clinical skills

signs and symptoms that raise suspicion of a serious pathology

signs and symptoms or clinical conditions where you should not treat the patient and immediately refer

signs and symptoms or clinical conditions that will require specific modification(s) of the patient management plan to ensure patient safety

- Patient’s age, demographic and general health status (i.e. multimorbidities) ​
- Pregnancy (especially in the 1st trimester), or immediately post-partum ​
- Intervertebral disc herniation ​
- Gross degenerative change (i.e. severe osteoarthritis) ​
- Osteoporosis ​
- Hypermobility syndrome or other connective tissue disorders ​
- Calcification of the aorta, vascular disease, blood clotting disorders, or anticoagulant therapy
- Active inflammatory disease (i.e. rheumatoid arthritis, gout) ​
- Previous history of cancer
- Acute or chronic systemic disease ​
- Local infection ​
- Vertigo ​
- Long term steroid therapy ​
- Adverse reaction by the patient to previous treatment ​
- Patient who has recently been treated by another practitioner or had recent surgery ​
- Patient who is currently using pain and/or blood thinning medication(s) ​
- Patient with a psychological dependency on treatment ​
- Absence of a plausible mechanical explanation for the patient’s symptoms

minor/transient, moderate/substantive, major/serious

- cauda equina syndrome: A pathology of the distal spinal cord roots (the cauda equina), which has the potential to cause loss of function to the lower limb and bowel and bladder
- fracture
- malignancy (cancer)
- infections

- Trauma/instability: Severe recent physical trauma, fracture, dislocation, or gross instability ​
- Bone weakening: Pathologies (e.g. osteoporosis), long-term corticosteroid use
- Serious neurological pathology: Acute myelopathy, spinal cord damage, upper motor neuron lesions, multi level nerve root pathology, worsening neurological function ​
- Serious vascular pathology: Including vascular insufficiency in the brain and cervical spine and DVT ​
- Clinical features of serious illness: Unremitting night pain, unremitting non-mechanical pain or active cancer, serious visceral pathology ​
- Inability to establish a working diagnosis ​
- Excessive pain and/or alarming physical signs or symptoms ​
- Informed consent for management not (or not able to be) given by the patien

- sensory change
- change in urinary function
- change in bowel movements
- motor weakness
- low back pain

- bone tenderness
- neurological signs
- thoracic pain

- neurological signs
- bony tenderness
- thoracic pain

- bony tenderness
- neurological signs
- fatigue
- fever

- minors (less than 18)
- certain psychological conditions: eg. schizophrenia, acute psychiatric episodes
- intellectually impaired
- affected by drugs or alcohol
- affected by a language barrier that impacts communication

- what will happen and why
- benefits and risks
- alternatives and option to withdraw consent
- any questions or clarifications
- ask for consent to proceed

- tissue texture change
- asymetry
- restriction of motion
- tenderness

lasts 0-72 hrs
includes: headache, tiredness, muscle tenderness, short term stiffness or soreness

lasts days- life
includes: long term pain or loss of function, peripheral nerve injury

lasts days-life
includes: fracture, dislocation, rapture of tendon, ligament and/or muscle

proportion of inviduals with a condition who test positive

proportion of individuals who do not have a condition and test negative

- Observation (e.g. swelling, redness, bruising)
- Functional movements / Activities of daily living
- Gait
- Posture
- Cervical spine motion
- Upper extremity screen
- Lumbar / Thoracic motion
- Thoracic cage
- Lower extremity screen

- Redness
- Bruising
- Scars
- Swelling
- Varicose veins
- Cuts / abrasions
- Infections

asking the pateint to demonstrate any daily movements they have trouble with

Limp
Poor coordination
Dragging one foot
Coordinated movement from heel strike to toe off

Head position
Shoulder heights
Clavicle heights
Arm carriage
Innominate levels
Anterior superior iliac spine
Patellae
Femur & tibia angles (& Q-angle)
Foot posture

Cervical spine curve
Head carriage
Scapulae position
Thoracic spine curve
Lumbar spine curve
Pelvis orientation
Knees
Ankles

Ear levels
Cervical spine
Shoulder heights
Inferior scapula angle
Thoracic spine (curvatures)
Pelvic crest levels
Gluteal folds
Popliteal folds
Achilles tendon
Foot arches

1. rotate head left and right
2. bend head forward and backward (up and down)
3. bend head side to side

- assess from posterior view to observe scapula movements
- ask if there is any pain or discomfort with those movements

ask patient to:
- bend forward (flexion)
- bend backward (extension)
- run their hands down their leg (side bending)
- roate their body (whilst we stabilise pelvis)

ask patient to take deep breaths, palpate:
- area of ribs 1
- upper ribs
- middle ribs
- lower ribs

squat down as low and possible without bringing feet off the floor

Physiological Barrier

Primarily active structures (muscles) but can also be passive structures (ligaments, joint capsules)

elastic barrier

Joint structures (ligaments, joint capsules)

elastic barrier

Joint structures (ligaments, joint capsules)

- decrease in pain
- promote mobility and movement
- promote fluid drainage
- support tissue healing and collagen remodelling

- provide pain reflief through central inhitory pathways
- improve circulation through muscular contraction and promoting venous return
- improve neuromuscular function, modulating spinal reflex excitabilityy and reducing muscle tention
- improve joint arthrokinematics by improving lubrication mechanisms within joints

- rate
- rhythm
- applitude

0 = absent
1+ = diminished
2+ = NORMAL
3+ = hyperactive without clonus
4+ = hyperactive WITH clonus

5 (normal)= complete ROM against gravity and full resistance
4 (good) = complete ROM against gravity and some resistance
3 (fair) = complete ROM against gravity, no resistance (acitve ROM)
2 (poor) = complete ROM with resistance and gravity removed
1 (trance) = evidence of slight muscular contraction, no joint motion evident
0 (zero) = no evidence of muscular contraction

- Range of motion
- Control of movement
- Patient willingness to perform movement
- Pain levels with movement
- Fear avoidance behaviours

Flexion
Extension
Abduction
Adduction
Internal rotation (in neutral and 90o flexion)
External rotation (in neutral and 90o flexion)

- Hypo-mobility
- Hyper-mobility
- Patient willingness to allow practitioner to perform movement
- Pain levels with movement

** take note of end feel

Flexion
Extension
Abduction
Adduction
Internal rotation (in neutral and 90o flexion)
External rotation (in neutral and 90oflexion)

1. Iliac crests
2. Iliac tubercles (approx. 5cm posterior to ASIS)
3. Anterior superior iliac spines (ASIS)
4. Greater trochanters
5. Pubic tubercles (immediately lateral to pubic symph.)

**TART**

- temp (back of hand)
- thinkness (pinching skin and roll)
- skin drag (place fingers on skin and drag)
- vitality (pinch, lift and see recoil)
- rouchness and smoothness (place hands on skin and feel)
-mobility (place hands on skin, drag hands up, down, left, right, rotation)

1. Posterior superior iliac spines (PSIS)
2. Sacrum
3. Inferior lateral angle of sacrum – ILA (post. Lat sacrum where starts to anglein sharply towards coccyx)
4. Coccyx (prone only)
5. Ischial tuberosity

- Trochanteric Bursa (over and inf. to GT)
- Iliotibial band (ITB) (lat iliac crest – lateral tibial condyle)
- Piriformis (ant sacrum – GT)
- Sciatic Nerve (mid piriformis: middle of line from S2-GT)

- Superior Border: Inguinal Ligament
- Medial Border: Adductor Longus
- Lateral Border: Sartorius
- Floor: Iliopsoas and Pectineus
- Contents: Femoral artery, lymph nodes if present.

- Psoas
- Iliacus
- Rectus femoris
- Sartorius

- gluteus max
- hamstrings
-> semtendinous
-> semimembranosus
-> bicpes femoris

- Adductor longus
- Gracilis
- Pectineus (too hard to palpate)
- Adductor brevis (too hard to palpate)
- Adductor magnus
->Adductor Part:
-> Hamstring Part:

- gluteus medius
- gluteus minimus
- TFL

prox: iliac fossa
distal: lesser trochanter of the femur

prox: lateral aspect of vertebra T12-L5 and intervertebral discs
distal: lesser trochanter of the femur

prox: anterior supeior iliac spine
distal: superior part of the medial surface of the tibia/ part of the pes anserine

prox: anterior inferior iliac spine
distal: inserts onto the patella via the quadriceps tendon, which then attaches to the tibial tuberosity by the patrllar ligament

prox: body of pubis
distal: middle third of the linea aspera of femur

prox: body of pubis
distal: superior part of the medial surface of the tibia/ part of the pes anserine

- adductor part:
prox: inferior ramus of pubis and ramus of ischium
distal: linea aspera and medial supracondylar line of femur
- hamstring part:
prox: ischial tuberosity
distal: adductor tubercle of the femur

prox: ilium , posterior surface of the sacrum and coccyx
distal: iliotibial tract or gluteal tuberosity of the femur

- long head
prox: ischial tuberosity
distal: head of fibula

- short head
prox: linea aspera and the lateral supracondylar line of the femur
distal: head of the fibula and the lateral condyle of the tibia

prox: ischial tuberosity
distal: superior part of the medial surface of the tibia (part of the pes anserine)

prox: ischial tuberosity
distal: posterior aspect of the medial condyle of the tibia

prox: ilium between the anterior and posterior gluteal lines
distal: greater tronchanter of the femur

prox: ilium between the inferior and anterior gluteal lines
distal: greater tronchanter of the femur

prox: anterior superior iliac spine
distal: iliotibial tract

- Flexion
- Extension
- Abduction
- Adduction
- External rotation (at neutral and 90o flexion)
- Internal rotation (at neutral and 90o flexion)

FADDIR test

Flexion/ internal rotation test

trendelenburg test

FABER test

resisted hip abduction

adductor squeeze test -

- flexion
- extension
- external rotation (at 90)
- internal rotation (at 90)

- flexion
- extension
- external rotation (90)
- internal rotation (90)

- patella
- trochlear groove
- tibial tuberosity

- lateral joint line
- lateral tibial plateau
- lateral tubercle (attatchment for gerdy's tubercle)
- lateral femoral epicondyle and condyle
- head of fibula

- medial tibial plateau
- medial joint line
- pes anserine
- medial femoral epicondyle and condyle
- adductor tubercle (hamstring and adductor magnus part)

- quadricpes
-> rectus femoris
-> vastus lateralis
-> vastus medialis
-> vastus intermedius
- patella tendon
- subcutaneous infrapatellar bursa
- pes anserine bursa
- infrapetella fat pad

- medial meniscus
- medial collateral ligament
- satorius
- gracilis
- semintendinosus
- pes anserine tendons

- lateral meniscus (within joint line)
- lateral collateral ligament
- anterior superior tibiofibular ligament
- common fibular/ peroneal nerve
- biceps femoris tendon
- iliotibial band

borders:
Supmed: semimembranosus & semitendinosis
Suplat: biceps femoris
InfMed: medial head of gastroc
LatMed: lateral head of gastroc

Contents
- tibial nerve (cannot palpate)
- popliteal artery
- popliteus (hard to palpate)

- tibiofemoral joint traction
- AP shear of tibia
- PA shear of tibia
- medial gapping of knee
- lateral gapping of knee
- medial/ lateral glide of the patella
- patella traction

- flexion
- extension
- external rotation
- internal rotation

anterior draw test

Lachman's test

Posterior draw test

Valgus stress test at 0 and 25

varus stress test at 0 and 25

Thessaly's test

Sweep test

- dorsiflexion (talocrural)
- plantarflexion (talocrural)
- inversion (subtalar)
-eversion (subtalar)
- toe flexion/ extension
- metatarsophalangeal flexion/extension (knuckles)
- interphalangeal felxion/extension
*Should be performed both weightbearing and non-weightbearing

- Dorsiflexion (talocrural)
- Plantarflexion (talocrural)
- Inversion (subtalar)
- Eversion (subtalar)
- Adduction (subtalar)
- Abduction (subtalar)
- Toe flexion/extension
- metatarsophalangeal flexion/extension (knuckles)
- interphalangeal felxion/extension

- Distal tibia
- Medial malleolus
- Sustentaculum tali (anteromedial calc- attachment point deltoid and spring lig)
- Medial Calcaneus
- Head of talus (articulate w/navicular)
- Navicular & navicular tubercle
- Medial cuneiform
- 1st metatarsal
- Great toe

- Distal fibula
- Lateral malleolus
- Fibular trochlear (peroneal tubercle) splits fib longus and brevis on calcaneus
- Calcaneus
- Sinus tarsi (tunnel b/w calc + talus)
- Cuboid
- Styloid process of 5th met
- 5th metatarsal
- 5th toe

- Calcaneus
- Medial tubercle of calcaneus (plantar fascia attachment)
- Sesamoid bones (under 1st MTP)
- Metatarsals 4-2 & heads of METs
- Phalanges

- Phalanges (distal, middle, proximal)
- Metatarsals
- Cuboid
- Cuneiforms: medial, intermediate, lateral
- Navicular
- Talar head

- 1st metatarsal bursa (medial to MTP)
- Spring ligament
- Deltoid ligament
- Tibialis posterior
- Flexor digitorum longus
- Posterior tibial artery and nerve
- Flexor hallicus longus

- Lateral ligaments
-> Anterior talofibular
-> Calcaneofibular
-> Posterior talofibular
- Anterior-inferior tibiofibular
- posterior-inferior tibiofibular ligaments (hard to palpate)
- Fibularis longus
- Fibularis brevis
- Extensor Digitorum Brevis
- 5th metatarsal bursa

- Tibialis anterior
- Extensor hallicus longus
- Dorsalis pedis artery
- Extensor digitorum longus
- Extensor digitorum brevis
- Fibularis (peroneus) tertius

- Achilles tendon
-> Gastrocnemius (medial and lateral heads)
-> Soleus
- Calcaneal bursa (post calc, superficial and deep to achilles)
- Plantar fascia (med calc tub – prox phalanges

- talocrural joint traction
- talocrucural AP shear (glide) of the talus
- subtalar spring
- shear of the cuniforms
- mid tarsal AP spring (glide)
- metatarsal shear
- MTP traction
- IP traction
- MTP medial/lateral gapping
- IP medial/lateral gapping

- Dorsiflexion
- Plantarflexion
- Inversion
- Eversion
- Toe flexion
- Toe extension

thompson test

anterior draw test

squeeze test