Musculoskeletal physiotherapy

In short

Musculoskeletal (ortho) physiotherapy is the assessment and treatment of pain and movement dysfunction of bones, joints, muscles, tendons, ligaments, fascia and nerves — from a Colles fracture or frozen shoulder to chronic low back pain and knee osteoarthritis. It is the largest employment area in Indian physiotherapy: most private clinics, orthopaedic hospitals, corporate OPDs and insurance-funded rehab work is musculoskeletal. BPT universities examine it as a full paper ("Physiotherapy in Orthopaedic Conditions" / "Musculoskeletal Physiotherapy"), with a practical viva on assessment, special tests, goniometry, MMT and exercise prescription. Entrance and recruitment tests (MPT entrances, AIIMS/PGIMER/JIPMER, state and ESIC physiotherapist posts, NTRUHS/MAHE/MUHS papers) draw heavily on it, and interviews test clinical reasoning — why this test, why this grade, why this progression.

Explained

Anatomy, biomechanics and tissue behaviour you are examined on

• Joint classification: fibrous (suture, syndesmosis), cartilaginous (symphysis pubis, growth plate) and synovial (hinge — elbow; pivot — atlanto-axial; ball-and-socket — hip, shoulder; saddle — 1st CMC; plane — intercarpal; condyloid — MCP).
• Arthrokinematics: roll, glide (slide) and spin. Concave-convex rule — if the moving surface is convex, glide is opposite to bone movement (glenohumeral); if concave, glide is in the same direction (tibia on femur in open chain). This rule decides the direction of mobilisation.
• Close-packed vs loose-packed position: close-packed (knee full extension, shoulder abduction + external rotation) = maximal congruence, taut ligaments, no mobilisation; loose-packed / resting position (knee ~25° flexion, shoulder ~55° abduction 30° horizontal adduction) = maximum joint play, used for mobilisation and traction.
• Capsular pattern: a proportional loss typical of arthritis — shoulder loses ER > abduction > IR; hip loses flexion, abduction, IR; knee loses flexion > extension. Non-capsular loss suggests ligament, meniscus, bursa or loose body.
• Tissue healing: inflammation (0–72 h, up to 5–7 days), proliferation/repair (fibroblast, collagen III, ~3 days to 3–6 weeks), remodelling (collagen III → I, weeks to 1–2 years). Treatment must match the stage — ice and offloading early, controlled loading later.
• Davis's law / SAID principle: soft tissue adapts along imposed demand; Wolff's law: bone remodels along lines of stress — the rationale for weight-bearing and resisted exercise.
• Length–tension relationship, active and passive insufficiency (hamstrings during simultaneous hip flexion + knee extension); force couples (deltoid–rotator cuff; upper trapezius–lower trapezius–serratus anterior for scapular upward rotation).
• Open vs closed kinetic chain: OKC (seated knee extension) isolates muscle, higher ACL anterior shear at 0–30°; CKC (squat, leg press) is functional, co-contraction protects the graft — standard in ACL protocols.

Assessment: the full sequence examined in the practical viva

1. Subjective: demographics, occupation, chief complaint, history of present illness, mechanism of injury, pain (site, onset, type, radiation, aggravating/relieving, 24-hour pattern — night pain and non-mechanical pattern are red flags), past and medical history, drugs, occupation and ergonomics, patient's goal.
2. Red flags (refer, don't treat): cauda equina signs (saddle anaesthesia, bladder/bowel change, bilateral leg weakness), unexplained weight loss, fever, night pain, history of malignancy, long steroid use, significant trauma, progressive neurological deficit, suspected fracture or infection.
3. Observation: gait, posture (forward head, rounded shoulders, increased lumbar lordosis, scoliosis, genu varum/valgum/recurvatum, pes planus), swelling, deformity, muscle wasting, scars, attitude of limb, walking aid.
4. Palpation: temperature, tenderness (grade I–IV), swelling type (effusion vs oedema), crepitus, muscle spasm, trigger points, bony landmarks and limb-length (ASIS to medial malleolus = true length; umbilicus to medial malleolus = apparent length).
5. ROM: active then passive, with a universal goniometer — fulcrum on axis, stationary arm on proximal reference, movable arm along distal segment. Record SFTR / 0–180 notation. End-feel: bony, capsular, tissue stretch, tissue approximation, springy block (meniscus), empty (acute pain), muscle spasm.
6. Muscle strength — manual muscle testing (MMT), Medical Research Council / Oxford grading 0–5 with ± modifiers; Daniels & Worthingham positions. Also girth measurement (e.g. 10 cm above patella) and dynamometry/1-RM.
7. Special tests — selected by the suspected structure, never run as a list.
8. Neurological: dermatomes, myotomes (L4 dorsiflexion, L5 EHL/hallux extension, S1 plantarflexion/eversion; C5 elbow flexion, C6 wrist extension, C7 elbow extension), reflexes (biceps C5–6, triceps C7, knee L3–4, ankle S1), neurodynamic tests (SLR, slump, ULTT 1–4), two-point and light touch.
9. Functional and outcome measures: VAS/NPRS, Oswestry Disability Index (low back), Neck Disability Index, SPADI/DASH/QuickDASH (shoulder/upper limb), WOMAC and KOOS (knee), LEFS, Harris Hip Score, 6-minute walk test, TUG, Berg balance (for fall risk), SF-36.
10. Diagnosis and problem list → short- and long-term SMART goals → plan → re-assessment. Documentation in SOAP (Subjective, Objective, Assessment, Plan) format with informed consent recorded.

Special tests by region (high-yield)

Common conditions and their physiotherapy management

• Adhesive capsulitis (frozen shoulder): freezing, frozen, thawing; capsular pattern ER > abd > IR; often with diabetes. Treat with heat/moist pack, Maitland grade I–II in painful stage and III–IV in stiff stage, inferior and posterior glides, Codman's pendular, wall/finger-ladder, pulley, scapular setting, home programme. Natural course 12–24 months.
• Rotator cuff tendinopathy / impingement: relative rest, isometrics → progressive eccentric cuff loading in scapular plane, posterior capsule stretch (sleeper stretch), scapular stabiliser training (serratus, lower trapezius), posture correction, ergonomic advice on overhead work.
• Lateral epicondylalgia: load management, Mill's manipulation or Mulligan lateral glide with movement, eccentric wrist extensor loading, deep transverse friction (Cyriax), counterforce brace, grip and forearm strengthening.
• Low back pain (mechanical, non-specific): stay active, avoid bed rest beyond 1–2 days; McKenzie MDT directional preference (extension in lying/prone for posterior derangement), core/lumbar multifidus and transversus abdominis motor-control training, Williams flexion for stenosis-type presentations, hip and hamstring flexibility, lumbar mobilisation/manipulation, graded activity, pain-education for chronic cases, ergonomics and lifting technique.
• Lumbar disc prolapse with radiculopathy: positioning, intermittent lumbar traction (where tolerated), neural mobilisation (sliders before tensioners), extension-based loading if symptoms centralise, progressive core and gluteal strengthening; refer if progressive deficit or cauda equina.
• Cervical spondylosis / neck pain: isometric deep neck flexor training (cranio-cervical flexion), scapular retraction, cervical mobilisation/SNAGs, postural re-education, intermittent cervical traction (~7–10% body weight, 15–20°flexion, 15–20 min — protocols vary), avoidance of end-range rotation manipulation with vertebrobasilar signs.
• Knee osteoarthritis: quadriceps and hip abductor strengthening (the strongest evidence), weight reduction, aerobic activity, quadriceps-setting and SLR in early stage, closed-chain work within pain limits, avoid deep squatting and Indian-toilet/floor-sitting postures, knee brace, cane in opposite hand, TENS/short-wave for symptom relief, patient education. Avoid prolonged immobilisation.
• Fracture rehabilitation: during immobilisation — isometrics, ROM of free joints, oedema care, elevation, respiratory care in elderly, gait training with aids per weight-bearing order (NWB → PWB → FWB). After union — ROM, PNF, progressive resistance, proprioception, return to function. Complications to screen: malunion, non-union, Volkmann's ischaemic contracture, complex regional pain syndrome, myositis ossificans, joint stiffness, DVT.
• Post-arthroplasty (THR/TKR): day-1 mobilisation, ankle-toe movements, static quads/glutes, bed mobility, walker gait, THR precautions for posterior approach (no flexion beyond 90°, no adduction past midline, no internal rotation) for ~6–12 weeks; TKR — early flexion target 90° by discharge, extension lag correction.
• ACL reconstruction (phased): Phase 1 (0–2 wk) effusion control, full extension, quads activation, patellar mobilisation; Phase 2 (2–6 wk) full ROM, CKC 0–60°, gait normalisation; Phase 3 (6–12 wk) progressive strengthening, proprioception, bike/elliptical; Phase 4 (3–6 mo) running, agility, plyometrics; return to sport usually ≥9 months with limb-symmetry index >90% and hop-test clearance. Protocol varies by surgeon and graft.
• Ankle sprain: PEACE & LOVE replaces RICE in current teaching — Protect, Elevate, Avoid anti-inflammatories early, Compress, Educate; then Load, Optimism, Vascularisation, Exercise. Add balance-board proprioception to cut recurrence.
• Others in syllabus: amputation and prosthetic training, torticollis, CTEV, scoliosis, spondylolisthesis, ankylosing spondylitis (extension and chest expansion programme), rheumatoid arthritis (joint protection, energy conservation, isometrics in flare), osteoporosis (weight-bearing, resistance, fall prevention), tuberculosis spine, plantar fasciitis, myofascial pain syndrome.

Treatment techniques and electrotherapy

• Maitland grades: I (small-amplitude at beginning of range, pain), II (large-amplitude within range, pain), III (large-amplitude up to limit, stiffness), IV (small-amplitude at limit, stiffness), V (thrust manipulation, trained hands only). Pain-dominant → I–II; stiffness-dominant → III–IV.
• Kaltenborn grades: I loosening (no taut), II tightening (take up slack — for pain), III stretching (for mobility).
• Mulligan: MWM (mobilisation with movement), NAGs/SNAGs for spine; a technique is retained only if it is instantly pain-free and reproducible.
• McKenzie MDT: classify as derangement, dysfunction or postural; use repeated movements to find directional preference; centralisation of distal symptoms is a good prognostic sign.
• Mobilisation vs manipulation: mobilisation is oscillatory, within patient control, reversible; manipulation (grade V) is a high-velocity low-amplitude thrust at end range, beyond patient control, with absolute contraindications — fracture, malignancy, infection, inflammatory arthropathy flare, osteoporosis, instability, vertebrobasilar insufficiency, anticoagulation.
• Muscle Energy Technique, myofascial release, trigger-point release, dry needling (scope and regulation vary by state), Cyriax deep transverse friction, taping (rigid and kinesiology), PNF — hold-relax, contract-relax, rhythmic stabilisation, slow reversals, D1/D2 patterns.
• Stretching: static (hold 20–30 s, 2–4 reps), dynamic pre-activity, PNF-based; prolonged low-load stretch for contracture. Strengthening: isometric (acute/immobilised), isotonic concentric/eccentric (DeLorme progressive resistance, Oxford regressive, 1-RM based), isokinetic (lab/testing).
• Thermotherapy: moist heat pack, paraffin wax bath (hand RA/OA), infrared, short-wave diathermy (deep heating; contraindicated with metal implants, pacemakers, pregnancy, malignancy, acute inflammation), ultrasound (1 MHz deep ~3–5 cm, 3 MHz superficial; continuous = thermal, pulsed 1:4 = non-thermal; avoid over growth plates, eyes, gonads, pregnant uterus, malignancy, pacemaker).
• Cryotherapy: ice pack/ice massage 10–15 min for acute injury; contraindicated in cold urticaria, Raynaud's, impaired sensation, peripheral vascular disease.
• Electrical stimulation: TENS — conventional high-frequency (80–120 Hz, low intensity, gate-control, quick short relief) vs acupuncture-like low-frequency (2–5 Hz, strong intensity, opioid-mediated, longer relief); IFT (two medium-frequency currents ~4,000 Hz crossing to give a low-frequency beat, deeper and more comfortable); Russian/NMES for quadriceps re-education; faradic current for innervated muscle and interrupted galvanic (direct) current for denervated muscle, plus electrodiagnosis. Contraindications for electrotherapy: pacemaker, over the heart/carotid sinus, pregnancy (abdomen/low back), malignancy, thrombosis, broken skin, impaired sensation, uncooperative patient.
• Traction, hydrotherapy, LASER, UVR, shockwave (ESWT for plantar fasciitis and calcific tendinopathy) and biofeedback also appear in the electrotherapy paper.
• Pain mechanisms to quote: gate-control theory (Melzack & Wall, 1965), descending inhibition/endogenous opioids, central sensitisation (explains chronic pain, yellow flags, fear-avoidance, catastrophising).

Indian regulation, practice and settings

• National Commission for Allied and Healthcare Professions Act, 2021 is the governing law; physiotherapy is a recognised category and the NCAHP and State Allied and Healthcare Councils regulate education, registration and professional conduct. Older state Acts and the Indian Association of Physiotherapists (IAP) code of ethics still shape day-to-day practice; registration requirements differ by state, so check your state council.
• BPT is 4 years + 6 months compulsory rotatory internship; MPT specialisations include Musculoskeletal/Orthopaedics, Sports, Neurology, Cardiopulmonary, Paediatrics and Community. Title and prescribing scope (e.g. direct access, "doctor" prefix) have been contested — the practical rule is to work within your state council's scope and refer appropriately.
• Where the work is: hospital ortho OPD and wards, standalone clinics, corporate and IT-park ergonomics and on-site physio, sports academies, insurance and TPA-funded rehab, home visits, teaching, and medical-device/implant companies' clinical support roles.
• Documentation and safety: written informed consent, SOAP notes, outcome measures at baseline and discharge, infection control and biomedical waste rules, chaperone and privacy for exposed-region examination, and clinical records retention as per hospital policy. Clinical establishment registration and GST treatment of healthcare services differ for therapy versus product sales — verify locally.
• Teaching references commonly prescribed: Cyriax, Maitland, Kisner & Colby, Magee's orthopaedic physical assessment, Tidy's physiotherapy, Dutton, Brotzman & Manske.

Key points

• Musculoskeletal PT — assessment and treatment of pain and dysfunction in bone, joint, muscle, tendon, ligament and nerve, by movement, manual therapy and electrotherapy.
• Concave–convex rule — convex moving surface glides opposite to bone motion; concave glides the same way; it sets mobilisation direction.
• Loose-packed position — maximum joint play, used for mobilisation and traction; close-packed position is never mobilised.
• Capsular pattern — proportional ROM loss indicating arthritis; a non-capsular pattern points to a mechanical or extra-articular lesion.
• Oxford/MRC grading 0–5 — 0 no contraction, 1 flicker, 2 full ROM gravity-eliminated, 3 full ROM against gravity, 4 against some resistance, 5 normal.
• Maitland I–V — grades I–II for pain, III–IV for stiffness, V is manipulation.
• Kaltenborn I–III — loosening, tightening, stretching; grade III only for mobility gain.
• McKenzie centralisation — distal symptoms moving proximally with repeated movement is a favourable sign and guides the exercise direction.
• End-feel — the quality of resistance at passive end range (bony, capsular, springy, empty, spasm) names the limiting structure.
• Red flags — cauda equina, malignancy, infection, fracture and progressive deficit mean referral, not treatment.
• Healing stages — inflammation, proliferation, remodelling; dose load to the stage, not to the calendar alone.
• OKC vs CKC — OKC isolates and loads the ACL anteriorly at low flexion; CKC gives co-contraction and function.
• TENS — conventional 80–120 Hz works by gate control; low-frequency 2–5 Hz by endogenous opioids.
• Ultrasound — 1 MHz for deep, 3 MHz for superficial tissue; pulsed is non-thermal, continuous is thermal.
• IFT — two ~4 kHz currents interfere to produce a comfortable deep low-frequency beat.
• Outcome measures — VAS/NPRS, ODI, NDI, SPADI, DASH, WOMAC, KOOS, LEFS; measure at baseline and discharge.
• NCAHP Act, 2021 — the Indian statute under which physiotherapy is regulated, through central and state allied-healthcare councils.
• SOAP — Subjective, Objective, Assessment, Plan: the standard clinical record and viva format.

Formulas and examples

Example 1 — limb length discrepancy. Right: ASIS–medial malleolus 86.0 cm, umbilicus–medial malleolus 94.0 cm. Left: ASIS–medial malleolus 86.0 cm, umbilicus–medial malleolus 90.5 cm.

• True length difference = 86.0 − 86.0 = 0 cm → no real bony shortening.
• Apparent length difference = 94.0 − 90.5 = 3.5 cm, left apparently shorter.
• Interpretation: apparent shortening with equal true length = pelvic obliquity, usually from hip adduction contracture on the short (left) side or scoliosis. Treat the contracture and pelvic alignment, do not prescribe a shoe raise.

Example 2 — strength prescription from 1-RM. A post-ACL patient does 8 repetitions of leg press with 60 kg to failure.

• Brzycki denominator = 1.0278 − (0.0278 × 8) = 1.0278 − 0.2224 = 0.8054.
• 1-RM = 60 ÷ 0.8054 = 74.5 kg.
• Hypertrophy phase at 70% = 0.70 × 74.5 = 52.1 kg, 3 sets × 10 reps.
• Strength phase at 85% = 0.85 × 74.5 = 63.3 kg, 4 sets × 5 reps.

Example 3 — DeLorme progressive resistance for quadriceps. 10-RM measured = 12 kg.

• Set 1 = 50% = 6 kg × 10; Set 2 = 75% = 9 kg × 10; Set 3 = 100% = 12 kg × 10.
• Re-test 10-RM weekly; if it rises to 15 kg, the sets become 7.5 kg, 11.25 kg (round to 11 kg) and 15 kg.

Example 4 — aerobic dose in knee OA. Patient aged 58, resting HR 76/min, cleared for moderate exercise at 50–65% heart-rate reserve.

• HRmax ≈ 220 − 58 = 162/min; HR reserve = 162 − 76 = 86/min.
• Lower limit = 76 + 0.50 × 86 = 76 + 43 = 119/min; upper limit = 76 + 0.65 × 86 = 76 + 55.9 = 131.9 ≈ 132/min.
• Prescription: stationary cycling or level walking at 119–132 beats/min, 30 min, 5 days a week; cycling preferred to reduce joint load.

Example 5 — ultrasound dosing and return-to-sport check. Plantar fascia area to treat ≈ 12 cm², transducer ERA = 4 cm².

• Area units = 12 ÷ 4 = 3 → time at 1.5 min per unit area = 4.5 min, 3 MHz pulsed 1:4 at 0.8 W/cm² (symptom-stage dependent; evidence for ultrasound in plantar fasciitis is weak — loading and ESWT are better supported).
• Hop test at discharge: involved limb single-leg hop 142 cm, uninvolved 155 cm → LSI = (142/155) × 100 = 91.6% → meets the ≥90% criterion.

Where it is used

• Hospital orthopaedic departments (AIIMS, PGIMER, CMC Vellore, Apollo, Fortis, Max, Manipal): pre- and post-operative rehab for arthroplasty, arthroscopy, spine surgery, trauma and polytrauma.
• Private and chain clinics (QI Spine, HCAH/Nightingales, Portea home physio, local OPD clinics): low back and neck pain, OA knee, frozen shoulder, post-fracture rehab, with packages priced roughly ₹400–₹1,200 per session depending on city and setting.
• Corporate and IT ergonomics programmes (Infosys, TCS, Wipro campuses, BPO/GCC on-site physio): workstation assessment, repetitive-strain and neck-shoulder programmes, return-to-work plans.
• Industrial and construction health under the occupational-safety framework of the labour codes in force from 21 November 2025: manual-handling training, back-injury prevention, fitness-for-duty screening.
• Sports academies and insurance/TPA rehab — ortho injury rehab and functional discharge testing; also ESIC, Railways, state health services and defence hospital physiotherapist posts.
• Industry roles — clinical application specialists for implant, brace, orthotic and electrotherapy-equipment companies; teaching posts in BPT colleges; tele-rehabilitation platforms.

Interview questions

• Q: What is the concave–convex rule and why does it matter? A: If the moving joint surface is convex, the glide goes opposite to the bone's movement; if concave, it goes the same way. It tells you which direction to mobilise to gain a particular movement.
• Q: A patient has a painful stiff shoulder losing external rotation most, then abduction, then internal rotation. Diagnosis and first-line treatment? A: That capsular pattern suggests adhesive capsulitis. Treat with heat, Maitland grade I–II glides while pain dominates, moving to grade III–IV inferior and posterior glides plus pendular and active-assisted exercise as pain settles.
• Q: How do you decide between Maitland grades II and IV? A: By what limits the movement — if pain comes before resistance, use grades I–II; if resistance (stiffness) comes before pain, use grades III–IV.
• Q: Which is the most sensitive clinical test for an ACL tear and why? A: The Lachman test, because at 20–30° flexion the hamstrings and meniscal wedge interfere least, giving a clearer anterior translation with a soft end-point.
• Q: What are the red flags in low back pain? A: Cauda equina signs, unexplained weight loss, fever, night or non-mechanical pain, malignancy history, major trauma, long-term steroids and progressive neurological deficit — all need medical referral first.
• Q: Difference between mobilisation and manipulation? A: Mobilisation is slow oscillatory passive movement within the patient's control; manipulation is a single high-velocity low-amplitude thrust at end range, beyond the patient's control, with far stricter contraindications.
• Q: Why are isometrics used in the immobilised or acutely inflamed joint? A: They maintain muscle recruitment and reduce atrophy without joint movement or shear, so they do not disturb healing tissue or provoke an inflamed joint.
• Q: How does TENS relieve pain? A: High-frequency conventional TENS stimulates large A-beta fibres and closes the spinal gate to nociceptive input; low-frequency acupuncture-like TENS triggers descending inhibition and endogenous opioid release.
• Q: Which precautions do you teach after a posterior-approach total hip replacement? A: Avoid hip flexion beyond 90°, adduction across the midline and internal rotation — so no low chairs, no crossing legs, no squatting or floor sitting, and use a raised toilet seat for the first few weeks.
• Q: A knee OA patient asks for ultrasound and short-wave only. What do you say? A: Modalities can ease symptoms briefly, but the evidence-based core is quadriceps and hip abductor strengthening, aerobic activity and weight reduction, so the exercise programme must stay central.
• Q: What is centralisation and why do you want it? A: It is the movement of referred distal pain towards the spine with a repeated direction of movement; it indicates a reducible derangement and a good prognosis, and it identifies the exercise direction.
• Q: Under which Indian law is physiotherapy regulated today? A: The National Commission for Allied and Healthcare Professions Act, 2021, through the NCAHP and state allied and healthcare councils; registration specifics vary by state, so the state council's rules apply.
• Q: When would you not use short-wave diathermy? A: With metal implants, pacemakers or other electronic implants, pregnancy, malignancy, active infection, acute inflammation with effusion, impaired sensation, or over the eyes and gonads.

Common mistakes

• Running a long list of special tests instead of selecting them from the history and movement findings — and over-reading a single positive test without the cluster.
• Confusing true and apparent limb length, so pelvic obliquity is mistreated as bony shortening with a shoe raise.
• Testing passive ROM before active, or doing MMT in the wrong gravity position and grading 3 as 4.
• Mobilising in the close-packed position, or using grade III–IV when pain, not stiffness, is the limit.
• Treating a red-flag presentation — night pain, bladder change, progressive weakness — instead of referring it.
• Prescribing modalities as the whole treatment and skipping progressive loading, home exercise and outcome measures.
• Ignoring the healing stage: aggressive stretching in the inflammatory phase, or indefinite rest well into the remodelling phase.
• Writing goals without numbers or timeframes, and no re-assessment, so SOAP notes show no measurable change.

Related topics

Sports physiotherapy · Neurological physiotherapy · Geriatric physiotherapy · Electrotherapy and actinotherapy · Biomechanics and kinesiology · Orthotics, prosthetics and gait analysis