6.1 Musculoskeletal Assessment Flashcards
Nonsynovial Joints
Nonsynovial Joints - Bones united by fibrous tissue or cartilage. Immovable such as sutures in the skull or can be slightly moveable
Synovial Joints
- Freely Moveable (separated and enclosed by joint cavity)
- Temporal-Mandible Joint
- Spine
- Shoulder
- Elbow
- Wrist/Hand
- Hip
- Knee
- Ankle/Foot
Muscle
Muscles include skeletal, smooth, and cardiac types
Key Terms
Flexion - Bending limb at the joint
Extension - Straightening limb at the joint
Abduction - Move limb away from midline of body
Adduction - Move limb towards midline of body
Pronation - Hand with palm facing down
Supination - Hand with palm facing up
Circumduction - Moving arm in circle around shoulder
Inversion - Moving sole of foot inward at the ankle
Eversion - Moving sole of foot outward at ankle
Rotation - Moving head around central axis
Key Terms (cont)
Protraction - Moving body part forward, parallel to ground
Retraction - Moving body part backwards, parallel to ground
Elevation - Raising body part
Depression - Lowering body part
Joints ROS
- Pain in the joints (when is it better or worse)
- Rheumatoid Arthritis (RA) is generally worse in the morning, osteoarthritis is worse at night
Type of pain
Sharp - Fracture
Popping Sound - Indicates a Tear
Myalgia-Type Pain - Viral Infection - Is there stiffness or swelling
Bone and Muscle ROS
- Trauma to bones?
- Pain or weakness in the muscles?
Functional ADL’s
- Can the patient preform ADL’s Independently?
- Is the patient taking any dietary supplements?
- Is there a history of smoking? (Causes bone loss)
Infant Data
- Trauma to infant during labor/delivery
Did infants head come first
Was there need for forceps (used for grasping)
Did infant need resuscitation
(Periods of anoxia - complete loss of oxygen - could mean hypotonia - decreased muscle tone)
Infant Data (cont)
- Were motor milestones achieved at the same time as siblings
- Any broken bones/dislocations (how were they treated)
- Bone deformities
Spinal Curvature
Unusual shape of toes or feet
Trauma increasing risk of fractures
Adolescent Data
- Is patient involved in sports
How frequently
What does patient do if they get hurt - How does sports fit in with other school demands and activities
It is necessary to assess safety measures for adolescents because they are less likely to report injuries
Older Adult Data
- History of weakness in the past few months
- Increase in falls or stumbling in the past few months
- Does patient use mobility aids such as cane or walker
Physical Assessment
- Purpose to assess function of ADL’s and screen abnormalities
- Supporting each joint at rest
(Muscles should be soft and relaxed to assess joints accurately) - Take care when examining inflamed areas where rough manipulation can cause pain and muscle spasms
- Comparing Corresponding Joints
(Expect symmetry of structure and function and normal parameters of each joint)
Head to toe approach
- Begin with inspection of TMJ (Temporomandibular joint) and work your way down to the ankles.
- Assessment technique is same for each joint but may be different movements to assess
Inspection
- Size and contour of each joint
- Inspect skin for color, swelling, masses/deformities
Deformities
Dislocation - Loss of contact between 2 bones and joint
Subluxation - Misalignment
Contracture - Shortening of Muscle
Ankylosis - Stiffness/Fixation of Joint
Swelling may cause joint irritation and could mean effusion, inflammation, bony enlargement
Palpation
Palpate each joint
- Assess temperature, muscles, bony articulations, area of joint capsule.
(Warmth can indicate inflammation)
- Joints should not be tender to palpate
(If there is tenderness, localize it to specific anatomic structure - Skin, Muscle, Bursae, Ligament, Tendon, Fat Pads, Joint Capsule)
Palpation
Note presence of articular disease which is swelling and tenderness (arthritis)
- This limits active and passive ROM
- Extra-articular disease affects active movement and may be a ligament or tendon injury
Note whether the synovial joint membrane is palpable
- Usually not palpable, membrane is doughy and boggy when thickened
(ROM) and Muscle Strength
Ask for active voluntary ROM
- Limitations in voluntary ROM attempt passive movement
- Note pain/tenderness/crepitation (audible crunching or grading with movement)
Assess Muscle Strength
Assess Muscle Strength
- Test strength of prime mover muscle groups for each joint
- Repeat motions for active ROM
- Ask patient to flex as you apply opposing force
- Muscle strength should be equal bilaterally
Muscle Strength Grade
Grade 5 - Normal
Grade 4 - Active movement against gravity with resistance
Grade 3 - Active movement against gravity without resistance
Grade 2 - Active movement with gravity eliminated
Grade 1 - Only trace or flicker of movement
Grade 0 - No movement
Temporomandibular Joint
- When palpating audible and palpable snap is normal when people open their mouth
- Ask patient to move jaw forward and laterally against resistance
- Ask patient to open mouth against your resistance
(Tests integrity of Cranial Nerve 5 - Trigeminal Nerve) - Note swelling or crepitus
Cervical Spine
- Inspect alignment of head and neck
(Should be straight and head should be erect) - Palpate spinous process and sternomastoid, trapezius, paravertebral muscles
- They should feel firm with no muscle spasms or tenderness
- Repeat motions while applying opposing force
- Maintain Flexion against full resistance is normal
(Tests cranial nerve 6 - spinal nerve)
Shoulder
Test strength of shoulder muscles
- Shrug shoulders, flex forward and up, abduct against resistance.
- Shoulder shrug tests cranial nerve 6 (spinal accessory nerve)
- Inspect/Palpate comparing both shoulders posteriorly and anteriorly.
DO NOT ATTEMPT IF YOU SUSPECT NECK TRAUMA
Elbow
Inspect size and contour of elbow in both flexed and extended positions
- Effusion and Synovial Thickening shows as a bulge in the groove of the sides of olecranon process.
(Occurs with gouty arthritis)
- Epicondyles, head of radius, and tendons are common sites of inflammation and tenderness
(Example - tennis elbow)
Hand and Wrist
- Inspect hands on both palmar and dorsal sides.
- Note position, contour, shape
(No swelling, redness, deformities, or nodules should be present)
(Skin should appear smooth with knuckle wrinkles present)
(Muscles should appear full)
Hand and Wrists
Palpate each joint in wrist and hands
- This tests for carpal tunnel syndrome with Phalen Test and Tinel’s Sign
Phalen Test - Patient places back of hands together and presses (if painful could mean carpal tunnel syndrome)
Tinel’s Sign - Apply direct percussion to median nerve
(Pain/Tingling can mean carpal tunnel syndrome)
Hip
- Lay patient in Supine Position
- Check for no crepitus, asymmetry or tenderness
Assess ROM - Hip flexion should be assessed with knee straight forward and flexed
- Preform external and internal rotation, adduction, abduction.
- Limited abduction while supine in the most common motion dysfunction of hip disease.
Hip (cont)
- Smooth, even gait reflects equal leg length and functional hip motion.
- Hip joint will be inspected later together with spine
Knee
- Patient supine with legs extended
- Inspect lower leg alignment, shape, and contour
(Hollows should be present on sides of patella) - Check quadriceps muscles in anterior thigh for atrophy
(Important because quadriceps is prime mover of knee and central to joint stability during weight bearing)
-
Knee
- Palpate knee in supine position by starting high anterior thigh above patella.
- Muscles should feel solid, joint should feel smooth with no warmth, tenderness, thickening, nodularity
ABNORMALITIES - Limited ROM, Pain, Contracture
- Sudden locking (inability to extend knee fully) or buckling (giving away - ligament injury)
Knee Bulge Test/Ballottement Test
Checks Fluid around Patella
- Bulge Sign confirms small amounts of fluid
Tap lateral side of patella positive sign would be fluid wave moving across patella
- Ballottement Test confirms larger amounts of fluid
While hold quadricep with one hand, use other hand to push upward on the patella
- If large amounts of fluid is present patella will float towards the femoral condyles.
McMurray Test
Test with reports of trauma
- Have patient flex knee
- Externally rotate hip while pushing inward on the knee
(clicking indicates torn meniscus)
Ankle/Foot Test
- Assess while both sitting and standing/walking
Compare both feet assessing for contour of joints - Foot should align with long axis of lower leg
- Weight bearing should fall on middle of foot
- Most feet have longitudinal arch, but can vary from flat feet to high instep
- Toes should point straight and forward and lie flat
(Note calluses or bursal reaction)
Ankle/Foot
- Palpate the joints between the thumb and plantar surface
- TEST ROM
Dorsiflexion, plantar flexion, eversion, and inversion
Full Spine
Inspect spine while patient is standing
- Assess straightness with vertical line from head through the spinous process to the gluteal cleft
(equal horizon positions of shoulder, scapulae, iliac crest, gluteal folds)
- Knees and feet should align with trunk and pointing forward
Full Spine
Assess abnormal curvature (kyphosis, lordosis, scoliosis)
- Check ROM of spine by asking patient to touch toes
- Look for flexion 75-90 degrees and smoothness/symmetry of movement
Assessing Infants
- Congenital Dislocation
Ortolani’s maneuver test - every visit until infant is 1 years old
Allis test - check for hip dislocation - Inspect hands, noting shape, number, position, of fingers and palmar creases
Note for single transverse palmar crease (simian crease) - Palpate length of clavicles, most frequently fractured at birth
Preschool/School Aged
- Assess gait
Bowlegged Stance (genuvarum) - Normal for 1 year after child begins walking
Knock-Knee (genuvalgum) - occurs between 2 and 3 and a half years old. (No treatment)
Inflammatory Disease
Rheumatoid Arthritis (RA) - Chronic, systemic inflammatory disease of joints and surrounding connective tissue - Causes fusiform (spine shaped swelling) Ankylosing Spondylitis - Chronic progressive inflammation of the spine and larger joints
Degenerative Diseases
Osteoarthritis - Noninflammatory, localized deterioration of articular cartilages and subchondral bone and formation of new bone.
Osteoporosis - Decrease in skeletal bone mass
Wrist and Hand Disease
Ulnar Deviation - fingers listing to the ulnar side of hand
Ankylosis - Extreme wrist flexion
Dupuytren’s Contracture - Chronic hyperplasia of palmar fascia which causes flexion contractures of the digits. (Band extends from midpalm)
Swan Neck Deformity - Flexion contracture resembles curve neck of swan
Polydactyty - Extra Digits
Shoulder/Elbow
Joint effusion - Condition causing swelling and excess fluid in capsule
Frozen Shoulder - Formation of fibrous tissue in capsule that causes stiffness, progressive limited ROM, and pain
Subcutaneous Nodules - Painless nodules due to RA
