The 6 Ps 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

Try touching right ear to right
shoulder, left to left (usual ROM 40)
Chin to chest, chin to ceiling (flexion
45, extension [backward] 55)
Rotationchin should be parallel to
shoulders
Spine
In profile, should be a slight reverse
S
Posteriorly, midline without deviation,
shoulders even
Testing for scoliosis
Standing
Uneven shoulder height
Unequal distance between arms
and body
Asymmetrical waistline
Uneven hip height
Sideways lean
Bending over
Asymmetrical thoracic spine
Prominent rib cage/hump on
either side
Asymmetrical waistline
Shoulders
Note asymmetry, muscle atrophy,
deformity
Palpate joint to note crepitus or
tenderness
Palpate muscles for firmness and
symmetry
Palpate elbow and ulna for
subcutaneous nodules occurring with
rheumatoid arthritis
Rotation: (1) external and (2) internal

Flexion (anteriorly over

extension 30-50
Elbows

head) 180,

Have patient place side of hand on

table top with thumb up
Flexion 90
Extension 90
Wrist
Ask to rotate each wrist
Flexion of wrist 90
Extension of wrist 70
Inspect for
Symmetry
Redness and swelling
Deformities
Palpate for
Tenderness
Nodules
Sponginess
Testing for carpal tunnel
Tinels signpositive if percussing
ligament over median nerve produces
discomfort
Phalens signpositive if flexing for 30
seconds
causes pain or numbness
Fingers
Keeping wrist still, flex (90) and
extend (30) fingers
Touch thumb to little finger of same
handshould reach base of little
finger
Form fist (abduction) and draw back
together (adduction)
Hips and knees
Inspect for contour and symmetry
Look for bowlegged (varus alignment),
knock-kneed (valgus alignment)
Palpate each hip over iliac crest and
rochanteric

area for tenderness or instability

Knees should feel smooth, tissues
solid
Hip range of motion

Flexion 120
Extension 30
Internal rotation 40
External rotation 45
Abduction 45
Adduction 30

Knee range of motion

Flexion 120-150
Extension 0-15

Assessing muscle tone

Muscular resistance to passive
stretching
Arm muscle tone: move shoulder
through passive ROMshould feel
slight resistance
Arm should fall easily to his side when
dropped
Leg muscle tone: move hip through
passive ROMshould feel slight
resistance
Leg should fall easily when dropped
Muscle strength

Grade 0 to 5 as a fraction
5/5normal: moves through full ROM
and against gravity with full resistance
4/5good: completes full ROM with
moderate resistance
3/5fair: completes ROM against
gravity only
2/5poor: completes passive ROM
1/5trace: attempts palpable, no
movement
0/5zero: no evidence of muscle
contraction

Biceps and triceps

Bicepspull down on flexor surface of

forearm as patient resists
Tricepspatient straightens arm as
you push against the extensor surface
Abnormal findings (1)
Arm pain is usually musculoskeletal,
but may be neurovascular or
cardiovascular
Crepituscrunching, grating from
roughened articular surfaces
Footdrop
Heberdens nodes (DIP)
Bouchards nodes (PIP)
Abnormal findings (2)
Leg pain usually a musculoskeletal
disorder, but may be vascular or
neurological
Muscle atrophy (wasting) from
denervationor prolonged disuse

Ballottement
Used to test for joint effusion
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
Phalens test
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
Tinels Sign
In carpal tunnel syndrome, percussion
of the median nerve produces burning
and tingling along its distribution,
which is a positive Tinels sign