1. Musculoskeletal Assessment
NURS 347 Towson University
Musculoskeletal Assessment

2. Anatomy and Physiology
Musculoskeletal Assessment Fundamentals:
Anatomy and Physiology

3. 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

4. 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

5. Range of Motion

6. 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

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

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

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

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

11. Range of Motion, Continued
Internal Rotation:
External Rotation

12. 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

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

14. Subjective Assessment

15. 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?

16. Objective Assessment

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

18. Palpation Joints Muscles Bones Range of Motion Tenderness Crepitus
Muscle Strength

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

20. 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

21. Musculoskeletal Assessment
Head to Toe
Musculoskeletal Assessment

22. 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

23. 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

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

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

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

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

28. 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

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

30. 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

31. 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

32. 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

33. 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

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

35. 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

36. 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)

37. 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

38. 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

39. Spinal Assessment

40. 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

41. 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

42. 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

43. Grading Muscle Strength