Musculoskeletal Assessment

Overview
⚫ 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 that disrupt the anatomy or physiology of musculoskeletal tissues
can greatly affect a patient’s function by causing impairments (Nagi disablement model).

⚫ An important key to effective management of a patient’s problems is to recognize functionally relevant

impairments.
⚫ Transition from language of early disablement models to the International Classification of Functioning,
Disability and Health (ICF) concepts and language.

⚫ Purpose of a musculoskeletal assessment:

1. To determine the presence or absence of impairments, activity limitations, and disability involving
muscles, bones, and related joint structures.
2. To identify the specific tissues that are causing/contributing to the impairment, activity limitation,
or disability.
3. To determine baseline status.
4. To help formulate appropriate anticipated goals (short-term), expected outcomes (long-term), and
plane of care.
5. To evaluate the effectiveness of rehabilitation, medical, or surgical management.
6. To identify risk factors to prevent the development of worsening of impairments, activity limitations,
or disabilities.
 7. To identify the need for orthotic and adaptive equipment necessary for functional performance of
activities of daily living (ADL), occupational, and/or recreational activities.
8. To motivate the patient.
⚫ Regardless of which system is selected for assessment, the examiner must establish a sequential method
to ensure that no crucial test or step is omitted.
Patient History (subjective examination)
⚫ Important of history-taking
1. To direct and focus examination to an area and system of the body.
2. To establish a baseline against which to judge treatment effectiveness.
3. To enable the examination and treatment of the patient to be conducted safely.
⚫ Sources of information about the patient’s history
1. Most of information is obtained by interviewing the patient
 The patient’s orientation to person, place and time as well as general arousal state, cognitive, and
communication abilities should be noted.
 In a quiet, well-lit room that offers a measure of privacy.
 The therapist and patient should be at a similar eye level, facing each other, with a comfortable
space between them.
 The therapist may wish to have paper and pen available to record.
 Open-ended questions ask for narrative information; closed or direct questions ask for specific
information. (ask one question at a time)
 Use conversational language rather than medical terminology.
2. Other information sources to supplement an interview
 Medical records.
 Referral summaries.
 Other members of the health care team.
 Patient-completed medical history form.

⚫ The following sequence is suggested as a way of organizing the interview

1. History of the present illness or chief complaint
2. Onset of symptoms
 If the onset was sudden, the mechanism of injury will help to identify the structures involved.
→ Determine the direction and magnitude of the injuring force and how the force was applied.
  If the onset was gradual or insidious, a systemic condition or chronic biomechanical problem
(predisposing factors 潛在的致病因子) may be more likely.
 A congenital onset is also a possibility.
3. Location of the symptoms
 A body chart can help document the location of symptoms
A. Small, localized area: the lesion is probably not severe or relatively superficial, or both.
→ Often the location of the symptoms coincides with the location of the lesion.
B. Diffuse area: the lesion is more severe or more deeply situated, or both.
→ Determine is it follows a pathway as in dermatomic radiation, or sclerotomic reference
of pain.
 “Has the pain changed in location?”
→ The area of pain enlarges or becomes more distal as the lesion worsens and becomes smaller
or more localized as it improves (peripheralization of symptoms or centralization of symptoms).
4. Severity and quality of the symptoms
 Severity: using verbal or numerical pain rating scale, visual analog scale (VAS), or thermometer
pain scale.
 Quality of the symptoms

 “Has it changed in quality or intensity since its onset ?”

5. Behavior of the symptoms
 “What makes your symptoms increase, or decrease?”
→ Helps to establish a diagnosis and determine which treatment techniques are more likely to
be effective.
 “When do you typically feel your symptoms?”
 Symptoms do not change in activity or body position are a red flag for more serious conditions.
6. Behavior of the symptoms over the last 48 hours
 Help the examiner judge the effectiveness of future treatment.
7. Previous treatment
 Help examiner to decide if further medical referrals are needed and to focus on the most effective
treatment for the condition.
8. Specific medical history
 “Has this problem occurred before?”
 Information about previous successful and unsuccessful treatments can help in treatment planning
for the current problem.
 9. General medical history / general health
 Conditions involving the cardiac, respiratory, neurological, vascular, metabolic, endocrine, GU,
genital urinary, visual, and dermatological systems should be noted.
 It is necessary to determine whether the patient has or has had any disease or problem that many
have contributed to the present problem or that may influence the choice of treatment procedures.
10. Current medication
 Analgesic, anti-inflammatory medications, or muscle relaxants.
 Corticosteroids: long-term produces osteoporosis; proximal muscle weakness; generalized tissue
edema; thin, fragile skin; collagen tissue weakening and increased pain threshold.
 Anticoagulants (抗凝血藥物)
11. Social history and occupational, recreational, and functional status
 The patient’s pre-injury condition is determined.
 Existing of a functional deficit?
 Particular occupational and activities may contribute to the problem or interfere with recovery.
12. Patient’s treatment goals and anticipated time frame of recovery
13. Concluding questions
Observation / Inspection
⚫ The following statements are a kind of objective examination
1. The patient’s (1) general appearance and (2) ability to perform functional tasks.
→ Provides information of severity, willingness to move, ROM, gait and muscle strength.
2. A (3) gross postural screening is performed; the patient must be suitably dressed.
3. Begin a careful inspection of the (1) body region implicated in the interview and (2) biomechanically
related areas and focus on: (通常會跟對側進行比較)
 Bony structure and alignment.
 Subcutaneous soft tissues: contour (活順度)and size.
 Skin and nails: color, texture, moisture, scar, blister, callus, open wound, and other abnormalities.
Palpation
⚫ Palpation of all tissues associated with the area of symptoms.
⚫ The uninvolved side should be palpated first.
⚫ Bone, soft tissue structures, and the skin need to be palpated by varying the examiner’s tactile pressure.
1. Skin: tenderness (壓痛), moisture and texture (質地), temperature, and mobility.
2. Subcutaneous soft tissues: tenderness, tissue tension (muscle tone), consistency (一致性), continuity,
and mobility, and pulse.
3. Bony structures (tendon and ligament attachment): tenderness, bony contour and relationships.
→該位置是常見的病變位置，因此可以藉由 palpation 來判斷受傷的位置
Vital Signs – Optional
⚫ A patient’s medical record or interview suggests a compromised cardiovascular system.
⚫ Patients getting out of bed for the first time following prolonged bed rest or recent surgery.
Screening Examination – Optional
⚫ The basic aims of the following physical examinations are
1. To reproduce the patient’s symptoms. (誘導病人的症狀來跟先前問診得到的資訊比較)
2. To detect the level of dysfunction by provocation of the affected joint or tissues.
⚫ Screening examination
1. The screening is a quick look or scan of a part of the body involving the spine and extremities.
2. It is divided into two screenings:
 The upper limb (or quarter) screening.
 The lower limb (or quarter) screening.

3. The purpose of screening examination:

 To rule out symptoms, which may be referred from one part of the body to another.
 To ensure all possible sources of pathology.
4. When to use the screening examination:
 There is no history of trauma.
 There are radicular signs (神經根) or spinal cord signs.
 There is altered sensation in the limb.
 The patient presents with abnormal patterns.
 There is suspected psychogenic pain.
Examination of Specific Joints – Movement Tests or Selective Tissue Tension Tests (STTT; Cyriax approach)
-----------------------------------------------------------Joint Tests-----------------------------------------------------------
⚫ Active movements
1. The patient performs active movement one at a time, and if possible, bilaterally and symmetrically.
2. These yield very general information:
 Patient’s willingness and ability to use the part.
 Relating primarily to the patient’s functional status.
3. Also asking the patient to perform common functional activities related to the part being evaluated.
4. The following should be noted:
 Range, quality (順暢度), and pattern of motion
A. Limitation in AROM may be due to (1) pain, (2) capsule, ligament, muscle and soft tissue
tightness, (3) joint surface abnormalities, or (4) muscle weakness.
  Pain associated with the movement
A. Pain during (contacting of contractile tissue) or at extremes of AROM (noncontractile tissue).
B. A painful arc of movement is felt throughout a small arc of movement in mid range of motion.
C. Suggests an irritable structure being (1) pulled across a protuberance or (2) pinched between
two structures.
 Joint sound on movement
A. Crepitus
- Usually indicates (1) roughening of joint surfaces or (2) increased friction between a
tendon and its sheath.
- Best detected on active movement, with the forces of weight bearing or muscle
contraction maintaining compression of joint surfaces.
B. Clicks
- Particularly common in hypermobile joints.
- The laxity of ligaments enables a bone to click as it moves in relation to its fellow bone
(normal vacuum click), or when a loose body lies inside a joint.
C. Snapping
- As ligaments or tendons catch and slip over a bony prominence.
D. Cracks
- Caused by a bubble of gad in synovial fluid collapsing.
5. Modifications are employed when no symptoms have been produced by full active movements →
provocation tests (or auxiliary tests).
 Gentle passive overpressure or sustained pressure at the end range.
→若這樣檢測完還是沒有症狀，則 passive movement 就不用施作
 Movements are repeated or sustained.
 Combined movements in two or three directions.
 Repeated movements at various speeds.
⚫ Passive physiologic movements
1. Passively moves the patient’s uninvolved limb through the ROM to determine the patient’s normal
PROM and normal end feels before performing the movement on the involved side.
2. Very specific information may be obtained by making the following assessments:
  Range of motion
A. Limitation in PROM may be due to (1) pain, (2) capsule, ligament, muscle and soft tissue
tightness, or (3) joint surface abnormalities.
B. If there is restriction of movement at joint, the first determination that should be made is
whether the restriction is in a capsular or noncapsular pattern.
- Capsular patterns (整個關節囊出問題)
i. Joint effusion or synovial inflammation, e.g., acute trauma to a joint, or arthritis.
ii. Relative capsular fibrosis, e.g., prolonged immobilization of joint, or
degenerative joint disease.
- Noncapsular patterns
i. Internal derangement (intra-articular mechanical bolckage), e.g., displaced torn
menisci, or cartilaginous loose bodies.
ii. Adhesion of isolated ligament or a part of a joint capsule.
iii. Extra-articular tissue tightness or inflammation, e.g., reduced length of muscles,
or acute bursitis.
 Pain on movement
A. Pain during or at extremes of PROM is often due to moving, stretching, or pinching painful
structures (a painful arc may occur).
 End feels
A. A proper evaluation of end-feel can help to
- Assess the type of pathology present.
- Determine a prognosis for the condition.
- Learn the severity or stage of the problem.
B. End feel that may be pathologic include:
- Soft vs. boggy end feel: muscular hypertrophy vs. joint effusion (usually occurs together
with a capsular pattern of restriction).
- Capsular, ligamentous, and muscular end feel.
- Muscle-spasm end feel: usually accompanies pain felt at the point of restriction.
- Internal derangement end feel: springy rebound at the end point of movement.
- Bony end feel: hypertrophic bony changes with accompanying a restriction of movement.
- Empty end feel
 Joint sound on movement
Comparison between the passive and active joint motion
✓ Provide information about the amount of motion permitted by the joint structure relative to the
subject’s ability to produce motion at a joint.
✓ Begin to determine which injured tissues are involved by comparing which motions cause pain
and noting the location of the pain.
3. Contraindications and precautions for AROM and PROM
 Both are contraindicated:
A. In the region of a dislocation or unhealth fracture.
B. Immediately after surgery if motion to the part will interrupt the healing process.
C. If myositis ossificans (骨化性肌炎) or ectopic ossification (異位性骨化).
  The therapist must take extra care:
A. In the presence of an infectious or inflammatory process in joint or the region around a joint.
B. In the region of marked osteoporosis.
C. In assessing a hypermobile or subluxed joint.
D. In the region of a newly united fracture.
⚫ Passive accessory or joint play movements (capsuloligamentous stress tests)
1. Place the joint in a resting position and perform wither a glide or traction to stress various portions
of the joint capsule and major ligaments to detect the
 Prresence of painful lesion affecting these structures.
 Loss of continuity of these structures (degree of mobility).
2. Results of joint-play testing
Findings Probable interpretations
Normal mobility + painless No lesion of the structure tested
Normal mobility + painful Minor sprain
Hypomobility + painless Contracture, fibrosis, or adhesion
Hypomobility + painful Acute sprain (muscle guarding)
Hypermobility + painless Complete rupture
Hypermobility + painful A partial teat
---------------------------------------------------------Muscle Tests----------------------------------------------------------
⚫ Resisted isometric testing
1. Designed to assess the status of musculotendinous (contractile) tissue.
2. Place the patient’ joint in a position through the ROM (neutral or resting position), so that minimal
tension is put on inert structures.
3. Maximal stabilization is required to prevent substitution and to minimize joint movement → Ask
the patient to perform maximal resisted isometric contractions.
4. Don’t let me move you rather than to tell the patient contract the muscle as hard as possible.
5. When performing resisted isometric tests, one must:
 Whether the contraction is strong or weak.
 Whether it is painful or painless (sometimes more pain is felt when the contraction is released
and lengthening occurs).
6. Results of resisted isometric testing
Findings Possible pathologies
Strong + painless No lesion or neurological deficit in the tested muscle and tendon
Strong + painful A minor lesion of the tested muscle or tendon
Weak + painless  Some interruption of the nerve supply to the muscle
 A complete rupture of the tested muscle or tendon
 Disuse atrophy
Weak + painful  A partial rupture of the tested muscle or tendon
 Result of painful inhibition (acute stage) in association with
some serious
pathologic condition
⚫ Muscle length
1. 病人有 faulty posture 或 ROM 問題時會施測的項目
2. The test position for assessment of muscle length is also a position for increasing the length or
stretching the muscle.
3. The purpose of assessment of muscle length (flexibility) is to determine whether the range of motion
occurring at a joint is limited by the intrinsic joint structure or by the muscle crossing the joint.
4. For biarticular muscle, the constant-length phenomenon can be used to differentiate.
當病人有 elbow extension 受限，且懷疑是 biceps 太短時
A. 先讓病人做 shoulder extension 再做 elbow extension，觀察 ROM 的變化
B. 先讓病人做 elbow extension 再做 shoulder extension，觀察 ROM 的變化
→若病人的 ROM 狀況都變小，則代表是因為 muscle 的問題導致的
→若病人的 ROM 狀況都維持，則表示非 muscle 的問題造成的症狀
⚫ Muscle strength
1. Manual muscle testing is the most fundamental of all strength tests.
2. Muscle weakness may be caused by (1) upper motor neuron lesion, (2) a nerve root lesion, (3) injury
to a peripheral nerve, (4) pathology at the neuromuscular junction, (5) a lesion of the muscle, tendons,
or bony insertions.
3. The pattern of muscle weakness will help to (1) identify the site of the pathology, (2) direct treatment.
⚫ Muscle control
1. Relative strength and control is assessed by
 Observing the pattern of muscle recruitment, the quality of movement.
 Monitoring the movement of the joints during active and passive motion.
 Palpating muscle activity in various position.
2. For example, during shoulder elevation one may note excessive upper trapezius activity or early
scapular elevation.
Neuromuscular Examination - Optional
⚫ These test help to identify conditions affecting peripheral nerves, spinal nerve roots, and the central
nervous system (常用在病人有神經問題時) →基礎物理治療學的內容
1. Muscle strength testing.
2. Sensory tests (myotone, dermatone)
3. Deep tendon reflexes.
4. Neural tension or extensibility test (neurodynamic tests).

Special Tests
⚫ Special tests, designed to focus on specific conditions in a particular region of the body, may be helpful
in confirming the diagnosis.
Anthropometric Characteristics - Optional
⚫ Abnormalities noted during observation and palpation may be further documented with anthropometric
measurement
1. Limb lengths.
2. Circumferential measurement.
3. Volumetric measurement can be taken if measurement are needed of the hands or feet.
Functional Assessment
⚫ The functional assessment should demonstrate whether an isolated impairment (ROM, accessory joint
motions, and motor performance) affects the patient’s whole-body ability to perform everyday activities.
⚫ Functional assessment may involve (1) observation of certain activities, (2) task analysis, or (3) a detailed
evaluation of the effect of the injury or disability on the patient’s ability to function in everyday life.
Diagnosis Imaging
⚫ As with special tests, diagnosis imaging should be viewed as one part of the assessment, to be used
when it will help confirm or establish a diagnosis.