MUSCULOSKELETAL ASSESSMENT

NURS 347Towson University

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

1. Joints: Pain, stiffness, swelling, warmth, or limited range of movement?

2. Muscles: Cramps, pain, or weakness?3. Bones: Pain, deformity, trauma (fractures,

sprains, dislocations?)4. Activities of Daily Living: Any difficulty bathing,

toileting, dressing, eating, communicating, or mobility?

5. Occupational Hazards: Heavy lifting, repetitive movement?

6. 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

1. Inspect paired joints for: Symmetry Size Contour Color Swelling Deformities or Masses

JOINTS: PALPATION

1. 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

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

Infants 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 Scoliosis: Spinal asymmetry

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