Musculoskeletal System Assessment

• Explain the purpose and principles of musculoskeletal assessment.
• Obtain a focused and comprehensive musculoskeletal history.
• Perform systematic inspection and palpation of joints and soft tissues.
• Assess range of motion (ROM), muscle strength, gait, and functional capacity.
• Perform selected special tests safely and accurately.
• Recognize and document common abnormal findings effectively.

A thorough understanding of anatomy is critical before examining a patient. The musculoskeletal system consists of interconnected structures working in harmony:

• Bones: Provide structural support, protection of internal organs, and mineral storage (e.g., calcium and phosphorus).
• Joints: The articulations between bones that permit movement and provide mechanical stability.
• Skeletal Muscles: Contractile tissues that produce voluntary movement and maintain posture.
• Tendons: Tough, fibrous connective tissues that connect muscle to bone (e.g., Achilles tendon).
• Ligaments: Strong, inelastic bands that connect bone to bone, providing crucial joint stabilization (e.g., Anterior Cruciate Ligament).
• Cartilage, Bursae, and Fascia: Structures that act as shock absorbers, reduce friction between moving parts, and support overall movement.

A focused musculoskeletal history is the foundation of an accurate diagnosis. Before touching the patient, you must understand exactly why they are seeking help and why now (Pain? Loss of function? Deformity? Preventative reasons?).

• Presenting complaint and detailed history of the presenting complaint.
• Family history (e.g., rheumatoid arthritis, osteoarthritis).
• Previous or current medical conditions (e.g., diabetes, gout).
• Medications taken (e.g., prolonged steroid use leading to osteoporosis).
• Previous operations or surgical interventions.
• History of accidents or trauma.
• General body systems review.

Always fully characterize the patient's pain and functional limitation. Use a structured approach to evaluate the characteristics of pain:

1. Site / Location: Exactly where is the problem? Can they point to it with one finger?
2. Onset & Duration: Was the onset sudden (e.g., acute trauma) or gradual (e.g., chronic osteoarthritis)?
3. Character / Type of Pain: Is it aching, sharp, burning, or associated with stiffness?
4. Severity / Intensity: Use a pain score from 0–10 (utilizing different pain scales appropriate for the patient's age and cognition).
5. Timing / Pattern: Is the pain constant or intermittent? Is it worse in the morning (inflammatory) or at night/after use (mechanical)?
6. Aggravating Factors: What specific movements or activities make it worse?
7. Relieving Factors: Does rest, ice, or medication help?
8. Associated Phenomena: Look for associated swelling, redness, severe weakness, numbness (paraesthesiae), instability, or fever.

Listening carefully to how the patient describes their pain can often tell you exactly which anatomical structure is damaged:

• Referred Pain: Pain perceived to be occurring in a part of the body located away from its actual source. While the affected area may be identified by the patient, it is usually not defined by sharp, distinct borders.
• Somatic Pain Referral: For example, an S1 nerve root compression (from a lumbar disc herniation) refers pain in a well-defined distribution down the back of the leg and into the foot.
• Visceral Pain Referral: Pain from internal organs is referred diffusely due to shared sympathetic and somatic nerve pathways in the spinal cord. For example, a myocardial infarction (heart attack) refers diffuse pain into the left arm, neck, and jaw.

• Explain and Consent: Always explain the procedure to the patient and obtain explicit verbal consent before touching them.
• Environment: Ensure privacy, adequate exposure of the area to be examined (while maintaining dignity), and excellent lighting.
• Symmetry is Key: Always compare both sides of the body. Assess the unaffected/normal side first to establish a baseline.
• Order of Palpation: Examine from less painful areas to more painful areas. Palpate the point of maximum pain last to maintain patient trust and prevent guarding.
• Systematic Approach: Always begin with visual Inspection before Palpation. (Look, Feel, Move).
• Safety First: Avoid forceful or sudden passive movements when a fracture or severe acute injury is suspected.
• Continuous Assessment: Assess the patient's face for signs of pain before, during, and after any movement.
• Documentation: Document all objective findings clearly and professionally.

Observe the patient carefully the moment they walk into the room, before formally touching them:

• Overall posture and whole-body alignment (e.g., stooped, leaning to one side).
• Symmetry of limbs and joints at a glance.
• General muscle bulk and any glaringly obvious gross deformities.
• Ability to easily stand, walk, and transfer from a chair to the examination bed.
• The use of walking aids or assistive devices (canes, crutches, walkers).
• Facial expression (are they grimacing with every step?).
• Overall mobility and activity level.

Ask the patient to walk normally across the room and carefully observe:

• Speed and rhythm of the walk.
• Step length and symmetry of stride.
• Base of support (is it a wide, unsteady stance?).
• Arm swing (lack of arm swing can indicate Parkinsonism or shoulder pathology).
• Turning mechanics and overall balance.
• Common Abnormal Gait Patterns:
  • Antalgic gait: A painful limp where the patient spends as little time as possible bearing weight on the painful leg.
  • Steppage gait: High-stepping walk due to "foot drop" (weakness of ankle dorsiflexors).
  • Ataxic gait: Uncoordinated, staggering, wide-based walk (often cerebellar origin).
  • Spastic gait: Stiff, dragging, circumducting leg (often seen in stroke or cerebral palsy).
  • Trendelenburg gait: The pelvis drops on the opposite, unsupported side during the stance phase, indicating severe weakness of the hip abductor muscles (Gluteus Medius) on the standing leg.

A complete musculoskeletal examination follows a rigid, systematic flow:
HISTORY ➔ INSPECTION ➔ PALPATION ➔ MOVEMENT ➔ MUSCLE POWER ➔ SPECIAL TESTS ➔ FUNCTION ➔ NEUROVASCULAR ASSESSMENT.

Inspect systematically from head to toe, always comparing affected and unaffected sides:

• Swelling, localized joint enlargement, or edema.
• Redness (erythema), bruising (ecchymosis), or skin changes (e.g., psoriasis plaques over joints).
• Deformity or abnormal anatomical alignment (e.g., squaring of the shoulder in anterior dislocation).
• Muscle wasting (atrophy) or hypertrophy.
• Surgical scars, traumatic wounds, or discharging sinuses (suggestive of underlying osteomyelitis).
• Limb length discrepancy and overall symmetry.
• Venous distention over the area.

Palpate gently and systematically. Evaluate joints, muscles, soft tissues, bony contours, and ligaments:

• Skin Temperature & Hydration: Use the back of your hand to feel for unnatural warmth (indicating inflammation or acute infection).
• Tenderness: Pinpoint the exact location of tenderness.
• Swelling / Effusion: Feel if the swelling is hard (bony), soft (tissue), or fluctuant (fluid inside the joint).
• Bony Contours: Palpate bony landmarks, joint margins, abnormal shapes, osteophytes (bone spurs), and step-off deformities (fractures).
• Muscles/Soft Tissues: Assess muscle tone (tonus, flaccidity, rigidity, spasticity), bulk, consistency, fasciculations (twitching), fibrosis, or calcification.
• Ligaments: Feel for scar tissue, tears, thickening, or nodules.
• Associated Structures: Palpate local lymph nodes, bursae, and arterial pulses.
• Crepitus: Feel for a grinding or crackling sensation during movement, indicating degenerative changes (osteoarthritis) or tissue/bone grinding.

Assess movements to evaluate joint function, coordination, muscle power, and willingness to move. Avoid putting unnecessary stress through damaged tissues.

1. Active ROM: The patient moves the joint completely independently. This demonstrates their true functional capacity and highlights any unwillingness to move due to pain.
2. Passive ROM: The examiner gently moves the patient's relaxed joint through its range. This helps differentiate between muscle/tendon problems (which hurt mostly on active movement) and joint/capsule problems (which hurt/restrict both active and passive movement).
3. Active-Resisted Movements: The patient pushes against the examiner's resistance. This specifically tests muscle and tendon strength and reproduces pain in tendinopathies.

Movements to Assess (Compare bilaterally):

• Shoulder: Flexion, extension, abduction, adduction, internal/external rotation.
• Elbow: Flexion and extension.
• Wrist: Flexion, extension, radial deviation, ulnar deviation.
• Hip: Flexion, extension, abduction, adduction, internal/external rotation.
• Knee: Flexion and extension.
• Ankle: Dorsiflexion, plantarflexion, inversion, eversion.

Evaluation during movement: Note whether movement is full, reduced, or increased (hypermobile). Note the intensity and quality of pain, stiffness, instability, crepitus, paraesthesiae, or weakness. Ensure painful movements are tested last!

• Bulk: Compare symmetry; look closely for unilateral wasting (disuse, nerve lesion) or enlargement.
• Tone: Assess the muscle's natural resistance to passive movement.
  • Hypotonia: Reduced resistance, limb feels floppy (lower motor neuron lesion).
  • Hypertonia: Increased resistance.
  • Spasticity: Velocity-dependent increase in tone (catches when moved quickly; upper motor neuron lesion).
  • Rigidity: Constant increased tone throughout the entire range of movement (lead-pipe or cogwheel, seen in Parkinson's).

Test movement against gravity and uniform resistance. Grade strength meticulously using the Medical Research Council (MRC) 0–5 scale:

Determine exactly how the musculoskeletal problem affects the patient's activities of daily living (ADLs). Mimicking activities that cause pain is highly diagnostic. Assess:

• Turning over in bed.
• Moving from sitting to standing; standing on tip-toes; squatting.
• Walking and climbing stairs.
• Dressing, bathing, putting on shoes, fastening buttons at the back.
• Combing the hair; opening door handles; feeding and fine hand function.
• Ability to perform work and usual hobbies.
• History of recent falls and the use of assistive devices.

This is particularly critical after trauma, casting, or orthopedic surgery to rule out limb-threatening ischemia or compartment syndrome. Assess the 6 Ps:

1. Pain: Especially severe, unrelenting pain that is out of proportion to the injury, or extreme pain on passive stretching of the muscles.
2. Pallor: Pale, white, or mottled skin distal to the injury indicating lack of arterial blood.
3. Pulselessness: Absent or diminished distal pulses (a very late, dire sign).
4. Paresthesia: Numbness, tingling, or "pins and needles" indicating nerve ischemia.
5. Paralysis: Inability to move the digits (another late, severe sign of nerve/muscle death).
6. Poikilothermia: The limb feels unnaturally cool to the touch compared to the rest of the body.

Action: Also rigorously assess capillary refill (< 2 seconds is normal). Urgent escalation to a doctor is required immediately if acute neurovascular compromise is suspected.

Special tests are provocative maneuvers performed only when clinically indicated by the history and basic exam. They isolate specific ligaments, tendons, or cartilages. Avoid causing injury during these tests.

These assess possible cervical nerve-root irritation, spinal cord involvement, and neck muscle function.

These assess the rotator cuff muscles, subacromial impingement, biceps tendon, shoulder instability, and the labrum.

These tests assess the critical stability provided by the cruciate ligaments (ACL/PCL), collateral ligaments (MCL/LCL), the shock-absorbing menisci, and patellar tracking.

These help assess hip flexion contractures, intra-articular hip joint pathology, sacroiliac-region pain, and abductor muscle weakness.

• Joint Swelling: Caused by acute inflammation, trauma (haemarthrosis), or chronic synovial effusion.
• Crepitus: Grating sound/feel signifying degenerative osteoarthritis cartilage loss, or the horrific grinding of fractured bone ends.
• Deformity: Visible anatomical distortion due to fracture, joint dislocation, or chronic rheumatoid disease (e.g., swan neck deformity).
• Muscle Wasting: Loss of muscle bulk due to prolonged disuse, joint immobilization, or severe peripheral nerve lesions.
• Reduced ROM: Can result from severe pain, joint inflammation, capsular stiffness, bony blocks, or muscle contracture.
• Weakness: Caused by direct neurological impairment, muscular tears, or systemic weakness.
• Red, Hot, Very Painful Joint: A massive red flag. Always highly consider septic arthritis (medical emergency) or acute gouty inflammation.

• Suspect a fracture? Immediately immobilize the limb and strictly avoid unnecessary movement or ROM testing to prevent severing arteries.
• Severe pain? Conduct a thorough pain assessment before attempting any active or passive ROM. Do not force movement through agonizing pain.
• Recent surgery? Strictly follow the surgeon’s prescribed weight-bearing and movement restrictions (e.g., hip precautions post-arthroplasty).
• Suspected spinal injury? Maintain strict spinal precautions (log-rolling, hard collar) until cleared by X-ray/MRI.
• Acute limb ischemia or compartment syndrome? Escalate to the surgical team immediately to save the limb from amputation.
• Maintain stringent infection-prevention precautions when handling open wounds, external fixator pins, or invasive devices.
• Always formally reassess the patient after administering pain interventions to document therapeutic changes.

Document objectively, completely, and specifically avoiding vague terms. Record:

• Exact joint or site examined (Left vs Right).
• Visual inspection findings (erythema, deformity, scars).
• Palpation findings: pinpoint location of tenderness, presence of swelling, or temperature changes.
• Measurements of Active and Passive ROM (in degrees if possible).
• Muscle power documented precisely using the MRC 0-5 grade.
• Detailed description of Gait and functional ability.
• Strict neurovascular findings (pulses, sensation, capillary refill).

If tested in a clinical skills exam, follow this exact fluid sequence without deviation:

1. Introduce yourself professionally and firmly confirm the patient's identity.
2. Explain the musculoskeletal procedure plainly and obtain explicit verbal consent.
3. Perform visible hand hygiene and ensure appropriate exposure of the joint (maintaining dignity).
4. General inspection of the patient from the end of the bed.
5. Assess overall posture and observe their gait as they walk.
6. Inspect closely and systematically palpate the affected area (feeling for temperature, swelling, joint lines).
7. Assess Active ROM, followed by Passive ROM.
8. Assess specific muscle power against resistance (using MRC grading).
9. Perform the relevant special tests (e.g., Anterior Drawer, Phalen's) based on the joint.
10. Complete a rapid neurovascular and functional assessment.
11. Thank the patient, ensure they are dressed and comfortable, wash your hands again, and systematically document your findings.

A complete musculoskeletal examination MUST be systematic:
HISTORY ➔ INSPECTION ➔ PALPATION ➔ MOVEMENT ➔ MUSCLE POWER ➔ SPECIAL TESTS ➔ GAIT/FUNCTION ➔ NEUROVASCULAR ASSESSMENT ➔ DOCUMENTATION
Always relentlessly compare sides and correlate your physical findings with the patient's history.

• Hutchison's Clinical Methods. (Latest Edition). An Integrated Approach to Clinical Practice. Elsevier.
• Macleod's Clinical Examination. (Latest Edition). Elsevier.
• Medical Research Council (MRC) Muscle Scale guidelines for strength assessment.
• Etonu Archbald (PHD, PGDME, MNS, PDHSM, BNS, DCN). Lecture Notes: Physical Examination of the Musculoskeletal System & Musculoskeletal Assessment.