Musculoskeletal Assessment

 Patient history and screening of red flag

Cancer  Constant pain at night
 Abnormal weight loss
 Loss of appetite
Cardiovascular  Shortness of breath
 Dizziness
 Pain and heaviness in the chest
 Ankle edema
Gastrointestinal  Frequent and severe abdominal pain
 Frequent heartburn and indigestion
 Frequent nausea and vomiting
Genitourinary  Problem with bowel and bladder function
Neurological  Change in vision, hearing, and speech
 Problem with balance and coordination
 Frequent and severe headache
 Drop attack
Miscellaneous  Fever
 Severe emotional disturbance
 Observation
 Palpation
 AROM and PROM
 Resisted isometric movement
 Passive accessory movement
 Neurological examination
 Special tests

Patient History
Patient’s age and sex
 Younger patient: muscle weakness or injury
 Older patient: degeneration
History of present illness (HPI)
 Chief complaint: pain and functional limitation (+/- pins and needles)
 Severity: Numerical Pain Rating Scale (NPRS)
 Area: location of pain
 Nature: dull ache, sharp and burning, diffuse
 Depth: superficial or deep
 Constancy: constant or intermittent
 Mechanism of injury: magnitude and direction of the injury force
 Onset: sudden or insidious
Manifestation of pain
 Severe: unable to move in a certain direction and hold a particular posture
 Irritable: progressively worse with movement and sustained posture
 Acute (0-10 days): severe and irritable, peripheral sensitization of nociceptors
 Chronic (>7 weeks): less severe, central sensitization of nociceptors
 Acute on chronic: acute exacerbation of a chronic condition
 Referred pain: radiated segmentally without crossing midline
Aggravating and easing factors
 Pain-provoking movement: do the movement last to avoid an overflow of pain
 Change in pain level
 How long does it take for the pain to subside
Musculoskeletal Pain Systemic Pain
 Generally lessen at night  Disturb sleep
 Sharp and superficial  Deep aching pain
 Aggravated by mechanical load  Not aggravated by mechanical load
 Reduced by rest  Reduced by pressure
 Associated with the following:
 Jaundice
 Skin rash
 Fatigue
 Weight loss
 Low-grade fever
Behavior of symptoms
 Pain on activity: mechanical problem
 Morning pain and stiffness: chronic inflammation
 Pain not affected by rest: systemic disorder
 Night pain: position of patient (supine, side-lying, prone)
 Intractable night pain: tumor
 Burning night pain: peripheral nerve entrapment
History of past injury
 Location and severity of the injury
 Treatment received
 Injury to other part of the kinetic chain
Progression of condition
 Change in intensity and frequency of pain
Neurological symptoms
 Bilateral spinal cord symptoms and drop attack: CNS problem
 Vertigo: cervical problem
 Saddle anesthesia: cauda equina syndrome
Past medical history (PMH)
 General health: hypertension (HT), hyperlipidemia, diabetes (DM)
 History of surgery
 Medication
 Long-term Steroid: osteoporosis
 Aspirin: increase chance of bleeding and bruising
Social history (SHx)
 Living environment and lifestyle
 Patient’s occupation: habitual posture and repetitive strain

Observation
Body alignment
 Anterior view: nose, xiphisternum, umbilicus in a straight line
 Lateral view: tip of the ear, acromion, highest point of iliac crest, anterior part of
lateral malleolus in a straight line
Deformity
 Malalignment
 Alteration of bone shape: fracture
 Alteration in articulating structure: subluxation and dislocation
Symmetry of bony contours and soft tissue contours
 Bony landmark and muscle bulk
Pelvic position
 ASIS 2-finger widths lower than PSIS
 Pelvic control while doing dynamic movement
Color and texture of skin
 Redness: acute inflammation
 Ecchymosis and bruising: bleeding
 Trophic changes (loss of skin elasticity and shiny skin): peripheral nerve lesion
 Cyanosis: poor blood perfusion

Palpation
Temperature: acute inflammation
Moisture of the skin
 Acute gouty joint: dry
 Septic joint: moist
Tenderness
Muscle spasm
Edema: abnormal accumulation of fluid in intercellular space
 Pitting edema: indentation after pressure is applied and removed
Sensation: hyperesthesia, dysesthesia, aesthesia

Principle of Examination
Test normal side first: establish a baseline of normal movement
 AROM  PROM  Overpressure at EOR if full PROM  Sustained movement
 PROM and ligamentous test: quality of movement (end feel)
 Resisted isometric movement: performed in neutral position

Vital Signs
Blood pressure (BP): 120/80 mmHg
 Hypertension: SBP>130 mmHg or DBP>80 mmHg
 Hypertensive crisis: SBP>180 mmHg or DBP>120 mmHg
Pulse (P): 60-100 bpm
 Tachycardia: >100 bpm
 Bradycardia: <60 bpm
Temperature (Temp): 35.7-37.5 °C
Respiratory rate (RR): 12-16

AROM and PROM

AROM
 When and where the onset of pain occurs (intensity of pain)
 Patient’s movement pattern
 Patient’s willingness to move the affected joint
PROM
 When and where the onset of pain occurs (intensity of pain)
 End-feel of movement: bone-to-bone, tissue approximation, tissue stretch
 ROM available

Resisted Isometric Movement

Isometric: focus on contractile tissues and exclude inert tissues
 If pain and weakness: concentric and eccentric movement (Graded by MMT)
Postural muscle (prone to tightness) Phasic muscle (prone to weakness)
 Iliopsoas  Gluteus
 Rectus femoris  Vastus medialis and lateralis
 Short hip adductors  Rectus abdominis
 Hamstrings  Rhomboids
 Gastrocnemius and Soleus  Deep neck flexors
 Erector spinae
 Pectoralis major
 Upper Trapezius
 Levator scapulae

Passive Accessory Movement

Joint in resting position: reduce joint surface contact area and minimize friction
 Very subtle movement: less than 4mm

Neurological Examination
Sensory distribution: dermatome (nerve root) and peripheral nerve innervation
Motor distribution: myotome (nerve root) and peripheral nerve innervation
Reflex: deep tendon reflex and pathological reflex
Neurodynamic test
 ULTT, straight leg raise, slump test, prone knee bend
Neuropraxia  Damage to myelin sheath
 No Wallerian degeneration: axon is intact
Axonotmesis  Wallerian degeneration: axon distal to injury site degenerates
Neurotmesis  Complete rupture of axon and endoneurium

Scanning Examination
Spinal assessment: AROM, PROM, resisted isometric movement
 Scan peripheral joint, myotome, dermatome
 If confirmed spinal problem: special test, joint play, palpation
Peripheral assessment: AROM, PROM, resisted isometric movement
 Scan spinal joint
 If confirmed peripheral problem: special test, reflex, joint play, palpation

Special Test
 Sensitivity: identify people who have a particular condition (true +ve)
 Specificity: determine people who do not have a particular condition (true -ve)

Patient History
Patient’s age and sex
 Frozen shoulder (Adhesive capsulitis): >45 yo
 Primary impingement: >35 yo
 Caused by structural changes resulting in narrowing of subacromial space
 Secondary impingement: <20 yo
 Caused by weakness of scapular muscles resulting in shoulder instability
History of present illness (HPI)
 Mechanism of injury
 Fall on outstretched hand: fracture-dislocation of GH joint
 Land on elbow: dislocation of AC joint
 Chief complaint
 Shoulder feeling unstable during movement: shoulder instability
 Pain during ER: anterior instability of GH joint
 Pain during Abd: shoulder impingement, scapular dyskinesia
 Weakness and heaviness in upper limb: vascular involvement
Aggravating and easing factors
 Overuse: paratenonitis and tendinosis
 Paratenonitis: inflammation of paratenon where a tendon rubs over bone
 Tendinosis: degeneration of tendon caused by chronic overuse
 Elevation relieves symptoms: nerve problem

Observation
Body alignment
 Forward head posture and rounded shoulder
 Tightness of pectorals, upper trapezius, levator scapulae
 Weakness of rhomboids, deep neck flexors
 Malpositioning of scapula: spine of scapula (T3) and inferior angle (T7)
 Weakness of serratus anterior, rhomboids, lower trapezius
Deformity
 Step deformity: lateral end of clavicle dislocated superior to acromion
 Torn AC ligament and coracoclavicular ligament
 Sulcus deformity: sulcus below acromion
 Inferior subluxation of GH joint caused by rotator cuff weakness
Symmetry of bony contours and soft tissue contours
 Flattened deltoid contour around deltoid tuberosity
 Anterior dislocation of GH joint
 Atrophy of upper trapezius
 Spinal accessory nerve palsy
 Atrophy of supraspinatus and infraspinatus
 Supraspinous nerve palsy
Palpation

AROM and PROM

Shoulder flexion (160-180°/tissue stretch)
Shoulder scaption (170-180°/tissue stretch)
Shoulder abduction (170-180°/tissue stretch)
 Painful arc: 60-120°
 Caused by subacromial bursitis, paratenonitis and tendinosis of rotator cuff
 Painful arc: 170-180°
 Caused by AC joint problem
 Scapulohumeral rhythm (1:2)
30° abduction Humerus 30° abduction
Scapula Minimal movement
Clavicle 5° elevation
30-90° abduction Humerus 40° abduction
Scapula 20° upward rotation
Clavicle 15° elevation
90-180° abduction Humerus 60° abduction and 90° lateral rotation
Scapula 30° upward rotation
Clavicle 15° elevation and 30-50° posterior rotation
 Reverse scapulohumeral rhythm: scapula moves more than humerus
 Caused by Frozen shoulder
 Excessive shoulder external rotation during abduction
 Caused weakness of deltoid and supraspinatus: biceps assists abduction
Shoulder internal rotation (60-100°/tissue stretch)
 Scapula winging and excessive protraction of scapula
 Caused by tightness of posterior capsule
 Abrasion sign: crepitus on rotation when shoulder is in 90° abduction
 Caused by abrasion of rotator cuff tendon against coracoacromial arch
 Glenohumeral internal rotation deficit (GIRD)
 Compared with glenohumeral external rotation gain (GERG)
 GIRD/GERG>1: shoulder problem
Shoulder external rotation (80-90°/tissue stretch)
 Excessive retraction of scapula
 Caused by frozen shoulder
 Abrasion sign: crepitus on rotation when shoulder is in 90° abduction
 Caused by abrasion of rotator cuff tendon against coracoacromial arch
Shoulder horizontal adduction with scapula protraction (130°/tissue approximation)
 Excessive protraction of scapula
 Caused by tightness of pectoralis minor
 Caused by weakness of lower trapezius and serratus anterior
Shoulder horizontal abduction with scapula retraction (45°/tissue stretch)
 Excessive retraction of scapula
  Caused by weakness of lower trapezius and serratus anterior

Resisted Isometric Movement

Passive Accessory Movement

Neurological Examination

Special Test

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Shoulder Anatomy

 Glenohumeral joint (GH joint): multiaxial ball-and-socket synovial joint

 Glenoid labrum: deepen the glenoid cavity
 Mainly depend on muscles and ligaments for stability
 Capsular pattern: ER>Abd>IR

Superior GH ligament  Limit inferior translation in Add

 Limit ER up to 45° Abd
Middle GH ligament  Limit ER between 45-90° Abd
Inferior GH ligament  Support humeral head above 90° Abd
Coracohumeral ligament  Limit inferior translation
 Limit ER up to 60° Abd
 Coracoacromial ligament  Limit superior translation

 Acromioclavicular joint (AC joint): plane synovial joint

 Capsular pattern: pain at extreme horizontal Add and elevation
AC ligament  Limit horizontal movement of clavicle
Coracoclavicular ligament  Limit vertical movement of clavicle
 Sternoclavicular joint (SC joint): saddle-shaped synovial joint
 Capsular pattern: pain at extreme horizontal Add and elevation
Anterior SC ligament  Support SC joint
Posterior SC ligament  Support SC joint
Interclavicular ligament  Support SC joint
Costoclavicular ligament  Maintain the integrity of SC joint

 Scapulothoracic joint (ST joint): stabilize the scapula

 Scapular muscles have to be strong to control UL movement