The Objective/Physical MSK Exam

• Non-MSK Systems Screening

• Cognitive, Cardio-pulmonary, Integumentary, Neuromuscular
• Observation & Posture Assessment
• Gait Evaluation
• Simple Functional & Balance Screening
• Referring or Related Structure(s) Screening
• Palpation
• Anthropometrics
• ROM Assessment
• AROM
• PROM
• Joint Play Assessment
• Muscle Length/Flexibility Testing
• Muscle Strength/Torque Testing
• Special Tests
• Complex Functional/Muscle Performance Testing
 Anthropometrics: Assessing Ankle
Swelling
• Volumetrics
• Figure-8 measurement (Esterson JOSPT 1979)
1. Start w/ tip of tape on tibialis anterior tendon
2. Pull tape medially over navicular tuberosity,
then infero-laterally across medial arch to 5th
MT base
3. Then pull superiorly & medially over tarsals,
then just distal to tip of medial malleolus,
around Achilles & then just distal to tip of
lateral malleolus then finish at tib anterior
tendon
• SEM ±0.2cm / Intra- & inter-rater ICC > 0.99
(Tatro-Adams et al. JOSPT 1995)
The Objective/Physical MSK Exam
• Non-MSK Systems Screening
• Cognitive, Cardio-pulmonary, Integumentary, Neuromuscular
• Observation & Posture Assessment
• Gait Evaluation
• Simple Functional & Balance Screening
• Referring or Related Structure(s) Screening
• Palpation
• Anthropometrics
• ROM Assessment
• AROM
• PROM
• Joint Play Assessment
• Muscle Length/Flexibility Testing
• Muscle Strength/Torque Testing
• Special Tests
• Complex Functional/Muscle Performance Testing
Joint ROM Assessment Technique:
P.R.E.
Hint: Use “P.R.E.” to remember correct sequence
• P: Passive ROM assessment
• R: Resting position measurement IF joint cannot achieve 0°
start angle
• E: Ending position measurement using goniometer or
inclinometer
LLAF ROM Competencies
• Measure ROM using a goniometer or inclinometer AND assess
overpressure end-feel
1. NWB Ankle dorsiflexion
2. WB Ankle DF (via the weightbearing lunge test-WBLT)
3. Ankle plantarflexion
4. STJ inversion
5. STJ eversion
6. Metatarsophalangeal flexion/extension
7. Interphalangeal flexion/extension
 Ankle DF via the WB Lunge Test
(WBLT)
• Pt: standing on floor
1. While keeping heel on floor,
flex knee to DF ankle to
limit
• PT:
1. Palpate calcaneus & cue pt.
to stop when it starts to lift
2. Measure ankle DF angle
using inclinometer placed
just below tibial tubercle
The Objective/Physical MSK Exam
• Non-MSK Systems Screening
• Cognitive, Cardio-pulmonary, Integumentary, Neuromuscular
• Observation & Posture Assessment
• Gait Evaluation
• Simple Functional & Balance Screening
• Referring or Related Structure(s) Screening
• Palpation
• Anthropometrics
• ROM Assessment
• AROM
• PROM
• Joint Play Assessment
• Muscle Length/Flexibility Testing
• Muscle Strength/Torque Testing
• Special Tests
• Complex Functional/Muscle Performance Testing
PROM Assessment
• Whenever AROM is limited, you
should try to find out “why?”

• Two exam techniques can help

answer “why?”

1. PROM

2. Joint Play Assessment (JPA)

PROM Assessment: Purpose
■ Scenario 1: Loss of AROM w/ NO loss of PROM suggests weakness
as cause of AROM loss
■ E.g. Pt. unable to actively dorsiflex ankle in supine but you can passively
dorsiflex patient’s ankle…suggests dorsiflexor weakness (which could be
due to a torn tibialis anterior muscle or tendon or denervation from
fibular nerve damage
■ Scenario 2: Loss of AROM w/ loss of PROM suggests joint
restriction or antagonist muscle tightness as cause of AROM loss
■ E.g. Pt. unable to actively dorsiflex ankle in supine and you cannot
passively dorsiflex ankle …suggests ankle joint impairment or short
plantarflexors/Achilles tendon
PROM not PROM also
limited limited

Joint restriction
or antagonist
Weakness
muscle
shortening
The Objective/Physical MSK Exam
• Non-MSK Systems Screening
• Cognitive, Cardio-pulmonary, Integumentary, Neuromuscular
• Observation & Posture Assessment
• Gait Evaluation
• Simple Functional & Balance Screening
• Referring or Related Structure(s) Screening
• Palpation
• Anthropometrics
• ROM Assessment
• AROM
• PROM
• Joint Play Assessment
• Muscle Length/Flexibility Testing
• Muscle Strength/Torque Testing
• Special Tests
• Complex Functional/Muscle Performance Testing
 Passive Joint Play Assessment (JPA)
• If passive EROM is limited, assess Passive
Joint Play i.e. passive arthrokinematic
movements to determine if a jt. restriction
is present
• JPAs enable clinician to assess joint surface
integrity, capsuloligamentous integrity, &
concordant symptom response
• Arthrokinematics = roll, glide/slide, spin
• Most of the time JPA refers to the
glide/slide element i.e. passive gliding
of one joint surface on another
 Passive JPA
• Jt. play movements are named for the
direction in which you are moving bony
segment
• E.g. “Lateral STJ glide”: while stabilizing
talus & distal tib/fib on table edge, glide
calcaneus in a lateral direction (how
would you do a medial glide of same
joint?)
• E.g. “Posterior TCJ glide”: while
stabilizing distal tib/fib on table edge,
glide talus in a posterior direction (how
would you do an anterior glide of same
joint?)
Document as hypomobile, normal,
hypermobile, or unstable
 Passive JPA
• E.g. “Posterior distal fibular glide”:
while stabilizing distal tibia on table
edge, glide distal fibula in a
posterior direction
• ‘Cup’ distal fibula & push w/ heel of
hand
• E.g. “Dorsal 1st MTPJ glide”: while
stabilizing distal 1st MC w/ one hand,
glide proximal phalanx in a dorsal
direction
Document as hypomobile, normal,
hypermobile, or unstable
 Passive JPA:
Great Toe Extension
• Pt: seated or supine
• PT:
1. Passively extend 1st MTPJ; note PROM
& end-feel
2. Compare bilaterally, starting on
unaffected side
• Clinical Implications:
• Hallux Limitus: limited 1st MTPJ extension d/t
soft-tissue tightness
• Hallux Rigidus: limited 1st MTPJ extension d/t
degenerative OA
• Most common type of foot arthritis
LLAF JPA Competencies (see
CANVAS)
Dutton pp. 1067-1070
1. TCJ anterior glide 7. Distal fibula anterior
2. TCJ posterior glide glide
3. TCJ inversion tilt 8. Distal fibula posterior
glide
4. TCJ eversion tilt
9. 1st MTPJ dorsal glide
5. STJ medial glide
10.1st MTPJ plantar glide
6. STJ lateral glide
11.1st MTPJ extension
PROM not PROM also
limited limited

Jt. Play
Weakness
Assessment

JPA is limited JPA not limited

Shortened soft
tissue
Jt. restriction
(contractile or
noncontractile)
 1st MTPJ extension
PROM not limited
PROM also limited

1st MTPJ Jt. Play

Weakness
Assessment

JPA is limited JPA not limited

Shortened soft
tissue= Hallux
Jt. restriction
Limitus (tight plantar
joint capsule
PROM not 1st MTPJ PROM
limited also limited

1st MTPJ Jt. Play

Weakness
Assessment

JPA is limited JPA not limited

Shortened soft
Jt. Restriction = tissue
Hallux Rigidus (contractile or
noncontractile)
Helpful Tip…
• When a joint restriction is
identified via JPA, the SAME
technique can be used to
mobilize the joint (assuming no
contraindications to mobilization)

• E.g. JPA → hypomobile → mobilize

using JPA technique → reassess using
same JPA → repeat process prn
The Objective/Physical MSK Exam
• Non-MSK Systems Screening
• Cognitive, Cardio-pulmonary, Integumentary, Neuromuscular
• Observation & Posture Assessment
• Gait Evaluation
• Simple Functional & Balance Screening
• Referring or Related Structure(s) Screening
• Palpation
• Anthropometrics
• ROM Assessment
• AROM
• PROM
• Joint Play Assessment
• Muscle Length/Flexibility Testing
• Muscle Strength/Torque Testing
• Special Tests
• Complex Functional/Muscle Performance Testing
Muscle Length Assessment:
Gastrocnemius/Soleus (NWB)
• Pt: supine or long sitting on
table w/ knee extended
(Gastroc.) or flexed ~45°
(Soleus) (bottom photo)
• PT:
1. Passively DF ankle to ROM
limit OR have pt. actively
DF to limit
2. Measure ankle DF angle
Muscle Length Assessment:
Soleus Option 2 (NWB)
• Pt: prone on table w/ knee flexed
• PT:
1. Passively DF ankle to ROM limit
2. Measure ankle DF angle

• NOTE: The WBLT can also be used to

assess ankle DF in WB, if talocrural
joint movement is not limited
The Objective/Physical MSK Exam
• Non-MSK Systems Screening
• Cognitive, Cardio-pulmonary, Integumentary, Neuromuscular
• Observation & Posture Assessment
• Gait Evaluation
• Simple Functional & Balance Screening
• Referring or Related Structure(s) Screening
• Palpation
• Anthropometrics
• ROM Assessment
• AROM
• PROM
• Joint Play Assessment
• Muscle Length/Flexibility Testing
• Muscle Strength/Torque Testing
• Special Tests
• Complex Functional/Muscle Performance Testing
The Objective/Physical MSK Exam
• Non-MSK Systems Screening
• Cognitive, Cardio-pulmonary, Integumentary, Neuromuscular
• Observation & Posture Assessment
• Gait Evaluation
• Simple Functional & Balance Screening
• Referring or Related Structure(s) Screening
• Palpation
• Anthropometrics
• ROM Assessment
• AROM
• PROM
• Joint Play Assessment
• Muscle Length/Flexibility Testing
• Muscle Strength/Torque Testing
• Special Tests
• Complex Functional/Muscle Performance Testing
MSK “Special” Tests
• Special tests are used to confirm or
rule-out tentative diagnoses and
assist in differential diagnosis
process by distinguishing between
competing diagnoses

• NOTE: Special tests are typically

deferred for pts. recovering from
MSK surgery
 Likelihood Ratios
+LR (Rule in) Explanation −LR (Rule out)

>10 Alters posttest probability of a diagnosis <0.1

to a significant degree (≥45%)

5-10 Alters posttest probability of a diagnosis 0.2-0.1

to a moderate degree (≥30%)

2-5 Alters posttest probability of a diagnosis 0.5-0.2

to a small degree (≥15%)
1 Alters posttest probability negligibly; as accurate as 1
a coin flip

Recommended LR’s for Clinical Decision Making

LR+ ≥5 / LR- ≤0.2
MSK “Special” Tests
• No test is perfect—Clinical tests can
never absolutely confirm or exclude
the presence of a specific condition
• Goal of testing is to increase
confidence in a diagnosis until you
reach the ‘treatment threshold’ i.e.
you have a solid sense of treatment
plan
• Goal of testing is to develop the best
care plan
LLAF Special Test Competencies
(see CANVAS)
• Anterior drawer test
• Medial talar tilt test (calcaneal varus PROM)
• ER/Kleiger test
• Fibular translation test
• Ankle impingement test
• Thompson test
• Windlass test
 Ankle Anterior Drawer Test (for
ATFL)
• Indications: Acute inversion MOI; c/o persistent lateral instability
• Pt: Short sitting on elevated table w/ knee flexed ~90° (Kovaleski et al. 2008, Nyska et al.
1992) & ankle PF’d ~20° (Kikumoto et al. 2019)
• PT: While stabilizing distal tib/fib at malleoli, glide calcaneus & talus anterior
• Positive test: Excessive translation vs. contralateral ankle
QUADAS
Study Reliability SENS SPEC LR+ LR- Score (0-14)

Hertel et al. NT 78 75 3.1 0.29 8

Comments: Examiner may see a dimple or sulcus sign in region of ATFL. This
test is typically painful after lateral ankle sprains & so it is often difficult to
determine if laxity is present or absent until pn. has subsided.
Medial Talar Tilt Test (for CFL)
• Indications: Acute inversion MOI; c/o persistent lateral instability
• Pt: Long sitting or supine
• PT: While stabilizing distal tib/fib at malleoli, apply varus force (medial tilt) to
calcaneus
• Positive test: Laxity/excessive translation vs. contralateral ankle
QUADAS
Study Reliability SENS SPEC LR+ LR- Score (0-14)

Hertel et al. NT 67 75 2.7 0.44 8

Comments: This test is typically painful after inversion sprains & so it is often
difficult to determine if laxity is present or absent until pn. has subsided.
Ankle Impingement (aka Forced DF)
Test
• Indications: Persistent pain with DF (esp. in WB)
• Pt: Long sitting or supine
• PT: While stabilizing distal tib/fib, press thumb into anterolateral aspect of ankle
near lateral gutter, then passively DF ankle
• Positive test: Reproduction of concordant pn. at anterolateral aspect of ankle
during forced DF
QUADAS
Study Reliability SENS SPEC LR+ LR- Score (0-14)

Molloy et al. NT 95 88 7.9 .06 8

Comments: Although diagnostic values for test are strong, reliability among
examiners is unknown
Ankle ER Test aka Kleiger test (for
Deltoid Lig.)
• Indications: Acute ER or eversion MOI; c/o persistent medial instability
• Pt: Short sitting
• PT: While stabilizing distal tib/fib, position ankle in slight PF, then passively ER
ankle
• Positive test: Laxity vs. contra. ankle &/or reproduction of concordant
symptoms
QUADAS
Study Reliability SENS SPEC LR+ LR- Score (0-14)
Alonso et al. .75 kappa NT NT NA NA NA
Beumer et al. NT NT 95 NA NA 8
Fibular Translation Test (for distal tib-fib
syndesmotic injury)
• Indications: Acute ER MOI (‘high’ ankle sprain); c/o persistent instability
• Pt: sidelying w/ side to be tested up
• PT: While stabilizing distal lower leg, apply anterior & posterior force on distal fibula at
level of malleolus
• Positive test: Pn. +/- greater displacement of fibula vs. contralateral side (Beumer: “Pain,
rather than increased displacement, should be considered the outcome measure of these tests.”)

QUADAS
Study Reliability SENS SPEC LR+ LR- Score (0-14)
Beumer et al. NT 82 88 6.8 0.2 8
Comments: Beumer et al. only found increased translation when all ligaments
were removed in cadavers.
Thompson Test (for torn Achilles tendon)
• Indications: Acute Achilles injury
• Pt: Prone w/ LLAF off table edge
• PT: Squeeze bulk of Gastrocnemius
• Positive test: Nonresponse during squeeze i.e. ankle does NOT PF
QUADAS
Study Reliability SENS SPEC LR+ LR- Score (0-14)
Thompson & NT 40 NT NA NA 7
Doherty
Comments: The test has surprisingly low sensitivity. Patient history is also
essential when performing this test.
Windlass Test (for Plantar fasciitis/osis)
• Indications: Plantar foot pain with WB
• Pt: Standing on step stool w/ MT heads
over edge of step & equal weight on both
feet
• PT: Passively extend 1st MTPJ (while
allowing IPJ to flex) to EROM or until pt’s
concordant foot/heel pn. is provoked
• 1st toe extension tightens plantar fascia
(‘Windlass mechanism’)
• Positive test: reproduction of pt’s.
concordant plantar foot/heel pn.
• SENS: 31.8%; SPEC 100% (De Garceau et al. 2003)
The Objective/Physical MSK Exam
• Non-MSK Systems Screening
• Cognitive, Cardio-pulmonary, Integumentary, Neuromuscular
• Observation & Posture Assessment
• Gait Evaluation
• Simple Functional & Balance Screening
• Referring or Related Structure(s) Screening
• Palpation
• Anthropometrics
• ROM Assessment
• AROM
• PROM
• Joint Play Assessment
• Muscle Length/Flexibility Testing
• Muscle Strength/Torque Testing
• Special Tests
• Complex Functional/Muscle Performance Testing
Complex Functional/Muscle Performance
Testing
• Physical performance tests (PPTs) are another
way to assess mm. function & functional ability
• E.g. hop tests, sit-stand test, stair climb test
• PPTs should be valid, reliable, responsive to change
• PPTs help pts. focus on achieving a result vs. their
pain
• Consider capturing video during tests to review
movement quality, perhaps w pt. present
• May not be appropriate during initial exam for
pts. w/ high levels of pn. or irritability
Selective Functional Movement
Assessment (SFMA)
• Consists of 7 ‘Top Tier’ tests
• Tests are graded: ‘Functional & Non-
painful (FN)’, ‘Functional Painful (FP)’,
‘Dysfunctional Non-painful (DN)’,
‘Dysfunctional Painful (DP)’
• Any test that is not FN undergoes add’l
testing to determine if a ‘Tissue Extensibility
Dysfunction (TED)/Joint Mobility Dysfunction
(JMD)’ OR a ‘Stability/Motor Control Issue
(SCMD)’ exists
• Validity is not well-established—watch for future
studies
• Good reliability when raters are experienced &/or
SFMA trained (Glaws et al. 2014; Dolbeer et al. 2017)
 **CPG: LAS (Martin et al. JOSPT
2021)
A • Clinicians should assess:
1. Ankle swelling
2. ROM (esp. DF via WB Lunge Test (WBLT)
3. Talar translation, talar inversion
4. Single-leg (SL) balance
• Static SL balance on a firm surface w/ eyes closed
• Dynamic SL balance w/ Star Excursion Balance Test
Star Excursion Balance Test (SEBT)
• Use 4 strips of athletic tape 6-8 ft. long
to make grid as shown
• All angles should be 45°
• While SL standing in grid center w/
hands on iliac crests, pt. reaches other
leg as far as possible to lightly touch 1st
toe to line then returns to start
• Repeat for all 8 lines
• When balancing on L leg, pt. should
perform CW circuit
• When balancing on R leg, pt. should
perform CCW circuit
 Star Excursion Balance Test (SEBT)
• Clinician marks spot on tape where front of 1st toe touched
• Pt. repeats this w/ same foot for all 8 directions then switches sides
• For location “8” patient crosses LE in front of body

• Repeat this process 2 more times (i.e. 3 full circuits per leg)

• Measure from grid center to touch spot on the line (to the nearest 0.5cm)
to calculate reach distance

• Calculate mean of 3 trials for each reach direction

• Relative (normalized) distance (%) = (Mean distance / leg length) * 100

• Measure leg lengths from ASIS’ to medial malleoli (“direct” technique)
 Star Excursion Balance Test (SEBT)
• The pt. cannot touch foot down on floor before returning to
start position—any loss of balance is a failed attempt
• The pt. cannot hold onto anything to aid their balance
• The pt. must keep their hands on iliac crests throughout test
• The pt. must lightly touch toe on the reach line while staying
in full control of their body—any loss of balance resulting in a
heavy toe/foot contact w/ floor should be regarded as a failed
attempt

• Hertel et al. (2000): reliability r = 0.85-0.96

• Plisky et al (2009): intra-rater reliability ICC 0.67-0.97 (moderate-to-good);
inter-rater reliability ICC 0.35-0.93 (poor-to-good)
 Line SL balancing on LEFT Relative (normalized) SL balancing on RIGHT Relative (normalized)
reach distance for LEFT reach distance for RIGHT
1 reach 1 + reach 2 + reach 3 (Line 1 mean reach ÷ L leg reach 1 + reach 2 + reach 3 (Line 1 mean reach ÷ R leg
3 length) x 100 3 length) x 100
2 reach 1 + reach 2 + reach 3 (Line 2 mean reach ÷ L leg reach 1 + reach 2 + reach 3 (Line 2 mean reach ÷ R leg
3 length) x 100 3 length) x 100
3 reach 1 + reach 2 + reach 3 (Line 3 mean reach ÷ L leg reach 1 + reach 2 + reach 3 (Line 3 mean reach ÷ R leg
3 length) x 100 3 length) x 100
4 reach 1 + reach 2 + reach 3 (Line 4 mean reach ÷ L leg reach 1 + reach 2 + reach 3 (Line 4 mean reach ÷ R leg
3 length) x 100 3 length) x 100
5 reach 1 + reach 2 + reach 3 (Line 5 mean reach ÷ L leg reach 1 + reach 2 + reach 3 (Line 5 mean reach ÷ R leg
3 length) x 100 3 length) x 100
6 reach 1 + reach 2 + reach 3 (Line 6 mean reach ÷ L leg reach 1 + reach 2 + reach 3 (Line 6 mean reach ÷ R leg
3 length) x 100 3 length) x 100
7 reach 1 + reach 2 + reach 3 (Line 7 mean reach ÷ L leg reach 1 + reach 2 + reach 3 (Line 7 mean reach ÷ R leg
3 length) x 100 3 length) x 100
8 reach 1 + reach 2 + reach 3 (Line 8 mean reach ÷ L leg reach 1 + reach 2 + reach 3 (Line 8 mean reach ÷ R leg
3 length) x 100 3 length) x 100
Composite Sum of means of 8 reach Sum of means of 8 reach
Reach distances for LEFT distances for RIGHT
SEBT Scoring
PPTs for Athletes
• PPTs help pts. (usu. athletes) “Despite numerous published
focus on achieving a result vs articles addressing PPTs at the
their pain knee, there is predominantly
limited and conflicting
evidence regarding the
• Consider capturing video during reliability, agreement,
tests to review movement construct validity, criterion
quality, maybe w pt. present validity and responsiveness of
commonly used PPTs.”
Hegedus et al. 2015
PPTs for Athletes: Hop Tests
Overview
• FOR ALL HOP TESTS:
• “HOP” = SL take off and landing
• Surface must be non-slip
• Shoes must be worn for all tests
• Landing must be controlled & held for a few seconds—no sliding, falling, etc.
• Hop distance is measured by adjacent tape measure on floor
• Repeat trials until you have 2-3 consistent/stable good-quality efforts
• Be consistent
• Always measure either toe-to-toe or heel-to-heel
• Allow hands to swing freely or have them clasped behind back for all trials
PPTs for Athletes: Single Hop for
Distance
• Stand on one leg w/ toe or heel against starting line
• Hop once as far as possible
• https://youtu.be/jos-AnG26Ug
PPTs for Athletes: Triple Hop for
Distance
• Same as single hop but pt. hops three
times in a row w/ no pause

• https://youtu.be/eVGLu2E8-x8
PPTs for Athletes: Triple Crossover
Hop
• Same as triple hop but pt. crosses
over 15 cm center line each time

• https://youtu.be/_bODeVBSquM
PPTs for Athletes: 6-m Hop Test
• Pt. hops as fast as possible over a 6-m
distance, w/o losing balance & w/
landing firmly
• Record time in secs

• https://youtu.be/QBppGOIb3iI
PPTs for Athletes: Medial Hop
• Stand on one leg w/ medial aspect
of foot against starting line
• Hop once medially
PPTs for Athletes: 90° Medial
Rotation Hop
• Stand on leg to be tested, w/ medial side
of foot perpendicular to hop direction
• Pt. hops, rotating 90° in midair in medial
direction from stance LE
• Hop distance is measured from medial side
of foot at takeoff to tip of toes at landing
Dingenen 2019
 **CPG: LAS (Martin et al. JOSPT
2021)
A • Clinicians should assess:
1. Ankle swelling
2. ROM (esp. DF via WB Lunge Test (WBLT)
3. Talar translation, talar inversion
4. Single-leg (SL) balance
• Static SL balance on a firm surface w/ eyes closed
• Dynamic SL balance w/ Star Excursion Balance Test
Complex Functional/Muscle Performance
Testing
• This is an opportunity to assess the impact
of a pt’s. problem on more complex
functional tasks & find solutions
• For example:
• ADL’s—are there everyday tasks that pt. cannot
perform e.g. bathing, showering, cooking?
• Transfers—can they transfer safely sit-stand, to
bed, to toilet, etc.
• Ergonomics—how is this affecting their work?
• Sport-specific—running, hopping, jumping,
throwing