Musculoskeletal structure, function and assessment

inversion/eversion

i: sole of foot inward

e: sole of foot outward

protraction/retraction

p: moving body part forward

r: moving body part backward

aging adult musculoskeletal changes

-kyphosis

-risk of osteoporosis accelerated for white females over 60

-loss of bone density after age 40 and significant loss at 60

-flexion of hips and Knees

-contour changes

-get up and go test

-marked bony prominences

-lengtheing of arm-trunk axis

subjective data

1. joints-> pain, swelling, stiffness, redness, heat?

2. muscles-> pain, weakness, claudication?

3. bone-> pain, numbess/tingling, deformities, fractures, prior injuries?

4. fcn assessment

5. pt centered care-> lifting, repetitive movements, meds, alc/smoking, hazards, typing=carpal tunnel

osteoarthritis vs rheumatoid arthritis

osteo-> worse at end of day

rheumatoid->symmetricc joints, pain worse in am, causes deformities

redness, swelling, and warmth indicate...

inflammation

popping sound heard during injury of the knee can indicate...

ligament tear or fracture

-needs XRAY

myalgia

cramping or aching muscle pain

atrophy

muscle wasting

-due to injury, surgery, disuse

-seen after casts

fractures are ...

worse with movement

musculoskeletal screening vs complete assessment

complete: patient w articular disease, history of musculoskeletal issues, or problems with ADLs.

screening: inspect and palpate joints, observe ROM and do age appropriate observations

order of assessment

1. inspection-> color, contour, size, swelling, deformities, masses

2. palpation->temp, muscles, bones, should not be tender

3. ROM-> active, passive, crepitation

4. muscle testing-> against resistance, compare bilaterally

swelling can signal...

1. joint effusion

2. thickening of synovial lining

3.inflammation

4. bony enlargement

subluxation

two bones in a joint stay in contact but alignment is off

ankylosis

stiffness or fixation of a joint

-extreme flextion of hands and fingers

-seen w RA

When the synovial membrane is thickened what does it feel like?

doughy or boggy

crepitation

an audible or palpable crunching or grating that occurs with movement

grading scale for muscle testing

0= no contraction

1= slight contraction

2= full ROM with gravity eliminated (passive ROM)

3= full ROM with gravity

4= full ROM against gravity, some resistance

5= full ROM against gravity, full resistance

Assessing TMJ

-snap or click can occur in healthy people

-palpate as person clenches teeth, look for symmetry

-have pt move jaw forward and laterally against resistance

--tests cranial nerve V (trigeminal)

-pain and crepitus=TMJ dysfunction

- bulging=swelling

cervical spine assessment

-inspect head is erected +spine straight

-spinous processes, trapezius etc should feel firm; no tenderness/spasms

-extension, flexion, rotation, lateral bending

--against resistance +shoulder shrug to test cranial nerve XI

shoulder assessment

-inspect front and back for symmetry, swelling, atrophy (occurs w disuse)

-shoulder pain that is local can be reproducible w palpation/motion

-forward flexion, hyperextension, internal/external rotation, abduction/adduction

-shoulder shrug-> cranial nerve XI

-shrug the shoulders, flex forward and up, and abduct against your resistance

elbow assessment

-inspect size, contour, deformity, masses, swelling in extended and flexed positions

-inspect olecranon bursa and hollows for ab swelling (could be fluid or gout)

-palpate flexed elbow while stabilizing

--shouldn't feel boggy or have SQ nodules (firm/raised)

-bend/straighten and pronate/supinate

-have pt try to extend against resistance

wrist and hand assessment

-inspect both sides noting position, contour, shape, nodules, deformities etc.

-palpate each joint

-wrist and fingers flex/extend, 5 and 4 fingers, make a fist

ulnar deviation

wrist shifts outward to ulna and is a sign of rheumatoid arthritis

phalan test

hold back of hands to each other flexing wrists 90 degree angle

-if feel numbness/burning= carpal tunnel

-no symps=normal

tineal sign

direct percussion of the median nerve

-positive for carpal tunnel= tingling/burning

-no symps=normal

hip assessment

-while patient stands along with spine

-equal gluteal folds, buttocks, and iliac crests

-palpate hip joints with patient supine

-flexion with legs straight and bent, abduction/aduction, internal/external rotation

a smooth equal gait means...

equal leg lengths

knee assessment

-inspect

-palpate 10 cm above knee joint for bulge sign and ballotement

-flexion/extension, gait, duck walk

angulation deformities

genu varum = bowlegs

genu valgum= knock knees

bulge sign

Occurs with very small amounts of effusion

Assessed by firmly stroking up the medial aspect of the knee 2-3 times to displace any fluid, tapping the lateral aspect, and watching the medial side in the hollow for a distinct bulge from a fluid wave

Ballotement of Patella

For major effusions

-use left hand to compress the suprapatellar pouch to move any fluid intothe knee joint, with right hand push patella sharply against femur

-no fluid=patella is snug against femur

-fluid=hear tap

pronouced crepitus of the knee...

degenerative disease of the knee

McMurray Test

Perform when reported history of trauma followed by locking, giving way, or local pain in the knee.

-flex and rotate leg

-if pain or click= torn meniscus

ankle and foot assessment

Inspect with person sitting, standing, weight bearing and walking

-palpate joints

-plantar flexion, dorsiflexion, inversion, eversion

- against resistance

spine assessment

-inspect-> straight, shoulder height

-palpate spinous processes should be straight and nontender

-touch toes, lean left and right, rotation

lateral tilting and forward bending occur with

herniated nucleus pulposus

A difference in shoulder elevation and height of illac crests/scapulae indicates...

scoliosis

Chronic axial skeletal pain occurs with

fibromyalgia syndrome

-not caused by injury

Lasegue test (straight leg raising)

raise straight leg while keeping the knee extended

-if produces pain= herniated nucleus pulpous

length discrepancy

Measures the legs to determine if one leg might be shorter than the other

-indicate back issues or fractures of the hip

rheumatoid arthritis

a chronic autoimmune inflammation of the tissues and joints

-symmetric, bilateral joint swelling, redness, and warmth

-swan neck and boutineare deformities, ulnar deviation and ankylosis

-may also have fatigue, weakness, anorexia, painful ROM weight loss, low gradenfever, and lymphadenopathy

-raised firm, nontender nodules over pressure points

ankylosing spondylitis

-chronic inflamed vertebrae that in extreme form leads to bony fusion of vertebral joints

-affects spine, pelvis and thoracic cage

-morning back stiffness that lasts greater or equal to 30 minutes

-decreases with activity

-curvatures of spine

osteoarthritis

non-inflammatory, localized progressive deterioration of articular cartilage (cushion between bones)

-increased risk with age, females, and obesity

-asymmetric joint involvement

-stiffness, swelling, pain and limited ROM

-Heberden and Bouchard nodes

-worse as day progresses

Osteoporosis

decrease in skeletal bone mass leading to impaired bone density

- risk for fractures

-post menopausal women at risk for

dislocation

occurs with trauma involving abduction, extension, and rotation (e.g., falling onan outstretched arm or diving into pool)

-need Xray

tear of rotator cuff

-hunched position

-limited abduction

-occurs from fall on shoulder, throwing or weight lifting

-can't shrug

Olecranon Bursitis

large, soft, "goose egg" knob on elbow

-redness and swelling

-occurs with trauma to elbow, RA or gout

epicondylitis

pain and inflammation from overuse

-occurs from excessive pronation/supination

ganglion cyst

round, nontender, fluid filled nodule on the wrist

-more common in females

carpal tunnel

-pain worse at end of day

-caused by repetitive movements or overuse of

-positive tinel and phelan test

-thenar muscle atrophy

Dupuytren Contracture

chronic hyperplasia of the palmar fascia causing flexion contractures;

-occurs with diabetes, epilepsy, and alcoholic liver disease

-painless but impairs hand function

swan neck and boutonniere deformity

caused by chronic RA, swan neck- flexion contracture of metacarp. boutonniere- knuckle looks as if pushed

heberden and bouchard nodes

hard non-tender non-inflammatory nodules

-on DIP as Heberden nodes

- on PIP are Bouchard nodes

-occurs with OA

mild synovitis (knee)

Loss of normal hollows on either side of the patella, which are replaced by mild distention

-Occurs with synovial thickening or effusion (excess fluid) as in RA

achilles tenosynovitis

inflammation, swelling and tenderness near the ankle

-pain increases w movement

gout

painful, inflammatory arthritis bc of excess uric acid

-tophi

-redness, swelling warmth

hallux vagus

lateral or outward deviation of the great toe

plantar fasciitis

repeated microtrauma to connective tissue causing inflammation and heel pain

risk factors: runners, prolonged standing, high arched feet and obesity

-worse in morning

-rest and ice

herniated disc

-occurs from lifting, twisting, fall onto buttocks

-may have low back pain,decreased mobility, numbness and tingling

-lasegue test