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The Musculoskeletal System
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Skeleton
• Consists of 206 bones
• Provides support for the soft tissue and organs of the body
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Types of Joint Articulation: Synovial,
Cartilaginous, and Fibrous
Synovial joint
• Joint is freely movable
• Bones are separated by
synovial cavity
• Synovial membrane secretes
synovial fluid that lubricates
joint movement
– Examples: shoulder, knee
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Types of Joint Articulation: Synovial,
Cartilaginous, and Fibrous (cont.)
Cartilaginous joint
• Joint is slightly movable
– Examples: vertebral
bodies of the spine
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Types of Joint Articulation: Synovial,
Cartilaginous, and Fibrous (cont.)
Fibrous joint
• Joints have no
appreciable movement
• Bones separated by
fibrous tissue or cartilage
– Example: sutures of
the skull
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Joint Movements
• Flexion
• Extension
• Rotation
• Circumduction
• Elevation
• Protrusion
• Retraction
• Abduction
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Joint Movements
• Adduction
• Pronation
• Supination
• Inversion
• Eversion
• Gliding
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Table 23.2 Joint
Movement
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Table 23.2 Joint
Movement (continued )
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Table 23.2 Joint
Movement (continued )
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Table 23.2 Joint
Movement (continued )
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Range of Motion-Active
• Ask the patient to move each joint through a full range of
motion.
• Note the degree and type (pain, weakness, etc.) of any
limitations.
• Note any increased range of motion or instability.
• Always compare with the other side.
• Proceed to passive range of motion if abnormalities are
found.
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Range of Motion- Passive
• Ask the patient to relax and allow you to support the
extremity to be examined.
• Gently move each joint through its full range of motion.
• Note the degree and type (pain or mechanical) of any
limitation.
• If increased range of motion is detected, perform special
tests for instability as appropriate.
• Always compare with the other side.
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Range of Motion-Specific Joints
• Fingers - flexion/extension/hyperextension; abduction/adduction
• Wrist - flexion/extension; radial/ulnar deviation
• Elbow - flexion/extension ; pronation/supination
• Shoulder - flexion/extension; internal/external rotation; abduction/adduction
• Hip - flexion/extension; abduction/adduction; internal/external rotation
• Knee - flexion/extension
• Ankle - flexion (plantarflexion)/extension (dorsiflexion), Inversion/Eversion
• Foot - inversion/eversion
• Toes - flexion/extension
• Spine - flexion/extension; right/left bending; right/left rotation
• Neck- flexion/extension/hyperextension; right/left rotation and bending
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Musculoskeletal System:
The Health History
Common or Concerning Symptoms
Low back pain
Neck pain
Monoarticular or polyarticular joint pain
Inflammatory or infectious joint pain
Joint pain with systemic features such as fever, chills,
rash, anorexia, weight loss, weakness
Joint pain with symptoms from other organ systems
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Musculoskeletal System:
Tips for Assessing Joint Pain
• Ask the patient to “point to the pain”
– This saves considerable time since patient
descriptions of the location of the pain may be vague
• Determine whether the pain is:
– Localized or diffuse
– Acute or chronic
– Inflammatory or noninflammatory
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Techniques of Examination:
Overview for Each of the Major Joints*
• Inspect for joint symmetry, alignment, or any bony
deformities
• Inspect and palpate surrounding tissues for any skin
changes, nodules, muscle atrophy, or crepitus
• Assess any degenerative or inflammatory changes,
especially swelling, warmth, tenderness, or redness
• Perform range of motion; use joint-specific maneuvers
to test:
– Joint function and stability
– Integrity of ligaments, tendons, and bursae
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Wrist and Hand: Review the Anatomy
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Wrist and Hand: Examination
• Inspect for smoothness of motion, surface contour,
alignment of wrist and fingers, and any bony deformities
– At rest, the fingers should be slightly flexed and
aligned almost in parallel
• Palpate
– Distal radius and ulna at the wrist, the eight carpal
bones, and the MCP, PIP, and DIP joints for swelling
or tenderness
– “Anatomic snuffbox” just distal to the radial styloid
process with lateral extension of thumb away from
hand
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Wrist and Hand: Examination (cont.)
• Check range of motion
– Wrist: flexion, extension, ulnar and radial
deviation
– Fingers: flexion, extension, hyperextension,
abduction (fingers spread apart), adduction
(fingers back together)
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Palpating the wrist.
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Palpating the hand.
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Extension and flexion of the wrist.
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Ulnar and radial deviation of the wrist.
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Testing the muscle strength of the wrist.
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Carpal Tunnel Syndrome
• Common condition; the median nerve in the wrist becomes compressed,
causing pain and numbness
• Common repetitive strain injury via occupational or sports motions
• Nonsurgical management: drug therapy and immobilization
• Possible surgical management
• Assess
– Tinel’s sign
– Phalen’s sign
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Carpal Tunnel Syndrome
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Tinel’s sign (Median Nerve).
• Use your middle finger tap over the carpal tunnel.
• Pain, tingling, or electric sensations strongly suggest carpal tunnel syndrome.
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Phalen’s test (Median Nerve).
• Ask the patient to press the backs of the hands together with the wrists fully flexed
• Have the patient hold this position for 60 seconds and then comment on how the
hands feel.
• Pain, tingling, or other abnormal sensations in the thumb, index, or middle fingers
strongly suggest carpal tunnel syndrome.
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Palpating the fingers.
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Flexion and extension/hyperextension of the fingers.
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Test for strength the finger (against your resistance)
• Ask the patient to spread his fingers, and try to force the
fingers together
• Ask the client to touch his or her little finger with thumb
while you place resistance on the thumb in order to
prevent the movement
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Flexion and extension of the elbow.
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Goniometer measure of joint range of motion.
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Supination and pronation of the elbow.
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Testing muscle strength using opposing force (flexion or
extension.
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Important Bones of the Shoulder
• Review bony anatomy
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Shoulder: Examination
• Inspect for swelling, deformity, muscle atrophy or
abnormal positioning
• Palpate over the three bony landmarks and any areas
of tenderness
• Check range of motion: flexion, extension, internal
(hands behind small of back) and external (hands
behind neck) rotation, abduction, and adduction,
• Test for strength the shoulder muscles (against
your resistance)
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Flexion and extension of the shoulders.
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Internal rotation of the shoulders.
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External rotation of the shoulders.
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Abduction and adduction of the shoulder.
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Spine: Anatomy of Representative
Cervical and Lumbar Vertebrae
• 7 cervical, 12 thoracic, and 5 lumbar vertebrae are stacked on the
sacrum and coccyx
• Review the anatomy below:
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Spine: Muscle Groups
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Lateral view of spine.
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Spine: Examination — Inspection
• With patient in gown,
directly inspect:
– From the side
o Cervical, thoracic,
and lumbar curves
– From behind
o Upright spinal column
o Alignment of the
shoulders, iliac crests,
and the gluteal folds
o Skin markings, tags,
or masses
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Spine: Examination — Palpation
• Palpate
– With patient standing or
sitting
o Spinous processes of
each vertebrae
o Facet joints in the
neck
o Lower lumbar area for
vertebral “step-offs”
or tenderness
– Paravertebral muscles for
tenderness or spasm
– Sacroiliac joint
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Spine: Examination — Range of Motion
• Neck
– Flexion and extension: chin to chest, look up at
ceiling
– Rotation and lateral bending: look over one
shoulder and then the other; bring ear to shoulder
• Spine (support the patient during exam if necessary)
– Flexion and extension: bend forward and try to
touch toes; bend backward
– Rotation and lateral bending: rotate trunk (pull
shoulder and then the opposite hip posteriorly);
bend to side from waist
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Lateral flexion of the spine.
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Forward flexion of the spine.
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Rotation of the spine (right + left rotation).
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Hip: Review Bony Anatomy
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Hip: Examination — Inspection
• Inspect the gait
• Inspect anterior and posterior surfaces of the hip
for muscle atrophy or bruising
• Palpation
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Hip: Examination – Range of Motion
• Assess
– Flexion – bend knee to chest and pull against
abdomen; check for flexion deformity (opposite knee
goes into flexion)
– Extension – leg extends posteriorly with patient
carefully positioned near edge of table
– Abduction and adduction – reach across and
grasp opposite hip; grasp ankle and move leg
laterally, then medially, toward opposite hip
– External and internal rotation – flex hip and knee
to 90°, grasp ankle, rotate flexed lower leg medially
then laterally
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Flexion of the hip.
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Hyperextension of the hip.
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Internal and external hip rotation.
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Abduction and adduction of the hip.
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Test for strength the hips (against your
resistance)
• Assist the client in returning to the supine position
• Press your hands on the client’s thighs and ask the client
to raise his or her hip
• Place your hands outside the client’s knees and ask the
client to spread both legs against your resistance
• Place your hands between the client’s knees, and ask the
client to bring the legs together against your resistance.
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Knee: Review the Anatomy
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Knee: Examination — Inspection and
Palpation
• Inspect
– Contours and alignment of knees for swelling
– Atrophy of quadriceps muscle
– Knee action during swing and stance phases of gait
• Palpate (patient sitting)
– Infrapatellar spaces adjacent to patella
– Medial and lateral femoral epicondyles and
condyles
– Medial and lateral margins of tibial plateau
– Insertion of patellar tendon at the tibial tubercle
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Knee: Examination — Palpation
• Palpate, with the knee flexed, and note any tenderness:
– Along the joint line, including menisci and bursae
– Along the medial and lateral collateral ligaments (MCL
and LCL)
– Over the patellar tendon. If tender, compress the patella
against the femur and check knee extension
• Palpate:
– Over the suprapatellar bursa above the knee
– Prepatellar bursa over the patella
– Pes anserine bursa on posteromedial knee
• If swelling, palpate for bulge sign or balloon sign, or
“balotte” the patella
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Knee: Examination —
Range of Motion and Maneuvers
• Assess range of motion, with patient sitting:
– Flexion and extension
Test for strength the knees (against your
resistance)
• Instruct the client to flex each knee while you apply opposing force
• Now instruct the client to extend the knee again
• The client should be able to perform the movement against resistance
• The strength of the muscles in both knees is equal.
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Palpating the knee.
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Testing for ballottement.
• Ask the patient to lie supine on the exam table with leg muscles relaxed.
• Press the patella downward and quickly release it.
• If the patella visibly rebounds, a large knee effusion (excess fluid in the knee)
is present.
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Flexion of the knee.
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Ankle and Foot: Review the Anatomy
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Ankle and Foot: Examination —
Inspection and Palpation
• Inspect the surfaces of the ankles and feet for any
deformities, nodules, swellings, calluses, or corns
• Palpate
– Anterior aspect of each ankle joint for bogginess,
swelling, tenderness
– Achilles tendon for nodules or tenderness
– Heel for tenderness
– Medial and lateral malleolus for tenderness
– Metatarsophalangeal joints for tenderness
– Heads of the 5 metatarsals by compressing
between your thumb and index finger
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Ankle and Foot: Examination —
Range of Motion
• Ankle extension (plantar flexion)
– Point foot toward the floor
• Ankle flexion (dorsiflexion)
– Point foot toward the ceiling
• Inversion
– Bend heel inward
• Eversion
– Bend heel outward
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Palpating the ankle.
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Eversion and inversion of the ankles.
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Test for strength the ankle and foot
(against your resistance)
• Ask the client to perform dorsiflexion and plantar flexion
against your resistances
• Ask the client to perform flex and extend the toes against
your resistances
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Common Abnormalities
• Ankylosis
– Scarring within a joint leading to
stiffness or fixation
• Atrophy
– Wasting of the muscle
– Decrease in size
– Flabby appearance
– Decreased function and muscle tone
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Common Abnormalities
• Contracture
– Resistance to movement of muscle or joint, fibrosis of soft
tissue
• Crepitus
– Crackling sound or grating sensation from
friction between two bones
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Common Abnormalities
• Kyphosis
–
Round back forward bending of spine
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Common Abnormalities
• Lordosis (Lumbar lordosis.)
–
Anteriorposterior curvature with concavity in posterior direction
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Common Abnormalities
• Scoliosis
–
Lateral curvature of the spine
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Common Abnormalities
Osteoporosis
• A disease in which loss of bone exceeds rate of bone formation;
usually increase in older women, white race, nulliparity.
• Clinical Manifestations – bone pain, decrease movement.
• Treatment – Calcium, Vit. D, estrogen replacement, Calcitonin,
fluoride, estrogen with progestin, exercise.
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