Dpt

1. By: Dr. Ayesha Anwer Ali

2.  Purpose of the Musculoskeletal Examination
 Examination Procedures
a) Patient History
b) Mental status
c) Vital signs
d) Observation/Inspection
e) Palpation
f) Anthropometric Characteristics
g) Range of Motion
h) Accessory Joint Motions
i) Muscle Performance
j) Special Tests
k) Additional Tests and Measures

3.  The musculoskeletal system includes bones; muscles with their
related tendons and synovial sheaths; bursa; and joint structures
such as cartilage, menisci, capsules, and ligaments.
 Acute injuries or chronic conditions of the musculoskeletal system
can greatly affect function by causing direct impairments such as
pain, inflammation, swelling, structural deformity, restricted joint
movement, joint instability, and muscle weakness.

4.  Examples of diagnoses that result in direct impairment of the
musculoskeletal system include fracture, rheumatoid arthritis (RA) and
other systemic diseases, osteoarthritis, (OA), joint dislocation, tendinitis,
bursitis, muscle strain/rupture, and ligament sprain/rupture.
 In addition to primary musculoskeletal impairments, many pathological
conditions that initially affect other body systems such as the neurological,
cardiovascular, or pulmonary systems, can result in secondary or indirect
impairment of the musculoskeletal system.
 Both direct and indirect musculoskeletal impairments can contribute to
activity limitations, participation restrictions, and disability that affect a
patient’s ability to perform certain tasks and roles in society.

5. PURPOSE OF MSK EXAMINATION
 Evaluation of data from the musculoskeletal examination
contributes to establishing a diagnosis and prognosis, setting
anticipated goals and expected outcomes, and developing and
implementing a plan of care (POC).

6.  The purposes of performing a musculoskeletal examination include the
following:
 To determine the presence and extent of impairments, activity limitations,
and disability involving muscles, bones, and related joint structures.
 To identify the specific tissues and pathology causing/contributing to the
impairment, activity limitation, or disability when possible.
 To establish objective baseline status that will be used to measure progress.
 To formulate appropriate goals, expected outcomes, and POC.
 To evaluate the effectiveness of rehabilitation, medical, or surgical
management.
 To identify risk factors to prevent the development or worsening of
impairments, activity limitations, or disabilities.

7.  To evaluate the effectiveness of rehabilitation, medical, or surgical
management.
 To identify risk factors to prevent the development or worsening of
impairments, activity limitations, or disabilities.
 To determine the need for orthotic and adaptive equipment necessary
for functional performance of activities of daily living (ADL),
occupational, and /or recreational activities.
 To motivate the patient.

8.  Patient History & Interview
 Before beginning the physical examination, it is important to gain as
much as information as possible about the patients current condition and
PMH.
 A thorough understanding of the patients medical background is critical
for selection of safe application of examination and treatment procedures.
 For example: History of MI would cause the therapist to limit and more
closely monitor the patient during muscle performance testing.

9.  A history of diabetes mellitus (DM) would cause the therapist to suspect
and test for potentially compromised peripheral vascular and peripheral
nervous systems, to avoid the use of heat modalities during treatment.
 Verbally reviewing the information with the patient may jog the patients
memory.
 Ideally, the patient interview should be conducted in a quiet, well-lit room
that offers a measure of privacy.

10.  To encourage good communication, the therapist and patient should be at
a similar eye level, facing each other, with a comfortable space between
them- about 3 feet apart is customary in the united states.
 Patients age and gender should be noted; some conditions are more
common in particular age groups and genders.
 Open-ended, objective questions that do not promote biased answers
should be used. For example , instead of asking “Is your right knee
Painful?” The therapist should ask, “Where are your symptoms located?”

11. • Opening questions
• Onset of symptoms
• Location of symptoms
• Quality of symptoms
• Behavior of symptoms
• Behavior of symptoms during last 48 hours
• Previous care of this problem
• Specific medical history
• General medical history
• Medications
• SH and Occupational, Recreational , and Functional status
• Anticipated goals, Expected outcomes, and Time frame of recovery
• Concluding Question

12. oWhat brings you to physical therapy today?
o What seems to be the problem?
oIf the patient is hospitalized, avoid having the patient retell the medical
history to every health care provider.
oThe patient should be given opportunity to present the story

13. Ask the patient , how did this pain (swelling, limitation, problem, etc.)
begin??
If the onset was SUDDEN: (e.g., caused by trauma such as fall, blow, skiing or
motor vehicle accident).
If the onset was more gradual or insidious, a systemic condition or Chronic
biomechanical problem may be more likely.
A congenital onset is also a possibility.

14.  Where is your pain? Can you point the location ?
Superficial/Deep/ Referred
A body chart can be used to help identify and document the specific
location of symptoms .
Often the lesion of symptoms coincides with the location of the lesion.
This is more likely if the lesion is in superficial and distal tissue.
For example: A lesion in a superficial tendon near the ankle will
usually cause pain over the tendon site.

15.  Lesions in deeper or more proximal tissue can refer pain distally
following sclerotome or dermatome pattern.
 Referred pain may be perceived as originating from any or all tissues
innervated by the same segmental spinal level in which the lesion is
located.
 For example: pain due to OA of the hip is often felt in the anterior
groin and thigh along the sclerotomes or dermatomes for L2 & L3.

16.  “Has the pain changed in location? Spread to other areas?
Become more focused?”
 Pain that is spreading usually indicates a worsening
condition, whereas more focused symptoms indicates
improvement.
 Changes in symptoms in relationship to varying body
positions, activities, and treatments should be noted.

17.  Refers to the muscles served by the spinal nerve root.
OR
 Set of muscles innervated by a specific, single spinal nerve.

19.  How severe is the pain?
 Is the pain sharp? Dull? Or throbbing?
 An effective way to ask the patient to rate his or her pain from 0 (no pain)
to 10 (most severe pain imaginable).
 Two types of numerical pain rating scales:
1. Visual analogue scale
2. Thermometer pain scale

21.  Dull, aching pain may indicate muscle or joint lesions.
 Numbness, tingling, shooting pain, or burning sensations may indicate
nervous system involvement.
 Deep, throbbing pain or coolness in a body may indicate vascular
problems.
 Weakness, clumsiness or in-coordination may suggest muscle and possibly
peripheral or central nervous system dysfunction.

22.  What makes your symptoms “increase’’ or “decrease”?
 Symptoms from musculoskeletal conditions typically vary in response to
rest, activity, and body positions that either increase or decrease
mechanical stress placed on the involved tissue.
 The BOS helps to establish a diagnosis & determine which treatment
techniques are more likely to be effective.
 For example: pain from overuse syndromes such as tendonitis will
decrease with rest, where as joint stiffness caused by OA often increase
following rest.

23.  If the patient reports that the sitting position reduces back
pain, then the therapist will probably have more success in
relieving of pain using back flexion exercises rather than
extension exercises.
 Behavior of symptoms during last 48 hours?

24.  What previous care has been sought for the problem?
 Who else (e.g., physician, therapist, athletic trainer, chiropractor) has
treated the problem?
 What test treatments did they perform?
 What have you done to relieve the problem?
 From these similar questions, all previous exercises, physical modalities,
manual treatments, medications, orthotics and surgical procedures
should be delineated.
 Answers to these questions help the therapist decide if further medical
referrals are needed, & focus on the most effective treatment for
condition.

25.  For example: a patient who fell 3 days ago is experiencing severe ankle
pain & swelling, the pt borrowed a friend’s crutches & has been self-
treating the ankle with ice and elevation.
 The therapist would recommend that the patient be examined by a
physician & have radiographs taken to rule out fracture before physical
therapy interventions.

26.  A brief history should be obtained.
 Conditions involving the cardiac, respiratory, neurological, vascular,
metabolic, endocrine, gastrointestinal, genital urinary, visual &
dermatological systems should be noted.
 Therapist needs to be aware of other conditions that mimic signs and
symptoms often attributable to the musculoskeletal system.
 For example: inflammation of the gallbladder (cholecystitis) may result in
right shoulder pain.

27.  The type, frequency, dose, and effect of medications the patient is taking
should be noted.
 The use of NSAIDs may reduce the intensity of symptoms at the time of
the examination.
 The secondary effects of some medications may necessitate the
modification of examination and treatment techniques.
 For example: prolonged use of corticosteroids is associated with
osteopenia (reduced bone mass) and reduce tensile strength of ligaments.
The therapist need to limit manual force applied through the lever of
long bones to prevent fracture or ligament tear.
 The use of anticoaguants may make the patient susceptible to contusions
and hemarthrosis.
 Such patients should be closely monitored for bruising & joint swelling.

28.  When the therapist has finished obtaining the above information, one
final type of open ended question needs to be asked:
 “Is there anything else you think I should know concerning your condition
that I have not asked about”?
 Without this type of questions at the conclusion of Interview, important
information that may affect treatment and recovery may be lost.

29.  During the interview, patient’s orientation to person, place and time as
well as general arousal state and cognitive and communication abilities
should be noted.
 If deficits in these areas are present, the examination may need to be
modified to gain accurate information.
 Communication difficulties may be overcome through the use of foreign
language interpreter, gestures, drawings, & language boards.
 Changes inn medications, upright positioning, and access to natural light
via windows and skylight may improve patient arousal and orientation to
time.

30.  If patients medical record or interview suggest a compromised
cardiovascular system, then the HR, RR, BP should be determined before
beginning other examination procedures.
 Patients who are getting out of bed for the first time following recent
surgery or prolonged bed rest should routinely have vital signs taken to
establish baseline values before movement.

32.  Observation begins with the therapist’s first contact with the patient,
whether at the bedside in case of hospitalized patients or in the waiting
room for the outpatients.
 To perform Physical Examination and inspect specific areas of the body,
the patient must be suitably dressed.
 Visual inspection should focus on bone, soft tissue structures, skin, and
nails.
 The therapist should view the body region anteriorly, posteriorly, and
Laterally.

33.  Bone shafts and joints are judged against normative models for symmetry,
comparing one side of the body to the other. Contour and alignment
should be considered.
 Common causes of changes in bone contour include:
 Acute fractures,
 Callus formation
 Bone angulations owing to healed fractures,
 Congenital variations
 Bone hyperplasia at tendon insertions
 Arthritis
 Alignment differences can be due to the above conditions as well as
muscle and soft tissue tightness, muscle weakness, muscle and ligament
laxity, and joint dislocation.

34.  For patients with musculoskeletal involvement, an examination for postural
alignment is often indicated.
 From an anterior view both eyes, shoulders (acromion processes), iliac
crests, anterior superior iliac spines, greater trochanters of the femur,
patellae, and ankle medial malleoli should be horizontally level. Waist angles
should be symmetrical. Patellae and feet should face anteriorly.
 Laterally the line of gravity should bisect the external auditory meatus,
acromion process, greater trochanter, lie just posterior to the patella and
approximately 2 inches (5 centimeters) anterior to the lateral malleolus.

36.  The cervical and lumbar spine should exhibit normal lordotic curves, and
the thoracic spine a normal kyphotic curve.
 From a posterior view the ear lobes, shoulders, inferior angles of the
scapula, iliac crests, posterior superior iliac spines, greater trochanters,
buttock and knee creases, and malleoli should be level.
 The spine should be straight, with the medial borders of the scapula
equidistant from the spine bilaterally.
 Varus and valgus deformities of the knee and calcaneus should be noted.

39.  The size and contour of soft tissue structures should be inspected and
compared bilaterally.
 An increase in size may indicate soft tissue edema, joint effusion, or
muscle hypertrophy.
 A decrease in size often indicates muscle atrophy.
 A loss of soft tissue continuity can suggest a muscle rupture.
 Cysts, rheumatoid nodules, ganglia, and gouty tophi can all change soft
tissue contour.

41.  Clubbing
 Cyanosis
 Pallor
 Erythema
 Callus Formation

42.  Palpation immediately follow or be integrated with observation and occur
before other testing procedures.
 Palpation requires detailed knowledge of anatomy and a
systematicapproach.
 Bone
 Soft tissue structures
 Myofascial mobility
 Skin temprature
 Edema (pitting or non pitting)
 Muscle spasm or adhesions
 All structures on one body surface should be palpated before proceeding
to another surface.

44.  The uninvolved side is palpated first to acquaint the patient with the
procedure and, in some cases, to serve as a normative model for
comparison.
 Usually the fingertips are used for palpation, but large, deeper structures
such as the greater trochanter of the femur or borders of the scapula are
easier to locate using the entire surface of the hand.
 Rolling the skin and soft tissue between the fingertips and thumb helps
the therapist judge myofascial mobility.
 Changes in skin temperature may be easier to detect using the posterior
surface of the therapist’s hand

45.  During palpation the therapist seeks feedback from the patient to help
localize painful structure.
 Often muscle spasms and adhesions in skin and connective tissue can be
found with palpation.

46.  Abnormalities noted during observation and palpation may be further
documented with anthropometric measurements.
 Using a cloth or flexible plastic tape measure, limb lengths are measured
from one bony landmark to another and compared bilaterally.
 For example, true leg length is commonly measured from the anterior
superior iliac spine to the medial malleolus.
 Circumferential measurements help substantiate joint effusion, edema,
and muscle hypertrophy and atrophy.

47. Included both AROM &PROM.
 Demonstrate and instruct the patient.
 The patient is asked to move a body part through the osteokinematic
motions at the involved and other biomechanically related joints.
 Active motion is a good musculoskeletal screening procedure to further
focus the physical examination.
 The amount, quality, and pattern of motion, as well as the occurrence of
pain and crepitus, should be noted.

48.  Capsule, ligament, muscle and soft tissue tightness, joint surface
abnormalities, and muscle weakness are all capable of causing limitations
in AROM.
 Pain during AROM may be due to:
 Muscles, tendons, and their attachments to bone,
 Due to the stretching
 Pinching of non-contractile tissues such as ligaments, joint capsules, and
bursa.

49.  Normally, PROM is slightly greater than AROM.
 Limitations in PROM may be due to bone or joint abnormalities or
tightness of soft tissue structures.
 Check joint hyper mobility & hypomobility.
 End feel
 In the clinical setting, PROM is usually measured with
 Universal goniometer
 Inclinometers
 Tape measures
 Flexible rulers.

50.  The end of each motion at each joint is limited from further movement by
particular anatomical structures.
 The type of structure that limits a joint motion has a characteristic feel,
which may be detected by the therapist performing the passive ROM.

 This feeling, which is experienced by the therapist as resistance, or a
barrier to further motion, is called the end-feel.

51.  Normal end-feels are generally described as soft, firm, or hard.
 A soft end-feel has a gradual increase in resistance as muscle, skin, and
subcutaneous tissues are compressed between body parts.
 A firm end-feel has a more abrupt increase in resistance as compared to a
soft end-feel.
 Firm end-feels include varying amounts of creep, or give, depending on
whether the barrier to the end of the motion is the stretching of muscle,
capsule, or ligamentous tissue.
 A hard end-feel is abrupt; there is an immediate stop to movement as
when bone contacts bone.

52.  End-feels are considered to be abnormal when they occur sooner or later
in the ROM than is typical, or if they are not the type of end-feel that is
normally found for that joint motion.
 Abnormal end-feels have been associated with more pain than normal
end-feels.
 Abnormal end-feels are:
 Soft
 Firm
 Hard
 Empty

53.  Cyriax initially described characteristic patterns of restricted joint ROM
due to diffuse, intra-articular inflammation involving the entire joint
capsule.
 These patterns of restricted motion, which usually involve multiple
motions at a joint, are called capsular patterns.
 Capsular patterns are due to one of two general situations:
(1) joint effusion or synovial inflammation or
(2) relative capsular fibrosis

54.  Pain triggered by stretching the capsule, and muscle spasms that protect
the capsule from further stretch, inhibit movement and cause a capsular
pattern of restricted motion.
 To plan an effective treatment, the therapist must determine whether the
capsular pattern is caused by joint effusion/synovial inflammation or
capsular fibrosis.
 If joint effusion or synovial inflammation is present, treatment methods
typically focus on resolving the acute
 inflammation with rest, cold modalities, compression, elevation, joint
mobilization using grade 1 sustained and grade 1 and 2 oscillations, gentle
ROM exercise, and anti-inflammatory medications.

55.  Capsular fibrosis, a more chronic condition, can be treated with heat
modalities, joint mobilization using grade 3 sustained stretch and grade 3
and 4 oscillations, passive stretching procedures, and more vigorous ROM
exercises.

56.  Restricted passive ROM that is not proportioned similarly to a capsular
pattern is called a noncapsular pattern of restricted motion.
 Noncapsular patterns usually involve only one or two motions of a joint,
in contrast to capsular patterns, which involve all or most motions of a
joint.
 Noncapsular patterns are caused by conditions involving structures other
than the entire joint capsule.
 Internal joint derangement, adhesion of a part of a joint capsule, and
extracapsular lesions such as ligament shortness, muscle strain, and
muscle shortness are examples of conditions that can result in
noncapsular patterns.

57.  For example, shortness of the ilio-psoas muscle will result in the non-
capsular pattern of limited passive hip extension; the passive range of
other hip motions will not be affected.
 This is in contrast to the capsular pattern of the hip caused by diffuse joint
effusion or capsular fibrosis, in which there is loss of passive internal
rotation, flexion, and abduction.

58.  If passive ROM is found to be limited or painful, an examination of arthro-
kinematic motions in indicated.
 Arthro-kinematics refers to the motion of joint surfaces.
 These motions, often called accessory or joint play motions, are used to
determine joint mobility and integrity.
 Accessory joint motions are typically described as slides (or glides), spins,
and rolls.
 Accessory motions are assigned a joint play mobility grade of 0 to 6.
 These mobility grades have implications for treatment.

59.  Muscle performance is the ability of a muscle to do work.
 Muscle power is work produced per unit of time, or the product of
strength and speed.
 Muscle endurance is the ability of the muscle to contract repeatedly over
time.

60.  Usually during a musculoskeletal examination, a component of muscle
performance—muscle strength—is tested.
 Muscle strength, as described in the Guide to Physical therapist Practice
is the force exerted by a muscle or group of muscles to overcome a
resistance in one maximal effort.
 Clinical methods of determining muscle strength include manual muscle
testing (MMT), handheld dynamometry, and isokinetic dynamometry.