Orthopaedic assessment for physiotherapist: Step-by-step method

The orthopaedic assessment for physiotherapist is different from orthopedic surgeons and this is because our treatment approach and goal are different. Assessment procedure largely involves interviewing the patient and reviewing the medical and investigation reports like X-ray, MRI CT Scan reports. Based on this data a physical therapist plan an effective treatment compatible with the needs and goals of the patient and members of the Healthcare team.

In this article, I will present not only the theoretical aspect of assessment but will also embed my 15 years of valuable practical experience in it. So without delay let’s get started.

Orthopaedic assessment for physiotherapist

Any medical assessment involves a series of interrelated steps that help a physiotherapist for clinical decision making and to set a goal for treatment.

One must note that the orthopaedic assessment for physiotherapist process starts as soon as the patient enters your clinic or department. So when a person or a patient enters department you have to observe for how he is coming to you, whether he is being carried by his family members or is using any walking aids, wheelchair or simply coming on his own.

Before we come to the actual point, let me give you an overview of the assessment procedure. Orthopaedic assessment involves the collection of data through interviews and case-specific tests and maneuvers.

1. Collection of data like: Name, Age, Sex, Address, Occupation.
2. Chief complaint (C/O).
3. History (H/O): History of present illness, Treatment history, History of past illness, Family history.
4. Observation (O/O).
5. Examination (O/E).
6.  provisional diagnosis.
7.  Advise.

Based on these steps I have made a sample orthopaedic assessment sheet for a physiotherapist that you may download for your future reference.

Now let’s discuss each and every point in detail and will try to cover what is the actual process it involves? what is the effective way to collect data? and everything related to it.

Basic information

The collection of basic information like name, age, sex, address, and occupation is important for documentation.

But, address and occupation have its other values as it also gives us an idea about what could be the possible cause of present illness. We can also correlate the present illness or disability with the occupation of the person.

Chief complaint

Chief complain is the most important complaint that a patient is presenting to us. It should be documented in the exact term or the views presented by the person.

For example, if suppose someone is suffering from sciatica or diagnosed with one, the person will never complain that he is suffering from sciatica.

The most probable complain would be like:

• I am having low back pain since one month that is radiating down to my leg.
• I am feeling like a pulling sensation on the back of the thigh upon standing walking or
• It is difficult for me to sleep to sit on the sofa long.

So the chief complaint would be the exact words exact views of the patient that we need to document.

Then comes the history taking.

History

History is a very important part of orthopaedic assessment for physiotherapist or any other medical assessment. This is because during history taking a physiotherapist actually interview or interact with your patient face to face, it gives us an opportunity to establish a rapport with the patient. The way we put our question is more of an art than a science.

During this, we should make him/her comfortable and allow him to express his opinion of his pain in his words. We should be like a patience listener so that we can as much information as possible.

We have already discussed history taking in a very detailed matter in one of our previous article “How to take History of a Patient in an impressive way?“, you can refer to this article for further details. Here we will just have an overview.

History taking involves the following important points:

History of present illness:

It involves the collection of data related to present complaints or illnesses. You have to ask the following questions to extract the information:

1. How old is the problem or illness?
2. How it was started?
3. Does it started spontaneously or related to the injury.
4. What kind of injuries sustained?
5. What makes comfortable or uncomfortable? whether sleeping makes him comfortable for sitting in a particular posture?

You will have to collect all this data that will help us to steer towards the probable cause of the present illness.

History of  treatment

Then we have to ask for whatever he has received any treatment for this particular illness. Whether he has got any medications, any kind of treatment, let it be of Physiotherapy treatment. What kind of Physiotherapy treatment has got?

Then ask for all medical reports of the previous treatment, review his x-ray reports, MRI reports, CT Scan reports (what’s the difference between CT-Scan and MRI?).

All this will give you a very clear picture of what may be the probable cause of the present illness.

History of past illness

In many of the cases, we need to go through past illnesses to correlate with present complain. You may need to ask for a similar illness or related illness in the previous years/ past years, and treatment he has received for it.

Family history

Many of the cases like Rheumatoid Arthritis, osteoarthritis, osteoporosis all these travel in the family. So sometimes it is worth to look for family history.

Observation

Under observation, we have to document everything that we have observed for in a patient right from when he enters the department. As we have already discussed, whether he came by walking himself or were carried by their family members or using a wheelchair.

After this, we have to observe the posture of the person:

• Whether he is sitting straight
• Make him stand and observe whether he is standing straight or tilted to sides, to front.
• Whether he is cooperative non-cooperative.
• Whether he seems to be worried about pain.

All these things come under observation.

Also read: How to become a good physiotherapist

Examination

As the term suggests, we have to now closely examine the patient and look for the exact cause of illness. However, until this point, we should have some blurry picture of the probable cause and examination helps clear this picture. So accordingly, you have to plan your examination steps.

The examination involves a test or a maneuver that is needed to be carried depending upon the case. Suppose if someone has a complaint of knee pain who he is too young to have osteoarthritis, also if he has describes that pain started immediately after a sports injury, then you have to plan tests related to that particular complaint.

Perform tests to exclude any ligament damage or meniscus injury.

Likewise, if someone is complaining of low back pain with pulling sensation on the right leg then there is no point going for knee test.

So accordingly you have to plan your tests like straight leg raise (SLR) test, or lateral PA, Central PA test or sciatica stretch test.

Provisional diagnosis

Now, its time to conclude a provisional diagnosis/ probable cause of illness. For this preview all the findings of the test, all the records of the interview and previous record medical and investigation report.

You must be able to pinpoint some specific disability, pain or illness and this will be your provisional diagnosis.

Advice

So let me once again repeat that you can download a sample sheet of orthopedic assessment for physiotherapists in PDF format by paying just Rs 15.00 designed by me.

Basing your diagnosis, complaints of the patient, need of the patients and member of other Healthcare teams you have to develop a goal treatment plan.

For any type of illness or pain we can broadly categorize our goals into two types:

1. Short term goals.
2. Long term goals.

Let me explain this goal by a simple sciatica case or slip disc case which I usually encounter in my clinic.

Suppose a person comes with the complaint of low back pain with pulling sensation on the right leg, then your short term goal would be to relieve the back pain around the lumbar region.

To treat the cause of sciatica that I due to PIVD or wrong posture or piriformis syndrome would be your long term goal.

Sunit. S. Ekka

Dr Sunit Sanjay Ekka is a physiotherapist in practice for the last 15 years. He has done his BPT from one of the premium Central Government physiotherapy colleges, ie, SVNIRTAR. The patient is his best teacher and whatever he gets to learn he loves to share it on his Youtube channel and blog.