Orthopaedic and musculoskeletal physiotherapy assessment: a complete checklist

A good musculoskeletal assessment answers four questions: what is wrong, how bad is it, is it safe to treat, and how will we know it is getting better. This checklist follows the order most physiotherapists work in, from the first question to the plan. Use it to build your own form, or to check that your current one has no gaps.

Subjective assessment

The complaint

• the main problem, in the patient's own words

• where it is (mark it on a body chart, front and back)

• when it started, and how: a specific injury, gradual onset, or after surgery

• how it has changed since: better, worse, the same

The pain

• severity now, at its best and at its worst, on a 0 to 10 scale

• type: aching, sharp, burning, throbbing, pins and needles

• what makes it worse and what eases it

• how it behaves over 24 hours: morning stiffness, worse at the end of the day, waking at night

• whether it spreads, and where

Red flags

Ask, and record the answers even when they are negative:

• unexplained weight loss, fever, night sweats

• constant pain that does not change with position or rest, or severe night pain

• history of cancer

• recent significant trauma

• changes in bladder or bowel control, or numbness around the saddle area

• progressive weakness or numbness in a limb

Any of these may need medical review before or alongside physiotherapy.

Background

• previous episodes and what helped

• other medical conditions, surgery, current medicines

• work, sport, daily activities and what the patient cannot do now

• the patient's own goal for treatment

Objective assessment

Observation

Posture, alignment, swelling, bruising, scars, muscle wasting, and how the patient moves as they walk in, sit and stand.

Palpation

Tenderness, temperature, swelling, muscle tone, with the exact location.

Range of motion

Active first, then passive, in degrees, for the joints involved and the joint above and below. Note pain, where in the range it starts, and end feel.

Muscle strength

Graded for the key muscle groups, both sides, so the difference is visible.

Special tests

Choose the tests that fit your working diagnosis for the region, and record the name of each test and the result. Common examples include ligament stress tests at the knee, impingement tests at the shoulder, and neural tension tests for the spine.

Neurological screen

Where symptoms spread into a limb: sensation, reflexes and power by nerve root level.

Function

A task that matters to the patient, measured: sit to stand, stairs, reaching overhead, walking distance or time. A validated questionnaire for the region is useful if you use one consistently.

Assessment

• your clinical impression and provisional diagnosis

• the main problems you will treat, in order

• factors that may slow recovery

Plan

• short-term and long-term goals, written so they can be checked ("reach a top shelf without pain in 4 weeks")

• treatment you will give

• home exercises, with dose

• how often you will see the patient, and when you will reassess

Consent

Record that you explained the assessment and treatment and that the patient consented.

Recording it in PhysioDesk

PhysioDesk is built around the same structure, so an assessment does not have to be typed twice:

• Open a diagnosis on the patient's record for what you are treating.

• Write the assessment in the first session note, which follows the SOAP shape: subjective, objective, assessment and plan.

• Record pain score, range of motion and strength as progress measures on the date of assessment. Each reassessment adds a new point, and PhysioDesk charts them, so improvement is visible to you and the patient.

• The patient's consent to treatment is signed by them in the portal, or recorded by your staff, against a written wording.

• Prescribe the home programme from your exercise library; it appears on the patient's phone.

See it in the 30-minute demo from the pricing page.