Shadow Health Musculoskeletal Assessment: How to Perform and Document It (ROM, Muscle Strength, Pain and Mobility)
11 min read In this guide
- The Shadow Health musculoskeletal assessment: what it covers and how it is scored
- How to perform a musculoskeletal assessment, step by step
- Shadow Health range of motion assessment and muscle strength assessment
- Shadow Health pain assessment guide
- Shadow Health Focused Exam: Mobility
- How to document a musculoskeletal assessment, with a practice case
Why the musculoskeletal assessment matters
The musculoskeletal system, made up of bones, joints, muscles, tendons and ligaments, allows people to move, work and care for themselves. Musculoskeletal problems such as arthritis, back pain, injuries and osteoporosis are leading causes of pain and disability, and mobility problems increase the risk of falls, especially in older adults (Jarvis & Eckhardt, 2024). In Shadow Health, the musculoskeletal assessment is usually paired with the neurological assessment because movement depends on both systems; together they form the Shadow Health musculoskeletal and neurological assignments in many health assessment courses. For the neurological half, see our Shadow Health Neurological Assessment guide.
Part 1: Subjective data for the musculoskeletal exam
Begin with the patient’s chief complaint, then ask about:
- Joints: pain, stiffness (especially morning stiffness and how long it lasts), swelling, redness, warmth, limited movement, locking or giving way
- Muscles: pain, cramps, weakness, atrophy
- Bones: pain, deformity, fractures, trauma
- Function: ability to perform activities of daily living (bathing, dressing, toileting, eating, walking) and instrumental activities (shopping, cooking, driving); use of assistive devices; falls
- History: previous injuries, surgeries, arthritis, osteoporosis, gout; medications such as NSAIDs, steroids or bisphosphonates
- Lifestyle: exercise, occupation and repetitive movements, weight, calcium and vitamin D intake, smoking and alcohol
Shadow Health pain assessment guide
Pain is the most common musculoskeletal complaint, and a thorough pain assessment earns points in nearly every Shadow Health exam. Use OLDCARTS or PQRST:
| Element | Sample question |
|---|---|
| Onset | “When did the pain start? Did anything happen, such as a fall or injury?” |
| Location and radiation | “Can you point to where it hurts? Does it spread anywhere?” |
| Duration and timing | “Is it constant or does it come and go? Is it worse in the morning or evening?” |
| Characteristics (quality) | “How would you describe it: aching, sharp, burning, throbbing?” |
| Aggravating factors | “What makes it worse? Walking, stairs, lifting?” |
| Relieving factors and treatment | “What helps? Rest, heat, ice, medication? How much and how often?” |
| Severity | “On a scale from 0 to 10, how bad is it now? At its worst? At its best?” |
| Impact | “How does the pain affect your sleep, work, mood and daily activities?” |
Also observe objective signs of pain: grimacing, guarding, limping, changes in vital signs and reluctance to move. Use a validated scale appropriate to the patient, such as the numeric rating scale for adults or the FACES scale for children.
Part 2: How to perform a musculoskeletal assessment
The physical exam follows inspection, palpation, range of motion and muscle strength testing, always comparing both sides (Jarvis & Eckhardt, 2024).
- General survey: posture, body build, gait, ease of movement, use of assistive devices.
- Inspection: size, symmetry, alignment, deformities, swelling, redness, skin changes, muscle atrophy, nodules.
- Palpation: temperature, tenderness, swelling, crepitus (a grating sound or feeling with movement), muscle tone.
- Range of motion: active, then passive if needed.
- Muscle strength: test each major muscle group against resistance.
- Special tests as indicated, such as the drawer test or McMurray test for the knee, Phalen’s and Tinel’s signs for carpal tunnel, and the straight leg raise for back pain.
- Spine: inspect curves (lordosis, kyphosis, scoliosis), palpate spinous processes, test flexion, extension, lateral bending and rotation.
- Gait and balance: observe walking, heel and toe walking, and tandem walking.
Order of examination
Work from head to toe: temporomandibular joint, cervical spine, shoulders, elbows, wrists and hands, thoracic and lumbar spine, hips, knees, ankles and feet. Examine the uninjured side first so you have a normal comparison and the patient trusts you.
Shadow Health range of motion assessment
Range of motion (ROM) describes how far a joint can move. Active ROM is when the patient moves the joint; passive ROM is when the examiner moves it. Never force a joint beyond the point of pain.
| Joint | Movements to test |
|---|---|
| Cervical spine | Flexion (chin to chest), extension, lateral bending, rotation |
| Shoulder | Flexion, extension, abduction, adduction, internal and external rotation |
| Elbow | Flexion, extension, supination, pronation |
| Wrist and hand | Flexion, extension, radial and ulnar deviation; finger flexion, extension, abduction; thumb opposition |
| Hip | Flexion, extension, abduction, adduction, internal and external rotation |
| Knee | Flexion, extension |
| Ankle and foot | Dorsiflexion, plantar flexion, inversion, eversion |
Document ROM as “full,” or describe limitations specifically, for example “knee flexion limited to about 100 degrees with pain.” A goniometer measures exact angles when precise measurement is needed.
Shadow Health muscle strength assessment
Ask the patient to move against your resistance and compare both sides. Grade strength on the standard 0–5 scale:
| Grade | Description |
|---|---|
| 5/5 | Full ROM against gravity and full resistance (normal) |
| 4/5 | Full ROM against gravity and some resistance |
| 3/5 | Full ROM against gravity, no resistance |
| 2/5 | Full ROM with gravity eliminated |
| 1/5 | Slight contraction, no movement |
| 0/5 | No contraction |
Test the major groups: shoulder shrug and abduction, elbow flexion and extension, wrist extension, grip, hip flexion and extension, knee flexion and extension, and ankle dorsiflexion and plantar flexion. Weakness on one side may suggest a neurological cause, such as stroke, and should prompt a full neurological exam.
Shadow Health Focused Exam: Mobility
A mobility focused exam evaluates a patient’s ability to move safely and independently, which is especially important for older adults and patients after surgery or illness. It combines musculoskeletal, neurological and functional assessment.
- History: recent falls or near-falls, fear of falling, dizziness, vision problems, medications that cause sedation or low blood pressure, use of assistive devices, home hazards, and ability to perform daily activities.
- Physical assessment: gait, balance, joint ROM, muscle strength, sensation in the feet, orthostatic vital signs.
- Standardized tools: the Timed Up and Go (TUG) test, in which the patient stands from a chair, walks 3 meters, turns, walks back and sits. The CDC’s STEADI fall-prevention initiative notes that a time of 12 seconds or more indicates an increased fall risk (Centers for Disease Control and Prevention [CDC], 2017).
- Interventions: physical therapy referral, assistive devices, home safety modifications, medication review, vision check, and strength and balance exercises.
Practice case: musculoskeletal and mobility focused exam
Original practice case for learning; not taken from Shadow Health and not an answer key.
Patient: Denise Carter, 68, retired postal worker. “My right knee hurts and I almost fell last week.”
Subjective: right knee pain for about two years, worse over the last three months; aching, 6/10 with walking and stairs, 2/10 at rest; morning stiffness lasting about 20 minutes; occasional swelling after long walks; knee “gave way” stepping off a curb last week, but she caught herself. Takes acetaminophen 500 mg twice daily with partial relief. Body mass index 32. Lives alone in a two-story house; bedroom upstairs; no grab bars in bathroom. Walks less because of pain. Takes amlodipine for hypertension. Denies trauma, fever, redness or numbness.
Objective: BP 136/82 sitting and 132/80 standing, HR 76. Antalgic gait favoring the right leg. Right knee: mild bony enlargement, no redness or warmth, mild effusion, crepitus with movement, tenderness along the medial joint line. Active ROM: right knee flexion limited to about 110 degrees with pain; full extension. Left knee normal. Strength: right quadriceps 4/5, left 5/5; all other groups 5/5. Sensation intact in both feet. Timed Up and Go: 14 seconds.
Clinical reasoning
- Cues: chronic knee pain worsening with activity, short morning stiffness, crepitus, bony enlargement, reduced flexion, quadriceps weakness, near-fall, TUG of 14 seconds, obesity, lives alone with stairs.
- Analysis: findings are consistent with osteoarthritis of the right knee (short morning stiffness, crepitus, no warmth or redness, unlike inflammatory arthritis) and an increased risk for falls.
- Priorities and actions: fall prevention and pain control. Report findings; recommend physical therapy for strengthening and gait training; assess for an assistive device such as a cane; suggest home safety changes (grab bars, stair rails, night lights); teach safe acetaminophen use and weight management; encourage low-impact exercise such as walking in water or cycling.
How to document a musculoskeletal assessment
- Separate subjective and objective data.
- Describe each joint examined, comparing sides.
- Document ROM and strength with specific values.
- Include gait, balance, assistive devices and fall-risk results.
- Include pertinent negatives, such as no redness, warmth or deformity.
Sample documentation
Subjective: 68-year-old female reports right knee pain × 2 years, worse × 3 months; aching, 6/10 with ambulation and stairs, 2/10 at rest; morning stiffness about 20 minutes; intermittent swelling after prolonged walking. Reports right knee “giving way” with near-fall 1 week ago. Takes acetaminophen 500 mg BID with partial relief. Lives alone in two-story home; no bathroom grab bars. Denies trauma, fever, joint redness or numbness.
Objective: BP 136/82 sitting, 132/80 standing; HR 76. Antalgic gait favoring right lower extremity; no assistive device. Right knee: mild bony enlargement and small effusion, no erythema or warmth; crepitus with ROM; medial joint line tenderness. Right knee active flexion limited to about 110° with pain; full extension. Left knee without deformity, full ROM, nontender. Strength 5/5 throughout except right quadriceps 4/5. Sensation intact bilateral feet. Timed Up and Go 14 seconds.
Common mistakes in the Shadow Health musculoskeletal exam
- Testing only the painful joint and not comparing with the other side
- Forgetting the spine, gait and functional assessment
- Not asking about falls, assistive devices and home safety
- Recording strength or ROM without specific values
- Skipping pain characteristics and the impact of pain on daily life
- Missing education opportunities about exercise, weight and medication safety
Quick musculoskeletal exam checklist
- Introduce yourself, confirm identity, explain the exam and ask about pain before touching the patient
- Ask about pain, stiffness, swelling, function, falls, assistive devices and home safety
- Observe posture, gait and how the patient moves on and off the exam table
- Inspect and palpate each joint, starting with the unaffected side
- Test active range of motion, then passive range of motion if active motion is limited
- Grade strength 0–5 for each major muscle group, right and left
- Examine the spine for curvature, tenderness and movement
- Perform special tests only when indicated, and stop if the patient reports significant pain
- Screen fall risk with the Timed Up and Go test for older adults or anyone with mobility concerns
- Teach about exercise, weight management, safe medication use and home safety, then document with specific values
Frequently asked questions
Do I need to test every joint in the Shadow Health musculoskeletal assessment?
Follow your assignment instructions, but in a full musculoskeletal exam you should inspect and palpate the major joints from the jaw to the feet, test range of motion and strength in each area, and assess the spine and gait. In a focused mobility or joint exam, examine the affected joint thoroughly, compare it with the other side, and check the joints above and below it.
What is the difference between active and passive range of motion?
Active range of motion is movement the patient performs independently. Passive range of motion is movement the examiner performs while the patient relaxes. If active motion is limited but passive motion is normal, weakness or pain may be the cause; if both are limited, the joint itself may be restricted.
How should I grade muscle strength in Shadow Health?
Use the 0–5 scale, test each muscle group against resistance and always compare the right and left sides. Record the grade for each group, for example “right quadriceps 4/5, left 5/5,” rather than writing “weak.”
Why does the mobility focused exam include blood pressure lying and standing?
Orthostatic hypotension, a drop in blood pressure on standing, can cause dizziness and falls, especially in older adults taking blood pressure medications. Measuring orthostatic vital signs helps identify a treatable cause of fall risk.
Continue the series: Shadow Health DCE: Complete Student Guide, Shadow Health Focused Exams and Shadow Health Musculoskeletal Reflection examples.
Deep-dive Shadow Health guides
- Shadow Health Focused Exam: Chest Pain and Cardiovascular Assessment
- Shadow Health Focused Exam: Cough and Respiratory Assessment
- Shadow Health Focused Exam: Abdominal Pain and Abdominal Assessment
- Shadow Health Special Populations Focused Exams
- Shadow Health Documentation: How to Document Your Assessment
References
Centers for Disease Control and Prevention. (2017). Assessment: Timed Up & Go (TUG) [STEADI fact sheet]. https://www.cdc.gov/steadi/pdf/steadi-assessment-tug-508.pdf
Jarvis, C., & Eckhardt, A. (2024). Physical examination and health assessment (9th ed.). Elsevier.
