MUSCULOSKELETAL Assessment Scripy

MUSCULOSKELETAL
1. Ask pt if she felt any muscle pain in her arms, legs or back, limitation to movement in her
ADLs, hx of previous sport injury, loss of function w/o pain.
2. Assess the pt. neck movements. Touch her neck with her chin. Touch the shoulders side-to-
side.
3. Inspect the upper extremities. Observe for skin color, presence of lesion, rashes and muscle
mass. Palpate for presence of lesions, rashes and presence of masses.
4. Inspect muscle size (arms, thigh, calves) (Normal): Pt. has equal body size, both sides of
her muscles in her arms, thighs and calves are equal as well.
5. Inspect the muscle and tendons for contractures. For muscle length testing, I will passively
move your extremity with the origin fixed while I elongate the muscle. I will just move your right
hip flexor and later on your left side as well. (Normal): Pt. doesn't have any tightness or
contractures on both of the right and left hip flexors. findings are normal.
6. Inspect the muscle for tremor. What I want you to do is stretch out your hands forward. Alright
good! (Normal): Based on my assessment, pt. did not have any shaky movements while
performing what is asked of her. This is a normal finding.
MUSCLE STRENGTH
UPPER
1. Deltoid
2. Biceps
3. Ask the patient to extend arms forward and then rapidly turn palms up and down.
4. Ask the patient to flex upper arm and to resist examiner’s opposing force.
5. Grip strength
6. Inspect and palpate the hands, fingers, wrists and elbow joints palpate the hands.
7. Palpate the radial and brachial pulses.
8. Ask the patient to close his/her eyes. Place a familiar objects such as a key in the patient’s
hand and ask him/her to identify the objects, Repeat on the other hand with a different object.
9. Ask the patient to close his/her eyes. Using your finger or applicator, trace a one digit number
on the patient’s palm and ask him or her to identify the number. Repeat on the other hand with
a different number.
LOWER EXTREMITIES
1. Assist the patient to a supine position, Examine the lower extremities. Inspect the legs and feet
for color, lesion, varicosities, hair growth, nail growth, edema and muscle mass.
2. Test for pitting edema in the pretibial area by pressing fingers into the skin of pretibial area. If
an indentation remains in the skin after the fingers have been lifted pitting edema is present.
3. Palpate for pulse and skin temperature at the posterior tibial, dorsalis pedis and popliteal
areas.
4. Have the patient perform the straight leg test with one leg at a time.
5. Hip ABDUCTION
6. Hip ADDUCTION
7. Knee FLEXION
8. Knee EXTENSION
9. Ask the patient to raise the thigh against the resistance off your hands, next have the patient
push outward against the resistance of your hands, then have the patient pull backward
against the resistance of your hand. Repeat on the opposite side.
(Normal): OK so Ms. Rose your muscle strength on both of your upper and lower
extremities is graded 5/5 which means good strength as you can resist maximal force. So
this is a normal finding.
10. Assess the patient deep tendon reflex
10.1 Place your fingers above the patient’s wrist and tap with reflex hammer, repeat on the
other arm.
10.2 Place your fingers over the antecubital area (biceps) and tap with a reflex hammer
repeat on the other side.
10.3 Place your finger over the with a triceps tendon area and tap with a reflex hammer,
repeat on the other side.
10.4 Tap just below the patella with a reflex hammer, repeat on the other side.
10.5 Tap over the Achilles tendon area with reflex hammer, repeat on the other side.
10.6 Stroke the sole of the patient’s foot with the end of a reflex hammer handle or other hard
object such as key; repeat on the other side.
(Normal): OK so upon inspection, the toes of the patient curls as I perform the plantar reflex
which means the pt. is negative for Babinski reflex.
Babinski Reflex – dorsiflexion & fanning of the toes common to children-up to 2 yrs of age. If this
is present in adults = Upper motor neuron disease.
11. Ask the patient to dorsiflex and then plantarflex both feet against the opposing resistance.
12. As needed, assist the patient to a standing position. Observe the patient as he/she walks with
a regular gait on the toes on the heels and then heel to toe.

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