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Musculoskeletal Assessment
Musculoskeletal System
Subjective
Malaise
This is an indefinite feeling of debility or lack of health often indicative of or
accompanying the onset of an illness, fever, malaise, and other flu like symptoms
Myalgia
Pain in one or more muscles
Cramps/spasms
This is a painful involuntary spasmodic contraction of a muscle, sharp abdominal
pain -- usually used in plural. Persistent and often intense though dull lower abdominal
pain associated with dysmenorrhea -- usually used in plural
Morning stiffness
This is often a symptom of arthritis
Phantom pain
An often painful sensation of the presence of a limb that has been amputated -called also phantom pain, phantom sensations
Ask the patient is they have joint pain
Ask the patient if they have muscle weakness
Ask the patient if they have fatigue
Ask the patient if they have low back stiffness
Ask the patient if they have butt pain (sciatica pain). The sciatic nerve runs down the
center of the gluteus and is often associated with spinal problems
Ask the patient about grip strength and check bilaterally
Ask the patient about leg strength and check pedal pushes
Ask the patient if they have pain in the great toe, especially at night (this is an indication
of gout)
Objective
Symmetry
This is when you are assessing the patient for overall definition and shape,
looking for abnormalities in shape.
Range of motion all four extremities
You are assessing the range of motion of all joints for limitations and pain. There
is passive and active ROM. With active the patient assists and with passive you do all the
work
Muscle strength (0-5) each extremity
You are assessing the strength of you patient, using common sense.
Kyphosis
This is an exaggerated outward curvature of the thoracic region of the spinal
column resulting in a rounded upper back
Lordosis
This is an exaggerated forward curvature of the lumbar and cervical regions of
the spinal column
Scoliosis
This is a lateral curvature of the spine, similar to an s-shape
Crepitus
This is a grating or crackling sound or sensation (as that produced by the
fractured ends of a bone moving against each other or as that in tissues affected with
gas gangrene)
Contractures
This is a permanent shortening (as of muscle, tendon, or scar tissue) producing
deformity or distortion
Amputations
This is to cut (as a limb) from the body
Heberden's and Bouchard's nodes
Bony bumps on the finger joint closest to the fingernail are called Heberden's nodes. Bony bumps
on the middle joint of the finger are known as Bouchard's nodes.
Assess the patient for assistive devices: cane, crutches, walkers, wheelchairs, traction,
casts.
If your patient has casts, traction or anything like that, perform neurovascular checks
Know the 7 Ps:
Pulslessness
Paresthesia
Paralysis or paresis
Polar temperature
Pallor
Puffiness (edema)
Pain
If your patient has external fixation or internal fixation, assess the sites (incision, staples,
pins, etc) for signs of infection (exudate, erythema, edema, etc).
Inspect the muscles of the shoulder, arm, forearm and hand.
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Note muscle size (bulk).
Look for asymmetry, atrophy and fasciculation.
Look for tremor and other abnormal movement at rest and with arms
outstretched.
Determine muscle power by gently trying to overpower contraction of each
group of muscles.
o Shoulder: Abduction (Deltoid), Adduction ( ), Shrug (Trapezius)
o Elbow: flexion (Biceps) and extension (Triceps),
o Wrist: Flexion ( )and extension().
o Hand: Grip, opposition of thumb and index finger, opposition of thumb
and little finger and finger abduction and adduction.
Determine limb tone (resistance to passive stretch). With the patient relaxed,
gently move the limb at the shoulder, elbow and wrist joints and note whether
tone is normal, increased or decreased
Normal:
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Muscles are symmetrical in size with no involuntary movements. In some,
muscles may be slightly larger on the dominant side.
Muscle power obviously varies. You should not be able to overpower with
reasonable resistance.
You have to learn to appreciate Inspect and palpate the palmar and dorsal
surface of hands.
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Note the color of palmar and dorsal surface of hand.
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Observe the thenar, hypothenar eminence and the interphalangeal space . Note
the bulk of the related muscles.
Compare both sides.
Pinch the skin in dorsum of hand to assess the thickness.
Feel the hands for moisture and temperature and texture.
Inspect the muscles of the hip, knee and ankle.
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Note muscle size (bulk).
Look for asymmetry, atrophy and fasciculation.
Look for abnormal movement.
Determine muscle power by gently trying to overpower contraction of each group
of muscles.
o Hip: Flexion (Iliopsoas), Extension (Gluteus maximus), Abduction,
Adduction.
o Knee : Flexion (Hamstrings), Extension (Quadriceps)
o Ankle : Dorsiflexion (Tibialis anterior), Plantar flexion (Gastronemius).
Determine limb tone (resistance to passive stretch). With the patient relaxed,
gently move the limb at the hip, knee and ankle and note whether tone is normal,
increased or dicreased.
Flex the hip and knee. Support the knee, dorsiflex the ankle sharply and hold the
foot in this position checking for clonu
Ask the patient to walk back and forth across the room.
Observe for equality of arm swing , balance and rapidity and ease of turning.
Next, ask the patient to walk on his tiptoes, then on heels.
Ask the patient to tandem walk.
Test patient's ability to stand with feet together with eyes open and then closed.
(Romberg's test). Reassure patient that you will support him, in case he becomes
unsteady.
Normal: Person can walk in balance with the arms swinging at sides and can
turn smoothly. Person should be able to stand with feet together without falling
with eyes open or closed.
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Fix the head with one hand while you examine neck
Inspection
o Note the normal concavity of cervical spine
o Identify Transverse process of C7
o Observe Trapezius and Sternomastoid muscles
Palpation
o Feel each spinous process looking for focal areas of tenderness
o Joint
 Feel for crepitus during passive motion
o
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Para spinal muscles
Range of motion
o Active
 Touch chin for flexion
 Throw head back for extension
 Touch each shoulder with ears for lateral flexion
 Touch each shoulder with chin for lateral rotation
o Passive
 Feel for crepitus during passive motion
Normal:
o 30 degree rotation, able to touch chest with chin, 55 degree extension and
40 degree lateral bend.
o No resistance during the range of motion.
Examine the Neck, Shoulder, Elbow, Wrist, Metacarpophalangeal and
Interphalangeal joints. Check each joint for the following:
Inspection
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Anatomical landmarks: to identify fractures and dislocations
o for deformity
o for symmetry
Erythema
o for signs of inflammation
Soft tissue swelling
Fluid in the joint
Muscles around the joint
o For wasting
o Tear and evulsion
Palpation
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Anatomical landmarks for
o Bony prominances and contours for fractures and dislocations
o focal areas of tenderness
Warmth for inflammation
Joint line
o focal areas of tenderness
o for cartilagenous injuries and arthritis
o Crepatus during passive motion
Feel for fluid in joint
Assess synovial membrane thickness
Musculo-tendon junctions and tendon insertions for evulsion , tear and bursitis
Range of motion
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Active
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Range for each motion
Comparison to opposite side and yourself (assuming that you are normal)
Observe the comfort with each motion
Passive
o Is necessary only when there is limitation of active motion.
o If there is no limitation with passive motion, most likely the limitation in
passive motion is due to neuromuscular problem and not the joint.
Neurological evaluation including sensory examination may be necessary
Palpate the joint with one hand while moving it with the other to feel for
crepitation.
While examining the joints, also note any muscle atrophy.
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Shoulder:
o Inspection
 Anatomical landmarks
 Head of humerus
 Bicipital grove
 Acromion process
 Subacromial area
 Corocoid process
 Sterno-clavicular joint
 Scapula
 Fluid in the joint
 Muscles around the joint
 Deltoid
 Supra and infraspinatus
o Palpation
 Check for tenderness over the biceps tendons, subdeltoid bursa,
rotator cuff and acromioclavicular joint.
o Range of motion
 Shoulder motion should be examined with one hand fixing the
scapula to the chest wall since 60o of shoulder motion is due to
rotation of the scapula.
 Active
 The glenohumeral joint range of motion is then
 120o abduction
 70o adduction
 180o Flexion
 60o Extension
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90o external rotation
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90o internal rotation
Elbow:
o
o
o
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Wrist:
o
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Inspection
 Anatomical landmarks
 Lateral and medial epicondyles
 Olecrenon process
 Radial head
 Ulnar grove
 Carrying angle
 Muscles around the joint
 Biceps
 Triceps
Palpation
 Anatomical landmarks for
 focal areas of tenderness of lateral and medial epicondyle'
Olecrenon process
 Ulnar grove for synovial membrane thickening
Range of motion
 Active
 Flexion: (160o)
 Extension : ( 0o)
 Pronation
 Supination
Inspection
 Anatomical landmarks
 Ulnar
 Styloid process of radius
 Snuff box
 Dorsal and palmar swelling
 Muscles around the joint
 Thenar and hypothenar muscles
o Palpation
 Anatomical landmarks for
 focal areas of tenderness of Ulnar, Styloid process of
radius, Snuff box for
o Range of motion
 Active
 Flexion: (90o)
 Extension: (70o).
 Radial deviation (20-30o)
 Ulnar deviation (20-30o)
Metacarpophalangeal joints
o Using the thumbs, to palpate the joint line of the metacarpo-phalangeal
joints
o Check for the ability to make a full fist and extend and spread fingers.
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Examine the hip, knee, ankle, midfoot, metatarsophalangeal joints and the
interphalangeal joints.
Examine each joint in weight bearing fashion, as well as lying down.
For each joint, check for deformity, soft tissue swelling, fluid in the join, focal
areas of tenderness and range of motion.
Palpate the joint with one hand while moving it with the other to feel for
crepitation.
If swollen, distinguish synovial swelling from pitting edema.
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Hip
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o
Inspection
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Anatomical landmarks
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Muscles around the joint
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o
Greater Trochanter
Quadriceps, Hamstrings, Gluteal muscles
Palpation
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Anatomical landmarks
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o
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Palpate for tenderness
 in the inguinal region
 laterally over the trochanteric bursa.
Range of motion. Check hip motion with knee flexed:
 Active
 Flexion 120o
 Extension
 External rotation 45o
 Internal rotation 40o.
 Abduction
 Adduction
Knee
o
Inspection
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Anatomical landmarks
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o
Limb alignment
Patellar alignment
Muscles around the joint
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Quadriceps
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Hamstrings
Palpation
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Anatomical landmarks for
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o
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Focal areas of tenderness of
Bony prominences and contours for fractures
 Tibial tubercle
 Epicondyles of femur
 Margins of Tibia
 Musculo-tendon junctions and tendon insertions for evulsions and
tear
 Joint line for cartilaginous injuries and arthritis
Range of motion
 flexion (130o)
 extension (0o)
 look for medial and lateral instability.
 Suspend legs with patella at equal levels and observe the height of
great toes. Uneven height of great toes indicates posterior lag and
loss full extension
 Flex knee to full extent and compare the distance between heel and
buttock. Disparity indicates impaired level of flexion
Ankle
o
Inspection
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o
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Alignment
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Distal fibula
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Lateral malleolus
Muscles around the joint
Palpation
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o
Anatomical landmarks
Anatomical landmarks for
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Talus
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Peroneal tendon
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Anterior joint line
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Medial ligament
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Sustentaculum tali
Range of motion
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Active
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Plantar flexion (45o).
Dorsiflexion (20o)
Inversion
Eversion
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Foot
o
Inspection standing
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Anatomical landmarks
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o
Look at the integrity of the plantar arch while the patient is
standing.
 Medial process of calcaneal tuberosity
 Heel foot pad
 Attachment of plantar fascia
Muscles around the joint
Palpation
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Anatomical landmarks
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o
Look for local tenderness of the Achilles tendon
The bottom of the foot at the calcaneus.
Look for tenderness of the metatarsophalangeal joints and
interphalangeal joints.
Range of motion
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Active
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Check eversion (20o) and inversion (30o) of the midfoot.
The examiner should stand behind the patient and observe the alignment of the
spine in the flexed position to determine scoliosis.
View the spine from the side to determine kyphosis.
Ask the patient if he is aware of sore spots. Palpate the spinous process and be
gentle with the sore spots. Percuss one vertebra at a time, starting from head.
Assess range of motion of spine by having patient bend down to pick up an
object without bending his legs while you hold his hips.
Normal:
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Gentle concavities in cervical and lumbar regions and a convexity in the thorax.
Vertebral line and gluteal cleft align.