Assessment of the Musculo-Skeletal System

Dr Essmat Gemaey 230 NUR

Outlines
1. Review of Anatomy and physiology of musculoskeletal system 2. Physical Exam 3. Inspection 4. Palpation 5. ROM (Rang of motion)

Objectives
Apply knowledge of Anatomy and physiology of musculoskeletal system Differentiate between normal and abnormal Implement physical assessment

What do muscles do ?
Muscles simply move you! Without muscles you couldn't open your mouth, speak, shake hands, walk, talk, or move your food through your digestive system. There would be no exploring, running, climbing, smiling, blinking, breathing. You couldn't move anything inside or outside you. The fact is, without muscles, you wouldn't be alive for very long

The skeleton is the name given to the collection of bones that holds our body up. Our skeleton is very important to us. It does three major jobs. 1. It protects our vital organs such as the brain, the heart, and the lungs. 2. It gives us the shape that we have. Without our skeleton we would just be a blob of blood and tissue on the floor. 3. It allows us to move. Because our muscles are attached to our bones, when our muscles move, they move the bones, and we move

Physical Exam
1. Inspection Observe any lack of symmetry and any evidence of trauma or disease. Look for muscle wasting; Inspect the joint contour (shape) and observe any evidence of swelling, deformity or inflammation.

 Ask the client to point to, or otherwise identify, any painful areas, including sites of radiation of pain.
Screening questions for musculoskeletal disorders 1. Do you have any pain or stiffness in your arms, legs or back? 2. Can you walk up and down stairs without difficulty? 3. Can you dress yourself in everyday clothes without any difficulty?

 Assessment of Gait Ask the patient to walk back and forth across the room . Observe for equality of arm swing , balance and rapidity and ease of turning . Next, ask the patient to walk on his tiptoes ,then on heels . Ask the patient to tandem walk . Test patient's ability to stand with feet together with eyes open and then closed. (Romberg's test .)Reassure patient that you will support him, in case he becomes unsteady . Normal :Person can walk in balance with the arms swinging at sides and can turn smoothly. Person should be able to stand with feet together without falling with eyes open or closed.

heels

tiptoes

tandem

Upper Extremity Muscles

Inspect the muscles of the shoulder, arm, forearm and hand. Note muscle size (bulk). Look for asymmetry, atrophy and fasciculation. Look for tremor and other abnormal movement at rest and with arms outstretched.

Determine muscle power by

Gently trying to overpower contraction of each group of muscles.
Shoulder:
Abduction

Abduction (Deltoid) , Adduction , Shrug (Trapezius)

Adduction

Trapezius)

 Elbow: flexion (Biceps)

Elbow extension (Triceps)

Wrist: Flexion ( )and extension().

 Hand: Grip
Grip

opposition of thumb and index finger

opposition of thumb and little finger and

finger abduction and adduction.

 Determine limb tone (resistance to passive stretch). With the patient relaxed Gently move the limb at the shoulder, elbow and wrist joints and note whether tone is normal, increased or decreased

Normal findings
Muscles are symmetrical in size with no involuntary movements. In some, muscles may be slightly larger on the dominant side. Muscle power obviously varies. You should not be able to overpower with reasonable resistance. You have to learn to appreciate the normal tone from practice.

Neck: Range of Motion of

Fix the head with one hand while you examine neck Inspection
Note the normal concavity of cervical spine Identify Transverse process of C7 Observe Trapezius and Sternomastoid muscles

Palpation

Feel each spinous process looking for focal areas of tenderness Joint
Para spinal muscles Active
Feel for crepitus during passive motion

Touch chin

Range of motion

Touch chin for flexion Throw head back for extension

Throw head back

 Touch each shoulder with ears for lateral flexion Touch each shoulder with chin for lateral rotation

Passive
Feel for crepitus during passive motion

Normal:
30 degree rotation, able to touch chest with chin, 55 degree extension and 40 degree lateral bend. No resistance during the range of motion.

Muscles of Lower Extremity

Inspect the muscles of the hip, knee and ankle . Note muscle size( bulk .) Look for asymmetry, atrophy and fasciculation . Look for abnormal movement . Determine muscle power by gently trying to overpower contraction of each group of muscles .
Hip :Flexion( Iliopsoas), Extension (Gluteus maximus), Abduction, Adduction .

Hip flexion

The Knee Exam

Inspection Make sure that both knees are fully exposed. The patient should be in either a gown or shorts. Rolled up pant legs do not provide good exposure ! Watch the patient walk. Do they limp or appear to be in pain? When standing, is there evidence of bowing (varus) or knockkneed (valgus) deformity? There is a predilection for degenerative joint disease to affect the medical aspect of the knee, a common cause of bowing .

varus Knee more ,deormity marked on the left leg

 Is there evidence of atrophy of the quadriceps, hamstring, or calf muscle groups? Knee problems/pain can limit the use of the affected leg, leading to wasting of the muscles .

While both legs have well developed musculature, the left calf and hamstring are bulkier than the right

 Determine limb tone resistance to passive stretch. With the patient relaxed, gently move the limb at the hip, knee and ankle and note whether tone is normal, increased or dicreased. Flex the hip and knee. Support the knee, dorsiflex the ankle sharply and hold the foot in this position checking for clonus .

Knee : Flexion( Hamstrings ,) Extension( Quadriceps ) Ankle : Dorsiflexion( Tibialis anterior), Plantar flexion (Gastronemius .)

Knee extension

Knee flexion

Dorsiflexion

Spine (Bone)
The examiner should stand behind the patient and observe the alignment of the spine in the flexed position to determine scoliosis . View the spine from the side to determine kyphosis .

Ask the patient if he is aware of sore spots. Palpate the spinous process and be gentle with the sore spots .Percuss one vertebra at a time, starting from head . .

 Assess range of motion of spine by having patient bend down to pick up an object without bending his legs while you hold his hips . Normal : Gentle concavities in cervical and lumbar regions and a convexity in the thorax . Vertebral line and gluteal cleft align