Mennonite College of Nursing
NUR 431 Diagnostic Reasoning
Musculoskeletal (MSK) Assessment
General Points
 Patients with MSK problems usually present with pain, deformity, or weakness
 Most common problem: Joint pain
 Most common disorder for which patients seek health care: Backache
 Conditions associated with joint pain
o Mechanical problems
o Soft tissue conditions
o Inflammatory diseases
o Noninflammatory diseases
 Conditions frequently associated with join pain
o Osteoarthritis
o Tendonitis
o Infection
o Gout/pseudogout
o Rheumatoid arthritis
The causes of most MSK complaints are self-limited and minor, but other causes may results in
significant disability, morbidity, and mortality.
Red Flags in the Assessment of the MSK System (presentations of urgent MSK problems)
 History of major trauma
o What might this indicate/lead to?

Hot and/or swollen joint(s)
o What conditions might exhibit this?

Systemic/constitutional symptoms such as ________________________________?

Weakness
o Focal
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o
What might cause focal weakness?
Diffuse
 What might cause diffuse weakness?

Neurogenic pain What underlying causes are associated with these pain patterns?
o Asymmetric
o
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Symmetric
Claudication pain How do the following differ in terms of relief with rest?
o Vascular
o
Neurogenic

Unrelenting nighttime pain

Poorly localized pain
What might this mean?
History
 Important to complete a thorough symptom analysis for any MSK complaint
o Questions to determine what causes and/or relives the pain
o Questions to identify the type or quality of the pain
 Burning, cramping, aching, sharp
 Constant, throbbing, shooting
 How bad is the pain on a 0-10 scale?
o Questions to determine the location and radiation of the pain
 Ask patient to point to the area where the pain is the worst
 Where does the pain radiate?
o Questions about associated symptoms
 Tingling, numbness, weakness, swelling, redness, limited motion, popping
 Any generalized symptoms: fever, malaise, decreased energy?
o Questions about the temporal sequence of the symptoms
 When pain first noticed; activity at the time
 Persistent or intermittent
 Pain worse or stayed the same?
 Include
o History of associated pain, discomfort, swelling, redness, stiffness, crepitus, limitation,
and weakness
o Onset and progression of symptoms (to help differentiate among traumatic or acute
problems and chronic conditions)
 Past Medical History
o History of MSK disorders and procedures
 Ask about any recent infections
o


History of remote and recent trauma and/or other injuries and how they occurred
(mechanism of injury)
o Treatment and response related to any identified MSK problems
 Include past treatments from PT, chiropractors, and alternative medicine
o Medications (with MSK effects)
 Diuretics (secondary hyperuricemia)
 Chemotherapy (may increase hyperuricemia)
 Hydralazine, procainamide, chlorpromazine, methyldopa, isoniazid, and OCPs
(triggers for SLE)
 Anti-inflammatories, statins, fibrates, erythromycins (may cause
rhabdomyolysis)
o Symptoms from possibly related systems
 Skin: gonococcal arthritis, Lyme disease, SLE
 Endocrine: hyperparathyroidism, hyper/hypothyroidism, diabetes
 Neurological
Family history: arthritis, osteoporosis, gout, other MSK disorders
Habits
o Drugs and herbal remedies used
o Use of assistive devices
o History of normal daily activity and any limitations associated with Chief Complaint
o Occupational, social, and recreational physical activities
 Watch for activities that require repetitive motion/MSK stress
Physical Examination
 General survey
o Body build
o Posture
o Obvious deformities Check bilaterally!
o General gait (limp, guarding, obvious weakness)
o Movement
o Assistive aids
o General skin condition
o Vital signs (including pain)
 Inspection
o Be sure you can see what you are assessing!
o Posture
o Deformities
o Limited motion
o Asymmetry of bony pairs or muscle groups
o Skin lesions, scars, bulges, areas of redness or swelling
o
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

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Direct patient through maneuvers to demonstrate ROM and general ability to control
movement (AROM = active ROM)
 Gaits: normal, heel-to-toe, on-toes, on-heels)
 Full ROM of all joints without resistance
o Focused attention to any area of complaint
 If effusion, bulging, and/or redness detected, cause is more likely an
inflammatory condition
Palpation
o Assess each joint, major muscle group and accessory structures, such as ligaments and
tendons
o Note any palpable deformities, nodularities, tenderness, swelling, or warmth
o Palpate muscles for tone, size, and tenderness
o Note any palpable crepitus
o Areas of warmth suggest inflammatory or infectious cause of pain
o Point tenderness potential indicator of bursitis or tendinitis, fibromyalgia
Range of motion
o AROM is determined prior to assessing PROM (passive and/or assisted ROM)
o Patient’s response to AROM provides clues to how the examiner should best support
the limb through PROM
 An injured or diseased joint will likely be painful on motion, and AROM may be
limited to a greater degree than PROM
 Motion in an abnormal plane may indicate looseness in ligaments
 Crepitus and grating on movement indicates roughness in the surfaces
of articulating bones.
 Clicks can occurs from previous injuries to the joints, abnormalities of a
meniscus, or merely fro soft tissue sliding over bone
o Can measure ROM with goniometer
Ligamentous Tests
o When c/o pain or injury to a joint, the stability of the joint should be determined
o Ligamentous tests involve applying stress to the ligaments by a variety of maneuvers
that typically involve the examiner flexing or extending the joint while applying pressure
in a particular direction and determining the “feel” of the resulting movement, including
any laxity, crepitus, or pain.
Muscle strength and tone
o Ask patient to either resist the examiner’s attempt to flex or extend a muscle group or
to flex or extend the muscles against the examiner’s resistance
o Grades 0 (no evidence of strength) to 5 (complete or full resistance)
 0 = no muscle contraction noted when resistance applied (0% of normal)
 1 = a slight muscle contraction seen or palpated but insufficient for joint
movement (10% of normal)



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2 = Weak contraction when the joint is held in position. Full passive ROM (25%
of normal)
3 = Contraction weak but these is full active movement against resistance (50%
of normal)
4 = some muscle strength against resistance (75% of normal)
5 = Normal strength is present (100% of normal)
Diagnostic Tests (examples, not inclusive)
 ESR
 Rheumatoid factor
 ANA
 CBC, U/A, renal and liver functions
 Lyme serology
 Synovial fluid aspiration
 X-rays
 MRI
 Bone scan
References:
Goolsby, MJ (2001). Clinical practice guidelines: Evaluating acute musculoskeletal complaints. Journal
of the American Academy of Nurse Practitioners (13),5 (195-199.
Goolsby, MJ & Grubb, L. (2011). Advanced assessment: Interpretting findings and formulating
differential diagnoses (2nd ed.). Philadelphia: FA Davis Company.
A Targeted Assessment: Low Back Pain
 History
 Vital signs
 ENT/Respiratory
 Heart
 Abdomen
 Inspection, gait, ability to sit
 Palpation of spinous and paraspinous areas
 Range of motion
 Straight leg raise
 Psoas, obturator
 Neuro of lower leg