Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins The Musculoskeletal System.

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

The Musculoskeletal SystemThe Musculoskeletal System


Skeleton Skeleton • Consists of 206 bones

• Provides support for the soft tissue and organs of the body



Types of Joint Articulation: Synovial, Cartilaginous, and Fibrous

Types of Joint Articulation: Synovial, Cartilaginous, and Fibrous

Synovial joint

• Joint is freely movable• Bones are separated by

synovial cavity

• Synovial membrane secretessynovial fluid that lubricates joint movement

– Examples: shoulder, knee


Types of Joint Articulation: Synovial, Cartilaginous, and Fibrous (cont.)


Cartilaginous joint

• Joint is slightly movable

– Examples: vertebral bodies of the spine




Fibrous joint

• Joints have no appreciable movement

• Bones separated by fibrous tissue or cartilage

– Example: sutures ofthe skull


Joint Movements Joint Movements

• Flexion

• Extension

• Rotation

• Circumduction

• Elevation

• Protrusion

• Retraction

• Abduction


Joint Movements Joint Movements

• Adduction

• Pronation

• Supination

• Inversion

• Eversion

• Gliding


Table 23.2 Joint MovementTable 23.2 Joint Movement


Table 23.2 Joint Movement (continued )Table 23.2 Joint Movement (continued )








Range of Motion-ActiveRange 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.


Range of Motion- PassiveRange 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.


Range of Motion-Specific JointsRange 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


Musculoskeletal System: The Health History

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


Musculoskeletal System:Tips for Assessing Joint Pain

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


Techniques of Examination:Overview for Each of the Major Joints*

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


Wrist and Hand: Review the AnatomyWrist and Hand: Review the Anatomy


Wrist and Hand: ExaminationWrist 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


Wrist and Hand: Examination (cont.)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)


Palpating the wrist.Palpating the wrist.


Palpating the hand.Palpating the hand.


Extension and flexion of the wrist.Extension and flexion of the wrist.


Ulnar and radial deviation of the wrist.Ulnar and radial deviation of the wrist.


Testing the muscle strength of the wrist.Testing the muscle strength of the wrist.


Carpal Tunnel Syndrome 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


Carpal Tunnel Syndrome Carpal Tunnel Syndrome


Tinel’s sign (Median Nerve).Tinel’s sign (Median Nerve).

• Use your middle finger tap over the carpal tunnel. • Pain, tingling, or electric sensations strongly suggest carpal tunnel syndrome.


Phalen’s test (Median Nerve).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.


Palpating the fingers.Palpating the fingers.


Flexion and extension/hyperextension of the fingers.Flexion and extension/hyperextension of the fingers.


Test for strength the finger (against your resistance)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


Flexion and extension of the elbow.Flexion and extension of the elbow.


Goniometer measure of joint range of motion.Goniometer measure of joint range of motion.


Supination and pronation of the elbow.Supination and pronation of the elbow.


Testing muscle strength using opposing force (flexion or extension.Testing muscle strength using opposing force (flexion or extension.


Important Bones of the ShoulderImportant Bones of the Shoulder

• Review bony anatomy


Shoulder: ExaminationShoulder: 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)


Flexion and extension of the shoulders.Flexion and extension of the shoulders.


Internal rotation of the shoulders. Internal rotation of the shoulders.


External rotation of the shoulders.External rotation of the shoulders.


Abduction and adduction of the shoulder. Abduction and adduction of the shoulder.


Spine: Anatomy of Representative Cervical and Lumbar Vertebrae

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:


Spine: Muscle GroupsSpine: Muscle Groups


Lateral view of spine.Lateral view of spine.


Spine: Examination — InspectionSpine: 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


Spine: Examination — PalpationSpine: 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


Spine: Examination — Range of MotionSpine: 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


Lateral flexion of the spine.Lateral flexion of the spine.


Forward flexion of the spine.Forward flexion of the spine.


Rotation of the spine (right + left rotation).Rotation of the spine (right + left rotation).


Hip: Review Bony AnatomyHip: Review Bony Anatomy


Hip: Examination — Inspection Hip: Examination — Inspection

• Inspect the gait

• Inspect anterior and posterior surfaces of the hip for muscle atrophy or bruising

• Palpation


Hip: Examination – Range of MotionHip: 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 andgrasp 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


Flexion of the hip.Flexion of the hip.


Hyperextension of the hip.Hyperextension of the hip.


Internal and external hip rotation.Internal and external hip rotation.


Abduction and adduction of the hip.Abduction and adduction of the hip.


Test for strength the hips (against your resistance)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.


Knee: Review the AnatomyKnee: Review the Anatomy


Knee: Examination — Inspection and Palpation

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


Knee: Examination — PalpationKnee: 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


Test for strength the knees (against your resistance)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.

Knee: Examination — Range of Motion and Maneuvers

Knee: Examination — Range of Motion and Maneuvers

• Assess range of motion, with patient sitting:– Flexion and extension


Palpating the knee.Palpating the knee.


Testing for ballottement.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.


Flexion of the knee.Flexion of the knee.


Ankle and Foot: Review the AnatomyAnkle and Foot: Review the Anatomy


Ankle and Foot: Examination — Inspection and Palpation

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


Ankle and Foot: Examination — Range of Motion

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


Palpating the ankle.Palpating the ankle.


Eversion and inversion of the ankles.Eversion and inversion of the ankles.


Test for strength the ankle and foot (against your resistance)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


Common AbnormalitiesCommon 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


Common AbnormalitiesCommon Abnormalities

• Contracture

– Resistance to movement of muscle or joint, fibrosis of soft tissue

• Crepitus

– Crackling sound or grating sensation from friction between two bones



• Kyphosis

– Round back forward bending of spine



• Lordosis (Lumbar lordosis.)

– Anteriorposterior curvature with concavity in posterior direction


Common AbnormalitiesCommon Abnormalities• Scoliosis

– Lateral curvature of the spine



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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Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins The Musculoskeletal System.

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