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Joint Assessment Essentials Framework for Shoulder, Hip, Knee, and Ankle

Capítulo 1

Estimated reading time: 8 minutes

Why a Standardized Framework Matters

A consistent joint assessment workflow helps you: (1) reduce missed findings, (2) compare sessions over time, (3) communicate clearly with other clinicians, and (4) decide priorities for treatment. This course uses the same sequence for shoulder, hip, knee, and ankle so that only the joint-specific tests change—your process stays stable.

Safety First: Universal “Stop Test” Decision Rule

Stop the current test immediately (and reassess your plan) if any of the following occur:

Sharp or escalating pain that is disproportionate to the movement or load
Guarding that prevents a smooth motion or makes the response unreliable
Neurological symptoms: new numbness/tingling, radiating pain, weakness that appears suddenly, or symptoms that spread distally during the test
Instability signs: giving way, clunking with apprehension, or the patient reports “it feels like it will pop out”
Systemic concern: dizziness, faintness, unusual shortness of breath, or the patient appears unwell

When you stop: document what provoked symptoms, return to a comfortable position, and shift to lower-irritability components (e.g., observation, gentle AROM within tolerance) or refer/escalate if red flags are present.

The Repeatable 8-Step Joint Assessment Workflow

Use this order every time unless symptoms require modification. The goal is to move from least provocative to more specific loading, while continuously monitoring symptom behavior.

Step 1 — Subjective Check-In (Symptom Behavior + Peripheral Joint Red Flags)

Keep this brief and targeted. You are clarifying irritability, mechanical behavior, and safety.

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Key questions (use as a script)

Primary complaint: “Where is it? What does it feel like? When did it start?”
Behavior over 24 hours: “What makes it worse? What makes it better? Any night pain or morning stiffness pattern?”
Load tolerance: “How far can you walk/lift/reach before symptoms change?”
Mechanical features: catching, locking, clicking, giving way, instability, stiffness after rest
Swelling: onset (immediate vs delayed), fluctuation, heat/redness
Neuro screen: numbness/tingling, radiating pain, weakness, changes in coordination
Red flags relevant to peripheral joints: recent significant trauma, inability to bear weight/use the limb, suspected fracture/dislocation, fever/unexplained illness, hot swollen joint with severe pain, unexplained weight loss, history of cancer, anticoagulant use with significant bruising/swelling, suspected infection, progressive neurological deficit

Practical rule: If the subjective suggests high irritability (pain easily triggered, lingering >24 hours after minor activity), keep testing gentle and prioritize observation, limited AROM, and minimal end-range PROM.

Step 2 — Observation (Posture, Swelling, Asymmetry, Avoidance)

Observe at rest and during simple transitions (sit-to-stand, reaching, stepping). Compare side-to-side.

Posture/alignment: scapular position, pelvic tilt, knee valgus/varus, foot posture
Swelling/effusion: visible fullness, loss of bony contours, sock-line edema
Skin changes: redness, bruising, surgical scars, temperature differences (if appropriate)
Movement avoidance: guarded arm swing, reduced stance time, reduced push-off, trunk lean, shoulder hiking

Practical tip: Ask the patient to point to the most symptomatic area, then watch what they do when they think you are “not testing yet.” Avoidance patterns often appear during casual movement.

Step 3 — AROM Screen (Active Range of Motion)

AROM tells you what the patient can control and what provokes symptoms under low load. Use a consistent sequence and record: range, pain location/intensity, quality of motion, and compensations.

How to run AROM (step-by-step)

Explain: “Move until you feel the first onset of pain or tightness; don’t push through sharp pain.”
Demonstrate once and have them mirror you.
Compare sides when possible.
Note: painful arc, end-range pain, mid-range pain, speed changes, shaking, substitution patterns.

Examples of what to document: “Shoulder flexion: 0–150°, painful arc 90–120°, scapular hiking.” “Ankle dorsiflexion: limited with early heel rise and medial collapse.”

Step 4 — PROM + End-Feel Interpretation

PROM helps differentiate limitation due to pain, stiffness, or guarding. Move slowly, support the limb, and assess the quality of resistance at end range (“end-feel”).

PROM procedure (step-by-step)

Position for comfort and joint isolation.
Stabilize proximal segment to reduce substitution.
Move gradually through available range.
Ask: “Tell me when you first feel pain/tightness and where.”
At end range, note: symptom response, resistance quality, and whether range improves with repeated gentle movement.

Common end-feels (interpretation guide)

End-feel	Typical description	Common implication
Firm	Gradual resistance, “leathery” stop	Capsular/soft tissue tightness (e.g., joint stiffness)
Hard	Abrupt stop, “bone-to-bone”	Bony block/degenerative change (interpret with caution)
Soft	Soft compression	Soft tissue approximation (often normal depending on motion)
Empty	Movement stops due to pain before resistance	High irritability; stop and reduce provocation
Spasm/guarding	Sudden protective contraction	Threat response; consider instability, acute injury, or fear

Practical note: End-feel is only meaningful if the patient is relaxed and the movement is controlled. If guarding dominates, document “guarded PROM” rather than forcing an interpretation.

Step 5 — Basic Strength Testing (Low-Tech, High-Value)

Strength testing identifies pain-limited force production, true weakness, and side-to-side asymmetry. Keep it simple and repeatable.

Strength testing options

Isometric “make test” (preferred early): patient gradually builds force against your resistance for 3–5 seconds
Repetition-based: e.g., heel raises, sit-to-stand reps, step-down reps
Manual muscle testing grades or a simple 0–10 effort/pain rating if grading is not feasible

How to document strength consistently

Position and lever arm used
Pain response: none / mild / moderate / severe; location
Quality: smooth vs shaky; holds vs breaks
Side-to-side comparison

Example: “Hip abduction isometric (side-lying, distal femur): R 4/5 with lateral hip pain 3/10; L 5/5 pain-free.”

Step 6 — Simple Functional Tests (Task-Based, Relevant)

Functional tests connect impairments to real tasks. Choose 1–3 tests that match the patient’s goals and the joint involved. Keep them safe, standardized, and easy to repeat.

Selection rules

Match the complaint (stairs → step test; reaching → overhead reach)
Scale the load (bodyweight before external load)
Standardize (same height, same distance, same tempo)

Examples (pick what fits)

Shoulder: hand-behind-back reach, hand-behind-head reach, repeated overhead reach with light object
Hip: single-leg stance time, sit-to-stand (timed or reps), step-up
Knee: squat to chair, step-down, single-leg sit-to-stand progression
Ankle: single-leg heel raises, balance reach, controlled hop-in-place only if appropriate

What to record: pain (0–10), quality (valgus collapse, trunk lean, early heel rise), confidence/apprehension, and capacity (reps/time).

Step 7 — Swelling/Effusion Checks (When Appropriate)

Use swelling checks when the history or observation suggests fluid, inflammation, or post-injury effusion. The goal is to confirm presence, estimate severity, and track change over time.

Practical options

Girth measurement: standardized landmarks (e.g., figure-of-eight for ankle; fixed distance above/below patella for knee)
Pitting edema check (lower limb): grade depth and rebound time if clinically appropriate
Joint-specific effusion tests: use when indicated and within your scope; stop if sharp pain or guarding increases

Documentation tip: Always record the exact landmark and method so the measure is repeatable (e.g., “10 cm above superior patellar pole”).

Step 8 — Synthesis: Likely Impairments + Priorities

Convert findings into a short list of impairments and what to address first. This is not about naming a diagnosis; it is about identifying the most plausible drivers of the patient’s limitation and choosing safe priorities.

Synthesis checklist

Pain driver: which movements/load reproduce symptoms most reliably?
Mobility: is limitation primarily AROM, PROM, or both? Is end-feel consistent with stiffness vs pain-limited?
Strength/control: which muscle groups show clear asymmetry or pain inhibition?
Function: which task breaks down first, and what compensation appears?
Swelling: is it present and does it correlate with loss of motion or inhibition?

Priority-setting rule (simple)

1) Safety: red flags, instability, neuro symptoms → modify/stop and escalate as needed
2) Irritability control: if symptoms flare easily, prioritize low-irritability movement and load management
3) Restore key motion: address the most function-limiting ROM restriction
4) Build capacity: strengthen and retrain the movement pattern tied to the functional limitation

Standardized Documentation Template (SOAP + Objective Table)

Use this template for every joint so your notes are comparable across shoulder, hip, knee, and ankle assessments.

SOAP template

Section	What to include (minimum)	Example phrasing
S (Subjective)	Location, behavior, irritability, key aggravating/easing factors, red flag screen, functional limitation	“Lateral ankle pain 4/10 with walking >10 min; swelling worse evenings; no numbness/tingling; no systemic symptoms.”
O (Objective)	Observation, AROM, PROM + end-feel, strength, functional tests, swelling measures, stop-test events	“AROM DF limited; PROM DF firm end-feel; heel raises 8 reps with pain 3/10; figure-of-eight +1.2 cm vs R.”
A (Assessment)	Likely impairments, contributing factors, severity/irritability, priority list	“Primary: dorsiflexion stiffness + plantarflexor weakness; secondary: balance deficit; irritability moderate.”
P (Plan)	Next steps: education, initial interventions, home tasks, retest measures, referral if needed	“Begin graded ROM + calf strengthening; retest DF and heel raise reps next visit; monitor swelling.”

Objective measures table (copy/paste format)

Observation: posture/alignment | swelling | asymmetry | avoidance patterns AROM: motion | range | pain (0-10) | quality/compensation PROM: motion | range | pain (0-10) | end-feel | guarding (Y/N) Strength: test | position | grade/metric | pain (0-10) | side-to-side Functional: test | standardization (height/time) | reps/time | pain (0-10) | quality Swelling/Effusion: method | landmark | value | side-to-side difference Stop-test events: trigger | symptoms | action taken

Putting the Framework Into Practice (Mini Walkthrough)

Example workflow snapshot (any joint)

Subjective: identifies moderate irritability and reports occasional giving way → plan to avoid high-load functional tests initially.
Observation: mild swelling and avoidance pattern noted.
AROM: limited and painful in one direction with compensation.
PROM: similar limitation with firm end-feel → stiffness likely contributes.
Strength: pain-inhibited isometric in a key muscle group.
Function: select a low-risk task that reproduces the complaint safely and reveals movement strategy.
Swelling check: quantify to track change.
Synthesis: prioritize irritability control + restore key ROM + build strength for the task.

Now answer the exercise about the content:

During a joint assessment, which situation best matches the universal “stop test” decision rule and the recommended next step?

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You missed! Try again.

New neurological symptoms that spread distally are a stop-test sign. The workflow advises stopping the test, documenting what provoked symptoms, returning to comfort, and shifting to lower-irritability testing or escalating if red flags exist.