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Assessment of the

Musculo-Skeletal System

Dr Essmat Gemaey
NUR 230

Outlines
1. Review of Anatomy and physiology
of musculoskeletal system
2. Physical Exam
3. Inspection
4. Palpation
5. ROM (Rang of motion)

Objectives
Apply knowledge of Anatomy and
physiology of musculoskeletal system
Differentiate between normal and
abnormal
Implement physical assessment

What do muscles do ?
Muscles simply move you!
Without muscles you couldn't open your
mouth, speak, shake hands, walk, talk, or
move your food through your digestive
system.
There would be no exploring, running,
climbing, smiling, blinking, breathing. You
couldn't move anything inside or outside
you. The fact is, without muscles, you
wouldn't be alive for very long

The skeleton is the name given to the


collection of bones that holds our body
up.
Our skeleton is very important to us. It
does three major jobs.
1. It protects our vital organs such as
the brain, the heart, and the lungs.
2. It gives us the shape that we have.
Without our skeleton we would just be
a blob of blood and tissue on the floor.
3. It allows us to move. Because our
muscles are attached to our bones,
when our muscles move, they move
the bones, and we move

Physical Exam
1. Inspection
Observe any lack of symmetry and
any evidence of trauma or disease.
Look for muscle wasting;
Inspect the joint contour (shape)
and observe any evidence of
swelling, deformity or inflammation.

Ask the client to point to, or


otherwise identify, any painful areas,
including sites of radiation of
pain.
Screening questions for
musculoskeletal disorders
1. Do you have any pain or
stiffness in your arms, legs or
back?
2. Can you walk up and down
stairs without difficulty?
3. Can you dress yourself in
everyday clothes without any
difficulty?

Assessment of Gait
Ask the patient to walk back and forth
across the room.
Observe for equality of arm swing ,
balance and rapidity and ease of
turning.
Next, ask the patient to walk on his
tiptoes, then on heels.
Ask the patient to tandem walk.
Test patient's ability to stand with feet
together with eyes open and then
closed. (Romberg's test). Reassure
patient that you will support him, in
case he becomes unsteady.
Normal: Person can walk in balance
with the arms swinging at sides and can
turn smoothly. Person should be able to
stand with feet together without falling
with eyes open or closed.

heels

tiptoes

tandem

Upper Extremity Muscles


Inspect the muscles of
the shoulder, arm,
forearm and hand.
Note muscle size (bulk).
Look for asymmetry,
atrophy and
fasciculation.
Look for tremor and
other abnormal
movement at rest and
with arms outstretched.

Determine muscle power


by
Gently trying to
overpower
contraction of each
group of muscles.

Abduction

Shoulder:

Abduction
(Deltoid)
, Adduction
, Shrug
(Trapezius)

Adduction

( Trapezius

Elbow: flexion (Biceps)

Elbow extension
(Triceps)

Wrist: Flexion ( )and


extension().

Hand: Grip
Grip

opposition of
thumb and index finge
r

opposition of
thumb and little finger
and

finger abduction and

Determine limb tone


(resistance to
passive stretch).
With the patient
relaxed
Gently move the
limb at the shoulder,
elbow and wrist
joints and note
whether tone is
normal, increased or
decreased

Normal findings
Muscles are symmetrical in size with
no involuntary movements.
In some, muscles may be slightly
larger on the dominant side.
Muscle power obviously varies. You
should not be able to overpower with
reasonable resistance.
You have to learn to appreciate the
normal tone from practice.

Neck: Range of Motion of


Fix the head with one hand while you
examine neck
Inspection
Note the normal concavity of cervical
spine
Identify Transverse process of C7
Observe Trapezius and Sternomastoid
muscles

Palpation

Feel each spinous process looking for focal


areas of tenderness
Joint
Feel for crepitus during passive motion

Touch chin

Para spinal muscles

Range of motion
Active

Touch chin for flexion


Throw head back for extension

Throw head back

Touch each shoulder with ears for


lateral flexion
Touch each shoulder with chin for
lateral rotation

Passive
Feel for crepitus during passive
motion

Normal:
30 degree rotation, able to
touch chest with chin, 55
degree extension and 40
degree lateral bend.
No resistance during the range
of motion.

Muscles of Lower Extremity

Inspect the muscles of the hip,


knee and ankle.
Note muscle size (bulk).
Look for asymmetry, atrophy
and fasciculation.
Look for abnormal movement.
Determine muscle power by
gently trying to overpower
contraction of each group of
muscles.
Hip: Flexion (Iliopsoas), Extension
(Gluteus maximus), Abduction,
Adduction.

Hip flexion

The Knee Exam


Inspection
Make sure that both knees are
fully exposed. The patient should
be in either a gown or shorts.
Rolled up pant legs do not provide
good exposure!
Watch the patient walk.
Do they limp or appear to be in
pain?
When standing, is there evidence
of bowing (varus) or knock-kneed
(valgus) deformity? There is a
predilection for degenerative joint
disease to affect the medical
aspect of the knee, a common
cause of bowing.

varus Knee
deormity, more
marked on the left
leg

Is there evidence of
atrophy of the
quadriceps, hamstring,
or calf muscle groups?
Knee problems/pain can
limit the use of the
affected leg, leading to
wasting of the muscles.

While both legs have


well developed
musculature,
the left calf and
hamstring are bulkier
than the right

Knee : Flexion (Hamstrings),


Extension (Quadriceps)
Ankle : Dorsiflexion (Tibialis
anterior), Plantar flexion
(Gastronemius).

Determine limb tone


resistance to passive stretch.
With the patient relaxed,
gently move the limb at the
hip, knee and ankle and note
whether tone is normal,
increased or dicreased.
Flex the hip and knee.
Support the knee, dorsiflex the
ankle sharply and hold the foot
in this position checking for
clonus.

Knee extension

Knee flexion

Dorsiflexion

Spine (Bone)
The examiner should stand behind the
patient and observe the alignment of the
spine in the flexed position to determine
scoliosis.
View the spine from the side to determine
kyphosis.

Ask the patient if he is aware of sore spots.


Palpate the spinous process and be gentle
with the sore spots. Percuss one vertebra at
a time, starting from head.
.

Assess range of motion


of spine by having patient
bend down to pick up an
object without bending his
legs while you hold his
hips.
Normal:
Gentle concavities in
cervical and lumbar
regions and a convexity in
the thorax.
Vertebral line and gluteal
cleft align