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TABLE OF CONTENTS

Page

Faculty Information .........................................................2

Differential Diagnosis of the Nearomusculoskeletal System ...........................3

History ..................................................................4

Observation ...............................................................8

Examination ....................................................... ......13

1. Inert Tissue ........................................................13

2. Con~actile Tissue ...................................................13

3. Nervous Tissue .....................................................15

4. Joint ..............................................................19

5. Principles of Examination ..............................................19

6. The Examination of Moving Parts of the Body ..............................19

Active Movements ................................................19Passive Movements ...............................................23Resisted Isometric Movements ................................~ ......23Functional Assessment .............................................23Special Tests ....................................................25Reflexes ........................................................25Sensory Assessment ...............................................28Joint Play .......................................................29Palpation .......................................................29Diagnostic Imaging ............................... ................32Differential Diagnosis ..............................................32

NOTE:

The majority of the information provided in this course is taken from the book, "OrthopedicPhysical Assessment" written by the presenter of this course. The book is published by theW.B. Saunders Co. of Philadelphia. If participants have a copy of the book, they should have itavailable during the gaining session.

FACULTY:

David J. Magee, BPT, PhD

David J. Magee is a Professor in the Department of Physical Therapy at the University of Albertain Edmonton, Alberta, Canada where he teaches undergraduate and graduate musculoskeletal andsports therapy courses. He is the consulting physical therapist for the Edmonton Oilers HockeyClub and the Edmonton Eskimos Football Club, and is the National Team Therapist of theCanadian Synchronized Swimming Team. Dr. Magee has taught several continuing educationworkshops nationally and internationally on assessment of the musculoskeletal system, sportsphysiotherapy, shoulder injuries, and functional outcomes and return to activity. Dr. Magee is theworld-renowned author of the text, "Orthopedic Physical Assessment" which is currentlypublished in English, French, Japanese, and Spanish.

DIFFERENTIAL DIAGNOSIS OF THE NEUROMUSCULOSKELETAL SYSTEM

Differential diagnosis is used to differentiate between one or more conditions, diseases or injuriesa patient is suffering from and complaining of by systematically comparing and contrasting theirsigns and symptoms.

The process of a differential diagnosis may involve a combination of clinical diagnosis, physicaldiagnosis, pathological diagnosis, a provocative diagnosis, laboratory diagnosis, and diagnosticimaging.

To perform a differential diagnosis, the examiner must have a good basic knowledge of pathologyand the process of tissue healing. As well, background knowledge in conditions and theirpathology, and signs and symptoms axe a definite asset.

To provide a systematic examination process to arrive at a differential diagnosis, the assessmentwill be described under the following headings:

HistoryObservationExamination

with the examination being divided into:

Active MovementsPassive MovementsResisted Isomeuic MovementsFunctional AssessmentSpecial Tests

Reflexes and SensationJoint PlayPalpation

Diagnostic Imaging

HISTORY

If you listen carefully, the patient will tell you what is wrong and what bothers him/her the most.Things to listen for or ask:

1. Age

2. Occupation

3. The Problem

Slow or sudden onset?

Has it occurred before?

How long has it been present?

What affects it?

NOTES:

4. Mechanism of Injury?

5. Pain

Where?

Spread?

Intensity?

Duration?

Frequency?

Type?

Constant/Periodic?

NOTES:

Referral?

Associated with Rest/Activity?

Associated with Certain Postures?

6. Abnormal Sensation

Paresthesia?

Numbness?

Pattern?

7. Locking?

NOTES:

8. Instability/Giving Way

9. Stress Situations

10. Other Questions

Radiograph Examination?

Medication?

Cord Symptoms?

"Drop Attacks"

Saddle Involvement

Vertigo/Dizziness

Surgery

NOTES:

OBSERVATION

The observation is the "looking" part of the examination. It primarily involves looking at theposture and noting any asymmetry.

1. Posture (Standing)

Anterior View:

Body Type Alignment

Head/Neck

Shoulders

Thorax/Ribs/Sternum

Waist Angles

Arm Position (Rotation, Carrying Angle)

NOTES:

Iliac Crest

Anterior Superior lilac Spines (ASIS)

Pubic Bones (Symphysis Pubis)

Greater Trochanter

Patella

Knee Angle

Fibular Head

MaUeoli

Foot Arches (Pes Planus, Pes Cavus)

NOTES:

Foot Angle (Fick Angle)

Foct Supination/Pronafion

Lateral View."

Alignment

Spi~al Curves

Shoulders

Chest/Abdomen/Back

Chest Deformities

Pelvic Angle

Knee Ar gle

NOTES:

Posterior View:

Alignment

Head/Neck

Shoulders

Scapula

Spinal Curve

Ribs

Waist Angles

Posterior Superior Iliac Spines (PSIS)

NOTES:

Gluteal Folds

Knees

Achilles Tendon

Heels

-2. Other Things to Note

Any Deformity?

Scars?

Signs of Inflammation?

Patients Attitude?

NOTES:

EXAMINATION

The examination involves movement testing combined with ligament testing and other provactivetests to enable one to differentiate between inert tissue, contractile tissue and nervous tissue,between nerve root symptoms and peripheral nerve symptoms, functional assessment, betweenjoint problems and surrounding structures. Mso included is palpation and diagnostic imaging.

1. Insert Tissue

What is it?

Pain and Restriction

What is it.?

Pain and Strength

NOTES:

Table 1. Differential Diagnosis of Contractile Tissue and Inert Tissue (Ligament)Pathology

Muscle Ligament

Mechanism of Overstretching OverstretchingInjury Crushing (pinching)Contributing Muscle fatigue Muscle fatigueFactors Poor reciprocal muscle strength

InflexibilityInadequate warmup

Active Pain on contraction (I, 2) Pain on stretch or compression (1, 2)Movement Pain on stretch (1, 2) No pain on stretch (3)

Weakness on contraction (1, 2, 3) ROM decreasedNo pain on contraction (3)

Passive Pain on stretch Pain on stretch (1, 2)Movement Pain on compression No pain on stretch (3)

ROM decreased

Resisted Pain on contraction (1 o, o) No pain (1 o, o, 3o)Isometric Weakness on contraction (1, 2, 3)Movement No pain on contraction (3)

Special Tests If test isolates muscle, weakness and pain If test isolates ligament, ROM andon contraction (1, 2) or weakness and no pain affectedpain on contraction (3)

Reflexes Normal unless 3 Normal

Cutaneous Normal NormalDistribution

Joint Play Normal Increased ROM unless restricted byMovement (in swellingresting position)

Palpation Tender Point tendernessGap if palpated early Gap if palpated earlySwelling Swelling

3. Nervous Tissue (see Table 2. p. 16"1

Nerve Root (see Table 3, p. 17)

Myotomes

Dermatomes

Peripheral Nerve

Upper Motor Neuron Lesion (see Table 4, p. 18)

Lower Motor Neuron Lesion (Mixed Nerve) (see Table 5, p.

Double Crush

NOTES:

Table 2. Differential Diagnosis of Cervical Nerve Root and Brachial Plexus Lesion

Cervical Nerve Root Lesion Brachial Plexus Lesion

Causes Disc herniation Stretching of cervical spineStenosis Compression of cervical spineOsteophytes Depression of shoulderSwelling with traumaSpondylosis

Contributing Congenital defects Thoracic outlet syndromeFactors

Pain Sharp, burning in affected Sharp, burning in all or most ofdermatome(s) ann dermatomes

Paresthesia Numbness, pins and needles in Numbness, pins and needles in allaffected dermatome(s) or most arm dermatomes (more

ambiguous distribution)

Tenderness Over affected area of posterior Over affected area of brachialcervical spine plexus or lateral to cervical spine

Weakness Transient paralysis usually Myotome affectedMyotome maay be affected

Deep Tendon Usually normal May be depressedReflexes

Provocative Test Side flexion, rotation and Side flexion with compressionextension with compression (same side) or stretch (oppositeincrease symptoms side) may increase symptomsCervical traction decreasessymptoms

Table 3. Nerve Root Dermatomes, Myotomes, Reflexes, and Paresthetic Areas

Nerve Muscle WeakneuRoot Dermatome (MyotameJ Reflexes Affected ParesthesiasCI Vertex of skullC2 Temple, forehead, occiputC3 Entire neck. posterior cheek. Cheek. side o[ neck

temporal area. prolonga-tion forward under mandi-ble

C4 Shoulder area, clavicular Horizontal band along clay[-area, upper scapular area cle end upper scapula

C5 Deltoid area, anterior aspectSupraspinatus, Intrasplna-Biceps, brachioradialisof entire arm to base of tug, deltoid, bicepsthumb

C6 Anterior arm, radial side of Biceps. supinator, wrist ex- Biceps, hrachioradialis Thumb and index fingerhand to thumb and index rangersfinger

C7 Lateral arm andforearm to Triceps. wrist flexors (rarely.Triceps index, long. and ring fingersindex, long. and ring fin- twist extensors)fiers

C8 Medial arm and forearm to Ulnar deviators, thumb ex- Triceps Little finger alone or withlong. ring. and little fin- tertsors, thumb adductors two adjacent fingers; notgets (rarely, triceps) ring or long fingers, alone

or together (C7JT1 Medial side of forearm to Disc lesions at upper two thoracic levels do not appear to give rise to root weakness.

base of litfle finger Weakness of intrinsic muscles of the hand is due Io other pathology (e.g., thoracicT2 Medial side of upper arm to oudet pressttre, neoplasm of lung, and ulnar nerve lesion}. Dural and nerve root stress

medial elbow, pectoral has TI elbow flexion with arm horizontal. Tt and T2 scapulae forward and backwardand midscapular areas on chest wall. Neck flexion at any thoracic level.

T3- T3-Tfl. upper thorax; T5- Axticular and dural signs and root pain ate common. Root signs [cutaneous analgesiaJ areTI2 T7, costa] margin; 3"8- rare and have such indefinite area that they have little lncalizing value. Weakness is not

TI2, abdomen and lumbar detectable.reflion

L1 Back. over trochanter and None None Groin; after holding posture.stein which causes pain

L2 Back. front of thigh to knee Peons. hip adductors None Occasionally anterior thighL3 Back, upper buttock, ante- Peons, quadriceps, thigh Knee jerk sluggish. PKB poe- Medial knee. anterior lower

riot thigh and knee, me- atrophy [rive, pain on full flLR legdial lower leg

L4 Medial buttock, lateral thigh.Tibialis anterior, extensor SLR limited neck fla.

Table 4. Signs and Symptoms of Upper Motor Neuron Lesion

Spacticity

Hypertonicity

Hyperreflexia (deep tendon reflexes)

Positive pathological reflexes

Absent or reduced superfxcial reflexes

Extensor plantar response (bilateral)

Table 5. Signs and Symptoms of Mixed Peripheral Nerve Lesions (Lower Motor Neuron)(primarily axonotmesis and neurotmesis)

Motor Sensory Sympathetic

Flaccid paralysis Loss of or abnormal Loss of sweat glandssensation (dryness)

Loss of reflexesLoss of vasomotor tone Loss of pilomotor response

Muscle wasting and atrophy (warm flushed [early] -->cold, white [later])

Lost synergic actionSkin may be scaly --> thin,

Fibrosis, contractures and smooth and shinyadhesions

Shallower skin creasesJoint weakness and instability

Nail changes (striations,Decreased range of motion ridges, dry, brittle,and stiffness abnormal curving, luster

4. Joint

End Feel (see Table 6, p. 20)

Capsular/Noncapsular Pattern (see Table 7, p. 21)

5. Principles of Examination (see Table 8. p. 22)

6. The Examination of Moving Parts of the Body

Active Movement (see Table 9. p. 22)

Combined Movement

Repetitive Movement

Sustained Movement

NOTES:

Table 6. Normal and Abnormal End Feel

Normal Example Abnormal Example

Bone to bone Elbow extension Early muscle spasm Protective spasmfollowing injury

Soft tissue Knee flexion Late muscle spasm Spasm due toapproximation instability

Tissue stretch Ankle dorsiflexion,Hard capsular Frozen shouldershoulder externalrotation, finger Soft capsular Synowus, soft tissueextension edema

Bone to bone Osteophyte formation

Empty Acute subacromialbursitis

Springy block Meniscus tear

Table 7. Common Capsular Patterns of Joints

Joint(s) Restriction*

Temporomandibular Limitation of mouth openingOccipitoatlanto Extension, side flexion equally limitedCervical spine Side flexion and rotation equally limited, extensionGlenohumeral Lateral rotation, abduction, medial rotationStemoclavicular Pain at extreme of range of movementAcromioclavicular Pain at extreme of range of movementHumeroulnar Flexion, extensionRadiohumeral Flexion, extension supination, pronationProximal radioulnar Supinafion, pronationDistal radioulnar Full range of movement, pain at extremes of rotationWrist Flexion and extension equally limitedTrapeziometacarpal Abduction, extensionMetacarpophalangeal and Flexion, extensioninterphalangeal

Thoracic spine Side flexion and rotation equally limited, extensionLumbar spine Side flexion and rotation equally limited, extensionSacroiliac, symphysis Pain when joints are stressedpubis, and sacrococcygealHipt Flexion, abduction, medial rotation (but in some cases medial

rotation is most limited)Knee Flexion, extensionTibioflbular Pain when joint stressedTalocrural Plantar flexion, dorsiflexionTalocalcaneal (subtalar) Limitation of varus range of movementMidtarsal Dorsiflexion, plantar flexion, adduction, medial rotationFirst metatarsophalangealExtension, flexionSecond to fifth Variablemetatarsophalangeal

Interphalangeal Flexion, extension

Table 8. Principles of Examination

Test normal side fixst

Active movements first, then passive movements, resisted isometric movements Painful movements done last

Apply overpressure with care Repeat or sustain movements if history !ndicates Do resisted isometric movements in a resting position With passive movements and ligamentous testing, both the degree and quality of opening

axe important With ligamentous testing, repeat with increasing stress Myotome testing must be held for 5 seconds

Warn of possible exaccerbations Refer if necessary

Table 9. Active Movements

On active movements, note:

When and where during each of the movements the onset of pain occurs

Whether the movement increases the intensity and quality of the pain The reaction of the patient to pain

The amount of observable restriction The pattern of movement

The rhythm and quality of movement The movement of associated joints 1~h~ w]l|inoneee nf tho nnrlent tn mnve tho n~rt

Hypomobility/Hyp ermobility

End Feel

Inert Tissue (see Table 10, p. 24)

Resisted Isometric Movement

Contractile Tissue (see Table 11, p. 24)

Other Findings

Functional As~ssment

ADL

Numerical Scoring

NOTES:

Table 10. Patterns of Inert Tissue Lesions

Painfree, full ROM Pain and limited ROM in every direction Pain and excessive/limited ROM in some directions PainfTee, limited ROM

Table I1. Patterns of Contractile Tissue and Nervous Tissue Lesions

No pain and movement is strong Pain and movement is relatively strong Pain and movement is weak

No pain and movement is weak

Special Tests

Reflexes

Deep Tendon (see Table 12, p. 26)

Superficial (see Table 13, p. 26)

Pathological (see Table 14, p. 27)

Look for:

hypo/hyper/areflexia

asymmetry

NOTES:

Table 12. Deep Tendon Reflexes

PertinentCentral Nervous

Reflex Site of Stimulus Normal Response System Segment

Jaw Mandible Mouth closes Cranial nerve V

Biceps Biceps tendon Biceps contraction C5-C6

BrachioradialisBrachioradialis tendon or just Flexion of elbow and/or C5-C6distal to the musculotendinouspronation of forearmjunction /

Triceps Distal triceps tendon above the Elbow extension C7-C8olecranon process

Patellar Patellar tendon Leg extension L3-L4

Medial hamstringsSemimembranosus tendon Knee flexion L5, S 1

Lateral hamstringsBiceps femoris tendon Knee flexion S 1-$2

Tibialis posteriorTibialis posterior tendon behind Plantar flexion of foot L4-L5medial malleolus with inversion

Achilles Achilles tendon Plantar flexion of foot S1-$2.\lagee, D., (~hopedic Physical Assessment,2nd ed., Table 1-11, W.B. Sauaders Comoanv

Table 13. Superficial Reflexes

PertinentCentral Nervous

Reflex Normal Response System Segment

Upper abdominal Umbilicus moves up and toward area being stroked T7-T9Lower abdominal Umbilicus moves down and toward area being stroked T1 l-T12Cremasteric Scrotum elevates T12, L 1Plant~r l~l~,xlnn nftn~c ~1 C~

I I

Table 14. Pathological Reflexes

Reflex How to Elicit Positive Response Pathology

Babinski Stroke lateral aspect of Extension of big toe Pyramidal tract lesionside of foot and fanning of four Organic hemiplegia

small toessNormal reaction innewborns

Chaddock Stroke lateral side of Same response as Pyramidal tract lesionfoot beneath lateral abovemalleolus

Oppenheim Stroke anteromedial Same response as Pyramidal tract lesiontibial surface above

Gordon Squeeze calf muscles Same response as Pyramidal tract lesionfirmly above

Piotrowski Percussion of tibialis Dorsiflexion and Organic disease ofanterior muscle supination of foot CNS

Brudzinski Passive flexion of one Similar movement Meningitislower limb occurs in opposite

limb

Hoffmanns "Flicking" of terminalReflex flexion of distalIncreased irritability(Digital) phalanx of index, phalanx of thumb and of sensory nerves in

middle, or ring finger of distal phalanx of tetanyindex or middle finger(whichever one wasnot "flicked")

Rossolimos Tapping the plantar Plantar flexion of toes .Pyramidal tract lesionsurface of tooes

Schaeffers Pinch achilles tendon Flexion of foot and Organic hemiplegiain middle third toes

Sensory_ Assessment

Scan

Detailed

Differentiate between nerve root and peripheral nerve

Superficial tactile

Pain

Temperature

Vibration

NOTES:

Joint Play

Joint Play (see Table 15, p. 30)

Joint Dysfunction

Resting (Loose Packed) Positions (see Table 16, p.

Close Packed Positions (see Table 17, p. 31)

Palpation (see Table 18. p. 31)

NOTES:

Table 15. Rules for Joint Play Testing

The patient should be relaxed and fully supported

The examiner should be relaxed and use a firm but comfortable grasp

One joint should be examined at a time One movement should be examined at a time

The unaffected side should be tested first

One articular surface is stabilized while the other surface is moved

Movements must be normal and not forced

Movements should not cause undue discomfort

Table 16. Resting (Loose Packed) Positions of Joints

Jolnt(s) Position

Facet (spine) Midway between flexion and extensionTemporomandibularMouth slightly open (freeway space)Glenohumeral 55 abduction, 30 horizontal adductionAcromioclavicularArm resting by side in normal physiological positionSternoclavicular Arm resting by side in normal physiological positionUlnohumeral (elbow) 70 flexion, 10 supinationRadiohumeral Full extension, full supinationProximal radioulnar 70 flexion, 35 supinationDistal radioulnar 10 supinationRadiocarpal (wrist) Neutral with slight ulnar deviationCarpometacarpal Midway between abduction-adduction and flexion-extensionMetacarpophalangealSlight flexionInterphalangeal Slight flexionHip 30 flexion, 300 abduction, slight lateral rotationKnee 250 flexionTalocrural (ankle) 10 plantar flexion, midway between maximum inversion and

eversion

1Table 17. Close Packed Positions of Joints

Joint(s) Position

Facet (spine) ExtensionTemporomandibular Clenched teethGlenohumeral Abduction and lateral rotationAcromioclavicular Arm abducted to 90Stemoclavicular Maximum shoulder elevationUlnohumeral (elbow) ExtensionRadiohumeral Elbow flexed 90, forearm supinated 50Proximal radioulnar 5 supinationDistal radioulnar 5 supinationRadiocarpal (wrist) Extension with radial deviationMetacarpophalangeal (fingers) Full flexionMetacarpophalangeal (thumb) Full oppositionInterphalangeal Full extensionHip Full extension, medial rotation*Knee Full extension, lateral rotation of tibiaTalocrural (ankle) Maximum dorsiflexionSubtalar SupinationMidtarsal SupinationTarsometatarsal SupinationMetatarsophalangeal Full extensionInterphalangeal Full extension

*Some authors include abductionM~g~e, D.. Orthopedic Physical .~sess~nent,2rid ed., Table 1-15, W.B. Saunders Company

Table 18. Palpation

When palpating, one should note: Differences in tissue tension and texture Differences in tissue thickness Abnormalities Tenderness Temperature variation

Radiographs

Arthrogram

Discogram

Arthrotomogram

Conventional Tomogram

CT-Scan

MRI

Bone Scan

Differential Diagnosis (see Tables 19.20. 21, p, 33-35)

NOTES:

Table 19. Symptoms and Differentiation of Claudication and Spinal Stenosis

Vascular Claudication Neurogenic Claudication Spinal Stenosis

Paint is usually bilateral Pain is usually bilateral but may Usually bilateral painbe unilateral

Occurs in the calf (foot, thigh, Occurs in back, buttocks, thighs,Occurs in back, buttocks, thighs,hip, or buttocks) calves, feet calves, and feet

Pain consistent in all spinal Pain decreased in spinal flexionPain decreased in spinal flexionpositions Pain increased in spinal Pain increased in spinal

extension extension

Pain brought on by physical Pain increased with walking Pain increased with Walkingexertion (eg. walking)

Pain relieved promptly by rest Pain decreased by recumbency Pain relieved with prolonged(1 to 5 minutes) rest (may persist hours after

resting)

Pain increased by walking uphill Pain decreased when walkinguphill

No burning or dysesthesia Burning and dysesthesia from Burning and numbness presentthe back to buttocks and leg(s) in lower extremities

Decreased or absent pulses in Normal pulses Normal pulseslower extremities

Color and skin changes in feet -- Good skin nutrition Good skin nutritioncold, numb, dry, or scaly skin,poor nail and hair growth

Affects ages from 40 to over 60 Affects ages from 40 to over 60 Peaks in seventh decade of life;affects men primarily

t"Pain" associated with vascular claudication may also be described as an "aching", "cramping", or "tired"feeling.

Table 20. Differential Diagnosis of Cervical Spondyiosis, Spinal Stenosis and DiscHerniation

Cervical Cervical Spinal Cervical DiscSpondylosis Stenosis Herniation

Pain Unilateral May be unilateral or May be unilateral (mostbilateral common) or bilateral

Distribution of Into affected Usually several Into affectedPain dermatomes(s) dermatomes affected dermatome(s)

Pain on Increases Increases, IncreasesExtension

Pain on Flexion Decreases Decreases May increase or decrease(most common)

Pain Relieved by No Yes NoRest

Age Group 60% over 45 years 11-70 years 17-60 yearsAffected 85% over 60 years Most common: 30-60

Instability Possible No No

Levels Com- C5-6, C6-7 C5-6monly Affected

Onset Slow Slow (may be Suddencombined withspondylosis or discherniation)

Diagnostic Diagnostic Diagnostic DiagnosticImaging

Table 21. Differential Diagnosis of Strains, Tendinitis, and Sprains

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