This document provides guidance on conducting a physical examination of the musculoskeletal system. It outlines general principles such as ensuring privacy and comfort for the patient. The objectives are to apply anatomy and physiology knowledge to differentiate normal from abnormal findings through physical assessment. Assessments should be conducted when examining bone, muscle or joint injuries, disorders, or pain. Common disorders are described. The assessment involves subjective history collection and physical examination. Key areas to examine include joints, muscles, nerves and blood vessels. Common examination techniques like inspection, palpation, and assessing range of motion are outlined for each body area. Common abnormalities that may be found and diagnostic tests are also summarized.

1. MUSCULOSKELETAL
SYSTEM
PHYSICAL EXAMINATION

2. General principles of joint
examination
 Ensure that the joints to be examined are fully exposed
and the patient is resting comfortably.
 Provide privacy
 Be sensitive to patients feeling and physical comfort

3. Objectives
 Apply knowledge of anatomy and physiology of
musculoskeletal system
 Differentiate between normal and abnormal
 Implement physical assessment

4. When to conduct Assessment
 Bone or muscle injury
 Medications to treat bone or muscle problem
 Past surgeries for muscle or bones
 Family history of bones or muscle disorders
 Pain
 Symptoms limiting your daily activities
 Frequent falling

5. Common musculoskeletal disorders
 Tendinitis
 Carpal tunnel syndrome
 Osteoarthritis
 Rhematoid arthritis
 Fibromalagia
 Bone fractures

6. Assessment of musculoskeletal
system
 Subjective Data
• History collection
 Objective Data
• Physical examination

7. Neurovascular Assessment

Assess for Note and report
• Color Pallor ,cyanosis, redness, or discoloration
• Temperature Unusual coolness or warmth
• Pain Pain that is worse on passive motion pain that no longer
responds to analgesics
• Movement Alteration in movement
• Sensation Alteration in feeling ,tingling or paresthesias
• Pulses Diminished or absent pulses
• Capillary
refill
Nailbed that does not blanch in 3 -5 seconds

8. The routine for joint examination is:
Inspection
Palpation
Movement of joint(s)

9. INSPECTION
 Observe any lack of symmetry and
any evidence of trauma or disease.
 Look for muscle wasting;
 Inspect the joint contour (shape)and observe
any evidence of swelling, deformity or inflammation
 Ask client to point to any painful areas including sites or
radiation of pain

10. INSPECTION
 BEHAVIOUR
─ Mental Status
 GENERALAPPEARANCE
− Age,Sex
− Posture
− Nutritional Status
 SKIN
− Turgor
− Texture
− Intregrity

11. − Temperature
− Erythema over joints
− Swelling
− Subcutaneous nodule
− Synovial cyst
− Tenderness
− General Hygiene
 NAILAND HAIR
 SYMMETRY

12. Palpation
 Palpate for warmth swelling and tenderness in
the areas of swelling redness and the areas where the
patient reported pain
 Hand should be warm to prevent spasm
 Both superficial and deep palpation are performed
 Usually begins from neck shoulder elbow wrist hand
back hip knees ankles and feet

13. MOVEMENTS
 Active ROM
 Passive ROM

14. The neutral position
 The range of most movements
are described with the neutral
position in mind
 In the neutral position
the limbs are extended with
the feet dorsiflexed at 90 degrees
and the forearms in mid-pronation

15. Main anatomical movements
 Adduction -movement of the part
distal to the joint towards the midline
 Abduction -movement away
from the midline

16. Main anatomical movements
 Flexion - bending of joint
away from neutral position
 Extension - movement to straighten
a joint towards the neutral position
 Hyperextension - occurs when
the joint can be extended beyond
the neutral position

17. Main anatomical movements
 Pronation - rotation of the
forearm so that the palm
faces backwards
 Supination - rotation of the
forearm so that the palm
faces forwards

18. Main anatomical movements
CIRCUMDUCTION

19. Main anatomical movements
 DORSIFLEXION
 PLANTAR FLEXION

20. Main anatomical movements
 Eversion
 Inversion

21. Main anatomical movements

22. Assessment -Gait:

23. GAIT
From behind:

24. GAIT
From side:

25. Examination of the spine
 Ask patient to undressndown to their underwear
 Inspect from the front,sides and behind ideally with patient sitting
and standing for:
• Pigmentations, abnormal hair growth or unusual skin creases
• Alignment of the neck and shoulder symmetry
• Kyphosis (thoracic spine curves giving a round shouldered or
hunched appearance)
• Lordosis (lumber spine curves pushing abdomen out, seen in
late stages of pregnancy)
• Scoliosis (thoracic and or lumbar spine curve laterally forming
a S or C shaped)

26. Inspection of spine
 Adams forward bend test :

27. Assessment of temporomandibular joint
 Inspection
 Palpation
 Muscle strength

28. Neck
 Palpation
 ROM
→Flexion
→Extension
→Lateral bending
 Muscle strength

29. Shoulder
 Inspect anteriorly: shoulder and
shoulder girdle
Posteriorly : scapula and muscles
 Inspect the shoulder contour
 Feel for tenderness and swelling,
redness and crepitus during motion
 Flexion -180 degrees
 Extension -approx. 65 degrees

30. Shoulder
Palpation:
 Clavicle
Tenderness of sternoclavicular joint , acromioclavicular joint greater tubercle
of humerus
 Glenohumeral joint (ball and socket joint)
 Scapula
 Acromioclavicular joint
 Glenohumeral joint
 sternoclavicular joint
 Scapulothoracic joint

31. Shoulder Movement
*Flexion * Abduction
*Extension * Adduction
*Internal rotation * External rotation

32. Shoulder movements
 Adduction -movement of the
distal part of the joint towards
the midline
 Abduction –movement
away from the midline

33. Shoulder movements
 Internal rotation -involves
moving the flexed forearm
across the front of the body.
The movement is limited by the
chest wall
 External rotation - the flexed
forearm is moved outwards

34. Elbow
 Inspection :
 Olecranon process for any tenderness or swelling
 Displacemnt of olecranon process
 ROM:
 Flexion
 Extension
 Pronation
 Supination
 Muscle strenghth

35. Wrist and hands
Inspection
 No redness or swelling
 No wrinkles
Palpation
 Palpate metacarpophalangeal joints
 Palpate interphallangeal joints

36. Interphalangeal joints
 Palpate the interphalangeal
joints individually between
finger and thumb
 DIP = distal interphalangeal
joint
 PIP = proximal
interphalangeal joint

37. Metacarpo-phalangeal joints
 Use a similar technique
to palpate metacarpo-phalangeal
joints
 With patient palms facing
down, support palms with fingers
 place thumbs on dorsal
metacarpo-phalangeal surface
and gently palpate

38. Finger movements
 Ask the patient to make a fist
(flexion of distal and proximal
interphalangeal and metocarpophalangeal joints)
 Then ask the patient to open their hand
(extension of interphalangeal and
metocarpophalangeal joints)
 Abduction, ask the patient to spread
their fingers apart.
 Adduction: ask them to put them back together.

39. Thumb flexion and extension
 Movement of flexion occurs
across the palm
 Extension takes the thumb
away from the lateral aspect
of the palm
 Occurs at the MCP joint
(Metacarpo-phalangeal joint)

40. Thumb abduction and adduction
 Abduction occurs at 90° to the palm
 Adduction returns the thumb
to the palm
 Occurs at CMC jointcarpo-metacarpal
joint

41. Thumb opposition
 The thumb is used to
touch the base of the little
finger
 This movement is important
for fine manipulative skills

42.  PHALEN’S TEST
Phalen's Test is also known a Wrist
Flexion Test and is an
orthopedic special test used to help
diagnose injury to the median nerve
in the wrist especially as it relates to
the carpal tunnel
 TINELS SIGN
A way to detect irritated nerves.
It is performed by lightly tapping
(percussing) over the nerve
to elicit a sensation of tingling
or "pins and needles" in the
distribution of the nerve

43. Movements of the spine
 Flexion
 Extension
 Lateral Flexion right and left
 Lateral Rotation right and left

44. Cervical spine movements

45. Cervical spine movements
 Lateral flexion - ask the patient
to touch their ears to their shoulders,
without raising the shoulders.
Normal approx. 45 degrees

46. Cervical spine movements
 Flexion -ask the patient to touch
their chin to their chest –normal
about 45 degrees
 Extension -ask the patient
to look upwards and back -normal
about 45 degrees

47. Cervical spine movements
 Rotation - ask the patient
to look back over each shoulder
in turn - normal approx. 70 degrees

48. Hip
 Inspection:
 Scars
 Asymmetry
 Pelvic tilt
 Leg length discrepancy
 Foot deformity
 Palpation

49. Movement of the Hip Joint
*Flexion * Abduction
*Extension *Adduction
*Internal and external rotation

50. Hip movements -flexion and extension
 Flexion-with the patient
lying supine and the knee flexed
passively flex the hip joint -normal
approx. 115 degrees
 Extension-with the patient
lying prone, support the knee and
with a hand on the buttock passively
extend the joint (normal approx. 30 degrees)

51. Hip movements -abduction and
adduction
 Abduction -normal approx. 45 degrees
 Adduction -judged by carrying
limb immediately in front of
other -normal approx. 30 degrees

52.  The person flexes the knee and hip
 The knee is held in one hand
and the foot in the other
 External rotation is achieved
by passively moving the foot
medially (normal approx. 45 degrees)
 Internal rotation is tested
by moving the foot laterally
(normal approx. 45 degrees
Hip movements -rotation

53. Thomas test
 Used to rule out hip
flexion contracture.

54. Inspection and palpation of the knee
 Inspect, comparing knees with patient supine
 Swellings may be detected by a loss of the medial and or lateral
dimples suggestive of an effusion
 Palpate for:
 presence / absence of patella and its mobility
 collateral ligaments
 the joint line for tenderness

55. Movements of knee
 Flexion
 Extension
 Hyperextension
 Lateral and medial collateral ligaments
 Anterior and posterior cruciate ligaments

56. Knee movements
 Flexion:The knee is flexed
with one hand resting on
the patella -normal
approx. 135 degrees
 Extension:The leg is
straightened to its fullest
extent -normal 5 degrees of
hyperextension

57. Movement of the ankle and foot
 Ankle
• Dorsiflexion
• flexion
• Inversion
• Eversion
 Toes
• Extension
• Flexion
• Abduction and adduction

58. Dorsiflexion and plantar flexion
 Ask the person to bend
their foot down into plantar
flexion -normal approx. 50 degrees
 Ask the person to bend
the foot upwards into
dorsiflexion –normal
approx. 20 degrees

59. Eversion and Inversion
 Isolate the heel by holding
it firmly
 Attempt inversion and
eversion by twisting the
mid-foot medially and laterally.

60. Muscle Strength scale
0 No detection of muscular contraction
1 A barely detectable flicker or trace of contraction
with observation or palpation
2 Active movement of body part with elimination of
gravity.
3 Active movement against gravity only and not
against resistance
4 Active movement against gravity & some
resistance
5 Active movement against full resistance without
evident fatigue (Normal muscle strength)

61. Common assessment abnormality
FINDINGS DESCRIPTION
• Ankylosis Abnormal stiffening and immobility of a joint
due to fusion of the bones
• Atrophy Gradually decline in effectiveness or vigour
due to underuse or neglect
• Contracture A condition of shortening and hardening of
muscles, tendons, or other tissue, often
leading to deformity and rigidity of joints.
• Pen planus Technical term for flatfoot.
• Crepitation A crackling sound or grating sensation as a
result of friction between bones

62. Common assessment abnormality
FINDINGS DESCRIPTION
• Effusion Escape of fluid into body part possibly with
swelling and pain
• Hypertrophy The enlargement of an organ or tissue from
the increase in size of its cells
• Kyphosis Excessive outward curvature of the spine,
causing hunching of the back.
• Lordosis Excessive inward curvature of the spine
• Scoliosis Abnormal lateral curvature of the spine.

63. Common assessment abnormality
FINDINGS DESCRIPTION
• Archiles
tendon
Achilles tendinitis is a common condition that causes
pain along the back of the leg near the heel.
• Dislocation Bone is displaced from its normal joint
• Ganglion
cyst
Fluid filled bump or mass over over a tendon sheath or
joint usually on dorsal surface of foot or wrist
• Lateral
epidondylytis
(tennis elbow)
Dull ache along outer aspect of elbow .Worsens with
twisting and grasping motions
• Myalgia General muscle tenderness and pain

64. Common assessment abnormality
FINDINGS DESCRIPTION
• Paresthesia Numbness or tingling sensation
• Plantar
fascitis
Burning sharp pain on the sole of foot
• Subluxation Partial dislocation of joint
• torticollis Neck is twisted in unusual position to one
side
• Valgum
deformity
(knock- knees)
When knees are together and there is more
than 1 inch (2.5cm)b/w medial malleoli
• Varum
deformity
(Bowlegs)
When knees are apart and the medial
malleoli are together space of more than
one inch (2.5cm)exists

65. Diagnostic Test
 Radiography(X-Ray)

66. ARTHROSCOPY

67. Athrocentesis

68. Arthrogram

69. MRI
 MRI scans are excellent for showing
up soft tissue such as ligaments and
tendons in joints. This is an MRI scan of
a knee

70. Electromyography(EMG)

71. Bone Sonometer

72. Bone scan

73. CT
 CT scan of sternoclavicular joints shows a needle in the right
sternoclavicularjoint while taking sample

74. Thank You