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Musculoskeletal System

Chapter 15

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Anatomy and physiology Review

MS consists of :

– Muscles

– Tendons

– Ligaments

– Bones

– Cartilage

– Joints

– Bursa

Bones

– 206 bones in human

skeleton

Joints

– Articulation of two or

more bones

– Classified by shape

and motion

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Temporomandibular Joint (TMJ)

Articulation of mandible and

temporal joint

Permits speaking and chewing

Hinge and gliding action

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Spine

33 connecting vertebrae

7 cervical

12 thoracic

5 lumbar

5 sacral

3 - 4 coccygeal

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Spine

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Shoulder

Articulation of humerus with glenoid fossa of the

scapula

Ball and socket

4 muscles and tendons make up the rotator cuff

Subacromial bursa

Acromion process

Greater tubercle

Coraciod process

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Shoulder

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Elbow

Articulations of humerus, radius, and

ulna

Hinge joint and rotation

Landmarks: medial and lateral

epicondyles, and olecranon process

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Elbow

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Wrist and Carpals of the Hand

Articulation of radius and carpal bones

Flexion and extension

Side-to-side deviation

Rotation

Midcarpal

Metacarpophalangeal and interphalangeal

permit finger motion

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Wrist and Carpals of the Hand

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Hip

Articulation between the acetabulum and

head of femur

Ball and socket

Weight-bearing function

Landmarks: anterior superior iliac spine,

ischial tuberosity, and greater trochanter

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Hip

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Knee

Articulation of femur, tibia, and patella

Hinge joint

Flexion and extension

Ligaments: cruciate and collateral

Landmarks: quadriceps and tibial

tuberosity

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Knee

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Ankle and Foot

Articulation of tibia, fibula, and talus

Hinge joint

Flexion (dorsiflexion)

Extension (plantar flexion

Inversion and eversion

Landmarks: medial and lateral malleous

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Ankle and Foot

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Health History

Ask pt about backache

Ask about pain in the neck and assess if associated with weakness, loss of sensation, loss of bladder or bowel function

Do you have any pains in your joints?,

Ask pt to point to the pain

Assess for limitation of motion

Assess for systemic feature as fever, rash, anorexia,

weakness, wt loss

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Assess mechanism of injury

Determine if it is inflammatory or noninflammatory e.g. fever, chills, warmth, redness in septic arthritis

Assess for symptoms elsewhere in the body as skin condition ( e.g. butterfly rash on a cheeks in SLE), preceding sore throat in acute RF.

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Additional Questions for Aging Adults

Do you have any loss of function?

Have you had weaknesses in the past month?

Have you had an increase in falls or have you

had trouble with balance?

Do you use any mobility aids? (cane, crutches,

walker)

Are you on any medications?

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Musculoskeletal Examination

Inspection: size and contour of joint, color,

swelling, masses, or deformity

Palpation: heat, tenderness, landmarks, and

any thickened synovial membranes

Range of Motion (ROM): active and

passive, flexibility of joint

Muscle Testing: test strength of muscle

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Muscular Movements

Flexion

Extension

Abduction

Adduction

Pronation

Supination

Circumduction

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Rotation

Protraction

Retraction

Elevation

Depression

Inversion

Eversion.

ROM’s

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Measuring Range of Motion

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Examination of TMJ

Inspection and palpation:

- Inspect for swelling or redness. Rounded bulge around 1/2cm anterior to the external auditory meatus suggest swelling

- To palpate the joint place the tips of the index finger in front of the tragus, then ask pt to open his mouth

Abnormalities: tenderness, swelling, lost of movement (lateral motion may be lost earlier and more significant than upper

vertical)

-

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check for smooth motion, note any swelling, tenderness

- Palpate the muscle of mastication( maseter, temporal, and pterygoid)

R.O.M and maneuvers:

- Ask pt to open and close the mouth

- Protrusion and retraction ( move mouth

backward, and forward)

- Side to side

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Examination of the Shoulder

Inspection :

- Posteriorlly & anteriorly

- Note any swelling, deformity, muscle atrophy, or fasciculation, or abnormal positioning

- Look for swelling of the joint capsule, or bulge in subacromial bursa

- Look for color changes, skin alteration, unusual bony contour

e.g. scoliosis may cause elevation of one shoulder

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Palpation:

- Locate the bony landmarks of the shoulder an then palpate the painful area.

R.O.M:

- flexion, extension, abduction, adduction, internal and external rotation

- Ask pt to raise both arms to shoulder level (90o ) with palm facing down ( test Glenohumeral motion)

- Raise the arms above the head palms facing each other.

- Place both hands behind the neck, elbows outside ( external rotation and abduction)

- Place both hands behind the back ( internal rotation and adduction)

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The Elbow

Inspection & palpation:

- Inspect the contour of the elbow, note any nodule or swelling

- Palpate the olecranon process& epicondyle for tenderness

- Note any displacement of the olecranon

- Palpate the groove between the epicondyles and the olecranon, note any tenderness, swelling, or thickening

e.g. swelling over the olecranon process indicate olecranon bursitis

Nodules over olecranon bursa in RA.30Ra'eda Almashaqba

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R.O.M:

- Flexion & extension at the elbow ( ask the pt

to bend and straighten the elbow)

- Pronation & supination of the forearm (

place pt arms at sides with elbow flexed, ask

pt to turn the palms up, and to turns the

palms down)

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The Wrist & Hands

Inspection:

- Observe the position of hands in motion to see if it smooth and natural

- Inspect the palmar and dorsal surface of the wrist and hand for swelling over the joint

- Note any deformities of the wrist, hands, fingers, radial or ulnar deviation

- Observe the palm contour( thenar& hypothenar eminences)

- Note any thickening of flexor tendon or flexion contractures in the fingers 33Ra'eda Almashaqba

Palpation:

- At the wrist palpate the distal radius and ulna on the lateral and medial surface

- Palpate the groove of each wrist by the thumb on dorsum and fingers beneath it. Note any swelling, bogginess, or tenderness

- Palpate the 8 carpal bones then each of the 5 metacarpals, proximal, medial, distal phalanges

- Note any swelling, bogginess, or tenderness

- Examine the finger and thumb by using index and thumb start at PIP joint then DIP joint

- Check for swelling, bogginess, tenderness, bony enlargement.

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R.O.M:

For the wrist:

- Flexion( stabilize pt forearm, extend the wrist,

ask the pt to flex the wrist)

- Extension (stabilize pt forearm, flex the wrist,

your hand on dorsal metacarpal of the pt hand,

ask pt to extend the wrist against gravity

- Ulnar & radial deviation( with the palms down,

ask pt to move the wrist medially and laterally)

- Test grip strength.

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For Fingers:

- Flexion, extension

- Adduction, abduction

For Thumb:

- flexion( ask pt to move the thumb across the palm an touch the base of the 5th finger

- Extension( move the thumb back across the palm and away from the fingers

- Abduction (move the thumb anteriorly away from the palm)

- Adduction (move thumb backdown)

- Opposition ( ask the pt to touch the thumb to each of the fingertips)

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Test sensation:

- Pulp of the index finger for median nerve

- Pulp of the 5th finger for ulnar nerve

- Dorsal web space of the thumb and index

finger for radial nerve

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The Spine

Inspection:

- Observe pt posture

- Assess erect position of the head, smooth, coordinate neck movement

- Inspect the pt from the side for spinal curvature

Palpation:

- Spinous process with your thumb

- Palpate the sacroiliac joint

- Percuss the spine for tenderness by using ulnar surface of your fist

- Palpate Paravertebral muscle for tenderness and spasm

- Flex pt hip and ask pt to lye in opposite side palpate the sciatic nerve( lies midway between the greater trochanter and the Ischial tuberosity 38Ra'eda Almashaqba

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R.O.M:

For the neck

- Flexion: chin touch the chest

- Extension: look up at the ceiling

- Rotation: turn the head to each side, look directly over the shoulder

- Lateral binding: each ear touching the shoulder

For the spinal column:

- Flexion: bend forward touch the toes

- Extension: place your hand on the posterior superior iliac spine, fingers pointed towered the midline, ask pt to bend backward as far as possible

- Rotation: one hand on the pt hip the other on the opposite shoulder, then rotate the trunk , repeat for the other side

- Lateral bending: place your hand on the pt hip, ask pt to lean to both side as far as possible

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The Hip

Inspection:

- Observe the pt gait( 2 phase)

1. Stance: foot on ground, bear wt

2. Swing: foot moves, no bear wt

- Observe the gait for width

- Assess the lumbar spine for lordosis, assess the

length of the legs for symmetry.

- Anterior and posterior surface of the hip for

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Palpation:

- Palpate the inguinal ligament

- NAVEL

- If hip painful palpate the psoas bursa (below

the IL)

- Pt resting on one side, hip internally rotated,

palpate the Trochanteric bursa, the

ischiogluteal bursa

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R.O.M:

- Flexion: pt supine, place your hand under lumbar spine,

ask the pt to bend each knee in turn up to the chest, and

firmly against the abdomen, observe the degree of

flexion at the hip and knee

- Extension:pt lying face down, extend the thigh

posteriorlly, then place the pt near the edge of the

examination table and extend the leg posteriorlly

- Abduction: press the opposite anterior superior iliac

spine with one hand, the other hand, grasp the ankle

and abduct the extended leg until you feel the iliac

spine move, then stand at the foot of the table, grasp

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Adduction: pt supine, hold one ankle, move the

leg medially across the body over the opposite

extremity

External & Internal rotation: flex the leg to 90o at

hip an knee, stabilize the thigh with one hand, the

other hand grasp the ankle and swing the lower

leg medially ( external rotation), and then swing

the leg laterally

( internal rotation)

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The Knee

Inspection

- Observe pt gait

- Check knee alignment, contour, any atrophy of quadriceps muscle

e.g. bowleg and knock knee common flexion contractures in limb paralysis

- Look for loss of the normal hollows around the patella , any other swelling in or around the knee

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Palpation:

- Palpate ligaments, menisci border, knee bursae

- Palpate the patellar tendon and ask pt to extend the leg to ensure intactness of the tendon

- Patellofemoral grinding test: pt in supine position knee extended, compress the patella against the underlying femur, ask pt to tighten the quadriceps muscle, check for smooth sliding motion

- Palpate while pt flex knee the MCL, LCL

- Palpate the lateral and medial menisci

- Note any irregular bony ridge along the joint margins 45Ra'eda Almashaqba

- Feel any thickening or swelling in the suprapatellar

pouch, and the side of the patella, 10 cm above the

superior border of the patella, feel with your thumb and

finger, note any tenderness, or warmth

- Palpate the bursae of the knee

Tests to detect fluid in the knee:

- Bulge sign (for minor effusion): knee extend, lt hand

above the knee, apply pressure on the suprapatellar

pouch, milking fluid downward, apply pressure on the

medial aspect of the knee, tap the knee with the Rt hand

behind the lateral margin of the patella, watch for

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Balloon sign (for major effusion): place the

index finger and thumb of your Rt hand on each

side of the patella, the Lt hand compress the

suprapatellar pouch against the femur, feel for

fluid entering the spaces next to the patella

under Rt thumb and index finger

Balloting the patella: to assess large effusion,

compress the suprapatellar pouch, watch for

fluid retuning to the suprapatellar pouch

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R.O.M:

- Flexion

- Extension

- Internal rotation ( ask pt to rotate foot

medially)

- External rotation ( ask pt to rotate foot

laterally)

- Review table p 550- 551

- To test Achilles tendon integrity ask pt to

kneel on chair, squeeze the calf muscle, watch

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The Ankle & foot

Inspection:

-observe all surface of the ankle and feet

- Note any deformity, nodules, swelling, calluses or corns

Palpation:

- With your thumb palpate the anterior aspect of each ankle joint, note any bogginess, swelling, or tenderness

- Feel along the Achilles tendon for nodules and tenderness

- Palpate the heel and the planter fascia for tenderness

- Palpate the MCP joint for tenderness by the thumb and the fingers

- Palpate the head of the 5 metatarsals and the grooves between them by the thumb (on dorsum) and index finger (on the planter surface)

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R.O.M:

- Flexion and extension at the ankle (tibiotalar)

joint

- Inversion and Eversion at the foot( the subtalar

and transverse tarsal joints)

- The Ankle (Tibiotalar) joint: dorsiflex and

planterflex the foot at the ankle

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Special technique

- Thumb abduction:

ask the pt to raise the thumb perpendicular to the palm

as you apply pressure on the distal phalanx ( test the

strength of the abductor pollicis brevis)

- Tinel’s sign:

Percuss by your finger in the volar aspect of the wrist

over the course of median nerve

- Phalen’s test:

flex the pt wrist and hold it for 60 sec

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For LBP with radiation to the leg:

- Check the straight leg raising (LaSegue’s Test ) on each side in turn : while pt on supine position, raise the straighten leg until pain occurs, then dorsiflex the foot, record the degree of elevation at which the pain occurs

- Examine the pt sensory, motor, reflexes at the lumbosacral levels

Measuring the length of the leg:

- Place pt on supine position

- Leg extended

- Measure the distance between the anterior superior iliac spine and the medial malleous, the tape should cross the knee on its medial side

– For the apparent leg length

• Measure from a nonfixed point (umbilicus) to a fixed point (medial malleous).

– Apparent leg length is unequal if patient have pelvic obliquity or adduction or flexion deformity in the hip.

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Describing limited motion of a joint:

- It is described in degrees

- By using goniometers

e.g. the normal angle for elbow flexion is from

0o to 160o, when there limitation documented

as follows elbow flex from 45o to 90o

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Rheumatoid arthritis

Chronic, systemic,

inflammatory disease

that attacks the joints,

and surrounding

tissues, hand, knees,

hips, and feet

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Deformities

of RA

Swan neck deformity

Boutinniere Deformity

Ulnar Shift

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Osteoarthritis

A chronic degeneration of joint cartilage caused by aging or trauma

Pain, stiffness, swelling

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Osteoarthritis: Cont.

Heberdens Nodes

Bouchards Nodes

Hard, nontender nodes

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Osteoporosis

A decrease

in bone

mass,

porous,

brittle, and

prone to

fracture

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Contractures

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Lordosis

Lordosis is the

abnormal

increase in

normal lordotic

(anterior)

curvature of the

lumbar spine

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Spinal Abnormalities

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