ASSESSMENT AND EVALUATION
Ahmed Alhowimel
ASSESSMENT AND EVALUATION
Good assessment is dependent upon:
 Knowledge of functional anatomy
 History
 Complete examination
EVALUATION
Structure governs function
 Anatomy is the structure
 Biomechanics/physiology are the function
EVALUATION PURPOSE
Develop database to establish Patient’s level of function
Plan a treatment program and establish outcomes
Evaluate results of treatment program
Modify treatment program
CLINICAL EVALUATION SEQUENCE
History
Inspection
Palpation
Functional Testing
 A/P/ROM
 Ligamentous Testing
 Special Tests
Neurological Testing
HISTORY
Most important portion of exam
 Any special test should confirm what is learned in the history
Key questions(identify forces on the body)
 Acute Injury= What is the mechanism
 Chronic Injury= Are there changes in treatment
routines/equipment/posture
HISTORY
Mechanism
 How did injury occur
 Macrotrauma (single traumatic force)
 Microtrauma (accumulation of repeated forces)
Relevant Sounds or sensations
 Pop
 “Giving Way”
Location of symptoms
 Localized
 Referred(pain from another source)
 Isolated vs. diffuse
Onset and duration of symptoms
 Immediate pain v. chronic
 Classification for overuse injuries
 Stage 1
 Pain after activity
 Stage 2
 Pain during/after activity
 Stage 3
 Constant pain
Description of symptoms
 Sharp/dull/achy
 Intermittent v. constant
 Weakness
 Paresthesia (numbness/tingling)
 Dysfunction/ inability to perform activity
Change in symptoms
 Intensity change with specific motions, postures, treatment, modalities,
medications
Previous history
 Previous injury
 When did previous episode occur
 Who evaluated and treated injury
 Diagnosis
 Course of treatment/rehab/surgery performed
 Did previous treatment plan decrease symptoms
Related history to opposite body part
 Previous history of injury to uninvolved side
General health status
 congenital abnormality/disease
INSPECTION
Gait
Gross Deformity
fracture/discoloration/serious bleeding
Swelling (localized v. diffuse)
Bilateral Symmetry
Discoloration
Keloids (surgical scars)
Infection
 Redness/warmth/pus/swelling/red streaks/lymph nodes
GIRTH MEASUREMENTS
Swelling
 Identify joint line using bony landmarks
Atrophy
 Make incremental marks (2,4,6 inch) from jt. line
Lay tape symmetrically around body
Take 3 measurement and record average
Repeat and record for uninjured limb
PALPATION
Detect tissue damage
 Bones (rule out fracture)
 Ligaments/tendons
 Soft tissue
 Pulses
Point tenderness
 Visualize structure which lie beneath fingers
 Compare bilaterally
Trigger Points
 Palpated points in muscle which refer pain to another body area
Change in tissue density (or feel of tissue) may indicate:
 Muscle spasm
 Hemorrhage
 Edema
 Scarring
 Myositis ossificans
Crepitus- repeated crackling sensations or sound emanating from the joint
or tissue
Symmetry
 Compare muscle tone, bony prominence
Increased tissue temperature
 Indicates active inflammatory process
RANGE OF MOTION (ROM)
Helps to assess functional status
Compare bilaterally
Test joints proximal and distal to injured area
FUNCTIONAL TESTING
AROM
Contraindications:
immature fracture sites
newly repaired
Cardinal Planes (test all planes of ROM)
Painful ARC
compression within range
FUNCTIONAL TESTING
PROM
Quantity of available movement
“End feel” reach limit of available ROM
Most accurate method is with goniometry measurements
NORMAL END FEEL
PHYSIOLOGICAL
Hard
Bone contacting bone
elbow extension
Soft
Soft tissue approximation
elbow flexion
Firm
Capsule stretch(ext of MCP jt)
Ligament Stretch
(forearm supination)
Muscle Stretch
(hip flexion with knee extended)
ABNORMAL END FEEL
PATHOLOGICAL
Soft tissue edema
synovitis
Capsular,muscular,
ligamentous shortening
osteoarthritis
Fracture
Bursitis, Joint inflammation
Soft
Firm
Hard
Empty
FUNCTIONAL TESTING
RROM
Contraindications for RROM
 Patient is unable to voluntarily contract injured muscle
 Patient is unable to perform AROM
 Underlying fracture site is not healed
 Involved tissues are not yet healed
Manual Resistance
 Stabilize limb proximally
 Resistance provided distally on bone to which muscle attaches
 Watch for compensation
GRADING SYSTEM FOR MANUAL MUSCLE
TESTING
0/5
Zero
No contraction
1/5
Trace
Palpable contraction
No muscle movement
2/5
Poor
Able to move body part
through gravity eliminated
3/5
Fair
Move against gravity
throughout ROM
4/5
Good
Moderate resistance
5/5
Normal Maximal resistance
CLINICAL SIGNIFICANCE
Strength
 Good
Pain
None
Finding
Normal
 Good
Present
Minor soft tissue
injury
 Weak
Present
Major injury
 Weak
None
Neurological or
Rupture or Chronic
LIGAMENTOUS AND CAPSULAR TESTING
Ligamentous testing
compare bilaterally
compare with baseline measures
correct positioning
(if incorrect positioning may lead to false results)
SPECIAL TESTS
Specific procedures applied to joint to determine presence of injury
Unique to each structure
Bilateral comparison
NEUROLOGICAL (RADIATING PAIN)
Involves Upper/lower quarter screen of:
 Sensory (dermatome)
 Motor (myotome)
 DTR (Deep Tendon Reflex)
SENSORY TESTING
 Bilateral
 Dermatone
 Area of skin innervated by a single nerve root
 Slight stroke over area/pin prick
 Sharp v. dull
 Hot v. cold
Motor Testing
Manuel Muscle Testing
POSTURAL ASSESSMENT
WHAT
IS
POSTURE?
Defined:
“The position of the body at a given point in time.” 
(Starkey)
“A set of muscle contractions that place the body in the 
necessary location from which a movement is
performed.” (Enoka)
“The situation or disposition of the several parts of the 
body with respect to each other for a particular
purpose.” (Webster)
WHAT IS GOOD POSTURE?
posture serves as a reference point.
Ideal posture…
 Distributes gravitational stress for balanced muscle function.
 Allows joints to move in their mid range to minimize stress on ligaments
and articular surfaces.
 Effective for the individual’s activities of daily living.
 Allows the individual to avoid injury.
POSTURAL DEVELOPMENT
Birth

Entire spine concave forward
(flexed)
“Primary curves”



Thoracic spine
Sacrum
Developmental
(usually around 3 mos.)



Secondary curves
Cervical spine
Lumbar spine
POSTURAL DEVELOPMENT
Factors affecting posture
Bony contours
Laxity of ligamentous structures
Fascial & musculotendinous tightness
Muscle tonus
Pelvic angle
Joint position & mobility
POSTURAL DEVELOPMENT
Causes of poor posture
 Positional factors
 Appearance of increased height (social stigma)
 Muscle imbalances/contractures
 Pain
 Respiratory conditions
 Typically can be managed conservatively through
therapeutic ex & education
POSTURAL DEVELOPMENT
Causes of poor posture
 Structural factors
 Congenital anomalies
 Developmental problems
 Trauma
 Disease
 Not typically easily managed
EXAMPLE: TOTAL SPINAL POSTURE
Ideal
1. Head sits straight on
shoulders
 nose in-line c/
manubrium, xiphoid,
umbilicus
 Earlobes in-line with
acromion process
2. Shoulders and clavicles level
are equal
3. normal appearance of
Shoulders
4. Arms equidistant from trunk
5. Normal spinal curves
6.
7.
8.
9.
10.
11.
12.
13.
Iliac crests, ASIS’s & PSIS’s .
ASIS sit lower than PSIS
Gluteal folds and knee joints
even
Patellae point forward
No Genu conditions noted
Heads of fibula and all
malleoli level
Achilles tendons & heels
appear to be straight
Evident arches
GOOD SPINAL POSTURE
WHAT IS BAD POSTURE?
Any position that deviates
from “good posture”
 Static
 Standing
 Sitting
 Sleeping
 Dynamic
 Running
 Throwing, etc.
Correct posture
 “Position in which minimum stress is placed on each joint.”
Faulty posture
 Any position that increases stress on joints
COMMON SPINAL DEFORMITIES
LordosisLordosis
 Excessive anterior curvature of the
spine
 Exaggeration of normal curves in
the cervical & lumbar spines
COMMON SPINAL DEFORMITIES
Lordosis causes:







Postural deformity
Lax muscles (esp. abs)
Heavy abdomen
Hip flexion contracture
Spondylolisthesis
Congential problems
Fashion (high heels)
COMMON SPINAL DEFORMITIES
Swayback deformity :
 Increased pelvic inclination (40)
 Typically includes kyphosis
COMMON SPINAL DEFORMITIES
Kyphosis
Excessive posterior curvature
of the spine
Round back
Humpback/gibbus
Flat back
Dowager’s Hump
COMMON SPINAL DEFORMITIES
Scoliosis
 Nonstructural
 “Functional”
 May be related to leg length
discrepancy
 Structural
 Lacks normal flexibility
 Asymmetric movements
COMMONLY SEEN POSTURAL DEVIATIONS
Shoulder/Scapula
Winging Scapula
Head and C-Spine
HIPS
History
Inspection
Palpation
Special (Functional) Tests
RELEVANT HISTORY
Identify factors that
influence posture
Overuse
Neurological Problems
Pain
Lack of awareness
Ms weakness/
Imbalance
Hypermobile Jts
Hypomobile Jts
Flexibility
Bony Abnormality
Leg Length Disc.
INSPECTION
Use of a plumb line
Anatomical reference
3 views
Lateral (sagittal plane
movements)
Anterior (frontal/
transverse plane
movements)
Posterior (frontal/
transverse plane
movements)
OBSERVATION
Body type
Ectomorph
Mesomorph
Endomorph
LATERAL VIEW
Look for:
 @ ankle?
 @ knee?
 @ hip?
 @ shoulder?
 @ neck?
 @ head?
Anterior view
Anterior view
 Head straight on shoulders
 Shoulders level
 Clavicles/AC joints
 Sternum & ribs
 Waist angles & arm positions
 Carrying angles
 Iliac crests
 ASIS
 Patellae
 Knees
 Fibular heads
Malleoli level 
Arches 
Foot rotation 
Bowing of bones 
Diastematomyelia (hairy patches) 
Pigmented lesions 
Café au lait spots 
POSTERIOR VIEW
Look for:
 @ heel?
 @ pelvis?
 @ lumbar spine?
 @ scapulae?
 @ neck?
 @ head?
PALPATION
In assessment position
(i.e., standing), palpate:
 Laterally
 ASIS vs. PSIS
 Anteriorly
 Patellae
 Iliac Crests
 ASIS heights
 Lateral Malleolar
heights
 Fibular Head heights
 Shoulder heights
Posteriorly
PSIS
positions
Spinal alignment
Scapular positions
FUNCTIONAL TESTS
 Assess muscular length
 ROM
 Resting muscle length
OTHER TECHNOLOGY
Video Analysis
3D Motion Analysis
Sway Measurement Tools
 Force Plate
 Biodex Stability System
 NeuroCom