The Musculoskeletal System Copyright 2009 Wolters Kluwer Health

Skeleton • Consists of 206 bones • Provides support for the soft tissue and

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Types of Joint Articulation: Synovial, Cartilaginous, and Fibrous Synovial joint • Joint is freely

Types of Joint Articulation: Synovial, Cartilaginous, and Fibrous (cont. ) Cartilaginous joint • Joint

Types of Joint Articulation: Synovial, Cartilaginous, and Fibrous (cont. ) Fibrous joint • Joints

Joint Movements • Flexion • Extension • Rotation • Circumduction • Elevation • Protrusion

Joint Movements • Adduction • Pronation • Supination • Inversion • Eversion • Gliding

Table 23. 2 Joint Movement Copyright © 2009 Wolters Kluwer Health | Lippincott Williams

Table 23. 2 Joint Movement (continued ) Copyright © 2009 Wolters Kluwer Health |

Range of Motion-Active • Ask the patient to move each joint through a full

Range of Motion- Passive • Ask the patient to relax and allow you to

Range of Motion-Specific Joints • Fingers - flexion/extension/hyperextension; abduction/adduction • Wrist - flexion/extension; radial/ulnar

Musculoskeletal System: The Health History Common or Concerning Symptoms Low back pain Neck pain

Musculoskeletal System: Tips for Assessing Joint Pain • Ask the patient to “point to

Techniques of Examination: Overview for Each of the Major Joints* • Inspect for joint

Wrist and Hand: Review the Anatomy Copyright © 2009 Wolters Kluwer Health | Lippincott

Wrist and Hand: Examination • Inspect for smoothness of motion, surface contour, alignment of

Wrist and Hand: Examination (cont. ) • Check range of motion – Wrist: flexion,

Palpating the wrist. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Palpating the hand. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Extension and flexion of the wrist. Copyright © 2009 Wolters Kluwer Health | Lippincott

Ulnar and radial deviation of the wrist. Copyright © 2009 Wolters Kluwer Health |

Testing the muscle strength of the wrist. Copyright © 2009 Wolters Kluwer Health |

Carpal Tunnel Syndrome • Common condition; the median nerve in the wrist becomes compressed,

Carpal Tunnel Syndrome Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Tinel’s sign (Median Nerve). • Use your middle finger tap over the carpal tunnel.

Phalen’s test (Median Nerve). • Ask the patient to press the backs of the

Palpating the fingers. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Flexion and extension/hyperextension of the fingers. Copyright © 2009 Wolters Kluwer Health | Lippincott

Test for strength the finger (against your resistance) • Ask the patient to spread

Flexion and extension of the elbow. Copyright © 2009 Wolters Kluwer Health | Lippincott

Goniometer measure of joint range of motion. Copyright © 2009 Wolters Kluwer Health |

Supination and pronation of the elbow. Copyright © 2009 Wolters Kluwer Health | Lippincott

Testing muscle strength using opposing force (flexion or extension. Copyright © 2009 Wolters Kluwer

Important Bones of the Shoulder • Review bony anatomy Copyright © 2009 Wolters Kluwer

Shoulder: Examination • Inspect for swelling, deformity, muscle atrophy or abnormal positioning • Palpate

Flexion and extension of the shoulders. Copyright © 2009 Wolters Kluwer Health | Lippincott

Internal rotation of the shoulders. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams

External rotation of the shoulders. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams

Abduction and adduction of the shoulder. Copyright © 2009 Wolters Kluwer Health | Lippincott

Spine: Anatomy of Representative Cervical and Lumbar Vertebrae • 7 cervical, 12 thoracic, and

Spine: Muscle Groups Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Lateral view of spine. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams &

Spine: Examination — Inspection • With patient in gown, directly inspect: – From the

Spine: Examination — Palpation • Palpate – With patient standing or sitting o Spinous

Spine: Examination — Range of Motion • Neck – Flexion and extension: chin to

Lateral flexion of the spine. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams

Forward flexion of the spine. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams

Rotation of the spine (right + left rotation). Copyright © 2009 Wolters Kluwer Health

Hip: Review Bony Anatomy Copyright © 2009 Wolters Kluwer Health | Lippincott Williams &

Hip: Examination — Inspection • Inspect the gait • Inspect anterior and posterior surfaces

Hip: Examination – Range of Motion • Assess – Flexion – bend knee to

Flexion of the hip. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams &

Hyperextension of the hip. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams &

Internal and external hip rotation. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams

Abduction and adduction of the hip. Copyright © 2009 Wolters Kluwer Health | Lippincott

Test for strength the hips (against your resistance) • Assist the client in returning

Knee: Review the Anatomy Copyright © 2009 Wolters Kluwer Health | Lippincott Williams &

Knee: Examination — Inspection and Palpation • Inspect – Contours and alignment of knees

Knee: Examination — Palpation • Palpate, with the knee flexed, and note any tenderness:

Knee: Examination — Range of Motion and Maneuvers • Assess range of motion, with

Palpating the knee. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Testing for ballottement. • Ask the patient to lie supine on the exam table

Flexion of the knee. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams &

Ankle and Foot: Review the Anatomy Copyright © 2009 Wolters Kluwer Health | Lippincott

Ankle and Foot: Examination — Inspection and Palpation • Inspect the surfaces of the

Ankle and Foot: Examination — Range of Motion • Ankle extension (plantar flexion) –

Palpating the ankle. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Eversion and inversion of the ankles. Copyright © 2009 Wolters Kluwer Health | Lippincott

Test for strength the ankle and foot (against your resistance) • Ask the client

Common Abnormalities • Ankylosis – Scarring within a joint leading to stiffness or fixation

Common Abnormalities • Contracture – Resistance to movement of muscle or joint, fibrosis of

Common Abnormalities • Kyphosis – Round back forward bending of spine Copyright © 2009

Common Abnormalities • Lordosis (Lumbar lordosis. ) – Anteriorposterior curvature with concavity in posterior

Common Abnormalities • Scoliosis – Lateral curvature of the spine Copyright © 2009 Wolters

Common Abnormalities Osteoporosis • A disease in which loss of bone exceeds rate of

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Types of Joint Articulation: Synovial, Cartilaginous, and Fibrous Synovial joint • Joint is freely movable • Bones are separated by synovial cavity • Synovial membrane secretes synovial fluid that lubricates joint movement – Examples: shoulder, knee Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Types of Joint Articulation: Synovial, Cartilaginous, and Fibrous (cont. ) Cartilaginous joint • Joint is slightly movable – Examples: vertebral bodies of the spine Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Types of Joint Articulation: Synovial, Cartilaginous, and Fibrous (cont. ) Fibrous joint • Joints have no appreciable movement • Bones separated by fibrous tissue or cartilage – Example: sutures of the skull Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Range of Motion-Active • Ask the patient to move each joint through a full range of motion. • Note the degree and type (pain, weakness, etc. ) of any limitations. • Note any increased range of motion or instability. • Always compare with the other side. • Proceed to passive range of motion if abnormalities are found. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Range of Motion- Passive • Ask the patient to relax and allow you to support the extremity to be examined. • Gently move each joint through its full range of motion. • Note the degree and type (pain or mechanical) of any limitation. • If increased range of motion is detected, perform special tests for instability as appropriate. • Always compare with the other side. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Range of Motion-Specific Joints • Fingers - flexion/extension/hyperextension; abduction/adduction • Wrist - flexion/extension; radial/ulnar deviation • Elbow - flexion/extension ; pronation/supination • Shoulder - flexion/extension; internal/external rotation; abduction/adduction • Hip - flexion/extension; abduction/adduction; internal/external rotation • Knee - flexion/extension • Ankle - flexion (plantarflexion)/extension (dorsiflexion), Inversion/Eversion • Foot - inversion/eversion • Toes - flexion/extension • Spine - flexion/extension; right/left bending; right/left rotation • Neck- flexion/extension/hyperextension; right/left rotation and bending; protraction/retraction Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Musculoskeletal System: The Health History Common or Concerning Symptoms Low back pain Neck pain Monoarticular or polyarticular joint pain Inflammatory or infectious joint pain Joint pain with systemic features such as fever, chills, rash, anorexia, weight loss, weakness Joint pain with symptoms from other organ systems Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Musculoskeletal System: Tips for Assessing Joint Pain • Ask the patient to “point to the pain” – This saves considerable time since patient descriptions of the location of the pain may be vague • Determine whether the pain is: – Localized or diffuse – Acute or chronic – Inflammatory or noninflammatory Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Techniques of Examination: Overview for Each of the Major Joints* • Inspect for joint symmetry, alignment, or any bony deformities • Inspect and palpate surrounding tissues for any skin changes, nodules, muscle atrophy, or crepitus • Assess any degenerative or inflammatory changes, especially swelling, warmth, tenderness, or redness • Perform range of motion; use joint-specific maneuvers to test: – Joint function and stability – Integrity of ligaments, tendons, and bursae Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Wrist and Hand: Examination • Inspect for smoothness of motion, surface contour, alignment of wrist and fingers, and any bony deformities – At rest, the fingers should be slightly flexed and aligned almost in parallel • Palpate – Distal radius and ulna at the wrist, the eight carpal bones, and the MCP, PIP, and DIP joints for swelling or tenderness – “Anatomic snuffbox” just distal to the radial styloid process with lateral extension of thumb away from hand Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Wrist and Hand: Examination (cont. ) • Check range of motion – Wrist: flexion, extension, ulnar and radial deviation – Fingers: flexion, extension, hyperextension, abduction (fingers spread apart), adduction (fingers back together) Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Carpal Tunnel Syndrome • Common condition; the median nerve in the wrist becomes compressed, causing pain and numbness • Common repetitive strain injury via occupational or sports motions • Nonsurgical management: drug therapy and immobilization • Possible surgical management • Assess – Tinel’s sign – Phalen’s sign Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Tinel’s sign (Median Nerve). • Use your middle finger tap over the carpal tunnel. • Pain, tingling, or electric sensations strongly suggest carpal tunnel syndrome. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Phalen’s test (Median Nerve). • Ask the patient to press the backs of the hands together with the wrists fully flexed • Have the patient hold this position for 60 seconds and then comment on how the hands feel. • Pain, tingling, or other abnormal sensations in the thumb, index, or middle fingers strongly suggest carpal tunnel syndrome. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Test for strength the finger (against your resistance) • Ask the patient to spread his fingers, and try to force the fingers together • Ask the client to touch his or her little finger with thumb while you place resistance on the thumb in order to prevent the movement Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Shoulder: Examination • Inspect for swelling, deformity, muscle atrophy or abnormal positioning • Palpate over the three bony landmarks and any areas of tenderness • Check range of motion: flexion, extension, internal (hands behind small of back) and external (hands behind neck) rotation, abduction, and adduction, • Test for strength the shoulder muscles (against your resistance) Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Spine: Anatomy of Representative Cervical and Lumbar Vertebrae • 7 cervical, 12 thoracic, and 5 lumbar vertebrae are stacked on the sacrum and coccyx • Review the anatomy below: Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Spine: Examination — Inspection • With patient in gown, directly inspect: – From the side o Cervical, thoracic, and lumbar curves – From behind o Upright spinal column o Alignment of the shoulders, iliac crests, and the gluteal folds o Skin markings, tags, or masses Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Spine: Examination — Palpation • Palpate – With patient standing or sitting o Spinous processes of each vertebrae o Facet joints in the neck o Lower lumbar area for vertebral “step-offs” or tenderness – Paravertebral muscles for tenderness or spasm – Sacroiliac joint Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Spine: Examination — Range of Motion • Neck – Flexion and extension: chin to chest, look up at ceiling – Rotation and lateral bending: look over one shoulder and then the other; bring ear to shoulder • Spine (support the patient during exam if necessary) – Flexion and extension: bend forward and try to touch toes; bend backward – Rotation and lateral bending: rotate trunk (pull shoulder and then the opposite hip posteriorly); bend to side from waist Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Hip: Examination — Inspection • Inspect the gait • Inspect anterior and posterior surfaces of the hip for muscle atrophy or bruising • Palpation Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Hip: Examination – Range of Motion • Assess – Flexion – bend knee to chest and pull against abdomen; check for flexion deformity (opposite knee goes into flexion) – Extension – leg extends posteriorly with patient carefully positioned near edge of table – Abduction and adduction – reach across and grasp opposite hip; grasp ankle and move leg laterally, then medially, toward opposite hip – External and internal rotation – flex hip and knee to 90°, grasp ankle, rotate flexed lower leg medially then laterally Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Test for strength the hips (against your resistance) • Assist the client in returning to the supine position • Press your hands on the client’s thighs and ask the client to raise his or her hip • Place your hands outside the client’s knees and ask the client to spread both legs against your resistance • Place your hands between the client’s knees, and ask the client to bring the legs together against your resistance. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Knee: Examination — Inspection and Palpation • Inspect – Contours and alignment of knees for swelling – Atrophy of quadriceps muscle – Knee action during swing and stance phases of gait • Palpate (patient sitting) – Infrapatellar spaces adjacent to patella – Medial and lateral femoral epicondyles and condyles – Medial and lateral margins of tibial plateau – Insertion of patellar tendon at the tibial tubercle Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Knee: Examination — Palpation • Palpate, with the knee flexed, and note any tenderness: – Along the joint line, including menisci and bursae – Along the medial and lateral collateral ligaments (MCL and LCL) – Over the patellar tendon. If tender, compress the patella against the femur and check knee extension • Palpate: – Over the suprapatellar bursa above the knee – Prepatellar bursa over the patella – Pes anserine bursa on posteromedial knee • If swelling, palpate for bulge sign or balloon sign, or “balotte” the patella Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Knee: Examination — Range of Motion and Maneuvers • Assess range of motion, with patient sitting: – Flexion and extension Test for strength the knees (against your resistance) • Instruct the client to flex each knee while you apply opposing force • Now instruct the client to extend the knee again • The client should be able to perform the movement against resistance • The strength of the muscles in both knees is equal. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Testing for ballottement. • Ask the patient to lie supine on the exam table with leg muscles relaxed. • Press the patella downward and quickly release it. • If the patella visibly rebounds, a large knee effusion (excess fluid in the knee) is present. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Ankle and Foot: Examination — Inspection and Palpation • Inspect the surfaces of the ankles and feet for any deformities, nodules, swellings, calluses, or corns • Palpate – Anterior aspect of each ankle joint for bogginess, swelling, tenderness – Achilles tendon for nodules or tenderness – Heel for tenderness – Medial and lateral malleolus for tenderness – Metatarsophalangeal joints for tenderness – Heads of the 5 metatarsals by compressing between your thumb and index finger Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Ankle and Foot: Examination — Range of Motion • Ankle extension (plantar flexion) – Point foot toward the floor • Ankle flexion (dorsiflexion) – Point foot toward the ceiling • Inversion – Bend heel inward • Eversion – Bend heel outward Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Test for strength the ankle and foot (against your resistance) • Ask the client to perform dorsiflexion and plantar flexion against your resistances • Ask the client to perform flex and extend the toes against your resistances Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Common Abnormalities • Ankylosis – Scarring within a joint leading to stiffness or fixation • Atrophy – Wasting of the muscle – Decrease in size – Flabby appearance – Decreased function and muscle tone Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Common Abnormalities • Contracture – Resistance to movement of muscle or joint, fibrosis of soft tissue • Crepitus – Crackling sound or grating sensation from friction between two bones Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Common Abnormalities Osteoporosis • A disease in which loss of bone exceeds rate of bone formation; usually increase in older women, white race, nulliparity. • Clinical Manifestations – bone pain, decrease movement. • Treatment – Calcium, Vit. D, estrogen replacement, Calcitonin, fluoride, estrogen with progestin, exercise. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins