MUSCULOSKELETAL ASSESSMENT

RECEIVING THE PATIENT

Good Morning, Sir. I’m your physiotherapist for today.

Before we start our treatment, I would like you to know that I will ask you some
questions and do some assessments on you. Do you have any problem with that?

You also must give me full cooperation in answering my questions to ensure the
accuracy of my assessment.

Please do tell me immediately if you have any doubts.

SUBJECTIVE ASSESSMENT

1. First, I would like to know general details about the patient such as :
- Name
- Age
- Date of birth
- Address
- Phone number
- sex
- Occupation – changed his work to cashier from building painter, due to
the restricted shoulder movement.
- Hobbies – fishing and badminton, but stop doing so due to the pain
occurred previously and the inconvenient of shoulder movement.

2. Present medical history

- Cause : idiopathic
- Onset : gradual
- Duration : 1 year 2 months
- Site : right shoulder
- Previous treatment : hydro collateral packs and PNF (hold relax
technique)
3. Past medical history
- Major surgery or illness in before
- Still on medication or not. E.g.Steroid
4. Social history
- Patient’s family / any supporter in family
- Patient house location
5. Personal history
- Do you Smoke?
- Do you drink alcohol?
- If yes how often?
 6. Pain assessment
- VAS
o Before activity - 2
o During and after activity - 4

0 2 4 10
- Aggravating factors – lifting weight
- Easing factors – heat therapy and immobilization of shoulder
- Time factor – 24 hours and worsen at night
- Severity – low
- Irritability – moderate
- Nature – inflammatory

7. Special investigations
- X-rays
- MRI scan
- Drop Arm test
- Empty Can test
- Arthrogram
- Blood tests

OBJECTIVE ASSESSMENT

In the objective assessment, I would like to observe the problem area first then the
total body.

1) Observation

In the observation, I shall observe any

- Arm swings (during walking) of the affected side of shoulder.

- Shoulder contour observation:
o Anterior view – the shoulder level.
o Lateral view – rounded shoulder and the posture of cervical
spine.
o Posterior view – scapular level.
- Muscle wasting on :
o Upper back region – the concavity between the upper trapezius
and scapular spine indicates the muscle wasting of
supraspinatus.
o Scapular region – the rhomboidal muscle.
o Shoulder region – the asymmetry of the upper trapezius muscle.
- Redness on the affected site
 2) Palpation

In the palpation, I shall palpate for:

- Any tenderness around the shoulder joint.

- Local temperature changes around the shoulder joint.
- Muscle tone: for the shoulder and scapular muscles.
o Outcome: decrease in muscle tone of deltoid and scapular
muscles.

3) Examination

I would like to do some physical examination please cooperate with me. I

would like to observe the quality (how good the movement is) and quantity
(ROM) of the movement.

- Range of motion (ROM) using the goniometer and compare the

difference of degree in both sides:
 Firstly, do active movement followed by passive movement and
lastly give some slight pressure to feel the end feels.
 Shoulder joint (active)
o Flexion – less than normal side.
o Extension – less than normal side.
o Abduction – more restricted than flexion and extension.
Observe the reverse scapulo humeral rhythm.
o Adduction – less than normal.
o Medial rotation – less than normal.
o Lateral rotation – more restricted than medial rotation.
 Passive – in all shoulder movements
o less restricted than the active movements.
 End-feel – firm due to the capsule tightness.

- Manual Muscle Testing

Joint Muscle group Right Left

Shoulder Flexors 4- 5
Extensors 4 5
Abductors 3- 5
Adductors 4 5
Lateral Rotators 3 5
Medial Rotators 4 5
Scapular Elevators 3+ 5
Depressors 3+ 5
Retractors 2 5
Protractors 4 5
 - Measurement of Muscle Bulk (deltoid)

Right Left Difference

Arm 12cm 14cm 2cm

 Make one point at the middle of deltoid region, and make 2

points along the arms with 2 inches distance. Measure the
circumference and compare with left side.
 Outcome: There are 2cm differences showing there is muscle
wasting of deltoid.

4) Problem List
- Muscle Weakness:
o Abductor – 3-
o Lateral rotator – 3
o Retractor – 2

- The restricted of shoulder movement (ROM)

 Shoulder flexion : 140°
 Shoulder extension : 25°
 Shoulder abduction : 90°
 Shoulder adduction : 20
 Shoulder medial rotation : 40°
 Shoulder lateral rotation : 20°

- Muscle wasting
 2cm differences in deltoid muscle
 On scapular region – supraspinatus.

5) Aim for Long Term or Short Term

- Short term – Pain relief

- Long term
 Improve muscle power of shoulder flexors, extensors,
abductors, adductors and rotators.
 Reduce the restricted shoulder joint movements (improve ROM).
 Deltoid muscle, retractors and scapular region (supraspinatus)
muscle bulk building.

6) Treatment
- Short wave diathermy – Pain relief purpose.
 - Heat therapy – hydrocollateral packs, before and after exercise.
- Ultrasound therapy.
- Relaxed passive movements.
- Strengthening rotator cuff muscles exercise within pain limit and range,
Active and Resisted
- Supraspinatus - Abduction
- Infraspinatus – Lateral Rotation
- Teres Minor – Lateral Rotation
- Subscapularis – Medial Rotation
- Deltoid – Flexion, Abduction and Extension.
- Scapular Stabilization Exercise,
Active and Resisted
- Protraction
- Retraction
- Elevation
- Depression

- Improve ROM by using Codman’s pendular exercise with a 500g

weight.
- Capsular stretching.
- Closed kinematic exercise for shoulder joint.

7) Home programs
- Apply warm towel on shoulder region for 30mins before and after
exercise
- Self strengthening exercise of shoulder and scapular muscles
- Wand exercise (assisted / resisted exercise)
- Self capsular stretching

8) Dos and don’ts

Dos Don’ts
Move your shoulder and arm as much Don’t lift up heavy objects
as possible
Do the exercise as instructed Don’t overdo the exercise
Don’t do any vigorous exercise
Don’t sleep on the affected side