Observation is the first step of your physical assessment. During observation, you’re trying to see if you can find any structural abnormalities that you can link to your patient’s complaints.
In order to conduct a good observation, I have to be able to see certain landmarks on the body, therefore, I’m going to ask my patient to take off their shirt, wear shorts and also take off their shoes. Now, that the patient is properly exposed, we can start with the observation.
I advise the patient to stand upright, looking straight ahead, relax the shoulders and let the arms hang naturally beside the body.
In the frontal plane, one of the first things I could look at is the line from the tip of the nose running through the middle of the chin to the manubrium of the sternum. The head could also be rotated or leaning to one side. Next, I could compare the level of the shoulders, assess the angle of both clavicles, and see if the nipples are on the same height. The latter should be disregarded with female patients. Moving downwards, I can compare both iliac crests and use the anterior superior iliac spine as another landmark.
The space in-between trunk and arms can also be compared. Furthermore, arm length differences can be examined, when comparing the level of the fingertips of both hands. Looking at the knees, I check if the apex of both patellas is leveled and whether they have an outward, so-called varus position, or an inward, so-called valgus, position. At last, I check the level of both medial malleoli.
In the sagittal plane, one of the first things to assess should be the lateral plumb line, the so-called line of Appleton, which is the line running from the earlobe through the humeral head. Check if the head is excessively positioned anteriorly or posteriorly. The shoulders might also be pro- or retracted. When looking at the patient from the side, it’s wise to examine the spine for abnormalities in the lordosis and kyphosis. On pelvic level, you can check the angle between the anterior superior iliac spine and the posterior superior iliac spine, which is usually around 15°. Lastly, check if the knees are hyperextended.
Now, let’s look at the patient from the back. Again, check if the head is rotating or leaning to one side. When examining the spine, you are looking for lateral shifts that could indicate scoliosis. Posterior reference points include both acromiae, the scapular spines, and both inferior angles of the scapula. Also, check how far away the medial borders of the shoulder blade are from the spine. Moving downwards, compare both iliac crests and check the posterior superior iliac spine. The gluteal fold could also be used as a reference point. On knee level, you could identify valgus or varus positioning, just like in the frontal plane. Lastly, compare both medial malleoli, and depending on the number of toes you see next to the Achilles tendon, one leg could be rotated more than the other.
Be aware though, that not everything that you consider abnormal, is also pathological. We have created a video about the correlation between posture & pain that you really need to watch.
21 OF THE MOST USEFUL ORTHOPAEDIC TESTS IN CLINICAL PRACTICE
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