1. Musculoskeletal System
Chapter 22

2. Structure and Function
Subjective Data—Health History Questions
Objective Data—The Physical Exam
Abnormal Findings

3. Structure and Function
Joints
Nonsynovial or synovial joints
Cartilage
Ligament
Bursa
Muscles
Fasciculi
Tendon
Skeletal muscle movements

4. Synovial Joint

5. Skeletal Muscle Movements

6. Skeletal Muscle Movements (cont.)

7. Structure and Function (cont.)
Temporomandibular joint
Spine
Vertebrae
Landmarks of the spine
Intervertebral disks
Shoulder
Glenohumeral joint
Rotator cuff
Subacromial bursa
Acromion process
Greater tubercle of the humerus
Coracoid process

8. Landmarks of the Spine

9. Shoulder

10. Structure and Function (cont.)
Elbow
Medial and lateral epicondyles
Olecranon process of ulna
Wrist and carpals
Radiocarpal joint
Midcarpal joint
Metacarpophalangeal joints
Interphalangeal joints

11. Right Elbow

12. Bones of the Hand

13. Structure and Function (cont.)
Hip
Acetabulum and head of femur
Anterior superior iliac spine
Ischial tuberosity
Greater trochanter of femur
Knee
Femur, tibia, and patella
Suprapatellar pouch
Medial and lateral menisci
Cruciate ligaments
Prepatellar bursa
Quadriceps muscle
Ankle and foot
Tibiotalar joint
Medial and lateral malleolus
Metatarsals

14. Hip Joint

15. Landmarks of the Knee

16. Ankle and Foot

17. Subjective Data— Health History Questions
Joints
Pain
Stiffness
Swelling, heat, and redness
Joints:
• Any problems with your joints? Any pain?
• Location: Which joints? On one side or both sides?
• Quality: What does the pain feel like: aching, stiff, sharp or dull, shooting? Severity: How strong is the pain?
• Onset: When did this pain start?
• Timing: What time of day does the pain occur? How long does it last? How often does it occur?
• Is the pain aggravated by movement, rest, position, weather? Is the pain relieved by rest, medications, application of heat or ice?
• Is the pain associated with chills, fever, recent sore throat, trauma, repetitive activity?
• Any stiffness in your joints?
• Any swelling, heat, redness in the joints?
• Any limitation of movement in any joint? Which joint?
• Which activities give you problems?

18. Subjective Data— Health History Questions (cont.)
Muscles
Pain (cramps)
Weakness
Muscles:
• Any problems in the muscles, such as any pain or cramping? Which muscles?
• If in calf muscles: Is the pain with walking? Does it go away with rest?
• Are your muscle aches associated with fever, chills, the "flu"?
• Any weakness in muscles?
• Location: Where is the weakness? How long have you noticed weakness?
• Do the muscles look smaller there?

19. Subjective Data— Health History Questions (cont.)
Bones
Pain
Deformity
Trauma (fractures, sprains, dislocations)
Bones:
• Any bone pain? Is the pain affected by movement?
• Any deformity of any bone or joint? Is the deformity due to injury or trauma? Does the deformity affect ROM?
• Any accidents or trauma ever affected the bones or joints: fractures, joint strain, sprain, dislocation? Which ones?
• When did this occur? What treatment was given? Any problems or limitations now as a result?
• Any back pain? In which part of your back? Is pain felt anywhere else, like shooting down leg?
• Any numbness and tingling? Any limping?

20. Subjective Data— Health History Questions (cont.)
Functional assessment (activities of daily living)
Self-care behaviors
Functional assessment (activities of daily living): Do your joint (muscle, bone) problems create any limits on your usual activities of daily living (ADLs)? Which ones? (Note: Ask about each category; if the person answers "yes," ask specifically about each activity in category.)
• Bathing—getting in and out of the tub, turning faucets?
• Toileting—urinating, moving bowels, able to get self on/off toilet, wipe self?
• Dressing—doing buttons, zipper, fasten opening behind neck, pulling dress or sweater over head, pulling up pants, tying shoes, getting shoes that fit?
• Grooming—shaving, brushing teeth, brushing or fixing hair, applying makeup?
• Eating—preparing meals, pouring liquids, cutting up foods, bringing food to mouth, drinking?
• Mobility—walking, walking up or down stairs, getting in/out of bed, getting out of house?
• Communicating—talking, using phone, writing?
Self-care behaviors: Any occupational hazards that could affect the muscles and joints? Does your work involve heavy lifting? Or any repetitive motion or chronic stress to joints? Any efforts to alleviate these?
• Tell me about your exercise program. Describe the type of exercise, frequency, the warm-up program.
• Any pain during exercise? How do you treat it?
• Have you had any recent weight gain? Please describe your usual daily diet. (Note the person's usual caloric intake, all four food groups, daily amount of protein, calcium.)
• Are you taking any medications for musculoskeletal system: aspirin, antiinflammatory, muscle relaxant, pain reliever?
• If person has chronic disability or crippling illness: How has your illness affected your interaction with family? Your interaction with friends? The way you view yourself?

21. Objective Data—The Physical Exam
Preparation
Screening musculoskeletal examination
Complete musculoskeletal examination
Equipment needed
Tape measure
Goniometer, to measure joint angles
Skin marking pen
Order of the examination
Inspection
Size and contour of joint
Skin and tissues over joint
Palpation
Skin temperature
Muscles, bony articulations, area of joint capsule
Range of motion
Muscle testing
Apply opposing force
Grading muscle strength

22. Objective Data—The Physical Exam (cont.)
Temporomandibular joint
Inspect joint area
Palpate as person opens mouth
Motion and expected range
Open mouth maximally
Protrude lower jaw and move side to side
Stick out lower jaw
Palpate muscles of mastication

23. Objective Data—The Physical Exam (cont.)
Cervical spine
Inspect alignment of head and neck
Palpate spinous processes and muscles
Motion and expected range
Chin to chest
Lift chin
Each ear to shoulder
Turn chin to each shoulder
Shoulders
Inspect joint
Palpate shoulders and axilla
Motion and expected range
Arms forward and up
Arms behind back and hands up
Arms to sides and up over head
Touch hands behind head

24. Objective Data—The Physical Exam (cont.)
Elbow
Inspect joint in flexed and extended positions
Palpate joint and bony prominences
Motion and expected range
Bend and straighten elbow
Pronate and supinate hand
Wrist and Hand
Inspect joints on dorsal and palmar sides
Palpate each joint
Motion and expected range
Bend hand up, down
Bend fingers up, down
Turn hands out, in
Spread fingers, make fist
Touch thumb to each finger
Phalen’s test
Tinel’s sign

25. Objective Data—The Physical Exam (cont.)
Hip
Inspect as person stands
Palpate with person supine
Motion and expected range
Raise leg
Knee to chest
Flex knee and hip; swing foot out, in
Swing leg laterally, medially
Stand and swing leg back
Knee
Inspect joint and muscle
Palpate
Bulge sign
Ballottement of patella
Motion and expected range
Bend knee
Extend knee
Check knee during ambulation
McMurray’s test

26. Objective Data—The Physical Exam (cont.)
Ankle and foot
Inspect with person sitting, standing, and walking
Palpate joints
Motion and expected range
Point toes down, up
Turn soles out, in
Flex and straighten toes
Spine
Inspect while person stands
Palpate spinous processes
Motion and expected range
Bend sideways, backward
Twist shoulders to each side
Straight leg raising
Measure leg length discrepancy

27. Sample Charting

28. Abnormal Findings Abnormalities Affecting Multiple Joints
Inflammatory conditions
Rheumatoid arthritis
Ankylosing spondylitis
Degenerative conditions
Osteoarthritis (degenerative joint disease)
Osteoporosis

29. Abnormal Findings Abnormalities of the Shoulder
Atrophy
Dislocated shoulder
Joint effusion
Tear of the rotator cuff
Frozen shoulder—adhesive capsulitis
Subacromial bursitis

30. Abnormal Findings Abnormalities of the Elbow
Olecranon bursitis
Gouty arthritis
Subcutaneous nodules
Epicondylitis—tennis elbow

31. Abnormal Findings Abnormalities of the Wrist and Hand
Ganglion cyst
Colles’ fracture
Carpal tunnel syndrome
Ankylosis
Dupuytren’s contracture
Swan-neck and boutonniere deformities
Ulnar deviation or drift
Degenerative joint disease or osteoarthritis
Acute rheumatoid arthritis
Syndactyly
Polydactyly

32. Abnormal Findings Abnormalities of the Knee
Abnormalities of the Ankle and Foot
Mild synovitis
Prepatellar bursitis
Swelling of menisci
Osgood-Schlatter disease
Chondromalacia patellae
Achilles tenosynovitis
Chronic/acute gout
Hallux vagus with bunion and hammer toes
Callus
Plantar wart
Ingrown toenail

33. Abnormal Findings (cont.)
Abnormalities of the Spine
Common Congenital or
Pediatric Abnormalities
Scoliosis
Herniated nucleus pulposus
Congenital dislocated hip
Talipes equinovarus (clubfoot)
Spina bifida
Coxa plana (Legg-Calvé-Perthes syndrome)
Edition change: note that routine screening for scoliosis is no longer recommended.

34. Ankylosis is… one or more bones in a joint being out of position
partial dislocation of a joint
shortening of a muscle leading to limited range of motion of joint
stiffness or fixation of a joint
Correct Answer: D. A is dislocation. B is subluxation. C is contracture.

35. Why would the examiner ask a high school athlete “what do you do when you get hurt?”
Because so many young athletes are injured that it is important to plan ahead.
Because many athletes are reticent to report injuries because they think it will limit their playing time.
Because it is important for young athletes to understand the risks involved in playing sports.
Because it is important for the athlete to report an injury to a clinician, rather than a coach, who may not take the injury seriously.
Correct Answer: B. It is important for athletes to understand that their health is more important than playing time and that their long-term ability is dependent upon prompt, thorough treatment of any injuries that do occur. A is incorrect because the planning should be focused on reducing the number of injuries. C is true but not the reason for this question. D implies a lack of professionalism on the part of the coaches, which is neither fair nor accurate.