Assessment of Musculoskeletal System Dr. Belal Hijji, RN, PhD March 7, 2012

Learning Outcomes At the end of this lecture, students will be able to: Describe the process of performing musculoskeletal assessment related to posture, gait, joint function, and muscle strength and size.

Introduction Physical assessment techniques of inspection and palpation are used to evaluate the patient’s posture, gait, bone integrity, joint function, muscle strength and size, skin, and neurovascular status. Due to time limitations, this presentation excludes skin and neurovascular status.

Posture The normal curvature of the spine is convex [محدب]through the thoracic portion and concave [مقعر] through the cervical and lumbar portions (slides 5 & 6). Common deformities of the spine include kyphosis (due to arthritis or osteoporosis); lordosis, frequently seen during pregnancy; and scoliosis (may be congenital, idiopathic, or the result of damage to the paraspinal muscles, as in poliomyelitis). (Continued on slide 10)

Kyphosis: an increased forward curvature of the thoracic spine

Lordosis: an exaggerated curvature of the lumbar spine

The forward bend test is used most often to screen for scoliosis The forward bend test is used most often to screen for scoliosis. The child bends forward with the feet together and knees straight while dangling the arms. Scoliosis: a lateral curving deviation of the spine

Posture (Continued …) During inspection of the spine, the entire back, buttocks, and legs are exposed. The examiner inspects the spinal curves and trunk symmetry from posterior and lateral views. Standing behind the patient, the examiner notes any differences in the height of the shoulders. Shoulder and hip symmetry, as well as the line of the vertebral column, are inspected with the patient erect and with the patient bending forward.

Gait Gait is assessed by having the patient walk away from the examiner for a short distance. The examiner observes the patient’s gait for smoothness and rhythm. Any unsteadiness or irregular movements are considered abnormal. Most frequently, limping is caused by painful weight bearing. If one extremity is shorter than another, a limp may also be observed as the patient’s pelvis drops downward on the affected side with each step. Abnormal gait is seen in some neurologic conditions. In spastic hemiparesis gait the leg on the affected side is extended and internally rotated. The upper limb on the same side is also adducted at the shoulder, flexed at the elbow, and pronated at the wrist with the thumb tucked into the palm and the fingers curled around it. In steppage gait, foot drop where the foot hangs with the toes pointing down, causing the toes to scrape the ground while walking, requiring someone to lift the leg higher than normal when walking. For shuffling gait, a video can illustrate it.

Joint Function Assess range of motion both actively (the joint is moved by the muscles surrounding the joint) and passively (the joint is moved by the examiner). Skeletal deformity, joint pathology, contracture (a permanent shortening of muscle or tendon) producing deformity or distortion, or osteoarthritis may limit range of motion and may reduce patient’s ability to perform activities of daily living. Joint (next slide) deformity may be caused by contracture, dislocation (complete separation of joint surfaces), subluxation (incomplete dislocation that occurs when a bone slips over another and eliminates the joint space), or disruption of structures surrounding the joint.

Typical Joint

Joint Function (Continued…) Examine the knee joint for effusion (excessive fluid within the capsule), if it is painful or if its motion is compromised, swelling, and increased temperature that may reflect active inflammation. An effusion is suspected if the joint is swollen and the normal bony landmarks are obscured. If a small amount of fluid is present in the joint spaces beneath the patella, it may be identified by the following maneuver. Perform the ballottement test (See below) to detect effusion.

Joint Function (Continued…) Palpation of a passively moved joint provides information about its integrity. Normally, the joint moves smoothly. A snap [طقطقة] may indicate that a ligament is slipping over a bony prominence. Slightly roughened surfaces, as in arthritic conditions, result in crepitus (crackling sound) due to movement of irregular joint surfaces across one another. Examine the tissues surrounding joints for nodule formation (As in Rheumatoid arthritis, gout). Rheumatoid arthritis produces soft nodules that occur within and along tendons (Slide 13) . In gout, the nodules are hard and lie within and immediately adjacent to the joint capsule itself.

Muscle Strength and Size Assess muscle strength by having the patient perform certain maneuvers with and without added resistance. When testing the biceps muscle, ask the patient to extend the arm fully and then to flex it against resistance you apply. Handshake may provide an indication of grasp strength. Biceps Muscle 

Muscle Strength and size (Continued…) To assess muscle size, measure the girth of an extremity to monitor increased size due to exercise, edema, or bleeding into the muscle. Girth may decrease due to muscle atrophy. The unaffected extremity is measured and used as the reference standard. Measurements are taken at the maximum circumference of the both extremities, same location and position, with the muscle at rest.