1.2 Musculoskeletal Examination & Evaluation
Key Takeaways
- Goniometry measures joint ROM; know normals such as shoulder flexion 0-180, elbow flexion 0-150, knee flexion 0-135, hip flexion 0-120, ankle dorsiflexion 0-20
- MMT uses a 0-5 scale: 0 none, 1 trace, 2 full ROM gravity-eliminated, 3 full ROM against gravity, 4 against moderate resistance, 5 normal
- Shoulder special tests: Neer and Hawkins-Kennedy (impingement), empty-can/Jobe (supraspinatus), Speed (biceps), drop-arm (cuff tear), apprehension (instability)
- Knee special tests: Lachman (most sensitive for ACL), anterior drawer (ACL), posterior drawer (PCL), McMurray (meniscus), valgus/varus stress (MCL/LCL)
- Dermatomes map sensation: C6 thumb, C7 middle finger, T4 nipple, T10 umbilicus, L4 medial leg, L5 dorsal foot, S1 lateral foot
- Myotomes map motor roots: C5 shoulder abduction, C6 elbow flexion, C7 elbow extension, L4 dorsiflexion, L5 great-toe extension, S1 plantarflexion
- Spurling reproduces cervical radicular symptoms; straight-leg raise reproduces lumbar (L4-S1) radicular pain at 30-70 degrees
- End-feels are normal (bony, soft-tissue approximation, tissue stretch) or abnormal (empty, spasm, springy block)
A musculoskeletal examination is systematic: history, observation/posture, ROM, strength, special tests, palpation, and neurologic screening. The NPTE tests your ability to select the right measure, perform it correctly, and interpret the result within the management model.
Range of Motion (ROM) and Goniometry
Goniometry is the standard for measuring joint ROM. Memorize these normals:
| Joint | Motion | Normal ROM (deg) |
|---|---|---|
| Shoulder | Flexion / Abduction | 0-180 |
| Shoulder | External / Internal rotation | 0-90 / 0-70 |
| Elbow | Flexion | 0-150 |
| Wrist | Flexion / Extension | 0-80 / 0-70 |
| Hip | Flexion / Extension | 0-120 / 0-30 |
| Hip | Abduction | 0-45 |
| Knee | Flexion | 0-135 |
| Ankle | Dorsiflexion / Plantarflexion | 0-20 / 0-50 |
Functional minimums matter: gait needs about 10 degrees of dorsiflexion at midstance and roughly 65 degrees of knee flexion in swing; stairs demand more. A capsular ROM limitation that affects all motions in a predictable ratio (the capsular pattern) suggests arthritis or capsulitis, whereas a single-plane block suggests a mechanical (e.g., meniscal) cause.
End-Feel Assessment
End-feel is the quality of resistance felt at the end of passive ROM, and it helps distinguish capsular from mechanical from irritable joints:
| End-Feel | Type | Description / Example |
|---|---|---|
| Bone-to-bone | Normal | Hard, abrupt; elbow extension |
| Soft-tissue approximation | Normal | Soft, compressible; knee/elbow flexion |
| Tissue stretch (firm/elastic) | Normal | Firm springy; ankle dorsiflexion, hip flexion (knee straight) |
| Empty | Abnormal | Patient halts from pain before mechanical resistance; acute bursitis, fracture |
| Spasm | Abnormal | Sudden guarding; acute inflammation/irritability |
| Springy block | Abnormal | Rebound; meniscal tear or loose body |
Manual Muscle Testing (MMT)
| Grade | Name | Patient ability |
|---|---|---|
| 5 | Normal | Full ROM vs gravity, holds maximal resistance |
| 4 | Good | Full ROM vs gravity, holds moderate resistance but breaks |
| 3 | Fair | Full ROM vs gravity, tolerates no added resistance |
| 2 | Poor | Full ROM only with gravity eliminated |
| 1 | Trace | Palpable/visible contraction, no joint motion |
| 0 | Zero | No detectable contraction |
3/5 is the pivotal grade — the minimum strength to move a part against gravity. Below 3/5, you must reposition the limb into a gravity-eliminated plane to test accurately. Plus/minus modifiers (e.g., 3+, 4-) refine grading.
Special Tests
Shoulder
| Test | Structure | Positive finding |
|---|---|---|
| Neer | Subacromial impingement | Pain on passive flexion with internal rotation |
| Hawkins-Kennedy | Subacromial impingement | Pain at 90 deg flexion then internal rotation |
| Empty can (Jobe) | Supraspinatus | Pain/weakness with resisted 'thumbs-down' elevation |
| Drop-arm | Rotator cuff tear | Cannot slowly lower arm from 90 deg abduction |
| Speed | Long head of biceps | Bicipital-groove pain on resisted flexion, elbow straight, forearm supinated |
| Apprehension/relocation | Anterior GH instability | Apprehension at 90 deg abduction + external rotation |
Knee
| Test | Structure | Positive finding |
|---|---|---|
| Lachman | ACL (most sensitive) | Excess anterior tibial translation at 20-30 deg, soft end-feel |
| Anterior drawer | ACL | Excess anterior translation at 90 deg |
| Posterior drawer | PCL | Excess posterior translation at 90 deg |
| McMurray | Meniscus | Click/pain with tibial rotation during extension |
| Valgus stress (30 deg) | MCL | Medial joint opening |
| Varus stress (30 deg) | LCL | Lateral joint opening |
The Lachman outperforms the anterior drawer because at 20-30 degrees the hamstrings are relaxed and cannot mask ACL laxity; at 90 degrees (drawer) they can splint the joint and produce a false negative.
Neurologic Screening: Dermatomes and Myotomes
Localizing a nerve-root lesion is one of the most testable MSK examination skills.
| Root | Dermatome (sensory) | Myotome (motor) |
|---|---|---|
| C5 | Lateral arm (deltoid patch) | Shoulder abduction (deltoid) |
| C6 | Lateral forearm, thumb | Elbow flexion / wrist extension |
| C7 | Middle finger | Elbow extension / wrist flexion |
| C8 | Little finger, medial forearm | Finger flexion |
| T4 / T10 | Nipple line / umbilicus | — |
| L4 | Medial leg | Ankle dorsiflexion (tib. anterior) |
| L5 | Dorsal foot, 1st web space | Great-toe extension (EHL) |
| S1 | Lateral foot, small toe | Ankle plantarflexion (gastroc/soleus) |
Spine and Peripheral-Nerve Tests
- Spurling (cervical): extension + ipsilateral side-bend + axial compression reproduces radicular arm symptoms — positive for nerve-root compression. Local neck pain alone is not positive.
- Straight-leg raise (SLR): reproduces L4-S1 radicular pain (below the knee) between 30-70 degrees of hip flexion; pain only in the posterior thigh suggests hamstring tightness.
- Slump test: progressive neural tension along the sciatic tract reproduces symptoms.
- Phalen (wrist): sustained 60-second flexion reproduces median-nerve paresthesia in carpal tunnel syndrome; Tinel taps the nerve to elicit tingling.
Sequencing the Examination
The order of an MSK examination is itself testable: gather history, then observe posture and willingness to move, then screen ROM and strength, then apply special tests, and reserve provocative or end-range maneuvers for last so that irritating the joint early does not contaminate the rest of the exam. Always include a neurologic screen (dermatomes, myotomes, reflexes) when symptoms could be referred from the spine, and clear the joint above and below the painful region. This systematic sequence both protects the patient and produces the clean, interpretable findings the exam expects you to act on.
Which special test is MOST sensitive for an ACL tear?
A patient completes full shoulder-flexion ROM against gravity but tolerates no added resistance. The MMT grade is:
Passive knee flexion produces a rebound at end range. This abnormal end-feel is:
Match each special test to the structure it assesses.
Match each item on the left with the correct item on the right
The Spurling test is positive when cervical extension, ipsilateral side-bend, and axial compression reproduce:
An MMT grade of _____ out of 5 means full ROM against gravity but no tolerance for added resistance.
Type your answer below
A positive straight-leg raise reproducing radicular pain at 45 degrees of hip flexion most likely indicates:
Normal ankle dorsiflexion ROM is approximately:
The C7 myotome is best tested by resisting which action?