Bone structure

Kyphotic posture due to compression fractures of the thoracic spine or poor posture

Thoracic extension, shoulder rotation, chin tuck exercises

Osteoporosis treatment to prevent new fractures

Compression fracture can be diagnosed by x-ray, and osteoporosis can be identified by bone mineral density testing.

Leg length differences

Heel lift

Usually, heel lift correction is not 100%.

Severe genu varus or valgus

Orthotics, bracing, strengthening of quadriceps

Knee replacement criteria should be reviewed.

Foot abnormality or pain

Hallux valgus (bunion)

Loss of longitudinal arch

Orthotics, podiatry care, custom shoes

Testing for plantar neuropathy with monofilament nylon is always done to detect risk of plantar ulceration.

Joint range of motion

Decreased hip internal rotation

Stretching of adductors, strengthening of abductors

Attempting to increase internal rotation by stretching is not usually effective but may prevent further loss of range of motion.

Decreased hip extension

Stretching of hip flexors, strengthening of hip extensors

Lying prone, arching back, and extending hip is often recommended.

Decreased ankle dorsiflexion

Stretching of calf muscles

Height of high-heel shoes is reduced.

Hallux rigidus (loss of dorsiflexion of the great toe)

Podiatry or orthopedic referral

An orthotic should be considered.

Muscle power

Weak hip extension

Chair rise exercises

Chair rise test may be helpful in diagnosis.

Weak knee extension

Chair rise exercises, knee extension with ankle sandbags, squats

Chair rise test may be helpful in diagnosis.

Weak ankle plantar flexion

Heel raises (using body weight)

To increase resistance during heel raises, patients can wear a weighted vest, backpack, or waist belt; they may need to stabilize themselves against a wall.

Weak ankle dorsiflexion

Muscle strengthening (eg, toe rises), ankle foot orthotic for footdrop

Patients place sandbag weights over their metatarsals. With their back to the wall for safety, patients rise on their heels (ie, lift toes off the floor).

Weak hip abduction

Hip abduction with ankle weights, side-lying position on the floor

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Sensory systems

Decreased or impaired position sense or balance when eyes are closed during a Romberg test

Appropriate footwear

Vitamin B12 level should be checked.

Decreased or impaired plantar touch sensation as measured by Semmes-Weinstein monofilaments

Appropriate footwear

Assess for diabetes and alcohol abuse and, if none, consider nerve conduction studies.

Dizziness or vertigo

See Dizziness and Vertigo: Treatment

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Motor control/balance

Tandem stance or single-leg stance < 5 seconds or turning 360° (both to right and left) requires > 10 steps or patient is unsteady during turning

Balance training involving static and dynamic balance, tai chi, or the equivalent

Forward lean

Bradykinesia

Leg hypertonia

Parkinsonian signs

Physical therapy training to maintain or improve motor control/balance

Assess for Parkinson disease.

CT or MRI can detect lacunar infarcts, cerebellar changes, and white matter disease.

Physical and cardiovascular fitness

Dizziness due to postural hypotension

Review of medications for possible cause, compression stockings

See Dizziness and Vertigo and Orthostatic Hypotension.

Fatigue, shortness of breath, inability to walk > 300 m at usual pace

Regular walking program

Patients should be assessed for angina, heart failure, pulmonary disease, and claudication.

A 6-minute walking distance is measured.