Chapter 21 Musculoskeletal System Musculoskeletal System The musculoskeletal

Chapter 21 Musculoskeletal System

Musculoskeletal System The musculoskeletal system provides the stability and mobility necessary for physical activity. Physical performance requires bones, muscles, and joints that function smoothly and effortlessly. 2

General Inspect the skeleton and extremities and compare sides for the following: Alignment Contour and symmetry of body parts Size Gross deformity Inspect the skin and subcutaneous tissues over muscles and joints for the following: Color Number of skinfolds Swelling Masses 3

General (Cont. ) Inspect muscles and compare contralateral sides for the following: Size Symmetry Fasciculations or spasms 4

General (Cont. ) Palpate all bones, joints, and surrounding muscles for the following: Muscle tone Heat Tenderness Swelling Crepitus Test each major joint for active and passive range of motion and compare contralateral sides. Test major muscle groups for strength and compare contralateral sides. 5

Joints that deserve particular attention include the following: Hands and wrists Elbows Shoulders Temporomandibular joint Cervical, thoracic, and lumbar spine Hips Legs and knees Feet and ankles 6

Musculoskeletal System Bony structure with its joints held together by ligaments, attached to muscles by tendons, and cushioned by cartilage Bones Joints Muscles Tendons Connect muscle to bone Cartilage Ligaments Connect bone to bone 7

Musculoskeletal System Functions Give structure to soft tissues Allows movement of body Protects vital organs Storage space for minerals Produces blood cells (hematopoiesis) Resorption Reformation 8

Joint Types Synarthrosis: no movement permitted Suture Cranial sutures Synchondrosis Joint between epiphysis and diaphysis of long bones Amphiarthrosis: slightly movable Symphysis pubis Syndesmosis Radius–ulna articulation 9

Joint Types (Cont. ) Diarthrosis (synovial): freely movable Ball and socket Hip, shoulder Hinge Elbow Pivot Atlantoaxial Condyloid Wrist between radius and carpals Saddle Thumb at carpal-metacarpal joint Gliding Intervertebral 10

Diarthrodial Joints Fibrous capsule, cartilage, and ligaments Covers ends of opposing bones Synovial membrane Lines the articular cavity Synovial fluid Provides lubrication Bursae Promote ease of motion at points where friction would otherwise occur 11

Muscles Size and strength affected by the following: Genetics Exercise Nutrition Muscles move joints through range of motion (ROM). 12

Upper Extremities Shoulder Elbow Forearm Wrist Hand 13

Head and Spine TMJ Spine Cervical vertebrae Thoracic vertebrae Lumbar vertebrae Sacral vertebrae 14

Lower Extremities Hip Knee Ankle Foot 15

Infants and Children Long bones increase in length and thickness throughout childhood. Cartilage in smaller bones ossifies. Ligaments are stronger than bones until adolescence. Fractures common Muscle fibers lengthen. Skeletal system grows. 16

Adolescents Rapid growth in puberty results in: Decreased strength in epiphyses Increased risk for injury Bone growth completed about age 20 Peak bone mass achieved at age 35 17

Pregnant Women Increased mobility of pelvic joints Hormones Progressive lordosis of spine Compensate for enlarging uterus Lower back pain Muscle cramps 18

Older Adults Loss of bone density At risk for fractures Deterioration of joint cartilage Decreased mobility Muscle mass decreases. Muscle tone and strength decrease. Reaction time and speed decrease. Endurance decreases. Sedentary lifestyle promotes degeneration of musculoskeletal system. 19

History of Present Illness Joint symptoms Character Associated events Temporal factors Efforts to treat Medications: NSAIDs, acetaminophen, biologic modifiers and other immunosuppressants, corticosteroids, topical analgesics, glucosamine, chondroitin, hyaluronic acid 20

History of Present Illness (Cont. ) Muscular symptoms Character Precipitating factors Efforts to treat Medications: muscle relaxants, salicylates, NSAIDs Skeletal symptoms Character Associated event Efforts to treat Medications: hormone therapy, calcium, calcitonin, bisphonates 21

History of Present Illness (Cont. ) Injury Sensation at time of injury Mechanism of injury Pain Swelling Efforts to treat Medications: analgesics, antiinflammatory drugs 22

History of Present Illness (Cont. ) Back pain Abrupt or gradual onset Character of pain and sensation Associated event Efforts to treat Medications: muscle relaxants, analgesics, antiinflammatory drugs 23

Past Medical History Trauma: nerves, soft tissue, bones, joints; residual problems; bone infection Surgery on joint or bone; amputation, arthroscopy Chronic illness Skeletal deformities and congenital anomalies 24

Family History Congenital abnormalities of hip and foot Scoliosis and back problems Arthritis Genetic disorders: osteogenesis imperfecta, skeletal dysplasia, rickets, hypophosphatemia, hypercalciuria 25

Personal and Social History Employment Exercise Functional abilities Weight and height changes Nutrition Tobacco and alcohol use 26

Infants and Children Birth history Presentation, large for gestational age, birth injuries (may result in fractures or nerve damage), type of delivery (vaginal vs. cesarean section), use of forceps Low birth weight, premature, resuscitation efforts, required ventilator support (may result in anoxia leading to muscle tone disorders) Fine and gross motor developmental milestones, appropriate for chronologic age 27

Infants and Children (Cont. ) Overweight or obese Quality of movement: spasticity, flaccidity, cog wheel rigidity Arm or leg pain Character Onset Participation in organized or competitive sports, weightlifting 28

Pregnant Women Muscle cramps Back pain Weeks of gestation, associated with multiple pregnancy, efforts to treat Associated symptoms: uterine tightening, nausea, vomiting, fever, malaise (could signify musculoskeletal discomfort if not from another condition) Type of shoes (heels may increase lordosis) 29

Older Adults Weakness Onset Associated symptoms Increases in minor injuries Change in ease of movement Nocturnal muscle spasm History of injuries or excessive use of a joint or group of joints, claudication, known joint abnormalities Previous fractures 30

Equipment Marking pencil Goniometer Tape measure Reflex hammer 31

Inspection Posture Erectness Symmetry Alignment Skin and subcutaneous tissues Swelling Redness Masses 32

Inspection (Cont. ) Extremities Size Deformities Enlargement Alignment Contour Symmetry Muscles Bilateral symmetry Hypertrophy Atrophy Fasciculations Spasms 33

Palpation Palpate bones, joints, and surrounding muscles for the following: Heat Tenderness Swelling Fluctuation Crepitus Resistance to pressure Muscle tone 34

Range of Motion Active ROM and passive ROM for each joint and related muscle group Note Pain Limited or spastic movement Joint instability Deformity Contracture 35

Range of Motion (Cont. ) Passive ROM may exceed active ROM by 5 degrees. Active ROM and passive ROM should be equal in contralateral joints. Discrepancies may indicate muscle weakness or disorder. Use goniometer where there is increased or limited ROM. 36

Muscle Strength Compare bilateral muscles Strength Symmetry Equality Resistance Muscle strength Graded 0 (no voluntary contraction) to 5 (full muscle strength) Weakness may result from: Disuse atrophy Pain Fatigue Overstretching 37

Hands and Wrists (Inspection) Inspect Contour Position Shape Number and completeness of digits Finger deviation 38

Hands and Wrists (Palpation) Palpate joints. Texture Swelling Tenderness Bogginess Nodules Bony overgrowths 39

Hands and Wrists (ROM) Assess ROM. Flexion of fingers: expect 90 degrees Hyperextension of fingers: expect 30 degrees Flexion of wrist: expect 90 degrees Hyperextension of wrist: expect 70 degrees Rotation of hand: expect radial motion of 20 degrees, ulnar motion of 55 degrees Assess muscle strength and grip 40

Elbows (Inspection/ palpation) Inspect Contour Carrying angle Subcutaneous nodules Palpate Tenderness Swelling Thickening 41

Elbows (ROM/ strength) Assess ROM. Flexion: expect 160 degrees Extension: expect 180 degrees Pronation: expect 90 degrees Supination: expect 90 degrees Assess muscle strength. 42

Shoulders (Inspection/ palpation) Inspect Size Symmetry Contour Dislocation or winging of scapula Palpate Joints Muscles 43

Shoulders (ROM) Assess ROM. Forward flexion: expect 180 degrees Hyperextension: expect 50 degrees Abduction: expect 180 degrees Adduction: expect 50 degrees Internal and external rotation: expect 90 degrees Shrug: evaluate shoulder girdle muscles and cranial nerve XI 44

Shoulders (Strength) Strength of rotator cuff muscles Supraspinatus: abduct arms 90 degrees and flex shoulders forward 30 degrees; apply downward pressure on distal humerus when arms are rotated so that thumbs point down or up Subscapularis: arm at side, elbow flexed 90 degrees; rotate forearm medially against resistance Infraspinatus and teres minor: arm at side, elbow flexed 90 degrees, and rotate arm laterally against resistance 45

Temporomandibular Joint (TMJ) Palpate Pain Crepitus, locking, and popping Assess ROM Open and close Lateral movement Protrusion and contraction Assess muscle strength Temporalis Masseter 46

Cervical Spine (Inspection/palpation) Inspect Head alignment Symmetry of muscles and skinfolds Palpate Tone Symmetry Tenderness Spasm 47

Cervical Spine (ROM/ strength) Assess ROM. Flexion: expect 45 degrees Extension: expect 45 degrees Rotation: expect 70 degrees Assess muscle strength. Sternocleidomastoid Trapezius 48

Thoracic and Lumbar Spine (Inspection/palpation) Inspect Alignment Straightness Curves Lordosis, kyphosis, and gibbus Scoliosis Palpate Tenderness 49

Thoracic and Lumbar Spine (ROM) Assess ROM. Flexion: expect 70 to 90 degrees Hyperextension: expect 30 degrees Lateral bending: expect 35 degrees Rotation of upper trunk: expect 30 degrees 50

Hips (Inspect/ palpate) Inspect Symmetry Size Gluteal folds Palpate Stability Tenderness 51

Hips (ROM/ strength) Assess ROM. Flexion: expect 90 degrees Hyperextension: expect 30 degrees Abduction and adduction Internal rotation: expect 40 degrees External rotation: expect 45 degrees Assess muscle strength 52

Legs and Knees (Inspect/ palpate) Inspect Landmarks Concavities Alignment Palpate Swelling Tenderness Bogginess Crepitus 53

Legs and Knees (ROM/ strength) Assess ROM. Flexion: expect 130 degrees Extension: expect 30 degrees of full extension Hyperextension: expect 15 degrees Assess muscle strength. 54

Feet and Ankles (Inspect/ palpate) Inspect Contour and position Size and number of toes Alignment Weight bearing Arch Palpate Heat Swelling Tenderness 55

Feet and Ankles (ROM/ strength) Assess ROM. Dorsiflexion and plantarflexion Inversion and eversion Abduction and adduction Assess muscle strength. 56

Hand Wrist Assessment Several procedures are used to evaluate the integrity of the median nerve. Certain patterns of pain, numbness, and tingling are associated with carpal tunnel syndrome. 57

Hand Wrist Assessment (Cont. ) Thumb abduction test Isolates the strength of the abductor pollicis brevis muscle, innervated only by the median nerve Tinel sign Tested by striking the patient’s wrist with your index or middle finger where the median nerve passes under the flexor retinaculum and volar carpal ligament Tingling sensation radiating from the wrist to the hand in the distribution of the median nerve is a positive Tinel sign 58

Hand Wrist Assessment (Cont. ) Phalen test Patient holds both wrists in a fully palmarflexed position with the dorsal surfaces pressed together for 1 minute. Numbness and paresthesia in the distribution of the median nerve are suggestive of carpal tunnel syndrome. 59

Shoulder Assessment Several procedures are used to evaluate rotator cuff for impingement or tear―increased pain associated with inflammation or tear Hawkins test Forward flexing shoulder to 90 degrees, flexing elbow to 90 degrees, and then internally rotating arm to its limit Neer test Internally rotate and forward flex arm at the shoulder: presses supraspinatus muscle against anteroinferior acromion 60

Lower Spine Assessment Straight leg raising (SLR) test SLR used to test for nerve root irritation or lumbar disk herniation at the L 4, L 5, and S 1 levels. Have the patient lie supine with the neck slightly flexed. Ask the patient to raise the leg, keeping the knee extended. No pain should be felt below the knee with leg raising. Radicular pain below the knee in a dermatome pattern may be associated with disk herniation. 61

Lower Spine Assessment (Cont. ) Femoral stretch test Used to detect inflammation of the nerve root at the L 1, L 2, L 3, and sometimes L 4 level. Have the patient lie prone and extend the hip. No pain is expected. The presence of pain on extension is a positive sign of nerve root irritation. 62

Hip Assessment Thomas test Detect flexion contractures of hip masked by excessive lumbar lordosis. Have the patient lie supine. Fully extend one leg flat on the examining table and flex the other leg with the knee to the chest. Observe the patient’s ability to keep the extended leg flat on the examining table. Lifting the extended leg off the examining table indicates a hip flexion contracture in the extended leg. 63

Hip Assessment (Cont. ) Ballottement: excess fluid or effusion Bulge sign: excess fluid Trendelenburg test Detect weak hip abductor muscle. Patient stands and balances first on one foot and then the other. Observing from behind, note any asymmetry or change in the level of the iliac crests. When the iliac crest drops on the side of the lifted leg, the hip abductor muscles on the weight-bearing side are weak. 64

Knee Assessment Lachman test: anterior cruciate ligament integrity Varus and valgus stress test: instability of lateral and medial collateral ligaments Mc. Murray test: torn medial or lateral meniscus Patient lies supine and flexes one knee. Palpable or audible click, pain, grinding, or lack of extension during outward (valgus) and inward (varus) stress during flexion of knee is a positive sign. 65

Knee Assessment (Cont. ) Anterior and posterior drawer test: instability of cruciate ligaments Patient lies supine and flexes the knee 45 to 90 degrees, placing the foot flat on the table. Draw the tibia forward and backward, forcing the tibia to slide forward of the femur. Anterior or posterior movement of the knee greater than 5 mm in either direction is an unexpected finding. 66

Limb Measurement Performed when difference is suspected Measure bilateral Circumference Length Should be no more than 1 -cm difference in length and circumference between matching extremities 67

Infants Inspect general Posture Spontaneous generalized movements Inspect back Hair tufts and dimples Discolorations Cysts or masses near spine Curvature of spine Inspect extremities. Symmetry Movement Equality Deformity 68

Infants (Cont. ) Palpate bones. Fractures or dislocations Crepitus Masses Tenderness Palpate spine. Shape Formation Splitting Palpate muscles and joints. Tone Mobility Subluxation or dislocation 69

Infants (Cont. ) Assess motor development. Fine Gross Assess ROM. Assess muscle strength. Assess tibial torsion. Barlow-Ortolani maneuver to detect hip dislocation or subluxation should be performed each time you examine the infant during the first year of life. 70

Infants (Cont. ) Barlow maneuver Position yourself at the supine infant’s feet, and flex the hip and knee to 90 degrees. Grasp the leg with your thumb on the inside of the thigh, the base of the thumb on the knee, and your fingers gripping the outer thigh with fingertips resting on the greater trochanter. Adduct the thigh and gently apply downward pressure on the femur in an attempt to disengage the femoral head from the acetabulum. A positive sign is when a clunk or sensation is felt as the femoral head exits the acetabulum posteriorly. 71

Infants (Cont. ) Ortolani maneuver Slowly abduct the thigh while maintaining axial pressure. Fingertips on the greater trochanter, exert a lever movement in the opposite direction so that your fingertips press the head of the femur back toward the acetabulum center. If the head of the femur slips back into the acetabulum with a palpable clunk when pressure is exerted, suspect hip subluxation or dislocation. 72

Children Assess motor development. Fine Gross Assess ROM. Inspect: Spine curvature Sitting posture Foot arch Alignment of feet and legs 73

Children (Cont. ) Evaluate for the following: Bowlegs (genu varum) Knock-knees (genu valgum) Palpate bones, muscles, and joints. Evaluate rising from seated position. 74

Adolescents Do same examination procedures as for adult. Note presence of scoliosis. Note slight kyphosis or rounded shoulders. 75

Pregnant Women Postural changes Lordosis Forward cervical flexion Waddling gait Assess for: Lumbosacral hyperextension Causes lower back pain Carpal tunnel syndrome Secondary increased fluid retention 76

Older Adults Assessment of activities of daily living for fine and gross motor skills Osteoporosis risk assessment instrument to screen for osteoporosis Inspect: Dorsal kyphosis Base of support broader (feet more widely spaced) Reduction in total muscle mass 77

Older Adults (Cont. ) Palpate muscle for the following: Tone Atrophy Assess muscle strength and ROM. 78

Abnormalities (Cont. ) Ankylosing spondylitis Hereditary, chronic inflammatory disease Initially affects the lumbar spine and sacroiliac joints Lumbosacral radiculopathy Herniated lumbar disk that irritates the corresponding nerve root Lumbar stenosis Hypertrophy of the ligamentum flavum and facet joints that results in narrowing of the spinal canal 79

Abnormalities (Cont. ) Gout Disorder of purine metabolism that results from an elevated serum uric acid level Form of arthritis Carpal tunnel syndrome Compression on the median nerve Lyme disease Tickborne disease that can lead to multisystemic infection 80

Abnormalities (Cont. ) TMJ syndrome Painful jaw movement Osteomyelitis Infection in the bone Bursitis Inflammation of the bursa Paget disease (osteitis deformans) Focal metabolic disorder of the bone 81

Abnormalities (Cont. ) Fibromyalgia Painful, nonarticular condition that leads to diffuse musculoskeletal discomfort Osteoarthritis Deterioration of the articular cartilage covering the ends of bone in synovial joints Rheumatoid arthritis Chronic systemic inflammatory disorder of the synovial tissue surrounding the joints 82

Sports Injuries Muscle strain Can be due to excessive stretching or forceful contraction beyond the muscles functional capacity Dislocation Complete separation of the contact between two bones in a joint Fracture Partial or complete break in the continuity of a bone 83

Sports Injuries (Cont. ) Tenosynovitis (tendonitis) Inflammation of the synovium-lined sheath around a tendon Rotator cuff tear Microtrauma and tearing of the rotator cuff muscles; most often the supraspinatus 84

Infants and Children Osgood-Schlatter disease Traction apophysitis (inflammation of a bony outgrowth) of the anterior aspect of the tibial tubercle Clubfoot (talipes equinovarus) Fixed congenital defect of the ankle and foot Metatarsus adductus Most common congenital foot deformity Metatarsus adductus can be either fixed or flexible Legg-Calvé-Perthes disease Avascular necrosis of the femoral head 85

Infants and Children (Cont. ) Slipped capital femoral epiphysis Disorder in which the capital femoral epiphysis slips over the neck of the femur Muscular dystrophy Group of genetic disorders involving gradual degeneration of the muscle fibers Scoliosis Concave curvature of the anterior vertebral bodies, convex posterior curves, and lateral rotation of the thoracic spine Radial head subluxation Known as nursemaid’s elbow, this is a dislocation injury. 86

Older Adults Osteoporosis Disease in which a decrease in bone mass occurs because bone resorption is more rapid than bone deposition Dupuytren contracture Contractures involving the flexor hand tendons 87