Musculoskeletal System

Question 0

What are you looking for in inspection?

Answer 0

Note the size and contour or joint
Inspect skin and tissue of joints for swelling, colour, masses or deformities (presence of swelling is significant and signals joint irritation)

Question 1

What are the elements of joint assessment?

Answer 1

Inspection
Palpation
Range of motion - active 
Range of motion - passive
Muscle testing

Question 2

Palpation

Answer 2

Palpate each joint, including its skin for temperature, it’s muscles, its bony articulations, and area of joint capsule
Note tenderness, heat, swelling or masses - normally masses are not tender; if tenderness occurs, try to localize it to specific anatomical structure (e.g., skin, muscles, bursae, ligaments, tendons, fat pads, or joint capsules);
Normally fluid in a joint is not palpable - there is a small amount of fluid in the joints

Question 3

Range of motion

Answer 3

Test range of motion by stabilizing body area proximal to that being moved; know each type of joint and expected range of motion so you can recognize any limitations.
Attempt passive range of motion when you notice any limitations; passive range of motion should be the same as active range of motion;
Joint motion normally causes no tenderness, pain or crepitation;
Use goniometer to measure angles of limited range of motion;

Question 4

Muscle testing

Answer 4

Test strength of prime muscle group for each joint; repeat ROM motions and ask patient to flex muscle while you apply opposing force; muscle strength should be equal bilaterally and should fully resist bilateral force

Question 5

Temporomandibular joint (TMJ) inspection

Answer 5

Inspect area anterior to ear, use first two fingers and instruct patient to open and close mouth, drop fingers into depressed area over joint, note smooth motion of mandible (an audible or palpable snap or click occurs in many healthy people)

Question 6

Temporomandibular joint ROM

Answer 6

1. Open mouth maximally - vertical motion, normal range is 3-6cm between upper and lower incisors
2. Partially open mouth, thrust lower jaw, and move it side to side - lateral motion, normal extent is 1-2cm
3. Stick out lower jaw - protrusion with no deviation
4. Clench teeth, palpate contracted temporalis and masseter muscles, compare bilaterally for firmness, size and strength

Question 7

Temporomandibular joint - muscle resistance

Answer 7

Move jaw forward and laterally against resistance, and open mouth against resistance
This also tests the integrity of cranial nerve 5, the trigeminal nerve

Question 8

Cervical spine - inspection

Answer 8

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

Question 9

Cervical spine - ROM

Answer 9

1. Touch chin to chest - flexion of 45 degrees
2. Lift chin toward ceiling - hyperextension of 55 degrees
3. Move ear to corresponding shoulder (do not lift shoulder) - lateral bending of 40 degrees
4. Turn chin toward each shoulder - rotation of 70 degrees

Question 10

Cervical spine - muscle resistance

Answer 10

Repeat motion while applying opposing force; normally patient can maintain flexion against full resistance.
This also tests the integrity of cranial nerve 11, spinal nerve

Question 11

Shoulders - inspection

Answer 11

Inspect and compare both shoulders posteriorly and anteriorly; check size and contour of joint, compare shoulders for equality of bony landmarks; normally no swelling, redness, muscular atrophy, or deformity are present; check anterior aspect of joint capsule and subacromial bursae for abnormal swelling

Question 12

Shoulders - palpation

Answer 12

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

Question 13

Shoulders - ROM

Answer 13

1. With arms at side and elbows extended, move both arms up and in wide vertical arcs - forward flexion of 180 degrees
2. Same position, move both arms back and up - hyperextension of up to 50 degrees
3. Rotate arms internally behind back and place hands as high as possible towards scapulae - internal rotation of 90 degrees
4. With arms at side and elbows extended, raise both arms in arcs in the coronal plane, touching palms above head - abduction of 180 degrees
5. Bring extended arm across torso - adduction of 50 degrees
6. Touch both hands behind the head with elbows flexed and rotated posteriorly - external rotation of 90 degrees

Question 14

Shoulders - muscle resistance

Answer 14

Test strength of shoulder muscles by asking patient to shrug shoulders, flex them forward and up, and abduct them against your resistance
Shoulder shrug tests integrity of cranial nerve 11, spinal nerve.

Question 15

Elbows - inspection

Answer 15

Inspect size and contour of both elbows in the extended and flexed positions; look for any deformities or swelling and redness; check the Olecranon bursa and the normally present hollows on either side of the Olecranon process for abnormal swelling

Question 16

Elbows - palpation

Answer 16

Palpate with patients elbow flexed at about 70 degrees and as relaxed as possible; palpate the extensor surface of the elbow (the Olecranon process and the media, and lateral elicondyles of humerus) (support the patients forearm)
Normally tissues and fat pad feel fairly solid; check for synovial thickening, swelling, nodules, tenderness; palpate area of Olecranon bursa for heat, swelling, tenderness, consistency and nodules

Question 17

Elbows - ROM

Answer 17

1. Bend elbow - flexion of 150-160 degrees
2. Straighten elbow - extension of 0 degrees (some healthy people lack 5 to 10 degrees of full extension, and some people have 5-10 degrees of hyperextension)
3. Hold hand midway; touch the front and back sides of hand to table - pronation and supination both at 90 degrees

Question 18

Elbows - muscle resistance

Answer 18

Stabilize patients arm with one hand, and apply resistance just proximal to wrist, and instruct patient to flex elbow against your resistance; then ask patient to extend elbow against your resistance.

Question 19

Wrist and hand - inspection

Answer 19

Inspect hands and wrists on dorsal and palmar sides, noting position, contour, and shape; normal functional position is wrist in slight extension so fingers can efficiently flex and thumb can oppose them for grip and manipulation, fingers lie straight in same axis as forearm; normally no redness, swelling, deformity, or nodules are present
Skin looks smooth with knuckle wrinkles present, and no lesions or swelling; muscles full with palm showing a rounded mound proximal to thumb and a smaller mound proximal to little finger.

Question 20

Wrist and hand - palpation

Answer 20

Palpate each joint in the wrist and hands; palpate with both thumbs on dorsum, make sure patients wrist is relaxed and in straight alignment; normally joint surfaces feel smooth with no swelling, bogginess, nodules, or tenderness.
Palpate metacarpophalangeal joints with thumbs, just distal to and on either side of the knuckle.
Palpate sides on interphalangeal joints with thumb and index finger; normally no synovial thickening, tenderness, warmth, or nodules are present.

Question 21

Wrist and hand - ROM

Answer 21

1. Bend hand up at wrist - hyperextension of 70 degrees
2. Bend hand down at wrist - palmar flexion of 90 degrees
3. Bend fingers up at metacarpophalangeal joint - hyperextension of 30 degrees
4. Bend fingers down at metacarpophalangeal joint - flexion of 90 degrees
5. With palms flat on table, turn them inward - radial deviation of 20 degrees
6. With palms flat on table, turn them outward - ulnar deviation of 50-60 degrees
7. Spread fingers apart - abduction of 20 degrees
8. Make a fist - tight fist, equal bilaterally
9. Touch thumb to each finger and base of little finger - ability to perform this maneuver and equal bilateral responses

Question 22

Wrist and hand - muscle resistance

Answer 22

Position patients forearms in supine position and resting on a table; stabilize patients arm by holding your hand at mid forearm; ask patient to flex wrist against your resistance at the palm.

Question 23

Hip - inspection

Answer 23

Inspect symmetrical levels of iliac crests, gluteal folds, and equal sized buttocks; smooth and even gait reflects equal leg lengths and functional hip motions

Question 24

Hip - palpation

Answer 24

Help patient into supine position and palpate hip joints, should feel stable and symmetrical, with no tenderness and crepitation.

Question 25

Hip - ROM

Answer 25

1. Raise each leg with knee extended - hip flexion 90 degrees 2. Raise each knee to chest while keeping other leg straight - hip flexion 120 degrees 3. Flex knee and hip to 90 degrees; swing foot outwards/swing foot inwards - internal rotation 40 degrees/external rotation 45 degrees 4. Swing leg laterally - abduction of 40 to 45 degrees 5. Swing leg medially - adduction of 20 to 30 degrees 6. (Examine when patient is standing) - instruct patient to swing straight leg back - hyperextension of 15 degrees

Question 26

Hip - muscle resistance

Answer 26

None. Need to clarify this!!!!!!

Question 27

Knee - inspection

Answer 27

Patient should remain in supine position, skin normally looks smooth, with even colouring and no lesions; inspect lower leg alignment, should be extended in same axis as thigh; inspect knee's shape and contour; normally distinctive concavities (hollows) are present on either side of the patella, check for fullness or swelling, also check prepatellar bursa and suprapatellar pouch for abnormal swelling; check quadriceps for muscle atrophy (prime mover of knee extension)

Question 28

Knee - palpation

Answer 28

Palpate patient's knee in supine position with complete relaxation of quad muscles, start high on anterior thigh about 10cm above patella; palpate with thumb and fingers in grasping manner, proceed down toward knee, exploring suprapatellar pouch; note consistency of tissues - muscles and soft tissues should feel solid and joint should feel smooth, no warmth, tenderness, thickening or nodules - If swelling is present, need to determine if it soft tissue swelling or increased fluid in the joint Continue palpation of tibiofemoral joint, note smooth joint margins and absence of pain; palpate infrapatellar fat pad and patella; check for crepitus by holding hand over patella when knee is flexed and extended

Question 29

Knee - ROM

Answer 29

1. Bend each knee - flexion of 130 to 150 degrees 2. Extend each knee - extension of 0 degrees (straight) in some; hyperextension of 15 degrees in others 3. Ambulate (examiner checks ROM during ambulation)

Question 30

Knee - Muscle resistance

Answer 30

Ask patient to maintain knee flexion while you oppose by trying to pull leg forward; patient demonstrates muscle extension by successfully rising from seated position in a low chair; rising from a squat without using hands for support.

Question 31

Ankle and foot - inspection

Answer 31

Inspect while patient is in a sitting, non-weight bearing position, as well as when standing and walking; compare both feet, noting position of feet and toes, contour of joints, and skin characteristics; feet should align with long axis of lower legs (an imaginary line should fall from mid-patella to between first and second toes) Weight bearing should be borne on middle of foot from heel along the midfoot to between second and third toes; arch can vary normally from flat feet to high instep Toes point straight and lie flat, ankles (malleoli) are smooth bony prominences; normally skin is smooth, with even colour and no lesions; note locations of any calluses or bursal reactions because they reveal areas of abnormal friction

Question 32

Ankle and foot - palpation

Answer 32

Support ankle by grasping the heel with your fingers while palpating with your thumb; explore joint spaces; should feel smooth and depressed, with no fullness or tenderness Palpate the metatarsophalangeal joints between your thumb on the dorsum and fingers on the plantar surface; palpate interphalangeal joints on the medial and lateral sides of toes

Question 33

Ankle and foot - ROM

Answer 33

1. Point toes toward the floor - plantar flexion of 45 degrees 2. Point toes toward your nose - dorsiflexion of 20 degrees 3. Turn soles of feet out - eversion of 20 degrees 4. Turn soles of feet in - inversion of 30 degrees 5. Flex and straighten toes

Question 34

Ankle and foot - muscle strength

Answer 34

Ask patient to maintain dorsiflexion and plantar flexion against your resistance

Question 35

Spine - inspection

Answer 35

Patient should be standing, draped in gown open at back; stand far enough back from the patient to see entire back Inspect and note whether the spine is straight, following an imaginary line from the head through the spinous processes and down through the gluteal cleft; note equal horizontal position for shoulders, scapulae, iliac crests, and gluteal folds; note equal space between the arm and lateral thorax on the two sides; patients feet and knees should be aligned with trunk and should be pointing forward. From the side, note normal convex thoracic curve and concave lumbar curve (an enhanced thoracic curve - kyphosis - is normal in older adults); (a pronounced lumbar curve - lordosis - is common in obese people and possibly toddlers)

Question 36

Spine - palpation

Answer 36

Palpate spinous processes; normally straight and not tender; palpate paravertebral muscles, they should feel firm with no tenderness or spasm

Question 37

Spine - ROM

Answer 37

1. Bend forward and touch toes - flexion of 75-90 degrees (look for smoothness and symmetry of movement), (note that concave and lumbar curve will disappear with this motion and back should appear as single convex C-shaped curve); if you suspect spinal curvature, have patient touch toes and mark dots on each vertebrae, when patient stands up, should be straight line 2. Bend sideways (both sides) - lateral bending of 35 degrees 3. Bend backwards - hyperextension of 30 degrees 4. Twist shoulders to one side, then the other - rotation of 30 degrees bilaterally (These maneuvers reveal only gross restriction; movement is still possible even if some spinal fusion has occured) 5. Walk on toes for a few steps 6. Walk on heels for a few steps

Question 38

Spinal - muscle strength

Answer 38

need answer

Question 39

What does a functional assessment entail?

Answer 39

1. walk (with shoes on) 2. climb up stairs 3. pick object up from the floor 4. rise up from sitting in a chair 5. rise up from laying in bed