1. What is the patient’s age and sex? Many conditions occur within certain age ranges. For example, various growth disorders, such as Legg-Perthes disease or Scheuermann disease, are seen in adolescents or teenagers. Degenerative conditions, such as osteoarthritis and osteoporosis, are more likely to be seen in an older population. Shoulder impingement in young people (15 to 35 years) is more likely to result from muscle weakness, primarily in the muscles controlling the scapula, whereas the condition in older people (40+ years) is more likely to be the result of degenerative changes in the shoulder complex. Some conditions show sex and even race differences. For example, some cancers are more prevalent in men (e.g., prostrate, bladder), whereas others occur more frequently in women (e.g., cervical, breast), yet still others are more common in white people.

2. What is the patient’s occupation? What does the patient do at work? What is the working environment like? What are the demands and postures assumed?7 For example, a laborer probably has stronger muscles than a sedentary worker and may be less likely to suffer a muscle strain. However, laborers are more susceptible to injury because of the types of jobs they have. Because sedentary workers usually have no need for high levels of muscle strength, they may overstress their muscles or joints on weekends because of overactivity or participation in activity that they are not used to. Habitual postures and repetitive strain caused by some occupations may indicate the location or source of the problem.

3. Why has the patient come for help? This is often referred to as the history of the present illness or chief complaint. This part of the history provides an opportunity for patients to describe in their own words what is bothering them and the extent to which it bothers them. It is important for the clinician to determine what the patient wants to be able to do functionally and what the patient is unable to do functionally. It is also essential to ensure that the clinician knows what is important to the patient in terms of outcome, whether the patient’s expectations for the following treatment are realistic, and what direction functional treatment should take to ensure the patient can, if at all possible, return to his or her previous level of activity or realize his or her expected outcome.8

4. Was there any inciting trauma (macrotrauma) or repetitive activity (microtrauma)? In other words, what was the mechanism of injury, and were there any predisposing factors? If the patient was in a motor vehicle accident, for example, was the patient the driver or the passenger? Was he or she the cause of the accident? What part of the car was hit? How fast were the cars going? Was the patient wearing a seat belt? When asking questions about the mechanism(s) of injury, the examiner must try to determine the direction and magnitude of the injuring force and how the force was applied. By carefully listening to the patient, the examiner can often determine which structures were injured and how severely by knowing the force and mechanism of injury. For example, anterior dislocations of the shoulder usually occur when the arm is abducted and laterally rotated beyond the normal range of motion (ROM), and the “terrible triad” injury to the knee (i.e., medial collateral ligament, anterior cruciate ligament, and medial meniscus injury) usually results from a blow to the lateral side of the knee while the knee is flexed, the full weight of the patient is on the knee, and the foot is fixed. Likewise, the examiner should determine whether there were any predisposing, unusual, or new factors (such as, sustained postures or repetitive activities, general health, or familial or genetic problems) that may have led to the problem.9

5. Was the onset of the problem slow or sudden? Did the condition start as an insidious, mild ache and then progress to continuous pain, or was there a specific episode in which the body part was injured? If inciting trauma has occurred, it is often relatively easy to determine the location of the problem. Does the pain get worse as the day progresses? Was the sudden onset caused by trauma, or was it sudden with locking because of muscle spasm (spasm lock) or pain? Is there anything that relieves the symptoms? Knowledge of these facts helps the examiner make a differential diagnosis.

6. Where are the symptoms that bother the patient? If possible, have the patient point to the area. Does the patient point to a specific structure or a more general area? The latter may indicate a more severe condition or referral of symptoms (yellow flag). The way in which the patient describes the symptoms often helps to delineate problems. Has the dominant or nondominant side been injured? Injury to the dominant side may lead to greater functional limitations.

7. Where was the pain or other symptoms when the patient first had the complaint? Pain is subjective, and its manifestations are unique to each individual. It is a complex experience involving several dimensions (Figure 1-1).¹⁰ If the intensity of the pain or symptoms is such that the patient is unable to move in a certain direction or hold a particular posture because of the symptoms, the symptoms are said to be severe. If the symptoms or pain become progressively worse with movement or the longer a position is held, the symptoms are said to be irritable.^11,12 Acute pain is new pain that is often severe, continuous, and perhaps disabling and is of sufficient quality or duration that the patient seeks help. Acute injuries tend to be more irritable resulting in pain earlier in the movement, or minimal activity will bring on symptoms, and often the pain will remain after movement has stopped.³ Chronic pain is more aggravating, is not as intense, has been experienced before, and in many cases, the patient knows how to deal with it. Acute pain is more often accompanied by anxiety, whereas chronic pain is associated with depression.¹³ When tissue has been damaged, substances are released leading to inflammation and peripheral sensitization of the nociceptors (also called primary hyperalgesia) resulting in localized pain. If the injury does not follow a normal healing pathway and becomes chronic, central sensitization (also called secondary hyperalgesia) may occur. Peripheral sensitization is a local phenomenon whereas central sensitization is a more central process involving the spinal cord and brain. Central sensitization manifests itself as widespread hypersensitivity to such physical, mental, and emotional stressors as touch, mechanical pressure, noise, bright light, temperature, and medication.^14,15
Has the pain moved or spread? The location and spread of pain may be marked on a body chart, which is part of the assessment sheet (see Appendix 1-1). The examiner should ask the patient to point to exactly where the pain was and where it is now. Are trigger points present? Trigger points are localized areas of hyperirritability within the tissues; they are tender to compression, are often accompanied by tight bands of tissue, and, if sufficiently hypersensitive, may give rise to referred pain that is steady, deep, and aching. These trigger points can lead to a diagnosis, because pressure on them reproduces the patient’s symptoms. Trigger points are not found in normal muscles.¹⁶
In general, the area of pain enlarges or becomes more distal as the lesion worsens and becomes smaller or more localized as it improves. Some examiners call the former peripheralization of symptoms and the latter, centralization of symptoms.17–19 The more distal and superficial the problem, the more accurately the patient can determine the location of the pain. In the case of referred pain, the patient usually points out a general area; with a localized lesion, the patient points to a specific location. Referred pain tends to be felt deeply; its boundaries are indistinct, and it radiates segmentally without crossing the midline. The term, referred pain, means that the pain is felt at a site other than the injured tissue because the same or adjacent neural segments supply the referred site. Pain also may shift as the lesion shifts. For example, with an internal derangement of the knee, pain may occur in flexion one time and in extension another time if it is caused by a loose body within the joint. The examiner must clearly understand where the patient feels the pain. For example, does the pain occur only at the end of the ROM, in part of the range, or throughout the ROM?⁹

8. What are the exact movements or activities that cause pain? At this stage, the examiner should not ask the patient to do the movements or activities; this will take place during the examination. However, the examiner should remember which movements the patient says are painful so that when the examination is carried out, the patient can do these movements last to avoid an overflow of painful symptoms. With cessation of the activity, does the pain stay the same, or how long does it take for the pain to return to its previous level? Are there any other factors that aggravate or help to relieve the pain? Do these activities alter the intensity of the pain? The answers to these questions give the examiner some idea of the irritability of the joint. They also help the examiner to differentiate between musculoskeletal or mechanical pain and systemic pain, which is pain arising from one of the body’s systems other than the musculoskeletal system (Table 1-2).¹⁸ Functionally, pain can be divided into different levels, especially for repetitive stress conditions.

9. How long has the problem existed? What are the duration and frequency of the symptoms? Answers to these questions help the examiner to determine whether the condition is acute, subacute, chronic, or acute on chronic and to develop some understanding of the patient’s tolerance to pain. Generally, acute conditions are those that have been present for 7 to 10 days, subacute conditions have been present for 10 days to 7 weeks, and chronic conditions or symptoms have been present for longer than 7 weeks. In acute on chronic cases, the injured tissues usually have been reinjured. This knowledge is also beneficial in terms of how vigorously the patient can be examined. For example, the more acute the condition, the less stress the examiner is able to apply to the joints and tissues during the assessment. A full examination may not be possible in very acute conditions. In that case, the examiner must select those procedures of assessment that will give the greatest amount of information with the least stress to the patient. Does the patient protect or support the injured part? If so, this behavior signifies discomfort and fear of pain if the part moves, usually indicating a more acute condition.

10. Has the condition occurred before? If so, what was the onset like the first time? Where was the site of the original condition, and has there been any radiation (spread) of the symptoms? If the patient is feeling better, how long did the recovery take? Did any treatment relieve symptoms? Does the current problem appear to be the same as the previous problem, or is it different? If it is different, how is it different? Answers to these questions help the examiner to determine the location and severity of the injury.

11. Has there been an injury to another part of the kinetic chain as well? For example, foot problems can lead to knee, hip, pelvic, and/or spinal problems; elbow problems may contribute to shoulder problems; and hip problems can contribute to knee problems.

12. Are the intensity, duration, or frequency of pain or other symptoms increasing? These changes usually mean the condition is getting worse. A decrease in pain or other symptoms usually means the condition is improving. Is the pain static? If so, how long has it been that way? This question may help the examiner to determine the present state of the problem. These factors may become important in treatment and may help to determine whether a treatment is helping. Are pain or other symptoms associated with other physiological functions? For example, is the pain worse with menstruation? If so, when did the patient last have a pelvic examination? Questions such as these may give the examiner an indication of what is causing the problem or what factors may affect the problem. It is often worthwhile to give the patient a pain questionnaire, visual analog scale (VAS), numerical rating scale, box scale, or verbal rating scale that can be completed while the patient is waiting to be assessed.20,21 The McGill-Melzack pain questionnaire and its short form (Figures 1-2 and 1-3)^22–24 provide the patient with three major classes of word descriptors—sensory, affective, and evaluative—to describe their pain experience. These designations are used to differentiate patients who have a true sensory pain experience from those who think they have experienced pain (affective pain state). Other pain-rating scales allow the patient to visually gauge the amount of pain along a solid 10-cm line (visual analogue scale) (Figure 1-4) or on a thermometer-type scale (Figure 1-5).²⁵ It has been shown that an examiner should consistently use the same pain scales when assessing or reassessing patients to increase consistent results.^26–29 The examiner can use the completed questionnaire or scale as an indication of the pain as described or perceived by the patient. Alternatively, a self-report pain drawing (see Appendix 1-1), which (with the training and guidelines of the raters) has been shown to have reliability, can be used for the same purpose.³⁰

13. Is the pain constant, periodic, episodic (occurring with certain activities), or occasional? Does the condition bother the patient at that exact moment? If the patient is not bothered at that exact moment, the pain is not constant. Constant pain suggests chemical irritation, tumors, or possibly visceral lesions.18 It is always there, although its intensity may vary. If periodic or occasional pain is present, the examiner should try to determine the activity, position, or posture that irritates or brings on the symptoms, because this may help determine what tissues are at fault. This type of pain is more likely to be mechanical and related to movement and stress.¹⁸ Episodic pain is related to specific activities. At the same time, the examiner should be observing the patient. Does the patient appear to be in constant pain? Does the patient appear to be lacking sleep because of pain? Does the patient move around a great deal in an attempt to find a comfortable position?

14. Is the pain associated with rest? Activity? Certain postures? Visceral function? Time of day? Pain on activity that decreases with rest usually indicates a mechanical problem interfering with movement, such as adhesions. Morning pain with stiffness that improves with activity usually indicates chronic inflammation and edema, which decrease with motion. Pain or aching as the day progresses usually indicates increased congestion in a joint. Pain at rest and pain that is worse at the beginning of activity than at the end implies acute inflammation. Pain that is not affected by rest or activity usually indicates bone pain or could be related to organic or systemic disorders, such as cancer or diseases of the viscera. Chronic pain is often associated with multiple factors, such as fatigue or certain postures or activities. If the pain occurs at night, how does the patient lie in bed: supine, on the side, or prone? Does sleeping alter the pain, or does the patient wake when he or she changes position? Intractable pain at night may indicate serious pathology (e.g., a tumor). Movement seldom affects visceral pain unless the movement compresses or stretches the structure.11 Symptoms of peripheral nerve entrapment (e.g., carpal tunnel syndrome) and thoracic outlet syndromes tend to be worse at night. Pain and cramping with prolonged walking may indicate lumbar spinal stenosis (neurogenic intermittent claudication) or vascular problems (circulatory or vascular intermittent claudication). Intervertebral disc pain is aggravated by sitting and bending forward. Facet joint pain is often relieved by sitting and bending forward and is aggravated by extension and rotation. What type of mattress and pillow does the patient use? Foam pillows often cause more problems for persons with cervical disorders because these pillows have more “bounce” to them than do feather or buckwheat pillows. Too many pillows, pillows improperly positioned, or too soft a mattress may also cause problems.

15. What type or quality of pain is exhibited? Nerve pain tends to be sharp (lancinating), bright, and burning and also tends to run in the distribution of specific nerves. Thus, the examiner must have detailed knowledge of the sensory distribution of nerve roots (dermatomes) and peripheral nerves as the different distributions may tell where the pathology or problem is if the nerve is involved. Bone pain tends to be deep, boring, and localized. Vascular pain tends to be diffuse, aching, and poorly localized and may be referred to other areas of the body. Muscle pain is usually hard to localize, is dull and aching, is often aggravated by injury, and may be referred to other areas (Table 1-3). If a muscle is injured, when the muscle contracts or is stretched, the pain will increase. Inert tissue, such as ligaments, joint capsules, and bursa, tend to exhibit pain similar to muscle pain and may be indistinguishable from muscle pain in the resting state (e.g., when the examiner is taking the history); however, pain in inert tissue is increased when the structures are stretched or pinched. Each of these specific tissue pains is sometimes grouped as neuropathic pain and follows specific anatomical pathways and affect specific anatomical structures.¹⁸ The Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) Pain Scale (Figure 1-6) has been developed to determine if neuropathic causes dominate the pain experience.³¹ Somatic pain, on the other hand, is a severe chronic or aching pain that is inconsistent with injury or pathology to specific anatomical structures and cannot be explained by any physical cause because the sensory input can come from so many different structures supplied by the same nerve root.¹² Superficial somatic pain may be localized, but deep somatic pain is more diffuse and may be referred.³² On examination, somatic pain may be reproduced, but visceral pain is not reproduced by movement.³²

16. What types of sensations does the patient feel, and where are these abnormal sensations? If the problem is in bone, there usually is very little radiation of pain. If pressure is applied to a nerve root, radicular pain (radiating pain) results from pressure on the dura mater, which is the outermost covering of the spinal cord. If there is pressure on the nerve trunk, no pain occurs, but there is paresthesia, or an abnormal sensation, such as a “pins and needles” feeling or tingling. Paresthesia is an unpleasant sensation that occurs without an apparent stimulus or cause (to the patient). Autonomic pain is more likely to be a burning type of pain. If the nerve itself is affected, regardless of where the irritation occurs along the nerve, the brain perceives the pain as coming from the periphery. This is an example of referred pain.

17. Does a joint exhibit locking, unlocking, twinges, instability, or giving way? Seldom does locking mean that the joint will not move at all. Locking may mean that the joint cannot be fully extended, as is the case with a meniscal tear in the knee, or it may mean that it does not extend one time and does not flex the next time (pseudolocking), as in the case of a loose body moving within the joint. Locking may mean that the joint cannot be put through a full ROM because of muscle spasm or because the movement was too fast; this is sometimes referred to as spasm locking. Giving way is often caused by reflex inhibition or weakness of the muscles, and so the patient feels that the limb will buckle if weight is placed on it or the pain will be too great. Inhibition may be caused by anticipated pain or instability.
In nonpathological states, excessive ROM in a joint is called laxity or hypermobility. Laxity implies the patient has excessive ROM but can control movement in that range and no pathology is present. It is a function of the ligaments and joint capsule resistance.33 This differs from flexibility, which is the ROM available in one or more joints and is a function of contractile tissue resistance primarily as well as ligament and joint capsule resistance.³³ Gleim and McHugh³³ describe flexibility in two parts: static and dynamic. Static flexibility is related to the ROM available in one or more joints; dynamic flexibility is related to stiffness and ease of movement. Laxity may be caused by familial factors or may be job or activity (e.g., sports) related. In any case, laxity, when found, should be considered normal (Figure 1-7). If symptoms occur, then laxity is considered to be hypermobility and has a pathological component, which commonly indicates the patient’s inability to control the joint during movement, especially at end range, which implies instability of the joint. Instability can cover a wide range of pathological hypermobility from a loss of control of arthrokinematic joint movements to anatomical instability where subluxation or dislocation is imminent or has occurred. For assessment purposes, instability can be divided into translational (loss of arthrokinematic control) and anatomical (dislocation or subluxation) instability.³⁴ Translational instability (also called pathological or mechanical instability) refers to loss of control of the small, arthrokinematic joint movements (e.g., spin, slide, roll, translation) that occur when the patient attempts to stabilize (statically or dynamically) the joint during movement. Anatomical instability (also called clinical or gross instability, or pathological hypermobility) refers to excessive or gross physiological movement in a joint where the patient becomes apprehensive at the end of the ROM because a subluxation or dislocation is imminent. It should be noted that there is confusion in the application of the terms used to describe the two types of instability. For example, mechanical instability is sometimes used to mean anatomical instability because of anatomical or pathological dysfunction. Functional instability may mean either or both types of instability and implies an inability to control either arthrokinematic or osteokinematic movement in the available ROM either consciously or unconsciously during functional movement. These instabilities are more likely to be evident during high-speed or loaded movements. Both types of instability can cause symptoms, and treatment centers on teaching the patient to develop muscular control of the joint and to improve reaction time and proprioceptive control. Both types of instability may be voluntary or involuntary. Voluntary instability is initiated by muscle contraction, and involuntary instability is the result of positioning. Another concept worth remembering during assessment for instability is the circle concept of instability, which was originally developed from shoulder studies^35,36 but is equally applicable to other joints. This concept states that injury to structures on one side of a joint leading to instability can, at the same time, cause injury to structures on the other side or other parts of the joint. Thus, an anterior shoulder dislocation can lead to injury of the posterior capsule. Similarly, anterolateral rotary instability of the knee leads to injury to posterior structures (e.g., arcuate-popliteus complex, posterior capsule) as well as anterior (e.g., anterior cruciate ligament) and lateral (e.g., lateral collateral ligament) structures. Thus, the examiner must be aware of potential injuries on the opposite side of the joint even if symptoms are predominantly on one side, especially when the mechanism of injury is trauma.

18. Has the patient experienced any bilateral spinal cord symptoms, fainting, or drop attacks? Is bladder function normal? Is there any “saddle” involvement (abnormal sensation in the perianal region, buttocks, and superior aspect of the posterior thighs) or vertigo? “Vertigo” and “dizziness” are terms often used synonymously, although vertigo usually indicates more severe symptoms. The terms describe a swaying, spinning sensation accompanied by feelings of unsteadiness and loss of balance. These symptoms indicate severe neurological problems, such as cervical myelopathy, which must be dealt with carefully and can (e.g., in cases of altered bladder function) be emergency conditions potentially requiring surgery. Drop attacks occur when the patient suddenly falls without warning or provocation but remains conscious.18 It is caused by neurological dysfunction especially in the brain.

19. Are there any changes in the color of the limb? Ischemic changes resulting from circulatory problems may include white, brittle skin; loss of hair; and abnormal nails on the foot or hand. Conditions such as reflex sympathetic dystrophy, which is an autonomic nerve response to trauma, however minor, can cause these symptoms, as can circulatory problems such as Raynaud’s disease.

20. Has the patient been experiencing any life or economic stresses? These psychological stressors are sometimes considered to be yellow flags that alter both the assessment and subsequent treatment.37,38 Divorce, marital problems, financial problems, or job stress or insecurity can contribute to increasing the pain or symptoms because of psychological stress. What support systems and resources are available? Are there any cultural issues one should be aware of? Does the patient have an easily accessible living environment? Each of these issues may increase stress to the patient. Pain is often accentuated in patients with anxiety, depression, or hysteria, or patients may exaggerate their symptoms (symptom magnification) in the absence of objective signs, which may be called psychogenic pain.^3,39,40 Thus, psychosocial aspects can play a significant role with injury.^41–44 Because of the importance of these psychosocial aspects related to movement, questionnaires such as the Fear-Avoidance Beliefs Questionnaire (FABQ)⁴⁵ (Figure 1-8) and the Tampa Scale for Kinesiophobia^46–49 have been developed. Most of the studies related to the psychosocial aspects of injury have been related to the low back but could be used for other joints. The focus of these questionnaires is on the patient’s beliefs about how physical activity and work affect his or her injury and pain.^42,50,51 Table 1-4 outlines some of the psychological processes affecting pain.⁴² These processes have been divided into different colored “flags” (Table 1-5), but it is important to note that these psychological flags, other than the red flag, are different from pathological “flags” previously mentioned.⁴⁴ Waddell and Main³⁷ consider illness behavior normal with patients who are exhibiting both a physical problem and varying degrees of illness behavior (Table 1-6). In these cases, it may be beneficial to determine the level of psychological stress or to refer the patient to another appropriate health care professional.³⁸ When symptoms (such as, pain) appear to be exaggerated, the examiner must also consider the possibility that the patient is malingering. Malingering implies trying to obtain a particular gain by a conscious effort to deceive.⁵²

21. Does the patient have any chronic or serious systemic illnesses or adverse social habits (e.g., smoking, drinking) that may influence the course of the pathology or the treatment? In some cases, the examiner may use a medical history screening form (Figure 1-9) to determine the presence of conditions that may affect treatment or require referral to another health care professional.

22.  Is there anything in the family or developmental history that may be related, such as tumors, arthritis, heart disease, diabetes, allergies, and congenital anomalies? Some disease processes and pathologies have a familial incidence.

23. Has the patient undergone an x-ray examination or other imaging techniques? If so, x-ray overexposure must be considered; if not, an x-ray examination may help yield a diagnosis.

24. Has the patient been receiving analgesic, steroid, or any other medication? If so, for how long? High dosages of steroids taken for long periods may lead to problems, such as osteoporosis. Has the patient been taking any other medication that is pertinent? Anticoagulants (such as, aspirin or anticoagulant therapy) increase the chance of bruising or hemarthrosis because the clotting mechanism is altered. Patients may not regard over-the-counter formulations, birth control pills, and so on as medications. If such medications have been taken for a long period, their use may not seem pertinent to the patient. How long has the patient been taking the medication? When did he or she last take the medication? Did the medication help?53 It is also important to determine whether medication is being taken for the condition under review. If analgesics or anti-inflammatories were taken just before the patient’s visit for the assessment, some symptoms may be masked.

25. Does the patient have a history of surgery or past/present illness? If so, when was the surgery performed, what was the site of operation, and what condition was being treated? Sometimes, the condition the examiner is asked to treat is the result of the surgery. Has the patient ever been hospitalized? If so, why? Health conditions such as high blood pressure, heart and circulatory problems, and systemic diseases (e.g., diabetes) should be noted because of their effect on healing, exercise prescription, and functional activities.3

1. What is the normal body alignment? Anteriorly, the nose, xiphisternum, and umbilicus should be in a straight line. From the side, the tip of the ear, the tip of the acromion, the high point of the iliac crest, and the lateral malleolus (anterior aspect) should be in a straight line.

2. Is there any obvious deformity? Deformities may take the form of restricted ROM (e.g., flexion deformity), malalignment (e.g., genu varum), alteration in the shape of a bone (e.g., fracture), or alteration in the relationship of two articulating structures (e.g., subluxation, dislocation). Structural deformities are present even at rest; examples include torticollis, fractures, scoliosis, and kyphosis. Functional deformities are the result of assumed postures and disappear when posture is changed. For example, a scoliosis due to a short leg seen in an upright posture disappears on forward flexion. A pes planus (flatfoot) on weight bearing may disappear on non-weight-bearing. Dynamic deformities are caused by muscle action and are present when muscles contract or joints move. Therefore, they are not usually evident when the muscles are relaxed. Dynamic deformities are more likely to be seen during the examination phase.

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