MSK physical therapy involves treating injuries and disorders of the musculoskeletal system through techniques like rehabilitation after surgery, management of acute injuries like sprains and strains, and treatment of chronic issues like tendinopathy and bursitis. The document outlines the components of a comprehensive MSK assessment, including collecting subjective information from the patient on their history, symptoms, and functional limitations and performing objective tests of physical functions, range of motion, and strength. Key parts of the subjective examination include understanding aggravating/relieving factors, the behavior of symptoms over 24 hours, and identifying red flags that could indicate a serious underlying condition.

1. MUSCULOSKELETAL PHYSICAL THERAPY
PRINCIPLES &CONCEPTS
DR. NAZISH RAFIQUE
ASSISTANT PROFESSOR

2. WHAT IS MSK PHYSICAL THERAPY?
• Msk physical therapy is a speciality of pt. that deals with
diagnosis, management and treatment of disorders and injuries of
the musculoskeletal system including:
• Rehabilitation after orthopedic surgery
• Acute trauma such as sprains, strains
• Injuries of insidious onset such as tendinopathy and bursitis.
• This speciality of physical therapy is most often found in the out-
patient clinical setting.
• Orthopedic therapists are trained in the treatment of post-operative
orthopedic procedures, fractures, acute sports injuries, arthritis,
sprains, strains, back and neck pain, spinal conditions, and
amputations.

3. CONTI…
• Additionally, an emerging adjunct to diagnosis and
treatment is the use of sonography for diagnosis and to
guide treatments such as muscle retraining.
• Those who have suffered injury or disease affecting the
muscles, bones, ligaments, or tendons will benefit from
assessment by a physical therapist specialized in MSK.

4. COURSE DESCRIPTION
• Study of anatomy and physiology of MSK system
• Pathological changes of system and function
• Diagnostic tests and measurements
• Evidence based physical therapy intervention for
musculoskeletal conditions.
• Dysfunctions, evaluation and treatment of peripheral joints
and spine.

5. COMPONENTS OF A COMPREHENSIVE MSK
ASSESSMENT
Subjective
Assessment/
History
Taking
Objective Assessment/
Physical Examination
Demograph
ic Data

6. DEMOGRAPHIC DATA
• Name
• Age
• Occupation – identify work
requirements
• Repetitive movements
• Position of limb at work
• Gender
• Marital status
• Address
• Nationality
• Activities of daily living
• Recreational pursuits/sports
• Date admitted (for in-patients)
• Admitting unit (for in-patients)
• Attending physician
• Date evaluated
• Date of initial evaluation
• Working diagnosis

7. SUBJECTIVE EXAMINATION
Area of
Examination
Information Gained
Body chart Type and area of current symptoms, depth, quality,
intensity, abnormal sensation, relationship of symptoms
Behavior of
symptoms
Aggravating factors, easing factors, severity and
irritability of the condition, 24-hour behavior, daily
activities, stage of the condition
Special questions General health. drugs, steroids, anticoagulants, recent
unexplained weight loss, rheumatoid arthritis, spinal cord
or cauda equina symptoms, dizziness, recent X-rays
History of present
condition
History of each symptomatic area, how and when it
started, how it has changed
Past medical
history
Relevant medical history, previous attacks, effect of
previous treatment
Social and family
history
Age and gender. home and work situation, dependants and
leisure activities

8. AREA AND TYPE OF SYMPTOMS
 May employ a body chart
 Identify areas and types of symptoms
 Initial determination of the relationship
between the symptomatic areas
 First step of subjective examination
 What are included in the body chart?
 Area of current symptoms
 Area relevant to the region being examined
 Quality of pain
 Intensity of pain
 Abnormal sensation
 Relationship of the symptoms
 Depth of pain
 Constant/intermittent symptoms

10. AREA OF CURRENT SYMPTOMS
• A clear demarcation between areas of pain, paraesthesia,
stiffness or weakness
• The area of the symptoms does not always identify the
structure at fault.
• When the manifestation of symptoms is distant to the
pathological tissue this is known as referred pain.
• The more central the lesion, the more extensive is the possible
area of referral.

11. AREAS RELEVANT TO THE REGION BEING
EXAMINED
• All other areas relevant to the region being
examined should be checked for symptoms.

12. ILLNESS BEHAVIOR
• A patient may demonstrate signs of illness behavior, also called
non-organic signs,
• Need to examine patient fully
• Isolated behavioral symptoms mean nothing; only multiple
findings are relevant
• It does not explain the cause of the patient's pain, nor does
it suggest that the patient has no 'real' pain
• It does not mean that there is no physical disease
• It is not in itself a diagnosis
• It does not mean that the patient is faking or malingering

13. QUALITY OF THE PAIN
• Refers to the description of pain
• Interprets pain based on the pathology or structures
involved
• Throbbing diffuse – vasculature/inflammation
• Cramping dull aching – muscle
• Sharp shooting – nerve
• Deep nagging dull – bone
• Sharp severe intolerable – fracture

14. INTENSITY
• Rating severity of the symptoms based on a scale
• NPRS: usually range from 0 (no pain) to 10 (severe pain)
• Visual analogue scale: a 10-cm line with pain
descriptors at each end (“no pain” to “pain as bad as it
could be”)
• May assist in determining prognosis
• May be a reliable indicator of progress as the patient is
providing information regarding the pain experience

15. • Mcgill pain questionnaire (melzack & wall 1996)
measures intensity of pain by asking the patient to
choose the word listed below that best describes the
intensity of their pain now/at its worst and at its least:
1. Mild
2. Discomforting
3. Distressing
4. Horrible
5. Excruciating
CONTI…

16. DEPTH
• It was previously believed that the depth of pain is related to
the depth of injury.
• The depth of pain may give some indication as to the structure
at fault but, like quality, this can be misleading
• Muscle pain does not refer superficially
• Skin rarely refers pain
• Visceral pain has cutaneous distribution/pattern and
sometimes produce autonomic symptoms
• Joints specifically zygapophyseal joint pain refer symptoms
superficially

17. ABNORMAL SENSATION
• Areas of abnormal sensation are mapped out on the body chart
and include:
• Paraesthesia (abnormal sensation: tingling, pins and needles)
• Anaesthesia (complete loss of sensation),
• Hypoaesthesia (reduced touch sensation),
• Hyperaesthesia (heightened perception to touch),
• Allodynia (pain provoked by stimuli that are normally
innocuous)
• Analgesia (absence of appreciation of pain),
• Hypalgesia (reduced sensitivity of pain)
• Hyperalgesia (increased sensitivity to pain).

18. CONSTANT/INTERMITTENT
• The word constant is used here to mean symptoms which are
felt unremittingly for 24 hours a day
• Any relief of symptoms even for a few minutes would mean
that the symptoms were intermittent.
• Frequency of intermittent symptoms: once a month to once an
hour
• Constant pain which does not vary is may be the
characteristic of malignancy.
• Constant pain which varies in intensity is suggestive of
inflammatory or infective processes or may occur following
trauma for the first 20 days

19. RELATIONSHIP OF SYMPTOMS
• Evaluate if the symptoms arise from one
source or multiple sources
• Identify whether symptoms are provoked
independently (unrelated) or worsen all
together (related)
Clinical Implication
• Related symptoms: one area to be
treated to relieve symptoms
• Unrelated symptoms: a need to
treat various areas to promote relief
of symptoms

20. AGGRAVATING/ALLEVIATING FACTORS
 What activities/positions aggravate/relieve the symptoms?
 Knowledge of these may help in the diagnosis (identifies presence or absence
of a mechanical problem),
• Pain aggravated by activity or relieved by rest can be suspected to arise
from a pathologic process except in the case of a disk problem that is
aggravated by sitting and relieved by walking and standing up
• Arthritic conditions cause pain on the weight-bearing joints
• Early stage: pain with prolonged walking or maintenance of
weight-bearing
• Late stage: pain prior to start of movement/walk that decreases
while walking then returns after prolonged walking

21. RELIEVING FACTORS
• The clinician should ask the patient about theoretically
known easing factors for structures that could be a source of
their symptoms;
• Crook lying for a painful lumbar spine eases pain by
reducing intradiscal pressure
• Reduces the forces produced by muscle activity
• However, if the patient feels that they can only manage the
pain by lying down regularly for long periods this may
indicate possible illness behaviour.

22. SEVERITY AND IRRITABILITY OF SYMPTOMS
• The severity of the symptoms is the degree to which symptoms
restrict movement and/or function and is related to the intensity
of the symptoms.
• If a movement at a certain point in range provokes pain and this
pain is so intense that the movement must immediately be
ceased, then the symptoms are defined as severe.
• If the intensity is such that the patient is able to maintain or
increase a movement that provokes the symptoms, then the
symptoms are not considered to be severe and in this case
overpressures can be performed.

23. IRRITABILITY OF THE SYMPTOMS
• The irritability of the symptoms is the degree to which
symptoms increase and reduce with provocation.
• If the pain eases immediately, the symptoms are considered
to be non-irritable and all movements can be examined.
• If the symptoms take a few minutes to disappear then the
symptoms are irritable and the patient may not be able to
tolerate all movements as the symptoms will gradually get
worse.

24. 24-HOUR BEHAVIOR
• Status of symptoms
• At night
• In the morning
• Throughout the day: do the symptoms
vary?
• Knowledge of the behavior of the symptoms
provides information in:
• Formulation of diagnosis
• Identifying plan of care
• Monitoring of the progress of condition
• Prognosis but only to a lesser extent

25. CONTI…
Night pain
Does the patient have any difficulty in
sleeping because of the symptoms?
Does the pain wake the patient during
sleep?
Determine worst and best sleeping
positions
Night time symptoms
• Intractable pain– serious
pathology
• Unremitting pain –
inflammatory pathology
• Night time pain– muscle
tears

26. Morning pain
• Musculoskeletal conditions respond well to rest
• Stiffness, if present, resolve quickly especially with warm
shower
• Morning pain lasting more than 30 minutes is a sign of
inflammatory arthritis
• Minimal or absent pain with gross stiffness in the morning is
associated with degenerative conditions such as osteoarthrosis.
CONTI…

27. EVENING SYMPTOMS
• Pain that is aggravated by movement and eased by rest
generally indicates a mechanical problem of the
musculoskeletal system.
• Pain that increases with activity may be due to repeated
mechanical stress, an inflammatory process or degenerative
process.

28. RED FLAGS
• These should alert that something is not quite right.
• Used by clinicians to detect potential serious pathology
Cancer
Persistent pain at night.
Constant pain anywhere in the body.
Unexplained weight loss e.g. 10-15 lb
in 2 weeks or less.
Loss of appetite.
Unusual lumps or growths.
Unwarranted fatigue.
Cardiovascular
Shortness of breath.
Dizziness.
Pain or a feeling of heaviness in the chest.
Pulsating pain anywhere in the body.
Constant and severe pains in lower leg
(calf) or arm.
Discolored or painful feet.
Swelling (no history of trauma).
Gastrointestinal
Frequent or severe abdominal pain.

29. CONTI…
Genitourinary
Frequent heartburn or
indigestion.
Frequent nausea or vomiting.
Change in problems with bladder
function (e.g. UTI).
Unusual menstrual irregularities.
Miscellaneous
Fever or night sweats.
Recent severe emotional disturbances.
Swelling or redness in any joint with no
history of injury.
Pregnancy.
TB.
Neurological
Changes in hearing.
Frequent and severe headaches with
no history of injury.
Problems with swallowing or changes
in speech
Changes in vision (e.g. blurriness or
loss of sight).
Problems with balance, coordination
of falling.
Fainting spells (drop attacks).
Sudden weakness.

30. YELLOW FLAGS
• Possible chronic pain behavioral indicators
• Possible signs of chronic pain behavior, this can sometimes be
apparent when a patient displays one or several behavioral
symptoms known as ‘yellow flags’
• Psychological beliefs about back pain & it’s vagaries
• Non consistent behaviors (Waddell signs)
• Compensation issues
• Conflicting medical diagnosis and advice
• Over protective or under supported family or co-workers
• Time of work in past with same problem
• History of current or past depression
• Dissatisfaction in employment

31. ONSET OF SYMPTOMS
• Provides information of the relative
stage of injury
• Acute: 0 - 7 days after injury
• Sub-acute: 7 days - 7 weeks after
injury
• Chronic: more than 7 weeks after
injury
• An insidious onset not
related to injury or
unusual activity is
suspicious
• Neoplasm
• Degenerative lesions
• Lesions due to tissue
fatigue

32. MECHANISM OF INJURY
• Direction, position, and nature of the injuring force
may provide clues which tissues could have been
injured
• Correlation can be made to the signs and
symptoms for interpretation
• The magnitude of the injuring force and the
severity of injury can be compared
• Take note of unusual injury patterns as these could be
a sign of an abnormal tissue status prior to injury

33. PROGRESS OF SYMPTOMS
• Inquire if the patient’s symptoms get better, worse and in
what way/manner
• Most musculoskeletal injuries get better over time
primarily due to the normal healing process (~ 6 weeks)
• Some disorders may actually get worse over time 
underlying pathology
• Pain that radiates: extends to include other areas
• Presence of paresthesia following initial pain

34. TREATMENT RECEIVED AND EFFECTS
• Noted changes for the better/worse?
• Provides information regarding:
• Prognosis
• Treatment selection
• Dosage of treatment

35. PAST MEDICAL HISTORY
 State of general health
 Recent unexplained weight loss
 Presence of osteoporosis
 Cord signs
 Dizziness
 Headache
 Other joints
 Operations
 Renal dialysis

36. FAMILY HISTORY
Note disease process that have a familial incidence
 Tumors
 Heart disease
 Arthritis
 Allergies
 Diabetes
Family history predisposes a patient to increased risk
for acquiring the same condition

37. PERSONAL SOCIAL HISTORY
• Employment status and requirements
• Domestic role
• No. of dependents
• Recreational activities
• Living conditions
• Lifestyle

38. MEDICATIONS
• Identify what medications the patient is taking, indication,
dosage
• Analgesics
• Steroid intake
• Maintenance medications
• Side effects of the medications should be considered as
these may interfere with the treatment

39. ANCILLARY PROCEDURES
• Either rule out or confirm the presence of a
condition that result to the patient’s symptoms
• Laboratory and diagnostic test performed
• Review of available records
• Review of other clinical findings

40. OBJECTIVE EXAMINATION

41. SELF REPORTED OUTCOME MEASURES
• Four types:
• Generic
• Disease specific
• Region specific
• Patient specific

42. GENERIC
• PASS (patient acceptable symptom state): “considering all the
different ways your disease is affecting you, if you would stay in this
state for the next months, do you consider that your current state is
satisfactory?”
• SANE (single assessment numeric evaluation): “how would you
rate your shoulder today as a percentage of normal 0%to100% scale
with 100% being normal ?”
• P4: a 0-10 pain range scale. Patients asked to rate pain over the
previous 2 days in the morning, afternoon, evening, and with
activity.
• PSFS: Patient Specific Functional Scale
• GROC: Global Rating of Change (health scale)

43. PATIENT SPECIFIC FUNCTIONAL
SCALE

44. GROC

45. INFORMAL OBSERVATION
• Relative health
• Cognition
• Affect
• Postural deviation
• Gait dysfunction
• Movement dysfunction/ability to function

46. FORMAL OBSERVATION
• Posture: kypholordosis, sway back, flat back
• Muscle form: shape, bulk, tone, muscle prone to weakness and
tightness.
• Soft tissues: color, scar, swelling, effusion, sweating, shiny,
hair loss
• Gait: antalgic, gluteus maximus, Trendelenburg, short leg,
drop foot gait.
• Patient’s attitude and feelings (bio-psycho-social)

47. COMMON SCREENING EXAMINATIONS
• Upper quarter screen
• Lower quarter screen
• Falls screening

48. COMPONENTS OF THE UQS
• Active movements of upper extremity and spine with
overpressure
• Sensory screen by dermatome
• Strength screen by myotome
• Deep tendon reflexes
• Upper motor neuron signs & if there are radicular sx, sensitive
tests include:
• ULTT
• TOS

49. COMPONENTS OF THE LQS
• Active movements of lower extremity and lumbar spine with
overpressure
• Sensory screen by dermatome
• Strength screen by myotome
• Deep tendon reflexes
• Upper motor neuron signs: Babinski & if there are radicular sx,
sensitive tests include:
• Slump
• SLR

50. FALLS INSTRUMENTS
• Activities specific balance confidence(abc scale)
• Falls efficacy scale (FES)
• FES (short form (FES-1)

51. PALPATION
• Temperature
• Moist
• Edema & effusion
• Mobility and feel of superficial tissue
• Tenderness
• Trigger points

52. JOINT TESTS
• Active physiological movements
• Passive physiological movements
• Accessory movements
• Joint integrity tests (special tests)

53. CONTI…
• Physiological movements with overpressure.
• Normal end feels
• Soft tissue approximation
• Capsular/ firm
• Bone to bone/ hard
• Abnormal end feels:
• Empty feel
• Springy block
• Spasm

54. NEUROLOGICAL TESTS
• Dermatomes
• Myotomes
• Reflex testing
• Neurodynamic tests:
• PNF
• Slump
• ULNT - tests: median, ulnar, radial

55. Dermatomes of Upper Limb

56. Nerve Root Level Motor Testing
C1 – C2 Neck Flexion
C3 Lateral Flexion
C4 Shoulder Shrug
C5 Shoulder Abduction
C6 Elbow Flexion and Wrist Extension
C7 Elbow Extension and Wrist Flexion
C8 Finger Flexion and Thumb Extension
T1 Finger Abduction
MYOTOMES OF UPPER LIMB

57. Dermatomes of Lower Limb

58. MYOTOMES OF LOWER LIMB
Nerve Root Level Motor Testing
L1 – L2 Hip Flexion
L3 Knee Extension
L4 Dorsiflexion
L5 Big toe Extension, Knee flexion, Hip
Extension
S1 Planter flexion, Knee Flexion, Hip
Extension
S2 Knee Flexion

59. 45 years old male came in physical therapy OPD with complain of
right upper shoulder pain which is radiating towards the lateral side of
arm. Patient has difficulty in shoulder shrugging and also feels
numbness over the effected part.

60. 38 years old obese female came with complain of low back pain
which is radiating towards b/l mid thigh, patient having difficulty to
perform hip flexion and knee extension. Pain is severe during
walking.

61. 52 years old diabetic male came in physiotherapy OPD
with numbness on sole of foot having difficulty in ankle
inversion and knee flexion.