Key Takeaways
- Goniometry measures joint ROM; normal values include shoulder flexion (180 degrees), knee flexion (135 degrees), and hip flexion (120 degrees)
- Manual Muscle Testing (MMT) uses a 0-5 grading scale: 0=No contraction, 1=Trace, 2=Full ROM gravity eliminated, 3=Full ROM against gravity, 4=Full ROM against moderate resistance, 5=Normal
- Special tests for the shoulder include Neer (impingement), empty can/Jobe (supraspinatus), Speed (biceps), and Hawkins-Kennedy (impingement)
- Special tests for the knee include Lachman (ACL — most sensitive), anterior drawer (ACL), McMurray (meniscus), and valgus/varus stress tests (MCL/LCL)
- Dermatome testing assesses sensory nerve root integrity: C5 (lateral arm), C6 (lateral forearm/thumb), C7 (middle finger), L4 (medial leg), L5 (dorsal foot), S1 (lateral foot)
- Myotome testing assesses motor nerve root integrity: C5 (shoulder abduction), C6 (elbow flexion/wrist extension), C7 (elbow extension/wrist flexion), L4 (ankle dorsiflexion), L5 (great toe extension), S1 (ankle plantarflexion)
- Posture analysis identifies common deviations: forward head, increased thoracic kyphosis, lumbar lordosis, genu valgum/varum, and scoliosis
- End-feel assessment distinguishes normal (bone-to-bone, soft tissue approximation, tissue stretch) from abnormal (empty, spasm, springy block) end-feels
Musculoskeletal Examination & Evaluation
Physical therapy examination of the musculoskeletal system requires a systematic approach using standardized tools and tests. The NPTE tests your ability to select appropriate examination techniques, interpret findings, and make clinical decisions.
Range of Motion (ROM) Assessment
Goniometry
Goniometry is the standard method for measuring joint ROM. Key normal values every PT should know:
| Joint | Motion | Normal ROM (degrees) |
|---|---|---|
| Shoulder | Flexion | 0-180 |
| Shoulder | Abduction | 0-180 |
| Shoulder | External rotation | 0-90 |
| Shoulder | Internal rotation | 0-70 |
| Elbow | Flexion | 0-150 |
| Wrist | Extension | 0-70 |
| Hip | Flexion | 0-120 |
| Hip | Extension | 0-30 |
| Hip | Abduction | 0-45 |
| Knee | Flexion | 0-135 |
| Ankle | Dorsiflexion | 0-20 |
| Ankle | Plantarflexion | 0-50 |
End-Feel Assessment
End-feel is the quality of resistance felt at the end of passive ROM:
| End-Feel Type | Description | Example |
|---|---|---|
| Bone-to-bone (normal) | Hard, abrupt stop | Elbow extension (olecranon into fossa) |
| Soft tissue approximation (normal) | Soft, compressible stop | Knee flexion, elbow flexion |
| Tissue stretch (normal) | Firm, elastic stop | Ankle dorsiflexion, hip flexion (with knee extended) |
| Empty (abnormal) | Patient stops motion due to pain before end range; no mechanical resistance | Acute bursitis, fracture |
| Spasm (abnormal) | Sudden muscle guarding stops motion | Acute inflammation, joint irritability |
| Springy block (abnormal) | Rebound at end range | Meniscal tear, loose body in joint |
Manual Muscle Testing (MMT)
The MMT grading scale assesses muscle strength on a 0-5 scale:
| Grade | Description | Patient Ability |
|---|---|---|
| 5 (Normal) | Full ROM against gravity with maximum resistance | Holds against strong resistance |
| 4 (Good) | Full ROM against gravity with moderate resistance | Holds against moderate resistance but breaks |
| 3 (Fair) | Full ROM against gravity only | Moves through range against gravity but no added resistance |
| 2 (Poor) | Full ROM with gravity eliminated | Moves through range only with gravity eliminated |
| 1 (Trace) | Visible or palpable muscle contraction | No joint motion produced |
| 0 (Zero) | No detectable muscle contraction | No visible or palpable contraction |
Plus (+) and Minus (-) modifiers can be used to further refine grading (e.g., 4+, 3-, 2+). A muscle graded 3/5 is the critical threshold — it indicates the minimum strength needed to move against gravity.
Special Tests
Shoulder Special Tests
| Test | Structure Tested | Positive Finding |
|---|---|---|
| Neer test | Subacromial impingement | Pain with passive shoulder flexion, arm internally rotated |
| Hawkins-Kennedy | Subacromial impingement | Pain with shoulder flexed 90 degrees, then internally rotated |
| Empty can (Jobe) | Supraspinatus (rotator cuff) | Weakness or pain with resisted abduction at 90 degrees, 30 degrees horizontal adduction, thumbs down |
| Drop arm test | Rotator cuff tear | Inability to slowly lower arm from 90 degrees abduction |
| Speed test | Biceps tendon | Pain in bicipital groove with resisted shoulder flexion, elbow extended, forearm supinated |
| Apprehension test | Anterior glenohumeral instability | Patient apprehension with shoulder abducted 90 degrees and externally rotated |
Knee Special Tests
| Test | Structure Tested | Positive Finding |
|---|---|---|
| Lachman test | ACL (most sensitive) | Excessive anterior tibial translation at 20-30 degrees flexion, soft/mushy end-feel |
| Anterior drawer | ACL | Excessive anterior tibial translation at 90 degrees flexion |
| Posterior drawer | PCL | Excessive posterior tibial translation at 90 degrees flexion |
| McMurray test | Meniscus | Click or pain with tibial rotation during knee extension from flexion |
| Valgus stress test | MCL | Excessive medial joint opening with valgus force at 30 degrees flexion |
| Varus stress test | LCL | Excessive lateral joint opening with varus force at 30 degrees flexion |
Cervical/Lumbar Special Tests
| Test | What It Assesses | Positive Finding |
|---|---|---|
| Spurling test | Cervical nerve root compression | Radicular symptoms with cervical extension, lateral flexion, and axial compression |
| Straight leg raise (SLR) | Lumbar nerve root (L4-S1) | Radicular pain at 30-70 degrees of hip flexion |
| Slump test | Neural tension (sciatic nerve) | Reproduction of symptoms with progressive neural tension |
| Phalen test | Carpal tunnel syndrome (median nerve) | Numbness/tingling in median nerve distribution with sustained wrist flexion for 60 seconds |
Which special test is considered the MOST sensitive for diagnosing an ACL tear?
A patient can move their arm through full shoulder flexion ROM against gravity but cannot hold against any added resistance. What is their MMT grade?
A PT performs passive knee flexion and feels a rebound at end range. This abnormal end-feel is classified as:
Match each special test to the structure it primarily assesses.
Match each item on the left with the correct item on the right
The Spurling test is positive when cervical extension, ipsilateral lateral flexion, and axial compression reproduce:
A Manual Muscle Testing grade of _____ out of 5 indicates the patient can complete full ROM against gravity but cannot tolerate any additional resistance.
Type your answer below
A positive straight leg raise (SLR) test that reproduces radicular symptoms at 45 degrees of hip flexion MOST likely indicates:
Normal ankle dorsiflexion ROM is approximately:
The C7 dermatome is tested by assessing sensation over which area?