N125 Comprehensive Musculoskeletal Assessment Study Guide

Functions of the Musculoskeletal System

• The system provides the fundamental support required for the human body to stand erect.

• It serves to protect vital internal organs from injury.

• The system acts as a primary storage space for essential minerals, such as calcium and phosphorus.

• It is responsible for the production of blood cells in the bone marrow, a process known as hematopoiesis.

• Bones possess a 'resorb and reform' capability, where they continuously dissolve and form new bone tissue to maintain structural integrity.

• The system provides both stability and mobility for the body.

Anatomy and Physiology Fundamentals

• Ligaments: Fibrous bands that connect bones to other bones and serve to stabilize joints.

• Tendons: Fibrous cords that attach muscles to bones.

• Cartilage: Flexible connective tissue that cushions bones at the joints and prevents friction.

• Bones: Rigid structures that grow in length and width through a process called remodeling.     * Lengthening occurs at the epiphyses (growth plates).     * This growth continues until approximately the age of $20$.     * Clinical Warning: Any trauma or infection at the epiphyses puts a growing child at high risk for permanent bone deformity.

Muscle Tone and Assessment

• Tone Definition: The normal degree of tension or contraction found in voluntarily relaxed muscles.

• Clinical Presentation: Tone manifests as a mild, even resistance to passive stretch (moving a limb through its range of motion while the patient remains relaxed).

• Assessment Technique: Testing tone involves performing full Range of Motion (ROM) on the patient. Findings are typically documented as stiff, rigid, or floppy (atonic).

Joint Structure and Classification

• Nonsynovial Joints: These joints are only partially moveable. Examples include the sutures in the skull, the vertebrae, and the jaw.

• Synovial Joints: These joints are freely moveable. The bones are separated from each other but enclosed within a joint cavity that is filled with synovial fluid to reduce friction. Examples include the knees, hips, shoulders, and elbows.

• Bursa: Small pouches filled with synovial fluid that cushion the movement of tendons and muscles over bony surfaces, typically located just under the skin.

Musculoskeletal Assessment Terminology

• Flexion: Bending a limb at a joint.

• Extension: Straightening a limb at a joint.

• Abduction: Moving a limb away from the midline of the body.

• Adduction: Moving a limb toward the midline of the body.

• Pronation: Turning the forearm so the palm is facing down.

• Supination: Turning the forearm so the palm is facing up.

• Circumduction: Moving the arm in a circle around the shoulder.

• Inversion: Moving the sole of the foot inward toward the ankle.

• Eversion: Moving the sole of the foot outward at the ankle.

• Rotation: Moving the head around a central axis.

• Distal: Located away from the point of origin or the center of the body.

• Proximal: Located toward the point of origin or the center of the body.

• AROM (Active Range of Motion): The patient moves the joint themselves.

• PROM (Passive Range of Motion): The practitioner moves the joint for the patient.

Personal, Social, and Medical History (Subjective Data)

• Social factors to assess: Employment (occupational risks), exercise routines, functional abilities for activities of daily living (ADLs), weight and height, nutrition, tobacco use, and alcohol use.

• Past Medical History (PMH):     * History of trauma to nerves, soft tissue, bones, or joints, including residual problems or bone infections.     * Previous surgeries on joints or bones.     * Chronic illnesses such as cancer, arthritis, osteoporosis, and renal or neurologic disorders.     * Presence of skeletal deformities or congenital anomalies.

Musculoskeletal Assessment Red Flags

• Loss of bowel or bladder control (potential spinal cord emergency).

• Pain that is out of proportion to the inciting event.

• Pain radiating down the leg (radiculopathy).

• Tingling and/or numbness (paresthesia).

• Asymmetrical weakness.

• Loss of function in a limb or joint.

• Fever associated with joint pain.

• Inflammation of a joint (redness, heat, swelling).

• Unremitting pain, especially when it does not improve with medication (RX).

Systematic Physical Examination Steps

1. Inspection: Observe the joint size, contour, skin color, and check for swelling, masses, or deformities. Compare both sides of the body for symmetry.

2. Palpation: Feel the joint for temperature and check bony articulations. Note any heat, tenderness, swelling, or masses.

3. Range of Motion (ROM): Initially ask for AROM to monitor strength, muscle control, and stability. Note any pain, limited movement, or crepitation (audible or palpable grating sounds).

4. Muscle Testing: Assess the strength and resistance of the muscles supporting the joint.

Muscle Strength Testing and Grading (MRC Scale)

• Grade 5 (100%): Normal assessment. Full ROM against gravity and full resistance.

• Grade 4 (75%): Good. Full ROM against gravity and some resistance.

• Grade 3 (50%): Fair. Full ROM with gravity.

• Grade 2 (25%): Poor. Full ROM with gravity eliminated (passive motion).

• Grade 1 (10%): Trace. Slight contraction visible or palpable.

• Grade 0 (0%): Zero. No contraction detected.

The 5 Ps of Musculoskeletal Complaint

Musculoskeletal assessments must include the following five indicators to evaluate neurovascular status:

1. Pulses: Assessment of blood flow distal to the injury/complaint.

2. Poikilothermia: The inability to regulate core body temperature (coldness in the affected limb).

3. Paresthesia: Numbness or tingling sensations.

4. Paralysis: Loss of muscle function.

5. Pallor: Paleness of the skin indicating poor perfusion.

• Note: Pain is considered the 5th vital sign and must also be assessed thoroughly.

Regional Assessment: Temporomandibular Joint (TMJ)

• Inspection: Observe the area for symmetry and swelling.

• Palpation: Palpate the joint while the patient opens their mouth.

• ROM Maneuvers:     * Open the mouth maximally.     * Protrude the lower jaw.     * Move the lower jaw from side to side.

Regional Assessment: Cervical Spine

• ROM Maneuvers and Expected Degrees:     * Flexion: Patient touches chin to chest (expected $45^\circ$).     * Extension/Hyperextension: Patient tilts head back (Extension up to $55^\circ$).     * Lateral Bend: Patient touches ear to shoulder (expected $40^\circ$).     * Rotation: Patient turns head to the right and left (expected $70^\circ$).

Regional Assessment: Shoulders

• Anatomy: The glenohumeral joint is a ball-and-socket joint between the humerus and scapula. The labrum is a ring-shaped cartilage providing a smooth surface for rotation. The rotator cuff is the primary muscle group involved.

• ROM Maneuvers: Flexion, Extension, Hyperextension, Internal rotation, External rotation, Abduction, and Adduction.

• Shoulder Pain: If pain is present, the patient should point to the spot using the unaffected hand. Pain may be local (reproducible by motion/palpation) or referred (e.g., from hiatal hernia, cardiac, or pleural conditions).

Regional Assessment: Elbows

• Anatomy: The elbow functions as a hinge joint (flexion/extension) and includes the radioulnar joint, which is a pivot joint (pronation/supination).

• Palpable Landmarks: Medial and lateral epicondyles of the humerus; Olecranon process of the ulna.

• Abnormal Findings:     * Lateral Epicondylitis ("Tennis Elbow"): Strain and inflammation of the lateral epicondyle.     * Medial Epicondylitis ("Golfer's Elbow"): Strain and inflammation of the medial epicondyle.     * Olecranon Bursitis: A soft "goose egg" or knob caused by inflammation of the olecranon bursa, often accompanied by redness.

Regional Assessment: Wrist and Hand

• Assessment: Inspect dorsal and palmar sides; palpate each joint. Loss of ROM is the most significant functional loss in the wrist.

• Wrist ROM: Flexion ($90^\circ$), Extension, Hyperextension ($70^\circ$), Radial deviation ($20^\circ$), Ulnar deviation ($55^\circ$), Pronation, and Supination.

• Hand ROM: Finger abduction, clenching the fist, and thumb circumduction.

• Carpal Tunnel Syndrome (CTS) Testing:     * Phalen’s Test: Patient holds wrists in acute flexion for $60$ seconds; positive if numbness/tingling occurs over the medial nerve.     * Tinel’s Sign: Percussion over the medial nerve; positive if it elicits an electric sensation.

Regional Assessment: Hip

• Palpable Landmarks: Iliac crest, Anterior Superior Iliac spine, Ischial tuberosity, Greater trochanter, and Lesser trochanter.

• Assessment: Inspect while standing; palpate while supine.

• Abnormal Findings:     * Limited internal rotation is an early and reliable sign of hip disease.     * Limitation of abduction while supine is the most common motion dysfunction in hip disease.

Regional Assessment: Knee

• Anatomy: The largest joint in the body and the largest synovial joint. It is a hinge joint involving the articulation of the femur, tibia, and patella. It is stabilized by cruciate and collateral ligaments.

• Special Tests:     * Bulge Sign: Detects knee effusion; positive result indicates the presence of $10-15\,ml$ of fluid.     * McMurray’s Test: Performed if meniscus damage is suspected; positive if a "click" or pain is felt, indicating a tear in the medial meniscus.     * Structural Abnormalities: Genu valgum (Knock Knees) and Genu varum (Bow Legged).

Anatomy and Assessment of the Spine

• Vertebral Column Segments: Cervical ($C1-C7$), Thoracic ($T1-T12$), Lumbar ($L1-L5$), Sacral ($S1-S5$), and the Coccyx.

• Bony Landmarks:     * $C7$ and $T1$ are prominent at the base of the neck.     * The inferior angle of the scapula is at the level of $T7$ and $T8$.     * The highest point of the iliac crest is at $L4$.     * The posterior superior iliac spine is at the level of $S2$.

• Intervertebral Discs: Act as shock absorbers; composed of the Nucleus Pulposus and Annulus Fibrosis. A rupture or bulge is known as a herniated disc.

• Specialized Assessment:     * Lasègue's sign (Straight Leg Raise Test): Positive if pain in the sciatic distribution is reproduced between $30$ and $70$ degrees of passive hip flexion of the straight leg.

Spinal Deformities

• Kyphosis: An exaggerated outward curvature of the thoracic spine (hunchback). Common in aging; results in decreased height, a shortened trunk, and a backward head tilt to compensate. Long bones do not shorten with age.

• Lordosis: An exaggerated inward curvature of the lumbar spine (swayback). Common during pregnancy; shifts the center of balance forward and causes back strain.

• Scoliosis: Lateral curvature of the spine. Most apparent during the preadolescent growth spurt; best inspected by having the patient bend forward.

Other Specific Procedures and Conditions

• Leg Length Measurement: Measured from the anterior iliac spine to the medial malleolus, crossing the medial side of the knee. Measurements should be equal or within $1\,cm$ of each other.

• Crepitus: Audible and palpable crunching or grating sounds occurring when articular surfaces are roughened, such as in Rheumatoid Arthritis (RA) or Osteoarthritis (OA).

• Fractures: Range from incomplete (hairline or greenstick) to complete breaks. Compound or open fractures involve the bone protruding through the skin.

• Contractures: Shortening of a muscle leading to limited ROM; causes include burns, stroke, cerebral palsy, muscular dystrophy, or prolonged immobility.

Rheumatoid Arthritis (RA) vs. Osteoarthritis (OA)

• Rheumatoid Arthritis (RA):     * Inflammatory, autoimmune condition.     * Symmetrical and bilateral joint involvement.     * Symptoms: Fatigue, weakness, muscle aches, weight loss, low-grade fever, lymphadenopathy.     * Timing: Pain is worse in the morning upon awakening and improves with movement.     * Hand deformities: Swan neck deformity (MCP and DIP flexion with PIP hyperextension), Boutonniere deformity, and Ulnar deviation.

• Osteoarthritis (OA):     * Degenerative Joint Disease (DJD).     * Asymmetric joint involvement.     * Timing: Pain becomes worse during the day and increases with movement.     * Features: Stiffness, swelling with hard bony protuberances.     * Hand findings: Heberden nodes (at the distal interphalangeal/DIP joint) and Bouchard nodes (at the proximal interphalangeal/PIP joint).

Metabolic Disorders and Health Promotion

• Osteoporosis: A disease characterized by a decrease in skeletal bone density because the rate of bone resorption is greater than bone formation.     * Risk Factors: Aging, being small and thin, family history, white or Asian descent, low bone density, and certain medications.     * Treatment: No medication exists to prevent the disease; medication only treats it after onset.

• Falls: The leading cause of fractures and non-fatal injury in older adults. $\frac{1}{3}$ of individuals over age $65$ who fall do not regain their prior level of function.

• Promotion Strategies:     * Maintain bone mineralization via Calcium and Vitamin D.     * Physical exercise to increase bone mass.     * Weight loss to reduce mechanical stress on joints.     * Smoking cessation.