Untitled Flashcards Set

Ankle and Foot

The Aging Adult

Peak bone mass or bone mineral density (BMD) is reached in the mid-20s, with males reaching their peak bone mass later than females.3,32 After peak bone mass is reached, bone remodeling occurs, which is the cyclic process of bone resorption and deposition responsible for skeletal maintenance at sites that need repair or replacement. The standard pattern is for bone resorption to equal bone replacement. When bone resorption (loss of bone matrix) occurs more rapidly, the net effect is a gradual loss of bone density or osteoporosis. Osteoporosis is a disease involving the loss of mineralized bone mass, which leads to porous bone and thus the risk of fractures. Although aging women have a greater amount of bone loss compared with aging men, decreased levels of estrogen in both sexes are partly responsible because osteoblasts that form new bone have estrogen receptors. To reduce the risk of osteoporosis, all adults should engage in regular physical activity, including strength training, balance training, and fast walking. In addition, maintaining a healthy body weight and getting the recommended amount of calcium and vitamin D are important.2,32 (See Health Teaching on p. 612 for more lifestyle changes to delay osteoporosis.)

Postural changes are evident with aging. Long bones do not shorten with age. Decreased height of 3 to 5 cm occurs with shortening of the vertebral column, caused by loss of water content and thinning of the intervertebral discs and by a decrease in the height of individual vertebrae from osteoporosis. A progressive decrease in height is not significant until 60 years. A greater decrease occurs in the 70s and 80s as a result of osteoporotic collapse of the vertebrae. Other postural changes are an increase in the thoracic curve (kyphosis), a backward head tilt to compensate for the kyphosis, and a slight flexion of hips and knees.

The distribution of subcutaneous fat changes through life. Usually men and women gain weight in their 40s and 50s. They begin to lose fat in the face and deposit it in the abdomen and hips. In the 80s and 90s, fat further decreases in the periphery, especially noticeable in the forearms, and increases over the abdomen and hips.

Loss of subcutaneous fat leaves bony prominences more marked (e.g., tips of vertebrae, ribs, iliac crests) and body hollows deeper (e.g., cheeks, axillae). An absolute loss in muscle mass occurs; some muscles decrease in size, and some atrophy, producing weakness.

Lifestyle affects musculoskeletal changes; a sedentary lifestyle hastens musculoskeletal changes of aging. However, physical exercise increases skeletal mass and helps prevent or delay osteoporosis. Physical activity delays or prevents bone loss in postmenopausal women and men32 (see Health Teaching on p. 612).

Subjective Data

1. Joints

Pain

Stiffness

Swelling, heat, redness

Limitation of movement

2. Knee joint (if injured)

3. Muscles

Pain (cramps)

Weakness

4. Bones

Pain

Deformity

Trauma (fractures, sprains, dislocations)

5. Functional assessment (ADLs)

6. Patient-centered care

Examiner Asks Rationale

1. Joints

• Any problems with your joints? Any pain?

Joint pain and loss of function are the most common musculoskeletal concerns that prompt a person to seek care.

• Location: Which joints? On one side or both sides?

Rheumatoid arthritis (RA) involves symmetric joints; other musculoskeletal illnesses involve isolated or unilateral joints.

• Quality: What does the pain feel like: aching, stiff, sharp or dull, shooting? Severity: How strong is it?

• Onset: When did it start?

Provides insight into potential cause. Tenderness with acute inflammation.

• Timing: What time of day does the pain occur? How long does it last? How often does it occur?

RA pain is worse in the morning when arising; osteoarthritis is worse later in the day; tendinitis is worse in the morning, improves during the day.

• Is the pain aggravated by movement, rest, position, weather? Is it relieved by rest, medications, application of heat or ice?

Movement increases most joint pain except in RA, in which movement decreases pain.

• Is the pain associated with chills, fever, recent sore throat, trauma, repetitive activity?

Joint pain 10 to 14 days after an untreated strep throat suggests rheumatic fever. Joint injury may be the result of trauma or repetitive motion.

• Any stiffness in your joints?

RA stiffness occurs in the morning and after rest periods.

• Any swelling, heat, redness in the joints?

Suggests acute inflammation.

• Any tick bite?

Assess risk of Lyme disease.

• Any limitation of movement in any joint? Which joint?

• Which activities give you problems? (See Functional Assessment on p. 583 and on p. 611.)

Decreased ROM may be caused by joint injury to cartilage or capsule or due to muscle contracture.

2. Knee joint (if injury reported)

• How did you injure your knee? Hit inside of knee? Outside? Twisting or pivoting? Overuse such as jumping or kneeling?

Inside knee injury can strain or rupture medial ligament; outside injury can strain or rupture lateral ligament; abrupt twisting can injure anterior cruciate ligament.19

• Hear a “pop” at injury? Can you stand on that leg? Can you flex the knee? Point to where it hurts the most.

Pop may mean tear in ligament or fracture. With direct knee trauma, obtain x-ray if the patient is unable to flex knee to 90 degrees or unable to bear weight for 4 steps, if pain is experienced at fibula head or patella, or if patient is over age 55 years (Ottawa knee rules).19

3. Muscles

• Any problems in the muscles such as any pain or cramping? Which muscles?

Myalgia is usually felt as cramping or aching.

• If in calf muscles: Is the pain with walking? Does it go away with rest?

Suggests intermittent claudication (see Chapter 21).

• Are your muscle aches associated with fever, chills, the “flu”?

Viral illness often includes myalgia.

• Any weakness in muscles?

• Location: Where is the weakness? How long have you noticed it?

Weakness may involve musculoskeletal or neurologic systems (see Chapter 24).

• Do the muscles look smaller there?

Atrophy.

4. Bones

• Any bone pain? Is the pain affected by movement?

• Any deformity of any bone or joint? Is the deformity caused by injury or trauma? Does it affect ROM?

• Any accidents or trauma ever affect the bones or joints: fractures; joint strain, sprain, dislocation? Which ones?

Fracture causes sharp pain that increases with movement. Other bone pain usually feels “dull” and “deep” and is unrelated to movement.

• When did this occur? What treatment was given? Any problems or limitations now as a result?

• Any back pain? In which part of your back? Is pain felt anywhere else, such as shooting down leg?

Low back pain occurs with degenerative discs, osteoporosis, lumbar stenosis, or is nonspecific.2

• Any numbness and tingling? Any limping?

• Have you been feeling worried or anxious?

Chronic pain can increase anxiety symptoms.

5. Functional assessment (ADLs). Do your joint (muscle, bone) problems create any limits on your usual ADLs? Which ones? (Note: Ask about each category; if the person answers “yes,” ask specifically about each activity in the category.)

Functional assessment screens the safety of independent living, the need for home health services, and quality of life (see Chapter 32).

• Bathing—Getting in and out of the tub, turning faucets?

Assess any self-care deficit.

• Toileting—Urinating, moving bowels, able to get self on/off toilet, wipe self?

• Dressing—Buttoning or zipping clothes, fastening opening behind neck, pulling dress or sweater over head, pulling up pants, tying shoes, getting shoes that fit?

• Grooming—Shaving, brushing teeth, brushing or fixing hair, applying makeup?

• Eating—Preparing meals, pouring liquids, cutting up foods, bringing food to mouth, drinking?

• Mobility—Walking, walking up or down stairs, getting in/out of bed, getting out of house?

Impaired physical mobility.

• Communicating—Talking, using phone, writing?

Impaired verbal communication.

6. Patient-centered care. Any occupational hazards that could affect the muscles and joints? Does your work involve heavy lifting? Or any repetitive motion or chronic stress to joints? Any efforts to alleviate these?

Assess risk for back pain or carpal tunnel syndrome.

• Tell me about your exercise program. Describe the type of exercise, frequency, the warm-up program.

A program of regular exercises increases bone strength and reduces fracture risk.6,32

• Any pain during exercise? How do you treat it?

• Have you had any recent weight gain? Please describe your usual daily diet. (Note the person’s usual caloric intake, all four food groups, daily amount of protein, calcium.)

• Are you taking any medications for musculoskeletal system: bisphosphonates, aspirin, antiinflammatory, muscle relaxant, pain reliever? Hormone therapy?

Review daily aspirin and NSAID schedule; screen for adverse effects such as GI pain, bleeding. Bisphosphonates are first-line therapy for osteoporosis for specific guidelines; hormone therapy is not recommended due to risk factors.2,6

• How about supplemental medications, calcium, or vitamin D? How many dairy products eaten per day? How many over-the-counter (OTC) medications taken daily?

Dietary calcium is better absorbed than supplements. Serum levels of vitamin D can be checked, and supplements recommended.

• If person has a chronic disability or crippling illness: How has your illness affected:

Your interaction with family?

Your interaction with friends?

The way you view yourself?

Assess for:

• Self-esteem disturbance.

• Loss of independence.

• Body image disturbance.

• Role performance disturbance.

• Social isolation.

• How about cigarettes/e-cigarettes—How much do you smoke per day? And alcohol use—How many drinks per day? Per week?

Smoking increases bone loss and risk of fracture in older women; moderate-to-heavy alcohol drinking increases falls risk.

Additional History for Infants and Children

1. Were you told about any trauma to infant during labor and delivery? Did the baby’s head come first? Was there a need for forceps? Did the baby need resuscitation?

Traumatic delivery increases risk for fractures (e.g., humerus, clavicle).

Period of anoxia may result in hypotonia of muscles.

2. Were the baby’s motor milestones achieved at about the same time as other children of the same age?

3. Has your child ever broken any bones? Any dislocations? How were these treated?

4. Have you ever noticed any bone deformity? Spinal curvature? Unusual shape of toes or feet? At what age? Have you ever sought treatment for any of these?

5. Involved in any sports? If so, which ones? How frequently? How does the sport fit in with other school demands (if applicable)?

Assess safety of sport. Make sure appropriate pads and protective equipment are being worn (e.g., helmet, mouth guard).

Additional History for Adolescents

1. Involved in any sports at school or after school? How frequently (times per week)? How does your sport fit in with other school demands and other activities?

Assess safety of sport. Discuss injury prevention and use of protective equipment.

2. Do you use any special equipment? Does any training program exist for your sport?

Use of safety equipment and presence of adult supervision decrease risk for sports injuries.

3. What do you do if you get hurt?

Students may not report injury or pain for fear of limiting participation in sport.

Additional History for the Aging Adult

Use functional assessment history questions to elicit any loss of function, self-care deficit, or safety risk that may occur as a process of aging or musculoskeletal illness. (Review the complete functional assessment in Chapter 32.)

1. Any change in strength over the past months or years? Any noticeable weakness? Any increase in falls or stumbling over the past months or years?

Encourage exercise to the best of person’s ability and safety.A history of falls increases risk of future falling.

2. Do you use any mobility aids to help you get around: cane, walker?

3. The U.S. government recommends screening women ages 65 years or older and postmenopausal women younger than 65 years who are at increased risk for osteoporosis with a low-dose x-ray called DXA. Have you had that image? Know the results? Do you have access to that test?

There is insufficient evidence to recommend routine screening of men. Screening of men should be based on clinical evaluation of risk factors. The optimal screening interval has not been identified for any population.30

Objective Data

Preparation

The purposes of the musculoskeletal examination are to assess function for ADLs and to screen for any abnormalities. You already will have considerable data regarding ADLs through the history. Note additional ADL data as the person goes through the motions necessary for an examination: gait; posture; how the person sits in a chair, rises from chair, takes off jacket, manipulates small object such as a pen, raises from supine.

A screening musculoskeletal examination suffices for most people:

• Inspection and palpation of joints integrated with each body region

• Observation of ROM as person proceeds through motions described earlier

• Age-specific screening measures such as Ortolani sign for infants or scoliosis screening for adolescents

A complete musculoskeletal examination as described in this chapter is appropriate for people with articular disease, a history of musculoskeletal symptoms, or any problems with ADLs.

Make the person comfortable before and throughout the examination. Drape for full visualization of the body part you are examining without needlessly exposing the person. Take an orderly approach—head to toe, proximal to distal (from the midline outward).

Support each joint at rest. Muscles must be soft and relaxed to assess the joints under them accurately. Take care when examining any inflamed area where rough manipulation could cause pain and muscle spasm. To avoid this, use firm support, gentle movement, and gentle return to a relaxed state.

Compare corresponding paired joints. Expect symmetry of structure and function and normal parameters for that joint.

Equipment Needed

Tape measure

Skin marking pen

Goniometer (occasional)

Normal Range of Findings Abnormal Findings

Order of the Examination

Inspection

Note the size and contour of every joint. Inspect the skin and tissues over the joints for color, swelling, and any masses or deformity. Presence of swelling is significant and signals joint irritation. Use the contralateral side for comparison. Swelling may be excess joint fluid (effusion), thickening of the synovial lining, inflammation of surrounding soft tissue (bursae, tendons), or bony enlargement.

Deformities include fracture (a break in a bone), dislocation (complete loss of contact between the two bones in a joint), subluxation (two bones in a joint stay in contact, but their alignment is off), contracture (shortening of a muscle leading to limited ROM of joint), or ankylosis (stiffness or fixation of a joint).

Palpation

Palpate each joint, including its skin for temperature, its muscles, bony articulations, and area of joint capsule. Notice any heat, tenderness, swelling, or masses. Joints normally are not tender to palpation. If any tenderness does occur, try to localize it to specific anatomic structures (e.g., skin, muscles, bursae, ligaments, tendons, fat pads, or joint capsule). Warmth and tenderness signal inflammation.

The synovial membrane normally is not palpable. When thickened, it feels “doughy” or “boggy.” A small amount of fluid is present in the normal joint, but it is not palpable. Palpable fluid is abnormal. Because fluid is contained in an enclosed sac, if you push on one side of the sac, the fluid will shift and cause a visible bulging on another side.

Range of Motion

Ask for active (voluntary) ROM while modeling the movements yourself as appropriate; thus you can use your own movements as a control. You may stabilize the body area proximal to that being moved. Familiarize yourself with the type of each joint and its normal ROM so you can recognize limitations. If you see a limitation, gently attempt passive motion with the person’s muscles relaxed while you move the body part. Anchor the joint with one hand while your other hand slowly moves it to its limit. The normal ranges of active and passive motion should be the same. Limitation in ROM is the most sensitive sign of joint disease.19 The amount of limitation may alert you to the cause of disease. Articular disease (inside the joint capsule [e.g., arthritis]) produces swelling and tenderness around the whole joint, and it limits all planes of ROM in both active and passive motion. Extra-articular disease (injury to a specific tendon, ligament, nerve) produces swelling and tenderness to that one spot in the joint and affects only certain planes of ROM, especially during active (voluntary) motion.

Joint motion normally causes no tenderness, pain, or crepitation. Do not confuse crepitation with the normal discrete “crack” heard as a tendon or ligament slips over bone during motion, such as when you do a knee bend. Crepitation is an audible and palpable crunching or grating that accompanies movement. It occurs when the articular surfaces in the joints are roughened, as with RA (see Table 23.1, Abnormalities Affecting Multiple Joints, p. 615).

Muscle Testing

Test the strength of the prime-mover muscle groups for each joint. Repeat the motions that you elicited for active ROM. Now ask the person to flex and hold as you apply opposing force. Muscle strength should be equal bilaterally and fully resist your opposing force. (Note: Muscle status and joint status are interdependent and should be interpreted together. Chapter 24 discusses the examination of muscles for size and development, tone, and presence of tenderness.)

A wide variability of strength exists among people. Use a grading system from no voluntary movement to full strength, as shown on the next page.

Grade Description % Normal Assessment

5 Full ROM against gravity, full resistance 100 Normal

4 Full ROM against gravity, some resistance 75 Good

3 Full ROM with gravity 50 Fair

2 Full ROM with gravity eliminated (passive motion) 25 Poor

1 Slight contraction 10 Trace

0 No contraction 0 Zero

Temporomandibular Joint

With the person seated, inspect the area just anterior to the ear. Place the tips of your first two fingers in front of each ear and ask the person to open and close the mouth. Drop your fingers into the depressed area over the joint and note smooth motion of the mandible. An audible and palpable snap or click occurs in many healthy people as the mouth opens (Fig. 23.15). Then ask the person to:

23.15

Swelling looks like a round bulge over the joint, although it must be moderate or marked to be visible.

Crepitus and pain occur with TMJ dysfunction during movement or chewing. Malocclusion of teeth also causes palpable crepitus or an audible click.

Instructions to Person Motion and Expected Range

• Open mouth as wide as possible.

Vertical motion. You can measure the space between the upper and lower incisors. Normal is 3 to 6 cm or three fingers inserted sideways.

• Partially open mouth, protrude lower jaw, and move it side to side.

Lateral motion. Normal extent is 1 to 2 cm (Fig. 23.16).

• Stick out lower jaw.

Protrude without deviation.

Decreased ROM occurs with TMJ inflammation and arthritis.

Lateral motion may be lost earlier and more significantly than vertical motion.

23.16

Palpate the contracted temporalis and masseter muscles as the person clenches the teeth. Compare right and left sides for size, firmness, and strength. Ask the person to move the jaw forward and laterally against your resistance and open mouth against resistance. This also tests the integrity of cranial nerve V (trigeminal). TMJ dysfunction causes tenderness with palpation.

Cervical Spine

Inspect the alignment of head and neck. The spine should be straight, and the head erect. Palpate the spinous processes and the sternomastoid, trapezius, and paravertebral muscles. They should feel firm, with no muscle spasm or tenderness.

Head tilted to one side.Asymmetry of muscles.

Tenderness and hard muscles with muscle spasm. An estimated 15% of the population complains of neck pain, and 80% to 90% have disc degeneration in the cervical spine.28

Ask the person to follow these motions (Fig. 23.17)a:

23.17

Three photos labeled A, B, and C show extension, lateral bending, and rotational movements of the head of a man. (A) The photo shows the lateral view of a man's face. A 0-degree vertical line passes through the anterior part of the ear. A 45 degrees line on the right of the vertical line represents flexion and a 55 degrees line on the left of the vertical line represents extension. (B) The photo shows the front view of a man's head and shoulders. The man bends his head toward his left. A 0-degree vertical line passes through the anterior part of the ear. A 40 degrees line on the right of the vertical line and a 40 degrees line on the left of the vertical line represent bending movements. (C) A photo shows a hand of a person on the right cheek of a man. A curved arrow corresponding to the brow represents rotational movement on both sides to 70 degrees. A 0-degree vertical line passes through the temporal side of the right eye.

Instructions to Person Motion and Expected Range

• Touch chin to chest.

Flexion of 45 degrees (Fig. 23.17A).

• Lift the chin toward the ceiling.

Hyperextension of 55 degrees.

• Touch each ear to the corresponding shoulder. Do not lift the shoulder.

Lateral bending of 40 degrees (Fig. 23.17B).

• Turn the chin toward each shoulder.

Rotation of 70 degrees (Fig. 23.17C).

Repeat the motions while applying opposing force. The person normally can maintain flexion against your resistance. This also tests the integrity of cranial nerve XI (spinal).

Limited ROM occurs with arthritis.

Pain with movement occurs with arthritis or muscle overuse.

The person cannot hold flexion.

Upper Extremity

Shoulder

Inspect and compare both shoulders posteriorly and anteriorly. Check the size and contour of the joint and compare shoulders for equality of bony landmarks. Normally no redness, muscular atrophy, deformity, or swelling is present. Check the anterior aspect of the joint capsule and the subacromial bursa for abnormal swelling.

Redness. Inequality of bony landmarks occurs with scoliosis. Atrophy, shows as lack of fullness, can signal rotator cuff problem or disuse.

Dislocated shoulder loses normal rounded shape and looks flattened laterally.

Swelling from excess fluid is best seen anteriorly. Considerable fluid must be present to cause a visible distention because the capsule normally is so loose (see Table 23.2, Shoulder Abnormalities, p. 616).

For reports of shoulder pain, ask the person to point to the spot where it hurts with the hand from the unaffected side. Be aware that shoulder pain may be from local causes or it may be referred pain from a hiatal hernia or a cardiac or pleural condition, which could be potentially serious. Pain from a local cause is reproducible during the examination by palpation or motion. Swelling of subacromial bursa is localized under deltoid muscle and may be accentuated when the person tries to abduct the arm.

While standing in front of the person, palpate both shoulders, noting any muscular spasm or atrophy, swelling, heat, or tenderness. Start at the clavicle and methodically explore the acromioclavicular joint, scapula, greater tubercle of the humerus, area of the subacromial bursa, the biceps groove, and anterior aspect of the glenohumeral joint. Palpate the pyramid-shaped axilla; no adenopathy or masses should be present.

Swelling.

Hard muscles with muscle spasm.

Tenderness or pain.

Test ROM by asking the person to perform four motions (Fig. 23.18). Cup one hand over the shoulder during ROM to note any crepitation; normally none is present.

23.18

Four photos labeled A through D show a man performing four types of body movements. (A) The photo shows the lateral view of a man. A vertical line labeled 180 degrees on top and 0 degrees at the bottom runs through the mid part of the body. A curved arrow corresponding to the anterior part of the body represents forward flexion. The man extends his arms backward such that his shoulder makes a 50 degrees angle with the vertical. This motion is labeled hypertension. (B) The photo shows the back view of a man standing with his hands folded behind his mid-back. A vertical line labeled 0 degree corresponds runs down the left shoulder behind his back. A rightward curved arrow labeled 90 degrees corresponding to the shoulder represents internal rotation. (C) The photo shows the anterior view of a man standing with his hands joined in a prayer position above his head. A vertical line labeled 180 degrees on top and 0 degrees at the bottom runs through the shoulder. A curved arrow on the left side of the vertical line represents abduction and a curved arrow on the right side of the vertical line represents adduction at 50 degrees. (D) The photo shows a man standing with his hands bent behind the base of the head. A vertical line labeled 0 degree runs down the left shoulder behind his back. A curved arrow pointing toward the back from the vertical line is labeled, 90 degrees external rotation.

Instructions to Person Motion and Expected Range

• With arms at sides and elbows extended, move both arms forward and up in wide vertical arcs and then move them back.

Forward flexion of 180 degrees. Hyperextension up to 50 degrees (Fig. 23.18A).

• Rotate arms internally behind back; place back of hands as high as possible toward scapulae.

Internal rotation of 90 degrees (Fig. 23.18B).

• With arms at sides and elbows extended, raise both arms in wide arcs to the side. Touch palms together above head, then bring arms back down and across the body.

Abduction of 180 degrees.Adduction of 50 degrees (Fig. 23.18C).

• Touch both hands behind the head with elbows flexed and rotated posteriorly.

External rotation of 90 degrees (Fig. 23.18D).

Limited ROM.

Asymmetry.

Pain with motion.

Crepitus with motion.

Rotator cuff lesions may cause limited ROM, pain, and muscle spasm during abduction, whereas forward flexion stays fairly normal.

Test the strength of the shoulder muscles by asking the person to shrug the shoulders, flex forward and up, and abduct against your resistance. The shoulder shrug also tests the integrity of cranial nerve XI, the spinal accessory.

Elbow

Inspect the size and contour of the elbow in both flexed and extended positions. Look for any deformity, redness, or swelling. Check the olecranon bursa and the normally present hollows on either side of the olecranon process for abnormal swelling.

Subluxation of the elbow shows the forearm dislocated posteriorly.

Swelling and redness of olecranon bursa are localized and easy to observe because of the close proximity of the bursa to skin.

Effusion or synovial thickening shows first as a bulge or fullness in groove on either side of the olecranon process, and it occurs with gouty arthritis and bursitis.

Palpate with the elbow flexed about 70 degrees and as relaxed as possible (Fig. 23.19). Use your left hand to support the person’s left forearm and palpate the extensor surface of the elbow—the olecranon process and the medial and lateral epicondyles of the humerus—with your right thumb and fingers.

23.19

Epicondyles, head of radius, and tendons are common sites of inflammation and local tenderness, or “tennis elbow.”

With your thumb in the lateral groove and your index and middle fingers in the medial groove, palpate either side of the olecranon process using varying pressure. Normally present tissues and fat pads feel fairly solid. Check for any synovial thickening, swelling, nodules, or tenderness.

Soft, boggy, or fluctuant swelling in both grooves occurs with synovial thickening or effusion.

Local heat or redness (signs of inflammation) can extend beyond synovial membrane.

Palpate the area of the olecranon bursa for heat, swelling, tenderness, consistency, or nodules. Use the same procedure for the other arm. Subcutaneous nodules are raised, firm, and nontender, and overlying skin moves freely. Common sites are in the olecranon bursa and along the extensor surface of the ulna. These nodules occur with RA (see Table 23.3, Elbow Abnormalities, p. 618).

Test ROM by asking the person to:

Instructions to Person Motion and Expected Range

• Bend and straighten the elbow (Fig. 23.20).

23.20

A photo shows the side view of a man standing with his elbow flexed at 160 degrees. The movement of the forearm toward the body is labeled Flexion and the away from the body is labeled. Two lines and a curved arrow indicate the angles and movement directions.

Flexion of 150 to 160 degrees; extension at 0. Some healthy people lack 5 to 10 degrees of full extension, and others have 5 to 10 degrees of hyperextension.

• Place forearm on table and move palm up and palm down (Fig. 23.21).

23.21

A photo shows a man's forearm placed on a table. An arrow in the shape of a semi-circle runs atop the thumb touching the table on both sides. The movement toward the left side indicates, 90 degrees pronation and the movement toward the right side indicates 90 degrees supination.

Hold the hand midway; then touch front and back sides of hand to table.

After a fall or trauma, full extension of the elbow can usually rule out fracture.

While testing muscle strength, stabilize the person’s arm with one hand (Fig. 23.22). Ask the person to flex the elbow against your resistance applied just proximal to the wrist. Then ask the person to extend the elbow against your resistance.

23.22

Wrist and Hand

Inspect the hands and wrists on the dorsal and palmar sides, noting position, contour, and shape. The normal functional position of the hand shows the wrist in slight extension. This way the fingers can flex efficiently, and the thumb can oppose them for grip and manipulation. The fingers lie straight in the same axis as the forearm. Normally no swelling or redness, deformity, or nodules are present.

Subluxation (partial dislocation) of wrist.

Ulnar deviation; fingers list to ulnar side.

Ankylosis; wrist in extreme flexion.

Dupuytren contracture; flexion contracture of finger(s).

The skin looks smooth with knuckle wrinkles present and no swelling or lesions. Muscles are full, with the palm showing a rounded mound proximal to the thumb (the thenar eminence) and a smaller rounded mound proximal to the little finger.

Swan-neck or boutonnière deformity in fingers.

Atrophy of the thenar eminence with carpal tunnel syndrome (see Table 23.4, Wrist and Hand Abnormalities, p. 619).

Palpate each joint in the wrist and hands. Facing the person, support the hand with your fingers under it and palpate the wrist firmly with both of your thumbs on its dorsum (Fig. 23.23). Make sure that the person’s wrist is relaxed and in straight alignment. Move your palpating thumbs side to side to identify the normal depressed areas that overlie the joint space. Use gentle but firm pressure. Normally the joint surfaces feel smooth, with no swelling, bogginess, nodules, or tenderness.

23.23

A photo shows the hands of a health care professional palpating the joints of the wrist on the dorsal side in the hand of a person, using the thumb of both their hands as the person straightens their hand.

Ganglion cyst is a localized swelling in wrist (see Table 23.4).

Synovial swelling on dorsum.

Generalized swelling with arthritis and infection.

Tenderness after a fall—check for fracture.

Rheumatoid arthritis (RA) shows bilateral swelling and tenderness.

Palpate the metacarpophalangeal joints with your thumbs, just distal to and on either side of the knuckle (Fig. 23.24).

23.24

RA shows boggy or tender MCPs; this does not occur in osteoarthritis (OA).

Use your thumb and index finger in a pinching motion to palpate the sides of the interphalangeal joints (Fig. 23.25). Normally no synovial thickening, tenderness, warmth, or nodules are present.

23.25

A photo shows the hands of a health care professional palpating the interphalangeal joint of a person's middle finger using their left thumb and index finger while supporting the wrist with their other hand.

Heberden and Bouchard nodules are hard and nontender and occur with osteoarthritis (see Table 23.4).

Test ROM (Fig. 23.26) by asking the person to:

Instructions to Person Motion and Expected Range

• Bend hand up at wrist.

Hyperextension of 70 degrees (Fig. 23.26A).

• Bend hand down at wrist.

Palmar flexion of 90 degrees.

• Bend fingers up and down at metacarpophalangeal joints.

Flexion of 90 degrees. Hyperextension of 30 degrees (Fig. 23.26B).

• With palms flat on table, turn them outward and in.

Ulnar deviation of 50 to 60 degrees and radial deviation of 20 degrees (Fig. 23.26C).

• Spread fingers apart; make a fist.

Abduction of 20 degrees; fist tight. The responses should be equal bilaterally (Fig. 23.26D-E).

• Touch thumb to each finger and to base of little finger.

The person is able to perform, and the responses are equal bilaterally (Fig. 23.26F).

Loss of ROM here is the most common and most significant functional loss of the wrist.

Limited motion.

Pain on movement.

23.26

Six photos labeled A through F show six types of movements involving the wrist and fingers. (A) The photo shows a person's hand-stretched forward with the fingers aligned together. An upward arrow labeled, extension represents an upward movement of the wrist at 70 degrees and a downward arrow labeled flexion represents a downward movement of the wrist at 90 degrees. (B) The photo shows a person's hand bent down at the wrist, with the fingers pointing downward. An upward arrow represents hyperextension of 30 degrees and a downward arrow represents flexion of fingers at 90 degrees. (C) The photo shows a person's hand with palms facing down and fingers aligned together. A vertical line labeled 0 degrees corresponds to the middle finger. A 20 degrees line on the right side represents radial deviation and a 55 degrees line on the left side represents ulnar deviation. (D) The photo shows the hand of a person with fingers spread apart. (E) The photo shows a person making a fist. (F) The photo shows a person's hand with the thumb on the base of the little finger.

For muscle testing, position the person’s forearm supinated (palm up) and resting on a table (Fig. 23.27). Stabilize by holding your hand at the person’s midforearm. Ask the person to flex the wrist against your resistance at the palm.

23.27

A photo shows a healthcare professional pressing the palm and fingers of their left hand against the mid-forearm of a person's hand, stretched palm up on a table while holding the fingers of the hand with his right hand.

Phalen Test

Ask the person to hold both hands back to back while flexing the wrists 90 degrees. Acute flexion of the wrist for 60 seconds produces no symptoms in the normal hand (Fig. 23.28).

23.28 Phalen test.

Phalen test reproduces numbness and burning in a person with carpal tunnel syndrome (see Table 23.4).

Tinel Sign In carpal tunnel syndrome percussion of the median nerve produces burning and tingling along its distribution, which is a positive Tinel sign.

Direct percussion of the location of the median nerve at the wrist produces no symptoms in the normal hand (Fig. 23.29).

23.29 Tinel sign.

A photo shows the hands of a health care professional touching the nerve at the wrist of a person who has their hands stretched palm up. The profession uses the middle finger of their right hand while supporting the wrist with their left hand.

Lower Extremity

Hip

Wait to inspect the hip joint together with the spine a bit later in the examination as the person stands. At that time note symmetric levels of iliac crests, gluteal folds, and equally sized buttocks. A smooth, even gait reflects equal leg lengths and functional hip motion.

Help the person into a supine position and palpate the hip joints. The joints should feel stable and symmetric, with no tenderness or crepitus.

Pain with palpation.

Crepitation.

Assess ROM (Fig. 23.30) by asking the person to:

Instructions to Person Motion and Expected Range

• Raise each leg with knee extended.

Hip flexion of 90 degrees (Fig. 23.30A).

• Bend each knee up to the chest while keeping the other leg straight.

Hip flexion of 120 degrees. The opposite thigh should remain on the table (Fig. 23.30B).

• Flex knee and hip to 90 degrees. (Examiner stabilizes by holding thigh with one hand and ankle with the other hand.) Please swing foot outward. Now swing foot inward. (The foot and thigh will move in opposite directions.)

Internal rotation of 40 degrees.External rotation of 45 degrees (Fig. 23.30C).

• Swing leg away from body and now toward the body, keeping the knee straight. (Examiner stabilizes the pelvis by pushing down on the opposite anterior superior iliac spine.)

Abduction of 40 to 45 degrees.Adduction of 20 to 30 degrees (Fig. 23.30D).

• When standing (later in examination), swing straight leg back behind body. (Examiner stabilizes the pelvis to eliminate exaggerated lumbar lordosis.) The most efficient way is to ask person to bend over the table and support the trunk on the table. Or the person can lie prone on the table.

Hyperextension of 15 degrees when stabilized.

23.30

Four photos labeled A through D show four types of movements involving the knee and the hip. (A) Hip flexion with knee straight: The photo shows the legs and hip of a person lying on his back. The person has lifted his left leg at 90 degrees to the hip. The right leg is straightened. A 0-degree horizontal line runs parallel to the surface. (B) Hip flexion with the knee flexed: The left knee is bent such that it makes at 120 degrees with the hip. The right leg is straightened. (C) External and Internal rotation. The photo shows a person lying on his back. The right knee is bent toward the body such that it makes 40 degrees with the hip(internal rotation). The bending of the right knee away from the body such that it makes 45 degrees with the hip is external rotation. (D) Abduction. The photo shows a person lying on his back with his legs apart. The movement of the right leg away from the body such that it makes 45 degrees with the hip is labeled abduction. The movement of the right leg toward the body such that it makes 30 degrees with the hip is labeled adduction.

Limited motion.

Pain with motion.

Flexion flattens the lumbar spine; if this reveals a flexion deformity in the opposite hip, it is a positive Thomas test.

Limited internal rotation of hip is an early and reliable sign of hip disease.

Limitation of abduction of the hip while supine is the most common motion dysfunction found in hip disease.

Knee

The person should remain supine with legs extended, although some examiners prefer the knees to be flexed and dangling for inspection. The skin normally looks smooth, with even coloring and no lesions.

Shiny and atrophic skin.

Swelling or inflammation (see Table 23.5, Knee Abnormalities, p. 621).

Lesions (e.g., psoriasis).

Inspect lower leg alignment. The lower leg should extend in the same axis as the thigh. Angulation deformity:

• Genu varum (bowlegs) (see p. 608)

• Genu valgum (knock-knees)

• Flexion contracture

Inspect the knee’s shape and contour. Normally distinct concavities, or hollows, are present on either side of the patella, the “peripatellar grooves.” Check them for any sign of fullness or swelling. Note other locations such as the prepatellar bursa and the suprapatellar pouch for any abnormal swelling. Hollows disappear; then they may bulge with synovial thickening or effusion.

Check the quadriceps muscle in the anterior thigh for any atrophy. Because it is the prime mover of knee extension, this muscle is important for joint stability during weight bearing. Atrophy occurs with disuse or chronic disorders. It first appears in the medial part of the muscle, although it is difficult to note because the vastus medialis is relatively small.

Enhance palpation with complete relaxation of the quadriceps muscle. Start high on the anterior thigh, about 10 cm above the patella. Palpate with your left thumb and fingers in a grasping fashion (Fig. 23.31). Proceed down toward the knee, exploring the region of the suprapatellar pouch. Note the consistency of the tissues. The muscles and soft tissues should feel solid, and the joint should feel smooth, with no warmth, tenderness, thickening, or nodularity.

23.31

Feels fluctuant or boggy with synovitis of suprapatellar pouch.

When swelling occurs, you need to distinguish whether it is caused by soft tissue swelling or increased fluid in the joint. Comparison with the unaffected knee is important. The tests for the bulge sign and ballottement of the patella aid this assessment.

Bulge Sign

For swelling in the suprapatellar pouch, the bulge sign confirms the presence of small amounts of fluid as you try to move the fluid from one side of the joint to the other. Firmly stroke up on the medial aspect of the knee 2 or 3 times to displace any fluid (Fig. 23.32A). Tap the lateral aspect (Fig. 23.32B). Watch the medial side in the hollow for a distinct bulge from a fluid wave. Normally none is present.

The bulge sign occurs with very small amounts of effusion, 4 to 8 mL, from fluid flowing across the joint (Fig. 23.32C).

Presence of the bulge sign identifies patients at high risk for knee pain and progressive osteoarthritis of the knee.31

23.32 (A) Stroke medial aspect.(B) Elicit bulge sign.(C) Note bulge sign. C, Dieppe, Cooper, & McGill, 1991.

Three photos labeled A,B, and C show the hands of a healthcare professional examining the knee of a person. (A) The professional presses his hand against the medial aspect of the joint. (B) The professional checks the radial aspect of the joint. (C) The professional presses the medial aspect of the joint with his index finger and presses the back of the fingers of his other hand on the radial side of the joint.

Ballottement of the Patella

This test is reliable when larger amounts of fluid are present. Use your left hand to compress the suprapatellar pouch to move any fluid into the knee joint. With your right hand push the patella sharply against the femur. If no fluid is present, the patella is already snug against the femur (Fig. 23.33A).

23.33 Ballottement. B, Dieppe, Cooper, & McGill, 1991.

Two photos labeled A and B show a health care professional examining the knee joint of a person. (A) The photo shows the right hand of the professional pressing the patella against the femur, while the left-hand grasps the upper part of the knee. (B) The photo shows the professional’s index finger on the patella, and the fingers of the other hand grasping the region above the joint.

If fluid has collected, your tap on the patella moves it through the fluid, and you will hear a tap as the patella bumps up on the femoral condyles (Fig. 23.33B).

Continue palpation and explore the tibiofemoral joint (Fig. 23.34). Note smooth joint margins and absence of pain. Palpate the infrapatellar fat pad and the patella. Check for crepitus by holding your hand on the patella as the knee is flexed and extended. Some crepitus in an otherwise asymptomatic knee may occur.

23.34

Irregular bony margins occur with osteoarthritis.

Pain at joint line.

Pronounced crepitus is significant, and it occurs with degenerative diseases of the knee.

Check ROM (Fig. 23.35) by asking the person to:

23.35

A photo shows a person's thigh and legs as he stands on his right leg. His left leg is flexed backward such that it makes 130 degrees with the knee. This movement is labeled flexion. The movement of the left leg forward, such that it makes 15 degrees with the knee joint is labeled hyperextension. The positioning of the left leg, such that it makes 0-degree with the knee is labeled extension.

Instructions to Person Motion and Expected Range

• Bend each knee (done while person is standing).

Flexion of 130 to 150 degrees.

• Extend each knee.

A straight line of 0 degrees in some people; a hyperextension of 15 degrees in others.

• Check knee ROM during ambulation.

• (Optional) If able, squat and try a duck walk.

Duck walk shows intact ligaments and no effusion or arthritis.

Limited ROM.

Contracture.

Pain with motion.

Limp.

Sudden locking—The person is unable to extend the knee fully. This usually occurs with a painful and audible “pop” or “click.” Sudden buckling, or “giving way,” occurs with ligament injury, which causes weakness and instability.

Check muscle strength by asking the person to maintain knee flexion while you oppose by trying to pull the leg forward. Muscle extension is demonstrated by the person’s success in rising from a seated position in a low chair or by rising from a squat without using the hands for support.

Special Test for Meniscal Tears

McMurray Test.Perform this test when the person has reported a history of trauma followed by locking, giving way, or local pain in the knee. Position the person supine as you stand on the affected side. Hold the heel and flex the knee and hip. Place your other hand on the knee with fingers on the medial side. Rotate the leg in and out to loosen the joint. Externally rotate the leg, and push a valgus (inward) stress on the knee. Slowly extend the knee. Normally the leg extends smoothly with no pain (Fig. 23.36).

If you hear or feel a “click,” McMurray test is positive for a torn meniscus. This must be referred to orthopedics for imaging and possible surgical repair.

23.36 McMurray test.

A photo shows a healthcare professional examining the right knee of a person. The professional uses her right hand to hold the heel and flexes it toward the hip while using her left hand to palpate the knee joint.

Use the Ottawa knee rules for any knee pain with injury for referral for imaging: (1) isolated pain of patella or head of fibula; (2) age ≥55 years; (3) cannot flex knee to 90 degrees; (4) cannot bear weight for 4 steps.19

Ankle and Foot

Inspect while the person is in a sitting, non–weight-bearing position and when standing and walking. Compare both feet, noting position of feet and toes, contour of joints, and skin characteristics. The foot should align with the long axis of the lower leg; an imaginary line would fall from midpatella to between the first and second toes.Weight bearing should fall on the middle of the foot, from the heel, along the midfoot, to between the 2nd and 3rd toes. Most feet have a longitudinal arch, although that can vary normally from “flat feet” to a high instep.

The toes point straight forward and lie flat. The ankles (malleoli) are smooth bony prominences. Normally the skin is smooth, with even coloring and no lesions. Note the locations of any calluses or bursal reactions because they reveal areas of abnormal friction. Examining well-worn shoes helps assess areas of wear and accommodation.Support the ankle by grasping the heel with your fingers while palpating with your thumbs (Fig. 23.38). Explore the joint spaces. They should feel smooth and depressed, with no fullness, swelling, or tenderness.

23.38

In hallux valgus the distal part of the great toe is directed away from the body midline (Fig. 23.37).

23.37 Hallux valgus with bunion. Lemmi & Lemmi, 2011.

Hammertoes.

Calluses.

Ulcers.

Swelling or inflammation.

Tenderness, occurs with arthritis, trauma to ligaments.

Plantar fasciitis shows localized tenderness under heel where fascia is torn (see Table 23.6, Ankle and Foot Abnormalities, p. 622).

Palpate the metatarsophalangeal joints between your thumb on the dorsum and your fingers on the plantar surface (Fig. 23.39).Using a pinching motion of your thumb and forefinger, palpate the interphalangeal joints on the medial and lateral sides of the toes. Swelling or inflammation, tenderness, occur with arthritis or trauma.

23.39

A photo shows the hands of the health care professional palpating the metatarsophalangeal joints on the foot of a person using their thumb on the upper side and the other fingers on the sole of the foot.

Test ROM (Fig. 23.40) by asking the person to:

Instructions to Person Motion and Expected Range

• Point toes toward the floor.

Plantar flexion of 45 degrees.

• Point toes toward the nose.

Dorsiflexion of 20 degrees (Fig. 23.40A).

• Turn soles of feet out, then in. (Stabilize ankle with one hand and hold heel with the other to test the subtalar joint.)

Eversion of 20 degrees.Inversion of 30 degrees (Fig. 23.40B).

• Flex and straighten toes.

Limited ROM.

Pain with motion.

Assess muscle strength by asking the person to maintain dorsiflexion and plantar flexion against your resistance.

23.40

Two photos labeled A and B show plantar flexion of the foot. (A) The foot is moved upward such that it makes 20 degrees with the ankle joint is labeled, dorsiflexion, and the downward movement of the foot such that it makes 45 degrees with the ankle joint is labeled plantar flexion. (B) The photo shows the foot moved sideways. Eversion at 20 degrees and inversion at 30 degrees.

Unable to hold flexion