History - These include, but are not limited to: Total ___/8 (1 pt each) 1 1 1 1 1 1 1 1 (quick mark offs)
| _____ What happened? | _____ Varus or valgus force? | _____ Medication(s) |
| _____ Direction of force applied | _____ When is pain worse? | _____ Changes in daily routine |
| _____ Rate pain level | _____ How did it happen? | _____Sounds/sensations |
| _____ Length of symptoms | _____ Location of pain | _____ Type of pain |
| _____ Movement ↑or ↓pain | _____ Radiating pain | _____ Referred pain |
| _____ Onset (acute or chronic) | _____ Pain constant/intermittent | _____ Sleeping Problems |
| _____ Is this your dominant arm | _____ Previous Rx | _____ Altered Sensations |
| _____ Did you fall on an outstretched hand | _____ Previous history (shoulder/wrist/hand problems/pain) |
Inspection/Observation - These include, but are not limited to: Total ___/ 8 (1 pt each) 1 1 1 1 1 1 1 1 (quick)
| _____ Bilateral comparison | _____ Deformity | _____ Swelling |
| _____ Gait symmetry | _____ Symmetry of muscle tone | _____ Skin color |
| _____ Scars/lacerations | _____ Atrophy/hypertrophy | _____ Clothing removal |
| _____ Facial expressions | _____ Wrist and hand posture | _____ Attitude of head |
| _____ Palmar creases | _____ Cascade sign | _____ Knuckles |
| _____ Subungual hematoma | _____ Thenar/ hypo eminencies | _____ Facial pain |
Palpations ***Total___/ 7 (Palpations) ( 1 pt each)
Bony Palpation - Reasons for bony palpation: AT palpates for: Total 2 points (.5 each) ______
| ____ Point tenderness | ____ Deformity | ___ Crepitus | ___ Symmetry |
Bony Palpations:
| ____ Medial Epicondyle | ____ Lateral Epicondyle | ___Head of the Radius | ___ Olecranon |
Soft Tissue Palpation - Reasons for soft tissue palpation: AT palpates for: 2 points (.5 each)_______
| _____ Point tenderness | _____ Symmetry | _____ Spasm/tone | _____ Swelling/warmth |
Soft Tissue Palpation:
| _____ Radial Collateral Ligament | _____Ulnar Collateral Ligament | _____Brachioradialis |
Range of Motion ***Total____/3 (ROM) (1 pt each)
| ___ Active ROM (F,E,S.P) | |
| ___ Passive ROM (F,E,S.P) | Bi-Lateral _________ 1 pt |
| ___ Manual muscle (F,E,S.P) |
Special tests ***Total_____/24 (Special tests) (1 each)***
| Golfer’s Elbow | Cozens |
| ___ Name | ___ Name |
| ___ + Test | ___ + Test |
| ___ Testing for Medial Epicondylitis | ___ Testing for Tennis Elbow |
| ___ Proper Mechanics | ___ Proper Mechanics |
| Tennis Elbow | Tinel’s Sign |
| ___ Name | ___ Name |
| ___ + Test | ___ + Test |
| ___ Testing for Lateral Epicondylitis | ___ Testing for Ulnar Nerve Comp. |
| ___ Proper Mechanics | ___ Proper Mechanics |
| Valgus | Varus |
| ___ Name | ___ Name |
| ___ + Test | ___ + Test |
| ___ Testing for MCL injury | ___ Testing for LCL injury |
| ___ Proper Mechanics | ___ Proper Mechanics |
Action: 6 points ________
What are three modalities you could use for treatment on the first visit to the clinic. Explain why you picked those modalities. (Modality each 1 pt explain the why for each modality 1 pt) Total 6 pts
- 1.
- 2.
- 3.
Tape Job: 4 points________
| ___ Correct Tape Job |
| ___ Proper application/mechanics |
| ___ Clean and Comfortable |
| ___ Timely |
Plan: 10 points________( 2 points for each phase)
Correctly and clearly describes what they would do.
| Phase 1: | Phase 2: | Phase 3: | Phase 4: | Phase 5: |
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