assessment
Musculoskeletal assessment
Introduction
It is word of 2 syllables
Muscle + Skeletal
So it Consists of:
• A. Muscles (accounts for approximately
50% of the body weight):
• B. Bony structures and connective tissue
(accounts for approximately 25% of the
body weight):
– 1-The Skeleton
– 2-Supportive connective tissues
– 3-Articular system(Joints)
1-Types
1. Skeletal muscles (voluntary
and striated),
2. Cardiac muscles
(involuntary and striated)
3. Smooth/visceral muscles
(involuntary and non-striated)
Skeletal muscles
Types of Muscle Contractions:
• 1-isometric contraction, the length of the
muscles remains constant but the force
generated by the muscles is increased; an
example of this is when one pushes against an
immovable wall.
• 2- Isotonic contraction, is characterized by
shortening of the muscle with no increase in
tension within the muscle; an example of this
is flexion of the forearm.
•
.
NB: Many muscle movements are a
combination of isometric and isotonic
contraction. For example, during
walking, isotonic contraction results in
shortening of the leg, and isometric
contraction causes the stiff leg to push
against the floor
The function of muscles is
Movement
Support: protects the internal body organs
factory which produces red blood cells from the
bone marrow of certain bones and white cells from
the marrow of other bones
a storehouse for minerals - calcium, for
example - which can be supplied to other parts of
the body
Consists of:
1. The Skeleton (bones)
2. Articular system (Joints)
3. Supportive connective tissues
(Cartilage, ligaments, tendons)
1-The Skeleton(Bones):
Mobility and weight-bearing capacity are
directly related to the bone’s size and shape.
Bones: composed of : cells, protein matrix,
and mineral deposits.
Typs of bones cells:
• 1-Osteoblasts :function in bone
formation by secreting bone matrix.
• 2-Osteocytes are mature bone cells
involved in bone-maintenance functions.
• 3-Osteoclasts: involved in destroying,
resorbing, and remolding bone.
TYPES OF BONE
There are 206 bones in the human body, divided into four categories:
Long bones
Short bones
Flat bones
Irregular
bones
Bones of the Cranium
Frontal View
Frontal
Frontal View
Parietal
Frontal View
Temporal
Frontal View
Nasal
Frontal View
Vomer
Frontal View
Zygoma
Frontal View
Maxilla
Frontal View
Mandible
Frontal View
Frontal
Parietal
Temporal
Nasal
Vomer Zygoma
Maxilla
Mandible
Frontal View
Lateral View
Frontal
Lateral View
Parietal
Lateral View
Temporal
Lateral View
Nasal
Lateral View
Zygoma
Lateral View
Maxilla
Lateral View
Mandible
Lateral View
Sphenoid
Lateral View
Occipital
Lateral View
Mastoid Process
Lateral View
External Auditory Meatus
Lateral View
Frontal Parietal
Sphenoid
Nasal
Temporal
Zygoma Occipital
Maxilla
Mastoid Process
Mandible
Lateral View
Sutures
Sagittal
Sutures
Frontal
(Coronal)
Sutures
Squamous
Sutures
Lambdoid
Sutures
Sagittal
Frontal
(Coronal)
Squamous
Lambdoid
Sutures
Bones of the
Appendicular
Skeleton
Clavicle
Scapula
Costals (Ribs)
Sternum
Vertebra
Humerus
Ulna
Radius
Clavicle
Scapula
Sternum Costals (Ribs)
Humerus
Ulna Vertebra
Radius
Sacrum
Ilium
Ischium
Pubis
Femur
Patella
Tibia
Fibula
Ilium Sacrum
Ischium Pubis
Femur
Patella
Fibula
Tibia
Bones of the Hand
Carpels
Carpels
Metacarpels
Carpels
Tarsals
Metatarsals
Tarsals
PHYSICAL EXAMINATION
COLLECTING SUBJECTIVE DATA
Current symptoms
Have you ever been diagnosed with diabetes mellitus, sickle cell anemia,
systemic lupus erythematous(SLE), or osteoporosis?
Have you started menopause? Are you receiving estrogen replacement therapy?
CON
Family History
Do you drink alcohol or caffeinated beverages? How much and how often?
Describe your typical 24- hours diet. Are you able to consume milk or milk-
containing products? Do you take any calcium supplements?
Describe your activities during a typical day. How much time do you spend in
the sunlight?
CON….
Describe any routine exercise in which you engage.
Describe your posture at work and at leisure. What type of shoes do you usually
wear?
Do you have difficulty performing normal activities of daily living? Do you use
assistive devices (e.g., walker, cane, braces) to promote your mobility?
How have your musculoskeletal problems interfered with your ability to interact
or socialize with others? Have they interfered with your usual sexual activity?
How did you view yourself before you had this musculoskeletal problem, and
how do you view yourself now?
Subjective Data
• History collection
Objective Data
• Physical examination
General principles of joint
examination
Inspection
Palpation
Movement of joint(s)
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 client to point to any painful areas including sites or
radiation of pain
Palpation
Active ROM
Passive ROM
Muscle Strength scale
0 No detection of muscular contraction
CIRCUMDUCTION
Main anatomical
movements
DORSIFLEXION
PLANTAR FLEXION
Main anatomical
movements
Eversion
Inversion
Main anatomical
movements
Assessment -Gait:
GAIT
From behind:
GAIT
From side:
GAIT
Observe Gait
Observe the client’s gait as the client enters and walks around the room.
Note:
Base of support
Weight bearing stability
Feet position
Stride
Stride length
Cadence
Arm swing
Posture
Assessment of temporomandibular
joint
Inspection
Palpation
Muscle strength
Inspect and palpate the TMJ
Test ROM
Test CN V function
TMJ palpation
TMJ
STEPS
1. As the client’s mouth opens, your fingers
should glide into a shallow depression of
the joints. Confirm the smooth motion of
the mandible
2. The joint may audibly or palpably clicks as
the mouth opens. This is normal
3. Palpate the CONTRACTED TEMPORALIS
AND MASSETER MUSCLES. HOW?
Test CN V function
– contract temporal and masseter
muscle
TMJ and cranial nerve 5 testing
-Instruct to clench teeth as you palpate
-compare right and left sides for size,
firmness and strength.
- ask the person to open mouth against your
resistance and to move jaw forward and
laterally against your resistance.
TMJ ROM
STEPS
1. Ask the client to open the mouth as wide
as possible. Confirm that the mouth
opens with ease to a smuch as 3 to 6 cm
between the upper and lower incisors.
2. With the mouth slightly open, ask the
client to push out the lower jaw and
return to neutral position. The jaw should
protrude and retract with ease.
3. Ask the client to move the lower jaw
from side to side.
.Confirm that the jaw moves laterally from 1
to 2 cm without deviation or dislocation.
4. Last, ask the client to close the mouth. The
mouth should close completely without pain
or discomfort.
Test ROM
o normal finding:
jaws move laterally 1 to 2 cm
(+) snapping and clicking – may be felt and heard
mouth opens 1-2 inches (distance bet upper and lower teeth)
jaw protrudes and retracts easily
o abnormal finding:
decreased ROM, swelling, tenderness, crepitus – arthritis
decreased muscle strength – muscle and joint dse
decreased ROM, clicking, popping, grating sound – TMJ
dysfunction
Sternoclavicular joint
STERNOCLAVICULAR JOINT
Inspection
Palpation
ROM
→cervical spine
→throracic and lumbar
Leg and back pain
Measur leg length
CERVICAL,THORASIC,AND LUMBAR SPINE
abnormal findings R
TEST ROM OF THE THORACIC ANDLUMBAR
SPINE
o flexion – bendforward, touch toes
o lateral bending
o lumbar extension
o rotation
o abnormal finding:
unequal leg lengths – scoliosis
equal true leg lengths but unequal apparent leg
lengths – abnormalities in structure or position
of hips and pelvis
Shoulders, Arms, and Elbows
INSPECTION
o normal finding:
shoulders –symmetrically round, no redness,
swelling, deformity or heat, no tenderness
muscles -fully developed
clavicle and scapulae – even and symmetric
o abnormal finding:
flat, hollow, less rounded shoulders –
dislocation
muscle atrophy – nerve or muscle damage or
lack of use
Shoulder
Palpation:
Clavicle
Tenderness of sternoclavicular
joint , acromioclavicular joint
greater tubercle of humerus
- tenderness, swelling, heat – shoulder stains,
sprains, arthritis, bursitis, degenerative joint
disease
Test ROM
o normal finding:
flexion - 1800 ; hyperextension - 500
adduction - 500 ; abduction - 1800
external and internal rotation - 900
o abnormalfinding:
painful and limited abduction, muscle weakness &
atrophy – rotator cuff tear
sharp catches of pain when bringing hands overhead –
rotator cuff tendinitis
chronic pain and severe limitation of all shoulder
motions – calcified tendinitis
unable shrug shoulders against resistance - lesion of
CN
XI
decreased muscle strength against resistance – muscle
and joint dse
ELBOWS
Test ROM
SUPINATION AND PRONATION
o normal finding:
flexion – 1600
extension – 900
pronation – 900
supination – 900
some – lack 5 to 10 0 ; or have
hyperextension
o abnormal finding:
decreased muscle strength against resistance
– muscle and joint dse
WRISTS
o palpate anatomic snuffbox
o hollow area on back of wrist at base of
fully extended thumb
o normal finding:
symmetric without redness, swelling
nontender, free of nodules
no tenderness anatomic snuffbox
#
o flexion – bend down ; extension – bend
back
o deviation – client hold wrist straight;
move hand outward and inward
Test ROM
Range Of Motion
Wrists, Hands, and Fingers.
onormal finding:
flexion - 90 0
hyperextension - 700
ulnar deviation - 55 0
radial deviation - 200
Swedes, Chinese – unequal lengths of ulna and
radius
o abnormal finding:
ulnar deviation of wrist and fingers with limited
ROM – rheumatoid arthritis
epicondylitis of lateral side of elbow– increased pain
with extension of wrist and fingers against resistance
epicondylitis of medial side of elbow– increased
pain with flexion of wrist and fingers against
resistance
decreased muscle strength against resistance –
muscle and joint dse
◦ Phalen’s test
◦ Tinel’s sign
Interphalangeal joints
Metacarpophalangeal joints
Radiocarpal groove an d
wrist
Maria Carmela L. Domocmat, RN, MSN
ask the client to
squeeze your first
two fingers as hard
as he or she can.
If you cross your
fingers, you will not
feel as much
discomfort if the
client is exceptional
strong.
Progressive sensory changes including paresthesias
and numbness of the thumb, index finger, and ring
finger of the involved hand; leads to pain waking
the patient up at night.
Motor changes beginning with clumsiness and
progressing to weakness; edema and thenar
atrophy may be noted.
Positive Tinel’s sign: Increased paresthesias on
tapping of tendon sheath (ventral surface of central
wrist).
Positive Phalen test: Increased symptoms with
acute palmar flexion for 1 minute.
Phalen’s test
In the first of these
tests, for 1 minute.
The experience of
numbness and
paresthesia over the
palmar surface of the
hand and the first
three fingers and part
of the fourth is called
Phalen’s sign. The
symptoms resolve
quickly after the hand
returns to the resting
position.
tapping over the median nerve
(palmar aspect of wrist).
The client’s sensation of tingling or
prickling is known as Tinel’s sign.
Tinel’s sign
o normal finding:
no tingling, numbness, pain
o abnormal finding:
(+)tingling, numbness, pain – (+) carpal tunnel
syndrome
numbness, pain , impaired function of hand
and fingers - median nerve entrapped in carpal
tunnel
o abnormal finding:
swollen, stiff, tender finger joints – acute rheumatoid
arthritis
boutonnière deformity – flexion of proximal
interphalangeal joint and hyperextension of distal
interphalangeal joint
swan-neck deformity - hyperextension of proximal
interphalangeal joint with flexion of distal
interphalangeal joint
swan-neck deformity boutonnière deformity
o abnormal finding:
thenar atrophy (atrophy thenar prominence) – carpal tunnel
syndrome
osteoarthritis
Heberden’s nodes - hard, painless nodules over distal
interphalangeal joints
Bouchard’s nodes - hard, painless nodules over proximal
interphalangeal joints
thenar atrophy
TEST ROM
Test ROM
http://www.ncbi.nlm.nih.gov/books/N
BK27290/bin/ch4f4-57.jpg
1. Extend the fingers while you push down on the dorsal
surface
2. Flex the fingers while you push up on the
ventral surface.
3. Spread the fingers as far apart as possible
while you try to push them together.
4. Push the fingers as close together as possible
while you try to pull th em apart.
Dupuytren’s contracture
o abnormal finding:
Dupuytren’s contracture – inability to
extend ring and little fingers
tenosynovitis (infection of flexor tendon
sheathes) - painful extension of finger
decreased muscle strength against resistance
– muscle and joint dse
o abnormal finding:
Tenosynovitis
infection of flexor tendon sheathes
painful extension of finger
decreased muscle strength against resistance
– muscle and joint dse
When a tendon (a fibrous, non-elastic band of
tissue which attaches a muscle to a bone) and its
surrounding soft tissue (called the tenosynovium)
are injured—either by a direct injury or due to
micro-trauma like excessive repetitive
movements—they become inflamed, swollen, and
painful. This condition is called Tenosynovitis. (A
less accurate and rarely used term to describe this
condition is tendonitis.)
While all of the tendons of the wrist and hand may
become inflamed and painful, the most common
form of tenosynovitis seen in the hand and wrist is
called deQuervain's Tenosynovitis. deQuervain's
Tenosynovitis affects the thumb and wrist.
deQuervain's
Tenosynovitis
Hips
Inspect and palpate
ostand
onormal finding:
buttocks – equally sized
iliac crests – symmetric height
hips – stable, nontender, without crepitus
o abnormal finding:
instability, inability to stand, and/or
deformed hip area – fractured hip
tenderness, edema, decreased ROM,
crepitus – hip inflammation, degenerative jt
dse
o
supine
o hip flexion
flexion with knees straight - raise extended
leg
flexion with knee flexed - flex knee to
chest; keep other leg extended
Note: if had total hip replacement – do not
test ROM unless physician gives
permission; reduce risk of dislocating
prosthesis
Test ROM
o abduction – move extended leg away from
midline of body as far as possible ; adduction –
toward midline of body as far as possible
o internal/ external hip rotation – bend knee and
turn leg inward then outward
o hyperextension – prone, lift extended leg off
table ; or client stand and swing extended leg
backward
o repeat all against resistance
onormal finding:
flexion with knees straight – 900
flexion with knee flexed -1200
abduction – 45-500 ; adduction – 20 to 300
internal hip rotation - 400 ; external hip rotation -
450
hyperextension - 150
oabnormal finding:
inability to abduct hip – hip dse
pain, decrease internal hip rotation –
osteoarthritis, femoral neck stress fracture
pain or palpation of greater trochanter; pain as
client moves from standing to lying down –
bursitis of hip
evaluates flexion contractures of the
hip
With the client in the supine position,
ask the client to pull one knee up
toward the chest as far as possible.
Approximate the extent of the flexion
contracture by noting the degree of
flexion of the opposite leg (the angle
between the client’s leg and the
table).
Thomas test
normal finding:
◦ when the hip is flexed, the opposite
leg remains flat on the examination
table
abnormal finding
◦ for the individual with an immobile
hip, the opposite hip and leg flex in
response to flexion of the leg.
Thomas test
Knees
Supine, sitting
Inspect size, shape, symmetry, swelling, deformities,
alignment, qudricep muscle atropy
Palpate tenderness, warmth, consistency, nodules
obegin 10 cm above patella
ouse fingers and thumb to move downward
the knee
Knee palpation
http://www.sciencephoto.com/image/265069/350wm/M3301436-Swollen_knee-
SPL.jpg
http://www.marvistavet.com/assets/i
mages/knee_meniscus_model.gif
o indication: if (+) swelling to determine cause
of swelling (if due to accumulation of fluid or
soft tissue swelling)
o helps detect small amounts of fluid in knee
o client supine – use ball of your hand firmly
to stroke the medial side of knee upward, 3-
4x – to displace any accumulated fluid
o then press lateral side of knee
o look for bulge on medial side of knee
Bulge test
A test for small effusions in the knee joint is
called the bulge sign.
Take the ball of your hand and firmly milk the
medial aspect of the knee upward two to three
times to displace fluid
Then press or tap behind the lateral margin of
the knee.
A positive bulge sign will show a swelling or
bulge of fluid in the hollow area medial to the
patella.
The bulge sign is useful for assessing small
effusions, but
It may be absent in large effusions.
Bulge sign
http://www.hipandkneeadvice.com/index.php/knee-procedures/
1. Quadriceps Tendon
2. Patella
3. Patellar Tendon
4. Tibia
5. Fibula
6. Posterior Cruciate Ligament
7. Anterior Cruciate Ligament
8. Lateral Collateral Ligament
9. Lateral Meniscus
10. Lateral Femoral Condyle
11. Femur
http://www.trialsightmedia.com/exhibit_store/images/kneeanatomy.jpg
http://static.howstuffworks.com/gif/adam/images/en/knee-arthroscopy-normal-
anatomy-picture.jpg
http://www.healthscout.com/common/images/8/8716_11265_5.jpg
The ligaments which attach the upper leg bone
(femur) to the large lower leg bone (tibia)
create a hinge joint called the knee. The
anterior and posterior cruciate ligaments are 2
short, strong ligaments which criss-cross each
other in the middle of the joint.
o normal finding:
no bulge of fluid appears on medial side
of knee
o abnormal finding:
bulge of fluid on medial side; with sml amt
of joint effusion
Bulge test
Maria Carmela L. Domocmat, RN, MSN
When considerable fluid is present in the
suprapatellar pouch, ballottement of the
patella may be possible.
Ballottement involves applying downward
pressure with one hand while pushing the
patella backward against the femur with a
finger of the opposite hand. Examine the
popliteal region with the client in the
prone position or while standing.
Swelling of the joint in the region, which
is called Baker’s cyst, is generally an
extension of the articular cavity.
Ballottement of the
patella
o helps detect large amts of fluid in knee
o client supine
o firmly press nondominant thumb and index
finger on each side of patella
this displaces fluid in suprapatellar bursa located
between femur and patella
o with dominant fingers – push patella down on
femur
o feel fluid wave or a click
o normal finding:
no movement of patella
patella rests firmly over femur
o abnormal finding:
(+) ballottement test – meniscal tears
(+) fluid wave or click – large amts of joint
effusion
Maria Carmela L. Domocmat, RN, MSN
o as compress the patella –
slide it distally against
the underlying femur
o normal finding:
no pain
crepitus may be present
o abnormal finding:
(+) pain and crepitus -
patellofemoral disorder
o fullROM against
resistance
Test ROM
o normal finding:
flexion – 1200 to 1300
extension - 00
hyperextension - 150
full ROM against resistance
o abnormal finding:
decreased ROM with synovial thickening –
osteoarthritis
inability to extend knee fully - flexion
contractures
decreased muscle strength against resistance
– muscle and joint dse
. To test range of motion of the
knee, ask the client to do the
following:
Straighten and stretch the leg.
Bend the knee.
Range of Motion
To test muscle strength in the
knee, ask the client to do the
following:
Extend the leg as you try to bend
it (quadriceps muscle strength)
Bend the knees as you try to
straighten them(hamstring
muscle strength)
Muscle Strength
Maria Carmela L. Domocmat, RN, MSN
McMurray’s test
McMurray’s test
o normal finding:
no pain or clicking
o abnormal finding:
(+) pain, clicking – torn meniscus of knee
Ankles and Feet
client
sit, stand, walk: inspect position,
alignment, shape skin
o normalfinding:
toes
usually point forward and lie flat
may point in – pes varus
may point out – pes valgus
toes and feet – in alignment with lower leg
smooth, rounded medial malleolar prominences with
prominent heels and metatarsophalangeal joints
skin – smooth, free of corns and calluses
longitudinal arh – most of weight bearing is on foot
midline
o abnormalfinding:
hallux valgus – laterally deviated great toe; possible overlapping of
2nd toe; formation enlarged, painful, inflamed bursa (bunion) on
medial side
pes planus or flat feet – feet with no arches
pes cavus – feet with high arches
corns – painful thickening of skin over bony prominences and at
pressure points
calluses – nonpainful thickened skin that occurs at pressure points
verruca vulgaris- painful warts
plantar warts – warts under a callus; appear as tiny dark spots
hammer toe – hyperextension at metatarsophalangeal joint with
flexion at proximal interphalangeal joint; common 2nd toe
hallux valgus
1.jpg
pes pplaannuussoorrffllaattffeeeett
pes cavus
Corns are areas of thick, hardened, dead skin. They form to protect the skin and structures
under the skin from pressure, friction, and injury. They may look grayish or yellowish, be less
sensitive to the touch than surrounding skin, and feel bumpy.
Corns
Corns are usually found where toes rub together. A soft corn is found between toes (usually
between the fourth and fifth toes), while a hard corn is often found over a bony part of a toe
(usually on the fifth toe).
calluses
Corns and calluses form on the skin because of repeated pressure
or friction. A corn is a small, tender area of thickened skin that
occurs on the top or side of a toe. A callus is a rough, thickened
area of skin that appears because of repeated irritation or
pressure to an area of skin. Calluses usually develop on the palms
of the hand and soles of the feet.
Warts, also called verrucae, are small benign growths usually
caused by a viral infection of the skin or mucous membrane. The
virus infects the surface layer of skin. The viruses that cause
warts are members of the human papilloma virus (HPV) family, of
which there are many different strains. Warts are not cancerous
but some strains of HPV, usually not associated with warts, have
been linked with cancer formation. Warts are contagious from
person to person and from one area of the body to another on
the same person.
verruca vulgaris
plantar warts
hammertoes are a contracture of the toes as a result of a muscle
imbalance between the tendons on the top and the tendons on
the bottom of the toe.
Hammer toe is a condition where a toe bends downward like a
claw. You can be born with hammer toe or develop it from
wearing short, narrow shoes. Symptoms of hammer toe include
foot pain, calluses on the sole of the foot, or corns on the top of
the toe. Treatment of mild cases and cases in children can include
foot manipulation and splinting of the toe. More severe cases may
need surgery to straighten the toe joint.
http://0.tqn.com/f/p/440/graphics/images/en/9360.jpg
http://images.rxlist.com/images/SlideShow/diabetes_foot_problems_s8_corns.jpg
A hammertoe is a toe that is bent because of a weakened muscle. The weakened muscle makes the tendons (tissues that
connect muscles to bone) shorter, causing the toes to curl under the feet. Hammertoes can run in families. They can also
hammer toe
be caused by shoes that are too short. Hammertoes can cause problems with walking and can lead to other foot problems,
such as blisters, calluses, and sores. Splinting and corrective footwear can help in treating hammertoes. In severe cases,
surgery to straighten the toe may be necessary.
http://feetdoc.com/hammer_toes.ht
m
o normal finding:
no tenderness, heat, swelling, nodules
o abnormal finding:
gouty arthritis- tender, painful, reddened, hot, swollen
metatarsophalangeal joint of great toe
rheumatoid arthritis – nodules of posterior ankle
pain and tenderness metatarsophalangeal joints –
inflammation of joints, rheumatoid arthritis,
degenerative joint dse
plantar fasciitis – tenderness of calcaneus of bottom
of foot
Test ROM
o abduction– rotate foot outward ;
adduction – inward
.
o normal finding:
200 dorsiflexion ankle and foot; 45 0 plantar
flexion
200 eversion; 300 inversion
100 abduction; 200 adduction
400 flexion; 400 extension
o abnormal finding:
decreased ROM without or against
resistance – muscle and joint dse
hammer toe – hyperextension of
metatarsophalangeal joint and flexion
of proximal interphalangeal joint
ABNORMAL WRISTS,
HANDS, AND FINGERS
Boutonniere and swan-neck deformities
Ganglion.
Osteoarthritis.
Tenosynovitis.
Acute rheumatoid arthritis.
Chronic rheumatoid arthritis
Thenar atrophy
ABNORMAL ANKLES,
FEET, AND TOES
Acute gouty arthritis.
Callus.
Corn.
Flat feet.
Hallux valgus
Hammer toe.
RELATED NURSING CARE
• Maintain privacy of patient
• patient is asked to remove some or all of his
clothes and to wear a gown during the exam.
• may also be asked to remove jewelry, removable
dental appliances, eye glasses and any metal
objects or clothing that might interfere with the
x-ray images.
• If contrast medium is used, assess for allergy to
shellfish, iodine, or contrast medium used in
previous tests. If allergy is present, test will not
be performed.