Musculoskeletal Assessment

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Musculoskeletal Assessment
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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

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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

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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

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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

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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

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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

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Review of Related History

• Current Complaints
• With full symptom analysis
• Joint complaints
• Muscular complaints
• Skeletal complaints
• Injury
• Back pain

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Review of Related History

• Past History
• Trauma
• Nerves
• Joints
• Bones
• Soft tissue
• Surgery on bone or joint
• Skeletal deformities
• Chronic illness

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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

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Review of Related History

• Personal and Social History
• Employment potential for injury
• Exercise patterns
• Functional abilities
• Weight changes
• Height changes
• Nutrition
• Tobacco
• Alcohol

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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

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Risk Factors Osteoarthritis

• Obesity
• Family history
• Lax ligaments with postural joint deformity
• gt 40 yoa

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Risk Factors Osteoporosis

• Race
• Caucasian
• Asian
• Native American
• Northwestern European
• Blonde or red hair with freckles
• Light body frame, thin
• Family history
• Nulliparous

• Post menopause
• Constant dieting
• Calcium intake lt 1500 mg
• Scoliosis, RA
• Metabolic disorders
• Some drugs
• Poor teeth
• Smoking
• Alcohol

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Equipment and Techniques

• Equipment
• Skin marking pencil
• Goniometer
• Measuring tape
• Reflex hammer
• Sphygmomanometer
• Techniques
• Inspection
• Palpation

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Inspection Overall

• Alignment
• Contour
• Symmetry
• Height/weight
• Gross deformity
• Posture
• Standing
• Sitting

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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
• gt50 but lt 100
• Full weight bearing

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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

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Indications of Gait Disturbance

• Hesitancy
• Unsteadiness
• Staggering
• Grasping for external support
• High stepping
• Floor scraping
• Excessive pointing of toes inward or outward
• Shuffling gait

• Waddling gait
• Slow, rapid step speed
• Asymmetry of step height or length
• Limping
• Stooping during walking

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Inspection and Palpation

• Always compare contralateral sides!!

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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 gt 3cm is abnormal

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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

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Inspection and Palpation Muscles

• Apply light pressure with finger pads
• Palpate while persons 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

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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

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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

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Inspection and Palpation Joints

• Palpate the joint from the periphery inward
  toward the center of the joint
• Swelling
• Tenderness
• Warmth
• Nodules

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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

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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

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Muscle Strength

• As you are testing ROM
• Test muscle strength
• Ability to perform the ROM against resistance
• Symmetry
• Involuntary movements

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Grading Muscle Strength

• 5 Normal 100 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

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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

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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

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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

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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

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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

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Scoliosis
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Kyphosis
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Dowagers Hump
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Lordosis
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List
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Thoracic and Lumbar Spine

• Palpate the spinal processes and paravertebral
  muscles
• Nodules
• Tenderness
• ROM
• Forward flexion (75)
• Hyperextension (30)
• Lateral bending (35)
• Rotation

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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)

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Shoulders

• Muscle strength
• Shrugging shoulders
• Tests CN
• XI Spinal accessory
• Forward flexion
• Abduction

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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

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Elbows

• ROM
• Flexion (160)
• Extension (180)
• Pronation and supination (90)
• Muscle strength
• Flexion
• Extension

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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

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Hands and Wrists

• Test for Tinels 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

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Tinel s Sign
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Hands and Wrists

• Test for Phelans 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

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Phelans Sign
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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

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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

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Hips

• Muscle strength
• Knee in flexion and extension
• Abduction and adduction

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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

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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

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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

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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

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Simian Crease
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Polydactyly
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Syndactyly
Also polydactyly!
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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

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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

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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

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• Genu valgum Genu Varum

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Developmental Variations

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

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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

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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 dont use it, you lose it!

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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