1. The Musculoskeletal System

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

4. 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

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

6. 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

7. Joint Movements Flexion Extension Rotation Circumduction Elevation
Protrusion
Retraction
Abduction

8. Joint Movements Adduction Pronation Supination Inversion Eversion
Gliding

9. Table Joint Movement 9

10. Table 23.2 Joint Movement (continued )10

11. Table 23.2 Joint Movement (continued )11

12. Table 23.2 Joint Movement (continued )12

15. 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.

16. 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.

17. 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

18. 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

19. 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

20. 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

21. Wrist and Hand: Review the Anatomy

22. 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

23. 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)

24. Palpating the wrist. 24

25. Palpating the hand. 25

26. Extension and flexion of the wrist.26

27. Ulnar and radial deviation of the wrist.27

28. Testing the muscle strength of the wrist.28

29. 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

30. Carpal Tunnel Syndrome

31. 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

32. 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

33. Palpating the fingers. 33

34. Flexion and extension/hyperextension of the fingers.34

35. 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

36. Flexion and extension of the elbow.36

37. Goniometer measure of joint range of motion.37

38. Supination and pronation of the elbow.38

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

40. Important Bones of the Shoulder
Review bony anatomy

41. 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)

42. Flexion and extension of the shoulders.42

43. Internal rotation of the shoulders.43

44. External rotation of the shoulders.44

45. Abduction and adduction of the shoulder.45

46. 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:

47. Spine: Muscle Groups

48. Lateral view of spine. 48

49. 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

50. 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

51. 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

52. Lateral flexion of the spine.52

53. Forward flexion of the spine.53

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

55. Hip: Review Bony Anatomy

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

57. 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

58. Flexion of the hip.

59. Hyperextension of the hip.59

60. Internal and external hip rotation.60

61. Abduction and adduction of the hip.61

62. 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.

63. Knee: Review the Anatomy

64. 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

65. 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

66. 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.

67. Palpating the knee. 67

68. 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

69. Flexion of the knee. 69

70. Ankle and Foot: Review the Anatomy

71. 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

72. 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

73. Palpating the ankle. 73

74. Eversion and inversion of the ankles.74

75. 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

76. 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

77. 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

78. Common Abnormalities
Kyphosis
Round back forward bending of spine

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

80. Common Abnormalities
Scoliosis
Lateral curvature of the spine

81. 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.