The orthopedic examination is an essential part of the diagnosis of complaints effecting the muscles, bones, joints and related tissues. These tests necessarily involve movement, or the application of a force to resist movement. The purpose of many of these tests is to measure muscle strength and joint ranges of motion. These tests are also used to search for the site and source of musculoskeletal pain. Hence, the tests themselves could be painful in some circumstances.

If it is necessary to perform a test which could be painful, it is best that the test be done properly and done only once to get the necessary information. This often requires that the patient be able to follow instructions and cooperate with the person performing the tests. It is therefore important that you give clear instructions and, if necessary, demonstrate the desired movement or position that you require for the test.

In order to provide an efficient assessment of the patient, the orthopedic examination should follow a logical sequence. This will normally begin with a visual inspection of the area of complaint. Then the clinician will palpate the area before choosing which specific tests to perform. Of the many tests that could be performed, the efficient clinician will choose those which form a path to the diagnosis.

This general guideline must be tempered by a consideration of the patient's condition. Particularly if a patient is in pain, you may not want to have them changing position frequently. Therefore, you may perform tests out of sequence to avoid painful movement. For example, you might do all of the tests that you think appropriate in the sitting position and then have the patient lie down and do tests in that position. In this way, you will avoid having the patient repeatedly sit up and lie down.

Orthopedic tests necessarily involve physical contact between the clinician and patient. This may be uncomfortable or embarrassing for some patients. By words or gestures, you should always try to explain to the patient that you are going to touch them before actually doing so. Depending on their culture, they may expect you to ask permission before touching. A professional, confident and respectful attitude will do as much as verbal communication to win the patient's trust and cooperation.

Situation 1: An orthopedic surgeon is examining the neck of a young woman who recently had a motor vehicle accident.

Surgeon: Ms. Jones, I am going to take a look at the range of motion of your neck. Can you bend your head forward and try to touch your chin to your chest. (Ms. Jones flexes her neck.) Good, and now back up. Good, was there any pain with that motion?

Ms. Jones: Here and here. (Ms. Jones runs her hands down the back of her neck and onto both shoulders.) Both of my shoulders are sore.

Surgeon: Now, can you bend your neck as far as you can to the left and right, and tell me if there is any pain. (Ms. Jones bends her neck laterally to the left and right.)

Ms. Jones: Here and here. Probably the pain is worse on the right side.

Surgeon: And now, can you look up at the ceiling and tip your head back as far as it can go. (Ms. Jones can hardly extend her neck at all.) Does that hurt?

Ms. Jones: That really hurts my neck, especially here. (She places her hand over the upper cervical region.)

Surgeon: Okay, now I will get you to turn your head as far as you can to the left and right, and tell me where it hurts. (The surgeon demonstrates by rotating his head to the left and right.)

Ms. Jones: (Turning rotating her head to the left and right.) That really hurts me when I turn to the left. (She runs her hand down the right side of her neck.)

Surgeon: Alright, now I am going to push down on the top of your head. Please tell me if this hurts. (The surgeon stands behind the patient, and pushes down on the top of her head with both hands.)

Ms. Jones: Oh, that really hurts. (She places both hands on the back of her neck.)

Surgeon: Okay, we are almost finished. I want you to hold your head in this position, and I'm going to push down again. (The surgeon holds the patients head in rotation and extension, and compresses again. He performs this motion with the head rotated first to the left and then to the right.)

Ms. Jones: That hurts a lot on both sides

Patterns:

* I am going to
...take a look at the range of motion of your neck
... push down on the top of your head
... push down again I am going to ...

* I will get ...you to turn your head as far as you can
* I want ...you to hold your head in this position

* Can you
...bend your head forward
...bend your neck as far as you can
... look up at the ceiling
Can you ...

* Tell me
...if there is any pain
... where it hurts
* Please tell me if this hurts

* Was there any pain with that motion

* Does that hurt

* Both of my shoulders are sore
* The pain is worse on the right side
* That really hurts my neck
* That hurts a lot on both sides
* That hurts ...

Situation 2: A chiropractor is examining a young female athlete who has recently injured her left knee.

Chiropractor: Ms. Hunter, I'm going to get you to lie on your back on the examination table and I'm going to examine your knee. (The patient lies on the table.) Is your knee painful at all while you are lying down?

Ms. Hunter: No, this is fine.

Chiropractor: Now, I'm going to get you to relax and I'm going to gently press around the knees. Tell me if this hurts. (The chiropractor palpates around both patellae.) There's no obvious swelling. Is it painful at all when I press?

Ms. Hunter: No, there is no pain now. It's only painful when I walk or run. It really hurts when I try to run up stairs.

Chiropractor: I'm going to get you to bend this knee and I'm going to challenge the joint just a little bit. Let me know if this is uncomfortable. (The doctor challenges the cruciate ligaments.) There doesn't seem to be any ligament damage. Was that painful at all?

Ms. Hunter: No, that didn't hurt at all.

Chiropractor: Good. Next I'm going to bend and straighten your leg while a push gently on the side of the knee. Tell me if this causes any pain. (The doctor performs the McMurray test for meniscal tears.) The cartilage in your knee appears to be fine. Was there any discomfort with that?

Ms. Hunter: Just a bit behind the knee cap as you straightened my leg.

Chiropractor: Okay, now this could be a little painful. Tell me if it hurts. I'm going to push down on your knee cap, and I want you to contract this muscle. (The doctor performs the patellar femoral grinding test.)

Ms. Hunter: Wow! That really hurts! That's the pain I usually feel when I'm going up stairs. It's right behind the knee cap.pr> Chiropractor: Yes, that's what I expected. Let me explain what's wrong and what weÕre going to do about this problem.

Patterns:

* I'm going to get you to
...lie on your back
... relax
... bend this knee
* I'm going to get you to ...

* I'm going to
... examine your knee
... gently press around the knees
... challenge the joint a little bit
... bend and straighten your leg
... push down on the knee cap
* I'm going to ...

* Is your knee
... painful at all
... painful at all when I press

* Was that painful at all
Was there any discomfort with that
* Is/was ... painful

* Tell me if
... this hurts
... it hurts
... this causes any pain

* Let me know if this is uncomfortable
* Tell me/let me know if ...