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Examination Principles in Musculoskeletal Practice

Original Editor - Shala Cunningham

Top Contributors - Ewa Jaraczewska, Jess Bell and Alexandra Stead  

Introduction

Musculoskeletal conditions cause 16% of global disability[1] and are a common reason for people to present to primary healthcare providers.[2] Rehabilitation professionals working in primary healthcare settings and musculoskeletal practice must be able to conduct a thorough, systematic examination to ensure accurate diagnosis, effective patient care and robust clinical decision-making. No single test stands alone—forming a complete clinical picture requires clinicians to synthesise information from all aspects of the evaluation, including the history, observation, movement analysis, functional testing, general assessment, as well as special tests.[3]

Musculoskeletal evaluations tend to follow a consistent flow, from subjective history to objective assessment. This article walks you through the essential components of the examination. It introduces history-taking, red flags, constitutional and psychological symptoms, observation, the upper and lower quarter medical screen, range of motion and manual muscle testing, and special tests.

History

A patient-centred subjective interview is a core element of any musculoskeletal assessment. The mnemonic LMNOPQRST provides a framework for history taking, ensuring all aspects are considered:[4]

  • L: location of symptoms and level of impairment
  • M: medical factors (including medications) and mechanism of injury
  • N: neurological symptoms
  • O: occupation, including limitations
  • P: palliating and provoking symptoms
  • Q: quality of symptoms
  • R: radiation of symptoms
  • S: severity of symptoms
  • T: timing of symptoms

If you would like more information on this approach to the subjective interview, please see: LMNOPQRST Framework for History Taking in Musculoskeletal Rehabilitation.

Screening for Serious Conditions

During the subjective history, clinicians must screen for conditions requiring immediate medical attention through careful questioning. This screening helps determine whether it is safe to proceed with the objective examination and treatment.

Red Flags

“Red flags are specific signs or symptoms that, when present during the patient’s history or physical examination, raise the level of suspicion of an underlying serious or life-threatening condition that may warrant referral for (immediate or urgent) medical attention.”[5]

Red flags are clinical prediction guides, not diagnostic tests. Their main function is to raise a clinician's suspicion of a serious disorder, such as an infection, cancer, or fracture.[6]

Red flags can be general or specific to particular body parts or joints. General red flags include signs such as severe/progressive neurological weakness (e.g. foot drop), significant trauma, unexplained structural deformity, and severe headaches, particularly around the temple.

The 5Ds and 3Ns of the cervical spine are examples of specific red flags. These include: dizziness, diplopia (double vision), drop attacks, dysarthria/dysphasia (speech disorders), dysphagia (swallowing difficulties), nausea/vomiting, numbness, and nystagmus (involuntary eye movements).

If you would like more information on red flags and identifying serious pathology, please see: An Introduction to Red Flags in Serious Pathology.

Constitutional Symptoms

A constitutional symptom is "a symptom or manifestation indicating a systemic or general effect of a disease [...] that may affect an individual's general well-being or status."[7]

Constitutional or systemic symptoms often suggest non-neuromusculoskeletal pathologies that may require specialist referral, such as infectious or oncologic conditions. These symptoms are considered important red flags and must be covered when taking a patient's medical history.[8]

Key constitutional symptoms include:[4]

  • fever
  • unintentional weight loss
  • fatigue that is not relieved by rest
  • night sweats
  • day sweats
  • shortness of breath
  • syncope, dizziness or vertigo
  • change in sleep pattern
  • nausea and vomiting
  • change in bladder and bowel habits

Psychological Screening

Musculoskeletal clinicians should screen for psychological risk factors using formal outcome measures to ensure appropriate and prompt care. According to Sugrue and colleagues,[9] there is a general tendency for clinicians to underestimate the presence of factors such as psychological distress, depression, and anxiety in adults with musculoskeletal back pain. They also note that relying on clinical impression alone cannot accurately identify these factors.[9] Screening questionnaires may help address this issue, enabling clinicians to identify signs of psychological distress and make appropriate referrals.[9]

If you would like to learn more about psychological conditions, interventions and red flags for rehabilitation professionals, please see: Psychological Support in Rehabilitation.

Observation

After completing the subjective history and determining it's safe to proceed, the objective examination begins with observation and progresses through a range of physical tests.

The initial observation can begin as soon as the patient enters the clinic, starting with a quick check of their gait (e.g. use of walking aids, gait deviations, etc.), their demeanour / facial expressions. This early observation provides valuable clues before formal testing begins.

After taking the patient history, it is time to conduct a full visual assessment. This includes a postural assessment (in sitting and standing), as well as looking for swelling, lumps, skin discolouration, bruising, scars, deformity or limb shortening, muscle asymmetry or atrophy, and skin temperature changes. It is also important to observe functional activities, such as a patient's ability to rise from a chair, transfer from sit-to-lie or other relevant movements. Some key areas to look at might include head and shoulder/scapula position, thoracic spine mechanics, and pelvic position.[10][11]

If you would like to read more about the postural assessment, please see: Posture and Sports Screening: Postural Assessment.

Upper Quarter Medical Screen

Completing a systems review is "imperative to [determine] if the patient's symptoms are musculoskeletal and if there is a need for referral. Constitutional symptoms are seen in all systems. The neurological exam determines the presence or absence of nervous system involvement."[4]

When reviewing a patient's medical history, clinicians should document all co-occurring conditions and current treatments, including medications. It is important to note any changes in symptoms since their last visit and to document information on the patient's medication schedule, surgical history, smoking history, and family history.

As mentioned, if new or changing constitutional symptoms are present, the patient may need to be referred to another healthcare provider.

The upper quarter includes the cervical spine, upper thoracic spine and upper limb. Several medical conditions can refer symptoms to the neck, shoulder, scapula, elbow, wrist and hand. Key systems to consider in the upper quarter screen are the cardiovascular, upper gastrointestinal, respiratory and endocrine systems.

Cardiovascular dysfunction can cause symptoms such as difficulty breathing/shortness of breath, nausea, syncope, fatigue, angina, and palpitations. Risk factors for cardiovascular dysfunction include hypertension, high cholesterol, diabetes, smoking, a sedentary lifestyle, poor diet, family history and age.

Dysfunction in the upper gastrointestinal system can cause nausea, vomiting, changes in bowel habits, weight loss, heartburn, and food-related pain.

Respiratory conditions can cause shortness of breath or difficulty breathing and fatigue. They may cause respiratory or chest wall pain and coughing. The diaphragm refers to the upper trapezius, while chest wall pain tends to be felt around the ribcage.

Endocrine system dysfunction can cause symptoms like fatigue, weight loss, frequent urination (associated with diabetes), anxiety, altered hair growth, or non-healing wounds.

The upper quarter neurological screen should include myotome, dermatome, peripheral nerve, and reflex testing. It is important to remember that single nerve root lesions cause subtle changes in strength and sensation, while peripheral nerve lesions cause significant weakness and sensory changes.

Please see Neurological Screen if you would like to learn more about screening reflexes, dermatomes and myotomes.

Lower Quarter Medical Screen

The lower quarter includes the lower thoracic spine, lumbar spine and lower limb. As with the upper quarter medical screen, the lower quarter medical screen should cover a person's medical history, constitutional symptoms and cardiovascular risk factors. It should also determine if there are symptoms associated with the gastrointestinal, genitourinary, endocrine, integumentary, and neurological systems.[4]

In the medical history, clinicians should find out about a patient's comorbidities, current treatments and medications, and if there have been any changes since the last consultation. It is important to find out about all medications, including over-the-counter medicines and supplements, and when they are taken. The history should include surgical history, family medical conditions, and smoking history.

Prompt referral is indicated if patients present with a cluster of constitutional symptoms that aren't attributed to existing conditions or medications.[4]

Various medical conditions can refer symptoms to the lower quarter and should be considered in the lower quarter screen. Key systems to consider are the cardiovascular, gastrointestinal, genitourinary, endocrine and integumentary systems.

Evaluating cardiovascular risk factors is essential. For the lower quarter, it's particularly important to consider vascular components. Major conditions to consider and differentiate between are arterial claudication and deep venous thrombosis (DVT). Individuals with arterial claudication tend to describe a burning, aching pain in the lower leg during activity or exertion. It is caused by insufficient arterial blood supply to the muscles. Deep venous thrombosis (DVT) signs and symptoms include unilateral swelling, calf tenderness/pain, and erythema. It's also important to consider risk factors for DVT, like recent lower-quarter surgery or periods of immobilisation. Remember, the Homan's sign is no longer recommended for DVT diagnosis.[12] If you would like information on these conditions, including assessment and management approaches, please see: Intermittent Claudication and Deep Vein Thrombosis.

Lower quarter symptoms associated with the gastrointestinal systems can include weight loss and changes in bowel habits (e.g., frequency, volume, consistency, colour) and incontinence. Lower abdominal pain and cramping may accompany these symptoms.

Genitourinary symptoms to look for include incontinence or changes in bladder habits (frequency, haematuria, dysuria). Important changes include new discharge or changes in menstruation in females and erectile dysfunction in males.

Endocrine system issues can be indicated by weight loss and fatigue. Polydipsia (excessive thirst) and polyuria (excessive urination) are associated with diabetes. Diabetic vascular changes can lead to reduced hair growth in the lower extremity ("sock alopecia"), dry/shiny skin, and poor nail growth.

When screening the integumentary system, clinicians should consider a person's risk factors for pressure injuries and screen the feet of all people with diabetes.[13] During the course of an assessment, musculoskeletal clinicians might spot suspicious skin lesions or moles. The ABCDE mnemonic for melanoma can be a useful tool:[14]

  • A = asymmetry
  • B = border irregularity
  • C = colour variability / change
  • D = diameter
  • E = evolving

The EFG mnemonic can also be added to this:[14]

  • E = elevated
  • F = firm
  • G = growing

If musculoskeletal clinicians notice a lesion or mole that looks suspicious to them, it's important to recommend that the patient be reviewed by their doctor or dermatologist. If you would like to learn more about this framework, please click here.

Like in the upper quarter, the neurological lower quarter screen assesses for weakness, altered sensation, and cauda equina symptoms (saddle numbness, bowel/bladder changes). It is important to differentiate overlapping dermatome involvement from peripheral nerve distribution changes.

Range of Motion

The active range of motion (AROM) assessment evaluates both contractile and non-contractile tissues. It helps clinicians determine the location and quality of pain or other symptoms, such as pulling, numbness, tingling, weakness, etc. Clinicians should also take note of movement quality and check if any compensatory movements are present. Various tools can be used to measure range of motion, including goniometers, inclinometers and various smartphone apps.[4]

The passive range of motion (PROM) assessment evaluates all tissues except for contractile tissue. When assessing passive range of motion, clinicians should look for pain/discomfort, taking note of the location and quality of pain, where in the patient's range pain occurs, and any neurological symptoms. Again, they should consider the quality of the movement, noting factors such as crepitus, resistance, and end feel.[4]

All findings from the active and passive range of motion assessment should be documented. These tests can be repeated to track progress or changes.

If you would like to learn more about these assessments, please see: Assessing Range of Motion.

Manual Muscle Testing

Manual Muscle Testing (MMT) is an effective way to assess muscle strength in clinical practice.[15] Manual muscle testing can also assess symptom response when weakness is not the primary concern. When testing for symptom response, the clinician performs the resisted test in three different ranges.[4]

To learn more about manual muscle testing and the strength assessment, please see: Assessing Muscle Strength.

Hypothesis Generation

Dr. James Cyriax developed a method called selective tissue tension testing to help clinicians determine the acuity or severity of an injury and which structures are most likely causing a person's pain.[16] This test includes active range of motion, passive range of motion, resisted tests, and palpation.[16]

This sequence of tests can help determine if the cause of a person's issue is non-contractile tissue (cartilage, capsule, ligament) or contractile tissue, motor control or coordination:[4]

  • if active and passive range of motion are painful and limited in the same direction, it is probably non-contractile tissue (e.g., cartilage, capsule, ligament)
  • if active and passive range of motion are painful and limited in opposite directions, and resisted motion is painful, it is probably contractile tissue (e.g., muscle)
  • if active range of motion is limited and passive range of motion is significantly improved or within normal limits, and painless, it is probably a motor control or coordination issue

By using this process, clinicians are able to narrow down which special tests to include in their assessment.

If you would like to learn more about Cyriax's theory, end feel, and capsular patterns, please see: Capsular and Non-Capsular Patterns and Resisted Isometric Movement Testing.

Special Tests

"Special tests never stand alone. Your test results should coincide with your previous testing. So your history, observation, palpation, active range of motion, passive range of motion, and resisted tests should all come together and form a picture."[4]

Special tests vary in terms of their reliability and diagnostic utility. Accuracy is also influenced by the examiner's proficiency and experience.[17] Special tests are often performed in clusters or groups. When all results from a cluster are considered together, a clinician is better able to rule a condition in or out.

For condition-specific discussions of some key special tests, please see these pages:

Reliability and Diagnostic Utility of the Clinical Exam

"The reliability of the test tells us if it can produce precise, accurate, reproducible information. (....) Diagnostic accuracy or validity tells us if the test is testing what we want it to test."[4]

The diagnostic utility of a special test is determined by its sensitivity, specificity, positive predictive value, and negative predictive value.[18] If you would like to learn more about these concepts, please see: Test Diagnostics and Psychometric Properties.

Treatment Planning

Clinicians must draw on all of the information gained during a systematic examination when developing their treatment plan, including symptoms, impairments and functional limitations. The hypothetical diagnosis must take into account all aspects of the patient's presentation—if you are unable to connect some aspects with your diagnosis, it may be necessary to refer your patient to another healthcare provider.

Your treatment plan must directly relate to a patient's diagnosis, impairments, and functional limitations. The patient's prognosis will depend on the range of factors identified in your assessment, including comorbid conditions, the number of impairments and their overall complexity.[4]

Resources

References

  1. ↑ Lowe C, Sephton R, Marsh W, Morrissey D. Evaluation of a Musculoskeletal Digital Assessment Routing Tool (DART): Crossover Noninferiority Randomized Pilot Trial. JMIR Form Res. 2024 Jul 30;8:e56715.
  2. ↑ Haas R, Gorelik A, Busija L, O'Connor D, Pearce C, Mazza D, Buchbinder R. Prevalence and characteristics of musculoskeletal complaints in primary care: an analysis from the population level and analysis reporting (POLAR) database. BMC Prim Care. 2023 Feb 4;24(1):40.
  3. ↑ Kumar R, Marla K, Sporn K, Paladugu P, Khanna A, Gowda C, Ngo A, Waisberg E, Jagadeesan R, Tavakkoli A. Emerging Diagnostic Approaches for Musculoskeletal Disorders: Advances in Imaging, Biomarkers, and Clinical Assessment. Diagnostics. 2025; 15(13):1648.
  4. ↑ 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 4.09 4.10 4.11 Cunningham S. Examination Principles in Musculoskeletal Practice Course. Physiopedia Plus, 2025.
  5. ↑ Storari L, Piai J, Zitti M, Raffaele G, Fiorentino F, Paciotti R, Garzonio F, Ganassin G, Dunning J, Rossettini G, Feller D, Heick JD, Mourad F, Maselli F. Standardized Definition of Red Flags in Musculoskeletal Care: A Comprehensive Review of Clinical Practice Guidelines. Medicina (Kaunas). 2025 May 28;61(6):1002.
  6. ↑ Finucane LM, Downie A, Mercer C, Greenhalgh SM, Boissonnault WG, Pool-Goudzwaard AL et al. International Framework for Red Flags for Potential Serious Spinal Pathologies. J Orthop Sports Phys Ther. 2020;50(7):350-372.
  7. ↑ Human Phenotype Ontology Browser. Available from https://www.informatics.jax.org/vocab/hp_ontology/HP:0025142 [last accessed 7.7.2025]
  8. ↑ Singh K. Spine Essentials Handbook: A Bulleted Review of Anatomy, Evaluation, Imaging, Tests, and Procedures. First edition. New York: Thieme. 2019
  9. ↑ 9.0 9.1 9.2 Sugrue J, McKenna S, Purtill H, O'Sullivan K. Screening for depression, anxiety, and psychological distress associated with low back pain by musculoskeletal and spinal clinicians. A scoping review. Eur Spine J. 2025 Apr;34(4):1319-1330.
  10. ↑ Weisman A, Masharawi Y. Does Altering Sitting Posture Have a Direct Effect on Clinical Shoulder Tests in Individuals With Shoulder Pain and Rotator Cuff Degenerative Tears? Phys Ther. 2019 Feb 1;99(2):194-202.
  11. ↑ Lobbos BS, Essa MMM, Khaireldin A, Gamal El-Din MY, Rizkallah P, Samy HA. Influence of pelvic position on shoulder range of motion. BMC Musculoskelet Disord. 2025 Jan 17;26(1):60.
  12. ↑ Ambesh P, Obiagwu C, Shetty V. Homan's sign for deep vein thrombosis: A grain of salt? Indian Heart J. 2017 May-Jun;69(3):418-419.
  13. ↑ George SZ, Beneciuk JM, Bialosky JE, Lentz TA, Zeppieri G Jr, Pei Q, Wu SS. Development of a Review-of-Systems Screening Tool for Orthopaedic Physical Therapists: Results From the Optimal Screening for Prediction of Referral and Outcome (OSPRO) Cohort. J Orthop Sports Phys Ther. 2015 Jul;45(7):512-26.
  14. ↑ 14.0 14.1 DermNet. ABCDEFG of melanoma. Available from: https://dermnetnz.org/topics/abcdes-of-melanoma (accessed 3 August 2025).
  15. ↑ Bittmann FN, Dech S, Aehle M, Schaefer LV. Manual Muscle Testing-Force Profiles and Their Reproducibility. Diagnostics (Basel). 2020 Nov 25;10(12):996.
  16. ↑ 16.0 16.1 The Cyriax Method. Available from https://cyriaxphysio.com/wp/the-cyriax-method/ [last accessed 9.7.2025]
  17. ↑ Special tests in injury examination. Available from https://us.humankinetics.com/blogs/excerpt/special-tests-in-injury-examination [last accessed 9.7.2025]
  18. ↑ Badrick T, Bowling F. Clinical utility - Information about the usefulness of tests. Clin Biochem. 2023 Nov;121-122:110656.
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