The continued evolution of health care necessitates careful changes in how we think about and approach the examination and diagnostic process for patients with orthopedic conditions. In this edition, we emphasize a patient-centered examination process using the World Health Organization’s International Classification of Functioning, Disability, and Health disablement model. This model reminds us to look for connections between what the patient can and cannot do and the involved body structures and functions.
We continue to highlight the practical integration of evidence into practice. Updated information regarding the clinical usefulness of selective tissue tests and other examination techniques is presented in the associated boxes using a standardized format. Most notable, perhaps, is how little continues to be known about the validity and reliability of some of the commonly used techniques. We have added multiple new techniques that have promising or established diagnostic value. The values we present are dynamic and are not intended to supplant current systematic reviews or meta-analyses.
The values used to represent the range of scores for inter- and intrarater reliability, sensitivity, specificity, and positive and negative likelihood ratios were obtained from the references cited in the Appendix. Ranges for metrics that had 12 or more data points were calculated using the 95% confidence interval, while those having 5 to 11 data points were calculated using the interquartile range. For those tests having two to four data points, the low value, high value, and median value were reported. Instructors and students are encouraged to regularly scan the literature for the most recent information.
Integration of outcome measures into daily practice is becoming the expectation for high-quality health care. Outcome measures provide a standard approach to understanding the patient’s current status, the impact of a condition on the patient’s life, and the extent to which an intervention is helping the patient. This text emphasizes the incorporation of outcome measures into the examination process and connects these outcomes to a brief description of the interventions used. A new opener for each section describes commonly used patient-rated outcome measures and region-specific functional assessments, and clinician-rated outcome measures are incorporated into each chapter.
Some chapters have been reorganized, with the cervical and thoracic spine now bundled together to reflect clinical reality. The chapter on environmental conditions has been removed since this content is not typically included in courses relating to orthopedic examination. The relevant content on thoracic, abdominal, and cardiopulmonary pathologies, a stand-alone chapter in the third edition, has been redistributed to the specific systems.
The content is now organized into five discrete sections. Section I presents the foundations of the examination process. Chapter 1 describes the clinical examination process used, and Chapter 2 presents the on-field processes used throughout the text. Chapter 3 introduces the elements of diagnostic evidence and describes the measures commonly used for assessing outcomes (which are then presented in the relevant Section Openers). Chapter 4 gets the messy vernacular used to describe pathology out of the way and presents the examination findings of common musculoskeletal disorders (e.g., sprains, inflammatory conditions, fractures). Chapter 5 describes diagnostic imaging techniques that are often the gold standard used to confirm the clinical diagnosis. Chapters 6 (Assessment of Posture) and 7 (Evaluation of Gait) emphasize general alignment and function that can contribute to a patient’s status.
Section II contains those chapters that describe the examination of the lower extremity. Although the content is presented in separate chapters, the actual clinical examination will most likely require the examination of the surrounding body parts. Section III presents the examination of the torso. Lumbar and sacral examination is presented in Chapter 13, while Chapter 14 covers the cervical and thoracic spine and the thorax. The upper extremity, shoulder and upper arm, elbow, wrist, hand, and fingers are covered in Section IV. The text concludes with Section V, involving injuries to the eye (Chapter 18), face (Chapter 19), and the brain and skull (Chapter 20).
The most visually striking change is the new full-color format, designed to provide still greater clarity of the pathologies and diagnostic techniques described in this text. We encourage both instructors and students to contact us with questions or comments. Chad’s e-mail address is firstname.lastname@example.org, and Sara’s is email@example.com. We also invite students and instructors to visit us on Facebook at facebook.com/EOAI4.