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Assessing Musculoskeletal Physical Examination Skill Decay in Medical Students

by Annie Lee, BA, Alexys Bermudez; MD, Jeffrey Leggit, MD, CAQSM; Department of Family Medicine Uniformed Services University of the Health Sciences, Bethesda, MD


Musculoskeletal (MSK) injuries are among the most common types of injuries, affecting individuals regardless of age or activity level. The burden of MSK conditions has been steadily increasing, with a significant 61.6% increase in disability-adjusted life years between 1990 and 20161. Additionally, MSK injuries can lead to secondary health issues such as obesity, insomnia, and mental health problems, contributing to a broader impact on public health. In 2015, the economic loss due to work absenteeism caused by MSK-related back pain alone amounted to $131.8 billion2. Given the substantial incidence and impact of MSK injuries, ensuring proficiency in their diagnosis and treatment is crucial.

The primary objective of this study is to determine the extent of decay in MSK physical examination skills among medical students during their medical school education. Additionally, we aim to identify the timing of skill decay and explore potential interventions to minimize this decline. By understanding the challenges associated with skill decay, medical educators can enhance the MSK curriculum and improve students' ability to diagnose and manage MSK injuries effectively.


Ideally, basic MSK concepts should be taught in medical school and refined in postgraduate training3. Despite the need for early training, many studies suggest that medical school training in MSK medicine is inadequate3,4. In a study conducted by Freedman and Bernstein, an MSK competency examination was administered to 85 individuals on the first day of residency, and 82% of the test group failed to demonstrate competency in four basic MSK concepts3. In conjunction with solid foundational knowledge of the MSK system, mastery of the physical examination is imperative in diagnosis and treatment 5. Despite its importance, there is increasing awareness that medical students are deficient in the basic principles of the physical exam6.


We conducted a longitudinal study with 155 medical students in the Uniformed Services University Class of 2021. During the first year of medical school, students were asked to perform knee and shoulder examinations on standardized patients, and these sessions were recorded on video. After core clerkships during their third year, the same students performed knee and shoulder examinations on standardized patients, and the sessions were recorded again. Video recordings of these examinations were graded by a single grader using a consistent scoring system.


Our recent decay study shows a significant decline in MSK physical examination skills between the first and third year of medical school. Specifically, the average shoulder examination score decreased by 30% from 84.68 to 59.27, while the knee examination score decreased by 30.65% from 75.82 to 52.58. These findings indicate a noteworthy decay in students' ability to conduct effective MSK examinations over the course of their medical school education.

Figure 1. Histogram displays distribution of individual scores on knee and shoulder exams.

From top to bottom: Knee pretest, shoulder pretest, knee posttest, shoulder posttest.

Figure 2. Pie charts characterize the degree of decay in individual exam skills. Bar graph displays the mean pre and posttest scores. Differences between mean pre and post-test scores are statistically significant (dependent t-test was used).

Discussion & Conclusion

We intend to replicate this study on a larger scale, ensuring the reliability and applicability of our results. Additionally, we aim to determine the precise timing of the decay in MSK physical examination skills by evaluating students' performance in objective structured clinical examinations (OSCEs) at designated intervals during the pre-clerkship and clerkship phases of their medical education.

In addition to assessing the timing of decay, we intend to explore interventions to mitigate this decline in MSK skills. Depending on the presence of decay during the pre-clerkship period, we plan to develop tailored interventions. For pre-clerkship, incorporating standardized refreshers and simulations into the curriculum just before clerkship might serve as effective strategies. During clerkship, we can encourage students to use passbooks and standardized cases covering relevant MSK topics and offer refresher courses during outpatient specialties.

Addressing the decay in MSK skills in the medical school curriculum is vital to improve the diagnosis and treatment of MSK injuries. Our findings also further underscore the significance of our institution’s early emphasis on the MSK system module within the first-year curriculum. This module serves as an introduction to anatomy, patient interviewing, as well as physical examination skills, forming the foundation for teaching sports medicine from a primary care perspective. Additionally, we believe that physical examination skills in other medical disciplines might also be susceptible to decline, making it crucial to address this issue systematically. Demonstrating the need for curriculum interventions to counteract decay will highlight the importance of maintaining proficiency across all medical specialties, ultimately leading to better patient care and outcomes.


1. Blackwell DL, Lucas JW, Clarke TC. Summary health statistics for U.S. adults: national health interview survey, 2012. Vital Health Stat 10. 2014; (260): 1-161.

2. Bull World Health Organ. 2018 May 1; 96(5): 366- 368. Published online 2018 Apr 12. Doi: 10.2471/BLT.17.204891.

3. Bernstein J, Garcia GH, Guevara JL, et al. Progress report: the prevalence of required medical school instruction in musculoskeletal medicine at decade’s end. Clin Orthop Relat Res. 2011;469(3):895-897.

4. Griesser MJ, Beran MC, Flanigan DC, et al. Implementation of an objective structured clinical exam (OSCE) into orthopedic surgery residency training. J Surg Educ. 2013 Aug 7;95(15):e106.

5. Corbett EC Jr, Elnicki DM, Conaway MR. When should students learn essential physical examination skills? Views of internal medicine clerkship directors in North America. Acad Med. 2008;83(1):96-99.

6. Hauer KE, Teherani A, Kerr KM, et al. Student performance problems in medical school clinical skills assessments. Acad Med. 2007;82(10 Suppl):S69-S72.



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