Evaluations should be based on the evidence at hand. What that means is there should be a subjective portion (input from the patient), and an objective portion (range of motion, palpation, and special tests). Lastly evaluations should be made by ruling out other differential diagnoses to come to a clinical impression. After coming to that conclusion then we will develop a rehab plan. There will always be nuance in an evaluation outcome but you should always make it based on the information in front of you.

Subjective input comes from the patient. This is the how, what, when, and why type of questioning. Part of our job as the healthcare professional is to take what the patient says and use it to guide our line of questioning. Often times questions can seem remote or unassociated but that doesn’t mean they aren’t important. A lot of times patients will say "I don’t know how to describe it or I don’t know to answer a question". It is up to us as healthcare professionals to help steer the conversation towards the facts as you know them.

Observation/Palpation: The first step is simply to look at the patient presentation. This literally starts from the moment you walk towards me and never stops. If it’s a lower body injury, I should be paying attention to how you walk/sit/stand. For an upper body injury I'm taking note of favoring one arm or the posture you're sitting with. I’m also going to look for any sort of deformity, discoloration, or swelling in the area. Palpation is simply checking anatomical landmarks for deformities, areas of tenderness, crepitus, or anything else out of the ordinary.

Range of Motion (ROM): The next step is to check the joint range of motion. That includes all directions the joints will move when healthy as well as passive, active, and resisted ROM. Each ROM reveals different clues to us. We are looking for differences in motion side to side, pain, and the ability to activate at different intensities.

Special Tests: The final part of the objective section is to complete special tests. We do the special test to rule in/rule out injuries based on anatomy and the subjective input. We choose our tests based on their sensitivity and specificity to what injury we suspect or want to rule out. A test might be very sensitive to a wide range of things but it might not be specific. That means we will use a cluster of tests to help make the decision. Almost all special tests are going to be compared bilaterally, in other words, your healthy side is going to give us the baseline for the injured side.

The "Left Turns": Sometimes our objective results will make us take a "left turn" away from where the primary area of complaint seems to be. Often injuries, especially chronic or overuse, stem from other segments of the body. For instance, the symptoms might show up in the neck but it might be a shoulder/thoracic issue that is driving the neck symptoms. Another example: clinicians that practice with overhead athletes, especially throwers, often will start looking at the hips knees or feet when an injury pops up in the shoulder.

Nerve involvment: The more I practice, the more I see a neurologic component to injuries. What that means is that a pain in your elbow/forearm might actually be coming from a cervical nerve irritation. A lot of times, I want to clear the nerve involvement before we dig into the soft tissue where the symptoms are presenting. This might seem a little unusual but if we treat only the soft tissue, and neglect the nerve involvement, the soft tissue symptoms may not improve.

The clinical impression is a combination of information from all parts of the evaluation. It’s easy to get caught up on one piece of information or part of the evaluation, but it is our job to read between the lines using ALL the data we have in front of us. The clinical impression combined with the history is what will drive our rehab plan. If any red flags are set off by the history or physical evaluation, we may not actually make it to the clinical impression. Above all we want to rule out any of the more potentially catastrophic injuries. So if history sounds benign, but upon palpation I feel crepitus over a bone or joint, I’m most likely to stop that evaluation and send you for x-rays to rule out a break. If they come back negative, then we know for sure that we can be as aggressive as the tissue will let us in rehab.

You could almost consider we have a three-way conversatio: what I know will make the injury better, how the injury and body is responding, and how the patient is tolerating everything. If we don’t address all components, then the injury may never get back to 100% or may set the patient up for re-injury. One of the most important things to consider are any underlying causes or contributors to the injury. I.E. If the the patient has weak hips and has patellofemoral pain, we will most likely have to address the hips not just the knee.

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