The Musculoskeletal System

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

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

Types of Joint Articulation: Synovial, Cartilaginous, and Fibrous (cont.) Cartilaginous joint Joint is slightly movable Examples: vertebral bodies of the spine

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

Joint Movements Flexion Extension Rotation Circumduction Elevation Protrusion Retraction Abduction

Joint Movements Adduction Pronation Supination Inversion Eversion Gliding

Table 23.2 Joint Movement 9

Table 23.2 Joint Movement (continued ) 10

Table 23.2 Joint Movement (continued ) 11

Table 23.2 Joint Movement (continued ) 12

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.

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.

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

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

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

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

Wrist and Hand: Review the Anatomy

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

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)

Palpating the wrist. 24

Palpating the hand. 25

Extension and flexion of the wrist. 26

Ulnar and radial deviation of the wrist. 27

Testing the muscle strength of the wrist. 28

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 S&P

Carpal Tunnel Syndrome

Tinel’s sign (Median Nerve). Use your middle finger tap over the carpal tunnel. Pain, tingling, or electric sensations strongly suggest carpal tunnel syndrome. 31

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. 32

Palpating the fingers. 33

Flexion and extension/hyperextension of the fingers. 34

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

Flexion and extension of the elbow. 36

Goniometer measure of joint range of motion. 37

Supination and pronation of the elbow. 38

Testing muscle strength using opposing force (flexion or extension. 39

Important Bones of the Shoulder Review bony anatomy

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)

Flexion and extension of the shoulders. 42

Internal rotation of the shoulders. 43

External rotation of the shoulders. 44

Abduction and adduction of the shoulder. 45

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:

Spine: Muscle Groups

Lateral view of spine. 48

Spine: Examination — Inspection With patient in gown, directly inspect: From the side Cervical, thoracic, and lumbar curves From behind Upright spinal column Alignment of the shoulders, iliac crests, and the gluteal folds Skin markings, tags, or masses

Spine: Examination — Palpation Palpate With patient standing or sitting Spinous processes of each vertebrae Facet joints in the neck Lower lumbar area for vertebral “step-offs” or tenderness Paravertebral muscles for tenderness or spasm Sacroiliac joint

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

Lateral flexion of the spine. 52

Forward flexion of the spine. 53

Rotation of the spine (right + left rotation). 54

Hip: Review Bony Anatomy

Hip: Examination — Inspection Inspect the gait Inspect anterior and posterior surfaces of the hip for muscle atrophy or bruising Palpation

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

Flexion of the hip.

Hyperextension of the hip. 59

Internal and external hip rotation. 60

Abduction and adduction of the hip. 61

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.

Knee: Review the Anatomy

Knee: Examination — Inspection and Palpation 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

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

Test for strength the knees (against your resistance) 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.

Palpating the knee. 67

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. 68

Flexion of the knee. 69

Ankle and Foot: Review the Anatomy

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

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

Palpating the ankle. 73

Eversion and inversion of the ankles. 74

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

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

Common Abnormalities Crepitus Contracture Resistance to movement of muscle or joint, fibrosis of soft tissue Crepitus Crackling sound or grating sensation from friction between two bones

Common Abnormalities Kyphosis Round back forward bending of spine

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

Common Abnormalities Scoliosis Lateral curvature of the spine

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. Metabolic disease, in which bone demineralization results in decreased density and subsequent fractures. Osteopenia (low bone mass, which occurs when there is a disruption in the bone remodeling process. Bone density scan altered, decrease density. Bone resorption exceeds bone formation. SERM – Selective Estrogen Receptor Modulators.