ORTHOPEDIC PHYSICALTHERAPY ASSESSMENT
Subjective assessment
• Name
• Age/ Sex
• Address
• Contact No.
• Occupation
• Dominance
• Date of assessment
Chief complaints
History
• History of Present illness (HOPI)
Pain assessment
o Mechanism of Injury
o Onset:- slow/ sudden
o Duration- since when it is bothering pt?
o Site/ location- body diagram
o Type/ quality of pain:▪ Sharp pain/ burning/bright:- nerve
▪ Deep, boring, very localized;- bone
▪ Diffuse, aching, poorly localized- vascular pain
▪ Hard to locate, dull aching:- muscular
o Character/: Nature▪ constant/ periodic/ episodic (occurring with certain activities)/ occasional
o Aggravating factor:o Relieving factor:o Diurenal Variation:
o Severity of pain
o Intensity of pain:▪ Self report- verbal numeric rating/ VAS/ wong- baker facial pain rating scale
▪ Multi-dimensional instrument- Mcgill pain Questionare/ Breif pain inventory (
BPI)
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Past medical history
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Surgical history ( Relevant)
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Personal history
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Family history
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Occupational history
Objective Assessment
• On Obesvervation:Generalo Body built
o Psychological status
o Posture
o Gait
o Any external appliance
Localo attitude of limb
o Swelling
o Deformity
o Muscle wasting
o Skin Scar/ bruises
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On Palpation:o Vital signs- BP, RR, Temp, HR
o Warmth
o Oedema- pitting/ non pitting
o Tenderness
o Spasm
o Scar- pliable/ non pliable
On Examination:• Motar Examinatono ROM
o MMT/ RIM
o Muscle length testing
o Joint play
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Neurological examination
o Sensations ( dermatomes)
o Myotomal examination
o Reflexes
Special Examination:• Posture analysis
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Gait Analysis
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Girth measurement/ Circumferential measurement
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Limb length measurement
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Scar examination
Functional Assessment:Special Test:Differential diagnosis:Investigations:Rehab diagnosis:Problem list:Goals:• Short term goals
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Long term goals
Treatment
Follow up