MSK Examination: Quick Reference

Examination Framework

  • NPTE-PT Test Content Outline (effective Jan 2018): evaluates entry-level knowledge; emphasizes safe, evidence-based clinical care and application of concepts.
  • MSK Exam scope: detailed history, review of systems, visual observation, ROM, resisted tests/MMT, neuro tests/dermatome/myotome, special tests, and function testing.

Goniometry and ROM

  • Goniometry steps (8 essential actions):
    1. Determine which joints to test
    2. Organize by body position
    3. Educate the patient
    4. Stabilize proximal segment
    5. Move through available motion and determine end-feel
    6. Make a clinical estimate
    7. Align goniometer and record starting position
    8. Record end position
  • PROM joint ranges (selected examples):
    Shoulder: Flexion =0∘ to 180∘ , Extension =0∘ to 60∘ , Abduction =0∘ to 180∘ , Internal rotation =0∘ to 90∘ , External rotation =0∘ to 90∘\text{Flexion }={0^\circ\text{ to }180^\circ}\,,\text{ Extension }={0^\circ\text{ to }60^\circ}\,,\text{ Abduction }={0^\circ\text{ to }180^\circ}\,,\text{ Internal rotation }={0^\circ\text{ to }90^\circ}\,,\text{ External rotation }={0^\circ\text{ to }90^\circ}
    Hip: Flexion =0∘ to 120∘ , Extension =0∘ , Abduction =0∘ to 45∘ , Adduction =0∘ to 30∘ , IR/ER =0∘ to 45∘\text{Flexion }={0^\circ\text{ to }120^\circ}\,,\text{ Extension }={0^\circ}\,,\text{ Abduction }={0^\circ\text{ to }45^\circ}\,,\text{ Adduction }={0^\circ\text{ to }30^\circ}\,,\text{ IR/ER }={0^\circ\text{ to }45^\circ}
    Elbow: Flexion =0∘ to 150∘ , Extension =0∘\text{Flexion }={0^\circ\text{ to }150^\circ}\,,\text{ Extension }={0^\circ}
    Forearm: Pronation =0∘ to 80∘ , Supination =0∘ to 80∘\text{Pronation }={0^\circ\text{ to }80^\circ}\,,\text{ Supination }={0^\circ\text{ to }80^\circ}
    Wrist: Flexion =0∘ to 90∘ , Extension =0∘ to 90∘ , Radial deviation =0∘ to 20∘ , Ulnar deviation =0∘ to 30∘\text{Flexion }={0^\circ\text{ to }90^\circ}\,,\text{ Extension }={0^\circ\text{ to }90^\circ}\,,\text{ Radial deviation }={0^\circ\text{ to }20^\circ}\,,\text{ Ulnar deviation }={0^\circ\text{ to }30^\circ}
    Ankle: Dorsiflexion =0∘ to 20∘ , Plantarflexion =0∘ to 50∘\text{Dorsiflexion }={0^\circ\text{ to }20^\circ}\,,\text{ Plantarflexion }={0^\circ\text{ to }50^\circ}
  • End-feel: Normal = hard, soft, or firm; Abnormal end-feels include early/late muscle spasm, mushy tissue stretch, spasticity, hard/soft capsular, empty, or boggy sensations.

End-Feel (Normal vs Abnormal)

  • Normal end-feels: Hard (bone-to-bone), Soft tissue approximation, Firm (tissue stretch).
  • Abnormal end-feels: Early/late muscle spasm, Mushy tissue stretch, Spasticity, Hard/Soft capsular, Empty, Springy block, Boggy, Protective spasm, etc.

Joint Positions: Open-Packed vs Closed-Packed

  • Glenohumeral: Open-pack = mid-range; Closed-pack = maximal abduction and external rotation.
  • Humeroulnar: Open-pack = 70° flexion and 10° supination; Closed-pack = full extension and supination.
  • Humeroradial: Open-pack = full extension and supination; Closed-pack = 90° flexion with 5° supination.
  • Proximal radioulnar: Open-pack = 70° flexion with 35° supination; Closed-pack = 5° supination and full extension.
  • Distal radioulnar: Open-pack = 10° supination; Closed-pack = 5° supination.
  • Radiocarpal: Open-pack = neutral; Closed-pack = full extension with radial deviation.
  • Vertebral: Open-pack = midway between flexion and extension; Closed-pack = maximal extension.

Shoulder Goniometry (examples)

  • Flexion: Supine, stabilization of thorax, end-feel firm, axis at acromion, stationary arm along thorax, movable arm along humerus toward lateral epicondyle.
  • Abduction: Supine, stabilization of thorax, end-feel firm, axis at acromion, stationary arm parallel to sternum, movable arm along humerus.
  • Internal/External Rotation: Supine with shoulder abducted 90°, elbow 90°; stabilization of humerus; axis at olecranon; stationary arm parallel to floor; movable arm along ulna.
  • Elbow: Supine; end-feel soft; axis at lateral epicondyle; stationary arm along humerus; movable arm along radius.
  • Pronation/Supination: Seated, elbow 90°; stabilization distal humerus; end-feel firm/hard; axis ulnar styloid; stationary arm along forearm; movable arm on dorsum of forearm.
  • Wrist: Seated; stabilization radius/ulna; end-feel firm; axis triquetrum; stationary arm along ulna; movable arm along 5th metacarpal.
  • Thumb, Hip, Knee, Ankle, etc.: listed ranges and landmark cues (see detailed prompts above).

Strength Testing (MMT)

  • Grading scale and descriptions (brief):
    5/5 – Against gravity and resistance; 4+/5 to 4-5 range – Against resistance with varying levels; 3+/5 to 3/5 – Against gravity only or partial; 2+/5 to 2/5 – Gravity eliminated; 1/5 – Contraction without movement; 0/5 – No contraction.

Special Tests: Shoulder to Hand (selected examples)

  • O’Brien Active Compression: Tests for SLAP lesions; standing with 90° flexion, max IR, then max ER; positive if first part painful/clicks, second part reduced.
  • Speed’s Test: SLAP tear or bicipital tendinopathy; elbow extended, forearm supinated; pain in bicipital groove.
  • Yergason’s Test: Bicipital tendonitis/tenosynovitis or transverse humeral ligament tear; resisted supination with elbow at 90°.
  • Apprehension Tests: Anterior instability (arm at 90° abduction, ER); Posterior instability (90° flexion, posterior force).
  • Impingement Tests: Hawkins–Kennedy, Neer; pain with impingement movements or full elevation; Painful Arc indicates SIS or AC joint involvement.
  • Drop Arm Test: RTC tear (supraspinatus); arm abducted 90–120°, slowly lowered or reproduces severe pain.
  • Lag Signs: ER Lag (supraspinatus/infraspinatus tear); IR Lag (subscapularis tear).
  • Biceps/SLAP tests: Biceps Load Test I/II; increased pain or apprehension with biceps activation.
  • Supraspinatus Empty Can (Jobe): Weakness or pain with resisted empty-can position.
  • Thoracic Outlet Tests: Adson, Roos, Allen; tests for neurovascular compression.

Rotator Cuff Anatomy (posterior and anterior view)

  • Supraspinatus, Infraspinatus, Subscapularis; Teres minor/major contributions; common impingement mechanisms.

Wrist and Hand Examination

  • Observations: Swan-Neck, Boutonniere, Ulnar Drift, Claw Fingers; implications for RA, neuropathies, and tendon integrity.
  • Hand deformities and nerve associations summarized (e.g., Ape hand, Bishop’s hand).
  • Froment’s Sign: Adductor pollicis weakness (ulnar); compensation with FPL.
  • Phalen’s and Reverse Phalen: Median nerve involvement at carpal tunnel; positive tingling.
  • Finkelstein: DeQuervain’s (APL/EPB) tenderness.

Grip and Biomechanics Quick Facts

  • Tenodesis grip: example of passive insufficiency; strongest grip at wrist extension around 30∘30^\circ.
  • Strongest plantarflexion occurs with knee extension; strongest dorsiflexion occurs with knee flexion.

Hip Tests and ROM for Functional Demands

  • Thomas Test: Hip flexor tightness (supine; knee to chest).
  • Ober’s Test: Tensor fasciae latae tightness/contracture.
  • Ely’s Test: Rectus femoris tightness.
  • FABER (Patrick’s) Test: Iliopsoas, SI, or hip joint abnormality.
  • Craig’s Test: Femoral anteversion; angle >8–15° indicates excessive anteversion.
  • Hip ROM for common activities: e.g., 120° for sitting, 125° for stooping, etc. (ranges given in material).

Pediatric Hip Dysplasia and Related Signs

  • Barlow’s signs and Ortolani’s sign: screen for developmental dysplasia of the hip (DDH).
  • Galeazzi Sign: leg length/hip dislocation indicator.
  • Slipped Capital Femoral Epiphysis (SCFE) and Legg-Calvé-Perthes Disease: adolescent and pediatric hip conditions with AVN risk; present with limp and reduced ROM.

Knee Examination: Key Tests

  • Lachman: ACL, posterior oblique ligaments integrity; mushy end-feel indicates tear.
  • Anterior Drawer: ACL injury; excessive tibial translation.
  • Pivot-Shift: Anterolateral rotatory instability (ACL tear).
  • McMurray’s: Meniscal tears; click/pain with tibial rotation.
  • Posterior Sag/Posterior Drawer: PCL integrity; posterior tibial sag.
  • Reverse Lachman/Posterior Drawer: PCL laxity.

Spine: ROM and Diagnostic Tests

  • Regions and ROM tendencies: Cervical, Thoracic, Lumbar ROM values; flexion/extension, lateral bending, rotation.
  • Foraminal Compression, Distraction, Shoulder Abduction, Valsalva, Lhermitte’s sign, Vertebral Artery Test: screen for radiculopathy, nerve root compression, myelopathy, and vertebrobasilar compromise.

Insufficiency Concepts

  • Passive Insufficiency: two-joint muscle cannot fully lengthen across both joints.
  • Active Insufficiency: two-joint muscle cannot shorten across both joints to produce full ROM.

Important Conditions (MSK) – Presenting Factors

  • Osteoarthritis: diminished joint space and osteophytes; WB joints affected.
  • Ankylosing Spondylitis: back stiffness, sacroiliitis, kyphotic changes; typically <40 years in males.
  • Psoriatic Arthritis: chronic erosive changes with skin involvement.
  • Rheumatoid Arthritis: symmetrical involvement with joints and characteristic deformities.
  • Osteoporosis: decreased bone mineral density (T-score ≤ -2.5).

Additional Important Conditions (MSK)

  • Glenohumeral Subluxation; Labral Tears (SLAP/Bankart);
  • Thoracic Outlet Syndrome (neurovascular compression);
  • Subacromial bursitis and Rotator Cuff Tendinopathy; Adhesive Capsulitis;
  • Humeral Fractures and potential radial nerve involvement.

Deformities of the Hand and Thumb

  • Swan-Neck, Boutonniere, Claw Fingers, Trigger Finger, Ape Hand, Bishop’s Hand, Zigzag Deformity of Thumb, Dupuytren’s Contracture, Mallet Finger, Clubbing.

Quick Reference: Common Tests for Carpal and Hand Pathologies

  • Finkelstein: DeQuervain’s syndrome.
  • Phalen’s / Reverse Phalen: Median nerve entrapment.
  • Froment’s Sign: Ulnar nerve palsy (adductor pollicis weakness).

Final Notes

  • This set provides compact, exam-focused cues for MSK evaluation, ROM, end-feel interpretation, major special tests, and common pathologies.