Musculoskeletal Assessment

Musculoskeletal System

 Bones
 Joints
 Skeletal muscles
 Supportive connective tissue
 Tendons: connect muscles to bones
 Ligaments: connect bones to each other at the joint
level
 Cartilage: cushioning tissue within a joint
 Positional Terminology

 Proximal
 Close to the center of the body
 Distal
 Away from the center of the body
 Abduction
 Moving the extremity laterally, away from the midline
 Adduction
 Moving the extremity medially, toward the midline
 Positional Terminology

 Internal Rotation
 Rotating the extremity medially along its own axis
 External Rotation
 Rotating the extremity laterally along its own axis
 Circumduction
 Moving the extremity in a conical fashion so the distal
aspect moves in a circle
 Opposition
 Moving the thumb outward to touch the little finger
 Positional Terminology

 Pronation
 Rotating forearm medially so palm faces down
 Supination
 Rotating forearm laterally so palm faces up
 Inversion
 Tilting the sole of the foot inward with the lateral side of the foot
lowered
 Eversion
 Tilting the sole of foot outward with the medial side of the foot
lowered
 Positional Terminology

 Changes in Joint Angles

 Flexion
 Bending a joint so the articulating bones are moved closer to
each other
 Decreasing the joint angle
 Extension
 Bending a joint so the articulating bones are moved away from
each other
 Increasing the joint angle
 Hyperextension
 Extension beyond the neutral (180) position
 Positional Terminology

 Changes in Joint Angles

 Dorsiflexion
 Flexing the foot at the ankle
so that the toes move
toward chest
 Decreasing the joint angle

 Plantar Flexion
 Moving the foot at the ankle
so the toes move away from
chest
 Pointing toes
 Review of Related History

 Current Complaints
 With full symptom analysis
 Joint complaints
 Muscular complaints
 Skeletal complaints
 Injury
 Back pain
 Review of Related History

 Past History
 Trauma
 Nerves
 Joints
 Bones
 Soft tissue
 Surgery on bone or joint
 Skeletal deformities
 Chronic illness
 Review of Related History

 Family History
 Congenital abnormalities or genetic disorders
 Hip or foot deformities
 Osteogenesis imperfecta
 Scoliosis or back problems
 Arthritis
 Rheumatoid arthritis (RA)
 Osteoarthritis
 Ankylosing spondylitis
 Gout
 Review of Related History

 Personal and Social History

 Employment – potential for injury
 Exercise patterns
 Functional abilities
 Weight changes
 Height changes
 Nutrition
 Tobacco
 Alcohol
 Risk Factors: Sports Injury

 Poor physical conditioning

 Failure to warm up muscles adequately
 Intensity of competition
 Collision and contact sports participation
 Rapid growth
 Overuse of joints
 Risk Factors: Osteoarthritis

 Obesity
 Family history
 Lax ligaments with postural joint deformity
 > 40 yoa
 Risk Factors: Osteoporosis

 Race  Post menopause

 Caucasian  Constant dieting
 Asian  Calcium intake < 1500 mg
 Native American
 Scoliosis, RA
 Northwestern European
 Metabolic disorders
 Blonde or red hair with
freckles
 Some drugs
 Light body frame, thin
 Poor teeth
 Family history  Smoking
 Nulliparous  Alcohol
 Equipment and Techniques

 Equipment
 Skin marking pencil
 Goniometer
 Measuring tape
 Reflex hammer
 Sphygmomanometer

 Techniques
 Inspection
 Palpation
 Inspection: Overall

 Alignment
 Contour
 Symmetry
 Height/weight
 Gross deformity
 Posture
 Standing
 Sitting
 Inspection: Overall

 Weight-Bearing Tolerance
 Non-weight bearing
 Affected foot/leg does not touch the floor
 Touchdown weight bearing
 Touches floor, but no weight placed
 Partial weight bearing
 30-50% of weight born
 Weight bearing as tolerated
 >50% but < 100%
 Full weight bearing
 Inspection: Overall

 Gait and Mobility

 Walking normally
 Forward
 Backward
 Step to right, then to left
 Walking on toes
 Walking on heels
 Tandem walking ( heel-to-toe)
 Walking with eyes closed
 Indications of Gait Disturbance

 Hesitancy  Waddling gait

 Unsteadiness  Slow, rapid step speed
 Staggering  Asymmetry of step height
 Grasping for external or length
support  Limping
 High stepping
 Stooping during walking
 Floor scraping
 Excessive pointing of toes
inward or outward
 Shuffling gait
 Inspection and Palpation

 Always compare contralateral sides!!

 Inspection and Palpation: Muscles

 Overall appearance of muscle mass

 Hypertrophy
 Increase in muscle size and shape
 Atrophy
 Reduction in muscle size and shape
 Thin, flabby muscles
 If a limb looks smaller/larger than its counterpart
 During muscle relaxation, measure both limbs at exactly
the same distance from a nearby joint at the site of
maximum limb diameter
 A discrepancy of > 3cm is abnormal
 Inspection and Palpation: Muscles

 Have person
 Contract muscle isometrically
 Isometric
muscle contraction: without inducing
movement
 Then relax muscle
 Then contract again
 Watch for any involuntary movements
 Inspection and Palpation: Muscles

 Apply light pressure with finger pads

 Palpate while person’s muscles are relaxing
and while they are isometrically contracting
 Hypotonicity
 Flaccidity
 Decreased muscle tine
 Spasticity
 Increased muscle tone
 Often noted with extreme flexion or extension
 Inspection and Palpation: Joints

 Observe the shape of the joint while the joint is in

its neutral anatomic position
 Contour
 Dislocation: dislodgment of one bone out of the joint cavity
 Subluxation: partial dislodgment of the bone from its place in
the joint cavity
 Symmetry
 Inspection and Palpation: Joints

 Visually inspect the 2-3 inches of skin and

subcutaneous tissue surrounding the joint
 Erythema
 Edema
 Ecchymosis
 Nodules
 Deformities
 Masses
 Skin atrophy
 Skin breakdown
 Inspection and Palpation: Joints

 Palpate the joint from the periphery inward toward

the center of the joint
 Swelling
 Tenderness
 Warmth
 Nodules
 Range of Motion (ROM)

 Active
 person does the moving
 Have person move joint through each of its various
ROM movements
 Note the angle of each joint movement
 Note any pain, tenderness, or crepitus
 Range of Motion (ROM)

 Passive
 person relaxes and allows you to move the joints
 Done if person is unable to do active ROM
 ALWAYS stop if the person complains of pain
 NEVER push a joint beyond its anatomic angle
 Use a Goniometer to determine exact ROM in
joints with limited ROM
 Muscle Strength

 As you are testing ROM

 Test muscle strength
 Ability to perform the ROM against resistance
 Symmetry
 Involuntary movements
 Grading Muscle Strength
 5 Normal100% Complete ROM against full
resistance
 4 Good 75% Complete ROM against
moderate resistance
 3 Fair 50% Complete ROM without
resistance
 2 Poor 25% Complete ROM only if joint
fully supported
 1 Trace 10% Muscle contraction visible
but insufficient to move joint
 0 None 0% No visible or palpable muscle
contraction
 Joints That Deserve Particular
Attention

 Temperomandibular Joint
 Cervical Spine
 Thoracic and Lumbar Spine
 Shoulders
 Elbows
 Hands and Wrists
 Hips
 Legs and Knees
 Feet and Ankles
Palpation: Temperomandibular Joint

 Place the tips of your

index fingers directly in
front of the tragus of each
ear
 Ask the person to open
and close the mouth
 Note any decreased range
of motion, tenderness, or
swelling
 Temperomandibular Joint (TMJ)

 ROM
 Open and close mouth
 Move jaw laterally side to side
 Protruding and retracting jaw
 Palpate joint space during these motions for
 Clicking
 Popping
 Pain
 Strength of temporalis and masseter muscles
 Palpate contracted muscles with jaw clenching
 You are simultaneously testing CN
 V Trigeminal
 Cervical Spine

 Inspect neck for

 Alignment
 Symmetry of skin folds and muscles
 ROM
 Forward flexion (45°)
 Hyperextension (55°)
 Lateral bending (40°)
 Rotation (70°)
 Strength of sternocleidomastoid and trapezius muscles
 ROM against resistance
 With rotation, you are simultaneously testing CN
 XI Spinal accessory
 Thoracic and Lumbar Spine

 Inspect spine for alignment

 Scoliosis
 Lateral curvature of the spine
 Becomes accentuated on forward flexion at the waist
 Kyphosis
 Excessive convexity of the thoracic spine
 Forward and downward hunching of head, neck, shoulders
 “Hunchback”
 Lordosis
 Excessive concavity of the lumbar spine
 “Swayback”
 List
 Leaning of the spine
 May be from herniated lumbar disc/painful paravertebral muscles
Scoliosis
Kyphosis
Dowager’s Hump
Lordosis
List
 Thoracic and Lumbar Spine

 Palpate the spinal processes and paravertebral

muscles
 Nodules
 Tenderness

 ROM
 Forward flexion (75°)
 Hyperextension (30°)
 Lateral bending (35°)
 Rotation
 Shoulders

 Inspect shoulders and shoulder girdle for contour

 Palpate the joint spaces and bones of shoulders
 ROM
 Shrugging shoulders
 Forward flexion (180°)
 Hyperextension (up to 50°)
 Abduction (180°)
 Adduction (50°)
 Internal and external rotation (90°)
 Shoulders

 Muscle strength
 Shrugging shoulders
 Tests CN
 XI Spinal accessory
 Forward flexion
 Abduction
 Elbows

 Inspect elbows in flexed and extended position

 Contour
 Carrying angle (5-15°)

 Palpate the extensor surfaces for tenderness,

warmth, nodules
 Ulna
 Olecranon process
 Medial and lateral epicondyles
 Elbows

 ROM
 Flexion (160°)
 Extension (180°)
 Pronation and supination (90°)

 Muscle strength
 Flexion
 Extension
 Hands and Wrists

 Inspect the dorsum and palms of hands

 Contour
 Position
 Shape
 Number and completeness of digits
 Palpate each joint of the hand and wrist
 Hands and Wrists

 Test for Tinel’s sign

 Strike the median nerve
 Tingling or prickling sensation radiating from wrist to the
hand especially to the thumb, index and middle fingers
 Positive sign is associated with carpal tunnel syndrome
Tinel’ s Sign
 Hands and Wrists

 Test for Phelan’s Sign

 Wrist flexed and dorsum of hands pressed together
 Hold for 1 minute
 Sensations of numbness and paresthesia in palmar
aspects of hand, especially the first 3 fingers
 Positive sign is associated with carpal tunnel syndrome
Phelan’s Sign
 Hands and Wrists

 ROM
 Metacarpophalyngeal flexion (180°) and extension (30°)
 Thumb opposition
 Forming a fist
 Finger abduction and adduction
 Wrist hyperextension (70°) and flexion (90°)
 Radial (20°) and ulnar movement (55°)
 Muscle strength
 Wrist extension and hyperextension
 Finger abduction and adduction
 Hand grip
 Hips

 Inspect hips for symmetry and level of gluteal folds

 Palpate hips and pelvis
 Instability
 Tenderness
 Crepitus

 ROM
 Flexion (120°), extension (90°), and hyperextension (30°)
 Abduction (45°) and adduction (30°)
 Internal (40°) and external (45°) rotation
 Hips

 Muscle strength
 Knee in flexion and extension
 Abduction and adduction
 Legs and Knees

 Inspect knees for natural concavities

 Palpate the popliteal space and joint space
 ROM
 Flexion (130°)
 Extension (0-15°)

 Muscle strength
 Flexion
 Extension
 Feet and Ankles

 Inspect feet and ankles during weight bearing and

non weight bearing
 Contour
 Alignment
 Size
 Number of toes

 Palpate the Achilles tendon and each metatarsal

joint
 Feet and Ankles

 ROM
 Dorsiflexion (20°) and plantar flexion (45°)
 Inversion (30°) and eversion (20°)
 Flexion and extension of the toes

 Muscle strength
 Plantar flexion
 Dorsiflexion
 Developmental Variations

 Newborns
 Look for abnormalities
 Simian crease
 Single crease across entire palm
 Associated with Down syndrome
 Polydactyly
 Extra digits
 Syndactyly
 Webbed digits
 Signs of hip dislocation
 Hip clicks
 Asymmetric gluteal folds
Simian Crease
Polydactyly
Syndactyly

Also polydactyly!
 Developmental Variations

 Infants
 Should be able to lift the head and trunk from the prone
position by 2 months of age
 Forearm strength
 Kyphosis of the thoracic and lumbar spine is normal
until the infant can sit without support
 About 7 months
 All babies are flat-footed
 Forefoot should be flexible. Straightening with abduction
 Developmental Variations

 Children
 Young children have a protuberant
belly and lumbar curvature
 Watch alignment especially
 Feet often slightly invert until about 30 months
 Caution parents about reverse tailor sitting
 Places stress on the joints and can lead to future problems in
lower limb alignment
 Developmental Variations

 Children
 Abnormalities
 Genu varum
 “Bow leg”
 Measure distance between knees when ankles are together
 2.5 cm space = genu varum
 Genu valgum
 “Knock knee”
 Measure distance between ankles when knees are together
 2.5 cm space = genu valgum
Genu valgum Genu Varum
 Developmental Variations

 Adolescents
 May have slight kyphosis and rounded shoulders
 Bone growth is complete by age 20
 Peak bone mass not until 35
Developmental Variations

 Pregnancy
 Postural changes
 Increased lordosis
 Increased mobility and instability of sacroiliac
joints
 Pregnancy waddle
 Symptoms of carpel tunnel syndrome related
to fluid retention
 Abate after birth
 Developmental Variations

 Older Adults
 Joint agility can be grossly assessed by functional ADLs
 Posture
 Increased kyphosis, especially with osteoporosis
 Reduction in total muscle mass
 Joint and muscle agility have tremendous extremes
among older adults
 “If you don’t use it, you lose it!”
 Videos of Musculoskeletal
Assessment

 Copy these URLs into your Web browser

http://www.conntutorials.com/chapter6.html

OR
http://medinfo.ufl.edu/other/opeta/musculo/MS_main.html