International Journal of Clinical Medicine, 2012, 3, 335-340
http://dx.doi.org/10.4236/ijcm.2012.35065 Published Online September 2012 (http://www.SciRP.org/journal/ijcm) 1
Musculoskeletal Examination Skills: Are We Still
Hani Almoallim1,2,3*, Abdulhadi Gelidan1
1Department of Medicine, Umm Alqura University, Makkah, KSA; 2Department of Medicine, King Faisal Specialist Hospital, Jed-
dah, KSA; 3Alzaidi Chair of Research in Rheumatic Diseases, Umm Alqura University, Makkah, KSA.
Received May 25th, 2012; revised June 26th, 2012; accepted July 14th, 2012
This article explores problems and solutions of Musculo skeletal (MSK) examinations skills an d points out that it is very
important to keep medical educators interested to improve the situation of MSK teaching. MSK conditions are usually
overlooked though they represent 20% of both primary care and emergency-room visits of the most common health
complications that require medical attention across the world. MSK disorders can lead to serious disabilities and sig-
nificant burden and though its problems are expected to increase, there is a continuous neglect in musculoskeletal ex-
amination skills in clinical practice. To participate in solving this problem, the article accentuates the necessity of de-
fining MSK competencies and of agreeing on standards of MSK exams and calls for an integrated teaching of MSK
examination skills that uses interactive methodologies like patients’ educators and peer-assisted learning. This article
comprises four parts, an introdu ction, a description of the deficiencies in musculoskeletal examination skills, the causes
of these deficiencies and finally some solution s of musculoskeletal examination skills deficien cies. We venture to bring
attention to an overlooked but major analyses constituent that impacts patients’ overall health.
Keywords: Examination; Musculoskeletal Examinations; Arthritis; Teaching
This paper is a theoretical exp loration of the problems of
musculoskeletal (MSK) examination. We argue that al-
though MSK sympto ms are a most common health com-
plications requiring medical attention and accounting to
20% of both primary care and emergency-room visits ,
MSK symptoms do not receive proper teaching attention.
Hence, it is very important to keep medical educators
interested to improve the situation of MSK teaching. The
paper also questions the causes of these deficiencies and
suggests some solutions to redeem this problem. In a
recent study where a standardised MSK examination of
the hand and wrist joints has been determined and vali-
dated, it was suggested that adopting such approach is
hoped to improve clinicians’ ability to diagnose arthritis
at an early stage, particularly in areas where rheumatolo-
gists have limited access to ultrasound (US) . This is
one of the first studies to call attention to the persistence
of the problem in Saudi Arabia specifically and to inves-
tigate causes of the problem and suggest educational so-
lutions to remedy it for the benefit of the patients.
MSK conditions affect one in five adults . In a
health survey, MSK disorders were ranked first in preva-
lence as the cause of chronic health problems, long term
disabilities, and consultations with a health professional
. In Saudi Arabia, MSK disorders is the second major
cause of outpatients visit in primary care centers and
private clinics . Low back pain is the most prevalent
of musculoskeletal conditions; it affects nearly everyone
at some point in time and about 4% - 33% of the popula-
tion at any given point . MSK disorders are a very
common cause of health problems. They result in limit-
ing work in developed countries. Besides, up to 60% of
people on early retirement or long term sick leave claim
a MSK problem as the reason . Furthermore, the im-
pact of MSK conditions is predicted to increase dramati-
cally in developing as well as developed countries with
the aging of the populatio n, changes in lifestyle resulting
in obesity and lack of physical fitness, and the increase in
road traffic accidents with the urbanization and motori-
zation of the developing world . This increasingly
high impact of MSK conditio ns is recognized now by the
United Nations, the World Health Organization, the
World Bank, and many governments throughout the
world through their support of the Bone and Joint Decade
2000-2011 initiative  that recognized MSK education
*Corresponding a uthor.
Copyright © 2012 SciRes. IJCM
Musculoskeletal Examination Skills: Are We Still Interested?
as a national and global priority [4,5,8] during the Bone
and Joint Decade (2000-2010).
A number of different medical specialties are usually
involved in treating patients with musculoskeletal com-
plaints. This comprises general practitioners, family phy-
sicians, internists, orthopedic and surgeons. However, the
various practitioners may work in teams with other
health professional, but they often lack a multispecialty
focus which results in treating the same patients in a
segmented manner and from different inconsistent an-
In the following part we are going to discuss the defi-
ciencies in MSK examination and the causes of these
deficiencies in order to arrive at a better understanding of
this problem, its causes, and possible solutions to im-
prove the MSK examination conditions.
2. Deficiencies in Musculoskeletal
Despite the impact of MSK disorders on health care,
rheumatological diseases are often overlooked or inade-
quately assessed by doctors [9-12] and there is a con-
tinuous neglect observed in musculoskeletal examination
skills in clinical practice. Thus problems of patients with
complaints about bones and joints are often ignored and
underestimated by doctors.
In a teaching hospital report, among 200 general
medical inpatients only 5.5% of the signs and 14% of the
symptoms of MSK disorder were record ed in the ho spital
examination notes. This compared poorly with recorded
examination of other systems and regions; for example,
cardiovascular symptoms were recorded in 100% of the
cases; respiratory and abdominal symptoms were re-
corded in 99%, the nervous system, skin and female
breasts symptoms were recorded in 77%, 13%, respec-
tively . In another report, only 40% of the patients
admitted to the general medicine ward had the history of
their MSK symptoms recorded and only 14.5% of these
patients received comprehensive MSK examination .
Furthermore, 80% of symptomatic patients received ei-
ther no treatment for their rheumatic disorder, or treat-
ment that was regarded as suboptimal or inappropriate
. A third report shows even a higher percentage; 63%
of all patients admitted to the general medicine ward had
MSK symptoms or its signs, but relevant MSK history
was missed in 49% of the patients records and MSK
signs were missed in 78%; 42% of those with MSK con-
ditions would have benefited from additional treatment
. A more recent report reviewed 150 patient notes in
three different hospitals from the acute admission wards
for medicine and surgery and the medical assessment
unit. Factors considered included whether GALS screen-
ings had taken place, documentation of MSK examina-
tions and assessment of confidence of junior doctors in
assessing MSK conditions. GALS screenings were per-
formed for 4% of patients on the medical assessment unit,
7% of acute medical and 0% of acute surgical patients on
admission. Examination of the MSK system yielded bet-
ter results with 16%, 22% and 10% on each of the re-
spective wards. Interviews with junior doctors found that
10% of the doctors routinely screened for MSK condi-
tions though 87% felt confident in taking MSK histories
. Furthermore, Matzkin et al. (2005) indicate that the
majority (79%) of the study respondents including medi-
cal students, residents, and staff physicians failed the
basic MSK cognitive examination . This suggests
that training in MSK medicine is inadequate in medical
schools and in most residency training programs. World-
wide, undergraduate and postgraduate medical teaching
of MSK disorders is brief currently an d not directly rele-
vant to the knowledge and skills commonly required for
management of these conditions in an outpatient setting.
In undergraduate education, inadequate MSK educa-
tion is reported. Medical students spend very few hours
on the MSK system, both in basic science and in clinical
training. It is quite common for students to leave medical
school without being able to make a general assessment
of the musculoskeletal system; on the other hand, it
would be considered a total neglect if a medical graduate
is incompetent at adequ ately assessing the heart or lungs.
Harvard medical students report general dissatisfaction
of their confidences in examining of MSK system com-
paring to their skill in examining pulmonary system 
and they suggested more integration between pre-medi-
cal and clinical courses and more time to be devoted to
The American Association of Medical Colleges,
AAMC (2005) claims that most medical schools do not
effectively educate future physicians on MSK medicine
in spite of the increasing prevalence of MSK conditions
across medical practice . The obvious discrepancy
between the magnitude of MSK conditions and physi-
cians competences, which stemmed mostly from the
educational deficiencies at the medical schools, contin-
ued across years [18-20]. Akesson and colleagues (2003)
argue that MSK teaching at the undergraduate and
graduate programs is not adequate and that the resulting
competence does not reflect the impact of these condi-
tions on individuals and society . A comprehensive
study reviewing the curricula of all Canadian medical
schools indicated that directors of undergraduate MSK
programs felt dissatisfied with the curricular time de-
voted to MSK education .
The same limitation subsists in postgraduate programs
since the 1980s. Goldenberg et al. (1985) reported that
the majority of directors of residency programs thought
that many basic skills and techniques were not taught
Copyright © 2012 SciRes. IJCM
Musculoskeletal Examination Skills: Are We Still Interested? 337
adequately and that the training of their rheumatology
residents was not equal to that of residents in cardiology
or gastroenterology . General dissatisfactions of
MSK training are reported in internal medicine residents
and family practice. United State residents express their
dissatisfaction of their competence in performing MSK
examinations at various parts of the body and relate that
to the inadequate or poor training . Woolf et al. rec-
ommend a musculoskeletal undergraduate curriculum
they developed to be applied in any country and culture
. They claim that the implementation of these recom-
mendations is well suited to the trend to integr ate courses
both vertically and horizontally.
In a wide range study based on a national survey in
Saudi Arabia using the Delphi technique, internal medi-
cine knowledge and skills competencies including rheu-
matology were determined and prioritized . In this
study, MSK exam skills were considered part of core
competencies that must be mastered by students at time
of their graduation. A standardized approach to the clini-
cal assessment of a musculoskeletal problem is suggested
. Such a standardized approach is to be conducted
whether the patient is presented to primary care, rheu-
matology or orthopedics. The study also provides a
benchmark for this competency that can be used as a
teaching aid .
A major objection against this study is its standardized
approach to the clinical assessment of a musculoskeletal
problem . It is considered that such standard ization is
an imposition in various medical disciplines. Therefore,
it remains to be seen whether this k ind of standardization
would be widely accepted by different disciplines or not
is debatable? The study does not address the important
issue of the actual MSK examination techniques; how
can a clinician perform a comprehensive and standard
MSK examination of the hand and wrist joints for exam-
ple? Feeling “over each joint line for tenderness and
bony or synovial swelling”  may not be adequate
enough in describing where to place the examiners hands?
Where to press? What is considered a positive test? Un-
fortunately, there is no standard technique or approach to
assess specifically any joint in the body, particularly if
the concern was to identify an inflamed joint due to ar-
In response to this lack, in a recent study , defini-
tions to an approach and techniques to examine the hand
and wrist joints to diagnose arthritis as exemplified in
Figures 1 and 2 was validated in comparison to ultra-
sound findings in patients presenting to rheumatology
clinics. These figures illustrate three techniques that
showed sensitivities ranges from 80% - 70% to detect
arthritis in comparison to ultrasound findings as gold
Figure 1. (a) MCP-scissor technique: first step, the exam-
iner should make a scissor like shape with his/her fingers.
(MCP: metacarpophalangeal joints); (b) MCP-scissor tech-
nique: second step, The examiner holds the patient hand
from the sides at MCP level, flexing the MCPs to 90 degrees.
The two free thumbs from both hands palpate the joint line
for every MCP joint. One thumb is pressing firmly for a
power causing whitening of the distal thumb nail while the
other thumb is pushing intermittently in and out to assess
for effusion, swelling and/or tenderness.
Figure 2. PIP-4 fingers technique: The examiner’s thumb
and index finger of one hand should hold each PIP from the
side and press firmly until the whitening of distal fingers
from low blood supply is clear. With the other thumb and
index finger of the other hand, the examiner should hold the
same PIP-joint from antro-posterior direction and push in-
termittently in and out to look for effusion, swelling and/or
tenderness (PIP: proximal interphalangeal joints).
3. Causes of Musculoskeletal Examination
Previous studies suggest many reasons related to MSK
poor clinical skills and physical examinations in particu-
lar [3,10,18-20,24 -28] such as:
Vague training of MSK disorders in undergraduate
Examination of the MSK system is often regarded to
Copyright © 2012 SciRes. IJCM
Musculoskeletal Examination Skills: Are We Still Interested?
be complex in comparison with other organ systems.
Underestimation of the prevalence of MSK conditions
and their impact on individuals and society.
MSK disorders are not considered to be main compe-
tencies of medical graduates because they are not life
The lack of standardized approach to the clinical as-
sessment of MSK problems, whether pertaining to
primary care, rheumatology or orthopedics. Such
standardize approach would present a competency
Lack of proper standard teaching in MSK disorders
results in the low competence in MSK examination
Lack of summative evaluation of MSK examination
skills contributes to low level of competency among
The disparity in the appro ach to examination between
rheumatologists and orthopaedic surgeons mostly
lead to poor perf ormances in MSK examinations.
The lack of appropriate teaching and evaluation in
MSK disorders; clinical teachers are not usually
skilled in MSK examinations and thus bone and joint
diseases are not screened.
4. Solution of MSK Examination Deficiency
We suggest that one of the basic steps in working
through the obstacles of the deficiencies in MSK exami-
nation skills is to define competencies that should be
mastered while dealing with MSK disorders and is to
agree on what MSK skills should be mastered by medical
students [5,29]. There is a comprehensive core recom-
mendations developed for a musculoskeletal undergradu-
ate curriculum to be applied in any country and culture
. It was claimed in this study that the implementation
of these recommendations is therefore well suited to the
trend to integrate courses both vertically and horizon-
It is also important that experts in various specialties
work more closely together and look for the commonal-
ity of approach wh en treating a patient as they often treat
the same patients but from separate angles. Another solu-
tion would be an integrated MSK disease course for
medical students, bringing together orthopedics, rheu-
matology, and physical medicine and rehabilitation has
been found to be effective .
The method of teaching MSK examination skills
should follow interactive approaches and hands-on tea-
ching sessions where learners are involved in the teach-
ing process. Patient educators can participate effectively
in teaching MSK examination skills in different educa-
tional interventions [30-33]. Peer-assisted learning (a
technique whereby students learn from and with each
other) can be used to enhance MSK teaching for the un-
dergraduate medical curricula [34-36].
5. Standardization Problems Can Be
Resolved in a Number of Ways
A step towards standardizing MSK examination is to
consider as an important step in every joint examinatio n;
a screening exam. It simply implies the examination of
active range of motion of that joint where the patient
should be able to demonstrate by himself a full range
without pain or limitations. This is to assure maintenan ce
of functionality, as diseased joints particularly due to
inflammatory arthritis tend to lose the function early.
GALS (Gait, Arms, Legs and Spine) is a MSK screening
tool developed and validated as a rapid screening proto-
col/system for MSK system with the aim for a quick
identification of significant abnormalities . Various
spectrums of health specialties could utilize this screen-
ing routine before specific examination of any joint can
One of the essential steps in teaching MSK examina-
tion skills then wou ld be to define an overall objectiv e of
examining this patient for a MSK problem. Examining a
young patient for a knee joint pain following a sport in-
jury should differ at least in the approach of the manag-
ing clinician in comparison to a young female complain-
ing of small joints pains and swelling. In the former, it is
important to assess joint stability as a major objective
while in the latter, it is essential to examine for inflam-
matory arthritis. The screening exam for MSK abnor-
malities would be abnormal in both examples but then
the objective of examining the first patient would be to
evaluate for sport injuries, i.e. soft tissue problems while
in the second patient would be evaluated for the presence
of inflammatory arthritis. This is not to say that it is im-
perative to have a very limited MSK exam based on this
objective, it is rather to be focused on the primary objec-
tive based on historical facts but at the same time, we
emphasize that there is no substitu te for a comprehensive
approach to any joint examination.
The suggested approach should start with the screen-
ing examination of that jo in t then followed by insp ectio n,
palpation, range of motion testing (active and passive)
and ends with special tests based on the clinician’s ob-
jective on conductin g this exam.
There is no doubt that MSK disorders are common. The
prevalence of these disorders is expected to rise given the
significant increase in our aging population. Despite the
early reports about the neglect in basic MSK examination
skills among clinicians, this process continues unfortu-
nately. Several causes are described well in MSK litera-
ture and several attempts to overcome these obstacles
Copyright © 2012 SciRes. IJCM
Musculoskeletal Examination Skills: Are We Still Interested? 339
have been designed and experimented with. Adjusting
the way of teaching MSK examination skills by focusing
on one general approach for conducting the exam then by
focusing on a primary objective for examining individual
patients should enable us to overcome many obstacles in
evaluating MSK disorders. Furthermore, examination
should be geared to patients’ specific conditions. For
example, a clinician attempting to evaluate a MSK prob-
lem should ask himself/herself: am I dealing with a sport
injury (for example) or an inflammatory arthritis? The
answer of this question should be based on careful his-
torical points. The future direction of research should
focus on defining and validating precise techniques of
how to examine joints. However, in order to make any of
this happen, a true interest and strong desire to overcome
this observed deficiencies in MSK examinatio n skills are
required among medical educators.
The authors would like to thank Alzaidi Chair of Re-
search in Rheumatic Diseases, Umm Alqura University
for supporting this work and Dr. Khadee jah Bawazeer for
reviewing the manuscript.
This work was fund ed and supported b y Alzaidi Chair
of Research in Rheumatic Diseases, umm Alqura Uni-
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