How to assess patients presenting with musculoskeletal conditions (2024)

This article explains how to conduct a musculoskeletal assessment, including observation, palpation, active and passive movements and muscle strength testing

Abstract

A musculoskeletal assessment includes an assessment of the active and passive range of motion, muscle strength testing and factors such as tenderness and inflammation of the joints. Understanding the key components is imperative for advanced nurse practitioners and other practitioners, who are the first point of contact for patients presenting with musculoskeletal conditions in primary care or other healthcare settings. This article provides a basic overview of the components that are used collectively to screen for, and assess, musculoskeletal conditions.

Citation: Lethbridge D (2024) How to assess patients presenting with musculoskeletal conditions. Nursing Times [online]; 120: 11.

Author: Daniel Lethbridge is physiotherapy lecturer practitioner, University of Hull, and former musculoskeletal extended scope physiotherapist.

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Introduction

The musculoskeletal (MSK) assessment is vital to screening, assessing and managing MSK conditions. Understanding the key components that are necessary to complete a basic competent MSK assessment is imperative for practitioners who are the first point of contact for patients presenting in primary care or other health care settings; this includes registered nurses working at an advanced level of practice. This article, the ninth in a series on advanced assessment and interpretation skills, provides a basic overview of the components that are used collectively to screen and assess MSK conditions.

The MSK system (also called the neuromusculoskeletal system) is a collective term encompassing all components of the muscular and skeletal systems of the human body. This includes:

  • Bone;
  • Ligament;
  • Muscle/tendon;
  • Connective tissue;
  • Nerves (as neural tissue makes up part of the MSK system and neural issues are common MSK complaints).

As a framework that functions to support, protect and allow voluntary motion of the human body, the MSK system is intimately connected to the nervous system that controls it. However, while a comprehensive neurological examination should be part of the objective assessment, along with special neurological tests for differing pathologies, these are beyond the scope of this article.

MSK conditions account for 30% of GP consultations (NHS England, no date a) and there are an estimated 20million people living with MSK conditions in the UK (Versus Arthritis, 2024). With the introduction of first-contact/advanced care practitioners, some of the burden of MSK management in primary care has shifted from GPs to nurse practitioners and allied health professionals.

Musculoskeletal conditions/diseases

The MSK system, like any other system in the body, is not immune to the effects of disease, injury or ageing. MSK presentations in primary care encompass more than 150 conditions, including impaired functioning of the osteogenic, arthrogenic, myogenic, and neurogenic systems (World Health Organization, 2022). These impairments can be short lived or long lasting, and can quite dramatically impact the lives of those who are affected, including their activities of daily living, work and leisure.

Dysfunctions in the MSK system fall into three general groups:

  • Inflammatory arthropathies;
  • MSK pain conditions;
  • Osteoporosis and osteoporotic fragility fractures (Office for Health Improvement and Disparities, 2022).

Inflammatory arthropathies

Inflammatory arthropathies are a group of systemic inflammatory conditions – such as rheumatoid arthritis, psoriatic arthritis and axial spondyloarthropathies – that are characterised by:

  • Joint pain and tenderness;
  • Inflammation;
  • Increased temperature;
  • Significant early morning stiffness (Poudel et al, 2023) lasting for >30 minutes (van Nies et al, 2015).

In the UK, rheumatoid arthritis affects >450,000 people; around 220,000 people have axial spondyloarthropathies and 190,000 people have psoriatic arthritis (Versus Arthritis, 2024).

MSK pain conditions

MSK pain conditions are a group of disorders such as lower back pain, osteoarthritis and tendinopathies (tendon disorders such as strains, tears or degenerative changes). In the UK, ~11million people are affected by lower back pain each year and 10million people have a probable diagnosis of osteoarthritis (Versus Arthritis, 2024).

Osteoporosis

Osteoporosis is a condition affecting the skeletal system and is characterised by a reduction in bone mineral density. This leads to deterioration in the microstructure of the bone, increasing its susceptibility to fracture (Sözen et al, 2017). Osteoporosis affects ~3million people in the UK annually, with around half a million fractures a year occurring as a result of it (Versus Arthritis, 2021)

MSK assessment

An MSK assessment is a systematic approach to screening a patient who presents in clinical practice with symptoms that are believed to originate from an MSK source. This type of clinical examination is fundamentally based in the medical model of care.

A basic MSK screening process is used to identify any underlying MSK source that may be responsible for the patient’s symptoms, by examining and testing various components of the MSK system and specific aspects of the nervous system. The key aspects to the MSK assessment are:

  • Gaining consent;
  • Subjective interview;
  • Objective examination;
  • Clinical reasoning process.

Gaining consent

Obtaining consent in healthcare is a legal and ethical requirement, and involves explaining to the patient the various components of the assessment so they are fully aware of what you are intending to do and why you are doing it (Dowie, 2021). Finally, it is imperative that patients are fully aware that they can stop the assessment or aspects of it at any point throughout the assessment (Dowie, 2021).

Subjective interview

The subjective interview should be patient centred from the outset and actively involve the patient in decision making along their journey. Identifying patient expectations, goals and preferences are all essential to MSK assessment and management to ensure that the patient’s personal preferences and values are respected and taken into consideration (NHS England, no date b) throughout the assessment and management process. This collaborative approach has been shown to give better patient outcomes, while also being more cost-effective than a non-collaborative approach (NHS England, no date b).

The subjective interview is key to any MSK assessment, as it gives the health professional the opportunity to obtain vital information they can use alongside the objective examination findings to:

  • Screen for red flags that might indicate conditions such as cancer, cauda equina syndrome (a rare and severe type of spinal stenosis), tumour, myelopathy (injury to the spinal cord due to severe compression) and other non-MSK pathologies, such as rheumatological conditions;
  • Ensure the patient is safe and the case is appropriate for MSK intervention following a thorough screening process;
  • Formulate a clinical diagnosis via a clinical reasoning process;
  • Direct treatment/management of the presenting MSK condition.

Subjective assessment

Screening for red flags is the first step of the subjective assessment. Red flags are a collection of subjective and objective indicators that potentially indicate serious underlying pathology (Ramanayake and Basnayake, 2018).

Identifying potentially serious underlying pathologies is imperative to patient safety, as delays in diagnosis can dramatically reduce the patient’s quality of life. These indicators are valuable to all clinicians because they can help with the decision making process when managing potentially serious pathology (Ramanayake and Basnayake, 2018).

Red flag indicators can be general (which may be considered for all patients presenting in clinical practice) (Box 1), or specific to certain body parts or joints (predominantly considered for symptoms involving those parts of the body to which they relate) (Boxes 2-4).

Box 1. General red flag indicators

  • Unexplained weight loss (>5% of body weight in months/weeks)
  • Previous cancer diagnosis
  • Aged <20 years or >50 years
  • Night sweats/fevers
  • Unremitting pain
  • Night pain
  • Severe/progressive neurological weakness (such as foot drop)
  • Significant trauma (for example, road traffic incident, such as car rollover or overturn)
  • Unexplained structural deformity
  • Severe headaches (particularly around the temple) and those that can be accompanied by jaw pain, bilateral shoulder and/or pelvic girdle pain, and pain when chewing. Consider giant cell arteritis, an inflammatory disease affecting large blood vessels of scalp, neck and shoulders

Source: Adapted from Refshauge et al (2004)

Box 2. Cervical spine specific red flags

Vertebrobasilar artery insufficiency and cervical artery dissection/dysfunction

Five Ds:

    • Dizziness
    • Diplopia (double vision)
    • Drop attacks (sudden weakness in face/arm/leg)
    • Dysarthria (speech disorder),
    • Dysphagia (swallowing difficulties)
  • Three Ns:
    • Nausea
    • Numbness (on one side of body)
    • Nystagmus (dancing eyes)

Cervical myelopathy

  • Bilateral upper-limb and/or lower-limb pins and needles
  • Gait disturbance/unsteadiness on the feet
  • Loss of grip strength and dexterity issues (for example, dropping things, inability to do up/undo shirt buttons or pick up coins)

Sources: Adapted from Myers et al (2021) and Davies et al (2018)

Box 3. Lumbar spine specific red flags

Cauda equina syndrome (condition involving compression of the nerve roots of the lower aspects of the spinal cord – for example, via a herniated disc):

  • Bilateral radicular leg pain (sciatica)
  • Worsening neurological deficit in the leg/s
  • Saddle anesthesia (altered sensation in the saddle area)
  • Bladder and/or bowel issues (incontinence, retention)
  • Inability to recognise the passing of stools or urine
  • Inability to fully empty the bladder or initiate urination
  • Water leakage or abnormal sensation during sexual intercourse (female)
  • Inability to gain an erection or to ejaculate (male)

Source: Adapted from National Institute of Health and Care Excellence (2023)

Box 4. Peripheral joint specific red flags

  • Swelling, redness and increased temperature (could, for example, indicate infection, inflammatory arthropathies)
  • Significant early morning stiffness lasting >30 minutes (could indicate inflammatory arthropathies, for example rheumatoid arthritis, ankylosing spondylitis)
  • Skin or eye problems (such as psoriasis and iritis or uveitis respectively) or bowel issues (Crohn’s disease, colitis) as linked to inflammatory arthropathies

Source: Adapted from Goodman and Snyder (2013)

Once you have screened for red flags and are happy that the patient is safe and appropriate for MSK management, the next step is to compile sufficient patient information to make a reasoned diagnosis with which to direct appropriate treatment and management. This involves questioning the patient on the following:

  • Presenting complaint/condition;
  • History of presenting complaint;
  • Past medical history;
  • Drug history;
  • Previous or current investigations;
  • Social history

The components of a subjective interview are detailed in Table1.

How to assess patients presenting with musculoskeletal conditions (1)

Objective assessment

The next stage is to use the information gathered from the subjective assessment to guide you in conducting an objective examination of the patient. An objective examination allows you to examine the patient physically to identify any pain or symptoms with movement, resistance or palpation. The stages are detailed below.

  • Observation;
  • Testing active range of movement;
  • Testing passive range of movement;
  • Resisted testing;
  • Palpation;
  • Neurological examination, including dermatomes, myotomes, reflexes, upper motor neurone (UMN) testing (clonus, Hoffman and Babinski signs);
  • Special tests (beyond the scope of this article).

Observation
Observation is the first stage of the objective examination and takes two forms.

  • Observe the patient from the waiting area, including their sit-to-stand and gait pattern. This may give clues as to the presenting problem, as well as indicating performance of some functional tasks. Assessing gait can help identify issues, such as:
    • Antalgic behaviours – disrupted walking pattern usually pain related;
    • Foot drop – foot uncontrollably hanging with toes pointing down so toes scrape the ground when walking;
    • High stepping gait (often associated with foot drop) – raising the thigh more than usual when walking,
      as though climbing stairs, which may cause the foot to slap down onto the floor. This may be a sign of an underlying neurological condition;
    • Trendelenburg gait – appearance of swaying from side to side when walking, with the affected hip dropping down due to weak hip abductor muscles. This may be a sign of an underlying neurological condition.
    • Observe the affected body part and surrounding structures. This can provide clues about a person’s posture and tell you whether there are any red flag indicators (for example, redness or deformity). Below are the various aspects that should be viewed:
    • Posture;
    • Swelling;
    • Lumps/bumps;
    • Colour changes (for example, redness, pallor);
    • Bruising;
    • Deformity (bony or muscular);
    • Muscle bulk symmetry;
    • Muscle atrophy;
    • Temperature changes.

Testing active range of movement
This assesses the movement a patient actively makes themselves in a joint or body part (Ryder and van Griensven, 2018). It allows the clinician to:

  • Assess for any pain reproduction;
  • Identify abnormalities in movement patterns of the joints being assessed;
  • Determine the available range of those joints;
  • Observe any resistance encountered during the movement (Ryder and van Griensven, 2018).

To assess active range of movement, instruct the patient to perform the movements available to them in the joint or location where they are experiencing symptoms. Record any pain response and the quality and degree of movement available. Table2 highlights the movements available in all joints/body parts and Fig1 shows how to test active movement in an elbow joint.

How to assess patients presenting with musculoskeletal conditions (2)How to assess patients presenting with musculoskeletal conditions (3)

Testing passive range of movement
This is an assessment of the movement available at a joint or body part that requires an external force rather than being performed by the patient (Magee and Manske, 2021). Passive range of movement is predominantly assessed by a clinician physically, taking the joint or body part through the range of movement without any active involvement by the patient. This allows the clinician to:

  • Determine the range available at a joint or body part (both restricted or excessive);
  • Ascertain whether there is any reproduction or reduction in symptoms;
  • Assess the end feel of the joint (hard, soft tissue approximation) (Magee and Manske, 2021).

This can be done by assessing the same movements as those outlined in Table2.
Instruct the patient to fully relax the area that is being assessed, while you physically move the joint or body part through the full available range of movements. Fig 2 illustrates examples of how you can assess the passive movement of a patient’s ankle.

How to assess patients presenting with musculoskeletal conditions (4)

Record any pain response or spasm, as well as the degree of movement available and the end feel that is apparent.

Resisted testing
Resisted testing is applying a force during the active movement of a joint or body part (Magee and Manske, 2021). This application of an external resistance can be either through the available active range of movement or statically (isometrically) where a force is applied to elicit a contraction but no movement occurs (Baffour-Awuah et al, 2023). Fig 3 shows elbow resisted isometric testing.

How to assess patients presenting with musculoskeletal conditions (5)

Resisted testing allows the health practitioner to:

  • Determine the strength of contraction available using the Oxford grading scale (Table 3) at a joint or body part;
  • Identify any strength deficits statically or at particular ranges;
  • Identify possible significant pathology to contractile structures (for example, tear/ruptures to muscle/tendon);
  • Ascertain the reproduction of any symptoms. (Magee and Manske, 2021)

How to assess patients presenting with musculoskeletal conditions (6)

To carry out resisted testing, assess the same movements as those performed actively in Table 2, either by resisting the movement throughout the joint range or resisting the movement statically by isolating the movement in the area tested (Fig 3). Do this by instructing the patient to try to carry out the active movement of the muscle, joint or body part that is being assessed, while you physically provide a resistance to that movement – in Fig 4, this is shown with the example of the knee.

How to assess patients presenting with musculoskeletal conditions (7)

Record any pain response or spasm, as well as the grade of muscle strength achieved and degree of movement in which the pain is elicited.

Palpation
Palpation is the act of examining various parts of the body during an assessment, while using touch and feel to identify any abnormalities or elicit a pain response. Below are the potential areas that may be commonly palpated during an MSK assessment:

  • Relevant bony landmarks (for example, greater trochanter of the hip, epicondyle of the humerus);
  • Relevant ligament locations (for example, medial collateral ligament of the knee);
  • Relevant myofascial locations (for example, muscle bellies or tendons);
  • Pulses (if indicated).

Neurological examination
A comprehensive neurological examination should form part of the objective assessment along with various special tests for differing pathologies. As previously highlighted, however, these are beyond the scope of this article.

Clinical reasoning process

Throughout the MSK assessment, you will need to use a logical clinical reasoning process to piece together information from the subjective interview and information from the objective assessment to determine an underlying diagnosis. Consider the:

  • Signs and symptoms that have been reported;
  • Onset of symptoms;
  • Location and description of the symptoms;
  • Associated risk factors for any differential diagnoses for the affected body area.

Use this information, along with any objective signs, to identify a diagnosis for the presenting complaint. Once you have the diagnosis, you can then use it as a basis for your decisions about appropriate treatment and management.

Conclusion

An MSK assessment involves a detailed evaluation of the patient’s subjective history alongside a thorough objective examination. Throughout the assessment, a logical clinical reasoning process is needed so that you can piece together the different components, give an accurate diagnosis and direct treatment and management.

Also in this series

  • How to conduct a clinical consultation in advanced practice
  • History taking for advanced clinical practitioners: what should you ask?
  • Assessing frailty in older people as part of holistic care
  • How to carry out a respiratory assessment in advanced practice
  • How to interpret chest radiographs (X-rays): a systematic approach
  • How to conduct a cardiovascular assessment in advanced practice
  • Performing a cranial nerve examination and interpreting the findings
  • How to assess and examine a patient with abdominal symptoms
  • Understanding microbiology tests and interpreting the results

Advanced practitioners

This series is aimed at nurses and midwives working at, or towards, advanced practice. Advanced practitioners are educated at master’s level and are assessed as competent to make autonomous decisions in assessing, diagnosing and treating patients. Advanced assessment and interpretation is based on a medical model, and the role of advanced practitioners is to integrate this into a holistic package of care.

  • Professional responsibilities -This procedure should be undertaken only after approved training, supervised practice and competency assessment, and carried out in accordance with local policies and protocols.

References

Baffour-Awuah B et al (2023) An evidence-based guide to the efficacy and safety of isometric resistance training in hypertension and clinical implications. Clinical Hypertension; 29: 9.

Carranza CL et al (2014) Endoscopic versus open radial artery harvest and mammario-radial versus aorto-radial grafting in patients undergoing coronary artery bypass surgery: protocol for the 2 × 2 factorial designed randomised NEO trial. Trials; 15: 135.

Copaci D et al (2017) New design of a soft robotics wearable elbow exoskeleton based on shape memory alloy wire actuators. Applied Bionics and Biomechanics; 2017: 1605101

Davies BM et al (2018) Degenerative cervical myelopathy. BMJ; 360: k186.

Dowie I (2021) Understanding the legal considerations of consent in nursing practice. Nursing Standard; 36: 12, 29-34.

Goodman CC, Snyder TEK (2013) Differential Diagnosis for Physical Therapists: Screening for Referral. Elsevier.

Magee DJ, Manske RC (2021) Orthopedic Physical Assessment. Elsevier.

Myers BJ et al (2021) Factors associated with cervical arterial dysfunction: a survey of physical therapist educators in the United States. Journal of Manual and Manipulative Therapy; 29: 1, 33–39.

National Institute of Health and Care Excellence (2023) Sciatica (lumbar radiculopathy): red flag symptoms and signs. cks.nice.org.uk, September (accessed 7 October 2024).

NHS England (no date a) Musculoskeletal health. england.nhs.uk (accessed 7 October 2024).

NHS England (no date b) Person-centred care. hee.nhs.uk (accessed 7 October 2024).

Office for Health Improvement and Disparities (2022) Musculoskeletal health: applying All Our Health. gov.uk, 1 March (accessed 7 October 2024).

Patel N (2023) Passive Range of Motion Exercise. samarpanphysioclinic.com, 3 September (accessed 7 October 2024).

Physiotutors (nd) Testing. physiotutors.com (accessed 7 October 2024).

Poudel P et al (2023) Inflammatory Arthritis. StatPearls Publishing.

Ramanayake RPJC, Basnayake BMTK (2018) Evaluation of red flags minimizes missing serious diseases in primary care. Journal of Family Medicine and Primary Care; 7: 2, 315–318.

Refshauge K, Gass E (2004) Musculoskeletal Physiotherapy: Clinical Science and Evidence-Based Practice. Elsevier.

Ryder D, van Griensven H (2018) Physical examination. In: Petty N, Ryder D (eds) Musculoskeletal Examination and Assessment: A Handbook for Therapists. Elsevier.

Sözen T et al (2017) An overview and management of osteoporosis. European Journal of Rheumatology; 4: 46-56.

van Griensven H, Ryder D (2018) Subjective examination. In: Petty N, Ryder D (eds) Musculoskeletal Examination and Assessment: A Handbook for Therapists. Elsevier.

van Nies JAB et al (2015) Reappraisal of the diagnostic and prognostic value of morning stiffness in arthralgia and early arthritis: results from the Groningen EARC, Leiden EARC, ESPOIR, Leiden EAC and REACH. Arthritis Research and Therapy; 17: 108.

Versus Arthritis (2024) The State of Musculoskeletal Health 2024: Arthritis and Other Musculoskeletal Conditions in Numbers. Versus Arthritis.

Versus Arthritis (2021) The State of Musculoskeletal Health 2021: Arthritis and Other Musculoskeletal Conditions in Numbers. Versus Arthritis.

World Health Organization (2022) Musculoskeletal health. who.int, 14 July (accessed 7October 2024).

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