WHA: Musculoskeletal System

bones

• Hard

• Rigid structure

• protection

• act as levers

• produce blood cells

• store calcium

muscles

• 40-50% of the body’s weight

• allow for movement and position

• produce heat

• 3 types

  • Skeletal

  • Smooth

  • Cardiac

bones

• Hard

• Rigid structure

• protection

• act as levers

• produce blood cells

• store calcium

muscles

• 40-50% of the body’s weight

• allow for movement and position

• produce heat

• 3 types

  • Skeletal

  • Smooth

  • Cardiac

joints

• points of bone articulation

• ROM

tendons

connect muscle to bone (Strain)

ligaments

connect bone to bone (Sprain)

cartilage

• supports and shapes

• shock absorber

bursae

• sacs filled with synovial fluid

  • cushion and reduce friction

temporomandibular joint (TMJ)

• Articulation of mandible and temporal bone

• Can feel it in depression anterior to tragus of ear

• This permits jaw function of speaking and chewing.

• Allows three motions:

  • Hinge action to open and close jaws

  • Gliding action for protrusion and retraction

  • Gliding for side-to-side movement of lower jaw

double-S; concave; convex; abduction

Spine

• Lateral view shows vertebral column having four curves, a ________ shape.

  • Cervical and lumbar curves are _____ (inward or anterior).

  • Thoracic and sacrococcygeal curves are ______.

• Motions of vertebral column:

  • Flexion, extension, _____, and rotation

shoulder girdle

Humerus, scapula, clavicle, joints and muscle

glenohumeral joint

• articulation of humerus with glenoid fossa of scapula

  • Ball-and-socket action allows mobility of arm on many axes

rotator cuff

Group of four (SITS) muscles and tendons support and stabilize shoulder.

subacromial bursa

Assists with abduction of the arm

shoulder girdle; top

Palpable landmarks to guide your examination:

• Scapula and clavicle form __________

• Can feel the bump of the scapula’s acromion process at very __ of shoulder

hip

• articulation between acetabulum and head of femur

  • ball-and-socket action permits wide range of motion on many axes

• more stability for weight-bearing function

• Muscles enhance stability and bursae facilitate movement.

• Palpation of bony landmarks will guide examination.

  • Iliac crest—anterior superior spine to posterior

  • Ischial tuberosity

  • Greater trochanter of the femur

knee

• articulation of three bones—femur, tibia, and patella—in common articular cavity

  • Largest joint in body; hinge joint, permitting flexion and extension of lower leg on single plane

• Synovial membrane is largest in body.

• Two wedge-shaped cartilages, called medial and lateral menisci, cushion tibia and femur.

infants and children musculoskeletal

• By 3 months, fetus has formed “scale model” of the skeleton of cartilage.

  • Ossification to true bone continues in utero.

• Bone growth continues rapidly during infancy and steadily in childhood, until adolescent growth spurt.

  • Bone growth occurs in two dimensions.

• Epiphyses: specialized growth plates at end of long bones

  • Longitudinal growth continues until closure of epiphyses; last closure occurs about age 20.

• Although skeleton contributes to linear growth, muscles and fat are significant for weight increase.

  • Muscles vary in size and strength in different people due to genetics, nutrition, and exercise.

epiphyses

• specialized growth plates at end of long bones

  • Longitudinal growth continues until closure of these; last closure occurs about age 20.

pregnant woman musculoskeletal

• Increased levels of circulating hormones cause increased mobility in joints.

  • Estrogen, Relaxin, and Corticosteroids

• Increased mobility in sacroiliac, sacrococcygeal, and symphysis pubis joints in pelvis contributes to noticeable changes in maternal posture.

  • Most characteristic change is progressive lordosis leading to increased back strain.

  • Compensatory postural change anterior flexion of neck and slumping of shoulder girdle

  • Pressure on ulnar and median nerves seen in last trimester

aging adult musculoskeletal

• Bone remodeling is cyclic process of resorption and deposition.

  • After age 40, resorption occurs more rapidly than deposition.

  • Risk for osteoporosis

• Postural changes and decreased height are most noticeable.

  • Kyphosis with slight flexion of hips and knees to compensate

• Distribution of subcutaneous fat changes leading to different contour

  • Loss of subcutaneous fat leaves bony prominences more marked.

• Absolute loss in muscle mass

  • Decrease in size and atrophy producing weakness

• Impact of sedentary lifestyle

bone mineral density

• Higher BMD = denser bone

• Low BMD consistent predictor of hip and vertebral fractures

subjective musculoskeletal data

• Joints: pain, stiffness, swelling, heat, redness, limitation of movement

• Injuries (past and present)

• Muscles: pain (cramps) or weakness

• Bones: pain, deformity, trauma (fractures, sprains, or dislocation)

• Functional assessment (ADLs)

• Patient-centered care

health history musculoskeletal questions

• Ask about

  • Do you have any pain in or problems with your joints bones

  • muscles?

  • history of accidents or trauma

  • Location: Unilateral or bilateral

  • Characteristics: Quality: and severity

  • Onset, duration and frequency

  • Location of pain or cramping.

  • Aggravating or precipitating factors

  • Associated clinical presentations

  • Limitation of motion, stiffness, swelling or erythema

    • Impact on ADLs

  • pain while walking versus pain relief at rest.

    • Associated clinical presentations.

  • characteristics: weakness and size?

functional assessment of ADLs

• Ask about

  • Do joint (muscle, bone) problems create any limits on your usual ADLs? Which ones?

  • Screens safety of independent living , need for home services and quality of life

  • Ask specific questions about all these topic areas:

    • Bathing

    • Toileting

    • Dressing

    • Grooming

    • Eating

    • Mobility

    • Communicating

patient-centered care

Ask about

• occupational hazards.

• exercise program pattern.

• dietary review: recent weight gain or weight loss.

• medications: Rx and OTC r/t muscle/bone health.

• supplemental vitamins and minerals: vitamin D and calcium.

• smoking history.

• impact on ADLs: acute versus chronic disability.

pain, paralysis, paresthesia, pallor, pulselessness

What are the five P’s for musculoskeletal symptoms or injuries?

inspection, then palpation, then range of motion

What is the order of examination for musculoskeletal assessment?

inspection

Note size and contour of joint; inspect skin and tissues over joints for color, swelling, and any masses or deformity.

palpation

• Palpate each joint, including skin for temperature, muscles, bony articulations, and area of joint capsule; notice any heat, tenderness, swelling, or masses which signal inflammation.

• Joints normally not tender to palpation.

• If tenderness occurs, localize to specific anatomic structures

range of motion (ROM)

• Ask for active voluntary ROM while stabilizing the body area proximal to that being moved.

• Limitation, gently use passive ROM.

muscle testing

• Test strength of prime mover muscle groups for each joint; repeat motions for active ROM.

• Ask person to flex and hold as you apply opposing force.

• Muscle strength should be equal bilaterally and should fully resist opposing force.

• Use standardized grading scale to report results (0 to 5 range).

muscle strength grading care

• 0: Unable to contract muscle in a gravity eliminated position

• 1: Able to contract muscle slightly

• 2: Able to move joint in a gravity eliminated position

• 3: Able to move joint against gravity

• 4: Able to move joint with some resistance through range of motion.

• 5: Able to move joint with full resistance through range of motion

gait inspection

• Purpose: To assess the ability of the patient to ambulate

• Have the patient walk away from you first and then back toward you.

  • Inspect any differences in leg swing and arm swing.

  • Assess the patient’s ability or inability to control any joints.

  • Assess if the patient uses any assistive devices.

posture inspection

• Purpose: To assess alignment of muscle and joints

  • If the patient is unable to perform activities in a standing position safely, have the patient sit.

  • Ask the patient about the presence of pain.

  • Inspect the patient’s posture while the patient is walking.

  • Assess position of shoulders and head.

  • Assess patient’s ability to stand and sit.

  • Ask the patient to bend forward at the waist; inspect the spinal curvature.

  • Ask patient to bend at the waist to the right and left, forwards and backwards.

TMJ inspection or palpation

• Audible and palpable snap or click occurs in many healthy people as mouth opens.

• Palpate contracted temporalis and masseter muscles as person clenches teeth.

• Compare right and left sides for size, firmness, and strength.

• Ask person to move jaw forward and laterally against your resistance, and to open mouth against your resistance.

  • This tests integrity of cranial nerve V (trigeminal nerve).

• Observe for swelling, limitation of motion and/or reported pain.

vertebral column inspection and palpation

Purpose: To assess for abnormalities in the structure of the vertebral column

• Have patient stand.

• Inspect alignment of vertebral column.

• Using two or three finger pads, starting at the top of the vertebral column, palpate the vertebral column for tenderness, deviations, or protrusions.

upper extremities inspection and palpation

Purpose: To assess for any abnormalities within the upper extremity

• Ask patient to perform specific motions independently first and then against resistance.

• Ask patient to perform the following ROM activities of the right and left upper extremity.

• Inspect each extremity and compare the right side with the left side.

• Assess any differences in symmetry of motion and the fluid nature of the motion.

• Assess strength: Graded 0–5

• Assess

  • Shoulder

  • Elbow

  • Wrist

  • Hand/fingers and joints

  • Tenderness

  • Depressions

  • Bulges

  • Changes in temperature

shoulder motion

• Flexion

  • Flexion against resistance

• Extension

  • Extension against resistance

• Abduction

  • Abduction against resistance

• Adduction

  • Adduction against resistance

• Internal rotation

  • Internal rotation against resistance

• External rotation

  • External rotation against resistance

elbow and knee motion

• Flexion

  • Flexion against resistance

• Extension

  • Extension against resistance

wrist motion

• Flexion

  • Flexion against resistance

• Extension

  • Extension against resistance

• Radial deviation

  • Radial deviation against resistance

• Ulnar deviation

  • Ulnar deviation against resistance

finger assessment

• Flexion

  • Flexion against resistance

• Extension

  • Extension against resistance

tinel’s test and phalen’s test

What are some tests that assess for carpal tunnel syndrome?

lower extremity inspection and palpation

Purpose: To assess for any abnormalities within the lower extremity

• Ask patient to perform specific motions independently first and then against resistance.

• Ask patient to perform the following ROM activities of the right and left lower extremity.

• Inspect each extremity and compare the right side with the left side.

• Assess any differences in symmetry of motion and the fluid nature of the motion.

• Assess strength: Graded 0–5

• Assess

  • Hip

  • Knee

  • Ankle

  • Foot

  • Toes

  • Tenderness

  • Depressions

  • Bulges

  • Changes in temperature

hip motion

• Flexion

  • Flexion against resistance

• Extension

  • Extension against resistance

• Abduction

  • Abduction against resistance

• Adduction

  • Adduction against resistance

ankle motion

• Dorsiflexion

  • Dorsiflexion against resistance

• Plantar flexion

  • Plantar flexion against resistance

foot motion

• Inversion

  • Inversion against resistance

• Eversion

  • Eversion against resistance

infant assessment

Examine infant fully undressed and lying on back; maintain temperature.

• Feet and legs

  • Note any positional deformities, a residual of fetal positioning.

  • Note relationship of forefoot to hindfoot.

  • Check for tibial torsion, a twisting of the tibia.

• Hips

  • Check hips for congenital dislocation; most reliable is Ortolani’s maneuver, which should be done at every visit until infant is 1 year old.

  • Allis test is also used to check for hip dislocation.

• Hands and arms

  • Inspect hands, noting shape, number, and position of fingers and palmar creases.

  • Palpate length of clavicles; the bone most frequently is fractured during birth.

• Back

  • Lift infant and examine back; note normal single C-curve of newborn’s spine.

  • Inspect length of spine for any tuft of hair, dimple in midline, cyst, or mass; normally none is present.

• Observe ROM through spontaneous movement.

  • Test muscle strength by lifting up the infant with your hands under the axillae; baby with normal muscle strength wedges securely between your hands.

preschool and school-age children assessment

• Back: note posture; you should note a “plumb line” from back of head, along spine, to middle of sacrum

• Shoulders: level within 1 cm; scapulae symmetric; lordosis common throughout childhood

• Observe legs and feet for various deformities, such as bowleg, knock knees, flatfoot, pigeon toes.

  • Check Trendelenburg sign progressively for subluxation of hip

• Particularly, check arm for full ROM and presence of pain.

  • Look for subluxation of elbow (head of radius).

• Palpate bones, joints, and muscles of extremities as in adult examination.

adolescent assessment

• Proceed with same musculoskeletal examination as for adult; pay special note to spinal posture.

  • Kyphosis is common during adolescence because of chronic poor posture.

  • Screen for scoliosis with forward bend test.

    • From behind standing child, ask child to stand with feet shoulder width apart and bend forward slowly to touch the toes.

  • Expect straight vertical spine while standing and also while bending forward; posterior ribs should be symmetric, with equal elevation of shoulders, scapulae, and iliac crests.

pregnancy assessment

• Proceed through same examination as for adult.

• Expected postural changes in pregnancy include:

  • Progressive lordosis

  • Toward third trimester, anterior cervical flexion

  • Kyphosis and slumped shoulders

  • When pregnancy at term, protuberant abdomen and relaxed mobility in joints create characteristic “waddling” gait.

aging adult assessment

• Postural changes include decrease in height, more apparent in eighth and ninth decades.

• Kyphosis common, with backward head tilt to compensate

• Contour changes include a decrease of fat in body periphery; fat deposition over abdomen and hips.

• Bony prominences become more marked.

• ROM testing

• Get Up and Go test

• Perform functional assessment for ADLs.

healthy people 2030

• Arthritis Goal: Reduce pain and disability from arthritis (ODPHP, 2020)

• Osteoporosis Goal: Prevent fractures and disabilities related to osteoporosis (ODPHP, 2020)

• Workplace Goal: Promote the health and safety of people at work (ODPHP, 2020)

• Chronic Pain Goal: Reduce chronic pain and misuse of prescription pain relievers (ODPHP, 2020)

health promotion and patient teaching

• Focus on the following areas:

  • Diet to protect and maintain healthy bones

  • Smoking cessation

  • Alcohol intake pattern

  • Exercise promotion

  • Osteoporosis Screening

  • Fall prevention risk

inflammatory joint conditions

• Rheumatoid arthritis

• Ankylosing spondylitis

degenerative conditions

• Osteoarthritis (********* joint disease)

• Osteoporosis

shoulder abnormalities

• Atrophy

• Dislocated shoulder

• Joint effusion

• Tear of rotator cuff

• Frozen shoulder—adhesive capsulitis

elbow abnormalities

• Olecranon bursitis

• Arthritis

• Rheumatoid nodules

• Epicondylitis—tennis elbow

spine abnormalities

• Scoliosis

• Herniated intervertebral disc

wrist and hand abnormalities

• Ganglion cyst

• Colles’ fracture

• Carpal tunnel syndrome with atrophy of thenar eminence

• Ankylosis

• Dupuytren’s contracture

• Conditions caused by chronic rheumatoid arthritis:

  • Swan-neck and boutonniere deformities

  • Ulnar deviation or drift

  • Degenerative joint disease or osteoarthritis

  • Acute rheumatoid arthritis

  • Syndactyly

  • Polydactyly

knee abnormalities

• Osgood-Schlatter disease

• Post-polio muscle atrophy

• Mild synovitis

• Prepatellar bursitis

• Swelling of menisci

ankle and foot abnormalities

• Achilles tenosynovitis

• Tophi with chronic gout/acute gout

• Hallux vagus with bunion and hammer toes

• Plantar fasciitis

• Ingrown toenail

• Plantar war

congenital or pediatric abnormalities

• Developmental dysplasia of the hip

• Talipes equinovarus (clubfoot)

• Spina bifida

• Coxa plana (Legg- Calvé-Perthes syndrome)