This essay will be split into three sections; The first will
explore reasons and mechanisms of pain, stiffness, and weakness. The second
will discuss factors to be considered when performing a physical examination of
a patient, including severity and irritability. And the final section will be an
outline of the steps to be taken during a physical examination.
The patient is a fourteen-year-old boy, who has suffered a
non-displaced closed mid shaft tibial fracture 14 weeks ago. He has had his leg
immobilised via a full leg cast, switching to a below the knee cast after six
weeks. He has now been out of his cast for two weeks, he describes pain in both
his knee and ankle. To discuss the reason for his pain, it is important to know
what pain is and the mechanism by which it operates. Pain Is described by the
International Association for the Study of Pain (IASP) as “an unpleasant sensory
and emotional experience, associated with actual or potential tissue damage, or
described in terms of such damage”. Pain follows a pathway of receptors and
nerves which work as follows.
When a pain stimulus occurs, chemicals are released which
stimulate the nociceptors contained in the periphery, which carry the response to
the spinal cord. There are two types of Nociceptor, the first are the Alpha Delta
fibres, which are small myelinated nerve cells which carry a fast, localised
pain response, often described as “sharp pain”. The other nociceptor is the unmyelinated
C fibre, which carry a slow pain response which is de-localised, described as “aching”
pain. These fibres carry a signal to the dorsal horn of the spinal cord through
to the centre. The signal is then received by a second order neuron, which then
passes over the midline, being transmitted up the spinothalamic tract to the
thalamus. Once in the thalamus, the signal is then taken by a third order
neuron to the corresponding part of the brain that is responsible for the pain
response for that part of the body, in this example the pain is in the right
ankle, so the signal would be sent to the part of the somatosensory cortex that
corresponds to the ankle, on the left side of the brain, due to the neuron
crossing midline in the spinal cord.
Aside from Nociceptive pain, there is also neuropathic pain.
Neuropathic pain refers to pain refers to pain being felt because of
In the case of this patient, the pain being described is
most likely an inflammatory pain, due to multiple factors, such as the patient’s
description of the area being described as swollen, their explanation of the
pain as “aching” and also the stage that they are currently at within the
fracture healing process.
There are five stages of fracture healing, the first stage
is inflammation caused by the rupture of blood vessels and nerves. At this
stage a haematoma is formed at the sight of the fracture, and necrosis of the
end of the fractured bone fragments is seen. Macrophages begin to remove necrotic
tissue from the area, such as osteoclasts removing dead bone fragments. This
stage lasts approximately 2 weeks in lower limb fractures. This is the point
that the initial x-ray was performed on the patient
The second stage of fracture healing is the formation of a
soft callus formation. In this stage the granulation tissue produces
fibroblasts that form fibrocartilage between the fracture, joining the two
sections, this formation remains quite weak to stress, hence why it is still
important to weight bearing is not recommended. This stage of healing usually
takes place around 3-7 weeks after the injury, this is when the callus
formation was observed via X-ray on the patient.
Fourteen weeks have passed since the injury. With this
information we can assume that the patient has moved on to the fourth stage of their
healing process, which is the consolidation stage. This is the stage in which a
woven, immature bone structure replaces the callus, but later in this process
this bone is replaced by stronger lamellar bone. This happens approximately
12-16 weeks after the healing process begins.
The patient also complained of having stiffness and weakness
in his knee and ankle. One reason this might happen is an aftereffect of long
term immobilisation. Initially, every
week that a muscle is at complete rest, it can lose up to 10%-15% of it’s
strength, and within 3-5 weeks, nearly half of its strength may be lost, and in
recovery, an expected return of around 6% per week can be achieved. The most
effected areas to this are the lower extremities, as they are normally resisting
against gravity. Stiffness is also attributed to disuse, as holding joints in
fixed positions for extended periods of time can result in shortened ligaments
and even possible contractures. Studies performed on animals have shown that
after immobilisation in a cast for 8 weeks resulted in a decrease to only 69%
of normal ROM in knee ligaments, and showed that this had still not recovered
fully within a year of the casts removal. Similar affects can be observed in the
patient, as he states that his ankle is both in more pain and stiffer than his
knee, as his ankle was immobilised for twice the time of his knee.
When performing a physical assessment of a patient, it is
important to consider all factors that may lead to the patient’s distress,
discomfort, or harm. By examining the patient’s history, it is possible to mitigate
the risk of this happening. How severe the patient’s irritability is will be one
If the patient has a high level of irritability, this means
that they will have a very poor tolerance for any form of tissue loading. This
means that the results of any physical examination may be un reliable and misleading,
and many important actions and movements required during assessment will be
limited, or not possible. It is important to employ a delicate and spaced out
examination strategy for patients of this nature. If the patient has moderate irritability,
then then their pain is still quite easy to aggravate, but with more specific movements
and actions to the affected area, and their symptoms will be much easy to discern,
with a lowered lingering affect. The patient will be able to handle a more
intense examination strategy, as this will generate more accurate results.
Finally, if the patient presents with mild irritability, then a full, rigorous
examination can most likely be performed, as the patient is at very low risk of
Based on information provided on the assessment form, the
patient is at a low level of irritability, meaning that a thorough examination
can most likely take place without causing too much undue discomfort. However,
it is stated that the patient is on some pain relief medication in the form of
Paracetamol. I the patient is under the effects of this medication during the
examination, then their pain may be suppressed, leading to inconsistencies in reported
level of pain, using a scale such as the NPRS (Numerical-Pain-Rating-Scale), when
asked during assessment, compared to normal.
The patient has also explained that he has “rough” and therefore,
sensitive skin on his leg. This may inhibit any examination of the patient, as performing
any passive mechanical examination would require the physiotherapist to the patient,
this may be uncomfortable, and might not be possible. It would be important to gauge
the severity of this skin irritation with the patient, and explore whether
manual manipulation would be possible. If not possible then having the patient
perform active movements of the limb may be more appropriate.
One more important piece of information to consider is that
this patient is a type 1 diabetic, for this reason it is important for us to
rule out diabetic neuropathy as a possible cause of his pain, as this condition
can have serious implications. We would test for this by asking the patient if
they have any numbness in their feet, or if they have any burning or tingling
sensations in that area, as these are common indicators of the disorder.
When planning a physical examination of a patient, it is important
to differentiate what Must be done, what should be done, and what can be done.
For what must be done, primary focus should be safety. Before
starting any aspect of the examination, we must explain through what is going
to take place, and gain full consent of both the patient, and their parent if necessary,
and to ensure that this consent is continues throughout.
I would then begin my examination considering my primary-hypothesis.
I would begin with tests on the effected joints and area, starting with
neurological tests, such as sensory and motor tests to see if there is
peripheral nerve involvement. Then moving onto palpitation, muscle, and joint
tests of the directly affected areas looking through ROM, end of range, and
areas of pain when passively moving the ankle through plantar-flexion, dorsi-flexion,
eversion, and inversion, and the knee through flexion and extension, applying
over-pressure when doing so, gauging patient feedback. Then moving through to muscle tests, observing
the length, control, and strength, of the; Gastrocnemius, soleus, tibialis
anterior, quadricep, and hamstrings.
Then testing what I should look for, such as any other abnormalities
in the hip that may be affecting structures further down the leg. Also considering
if anything that has been observed fits with a secondary-hypothesis.
Finally, for what I can do, I would check on the patient’s
overall posture, gait pattern, or anything else that may be affecting the condition
in the patient. Also considering any other hypothesis that were not initially
considered, but fit what has been observed better.