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Safety, Symptom Screening, and Test Setup for Peripheral Joint Assessment

Capítulo 2

Estimated reading time: 8 minutes

Safety First: Why Screening and Setup Matter

Peripheral joint tests (ROM, strength, special tests) are only as useful as the safety checks and setup that come before them. Good screening reduces the risk of aggravating an injury, and consistent setup improves reliability (you can trust what you find and compare it over time).

Pain Rating: Acceptable Discomfort vs. Stop Signs

Use a simple pain scale and define what it means

Before you touch the joint, agree on a pain rating method. A 0–10 scale is practical: 0 = no pain, 10 = worst imaginable. Ask for (1) current pain, (2) worst pain in the last 24–48 hours, and (3) pain at rest vs. with movement.

Set expectations for “testing discomfort”

Many assessments reproduce symptoms; that does not automatically mean harm. Define acceptable discomfort and stop signs in plain language.

During testing	Usually acceptable	Stop / modify immediately
Pain intensity	Mild to moderate discomfort that stays ≤3/10 above baseline and settles quickly	Sharp, escalating pain; pain that jumps suddenly; pain ≥7/10; pain that does not settle after stopping
Symptom quality	Stretching sensation, muscular effort, familiar ache	New numbness/tingling, burning, electric pain, catching/locking, giving way
After-effects	Temporary soreness that resolves within minutes to a few hours	Increasing swelling, warmth/redness, new bruising, significant loss of function after testing
Systemic signs	None	Fever, chills, feeling unwell, unexplained night pain, sudden shortness of breath or chest pain (urgent)

Script you can use (quick and clear)

Example cue: “Some tests may feel tight or uncomfortable. Tell me your pain number as we go. If you feel sharp pain, pins and needles, or it feels unstable, say ‘stop’ and we’ll stop right away.”

Symptom Screening Questions (Fast, High-Value)

Use brief screening to identify red flags and precautions before ROM or strength testing.

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Mechanism and timeline: “What happened? When did it start? Was there a fall, twist, or direct blow?”
Severity and irritability: “What movements make it worse? How long does it stay aggravated?”
Swelling and heat: “Did it swell right away? Is it hot or red?”
Function: “Can you bear weight/use the arm? Any giving way or locking?”
Night/rest pain: “Does it wake you at night? Is it unexplained or worsening?”
Systemic/infection risk: “Fever, recent illness, wound, recent injection/surgery, immunosuppression?”
Post-op status: “Any surgical restrictions or protocols? Any braces or weight-bearing limits?”

Patient Positioning Principles: Stabilization, Exposure, Comfort, Privacy

1) Stabilization: isolate the joint you are testing

Stabilization prevents “cheating” by adjacent joints and makes findings repeatable.

Rule: Stabilize the segment proximal to the joint; move the distal segment.
Example: For shoulder rotation, stabilize the scapula/upper arm position so motion is not coming from trunk rotation.
Example: For ankle dorsiflexion, stabilize the lower leg and keep the heel from lifting if you are measuring talocrural motion.

2) Exposure: see what you need, not more

Reliable assessment requires visual landmarks and observation of swelling, bruising, deformity, and muscle activation.

Explain what you need to see and why: “I need to see the knee cap and the area above it to compare swelling and alignment.”
Use draping strategically: expose the joint and one segment above/below; cover everything else.
Match exposure bilaterally when comparing sides.

3) Comfort: reduce guarding and improve accuracy

Guarding can mimic weakness and limit ROM. Comfort improves validity.

Support the limb with pillows/towels; avoid end-range positioning before you start.
Warm hands, slow pace, and clear instructions reduce protective muscle activity.
Ask: “Is this position comfortable enough to test in?” Adjust before proceeding.

4) Privacy and consent: make it routine

Explain each step, obtain consent, and offer a chaperone when appropriate. Confirm the patient is comfortable with clothing adjustments and physical contact.

“I’m going to place my hand here to stabilize the hip; is that okay?”
Provide a gown/sheet and step out if clothing needs to be adjusted.

Test Setup: Make Your Measurements Repeatable

Standardize the “starting position”

Before ROM or strength testing, define and document the start position so you can reproduce it later.

Joint position: neutral vs. slight flexion, rotation, or abduction
Body position: supine, prone, sitting, standing
Support: towel roll under knee, arm supported on table
Stabilization points: where your hands/straps are placed

Control the environment

Space: enough room for full ROM without obstacles
Surface height: table height that allows your body mechanics without leaning
Footwear/bracing: decide whether to test with shoes/brace on or off; keep it consistent
Equipment ready: goniometer, towel rolls, step, resistance band, alcohol wipes (if needed)

Sequence to reduce symptom flare

For beginners, a safe default sequence is: observe → active ROM → passive ROM (if appropriate) → isometrics → dynamic strength → provocative/special tests. If symptoms are highly irritable, shorten the sequence and prioritize low-load tests.

How to Cue Movement Without Leading the Patient

Leading cues can bias results by teaching the patient how to “pass” the test. Use neutral instructions first, then clarify only as needed.

Principles for neutral cueing

One task at a time: avoid multi-step instructions that confuse the patient.
Show the direction, not the solution: demonstrate the movement arc without demonstrating compensations.
Avoid naming a suspected diagnosis: keep language descriptive, not interpretive.
Use consistent wording across sides: same cue, same pace.

Examples: neutral vs. leading cues

Test situation	Neutral cue	Leading cue to avoid
Shoulder elevation AROM	“Lift your arm up as high as you comfortably can.”	“Try not to shrug; keep your shoulder blade down; go straight up.” (too corrective too early)
Hip flexion AROM	“Bring your knee toward your chest.”	“Keep your pelvis perfectly still and don’t let it tilt.” (may create guarding)
Knee extension strength	“Straighten your knee and hold. Don’t let me move you.”	“This checks your ACL/meniscus; push hard.” (creates fear/over-effort)
Ankle dorsiflexion AROM	“Pull your toes up toward your shin.”	“Don’t turn your foot out; don’t lift your heel.” (over-coaching before you observe)

Step-by-step cueing ladder (use this progression)

Neutral instruction: “Move your ankle up and down.”
Clarify the plane: “Keep the sole facing forward.”
Light tactile cue (if consented): touch the segment to indicate where to move from.
Stabilize to prevent compensation: hold the proximal segment and repeat the same instruction.
Document the modification: note if stabilization or repositioning was required to obtain the movement.

Comparing Sides: The Built-In Control

Side-to-side comparison helps you interpret what is “normal” for that person. It is especially useful for ROM, strength, swelling, and symptom reproduction.

Rules for reliable comparison

Test the less symptomatic side first when safe. This sets expectations and reduces fear.
Match position and setup exactly: same body position, stabilization, lever arm, and instruction.
Compare more than range: note quality (smooth vs. jerky), end-feel, compensations, and symptom location.
Use the same resistance placement for strength tests (same distance from the joint).
Record both sides even if one seems “normal.”

Practical example: documenting a side-to-side ROM finding

Hip flexion AROM (supine): R 105° with anterior pinching 4/10; L 120° pain-free. Pelvis begins to posteriorly tilt at ~95° on R, ~110° on L.

Contraindications and Precautions for ROM and Strength Testing

When in doubt, prioritize safety. If a contraindication is present, do not proceed with provocative ROM/strength testing; escalate appropriately (medical review, imaging referral pathway, or follow local protocols).

Do not test (or stop) if you suspect:

Acute fracture or dislocation suspicion
- Red flags: significant trauma, deformity, inability to bear weight/use limb, bony tenderness, sudden swelling, audible crack with immediate loss of function.
- Action: immobilize/support, avoid ROM/strength testing, urgent medical evaluation.
Post-operative restrictions not clarified
- Red flags: recent surgery with unknown protocol, unclear weight-bearing status, brace locked, surgeon precautions not available.
- Action: confirm restrictions before testing; avoid end-range and resisted testing until cleared.
Suspected infection (septic joint or serious soft tissue infection)
- Red flags: fever, chills, hot/red swollen joint, severe pain with minimal movement, feeling unwell, recent wound/injection.
- Action: avoid testing; urgent medical evaluation.
Severe swelling or rapidly increasing effusion
- Red flags: tense swelling, marked warmth, significant loss of ROM due to swelling, pain at rest.
- Action: limit testing to gentle observation and very light active movement if appropriate; avoid strong resistance and aggressive passive ROM.
Unexplained night pain or constant progressive pain
- Red flags: pain not linked to movement/load, wakes from sleep, unexplained weight loss or systemic symptoms (if present).
- Action: pause testing and refer for medical assessment per local guidelines.

Precautions: modify rather than cancel

These situations often allow testing with adjustments (lower load, smaller range, slower pace), provided symptoms remain within agreed limits.

High irritability: keep ROM mid-range, use isometrics, reduce repetitions, avoid end-range overpressure.
Acute flare-up: prioritize active ROM and gentle isometrics; defer maximal strength testing.
Neurological symptoms during movement: stop and reassess; avoid reproducing numbness/tingling repeatedly.
Anticoagulation or bleeding risk: avoid aggressive techniques that could cause bruising; monitor for hematoma.

Pre-Test Checklist (Use Before Assessing Shoulder, Hip, Knee, or Ankle)

Identity & consent: correct patient, explain plan, obtain consent, offer chaperone if appropriate.
Baseline symptoms: current pain (0–10), location, irritability, and what movements are feared.
Stop rules agreed: sharp pain, escalating pain, numbness/tingling, instability, dizziness, or feeling unwell.
Screen for contraindications: fracture/dislocation suspicion, post-op restrictions unknown, suspected infection, severe swelling, unexplained night/rest pain.
Environment ready: space clear, table height set, equipment available, hygiene performed.
Exposure & privacy: joint and one segment above/below visible; drape appropriately.
Position standardized: body position, limb support, stabilization points planned.
Side-to-side plan: less symptomatic side first (when safe), same cues and setup both sides.
Cueing strategy: neutral instruction first; clarify only if needed; avoid coaching compensations before observing.
Documentation ready: record position, range/grade, symptom response, and any modifications made.

Now answer the exercise about the content:

During peripheral joint testing, which finding should prompt you to stop or modify the assessment immediately?

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Stop or modify if symptoms suggest harm or instability, such as sharp/escalating pain, sudden severe pain that doesn’t settle, or new numbness/tingling. Mild, familiar discomfort that resolves quickly is usually acceptable.