MSK Assessment

History of Presenting Injury

  1. Region
  2. Date of Onset
  3. Mechanism of Injury
  4. Medical Attention to date
    1. Physician
    2. Imaging
    3. Medications
  5. Pending Consults / Orders
  6. Getting better?

Medical History

  1. Previous Injury?
  2. Did it fully resolve?
  3. Family Hx
  4. Hx of Surgery
  5. Other
  • Recent illness / fevers / sweats
  • Recent overseas / long haul travel / immobilization (eg for suspected DVT)
  • Loss of appetite / loss of weight, etc

Subjective

  1. Primary Complaint
  2. Location
  3. Referred pain?
  4. Nature
  5. Frequency
  6. Intensity
  7. Time to resolve
  8. Triggers
  9. Relieves
  10. Wake patient?

Physical Exam

  1. Observation
    1. Need to look at site of interest, as well as joints above and below
    2. expose the bodypart
    3. Deformity / Swelling / Bruising
  2. Quick Tests
    1. Gait
    2. Deep squat
    3. Single leg
    4. Proprioception / Balance
  3. Active ROM
    1. Physiological Movements (including joints above and below)
    2. Ask to the patient to move actively
    3. Active assisted if reluctant to move and does not cause distress
  4. Palpation
    1. Palpate the bones from the joint above the problem, to the joint below
    2. Palpate soft tissue structures
    3. Be specific to what you are palpating
  5. Special Tests
    1. Specific to the area(s) of interest
    2. Used to:
      1. Clear a region
      2. Potentially diagnose pathology eg Lachmans
  6. Distal Neurovascular Function
    1. Sensation
    2. Power
    3. Reflexes
    4. Colour
    5. Movement
    6. Warmth
    7. Sensation
    8. Capillary Refill
    9. Pulses
      1. Upper Limb (Radial, Brachial)
      2. Lower Limb (Dorsalis Pedis, Posterior Tibial, Popliteal)

Social History

  1. Occupation
  2. Residence / Live with
  3. Stairs
    1. Entry and #
    2. Inside and #
  4. Support System
    1. Who would they call for help
    2. Community Services
    3. Social Program
    4. Home Care
  5. Home equipment
    1. Walking
    2. Bathroom
    3. Bedroom
    4. Washroom
    5. Shower / Tub
  6. History of Falls
    1. How many
    2. Last fall
    3. Where
    4. Reason why?
    5. Able to Get up
    6. Call for help?
    7. Injuries
    8. Fear
  7. Mobility PRIOR
    1. Supine to Sit
    2. Sit to Stand
    3. Ambulation
    4. Stairs
    5. BADL
    6. IADL