Musculoskeletal assessment in nursing: a step-by-step guide

Musculoskeletal (MSK) assessment is the systematic examination of bones, joints, muscles, ligaments, and tendons to identify injury, dysfunction, or disease. Nurses perform it during admission assessments, orthopedic and surgical care, post-fracture monitoring, fall risk evaluation, and any time a patient reports pain, weakness, or limited movement. A thorough MSK exam detects fractures, arthritis, neurovascular compromise, compartment syndrome, and functional limitations that affect a patient’s independence and safety.

Core answer: what every MSK assessment must include

• General inspection: gait, posture, symmetry, deformity
• Palpation: bony landmarks, joint lines, temperature, crepitus
• Range of motion (ROM): active and passive, measured in degrees
• Muscle strength: Medical Research Council (MRC) 0–5 scale
• Special orthopedic tests: SLR, McMurray, Lachman, Phalen’s, Finkelstein, drop arm
• Neurovascular check: the 5 P’s (Pain, Pallor, Paresthesia, Pulselessness, Paralysis)
• Functional assessment: ADLs, assistive devices, fall risk

MSK assessment is one component of the full head-to-toe assessment and is performed alongside neurological, vascular, and integumentary evaluation in most acute and orthopedic settings.

Preparation and general inspection

Before touching the patient, set up the environment correctly. The patient should be gowned with appropriate draping to preserve dignity while allowing full joint visualization. The room should be well lit, warm, and private. You need clear visual access to both sides of each joint for symmetry comparison.

Pre-assessment steps:

1. Review the chart for mobility restrictions, fall risk classification, weight-bearing status, and prior fractures or surgeries
2. Confirm the patient’s identity with two identifiers
3. Explain the assessment and what you’ll be asking them to do
4. Warm your hands before palpation

General inspection

Begin with the patient standing, if safe. Observe from the front, side, and behind before the patient moves.

What to observe:

• Symmetry: Compare bilateral structures – shoulders level? Iliac crests level? ASIS symmetric?
• Posture: Identify spinal curvatures. Kyphosis is an exaggerated posterior thoracic curve (the “hunchback” posture common in osteoporosis). Lordosis is an exaggerated anterior lumbar curve. Scoliosis is a lateral spinal curvature – have the patient bend forward at the waist (Adam’s forward bend test) to reveal the rib hump that confirms structural scoliosis.
• Alignment: Note varus alignment (bowing – knees apart when feet together) or valgus alignment (knock-knees – knees touching when feet apart).
• Deformities: Obvious swelling, joint enlargement, muscle atrophy, limb length discrepancy, or abnormal positioning (external rotation of a hip after fracture).

Gait assessment

Ask the patient to walk away from you, turn, and walk back. A normal gait has symmetric stride length, appropriate arm swing, upright posture, and smooth heel-to-toe progression.

Key abnormal gaits:

• Antalgic gait: The patient shortens the stance phase on the painful side to minimize weight-bearing. Indicates pain in the hip, knee, ankle, or foot.
• Trendelenburg gait: The pelvis drops on the non-stance side (the opposite side from the weak hip abductor). The patient compensates by lurching the trunk over the stance leg. Indicates weak gluteus medius on the stance side.
• Steppage gait: High step with foot drop – suggests peroneal nerve injury or L4–L5 radiculopathy.

Palpation technique

Palpation follows inspection and provides data that cannot be seen. Use the palmar surface of your fingers (the most sensitive area for fine discrimination) and the dorsal surface for temperature comparison. Always palpate bilateral structures for comparison.

What to assess during palpation:

• Bony landmarks: Identify bony prominences to orient you to the joint. Tenderness over a bony prominence suggests fracture, avulsion, or bursitis.
• Joint lines: Tenderness directly over the joint line of the knee, for example, suggests meniscal pathology.
• Muscle bulk: Assess for atrophy (loss of muscle mass) by comparing the circumference of bilateral limbs at the same measured distance from a bony landmark. Atrophy suggests disuse, nerve injury, or chronic disease.
• Temperature: Use the dorsum of your hand. Warmth indicates inflammation or infection; coolness indicates poor perfusion.
• Tenderness: Grade as mild, moderate, or severe. Note if the patient guards the area.
• Crepitus: A palpable or audible grating or cracking with joint movement. Fine crepitus is often benign (gas in joint fluid); coarse crepitus over a fracture site indicates bone-on-bone contact; crepitus in a joint with swelling and pain suggests degenerative arthritis or cartilage loss.

Major joint palpation landmarks

• Spine: Spinous processes (tenderness = fracture risk), paraspinal muscles (spasm), sacroiliac joints
• Shoulder: Acromion, clavicle, AC joint, greater tuberosity of the humerus, bicipital groove (tenderness = biceps tendinopathy)
• Elbow: Medial and lateral epicondyles (epicondylitis), olecranon (bursitis)
• Wrist/hand: Anatomical snuffbox (tenderness = scaphoid fracture), MCP and PIP joints, CMC joint of thumb
• Hip: Greater trochanter (bursitis), inguinal ligament, anterior superior iliac spine (ASIS)
• Knee: Patella, medial and lateral joint lines, popliteal fossa, tibial tubercle (Osgood-Schlatter in adolescents)
• Ankle/foot: Medial and lateral malleoli, Achilles tendon, plantar fascia at calcaneal insertion

Range of motion assessment

Range of motion (ROM) is the arc of movement a joint can travel through, measured in degrees from the anatomical neutral position (0°). ROM assessment has two components:

• Active ROM (AROM): The patient moves the joint through its available range using their own muscle strength. This reflects both joint mobility and muscle function.
• Passive ROM (PROM): The examiner moves the joint while the patient remains relaxed. This isolates joint mobility from muscle strength. PROM should be equal to or slightly greater than AROM. If PROM is significantly greater than AROM, suspect muscle weakness. If PROM is also limited, suspect joint pathology (effusion, ankylosis, contracture).

Always assess AROM first. Move to PROM only if AROM is limited or if you need to assess end-feel.

End-feel is the quality of resistance felt at the limit of passive motion:

• Soft end-feel (tissue approximation) — normal at elbow flexion; soft and spongy in effusion
• Firm end-feel (capsular or ligamentous) — normal at most joints
• Hard end-feel (bone on bone) — normal at elbow extension; abnormal elsewhere (osteophytes)

Normal ROM by joint

ROM values from: Bickley LS, Szilagyi PG. Bates’ Guide to Physical Examination and History Taking, 13th ed.; Potter PA, Perry AG. Fundamentals of Nursing, 11th ed.

Document ROM using precise degree measurements, not qualitative terms like “decreased” or “limited.” For example: “Right knee flexion 95°, extension –10° (lacks full extension); left knee flexion 130°, extension 0°.”

For nursing students interested in how ROM exercises differ from ROM assessment in rehabilitation, see our guide to range of motion exercises in nursing.

Muscle strength grading

Muscle strength is graded using the Medical Research Council (MRC) Manual Muscle Testing Scale. This 0–5 scale is universally used in nursing and medicine and must be applied consistently.

MRC muscle strength scale

A score of 4/5 is clinically significant and should not be dismissed as “almost normal.” It indicates real weakness that may reflect nerve injury, muscle disease, pain inhibition, or disuse atrophy. Always document which side and which muscle group: “Right hip flexors 3/5, left 5/5.”

Major muscle groups to test:

• Upper extremity: deltoids (shoulder abduction), biceps (elbow flexion), triceps (elbow extension), wrist extensors, grip strength
• Lower extremity: iliopsoas (hip flexion), quadriceps (knee extension), hamstrings (knee flexion), tibialis anterior (ankle dorsiflexion), gastrocnemius/soleus (ankle plantarflexion), extensor hallucis longus (great toe extension – tests L5 nerve root)

Special orthopedic tests

Special orthopedic tests are provocative maneuvers designed to stress specific structures. Positive findings help identify the source of a patient’s symptoms. These are high-yield for the NCLEX and essential for orthopedic and emergency nursing practice.

Special orthopedic tests: technique and interpretation

Neurovascular assessment and compartment syndrome

Neurovascular assessment is performed after any orthopedic injury, fracture, cast application, or orthopedic surgery. It evaluates the adequacy of blood flow and nerve function to the affected extremity.

For more on the overlap between neurological and vascular assessment, see neurological assessment in nursing.

The 5 P’s of compartment syndrome

Compartment syndrome occurs when pressure within a closed muscle compartment exceeds perfusion pressure, causing ischemia of muscle and nerve tissue. It is a surgical emergency with a narrow treatment window. Fasciotomy must occur within 6 hours of ischemia onset to prevent permanent muscle and nerve death.

When to escalate: Do not wait for all 5 P’s. Pain out of proportion + paresthesia is sufficient clinical suspicion to call the provider immediately and escalate to surgery. Request compartment pressure measurement (>30 mmHg or within 30 mmHg of diastolic pressure is a surgical threshold).

Compartment syndrome risk factors: Long bone fractures (especially tibial shaft), crush injuries, circumferential casts or tight dressings, reperfusion after arterial repair, high-voltage electrical burns.

Nursing interventions while awaiting provider:

1. Remove all circumferential dressings, casts, or tight wrappings immediately
2. Keep the limb at heart level – do NOT elevate (elevation reduces arterial perfusion pressure)
3. Administer supplemental oxygen
4. Establish IV access; hold NSAIDs (they may mask pain that is your primary monitoring tool)
5. Prepare for emergency fasciotomy

Grading scales reference

Pitting edema grading

Pitting edema in a post-fracture or post-surgical limb should be documented and trended. Progressive edema that develops alongside pain and paresthesia warrants urgent neurovascular reassessment.

Functional assessment

MSK assessment extends beyond the physical examination to understand how the patient’s condition affects daily life. Functional limitation is the bridge between clinical findings and nursing care planning.

ADL assessment: Ask specifically about difficulty with:

• Dressing and grooming (shoulder and hand function)
• Bathing and toileting (hip, knee, and back function)
• Transfers (bed-to-chair, chair-to-standing) and mobility
• Stair climbing
• Driving and community mobility

Assistive devices: Document which device the patient uses and whether they use it correctly:

• Walker (standard or rolling): Provides maximum stability; both sides equally; used for bilateral weakness or balance impairment
• Cane: Single-point cane held on the contralateral side (opposite the affected limb) to offload weight. A cane held ipsilaterally provides no mechanical advantage.
• Crutches: Non-weight-bearing or partial weight-bearing; axillary crutches must clear the axilla by 2–3 finger widths to prevent brachial plexus compression (“crutch palsy”)
• Orthoses (braces): Inspect for skin breakdown under brace margins; document whether correctly applied

Transfer ability: Document transfer status using standardized terms – independent, supervision, minimal assist (25%), moderate assist (50%), maximal assist (75%), or dependent. This directly informs care planning and discharge disposition.

Fall risk: MSK findings that elevate fall risk include: lower extremity weakness <4/5, impaired gait, recent fall history, use of an assistive device, impaired proprioception, and orthostatic hypotension. Activate fall precautions and document findings in the fall risk assessment tool used by your facility (Morse Fall Scale, STRATIFY, or facility equivalent).

For comprehensive post-fracture and post-surgical nursing care, see orthopedic nursing.

Documentation

Accurate, specific documentation of MSK findings allows other clinicians to track changes over time and identify deterioration. Vague documentation (“ROM decreased, strength diminished”) has no clinical value.

What every MSK documentation entry must include:

• ROM: specific degrees, which joint, which direction, which side (e.g., “Right knee flexion 90°, extension 0°; left knee flexion 130°, extension 0°”)
• Strength: MRC grade, which muscle group, which side (e.g., “Right quadriceps 4/5, left 5/5”)
• Symmetry comparison for all findings
• Special test results: name the test, describe the maneuver, state positive or negative, note the patient’s response
• Neurovascular findings: all 5 P’s, pulse quality (strong/weak/absent), capillary refill time in seconds
• Functional status: transfer ability, assistive device, any ADL limitations identified

Charting example (narrative format)

MSK Assessment – Right knee, 0800: General inspection: no swelling, ecchymosis, or deformity. Gait antalgic with shortened stance phase on the right. Palpation: tenderness over the medial joint line at moderate intensity; no bony tenderness; no warmth or crepitus. ROM active: flexion 85°, extension 5° (lacks full extension); passive: flexion 95°, extension 0°. Muscle strength: right quadriceps 4/5, hamstrings 4/5; left 5/5 bilaterally. McMurray test: positive – click palpated with valgus stress and external tibial rotation, reproducing medial knee pain. Lachman test: negative. Neurovascular: extremity warm, skin pink, capillary refill <2 seconds bilaterally, dorsalis pedis pulses 2+ bilaterally, sensation intact throughout, no paresthesia reported. Transfer: ambulating with supervision using a single-point cane (held in left hand). Fall precautions in place.

NCLEX tips

1. Compartment syndrome priority: Pain out of proportion to injury + paresthesia = call the provider immediately. Do not wait for pulselessness – that is a late sign. The nurse’s first action is to remove all circumferential dressings.

2. MRC scale values: 0 = no contraction. 1 = flicker only. 2 = moves without gravity. 3 = moves against gravity only. 4 = moves against some resistance. 5 = normal strength. Know the distinction between 2 (gravity eliminated) and 3 (against gravity).

3. Post-fracture neurovascular checks: The frequency depends on facility protocol, but the NCLEX expects you to prioritize neurovascular assessment above comfort measures in a new cast or post-reduction scenario.

4. Fat embolism syndrome (FES) triad: After a long bone fracture (femur, tibia, pelvis), watch for the FES triad: hypoxemia (sudden respiratory distress, decreased SpO2) + neurological changes (confusion, restlessness, decreasing LOC) + petechiae (pinpoint hemorrhages across the chest, axillae, and conjunctivae – this is pathognomonic). FES typically presents 24–72 hours after the fracture. If you see petechiae in a post-fracture patient – this is your tell.

5. Cast care assessment: The nurse assesses for the 5 P’s under every cast. The first nursing action for suspected compartment syndrome under a cast is to cut or bivalve the cast and remove all padding.

6. Crutch fit: Axillary crutches should fit with 2–3 finger widths between the axilla and the crutch pad. Resting weight on the axillary pad causes radial nerve (crutch palsy) or brachial plexus injury.

7. Cane placement: The cane is held in the hand opposite the affected extremity. The cane and affected leg advance together, then the unaffected leg advances.

8. Hip replacement precautions (posterior approach): No hip flexion >90°, no adduction past midline, no internal rotation. These precautions prevent posterior dislocation of the prosthesis. If the hip dislocates, the leg will appear shortened and externally rotated.

9. SLR specificity: A positive SLR requires radicular pain below the knee (not just back pain) at 30–70° of hip flexion. Pain only in the back does not constitute a positive SLR.

10. Scoliosis screening: Adam’s forward bend test identifies the rib hump of structural scoliosis. The patient bends at the waist with arms hanging – the examiner looks from behind for asymmetric rib elevation.

11. Finkelstein test tests for de Quervain tenosynovitis, not carpal tunnel. Phalen’s test is for carpal tunnel. Do not confuse them on the NCLEX.

12. Muscle atrophy documentation: Always measure circumference at the same point (e.g., 10 cm proximal to the knee) to allow accurate comparison across assessments.

13. Antalgic gait vs. Trendelenburg: Antalgic = shortened stance phase on the painful side (protecting a painful limb). Trendelenburg = pelvis drops to the opposite side because the stance-side hip abductor is weak.

14. Fat embolism prevention: Early fracture immobilization reduces fat embolism risk. Long bone fractures should be splinted promptly. Report any post-fracture respiratory changes to the provider.

15. Phalen’s test duration: Phalen’s test must be held for 60 seconds. A shorter hold reduces the sensitivity of the test significantly.

NCLEX scenarios

Scenario 1 — Compartment syndrome recognition

A 24-year-old male sustained a tibial shaft fracture 6 hours ago. He has a fiberglass cast applied. He rates his pain as 9/10 despite IV morphine and reports tingling in his toes. Pedal pulses are 2+ bilaterally. Which intervention does the nurse perform first?

A. Elevate the affected limb above heart level
B. Administer an additional dose of morphine as ordered
C. Notify the provider and prepare to bivalve the cast
D. Apply ice to the cast to reduce swelling

Answer: C.

Rationale: Pain out of proportion to injury and paresthesia (tingling) are early signs of compartment syndrome. Pulselessness is a late sign – its absence does not rule out compartment syndrome. Elevation (A) is contraindicated because it reduces arterial perfusion pressure to the ischemic compartment. Additional analgesia (B) addresses symptoms but not cause. Ice (D) is inappropriate. The immediate priority is to remove external pressure by cutting the cast, then escalate to the surgeon.

Scenario 2 — Fat embolism syndrome

A 38-year-old woman is 36 hours post right femur fracture fixation. The nurse notices she is confused and agitated (her baseline was alert and oriented). Vital signs: BP 118/76, HR 104, RR 26, SpO2 90% on room air. On inspection, pinpoint red spots are visible across her chest and axillae. Which condition does the nurse suspect?

A. Pulmonary embolism
B. Fat embolism syndrome
C. Opioid toxicity
D. Postoperative delirium

Answer: B.

Rationale: The classic triad of fat embolism syndrome is hypoxemia (SpO2 90%, RR 26), neurological change (confusion, agitation), and petechiae (pinpoint hemorrhages across chest and axillae). FES typically presents 24–72 hours after long bone fracture. Pulmonary embolism (A) does not cause petechiae. Opioid toxicity (C) would produce decreased respiratory rate and miosis, not tachypnea. Postoperative delirium (D) does not explain hypoxemia or petechiae.

Scenario 3 — Total hip replacement precautions

A nurse is caring for a patient 1 day post total hip replacement (posterior approach). Which position or activity requires immediate correction?

A. The patient is lying with the operative leg in slight abduction with a pillow between the knees
B. The patient has bent forward to pick up their slippers from the floor
C. The patient is using a raised toilet seat to avoid deep hip flexion
D. The patient is sitting upright in the chair with hips at 80° of flexion

Answer: B.

Rationale: After a posterior approach total hip replacement, the precautions are: no hip flexion >90°, no adduction past midline, no internal rotation. Bending forward past 90° violates the flexion restriction and risks posterior dislocation. A pillow between the knees (A) maintains abduction – correct. A raised toilet seat (C) prevents excessive flexion – correct. Sitting with hips at 80° (D) is within the 90° limit – acceptable.

Scenario 4 — Fall risk and assistive devices

A patient uses a single-point cane after a right knee replacement. Which observation indicates the patient needs cane gait re-education?

A. The patient advances the cane and the right leg simultaneously
B. The patient holds the cane in the left hand
C. The patient uses the cane on stairs going up with their right leg first
D. The patient holds the cane in the right hand (same side as the affected knee)

Answer: D.

Rationale: The cane should be held in the hand opposite the affected extremity to shift weight away from the weak or painful limb. Holding the cane on the same side as the affected limb provides no mechanical advantage and does not reduce joint loading. Advancing the cane and affected leg together (A) is the correct pattern. Holding the cane in the left hand with a right-sided deficit (B) is correct. Going up stairs with the unaffected leg first (uninstructed here, but implied) is the standard teaching.

Scenario 5 — Lachman test interpretation

During an emergency department assessment, a nurse assists with a Lachman test on a 19-year-old athlete who fell awkwardly during a soccer match. The test reveals excessive anterior tibial translation with a soft endpoint. Which structure is most likely injured?

A. Medial meniscus
B. Medial collateral ligament
C. Anterior cruciate ligament
D. Posterior cruciate ligament

Answer: C.

Rationale: The Lachman test applies an anterior force to the tibia at 20–30° of knee flexion. A positive result – excessive anterior tibial translation with a soft or absent endpoint – indicates anterior cruciate ligament (ACL) disruption. The McMurray test (not Lachman) evaluates the menisci. The valgus stress test evaluates the medial collateral ligament. The posterior drawer test evaluates the posterior cruciate ligament.