The 6 “P”s of musculoskeletal assessment
 Pain:
On palpation
On movement
Constant
 Pallor - pale skin or poor cap refill
 Paresthesia - “pins and needles” sensation
 Pulses - diminished or absent
 Paralysis
 Pressure
Palpation and inspection
 Swelling/Ecchymosis
Hemorrhage/Fluid at site of trauma
 Deformity/Shortening of limb
Compare to other extremity if norm is
questioned
 Guarding/Disability
Presence of movement does not rule
out fracture
 Tenderness
Use two point fixation of limb with
palpation with other hand.
Tenderness tends to localize over injury
site.
 Crepitus
Grating sensation
Produced by bones rubbing against
each other
Do not attempt to elicit.
Minor musculoskeletal injury
 Cold/Heat application
◦ cold best if in first 48 hours to reduce
swelling
◦ heat best if after 48 hours to increase
circulation
◦ no direct application to soft tissue
 wrap in towel or gauze
Routine assessment principles
 Have patient undress to underwear, provide
gown
 Note size and shape of joints, limbs, body
regions
 Inspect, palpate skin and tissues around joints,
limbs and body regions
 Have patient perform active range of motion
 If unable, perform passive range of motion
 Support joint during passive range of motion
 Never force movement!
Observe how patient walks
 Should be only slight torso swaying
 Gait should be even
 Posture should be erect
 Each foot should flatten and bear weight
completely
 Toes should flex as he pushes off to walk
 Foot should clear the floor, pass other leg in
midswing
Head, jaw and neck
 Inspect for swelling, symmetry, evidence of
trauma
 Mandible midline
 Evaluate for TMJ
◦ Determine if click when patient opens
mouth
◦ Swelling
◦ Crepitus
◦ Pain
Neck
 Note muscle asymmetry or masses
 Palpate spinous processes
 Areas above each clavicle
◦ Tenderness
◦ Swelling
◦ Nodules
 Listen and palpate for crepitus
Neck range of motion  Extension of wrist 70◦
 Inspect for
 Try touching right ear to right shoulder, left to
◦ Symmetry
left (usual ROM 40◦)
◦ Redness and swelling
 Chin to chest, chin to ceiling (flexion 45◦,
◦ Deformities
extension [backward] 55◦)
 Palpate for
 Rotation—chin should be parallel to shoulders
◦ Tenderness
Spine ◦ Nodules
◦ Sponginess
 In profile, should be a slight reverse “S”
 Posteriorly, midline without deviation, Testing for carpal tunnel
shoulders even
 Tinel’s sign—positive if percussing ligament
Testing for scoliosis over median nerve produces discomfort
 Phalen’s sign—positive if flexing for 30 seconds
 Standing causes pain or numbness
◦ Uneven shoulder height
◦ Unequal distance between arms and Fingers
body
 Keeping wrist still, flex (90◦) and extend (30◦)
◦ Asymmetrical waistline
fingers
◦ Uneven hip height
 Touch thumb to little finger of same hand—
◦ Sideways lean
should reach base of little finger
 Bending over
 Form fist (abduction) and draw back together
◦ Asymmetrical thoracic spine (adduction)
◦ Prominent rib cage/hump on either side
◦ Asymmetrical waistline Hips and knees

Shoulders  Inspect for contour and symmetry

 Look for bowlegged (varus alignment), knock-
 Note asymmetry, muscle atrophy, deformity kneed (valgus alignment)
 Palpate joint to note crepitus or tenderness  Palpate each hip over iliac crest and rochanteric
 Palpate muscles for firmness and symmetry area for tenderness or instability
 Palpate elbow and ulna for subcutaneous  Knees should feel smooth, tissues solid
nodules occurring with rheumatoid arthritis
 Rotation: (1) external and (2) internal Hip range of motion
 Flexion (anteriorly over head) 180◦, extension
 Flexion 120◦
30-50◦
 Extension 30◦
Elbows
 Internal rotation 40◦
 Have patient place side of hand on table top  External rotation 45◦
with thumb up  Abduction 45◦
 Flexion 90◦  Adduction 30◦
 Extension 90◦
Knee range of motion
Wrist
 Flexion 120-150◦
 Ask to rotate each wrist  Extension 0-15◦
 Flexion of wrist 90◦
Assessing muscle tone Ballottement

 Muscular resistance to passive stretching  Used to test for joint effusion

 Arm muscle tone: move shoulder through
passive ROM—should feel slight resistance
 Arm should fall easily to his side when dropped
 Leg muscle tone: move hip through passive
ROM—should feel slight resistance
 Leg should fall easily when dropped
 If there is an effusion present a palpated tap
will be present and the transmitted impulse will
be felt by the fingers on either side of the
patella
Phalen’s test

Muscle strength
Grade 0 to 5 as a fraction
 5/5—normal: moves through full ROM and
against gravity with full resistance
 4/5—good: completes full ROM with moderate
resistance
 3/5—fair: completes ROM against gravity only
 2/5—poor: completes passive ROM
 1/5—trace: attempts palpable, no movement
 0/5—zero: no evidence of muscle contraction
Biceps and triceps
 Ask the person to hold both hands back to back
while flexing the wrists 90 degrees. Acute
flexion of the wrist for 60 seconds produces
numbness and burning in a person with carpal
tunel syndrome
Tinel’s Sign
 In carpal tunnel syndrome, percussion of the
median nerve produces burning and tingling
along its distribution, which is a positive Tinel’s
sign

 Biceps—pull down on flexor surface of forearm

as patient resists
 Triceps—patient straightens arm as you push
against the extensor surface

Abnormal findings (1)

 Arm pain is usually musculoskeletal, but may be

neurovascular or cardiovascular
 Crepitus—crunching, grating from roughened
articular surfaces
 Footdrop
 Heberden’s nodes (DIP)
 Bouchard’s nodes (PIP)

Abnormal findings (2)

 Leg pain usually a musculoskeletal disorder, but

may be vascular or neurological
 Muscle atrophy (wasting) from denervationor
prolonged disuse