ascertain if their glutes

are strong or weak. I have patients do 10 repetitions, while I look to see if they can

get full hip extension excursion. In addition, I like to use repeated Is, Ts, Ws, cervical

flexion test, and anterior step-downs to test the scapular retractors and external

rotation, deep neck flexors, and quadriceps muscles respectively. This can be used

for basically any muscle and I have found this more clinically relevant.


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12 Special Test:

By this stage in the examination, we have covered everything to get a solid

diagnosis. The special test is used to help either rule in or rule out pathology or the

tissue in lesion. Many clinicians place value on the special test results alone, which

is a big mistake. Special tests just help confirm your hypothesis or reject it.

For more information on special tests, please refer to Orthopaedic Physical

Assessment by Magee.

DR.SCOTT GRAY

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13 PFT- Palpation for Tenderness

Sometimes a diagnosis still isn’t clear after going through the examination process,

whether because patient hasn’t communicated to the clinician effectively or

something else. In this instance, just palpating the effected area for specific tissues

can really help. For example, palpating the RTC tendons, such as supraspinatus,

can help confirm your diagnosis. Similarly, if someone comes in after twisting their

knee into valgus, and you palpate the MCL, this could be more evidence of irritation

of this ligament. Use this step through palpation to help you come up with a solid

diagnosis.


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14 Movement

The steps below really will help you postulate or confirm which tissue may be

irritated in a pathological state. You should skip this step and re-test at a later date if

the patient is acute or it will make the patient worse.

I like the movement step because, to me, it really helps what I call “figure out” what

caused the pain in the first place. For instance, do they have inadequate functional

dorsiflexion so now they have knee pain? Or do they have inadequate thoracic spine

mobility so now they have irritated their neck as compensation? How well do their

hips move, and do they have a limitation? If so, what plane? These are just some of

things that you should be looking at as a clinician.

Some key books and resources all clinicians should read to develop your analysis of

looking at movement are:

1. Shirley Sharaman’s Diagnosis and Treatment of Movement Impairment

Syndromes

2. Gray Cook’s Movement

3. 3DMAPS through the Gray Institute

Personally, I use an eclectic approach of these systems to break down movement

but the majority stems from my training with the Gray Institute having gone through

their fellowship. It has been a game changer in the way I practice and treat.

These resources are just a framework to look at movement, but at the end of the

day, if your patient comes in and has pain only when bending, you’d better look at

DR.SCOTT GRAY

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how they bend. Likewise, if your athlete only has pain when throwing, you should

look at their throwing mechanics or whatever other activities they are required to

execute in their sport.

Let’s recap the examination process up to this point. In the earlier stages you should

have figured out what makes your patient better, and what makes them worse. You

will have discerned if their pain was constant, which case you should be thinking that

they are inflamed or they may have some psychosocial component, especially if it

has been going on for years. After finishing your subjective analysis, you really

should have formulated a hypothesis on what you think the diagnoses are or aren’t

and you are using your physical examination to help rule in or rule out your

hypotheses. Along the way, you should have picked up on impairments that you can

work on that are contributing towards the compensation or pain. Likewise, looking at

their sport or movement will pick up clues to what they may also need to work on.


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15 Diagnosis

At this point, you really should have a good idea of what the diagnosis is, or at least

what it is not. Sometimes you may not have all the answers, which is OK, but as the

patient comes back in for more follow up visits the picture will get a little more clear.

As the expert, you want to give a sound diagnosis and be confident with it, whether

you are ultimately right or wrong. If your patient believes you and knows that you are

the “expert” they will probably get better, especially if they think you know what you

are talking about.

The second part of getting a strong diagnosis is determining what type of tissue is

pathological at this time. In knowing this information, you can provide optimal

stimulus for repair. For instance, if cartilage is the tissue in lesion, you know that it

heals with compression and decompression in a cyclical nature. Meanwhile, if it is

collagen trauma to a ligament or muscle tissue, you can place modified tension to

these structures for your body to lay down new tissue. This is known as Wolf’s Law.

When you have a solid diagnosis, you can also configure what types of treatments to

avoid. For instance, if a patient has anterior shoulder laxity, I don’t want to stretch

them into external rotation initially. Meanwhile, I don’t want to do exercises in the end

range of flexion, abduction, or external rotation. I also will want to look closer at the

hips and thoracic spine mobility to discern why the capsule got irritated in the first

place.

DR.SCOTT GRAY

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16 Prognosis

When getting a solid diagnosis with the above steps, you can advise on how much

better your patient will get with skilled PT care and how long treatment is likely to be

required. If it is a more severe disorder such as instability, the prognosis probably

isn’t as great since it will be more of a management condition. Meanwhile, if it is a

simple muscle strain, your patients will get better with time.


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17 Intervention

Last but not least, your intervention is to work on the impairments directed in the

examination but to provide optimal stimulus for repair for the affected tissue. It is a

constant cycle of evaluating, treating, and evaluating. Therefore, do not lose sight of

this when providing your interventions.

DR.SCOTT GRAY

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CONCLUSION

There you have it! A step-by-step guide to how I assess each and every single one

of my patients. While there are other ways of doing things, taking this structured

approach sets a valuable framework for orthopaedic, sport, and manual physical

therapists. After all, getting the correct diagnosis is essential for better clinical

outcomes.

If you have any further questions about how I integrate this approach into my clinical

practice, you can e-mail me directly at [email protected].

I hope this is just the beginning of a productive relationship between you and me. As

an astute and inspiring clinician, I hope to continue to share my wisdom and

mistakes. Be on the lookout for more emails from me as well as related posts on my

website www.scottgraypt.com.

mailto:[email protected]

http://www.scottgraypt.com/

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