Randa M. Albusoul

Musculoskeletal System

Introduction

•This system consist of: bones, joints, muscles.

Joints: articulation where 2 or more bones are joined.Ligaments: Fibrous bands that hold bone to bone.Tendons: Collagen at end of muscles that attaches muscle to boneBone: hard, rigid and dense connective tissue.Cartilage: Smooth connective tissue.

Synovial joints: example: knee, shoulder, freely movable because they have bones that are separated from each other with synovial fluid present to allow sliding of opposing surfaces.

Cartilaginous Joints: Example: between vertebrae and thesymphysis pubis, are slightly movable. Fibrocartilaginous discs separate the bony surfaces. Nucleus pulposus serves as a cushion or shockabsorber between bony surfaces.

Fibrous Joints: example: sutures of the

skull, immovable, intervening layers of

fibrous tissue or cartilage hold the bones

together.

Types of Synovial Joints:

The shape of synovial joints differ

determining the direction and degree of

motion.

1) Spheroidal joints: ball and socket

configuration, wide range of rotatory

movement, ex. Hip and shoulder.

2) Hinge joints: flat, plantar, or slightly curved,

allowing for a small motion in a single plane such as

flexion or extension of the digits.

3) Condylar

joints: one

convex, and

one concave

structures, such

as knee.

Bursae: disc-shape synovial sacs that allow muscles

and tendons to glide over each other during

movement. Are present between the skin and

convex surface of a bone or joint or in area were

tendons and bones rub against bone, ligaments, or

other tendons or muscles.

Muscles:

•Account for 40-50% of body’s weight.

•When contract produce movement

•Types:

Skeletal- voluntary muscles

Smooth- involuntary muscles

cardiac

Flexion: Bending a limb at a joint.Extension: Straightening a limb at a joint.

Pronation:Turning the forearm ̶ palm is

down.

Supination: Turning the forearm ̶ palm is

up.

Abduction: moving a limb away from the

midline

Adduction: moving a limb toward the

midline.

Circumdution: Circular movement of the arm

around the shoulder.

Inversion: moving the sole of the foot inward

at the ankle.

Eversion: moving the sole of the foot outward

at the ankle.

Rotation: moving the head around a central axis.

Protraction: moving forward and parallel to the ground.Retraction: moving backward and parallel to the ground.

Elevation: raising

Depression: lowering

Subjective Data

Common symptoms:

Joint pain

Joint pain with systematic symptoms;

rash, chills, fever, weight loss,

weakness

Low back pain

Neck pain bone pain muscle pain,

cramps, weakness

Myalgias: pain in the muscle.

Arthralgia: pain in the joint.

Ostealgia: pain in the bones.

Some questions: location of the pain? Only one joint

or all? Any trauma?

Low back pain: any associated numbness or

paresthesias? Any bladder or bowel dysfunction?

Neck pain: any radiation to arm? Or arm/leg

weakness, paresthesias, bowel or bladder

dysfuction?

Objective Data

1- inspect joints size, shape, color, symmetry, note any masses, deformities, or muscle atrophy. Compare bilateral.2- palpate for skin changes, crepitus, nodules, atrophy, assess for inflammation: redness, swelling, tenderness, warmth3-Test joints range of motion (ROM) passive, active; to test function, stability, and integrity. 4-assess of muscle strength.

Muscle bulk:

•When looking for atrophy pay attention to the hands,

shoulders, and thighs.

•Be alert for fasciculations in atrophic muscles.

Fasciculation: small, local, involuntary muscle

contraction and relaxation, which may be visible

under the skin.

•Muscle tone: when normal muscle with intact

nerves is relaxed voluntarily it maintain a slight

tension known as muscle tone. It can be assessed

best by feeling the muscle’s resistance to passive

stretch.

•Muscle strength:

•Note the age, gender, and muscular training.

•A dominated side may be slightly stronger.

•Shorter muscles are stronger.

1- Test muscle strength by asking patient to move

each extremity in its full ROM against resistance.

-If can’t move against resistance, ask client to move

against gravity.

-If can’t against gravity, eliminate the gravity.

When documenting muscle strength, indicate the scale

used, e.g., muscle strength 3 out of 5 or 3/5.

Temporomandibular Joint

•The muscles that open the mouth are external

pterygoids.

•The muscles that close the mouth are internal

pterygoids, masseter, temporalis and are innervated by

cranial nerve V (trigeminal nerve).

Inspect and palpate the joint:

- Ask patient to open mouth as widely as possible.

-Move jaw from side to side; lateral.

-Protrude (push out), retract (pull in).

Normally; jaw move laterally 1-2 cm. snapping and

clicking is normal.

mouth open 1-2 inches (3 fingers)

Jaw protrude and retract easily; bottom teeth can be

placed in front of the upper.

•To locate and palpate the joint place the tip of your

index finger in front of the tragus of each ear and ask

the pt to open her mouth.

•Check for smooth ROM .

•Note any swelling or tenderness.

•Palpate the masseters and temporal muscle.

Muscle strength:

•Perform ROM maneuvers

(projection, lateral, openning)

against your resistance.

The Shoulder

Shoulder girdle: is the complex interconnection

structure of joints, bones, and muscles that moves

the shoulder.

The bones are: humerus, clavicle, and scapula.

The joints are: sternoclavicular, acromioclavicular,

and glenohumeral.

Inspection:

•Note any swelling, deformity, muscle atrophy,

fasciculations, abnormal positioning, symmetry.

•Color change, skin alterations, bony contours.

Palpate:

•Heat, tenderness, muscular spasm or atrophy.

•ROM: the motions of shoulder girdle are flexion,

extension, abduction, adduction, internal and

external rotation.

Flexion: Raise your arms in front of you

and over head.

Extension: raise your hands behind you.

Abduction: raise your arms out to the side and

overhead.

Adduction: cross your arm in front of your

body.

Internal rotation: place one hand behind your back

and touch your shoulder blade.

Raise your arm to shoulder level, bend your

elbow and rotate your forearm toward the

ceiling.

The Elbow

•Note the bones,

muscles, and joints

of the elbow.

•Biceps and

brachioradilis

(flexion), triceps

(extension),

pronator teres

(pronation),

supinator

(supination).

The bursa is normally

palpable but swells

and becomes tender

when inflamed.

•Inspect: the size & contour in both flexed & extended

elbows; redness, deformity, swelling.

•Palpate elbow note any displacement and tenderness.

ROM and muscle strength:•Stabilize the arm with one hand.•Ask the pt. to flex elbow against resistance applied to the wrist.•Ask the pt. to extend elbow while adding resistance.

The Wrist and Hands

Note the bones

and joints in the

arm.

•Ulna does not

articulate directly with

the carpal bones.

•Radiocarpal joint

provides most of the

flexion and extension

of the wrist.

•inspect the dorsal & palmer sides; position; shape,

and deformities.

•Inspect skin; color, smoothness, muscle mass.

•Palpate each joint in the wrist & hands.

•Palpate thumbs side to side to identify the normal

depressed area “anatomic snuffbox”.

•Palpate the interphalangeal joints by thumb & index.

•Normal joints surface feel smooth no swelling,

nodules or tenderness.

Wrist ROM:

Flexion, extension, adduction (radial deviation),

abduction (ulnar deviation).

Muscle strength:

Extension at the wrist (C6,

C7, C8, Radial nerve), ask

the pt to make a fist and

resist your pulling it down

Test the grip (C7, C8, T1), ask pt to squeeze two of

your fingers as hard as possible and not let them go.

For complaints of dropping objects, inability to twist

lids off jars, aching at the wrist or even the forearm,

and numbness of the first three digits, use the tests

on the next page for assessing carpal tunnel

syndrome.

For carpal tunnel syndrome test:

•The index finger- median nerve.

•The 5th finger (small finger)- ulnar nerve.

•Dorsal web space of the thumb and index finger-

radial nerve.

Thumb abduction (ask the pt to raise the thumb

straight up as you apply downward resistance)

Tinel’s sign for median

nerve compression by

tapping lightly over the

course of the median nerve

in the carpal tunnel.

Phalen’s sign for median

nerve compression, hold

wrists in flexion for 60 sec.

Fingers and thumb ROM:

Flexion: make a tight fist with each hand, thumb

across the knuckles.

Extension: extend and spread the fingers.

Abduction and adduction: ask the pt to spread the

fingers and back together.

ROM of Thumb:

Assess flexion, extension, abduction, adduction, and

opposition.

Finger muscle strength test:

Finger abduction (C8, T1, ulnar nerve) hand with palm

down and fingers spread, instruct the pt not to let you

move the fingers, try to force them together.

Test opposition of the thumb (C8, T1, median nerve)

the pt should try to touch the tip of the little finger

with the thumb, against your resistance.

The Spine

•Vertebra-33 connecting bones stacked in a vertebral column.

•Humans have 7 cervical, 12 thoracic, 5 lumbar, 5 sacral, & 3-4 coccygeal vertebra.

•Surface Landmarks-Spinous process C-7 & T-1Inferior angle of scapula- T-7 & T-8Imaginary line connecting highest point on each iliac crest crosses L-4

•Lateral view of spine- double S shape.•These curves together with the intervertebral disks allow the spine to absorb a great deal of shock.•Intervertebral Disks- elastic fibro cartilaginous plates that constitute ¼ of the length of the column.•Each disk has a nucleus pulposus•The disks cushion the spine & help it move.•As spine moves - elasticity of the disks allow compression on one side, with compensatory expansion on the other. Sometimes compression is too great—disk can rupture and the nucleus pulposus can herniated out the vertebral column—compressing on spinal nerve & causing pain.

Inspection:

•Observe the pt posture and position of neck and

trunk.

•Assess the pt for erect position of the head,

coordinated neck movement, and ease of gait.

•Assess the landmarks and spinal curvatures.

Palpation:

•Palpate the spinous process of each vertebra.

•Palpate for tenderness.

ROM of neck:

Flexion and extension (C1), rotation (C1-C2),

lateral bending (C2-C7).

Muscle strength:

Can be tested when the

examiner place his hand to

resist the motion of the pt.

ROM for spinal column:

Flexion: bend forward and try to touch your toes.

Extension: bend back as far as possible.

Rotation: rotate from side to side.

Lateral bending: bend to the side from the waist.

Muscle strength test:

Assessment of muscle strength of the spinal column

may also be performed during the range-of-motion

assessment by having the patient flex, extend, and

flex laterally against resistance.

The Hip

Inspection:

Inspect the gait of the pt when entering the room.

Palpate:

Palpate the hip joints and landmarks; feel stable and

symmetric, not tender or crepitance.

ROM:

Include flexion, extension, abduction, adduction,

external rotation, internal rotation.

For further examination see this maneuver:

•Flexion: With the patient supine, place your hand

under the patient’s lumbar spine. Ask the patient to

bend each knee in turn up to the chest and pull it

firmly against the abdomen. When the back touches

your hand, indicating normal flattening of the lumbar

lordosis. As the thigh is held against the abdomen,

observe the degree of flexion at the hip and knee.

Normally the anterior portion of the thigh can almost

touch the chest wall. Note whether the opposite thigh

remains fully extended, resting on the table.

Muscle strength test:

•Flexion: place your hand of the pt thigh and ask

him to raise the leg against your hand.

Extension: by having the supine pt push the

posterior thigh against your hand.

•Abduction: place your hands firmly on the bed

outside the pt knees and ask the pt to spread both legs

against your hands.

•Adduction: place your hands firmly on the bed

between the pt knees. Ask the pt to bring both legs

together.

•External and internal rotation:

Flex the leg to 90° at hip and knee, stabilize the thigh

with one hand, grasp the ankle with the other, and

swing the lower leg medially for external rotation at

the hip and laterally for internal rotation.

The Knee

Inspect:

•Observe the gait when entering the room. •The skin; smooth, even color no lesion.•Lower leg alignment; extend in the same axis.•The shape and contour of knee; distinct, concave or hollows on both side of patella.•Prepatellar bursa & suprapatellar pouch; no swelling.•Quadriceps muscle in the anterior thigh; no atrophy.

Palpate:•The anterior thigh, above patella; consistence, soft smooth, non tender, not hot. no lesions.•Bulge sign; for swelling in the suprapatellar pouch: no fluids.•Ballottement test; large amount of fluid in the suprapatellar pouch smooth margins, non tender.

ROM for knee:

Note; muscles affecting movement for self reading

Muscle strength test:

Flexion: Support the knee in flexion and ask the pt to

straighten the leg against your hand.

Extension: Place the patient’s leg so that the knee is

flexed with the foot resting on the bed. Tell the patient

to keep the foot down as you try to straighten the leg.

The Ankle and Foot

Inspection:

•Observe all surfaces of the feet and ankles noting

any deformity, nodules, swelling.

Palpate:

•Palpate the joints, note any swelling, or tenderness.

ROM:

Muscle strength test:

Test muscle strength during dorsiflexion and planter

flexion by asking the pt to pull up and push down

against your hand.

The subtalar (talocalcaneal) joint: stabilize the ankle

with one hand, grasp the heel with other and invert

and evert the foot.

Transverse tarsal joint: stabilize the heel and invert

and evert the forefoot.

Metatarsophalangeal joints: flex the toes in relation to

the feet.