Musculoskeletal System
Assessment – Musculoskeletal System
MSK Assessment consists of the following:
- Basic screening exam
- Assessment of the spine
- Assessment of the lower extremities
- Assessment of the upper extremities
Preparation for Assessment
Equipment & Assessment Sequence
There is no special equipment required to conduct the MSK exam; preparation for the assessment includes washing hands and donning appropriate PPE (as needed). The assessment sequence is inspection, palpation, Assessing ROM, and strength.
Physical Assessment
Basic MSK Screening Exam
- Patient stands facing examiner
- Patient looks at ceiling, floor, over both shoulders, touch ears to shoulder (Neck ROM: observe for restriction [symmetric or asymmetric], pain, and crepitus.)
- Patient shrugs shoulders (resistance)
- Patient abducts arms to 90º (resistance at 90º) (Observe for restriction [symmetric or asymmetric], pain, and crepitus.)
- Patient performs full external rotation of arms (Observe for restriction [symmetric or asymmetric], pain, and crepitus.)
- Patient flexes and extends elbows (Observe for restriction [symmetric or asymmetric], pain, and crepitus.)
- With arms at sides and elbows flexed 90º, patient pronates and supinates hands
- (Observe for restriction [symmetric or asymmetric], pain, and crepitus.)
- Patient spreads fingers and makes fist (Observe for restriction [symmetric or asymmetric], pain, and crepitus.)
- Patient tightens (contracts) quadriceps (Leg extension strength.)
- Patient turns back to examiner (Check spine for abnormal curvature.)
- With knees straight, patient touches toes (Check for flexibility and curvature of the spine, such as scoliosis, smoothness and symmetry of motion, flattening of the lumbar curve with flexion.)
- Patient rises onto toes then heels
- Patient “duck walks” away from and toward examiner (Based on patient mobility, have patient assume a squatting position with knees flexed to the fullest and take at least 4 steps in that position without holding on to any objects for support.)
Assessment of the Spine
- Note position of head and posture of neck and trunk (assess for muscle spasm and abnormal positioning such as torticollis)
- Assess cervical, thoracic, and lumbar curves for increased or decreased concavity or convexity (note presence and degree of cervical and lumbar lordosis and thoracic kyphosis)
- Assess for straight line from C7 through gluteal cleft (both standing and flexed forward at the waist; assess for lateral curvatures such as scoliosis)
- Assess alignment of shoulders and iliac crests with patient standing erect and then in flexion, noting asymmetry (palpate iliac crests to be able to assess them accurately)
- Note ease of gait
- Palpate spinous processes for tenderness or step-off (patient may be standing or sitting up straight)
- Palpate cervical facets for tenderness (palpation may require relaxation of the trapezius muscle for optimal feel of the facets)
- Palpate paravertebral muscles for tenderness or spasm (throughout the spine)
- Palpate sacroiliac joints for tenderness
- Palpate for tenderness in any other areas suggested by the patient’s symptoms
- Fist percussion over spinous processes for tenderness (use caution with the amount of force applied)
- Neck: flexion, extension, rotation, lateral bending
- Spine: flexion, extension, rotation, lateral bending
- Note the location of localized or radiating pain or any limited range of motion
Assessing the Upper Extremities
Shoulder, elbow, wrist, hands
Inspection
Inspect upper extremities (UEs) for symmetry, swelling, deformity, contours, and abnormal positioning.
Shoulder
- Inspect shoulder and shoulder girdle anteriorly, scapulae and related muscles posteriorly; look for swelling, deformity, muscle atrophy or fasciculations, or abnormal positioning; look for swelling of joint capsule and observe entire UE for color change, skin alteration, or unusual bony contours.
Elbow
- Flex elbow to ~70º, inspect contours, note any nodules or swelling.
Wrist and Hand
- Observe position of hands in motion and at rest, look for swelling over joints, note any bony deformities or abnormal contours, look for radial or ulnar deviation.
Palpation
Palpate bony landmarks, muscles, tendons, and ligaments for swelling, tenderness, bogginess, or bony enlargement
Shoulder
- Begin medially at sternoclavicular joint and trace along clavicle; from behind, trace scapula to acromion, move thumb medially to acromioclavicular [AC] joint, move thumb medially and down a short step to coracoid process, keep thumb on coracoid process and grasp lateral aspect of humerus to palpate greater tubercle, palpate biceps tendon in the intertubercular groove. Next, lift elbow posteriorly to palpate subacromial and subdeltoid bursae, then supraspinatus, infraspinatus and teres minor.
Elbow
- Palpate lateral and medial epicondyles and olecranon process for tenderness; palpate for ulnar nerve between olecranon process and medial epicondyle.
Wrist and Hand
- Palpate groove of each wrist joint with thumbs on the dorsum of medial and lateral surfaces [distal radius and ulna], palpate radial styloid bone and anatomical snuffbox just distal, palpate carpal bones and metacarpals, compress the metacarpophalangeal joints, palpate medial and lateral aspects of proximal [PIP] and distal interphalangeal joints [DIP].
Assess Range of Motion (ROM) Note Symmetry and Rhythm of Movement
Shoulder
Elbows are straight except during external and internal rotation.
- Flexion
- Raise hands forward from sides to above head.
- Extension
- Bring hands backwards from sides.
- Abduction
- Raise hands sideways from sides to shoulder level with palm down, then above headwithpalmsturnedup.
- Adduction
- Cross arm in front of body–this is sometimes known as the crossover test, useful in assessing the AC joint.
- External Rotation
- With elbow bent 90º, raise arm to shoulder level, rotate forearm toward ceiling.
- Internal Rotation
- Place hand behind back and touch shoulder blade. Note: Apley scratch test can be used to assess adduction and internal rotation, then abduction and external rotation.
Elbow
- Flexion
- Bendelbow.
- Extension
- Straightenelbow.
- Supination
- Turn palms up.
- Pronation
- Turn palms down.
Wrist
- Flexion and extension
- Point fingers toward floor or ceiling, palms down.
- Ulnar and radial deviation
- Bring fingers away from midline, toward midline, palms down.
Thumb
- Flexion
- Movethumbacrosspalmandtouchbaseoffifthfinger.
- Extension
- Move thumbback.
- Abduction
- Movethumbanteriorlyawayfrompalm.
- Adduction
- Move thumb back.
- Opposition
- Touch thumb to each of the other fingertips.
Fingers
Look for smooth coordinated movements
- Flexion
- Make a tight fist. Flex DIP tips to distal palmar crease; flex PIP tips to heel of hand. Extension: Extend and spread the fingers.
- Abduction
- Spread fingers apart.
- Adduction
- Bring fingers back together.
Advanced Assessment Techniques Upper Extremities
Shoulder, elbow, wrist, hands
Shoulder: Evaluate for rotator cuff injury
- Neer Impingement Sign
- Press on the scapula with one hand and raise the patient’s arm with the other.
2. Hawkin Impingement Sign
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- Flex shoulder and elbow to 90º with palm facing down, and rotate arm internally.
3. Supraspinatus [“empty-can test”]
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- Elevate arms to 90º, internally rotate with thumbs pointing down; apply downward pressure.
4. Infraspinatus Strength
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- Arms at side, elbows flexed 90º with thumbs turned up; resist as patient pushes outward.
5. Forearm Supination
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- Arms at side, elbows flexed 90º wrists pronated; resist as patient supinates the forearm.
6. Drop-arm Sign
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- Fully abduct the arm to shoulder level and then lower it slowly.
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Wrist/hand: Tests for carpal tunnel syndrome
- Tinel Sign
- Tap lightly over the median nerve.
2. Phalen Sign
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- Hold wrists in flexion for 60 seconds or press the back of both hands together.
Assessing the Lower Extremities
Hip, knees, ankle, foot
Inspection
Observe the gait looking for width of the base, the shift of pelvis, and flexion of knee. Inspect the lower extremities for symmetry, swelling, or deformity
Hip
- Muscle atrophy or bruising anteriorly or posteriorly
Knee
- Alignment and contours, atrophy of quadriceps, or swelling in or around the joint
Ankle and Foot
- Deformities, nodules, swelling, calluses or corns
Palpation
Palpate bony landmarks, muscles, tendons, and ligaments for swelling, tenderness, bogginess or bony enlargement.
Hip
- Palpate iliac crest, anterior-superior iliac spine (ASIS), greater trochanter, posterior-superior iliac spine (PSIS) just below the dimples (Note: Sacroiliac joint inferior to PSIS is not always palpable, but check for tenderness).
- Palpate trochanteric bursa if the patient has hip pain.
Knee
- Seat patient on exam table with knees flexed.
- With thumbs on either side of the patellar tendon, palpate medially and laterally along the groove of the tibiofemoral joint for bony irregularities.
- Palpate in the same area for the medial and lateral menisci, checking for tenderness.
- Move thumbs upward to palpate medial and lateral femoral condyles, then downward to palpate medial and lateral tibial plateaus.
- Palpate the medial and lateral collateral ligaments.
- Trace the patella and palpate the patellar tendon to its insertion at the tibial tuberosity. Palpate the suprapatellar and prepatellar bursae.
Ankle and Foot
- Use thumbs to palpate along the anterior joint space for bogginess, swelling or tenderness.
- Palpate the Achilles tendon for nodules or tenderness.
- Palpate the posterior and inferior calcaneus and plantar fascia for tenderness.
- Palpate medial and lateral malleoli, metatarsophalangeal joints and the grooves between the heads of the metatarsals.
- Compress the forefoot between the thumb and fingers.
Assess Range of Motion (ROM)
Hips (Can also be done with patient standing.)
- Flexion
- With the patient supine, place hand under lumbar spine and ask patient to bend each knee to chest and pull it firmly against abdomen.
- Extension
- With patient prone, knee bent, lift the leg toward the ceiling; can also be done supine.
- Adduction
- With patient supine, stabilize the contralateral ASIS with one hand, move lower leg toward midline.
- Abduction
- With patient supine, stabilize the contralateral ASIS with one hand, move lower leg away from midline.
- Internal and External Rotation
- With patient supine, flex leg to 90º at knee and hip, stabilize thigh with one hand, and grasp ankle; swing lower leg medially for external rotation and laterally for internal rotation.
Knees
- Flexion
- With patient sitting on very edge of table or prone on table, bend knee.
- Extension
- Straighten the knee from the fully flexed position–having the patient squat then stand assesses both.
- Internal and External Rotation
- With patient sitting on exam table, place hand on thigh to stabilize femur, grasp the heel and rotate tibia medially and laterally.
Ankles (Active ROM can be assessed by having the patient walk on toes, heels, and lateral and medial borders of the feet.)
- Dorsiflexion and Plantar Flexion
- Grasp the hindfoot with one hand and forefoot with the other, and move the foot into dorsiflexion [up] and plantar flexion [down].
- Inversion and Eversion
- Stabilize the ankle with one hand just at or above the malleoli, grasp the heel with the other hand and invert and evert the foot.)
Feet and Toes
- Forefoot Abduction and Adduction
- Stabilize the heel and move the forefoot medially and laterally.
- Toe Flexion and Extension
- Stabilize the patient’s foot and move toes through flexion and extension.
Advanced Assessment Techniques Lower Extremities
Hip, knees, ankle, foot
Knee
Tests for Effusion
- Bulge Sign for Minor Effusion
- Place your hand on the suprapatellar pouch and milk fluid downward, and tap just behind the margin of the patella.
- Balloon Sign for Major Effusion
- Compress the suprapatellar pouch against the femur feel for fluid entering the spaces next to the patella.
Test for Meniscus Injury
- McMurray Test
- With the patient supine, flex the knee, grasp the heel with one hand, and cup the knee joint with the other, touching both the medial and lateral joint lines, rotate the tibia internally and externally, then apply valgus stress while externally rotating and slowly extend the knee.
- An audible or palpable click is a positive test
https://youtu.be/Db5vf92pcgk?si=EXyaSK29YBlGphaF
Tests for Ligamentous Injury
- Valgus/Varus Stress
- With the knee in a slightly less than full extension position, secure ankle and place other hand at knee, apply valgus stress [push medially] on knee to assess medial collateral ligament, apply varus stress [push laterally] to assess lateral collateral ligament.
Valgus Stress Test:
Varus Stress Test:
- Anterior/Posterior Drawer
- With patient supine, hips and knees flexed, feet flat on table, examiner sits on feet.
- Cup hands around knee joint with fingers behind and thumbs anteriorly over medial and lateral joint lines.
- Draw tibia toward you (anterior drawer) or away from you (posterior drawer) to assess cruciate ligaments.
- Lachman Test
- With patient supine, knee flexed 20º–30o, one hand on thigh and the other hand is on lower leg with thumb on the tibial tuberosity, pull anteriorly on tibia.
Ankle
Test for Ligamentous Injury (Anterior Talofibular Ligament)
- Anterior Drawer
- With the patient sitting, knee flexed, and foot slightly in plantar flexion, grasp the heel and pull forward while exerting posterior force on the anterior distal tibia with the opposite hand.
Video
VIDEO 11.0
MSK – Complete Examination
MSK Assessment: Brief Review
Examination Checklist
PRINTABLE 11.0
PRINTABLE 11.1
PRINTABLE 11.2
PRINTABLE 11.3
PRINTALE 11.4
Documenting Assessment Findings
Example of documentation of normal MSK assessment findings:
Patient reports no previous history of bone trauma, disease, infection, injury, or deformity. No symptoms of joint stiffness, pain, swelling, limited function, or muscle weakness. Patient can perform and manage regular daily activities without limitations. Joints and muscles are symmetrical bilaterally, with no visible swelling, deformity, masses, or redness noted upon inspection. Joints are non-tender and without crepitus on palpation. There is full ROM of the arms and legs with smooth movement. Upper and lower extremity strength is rated 5/5, patient can maintain full resistance of muscles without tenderness or discomfort.