2. What the clinician must assess

A complete musculoskeletal assessment addresses each of the following each visit, scaled to the patient’s condition and orders, and compares each finding to baseline.

• Inspection — deformity, swelling, asymmetry, muscle atrophy, surgical incisions, bracing, and posture.
• Palpation — tenderness, warmth, effusion, crepitus, and muscle tone.
• Range of motion — active and passive, at the affected and adjacent joints, against the patient’s baseline and any post-operative restriction.
• Strength — manual muscle testing graded 0–5, compared limb to limb and to baseline.
• Gait and balance — pattern, steadiness, assistive-device use, and a timed or functional measure where appropriate.
• Assistive-device fit and use — correct height, condition, and safe technique.
• Weight-bearing status and post-operative precautions — verified against the order (e.g. hip precautions, weight-bearing-as-tolerated).
• Pain with movement and at rest, on a validated scale, and its functional impact.
• Functional impact — the effect on transfers, ambulation, and ADLs (cross-reference Function).
• Fall risk indicators and the home environment as it bears on safe mobility (cross-reference Safety).