Musculoskeletal Assessment NURS 347 Towson University Musculoskeletal Assessment

Anatomy and Physiology Musculoskeletal Assessment Fundamentals: Anatomy and Physiology

Structure & Function Bones: 206 126 appendicular, 80 axial Joints: Where two or more bones join Muscles: Contraction = movement Voluntary skeletal muscles under conscious control Support: Maintain stature Movement Protect vital organs Produce red blood cells in bone marrow (hematopoiesis) Storage of minerals, such as calcium and phosphorus

Joints (Articulation) Synovial Joints Bones are separated but enclosed in a joint cavity Opposing bones covered with cartilage Freely moveable Ligaments: Fibrous bands connect two bones, strengthen joint Bursa: Enclosed sac filled with synovial fluid that aim to reduce friction in areas such as the knee, shoulder. Tendon: Attached the skeletal muscle to the bone

Range of Motion

Range of Motion Active and Passive Range of Motions should the be same Active: When the patient can perform range of motion independently Passive: When the patient has a limitation Anchor the joint with one hand Use your other hand and move to the joint’s limit

Range of Motion Assessing and Documenting a Limitation: Goniometer: Used to precisely measure joint angles

Range of Motion Flexion: Bending limb at a joint Extension: Straightening a limb at a joint

Range of Motion, continued Abduction: Moving a limb away from body’s midline Adduction: Moving a limb towards the body’s midline

Range of Motion, Continued Pronation: Turning forearm so palm is down Supination: Rotating forearm so palm is up

Range of Motion, Continued Internal Rotation: External Rotation

Range of motion, Continued Inversion: Moving the sole of the foot inward at the ankle Eversion: Moving the sole of the foot outward at the ankle

Range of Motion, Continued Circumduction: Movement of the arm in a circle around the shoulder

Subjective Assessment

Subjective Interview Joints: Pain, stiffness, swelling, warmth, or limited range of movement? Muscles: Cramps, pain, or weakness? Bones: Pain, deformity, trauma (fractures, sprains, dislocations?) Activities of Daily Living: Any difficulty bathing, toileting, dressing, eating, communicating, or mobility? Occupational Hazards: Heavy lifting, repetitive movement? Self-Care: Recent weight gain, exercise program?

Objective Assessment

Inspection Skeleton: Symmetry of skeleton; Size and contour of joint(s) Skin: Color or swelling Gait: Steady or unsteady

Palpation Joints Muscles Bones Range of Motion Tenderness Crepitus Muscle Strength

Joints: Inspection Inspect paired joints for: Symmetry Size Contour Color Swelling Deformities or Masses

Joints: Palpation Palpate to: Stage edema: Pitting versus Non-Pitting Masses Warmth Tenderness Range of Motion (ROM) Crepitus: An audible or palpable “crunching” or “grating” with movement

Musculoskeletal Assessment Head to Toe Musculoskeletal Assessment

Temporomandibular Joint Inspect: Area anterior to ear for: masses, symmetry, discoloration Palpate: Crepitus or tenderness temporalis and masseter muscles when teeth are clenched Range of Motion: Open mouth maximally  Vertical motion Partial mouth open  Lateral motion Stick out lower jaw  Protrusion without deviation

Cervical Spine Inspect the alignment of the head and neck Palpate the spinous processes and sternomastoid, trapezius, and paravertebral muscles Range of motion: Chin to chest  45’ flexion Chin to ceiling  55’ hyperextension Touch ear to shoulder  40’ lateral bend Turn chin to shoulder  70’ rotation DO NOT ASSESS IF SUSPECTED CERVICAL TRAUMA

Upper Extremities: Shoulder Inspect posteriorly and anteriorly: Joint size and contour Equality of bony landmarks Palpate: Spasm Atrophy Swelling Heat Tenderness Crepitus during ROM

Upper extremities: Shoulders How would you assess Range of Motion?

Upper extremities: Shoulders How would you assess Range of Motion? Circumduction Abduction Adduction Internal Rotation External Rotation

Upper extremities: Shoulders Strength Shrug Shoulders (also assesses which CN?) Flex arms forward and up against resistance

Upper Extremities: Elbow Inspect joint and tissue Range of Motion: Bend and Straighten elbow (Flexion and Extension) With slightly extended elbow, touch thefront and back of the hand to the table (Pronation and Supination) Strength: Flex and extend elbow against resistance

Upper Extremities: Wrist and Hands Inspect joints (knuckles) and surrounding skin Palpate for warmth, crepitus, tenderness, or nodules

Upper Extremities: Wrist and Hands ROM: Bend hand up and down at wrist Bend fingers at metacarpophalangeal joints Palms flat on table: Rotate in and outward Spread fingers apart, make a fist Touch thumb to each finger

Lower Extremities: Hip Inspection of the Hips should be delayed until spinal he assessment With patient in the supine position, palpate the hip joints for crepitus or tenderness

Lower Extremities: Hip Range of Motion Raise each leg with knee extended Bend each knee up to the chest, keeping the other leg straight Extend leg straight, then direct foot inward and outward Swing leg laterally and medially, keeping knee straight

Lower Extremities: Knee Inspection and Palpation: Skin free from lesions, smooth and even in coloring Bilateral comparison: length and alignment Swelling or fullness at the knee, pre- and suprapatellar bursa Atrophy at quadriceps Strength: Ask patient to push your hand away using their foot, assessing quadriceps’ strength

Lower Extremities: Knee Range of Motion Bend and Extend each knee Assess ROM during ambulation

Lower Extremities: Foot and Ankle Inspect and compare both feet and toes, and their position. Examine: skin color Lesions Contour alignment with the upper leg Note areas of calluses or bursal reactions, as they reveal areas of abnormal friction

Lower Extremities: Foot and Ankle Range of Motion Point toes towards floor Point toes towards nose Turn soles of feet in and out Flex and straighten toes Strength Maintain dorsiflexion and plantar flexion against resistance (hand)

Spinal Assessment: Posterior Stand behind patient so you can see the entire back Inspect for spine’s straightness by following an imaginary vertical line from the head to the gluteal cleft Inspect for symmetry of shoulders, scapulae, and iliac crests (hips) bilaterally. Knees should be aligned and pointing forward

Spinal Assessment: Lateral Inspect for normal curvature of the spine Convex thoracic curve Concave lumbar curve Range of Motion Bend forward, touch toes (concave curve should disappear) Bend Sideways (35’) Bend backward (Hyperextension 30’) Assess for pain and decreased ROM

Spinal Assessment

Age Considerations: Infants & Children Barlow-Ortolani’s Maneuver: Assesses for congenital dislocation of hips in infants. Normal finding reveals smooth abduction and adduction of bilateral legs while in the supine position Spina Bifida: A tuft of hair over a dimple on the spinal midline may indicate spinal bifida Children Juvenile Rheumatoid Arthritis: Discomfort greater in the morning, decreased ROM and pain in bilateral joints. Scoliosis: Spinal asymmetry Adolescents

Age Considerations & Pregnancy Older Adults Dorsal kyphosis Rheumatoid Arthritis: Bilateral joint pain and decreased ROM, worse in the morning Osteoarthritis: Unilateral or unrelated joint pain in which pain increases later in the day Osteoporosis: Risk Factors & Prevention Pregnancy Waddling Gait Backache Muscle cramps Lordosis

Functional Assessment Walk (with shoes on) to observe gait and balance Climb up and down stairs to assess balance and bilateral strength Pick up object from the floor Rise from sitting in chair Rise from lying in bed

Grading Muscle Strength